Lobar Pneumonia.—Lobar pneumonia following measles occurred in 4 instances. Onset in these cases was on approximately the 9th, 10th, 11th, or 14th day of measles; the onset of bronchopneumonia bore a similar time relation to the onset of measles, the average interval being nine days. Hepatization with lobar pneumonia was in 1 instance red, in 3 instances gray, and in all save 1 instance the consolidation was firm and coarsely granular on section. In the exceptional instance the greater part of the right upper lobe was laxly consolidated and rather finely granular but the microscopic appearance was in all instances that of lobar pneumonia. Lobar pneumonia in 2 of these cases was associated with purulent bronchitis present in parts of the lung that had not undergone consolidation, whereas in the other 2 instances there were acute bronchitis and peribronchiolar pneumonia recognized by microscopic examination.
In one instance hepatization of the lung presented some noteworthy features.
Autopsy 450.—G. D., white, aged twenty-one, a farmer, resident of Arkansas, had been in military service twenty-nine days. Onset of illness began on October 2, nineteen days before death, and on admission on the same day the diagnosis of measles was made. Signs of pneumonia, regarded as bronchopneumonia, were recognized five days before death. Three days later there was otitis media and paracentesis was performed. On October 3 and 10 neither S. hemolyticus nor B. influenzæ was found in the sputum; on October 17 and 20 S. hemolyticus was not found but B. influenzæ was present.
Anatomic Diagnosis.—Acute lobar pneumonia with gray and red hepatization in right upper and lower lobes; edema and peribronchial hemorrhage in left lung.
Fig. 29.—Lobar pneumonia following measles, showing extension of gray hepatization from lower to upper lobe through a defect in the septum separating the two lobes. Autopsy 450.
The entire lower lobe of the right lung (Fig. 29) with the exception of a narrow air-containing zone in contact with basal surface is firmly consolidated. The greater part of the consolidated tissue is yellowish gray, firm and coarsely granular. The uppermost part of the consolidated tissue is softer than elsewhere as if it has undergone autolysis. The lowermost part of the consolidated tissue in a zone from 2.5 to 3.5 cm. in breadth is firmly consolidated but deep red. The bronchi contain stiff plugs of fibrin. In the upper lobe continuous with the consolidated part of the lower is a semicircular patch of yellowish gray consolidation. It overlies the line of the interlobular cleft at the site of a break in its continuity. Consolidation appears to have spread from the lower lobe into the upper at the site where the alveolar tissue of the two lobes is continuous but is absent from that part of the upper lobe separated from the lower by the interlobular cleft. This semicircular patch of yellowish gray consolidation is separated from air containing tissue of the upper lobe by a zone of red hepatization about 1 cm. in thickness.
Bacteriologic examination showed the presence of Pneumococcus IV in the blood of the heart; B. influenzæ alone was obtained from the right lower lobe and B. influenzæ and staphylococcus from the left main bronchus.
The distribution of lobar pneumonia in the foregoing autopsy indicates that it has spread like a wave from the upper part of the lower lobe (Fig. 32) penetrating into the upper where the alveolar tissue of the two lobes is in contact; gray hepatization is everywhere separated from air containing tissue by an advancing zone of red hepatization.
It may be assumed that lobar pneumonia was caused by Pneumococcus II atypical in 3 instances although it was recovered from the lungs only twice, for in the third instance (Autopsy 486) it was found in the bronchus and in the inflamed pleural cavity; pneumococci were doubtless previously present in the lung, but had disappeared at least from that part from which the culture was made. Pneumococcus IV was evidently the cause of pneumonia in 1 instance (Autopsy 450), for it was found in the blood of the heart although it was absent in the culture from the lung.