932 The Philippine Journal of Science 1915 
The entire pharyngeal ring may be thus involved, or the lesions 
may be largely confined to the faucial tonsils. In the latter case 
enlargement, with congestion and the formation of a pseudo- 
membrane or deep ulceration, may be present. 
These tonsillar and pharyngeal lesions may represent the re- 
action of the tissues at the portal of entrance of the bacilli to 
the body, or they may occur as the result of infection of the 
parts through the blood stream when the primary portal of 
entrance of the bacilli is in a distant part of the body. Refer- 
ence has also already been made to the possibility of the exudate 
about an axillary bubo extending by direct continuity of tissue 
to the pharynx. It has also been suggested that these pharyn- 
geal lesions may be secondary to primary cervical buboes when 
the portal of entrance occurs on the skin surface. 
In my series necrotic and ulcerative lesions of the tonsils were 
present in 3 cases (1894, 2171, 2259) with primary femoral 
buboes and in 2 cases (2148, 3012) with primary axillary buboes. 
In the cases of primary buboes of the parotid or submaxillary 
lymphatic glands (2134, 2150, 2267) the tonsils have not been 
markedly affected. On the contrary, when the deep preverte- 
bral cervical glands are the ones chiefly involved, severe changes 
in the tonsils (and sometimes other parts of the pharynx) have 
been found (2074, 2160, 2335, 2389, 2993, 3129). 
These facts would seem to indicate that the tonsils in these 
latter cases have formed the portal of entrance for the bacilli, 
and that the involvement of the prevertebral cervical glands 
occurs secondarily, through the lymph stream. 
Plague bacilli are known to multiply rapidly in lymphadenoid 
tissue, and such tissue forms the major portion of the tonsils. 
Since, when infected by the plague bacilli, the tonsils undergo 
changes which are exactly analogous to the changes occurring 
in the ordinary plague bubo in a lymphatic gland, it is a question 
whether such primarily affected tonsils may not properly be 
spoken of as “primary tonsillar buboes.” There seems no valid 
reason why such a term should not be applied to them. There 
occur in the tonsils congestion, ceedema, exudation, hemorrhage, 
necrosis, enormous bacterial multiplication, and destruction of 
the capsule, with involvement of the surrounding structures, and 
these are the changes that occur in an ordinary plague bubo in 
a lymphatic gland. On such a basis the prevertebral cervical 
glands would be called primary buboes of the second order. 
From the figures quoted above it will be seen that tonsillar 
lesions are a not infrequent occurrence in bubonic plague (about 
15 per cent in this series). 
