214 ACUTE PNEUMONIA. 



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 accom- 

 panied by the pneumococcus, 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 associ- 

 ated with the presence of the pneumococcus. By direct 

 extension to neighbouring parts empyema, pericarditis, 

 and lymphatic enlargements 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, joints, kidneys, liver, etc.), in 

 otitis media, ulcerative endocarditis (p. 184), and menin- 

 gitis. These conditions may take place either as complica- 

 tions of pneumonia, or they may constitute the primary 

 disease. The occurrence of meningitis is of special im- 

 portance, 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 frequency of 

 the primary infections by the pneumococcus in man : 



(1) In adults 



Pneumonia . . . . 65.95 per cent 

 Broncho-pneumonia \ 



Capillary bronchitis / T 5' 5 



Meningitis .... i3-o 

 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 i pneumonia, in I pleurisy, in I pericarditis. 



