There is a question whether the tonsil ever serves as the site of infection from which cervical buboes result. It would seem that the greater frequency of inguinal buboes is because a greater area of skin drains into these glands. There may be multiple buboes and it must not be forgotten that the lymphatic glands of any region may become enlarged. There may also be lymphangitis. Only one gland of a group may be involved or the whole group may show enlargement. Very characteristic for plague buboes is the oedema of the periglandular tissues, which is largely responsible for the great size of some of these buboes; they may vary from the size of an almond or walnut to that of a child’s head. The patient tends to assume an attitude to relieve any tension on the very painful bubo. Particularly over these buboes, but at times elsewhere, the skin may show areas of inflammation, often several inches in diameter. Necrosis of this area occurs and a slough separates. These lesions are often termed carbuncles but are really not such, but only gangrenous patches of skin. When these areas of cutaneous necrosis are a marked feature the designation of _cellulo-cutaneous plague_ is at times given. Petechiae or large purpuric spots may be conspicuous in some epidemics and it was from these “tokens,” as they were called, that plague received the designation “black death.” As the case progresses, the anxious countenance gives way to one of apathy, the control of speech and cerebration become more and more impaired and the patient may go into a typhoid state. Cases with buboes in the axillae give the gravest prognosis, as for example, 80% mortality for axillary, and 70% for inguinal. The buboes may suppurate towards the end of a week or they may undergo a slow resolution. Secondary broncho-pneumonia may develop in the course of bubonic plague. Pulmonary congestion is however not infrequent and may cause dyspnoea, accelerated respiration and cough. Owing to the tendency to degeneration of the endothelial lining of capillaries, various haemorrhagic manifestations, other than those of the skin, may be observed, such as epistaxis, haematuria, etc. There is usually a rather marked leucocytosis in which the increase is chiefly of the polymorphonuclears. [Illustration: FIG. 67.—A, Temperature chart of fatal case of bubonic plague. B, Chart of case of bubonic plague going on to recovery but with suppuration of plague bubo. C, Chart of fatal case of pneumonic plague.] =A Typical Case of Pneumonic Plague.=—Besides those cases where pulmonary involvement sets in during the course of an attack of bubonic plague and which are classified as secondary plague pneumonias we have sporadic cases and epidemics when the clinical course of the disease is predominantly and primarily pulmonary.