Part 19

───────┬───────────────┬────────────┬────────────── AUTOPSY│ OTHER G—B. │ OTHER │ NOTES. NUMBER.│ │ BACTERIA. │ │ │ │ ───────┼───────────────┼────────────┼────────────── │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 741│ │ │Nine plates │ │ │used to │ │ │isolate B.I. │ │ │Sp.a. overgrew │ │ │all cultures. │ │ │B.I. seen in │ │ │blood smear │ │ │agar in 24 │ │ │hours. ───────┼───────────────┼────────────┼────────────── 743│Br. lux. white │ │Pericard, │almost coccoid.│ │fluid and │ │ │liver juice, │ │ │no growth. │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 744│ │ │Pneumococcus │ │ │from lung. No │ │ │attempt after │ │ │first plate to │ │ │isolate B.I. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 745│ │ │Swab from │ │ │ruptured │ │ │rectus. │ │ │Sterile. No │ │ │material from │ │ │lung. ───────┼───────────────┼────────────┼────────────── 746│B. coli from │B. xerosis │The overgrowth │bronchi and │from │of B. coli in │lung. │bronchus. │lung material │ │ │prevented │ │ │further │ │ │attempts to │ │ │isolate B.I. │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 747│ │B. subtilis │Five picks │ │group from │from blood │ │pleural │agar plate │ │fluid. │failed to │ │ │recover B.I. │ │ │from lung. │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 748│ │ │B.I. not seen │ │ │nor isolated │ │ │from the │ │ │bronchi. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 749│B. coli from │ │The overgrowth │bronchus and │ │of B. coli │lung. │ │prevented any │ │ │further │ │ │attempts to │ │ │isolate B.I. │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 750│B. coli from │ │B. coli again │bronchi and │ │present as in │lungs. │ │No. 749. │ │ │Direct smear │ │ │suggests heavy │ │ │contamination. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 751│ │Spore-bearer│ │ │with tiny │ │ │cols, pleur.│ │ │B. xerosis │ │ │from bron. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 752│ │ │B.I. like seen │ │ │in original │ │ │culture on │ │ │blood agar but │ │ │not isolated │ │ │from bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 756│B. coli from │B. xerosis │Compare No. │bronchus and │from │749 and 750. │pleural fluid. │bronchus. │Fluid from │ │ │lung not │ │ │obtained for │ │ │culture. │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 757│ │B. xerosis │This case 14 │ │from │hours P. M. │ │bronchus. │gave B.I. from │ │ │all the │ │ │material. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 758│B. coli from │ │The B. coli │bronchus. │ │did not │ │ │prevent the │ │ │isolation of │ │ │B.I. like seen │ │ │in original │ │ │blood agar │ │ │cultures of │ │ │lung. │ │ │ ───────┼───────────────┼────────────┼────────────── 761│B. coli from │ │Even after 19 │bronchus. │ │hours P. M. │ │ │the B.I. was │ │ │isolated. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 762│ │B. xerosis │ │ │from lung. │ │ │B. subtilis │ │ │from │ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 763│ │ │No growth from │ │ │lung on plate. │ │ │B.I. like seen │ │ │in original │ │ │culture from │ │ │pleural fluid. │ │ │No material │ │ │from bronchus. ───────┼───────────────┼────────────┼────────────── 764│ │ │Material only │ │ │from bronchi. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 765│B. coli from │ │ │bronchus and │ │ │lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 767│ │ │Blood culture │ │ │15/10 gave │ │ │pure growth of │ │ │pneumo. │ │ │mucosus. │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 770│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 773│ │B. xerosis │No growth from │ │from │lung except │ │bronchus. G │sarcina. Only │ │+ B lux. │2 colonies │ │white │from pleural │ │pleura. │fluid on blood │ │fluid. │agar plates. │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 778│Non-motile, │ │Ten plates and │non-fermenting,│ │30 picks were │lux, white from│ │done for the │bron. │ │isolation of │ │ │B.I. │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 781│ │ │B.I. like seen │ │ │from 24 hour │ │ │Ht. blood agar │ │ │from bronchi │ │ │and lung but │ │ │only isolated │ │ │from lung on │ │ │replating. Bl. │ │ │culture 25/10 │ │ │sterile. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 782│ │ │No B.I. like │ │ │on 24-hour Ht. │ │ │blood agar │ │ │from lung. │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 783│ │ │No B.I. like │ │ │on 24-hour Ht. │ │ │blood agar │ │ │from lung. │ │ │ ───────┼───────────────┼────────────┼────────────── 784│ │ │Numerous B.I. │ │ │like on │ │ │24-hour Ht. │ │ │blood agar of │ │ │bronchi and │ │ │fewer from │ │ │lung. Isolated │ │ │by replating. ───────┼───────────────┼────────────┼────────────── 786│ │ │Pleural fluid │ │ │not collected │ │ │sterilly, │ │ │Haemol. │ │ │strept. │ │ │isolated. │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 787│B.M.C. from │ │All the │bronchi. │ │bacteria │ │ │isolated were │ │ │seen in │ │ │24-hour Ht. │ │ │blood agar │ │ │cultures from │ │ │bronchi and │ │ │lung. │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 791│ │ │Replated from │ │ │Ht. blood agar │ │ │to isolate │ │ │B.I. from │ │ │lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 792│ │ │B.I. like seen │ │ │on 24-hour Ht. │ │ │blood agar │ │ │from bronchi │ │ │and lung but │ │ │not pleural │ │ │fluid. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────────┼────────────┼────────────── 793│B. coli from │ │B.I. like │throat. │ │never seen │ │ │except from │ │ │throat which │ │ │may have been │ │ │B. coli. ───────┼───────────────┼────────────┼────────────── │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┴───────────────┴────────────┴──────────────

EXPLANATORY NOTE.

B.I.—B. influenzæ.

S.P.A.—Staphylococcus pyogenes aureus.

M. pharyog—Micrococcus pharyngis siccus.

Br.—Bronchus.

Phago.—phagocytosis.

Ht.-Heated blood agar.

B. W.—B. welchii.

Staphylococci develop opaque, paint-like colonies of varying size, with or without hemolysis, and so do other less frequently found bacteria give more or less distinctive colonies. The heated blood agar does not show these differences.

The colonies most liable to be confused with those of B. influenzæ are, therefore, those of B. xerosis, immature colonies of the Gram negative cocci and certain colonies of the streptococcus viridans group. Transfers should always be made to heated blood agar of all colonies suggestive of B. influenzæ, or when the growth of the B. influenzæ has only occurred in the more crowded portions of the plate, and it is difficult to pick pure cultures, attempted pickings should be made to this medium for further platings. It is frequently necessary to make further blood agar plates from the original blood agar, blood broth or heated blood agar cultures after longer incubation periods, depending on the findings in smears from these media. The heated blood agar is the best of these to encourage the growth of B. influenzæ. It must, however, be used at once, or within a very few days of its preparation, and cannot be kept on hand as a stock medium. I have not found it as useful for plating because of the difficulty of differentiating colonies. The phenomenon of the star-like and more luxuriant growth of the colonies of B. influenzæ about colonies of other bacteria has often been noted, and will be referred to in a later portion of this report. Here it may be said that this is at times a marked feature of certain mixtures and must be recognized in studying the plates. The finding of B. influenzæ in picks from apparently isolated colonies of other forms is not uncommon, and is the same type of difficulty which I have discussed in papers on streptococci. It is important to recall, in connection with cultures taken from the lungs at autopsy, the experimental work of Norris and Pappenheimer, who showed that B. prodigiosus put in the mouth immediately after death could be recovered from the lungs in over 50 per cent. of the cases studied.

_Results of the Author_

In Table I are shown my results from the 32 cases which came to autopsy. The B. influenzæ was isolated from one or more sources in 25, making a total of 78 per cent. Most of the negative cases probably also had this organism, but I did not grow it from the material which I used for culturing. The work of others would indicate that it may have been present in other regions, such as the sinuses of the head or other portions of the lung and respiratory tract. The positive results show B. influenzæ present in 20 out of 30 cases from the bronchi; in 13 of 28 from the lungs; in 2 of 14 from the pleural cavity; in 9 of 26 from both bronchi and lung where both were cultured; in 8 of 26 from the bronchi with the lung negative; in 3 of 26 from the lung with the bronchi negative; once of 10 from the pleural cavity with both the bronchi and the lung negative, and once from all three sources.

The negative results occurred in seven cases. In three of these (749, 750, 756) B. coli overgrew the cultures from the bronchus, in two also from the lung, and in one, without lung culture, from bronchus and pleural cavity. The mere presence of B. coli, however, did not preclude the isolation of B. influenzæ, as is seen in cases 746, 758, 761 and 765. The finding of B. coli would suggest a post-mortem invasion. The hours after death before the autopsy was done were in these seven cases, ½, 15, 6, 18, 16, 19, 16, respectively. That delay in performing the autopsy, as emphasized by Spooner, Scott and Heath, adds to the difficulty is self-evident, but successful isolations of B. influenzæ have been obtained after even longer periods than in the negative cases (761). In the fourth negative case (763) the bronchus was not cultured. A pneumococcus was grown from the pleural cavity and no growth was obtained from the lung. In the original culture from the pleural cavity influenza-like forms were seen but could not be isolated. In the fifth case (767) a blood culture three days before death gave a growth of pneumococcus mucosus which was also grown from the lung at autopsy. Direct smear from the bronchus showed very few influenza-like forms. Our sixth negative finding was in a case of 20 days’ illness, the patient having had a recurrence (773). Staphylococcus pyogenes aureus, streptococcus viridans and B. xerosis were grown from the bronchus. Only a sarcina form grew from the lung, and a further probable air contamination occurred on the media from the cultures of the pleural cavity. The B. xerosis colonies were confusing, picked as possible B. influenzæ, and, before this was discovered, the overgrowth prevented further attempts to isolate the influenza bacilli. The last unsuccessful case was one with a general infection of a hemolytic streptococcus from an acute otitis media. The streptococcus was isolated from the bronchus, lung, spleen, arm vein and the middle ear at autopsy.

It will be seen that in these seven negative cases technical difficulties prevented the isolation of the B. influenzæ, even if it had been present. I would not, therefore, conclude that the organisms were necessarily absent, but rather that we have failed either to secure material from the focus of infection or on account of the other reasons mentioned.

It is very evident that a variety of secondary organisms very frequently overgrow the field and become numerically predominant. In our first case staphylococcus pyogenes aureus overgrew all the other organisms present in cultures from the lung material. B. influenzæ was, however, seen in the original 24-hour blood agar culture. It required 9 blood agar plates before the organism could be isolated. In another case 10 plates were used for the isolation.

The findings of the bacteria in the lung sections are particularly interesting and instructive. The entire series of cases have not been completely studied, so I am unable to tabulate the findings. In cases 761 and 762 sections of the lung showed influenza-like bacilli to be almost pure in the earlier stages of the process, while in areas with purulent foci pneumococcus-like and other Gram positive cocci were also numerous. In some cases B. influenzæ-like organisms were to be seen in overwhelming numbers. In others they were scarce, while in some nothing resembling B. influenzæ could be found in the sections. Positive cultures were often independent of whether the influenza-like forms were to be seen in smears or sections or not, although they were found in the great majority of the cases. The findings in the direct smears and the bacteriological results make useful material for comparison.