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No. 6.— On the Diplococcoid Form of the Colon Bacillus. f BY j)^eorge adami, m.a., ivid., maude i^^bott, b.a., m.d., e/jMjicmc AND fICMOLSON, B.A., M.D. o-.^-^^l With Three Plates. [Reprinted frtmi the Tnuuac^on* of the AtiooUtion of American Physicians, Montreal, 1899. QlHKiiitfrtt ■i mamtm^ I [F-eprinted from tho TrnnsnotinnR of the Assnciatinn of American I'liyBiciaiifl, IHHH.] 4- ON THE DIPLOCOCCOID FORM OF THE COLON BACILLUS. Hy J. GEORGE ADAMI, ^[.A., M.I)., F.R.S.E., MAUDE K. ABBOTT, B.A., M D., AND F. .1. NICHOLSON, B.A , M.D. {From the Patkological iMhoratnri/ of the Roi/ul Vintoria Ifo.tpita/, ^hn^reublioation on the subject, I have miule myself pecu- liarly res|M)Usible for these observations upon the colon bacillu?, I would very gladly have left my own name oil' the titlepage, for, In consequence of prolonged absence from my labora- tories, the observations have been throughout conducted by Dr. Abbott, and Mr., now Dr. Nicholson, and I cannot sumciently acknowledge the enthusiasm which they have thrown into the work.— J. G. A. I'culiiir to >\vii their winded iis \' are one (ler tlicHc lit ill the lir()wni.s)i (•■^nizablo IS att(Mui- HU'ulatioii stock cul- tlii' liver inl)ors. t be that Miraiice in ; can show ndnctcd « liis (lipid- isible into n bacillus issues. "Jicliolson ; (Is by Dr. :ioiD FORM body and olon is an e myself iiecu- lartly have left m my labora- Mr., now Dr. ■ have thrown 1 I DlI'l.OCOUCOlI) KOKM OK T »I K COLON HACIM.US. 3 undoubted bacdliis with no rec()^iiizal)le internal orpinizatioti, it lias been a matter of fre(jiieiit observation that it nii^ht present distinct polar stainin<^, and, indeed, when stained by f'uehsiii or other strong reagent for purposes ot photoj^raphy this so-called polar stainin<: is very conspicuous. We need but refer to the various published pho- toi^raphs to contirin this statement, in tliesc! jihoto^raphic reproduc- tiotis of film preparations from cultures the majority of the bacilli are seen to be present as two rounded coccus-like bodies lyinj.; in dose apposition, a coninion enclosing or joining sheath being more or l«.'^s clearly evident. The appearance here observed is that which is generally spoken of as " polar staining." It is commcui to a largo number of bacteria, and, in not a few cases, as, for example, among the bacteria of h«m- orrhagic septiciemia, has led in the past lo not a liti!.- cjnriision iti descriptions, authorities having been divided as to wlietlier to cla.s.s bacteria, exhibiting the property in a marked degree as bacilli f>r diplococci. In certain cases, as in connecti with the typhoid bacillus, 't has been attributed to a retraction of the ' rotoplasin to the [)oles during the process of preparation and stninin-' of the film of bacteria, and thus has been regardeil as an artefact. We shall not here enter into the discussion concerning jiolai and metachromatic granules, but simply state that our observations, so fur as they go, would seem to negative this hitter supp3sition and to ren- der it evident that, in the case of the colon bacillus at least, f/un-e is a structural condition or internal orijanization of the ynicrohe under- lying and explaining such polar stainiiu/. What is more, tluy show us that the appearances .seen in the colon bacillus are closely allied to the " beading " to be made out in the tubercle bacillus under cer'-ain conditions of growth and anvironment. As already pointed out by A. Schmidt,- Ilodot,^ and others, the colon bacillus varies according to the length of time it is kept outside the body, according to the medium in which it is grown, the reaction of the medium, the temperature, and the part from Avhich it has been isolated. Rodet has found that when it is taken from the healthy intestine the individuals during the earlier generations outside the body are singularly even in their length and thickness and stain well throughout ; w hen taken from diseased tissues, from the inflamed gall-bladder, for e.vample, this is no longer the case ; they are irregu- 4 AUAMI, ABBOTT, AND NICHOLSON, lur, l)oth in length and thickness ; they stain irrcguhirly, and sliow clear spaces and deeper staining portions. He points out that a temperature of 4-1° to 45° leads, during the first fev hours, to the appearance of very long filameits, though other individual forms are of the normal length. All these filaments show refractive bodies which take up intensely the basic aniline color. After twenty-four hours these long filaments disappear. In addition, accord- ing to this author, growth upon broth containing 2,5 per cent, lactose leads to the peculiar short and small forms, almost like cocci, the majority of which are double and in the form of diplococci. These observations of Rodet have just come into our hands, and we can in the main confirm them. Indeed, in ignorance of this work, pub- lished two years ago, we have been Avorking very much along the same lines as those indicated by Rodet, ,vho, however, it may be added, has noted these appearances without studying more fully their nature. We find that the long filaments mentioned by Rodet are to be observed in cultures kept for a few hours at a high temperature. It must not, however, be thought that they are exclusively confined to this period. Similar long filaments, showing even more clearly the presence of deeper staining bodies within them, are to be gained from old cultures associated with involution forms. Thus, in a specimen of our stock colon bacillus grown for a fortnight in broth containing a trace of bile we found great numbers of these long bodies, and associated with them numerous small diplococcoid forms. Perhaps the most interesting of these long filaments were observed in an a car CD CD ^ plate culture obtained from tho liver in a case of cirrhosis, which had been subjected for a few hours to a temperature of al)out 45° or 4t)°; removed from the incubator, tliij had grown, under difficulties (brought about by the partial drying-up of the medium), for four days at the ordinary temperature. In this the disposition of the deeper staining points was remarkable. ( Vide Fig. 8, Plate I.) Seen undei- the j'g immersion lens, after staining by carbol-fuclisin and decolorizing by weak acetic acid, these fine deeper staining points were ari'anged in a succession of pairs with occasional larger single ovoid bodies in- terposed. AVe have come across one other specimen of a rather pro- longed growth, in which the same appearance was recognizable, though not quite s:, clearly. Possibly the exact extent of the staining and subsequent decolorization may have something to do with the diflfi- ■■ larly, and show .'ads, during the ts, though other 3 fihunpiits show line color. After addition, accord- per cent, lactose t like cocci, the cocci. ir hands, and we f this work, pub- h along the same ay be added, has their nature. Rodet are to be temperature. It vely confined to more clearly the J be gained from s, in a specimen jroth containing ong bodies, and forms. Perhaps erved in an agar hosis, which had !)out 45° or 4(5°; i'iculties (brought four days at the } deeper staining Seen under the and decolorizing ts were ari'anged ovoid bodies in- of a rather pro- )gnizable, though :he staining and with the difl5- DIl'LOCOCCOII) FOKM OF THE COT, OX HACILLUS. 5 culty in recognizing this particular arrangement of the contained bodies. We have also found that taking saliva, filtering and sterilizing it, and making cultures in this medium at the ordinary temperature, we obtain the production of those long filaments, which may be present in the growth not only during the first twenty-four hours, but during the continuance of the culture. Under these conditions in the saliva of one of us (F. .f. N.) the bacilli were throughout singularly slim, and in the later growths again they tended to sliow the development within the bodies of the bacilli of a succession of deeply-staining dots. A. Schmidt has noted that be obtained tlieso filamentous t'ornis of the colon bacillus by the addition of caustic soda to broth. We found that we oblained the longest forms I)y employing lactose broth rendered l.o° aeid to pbenolphtiiallein and containing 'I.-') per cent, lactose. Mere, more especially on the surface exposed to the air, at the end of twenty four hours, we ol:"ained remarkably long filaments. Indeed, we cannot agree with Jiodet that the additi(Ui of this relatively large percentage of lactose to broth results in the production of the diplococcus forms. It is a misfortune that Rodet did not state more precisely the composition and the reaction of his l)rotli. In order to obtain the diplococcus form of the bacillus we conducted a series of experiuK^nts upon growth in broth of varying degrees of alkalinity and acidity at a temperature of 4oth of these gave cultures upon broth and agar, showing diplocoeei merging into stumpy ovoid forms. Here, again, cultures when made immediately from the ascitic fluid sliowed forms of the colon liacillus, but the ascitic Huid kept in the incubator presented oidy pure cultures of an extremely Tuinute diplococcus. After kee]iing for three weeks, subcultures upon agar made from the ascitic fluiil no longer gave the typieal colon form : instead of this a modified form was obtained ; the individuals remained relatively small and very short. {Mile Kig. 5, Plato I.) Only after prolonged sub- cidture and successive iiuiculation from 1 per cent, glucose broth did the fornis become slightly larger and develop into a stumpy diplo- bacillus smaller than the typical colon. What is more, they did not induce fermentation of glucose or KUKM OV T 11 K COLON HAOILM'S. mg killi'd fVotii twelve to twenty-four lioiirs after intraperitoneiil inocula- tion) iinil growtli upon l'.'> per cent, lactose broth the form has become still larjrer and more typical, but wc still fail to obtain gas production. {Vuh Fig. »), I'late I.) Within the last few days we have again obtained this diplococcus form from the human liody. The patient, under Dr. (Jarrow, in the surgical wards of the lloyal Victoria Hospital, suffering from marked biliary crises, was operated upon, in the expectation of finding a con- dition of cholecystitis with gallstones. Tpon opening the ahrlomen a small amount of fluid presented, and a platinum loop of tliis was smeared upon agar-agar — this remained sterile — and immediately about a drachm of the Huid was collected, under strict aseptic pre- cautions, in a sterile flask and brought over to the pathological labor- atory. Here this was added to about an e^ual (juantity of sterilized broth and placed in the incubator. Upon continuing the operation the gall-bladder and ducts were found |)orvious ; there was, however, a condition of perihepatitis, with subacute peritonitis affecting the upper half at least of the abdominal cavity, and with this was associated some thickening of the great omentum. Upon examining the above-mentioneil broth culture after twenty- four hours. Dr. IJrown, the resident surgeon, found that it contained a pure culture of minute diplococci, and immediately called our atten- tion to it. In the features of this growth upon various media this form has so far been found to resemble the minute dipiococci already mentioned as obtained from tlie case of cirrhosis, thougli the growth is sligiitly more active and free. Passage through guinea-pigs and lac- tose broth has resulted in the development of a form identical with that just mentioned. (Viih' Fig. 7, Plate I.) There is very slow development of turbidity in ordinary broth, rather more rapid in glucose broth, but absence of any sign of fermen- tation. The growths upon the surface of agar in both wei'e at first singularly fine, so that they resembled closely those of the strepto- coccus pyogenes, though possibly more transparent than the latter. Upon potato the growth was invisible ; upon blood-serum the colonies were also very fine, and were of an opaijue white fading on to a yel- low tinge. Upon gelatin there was slow growth witliout liquefaction, while litmus-milk was decolorized until it became almost perfectly 10 ADAMl, AHHOTT, A X I) NlCHOIiSON, white; tlioii slowly, in tlio course of the fifth day or ho, a fine pink color was (level. jped in the iiiediuni ; the milk is coa>;ulate(l at the end of a week. Growth upon hroth was definite, hut not ahundant, and was associated with siii;j;ularly little turbidity, a white somewhat stringy ))reeipitate being slowly formed. In the fermentation tube the open limb became opalescent or moderately turbid in the course of forty- eight hours, the closed limb remained perfectly clear, and, in a(Mition, in neither glucose nor iti lactose broth was there any production of gas ; further, there was and is no indol reaction, and if turbidity be present it is still singularly slight. It is unnecessary here to describe all the methods that we have employed in order to cause these forms to revert to type. Briefly, y\i) may say that we have obtained the greatest change by culture for twenty-four hours upon broth rendered J. 5° acid, according to the method recommended by the Committee of Bacteriologists, to which 2.0 per cent, of lactose has been added. In this medium, already at the end of twenty-four hours, there is abundant growth md well-de- veloped turbidity, and the individual forms are relatively large ani^ ovoid, frequently arranged as stumpy bacilli. ( Vide Figs. H and ^ Plate I.) When this form is inoculated into the guinea-pig intraperitoneally and cultures made from the peritoneal fluid at the end of nine hours, both upon agar and glucose broth, growth upon glucose broth in the fermentation tul)e is much more active than before inoculation ; and, whereas, previous to inoculation, only the open end of the tube had been rendered opalescent, now there is turbidity throughout both tubes. As already stated, after passage through three guinea-pigs and growth on this medium the form produced is undistinguishable from the normal colon bacillus. It is possible that this remarkable and somewhat persistent di[)lo- coccoid form, obtained both from the bile of the inoculated guinea-pig and from the ascitic and peritoneal fluids, has become attenuated dur- ing its stay in the body, and that in the case of the bile, for example, during the passage through the liver, the colon bacilli have been mark- edly modified. We have taken sterilized human bile and added to this a minute (piantity of a stock culture of the colon bacillus, and have not been able to obtain in the bile the diplococcoid form alone, although it is true that diplococcoid forms have been relatively abundant. UlPIiOCOCCOII) FORM OK THK COLON' BACILLUS. 11 Here it is interesting to note a point wliieli \vc again find observed by Rodet— namely, that tlie human bile has a distinct iidiibitory effect upon the multiplication of the colon bacillus. Bile to which a minute drop of a twenty-four-hour old culture had been adiled remained to all appearances perfectly clear, and apparently no growth had occurred during four diys; but when a drop of this bile was added to about 10 c.em. of slightly alkaline broth and placed in the incubator, that broth rapidly became turbid, and there was most abundant de- velopment of the bacilli. We are making further observations upon this modification of the bacillus by growth in bile. This, however, may be said at the present time, that jmssibly the existence of bac- teria in the bile may easily be overlooked when tlie ordinary methods of culture upon solid media are employed, the concentrateil bde inhibiting their growth. One of us (M. E. A.) has already found that human bile (three cases), which was apparently sterile when streaked upon agar-agar, gave abundant cultures of the cohm bacillus wlien a suiall drop was added to about 10 c.cm. of glucose broth. CoxCLUSloNr^. Thus far, then, our observations upon the colon bacil- lus grown outside the body have led us to the following.conclusions : 1. The sliort form of the normal colon bacillus cultivated upon the ordinary bacteriological media fre(iuently presents polar staining, the appearance given being that of two rounded bodies, staining more deeply than the rest of the bacillus, lying in and united by less deeply sti'ining material. 2. In tiie more filamentous form a succession of these more deeply staining bodies is at times to be recognized. 3. Growth outside the body under relatively unfavorable conditions renders the polar staining more prominent, so that the shorter forms may closely resemble diplococci, and the filamentous forms show a common unstained or lightly-staining sheath, in which is to be made out a succession of minute dots in pairs and of somewhat larger single ovoid dots. 4. We have so far been unable by modifying the reactions of ordi- nary media, and l)y continiieil growth at a high temperature (4f')°), to produce cultures in which the diplococcoid form alone has been present, although by these means we have gained cultures in which this form has predominated. 12 AHAMI, AHHOTT, AM) NUMIOLSON, T). On the otlicr liaiid, certain bodv HiiidsRown iiiitiinillv, if we may so term it, with tlie colon bacillus — i. c, tlie ascitic and peritoneal fluids from ii case of hepatic cirrhosis and of peritonitis respectively, and the liileof a guinea-pij^ inoculated with ( ? an attenuated form of) the colon hacdius have yielded us diplococcoid j^rowths so modified that we have not so far been able to cause them to revert completely to type. ti. It has been by the prolonjied action of these fluids that these races of the colon bacillus have l)een ))roduced : cultures made from them immediately after removal from the body have yielded us, either immediately or after one or two transfers, typicid cultures of the colon bacillus. Where the fluid has been kept from ten to twenty days the modified diplococcoid form has been produced. 7. The slight but definite inhibitory action of bile upon the growth of the colon bacillus is shown in two ways : (r/) Smear cultures of bile upon agar may remain sterile, whereas the same bile added to ordinary peptone broth may be the seat of active griiwth. {b) Simi- lar bile kept for several days in the inctibator remains clear and shows singularly little evidence of growth within it, though subcultures from this yield fairly numerous colonies of a modified diplococcoid form of the bacillus. 8. The axitic fluid from a ca.sc of hepatic cirrhosis was found to possess similar properties of modifying the colon bacillus and inhibiting its growth. 9. These modified colon bacilli are relatively minute, assume a diplococcoid form, are non-motile, form pin-point colonies upon agar- agar, cause but slight turbidity in broth and an almost invisible growth upon potato ; act but slowly upon litmus-milk, have lost the power of fermenting glucose, lactose, and dextrose broth, and do not develop the indol reaction. Part II. ox Tin-: D11'I,0C0CCU8-MKH MODIl'lCATION OK THE COLON HACILl.US IN Til 10 TISSUES. Taking a series of four young rabbits weighing from 225 to 305 grammes, we inoculated into the marginal vein of each 0.75 c.cm. of a twenty-four-hour growth of the colon bacillus, and killed the animals DIPLOCOCCOID KOKJI OF THK COLON HACILM'S. 13 iit intervals of lifteen iiiinutes, tliirtv iniiuitcs, one and two liours. The various organs were immediately jdaced in t'orniol-Miiller, and were sul)se(|uently cut in celloidin and parallin. the sections heing stained by carbol thionin. Our attention was at first es[)ecially directed to the liver. Here ah'eaily in the animal killed at fifteen minutes after intravenous inocu- lation a definite series of changes was seen to have occurred. ( KA/e Figs. 13 and 14, Plate IT.) In the bloodvessels of the liver free bacilli of normal size and appearance were occasionally to be observed, but alreaily bacilli could be recognized within the leucocytes in the blood- stream. ( Vide Fig. T3.) The number of these leucocytes was not excessive, but each contained a relatively large number of bacilli. In addition, already the endothelium lining the vessels was seen to be very prominent ; here and there these cells containeil a fairly large number of bacilli. In thirty minutes the number of bacilli in the endothelium cells and the number of endothelial cells containing bacilli were markedly increased. The bacilli, situated within the endothelial cells, already show strongly marked differences from those free in the blood-stream. The latter were of normal length and thickness, and took on a homo- geneous stain. Those within the endothelial cells were short and stumpy, sometimes almost coccus like. The appearance given is that of primitive bacilli having been broken up into shorter lengths. In the rabbit killed at the end of one hour the number of bacilli seen in the blood-stream was distinctly less, but there was a further increase of those in the endothelial cells. Occasionally, in the endo- thelial cells relatively large bacilli could be seen, but the majority of forms were, as in previous specimens, very short and stumpy, and the impression gained by a study of the sections is that the bacillus is taken up in the long form and subseijuently broken up into shorter sections. So far no well-stained bacilli could be seen in the liver cells. Already in the endothelial cells certain of these stumpy forms had the appearar'ce of diplococci of fair size. In the liver of the rabbit killed at two hours after inoculation the same appearances were to be made out as those seen in the rabbit of one hour — namely, the presence of short and stumpy bacilli in the endothelial cells; we were of the opinion that a larger proportion of these had the appearance of diplococci than in the previous sections. 14 AI>AMI, AHUOTT, AM> NICHOLSON, III st'vcnil pliiccs l)ot\v('cii tlio liver cells, as iiulciMl also in sections taken at an earlier peiioij, there were to be made out hyaline masses, apparently situated within the vessels, wliieh hyaline musses contained numerous hacilli. We have found scmie little dilliculty in eouiinj,' to a conclusion as to the nature of these masses ; the lar^e ones would seem certainly to he hyaline thrombi, l)Ut in the smaller ones it was often ditRcuUto make ipiite certain whether we were not dealinj^with some phenomenon in c(mnection with the endothelial cells; for very frequently a nucleus of endothelial type was in close connection with these smaller hyaline masses. We could not absolutely leave out of account the possibdity that we were dealing with very greatly swollen endothelial cells. I'p to this i)oint we were unable to recognize in any of the sections of this series indications that the Imcilli had been taken up by the liver cells. F.ut in a rabbit killed four hours after inoculation we came across great nuud)ers of extremely miinite brownish shadows de- finitely within the hepatic parenchyma. ( Viih Fig. 1 5.) We have been wholly unable to stain these little bodies, and, indeed, only by very careful examination with the ^^^ immersion lens have we been able to see them found in thein the presence of bacilli in the endothelial cells, while ^he brown shadows, as we may term them, have been present in ene-mous numbers in the liver cells. Thus far, then, from what we have said, it would appear evident that when the colon bacillus enters into the circulation it is liable to be taken up rapidly by the endothelium lining the hejiatic vessels, and in this process undergoes N 10 IfO I,«ON , To (.J.viiitr tliis ilillicnlt.v. it smiicd to uh tliiit we ini;:lit obtain more •Iccisivc n-sulfs l.y .'inpioyin^' wry yoiiiin; nil.l)its from tliiw to six wooks ,,1(1. In our control sco'tions of tlu> livers of tlit'se very younj; nil.I.its \v(« liavt' foun.l that tlic diplococci appear to Ix- iibseiit. Upon making a like scries of inoeiilations into these very yoiinji ral)l>its, and killing at two, four, and twenty-four liours, we Imped definitely to settle the ([uestion. But here, at lirst, we had wholly negative results, By our routine methods of staining we were unahle to detect any bacteria within the cells, even when we employed scctioi.s that had been cut in paralVm. So ojjposed to all our |>rovious results and conclusions did these aj.pear that for a time we were on the point of relin(pushing this paper, it is possible that either the carbol-thionin used by us for the experiments was defective or our techni(iue motlified in some sli.'ht degree, for at the best the carbol-thionin method does at times show itself wanting. I'>ut our failure was so constant that we hardly believed that tliis explanation would suiUce. Now we have attempted to stain other sections from the same blocks bv other methods, and we eventually found that staining for half an hour with Loelller's methylene-blue, washing with te[iid water, and then passing thr iKjr cent, lactose broth : Ihe bacillus now is m. rpliologically indistinguish- able from the forms seen in Fig. 1 and (save in absence of llagella) from tlie ordinary colon l>acillU9. Flo. 7. -Microbe isolated from peri:oueal exusive hepaiic cirrhosis. From a colony on an agar iilate kept live days under unfavorable conditions (vide «r(7(.-7( Mnliral Joiinml, Octo- ber -ll. l.siW). Kt(i. '.(.—From film made from tlie bile ol a rabbit killed seven hoinsafter intravenous Inocu- lation with the colon bacillus; the l)ile was kept fourleeii days in pipette before examination. Note variety of forms : rare short l)acilli and di|ilo-biicilli with slight capsule, diploeocci witli well-marked caixnles, minute diploeocci devoiil of capsule (■.' destroyed). Fio. 10.— fells from peritoneal lliiid of guinca-|iig killed nine laairs ofter intraperitoneal inoculation with a forly-eight-lionr broth culture of form shown in Fig. ,'i—(. e, from agar cultures deriveil from the ascitic lUiid from a case of cirrliosis. Stained with carbol-tliicmin, oo DISCUSSION' llciclierl 1 ,s in. iminei>iiin, dculiir I, ilrawii under a Zeiss camera Incida. a. Deeply staining Ijncterial and diplcirceeoid Inrins. h. Atlenuatod dipNieoeeolds in large vacuoles, c. Still fur- tlier atlenuate"^v .'> ■I-^ -S?' «?a> IM.ATK I Adatni — Diplococcolil Form of tlie Colon Bacillus. TRANS. ASSOC. AM. PHYS, VOL. XIV, 1899 Ci JO \ 'lX^f:5-V\^^'^^^ J » a o o o MlilUWIIIl wm TRANS. ASSOC. AM. PHYS. VOL. XIV, 1899 FIG. 15. I'l.A'iK III I'l.A'iK III Aaiimi -Dil'locociMiid Kcrin <>f tin- Colon Uiirillus. DIPLOCOCOOII) FOKM oK T If K CoLoN HACII.M'rt. 2."{ DISCUSSION. I)K. WRi.f'll ; Dr. .Vilnmi's olwerviitioim iire of f^reiit iiitercHt mid mont «iigge«tive, nlthoiigli tlieir intiTprotiUioii Ih imt witliout ilillicullif!*. The colon bacilluH in undoubtedly fiicountereil very ofUii In bHeterioloniciil p.\- aminations* ul auto|mieH, but only in ii relatively wmall number of tb< .!• runes doeH itM presence seem to be of any pallioj;eiiii! si>;ni(icance. UbieliNtein's experiinentH Hhowed that colon bacilli injected into the circulation not infre- quently cau«e necrotic foci in the liver, where they may nurvive a long time, and that the bacilli are often elimiiuited by the bile. We found \veek«, and even monthH, after the injection the bacilli in the bile, in which they had induced certain chanjte« miggestive of the causation of gallstone by biliary infections. Dr. Adami and his coworkers have brought forward new observations in support of the opinion that bacteria are very frequently absorbed from the intestinal tract, and that certain organs, particularly the liver, dispose of these bacteria by intracellular digestion. Inder the designation of the "diplococcus form" of the colon bacillus, Dr. Adami describes conditions and appearances of this bacillus, which I judge not to be identical, and it is possible that some better designation miglit be used. I confess to a feeling of some uncertainty as to the exact interpretation of the small coccoid bodies demonstrated by Dr. Adami in the hepatic and other cells, but I ilo not