Part 21

The material used in the study I am reporting included swabs from the large bronchi and fluid from the lungs and pleural cavities of 32 autopsies, as well as blood cultures from 22 patients and swabs from the nasopharynx of 31 individuals. Fifteen sera were tested for fixation of complement with an antigen made from several strains of B. influenzæ. Fourteen other sera were tested for agglutinins. Complement content was determined in the sera of 25 patients. Skin tests after the Von Pirquet method were done on 14 convalescents, and carefully stained nasopharyngeal smears without cultures were studied from 48 patients.

The chief attention was given to the study of the autopsy material and we concentrated on the isolation of B. influenzæ. At the same time we did not neglect the other bacteria making up the flora of the bronchi, lungs and pleural cavity in these cases. The various types were isolated and most of them fully identified.

Technique

Direct smears were made on sterile slides of all material studied and stained by Gram’s method. The counterstain was always alcoholic fuchsin diluted 1-20 in distilled water. Direct cultures were made on a human blood agar plate containing 5 per cent. blood, which was further smeared just before use with defibrinated blood. This latter procedure was later discarded, as it did not appear to assist to any marked extent the growth of B. influenzæ. Blood broth containing a few drops of defibrinated blood and blood agar slants smeared with blood were also used. Heated blood agar (2-3 c.cm. of defibrinated human blood added to 100 c.cm. of ordinary agar at a temperature of from 90 to 100° C., or as the agar comes from the sterilizer) was used in the last nine cases to replace the blood agar slant in the direct cultures and as the medium of choice for transfers of the B. influenzæ.

I prefer the ordinary blood agar plate to the heated blood plate because the former gives readings which are very helpful in distinguishing colonies of various types. B. influenzæ appears as clear, tiny, pinpoint, inert colonies. B. xerosis or the pseudodiphtheria group gives more opaque but often rather similar colonies. Gram negative cocci as M. pharyngis siccus have dry, raised, soon becoming wrinkled, inert colonies, varying greatly in size; M. catarrhalis, more moist, inert colonies. The cocci of the streptococcus viridans group appear as very small colonies with greening, or are not infrequently inert, while thin, flattened colonies with central thickening may sometimes be noted. Those of the streptococcus hemolyticus group occur as small, frequently nipple-like colonies with clear, wide zones of hemolysis; pneumococci as moderately small, moist, dewdrop-like colonies with center collapsing early and with greening; streptococcus or pneumococcus mucosus as larger, watery, sticky colonies with greening and frequently an early clearing near the colonies.

TABLE I.

BACTERIOLOGY OF THIRTY-TWO AUTOPSIES FROM INFLUENZA CASES.

───────┬─────┬───────────┬─────┬──────────────────┬───────────────────── AUTOPSY│DATE.│ DAY OF │HOURS│ DIRECT │ B. INFLUENZÆ NUMBER.│ │ DISEASE. │P.M. │ SMEAR—GRAM’S │ │ │ │ │ METHOD. │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┬─────┬─────── │ │ │ │ │BRONCH.│LUNG.│PLEURAL │ │ │ │ │ │ │FLUID. ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 741│ 1918│ 3│ 16│G +staph. Few │ 0 │ + │ 0 │ Oct.│ │ │ pneumo-like. Few│ │ │ │ 9│ │ │ chains of elong.│ │ │ │ │ │ │ cocci. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 743│ 11│ 5│ 8│Br. G—bac. from │ + │ 0 │ – │ │ │ │ coccoid to short│ │ │ │ │ │ │ threads. Mostly │ │ │ │ │ │ │ scattered. Some │ │ │ │ │ │ │ phagocyted. │ │ │ │ │ │ │ Fewer G +cooci │ │ │ │ │ │ │ in short chains.│ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 744│ 11│ 7│ 11│Br. G—bac. │ + │ – │ 0 │ │ │ │ moderately stout│ │ │ │ │ │ │ about in small │ │ │ │ │ │ │ groups and │ │ │ │ │ │ │ scattered. │ │ │ │ │ │ │ G+diploc │ │ │ │ │ │ │ (pneumo) also G—│ │ │ │ │ │ │ threads. Phago. │ │ │ │ │ │ │ of both in a few│ │ │ │ │ │ │ cells. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 745│ 12│ 10│ 6│Br. G +—large │ + │ 0 │ –– │ │ │ │ bac., strept. │ │ │ │ │ │ │ short, G—B, few,│ │ │ │ │ │ │ very short, no │ │ │ │ │ │ │ threads. │ │ │ │ │ │ │ │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 746│ 12│ 5│ ½│Br. G—B very │ + │ – │ 0 │ │ │ │ short, no │ │ │ │ │ │ │ threads. │ │ │ │ │ │ │ Irregularly │ │ │ │ │ │ │ scattered. More │ │ │ │ │ │ │ seen in left │ │ │ │ │ │ │ bronchus. A few │ │ │ │ │ │ │ cells │ │ │ │ │ │ │ phagocyted. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 747│ 13│ 6│ 3│Br. G+diploc, │ + │ – │ – │ │ │ │ fairly numerous.│ │ │ │ │ │ │ G—B tiny, as │ │ │ │ │ │ │ diplos and in │ │ │ │ │ │ │ long threads │ │ │ │ │ │ │ scattered or in │ │ │ │ │ │ │ small groups. │ │ │ │ │ │ │ Pleural fluid │ │ │ │ │ │ │ and lung no │ │ │ │ │ │ │ bacteria seen. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 748│ 13│ 4│ 4│Br. nothing like │ – │ + │ 0 │ │ │ │ B. I. seen. G+ │ │ │ │ │ │ │ small elong. │ │ │ │ │ │ │ diplo. Numerous │ │ │ │ │ │ │ G + diploc. in │ │ │ │ │ │ │ lung. │ │ │ │ │ │ │ Comparatively │ │ │ │ │ │ │ few Q-B, very │ │ │ │ │ │ │ short. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 749│ 14│ 4│ 15│Br. G+large pneumo│ – │ – │ 0 │ │ │ │ like, many │ │ │ │ │ │ │ G+large bacilli,│ │ │ │ │ │ │ single and in │ │ │ │ │ │ │ pairs. Few G—B │ │ │ │ │ │ │ very tiny and │ │ │ │ │ │ │ widely │ │ │ │ │ │ │ scattered; lung,│ │ │ │ │ │ │ heavy mixture as│ │ │ │ │ │ │ in bronchi. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 750│ 14│ 9│ 6│Br. G+B large like│ – │ – │ 0 │ │ │ │ B. welchii, │ │ │ │ │ │ │ G—rather stout │ │ │ │ │ │ │ coccoid forms, │ │ │ │ │ │ │ G+C in pairs and│ │ │ │ │ │ │ short chains. │ │ │ │ │ │ │ Tiny G—coccoid │ │ │ │ │ │ │ forms like B. I.│ │ │ │ │ │ │ Lung G+ │ │ │ │ │ │ │ pneumo-like and │ │ │ │ │ │ │ caps, chains; no│ │ │ │ │ │ │ B. I. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 751│ 14│ 7│ 6│Br. G +cocci large│ – │ – │ + │ │ │ │ elong.? caps, │ │ │ │ │ │ │ also G +C in │ │ │ │ │ │ │ flat pairs. │ │ │ │ │ │ │ G—coccoid forms.│ │ │ │ │ │ │ Lung, numerous │ │ │ │ │ │ │ bacteria. │ │ │ │ │ │ │ G+strept. with │ │ │ │ │ │ │ flattened cocci.│ │ │ │ │ │ │ Some G-short │ │ │ │ │ │ │ forms? │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 752│ 15│ 13│ 15│Br. G+pneumo-like.│ – │ + │ 0 │ │ │ │ G+B smaller than│ │ │ │ │ │ │ B. welchii, │ │ │ │ │ │ │ occasionally │ │ │ │ │ │ │ tiny G │ │ │ │ │ │ │ -diplobacillus. │ │ │ │ │ │ │ Lung, G+chains │ │ │ │ │ │ │ of cocci Gram │ │ │ │ │ │ │ weak. Few G—tiny│ │ │ │ │ │ │ bacilli │ │ │ │ │ │ │ scattered or in │ │ │ │ │ │ │ groups. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 756│ 16│ 8│ 18│Br. numerous G+B. │ – │ 0 │ – │ │ │ │ B welchii like. │ │ │ │ │ │ │ G—B large and │ │ │ │ │ │ │ few tiny. │ │ │ │ │ │ │ G+round diploc. │ │ │ │ │ │ │ Pl. fluid almost│ │ │ │ │ │ │ pure │ │ │ │ │ │ │ pneumo-like, few│ │ │ │ │ │ │ G-forms probably│ │ │ │ │ │ │ the same. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 757│ 16│ 6│ 14│Br. G—B tiny, to │ + │ + │ 0 │ │ │ │ medium. G—like │ │ │ │ │ │ │ M. catarrhalis. │ │ │ │ │ │ │ G+cocci, pairs │ │ │ │ │ │ │ and chains. Few │ │ │ │ │ │ │ B. W. like. │ │ │ │ │ │ │ Lung, many G—B │ │ │ │ │ │ │ like B. I. Some │ │ │ │ │ │ │ cells filled, │ │ │ │ │ │ │ also G—cocci. M.│ │ │ │ │ │ │ catarrhalis like│ │ │ │ │ │ │ and rare B. │ │ │ │ │ │ │ welchii like. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 758│ 16│ 14│ 16│Br. pneumo-like in│ + │ ? │ 0 │ │ │ │ excess. G—B from│ │ │ │ │ │ │ tiny to forms │ │ │ │ │ │ │ stouter than B. │ │ │ │ │ │ │ I. Few strept. │ │ │ │ │ │ │ rare M. │ │ │ │ │ │ │ catarrhalis. │ │ │ │ │ │ │ Lung, │ │ │ │ │ │ │ pneumo-like. │ │ │ │ │ │ │ Phago. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 761│ 17│ 7│ 19│Br. pneumo-like. │ + │ – │ 0 │ │ │ │ B. I. like │ │ │ │ │ │ │ common, M. │ │ │ │ │ │ │ catarrhalis │ │ │ │ │ │ │ like. Both B.I. │ │ │ │ │ │ │ and M. │ │ │ │ │ │ │ catarrhalis │ │ │ │ │ │ │ phagocyted. B.I.│ │ │ │ │ │ │ single or in │ │ │ │ │ │ │ threads. Some │ │ │ │ │ │ │ typical groups. │ │ │ │ │ │ │ Lung, pneumo, │ │ │ │ │ │ │ caps, rare, M. │ │ │ │ │ │ │ catarrhalis │ │ │ │ │ │ │ like. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 762│ 17│ 10│ 12│Br. numerous B.l. │ + │ + │ + │ │ │ │ like typical, │ │ │ │ │ │ │ also many │ │ │ │ │ │ │ pneumo. and M. │ │ │ │ │ │ │ catarrh. Lung │ │ │ │ │ │ │ same. M. │ │ │ │ │ │ │ catarrh. │ │ │ │ │ │ │ phagocyted. B.I.│ │ │ │ │ │ │ smear, many │ │ │ │ │ │ │ phagocyted, many│ │ │ │ │ │ │ pneumo. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 763│ 17│ 11│ 13│Lung, pneumo-like,│ 0 │ – │ – │ │ │ │ slight │ │ │ │ │ │ │ phagocytosis. │ │ │ │ │ │ │ Pl. fl., pneumo │ │ │ │ │ │ │ and few strept.,│ │ │ │ │ │ │ slight │ │ │ │ │ │ │ phagocytosis. │ │ │ │ │ │ │ │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 764│ 17│ 9│ 6│Br. B.I. smear. │ + │ 0 │ 0 │ │ │ │ Cells crowded. │ │ │ │ │ │ │ Pneumo-like │ │ │ │ │ │ │ fewer, │ │ │ │ │ │ │ occasional │ │ │ │ │ │ │ G—stouter │ │ │ │ │ │ │ thread. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 765│ 17│ 9│ 16│Br. pneumo. B.I. │ + │ + │ 0 │ │ │ │ few scattered. │ │ │ │ │ │ │ G+flattened │ │ │ │ │ │ │ diploc. Phago. │ │ │ │ │ │ │ of B.I. and │ │ │ │ │ │ │ pneumo. Lung, │ │ │ │ │ │ │ pneumo-like, │ │ │ │ │ │ │ rare strept. │ │ │ │ │ │ │ very │ │ │ │ │ │ │ questionable G—B│ │ │ │ │ │ │ free and in │ │ │ │ │ │ │ cells. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 767│ 18│ 10│ 14│Br. rather round │ – │ – │ 0 │ │ │ │ pneumo-like with│ │ │ │ │ │ │ caps. B.I. few. │ │ │ │ │ │ │ Scattered, also │ │ │ │ │ │ │ in cells. Lung, │ │ │ │ │ │ │ few bacteria. │ │ │ │ │ │ │ G+strep. often │ │ │ │ │ │ │ phagocyted. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 770│ 19│ 11│ 9│Br. crowded with │ + │ + │ – │ │ │ │ B.I. like. Few │ │ │ │ │ │ │ G+cocci and │ │ │ │ │ │ │ fewer M. │ │ │ │ │ │ │ catarrh. like. │ │ │ │ │ │ │ Pl. fluid │ │ │ │ │ │ │ G+flattened │ │ │ │ │ │ │ pairs, pus │ │ │ │ │ │ │ cells, │ │ │ │ │ │ │ phagocyted. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 773│ 21│ 20│ 3│Br. few bacteria │ – │ – │ – │ │Recurrence.│ │ G+and │ │ │ │ │ │ │ G—pneumo-like. │ │ │ │ │ │ │ Rare G+—thread. │ │ │ │ │ │ │ Lung, pneumo and│ │ │ │ │ │ │ rare strept. Pl.│ │ │ │ │ │ │ fluid, │ │ │ │ │ │ │ pneumo-oat │ │ │ │ │ │ │ shapes, etc. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 778│ 24│ 23│ 17│Br. B.I. smear. │ + │ + │ – │ │ │ │ Fewer large │ │ │ │ │ │ │ pneumo. Lung, G │ │ │ │ │ │ │ + small diploc. │ │ │ │ │ │ │ Few B.I. like. │ │ │ │ │ │ │ Pl. fluid, few │ │ │ │ │ │ │ cells, no │ │ │ │ │ │ │ bacteria. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 781│ 26│ 5│ 4│Br. crowded with │ – │ + │ – │ │ │ │ staph. like. │ │ │ │ │ │ │ Fewer G—B, │ │ │ │ │ │ │ larger than │ │ │ │ │ │ │ B.I., few M. │ │ │ │ │ │ │ catarrhalis │ │ │ │ │ │ │ like. Lung G+ │ │ │ │ │ │ │ small staph. │ │ │ │ │ │ │ like, caps, │ │ │ │ │ │ │ cocci in pairs │ │ │ │ │ │ │ and chains. Few │ │ │ │ │ │ │ tiny G—B. Pl. │ │ │ │ │ │ │ fluid │ │ │ │ │ │ │ pneumo-like and │ │ │ │ │ │ │ elong. cocci in │ │ │ │ │ │ │ chains │ │ │ │ │ │ │ capsulated. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 782│ 26│ 8│ 3│Br. numerous B.I. │ + │ – │ 0 │ │ │ │ like scattered, │ │ │ │ │ │ │ some phagocyted.│ │ │ │ │ │ │ Fewer G+ flat │ │ │ │ │ │ │ pairs with │ │ │ │ │ │ │ capsule. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 783│ 26│ 8│ 1│Br. G+small caps, │ + │ – │ 0 │ │ │ │ pneumo-like. │ │ │ │ │ │ │ Lung poor smear,│ │ │ │ │ │ │ occasional │ │ │ │ │ │ │ pneumo-like. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 784│ 28│ 8│ 6│Br. capsulated │ + │ + │ 0 │ │ │ │ pneumo-like, few│ │ │ │ │ │ │ strep. Lung, │ │ │ │ │ │ │ chiefly │ │ │ │ │ │ │ pneumo-like. few│ │ │ │ │ │ │ G—B like B.I., │ │ │ │ │ │ │ also │ │ │ │ │ │ │ G—pneumo-like. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 786│ 29│ 4│ 2│Br. G+cocci in │ + │ – │ 0 │ │ │ │ round pairs and │ │ │ │ │ │ │ rather flat │ │ │ │ │ │ │ chains, │ │ │ │ │ │ │ suggested caps. │ │ │ │ │ │ │ Tiny G—B very │ │ │ │ │ │ │ rare. Lung │ │ │ │ │ │ │ streptococci │ │ │ │ │ │ │ flattened, often│ │ │ │ │ │ │ phagocyted. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 787│ 29│ 8│ 2│Br. numerous │ + │ + │ 0 │ │ │ │ pneumo-like, │ │ │ │ │ │ │ bacillary forms.│ │ │ │ │ │ │ A rare │ │ │ │ │ │ │ suspicious B.I. │ │ │ │ │ │ │ like, some of │ │ │ │ │ │ │ these in cells. │ │ │ │ │ │ │ Lung, caps, │ │ │ │ │ │ │ elongated │ │ │ │ │ │ │ diplos, and │ │ │ │ │ │ │ chains of elong.│ │ │ │ │ │ │ cocci. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 791│ Nov.│ 6│ 6│Br. few bacteria. │ + │ + │ – │ 1│ │ │ G+pneumo-like │ │ │ │ │ │ │ round, G—B and │ │ │ │ │ │ │ threads, size │ │ │ │ │ │ │ varies, like │ │ │ │ │ │ │ B.I. Lung, G + │ │ │ │ │ │ │ caps, pneumo. │ │ │ │ │ │ │ G+Large B. few │ │ │ │ │ │ │ suspicious │ │ │ │ │ │ │ G—coccoid forms.│ │ │ │ │ │ │ Pl. fl. caps, │ │ │ │ │ │ │ pneumo and caps,│ │ │ │ │ │ │ elong. chains. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 792│ 2│ 6│ 3│Br. caps, │ + │ + │ – │ │ │ │ pneumo-like bac.│ │ │ │ │ │ │ forms and │ │ │ │ │ │ │ chains. G-caps, │ │ │ │ │ │ │ pneumo-like. Few│ │ │ │ │ │ │ G—B. │ │ │ │ │ │ │ questionable. │ │ │ │ │ │ │ Lung. caps, │ │ │ │ │ │ │ pairs and chains│ │ │ │ │ │ │ of elong. cocci,│ │ │ │ │ │ │ in cells. Pl. │ │ │ │ │ │ │ fluid, numerous │ │ │ │ │ │ │ caps, chains of │ │ │ │ │ │ │ diploc. │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── 793│ 4│ 10│ 3/2│Br. M. catarrh. │ – │ – │ – │ │ │ │ and G+cocci, few│ │ │ │ │ │ │ bacteria, few │ │ │ │ │ │ │ G—B. Ear, │ │ │ │ │ │ │ G+cocci. │ │ │ │ │ │ │ │ │ │ ───────┼─────┼───────────┼─────┼──────────────────┼───────┼─────┼─────── │ │ │ │ Total │ 20 │ 13 │ 2 │ │ │ │B. influenzæ │ 66½ │ 46 │ 14 │ │ │ │ found—Percentage│ │ │ │ │ │ │ │ ——— │ ——— │ ——— │ │ │ │Total percentage │ │ 78 │% │ │ │ │ for B. influenzæ│ │ │ ───────┴─────┴───────────┴─────┴──────────────────┴───────┴─────┴───────

───────┬───────────┬─────────┬─────────┬─────────┬──────────────── AUTOPSY│PNEUMCOCCI.│ STREPT. │HEMOLYTIC│ S.P.A. │ OTHER COCCI. NUMBER.│ │MOCOCCI. │ STREPT. │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 741│ │ │ │+ │G+ diploc. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 743│ │Pleural │ │ │Br. G + diploc. │ │fluid and│ │ │not like pneumo. │ │seen as │ │ │ │ │diplos in│ │ │ │ │direct │ │ │ │ │smear. │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 744│Lung + │ │ │ │M. tetrag. in │ │ │ │ │Br. M. pharyng. │ │ │ │ │in Br. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 745│ │ │Pleural │Pl. │ │ │ │fluid, │fluid, │ │ │ │also seen│also seen│ │ │ │in smear.│in │ │ │ │ │smears. │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 746│ │ │ │ │Strept. viridans │ │ │ │ │from bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 747│ │ │ │Bronchus │Strept. viridans │ │ │ │and │from bronchi and │ │ │ │pleural │lung. │ │ │ │fluid. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 748│Lung+, not │ │ │ │Strept. viridans │isolated │ │ │ │from bronchus. │from │ │ │ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 749│Bronchus │ │ │Bronchus │ │Lung? │ │ │and lung.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 750│Bronchus? │ │ │ │ │Lung? │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 751│ │Pleura. │ │ │M. tetragenous │ │Lung. │ │ │from bronchus. │ │Bronchus.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 752│Bronchus │ │ │ │Strep. viridans │and lung. │ │ │ │from bronchus │ │ │ │ │and lungs. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 756│ │ │ │Pleural │Strep. viridans │ │ │ │fluid. │from bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 757│Bronchus │ │ │Bronchus │M. tetragenous? │and lung. │ │ │and lung.│from lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 758│Bronchus │ │ │ │M. │and lung. │ │ │ │catarrhalia-like │ │ │ │ │from lung. │ │ │ │ │Strep. viridans │ │ │ │ │from lung and │ │ │ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 761│Bronchus │ │ │Bronchus │ │and lung. │ │ │and lung.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 762│Pleural │ │ │ │M. catarrh. like │fluid and │ │ │ │from lung and │bronchus. │ │ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 763│Pleural │ │ │ │ │fluid. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 764│Bronchus. │ │ │ │Staph, albus │ │ │ │ │from bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 765│ │ │Lung. │ │M. catarrh. from │ │ │ │ │bronchus and │ │ │ │ │lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 767│Bronchus. │Lung. │ │Bronchus.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 770│Bronchus. │ │ │Bronchus,│ │ │ │ │lung, │ │ │ │ │pleural │ │ │ │ │fluid. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 773│ │ │ │Bronchus.│Strept. viridans │ │ │ │ │bronchus. │ │ │ │ │Sarcina albus │ │ │ │ │lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 778│Bronchus │ │ │Lung. │ │and lung. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 781│ │Lung and │ │Bronchus │Staph. albus and │ │pleural │ │and lung │sarcina from │ │fluid. │ │abscess. │pleural fluid. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 782│ │Bronchus │ │ │ │ │and lung.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 783│Lung. │ │ │Bronchus.│M. catarrh. like │ │ │ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 784│Bronchus │Bronchus │ │ │M. catarrh. like │and lung. │and lung?│ │ │bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 786│Bronchus. │ │Bronchus │ │Staph, albus │ │ │and lung.│ │from bronchus. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 787│ │ │ │Bronchus │ │ │ │ │and lung.│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 791│Bronchus │ │ │Bronchus │ │and pleural│ │ │and lung.│ │cavity. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 792│Bronchus, │ │ │ │Staph. albus, │lung and │ │ │ │lung, strept. │pleural │ │ │ │viridans lung, │fluid. │ │ │ │M. catarrh. like │ │ │ │ │lung and │ │ │ │ │bronchi. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── 793│?Throat. │ │Bronchus,│Throat, │Strept. viridans │ │ │lung, arm│ear and │from throat. │ │ │vein, │bronchus.│ │ │ │spleen │ │ │ │ │ear. │ │ │ │ │ │ │ ───────┼───────────┼─────────┼─────────┼─────────┼──────────────── │20 │6 │4 │16 │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───────┴───────────┴─────────┴─────────┴─────────┴────────────────

───────┬───────────────┬────────────┬────────────── 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.

Swabs from the nasopharynx were cultured from 31 individuals; nearly all of these were cases suspected of diphtheria or as carrying the diphtheria bacillus, and no particular effort was made to isolate the B. influenzæ. They were seen in the mixed culture occasionally. In the last eight cases the heated blood agar, ordinary blood agar and Loeffler’s serum were seeded from the throat swabs. B. influenzæ practically overgrew all the other bacteria from seven of these cases on the heated blood agar medium and was isolated without difficulty; all eight showed M. catarrhalis. The two other media gave little or no evidence of the presence of B. influenzæ. As I have said above, our attention was concentrated on the autopsy material. These cultures from the throat were simply made to demonstrate the usefulness of the heated blood agar.

TABLE II