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318 recalled that one patient had suffered from an attack of I bronchitis" previously to the joint affection, a second an attack of otorrhoea, and a third one of "pneumonia." " Assuming that these diagnoses were correct we have a possibly exciting cause for three out of the five cases. Netter, quoted by Muir and Ritchie, states that out of 46 cases of pneumococcic infection of children, otitis media was the primary lesion in 29, broncho-pneumonia in 12, meningitis in two, pneumonia in one,
... umonia in one, pericarditis in one, and pleurisy in one. No case of primary arthritis enters his list. The important and variable part played by the pneumococcus in children can be well illustrated by the following facts. During the last six months 15 cases of pleuritic effusion have supplied fluid for bacteriological examination at the East London Hospital. In 11 the pneumococcus was isolated in pure culture, in two the culture was sterile, and two gave a growth of staphylococcus albus. The pneumococcus was also obtained during that period from two cases of suppurative pericarditis, four cases of meningitis, and two of peritonitis. In many of these cases it is impossible to be certain of the primary lesion but probability inclines to the middle ear. Cave, in an excellent monograph on this subject, found in a total of 31 cases an antecedent pneumonia as the cause in 28, a result widely differing from our own ; but his cases were almost entirely confined to adults, while ours were all in young children. In two cases quoted by him in which the disease affected children a pneumonia followed the arthritis. There was no suggestion of trauma in the cases under notice, a fact that eliminates a possible explanation, for it has long been known that injury to a joint, followed by inoculation elsewhere with the staphylococcus aureus, will in animals determine a suppurative arthritis of the injured joint. The same thing is true of the pneumococcus ; indeed, arthritis has been produced by section of the sciatic nerve and subsequent inoculation with the pneumococcus, the inflammation affecting the joints of the injured limb. Cave found direct evidence of previous damage to the affected joint in ten of his 31 cases, but no doubt the greater age of the patients in his series increased their liability to injuries of the joint by comparison with the youthful subjects of this paper. Our best thanks are due to Mr. Dunn, Dr. Morley Fletcher, and Mr. Betham Robinson for permission to make use of the above cases. Bi6liograplay.-Fernet and Lorraine (quoted by Herrick) : Note sur un cas d'Infection Pneumococcique a Manifestations Articulaires et Meaingees.