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marily as the most frequent infectious agent in pneumonia of the lobar type. While other organ- isms have been isolated, occasionally in pure cult- ure and frequently as mixed infections, the Dip- lococc2Ls lanceolatus of Fraenkel and Weichselbaum, described in 1886, is considered the specific etiolog- ical factor in 90 per cent, of cases'. There are several facts, however, which complicate the eti- ological significance of the pneumococcus and make it necessary to presuppose what is generally accept- ed, accessory causal factors, such as diminished 434 MEDICAL RECORD. [September 11, 1915 resistance and local changes in the respiratory sys- tem favoring infection. In the first place, it is a well known fact that the pneumococcus appears in the sputum of healthy normal individuals and is not to be considered an abnormal inhabitant of the mouth and throat'. It may very likely be that the pneumococcus, found in the mouth and throat cavities of apparently healthy persons, belongs to one of the less virulent strains or races of pneu- mococci, as it has been shown by investigation that there are a number of different strains or races, varying in degree as to the severity of to.xic effects'- '. Again, so-called pneomococcus carriers appear from time to time in the case of persons who may have suffered from pneumonia some months before and in whose mouth or throat cavities the presence of the pneumococcus may be discovered only by accident"' '. Such an instance was recently observed by a colleague. Dr. Walter H. Sanford: A robust individual who had had pneumonia a year previously and who consulted the physician for the re- lief of a cough. The latter almost disappeared under treatment, but two weeks later, on a second examina- tion, the patient was again coughing more or less con- stantly and expectorating a pinkish tenacious mucous which seemed to come from the trachea and larger bronchi. The sputum when stained seemed to be an almost pure culture of pneumococci. He had no fever, felt quite well and seemed in good physical condition aside from the cough. Examination of the chest was practically negative, there being heard only a few rales beneath the sternum. The cough yielded readily to treatment, and a second smear showed only isolated pneumococci. There was evidently a slight degree of bronchitis, but the patient did not appear to be ill and only consulted a physician largely because of the peculiar expectoration. Although pneumonia may be regarded as the most usual result of a pneumococcic infection, yet other portions of the body are attacked with vary- ing frequency. As complications of viagras para hombres a pneumonia, or more rarely as apparently primary conditions, conjunctivitis, pleurisy, empyema, pericarditis, endocarditis, meningitis, otitis media, osteomyelitis, arthritis, and peritonitis', may be mentioned. Cases of ulcerative endocarditis without pulmonary lesions have been not infrequently observed'. Pneumo- coccic septicemia, about which there has been some difference of opinion as to frequency of oc- currence, certainly may be proven in severe pneu- mococcic infections'' \ substitute of viagra in india Recently a case of extensive destruction of the vulva and adjacent tissues', probably due to pneumococcic viagras para hombres infection, was re- ported. Inflammations of the nasopharynx, due to the pneumococcus are, according to the literature, rather rare but important, especially from the standpoint of prognosis. Walb' has called atten- tion to numbers of cases of a febrile aft'ection which have occurred at Bonn during the last few years and which seemed to be typically influenza. In none of the cases, however, was the influenza viagras para hombres bacillus found but, on the contrary, the pneumo- coccus proved to be responsible. The lesions were in the nasopharynx and at times involved the ear and the sinuses of substitute of viagra in india the nose. A few instances of a septic condition of the throat of pneumococcic origin are on record, some of which have shown a viagras para hombres peculiarly fatal course. Tweedie┬░ reported "three fatal cases of pneumo- coccal infection of the throat." Two of the cases, called by the author "asthenic" were rather chronic conditions, lasting several months, while the third, called "sthenic" ran a comparatively rapid course. lasting about ten days. All three showed e.xtreme resistance to all forms of treatment and no cause, apart from the presence of the pneumococcus viagras para hombres in the throat, could be ascertained. The organism ap- peared in large numbers in pure culture on the swabs or sputa. The first two cases substitute of viagra in india showed prac- tically nothing abnormal in the nose, ears or pharynx. There was an inflammation of the car- tilages of the larynx, accompanied by a purulent discharge, which abounded with pneumococci. A phlegmonous condition of the neck added to the marked dysphagia. The third case showed a gener- alized subacute nasopharyngitis and a severe cellu- litis of both submaxillary and submental regions. In none of the cases did incisions in the neck dis- close pus. A postmortem examination in the third showed a small necrotic area about a half inch in diameter in the depths of the right subma.xillary lymph glands. Blood and cerebrospinal fluid taken after death proved sterile. Theisen's' cases, which recovered, were accom- panied by severe edema substitute of viagra in india of the pharyn.x, including tonsillar region, soft palate, and uvula, in several