ENDOGENOUS INFECTIONS 



373 



necrotic area is seen close around the capillary bacterial embolism, and around that 

 again is a collection of cells. 



On account of the rarity of staphylococcal metastases, and the scarcity of 

 bacteriological and anatomical examination of such cases, we cannot give any rules 

 concerning them. 1 Fig. 83 shows a metastatic choroido-retinal abscess, from which 

 I cultivated highly virulent Staphylococcus pyogenes atireus. It was a case of 

 a rather localized abscess, with a slight diffuse affection of the retina. In the neigh- 

 bourhood of the masses of cocci there 

 was a widespread necrosis. 



Pneumococcal suppurations less fre- 

 quently show this concentrated necrotic 

 action. The organisms appear to pass 

 out of the infected vessel into the sur- 

 rounding tissues at a relatively earlier 

 stage. An intravascular growth, such 

 as takes place with the Streirtococci, 

 has not been shown to occur with 

 them. On the contrary, it is very rare 

 to find a capillary embolism with Pneu- 

 mococci, such as is shown in Fig. 83, in 

 a commencing retinitis during menin- 

 gitis. Lenhartz records a similar case. 



In the pneumococcal cases there is 

 a free phagocytosis, not only in the mild 

 cases, but also in the severe ones lead- 

 ing to panophthalmitis. This is quite 

 analogous to pneumonia and pneumo- 

 coccal meningitis. As in the ulcus 

 serpens, the leucocytes and the cocci 

 are intimately mixed ; there is no 

 obvious zone where toxic action is 

 intense, and where wandering cells do 

 not occur, as is the case in the staphylo- 

 coccal abscess shown above. The degree 

 of the leucocytosis is not related to 

 the mildness of the process. 



From the material available we con- 

 clude that the pneumococcal metastases FIG. 84. CAPILLARY PNEUMOCOCCAL EM- 

 have a milder course than those due to BOLISM IN THE RETINA IN A CASE OF 



the other important pyogenic organ- SUPPURATIVE CEREBRO-SPINAL MENIN- 



isms.'- This is shown by the observa- ems. GRAM-WEIGERT STAIN. 



tion that metastases in the course of a 



pneumonia rarely lead to panophthalmitis, and also from the previously recorded 

 findings of Axenfeld and Goh (cf. Figs. 77 and 78). In very mild cases it is, there 



1 Cases of metastatic stapbylococcal ophthalmia in the literature : Herrnheiser, Axen- 

 feld. Mitvalsky (cf. collected cases and tables, Axenfeld, loc. cit.). Lavagua, Bif. Med. di 

 Napoli, x., 94, p. 34. Pooley, Amer. Jour, of Ophth., 1895, p. 130. Liebrecht, K. M. f. A., 

 1903, xli., ii., p. 124. Holmes Spicer, T. 0. S., 1906. Schanz, Munch. Med. Woch., 1.906, 

 No. 25. Gerok, Wurtcm. Korr.-Bl., 1902. Trokopenko, Arch. d'Ophth., 1901, p. 422. 

 Spicer, T. 0. S., 1907. 



The case of purulent scleritis recorded by Sachsalber (Wien. Med. Woch., 1898, No. 32) 

 belongs to this class. 



2 Pneumococcal metastases: Fuchs, 'Tenonitis,' Wicn. Klin. Woch., 1890, No. 11. 

 Herrnheiser, Axenfeld (four cases), A. f. 0., 1894, xl. Axenfeld and Goh, A. f. O., 1897, 

 xliii., S. 147, and Ophth. Kongr., Heidelberg, 1896. Ferri, Ann. di Ottal, 1897, 



