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It has been stated that a considerable number of cases of influenza developed a more or less extensive purulent bronchitis. This term is used as descriptive of a group of cases showing clinically evidence of a diffuse bronchitis as manifested by numerous medium and fine moist râles scattered throughout the chest and evidence of a definitely purulent inflammatory reaction as indicated by the expectoration of fairly copious amounts of mucopurulent or frankly purulent sputum. This condition is regarded as quite distinct, on the one hand, from the common type of mucoid bronchitis frequently associated with “common colds” and a fairly common feature of uncomplicated cases of influenza, in which physical examination of the chest reveals only transient sibilant and musical râles without evidence of extension to finer bronchi, and, on the other hand, from bronchopneumonia.

Bacteriology.—Thirteen cases of purulent bronchitis following influenza in none of which was there any evidence of pneumonia at the time cultures of the sputum were made nor later were subjected to careful bacteriologic study. Specimens of bronchial sputum were collected in sterile Petri dishes and selected portions thoroughly washed to remove surface contaminations before bacteriologic examinations were made. The results are shown in Table XIII.

Table XIII
Bacteriology of the Sputum in Cases of Purulent Bronchitis Following Influenza
CASE	STAINED FILM OF SPUTUM	DIRECT CULTURE ON BLOOD AGAR PLATE	MOUSE INOCULATION
GJ	B. influenzæ + + +	B. influenzæ + + + +	B. influenzæ
	Gram + diplococci +	Pneumococcus +	Pneumococcus (type undetermined)
WAL	B. influenzæ + +	B. influenzæ + + +
	Gram + diplococci + +	Pneumococcus IV + +
TH	B. influenzæ + + +	B. influenzæ + + + +
	Gram + diplococci + + +	Pneumococcus IV + +
LH	B. influenzæ +	B. influenzæ + +
	Gram + diplococci +	Pneumococcus IV + +
FBD	Gram + diplococci + + + +	Pneumococcus IV + + +	Pneumococcus IV
		B. influenzæ +	B. influenzæ
Wa	B. influenzæ + +	B. influenzæ + +
	Gram + diplococci + +	Pneumococcus IV + +
Sh	B. influenzæ + + +	B. influenzæ + +
	Gram + diplococci + +	Pneumococcus IV + + +
Wal	Gram + diplostrep + + +	S. viridans + +
	B. influenzæ +	B. influenzæ + +
CLF	B. influenzæ + + + + +		B. influenzæ
	Gram + diplococci +		Pneumococcus IV
NCC	B. influenzæ + +	B. influenzæ + + +	B. influenzæ
	Gram − micrococcus +	M. catarrhalis + +	M. catarrhalis
	Gram + diplostrep. +	S. viridans + +
JCM	B. influenzæ + + +	B. influenzæ + + + +	B. influenzæ
	Gram + streptococcus +	S. hemolyticus +	S. hemolyticus
	Gram − micrococcus +	M. catarrhalis +	Pneumococcus IV
	Gram + diplococcus +
Bl	B. influenzæ +		B. influenzæ
	Gram + diplococcus +		Pneumococcus IIa
Bu	B. influenzæ + + + +	B. influenzæ + + +	B. influenzæ
	Gram + diplococcus + + + +	Pneumococcus IV + + +	Pneumococcus IV

From the data presented in Table XIII it is evident that a mixed infection existed in all cases. The results obtained by stained sputum films and by direct culture on blood agar plates are of special significance. B. influenzæ was present in all cases, being the predominant organism in 6 cases, abundantly present in others, and few in number in 2. Of other organisms the pneumococcus was most frequently found, occurring in 11 of the 13 cases, in all but 2 instances being present in considerable numbers. S. viridans was encountered twice, once in association with a Gram-negative micrococcus resembling M. catarrhalis culturally. S. hemolyticus was found once, together with M. catarrhalis and a few pneumococci, Type IV, coming through in the mouse only and of doubtful significance. The stained sputum films and direct cultures always showed these organisms present in sufficient abundance to indicate that they were present in the bronchial sputum and were not merely contaminants from the buccal mucosa.

It seems quite probable from these results that purulent bronchitis following influenza is, in most cases at least, due to mixed infection of the bronchi and should be looked upon as a complication of influenza. Whether the condition may be caused by infection with B. influenzæ alone is difficult to say. No evidence that it may be caused by B. influenzæ alone was obtained in the cases studied. It is not intended to enter here into a discussion as to whether B. influenzæ should be regarded as a secondary invader or not; the other organisms encountered certainly are. It would seem most probable that purulent bronchitis is caused by the mixed infection of B. influenzæ and various other organisms, commonly the pneumococcus, but that the condition is initiated by the invasion of the bronchi by these other organisms in the presence of a preceding infection with B. influenzæ.

Clinical Features.—Purulent bronchitis following influenza began insidiously without any prominent symptoms to mark its onset. About the third or fourth day of influenza, when recovery from the primary disease might be looked for, the patient would begin to cough more frequently, raising increasing amounts of mucopurulent sputum. This sputum was yellowish green in color, copious in amount, and often somewhat nummular in character, sometimes streaked with blood. These symptoms were accompanied by the appearance of coarse, medium and fine moist râles more or less diffusely scattered throughout the chest and usually most numerous over the lower lobes. The percussion note, breath and voice sounds, and vocal and tactile fremitus remained normal. There was no increase in the respiratory rate or pulse rate, and cyanosis did not develop in the absence of a beginning pneumonia. Many such cases, of course, developed bronchopneumonia; in this event areas showing diminished resonance, suppressed breath sounds, and fine crepitant râles with the “close to the ear” quality would appear, the respiratory rate would become increased and cyanosis would become evident. In those cases of purulent bronchitis not developing pneumonia, a moderate elevation of temperature, rarely above 101° F., and irregular in character usually occurred and persisted for a few days or a week.

Many cases maintained a persistent cough, raising considerable amounts of sputum throughout the period of their convalescence in the hospital, which was often considerably prolonged when this complication of influenza occurred. Although no clinical data are available on such cases over a prolonged period of observation, it seems probable that some of them, at least, had developed some degree of bronchiectasis. This would seem all the more probable, since many cases of pneumonia following influenza showed at autopsy extensive purulent bronchitis with well-developed bronchiectasis. Bronchiectasis will be discussed in greater detail in another section of this report. It is this group of cases with more or less permanent damage to the bronchial tree that makes this type of bronchitis following influenza a serious complication of the disease.