x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 279 
other superficial lymphatic glands are somewhat enlarged, but not hemor- 
rhagic nor cedematous. 
In this case both popliteal and femoral glands appear in the gross like 
primary buboes of the first order.* 
AXILLARY BUBOES 
When the primary bubo affects the axillary glands, the swell- 
ing may be high up in the concavity of the axilla or lower on the 
thoracic wall at the margin of the pectoral muscles. In the 
former condition the axillary space may be completely filled up 
by a large, elastic swelling through which individual glands can- 
not be palpated. If the swelling be lower, it will be seen along 
the anterior border of the axilla as a diffuse swelling, some 
oedema extending in all directions about it. On section the glands 
and periglandular tissue will be found in the same condition as 
has been described in the groin. The cedema not infrequently 
extends upward along the muscle fascia beneath the clavicle, as - 
far as the postpharyngeal wall, and this cedema may be very 
evident in the pharynx. The cervical prevertebral glands may 
show the lesions of a primary bubo of the second order. These 
will be further discussed along with the primary cervical buboes. 
The enlargement of the axillary glands may lead to a diffuse 
cedema of the upper extremity of the affected side, as the result 
of pressure upon the vessels. 
Among my cases 6 presented axillary buboes—2 on the right 
and 4 on the left. The liability of the deep cervical glands to 
involvement as primary buboes of the second order, with infection 
spreading from them more readily to the lung, would seem to 
render the lungs more liable to specific plague infection in the 
case of primary axillary buboes than is the case with primary 
buboes in the groin. This a priori hypothesis is shown to be 
true in our cases, as 50 per cent of the cases with primary axillary 
buboes had specific pulmonary involvement as compared with 
about 7 per cent of the cases with primary buboes in the groin. 
These figures must not, however, be accepted without due 
allowance for the disparity in incidence of buboes in the axilla 
and groin. 
CERVICAL BUBOES 
Fiexner °° says: 
The buccal mucous membrane forms one of the portals of entry into 
the body of the plague bacilli. It is probable that the cervical buboes arise 
* This case is almost exactly analogous to case 18/XLVIII of the Austrian 
Commission [Uber die Beulenpest in Bombay (1898), II B, 315], in which 
cubital and axillary glands were similarly involved. 
*Am. Journ. Med. Sci. (1901), n. s. 122, 405. 
