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[SJJRGICAL

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PATH OLOG Y



AND



THERAPEUTICS




JOHN COLLINS WARREN, M. D.
X-

PROFESSOR OF SURGERY IN HARVARD UNIVERSITY ; SURGEON TO THE
MASSACHUSETTS GENERAL HOSPITAL.



ILLUSTRATED.



PHILADELPHIA

W. B. S AU N D E RS

925 WALNUT STREET.
1895.



'






Copyright, 1894, by
W. B. SAUNDERS.



ELECTROTYPED 8V
WESTCOTT & THOMSON. PHILAOA



PRESS OF
W B SAUNDERS. PHILAOA.



FELIX QVI POTVIT RERVM COGNOSCERE CAVSAS
ATQVE METVS OMNES ET INEXORABILE FATVM
SVBIECIT PEDIBVS STREPITVMQVE ACHERONTIS AVARI.

VIRGIL, Georg. II. 490.



5



PREFACE.



THE scientific portion of a surgical education was formerly re-
garded as something apart and ornamental, but it has now become
an eminently practical feature of the student's curriculum.

No yonng practitioner can be regarded as thoroughly equipped
for surgical work who is not both a good pathologist and an expert
bacteriologist. The confidence born of a knowledge of Pathology
and Bacteriology enables him to assume grave responsibilities and
to grapple successfully with the most complicated problems. It is
from men thus equipped that we have a right to hope that the
future masters of surgery are to be evolved.

An attempt is therefore made in this book to associate pathologi-
cal conditions as closely as possible with the symptoms and treatment
of surgical diseases, and to impress upon the student the value of
these lines of study as a firm foundation for good clinical work.

It is the Author's hope that the following pages will present to a
large number of practising physicians, in a readable form, many
subjects that received but little attention when they graduated.

The illustrations by Mr. William J. Kaula are, with one or two
exceptions, original. The drawings of microscopical sections are
taken from specimens prepared for the purpose, and are intended
to illustrate as closely as possible the results of modern micro-
scopical technique.

The Author takes this opportunity to acknowledge his indebted-
ness to Dr. Arthur K. Stone for valuable assistance, and to express
his appreciation of the courtesy extended to him by many of his
colleagues during his labors.

BOSTON, MASS.,
December, 1894.



CONTENTS.



I. BACTERIOLOGY 17

II. SURGICAL BACTERIA 43

III. HYPER^EMIA 79

IV. SIMPLE INFLAMMATION 92

1. The Process . 92

V. SIMPLE INFLAMMATION (continued') no

2. Symptoms and Causes of Inflammation no

3. Varieties and Treatment of Inflammation 125

VI. INFECTIVE INFLAMMATION 135

1. Etiology 135

VII. INFECTIVE INFLAMMATION (continued] 155

2. Suppuration 155

3. Abscess 161

4. Ulcer 182

5. Fistulae 190

VIII. INFECTIVE INFLAMMATION (continued} 193

6. Acute Osteomyelitis 193

IX. THE PROCESS OF REPAIR 218

X. GANGRENE 256

XI. SHOCK 277

XII. FEVER 301

XIII. SURGICAL FEVERS 316

XIV. SEPTIC.^MIA 334

XV. PY.EMIA 356

XVI. ERYSIPELAS , 381

XVII. HOSPITAL GANGRENE 409

XVIII. TETANUS 435

XIX. HYDROPHOBIA 453

7



8 CONTENTS.

PAGE

XX. ACTINOMYCOSIS 469

XXI. ANTHRAX 477

XXII. GLANDERS 485

XXIII. SNAKE-BITE 495

XXIV. TUBERCULOSIS 504

XXV. SURGICAL TUBERCULOSIS OF JOINTS 529

XXVI. TUBERCULOSIS OF THE SOFT PARTS 558

1. Tuberculosis of the Skin 558

2. Tuberculosis of the Mucous Membranes 565

3. Tubercular Peritonitis 569

4. Tuberculosis of the Genito-urinary Organs 573

5. .Tuberculosis of the Mamma 583

6. Tuberculosis of the Lymphatic Glands . 585

7. Tuberculosis of the Tendon-sheaths 589

8. Scrofula 593

XXVII. DISEASES OF BONE 597

1. Osteomalacia 597

2. Rickets 603

I 3. Osteoporosis 609

4. Hyperplasia of Bone 612

5. Phosphorus-necrosis 617

6. Arthritis Deformans 620

7. Spinal Arthropathy 624

8. Ankylosis 625

9. Periostitis 628

XXVIII. TUMORS 633

XXIX. CARCINOMA 638

1. Carcinoma of the Skin 648

2. Carcinoma of the Breast 662

3. Carcinoma of the Uterus 672

4. Carcinoma of the Tongue 677

5. Carcinoma of the (Esophagus 684

6. Carcinoma of the Larynx 686

7. Carcinoma of the Stomach 688

8. Carcinoma of the Intestines 689

9. Carcinoma of the Rectum 690

10. Carcinoma of the Bladder 694

11. Carcinoma of the Kidney 696

12. Carcinoma of the Testicle 698



CONTENTS. 9

PACK

XXX. SARCOMA 702

1. Sarcoma of Skin 709

2. Sarcoma of Bone 712

3. Sarcoma of Kidney 718

4. Sarcoma of Bladder 719

5. Sarcoma of Uterus 720

6. Sarcoma of Testis 721

7. Sarcoma of Breast 723

8. Sarcoma of the Air-passages 725

9. Sarcoma of the Digestive Tract 729

10. Sarcoma of Brain 729

11. Lymphosarcoma 730

XXXI. BENIGN TUMORS 737

1. Adenoma 737

2. Goitre 743

3. Cystoma 748

4. Papilloma 751

5. Fibroma 753

6. Myxoma 758

7. Lipoma 760

8. Glioma 763

9. Chondroma 765

10. Osteoma 769

11. Neuroma 771

12. Myoma 774

13. Angioma 777

14. Lymphangioma 781

XXXII ASEPTIC AND ANTISEPTIC SURGERY 784



APPENDIX.

A. BLOOD-SERUM THERAPY IN RABIES 803

B. TETANUS 804

C. TREATMENT OF CANCER 804

D. METHODS OF PREPARING ERYSIPELAS TOXINE 806

E. EXAMINATION OF TUMORS 807

F. STAINING METHODS. TUMORS 808

G. SO-CALLED PARASITES OF CANCER 808

H. DECALCIFICATION OF BONE 809



LIST OF ILLUSTRATIONS.



FIG- PAGE

1. Arnold Sterilizer 32

2. Potato Culture 33

3. Method of Filling Test-tubes with Nutrient Material 35

4. Petri Dish with Colonies 36

5. Bacteriological Syringe (H. C. Ernst) 40

6. Staphylococcus Pyogenes Aureus (Colored) 43

7. Staphylococcus Pyogenes Albus (Colored) 44

8. Streptococcus Pyogenes (Colored) 45

9. Streptococcus Pyogenes (culture) (Colored) 46

10. Bacillus Pyocyaneus (Colored) 47

11. Bacillus Coli Communis (Colored) 49

12. Gonococci (Colored) 51

13. Bacillus Tetani (Colored) 54

14. Hydrogen Jar for Anaerobic Cultures 55

15. Tuberculous Sputum (Colored) 58

16. Tuberculous Urine (Colored) 58

17. Bacillus of Tuberculosis on Glycerin- Agar (Colored) 60

18. Bacillus Mallei (Colored) 62

19. Bacillus of Malignant CEdema (Colored) 68

20. Bacillus Anthracis (Colored) 71

21. Section of Kidney from an Animal dead of Anthrax (Colored) ... 73

22. Section of Tumor of a Calf, showing Actinomyces (Colored) ... 77

23. Blood-vessel, showing Diapedesis of Leucocytes 93

24. Leucaemic Blood, showing various forms of Leucocytes (Colored) . 99

25. Amoeboid Movements of a Leucocyte 101

26. Karyokinesis in the Cells of a Sarcoma (Colored) 105

27. Metastatic Abscess of Kidney (Colored) 156

28. Portion of Wall of Lung Abscess, natural injection (Colored) . . 157

29. Pus-cells with Staphylococci 159

30. Pus-cells treated with Acetic Acid, and Crenated Red Blood-cor-

puscles 159

31. Sterilized Test-tube and Swab for Collecting Pus and Fluids for

Bacteriological Examination 160

32. Diagram of Tendon-sheaths of the Hand (Tillaux) 169

33. Columna Adiposa 176

11



12 LIST OF ILLUSTRATIONS.

FIG. PAGE

34. Infiltration of Columna Adiposa and Subcutaneous Tissue with Pus

in Carbuncle 178

35. Diagram of a Carbuncle 178

36. Ulcer of Leg (Colored} 183

37. Point of Origin of Suppuration in Osteomyelitis 197

38. Extension of Suppuration in Osteomyelitis 199

39. Necrosis of the Shaft and Periosteal Formation of Bone 199

40. Separation of Sequestrum and Formation of Involucrum 201

41. Unhealed Abscess-cavity, with Eburnation of Bony Tissue .... 201

42. Necrosis of Femur, the result of Acute Osteomyelitis (Colored} . . 207

43. Healing of Blood-clot, and Senn's Bone-chips 216

44. Healing by Second Intention (Colored] 226

45. Vascular Spaces with Tissue filled with Leucocytes 227

46. Detail Study from a Deep Layer of Granulation Tissue, showing a

vessel with epithelioid cells and spindle-cell growth 228

47. Development of Blood-vessel in Mesentery of an Embryo 230

48. Development of Blood-vessel in Mesentery of an Embryo : forma-

tion of vascular loops 231

49. Granulations compressing Blood-clot ; injected specimen (Colored] . 232

50. Healing of Tendon : callus formation with absorption of blood-clot 233

51. Detail Study of the End of the Divided Tendon (Colored} .... 234

52. Repair of Muscular Fibre (Colored} 237

53. Changes seen in the Repair of a Nerve after Division (Colored} . . . 239

54. Experimental Fracture (Dog) at the end of the first week, showing

blood-clot and detached fragment of bone (Colored} 244

55. Experimental Fracture (Dog) after forty-six days: ossification of

callus (Colored} 245

56. Ossification of Osteoid Substance in Callus of a Dog (Colored} . . 247

57. Experimental Callus of a Dog (Colored} 248

58. Detail Study of Three-weeks' Callus, showing osteoblasts forming

new bone (Colored} , . 248

59. Carotid Artery of Horse two weeks after ligature (Colored} .... 251

60. Carotid Artery of Horse two months after ligature (Colored} . . . 252

61. Femoral Artery of Man three months after ligature (Colored) . . 253

62. Tibial Artery from a case of Senile Gangrene of the Foot (Colored) . 258

63. Gangrene of the Toes from Frost-bite (Colored) 269

64. Ganglion-cells from the Cord of a Cat ; stimulated and resting-cells 286

65. Traumatic Fever (chart) 318

66. Aseptic Fever due to the absorption of blood-clot (chart) 320

67. Infiltration of Muscular Tissue with Streptococci in a case of Septi-

caemia of Man (Colored) - . . 340



LIST OF ILLUSTRATIONS. 13



PAGE



68. Sapraemia (chart) ........................ 345

69. Septicaemia (chart) ........................ 346

70. Capillary Embolus of Streptococci in a Sarcoma (Colored) .... 350

71. Infiltration of Vessel -wall in Sarcoma (Colored} .......... 351

72. Thrombus of Femoral Vein (Colored) .............. 362

73. Pyaemia (chart) ......................... 368

74. Traumatic Fever followed by Erysipelas in a case of Lithotomy

(chart) ............................ 391

75. Extravasation or " Miliary Abscess" in the cervical cord in a case

of hydrophobia (Colored) ................... 463

76. Submiliary Tubercle, showing giant - and epithelioid cells ..... 506

77. Tubercular Nodule of the Head of the Tibia (Colored) ...... 516

78. Tubercular Abscess-cavity, being the point of origin of disease of

the hip-joint (Colored) ... ................. 517

79. Deformity from Absorption of Phalanx due to tubercular disease

(Colored) ........................... 522

80. Angular Deformity from Pott's Disease (Colored) ......... 524

81. Tuberculosis of the End of the Humerus, showing caries of the

articular surface and osteophytes due to inflammation of the peri-

osteum (Colored) ....................... 533

82. Tuberculosis of Tendon-sheaths or Palmar Bursal Tumor (Colored) 592

83. Trabecula of Bone in a case of Osteomalacia on the left osteoclasts,

and on the right osteoblasts (Colored) ............. 597

84. Section of Femur in a case of Osteomalacia : below is the medulla

rich in cells, and above, the periosteum (Colored) ........ 599

85. Extreme Deformity of Skeleton due to Rickets .......... 606

86. Calvarium of a case of Ostitis Deformans (Colored) ....... 614

87. Arthritis Deformans, with Eburnation of Bone due to absorption of

cartilage (Colored) ....................... 621

88. Ankylosis of the Hip-joint ( Colored ) ............... 626

89. Cell-inclusions in Cancer of the Breast, the so-called "protozoa"

(Colored) ........................... 642

90. Cell-nests in Cancer of the Lip (Colored) ............. 649

91. Tubular Epithelioma, from a case of Rodent Ulcer (Colored) ... 651

92. Noli-me-Tangere (Colored) .................... 654

93. Medullary Carcinoma of the Breast ............... 664

94. Scirrhous Cancer of Breast (Colored) .............. 665

95. Brawny Infiltration of Breast in Cancer (Colored) ......... 667

96. CEdema of Arm in late stages of Cancer of Breast (Colored) . . . . 668

97. Cancer of the Uterus ....................... 674

98. Cancer of the Rectum ...................... 691



14 LIST OF ILLUSTRATIONS.

FIG. PAGB

99. Cancer of the Rectum, showing cylinder-cells 691

zoo. Alveolar Sarcoma 705

101. Spindle-cell Sarcoma 706

102. Giant-cell Sarcoma {Colored} 706

103. Periosteal Sarcoma : amputation at the hip-joint (Colored] .... 714

104. Retroperitoneal Lymphosarcoma, showing cells and stroma ... 731

105. Lymphosarcoma (Colored} 732

106. Fibro-adenoma of Breast (Colored} 739

107. Diffuse Hypertrophy of the Breast (Colored] 741

108. Adenoma of Thyroid Gland (Colored} 744

109. Cystic Goitre (Colored} 744

1 10. Accessory Thyroid Gland at the Base of the Tongue 745

in. Section of Accessory Thyroid Tumor 745

112. Thyreoglossal Tract 746

113. Dermoid Cyst of Ovary ( Colored } 750

114. Fibroma (Colored} 754

115. True Keloid (Colored} 756

116. Naso-pharyngeal Fibroma (Colored} 757

117. Myxoma (Colored} 759

118. Lipoma of Thigh (Colored} 761

119. Diffuse Lipoma of the Neck and Abdomen (Colored} 762

120. Enchondroma of the Tibia (Colored} 765

121. Hyaline Enchondroma (Colored} 766

122. Enchondroma of the Thumb (Colored} ... 767

123. Mixed Cartilaginous Tumor of the Parotid Gland (Colored} . . . 767

124. Hyaline Enchondroma of the Scapula (Colored) 768

125. Ivory Exostosis of the Orbit (Colored) 769

126. Osteoma of the Lower Jaw ( Colored ) 770

127. Neuroma from an Amputation-stump (Colored) 773

128. Myoma of the Uterus (Colored) 774

129. Angioma of the Lip and the Neck (Colored) 778

130. Cavernous Angioma (Colored) 779

131. Angioma of the Scalp (Colored) 780

132. Lymphangioma (Colored) 782



FULL-PAGE COLORED PLATES.



PAGE



PLATE I. Shaft of Femur, showing the results of osteomyelitis . . 209

PLATE II. Healing by first intention of an abdominal wound .... 223

PLATE HI. Diabetic Gangrene 264

PLATE IV. Gangrene of Leg, following ligature of femoral artery . . . 265



SURGICAL



PATHOLOGY AND THERAPEUTICS.



SURGICAL PATHOLOGY AND THERAPEUTICS.



I. BACTERIOLOGY.

IF one were to search literature for the earliest accounts of the
germ-theory of disease, it might be necessary to consult the oldest
writings of which we have any knowledge, for even among the
ancients there were those who thought that disease was due to the
invasion of the system by minute organisms. But it remained for
Leeuwenhoek, in 1675, actually to demonstrate with his rude micro-
scope the presence of infusoria in the saliva. The theory of a con-
tagium vivum was taken up from time to time after that date, and
Robert Boyle, a prominent writer of the same century, maintained
that he who obtained a proper comprehension of fermentation
would be able to interpret satisfactorily the various phenomena of
disease, particularly of fevers. Spallanzani, in the eighteenth
century, and after him Gay-Lussac, in 1810, experimented with
fermentation. Cagniard-Latour and Schwann, in 1837, recognized
that alcoholic fermentation was due to the presence of a living
organism, the yeast plant ; but this view was opposed with all the
weight which the authority of Liebig could bring to bear upon it,
who believed that fermentation was of a purely chemical origin.

In 1840, Dr. Farr applied the term "zymotic" (Cufjuoat^, a fer-
ment) to certain diseases supposed to be due to a fermentative pro-
cess. Ten years later Davaine demonstrated the bacillus anthracis
in the bodies of animals which had died of splenic fever. It was
at that time thought, however, that disease might arise de novo,
and that, although organisms might be present, it was possible that
they might have been formed by "spontaneous generation." It
was not, however, until Pasteur, in 1858, unveiled the mysteries
of fermentation, and later disproved the theory of spontaneous
generation, that the relation of micro-organisms to disease began
to be understood. Pasteur's law of fermentation has been likened
in its importance to Newton's law of gravitation. It is undoubt-
2 17



l8 SURGICAL PATHOLOGY AND THERAPEUTICS.

edly to him that credit should be given for furnishing the first
reliable data from which the modern science of bacteriology has
been evolved. Davaine, stimulated by Pasteur's researches, re-
newed his studies of the bacillus of anthrax, and fully identified
the organism as the cause of the disease. This bacillus may there-
fore be placed, chronologically, at the head of the list of patho-
genic bacteria.

Pasteur showed also that putrescence is a form of fermentation
due to the presence of micro-organisms, and he demonstrated that
the changes taking place in the secretions of a wound were of a
similar character. It was at about this time (1865) that Lister began
to appreciate the bearing of this scientific work upon surgery, and
commenced his studies upon the antiseptic treatment of wounds.
This gave a powerful impetus to the study of the relation of micro-
organisms to disease. No great advances were made at first, and
much of the work done by Pasteur and his pupils at that period in
the study of the diseases of man suffered for the want of suitable
methods of investigation. Bacteria were cultivated almost exclu-
sively in liquids, the bouillon of Pasteur. The cut surface of
potatoes was found to give an idea of the coarse appearance of the
growths, which the bouillon failed to show. When, finally, solid
media were substituted as soil for the growths of the organisms
an improvement for which we are indebted to Koch, the great
German observer the separation of bacteria, and consequently
their identification, for the first time became possible.

Bacteria belong to the lowest order of the vegetable kingdom,
and, with a few apparent exceptions, they may be said to form one
group of the fungi, the schizomycetes or fission-fungi, in distinction
from saccharomycetes or yeast-fungi, which produce alcoholic fer-
mentation, and the mucorini or mould-fungi. The fungi are chiefly
distinguished by the absence of chlorophyll, and therefore by their
lack of power to assimilate inorganic substances, being thus depend-
ent for their food upon living or upon dead organic matter ob-
tained from other plants or from animals. Bacteria derive their
name from fiaxTrjpiov, a rod, which many of them resemble in
shape.

The developed organism is in form a cell with a membrane and
contents, but no nucleus. The contents consist of a more or less
homogeneous protoplasm. This protoplasm possesses, in common
with the nuclei of the cells of the tissues of the body, the property
of being strongly stained by the aniline dyes. It is surrounded by
a delicate membrane, which, according to Thoinot, appears like a



BACTERIOLOG Y. 19

condensation of the peripheral layers of the protoplasm, from
which it is with difficulty separated. According to De Bary, this
membrane is a condensation of the innermost and most compact
layers of a gelatinous envelope, and consists of a substance closely
allied to cellulose. When stained with aniline dyes the difference
between protoplasm and envelope is not visible, but by special
methods of treatment the contents may shrink, and the envelope
then becomes more apparent; or, when treated with water, the
outer layers swell up and their gelatinous nature becomes evident.
The cells thus appear to be enclosed in a capsule. During the
process of division this material holds the organisms together, and
forms at times a zooglcea, or glue-like mass, in which they are im-
bedded. It is this material which may give the cultures their form
and consistency when growing on solid or in fluid media. In
water it collects at times in large masses after the enclosed bacteria
have attained their growth and have died, and becomes an efficient
aid in the sand filtration of water-supplies. Many of the bacterial
growths are in the presence of oxygen highly colored, being red,
yellow, green, or blue. According to some this coloring matter is
in the protoplasm, but according to others it lies outside the cells,
as in the case of the bacillus prodigiosus, a beautiful red growth,
where the pigment is in granules which have been exuded.

A considerable number of the bacteria possess no movement
whatever. Among these are the entire family of micrococci and
some bacilli, as the anthrax and tubercle bacilli. The great major-
ity of bacteria are, however, according to the conditions under
which they live, able to change from the motile state to the non-
motile, or vice versa. When examined in fluid they may be seen
moving about in serpentine-like curves, or they may have a sort of
oscillating movement around a central axis. These movements of
the bacilli are supposed by some to be effected by cilia projecting
from different portions of their bodies, but these prolongations have
been shown to be continuous, not with the protoplasm, but with the
cell-membrane, and therefore, according to some authorities, are
not organs of locomotion. Moreover, many bacilli which have
active movements are found to possess no cilia whatever, being
propelled by the vibratory movements of the flexible cells. The
oscillations of the micrococci, so familiar to all observers, are not
true movements of the cells, but are due to molecular agitation,
the so-called " Brownian movement."

The principal forms of bacteria are the small globular forms, or
micrococci (xoxxoc, a berry), the bacilli or staff-shaped bacteria,



20 SURGICAL PATHOLOGY AND THERAPEUTICS.

and the spirilla or spiral forms. The shape of the micrococci or
" cocci," as they are often called is usually round, although some
have a more or less oval contour. There are certain prefixes to the
noun coccus that indicate the different groupings which this variety
of bacteria take in their growth. Thus if the cocci tend to form in
pairs, or two cocci are seen still connected together, they are termed
" diplococci ; " those arranged in single rows of "chains" are called
"streptococci ;" and those grouped together in grape-like bunches
are called " staphylococci. " The long, staff-shaped bacteria are
known as "bacilli" (bacillus, a rod). When unusually long they
have a slightly undulating shape, and are then known as " lepto-
thrix" (leptothrix buccalis). Under the head of "spirilla" are in-
cluded those bacteria which take the form of an arc of a circle or of
a spiral. The "comma bacilli " of cholera are included in this cat-
egory. There are in bacteriological nomenclature a great variety of
terms which are hardly worth studying, as some of them have been
discarded altogether, and about others little will be heard in labora-
tory-work. The two principal forms seen in the different varieties
of surgical bacteria are the micrococci and the bacilli.

Nageli attached little importance to form : he believed that
bacteria might not only change their shape from time to time, but
in the course of years and under varying conditions also change in
their pathogenic qualities. The same species, he believed, might
at one time be concerned in the different forms of fermentation, at
another in the decomposition of albuminous substances, or in typhus,
cholera, or intermittent fever. The present opinion is that bacteria
are divided into a limited number of varieties according to their
action and form, but these varieties are never changed into other
forms. The possibility of such a change from a harmless variety
to a most malignant type, as Buchner supposed in the case of the
hay and anthrax bacilli, is now understood to have been due to
impurities of culture. Slight changes in form and appearance
may be brought about by methods of preparation, staining, or cul-
ture. The organism may vary also in appearance with age and
activity, but there is nevertheless a form which it always preserves
as the type of its normal development.

Bacteria multiply either by division of the cells into two equal
halves that is, by "fission" or by spore-formation. When a
coccus divides, it becomes elongated or oval in shape, the middle
portion becomes slightly contracted, and a delicate line appears
between the two portions thus indicated. This line of division
subsequently swells, and develops into a new membrane for each



BA CTERIOLOG Y. 21

of the daughter-cells thus formed. If the mother-cell is origin-
ally separated from other cells, this division forms the so-called
" diplococcus. " If, on the contrary, a number of cocci are attached
to one another and remain so during division in a linear direction,
we have the "streptococcus" formation. If the fission takes place
in two directions perpendicular to one another, we have as a result
an arrangement of the cells such as is seen in the micrococcus
tetragenus. If, however, segmentation takes place in different
directions in the different cells, then we obtain the grouping of
cells characteristic of the " staphylococcus. " Each form of micro-



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