234 THE ACUTE PNEUMONIAS 



other cases, especially when the condition is secondary to in- 

 fluenza, gangrene may supervene and lead to destruction of large 

 portions of the lung. In these a great variety of bacteria, both 

 aerobes and anaerobes are to be found. 



In ordinary broncho-pneumonias also Fraenkel's pneumo- 

 coccus is usually present, sometimes along with pyogenic cocci ; 

 in the broncho-pneumonias secondary to diphtheria it may be 

 accompanied by the diphtheria bacillus, and also by pyogenic 

 cocci ; in typhoid pneumonias the typhoid bacillus or the b. coli 

 may be alone present or be accompanied by the pneurno- 

 coccus, and in influenza pneumonias the influenza bacillus may 

 occur. In septic pneumonias the pyogenic cocci in many cases 

 are the only organisms discoverable, but the pneumococcus may 

 also be present. Especially important, as we shall see, from the 

 point of view of the etiology of the disease, is the occurrence in 

 other parts of the body of pathological conditions associated 

 with the presence of the pneumococcus. By direct extension to 

 neighbouring parts empyema, pericarditis, and lymphatic enlarge- 

 ments in the mediastinum and neck may take place ; in the first 

 the pneumococcus may occur either alone or with pyogenic cocci. 

 But distant parts may be affected, and the pneumococcus may 

 be found in suppurations and .inflammations in various parts of 

 the body (subcutaneous tissue, peritoneum (especially in children), 

 joints, kidneys, liver, etc.), in otitis media, ulcerative endocarditis 

 (p. 216), and meningitis. In fact, there is practically no inflam- 

 matory or suppurative condition in the body in which the 

 pneumococcus in pure culture may not be found. These condi- 

 tions may take place either as complications of pneumonia, or 

 they may constitute the primary disease. The occurrence of 

 meningitis is of special importance, for next to the lungs the 

 meninges appear to be the parts most liable to attack by the 

 pneumococcus. A large number of cases have been investigated 

 by Netter, who gives the following tables of the relative fre- 

 quency of the primary infections by the pneumococcus in man : 



(1) In adults- 

 Pneumonia . . . . . . . 65 '95 per cent. 



Broncho-pneumonia) 15 -85 



Capillary bronchitis) 



Meningitis . 13'00 



Empyema . . . . . . . 8'53 



Otitis 2-44 



Endocarditis 1'22 



Liver abscess . . . . . . ,1'22 



(2) In children 46 cases were investigated. In 29 the primary affection 

 was otitis media, in 12 broncho-pneumonia, in 2 meningitis, in 1 pneu- 

 monia, in 1 pleurisy in 1 pericarditis. 



