| Table LXXIII | ||||
|---|---|---|---|---|
| WITH NO SUPPURATION | SPUTUM IN LIFE | BACTERIA IN BLOOD OF HEART | BACTERIA IN LUNGS | BACTERIA IN BRONCHUS |
| Autopsy 443 | 0 | B. coli | B. inf., B.coli | |
| 481 | 0 | B. inf. | B. inf., Pneum. II, atyp., S. hem. | |
| 484 | Pneum. IV., B. inf. | 0 | 0 | B. inf., diphtheroids |
| 496 | Pneum. IV., B. inf. | 0 | 0 | B. inf. |
| With Suppuration: | ||||
| Autopsy 438 | B. inf. | 0 | Pneum. II atyp., S. vir. B. inf. S. hem. | S. hem., B. inf. |
| 492 | St. hem., B. inf. | S. hem. | S. hem., Pneum. IV, B. coli, B. inf. | |
Whereas with acute bronchopneumonia death has been accompanied and perhaps caused by bacterial invasion of the blood by pneumococci or streptococci in 5 of 7 instances, with unresolved or chronic bronchopneumonia, bacteriemia has been present only once, namely, in Autopsy 492 in which with suppurative pneumonia hemolytic streptococci have entered the blood. It is probable that pneumococci have likewise had an important part in the causation in these instances of bronchopneumonia which have run a chronic course but in all save 2 cases (Autopsies 438 and 492) have disappeared from the lungs. Pneumococcus II atypical has been found twice.
B. influenzæ has been found in association with acute bronchopneumonia in the lungs in 1 of 6 examinations and in the bronchi in 5 of 6 examinations. These figures indicate that it is present in small numbers if at all in the consolidated lung tissue but is relatively abundant in the bronchi. With chronic bronchopneumonia B. influenzæ has been found in every instance, in half of the examinations of lungs and in all of the examinations of bronchi. In 1 instance (Autopsy 481) B. influenzæ has been found in pure culture in the lung; Pneumococcus II atypical has been found in the bronchus and has perhaps disappeared from the pneumonic lung, since this microorganism is often destroyed in the late stages of pneumonia so that its demonstration at autopsy is no longer possible. In 1 instance B. influenzæ found in the bronchus has been the only microorganism isolated at autopsy, although the sputum during life contained B. influenzæ and Pneumococcus IV.
Suppurative Pneumonia.—Suppurative pneumonia with formation of abscesses has occurred in 2 autopsies with pneumonia following measles (Autopsies 438 and 492), both instances of chronic bronchopneumonia. In Autopsy 438 the lower and posterior part of the left lower lobe has been consolidated and has had on section a cloudy, grayish red color; within this area of consolidation and immediately below the pleural surface there have been opaque, yellow spots where the tissue has been softer than elsewhere. Microscopic examination shows that the tissue has here undergone widespread necrosis so that all nuclear stain has disappeared; at the edges of the necrotic tissue polynuclear leucocytes are often present in large numbers, but necrosis is much more conspicuous than suppuration. In the necrotic tissue and at its edges streptococci are present in vast numbers. Hemolytic streptococci have been grown both from the lung and from the bronchus, but these have not been the only microorganisms present, for Pneumococcus II atypical and S. viridans have been obtained from the lungs and B. influenzæ from lungs and bronchus.
In Autopsy 492 with chronic bronchopneumonia the posterior half of the right lower lobe is laxly consolidated, deep red in color and with the cloudy appearance often associated with streptococcus pneumonia; upon this background are peribronchiolar spots of yellow color, in places well seen below the pleura; in the corresponding part of the left lower lobe similar nodules have been converted into small abscesses by central suppuration. There is empyema on the right side, fibrinopurulent pericarditis, and purulent peritonitis. Hemolytic streptococci had been found in the sputum three times, the first examination being thirteen days before death. This microorganism is found in pure culture in the blood of the heart and with Pneumococci IV, B. coli and B. influenzæ in the lung. Hemolytic streptococci were found in the right pleural exudate and peritoneum.
The pneumonias following measles give opportunity to consider the relationship of suppurative interstitial pneumonia to unresolved or chronic bronchopneumonia, which is characterized by infiltration and proliferation of the fibrous tissue of the lungs. A number of those who have studied the pneumonia of measles have recognized that this chronic interstitial lesion is a common sequela of measles. MacCallum has designated the lesion “interstitial bronchopneumonia,” and has included under this name its acute stage in which the interstitial character of the lesion is not more evident than with other forms of acute bronchopneumonia. He has regarded S. hemolyticus as the cause of “interstitial bronchopneumonia” following measles. A review of the autopsies which he has described shows that he has included under the same designation typical instances of interstitial suppurative pneumonia associated with suppurative lymphangitis. Instances of unresolved, chronic or “interstitial” bronchopneumonia and of interstitial suppurative pneumonia which we have observed after measles, demonstrate that the two lesions are distinguishable both by their anatomic characters and by their etiology.
Three instances of suppurative interstitial pneumonia occurred among the pneumonias following measles (Autopsies 442, 491 and 507). The lesion is characterized by suppuration of the interlobular septa and particularly noteworthy is the occurrence of suppurative lymphangitis, lymphatics being immensely dilated and distended with purulent fluid so that their irregularly dilated, beaded appearance is recognizable upon the section of the lung. In the group of pneumonias following measles this lesion has not been associated with unresolved or chronic bronchopneumonia; no nodular tubercle-like foci of bronchopneumonia have been found at autopsy, and there has been no thickening of the interstitial tissue. The lesion has accompanied confluent lobular pneumonia in 2 instances (Autopsies 442 and 491). In the third instance (Autopsy 507) there was in the neighborhood of the suppurative lesions diffuse consolidation which had the cloudy, gray red color of streptococcus pneumonia, but this consolidation was not lobular in distribution.
The etiology of interstitial suppurative pneumonia established by study of instances following influenza is confirmed by Table LXXII (p. [345]) showing the bacteriology of instances of acute bronchopneumonia following measles. Pneumococci are almost invariably found in uncomplicated instances of bronchopneumonia and hemolytic streptococci have been absent, whereas in 3 instances of suppurative interstitial pneumonia hemolytic streptococci have been found in the sputum during life, in pure culture in the blood of the heart and in the lungs and bronchus (missed in the bronchus in one instance, Autopsy 507). In the 3 instances of the disease B. influenzæ has been found in the bronchi.
Table LXXIII shows that suppuration has accompanied unresolved bronchopneumonia (“interstitial bronchopneumonia”) in 2 instances (Autopsies 438 and 492), but in these instances the interlobular tissue of the lung has not been the site of suppuration and there has been no suppurative lymphangitis. Localized abscesses have been formed; hemolytic streptococci, as with abscesses following influenza, have been found.
Empyema has occurred only 5 times in association with pneumonia following measles and in these 5 instances has been associated with suppurative pneumonia caused by hemolytic streptococci. In Autopsy 492 there was fibrinopurulent pleurisy on both sides. Aspiration had been performed 3 times and at autopsy the right pleural cavity contained 150 c.c. of purulent fluid. In small pockets, corresponding to shallow oval depressions upon the anterior surface of the lung, fluid was walled off from the general cavity. The pericardial cavity contained 25 c.c. of turbid yellow fluid containing yellow flakes of fibrin and the peritoneal cavity contained thick purulent fluid. Hemolytic streptococci present in the heart’s blood and lung were recovered from the right pleural cavity and from the peritoneum. Among 3 instances of empyema accompanying interstitial suppurative pneumonia, in 1 (Autopsy 491) there were walled off pockets of fluid similar to those just described. Aspiration of the right pleural cavity had been performed 3 times; at autopsy 100 c.c. of fibrinopurulent fluid was found on the right side and 450 c.c. on the left. There was general purulent peritonitis and the peritoneal cavity contained 350 c.c. of thick yellow pus. Hemolytic streptococci were obtained from the heart’s blood, right lung, right pleural cavity and peritoneum.