and in pairs; (b) bacilli about the size and shape of tubercle bacilli; (c) short, plump bacilli of some magnitude; (d) cocci and streptococci; (e) saccharomyces; and (ƒ) moulds. Inoculated into broth, this exudation grew short bacilli, in pairs and short chains. Some of the chains might have consisted of streptococci, some of which were seen in the exudation. In the case (Case 2) to which I have just referred, we have to consider the possibility of the original infection having been one of micrococci. In this event the bacilli may have emigrated into the lymph which the cocci had produced from the intestines and after the death of the patient. Before saying anything more about perforative peritonitis I propose to contrast a case of streptococcus peritonitis with those which have just been described.

STREPTOCOCCUS PERITONITIS.

Case 4.-A girl, sixteen years of age, was admitted with inflammatory swellings about the right humerus, the lower end of the left radius and ulna, and of the left calf. She also had a distended and tender abdomen, but without sickness or obstruction. She had not been well for three weeks and attributed her illness to a wound of the thumb which she received

whilst at work making lace. The scar of a recently healed wound was seen upon the thumb. The swelling about the right humerus was opened, and some greenish pus escaped. Soon after the operation she began to vomit and speedily died. During her illness her temperature was usually about 101° F.

At the

FIG. 4.-Streptococcus peritonitis. Lymph upon the surface of the peritoneum.

examination, which was made in the winter twentysix hours and a-half after death, the swellings of the arms and legs were noted, and an abscess the size of a hazel nut was found near the root of the tongue, amongst its muscular fibres. The thoracic viscera were normal, except the bases of the lungs, which were

congested.

The peritoneum, was much inflamed and contained a quantity of pus, some of which filled the pelvis. The vagina, uterus, and Fallopian tubes were healthy; but the left ovary contained an abscess as large as an orange, which had burst, and, Mr. Berry believes, started the diffuse septic peritonitis.

The

FIG. 5.-Streptococcus peritonitis. Streptococci in the depths of the peritoneum.

spleen was large and soft, and the liver covered with punctiform hæmorrhages. The histological examination showed that the surface of the peritoneum was covered with lymph consisting mainly of corpuscles with very little fibrin (Fig. 4). This lymph contained vast numbers of cocci, singly, in pairs, and in

chains of various lengths. In places these cocci had penetrated far into the substance of the peritoneum and had reached the subperitoneal fat. Here they were thickly crowded in the connective tissue trabeculæ between the fat cells (Fig. 5). Many of the lymph paths were crowded with vast numbers of cocci, diplococci, and streptococci. The blood vessels of the peritoneum were engorged with blood, but contained no bacteria. The substance of the peritoneum was comparatively free from cellular infiltration. Here and there the surface lymph had in it leptothrix of slender bacilli. These were few and scattered, and, I believe, had grown after death. It is to be regretted that the liver, spleen, and other organs were not obtained for examination. Before the history of this case was known to me, and judging solely from the microscopical appearances, I had come to the conclusion that the peritoneum had been infected with streptococcus pyogenes. This is usually found in abscesses and suppurations about the female genital organs, and is also one of the commonest causes of pyæmia. Döderlein and others have shown that vaginal pus usually contains streptococcus pyogenes, often associated with other microbes. Thus the case may have been one in which an abscess of the ovary had existed for some time, and then suddenly burst and caused

diffuse septic peritonitis, followed by pyæmia; or the original point of inoculation may have been the thumb; and the abscess in the ovary, like those of the root of the tongue and of the arm, may have been an ordinary pyæmic abscess. Whichever way the ovarian abscess formed, it seems to have been the source from which the peritoneum became infected. The histological appearances support the view that at first the micrococci grew upon the surface of the peritoneum, afterwards penetrated into its substance and into its lymph paths, and finally caused a general infection. It is unnecessary to point out that in such a condition as this our present surgical remedies would be of no avail. The histological examination of this case is, unfortunately, very incomplete. I was only furnished with some portions of the peritoneum. Further knowledge of these peritoneal infections is urgently needed, but it is doubtful whether culture media will supply what is wanted.

STREPTOCOCCUS PLEURITIS; STREPTOCOCCI AND
BACILLI IN WOUND.

I have now described several cases illustrating the effects of bacteria upon the peritoneum. I next purpose to describe a case to show their effects upon the