THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR

VOLUME XII

PATHOLOGY OF THE ACUTE RESPIRATORY DISEASES, AND OF GAS GANGRENE FOLLOWING WAR WOUNDS

PREPARED UNDER THE DIRECTION OF

MAJ. GEN. M. W. IRELAND
The Surgeon General

BY

MAJ. GEORGE R. CALLENDER, M. C.
AND
MAJ. JAMES F. COUPAL, M. C

WASHINGTON U. S. GOVERNMENT PRINTING OFFICE 1929

ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCUREDFROM THE SUPERINTENDENT OF DOCUMENTS
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LETTER OF TRANSMISSION

I have the honor to submit herewith Volume XII of the history of the MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR. The volume submitted is entitled "PATHOLOGY OF THE ACUTE RESPIRATORY DISEASES, AND OF GAS GANGRENE FOLLOWING WAR WOUNDS."

M. W. IRELAND,
Major General, the Surgeon General.

The SECRETARY OF WAR.

IV

Lieut. Col. FRANK W. WEED, M. C., Editor in Chief.
Loy MCAFEE, A. M., M. D., Assistant Editor in Chief.

EDITORIAL BOARD ^a

Col. BAILEY K. ASHFORD, M. C.
Col. FRANK BILLINGS, M. C.
Col. THOMAS R. BOGGS. M. C.
Col. GEORGE E. BREWER, M. C.
Col. W. P. CHAMBERLAIN, M. C.
Col. C. F. CRAIG, M. C.
Col. HAVEN EMERSON, M. C.
Brig. Gen. JOHN M. T. FINNEY, M. D.
Col. J. H. FORD, M. C.
Lieut. Col. FIELDING H. GARRISON, M. C.
Col. H. L. GILCHRIST, M. C.
Brig. Gen. JEFFERSON R. KEAN, M. D.
Lieut. Col. A. G. LOVE, M. C.
Col. CHARLES LYNCH, M. C.
Col. JAMES F. MCKERNON, M. C.
Col. S. J. MORRIS, M. C.
Col. R. T. OLIVER, D. C.
Col. CHARLES R. REYNOLDS, M. C.
Lieut. Col. G. E. DE SCHWEINITZ, M. C.
Col. J. F. SILER, M. C.
Brig. Gen. W. S. THAYER, M. D.
Col. A. D. TUTTLE, M. C.
Col. WILLIAM H. WELCH, M. C.
Col. E. P. WOLFE, M. C.
Lieut. Col. CASEY A. WOOD, M. C.
Col. HANS ZINSSER, M. C.
___________________________________________________
^a The highest rank held during the World War has been used in the case of each officer.

TABLE OF CONTENTS

PREFACE
SECTION I.-PATHOLOGY OF THE ACUTE RESPIRATORY DISEASES. By Maj. GEORGE R. CALLENDER, M. C.
CHAPTER I. In camps in the United States
    I. In camps in the United States, cont.
    II. In the American Expeditionary Forces
    III. Pathological anatomy
    III. Pathological anatomy cont
    IV. Lesions in organs outside the respiratory tract
    V. Bacteriology
SECTION II.-PATHOLOGY OF GAS GANGRENE FOLLOWING WAR WOUNDS. By Maj. JAMES F. COUPAL, M. C.
SECTION II. PATHOLOGY OF GAS GANGRENE FOLLOWING WAR WOUNDS. BY Maj. JAMES F. COUPAL, M.C. cont.
APPENDIX

LIST OF CHARTS
CHARTS

    I. The incidence and fatality of the acute respiratory diseases at Camp Beauregard
    II. The incidence and fatality of the acute respiratory diseases at Camp Bowie
    III. The incidence and fatality of the acute respiratory diesases at Camp Cody
    IV. The incidence and fatality of the acute respiratory diseases at Camp Custer
    V. The incidence and fatality of the acute respiratory diseases at Camp Devens
    VI. The incidence and fatality of the acute respiratory diseases at Camp Dix
    VII. The incidence and fatality of the acute respiratory diseases at Camp Dodge
    VIII. The incidence and fatality of the acute respiratory diseases at Camp Fremont
    IX. The incidence and fatality of the acute respiratory diseases at Camp Grant
    X. The incidence and fatality of the acute respiratory diseases at Camp Lewis
    XI. The incidence and fatality of the acute respiratory diseases at Camp MacArthur
    XII. The incidence and fatality of the acute respiratory diseases at Camp Pike
    XIII. The incidence and fatality of the acute respiratory diseases at Camp Sherman
    XIV. The incidence and fatality of the acute respiratory diseases at Camp Taylor

LIST OF PLATES

    I. Diffuse, hemorrhagic pneumonia; Streptococcus hemolyticus infection following influenza
    II. Generalized streptococcus lymphangitis secondary to confluent, lobular pneumonia following influenza
    III. Hemorrhagic edema with beginning leucocytic infiltration
    IV. Hemorrhagic edema, acute bronchiectasis, beginning purluent consolidation
    V. Perivascular proliferation
    VI. Two ruptures in an atrial wall
    VII. Peribronchiolar, hemorrhagic consolidations
    VIII. Organizing pneumonic process
    IX. Organization of exudate in influenzal pneumonia

VIII

    X. Organization following influenzal pneumonia
    XI. Bronchopneumonia. Spreading or confluent consolidation
    XII. Peribronchial and perivascular lymphangitis
    XIII. Zenker's degeneration, rectus abdominis muscle
    XIV. Zenker's degeneration
    XV. Debrided wound of the right thigh
    XVI. Vertical section of the amputated thigh
    XVII. Gas gangrene of the calf muscles
    XVIII. Edema within muscle envelopes and between muscle bundles
    XIX. Cross section of muscle taken from an area of toxic edema near the wound tract
    XX. Typical brick-red discoloration of the calf muscles due to gas gangrene
    XXI. Muscle fibers from an area of putrefactive gangrene
    XXII. Comminution of bone; putrefactive infection of the marrow
    XXIII. Showing the typical color of the bronzing in avirulent gas gangrene
    XXIV. Putrefactive gangrene. Cross section of leg shown in Plate XXIII

LIST OF FIGURES

1. Postinfluenzal pneumonia
2. Dilated small vessel in a lung in the congestive stage of lobar pneumonia
3. Alveolus in the early stage of red hepatization
4. Stage of late red hepatization stained for reticulum
5. Alveolus of early gray hepatization
6. Lung in gray hepatization
7. Postinfluenzal pneumonia
8. Postinfluenzal pneumonia
9. Subdural abscess following suppurative frontal sinusitis after influenza
10. Hemorrhagic, necrotic inflammation of the lining of the trachea
11. Cellular reaction in a bronchial lymph node in pneumonia following influenza
12. Pneumonia following influenza. Diffuse, hemorrhagic inflammation of the lungs
13. Postinfluenzal pneumonia
14. Early changes in bronchiolar epithelium
15. Degeneration of bronchial mucosa
16. Gram-negative bacilli along bronchiolar epithelium
17. Wall of bronchiole. Epithelium being raised and separated by serous exudate beneath
18. Lobular pneumonia
19. Lobular pneumonia
20. Minute Gram-negative bacteria in bronchiolar mucosa
21. Minute Gram-negative bacteria, free and in phagocytes
22. Ductus alveolaris showing streptococci and minute Gram-negative bacteria
23. Minute Gram-negative bacteria and streptococci in the exudate along the epithelium of the beginning of a ductus alveolaris
24. Gram-negative bacteria and a few streptococci along the wall of a ductus alveolaris
25. Bronchiole infiltrated with leucocytes, Gram-negative bacteria and streptococci
26. Seropurulent exudate in a bronchiole
27. Longitudinal section of a bronchiole containing purulent exudate
28. Bronchiole showing purulent inflammation
29. Bronchiole showing purulent exudate
30. Serous exudate in a ductus alveolaris
31 Cross section of an atrium containing air and hemorrhagic exudate

IX

32. Early exudate in a diffuse inflammation of the lungs
33. Early exudate in a confluent, lobular pneumonia
34. Proliferated adventitia
35. Early hemorrhagic lesion
36. Degenerated wall of atrium
37. Peribronchiolar consolidation, surrounded by zones of hemorrhage
38. Gram-negative bacillary forms in the alveolar wall
39. Minute Gram-negative bacteria in the alveoli
40. Minute Gram-negative bacteria in alveolar wall
41. Peribronchiolar lesions in pneumonia following influenza
42. Pneumonia following influenza
43. A bronchiole showing absence of columnar cells at either side
44. Ductus alveolaris surrounded by purulent exudate
45. Peribronchiolar pneumonia
46. Consolidation about a ductus alveolaris
47. Infiltration of alveolar wall by mononuclear leucocytes
48. Section of the trachea showing complete loss of the columnar cells
49. Section of trachea showing practically complete loss of columnar cells, with marked proliferation of the basal layer
50. Bronchus showing purulent exudate and air in the lumen
51. Proliferation of alveolar epithelium
52. Proliferation of basal layer appearing as a stratified, squamous type of epithelium
53. Alveoli and atria filled with masses of epithelium
54. Exudate in an atrium in an early stage of the process of organization
55. Types of cells in organization
56. Early stage of organization of exudate in an alveolus
57. Early stage of organization of the exudate in a pulmonary atrium
58. Early organization of the exudate in a pulmonary atrium
59. Organization of exudate in influenzal pneumonia
60. Organization following influenzal pneumonia
61. Organization complete in an alveolus
62. Collagenous fibers extending to the group of mononuclear cells
63. Practically complete organization of a group of alveoli
64. Newly formed capillaries about a small blood vessel
65. Increase in the number of capillaries in alveolar walls
66. Alveolar walls showing new formation of connective tissue
67. Organization extending from an ulcerated area in a bronchiole
68. Granulation tissue in the wall of a bronchiole
69. New fibrous tissue encroaching on the lumen of a bronchiole
70. Late stage of interstitial reaction about bronchioles
71. Purulent bronchiolitis with bronchiectasis following influenza
72. Purulent bronchitis with marked dilatation and bronchiectasis
73. Acute, ulcerative bronchitis and bronchiectasis
74. Bronchiectasis
75. Pneumonic consolidation spreading out about the bronchi
76. Experimental bronchopneumonia in a monkey
77. Experimental bronchopneumonia in a monkey
78. Acute bronchitis
79. Bronchus showing an acute inflammatory reaction
80. Purulent bronchiolitis with ulceration
81. Purulent bronchitis
82. Purulent bronchitis and bronchiectasis
83. Bronchitis and bronchiectasis
84. Bronchiole involved in an inflammatory reaction
85. Postinfluenzal pneumonia
86. Bronchopneumonia spreading out about bronchi and blood vessels

X

87. Wall of bronchiole containing numerous pneumococcus forms
88. Alveolar walls containing numerous pneumococcus forms
89. Walls of alveoli and exudate containing pneumococcus forms
90. Early stage of reaction in the alveoli
91. Section of wall of the main bronchus showing desquamation of epithelium
92. Section of wall of bronchus showing the lumen of a duct plugged with serofibrinous exudate
93. Section of wall of bronchus showing fibrinous exudate
94. Blood vessels and alveoli in a case of pneumococcus Type II infection
95. Peribronchiolar consolidations
96. Postinfluenzal pneumonia
97. Postinfluenzal pneumonia
98. Lobular, pneumonic consolidation
99. Pneumonia following influenza
100. Postinfluenzal pneumonia
101. Lobular pneumonia
102. Section of a bronchial wall in a streptococcus bronchitis
103. Wall of main bronchus in a case of streptococcus bronchitis and bronchopneumonia
104. Bronchus showing the extension of inflammation between the cartilages
105. Bronchus containing serous exudate
106. Streptococci in lymph spaces
107. Streptococcus forms beneath the bronchial mucosa
108. Serofibrinous exudate in an early stage of a lobular pneumonia caused by hemolytic streptococci
109. Early stage of consolidation in a lobular pneumonia
110. Purulent exudate in a lobular pneumonia
111. Early stage of streptococcus, lobular pneumonia
112. Hyaline membrane in a group of atria and alveoli
113. Hemorrhagic inflammation of alveolar walls
114. Confluent, lobular pneumonia
115. Alveolus with serious exudate containing streptococci
116. Streptococci in lymph spaces in alveolar walls
117. Postinfluenzal pneumonia
118. Postinfluenzal pneumonia
119. Postinfluenzal pneumonia
120. Confluent, lobular pneumonia
121. Confluent, lobular pneumonia with central necrosis
122. Confluent, lobular pneumonia with extensive central necrosis
123. Necrotic confluent lobar pneumonia
124. Streptococcus, lobular pneumonia showing beginning abscess formation
125. Abscess formation in the center of a lobule of streptococcus, lobular pneumonia
126. Lobule going on to abscess formation
127. Pneumonia due to hemolytic streptococci, showing abscess formation
128. New capillaries in granulation tissue projecting into an abscess caused by streptococci
129. Purulent bronchitis
130. Exudate in a bronchiole
131. Bronchus showing almost complete desquamation of columnar cells and proliferation of the basal layer
132. Small bronchus showing proliferation of basal layers
133. Lungs, heart, pericardium, pleura and mediastinal tissues of a case of empyema, pericarditis and mediastinitis
134. Bronchus in an area of lobular pneumonia from which Streptococcus hemolyticus was cultivated
135. Oblique section of a bronchus in an area of lobular pneumonia

XI

136. Oblique section of a bronchus (next to that shown in Figure 134), showing increases in vessels in submucosa
137. Peribronchial lymphangitis
138. Perivascular lymphangitis about a small pulmonary vein
139. Interlobular lymphangitis in a lobular pneumonia due to hemolytic streptococci
140. Lymphatics of an interlobular septum filled with fibrinopurulent exudate
141. Streptococcus hemolyticus pneumonia
142. Phlegmonous inflammation of interlobular septa
143. Purulent lymphangitis in an interlobular septum
144. Fibrinopurulent pleuritis with subpleural lymphangitis
145. Abscesses in interlobular septa arising in thrombosed lymphatics
146. Interlobar empyema
147. Pneumonia following measles
148. Pneumonia following influenza complicated by empyema
149. Purulent phlebitis of a pulmonary vein
150. Dilated capillary in the mediastinal tissues
151. Pneumonia following measles with fibrinopurulent pleuritis
152. Late streptococcus lymphangitis following influenzal, lobular pneumonia
153. Organization in an interlobular septum
154. Advanced fibrosis in an interlobular septum
155. Organizing process in interlobular septa
156. Staphylococcus pneumonia. Abscesses arising in the bronchioles
157. Staphylococcus pneumonia. Multiple abscesses in bronchi
158. Multiple abscesses arising in bronchi, due to staphylococcus
159. Confluent, lobular pneumonia with groups of staphylococcus abscesses
160. Purulent staphylococcus bronchiolitis
161. Purulent staphylococcus bronchiolitis
162. Zenker's degeneration of rectus abdominis muscle in a case of influenza and pneumonia
163. Zenker's degeneration in the rectus abdominis muscle in a case of pneumonia following influenza
164. Zenker's degeneration in the rectus abdominis muscle
165. Zenker's degeneration in the rectus abdominis muscle
166. Hemorrhagic adrenalitis
167. Hemorrhagic adrenalitis
168. Rupture of the long saphenous vein, probably produced by shell fragment, through hydraulic transmission of its force
169. Vein filled with large bacteria of putrefactive type
170. Vertical midsection through the thigh
171. Section of gangrenous muscle
172. A gaseous area in muscle
173. Gangrenous area in muscle
174. Gram-positive round-ended rods between muscle fibers
175. Cross section of a nerve which shows a spiral rupture
176. Medium sized vein which shows numerous Gram-positive rods in the muscularis and in the lymphatics
177. Longitudinal section of a muscle near the debrided wound
178. Spiral rupture of muscle caused by gases within the muscle fascia
179. Accumulations of gas between muscle bundles and within muscle fibers
180. Connective tissue and fat which shows gas and edema and digestion of fat cells
181. Left knee with a debrided wound
182. Midsection of the knee in Figure 181, showing gas formation
183. Medium sized artery with marked shredding of the adventitia and hemorrhage into the subcutaneous tissues
184. Medium sized vein and artery, branches of the vessels shown in Figure 183

XII

185. Area of advanced emphysematous gangrene
186. Muscle fibers with two-thirds of their diameter occupied by gas bubbles
187. Gas infiltration of one muscle fiber
188. Gas gangrene change in muscle infiltrated with large coccobacilli
189. Thigh amputated at the level of a fracture in the middle third of the femur
190. Vertical section of the limb in Figure 189, showing putrefactive gangrene
191. Midsection of the amputated limb shown in Figure 189, with accumulation of large gas bubbles
192. X ray of limb showing gas bubbles
193. Section from the gangrenous area
194. Section from the emphysematous area
195. Section from the putrefactive, gangrenous process
196. Anterior surface of the right thigh with a debrided. high-explosive wound, and midsection of the limb
197. X ray of the thigh showing gas in the muscle
198. Two muscles, one of which shows rupture of fibers in gas gangrene
199. Area of advanced emphysematous gangrene
200. Gangrenous area close to the wound tract
201. Muscle fiber with numerous fine bubbles
202. Two isolated muscle fibers which have been split by gas
203. Area of comparatively pure emphysematous gangrene
204. Cross section of the leg showing surgical free dissection of muscles
205. Muscles invaded by gas
206. Infiltration of muscle fibers by gas
207. Section from the gangrenous muscles
208. Ground-glass appearance of muscle fibers
209. Muscle fibers in the putrefactive gangrenous process
210. Left arm with a debrided bullet wound
211. Large gas bubble between fibers of an isolated muscle bundle
212. Section of muscle in an area of gas gangrene
213. Section from the brachial nerve showing edema and gas and numerous roundended Gram-positive rods between fibers
214. Section of fascia and fat from the area of putrefactive gangrene over the biceps muscle
215. High explosive shell wound caused by contact explosion
216. Opposite side of thigh shown in Figure 215
217. Fractured tibia and fibula and gas gangrene of the calf muscles
218. Shredding and thrombosis of the popliteal vessels with beginning putrefactive gas gangrene
219. Putrefactive change in the clot around the upper end of the fractured tibia
220. Destruction of muscle fibers and surrounding fascias
221. Bubbles of gas within the fibers and small collections of gas around them
222. Deeper portion of the wound which contained bacteria
223. Gas within a ruptured muscle fiber
224. Variation in the wavy muscle fibers retain the basic dye
225. Separation of myomeres
226. Putrefactive infection of superficial hemorrhages of right thigh following several small wounds due to high-explosive shell fragments
227. Debrided, high-explosive wound with projecting muscle masses
228. Putrefactive infection around the wound tract
229. High explosive wound of the middle of the biceps
230. Section of the wound showing fragments of bone, dirt, and foreign bodies
231. Rupture of a muscle fiber
232. Splitting of fibers due to direct trauma
233. Muscle fiber completely honeycombed with fine bubbles
234. End of a muscle fiber showing large rod-shaped organism with an end spore

XIII

235. Area of hemorrhage around the wound tract
236. Debrided wound below the external malleolus and putrefactive gangrene
237. Putrefactive gangrene of the os calcis
238. Gas bubbles within muscle fibers
239. Emphysematous gangrene in the interosseus muscles
240. Swollen muscle fibers showing gas and a marked variation in their staining reaction
241. Section nearer the wound tract
242. Section through putrefactive gangrenous area
243. Vertical section of left leg injured by high-explosive shell fragments
244. Wound tract with a surrounding putrefactive gangrene
245. X ray showing numerous foreign bodies and emphysematous gangrene
246. Section from the gangrenous, emphysematous gastrocnemius
247. Accumulation of gas between muscle bundles
248. Putrefactive gangrenous process
249. A lymphatic distended with gas and lined by masses of bacteria
250. Chemical changes of the muscle fibers as indicated by retention of the basic dye
251. Thrombosis of the femoral artery and vein and gas gangrene of muscle
252. Secondary infection of the bone marrow, extensive gas gangrene
253. Shredding of the adventitia of artery, with gas gangrene of the muscular coat
254. Muscle fibers from the putrefactive area
255. Large gas bubbles in muscle bundles
256. Debrided wound of arm
257. Injury to the musculospiral nerve
258. Beginning putrefactive gangrene around the humerus
259. Edematous muscle around the fractured humerus
260. Edema along the fascial planes
261. Edema of muscle fibers and muscle bundles and gas within muscle fibers
262. Edema within muscle envelops and between muscle bundles
263. Edema, swelling and loss of markings in muscle fibers
264. Biceps muscle which shows reaction of the muscle fibers to the basic dye
265. Early regeneration of muscle fibers
266. Emphysematous gangrene around the fracture of the humerus
267 Gangrene due to failure of the blood supply
268. Cross section of the forearm showing emphysematous gangrene
269. X ray showing accumulations of gas around the fracture
270. Loss of normal markings of muscle fibers; accumulation of gas and hemoglobin detritus
271. Leucocytic exudate in the debrided wound
272. Intense basic staining of parts of muscle fibers
273. Debrided high-explosive shell wound of thigh. Toxic, edematous gangrene
274. Gas gangrene of muscles, and edema
275. X ray showing gas gangrene, comminution of the fracture and a piece of high-explosive shell
276. Muscles of the calf above the fragment showing gas gangrene
277. Comminuted fracture of tibia with mixed putrefactive and edematous gangrene
278. A fragment of bone surrounded by putrefactive gangrene
279. Shredding of the coats of a medium-sized vein
280. Muscle fibers from the gaseous area of gangrene
281. Muscle fibers in the putrefactive area of grangrene
282. Muscle fibers from an area of putrefactive change in gas gangrene
283. Muscle fibers from a contaminated area near the wound tract
284. Popliteal and thigh muscles affected by a putrefactive gangrene
285. X ray of the leg showing gas bubbles in the muscles
286. Muscle fibers from the putrefactive area
287. Section from the gaseous area of the calf muscle showing foreign bodies

XIV

288. Left leg with high-explosive wound
289. Debrided wound exposing fractured ends of the tibia and fibula
290. Clot in the marrow of the tibia undergoing a putrefactive process
291. X ray showing fracture of both bones, and foreign bodies
292. Section from the putrefactive area around the larger blood vessels, showing missile tract which scores the margin of the posterior tibial artery
293. Missile tract showing a tear through the adventitia and media of the artery
294. Beginning chemical change in the muscle fiber
295. External surface of an amputated left thigh showing machine gun bullet wound
296. Putrefactive change along the wound tract
297. Muscle from the putrefactive area
298. Liquefaction of muscle fiber
299. Gram-positive bacilli between muscle fibers from an area of putrefactive gangrene
300. Cross section of a small nerve showing accumulation of gas
301. Rupture of muscle fibers, in close relation to the wound tract, probably caused by the trauma of the missile
302. Muscle fiber separated by gas and exudate
303. Necrotic muscle fibers in the gaseous area
304. A cross section of a medium-sized artery showing marked shredding and swelling of the adventitia
305. Clot in tissue near the vessel shown in Figure 304
306. Field of hemorrhage in the gangrenous area
307. A small vessel in the putrefactive area
308. Showing four cross sections of leg shown in Plate XXI
309. An area of putrefactive gangrene of the muscles with beginning gas gangrene
310. Field from the putrefactive gangreneous area with a beginning gaseous process
311. A typical picture in putrefactive gangrene
312. Putrefactive gangrene of muscle with considerable gaseous change