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Bronchopneumonia Due to Hemolytic
 Streptococci Following Influenza
ERNEST W. GOODPASTURE, M.D.
      (Boston)
  Lieutenant (Junior Grade), M. C, U. S. N. R. F.

     CHELSEA, MASS. 
 
BRONCHOPNEUMONIA   DUE   TO   HEMO-
    LYTIC   STREPTOCOCCI   FOLLOWING
                  INFLUENZA *
ERNEST  W.  GOODPASTURE,  M.D.  (Boston)
    Lieutenant (Junior Grade), M. C., U. S. N. R. F.

                CHELSEA, MASS.
  The bacteriology  and  pathology  of bronchopneu-
monia  during the last two  months  (December and
January)  have become quite different, at the Chelsea
Naval  Hospital, from that found during the preceding
three months, including the  most severe period of the
first local  outbreak of influenza.   In the earlier period,
cultures of Pfeiffer's bacillus were obtained  from the
lungs in 86 per cent, of cases postmortem, the organ-
ism often being found in pure culture, pneumococci in
50 per cent., and hemolytic streptococci in 13 per cent.;
while during  the last two months, cultures of hemolytic
streptococci have been obtained  from the lungs in 100
per cent,  of  those examined at necropsy,  and in the
majority  of  instances  pure cultures  were  obtained.
Pfeiffer's bacillus was demonstrated in only two cases
of a total  of  sixteen, and these two were examined the
first week of December.
  This marked variation in the type of invading organ-
ism in bronchopneumonia  is  of particular interest since
it represents  the experience of a single station during
a relatively  short period of  time;  and we  are now
familiar with wide differences in bacteriologic observa-
tions from various  sections  of  the country  since the
epidemic of influenza began.
  From the twenty-six cases studied during the height
of the epidemic in the  early fall,  we became more or
less  familiar  with  a type of pneumonia  which was
fairly typical of that series, and  were able to  recognize
many modifications  obviously due to secondary inva-
sion by pathogenic organisms.   An acute bronchiolitis
* From the U. S. Naval Hospital. 
4
 characterized by  the  presence  within the bronchioles
 nf a dry exudate  consisting of a few leukocytes, poly-
 morphonuclear  and  mononuclear,  mucus and  fibrin,
 usually with partial or complete necrosis of the mucous
 membrane, and the  presence of  a  characteristic irreg-
 ular hyaline membrane  on the infundibular and alve-
 olar  walls,  were regarded as  typical early lesions.
 Bronchopneumonia  following this  was fulminating  in
 type  and  consisted  in a  widespread toxic injury  to
 alveolar tissues,  so  that they became filled with fluid
 exudate, fibrin, and  hemorrhage  with extensive  injury
 to alveolar walls and capillaries.   From  a  study of
 these cases we stated  that "the pulmonary injury and
 reaction being so acute and often widespread, and the
 fact that in certain very  early cases bacteria of any
 kind are so scarce or not found at all, make us feel,
 notwithstanding the demonstration of influenza  bacilli
 in pure  culture in the lungs in  all but one  instance,
 that at  tbis stage organisms are as yet  comparatively
 few within alveoli, and their primary injury is due to
 a \ery  potent toxic substance elaborated  in  and  dis-
 -eminated  through  larger  air passages."   following
 ibis  initial injury, pathogenic bacteria readily  invaded
 the pulmonary tissue, producing injury and  reaction
 more or less typical for the organism concerned.   In
 striking contrast to the group of cases that constitutes
 the material  for the present report, hemolytic  strepto-
 cocci at  that time played  a  relatively small role as  a
 secondary  invader, complicating only five, or 13  per
 cent., of the cases. In three of these, multiple abscesses
 were present in the lungs, and in the other two  strepto-
 cocci and influenza bacilli  were associated in  the pro-
 duction  of widespread  bronchiectatic abscesses and
 ulcerative  bronchitis.
  The present report is  based  on  the postmortem
 examination of  sixteen  cases,  constituting  all  the
ca-es of  bronchopneumonia examined at necropsy
during the past  two months.  Eleven of the patients
developed  empyema, and the pleural  exudate  yielded
pure cultures of hemolytic streptococci.
  The  accompanying  table  presents  these   cases.
Although some  of the  patients  entered  the  hospital
with  well-developed  bronchopneumonia,   in  several
instances the clinical diagnosis  of  influenza or  post-
influenzal pneumonia was made. 
5
  In five cases the empyema was bilateral, in  four on
the left, and once on the right side.   In each instance
bronchopneumonia was bilateral.  One  case  showed
an  extensive  streptococcal  pneumonia in each  lung
CASES OP BRONCHOPNEUMONIA WITH PATHOLOGIC
                  DIAGNOSIS
	Range of	Patho-	Bacteriology	Clinical
Case	Leukocyte	logic Diag-	of	Diagnosis on
No.	Counts	nosis	Lungs	Admission
1	6,600-12,800	Bronchopneumonia; no empyema	Influenza bacilli; hemolytic strep-tococci ; pneu-mococcus Type IV	Influenza
2	15,000-13,000	Bronchopneumonia;	Hemolytic strep-	Influenza;
		empyema (bi-	tococci; non-	bronchopneu-
		lateral)	■ hemolytic strep-tococci; influ-enza bacilli	monia
3	3,200	Bronchopneumoni a; no empyema	Hemolytic strep-tococci	Influenza
4	13,000-48,000	Empyema (bilater-	Hemolytic strep-	Bronchopneu-
		al); pericarditis;	tococci	monia
		slight pneumonia		
j	25,000	Bronchopneumoni a;	Hemolytic strep-	Bronchopneu-
		peritonitis;	tococci	monia
		empyema		
fi	12.000	Bronchopneumonia;	Hemolytic strep-	Bronchopneu-
		empyema (bi-	tococci	monia; em-
		lateral)		pyema
'	4,700-3,400	Bronchopneumonia; empyema (bi-lateral)	Hemolytic strep-tococci	Influenza
S	6,900	Bronchopneumonia;	Hemolytic strep-	Influenza;
		empyema (left)	tococci	bronchopneu-monia
9	4,000-15,000	Bronchopneumonia; empyema (bilat-eral); peritonitis	Hemolytic strep-tococci	Influenza
10	8,000-10.200	Bronchopneumonia;	Hemolytic strep-	E m pyema;
		empyema (bi-	tococci	bronchopneu-
		lateral)		monia
11	7,000	Bronchopneumoni a; empyema (left)	Hemolytic strep-tococci	Influenza
12	16,800	Bronchopneumonia;	Hemolytic strep-	E m pyema;
		empyema (left)	tococci	bronchopneu-monia
13	5,000-8,200	Bronchopneumonia; no empyema	Hemolytic strep-tococci	Influenza
14	0,000-19.200	Bronchopneumonia	Hemolytic strep-tococci	Influenza
15	3,000-6,000	Bronchopneumonia	Hemolytic strep-tococci Hemolytic strep-	Influenza
lfi	5,000	Bronchopneumoni a		Influenza
			tococci	
with no  pleural exudate, and  is of  interest  because
numerous  fibrous  adhesions were  present over  the
lungs, suggesting the possibility of an increased resis-
tance to  the  infection because  of  previous  inflam-
mation.
  The  lungs were moist and congested, often atelec-
tatic where pleural  exudate was voluminous.   The 
6
areas of consolidation  were grayish purple, and  cut
surfaces exuded a  fairly  thick, purplish  pus.   In  the
early stages  of pleural  inflammation the exudate is
serous,  containing relatively  few cells and organisms;
later it  becomes thick pus containing enormous num-
bers of  streptococci.  In four cases the  infection was
verv  prominent  in  the lymphatics  and  interlobular
tissue of the  lungs.  The lobules in areas of consider-
able size  were found outlined by wide (from 3  to
4 mm.)  yellow  bands.  These bands followed the veins
and bronchi to the hilum. The lymphatics of the pleura
may also  be  filled with streptococci.   Abscesses have
occasionally been  found.   Microscopically the  alveoli
are  filled  with  polymorphonuclear  leukocytes  and
usually  enormous  numbers of  streptococci, with little
or no fibrin.  Often there  is widespread  necrosis.   In
no instance have we observed the appearances of inter-
stitial bronchopneumonia,  described  by  MacCallum,
which occurs so frequently as a sequel to measles. The
distribution of  the pneumonia is  usually lobular and
rather massive.   In cases of short duration it may  be
lobar in distribution  and involve  the greater  part  of
the lung tissue.  Xor have  we  recognized  the toxic
lesions  of early influenzal  pneumonia as seen  during
the first weeks of the epidemic,  and I regard  all  the
cases in this report as instances  of  primary strepto-
coccus  pneumonia  frequently following an  attack  of
influenza.
  The question naturally arises whether  some of these
cases were not primarily streptococcus infections with-
out influenza. Eleven of the sixteen had attacks typical
of influenza which terminated in pneumonia; the diag-
noses of  the other  five were questionable  as to   an
attack of influenza.   In view of  the experiences last
year at  various  stations of epidemic streptococcal infec-
tions of the respiratory tract, it does not seem unlikely
that similar outbreaks will occur or are occurring this
winter.and with the impressions of influenza so recently
in mind there will probably be considerable confusion
of the two diseases, especially as there do not appear to
be any  very certain  criteria which distinguish them,
particularly  when   bronchopneumonia  is   present.
Symptoms of  onset, leukocyte count and the  fever
chart may be quite similar, although apparently there 
/
is usually more complaint of sore  throat with strepto-
coccal  infections.
  At this hospital, during the period covered by  the
present  report,  hemolytic  streptococci  have  been
exceedingly prevalent in various  forms of inflamma-
tion,  and  this  unusual  prevalence  explains in part
their high  incidence as a  cause  of bronchopneumonia
attacking persons  whose  resistance  is  lowered  by
influenza.
  The absence of the pathologic  evidences of a preced-
ing or accompanying toxic inflammation of the lungs,
which in the  early part  of the  epidemic of influenza
appeared fairly characteristic of the pulmonary lesions
of this disease per se, makes me regard the cases of  the
present  series as  examples of  primary  streptococcal
pneumonia.
  Bronchopneumonia following influenza has at present
absolutely no  etiologic or pathologic definition, for  the
type of organism  concerned and the  type of lesion in
the lungs are  decidedly variable at different times even
at the  same station.  It is essential to bear this fact in
mind in any  consideration of the pneumonic compli-
cations of  influenza, especially from the standpoint of
prospective treatment.
Reprinted from The Journal of the American Medical Association
          March 8, 1919, Vol. 72, pp. 724 and 725
                 Copyright, 1919
American Medical Association, 535 N. Dearborn St., Chicago