examination throws a certain amount of light upon a point in the clinical history. Towards the end of the disease it may be remembered that the pulse beat rapidly and the heart's failure was so marked that cardiac stimulants were given for its relief. The accumulation of bacteria in the cardiac vessels may help to explain these cardiac symptoms.

BACILLI IN THE BLOOD DURING LIFE.

I have reason to think that small short bacilli, such as were found in the foregoing cases, may be seen in the blood of living patients. Mr. Maxwell has given me preparations of blood which certainly contain bacilli with similar morphological characters, and which were made under the following cicumstances:--

Case 10.-A man, aged twenty-three years, was admitted into the medical wards of St. Bartholomew's Hospital in November 1894, with ulcerative endocarditis and septicemia. The endocarditis was probably an acute attack which had supervened upon an old disease. Twice before the patient had had rheumatic fever, and once before an attack of chorea. The acute endocarditis was accompanied with aphasia, paralysis of the right side, and double optic neuritis. Although the signs of septicemia were not of the acutest kind,

nevertheless they were very clear. The temperature was raised, and usually ranged betwixt 100° and 103° F. A hæmorrhagic rash appeared upon the buttock. Delirium was almost constant at night, and towards the end he became restless and unconscious. The urine contained a trace of albumen, but was not examined for bacteria. The duration of the septicemia may have been a little over a month. When the disease was at its height Mr. Maxwell obtained blood from the finger which contained small short bacilli singly, in pairs, and in small swarms. Their size was variable, some being as big as staphylococcus aureus and others thrice the size. They all, however, belonged to the same species, and the large elements were simply those which were in the act of division. The specimen which contained such an abundance of bacteria was obtained after the skin had merely been washed with soap and water; but four days later some blood was obtained after the skin had been scrubbed with soap and water, rubbed with ether, and disinfected with a 5 per cent. carbolic lotion. The blood still contained the same bacteria, but in much fewer numbers. Attempts to grow these bacteria upon culture media ended in failure.

Experimentalists are quite familiar with the disappearance of bacteria from the blood after massive doses have been injected. Saprophytes disappear

most quickly, and in a few hours none survive; but even pathogenic bacteria soon diminish in numbers, and may entirely vanish.1 Thus, there is nothing surprising in the occurrence of many bacteria upon one day and their diminution upon another. Dr. Kanthack, our pathologist, has of late had no difficulty in finding staphylococcus aureus and streptococcus pyogenes in the blood during life in pyæmia and ulcerative endocarditis. In cases of so-called septicemia none were found, and these all recovered.

SEPTICEMIA WITH BACTERIAL INVASION OF THE HEART, PERICARDIUM, AND PLEURA.

Case 11.-One of the cases of septicemia (Case 8) which has been described died on 19th May 1893. It was preceded by another in the same ward which died rather less than a month before, on 26th April 1893. The two cases resemble one another in some particulars, but differ widely in others. They will be contrasted after I have given the details of this, which was the first to occur. The patient was sixtyfive years old and had been a widow for two years.

1 Numerous references are given by Thomas in Neubauer and Vogel's "Harnanalyse ;" also by Wyssokowitsch in the Ztschr. f. Hyg., Leipzig, 1886.

In August 1890, a small carcinoma was removed from the right breast, together with some enlarged axillary glands. This operation was followed by no recurrence in loco, but in April 1893, the left breast was amputated for the same disease, and the axillary lymphatic glands,

FIG. 13.-Bacillary septicemia. Bacilli in blood clot in the anterior jugular vein. In some parts of this clot the bacilli grew in leptothrix.

being enlarged, were removed.

The day after the

operation the woman was quite comfortable, without pain, and with a normal temperature. Upon the third day her temperature had risen to 102.2° F., and on the

fourth she was very ill with a temperature of 102.3°, an inflamed throat, and some redness of the wound, unaccompanied with discharge or suppuration. Upon the fifth day, although she felt better, there was some fulness in the axilla, with tenderness about the shoulder. The mind was quite clear except at night, when she was slightly delirious. The urine was acid, with a specific gravity of 1022, and a cloud of albumen when heated. Upon the seventh day she died with failure of the heart's action; her pulse, which had been at the rate of 118 to 120 per minute, fell to 112 and then to 60. The respiration, too, was rapid, having risen from 27 to 42 during the course of her illness. The temperature, which had averaged 102° F., fell to 99.8° on the day she died. There was never any coma, and the mind was clear throughout.

The examination was made twenty-five hours after death. The operation wound was said to have appeared healthy. The brain and organs were normal, with the exception of those in the thorax. The surface of the pericardium was covered with a thin layer of recent lymph, and contained about an ounce of purulent fluid. The lungs were slightly congested and the pleuræ universally adherent by a thick layer of recent yellow lymph. fluid in the pleural cavities.

There was very little

Recent thrombi were