C. THE RELATION OF DIFFERENT ORGANISMS TO THE TYPE OF PNEUMONIA
Various observers have emphasized the types of organism associated with different gross and microscopic manifestations of influenzal pneumonia. Pfeiffer described the peribronchial type with purulent bronchitis, from which the influenza bacillus was isolated, and the same association has been noted by MacCallum (92), Wolbach (162), Wegelin (156), Dietrich (34), and others. Opie et al (110), however, in a series from which B. influenzæ was isolated in over eighty-five per cent of the necropsies rarely found this picture. Wolbach states that the gross anatomical picture in influenzal pneumonia is similar to that following measles, from which a hemolytic streptococcus has been isolated in a high percentage of cases. MacCallum (93) classified this type as interstitial pneumonia. It is interesting to note that interstitial pneumonia has been rare in many localities where the hemolytic streptococcus has been prevalent during the past year. Stone and Swift (138) state that “despite the prevalence of the streptococcus at necropsy, only eight instances of so-called interstitial pneumonia were found in a series of fifty-five cases,” and Goodpasture (48) failed to find a single example in a series of sixteen cases. The pneumococci Types I and II, frequently encountered in the usual forms of lobar pneumonia, have been found exceptionally in this epidemic. Type II, however, has been reported (67, 107) present in about the same proportion as in true lobar pneumonia (5). Chickering and Park (25) described a series of cases of pneumonia due to the staphylococcus characterized by multiple miliary abscesses. Necrotization and abscess formation, however, have been striking features of the pathology of this epidemic, even when the staphylococcus has not been demonstrable. Recently Wadsworth (154) demonstrated experimentally that organization in pneumonia does not result from the pneumococcus or the staphylococcus alone, but only follows when both organisms are associated. On the contrary, Blanton and Irons (12) found that “there was no difference to be made out in the nature of the process caused by the streptococcus, pneumococcus, or influenza bacillus.”
FIG. XLVII. AUTOPSY NO. 100. PROLIFERATION OF THE ALVEOLAR EPITHELIUM IN A PORTION OF THE LUNG ONLY SLIGHTLY INVOLVED BY THE ACUTE INFLAMMATORY PROCESS. COMPARE FIGURES [IV], [XI], [XLVIII], AND [XLIX].
HELIOTYPE CO. BOSTON
| TABLE I. | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Post Mortem Bacteriology. | |||||||||||||||||
| Acute Fulminating (34 cases) | Necrotizing (36 cases) | Organizing (12 cases) | Total All Types (82) | ||||||||||||||
| Blood | Lung | Pleural fluid | Trachea and Bronchi | Total Cases | Blood | Lung | Pleural fluid | Trachea and Bronchi | Total Cases | Blood | Lung | Pleural fluid | Trachea and Bronchi | Total Cases | Total | Per cent. | |
| Strep. hemolyticus | 8 | 12 | 7 | 2 | 12 | 8 | 9 | 3 | 1 | 9 | 7 | 8 | 5 | 3 | 8 | 29 | 35.4 |
| Strep. non-hemolyticus | 7 | 7 | 2 | 5 | 1 | 5 | 5 | 0 | 12 | 14.6 | |||||||
| Strep. “viridans” | 0 | 2 | 1 | 2 | 2 | 0 | 2 | 2.4 | |||||||||
| Strep. mucosus capsulatus | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1.2 | |||||||||
| Pneumococcus Type II | 3 | 4 | 3 | 1 | 4 | 3 | 4 | 1 | 2 | 4 | 1 | 3 | 1 | 3 | 11 | 13.4 | |
| Pneumococcus Type III | 4 | 4 | 3 | 4 | 2 | 1 | 2 | 1 | 1 | 1 | 7 | 8.6 | |||||
| Pneumococcus Type IV | 4 | 6 | 2 | 3 | 6 | 6 | 11 | 2 | 5 | 11 | 1 | 1 | 1 | 18 | 22. | ||
| Pneumococcus (Type undetermined) | 2 | 3 | 3 | 3 | 2 | 5 | 5 | 0 | 8 | 9.7 | |||||||
| B. influenzæ | 1 | 4 | 2 | 5 | 1 | 12 | 0 | 4 | 12 | 1 | 1 | 2 | 19 | 23. | |||
| Staphylococci | 3 | 2 | 2 | 4 | 1 | 9 | 3 | 4 | 9 | 6 | 2 | 6 | 19 | 23. | |||
| B. mucosus capsulatus | 1 | 1 | 1 | 2 | 1 | 1 | 2 | 0 | 3 | 3.7 | |||||||
| M. catarrhalis | 2 | 1 | 2 | 2 | 2 | 2 | 0 | 4 | 4.9 | ||||||||
| Diphtheroids | 1 | 1 | 0 | 1 | 1 | 1 | 2 | 2.4 | |||||||||
| Enterococcus | 1 | 1 | 0 | 0 | 1 | 1.2 | |||||||||||
| TABLE II. | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Bacteriology of Pleural Exudates. | ||||||||||||||||||||||
| Acute Fulminating (34) | Necrotizing (36) | Organizing (12) | Total (All Types) (82) | |||||||||||||||||||
| Fibrinous | Serofibrinous | Serofibrinopurulent | Empyema | Total | Fibrinous | Serofibrinous | Serofibrinopurulent | Empyema | Total | Fibrinous | Serofibrinous | Serofibrinopurulent | Empyema | Total | Fibrinous | Serofibrinous | Serofibrinopurulent | Empyema | Total | Total number of cases with positive cultures | Effusion present percent. | |
| Strep. hemolyticus | 1 | 5 | 2 | 8 | 3 | 2 | 1 | 6 | 1 | 1 | 3 | 2 | 7 | 5 | 8 | 6 | 2 | 21 | 29 | 55% | ||
| Strep. non-hemolyticus | 1 | 2 | 3 | 1 | 2 | 1 | 4 | 0 | 2 | 2 | 3 | 7 | 12 | 42% | ||||||||
| Strep. “viridans” | 0 | 1 | 1 | 2 | 0 | 1 | 1 | 2 | 2 | 50% | ||||||||||||
| Strep. mucosus capsulatus | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 100% | ||||||||||||||
| Pneumococcus Type II. | 2 | 1 | 1 | 4 | 2 | 1 | 1 | 4 | 1 | 1 | 2 | 4 | 2 | 3 | 1 | 10 | 11 | 54% | ||||
| Pneumococcus Type III. | 2 | 1 | 3 | 2 | 2 | 0 | 2 | 3 | 5 | 7 | 71% | |||||||||||
| Pneumococcus Type IV. | 1 | 2 | 2 | 5 | 5 | 4 | 2 | 11 | 1 | 1 | 2 | 6 | 7 | 4 | 1 | 18 | 18 | 67% | ||||
| Pneumococcus (Type undetermined) | 0 | 1 | 1 | 2 | 4 | 0 | 1 | 1 | 2 | 4 | 8 | 37.5% | ||||||||||
| B. influenzæ | 1 | 1 | 2 | 4 | 5 | 4 | 2 | 11 | 1 | 1 | 2 | 7 | 5 | 5 | 17 | 19 | 52% | |||||
| Staphylococci | 3 | 3 | 3 | 3 | 3 | 9 | 1 | 1 | 1 | 1 | 4 | 4 | 4 | 7 | 1 | 16 | 19 | 63% | ||||
| B. mucosus capsulatus | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 2 | 3 | 67% | ||||||||||||
| Number of cases of pleurisy | 3 | 12 | 6 | 21 | 13 | 7 | 10 | 30 | 1 | 1 | 5 | 2 | 9 | 17 | 20 | 21 | 2 | 60 | ||||
| Percent of cases showing excess of Pleural fluid. | 53% | 47% | 67% | 52.4% | 52.4% | |||||||||||||||||
FIG. XLIX. AUTOPSY NO. 122. HIGHER POWER ILLUSTRATION OF EPITHELIAL PROLIFERATION AS ILLUSTRATED IN FIGURE [XLVIII].
FIG. LII. AUTOPSY NO. 107. THROMBUS ASSOCIATED WITH AN ACUTE INFLAMMATION IN THE WALL OF A PULMONARY ARTERIOLE.
FIG. L. AUTOPSY NO. 209. BRONCHIECTATIC CAVITIES AT THE BASE OF A LUNG. THE HISTOLOGY OF THIS LESION IS ILLUSTRATED IN FIGURE [XII].
| TABLE III.—Bacteriology in Relation to the Pneumonia. | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Acute Fulminating (34) | Necrotizing (36) | Organizing (12) | (82) | |||||||||||||
| Lo-bar | Pseu-do-lo-bar | Per-i-bron-chi-al | Lob-u-lar | To-tal | Lo-bar | Pseu-do-lo-bar | Per-i-bron-chi-al | Lob-u-lar | To-tal | Lo-bar | Pseu-do-lo-bar | Per-i-bron-chi-al | Lob-u-lar | To-tal | To-tal | |
| Strep. hemolyticus | 1 | 4 | 5 | 4 | 4 | 1 | 1 | 2 | 11 | |||||||
| Strep. hemolyticus and Pneumococcus II | 0 | 0 | 1 | 1 | 2 | 2 | ||||||||||
| Strep. hemolyticus and Pneumococcus IV | 1 | 1 | 1 | 1 | 0 | 2 | ||||||||||
| Strep. hemolyticus and Pneumococcus IV and staphylococci | 0 | 0 | 1 | 1 | 1 | |||||||||||
| Strep. hemolyticus and Strep. non-hemolyticus | 1 | 1 | 0 | 0 | 1 | |||||||||||
| Strep. hemolyticus and B. influenzæ | 1 | 1 | 2 | 0 | 0 | 2 | ||||||||||
| Strep. hemolyticus, B. influenzæ and Strep. non-hemolyticus | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. hemolyticus, B. influenzæ and staphylococci | 0 | 0 | 1 | 1 | 1 | |||||||||||
| Strep. hemolyticus and staphylococci | 2 | 2 | 2 | 2 | 1 | 1 | 2 | 6 | ||||||||
| Strep. hemolyticus and M. catarrhalis | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. hemolyticus, M. catarrhalis and B. mucosus capsulatus | 1 | 1 | 0 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus | 3 | 3 | 1 | 1 | 0 | 4 | ||||||||||
| Strep. non-hemolyticus, Pneumococcus II and staphylococci | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus, Pneumococcus IV and staphylococci | 1 | 1 | 0 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus and staphylococci | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus and B. mucosus capsulatus | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus and M. catarrhalis | 1 | 1 | 0 | 0 | 1 | |||||||||||
| Strep. non-hemolyticus and diphtheroids | 1 | 1 | 0 | 0 | 1 | |||||||||||
| Strep. mucosus capsulatus | 0 | 0 | 1 | 1 | 1 | |||||||||||
| Strep. “viridans” and Pneumococcus IV | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Strep. “viridans,” Pneumococcus IV and staphylococci | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Pneumococcus Type II | 3 | 3 | 1 | 1 | 0 | 4 | ||||||||||
| Pneumococcus Type III | 4 | 4 | 1 | 1 | 0 | 5 | ||||||||||
| Pneumococcus Type IV | 2 | 2 | 1 | 1 | 2 | 0 | 4 | |||||||||
| Pneumococcus (Type undetermined) | 3 | 3 | 3 | 3 | 0 | 6 | ||||||||||
| Pneumococcus Type II and B. influenzæ | 1 | 1 | 0 | 1 | 1 | 2 | ||||||||||
| Pneumococcus Type II and B. mucosus capsulatus | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Pneumococcus Type II and staphylococci | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Pneumococcus Type III and B. influenzæ | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Pneumococcus Type III and staphylococci | 0 | 0 | 1 | 1 | 1 | |||||||||||
| Pneumococcus Type IV and B. influenzæ | 2 | 2 | 3 | 3 | 6 | 0 | 8 | |||||||||
| Staphylococci | 0 | 0 | 1 | 1 | 1 | |||||||||||
| Staphylococci and B. influenzæ | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Staphylococci, B. influenzæ and M. catarrhalis | 0 | 1 | 1 | 0 | 1 | |||||||||||
| B. influenzæ and Pneumococcus (Type undetermined) | 0 | 2 | 2 | 0 | 2 | |||||||||||
| B. influenzæ and a pleomorphic diplococcus | 0 | 1 | 1 | 0 | 1 | |||||||||||
| Enterococcus | 1 | 1 | 0 | 0 | 1 | |||||||||||
The type of the pneumonic process, as well as the invading organism, has varied widely in different localities. From the foregoing brief survey, it will be seen that before the associations suggested above can be proven, much more definite evidence must be presented.
An attempt has been made to correlate the bacteriological findings in this series with the distribution and type of pneumonic process. These are tabulated in Table III. It will be seen at a glance that no relationship is demonstrable between the type of single or associated organisms and the distribution of the pneumonia, whether it is lobar, pseudolobar, peribronchial or lobular and whether acute fulminating, necrotizing or organizing. (See Table No. [III].)