MICRO-ORGANISMS BEL(>.\',I \<; TO THE HIGHER BACTERIA 425 



pathological picture of a case of this infection that a considerable 

 portion of it is repeated here: 



Six days before her admission to the hospital her illness began with 

 a severe chill, and fever, and pain in her left side and back. The fol- 

 lowing day the pain in the side was worse and breathing was difficult. 

 She began to cough and had some expectoration, but no blood 

 noticed in the sputa. At irregular intervals she had alternating hot 

 and chilly sensations. 



On admission, the patient complained of pain in the left side of the 

 chest, cough, fever, weakness, and prostration. Her temperature was 

 103, and her pulse and respirations were rapid. 



Physical Examination. The patient is poorly nourished and ana-mic. 

 Lungs: Anteriorly the right lung is normal. On the left side, over an 

 area two inches by three inches just to the left of the nipple, there is 

 marked dulness to percussion, and bronchial voice and breathing. No 

 rales are heard. Posteriorly, the left lung is normal. At the extreme 

 base of the right lung there is slight dulness and diminished breathing, 

 with crepitant rales after coughing. The voice is normal. 



The history of the disease and the physical signs indicated an attack 

 of acute lobar pneumonia, the area of consolidation being small and 

 situated in the lower part of the left upper lobe in front. Frequent 

 and violent coughing, with almost no expectoration, pain in the affected 

 side and in the lumbar region, restlessness and sleeplessness, and 

 involuntary urination were the symptoms noted during the first four 

 days in the hospital. The pneumonic area increased somewhat, and 

 extended backward to the posterior axillary line, and the temperature 

 was continuous at 103 to 103.5. On the fifth day the temperature 

 fell two degrees, and signs of resolution appeared in the consolidated 

 area. The apparent improvement, however, was of short duration. 

 On the sixth day the temperature rose to 104.5, and continued to 

 rise each day, reaching 107.5 shortly before death, which occurred 

 on the ninth day in the hospital and the fifteenth day of the disease. 

 During the last four days the patient complained bitterly of pain in the 

 lumbar region and in the thighs and legs, and of intense vesical tenesmus. 

 The stools and urine were passed involuntarily. Signs of consolidation 

 were found in the right lower lobe, behind. There were repeated attacks 

 of profuse sweating. On the day before her death three indurated 

 swellings beneath the skin were noticed. One, on the left forearm, 

 about the size of a walnut, apparently contained pus. Two, of smaller 

 size, were situated in the right groin. 



Blood cultures from a vein in the arm, taken on the sixth day, re- 

 mained sterile. Subsequent attempts failed on account of the feeble 

 circulation. The leukocyte count on the seventh day was 36,000. 



Autopsy. On the right arm, the left forearm, the abdominal wall, 

 and on both thighs there are eight or ten slightly projecting, roundel, 

 fluctuating, subcutaneous swellings from one-half inch to one inch in 

 diameter. The skin over most of these nodules is unaltered, but over 

 the larger ones there is a slight bluish discoloration. The nodules were 



