Autopsy 380.—Bronchopneumonia with gray and red lobular consolidation in right upper and lower lobes; peribronchiolar nodules of consolidation in left lower lobe; abscess, 1.5 cm. across, below the pleura of the posterior border of the left lower lobe near its base; fibrinopurulent pleurisy (300 c.c.) on right side; serous pleurisy (200 c.c.) on left. Pneumococcus III was found in cultures from the blood of the heart from the right lung and with B. influenzæ from the right pleural cavity. No culture was made from the left lung which contained the abscess. In sections of the abscess gram-positive streptococci in chains of 4 to 8 cocci were numerous.
Autopsy 406.—Acute lobar pneumonia with red hepatization of greater part of right lung; patch of consolidation in lower lobe of left lung containing an abscess cavity 2.5 x 1.5 cm.; localized seropurulent pleurisy (375 c.c.) on left side. Pneumococcus IV was obtained from the blood of the heart; a culture from the lung was contaminated. Tissue from the abscess was not saved for histologic examination.
Autopsy 416.—Suppurative pneumonia with necrosis and abscess formation in right lower lobe; fibrinous pleurisy on right side. Pneumococcus IV was obtained from the blood, right lung and right main bronchus. No streptococci were found in sections from the abscess in the right lung.
The foregoing observations demonstrate that suppurative pneumonia with abscess formation following influenza is with few exceptions caused by S. hemolyticus.
The autopsies (Table XLVI) in which pneumococci have been found in association with hemolytic streptococci in the blood or lungs indicate that pneumococci have had a part in the production of fatal pneumonia.
| Table XLVI | |||
|---|---|---|---|
| AUTOPSY | CULTURE FROM BLOOD | CULTURE FROM LUNGS | CULTURE FROM BRONCHUS |
| 258 | S. hem. | S. hem., Pneum. IV B. inf. | |
| 282 | S. hem., Pneum. II | S. hem., Pneum. II | S. hem., B. inf. Pneum. II, staph. |
| 345 | S. hem., Pneum. II, staph. | ||
| 378 | Pneum. atyp. II | S. hem., Pneum. atyp. II | S. hem., B. inf., Pneum. atyp. II |
| 381 | S. hem. | S. hem., Pneum. II Pneum. IV, staph. | |
| 383 | Pneum. III | S. hem., Pneum. III B. inf. | |
| 387 | S. hem. | Pneum. II, staph., B. inf. | S. hem., pneum., staph., B. inf. |
These autopsies, notably those in which pneumococci have been found in the blood, suggest that infection with pneumococci has preceded suppurative pneumonia caused by hemolytic streptococci. In a small number of instances the sputum was examined in life after onset of pneumonia.
| Table XLVII | ||
|---|---|---|
| AUTOPSY | SPUTUM | CULTURES FROM BLOOD, LUNGS AND BRONCHUS |
| 282 | Pneum. IV. B. inf. | S. hem., Pneum. II, staph., B. inf. |
| 288 | S. hem., B. inf. | S. hem., B. inf. |
| 376 | (No S. hem., Oct. 8) | S. hem., staph., B. inf. (Oct. 11) |
In 2 of these 3 cases infection with hemolytic streptococcus occurred subsequent to the onset of pneumonia.
Several observations help to explain the occurrence of abscess in association with the pneumonia of influenza. The fissures which will be described in association with bronchiectasis represent traumatic ruptures of the bronchial wall consequent upon weakening by necrosis and over distention. They expose the injured bronchial wall and the alveolar tissue adjacent to it to infection by the microorganisms contained within the lumen of the inflamed bronchus. Occasionally a favorable microscopic section demonstrates the relation of pulmonary necrosis and consequent suppuration to injuries of the bronchial wall. Peribronchial fibrinous pneumonia occurs about the bronchi of which the epithelial lining has been destroyed, and when a fissure penetrates the bronchial wall fibrinous pneumonia is almost invariably found in a zone about the tear; it doubtless tends to limit the extension of the process. Occasionally, wide areas of necrosis occur within consolidated tissue near the site of the fissure (Autopsy 312 with S. hemolyticus and B. influenzæ, p. [254]). Accumulation of polynuclear leucocytes between living and dead tissue may form a line of demarcation (Autopsy 387); finally, fairly large, irregularly formed, abscess cavities are found.