Chapter 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) ────────────────────────────────┼──────────────────────────────── │ Trachea │ Pleural and Total │Blood Lung fluid Bronchi Cases ────────────────────────────────┼──────────────────────────────── Strep. hemolyticus │ 8 12 7 2 12 Strep. non-hemolyticus │ 7 7 Strep. “viridans” │ 0 Strep. mucosus capsulatus │ 0 Pneumococcus Type II │ 3 4 3 1 4 Pneumococcus Type III │ 4 4 3 4 Pneumococcus Type IV │ 4 6 2 3 6 Pneumococcus (Type undetermined)│ 2 3 3 B. influenzæ │ 1 4 2 5 Staphylococci │ 3 2 2 4 B. mucosus capsulatus │ 1 1 1 M. catarrhalis │ 2 1 2 Diphtheroids │ 1 1 Enterococcus │ 1 1 ════════════════════════════════╧════════════════════════════════

════════════════════════════════╤════════════════════════════════ │ │ Necrotizing │ (36 cases) ────────────────────────────────┼──────────────────────────────── │ Trachea │ Pleural and Total │Blood Lung fluid Bronchi Cases ────────────────────────────────┼──────────────────────────────── Strep. hemolyticus │ 8 9 3 1 9 Strep. non-hemolyticus │ 2 5 1 5 5 Strep. “viridans” │ 2 1 2 2 Strep. mucosus capsulatus │ 0 Pneumococcus Type II │ 3 4 1 2 4 Pneumococcus Type III │ 2 1 2 Pneumococcus Type IV │ 6 11 2 5 11 Pneumococcus (Type undetermined)│ 3 2 5 5 B. influenzæ │ 1 12 0 4 12 Staphylococci │ 1 9 3 4 9 B. mucosus capsulatus │ 2 1 1 2 M. catarrhalis │ 2 2 2 Diphtheroids │ 0 Enterococcus │ 0 ════════════════════════════════╧════════════════════════════════

════════════════════════════════╤════════════════════════════════ │ │ Organizing │ (12 cases) ────────────────────────────────┼──────────────────────────────── │ Trachea │ Pleural and Total │Blood Lung fluid Bronchi Cases ────────────────────────────────┼──────────────────────────────── Strep. hemolyticus │ 7 8 5 3 8 Strep. non-hemolyticus │ 0 Strep. “viridans” │ 0 Strep. mucosus capsulatus │ 1 1 1 1 Pneumococcus Type II │ 1 3 1 3 Pneumococcus Type III │ 1 1 1 Pneumococcus Type IV │ 1 1 1 Pneumococcus (Type undetermined)│ 0 B. influenzæ │ 1 1 2 Staphylococci │ 6 2 6 B. mucosus capsulatus │ 0 M. catarrhalis │ 0 Diphtheroids │ 1 1 1 Enterococcus │ 0 ════════════════════════════════╧════════════════════════════════

════════════════════════════════╤═══════════ │ Total All │ Types │ (82) ────────────────────────────────┼─────┬───── │ │ │ │ Per │Total│cent. ────────────────────────────────┼─────┼───── Strep. hemolyticus │ 29│ 35.4 Strep. non-hemolyticus │ 12│ 14.6 Strep. “viridans” │ 2│ 2.4 Strep. mucosus capsulatus │ 1│ 1.2 Pneumococcus Type II │ 11│ 13.4 Pneumococcus Type III │ 7│ 8.6 Pneumococcus Type IV │ 18│ 22. Pneumococcus (Type undetermined)│ 8│ 9.7 B. influenzæ │ 19│ 23. Staphylococci │ 19│ 23. B. mucosus capsulatus │ 3│ 3.7 M. catarrhalis │ 4│ 4.9 Diphtheroids │ 2│ 2.4 Enterococcus │ 1│ 1.2 ════════════════════════════════╧═════╧═════ TABLE II. _Bacteriology of Pleural Exudates._ ════════════════════════════╤══════════════════════════════════════════ │ Acute Fulminating (34) ────────────────────────────┼────────────────────────────────────────── │ │ │ │ Sero- │ Sero- fibrino- │Fibrinous fibrinous purulent Empyema Total ────────────────────────────┼────────────────────────────────────────── Strep. hemolyticus │ 1 5 2 8 Strep. non-hemolyticus │ 1 2 3 Strep. “viridans” │ 0 Strep. mucosus capsulatus │ 0 Pneumococcus Type II. │ 2 1 1 4 Pneumococcus Type III. │ 2 1 3 Pneumococcus Type IV. │ 1 2 2 5 Pneumococcus (Type │ undetermined) │ 0 B. influenzæ │ 1 1 2 4 Staphylococci │ 3 3 B. mucosus capsulatus │ 1 1 Number of cases of pleurisy │ 3 12 6 21 Percent of cases showing │ excess of Pleural fluid. │ 53% ════════════════════════════╧══════════════════════════════════════════

════════════════════════════╤══════════════════════════════════════════ │ Necrotizing (36) ────────────────────────────┼────────────────────────────────────────── │ │ │ │ Sero- │ Sero- fibrino- │Fibrinous fibrinous purulent Empyema Total ────────────────────────────┼────────────────────────────────────────── Strep. hemolyticus │ 3 2 1 6 Strep. non-hemolyticus │ 1 2 1 4 Strep. “viridans” │ 1 1 2 Strep. mucosus capsulatus │ 0 Pneumococcus Type II. │ 2 1 1 4 Pneumococcus Type III. │ 2 2 Pneumococcus Type IV. │ 5 4 2 11 Pneumococcus (Type │ undetermined) │ 1 1 2 4 B. influenzæ │ 5 4 2 11 Staphylococci │ 3 3 3 9 B. mucosus capsulatus │ 1 1 Number of cases of pleurisy │ 13 7 10 30 Percent of cases showing │ excess of Pleural fluid. │ 47% ════════════════════════════╧══════════════════════════════════════════

════════════════════════════╤══════════════════════════════════════════ │ Organizing (12) ────────────────────────────┼────────────────────────────────────────── │ │ │ │ Sero- │ Sero- fibrino- │Fibrinous fibrinous purulent Empyema Total ────────────────────────────┼────────────────────────────────────────── Strep. hemolyticus │ 1 1 3 2 7 Strep. non-hemolyticus │ 0 Strep. “viridans” │ 0 Strep. mucosus capsulatus │ 1 1 Pneumococcus Type II. │ 1 1 2 Pneumococcus Type III. │ 0 Pneumococcus Type IV. │ 1 1 2 Pneumococcus (Type │ undetermined) │ 0 B. influenzæ │ 1 1 2 Staphylococci │ 1 1 1 1 4 B. mucosus capsulatus │ 0 Number of cases of pleurisy │ 1 1 5 2 9 Percent of cases showing │ excess of Pleural fluid. │ 67% ════════════════════════════╧══════════════════════════════════════════

════════════════════════════╤══════════════════════════════════════════ │ Total (All Types) (82) ────────────────────────────┼────────────────────────────────────────── │ │ │ │ Sero- │ Sero- fibrino- │Fibrinous fibrinous purulent Empyema Total ────────────────────────────┼────────────────────────────────────────── Strep. hemolyticus │ 5 8 6 2 21 Strep. non-hemolyticus │ 2 2 3 7 Strep. “viridans” │ 1 1 2 Strep. mucosus capsulatus │ 1 1 Pneumococcus Type II. │ 4 2 3 1 10 Pneumococcus Type III. │ 2 3 5 Pneumococcus Type IV. │ 6 7 4 1 18 Pneumococcus (Type │ undetermined) │ 1 1 2 4 B. influenzæ │ 7 5 5 17 Staphylococci │ 4 4 7 1 16 B. mucosus capsulatus │ 1 1 2 Number of cases of pleurisy │ 17 20 21 2 60 Percent of cases showing │ excess of Pleural fluid. │ 52.4% ════════════════════════════╧══════════════════════════════════════════

════════════════════════════╤════════╤════════ │ │ ────────────────────────────┼────────┼──────── │ Total │ │ number │ │of cases│ │ with │Effusion │positive│present │cultures│percent. ────────────────────────────┼────────┼──────── Strep. hemolyticus │ 29│ 55% Strep. non-hemolyticus │ 12│ 42% Strep. “viridans” │ 2│ 50% Strep. mucosus capsulatus │ 1│ 100% Pneumococcus Type II. │ 11│ 54% Pneumococcus Type III. │ 7│ 71% Pneumococcus Type IV. │ 18│ 67% Pneumococcus (Type │ │ undetermined) │ 8│ 37.5% B. influenzæ │ 19│ 52% Staphylococci │ 19│ 63% B. mucosus capsulatus │ 3│ 67% Number of cases of pleurisy │ │ Percent of cases showing │ │ excess of Pleural fluid. │ │ 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) ─────────────────────────────────┼─────────────────────────────── │ Pseu- Peri- │ do- bron- │Lobar lobar chial Lobular Total ─────────────────────────────────┼─────────────────────────────── Strep. hemolyticus │ 1 4 5 Strep. hemolyticus and │ Pneumococcus II │ 0 Strep. hemolyticus and │ Pneumococcus IV │ 1 1 Strep. hemolyticus and │ Pneumococcus IV and │ staphylococci │ 0 Strep. hemolyticus and Strep. │ non-hemolyticus │ 1 1 Strep. hemolyticus and B. │ influenzæ │ 1 1 2 Strep. hemolyticus, B. influenzæ │ and Strep. non-hemolyticus │ 0 Strep. hemolyticus, B. influenzæ │ and staphylococci │ 0 Strep. hemolyticus and │ staphylococci │ 2 2 Strep. hemolyticus and M. │ catarrhalis │ 0 Strep. hemolyticus, M. │ catarrhalis and B. mucosus │ capsulatus │ 1 1 Strep. non-hemolyticus │ 3 3 Strep. non-hemolyticus, │ Pneumococcus II and │ staphylococci │ 0 Strep. non-hemolyticus, │ Pneumococcus IV and │ staphylococci │ 1 1 Strep. non-hemolyticus and │ staphylococci │ 0 Strep. non-hemolyticus and B. │ mucosus capsulatus │ 0 Strep. non-hemolyticus and M. │ catarrhalis │ 1 1 Strep. non-hemolyticus and │ diphtheroids │ 1 1 Strep. mucosus capsulatus │ 0 Strep. “viridans” and │ Pneumococcus IV │ 0 Strep. “viridans,” Pneumococcus │ IV and staphylococci │ 0 Pneumococcus Type II │ 3 3 Pneumococcus Type III │ 4 4 Pneumococcus Type IV │ 2 2 Pneumococcus (Type undetermined) │ 3 3 Pneumococcus Type II and B. │ influenzæ │ 1 1 Pneumococcus Type II and B. │ mucosus capsulatus │ 0 Pneumococcus Type II and │ staphylococci │ 0 Pneumococcus Type III and B. │ influenzæ │ 0 Pneumococcus Type III and │ staphylococci │ 0 Pneumococcus Type IV and B. │ influenzæ │ 2 2 Staphylococci │ 0 Staphylococci and B. influenzæ │ 0 Staphylococci, B. influenzæ and │ M. catarrhalis │ 0 B. influenzæ and Pneumococcus │ (Type undetermined) │ 0 B. influenzæ and a pleomorphic │ diplococcus │ 0 Enterococcus │ 1 1 ═════════════════════════════════╧═══════════════════════════════

═════════════════════════════════╤═══════════════════════════════ │ Necrotizing (36) ─────────────────────────────────┼─────────────────────────────── │ Pseu- Peri- │ do- bron- │Lobar lobar chial Lobular Total ─────────────────────────────────┼─────────────────────────────── Strep. hemolyticus │ 4 4 Strep. hemolyticus and │ Pneumococcus II │ 0 Strep. hemolyticus and │ Pneumococcus IV │ 1 1 Strep. hemolyticus and │ Pneumococcus IV and │ staphylococci │ 0 Strep. hemolyticus and Strep. │ non-hemolyticus │ 0 Strep. hemolyticus and B. │ influenzæ │ 0 Strep. hemolyticus, B. influenzæ │ and Strep. non-hemolyticus │ 1 1 Strep. hemolyticus, B. influenzæ │ and staphylococci │ 0 Strep. hemolyticus and │ staphylococci │ 2 2 Strep. hemolyticus and M. │ catarrhalis │ 1 1 Strep. hemolyticus, M. │ catarrhalis and B. mucosus │ capsulatus │ 0 Strep. non-hemolyticus │ 1 1 Strep. non-hemolyticus, │ Pneumococcus II and │ staphylococci │ 1 1 Strep. non-hemolyticus, │ Pneumococcus IV and │ staphylococci │ 0 Strep. non-hemolyticus and │ staphylococci │ 1 1 Strep. non-hemolyticus and B. │ mucosus capsulatus │ 1 1 Strep. non-hemolyticus and M. │ catarrhalis │ 0 Strep. non-hemolyticus and │ diphtheroids │ 0 Strep. mucosus capsulatus │ 0 Strep. “viridans” and │ Pneumococcus IV │ 1 1 Strep. “viridans,” Pneumococcus │ IV and staphylococci │ 1 1 Pneumococcus Type II │ 1 1 Pneumococcus Type III │ 1 1 Pneumococcus Type IV │ 1 1 2 Pneumococcus (Type undetermined) │ 3 3 Pneumococcus Type II and B. │ influenzæ │ 0 Pneumococcus Type II and B. │ mucosus capsulatus │ 1 1 Pneumococcus Type II and │ staphylococci │ 1 1 Pneumococcus Type III and B. │ influenzæ │ 1 1 Pneumococcus Type III and │ staphylococci │ 0 Pneumococcus Type IV and B. │ influenzæ │ 3 3 6 Staphylococci │ 0 Staphylococci and B. influenzæ │ 1 1 Staphylococci, B. influenzæ and │ M. catarrhalis │ 1 1 B. influenzæ and Pneumococcus │ (Type undetermined) │ 2 2 B. influenzæ and a pleomorphic │ diplococcus │ 1 1 Enterococcus │ 0 ═════════════════════════════════╧═══════════════════════════════ ═════════════════════════════════╤═══════════════════════════════╤═════ │ Organizing (12) │(82) ─────────────────────────────────┼───────────────────────────────┼───── │ Pseu- Peri- │ │ do- bron- │ │Lobar lobar chial Lobular Total│Total ─────────────────────────────────┼───────────────────────────────┼───── Strep. hemolyticus │ 1 1 2│ 11 Strep. hemolyticus and │ │ Pneumococcus II │ 1 1 2│ 2 Strep. hemolyticus and │ │ Pneumococcus IV │ 0│ 2 Strep. hemolyticus and │ │ Pneumococcus IV and │ │ staphylococci │ 1 1│ 1 Strep. hemolyticus and Strep. │ │ non-hemolyticus │ 0│ 1 Strep. hemolyticus and B. │ │ influenzæ │ 0│ 2 Strep. hemolyticus, B. influenzæ │ │ and Strep. non-hemolyticus │ 0│ 1 Strep. hemolyticus, B. influenzæ │ │ and staphylococci │ 1 1│ 1 Strep. hemolyticus and │ │ staphylococci │ 1 1 2│ 6 Strep. hemolyticus and M. │ │ catarrhalis │ 0│ 1 Strep. hemolyticus, M. │ │ catarrhalis and B. mucosus │ │ capsulatus │ 0│ 1 Strep. non-hemolyticus │ 0│ 4 Strep. non-hemolyticus, │ │ Pneumococcus II and │ │ staphylococci │ 0│ 1 Strep. non-hemolyticus, │ │ Pneumococcus IV and │ │ staphylococci │ 0│ 1 Strep. non-hemolyticus and │ │ staphylococci │ 0│ 1 Strep. non-hemolyticus and B. │ │ mucosus capsulatus │ 0│ 1 Strep. non-hemolyticus and M. │ │ catarrhalis │ 0│ 1 Strep. non-hemolyticus and │ │ diphtheroids │ 0│ 1 Strep. mucosus capsulatus │ 1 1│ 1 Strep. “viridans” and │ │ Pneumococcus IV │ 0│ 1 Strep. “viridans,” Pneumococcus │ │ IV and staphylococci │ 0│ 1 Pneumococcus Type II │ 0│ 4 Pneumococcus Type III │ 0│ 5 Pneumococcus Type IV │ 0│ 4 Pneumococcus (Type undetermined) │ 0│ 6 Pneumococcus Type II and B. │ │ influenzæ │ 1 1│ 2 Pneumococcus Type II and B. │ │ mucosus capsulatus │ 0│ 1 Pneumococcus Type II and │ │ staphylococci │ 0│ 1 Pneumococcus Type III and B. │ │ influenzæ │ 0│ 1 Pneumococcus Type III and │ │ staphylococci │ 1 1│ 1 Pneumococcus Type IV and B. │ │ influenzæ │ 0│ 8 Staphylococci │ 1 1│ 1 Staphylococci and B. influenzæ │ 0│ 1 Staphylococci, B. influenzæ and │ │ M. catarrhalis │ 0│ 1 B. influenzæ and Pneumococcus │ │ (Type undetermined) │ 0│ 2 B. influenzæ and a pleomorphic │ │ diplococcus │ 0│ 1 Enterococcus │ 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.)