Microscopic examination.- Trachea: It the trachea is
deep-seated necrosis, which involves the epithelium
and underlying tissue to a considerable depth. Incorporated in this
necrotic area is a dense fibrinous membrane
infiltrated with many pycnotic leucocytes, and in a few places there
are clefts which separate the membrane of dead
tissue from the underlying living tissue, and these are lined with
flattened cells, possibly derived from the remains of
the epithelium. There is extreme distension of all the blood vessels
which form wide sinuses almost like a cavernous
angioma. The mucous glands are compressed and distorted. (See fig. 13.)
Lungs: The picture is unusual. There is an
extensive hemorrhagic and fibrinopurulent exudate in the alveoli, the
arteries of which are rendered indistinct by the
fragmentation of the nuclei and the abundance of chromatin debris in
the septa. (See fig. 23.) The elastic framework
is torn and disrupted, as can be seen in appropriately stained
sections. There is great edema of the interstitial tissue
and the interlobular septa. There are masses of Gram-positive bacteria
scattered through the section.
of mustard-gas poisoning of five days' duration. There was the usual
diphtheritic necrosis of the upper respiratory passages. Pneumonic
lesions of the hemorrhagic
"influenzal" type, with infarct-like areas of necrosis.
23.- J. B., 2810342, Pvt., Co. C, 344th M. G. Bn. Died at 6 p.
October 7, 1918,
Justice Hospital Group, Toul. Autopsy No. A9. Autopsy performed, 19
hours after death, by
Capt. Jean Oliver, M. C. Clinical data.-Severe mustard-gas
intoxication, incurred October 2,
Anatomical diagnosis.- Pigmentation of skin of face; suppurative
and hemorrhagic tracheobronchitis;
congestion and edema of lungs; interstitial emphysema.
appearance.- The skin over face is brown. The
epithelium is excoriated in small areas and can be
rubbed off on pressure. No typical mustard-gas burns. Skin of scrotum
shows similar changes. No other cutaneous
removing sternum there is found interstitial emphysema which extends
portion of pharynx and lower portion of neck. Marked hyperemia and
edema of all lobes of both lungs posteriorly.
Anteriorly, lungs are emphysematous. Larynx, trachea, and primary
bronchi contain purulent exudate. Mucosa is
slightly roughened, but there is no definite false membrane. There are
many small hemorrhages. There is a necrosis
of the mucosa of certain bronchi, only in the upper lobes of both
lungs. Some of them are lined with a definite
grayish-green membrane. There is little fibrinous pleural exudate.
Microscopic examination.- Trachea: The epithelium of trachea is completely
necrotic and desquamated.
Exudate consists principally of pus cells and necrotic material without
definite fibrin. Corium is edematous,
congested, and infiltrated with leucocytes. Bronchi are similar, but
some of them contain an edematous exudate in
addition to their other components. Terminal bronchioles are also
denuded of epithelium. Many of them are lined
with distinct diphtheritic membrane. Lungs: Capillaries and
alveoli contain an excessive lumber of polynuclears.
There is a granular coagulum in the alveolar spaces and exfoliated,
pigment-containing alveolar cells. Polynuclears
are not numerous. In Gram-Weigert preparations a wavy, bluish-staining
network is seen lying against the alveolar
wall in many of the air spaces. Bacteria are not numerous.
Predominating type are Gram-positive cocci, arranged in
groups. Kidneys: There is marked cloudy swelling, especially in
the cells of the convoluted tubules. Some tubules
contain a pink-staining coagulum, others red blood cells, and still
others, desquamated epithelial cells. Liver:
Capillaries are congested. There is a moderate diffuse fat
infiltration. Adrenals: Are edematous and congested.
of life after gassing was 5 days. The interesting points in the case
Very slight cutaneous lesions and apparent absence of ocular lesions.
2. Trachea and large
bronchi showed a necrosis and purulent exudate, but no membrane
formation. 3. Smaller bronchi
were the seat of a typical membranous inflammation, but this was marked
only in the upper
lobes. 4. Absence of definite pneumotic lesions after five days is
unusual. There was, however,
a hyaline necrosis of atrial and alveolar epithelium,
which in absence of
general lung infection, may be ascribed to the direct action of the
CASE 24.- W. D., 238318, Pvt., Co. I, 103d
lnf. Died, 7.30 a.m., October 3,1918 Base Hospital 15, Autopsy
No. 214. Autopsy, October 3, three and one-half hours after death, by
Maj. Daniel J. Glomset, M. C.
data.- Mustard-gas burns and inhalation received in action
28, 1918. Clinical diagnosis,
gas inhalation complicated by lobar pneumonia.
diagnosis.- Superficial ulcers of lips; acute conjunctivitis;
first-degree burns of scrotum;
pseudomembranous and hemorrhagic laryngitis, tracheitis, and
bronchitis; peribronchial hemorrhages; confluent
lobular pneumonia, left and right upper lobes; hemorrhage into
appearance.- The epidermis about the eyes and conjunctive is rough
and reddened and covered
on the left side by an exudate. Lower lip is swollen and ulcerated.
There is a purplish blotch over thorax and
abdomen. Skin over penis is swollen, while that over scrotum is swollen
and purplish. Blood is laked and black.
Gross findings.- Pleural cavities: There are a few fibrous pleural adhesions
on the left side, but no fluid.
Lungs: Do not collapse readily. Left lung: Anteriorly is
crepitant. Posteriorly it is partially consolidated. On section
there are solid areas in lower lobe posteriorly and few discrete
nodules anteriorly. These are dark red in color and
vary from pinhead in size to several millimeters across and have
grayish centers. In one case outside this dark-red
area is a slightly raised granular pink zone. In the upper lobe in
addition to similar dark areas there is a distinct well-defined
consolidation involving one-third of the lobe. Right lung:
Shows a similar picture. The mucosa of larynx is
swollen and roughened. The trachea and bronchi contain greenish thick
flocculent material. Mucosa is thick and
peels off, leaving a hemorrhagic surface. Bronchi show similar changes.
Heart: Is normal. Stomach: Shows small
erosions in the region of the fundus. Small and large intestines are
injected. Kidneys: Are pale, swollen, and opaque.
Remaining viscera seem normal.
examination.- The trachea is
covered with an exudate,
composed of mucus and desquamated
and degenerating epithelial cells. There is practically no fibrin and
very few leucocytes are present. The epithelium is
conserved except at openings of ducts of the glands. It shows striking
metaplasia into cells of the squamous-cell
type. (See fig. 17.) Submucosa is slightly edematous and vessels are
injected. There is very little leucocytic reaction.
In the small and medium-sized bronchi the epithelium is partially
intact and ciliated. The lumina are filled with
purulent exudate. A few of the large bronchi show complete epithelial
necrosis with false membrane formation and
contain laminated fibrin. The bacteria in the exudate are chiefly
Grain-positive diplococci. The blood vessels of the
bronchial walls are engorged, and there are hemorrhages in the
surrounding alveoli. (See Pl. IX.) The lung shows
widespread pneumonic areas. There is an exudate of fibrin and in other
places hemorrhage. Leucocytes and red
blood cells are well preserved. The process is apparently quite recent.
Bacteria are not numerous in the pneumonic
patches; in the bronchioles they are quite abundant. There is capillary
thrombosis. Interlobular septa are edematous
and show an inflammatory infiltration. The unconsolidated portions of
the lungs are the seat of patchy nonfibrinous
edema, and there is exfoliation of the alveolar epithelium with many of
the cells containing pigment. Capillary
congestion is marked. Stomach: Fresh hemorrhages into the
mucosa without necrosis or inflammatory reaction.
Kidneys: Capsular spaces contain a granular coagulum. There are
numerous hyaline casts in Henle's tubules and
tubuli recti. Penis: The skin over the glans penis is in part
denuded. Where it is conserved there is a marked increase
in the pigment of the rete mucosum. There is slight papillary edema.
Corium contains numerous chronmatophores.
NOTE.- Duration of life
after gassing was five days. The skin lesions were slight but typical
mustard gas in their character and distribution. The tracheal lesions
were slight and regeneration
of the epithelium, with the usual metaplasia into the squamous-cell
type, had already occurred. Some of the smaller bronchi showed a simple
purulent inflammation with intact ciliated
epithelium; others showed characteristic diphtheritic necrosis. There
patches of bronchopneumonia which were not of
the influenzal type. On the whole the respiratory lesions were not
intense, and in conjunction with the mildness of the cutaneous lesions,
imply a short exposure or a low concentration
of the gas.
CASE 25.- A. W. G., 2088223, Pvt., Co. A, 355th Inf.
Died, August 13, 1918, Base Hospital 116, autopsy
No. 12. Autopsy, four hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Mustard-gas
inhalation. Date of gassing not recorded. Co. A, 255th Infantry, was
exposed to yellow, blue, and green cross shell
on August 7 and 8. Autopsy protocols of 9 fatal cases from this gas
attack are on file. Admitted in severe condition
with burns of face, chest, neck, scrotum, and penis. Temperature and
pulse rather high. Respiration short and
mustard-gas burns of scalp, face, conjunctiv , neck, buttocks, scrotum,
and penis. Acute membranous and ulcerative pharyngitis, laryngitis,
esophagitis, tracheitis, and bronchitis.
Bronchopneumonia. Marked pulmonary edema. Acute bronchial
lymphadenitis. Slight cardiac dilitation.
Parenchyymatous degeneration of liver and spleen.
appearance.- The skin has a
slight sallow brown appearance. There are extensive superficial
burns of the scalp, face, neck, bend of each elbow, the scrotum, penis,
the skin of the genital folds and lower
buttocks, and in the undersurface of the right knee. There is
considerable desquamation of the skin in these areas.
There is some brownish pigmentation of the dermis, which is most marked
on the inner aspect of both thighs. Superficial glands are somewhat
enlarged. Eyelids puffy and glued together by tenacious viscid exudate.
conjunctivae are edematous and injected. The pupils dilated 5 mm. in
diameter. Ears: No abnormalities, except the
superficial burn of the skin. Nose: In the nostrils there is
some mucopurulent material. Mouth: Shows superficial
ulcerated areas of the lips, covered with sordes and viscid exudate. A
number of the teeth show gold filling. There is
a viscid material over the gums.
Gross findings.- Pleural cavities: On opening
a small amount of fibrino-purulent exudate found
free over the pleura of the lower lobe on the right side. On the left
there is likewise a small amount of fibrinopurulent
exudate, especially marked over the lower portion of the upper and
upper portion of the lower lobe. Heart is
somewhat enlarged to the right. On incising the pericardium no
abnormalities of or in the sac. Heart: Weighs 380
grams, the right auricle is moderately dilated. Otherwise normal. Right
lung: All lobes are voluminous. Upper and
middle lobes in great part cushiony, inelastic. In the middle lobe
is a large solid area palpable. Binding the
middle lobe to the upper lobe, just above the solid patch there are a
number of sheetlike fibrous bands. The pleura
shows laterally and posteriorly a considerable amount of fibrinous
exudate, below which the pleura is considerably
injected and shows numerous
small discrete and confluent red hemorrhages. Medially over the upper
lobes the pleura is thin and delicate. The glands at the hilum
considerably enlarged, pigmented, pulpy, and injected;
there is no scarring. Vessels at the hilum show no abnormalities. The
bronchi show considerable ulceration of the
mucosa; submucosa swollen and injected. Overlying it and the small
amount of intact mucosa, there is a cast-like
friable gray membrane about 0.5 mm. in thickness. On section of the
upper lobe, a moist pink surface presents
medially. Posteriorly a pinkish-red surface presents. There is a small
amount of thin frothy fluid in the air sacs.
Scattered throughout this lobe there are several vaguely outlined dull
grayish-red solid patches varying in size from 1
cm. in diameter to several centimeters. The largest patch is present
posteriorly. On pressure here viscid fluid exudes
from the air spaces. The finer bronchioles are filled with viscid
purulent material. The larger bronchial branches
show a tenacious fibrino-purulent membrane. The middle lobe on section
is in great parts pink and well aerated.
There is a small amount of thin frothy fluid in the air sacs. The large
solid area is found to be a patch 6 by 4 by 3 cm.
uniformly consolidated, dull, and reddish. This portion of the lung is
apparently less ventilated than the rest. In the
center of the lobe there is a small patch similar in appearance, 1 cm.
in diameter. The lower lobe on section presents
a moist pinkish-red surface. The air sacs contain a moderate to
considerable amount of thin frothy fluid. The
bronchial branches show
ulceration of the mucosa, with adherent friable gray membrane. About
branches small and large, there is deep red consolidation
extending for a small distance into the lung.
At the periphery of the lung the consolidation about the bronchioles is
most marked. Left lung: Both lobes are much more voluminous
than normal. In the median portion of the lower lobe
the tissue is well aerated, cushiony; posteriorly, it is soggy. The
lower lobe in great part is soggy, and covering the
pleura of practically the entire lobe there is a considerable amount of
tenacious fibrinous exudate. There is some
fibrinous exudate over the lower portion of the upper lobe, especially
posteriorly. The glands at the hilum are
somewhat enlarged, pulpy, and deeply injected. The vessels and bronchi
arc similar in appearance to those on the
right. On section of the upper lobe it is similar in appearance to the
right upper lobe. There is a walnut-sized solid
patch posteriorly and a few smaller patches more medially. The lower
lobe on section in general is similar in
appearance to the right lower lobe, except that here the
bronchopneumonic patches are much more numerous and
extensive. The edema is most marked in the left lower lobe. Neck
organs: The glands in the lower portion of the
neck are swollen pulpy, edematous injected, and pigmented. In the upper
portion of the neck the glands likewise are
swollen and injected. The thyroid much larger than normal. Each lobe
measures 6.5 by 4 by 3.25 cm. There is a
prominent isthmus. On section, the acini are distended with colloid,
the tissue gelatinous and pale. In the left lobe
there is a hazel-nut sized large cyst filled with gelatinous
blood-tinged fluid. The larynx shows marked swelling of
the mucosa and deeper tissue. In places the epithelium is gone. In
these areas the injection of that tissue below is
prominent. Covering the membrane there is a tenacious fibrinous and
fibrinopurulent membrane. The process is
quite uniform throughout the larynx and trachea and is present likewise
in the upper esophagus and the base of the
tongue. The tonsils are small and buried. On section there is little
lymphoid tissue visible and there is much scarring.
In the crypts of the right tonsil there is caked and viscid yellow
opaque material. Alimentary tract: The stomach,
cardiac end, shows moderate patchy injection of the mucosa and there
are tiny hemorrhages here and there in this
region. Duodenum: No abnormalities. Throughout the tract the lymphoid
tissue is somewhat more prominent than
normal, especially so in the lower ileum. Appendix: No abnormalities.
Cecum: No abnormalities. The mucosa of the
colon pale, the walls thinned. Mesenteric lymph glands are slightly
enlarged, pulpy, and pale. Liver: Weighs 1,800
grams, slight fat infiltration. Remaining organs show no significant
examination - Treachea: Lined with well-formed laminated fibrinous
invaded with leucocytes and containing in one area in its meshes a
large mass of mucus. Beneath the membrane in
places is preserved a single row of epithelial cells with pyenotic
distorted nuclei, cilia of which are intact. There is
marked swelling of membrana propria. Subepithelial tissue, edema,
intense congestion, and hemorrhage. Marked
leucocytic infiltration. Ducts of the mucous glands are distended with
thick plugs of mucus. Epithelium in the
superficial portions is destroyed. Additional sections cut from fresh
block shows a slightly different picture. Mucosa
is partly ulcerated down to perichondritum, the submucosa being in
these areas very dense and showing great
distortion of nuclei in inflammatory infiltration with pycnotic
leucocytes. In other places the epithelium is
regenerating, pale, flattened cells covering the denuded surface. These
are continuous with the proliferating
epithelial cells of the mucous ducts. The subepithelial tissue here has
the character of very vascular granulation
tissue and the predominating cells are lymphoid. There are capillary
extravasations and in places much edema.
Mucous glands are edematous but the epithelium is preserved. Lung:
In the terminal bronchioles the epithelium is
still present but shows degenerative changes. There is marked
leucocytic exudate in the lumina. Consolidation is
almost entirely peribronchial. There is a recent pneumonic exudate in
which polymorphonuclear cells are
predominating. Infundibula are dilated. Another section contains a
medium-sized bronchus lined by thickened
laminated fibrinopurulent membrane which, together with the looser more
purulent exudate, practically occludes the
lumen. (Fig. 29.) The epithelium is destroyed and invaded with
wandering cells. There is early fibroblastic
proliferation. The smaller bronchi on the other hand are free from
exudate and show an intact epithelium. Lung
tissue itself is emphysematous and atria are dilated. There is
practically no pneumonia although there is a little
epithelial desquamation and masses of leucocytes in the capillaries.
Still another block shows marked dilatation of
the atria with some hyaline necrosis of the wall and lobular pneumonia
surrounded by areas of patchy edema.
Exudate consists chiefly of polymorphonuclears, red blood cells,
and desquamated alveolar epithelium, very
little fibrin. There is a purulent bronchiolitis. Gram-positive
very few Gram-negative bacteria. Remaining organs show no interesting
report.- Smears of exudate in larynx, Grain stain, show innumerable
Grain-positive cocci in
pairs and some in small chains. Those in pairs, lancet shape, others
rounded. There are also Gram-negative cocci and
bacilli. Smears of the consolidated lung show a small number of
Gram-positive cocci, most in diplococcus form. No
Gram-negative organisms seen. Cultures: Trachea, staphylococcus
aureus, streptococcus nonhemolyticus.
Case 25. Yellow, blue, and green
cross shell, exposure
5 or 6 days before death. Dilated bronchiole
lined with laminated fibrinopurulent membrane. Complete loss of
early case of mustard-gas poisoning. There are no precise data given as
to exact date of gassing. Since, however, other soldiers of Co. A,
355th Infantry, were gassed
on August 7 and 8, 1918, duration of life after gassing may be
estimated as 5 or 6 days which
corresponds with the anatomical findings.
of interest are: The early epithelial regeneration of the trachea, the
diphtheritic necrosis of the medium sized bronchi, and relatively
slight lesions in the bronchioles
which seem to have escaped the direct action of the irritant. There was
the early lobular
pneumonia which presented Some of the features of influenzal pneumonia,
atrial walls. There was less hemorrhage and edema and more marked
exudation than in the typical case of early influenzal pneumonia.
CASE 26.- I. G.,48449, Pvt., Co. M, 18th Inf.
Died, October 6, 1918, 8 p. m., Gas Hospital, Julvecourt.
Autopsy, October 7, 20 hours after death, by Capt. James F. Coupal, M.
Clinical data.- Gassed with
shell on October 1, near Verdum. Diagnosis of mustard-gas poisioning.
diagnosis.- Inhalation of mustard gas. Purulent
bronchitis and tracheitis. Bronchial pneumonia.
appearance.- Extensive burns of face, conjunctive
and cornea. Slight burn scrotum.
Gross findings.- Pleural
cavities: Lungs do not
retract on opening the chest. There are a few fresh fibrinous
adhesions in the left sac. The right is free. Right lung is
large. Entire middle, lower, and greater portion of the upper
lobes are inflated. There are dark sunken patches along the posterior
part of the lower lobe. Firm nodular masses up
to 3 or 4 cm. in diameter can be felt through the pleura. Section shows
these to consist of areas of peribronchial
consolidation. In the center of these areas bronchi appear to be
somewhat dilated and filled with pus. The middle
lobe shows bronchial lesions, but somewhat less intense than in the
remaining lobes. The lower lobe is somewhat
edematous, with a few irregular areas of consolidation about the
bronchi. Left lung: Is very
large and heavy,
especially about the upper lobe. There is diffuse edema and marked
congestion in the posterior portions. The bronchi
exude pus and are surrounded by dark-red areas of collapse and
hemorrhagic infiltration. The bronchial lymph nodes
are dark red, succulent and hyperemic. Trachea, as well as the larnyx
and epiglottis, show intense congestion and
numerous superficial erosions covered in places by shreds of fibrin.
This condition becomes more marked in the
larger bronchi, where the wall is completely covered by necrotic gray
slough. In the smaller branches there is
hemorrhagic exudate. Heart: Is dilated on the right side.
Valves are normal. Alimentary tract: Injection of small
intestines and stomach; otherwise negative. Liver, spleen, kidneys:
Show no significant lesions.
Microscopic examination.- Trachea: No section preserved. Bronchi: The
epithelium is desquamated. Lumen
filled with pus cells. There is marked peribronchial congestion. Lungs:
There is general capillary congestion. Alveoli
contain polymorphonuclear leucocytes, red blood cells, and edematous
fluid and fibrin. The most striking lesion is
the marked dilatation of the infundibula with hyaline necrosis of their
lining. Liver and kidneys negative.
mustard-gas case of five days' duration, with moderately severe
bronchial lesions. There are no unusual features.
CASE 27.- E. S., 2915502, Pvt., Co. A, 355th
Inf. Died, August 13, 1918, Base Hospital No. 46. Autopsy
No. 4. Autopsy, 10 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on August 8, 1918.
Exposed to yellow,
blue, and green cross shell. Admitted to Base
Hospital No. 46 on August 10 with extensive gas burns of face, neck,
trunk, back, and scrotum. Severe burns of
eyes. Short of breath. Cyanosis. Pulse rapid. Temperature high. Loud
moist rales over both chests. Complete
aphonia. August 12, slight dullness over both lower lobes posteriorly.
diagnosis.- Mustard-gas burns of conjunctiv ae, right ear, mouth,
chin, genital folds, scrotum,
and penis. Ulcerative and membranous esoplhagitis, laryngitis,
tracheitis, and bronchitis. Purulent bronchiolitis. Bronchopneumonia.
Acute lymphadenitis of bronchial nodes. Pulmonary edema. Gastric and
appearance.- The skin in general is sallow. There are areas of
superficial ulceration of the skin
about the mouth and chin, back of right car, in the genital folds,
scrotum and prepuce. These superficial ulcerated
areas extend into the dermis. Those about the mouth are covered with
dry scabs; those about the right ear and over
the scrotum and penis covered by a moderate amount of seropurulent
exudate. The eyelids are matted together by a
small amount of mucopurulent exudate. The conjunctiva are edematous,
injected. There are small hemorrhages
below the bulbar conjunctive. The
corneae are slightly cloudy. Pupils 2.5 mm. in diameter. Superficial
glands are somewhat enlarged. Nose: In the nostrils there is
considerable tenacious mucopurulent secretion. The
mucosa is injected.
Gross findings.- Pleural cavities: On opening the thorax the right pleural
cavity is free of fluid and
adhesions. The left pleural cavity contains about 10 c. c. of slightly
turbid fluid. The heart lies in normal position. On
incising the pericardial sac, no abnormalities of or in the sac. Heart:
The right auricle and ventricle are slightly
dilated. Otherwise normal, except for small grayish flecks in the
myocardium. Right lung: All lobes are voluminous.
The upper lobe is cushiony, inelastic in the upper portion. In the
median and lower portion there are solid masses
palpable. The middle lobe is cushiony and inelastic. Lower lobe is
cushiony and soggy. Near the pleura posteriorly
solid masses are palpable. The pleura in general is thin and delicate.
Below it, especially posteriorly over the lower
lobe, there are scattered and confluent deep red hemorrhages; the small
ones pinhead in size and the large ones
having an area of a few square centimeters. The glands at the hilum are
greatly enlarged, pulpy, edematous, injected,
and pigmented; some contain firm gray areas. Vessels at the hilum, no
abnormalities. The bronchi show considerable
ulceration of the mucosa and covering the ulcerated and intact membrane
there is a thin tightly adherent yellowish-gray membrane. Upper lobe on
section is pink; in the median portion posteriorly it is red. The
fibrinous casts; there is no consolidation about the walls. The air
sacs posteriorly contain a considerable amount of
thin frothy fluid. The vessels here are somewhat congested. In the
median portion there are vaguely outlined dull
grayish-red consolidated patches 1 to 2 cm. in diameter. The middle
lobe on section presents a very moist red
surface. There is a very large amount of thin frothy fluid in the air
sacs. Mottling the surface there are large, deep-red, solid,
non-air-containing areas varying in size up to 2.5 cm. in diameter.
There are larger bronchial branches
showing a tenacious fibrinous membrane. The smaller likewise show a
fibrinous membrane which in places
practically occludes the lumen. At the very periphery of the lobe the
bronchi contain a purulent exudate in
considerable amount. Left lung: Both lobes are much more
voluminous than normal. Upper lobe is cushiony,
inelastic. The lower lobe is soggy. There are few small solid patches
palpable. The pleura is thin and delicate, except
posteriorly, where there is some fibrinous and a small amount of
fibrinopurulent exudate. Below the pleura here, as
on the right side, there are numerous scattered discrete and confluent
hemorrhages. The vessels and glands at the
hilum similar to those on the right. The bronchi show patchy injection
of the mucosa. Everywhere there is
considerable tenacious fibrinous exudate. Deep in the smaller bronchial
branches there is viscid purulent material in
the lumen. The tipper lobe on section, a moist red surface presents.
The air sacs contain a moderate amount of thin
frothy fluid. Posteriorly a few small, solid, non-air-containing,
discrete gray consolidated areas observed. Medially
there is a small, walnut-sized, solid, dull, pinkish-gray patch. In the
lower lobe on section, a deep-red surface
presents. The air sacs contain a moderate amount of thin, frothy fluid.
Scattered throughout there are deep-red, solid,
and non-air-containing solid patches varying in size up to 2.5 cm. in
diameter. In addition in this lobe there is some
consolidation in the neighborhood of the small bronchioles which are
filled with viscid pus. Neck organs: Glands in
the lower portion of the neck are considerably enlarged, pulpy, and
edematous and injected. Some show scarred
areas. The glands in the upper portion of the neck moderately enlarged,
pulpy, and infected. The thyroid is of
average size. On section the tissue is spongy. The acini contain a
moderate amount of colloid. Larynx: Mucosa is
swollen and injected. In places, especially in the region of the true
and false vocal cords, the mucosa is ulcerated.
The process is similar throughout the trachea, where there are areas of
ulceration of the mucosa with injection of the
submucosa. Over the intact mucosa and covering the ulcerated portion
there is tenacious purulent exudate. The
process is present also in the upper portion of the esophagus and base
of the tongue, in the region of the glottis Here,
however, there is intense injection of the mucosa and but a few areas
of ulceration and fibrinous exudate. The tonsils
are buried, scarred, but the crypts are clean. Alimentary tract:
No other abnormalities of the esophagus. Stomach: In
the pyloric region shows some 12 or 14 erosions of the mucosa a few
millimeters in diameter. In the base of some of
these there is a deep-red hemorrhage. Others show a small injected zone
about them. The edges somewhat thickened.
There is similar eroded area a few millimeters in diameter just beyond
the pylorus. The duodenojejunal mucosa is
bile stained. Ileum: There are scattered patches of injection of the
mucosa. The mucosa here, likewise stained with
bile. In the lower ileum the lymphnoid tissue is somewhat more
prominent than normal. There is some injection of
the mucosa of the appendix.
There is some patchy injection of the cecum.
There is slight diffuse injection of the rectum for a distance of
a few centimeters from the anus. The mesenteric lymph glands are
slightly enlarged, pulpy, injected. Liver: Slight
fat infiltration. Spleen: Shows moderate lymphoid hyperplasia
and hemorrhages into the pulp. Adrenals: Show
moderate lipoid depletion. Kidneys: Negative. Remaining organs show no
Microscopic examination.- Trachea: Has a well-marked membrane consisting of
fibrin, leucocytes, and
necrotic cells. The epithelium is lost with the exception of a few
squamous cells adherent here and there and a
thickened basement membrane. Section of large bronchus also shows
epithelial necrosis, the bronchus being lined
with necrotic fibrinopurulent exudate which is firmly attached and does
not form a loose membrane except in a few
places. The wall of the bronchus shows marked inflammatory edema with
leucocytic infiltration and intense
congestion. Caryorrhexis of the nuclei is very striking. Much chromatin
is drawn out into bizarre forms as if melted.
Lungs: Two blocks of tissue show similar lesions. Very marked
edema with little or no fibrin. Alveolar capillaries
contain an excess of leucocytes, a few of which have emigrated. There are occasional epithelial
cells in the alveoli
and scattered hemorrhage. Bronchioles and atria show intact and
relatively uninjured epithelium, but contain purulent exudate. There
are a few
small patches of lobular pneumonia. Stomach: Section passes
through erosions described in the gross. Liver, spleen,
kidneys show no significant lesions.
examination.- Smear of exudate from larynx shows Gram-positive
cocci and Gram-negative bacilli. The predominating organism is a
Gram-positive coccus in diplococcus form.
Smear from consolidated lung shows relatively few organisms. There are
Gram-positive diplococci, some lancet
shaped, others rounded. No Gram-negative organisms seen. Culture: Lung,
staphylococcus albus, streptococcus nonheinolyticus. Trachea,
streptococcus nonhemolyticus, Gram-positive bacilli.
very typical early case of mustard-gas poisoning of five days, with
the tracheal and bronchial epithelium and marked edema. The small
bronchioles and atria
showed an intact epithelium, although there was a purulent
inflammation. There was an early
bronchopneumonia. The gastric and duodenal erosions should be noted.
CASE 28.- F.
S., 14555, Cpl., 1/4 Highlanders.
Died, October 24, 1918, at 6.30 p. m., at Base Hospital No.
2. Autopsy, five hours after death, by Capt. B. F. Weems, M. C.
data.- October 20, admitted to No. 5, Casualty Clearing Station,
with diagnosis of shell-gas
poisoning (irritant). October 22, admitted to Base Hospital No. 2. Well
nourished; breathes with marked exertion,
rapid and fairly deep respirations. Lungs edematous; pale and also
somewhat cyanotic. Heart: No increase of cardiac
dullness beyond normal limits. Pulse 130. Blood pressure 120/85. Lungs:
Tracheal and bronchial rȃles; also fine
moist rȃles at both bases. Burn of scrotum. October 23
in condition. Digitalis and oxygen
inhalations; pulse 130, weak and irregular. Chest filled with moisture.
October 24, still bravely holding on, but
getting tired. Breathing with increasing difficulty. Pale and slightly
cyanotic. Becoming very restless. Fully
conscious. Anterior chest shows good resonance. Harsh respiratory
sound, expiratory sound suppressed. Pulse 140,
weak but regular. Died at 6.30 p. m.
Anatomical diagnosis.- Acute conjunctivitis; acute ulcerative
pharyngitis; membrano- ulcerative
tracheobronchitis; peribronchial adenitis; massive congestion and edema
of lungs; ulcerative bronchitis and
extensive bronchopneumonia of both lungs; pleural adhesions, right;
influenzal pneumonia, following inhalation of
poisonous irritant gas (?).
appearance.- Moderate post-mortem lividity. Conjunctiva markedly
injected; corners of the eyes
stuck together by dried exudate. Mucopurulent exudate in the nares,
nasal mucosa inflamed. No certain evidence of
burns upon the skin, but there is one scabbed-over ulceration on the
left leg, of uncertain origin. External genitalia
are apparently normal.
Findings.- Pleural cavities: Lungs meet in almost full inflation.
Right pleura free of fluid and
adhesions; upon the left side there are soft fibrinous adhesions over a
small region beneath the fifth rib in the
mammary line and likewise over the dome of the diaphragm. Pericardial
sac: Contains about 50 c. c. of a slightly
turbid, lemon-colored fluid; the membrane
appears quite normal. Right lung:
Covered over posterior portions by fibrous adhesions. The lung is
rather heavy, especially in the posterior part; a blotchy gray and
purple, very lumpy in consistence. The cut surface
is, in general, deep purple, roughly nodular and exudes a large
quantity of bloody serum. About the bronchi are
grayish red elevated areas of firmer consistence. Upon pressure
numerous fine points of pus appear over the surface.
The necrosis of the mucous membrane of the bronchi extends into the
smallest branches, becoming purulent near the
terminal branches. Left lung: Early fibrinous pleurisy; quite
voluminous; rather firmer in its lower lobe than the right;
coarsely nodular throughout. Cut surface presents about the same
characteristics as on the right side; there is a rather
large area of consolidation in lower portion of upper lobe. Small
bronchioles are universally involved and contain
either fluid pus or fatty looking plugs of exudate. The edema is
exceedingly pronounced. The glands at hilum are
acutely inflamed, not frankly suppurative. There is a moderate amount
of interstitial emphysema over both lungs.
Organs of the neck: Pharynx is deeply congested and presents a
marked membrano- ulcerative type of inflammation.
Tonsils: Are quite small. The inflammatory exudate extends down
to the lowest portion of the pharynx. Esophagus:
Appears quite normal, but a necrotic membrane extends downward into
the glottis. Trachea is filled with a grumous
purulent exudate, very foul in odor; the mucous membrane over the vocal
cords is entirely sloughed away, and the
necrosis extends down the entire trachea into the primary bronchi;
beneath the necrotic mucous layer, a roughly
granular hemorrhagic surface is revealed. Heart: Both
ventricles in fair contraction, no lesions. Remaining viscera
normal, save for congestion. Stomach shows advanced autolysis.
Intestines are not recorded.
Microscopic examination.- Pharynx: In some areas the epithelium is still
adherent, but dense and shrunken;
in other places, the cells show marked vacuolization; in still others,
the epithelial cells are vacuolated, but still fairly
preserved and probably viable. Where the corium is exposed, it is
densely infiltrated with pyonotic leucocytes, and
there is fibrin and hemorrhage. The small superficial vessels are
thrombosed. Elsewhere, that is in the non-ulcerated
areas, there is merely edema with very little inflammatory reaction.
The vessels are much congested. The deeper
glands are not affected. Trachea: No section. Lungs:
There are extensive patches of pneumonia. The exudate is
composed largely of leucocytes which are probably polymorphonuclears,
but are remarkable for the fact that the
nucleus is displaced to the periphery of the cell, taking a more or
less crescentic form. This seems to be due to the
ingestion within the cytoplasm of one or more red blood cells and
enormous numbers of minute Gram-negative
bacilli (B. influenzae ?), and
lesser numbers of Gram-positive cocci.
The same leucocyte not infrequently contains a
red blood corpuscle and masses of bacteria. Fibrin is present to a
variable extent. The capillaries are engorged with
red blood cells, and occasionally contain fibrin thrombi. (See Fig.
20.) There are no larger bronchi in the sections. A
medium-sized bronchus shows complete necrosis of the wall, with an
adherent fibrin network. The smaller
bronchioles contain purulent exudate; and show an epithelial lining
which is more or less exfoliated, but not necrotic.
Bronchial lymphnodes contain a circumscribed area of fibrinopurulent
exudate. Liver, myocardium, spleen,
pancreas show no significant
changes. Adrenal shows marked edema of
cortex, with dilatation of cortical capillaries.
Areas of focal necrosis (?) in glomerular zone.
report.- Blood culture (post-mortem) sterile.
an early mustard-gas case, the estimated duration of life after gassing
being four to five days. Like a previous case (Case 19), there was
slight conjunctivitis, but the
cutaneous lesions clinically and at autopsy were insignificant. There
was, however, a
characteristic diphtheritic necrosis of the upper respiratory passages,
in all respects like that of
other severe mustard cases. The lung lesions were those of an
CASE 29.- J.
F., 22221, 1/4 Highlanders R.
Died, October 25, 1918, at 10.30 a. m., at Base Hospital No. 2.
Autopsy, four hours after death, by Capt. B. F. Weems, M. C.
data.- October 20, admitted to No. 5 Casualty Clearing Station,
diagnosis of shell-gas
poisoning (irritant). October 22, admitted to Base Hospital No. 2.
Gassed three days ago. Now feels worse. Slight
burns of face; eyelids edematous; slight cyanosis; breathes with
difficulty; tracheal rales; mucopurulent sputum.
Chest: Good resonance; coarse and fine rales. Roughened inspiration;
expiration markedly reduced. Heart: No
dilatation ascertainahle. Died at 10.30 a. m. Sputum contained
pneumococcus, Type III.
Anatomical diagnosis.- Ulceration of upper respiratory passages;
acute purulent bronchitis;
bronchopneumonia, following inhalation of poisonous irritant gas (?).
appearance- Eyelids are edematous and discolored; left ear
side of face are purple.
findings.- Pleural cavities: No fluid or adhesions. The lungs do
collapse and are greatly inflated.
Left lung: Covered with smooth pleura; larger branches of the
bronchi contain thick yellow pus, and their surfaces
are in places eroded. On section, droplets of pus exude from each cut
bronchiole, and the lung soon collapses
markedly. No definite areas of consolidation. Right lung: In
every way similar to the left, except that there are some
small areas of consolidation in the lower lobe. Organs of neck:
Marked ulceration of the epiglottis and trachea,
without a definite membrane. Heart: Normal. Spleen:
Enlarged to about three times normal size. On section, pulp is
dark red, moderately firm, follicles small and distinct. Remaining
viscera show no noteworthy changes.
Gastrointestinal tract not described.
examination.- Large bronchi: The surface is formed by the wavy
membrana propria, loosely
attached to which are shreds and flakes of very well preserved
epithelial cells, in a single flattened row, or in a partly
exfoliated layer several cells deep. The cilia are lost, and the cells
are partially dissociated by hydropic swelling and
leucocytic invasion. The subepithelial tissue is loose and edematous.
There is marked congestion and a moderate
leucocytic accumulation, chiefly
of polymorphonuclears. In the deeper layers the connective tissue cells
character of fibroblasts and appear to be proliferating. The glands are
not affected. There is no membrane or surface
exudate. Very few bacteria are present; they are limited to the
surface. Lungs: There are discrete 2 or 3 cm. sized
areas of consolidation between which the parenchyma is relatively
normal. These areas are definitely peribronchial.
The small bronchioles show a fairly intact ciliated epithelium, but
contain a dense purulent exudate with little or no
fibrin. The peribronchiolitis shows no special features, apart from the
number of large pigment containing alveolar
cells. The leucocytes, almost wholly polymorphonuclear, are well
preserved. In some of the alveoli are loose masses
of cylindrical epithelium, aspirated from the bronchi. Very few
bacteria can be demonstrated in Gram-stained
sections. Liver and kidneys: Show congestion. Spleen:
Also greatly congested; very few leucocytes in pulp.
NOTE.- A case of
poisoning by irritant gas, presumably mustard gas, of five days'
duration. There was edema and discoloration about the eyes, but no
definite conjunctivitis. The acute
ulcerative tracheobronchitis was not membranous in character, and the
smaller bronchi showed
an acute inflammation, without evidence of chemical injury to the
epithelium. The pulmonary
lesions were limited to small peribronchial pneumonic areas, and did
not have the character of
the prevailing influenzal pneumonia. This and the two previous cases
(Cases 19 and 28) are
peculiar because of the minimal cutaneous lesions. Since the
individuals were members of the
same organization and were admitted on the same day to the same
casualty clearing station, it is
very probable that they were exposed to the same gas.
CASE 30.- C. M. S., 134772, Pvt., Battery B,
102d F. A. Died, 1.30 a. m., October 16, 1918, at Base
Hospital No. 58. Autopsy No. 5. Autopsy, October 16, 1918, 7 hours
after death, by Lieut. H. E. Schoonover, M. C.
data.- Exposed on night of October 9-10 to bombardment of 2,000
105-mm., and 1.50-mm. shells
of mustard gas and chloropicrin. Masks removed prematurely, and
soldiers slept in gassed area. Small area attacked,
and current kept bringing over the persistent gas. Admitted to Base
Hospital No. 58 on October 14. Temperature 103 . Definite signs of
diagnosis.- Multiple superficial gas burns. Fibrinopurulent
Bronchopneumonia. Emphysema. Chronic fibrinous pleurisy.
appearances.- Superfieial burns over right subclavicular region and
both axillary spaces. Rather
severe burns about scrotum. Superficial burns on inner aspect of both
thighs. Slight burns on both upper eyelids.
findings.- Pleural cavities: There are fibrous adhesions at the
right apex anmd over the entire left
lung. Left htug: There are large extensive subpleural hemorrhages
and a little fresh fibrinous exudate. In the
upper lobe the bronchi are thick and surrounded by a narrow, sunken red
zone. No consolidation. A few small patches of hemorrhagic pneumonia.
The smaller bronchi contain pus. Right
lung: The posterior portion of the upper lobe is congested and
edematous. There are ill-defined areas of
consolidation. Middle lobe, posterior portion presents the same
picture. Lower lobe, extreme base posteriorly shows
an area about 3 cm. wide that is definitely consolidated, the cut
surface being dark red and granular. The main
bronchus to this area shows a moderate diffuse dilatation. Trachea and
bronchi show intense congestion and multiple
small hemorrhages. Mucosa is opaque and smooth like that of the
esophagus and is covered in places by shreds of
fibrinous exudate. Mucosa of the bronchi is definitely necrotic and
their lumina are filled with exudate.
Microscopic examination.- Trachea: On section, shows complete desquamation of
the epithelium, which is
replaced by thick adherent membrane composed of leucocytes, fibrinous
detritus,and masses of Gram-positive
organisms. Subepithelial tissue is edematous. The bronchi show no
membrane, but the epithelium is necrotic and the
lumnina are filled with leucocytes. There are many Gram-positive
bacteria. Lungs: Are slightly edematous with a
patchy peribronchial and
alveolar exudate of leucocytes with very little fibrin and few red
blood cells. The lung
lesions, on the whole, are insignificant in the sections examined.
mustard-gas case of six days' duration with early mem- branous
tracheobronchitis and few small areas of lobular pneumonia. There are
no features of special
interest. Regenerative changes were not present.
CASE 31.- F. J. M., 2280979, Pvt., Co. L,
147th (47th) Inf. Died, August 14, 1918. Base Hospital No. 18.
Autopsy No. 79. Autopsy, August 15, 26 hours after death, by Lieut. B.
S. Kline, M. C.
Clinical data.- Gassed August 8, 1918, with
shell. Marked erythema over the entire body,
particularly marked over chest and about genitals. Marked
conjunctivitis, dyspnea, bronchitis, no evidence of
consolidation. Frothy, bloody sputum. Burns im- proved but respiratory
symptoms persisted. Pulse rapid and
diagnosis.- Extensive burns of respiratory
tract, skin, and conjunctiva. Purulent conjunctivitis.
Acute pharyngitis and esophagitis. Acute fibrinopurulent
tracheo-bronchitis. Purulent bronchiolitis. Extensive
bronchopneumonia. Pulmonary edema. Acute fibrinous pleurisy. Fatty
infiltration of liver. Tuberculous
External appearances.-There is a moderate hypostasis. The skin in
general has a muddy sallow-brown
appearance. There are in addition scattered areas of deeper brownish
pigmentation, especially marked on the inner
surface of the thighs, about the knees. The skin shows numerous
superficial burns. The burns are most marked in the
skin of the back, commencing in the axilla, extending down the sides,
the greater portion of both buttocks being
involved. The skin about both shoulders and neck likewise shows
superficial ulceration and desquamation. There
are large burns on the upper arms, at the bends of both elbows, and on
the left forearm. There are scattered
superficial burns over the chest and abdomen anteriorly, the skin of
the neck and greater portion of the face is
desquamated, and in places there are superficial ulcerated areas. The
scrotum and penis show superficial ulceration.
The base is covered by dry serum. Genital folds show considerable
superficial ulceration and desquamnation. There
are also burns on the under surface of each knee. Above and below the
knee oil both sides there are areas of clear
vesicles, one large bleb. Nowhere does the burn extend deeper than the
dermis. Most of the areas are covered by dry
serum, below which injected dermis is visible. Eyes: Eyelids
puffy, matted together bv tenacious mucopurulent
secretion. The conjunctivie somewhat injected, and there are small
hemorrhages. The corneae are somewhat cloudy,
especially the left. The pupils, 3 mm. in diameter. Nose:
Tissues puffy. Considerable amount of mucopurulent
material in the nostrils. Ears: Tissues of the ears are puffy.
There are superficial burns about them, covered by
desquamated skin and dry serum. Mouth: There are superficial
ulcerated areas of the lips. The teeth show
considerable erosion of the cutting edges. The mucous membrane is
findings.- Pleural cavities: The right pleural cavity contains a
small amount of fibrinous exudate,
lying over the posterior portions of the lower lobe. The left pleural
cavity is obliterated in great part by sheetlike
fibrous bands. Pericardiun normal. On
removing the left lung a small amount of
fibrinous exudate is visible over the posterior portion of the lower
Right lung: Weighs 1,025 grams. The lower lobe shows a large,
deep, congenital fissure dividing it imperfectly in
two. The fold is covered by norml pleura. All lobes very voluminous,
cushiony, slightly soggy. The pleura over the
lower lobe is somewhat glazed posteriorly and laterally, covered by a
moderate amount of fibrinous exudate. Below
the pleura of all lobes there are scattered small hemorrhages. The
vessels at the hilum show no abnormalities. Lymph
glands are greatly enlarged, pulpy, edematous, pigmented, injected.
Bronchi show considerable ulceration of the
mucosa, the underlying submucosa injected. Covering intact and
ulcerated mucosa there is a tenacious fibrinous and
fibrinopurulent membrane, yellowish in color. On section of the upper
lobe a moist pink surface presents medially;
posteriorly the surface is a moist red. The air sacs contain a moderate
amount of thin frothy fluid. The smaller
bronchioles contain a viscid blood-tinged material, the walls are
deeply injected, and immediately about the walls
the adjoining alveoli are consolidated and deep red. There are a few
grayish-red consolidated areas from a few
millimeters to 12 cm. in diameter in the posterior portion of this
lobe. The middle lobe on section presents a pink
surface. There is a injected, the adjoining lung tissue
consolidated for a small distance, deep red. In
addition there are a number of vaguely outlined, dull, pinkish-gray,
amount of fluid in the air sacs. The filler bronchioles, similar in
appearances to those in the upper lobe, contain
fibrinous and purulent exudate. There is but little peribronchial
involvement. On section of the lower lobe a moist
pink surface mottled with deep red is presented. There is abundant
thin, frothy, purulent exudate in places. The walls
are varying in size from a few
millimeters to a few centimeters in diameter. These areas are
associated with the
inflamed bronchioles. Left lung: Weighs 1,270 grams. Vessels,
glands, and bronchi are similar to those on the right.
The pleura over the median portion of the upper lobe is thickened,
bound tightly to the parietal pleura by sheetlike
fibrous bands. Over the posterior portion of this lobe and the lower
lobe thepleura is thin and covered by moderate
amount of fibrinous exudate. On section, the left upper lobe is similar
to the right upper in appearance. The left
lower in general similar to the right lower, but here the consolidation
extending from the small bronchioles is much
more extensive; reddish gray, involving about one-third of the lobe. In
places in the dull, reddish-gray, consolidated
portion there are small yellowish areas. Heart: There is
moderate dilatation of the right auricles and ventricles.
Muscle is pale and opaque. Neck organs: The lymph glands of the
neck and especially those in the lower portion are
considerably enlarged, pigmented, pulpy, injected. Thyroid is of
average size, tissue spongy, gelatinous.
contain a moderate amount of colloid. Larynx: There is
considerable swelling due to edema of the mucosa;
membrane is injected, infiltrated, and covered in places by fibrinous
and fibrinopurulent exudate. There are areas of
ulceration, especially marked over the true vocal cords. The submucosa
is intensely injected throughout lower larynx
and trachea. There are small hemorrhages present likewise in this coat.
Throughout the lower larynx and trachea
there is considerable tightly adherent fibrinous exudate, also a small
amount of fibrinopurulent exudate. The
injection of the mucosa continues over the glottis into the adjoining
esophagus and base of tongue; attached to the
injected mucosa in these situations there is a small amount of
fibrinous exudate. Tonsils somewhat enlarged, pulpy,
and injected. Lymphoid tissue present in moderate amount. There is some
scarring. On the left the tonsils show
several crypts filled with viscid purulent material. Liver:
Weighs 2,710 grams. Irregular fat infiltration. Alimentary
tract: Injected. Stomach and duodenal mucosa injected. Jejunum and
ileum edematous. The remaining organs show
no significant changes except for the left epididymis, which is thick
and on section shows areas of caseation and
Microscopic examination.- Bronchus: There is a complete necrosis of the
epithelium, limited in places by
the membrana propria, but in other places involving the connective
tissue as far down as the glands. There is edema,
intense congestion, hemorrhage, and localized collections of
polynuclears, all more or less fragmented. The
epithelium of the mucous ducts is also completely destroyed. The glands
are edematous but still intact. Small
bronchus: Shows a similar picture except that there is a portion
of thick fibrinous membrane still adherent. Masses
of bacteria are present on the surface. Lung: The bronchioles and atria
show complete necrosis of the entire wall; the
lumen is filled with detritus and masses of bacteria. The parenchyma
throughout shows alveoli filled with
exudate, serous, fibrinous, or hemorrhagic.
There are few cells, and these chiefly degenerating and exfoliating
epithelium and mononuiclears. The relatively few polynuclears show
nuclear pycnosis and fragmentation. The
alveolar walls are infiltrated with leucocytes, edematous, and often
Bacteriological examination.- Smears of
trachea show innumerable Gram-positive bacilli and cocci.
Smears of consolidated lungs show many Gram-positive lancet-shaped
diplococci and rounded Gram-positive
cocci. Cultures of tracheal exudate show staphylococcus, nonhemolytic
streptococcus, B. coli and Gram-positive
bacillus. Cultures of consolidated lung show staphylococcus and
NOTE.- Case of
poisoning of six days' duration with typical skin and eye lesions
and a severe necrotizing inflammation of the entire upper respiratory
tract and extending into
the smallest bronchi. The complete destruction of the epithelium would
have made repair
impossible. The parenchyma of the lung showed a hemorrhagic and
fibrinous inflammation like
that commonly seen in the influenzal pneumonias. The case illustrates
the difficulty in
estimating the part played by the original injury and by the
supervening infection, respectively.
CASE 32.- R. A., 91283, Pvt., Co. K, 165th
Inf. Died, March 28, 1918, 7 a. in., at Base Hospital No. 18.
Autopsy, performed nine hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on March 20 and
21, 1918. On admission, cyanosis, accelerated breathing, irrational.
Bronchial fremitus, no signs of consolidation. Dypnea and polypnea.
Pulse rapid and of bad quality. Lungs,
hyperresonant and movements limited (inflation). Moist and bubbling
rales front and back. At bases are areas of
Anatomical diagnosis.- Superficial burns on eyes, lips, scrotum,
and penis. Ulcerative laryngitis, tracheitis,
and bronchitis. Bronchopneumonia. Acute fibrinous pleurisy. Obsolete
tuberculous bronchial lymph nodes. Healed
chronic epididymitis. Fibrosis of myocardium. Dilatation of right
ventricle and auricle.
appearance.- Eyes, bulbar and palpebral
conjunctive, irregularly injected with small hemorrhages
here and there. Gluing the eyelids together is considerable caked
exudate. About the eyes a few scabs, especially
near the inner canthus on each side. There are similar scabs at the
junction of the mucous membrane and skin of the
lips. External genitals: A portion of the glans penis and
greater portion of the scrotum show superficial ulceration,
apparently just through the epidermis. The area is dry. In the scrotum
at the periphery of the dry area there is an area
of moist, very superficial ulceration limited to the epidermis and
tissue immediately below. There is a small amount
of grayish exudate here and there covering the skin and denuded areas.
In the affected parts there is moderate
injection of the vessels.
Gross findings.- Cavities: On opening the thorax a number of fibrous
adhesions are seen between the right
middle lobe and chest wall. In the left pleural sac there are a few
centimeters of turbid fluid. Heart is displaced
slightly to the right. Right lung: Weighs 800 grams. All lobes
are voluminous. The pleura over the middle lobe is
considerably thickened and there are numerous fibrous tags here. Below
the pleura in the interlobar region there are
numerous discrete pinpoint to pinhead sized hemorrhages. They are
present also below the pleura posteriorly. In
addition over the posterior portion of the upper and lower lobes there
are areas of fibrinous exudate overlying the
pleura. The glands at the hilum are strikingly enlarged, pulpy,
edematous, and somewhat injected. Some of them
contain grayish and yellowish nodules, pinhead to grapeseed in size. On
section of the tipper and middle lobes a
moist pink surface presents. On the section of the lower a moist red
surface presents. The bronchial branches are
everywhere prominent. They are filled with viscid pus. The mucosa is
swollen and injected. In places the mucosa is
ulcerated. In all three lobes the air sacs contain a moderate amount of
thin fluid, and in places about the finer
bronchioles there are small areas of dull grayish-pink consolidation.
The consolidation in the lobes on the right is not
marked. In most places the consolidation is limited to the area
immediately about the bronchial branches. Left lung:
Weighs 770 grams. All lobes voluminous, soggy in great part. In the
lower lobe large solid patches
are palpable. The pleura, especially
posterially, over both lobes, covered in places by fibrinous exudate.
pleura between the lobes there are innumerable pinhead in size
hemorrhages. Here, also, there is much fibrinous
exudate. Glands at the hiljum are similar to the one on the right. On
section of the upper lobe a dull pinkish-red
surface presents; moist. Air sacs contain a considerable amount of
thin, frothy fluid. The bronchial tree throughout
filled vith viscid pus. The mucosa is injected. The swelling,
injection, and ulceration of the bronchial tree is very
striking near the roots of both lungs. In the left upper lobe there are
scattered small pinkish-gray areas of
consolidation associated with the bronchi. In the lower lobe there are
scattered throughout a considerable mumber of
grape-seed to hen's-egg sized areas of pinkish-gray consolidation. In
addition there is much fluid in the air sacs.
Heart: Weighs 380 grams. There are small subpericardial
hemorrhages. Right ventricle and auricle dilated. Muscle
pale with few small scars in left ventricle. Slight chronic aortic
valvular disease. Neck organs: The larynx and
trachea present a striking appearance. The mucosa is swollen, intensely
injected, especially in the lower portion of
the trachea. There are in places numerous small hemorrhages in this
portion. In the lumen there is a considerable
amount of viscid mucopurulent material. Tonsils are somewhat buried and
small, overlying them there is some
desquamation of the epithelium. Tonsils scarred, crypts in general
clean. Liver: Weighs 2,110 grams. Local areas of
fat infiltration. The remaining organs, including the alimentary tract,
are normal except for fibrosis of right
examination.- Trachea: There are shreds of epithelium still
adherent, but in most places the
denuded and swollen membrana propria lies exposed. There is active
proliferation of the duct epithelium. In a few
places there is necrosis of the superficial portion of the
subepithelial connective tissue, which generally is
edematous and infiltrated with leucocytes. Bronchus:
Practically the same picture as the trachea. There is no
membrane and the lumen is free from exudate. Lung: Two blocks
showing similar lesions. The picture is not that of
the usual "mustard lung." There is marked and diffuse edema, in places
homogeneous, in places distinctly
The atria are filled and lined often with a hyaline band. There are
dense plugs of exudate in many of the alveoli, the
cells differing from normal polynuclears in the shape of their nuclei,
which are reniform rather than lobulated. There
are many exfoliated epithelial cells, some of which contain pigment,
also moderate number of red blood cells. It is
hard to make out the walls of the alveoli distinctly. The capillaries
are empty, and some appear to contain fibrin
thrombi. A small bronchus is filled with pus, but the epithelium is
still largely intact. Sections stained with Gram-safranine show
innumerable bacteria in the exudate; the predominating organisms are
Gram-positive cocci in pairs;
and short chains. A few Gram-negative cocci and minute influenza
bacillus-like rods are also seen.
examination.- Smears from
bronchus show innumerable
intracellular and extracellular
mouth organisms (Gram-positive diplococci), Gram-negative and positive
diplococci, tiny Gram-negative bacilli and
diplobacilli. Culture from consolidated lung lost by accident.
NOTE.- Duration of life
after gassing, six days. The nature of the gas to which soldier was
exposed is not established, but there were characteristic mustard-gas
lesions of skin with the
usual changes in the trachea and bronchi. There was extensive
the "influenzal" type. No other special features.
CASE 33.- J. G., 485952, Pvt., Co.
B, 47th Inf. Died, 11.30 p. m., October 18, 1918, at Evacuation
Hospital No. 7.
Autopsy No. 61. Autopsy, October 19, 1918, nine and one-half hours
after death, by Capt. James F. Coupal, M. C.
Clinical data.- Gassed on October 12 near
Verdun, exposed to
blue, green, and yellow cross shells.
diagnosis.- Multiple superficial burns. Necrotic inflammation of
larynx, pharynx, trachea, and
bronchi. Bronchopneumonia (bilateral).
appearance.- Superficial burns of face, neck, axillae, hands,
scrotum, and conjunctiva .
findings.- Pleural cavities: Left contains many fresh fibrinous
adhesions, about 100 c. c. of
serosanguineous fluid. The right is obliterated by fresh dense
Moderate mitral stenosis. Left lung: Is alternately
consolidated and congested. Emphysematous along the
anterior margins and edematous in dependent portions. The smaller
bronchi contain pus. Right lung: Same as the
left. Larynx and pharynx: Markedly injected. Trachea and larger bronchi
are denuded of mucosa throughout and are
lined with a purulent exudate.
examination.- Trachea: A few deeply-staining cells are still
adherent to the basement
membrane. The duct epithelium is also preserved. There is no membrane
or exudate on the smooth surface formed
by the membrana propria. The subcutaneous tissue is moderately
edematous. There is probably a little fibrinous
exudate. Very few wandering cells. The congestion of all vessels is
marked. Lung: (a) Sections show the alveoli
lined with coagulum, partly homogeneous, partly hemorrhagic and
fibrinous. Leucocytes, mostly polymorphonuclears, are present in
variable numbers. Occasional exfolitated alveolar cells are found, but
they are not distinct. There is marked edema of the interlobular septa,
fibrinous and hemorrhagic. No bronchi in
section. (b) This block shows a diffuse edema, not intense. A small
bronchus is filled with debris of fibrin,
fragmenting leucocytes, necrotic epithelial cells. There arc fibrin
plugs in the adjacent alveoli. In a few places the regenerating
epithelium forms a single layer of low cuboidal cells. Liver: Central
congestion with fatty infiltration
and degeneration of cells in center of lobules.
NOTE.- The case
usual lesion at this stage (six days) following a not too severe
injury. There was beginning organization of the tracheal and bronchial
epithelium and also the
alveolar epithelium in the less damaged regions of the lung. The
widespread hemorrhagic edema
suggests the prevailing "influenzal" type of infection. The lesions may
be ascribed to mustard gas, although there is a history of mixed
CASE 34.- H. S., 1565196, Pvt.,
Hdqrs. Co., 18th Inf. Died, October 7, 1918, 3 p. m., Gas hospital,
Autopsy, two hours after death, by Capt. James F. Coupal, M. C.
Clinical data.- Gassed, October 1, near Verdun.
digging into old gas-shelled hilltop a second gas
attack was launched upon the detachment to which the soldier belongs.
Nature of gassing not recorded. Clinical
diagnosis of mustard-gas poisoning.
diagnosis.- Inhalation of mustard gas. Purulent tracheobrolnchitis.
appearance.- Marked burns of face, neck, axillae, buttock, scrotum,
upper arms, conjunctivie,
findings.- Pleural cavities normal. Heart normal. Lungs:
Voluminous. Markedly edematous on
section with central areas of bronchopneuumonia. Bronchi yield plugs of
pus. The remaining organs show no
following note upon the lesions of the respiratory tract was made at
the pathological laboratory,
Experimental Gas Field.)
normal. The under surface of the trachea and epiglottis rough and
covered with bloody mucus, not
definitely ulcerated. Bronchi are filled with very abundant
blood-stained purulent exudate. No membrane. Right
lung: Is very fluffy and voluminous, especially the middle lobe,
which shows maximum inflation. The pleura is
everywhere smooth. On section the upper lobe is dry and air containing.
The middle lobe is pale, emphysematous,
and dry. Lower lobe is also free from consolidation. No edema. All
bronchi exude pus on pressure and show
swollen mucous membrane. A small nodular focus of bronchopneumonia
about the size of a bean is found on the
mesial surface just below the main branch of the pulmonary vein. Left
lung: Is also large and emphysematous, and
there are a few irregular areas of atelectasis which extend a
millimeter or so into the lung substance. On section, the
lobes are dry, free from edema and consolidation. The bronchi are
filled with purulent blood.
Microscopic examination.- The lung is slightly emphysematous in one
section. The smaller bronchi are
filled with pus cells, there being a general capillary bronchitis.
There are a few patchy areas of pneumonia where the
groups of alveoli contain polymorphonuclear leucocytes and large cells
filled with anthracotic pigment. Capillary
vessels are congested.
NOTE.- The case is one of
six days' duration. The pulmonary lesions were practically confined to
the small bronchi and infundibula, and the emphysema and atelectasis
resulting from their partial
occlusion. There were typical skin burns, so that the diagnosis of
mustard-gas poisoning is
CASE 35.- S. 2108. L/Cpl. 1/Gloucester R.
Died, September 24, 1918, at 5.30 p. m., at Base Hospital No. 2.
Autopsy, three and one-half hours after death, by Capt. B. F. Weems, M.
Clinical data.- September 18
admitted to No. 47 Casualty Clearing Station. Poisoned by shell gas
(irritant). September 19 admitted to Base
Hospital No. 2. Markedly cyanotic and breathing with much difficulty;
profuse mucoid sputum. Burns of lips and
nose; congested conjunctivae. Lungs:
Moisture generally; pulse, 116;
heart, dullness 2 cm. to right of right sternal
margin, left to nipple line. Oxygen administered. 1 p. m., pulse 150,
marked cyanosis. Venesection 400 c. c.
Strophanthin 1/500 gr. intravenously. At 2 p. m., much improved.
September 20, doing nicely. Has been getting
digitalis. Blood culture sterile. Sputum: Hemolytic streptococci
predominating. No tubercle bacilli. September 22,
feels much improved; still cyanotic; mucoid sputum. Heart: No
enlargement. Lungs: Marked prolongation of
expiratory sounds, few squeaks and coarse rales. September 24, still
cyanotic, respiratory difficulty. Lungs: No signs
of consolidation. Expiration prolonged. Pulse good. 2 p. in., acute
attack of severe dyspnea and cyanosis. Pulse rapid
and weaker; died at 5.30 p. in.
diagnosis.- Acute pharyngitis and laryngitis; intense purulent and
ulcerative inflammation of
trachea and bronchi; diffuse bronchopneumonia and multiple abscesses of
both lungs; pulmonary edema; interstitial
emphysema; acute fibrinous pleurisy; old pleural adhesions; healed
tuberculosis of right apex; acute suppurative
adenitis of peribronchial glands; healed tuberculosis of bronchial
glands; congestion of abdominal viscera.
External appearance.- Herpetic eruption on lips (burns?); teeth
in very poor condition, many missing, others
carious. Dried blood-tinged exudate in the corners of the eyelids,
evidence of recent conjunctival inflammation;
several small ecchymoses in the bulbar and palpebral conjunctivn. Dusky
cyanosis about ears, cheeks, and posterior
part of neck. Mucous membrane over nasal septum much injected; external
findings.- Pleural cavities: Lungs are fully inflated and pale. No
fluid in pleural sacs. Left lung:
Exceeding voluminous and does not collapse in the least after severing
the bron- chus. There are a few fibrous
adhesions between the lobes, and several bands near the apex, in
which there is a firm calcified nodule.
There are a
few soft adhesions at the tipper portion of the interlobar fissure,
which reveals a congested and roughened pleural
surface; there is fresh fibrinous exudate along the posterior surface of the lower lobe. The tipper and
of the primary bronchus appear very much smaller than usual and are
almost entirely occluded by a yellowish-gray,
fatty-looking material, and some thinner, almost clear fluid. An
occasional bubble of air escapes as the lung slowly
collapses. A portion of this occluding material separates readily from
the bronchial wall and suggests a fibrino-purulent exudate. A quantity
of deep-yellow pus entirely occludes the
branches of the bronchi immediately distal.
Upon dissection, the mucous membrane of the bronchus appears very
considerably thickened, congested at its base,
extensively ulcerated superficially,
covered by a rather dense, shaggy exudate. Upon section, a striking
was revealed, bright-yellow points of pus appeared immediately in large
numbers, standing out sharply against the
bright-red background. There is a deep red areola surrounding each of
these purulent points. There are a few small
abscesses about the terminal bronchioles. In some areas the
inflammation has extended several millimeters about
the bronchioles. Right lung: Also exceedingly voluminous;
heavier in posterior portion than left and has an almost
drum-like tightness over the middle and upper lobes, which seem
homogeneous and air containing. The lower lobe is
firmer, of a peculiar soft doughy consistence. Although there is a
great deal of air in the lung, almost no crepitation
is felt. The pleural membrane has a glassy appearance and is definitely
edematous. Over the lower lobe there is a
striking milky opacity of the pleura and a conspicuous edema of the
interlobular connective tissue. The superficial
blood vessels in the pleura at the base are very much congested; there
are a few minute subpleural hemorrhages. The
bronchi at the root present a deep congestion with hemorrhages. The
glands at the hilum are enlarged and
extensively calcified. Upon longitudinal section, a picture similar to
that in the left lung is observed. The tissue,
however, is somewhat firmer; the surface is more moist and in
consistence is firmly nodular. A considerable amount
of clear fluid issues from the surface, which has a rather translucent
appearance. The general pulmonary
inflammation appears more diffuse; otherwise there is little difference
from the condition in the left lung. Heart: Left
ventricle contracted, right rather flabby. No other lesions. Organs of
neck: The base of the tongue and entire
pharynx are deeply congested and granular.
There is a large amount of muco-pus about the epiglottis and the
larynx. The larynx itself and the entire trachea are filled with a foul
mucopurulent exudate. The epiglottis is markedly
inflamed and covered over its lower portion by a diphtheroid membrane;
this extends over the false and true vocal
cords, which are congested and swollen. The trachea is inflamed and
covered with patches of the whitish membrane.
The esophagus is normal. The lymph glands above the bifurcation of the
trachea are much enlarged and contain
some calcified nodules. Stomach and duodenum: Mucous membrane normal.
Intestine: Not recorded. Other viscera:
No significant changes.
examination.- Trachea: Patches of necrotic membrane between which
the edematous and
infiltrated submucosa is covered by a single layer of regenerated
epithelial cells, proceeding from the duct
epithelium. The new cells are flattened. There is much fibrin and many
polymorphonuclears in submucous tissues.
Also marked congestion but no hemorrhage. Large bronchus: Filled with
fibrinopurulent exudate. There is an acute
inflammation of the wall which extends to the cartilages. The mucous
glands are in hypersecretion. Lung: The
section includes a medium-sized bronchus entirely filled with purulent
exudate, with practically no fibrin.
Epithelium is in the form of a single layer of flattened nonciliated
cells. Bronchial wall, edematous, hyperemic and
infiltrated with leucocytes. There is no peribronchial abscess
formation, as was indicated by the gross appearance,
but the bronchus is surrounded by a zone of pneumonia in which the
exudate is largely fibrinous and beginning to be
covered by proliferating alveolar epithelium. In some alveoli there is
hemorrhage. Where the pleura is included in
the section, it is found to be thickened by edema; the vessels of the
deeper tissue are congested. Sections of
myocardium, liver, spleen, adrenals, and pancreas show
Bacteriological report.- Blood culture, aerobic and anaerobic
no growth. Pus from bronchiole:
Smear shows a preponderance of short Gram-negative rods, probably B.
influenza , also pneumococci and a few
streptococci. Culture on agar slant shows only streptococci, which
prove to be hemolytic.
of six days' duration, probably mustard gas. The burns appear to have
insignificant, being limited to the region of the eyes, lips, and nose.
There was a necrotic
inflammation of the larynx, trachea, and large bronchi, without the
formation of a definite
coherent membrane. Epithelial regeneration had begun. There was
purulent bronchitis and
infundibulitis, with exudate into the surrounding parenchyma, largely
fibrinous or hemorrhagic.
The alveoli in these peribronchial areas showed beginning epithelial
there was emphysema and alveolar and interstitial edema.
CASE 36.- E.
P. 569343, (?); Sgt., Co. H, 59th
Inf. Died, August 14, 1918, at 2.35 p. m.. at Base Hospital
No. 27. Autopsy, No. 32, performed one and one-half hours after death,
by Capt. H. H. Permar, M. C.
Clinical data.- Exposed to mustard-gas shelling
8. Extensive skin burns. Gunshot wounds of both
feet and left knee; also compound comminuted fracture of first left
metatarsal. Admitted to Base Hospital No. 27 on
August 12, in a critical condition. Died in delirium.
of gross lesions.- Extensive second-degree burns of face, neck,
back, shoulders. arms, and
genitals. Left lung weighed 298 grams, right lung 299 grams. All lobes
crepitant; no edema or consolidation.
Bronchi and trachea negative. Heart muscle flabby; marked dilatation of
examination.- Large bronchus and adjacent lung: The bronchus is
lined with a single row of
ciliated epithelium. There is no exudate and the bronchial wall is free
from inflammatory changes. The adjoining
lung tissue is moderately emphysematous, but not otherwise abnormal.
The smallest bronchioles are normal. A
medium-sized branch of pulmonary artery shows some adventitial
thickening, but is otherwise unchanged. Lung
(two blocks examined): There is marked emphysema, but no other changes
are seen. All bronchioles and infundibula
and extensive mustard-gas burns of skin, without involvement of the
respiratory tract. Death probably due to traumatic injuries six days
after exposure to gas.
CASE 37.- J. B., 546888. Cpl., Co. G, 30th
Inf. Died, August 16, 1918, at 9 p. m., at Base Hospital No. 27.
Autopsy No. 37, performed 28 hours after death, by Capt. H. 11. Permar,
M. C. (Lieut. F. M. Jacob, M. C.?)
data.- Exposed to Yellow and Blue Cross shelling on August 10, at
Fismes, 75, 77, and 105 mm.
shells in attack. Admitted on same day to Field Hospital No. 7 with
diagnosis of mustard-gas contact and shrapnel
wound of left index finger. August 11 transferred to Evacuation
Hospital No. 6. August 12 admitted to Base Hospital
No. 27. Severe burns. August 14 crepitant rȃles and
over both tipper lobes. August 15 diffuse
crepitant, moist, and bubbling rȃles at various points
chest; harsh expiration with loud sibilant rhonchi
over lower left lobe. Moderate cyanosis. Bronchial breathing at angle
of left scapula. August 16, bronchial breathing
over right middle lobe. Breath sounds emphysematous; no signs of edema.
diagnosis. - Burns of abdomen, left thigh, and genitals; acute
tracheitis and bronchitis, purulent;
beginning lobar (?) pneumonia of both tipper lobes; emphysenma;
dilatation of right side of heart.
examination.- Small bronchus: Purulent exudate fills the lumen. The
epithelium is reduced to a
few flattened and degenerating cells between the membrana propria and
the exudate. There is intense congestion and
abundant fresh hemorrhage into the bronchial wall. Lung: A
medium-sized bronchus shows a partially attached
fibrinous membrane. Flattened and
highly atypical epithelial cells in a single row are insinuating
the false membrane and the membrana propria. The wall of the bronchus
is thick, edematous, and shows fibroblastic
proliferation. There is little infiltration with inflammatory cells.
The same edematous tissue surrounds the blood
vessels. The parenchyma is the seat of confluent lobular pneumonia. The
exudate is rich in laucocytes and fibrin.
The most striking feature is the regeneration of the alveolar
epithelum, the new cells standing out because of their
deeper staining. Some of the atria show hyaline necrosis. In another
section a large bronchus is completely plugged
with a fibrinoums mass. Attached to this at the periphery are strips of
the original epithelium surprisingly little
altered. A single layer of flattened cells, many of them degenerated,
line the bronchus. The lung tissue shows an
extensive fibrinous and hemorrhagic edema very poor in cells. The
consolidation produced in this way, though
incomplete, is uniform and diffuse. The interlobular lymphatics are
distended and contain fibrin clots.
case of mustard-gas poisoning of six days' duration presenting the
picture at autopsy. There was beginning epithelial regeneration in
bronchi and alveoli.
CASE 38.- C. E. F., 2105082, Pvt.,
Co. H, 59th Inf. Died, August 15, 1918, 4.45 p. m., at Base Hospital
46. Autopsy No. 5, August 15, 11 hours after death, by Lieut. B. S.
Kline, M. C.
Clinical data.- Gassed with mustard gas August
receiving severe burns of face, eyes, chest, back,
scrotum, penis, and extremities. Unable to talk above a whisper.
Eyelids matted together. Foul, purulent discharge
from nose. Blood pressure 160/85. Respiration 26, temperature 101,
pulse 90, labored respiration. General large
moist rales which began on right. Excursion
greater on left. Slight flatness over both lower lobes. August 11,
diarrhea with bloody involuntary stools, persisting until death.
Anatomical diagnosis.- Extensive burns
respiratory tract, skin, conjunctiva. Seropurulent
conjunctivitis. Acute fibrinous and fibrinopurulent pharyngitis,
esophagitis, laryngitis, tracheitis, bronchitis, larynx
most marked. Bronchopneumonia both upper lobes. Acute fibrinous
pleurisy, left. Acute lymphadenitis regional
lymph nodes. Proctitis and colitis, ulcerative. Replacement fibrosis of
testes. Cardiac dilatation slight. Pulmonary
External appearance.- The body is that of a well-built adult
male, 168 cm. long. Rigor present to a
considerable degree in voluntary muscles. There is considerable
hypostasis. The skin in general pale, slightly lemon
tinged. There are large areas of ulceration of the epidermis over both
buttocks, in the genital fold, backs of both
elbows, right shoulder, right upper arm, both forearms, right and left
hands. There is considerable ulceration of the
epidermis of the scrotum and penis, and there is some matted
seropurulent material there. A similar exudate is
present over the ulcerated areas of the buttocks and the genital
elsewhere the ulcerated areas are covered by
small amount of clotted serum. In the neighborhood of the ulcerated
areas there is considerable desquamation of the epidermis. Eyes:
The eyelids somewhat puffy, conjunctive
edematous, deeply injected. There are small hemorrhages. Between the
lids there is a small amount of caked
mucopurulent secretion. Nose: Mucous membrane somewhat
injected. In the nostrils there is mucopurulenit material.
Mouth: There is some superficial ulceration of the membrane of
the lips with slimy material covering the gums.
Teeth: Show considerable erosion of the cutting edges. Neck:
Somewhat full in thyroid region. Chest: Slightly
flattened anteriorly; costal angle about 90 Abdomen:
findings.- On opening thorax, no fluid, no adhesions in right sac.
In left sac about 100 c. c. of slightly
turbid yellow fluid. Heart enlarged somewhat to right, and on incision
no abnormalities, except that there is less fluid
present than normal. Heart: Normal. Right lung: Upper,
voluminous; upper portion cushiony; inelastic; lower
portion cushiony, soggy, solid. The middle lobe cushiony throughout.
The lower lobe cushiony, soggy in addition;
small solid patches palpable. Pleura thin and delicate everywhere;
below it posteriorly a moderate number of small
red hemorrhages. Pulmonary vessels, no abnormalities. Glands greatly
enlarged, pulpy, edematous; most of them
contain large coherent yellow opaque nodules encapsulated by firm, gray
tissue. Bronchi show swelling and intense
injection of the mucosa. There is a small amount of fibrinous and
fibrinopurulent exudate in places. Upper lobe, on
section, upper portion moist, pink; tissue contains a small amount of
thin frothy fluid. Section of the lower portion of
the lobe shows a very moist, pink and red surface. Air sacs contain a
considerable amount of thin frothy fluid. In
addition there are good-sized, solid, somewhat granular, dry,
nonaerated, deep-red patches, varying in size up to 3
cm. in diameter; associated with these solid areas the bronchioles
contain a considerable amount of fibrinous and
tenacious fibrinopuruleiit exudate. These areas are just below the
pleura. Middle lobe on section is well aerated. Air
sacs contain a small amount of thin, frothy fluid. Lower lobe, on
section, tissue in the upper portion pink medially,
red posteriorly. There is a moderate amount of thin, frothy fluid in
the air sacs. Posteriorly in the upper portion there
are numerous deep-red hemorrhages, each several millimeters in diameter.
Toward the lower portion of the lobe,
deep-red hemorrhages are more numerous. The tissue contains a moderate
amount of thin, frothy fluid. Left lung:
Both lobes are much more voluminous than normal, especially the upper.
Pleura in great part glazed and covered by
small amount of tightly adherent fibrinous exudate. The upper lobe
cushiony medially, elsewhere soggy. In the mid
portion there is an orange-sized, solid, deep-red patch, reaching to
and involving the pleura; lower, cushiony soggy.
The vessels and bronchi are similar to those in the right. Lymph gland
considerably swollen, edematous, injected,
and somewhat scarred. On section of the upper lobe, tissue is pinkish
red. The air sacs contain a large amount of
thin, frothy fluid. In the upper central portion of the lobe there is
large, egg-sized, solid, patch relatively dry,
granular, and airless. The bronchioles in this lobe toward the
periphery show a considerable amount of fibrinous
exudate within them. The lower lobe on section similar to the right
lower lobe. No distinct, solid, patches; numerous
hemorrhages. In this lobe the bronchi show intensely injected, swollen
mucosa, with, however, very little exudate.
Neck organs: The structures of the lower portion of the neck
particularly, somewhat edematous. The glands
throughout are considerably enlarged, pulpy, injected. Thyroids much
smaller than normal. Tissue, spongy and pale.
The acini contain but a small amount of colloid. The larynx presents a
striking picture; almost completely filling the
lumen, there is a large amount
of gelatinous fibrinopurulent exudate. The mucous membrane greatly
intensely injected, and covered by tightly adherent, gelatinous,
fibrinopurulent exudate. The process is perhaps more
marked over the true cords. The mucosa of the trachea is considerably
swollen, intensely injected, covered in places
by tightly adherent fibrinous and fibrinopurulent exudate. The upper
portion of the esophagus and base of tongue
show considerable edema of mucous membrane, with scattered patches of
injection, in the neighborhood of which
there is a moderate amount of tightly adherent, fibrinous, and
fibrinopurulent exudate. Tonsils: Good size, show
considerable amount of lymphoid tissue. There is some injection
throughout. Alimentary tract: Lower portion of the
esophagus, no abnormalities. Stomach shows considerable post-mortem
change. Jejunum, ileum, and appendix: No
abnormalities. Cecum and ascending colon show considerable diffuse
edema of walls, especially of the mucosa.
Beginninig in the hepatic
flexure and continuing throughout the large
intestines and rectum there is marked edema of the mucosa, with
innumerable areas of ulceration, about which there is considerable
injection, giving the gut a moth-eaten appearance.
The ulceration extends into the submucosa. Overlying the ulcerated
areas in most places there is an adherent
fibrinous and fibrinopurulent exudate in considerable amount. The
retroperitoneal and mesenteric glands are
considerablh enlarged, edematous and pulpy, and injected. The remaining
organs show no significant lesions.
examination.- Trachea: Desquamation of the mucosa; islands of
regenerating epithelium still
attached here and there. Sections show no membrane or exudate and no
inflammatory infiltration of submnucosa,
which is intact. Lungs: (a) The greater portion of the slide
presents the picture of an infected hemorrhagic infarct.
There is necrosis of the alveolar walls, blood vessels, and bronchi,
with much nuclear fragmentation and scattered
colonies of bacteria. The blood cells in some areas are partially
decolorized. Thrombi are not found, however. (b)
The appearance is that of lung following suffocant-gas inhalation.
There is intense alveolar and interstitial edema,
partly fibrinous or hemorrhagic, alternating with areas of acute
emphysema, in which the dilatation of the
bronchioles and infundibula is a striking feature. The epithelium of
the bronchioles is perfectly preserved; and there
is no pneumonic exudate, although the alveolar capillaries show an
increased number of leucocytes. Large intestine:
Complete necrosis of mucosa, involving the subjacent tissue to a
variable depth. The superficial vessels are
plugged with hyaline and fibrinous thrombi. The deeper layers of the
submucosa show an intense hemorrhagic and
fibrinous edema, with a moderate lymphoid inflammatory reaction. The
muscular coats are not involved. Testis:
Coarse interstitial fibrosis, with groups of atrophic hyalinized
description.- Smears.--Trachea: Innumerable Grain-positive and negative bacilli and
Lung: Very few organisms, rounded Gram-positive cocci. Cultures.-
Trachea: Staphylococcus aureus, streptococcus
nonhemolytic. Gram-positive and negative bacilli (few), aerobe. Lung:
Staphylococcus aureus, streptococcus, Gram-negative bacilli (few),
occurred seven days after gassing. The history and typical skin burns
confirm the diagnosis of mustard-gas poisoning. The lesions of the
upper respiratory tract were
also typical. The lung lesion, however, differed in some respects from
the usual picture. The
intense hemorrhage, with infarct-like areas of bacterial necrosis were
more like those of the later
stages of influenzal pneumonia, although the case occurred at a time
when there were few fatal
influenzal cases coming to autopsy. Blocks from other portions of the
lung showed only an
intense edema and congestion, with intact bronchiolar epithelium, and
taken by themselves
would suggest a diagnosis of phosgene or other gas of the suffocative,
rather than irritant or
vesicant type. Another interesting feature in the case is the intense
hemorrhagic and necrotic
colitis, evidently an acute lesion developing after the gassing, and
possibly referable to it.
CASE 39.- W. F., 3113960, Pvt., Co. E, 316th
Inf. Died, October 16, 1918, 1.45 p. m., at Evacuation
Hospital No. 6. Autopsy, October 17, 1918, 20 hours after death, by
Capt. James F. Coupal, M. C.
data.- Mustard-gas burns and inhalation, incurred October 9.
diagnosis.- Multiple superficial burns of body. Ulcerative
tracheitis (acute). Bronchopneumonia.
Acute fibrinous pleurisy.
appearance.-Marked lividity and diffuse pigmentation over entire
body. Burns of cornea,
conjunctiva, face, scalp, penis, scrotum, buttocks, wrists, thighs,
Gross findings.- Heart normal. Pleural cavities:
contains 100 c. c. of serosanguineous fluid. Right
is negative. Lungs: Both are voluminous, alternately
consolidated, edematous and
congested, and yield, on section,
quantities of dark blood and frothy mucus. Emphysema along the anterior
margin. Base of tongue, pharynx, and
larynx: Show beginning ulcerative inflamation extending into whole
bronchial tree, with plugs of pus in finer
bronchi. Trachea: Is denuded of mucosa, which lies in lumen as
membrane. Abdominal viscera: Congested.
Microscopic examination.- Tracheal epithelium is desquamated to the
basement mem- brane. Here and there
a single layer of squamous cells remain. No false membrane is included
in the specimen. Corium shows edema,
congested capillaries, and round cell infiltration, particularly near
the congested capillaries. Lungs: Only one block
preserved. There is practical occlusion of the small bronchi with dense
fibrinopurulent exudate, the epithelium of
which shows complete necrosis. There is a zone of fresh hemorrhage
about the affected bronchi. Elsewhere no
pneumonic exudation or edema except for thready coagulum in a few
alveolar spaces. There is a diapedesis of red
blood cells throughout the section. Skin: Probably of scrotum.
The stratum corneum is desquamated. Cells in deeper
portion of the epidermis are vacuolated. There is a slight edema of the
corium. Section taken from skin of eyelid
shows similar changes, the edema being more marked. Cornea: There is a
desquamation of the epithelium of the
anterior limiting membrane. Corneal cells and fibrils near the surface
are separated, giving a reticulated appearance.
Small intestine, liver, and kidneys show no significant
case of mustard-gas poisoning dying on the seventh day after gassing.
Although the protocol is not given in great detail and the histological
material is inadequate, the
case seems to have shown tracheo-bronchitis with membrane formation.
The lung lesions
appear to be limited to the vicinity of the bronchi, but only one block
of tissue was available for
CASE 40.- W. B., 1430805, Pvt., Battery B,
102d F. A. Died, October 17, 1918, at 10.30 p. m., at Base
Hospital No. 59. Autopsy No. 9. Autopsy, October 18, 11 hours after
death, by Capt. M. Flexner, M. C.
data.- Exposed on night of October 9-10 to bombardment of 2,000
105-mm. and 150-mm. shells of
mustard gas and chloropicrin. Masks removed prematurely, and soldiers
slept in gassed area. Admitted to
Evacuation Hospital No. 10 on October 12 with diagnosis of gas
inhalation severe, conjunctivitis, scrotal burns.
diagnosis.- Mustard-gas burns of eyes, nose, mouth, and genitals.
Acute fibrinous pleurisy.
Emphysema. Bronchopneumonia with miliary abscesses. Membranous and
appearance.- Scabs of mustard-gas burns about eyelids, nares,
and chin. Prepuce and
scrotum badly burned. No other severe lesions.
findings.- Pleural cavities: No fluid. Right lung: Shows a
pleurisy over the lower two-thirds
of the upper, the entire middle, and lower lobes. On section there are
scattered elevated flesh-colored and reddened
areas of consolidation tending to become confluent at the base of the
upper lobe. Thick yellow pius exudes from the
bronchi and smaller bronchioles. Left lung: Also shows
fibrinous pleurisy. On section there are similar areas of
consolidation, in addition to which at the base of the upper lobe many
rnilitary abscesses, from which
a thick yellow
pus exudes on pressure. These are from 3 to 6 mm. in diameter. Walls
are roughened. Consolidated portions of the
lung are dark red in color. The entire trachea, from the epiglottis
down to the bronchial tubes, as well as the smallest
visible branches are reddened and covered to a greater or lesser extent
with a fibrino-purulent exudate, which varies
in amount very markedly in different bronchi. In the pharynx is a
slight redness and delicate white film. Same in the
upper portion of larynx. Below the vocal cords is a heavy scaly
membrane, white in color, which merges in the
trachea into a mucopurulent exudate, which is less adherent. Mucosa is
eroded. Peribronchial lymph nodes are
swollen and edematous. The remaining organs show no lesions of
examination.- Large bronchus: Shows the entire bronchial wall
edematous, congested and
infiltrated with polynuclear leucocytes. Some of the epithelial cells
persist or are in various stages of degeneration.
Lungs: The alveolar capillaries are congested and contain an
excess of polynuclears. The contents of the alveoli are a
collection of fibrin and granular coagulum, in which there are large
pigmented alveolar cells; some of them
containing several nuclei, and moderate numbers of polymorphonuclear
leucocytes. Pleura is covered with a recent
fibrinopurulent exudate. The smaller bronchi are filled with pus. A
second section of lung shows definite abscesses,
possibly occupying the distended atria and surrounded by ecompressed alveoli filled with coagulated blood and
serum. Liver: In some lobules the liver cells about the central
veins are atrophic. Protoplasm shows fatty infiltration.
A few cells are necrotic. Capillaries in these areas are congested.
NOTE.- The duration of
gassing was seven days. Although there is a history of exposure
to both mustard gas and chloropicrin, the lesions do not differ from
those found at this stage in
cases exposed to mustard alone. There was no definite membrane
formation in the upper
respiratory passages, but much necrosis, hemorrhage, and
fibrinopurulent exudate. The miliary
abscesses in the lungs were probably an extension of the suppurative
inflammation of the atria.
CASE 41.- J. T. A., 3106661, Mech., Co. D,
313th Inf. Died, October 18,1918,12.15 p. m., Base Hospital
No. 15. Autopsy, October, 18,--hours after death, by Maj. Daniel J.
Glomset, M. C.
Clinical data.- Gassed with mustard gas October 9 to 10,
near Fresnes; 1,000 77-mm. shells used; exposed
five and one-half hours; acute conjunctivitis and bronchopneumonia.
Anatomical diagnosis.- First-degree
burns of head, neck,
and scrotum. Membranous pharyngitis, tracheitis,
and bronchitis. Focal pneumonia in left lower lobe, with patchy
hemorrhages in both lungs. Marked congestion of
abdominal viscera. There is no detailed description of the gross organs
Microscopic examination.- Trachea: Is lined with stratified
epithelium, showing numerous mitoses (See fig.
30). Superficial layer is flattened and devoid of cilia. Subepithelial
layer is not edematous and shows no leucocytic
infiltration. There is marked congestion. Mucous glands are normal. Lungs:
Some of the bronchioles are completely
filled with loose fibrin plugs, in which are few polynuclears.
Epithelium in places is flattened and evidently regenerating; in other
places it is destroyed. The bronchial wall is
thickened by marked fibroblastic growth. The
parenchyma shows a patchy edema, which about the bronchioles is
fibrinous and in some places hemorrhagic. There
are desquamated pigmented epithelial cells in many of the alveoli.
Another section, evidently taken from the "patchy
hemorrhages" mentioned in the anatomical diagnosis, shows a very
different picture. The alveoli are everywhere
filled with a granular coagulum, more or less decolorized, red blood
cells, and pyenotic leucocytes in small numbers,
exfoliated and degenerating alveolar cells. The capillaries are filled
with poorly staining red cells. There are many
bacteria. Not only the alveolar epithelial cells but the endothelial
and connective tissue cells showv degenerative
changes, whether from the infection or the direct action of the
irritant it is impossible to say. The changes are
evidently not post-mortem because of the excellent preservation of the
trachea and other portions of the lung.
Probably an overwhelming streptococcal infection on the basis of local
seven days there was a relining of the trachea with epithelium, which
nonciliated. The initial destruction of the epithelium was probably
superficial. The lungs showed
areas of hemorrhagic pneumonia, in which there was evidently intense
infection and damage to
the framework of the alveoli. In other areas the lesions were milder in
type and regeneration of
the alveolar epithelium was in progress. The walls of the small
bronchioles were becoming
CASE 42.- H. B. M., 1786923, Pvt., Co. F,
316th Inf. Died, October 16, 1918, 7.30 p. m., at Base Hospital
No. 59. Autopsy No. 8. Autopsy, 1012 hours after death.
data.- Gassed on October 9, 1918; inhalation and contact.
Conjunctivitis. Signs of
diagnosis.- Superficial burns about the eyes and scrotum. Extensive
pneumonia with infarct-like areas. Acute membranous tracheobronchitis.
appearances.- Conjunctivitis with keratitis of both eves. Burns of
lower eyelids. Healing burns
about the scrotum. Large amount of reddish-brown fluid escapes from the
Gross findings.- Pleural
cavities.-There is no fluid. There are a few adhesions between the
visceral and diaphragmatic pleurae of the lower
lobe. Heart: Right auricle and ventricle dilated and flabby;
otherwise normal. Right lung: Shows a fine fibrinous
to the middle lobe. The lung is purplish or
bluish-red in color with localized dark, reddish-black areas in the
and lower lobe. On section, these are rather friable and firm. Some of
them resemble infarcts. The remaining lung
tissue exudes blood-tinged, frothy fluid. Left lung: Shows an
even more intense edema. Otherwise is the same as the
right except for older, more pinkish, patches of consolidation in the
lower lobe. Larynx: In the region of the piriform
sinuses shows a grayish necrotic membrane. The mucosa of the trachea is
entirely necrotic, replaced by adherent
grayish-yellow membrane. The underlying tissue is blotched with
hemorrhages. Same condition obtains in larger
bronchi. Lumina are filled with large amount of frothy, blood-tinged,
Microscopic examination.- Trachea: There is a complete epithelial necrosis,
involving the duct epithelium
as well as that on the surface. There is no regeneration. There are
shreds of adherent false membrane containing
colonies of bacteria. There is intense filling of blood vessels of
submucosa and deeper layers of connective tissue,
with capillary hemorrhages. In places there is a beginning
sequestration of the edematous and partially necrotic
layer from the deeper tissue beneath. Mucous glands are flattened,
atrophied, and in some places necrotic. There is
very little cellular inflammatory reaction. Lungs: In some of
the bronchioles, at least, the epithelium is well
preserved. In other lumina there is an exudate; in some places serous
and in others purulent and more hemorrhagic.
Lung parenchyma shows areas in which alveoli are filled with exudate of
leucocytes, red blood cells, and well-marked fibrin network, the
adjacent regions showing edema or simply hemorrhage. Capillaries and
distended with blood. Many of the atria and alveoli are lined with a
pink-staining hyaline band, which appears to be
partly formed from the swollen basement membrane. Epithelium is not
present. In some of the capillaries there are
hvaline thrombi, apparently originating from the fused red blood cells.
Another striking feature is the pyenosis of the
leucocytes in the exudate and the relatively large percentage of
mononuclear cells. Gram-safranine stain shows large
number of Gram-positive streptococci.
poisoning of seven days' duration. There was a complete necrosis of
the bronchial epithelium involving the ducts of the mucous glands.
There were therefore no
reparative changes. There was an extensive hemorrhagic lobular
pneumonia, more cellular and
fibrinous than the usual influenzal type.
CASE 43.- L. K. J., Lieut., 120th Inf. Died,
October 26, 1918, at Base Hospital No. 2, at 9 p. m. Autopsy, 13
hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- Exposed on October 19 to blue,
yellow cross shells. October 20, admitted to No.
47 Casualty Clearing Station. October 22, admitted to Base Hospital No.
2. Pyrexia of unknown origin in May,
1918. In hospital two months; has been well since. Now suffering from
sore eyes, cough, pain in throat and chest;
vomiting; has not eaten for three days. Physical examination:
Well nourished; slight cyanosis; breathing with slight
difficulty; eyes congested, lids swollen; nares discharging; pharynx
congested. Heart normal. Lungs:
rales, heard generally; fine moist rales at left base; resonance
normal. Slight first-degree burns of axilla and thighs.
October 24, condition unchanged. Profuse mucopurulent sputum. Fine
moist rales at left base, no localized signs of
consolidation. Sputum shows M.
catarrhalis and pneumococcus, not
typed. October 25, no improvement in
general condition. October 26, much worse this morning. Cyanosis
deeper. Respiration rapid, bloody sputum.
Dullness marked in left axilla, extending posteriorly to left base.
Distant bronchial breathing. Moist rales over both
lower lobes. Pulse, 150. Died at 9 p. m.
Anatomical diagnosis.- Acute tracheolaryngitis and hemorrhagic
bronchitis; diffuse lobular pneumonia, with
marked edema and congestion; acute serous pleurisy; old pleural
adhesions; poisoning by irritant gas, nature
appearance.- Quantity of blood is issuing from
nostrils and a sanguineous froth from mouth.
External genitalia apparently normal. No cutaneous burns. Slight
pigmentation and dried exudate about corners of
eyelids; conjunctive are normal.
findings.- Pleural cavities: Right contains about 100 c. c.
of blood-tinged fluid, left about the same
quantity. There are fibrous adhesions over entire posterior and lateral
surfaces of left upper lobe. Right lung:
Moderately voluminous; grayish-red and purple
color; pleura over middle and greater part of
lower lobes shows fresh fibrinous exudate. Bronchi contain a
of bloody froth; their mucous membrane is deeply injected and hemor-
rhagic. Blood vessels and glands at the hilum
are normal. The lung has a lumpy consistence; all three lobes contain
extensive areas of incomplete consolidation.
The cut surface presents a blotchy reddish-gray and purple appearance,
with some areas of a deep-reddish brown; the
darker areas stand out somewhat from the surface, are of firmer
consistence and almost airless. No evidence of
infarction is present. Left lung: Is moderately voluminous,
rather heavy; the upper lobe is covered with fibrous
adhesions; the lower lobe presents a mottled appearance, the
light-grayish areas being somewhat elevated but not
firm, apparently emphysematous. The lower lobe is pretty diffusely
consolidated, but contains a small quantity of air
throughout and is flabby. The upper lobe on section presents the same
characteristics over the lower half; the anterior
and upper half are only slightly involved. There is a group of enlarged
firmly calcified glands at the hilum. No acute
pleurisy. Blood vessels normal. The bronchi display the same injection
and diffuse hemorrhagic inflammation with
very little exudate. The cut surface of the lung also has the same
general appearance as that of the right, a mottled
grayish-red and purple and deep red color with diffuse irregular and
firmer areas of partial consolidation. There is a
large quantity of sanguineous and serous exudate upon the surface. The
smaller bronchi are microscopically normal.
No exudate or plugs within their lumina are demonstrable. Organs of
neck: Pharynx is rather deeply congested.
Tonsils are small and scarred. Laryngeal surface of epiglottis reveals
an acute membranoulcerative inflammation.
There is considerable erosion of mucous membrane over vocal cords and a
slight superficial necrosis of the mucous
coat along the entire trachea, with a slightly granular looking
exudate. A deep fiery injection extends down the
trachea, becoming more intense at the bifurcation. Esophagus is normal.
Thyroid gland is somewhat enlarged.
Stomach normal. Intestines not recorded. Other viscera show no
examination.- Trachea: Epithelium defective, save for a few
unattached strips in which the
cells are not much altered. The somewhat thickened basement membrane
lies exposed, uncovered by inflammatory
exudate. There is much hyperemia of the cerium, with slight diapedesis and a moderate accumulation
cells, principally small mononuclears. The picture is not that of a
severe necrotizing inflammation. Very few bacteria
are found on the surface, none in the substance of the trachea. Lung:
The capillaries throughout are filled with well-stained cells, and
there are in places profuse alveolar hemorrhages. In addition the
alveoli contain a faintly-stained
shreddy coagulum, occasional pigment cells and lelcocytes, many of
which are pycnotic and fragmented. The most
interesting feature of the section is the lining of the walls of the
alveoli and of the alveolar ducts, with a pink-staining, fibrinoid
membrane, representing probably the hyaline necrosis of the alveolar
epithelium plus the
basement membrane. The remaining blocks of lung show in sections a
similar picture, with one exception, in which
there is an area resembling a hemorrhagic infarct, with beginning
decolorization of the red cells and massive
bacterial growth. The alveolar septa in these areas are necrotic.
Sections stained with Gram-Weigert-safranine show
practically but one type of organism, Gram-positive cocci, occurring in
pairs, or more commonly groups, rarely in
short chains, rounded and morphologically resembling a staphylococcus.
Many of them are intracellular and partially
decolorized. They are irregularly distributed, being more abundant
where there is a leucocytic reaction, and very
sparse or absent in the areas of simple hemorrhagic edema. Myocardium,
liver, spleen, adrenals, thyroid, and
pancreas show no significant
case dying seven days after a definite history of being exposed to a
irritant and suffocant shell gases. The ocular lesions appear to have
been very trifling, and no
note was made at the autopsy of the "slight burns of thigh and axilla"
recorded in the clinical
history. The lesions of the upper respiratory tract were not
sufficiently destructive, and their
superficial character after seven days argues against exposure to
mustard gas. The smaller
bronchi showed only hemorrhage. There was widespread congestion,
hemorrhage, and edema of
the lungs, but no peribronchiolitis of the type so commonly associated
with mustard gas. The
inflammatory changes .were early and appeared to be associated with a
staphylococcus, or mixed
staphylococcus and streptococcus, infection.
The case is certainly
characteristic of mustard gas, and the lesions are either to be
to a mixture of other irritant and asphyxiating gases or to the
development of a severe influenzal
pneumonia in an individual who had received very light mustard-gas
injuries. The case
illustrates very well the difficulties in interpretation which may
CASE 44.- H. W. T. L., 88715,
Pvt., R. A. F. 3 K. B. S. Died, October 28, 1918, at 4.30 p. m., at
Base Hospital No.
2. Autopsy, four and one-half hours after death, by Capt. B. F. Weems,
Clinical data.- October 21, admitted to No. 47
Clearing Station. Gassed and wound of right foot.
October 22, admitted to Base Hospital No. 2. Generalized inflammation
of the bronchi with signs most marked at
left base; also many rȃles at right base. Severe scrotal
26, doing very poorly; right lower lobe
practically useless; stifling inspiration sound; short and faint gurgle
as expiratory sound. Outlook bad. Left chest
filled with coarse and fine rates. Sputum: Direct smear-short
Gram-negative bacillus is predominating organism.
October 28, much more rattling in chest. Pulse, 120. Died at 5 p. m.
diagnosis.- Extensive burns of skin; acute conjunctivitis; acute
pharyngitis, laryngitis, and tracheobronchitis; diffuse
peribronchiolitis and bronchopneumonia; emphysema; acute
fibrinous pleurisy; old pleural adhesions; acute peritracheal and
peribronchial adenitis; congestion of abdominal
External appearance.- The skin has a dusky discoloration and is
extensively desquamating; large areas of
maceration and peeling of the epidermal layer over abdomen, chest, and
thighs. There is much edema and erosion of
the skin over the penis and scrotum and a good deal of moist exudate
about the groins and inner aspects of the
thighs. There is considerable pigmentation of the skin over the neck
and face, a dusky purple discoloration about
the eyes, the lids of which show some desquamation of the epidermis and
rather marked injection and hemorrhagic
inflammation of the conjunctive. There is bloody dried exudate in the
nares; there are extensive erosions over the
buttocks and back. Typically adenoid facies.
Gross findings.- Pleural cavities:
Lungs in full inflation; there is fresh fibrinous pleurisy over a large
the posterior surface of the right lung and a few chronic adhesions
over base. There is a fresh adhesive pleurisy over
lower portion of the lung and old adhesions at base. No free fluid in
pleural sacs. Pericardium
normal. Right lung:
Quite voluminous, rather light, somewhat denser in posterior portion;
does not collapse in the least after severing
bronchi, and has a peculiar fluffy feel; grayish white in color
anteriorly, blotchy red posteriorly. Almost the entire
pleural surface is covered by very thin fibrinous exudate and the
pleural vessels are injected. The apex and posterior
half of the lung is perfectly aerated and soft; the tissue is
air-containing throughout and of an almost homogenous
consistence. The bronchi display considerable tightly adherent, rather
elastic, semimucous exudate, which is
purulent and slightly blood-streaked; the membrane is deeply injected
and covered by an ulcerating, partly necrotic
layer. There is comparatively
small content of fluid in the larger bronchi. Blood vessels normal.
Lymph nodes are
slightly enlarged and acutely inflamed. On cut surface the lung
presents a grayish-pink color with deep reddish-brown spots; surface is
moderately moist but not in the least bloody; the dark areas are
slightly elevated and
somewhat firm; they surround small bronchi, which appear to contain
small yellowish-gray plugs of exudate. Left
lung: Presents the same general appearance as right, and is equally
voluminous; bronchi contain the same kind of
exudate. Upon cut section exactly the same picture is seem. The tissue
is everywhere spotted by small dark areas of
bronchopneumonia, surrounded by emphysema. Organs of neck.-
Pharynx: Shows an acute ulcerative and
membranous inflammation; the arytenoepiglotti-dean folds are
considerably thickened and covered by a yellowish-gray membrane. Larynx:
Is covered by membrane and froth; its mucous surface is considerably
eroded. The upper portion of the trachea is pale in color; the mucous
membrane is in a fair state of preservation; the lower half is deeply
injected and covered by a patchy necrotic membrane. The peritracheal
lymph nodes are somewhat enlarged and
considerable congested. Esophagus: Normal. Thyroid appears normal.
Intestines not recorded. Stomach and
duodenum normal. Heart:
Left chamber contracted, right flaccid.
Remaining viscera show congestion, but no other
Microscopic examination.-No blocks of trachea and large bronchi. Lungs:
The largest bronchus in the
section is lined with normal epithelium showing hypersecretion of
mucus. The lumen is filled with blood cells and
leucocytes. Several smaller bronchi also contain blood and show an
intact epithelial lining. The parenchyma shows
very intense congestion, with areas of alveolar hemorrhage and
emphysema. There is a little shreddy coagulum in
some of the air spaces and a very moderate stasis of leucocytes in the
capillaries and the interstices of the septal
tissue. Very few have emigrated into the alveolar spaces. Another block
shows a large infected thrombus filling a
vessel, which is probably a distended artery; the wall, however, is
thinned and infiltrated with leucocytes, so that it is
difficult to be certain. The center of the thrombus shows suppurative softening and contains large
masses of cocci
(Gram-positive), which in some places line the necrotic wall of the
vessel. The adjoining lung tissue for a distance of
several millimeters is profusely infiltrated with hemorrhage. In this
hemorrhagic zone are scattered bacteral masses
about which the lung tissue is necrotic. A small bronchus included in
this area contains a hemorrhagic purulent
exudate, hut the epithelium is intact. The predominant organisms in the
thrombus are: Grain-positive cocci, 1; in
tetrads and groups, 2; in chains, probably staphylococci and
streptococci. Myocardium: In the adventitia of a small
artery is a loose collection of leucocytes, chiefly polymorphonuclear.
No other lesions noted. Liver: Moderate fat
infiltration. Adrenal: There are some interesting features. The
cortical tissue is very edematous, the capillaries of the
reticular zone congested. The cortical cells are not vacuolated. Many
of them are in various stages of necrosis;
others are deeply stained and give the appearance of regenerated cells.
This is supported by the finding of numerous
mitotic figures, especially in the deeper layers of the fascicularis
and reticularis. The chromaffin staining of the
medullary tissue is faint or absent in many cells. There are small
groups of lymphoid and plasma cells in the
medulla. In some areas of the cortex the cells have disappeared, being
replaced by the edematous stroma; about the
degenerating remains are leucocytes. Spleen: Pulp shows
hemorrhages, is cellular, and contains a slightly increased
number of polymorphonuclear leucocytes. Kidney: Intense congestion. In
one block there are suppurative foci
surrounding bacterial emboli in the pyramidal capillaries. There is
hemosiderin deposit in the epithelial cells of the
loops of Henle, such as is seen in chronic passive congestion. Small
intestine: There is hemorrhage into the tips of
the villi, with exfoliation (post-mortem ?) of the overlying
epithelium. No thrombi, no inflammatory reaction.
report.- Blood culture (post-mortem): Pneumococcus, not typed. Lung
culture (post-mortem) on blood
agar plate, B.
influenzae greatly predominates; few hemolytic streptococci, few
aureus, few M. catarrhalis,
Gram-positive and negative bacilli,
case of seven days' duration. The diagnosis is evident from the gross
cutaneous lesions and the intense diphtheritic inflammation of the
upper respiratory passages.
The presence of an infected thrombus in one of the lung arteries and a
suppurative lesion in the
kidney suggest a generalized bacterial infection; the acute focal
myocarditis further supports this
view. Although pneumococci were recovered from the heart's blood at
autopsy, it is doubtful
whether these were responsible for the metastatic lesions. The source
of the generalized sepsis is
also uncertain. It may have been in the infected wound of the foot,
which is recorded in the
clinical history, though not described in the autopsy protocol. The
lesions in the adrenal cortex
are interesting and suggest a severe injury, with early regeneration.
The hemorrhages in the
intestine may be comparable to those produced by the intravenous
dichlorethysulphide in animals, or they may be associated with the very
extensive skin burns.
CASE 45.- J. T., 552741, Pvt., Co. M., 38th
Inf. Died, August 15, 1918, at 10.30 a. m. at Base Hospital No.
27. Autopsy No. 33, performed two and one-half hours after death, by
Capt. H. H. Permar, M. C.
data.- Exposed to mustard-gas shelling on August 8. After passing
through Field Hospital No. 6
and Evacuation Hospital No. 7, was admitted on August 12 to Base
Hospital No. 27. August 14, diffuse large
moist rȃles, especially on left side. Pulse, 132. August
high-pitched percussion noted; prolonged harsh respiration. Died at
10.30 a. m.
of gross lesions.- Excoriations of skin of face, arms, buttocks,
genitals. Pleural cavities: Clear.
Both lungs voluminous, weight (of each) 750 grams. Cut section shows
marked edema with areas of peribronchial
consolidation. The bronchi are filled with fibrinous exudate; there is
loose membrane in the larger branches. Trachea
and larynx: Ulcerated, partially covered with exudate. Circulatory
organs: Negative. Old tuberculosis of
examination.- Trachea: There is a continuous false membrane. In the
areas where this is
unattached, a single row of flattened epithelial cells is interposed.
The submucosa is edematous but not congested.
There is a striking paucity of leucocytes; the few that are present are
fragmented and pycnotic. The epithelium of the
mucous ducts is in active proliferation. Medium-sized
bronchus: There is diphtheritic
necrosis, with masses of
bacteria in the lumen, and here and there early regeneration of
epithelium. The outstanding feature is the copious
hemorrhage in the walls of the bronchi and the adjacent alveoli. Lungs:
Bronchioles are filled with plugs of fibrin, in
which are masses of bacteria and nuclear detritus. There is profuse
alveolar hemorrhage in the neighborhood of the
bronchi. In other areas the exudate is rather fibrinous. There are very
few leucocytes. Another block shows similar
changes in the bronchi and peribronchial tissues. The rest of the lung
is markedly emphysematous and anthracotic.
case of mustard-gas poisoning of seven days' duration. There was the
diphtheritic necrosis of trachea and bronchi. The pulmonary lesions
were chiefly a fibrinous and
hemorrhagic edema and appear to have been confined to the vicinity of
CASE 46.- H. S., 310789, Pvt., Co. E, 304th
Eng. Died, 7.10 a. m., October 14,1918, at Base Hospital No.
52. Autopsy six hours after death, by Capt. M. Flexner, M. C.
data.- Gassed with mustard gas shells October 6. Admitted to Base
Hospital No. 52 on October 8.
For six days fever, rapid pulse, and respiration. Severe mustard-gas
burns over face and upper part of body.
diagnosis.- Mustard-gas burns on left side of face, neck, and
Bronchopneumonia. Disseminated tuberculosis, both lungs with cavity
formation at both apices. Cloudy swelling of
appearances.- Burns over entire left side of face, ear, and neck,
extending up to scalp. Scab
formation with beginning healing in deeper areas, left ear particularly
involved. Burns of first degree with vesicles
on right hand. Occasional small vesicles on abdominal wall. No burns of
penis or scrotum.
Gross findings.- Pleural cavities: There are a few
old fibrous adhesions on both sides but no fluid. Right
lung: At the apex there is a small calcified nodule one-half
centimeter in diameter. At the base of the upper lobe is
an area 3 to 4 cm. in diameter, grayish purple in color. The remainder
of the lobe is mottled pinkish gray. Much
fluid can be expressed. Middle lobe is normal. Pleura over the lower
lobe is covered with a fine yellow layer of fibrin. Upper pole of the
lobe is firm with scattered grayish areas varying in consistency from
material to that undergoing purulent degeneration. Left lung:
The pleural surface is dull. At the apex of the upper
lobe is an old dimpled scar 4 cm. in diameter, beneath which on section
is a cavity 2 by 3 cm. with fibrous
thickened wall. Throughout the entire lower lobe are small calcified
nodules. Lung tissue is purplish red in color
with scattered irregular yellowish areas 2 to 5 mm. in diameter. A
moderate amount of blood-stained fluid. Trachea
appears red and congested. Peribronchial lymph glands are injected and
pigmented. Heart: Normal. Stomach and
intestines are "grossly normal." Kidneys show cloudy swelling.
Remaining organs present nothing of interest.
examination.- Trachea: On section, the epithelium is
stratified, the lower layer of cells being
columnar, the upper layers being polymorphous and generally polygonal.
In another section, presumably a main
bronchus, epithelimm is largely desquamated; it is composed of a single
layer of polygonal or columnar cells, very
ragged and irregular in their arrangement. Submucous layer is
congested, somewhat edematous, and infiltrated with
various mononuclear inflammatory cells,
especially about the submucous glands. Lung: The parenchyma is the seat
of an extensive pneumonic process, showing red cells, leucocytes,
fibrin, and large mononuclear cells with pigment,
etc. Capillaries are congested. In some areas there are large clumps of
bacteria in the alveoli and the surrounding
tissue is necrotic. One very extensive area of necrosis is associated
with a thrombus in a branch of the pulmonary
artery. There is no suggestion of tuberculosis in the three blocks
taken. Skin: Under the intact epithelial layer there
are pigment cells in the corium. Vessels are congested. In another part
epithelium is congested and composed of two
layers of polymorphous cells with layer of keratin above them.
far as can be judged from the gross lesions and section, the injury to
the upper air passages was
slight and repair almost complete. There was an extensive hemorrhagic
lobular pneumonia with areas of definite
necrosis, in part associated with thrombosis of the vessels. Although
from the gross description there were
obviously a few obsolete tuberculous lesions at the apex, the
histological studies show that there was no
disseminated tuberculosis. The occasional areas described might
correspond to the areas of definite necrosis. The
burns confirm the diagnosis of poisoning by mustard gas. The
of life was eight days.
CASE 47.- R. T., 113314, Pvt.,
Co. B, 150th M. G. Bat. Died,
March 29, 1918, at Base Hospital No. 18.
Autopsy No. 52. Autopsy, 21 hours after death, by Lieut. B. S. Kline,
data.- Gassed in front-line trenches, March 21, 1918. Thirty
later his eyes became sore;
after one hour vomited. At hospital at Luneville developed dry cough.
On admission to Base Hospital No. 18 eyes
closed, purulent discharge; pharynx much injected. Blisters on face,
neck, and legs. Slight general glandular
enlargement; harsh breathing and moist general riles. On March 26,
signs of consolidation in left chest, dullness,
tubular breathing, and rȃles. March 27, much tenacious
rȃles, harsh breathing with dullness,
bronchophony, etc., below right scapula. Dyspnea and cyanosis.
Temperature, 103; pulse, 120; respiration, 20 to 36.
diagnosis.- First-degree mustard-gas burns of conjunctum, eyelids,
nose, lips, wrists, axillae,
buttocks, penis, scrotum. Membranous laryngitis, esophagitis,
pharyngitis, tracheitis, and bronchitis. Purulent
bronchiolitis. Bronchopneumonia. Pulmonary edema. Acute lymphadenitis
of regional lymph nodes. Cardiac
dilatation. Cloudy swelling of liver and spleen.
appearance.- Cyanosis of face and scalp. There is considerable
desquamation of the skin over the
buttocks, to a less extent in the neighborhood of the armpits. Also
some on the undersurface of both wrists, about
both knees, and in both popliteal areas. There is extensive necrosis of
the superficial layers of the epidermis with
sheetlike shedding of this necrotic skin. Underlying base, quite clean
and moist. A similar picture is seen over the central surface of the
scrotum and under surface of the penis. There are also superficial
burns about the nostrils, lips,
and eyes. In these areas necrotic skin is covered by brown scabs. The
necrosis extends a small way into both nostrils
and a little beyond the line of closure of the lips. Both conjunctivai
considerably injected, and over the left cornea
there is a wedge-shaped area of grayish thickening a few millimeters in
diameter. The eyelids are somewhat puffy.
The pupils about equal, dilated 5 mm. The greater portion of the nasal
and buccal mucosa is pale. Teeth and gums
in fair condition. Chest, abdomen, and extremities, except for burns,
natural looking. Over the buttocks and wrists
there are areas of superficial ulceration. The bases clear. In the left
lumbar region behind there is an area of superficial ulceration about
2.1 by 1.5 cm. covered by a dense brown-black scab. About this area
there is a zone of
desquamated superficial epidermis. There is considerable desquamation
of the superficial epitheliuni of the scalp.
No definite ulceration, however.
findings.- Pleural cavities: On opening thorax pleural cavities
no abnormalitics. Heart: Is
enlarged somewhat to the right. Weighs 400 grams. All chambers,
particularly the left ventricle, moderately dilated.
Dilatation most marked in the conus. No abnormalities except
endocardium of the left ventricle diffusely thicker
than normal. The myocardium is boiled in appearance. Right lung:
Weighs 650 grams; left lung, 530 grains. All
lobes voluminous and soggy. In addition in the right upper lobe a
solid patches of good size are felt. Over one
of these the pleura is slightly glazed, glistening everywhere else. The
glands at the hilum greatly enlarged, pulpy, edematous, injected. The
bronchial tree throughout shows almost
complete necrosis of the epithelium. Only here and there are islands of
intact mucosa observed. The underlying
tissue is intensely injected, and in the smaller branches there are
almost occluding fibrinous casts. In places the finer
bronchioles contain viscid pus. This picture is present in all lobes.
In addition there are scattered areas of whitish-yellow consolidation.
In some places these solid patches are associated with atelectatic
lung, in others there is no
associated atelectasis. The solid areas, varying in size from grape
seed to walnut, are most numerous in the right
upper lobe. Some are present in the right lower. A few small patches
only in the left lower and upper lobes. In
addition all lobes contain a moderate to considerable amount of thin
frothy fluid in the air sacs. The edema is most
marked in the upper lobes. Between the lobes on the right there is a
very small amount of fibrinous exudate. Here
also there are a few small discrete red hemorrhages below the pleura.
There is a moderate number of discrete recent
sub- pleural hemorrhages between the left upper and lower lobes.
Organs of neck: The anterior mediastinal, tracheal,
and cervical glands, especially those in the lower portion of the neck, greatly swollen,
edematous, injected. Thyroid,
no abnormalities. Acini contain considerable colloid. The trachea and
larynx show practically complete necrosis of
the epithelium. In places the necrotic epithelium is gone, and in
places it is present and readily strips. The underlying
tissue intensely injected, especially marked lower down in the trachea.
In the lumen there is some fibrinopurulent
exudate. In the larynx, affecting the epiglottis and vocal cords true
and false, in addition to the necrotic epithelium
there is a considerable amount of caked fibrinous exudate. Epithelium
and exudate strip fairly readily. The upper
portion of the esophagus presents picture similar to that of the
larynx. The posterior pharynx, especially about the
uvula, similar in appearance. Tonsils are somewhat enlarged, buried, in
part, scarred, in part pulpy. Many of the
crypts contain viscid or caked
purulent and necrotic material. Alimentary tract: In addition to the
lesions in the upper
esophagus there is considerable digestion of the mucosa of the lower
portion and of the gastric mucosa. The
lymphoid tissue of the tract slightly more prominent than usual. The
large intestines considerably distended with
gas as far as the splenic flexure. Adrenals: There is some
diminution of the lipoid material in the cortex and in
addition the vessels in the deeper layer of the cortex injected. In
places there appear to be small hemorrhages. The
meseteric glands are slightly enlarged, pulpy, pale. The remaining
organs show no lesions of interest.
Microscopic examination.- Trachea: No preserved epithelium;
surface formed by a wavy hyaline band. No
exudate or membrane. Submucosa moderately edematous. Loose infiltration
of polymorphonuclears, lymphocytes,
and plasma cells. Glands show little alteration. Vessels dilated, few
capillary hemorrhages. Very few bacteria on
surface. Lungs: Bronchi present a variable picture. One shows
in one place a thick adherent fibrino-purulent
membrane, beneath which the epithelium is necrotic. On the opposite
wall the bronchus is lined with a single layer
of flattened nonciliated epithelium. (Fig. 30.) The picture in the
alveoli is a complicated one. There are areas of
lobular pneumonia, hemorrhagic in the periphery, which arc not
especially distinctive. The leucocytes are
fragmented. In the unconsolidated areas the alveolar septa are thick
and cellular. The cells include relatively few
polynuclears, but many large and small mononuclears, plasma cells, and
a fair number of eosinophiles. In the alveoli
are desquamated epithelial cells, entangled in a fibrinous matrix, over
which the regenerated cylindrical epithelium is
often growing. In some alveoli are sheets of cells with pale nuclei and
indefinite outline, probably actively growing
masses of epithelium. Some of the new cells are multinucleated. In
other alveoli there is a structureless coagulum
incompletely filling the space. A few cocci are present in the
pneumonic areas, especially the somewhat dilated
infundibuli. Elsewhere they are not found.
Bacteriological examination.- Smears of the bronchus show a large number
of Gram- positive and negative
diplococci; many tiny Gram-negative bacilli. Smears of the lung show a
few Gram-positive diplococci. Cultures
from the bronchus show Gram-positive cocci and numerous Grain-negative
diplobacilli (influenza). Cultures from
the lung show Gram-positive cocci, suggesting pneumococci.
poisoning of eight days' duration. Typical lesions of skin and
passages. Trachea had been cleaned of exudate.
No epithelial regeneration in section
examined. Bronchi showed early regenerative changes along with the
of the injury and the supervening infection. Lung showed in some areas
active bronchopneumonic lesions; in others,
as in previous case, epithelium in the alveoli was being restored and
the subsidence of the process is shown by the
presence of lymphoid and plasma cells in numbers. Eosinophilic
polynuclears were also found, with an edema which
is apparently not related to the pneumonic infection.
30.- Case 47. Mustard-gas burn, 8
days' duration. Longitudinal section of bronchiole, completely occluded
fibrinopurulent exudate. A few shreds of epithelium are
CASE 48.- W. G., 3322314, Pvt.,
Co. C, 109th M. G. Bat. Died,
November 8, 1919. 9 p. m., at Base
Hospital No. 87. Autopsy, November 9, 13 hours after death, by Lieut.
H. H. Robinson, M. C.
data.- Detachment exposed to 1,000 mustard-gas shells and 400 blue and greet] cross shells on
night of October 31, northeast of Xammes. Went to sleep in
headquarters' dugout, 4 a. in., October 31. When he
awoke the place was full of gas. Severe pain in eyes and chest;
vomiting. Admitted to Base Hospital No. 87 the
same day. Increasing bronchitis.
diagnosis.- Conjunctivitis. Acute tracheobronchitis. Suppurative
External appearance.- No cutaneous lesions. Edema of eyelids
crusts. Slight reddening of scrotum.
findings.-Trachea: From epiglottis down, reddened and
granular. Lungs: Minute foci of
consolidation, with small areas of atelectasis and marked emphysema.
Lumen of trachea and bronchi filled with
examination.- Bronchi: The epithelium is intact; there is an
albuminous exudate with
leucocytes in lumen. Wall inflamed and infiltrated with polynuclear
leucocytes. Lung: Small patch of beginning
bronchopneumonia. Alveoli are air containing. Alveolar capillaries are
congested and infiltrated with leucocytes
(polvnuelear). Liver and kidney: Cloudy swelling.
examination.- Staphylococcus and streptococcus in cultures from
occurred eight days after gassing. Nature of gas was somewhat
uncertain. Conjunctivitis and
reddening of scrotum suggest mustard gas, but there were no typical
cutaneous lesions and the bronchi did not show
the usual diphtheritic necrosis. The material and records of this case
CASE 49.- A. H. P., 2214110, Pvt., Co. G, 4th
Inf. Died, August
4, 1918, 12.30 p. m., at Base Hospital No.
46. Autopsy No. 2. Autopsy, August 4, four hours after death, by Capt.
Robert Benson, M. C.
data.- Patient's burns confined to lower extremities and scrotum.
Considerable irritative effects of
gas could be seen over entire body. Prognosis seemed favorable until 24
hours before death, when patient became
delirious and finally toxic. The heart showed the effects of the
toxemia and became definitely rapid and weak.
Twenty-four hours before death patient had numerous illusions in which
he imagined himself in the trenches
performing very difficult tasks. At all times he was very restless and
complained a great deal of pain about the
various parts affected by the gas. Twelve hours before death patient's
pulse became almost imperceptible and patient
entered a state of coma from which it was almost impossible to arouse
him. Restlessness continued until death.
diagnosis.- Extensive first and second-degree burns of trunk,
extremities and genitalia. Edema
and congestion of lungs. Pericardial effusion. Cloudy swelling of liver
appearance.- Surface layers of epidermis denuded and underlying
of deep red color over
greater portion of right arm, upper three-fifths of left arm, greater
part of back, nearly whole left flank of trunk, both
buttocks, about half of each thigh, greater portion of right leg,
portion of left leg, and over penis and scrotum.
findings.- Pericardial cavity: Contains 75 c. c. of clear fluid.
Both pleural and parietal surfaces show
petechiam. Lungs: The anterior portion is normal; posteriorly,
are dark reddish blue in color with many petechize.
Bloody fluid exudes on section. Heart normal. Alimentary tract normal
except for reddened duodenal mucosa. Left
adrenal, dark red in color, almost black in places. Right adrenal,
somewhat enlarged but normal in appearance.
Trachea and bronchi, apparently were not examined.
examination.- Lungs: Bronchial epithelium is intact. There is no
exudate in the lumen. Alveolar
capillaries are tortuous and congested. Slight epithelial congestion
and hemorrhage, but no pneumonia. (Two blocks
examined.) Adrenals: Show
excellent preservation. There is no
chromaffin staining of the medullary tissue (Zenker's
precise data are given as to the date of gassing. Since he was admitted
hospital on July 27, the duration of life after gassing must have been
over eight days.
are important omissions in the protocol and material for histological
examination, since no mention is
made of lesions found in the trachea and bronchi, and no sections of
these tissues are available. The smaller bronchi
showed an intact mucosa and no inflammatory or degenerative changes.
The lung tissue itself was congested and
edematous, but there was no pneumonia. So far as these findings go,
they argue against mustard gas inhalation in
concentration, and this is borne out by the
clinical history, which emphasized the mental symptoms, but does not
record any respiratory complications. The cause of death in this case
is therefore obscure, although the extensive
skip lesions with characteristic distribution make it certain that the
soldier had been exposed to mustard gas.
CASE 50.- R. P., 2214109, Pvt., Co.--, 4th Inf.
Died, August 4,
1918, 10.15 a. m., at Base Hospital No. 46.
Autopsy No. 1. Autopsy, August 4, three hours after death, by Capt.
Robert Benson, M. C.
Clinical data.- On admission patient was found
extensive burns over entire back and legs, involving
both anterior and posterior surfaces of legs and scrotum. At first
patient's appetite was fairly good and he was
mentally rational, but patient was seen to be suffering from
considerable toxemia. Later as toxemia advanced patient
became irrational, stuporous. Temperature remained fairly high; heart
action fairly good until 10 hours before death,
when it became rapid and irregular. At this time patient became
comatose and remained so until death.
diagnosis.- First and second degree burns from
chemical irritant. Pulmonary
edema. Bronchopneumonia, left
lower lobe. Pericarditis with effusion.
appearance.- The skin is denuded over large portion of the body,
namely, over left arm from wrist
to shoulder, right forearm, whole of left flank, back of trunk. Surface
epithelium in these areas is denuded and
underlying skin of a deep crimson color. There are a few areas 6 to 8
mm. in diameter in which the deeper tissue is
destroyed. Right lower leg and both buttocks are also affected. Skin
over penis and scrotum is deep red and swollen
but not denuded. Foreskin is greatly swollen but completely covers the
Gross findings.- Pleural cavities: Lungs show no adhesions. There is no fluid
in the ravities. Left lung: Is
somewhat firm; over both lobes are areas of annular deep red spots 4 to
8 mm. Cut surface of lower lobe is reddish
gray in color and large amount of fluid exudes. The upper lobe is
similar but contains more air and is less firm. The
pleura, especially in the areas between the lobes, is greenish and
edematous. Right lung: Lobes on section, are
reddish gray and exude a large amount of blood. Pericardial cavity:
Contains fully 50 c. c. of thin watery fluid. A
peculiar pungent odor is observed. Heart:
Normal. Remaining organs
show no significant lesions. Trachea
apparently was not examined.
Microscopic examination.- Lung: Largest bronchus, in section
shows practically coIn- plete necrosis of
epithelium. Membrana propria is swollen and hyaline, resting upon a
layer of new formed granulation tissue,
infiltrated with polvmorphonuclear leucocytes and mononuclear
leucocytes. In the lumen is an exudate containing
numerous Gram-positive and negative cocci. Other bronchi contain an
exudate but show a normal epithelium. Infundibula are somewhat
distended and surrounded by areas of lobular
pneumonia, with very little fibrin and cellular
exudate of predominately polymorphonuclear leucocytes. There is marked
congestion and patchy edema. Liver
shows caryolytic changes in many of the cell nuclei.
case similar in many respects to the preceding, and since the patient
to the same company, was admitted to hospital the same day and died on
the same day, the
duration of life after gassing was probably the same, namely, over
eight days. The skin burns
were very extensive, but no mention is made of ocular lesions. The
findings in the trachea and
bronchi are not given in the protocol and no histological material was
preserved. Lung sections
showed a bronchiolitis and a peribronchiolitis, the injury to the
epithelium varying. Complete
necrosis with membrane formation, such as one would expect to find at
this stage of mustard-gas
poisoning, was nowhere present. These two cases therefore differ
somewhat from the usual
picture: (1) Clinically, in the marked mental disturbance. (2) In the
absence of ocular lesions. (3)
In the relatively slight lesions of the lower respiratory tract. It is
unfortunate that the records and
material are incomplete. It is possible that in these cases the toxemia
was comparable to that seen
in burns involving
a large part of
the body surfaces. It is possible also that the patients were poisoned
other irritant gas, possibly an arsene compound, and that the
divergence from the usual picture is
due to this. No evidence is at hand to decide the question.
CASE 51.- J. M., 2181256, Corpl., Co. A, 355th
Eng. Died, August 16, 1918, Base Hospital No. 116.
Autopsy No. 16. Autopsy, 10 hours after death, by Lieut. B. S. Kline,
Clinical data.- Mustard-gas inhalation and
incurred August 8, 1918. First degree burns of face,
neck, scrotum, penis, and conjunctiva. On August 12, auricular
fibrillations; coarse râles on both sides; labored
respiration. August 14, restless and delirious. Last three days signs
of bronchopneumonia; purulent sputum; pus and
blood from nostrils; edema of face and eyelids.
diagnosis.- Gas burns of skin, conjunctivae, lips.
Acute fibrinous pharyngitis, esophagitis,
laryngitis, tracheitis, and bronchitis. Acute peribronlchitis. Broncho-
pneumonia. Pulmonary edema. Serofibrinous
pleurisy. Acute fibrinous pericarditis.
appearance.- Skin in general has a slightly bluish tinge, backs of
hands, face to a slightly less
extent, thighs and upper legs show a diffuse brownish pigmentation.
Superficial areas of ulceration of epidermis of
genital folds of scrotum and penis, about both lips, right nostril,
over left eye, and under surface of both knees,
where there is desquamation of the skin with apparently new epidermis
belovw. There is considerable caked
desquamation of the scalp, about the ears, chin, and also in the region
of the superficial ulcerated areas mentioned
above. Along the inner aspect of both thighs, at some distance from the
ulcerated areas, there are numerous pinpoint
to pinhead sized vesicles. Eyelids are edematous; there is a moderate
amount of mucopurulent exudate between the
lids. Conjunctiv e are injected with small dark-red hemorrhages.
Moderate amount of mucopurulent exudate in
Gross findings.- Thorax: Left pleural cavity
700 c. c. of slightly turbid yellow fluid in which are
flecks of fibrinous exudate suspended. Pleural and pericardial
adhesions on both sides. Pericardium: Both visceral
and parietal layers swollen, diffusely injected, and covered by
moderate amount of fibrinous exudate, binding the
two layers together. Heart: Right side is dilated. Myocardium
is opaque and flabby. Lungs: Right upper and lower
lobes are much more voluminous than normal, cushiony, and soggy. In the
lower lobe solid patches are palpable.
The middle lobe more voluminous than normal, cushiony, slightly soggy.
The lower lobe shows a congenital fissure
7 cm. long from the interlobar septum. Pleura posteriorly and between
the lobes shows a small amount of fibrinous
exudate. The glands at the hilum moderately enlarged, pulpy, edematous,
injected, pigmented, show in places old
scars. Bronchi: Mucosa is moderately swollen and intensely
injected, covered in places by fibrinous and
fibrinopurulent exudate. There is mucopurulent exudate and thin frothy
blood-tinged fluid. On section, upper lobe, a
moist pink surface presents. The air sacs contain a moderate amount of
thin frothy fluid. The smaller bronchial
branches contain a considerable amount of fibrinous and
fibrinopurulent exudate, friable in places, and practically
occluding the lumen. The walls of these small bronchioles show
considerable injection, and the lung tissue about
them likewise deeply injected for a small distance. In places in this
lobe there is a small amount of peribronchial
consolidation. The middle lobe on section presents a mottled pink and
red surface. The air sacs contain a small
amount of thin frothy fluid. The bronchi are similar to those in upper
lobe in appearance. The changes, however, are
not quite so marked. In the median portion there is an area of
atelectasis. Lower lobe on section presents a mottled
pinkish red and reddish purple surface. The bronchial changes are
similar to those described above. About the
bronchial branches there is considerable injection of the tissue, and
toward the periphery there are numerous
extensive areas of dull reddish-gray consolidation. Left lung: Upper
lobe is much more voluminous than normal.
Lower lobe somewhat collapsed. The vessels, glands, and bronchi similar
in appearance to those on the right. On
section of the upper lobe a pink and red surface presents. The air sacs
contain a moderate amount of thin frothy fluid.
The picture is quite similar to that of the right upper lobe. In this
lobe, however, there are a few consolidated patches
toward the periphery. The cut section passes through a large pulpy injected lymph
gland with numerous soft and
firm yellow opaque nodules, varying in size from less than a pinhead to
a grape seed.
The consolidation in this lobe is more marked
in the lower portion. On section of the lower lobe the tissue
is rubbery in consistency, poorly aerated, deep red. Bronchial tree
shows a picture similar in general to those
elsewhere. The pleura everywhere is glazed and covered by a large
amount of fibrinous exudate. On stripping this
exudate in places numerous injected vessels can be seen in the pleura. Neck
organs: Glands through neck
considerably enlarged, pulpy, edematous, deeply injected, especially
those in the lower portion. Thyroid: Of good
size, spongy, and gelatinous. There is a moderate amount of colloid in
the acini. Larynx: There is marked swelling
and injection of the mucosa, with small areas of ulceration, especially
about the true vocal cords. Within and
adherent to the mucosa there is consider- able amount of fibrinous and
fibrinopurulent exudate. In the trachea the
change is less marked. The mucosa is swollen, intensely injected. There
are scattered small flecks of yellow opaque
exudate. In the lumen there is much mucopurulent and some thin frothy
blood-tinged fluid. The posterior
plharyngeal wall and upper esophagus adjoining the glottis shows
considerable edema and injection of the mucosa;
covering the mucosa in several places there is a moderate amount of
adherent fibrinous and a small amount of
fibrinopurulent exudate. Tonsils:
Right tonsil not removed. Left tonsil somewhat swollen. On section
pulpy, edematous, injected, lymphatic tissue present. Crypts, clean.
Alimentary tract: No
abnormalities of esophagus
other than those mentioned above. Stomach contains a small amount of
mucus. The mucosa in the fundus is
somewhat swollen. The duodenum, the jejunum, and the ileum, no
abnormalities, except that the lymphoid tissue is more prominent than
normal. Appendix, cecum, colon, rectum, no abnormalities. The remaining
viscera show no
examination.- Trachea and large bronchi: No material
preserved. Lung: (Block A) Picture
that of late lobar pneumonia. Alveoli are filled with exudate in which
there are many fragmented leucocytes and
fibrin. Capillaries are thin, collapsed, and empty. Some alveoli are
being relined with irregular syncytial growth of
epithelium, amongst which are large cells with pale nuclei. (Block B) Intense
hemorrhagic edema and epithelial desquamation. Bronchi are distended
with solid plugs of exudate. Epithelium completely necrotic. (Block C)
Smaller bronchi are the seat of an intense necrosis, often with
fibrinous membrane formation. Peribronchial exudate
with much fibroblastic activity, especially in the thickened septa.
Alveoli contain an exudate which in places is
fibrinous, in others hemorrhagic, and others serous. There is not much
epithelial proliferation. Atria are filled with
purulent plugs. There is an edema of the interlobular septa. (Block D)
Evidently taken from the left collapsed lobe,
showing usual picture of atelectasis. It is interesting that the
bronchi in section show very
slight changes, their
epithelium being preserved and their lumina free from exudate.
Myocardium: Recent acute fibrinous pericarditis.
Liver, spleen, and kidneys normal.
examination.- Smears from exudate on right side of larynx show
innumerable Gram-positive and Gram-negative cocci. Smear from
consolidated lung show few Gram-positive cocci, most in
mustard-gas case, of eight days' duration, with multiple skin burns and
diphtheritic necrosis of the larynx, trachea, and bronchi. There was
pleurisy and percarditis. It is worthy of note that the bronchial
lesions in the atelectatic lobe were
less severe than elsewhere. The focal areas of pneumonia were not of
the influenzal type.
CASE 52.-P. B., 113251, Pvt., Co. B, 150th M.
G. Bat. Died, March 29, 1918, at Base Hospital No. 18.
Autopsy No. 53. Autopsy, 20 hours after death, by Lieut. B. S. Kline,
data.- Gassed on March 21, 1918. On same day, smarting of eyes,
burning and blistering of
scrotum, and following morning vomiting. Night of 22d, pain in chest
and coughing. On admission, severe
conjunctivitis. First degree burns of buttocks, thighs, and legs 5 cm.
below knee. Anteriorly from patella up to
scrotum and perineum. Severe burns of hands and fingers and forearms.
March 28, burns healing nicely, but patient
appears intoxicated. Acetonuria, March 29, semidelirious.
diagnosis.- Second-degree mustard-gas burns of skin over thighs,
Conjunctivitis. Acute pharyngitis, esophagitis, laryngitis,
tracheitis, and bronchitis. Bronchopneumomia. Marked
External appearance.- There is considerable hypostasis, with,
cyanosis of the face and extremities. From the
level of the symphysis downward anteriorly and posteriorly the greater
portion of the skin of the thighs shows almost
sheetlike necrosis, desquamation, and ulceration, which extends in
places a small way into the subcutaneous tissue.
The base shows patchy injection, and especially toward the genital fold
there is a moderate mount of moist, foul-smelling exudate. The penis
and the scrotum show necrosis of the epithelium with superficial
ulceration. There are
well-marked areas of ulceration over both buttocks. The burn continues
down and involves the popliteal area. The
most extensive ulceration is present over the backs of the hands and
undersurface of the wrists, where the
subcutaneous tissue is involved. The epithelium over the dorsal surface
of the wrists, hands, and to a less extent left
forearm is gone entirely. The base of the denuded tissue shows
considerable injection. There is a moderate amount
of exudate over the wrists. On the left the base is quite dry, brown.
There is some desquamation and superficial
ulceration of the left forearm. No involvement in the axillae . Slight
involvement of the eyes, especially the left.
Conjunctiva on this side moderately injected. Corneae show slight milky
thickening. There is a small burn at the left
angle of the mouth. There is some desquamation of the epidermis over
the abdomen, but no ulceration. Left leg and
left foot show few areas of necrosis of the epidermis without
ulceration, however. Nose: The mucosa is somewhat
swollen, slightlv injected. Mouth: There is superficial
ulceration of the lips along the line of closure. The buccal
mucosa beyond, however, pale, apparently uninvolved. Gums in fair
condition. A number of teeth poorly formed.
Gross findings.- Both pleural cavities: Free from adhesions. Each contains a few
centimeters of fluid. The
heart is enlarged somewhat to the right. Heart: The right
auricle and ventricle moderately dilated. Myocardium is
boiled, slightly greasy. No valvular lesions. Right lung weighs 655
grams. Pleura thin and glistening in great part.
Over the posterior portion of the left lower lobe, however, it is dull
gray, and there is a very small amount of
fibrinous exudate. Below the pleura, especially posteriorly, there are
innumerable discrete and in places confluent
hemorrhages varying in size from one to several millimeters. All lobes
are quite voluminous, especially both lowers
and the posterior portion of the uppers. These areas are soggy in
great part. Glands at the hilum are moderately
enlarged, pulpy, edematous, injected. The bronchial tree toward the
hilum shows considerable diffuse injection of
the mucosa without outspoken ulceration. In the lumen there is some
frothy blood-tinged fluid and some
mucopurulent material. In the smaller bronchial branches, especially in
the posterior portion of both lower lobes,
there is a fibrinopurulent exudate present, and in the posterior
portion of both upper lobes to a less extent. In the
tipper lobes there are numerous patches of consolidation, deep red, dry, granular, varying in size from
walnut. In addition both lower lobes and the posterior portion of both
uppers show a large amount of thin, frothy
fluid in the air sacs. The right middle lobe is relatively uninvolved.
The cut surface is pink. Organs of neck: The
mediastinal and tracheal glands are moderately enlarged, pulpy, and
edematous. Thyroid: Of average size, pale.
Acini contain a moderate amount of colloid. The neck organs present a
striking picture. There is moderate necrosis
of the epithelium of the posterior pharynx, upper portion of the
esophagus, larynx, and tipper portion of the trachea.
Associated with the necrosis there is a membranous exudate having a
necrotic greenish appearance. Throughout the
larynx and trachea there is considerable injection and swelling of the
mucosa with no ulceration. In the ulcerated
area the base is well in the mucosa. Tonsils fair size, buried, in part
scarred. The crypts in general are clean.
Alimentary tract: There is pigmentation of the solitary
follicles and Peyer's patches. No ulceration or hemorrhage.
Liver enlarged and fatty. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: Epithelium is lost and no pseudomembrane is
layers are congested, edematous, and infiltrated with round cells. Lungs:
Parenchyma is very much congested. There
are areas where the alveoli are filled with red blood cells, and the
alveolar walls are necrotic. There is no
inflammatory exudate. Bronchial epithelium is preserved. No exudate in
the lumina. Liver and kidneys show
examination.- Smears of exudate from the trachea show innumerable
Smears of the exudate from the lung show large numbers of Gram-positive
diplococci, lancet-shaped. Culture of
exudate from trachea shows Gram-positive diplococci and tiny
Gram-negative influenza bacilli.
of life after gassing was eight days. Lesions of the respiratory tract
not typical of mustard-gas inhalation. Absence of
necrosis in trachea and large bronchi, and
simple congestion and hemorrhagic edema of lungs without inflammatory
changes did not conform to the usual pictures. Histological material
was inadequate, but the clinical and gross
findings were sufficiently characteristic to justify a diagnosis of
mustard-gas poisoning. The marked post-mortem
changes in the adrenal and kidney, and other organs made the
interpretation of the findings in these organs difficult.
53.- L. P. G., 91249, Pvt., Co. K, 165th Inf. Died, March 29, 1918, at
Base Hospital No. 18. Autopsy
No. 50. Autopsy, four hours after death, by Lieut. B. S. Kline, M. C.
data.- Gassed on March 20 and 21.
On admission severe conjunctivitis (blindness). Many small blisters on
wrists and hands. Forehead hyperemic.
Superficial burns of scrotum and inner aspect of thighs. Generalized
coarse râles. March 25, eyes better.
Temperature elevated. Increased râles, cyanosis. March 27 and 28,
bloody sputum, bronchovesicular respiration
left axillae, dyspnea, and increasing rales.
diagnosis.- Mustard gas burns of conjunctivse and scrotum.
Fibrinous and fibrinopurulent esophagitis, laryngitis, tracheitis, and
bronchitis. Purulent bronchiolitis. Extensive
bronchopneumonia. Acute fibrinous pleurisy. Pulmonary edema.
External appearance.- There is considerable hypostasis; marked
cyanosis of left side of face and scalp, less
marked in lips and right side of face. Over the proximal portion of the
upper and lower extremities, especially in the
folds, there is much scaling of the epidermis and numerous groups of
pinpoint to pinhead sized vesicles, filled with
transparent fluid. This condition is present also over the upper and
lower back and is most marked on the backs of
the hands, scrotum, and penis, where there are outspoken first-degree
burns. There are several superficial ulcerated
areas covered by scabs about the lips. Superficial glands are palpable.
Eyes: The right pupil is larger than the left, 4.5
mm.; left, 3 mm. Bulbar and palpebral conjunctive somewhat swollen,
show extensive patchy injection, and on the
left side particularly there are good-sized deep red hemorrhages below
the conjunctivae. The lids are somewhat
puffy and glued together by caked exudate. Nose: Both nostrils contain
clotted blood. Mucosa not appreciably
swollen, but pale. Mouth: Teeth in fair condition. Gums quite
clean. Buccal mucous membrane pale, apparently
findings.- Pleural cavities: A few cubic centimeters of fluid in
each pleural sac. No fibrous adhesions.
Heart enlarged somewhat to the right. Heart: Weighs 375 grams. The
heart is somewhat enlarged. The tricuspid and
pulmonary rings moderately stretched. The conus is greatly dilated.
Left ventricle moderately dilated. Valvular
endocardium, no abnormalities. Chambers contain large elastic clots.
Lungs: Right, weighs 630 grams. Left,
weighs 475 grams. All lobes are moderately voluminous. Upper and middle
lobes cushiony, somewhat soggy. The
lower lobes soggy and solid. Covering both lower lobes posteriorly
there is a moderate amount of fibrinous exudate.
In these regions and also in the interlobar areas there are numerous
subpleural pinhead sized red hemorrhages.
Glands at the hilus on each side greatly enlarged, pulpy, edematous, moderately injected, some
areas show scarring.
The bronchial tree throughout presents a striking picture. There is
practically complete desquaination of the
epithelium. The submucosa is apparently injected and covered by a layer
of friable to elastic coherent light whitish-yellow exudate, in the
larger bronchi over 1 mm. in thickness. These fibrinous masses form a
large cast of the
bronchi and are readily stripped from the walls. The process is most
marked in the lower lobes, is present also in the
right upper and middle, and less marked in the left tipper lobe. In the
finer bronchioles of all lobes,
but most marked
in both lowers and the right upper, the exudate is viscid purulent,
rather than fibrinous. Associated with some of
these areas of purulent bronchitis there are patches of gravish red
consolidation of the lungs. These areas of consolidation are most
numerous in the lower lobes, perhaps more numerous
in the left than the right, and here they vary
considerably in size up to large walnuts. In addition all lobes,
especially the lower, show a moderate amount of thin
frothy fluid in the air sacs. Organs of neck: The cervical and
tracheal glands are considerably swollen, pulpy,
edematous, apparently injected. Thyroid, no abnormalities. Larynx and
trachea present a striking picture, the
edematous, practically entirely gone. Attached to the underlying
submucosa which lines the considerably injected
lower portion of the trachea there is a layer of exudate,
riable and elastic, like that in the bronchi
and about 1.5 mm. in thickness. This exudate practically forms a cast
trachea and of the greater portion of the larynx. Both vocal cords are
covered. There are, however, several islands
uncovered by exudate in the larynx. The exudate is coherent and strips
quite readily in one mass from the walls. The
process is quite similar at the base of the tongue and at the upper
portion of the esophagus down to the level of the
mid-portion of the thyroid cartilage. Tonsils, buried, cryptic, and
somewhat scarred, in part pulpy. Crypts in general
clean. Alimentary tract: There is some suggestion of pigmentation of
the pharyngeal epithelium in patches in the
mid-portion. There is considerable digestion of the gastric mucosa
and toward the pylorus, apparently ante-mortem,
small hemorrhages below the mucosa. No other abnormalities in the
tract. Mesenteric glands are somewhat swollen.
The remaining organs show no significant lesions.
examination.- Trachea: There are patches of a very thick
fibrinopurulent membrane still
adherent. The injury to the subepithelial connective tissue has been
very deep in some places extending almost to the
cartilage. In other places, the preserved tissue is thicker, but
edematous, and hemorrhagic, with exudate of fibrin and
polynuclears. In those areas where the destruction was greatest, the
mucous glands have practically disappeared, only
a few atrophic acini remaining. The original epithelium has doubtless
been destroyed, buta new layer of flattened
and highly atypical cells, apparently derived from the mucous ducts, is
interposed in places between the edematous
subepithelial connective tissue and the overlying membrane. The new
cells are pale and hydropic; many of them
have pale nuclei of excessive size. Bronchi: The changes are
like those in the trachea. The lumen of one of the larger
branches is almost obstructed by the thick partly detached membrane.
The wall of the bronchus is thickened by
inflammatory changes, but in the deeper portions between the cartilage
rings there is active growth of new
connective tissue. There is almost complete reinvestment with atypical
flattened epithelial cells like those in the
trachea, but they seem to be leading a precarious existence, many of
them showing evidence of degeneration. Some
of the medium sized bronchi are greatly thickened by an active growth
of granulation tissue about them. This fuses
into the organizing tissue about the arteries, where they are
juxtaposed. There is no obvious dilatation.
Organization of the fibrinous exudate in the edematous interlobular
septa is also in progress, many fibroblasts and
occasional new forming vessels being found. Parenchyma: There
are confluent areas of lobular pneumonia. The
exudate contains many well preserved polynuclears in places mixed with
fibrin or coagulated serum. It is not
hemorrhagic. There is no organization and no obvious epithelial
proliferation. The bronchioles and atria are lined
with well preserved, though often desquamated, ciliated cells. They are
filled with purulent exudate.
54.- R. G., 93377, Corpl., Co. D, 166th Inf. Died, October 8, 1918, at
Justice Hospital, Toul. Autopsy
No. A-8. Autopsy, October 8, - hours after death, by Capt. Jean Oliver,
data.- Gas intoxication, mustard-gas, severe, incurred October 1.
diagnosis.- Second degree burns of eyes, mouth, and scrotum.
bronchitis, and bronchopneumonia. Marked hyperemia and edema of the
full autopsy report is not available. The following is a description of
the gross specimens received at the
experimental gas field.
findings.- Left lung: In the upper lobe there are small groups of
abscesses beneath the pleura with
overlying fibrinous pleurisy. Bronchi to these areas show slightly
dilated lumina and in the terminal portions are less
severely injured than the larger bronchi. There is no extensive false
membrane. Lower lobe shows lobular
pneumonia with beginning pleurisy. One bronchus shows thickened opaque
mucosa (squamous epithelium ?). Right
lung: Shows scattered areas of fibrinous pleuritis. Necrosis of
bronchial epithelium and false membrane do not
extend beyond the second branching, outside of which the mucosa is both
hyperemic and smooth. Lumina contain
fibrin plugs. There is marked patchy edema, and hemorrhage and
atelectasis about the smaller bronchi.
examination.- Trachea: The epithelium is desquamated and necrotic.
The denuded surface is
covered with necrotic pus cells and fibrin. Larger bronchi: The
surface epithelium is wholly lost. Bronchus is lined
with necrotic material upon which are flakes of adherent slough.
Superficial tissue is elsewhere invaded with
polynuclears, the nuclei of which become progressively fragmented as
they approach the surface. Bacteria are
chiefly Gram-positive cocci, which are
plentiful on the surface and in the adherent slough. The submucosa is
edematous and infiltrated with wandering cells, among them many
polynuclears and many fibroblasts. Vessels are
intensely congested, not thrombosed. Mouths of the ducts of the mucous
glands contain exfoliated cells. Cells lining
the ducts are of the flat squamous type and tend to creep over the
adjacent tissue. Adherent lymph node shows
caseous foci. Inflammation of submucosa extends between the cartilages
to involve the periglandular areolar tissue.
There is much inflammatory exudation, fibrin, etc., and a focal area of
suppuration in which no bacteria are
demonstrable. Medium-sized bronchus: Is lines with membrance composed
of dense layers of leucocytes enmeshed
in a fibrin network. Bacteria, chiefly Gram-positive cocci, in small
groups (staphylococcus) are abundant throughout this layer. The
bronchial wall itself is edematous and shows
inflammatory infiltration. The adjoining alveoli are
filled with dense plugs of fibrin, passing over from one alveolus to
another. In it are a few desquamated alveolar
cells and leucocytes. External to this, the alveoli are collapsed and
there is abundant hemorrhage. Lung: The
epithelium of the terminal bronchioles and infundibula is well
preserved. There is a great variety in the contents, as
in the alveoli. In some alveoli, the exudate is more or less
homogeneous. In others the coagulum is mixed with
fibrin, red blood cell, etc. Some alveoli are filled with desquamated
pigment-containing cells. Capillaries are
congested. There is no periarterial edema. Section through eyelid:
There is a superficial desquamation of the
epidermis at the junction of the epidermis and mucous membrane. There
is partial necrosis with edema, hemorrhage,
and leucocytic infitration of the underlying corium. The hair follicles
show varying degrees of necrosis.
NOTE.- The duration of
gassing was eight days. Findings were typical of severe
mustard-gas burns of skin and respiratory passages. There were very
early attempts at
regeneration in the trachea and lungs. The lungs showed suppurative
foci and in one area there
was slight bronchiectatic dilatation.
55.- W. B., 1025112, Corporal, Co. G, 34th Inf. Died, November 8, 1918,
at Base Hospital No. 87.
Autopsy No. 5. Autopsy, November 9,--hours after death, by Maj. M. C.
Farr, M. C., and Lieut. H. H. Robinson, M.
data.- Severely gassed with mustard gas on October 31, 1918.
Symptoms began with dyspnea and
vomiting. Later, moist bubbling rȃles throughout.
diagnosis.- Slight mustard-gas burns of scrotum. Estensive
pigmentation. Fibrinous and necrotic
pharyngitis, laryngitis, and tracheitis. Purulent bronchitis.
Peribronchial pneumonia. Acute fibrinous pleurisy.
Intense edema and congestion of lungs.
appearance.- There is deep brownish pigmentation of skin of face,
neck, scalp, shoulders, back,
and flexor surface of arms. There is an apronlike patch over the
abdomen and a triangular area with apex downward
at pubis, extending over genitalia and anterior aspects of the thighs.
There are some slight erosions and thickening of
the skin over scrotum.
findings.- Pleural cavities: There is no free fluid. There are a
fresh adhesions over the right lower
lobe. Heart normal. Lungs: Are voluminous and heavy, and do not
col- lapse. Firm and elastic on palpation,
especiaUy at the bases. On section, of a uniform appearance. Diffuse
copious edema. No definite pneumonic areas.
Drops of pus can be expressed from the bronchioles. There are patches
of fibrin over the posterior surface of both
upper lobes and over the entire right lower lobe. Organs of neck:
Tonsils are scarred and fibrous. Pharynx is
reddened and there are a few small necrotic membranous patches.
Epiglottis, larynx, trachea, and bronchi are
covered with an adherent necrotic membrane, somewhat patchy in its
distribution. Alimentary tract normal.
remaining organs show no lesions of interest.
examination.- Trachea: The epithelium is completely
destroyed. There is a pseudomembrane
consisting of fibrin network in which are numbers of polynuclear
leucocytes and in some areas numerous bacteria.
Submucous layers are edematous, vessels are congested, and there is
infiltration by polymorphonuclear leucocytes
and a few lymphoid cells, even as deep as the submucous glands. No
metaplasia, regeneration, or fibrosis. Larger
bronchi: Show the same lesions as the trachea. There is marked
peribronchial inflammation with hemorrhage and
fibrinous exudate in the alveoli. Terminal bronchioles
show an intact epithelium, which, however, is
invaded by leucocytes. There is pus in the lumina. Lungs: Show
marked dilatation of the terminal bronchioles and infundibula, many of
which are completely filled with loose
fibrinopurulent exudate. There are strips of apparently well-preserved
epithelium lying detached in the exudate or
partially investing the walls of the bronchioles. In some bronchi, the
necrotic lining is replaced by vascular
granulation tissue. The alveolar exudate is of varying composition.
There are areas which are emphysematous but
entirely free from pneumonic changes. The peribronchial character of
the consolidation is very evident. There is no
periarterial or perivascular edema.
report.- Cultures from trachea and lungs yield staphylococci and
mustard-gas case of eight days' duration. Extensive diphtheritic
of trachea and bronchi. Characteristic peribronchial lesions, and
rather widespread edema.
There was an early fibrosis of the bronchial walls and no epithelial
CASE 56.- R. L., Pvt., 2088261, Co. A, 355th
Inf. Died, August 17, 1918, at Base Hospital No. 42. Autopsy
No. 1. Autopsy, August 18, 24 hours after death, by Lieut. B. S. Kline,
Clinical data.- Exposed to heavy shelling for 6
yellow, blue, and green cross shells on August 8.
Admitted to Field Hospital No. 325, with diagnosis "Gas inhalation,
delirious, burns of eyes and genitals." On
admission to Base Hospital No. 42, diagnosis of diffuse bronchitis,
followed by bronchopneumonia. Respiration
labored, inspiration and expiration prolonged. Temperature 103.6°
diagnosis.- Extensive gas burns of skin and superficial mucous
membranes, conjunctive, lips,
and respiratory tract. Membranous and fibrinopurulent pharyngitis,
esophagitis, laryngitis, tracheitis, and purulent
bronchiolitis. Extensive peribronchial pneumonia. Acute fibrinous
pleurisy. Pulmonary edema, marked. Cloudy
swelling of liver and kidney. Lymphoid hyperplasia of spleen,
intestines, and lymph nodes. Adenomata of thyroid
appearance.- The skin of the
penis and scrotum shows considerable ulceration of the epidermis,
associated with desquamation in the neighborhood. The base of the
ulcers covered with some soropurulent exudate.
The skin about the nose and lips shows considerable ulceration, the
base covered by a thick brown scab. There is a
similar burn of the mucous membrane of the lips, especially the lower,
covered with a thick brown scab. At the bend
of both elbows and on the inner aspects of both thighs there are many
pinpoint to pinhead sized vesicles filled with
clear fluid. No ulceration of these areas. There is a however, some
desquamation of the skin. A similar picture
presents in both axillae. Eyes: In the skin of both upper lids
there are a few superficial ulcerated areas covered by
red-brown scabs. The bulbar conjunctivae are somewhat edematous,
considerably injected. There are scattered small
deep red hemorrhages. Over the cornea there is a small amount of
muco-purulent exudate. Pupils: 4 mm. in
diameter. Ears: No abnormalities. Nose: The superficial ulceration
extends into both nostrils, affecting the mucous
membrane for a distance of 1 cm. on each side. The ulceration is
covered by a brown scab. Mouth: Teeth in fair
condition. Some slimy, cheesy material over the gums.
findings.- Pleural cavities: On opening the thorax, the right
pleural cavity contains about 30 c. c. of
slightly turbid yellow fluid. There is a small amount of fibrinous
exudate over all lobes. In the left pleural cavity
about 15 to 20 c. c. of similar fluid. Heart enlarged slightly to the
right, right border reaching almost to the
costochondral line. On incising the pericardium there are no
abnormalities in sac. The parietal pericardium toward
the right lung shows a number of tiny deep-red hemorrhages. Heart:
Weighs 325 grams. Right auricle and ventricle
dilated. Left ventricle and
auricle contracted. Otherwise, normal. Right lung: Middle lobe is
There is no fissure medially separating it from the upper lobe. All
lobes are voluminous. The upper lobe and upper
portion of the middle are cushiony and inelastic. The lower portion of
the upper lobe and the lower lobe are soggy
and solid. The pleura everywhere except medially, and here also, in
places, is glazed and covered by small amount
of fibrinous exudate. Vessels at the hilum; no abnormalities. The
bronchial lymph nodes are greatly swollen, pulpy,
edematous, deeply injected. pigmnented. Bronchi: The mucosa
shows considerable ulceration. The underlying sub-
mucosa is intensely injected, somewhat
swollen. Covering intact and ulcerated mucosa; there is a large amount
fibrinous and fibrinopurulent exudate, which in places forms a
membrane. In the smaller branches the lumen is
almost occluded. Upper lobe on section presents mottled moist pink and
red surface. Air sacs contain a moderate
amount of thin frothy fluid. Medially there is a small egg-sized dull
reddish-gray patch of consolidation. The tissue
is relatively dry and slightly granular. In the posterior and inferior
portions of the lobes the smaller bronchi show
considerable amount of fibrinopurulent, and more peripherally
purulent, exudate. The walls of the bronchioles are
injected throughout, and the lung tissue adjoining for a distance of a
few centimeters in places is consolidated,
grayish red, dry and granular. On section of the lower lobe a moist
pinkish-red and deep-red surface presents. Air
sacs contain a moderate amount of thin frothy fluid. Left lung:
Both lobes are more voluminous than normal. The
upper lobe, upper portion, cushiony, inelastic. Lower portion, soggy
and solid. Lower lobe, soggy, solid patches flat
in places. The pleura, vessels, bronchi, and lymph glands similar in
appearance to those on the right. The left upper
lobe on section presents a mottled pink and red surface. The air sacs
contain a considerable amount of thin, frothy
fluid. Medially there is a large uniform consolidated area about the
size of a large orange. The consolidation
resembles gray hepatization. There are no intervening aerated areas. In
the mid-inferior and posterior portions there
are areas of peribronchial consolidation and larger bronchopneumonic
patches. The lower lobe on section presents a
red and mottled reddish-purple surface. The changes are similar to
those in the right lower lobe. Organs of neck: The
glands throughout, especially marked in the lower portion, considerably
swollen, pulpy, injected. Thyroid: Average
size, tissue spongy. The acini contain but a moderate amount of
colloid. In the right lobe there is a large filbert-sized, sharply
circumscribed area, the tissue at the periphery resembling the
neighboring tissue somewhat. The
architecture is finer, however. The greater portion of the tumor has an
almost uniform gelatinous translucent, faintly
green-tinged appearance. Near by there is a grape-seed sized mass
similar in appearance. Larynx: Shows
considerable swelling of the mucosa. In places, especially about the
true vocal cords, there is some ulceration of the
mucosa. The picture throughout the trachea is similar. Covering intact
and ulcerated mucosa, there is an adherent
membranous mass of fibrinous and tenacious fibrinopurulent exudate. The
process is similar in character and almost
as extensive in the upper esophagus, posterior pharynx, and base of
tongue. The mucosa and deeper tissues here are
considerally swollen, mucosa greatly injected. In places there is some
ulceration, and covering it there is fibrinous
and fibrinopurulent exudate. Tonsils: Somewhat enlarged,
buried. On section there is a small amount of lymphoid
tissue present. There is some scarring. Some of the crypts contain
inspissated material. Alimentary tract: Esophagus
below the area mentioned above shows no abnormalities. Stomach shows
considerable post-mortem change.
Duodenum, jejunum, and ileum: No abnormalities, except
that the lymph
tissue is somewhat more prominent than
normal. Toward the lower end of the ileum the Peyer's patches have a
shaven-beard appearance. Mucosa
everywhere intact. Appendix
shows some injection of the mucosa toward
the distal end. The eccum is considerably
dilated. The lymphoid tissue in the cecum and large intestine is
somewhat more prominent than normal. No other
abnormalities of the colon or rectum. Mesenteric glands are somewhat
enlarged, pulpy Some show moderate
injection. Liver: There are focal areas of fat infiltration.
The remaining organs show no significant changes.
examination.- Trachea: Shows a thick fibrinous membrane still
adherent in places. Fibrin
threads ramify in the superficial portion of the submucosa. Bacteria,
chiefly Gram-positive cocci, on surface.
Polynuclear infiltration with mononuclears predominating in deeper
tissues. Congestion is marked, but there is little
hemorrhage. Epithelitim is destroyed even in the duets of the mucous
glands. Lung: There is an infarct-like area at
the margin of which the lung tissue shows merely intense congestion and
slight alveolar hemorrhage. In the infarcted
area, the medium sized bronchi show a necrosis of the bronchial wall
down to the cartilage. They are found with
thick membranes, composed of meshwork of coarse fibrin, including
nuclear fragments and bacterial masses. What
remains of the lumen is filled with masses of degenerating
leucocytes-bacteria, and the necrotic wall of the bronchus
is infiltrated with pycnotic leucocytes. One dilated infundibulum is
filled with i a plug of fibrinotis material, of loose
mesh, with leucocytes. About the necrotic bronchi there
is intense hemorrhage, in places with
necrosis of the alveolar septa and decolorization of blood cells. At
periphery of the infarct are groups of alveoli filled with pneumonic
exudate; many bacteria, cocci predominating.
examination.- Cultures of trachea: Staphylococcus aureus,
Gram-negative bacilli. Lung same flora as trachea.
NOTE.-The duration of
gassing was nine days. The case illustrates a very severe type
of mustard-gas injury with necrosis in many of the bronchi, involving
the entire wall, and
leading to extensive hemorrhage in the adjoining tissue. It is by the
confluence of such adjacent
hemorrhagic areas with subsequent necrosis of the more central
portions, and a reaction of the
fixed elements at the periphery, that the infarct-like areas described,
are formed. There was a
massive bacterial infection in the walls of the necrotic bronchi. The
injury was so intense that
even the cartilages in some of the bronchi were destroyed. Because of
the complete loss of all
of the epithelial elements, including the ducts of the mucous glands,
no regeneration took
CASE 57.- W. J. B., 91290,
Pvt., Co. K, 165th Inf. Died, March 29, 1918, at 6.45 a. m., at Base
No. 18. Autopsy No. 51. Autopsy, 10 hours after death, by Lieut. B. S.
Kline, M. C.
Clinical data.- Gassed on March 20. On admission, severe
conjunctivitis, second degree burns of right eye,
nose, forehead, nasal mucosa. Pulse rapid. General rales. March 24,
elevated temperature. No definite consolidation.
Pain in chest. Respiration difficult. From this time until death
temperature remained above 102°.
diagnosis.- Mustard-gas burns of skin,
conjunctive, nasal and buccal mucosa, scrotum.
Membranous esophagitis, laryngitis, tracheitis, and bronchitis.
Purulent bronchiolitis. Extensive bronchopneunionia. Acute
fibrinous pleurisy. Marked pulmonary edema. Cloudy swelling of
liver and kidneys.
appearance.- There are superficial gas burns of the forehead and
face, particularly marked over
both upper and lower eyelids on the right side. Also present about the
left eve and nostrils and lips. There is also a
first degree burn of the scrotum. All burns are covered with thick
brownish dry scabs. At the bend of the left elbow
there is a small recent incision closed with sutures. Superficial
glands palpable. Eyes: The conjunctive on both sides
bulbar and palpebral, injected, especially marked on the right. Eyelids
on both sides glued together by viscid and
caked exudate, most marked on the right side. There are small
hemorrhages below the conjunctiva on the right.
Right pupil 4 mm. in diameter, left 2.5 mm. The ulceration and scabbing
continues about 1 cm. into each nostril.
Along the line of closure of the lips, especially the upper, there are
small superficial ulcerated areas covered by dry
brown scabs. Internal to this, however, the buccal mucosa is pale and
findings.- Pleural cavities: On opening the thorax a number of
fibrous adhesions found over the
posterior portion of the right lower lobe. Somewhat more numerous at
the apex. Also a number of fibrous adhesions
over the posterior portion of the lower left lobe, binding the left to
the diaphragm. The heart is enlarged somewhat to
the right. Heart: Weighs 335 grams. The right auricle and
ventricle somewhat dilated. Myocardium is of good color,
somewhat boiled in appearance. Lungs: Right weighs 715 grams.
Left weighs 660 grams. All lobes quite
voluminous, cushiony and soggy. In all but the middle lobe solid
patches are palpable. The pleura over the posterior
and interlobar portions of all lobes glazed and covered by a thin layer
of fibrinous exudate. Glands at the hilum
enlarged, edematous, injected. The bronchial tree throughout shows
extensive necrosis of the epithelium. Islands of
intact mucosa are present only here and there. The underlying tissue is
considerably injected. There is considerable
diffuse extravasation of blood. In some of the larger bronchial
branches there is associated with the necrotic
epithelium a moderate amount of fibrin. The exudate is membranous. In
the finer bronchioles the lumen contains
viscid pus. About some of the finer bronchioles, especially in the
right lower lobe, there is considerable hemorrhage.
Scattered throughout all lobes, most marked in the lower and left
upper, there are numerous irregular areas of dull
reddish gray and in
places deep-red consolidation. In addition
there is much thin frothy fluid in both upper lobes and the left lower.
Organs of neck: The anterior
rnediastinal, cervical, and tracheal
glands, especially those low down in the neck,
greatly enlarged, pulpy, edematous, injected. Thyroid, no
abnormalities. Acini contain a considerable amount of
colloid. In the trachea there is some swelling of the mucosa, with
considerable diffuse necrosis of the epithelium. In
the lower portion the appearance is moth-eaten. The underlying tissue
is intensely injected. Towards the larynx the
desquamation and injection is less marked. In the larynx, although the
underlying tissue is relatively pale, there is
considerable desquamation of the epithelium, and in places associated
with this desquamation there is fibrinous
exudate. The appearance is that of a true membranous exudate. This is
well marked on both true and, to a less extent,
on the false vocal cords. A similar appearance is seen in the pockets
at the upper end of the esophagus. The
pharyngeal tissue about the tonsils is boggy. Tonsils: Somewhat buried, show
large crypts, most of them filled with
viscid or dry purulent necrotic material. Alimentary tract: The lymphoid
tissue is somewhat more prominent than
normal. There is patchy injection of the mucosa of the rectum. The
mesenteric glands are somewhat enlarged. There
is some injection of the distal one-third of the mucosa of the
appendix. Liver: Shows focal areas of fat infiltration.
Remaining organs show no significant lesions.
examination.- Trachea: In places ulcerated, in others
reinvested with stratfied squamous
epithelium showing numerous mitotic figures. The epithelium in places
is elevated from the basement membrane by
a foamy coagulum as if blistered. The subepithelial connectivetissue
contains lymphocytes in moderate numbers, no
polynuclears. It is edematous and all the vessels are very congested.
Large bronchus shows a very
There is a metaplasia of the epithelium where present, but a large
portion of the connective tissue is bare. There is no
membrane or exudate upon the surface. The ducts of the mucous glands
are proliferating. A Gram stain shows no
fibrin, and only occasional bacteria (Gram- positive rods) on the
surface. Lung: The bronchioles and atria contain
purulent exudate, in which are groups of Gram-positive cocci. They are
relined, for the most part with flattened
epithelial cells. The alveolar septa appear stout and cellular with the
low power. Microscopically, there are numerous
round cells and plasma cells in the walls, and occasionally a new
growth of fibroblasts. Stout filaments of fibrin are
seen, both within the capillaries and between the capillary wall and
the epithelium. There are, however, no thrombi.
The alveolar epithelium shows widespread changes which are interpreted
as regenerative. The cells are elevated,
rounded or cuboidal, with deeply staining, sometimes vacuolated,
cytoplasm. The epithelium is sometimes elevated
by the accumulation of edematous fluid, appearing as granular coagulum.
There are multinucleated flattened cells.
The alveolar spaces are largely filled with pink-staining homogeneous
material, but in spaces this is definitely
fibrinous. The fibrin is swollen and stains poorly. In addition there
are exfoliated epithelial cells, small and large
mnononuclears, occasional plasma cells, numerous polynuclear
eosinophiles, but rarely a polymorphonuclear
neutrophile. Careful search in well-stained Gram section fails to show
bacteria in these areas. Here and there are
strands of fibroblasts growing into the fibrinous exudate. Spleen shows
nothing of interest except irregular hem-
orrhage. Liver: The cells are swollen and very homogeneous, the capillaries narrowed.
of mustard-gas poisoning, dying nine days after gassing. There were
well-advanced reparative changes. Trachea and bronchi were lined with
stratified epithelium. Small
bronchioles and atria still showed suppurative inflammation. There was
regeneration of the alveolar epitheliurn and a subsidence of the
inflammation in the lung, as
shown by the large proportion of plasma and mononuclear cells in the
septa. An interesting and
unusual finding was the presence in some areas of great numbers of
polymorphonuclear leucocytes. There was extensive edema. largely
fibrinous, and, so far as
could be ascertained from a Gram-stained section, unassociated with the
presence of bacteria. Aside from the lesions in the trachea and large
bronchi, the picture resembled very closely that
seen at a corresponding stage of "influenzal" pneumonia. In this
particular instance, however,
bility that a secondary influenzal
had supervened upon the gassing can be excluded by the fact
occurred in March at a time when "influenzal " pneumonia was not
prevalent among the troops.
58.- W. G. S., 107837, Corpl., 5th M. G. Bat., Battery D. Died, June
1918, at Base Hospital No.
15. Autopsy, three hours after death, by Maj. A. M. Pappenheimer, M. C.
data.- Gassed on June 21, 1918. Admitted to Base Hospital No. 15 on
June 26. Diagnosis: Mustard
gas. Dyspnea, cyanosis, conjunctivitis, large blebs on back and arms.
diagnosis.- Superficial burns on back, shoulders, neck, and
tracheobronchitis, lobular pneumonia. Pulmonary edema. Fibrinous
appearance.- There is marked lividity of the head and dependent
portions of the body. Eyes show
intense conjunctival edema with several fresh hemorrhages beneath the
bulbar conjunctiva. There is a bloody
discharge from the nares, and a large amount of thin greenish fluid
issues from the mouth. Over the neck, shoulder,
and upper portion of the thorax there are very numerous superficial
elevated blebs, filled with clear fluid. Over the
back these have become confluent and the epidermis macerated and lifted
up in large sheets, exposing the wet
corium. There is no edema of the penis, but the anterior surface of the
scrotal sacs shows loss of hair, pigmentation,
and superficial desquamation, and was evidently slightly burned. There
are no other cutaneous changes.
findings.- Pleural cavities: Lungs: The right and left
present almost the same changes and can
be described together. They are voluminous and heavy, but not extremely
so. There are patches of fresh, very
delicate, fibrinous exudate, and a few larger sheets of edematous
fibrin over the posterior surface of the lower lobe of
the right lung. The interlobular septa appear as a translucent grayish
network and are obviously edematous. There are
a few small areas of interstitial emphysema in the region of the
lingula of the left lower lobe. On section there is a
very marked edema of all the lobes. A
large amount of thin frothy fluid exudes from the cut surface. Here
are small partially atelectatic patches of a dark red color scattered
through the substance of the lung, but there are no
extensive areas of collapse. The bronchi appear on section to be filled
with purulent exudate and their mucosa in the
case of the larger branches covered with slough. They show no obvious
dilatation or contraction. Very striking is the
surrounding zone, several millimeters in extent, which is darker in
color, very translucent and apparently airless and
slightly sunken below the adjacent aerated tissue. There are a very few
small pneumonic patches scattered through
both lungs. These are dry, grayish, granular, and have not undergone
suppurative softening. Some of them are
surrounded by irregular darker areas of partial atelectasis. In
general, there is strikingly little consolidation, the
changes being limited to the
normal. Alimentary tract: Normal. Histological material lost.
case of nine days' duration. Gross lesions are very typical. There
were the usual cutaneous lesions, and a very intense diphtheritic
necrosis of the upper respiratory
passages. Lung lesions aside from the widespread edema were almost
wholly limited to the
peribronchial regions. There were only a few small patches of focal
CASE 59.- F. C., 1526296, Pvt., Co. H., 147th
Inf. Died, October 23, 1919, 11 p. m. at Base Hospital No.
45. Autopsy, 28 hours after death, by Lieut. Perry J. Manheims, M. C.
Clinical data.- Gassed with mustard gas at 6 a.
October 14. Subsequent informa- tion based on
Chemical Warfare Service reports. Co. H, 147th Infantry, was exposed on
October 12 to mustard-gas bombardment
of 2,000 150-mm. shells. October 18, developed bronchopneumnonia.
Condition serious. Clinical diagnosis:
Bronchopneumonia, following inhalation of mustard gas.
of anatomical findings.- Small hemorrhages in both conjunctiva.
Characteristic burn of scrotum.
Pigmentation of skin of inner side of thighs. Heart normal.
Gross findings.- Pleural
cavities: Left contains no
fluid or adhesions. Right
shows fresh fibrinous adhesions
between the lobes. Left lung: Is reddish grey in color. On
section, it is hyperemic with areas of consolidation. Right
lung: There is a small sear with three small partly calcified
nodules. The upper lobe in general is grey in color,
generally crepitant with a few small areas of consolidation. The middle
and lower lobes are the same. Stomach and
small intestines contain a few hemorrhagic areas. Large
intestine normal. Larynx and trachea: Erosions of the
mucosa with general hyperemic color and hemorrhagic areas. The
remaining organs show nothing of interest.
Microscopic examination.- No section
of trachea preserved. Large bronchi: Desquamation or complete
necrosis of the epithelium. Exudate of polymorphonuclears, epithelial
cells and bacteria in the lumen. Extensive
congestion of bronchial vessels. Edema of walls and of peribronchial
tissue. There is a loose leucocytic infiltration.
Lungs: Show intense congestion of all capillaries, hemorrhages into
alveoli, numerous pigment containing cells, very
little fibrin. Fresh fibrinous exudate on pleura. Another section shows
a definite suppurative focus with necrosis
and masses of bacteria, destruction of alveolar septa, etc. There is
marked periarterial edema. Section stained for
bacteria shows numerous Gram-positive cocci, some in long chains, but
chiefly confined to bronchial exudate.
examination.- Heart's blood at autopsy showed long chained
Culture from lung showed hemolytic streptococcus.
case of nine days' duration. No special features of interest. No
reparative changes noted in section. There was an obsolete apical
tuberculosis, which did not
appear to have been activated by the gassing.
CASE 60.- J.
L., 44533, Corpl.. Co. M, 16th
Inf. Died, October 10, 1918, 9.45 a. m., at Base Hospital No.
15. Autopsy, six hours after death, bv Maj. Rolfe Floyd, M. C.
data.- Mustard-gas inhalation and contact, received in action
October 1, 1918.
diagnosis.- Extensive mustard-gas burns of skin. Diphtheritic
laryngitis, pharyngitis, and bronchitis. Edema and
congestion of lungs. Peritoneal and pleural adhesions.
appearance.- Extensive first degree burns and desquamation of
epidermis over upper part of chest
and almost whole of back. Burns of first and second degree about lips,
nostrils, and eyelids. No burns of scrotum or
findings.- Peritoneal cavity: There are extensive old organized
adhesions, binding together the
abdominal viscera. Pleural cavities:
The left is obliterated by fibrous
adhesions. The right also shows fibrous
adhesions less dense than on the left side. Left lung: There is
extensive bronchopneumonia in the lower lobe with
areas of intense hemorrhagic exudate. Consolidated areas are numerous but not
confluent. Small bronchi contain
pus. The unconsolidated lung is very edematous and congested. Larger
bronchi show extensive diphtheritic necrosis
extending down through the medium-sized tubes. In the lower lobe there
are small calcified and fibrous nodules
surrounded by scar tissue. Lymph nodes at hilus contain small caseous
nodules. Right lung: Shows extensive edema
and congestion with areas of diffuse consolidation. No tuberculous
foci. Organs of neck.--Pharynx,
tonsils: Show a diphtheritic
membrane which extends down the entire
length beyond the trachea into the bronchi.
False membrane is yellow in color and fairly tenacious, still adherent.
Esophagus beyond the pharynx is normal.
Stomach and intestines: Areas of acute
congestion. Abdominal vessels
are congested. Kidneys show
The remaining organs are normal.
Microscopic examination.- Trachea: No sections. Medium-sized
bronchi: Are lined with a thick
fibrinopuruilent membrane. Entire bronchial wall is infiltrated with
leuceocytes, the nuclei of which are pycnotic.
Lungs: The terminal bronchioles contain an exudate which in some
is composed almost entirely of polvnuclears, in
others of a granular coagulum. The lining epithelium is in general
well preserved, though the desquamation in
places is probably the result of post-mortem change. The exudate about
bronchus is largely fibrinous and
hemorrhagic. There is no organization in progress. Elsewhere there are
patches of lobular pneumonia, not definitely
in relation to bronchi, and surrounded by an edematous zone. An
interesting histological feature is the lifting up of
the pleura, with its intact
mesothelial cells, by a layer of edema.
Section stained for bacteria shows few cocci in bronchial exudate, and
practically none in the parenchyma. Liver, spleen, and kidney show no
mustard-gas case of nine days' duration with extensive diphtheritic
necrosis of trachea and bronchi, large areas of bronchopneumonia and
pulmonary edema. No
special features except perhaps the absence of reparative changes.
CASE 61.- M. M., 3105447, Pvt., Co. C, 109th
Inf. Died, October 11, 1918, 8.55 a. m., at Base Hospital No.
42. Autopsy No. 53. Autopsy, six hours after death, by Lieut. B. S.
Kline, M. C.
data.- Gassed October 2, 1918, bled at Field Hospital No. 110.
Contact burns of face, scrotum,
penis, and thighs. Conjunctivitis and laryngitis. On admission,
respiratory distress, general râles, heart enlarged to
right. Accessory muscles of respiration active, chest hyperresonant,
expiration prolonged. Clinical diagnosis:Gas
inhalation and contact burns, emphysema, cardiac dilatation, and
diagnosis.- Superficial gas burns of conjunctivae and skin. Acute
pharyngitis, laryngitis and
esophagitis, tracheitis and bronchitis. Peribronchial pneumonia of all
lobes. Pulmonary edema. Cardiac dilatation of
right side. Cloudy swelling of liver and spleen. Detailed protocol not
examination.- Trachea: There is a dense membrane firmly attached to
the adjacent tissue.
Epithelium in general is wanting, in places there is a single row of
flattened cells beneath the slough. Leucocytic
infiltration is moderate and accompanied by pycnosis and fragmentation
of the nuclei. There is marked hyerpemia
and hemorrhage. Epithelium of mucous glands is desquamated, and the
cells of the duets show proliferation and
mitotic figures. (See fig. 15.) There are numerous bacteria on the
surface. Bronchi: There is complete epithelial
necrosis. Many bronchi are filled with purulent exudate and bacteria.
In many places the entire bronchial wall is
involved as well as the adjacent alveoli, so that these are practically
small abscesses. About these
there is hemorrhage. A few of the bronchi show regenerating new
epithelial cells being interlaid between the still
adherent membrane and the granulating submucous tissue. Lungs:
Edema is marked and diffuse in two of the blocks.
A third block shows no edema but marked emphysema and dilatation of the
infundibula together with
bronchopneumonia of the usual type. In some places, especially in the
vicinity of the inflamed bronchi, the exudate
is fibrinous, in others a uniform coagulum. In places there are
definite abscesses with masses of bacteria, which
appear to have originated in the distended atria, but involve the
adjoining tissue. Pharynx: The section passes
through localized areas in which the epithelium is replaced by an
adherent superficial slough, the base of which
shows an acute leucocytic infiltration. (Fig. 31.) A section of skin,
probably from the scrotum, shows a partial
desquamation of the superficial squamous cells with vacuolar
degeneration of the upper layers. There are some
areas in which there is total necrosis of the entire epithelium, with
edema and leucocytic infiltration of the corium. In
the ulcerated areas the pigment in the rete mucosum is clumped and
there are numerous chromatophores. There is no
evidence of regeneration at the margins of the ulcerated areas. Kidney and
liver show cloudy swelling.
case, dying nine days after exposure. Severe destructive lesions of
the upper respiratory tract extending into the smaller bronchioles.
There was widespread
hemorrhagic edema, lobular pnuemonia, and suppurative foci, probably
originating in the
smallest bronchioles or atria. The evidences of repair were very
slight, being limited to the
earliest proliferation of the epithelium in the larger bronchi.
CASE 62.- O.H., Corpl.,45273,Hdqrs.Co.,18th.
Inf. Died October,1918, at 4 a.m., at Base Hospital No. 18.
Autopsy No. 128. Autopsy, October 11, 14 hours after death, by Lieut.
B. S. Kline, M. C.
data.- Gunshot wounds of right arm and hip, with subsequent gas
bacillus infection. Gas
inhalation incurred in action October 2.
Anatomical diagnosis.- Extensive gunshot wounds of upper right
arm, with infection. Gunshot wounds of
right buttock. Healing conjunctivitis and superficial burns of skin.
Infected burn of scrotum. Healing gas burns of
upper respiratory tract. Small areas of organized pneumonia especially
marked in right upper and lower lobes. Few
small bronchiectatic cavities, filled with exudate. Ascaris
lumbricoides. Healed and recent ulcerations of lower
ileum and cecum, possibly due to worm. Localized fibrinous peritonitis.
appearance.- Externally there is a large wound of the right upper
arm 15 by 8 cm. The shoulder
and anterior chest in the neighborhood are puffy. On palpation a
considerable amount of gas is felt. The wound
shows necrotic injected muscle in the base. A thin watery grayish-black
exudate in small amount in places. On
pressure of the wound crepitation is made out. The neck, axillary
folds, and abdomen show numerous tiny vesicles
filled with clear fluid. In the axillary folds there is some bloody
pigmentation of the skin.
FIG. 31.- Case 61. Mustard-gas
days' duration. Pharynx.
Localized superficial necrosis of epithelium with
The scrotum, penis, toward the
head, show superficial ulceration of the epidermis and some matted
seropurtilent exudate. Eyes: The outer corners are glued
together with matted exiu- date. Over the right buttock,
upper portion laterally, there is a wound in the skin about 6 by 4 cm.
extending into the muscle. In the skin of the left
ankle there is a large irregular bleb filled with thin fluid.
findings.- Peritoneal surfaces: In the right hypochrondrium show
patchy injection and small
hemorrhages. The hepatic flexure of the colon glued to the liver by
fibrinuos exudate. There is considerable post-mortem discoloration,
greenish black in the neighborhood. The stomach is considerably
distended with gas. Pleural cavities.-Right lung: The lobes are
voluminous and cushiony in great part. The pleura is thin. The glands
the hilum are somewhat enlarged, pulpy, and scarred. There is slight to
moderate diffuse injection of the mucosa. In
the lumen there is thin fluid. The upper lobe, on section, in great
part is well aerated and pink. Toward the apex there
is considerable scarring. There are strands
and small nodules of firm gray tissue. In one
place there is a small pea-sized calcified nodule. Toward the apex
is a bronchus showing considerable dilatation, filled with coherent
mucopurulent fluid. On tracing the bronchi from
the hilum they are found to become stenotic quite quickly. At one place
near the pleura there is a pea-sized yellow,
opaque, cheesy mass involving the bronchial lumen and wall. On repeated
section, dilated and stenotic bronchi, with
small pigmented firm gray streaks and nodules are found, in the
posterior portion of this lobe, suggesting the end
result of gas inhalation. The middle lobe on section fairly well
aerated, pink-red. Throughout the lobe there are firm
gray strands and flat nodular areas, a few millimeters in diameter. The
picture suggested tiny organized areas
following rather extensive peribronchial consolidation. The walls of
the bronchi themselves are not appreciably
thickened. In general the lumen is considerably smaller than the
average. In this lobe, the air sacs contain a moderate
amount of thin frothy fluid. Left lung: Both lobes fairly
voluminous and cushiony. The artery at the hilum shows no
abnormalities of its larger branches. The bronchi and glands are
similar to those on the right. On section of the upper
lobe toward the apex and elsewhere, firm gray streaks and small nodules
suggesting organized pneumonia are seen
and peribronchial thickening. The lower
lobe on section, in general similar to the upper. Liver weighs 2,000
and shows marked fatty infiltration. Spleen,
kidneys, adrenals, and
bladder normal. Organs of
Average size and presents no abnormalities. There is considerable
colloid present. Larynx and trachea: There is
much viscid exudate in the lumen. Toward the bifurcation there is
patchy injection of the mucosa. The base of the
tongue, posterior pharynx and
upper esophagus as far as the level of the cricoid cartilage show a
of the mucosa. Tonsils: Show a moderate amount of pulpy pale
lymphoid tissue, somewhat scarred. Alimentary
tract: The esophagus shows some dilatation. The stomach is
considerably distended with gas and contains about 200
to 300 c. c. of bile-tinged contents, partially digested. In the lower
ileum there are several apparently healed
ulcerated areas in the neighborhood of the valve. The cecum and
ascending colon show a number of ragged
perforations of the mucosa. In one place the ulceration is about 1 cm.
in diameter, the edge heaped upon the base
formed by the muscle. Just beyond the ileocecal valve there is a ragged
perforation of the mucosa. The scrosa and
outer muscular coats dissected up for a considerable distance forming a
cavity about 3 cm. in diameter,
communicating with the interior of the gut by the perforation mentioned
above. The walls are moth-eaten in
appearance, apparently the habitat of the ascaris mentioned above. It
is over this region that the fibrinous exudate
mentioned above is found. The remainder of the tract shows no
examination.- Large bronchus: Covered for the most part with one or
two layers of flattened
cells, very pale and large wvith distinct cell membrane. Individual
cells show pycnosis of nuclei and hyaline
condensation of cytoplasm. The superficial portion of the subepithelial
tissue is very dense, the membrana propria
and collagen fibres are swollen and indistinct. There are very few
wandering cells in this zone; the connective tissue
and endothelial nuclei are large and succulent. Deeper clown there is a
rather dense infiltration of lymphoid and
plasma cells, especially about the mucous glands. The ducts show the
usual epithelial proliferation, with occasional
mitotic figures. Lungs: Two blocks examined. In one there are
definite encapsulated areas with smaller tubercles at
the periphery. The granulation tissue at time margin of the tuberculous
area is intensely injected, and in one place
there is an extensive fresh hemorrhage. The caseation involves the wall
of an adjacent pulmonary artery. The section
passes through a small bronchiectasis which is situated in the scarred
tuberculous area. Elsewhere there is a
suppurative bronchiolitis and infundibulitis, with involvement of the
adjacent alveoli. The smallest bronchioles are
filled with pus and have lost their epithelium. Their wall shows a good
deal of fibrous thickening, and
appear narrowed. The remaining part of the lung tissue shows nothing of
special interest. The capillaries are
congested; there is moderate diapedesis and edema, and here and there
alveoli containing leucocytes and fibrin.
There are various types of bacteria in the bronchial exudate.
Gram-positive cocci predominating.
poisoning of nine days' duration, complicated with multiple gunshot
wounds. The cutaneous lesions tire typical, and the trachea and bronchi
evidence of previous gassing with very early reparative changes. There
were associated obsolescent tuberculous
lesions in the lung, to which were
due the small bronchiectases and scars described in the protocol. It is
not probable that the gas bronchitis after nine days could lead to the
formation of bronchiectasis, and in support of
this idea is given the histological study, which shows at least one
dilated bronchiole in definite relation to the
tuberculous focus. Of interest, in view of the possible activation of
old tuberculous foci by exposure to gas, is the
intense congestion and hemorrhage about the tuberculous areas. It is
conceivable that such a hemorrhage might favor
the extension of the tuberculous foci.
CASE 63.- J. W. H., 1627698, Corpl., Co. M., 109th
August 19, 1918, at Base Hospital No. 46.
Autopsy No. 7. Autopsy, two hours after death, by Lieut. B. S. Kline,
data.- Date of gassing not known. Admitted to hospital August 10.
Cyanosis, air hunger, cough,
abundant mucopurulent sputum. Somewhat relieved by venesection. On
fifth day, temperature 104°. Dullness, and
bronchial breathing. From then until death, periods of improvement;
temperature up to 106°.
diagnosis.- Extensive gas burns of skin, in part infected, in part
healed, associated with local
pigmentation. Acute ulcerative laryngitis, tracheitis, bronchitis.
Purulent bronchiolitis. Extensive
bronchopneumonia. Fibrinous pleurisy. Pulmonary edema. Miliary
tuberculosis (obsolete) of bronchial lymph nodes,
lung, liver, and spleen. Rupture of right rectus muscle with hemorrhage.
appearance.- The skin in general has a sallow appearance. In
addition, the face, neck, and upper
portion of the body has a somewhat bluish cast. The skin of both arms
almost to the wrists show extensive areas of
superficial ulceration and desquaination. In places there is a small
amount of matted skin and purulent exudate over
the ulcerated areas. The ulceration extends only into the dermis. There
is similar ulceration and desquamation of the
skin in both axillae and upper backs. The head of the penis and body
show similar ulceration, with some puruilent
exudate. Over both buttocks, in the right axillw, the outer aspect of
the right thigh, there are a number of old
ulcerated areas varying in size from a few millimeters to several
centimeters in diameter, practically healed, showing
new epidermis with brownish pigmentation about them. There are large
blotches of brown pigmentation of the skin
over the chest and thighs. Associated with all these there are
innumeral)le tiny vescieles filled with clear fluid. The
skin of the neck and a portion of the face and scalp shows considerable
desquamation. The superficial lymph glands
are somewhat enlarged. Eyes: Eyelids are somewhat edematous
toward the inner canthus. On each side there is a
small superficial ulcerated area covered by a reddish-brown scab. There
is some desquamation of the skin of the lids.
Conjunctive are pale. The pupils a few millimeters in diameter. Nose:
In both nostrils there are superficial ulcerated
areas, covered by scabs. In the nose there is a moderate amount of
mucopurulent secretion. External genitalia: No
addition to the note above. The skin of the scrotum in two places shows
healed superficial areas. Attached to the new
epidermis there is some desquamated epithelium.
Gross findings.- Abdomen: On opening the
peritoneal surfaces in general are delicate and pale.
In the region of the attachment of the internal rectus on the left, the
peritoneal surface shows extensive deep red
hemorrhage. In the pelvis there is about 30 c. c. of clear yellow
fluid. Binding the lateral portion of the right lobe of
the liver to the abdominal wall there is a small amount of apparently
organizing gelatinous fibrinous exudate. On
incising the rectus muscle on the left, a small egg-sized mass of fluid
and clotted blood is found. There appears to be
a loss of continuity in the rectus muscle about 6 cm. from the
attachment to the pubic bone. There is some apparent
scarring of the musculature at the point of rupture. The diaphragm
reaches to the fifth rib right, fifth space left.
Thorax: On opening the thorax about 50 c. c. of turbid yellow
fluid found in the right pleural sac. There is some
fibrinous exudate posteriorly between the lobes and the chest wall. A
similar picture presents on the left. There is
perhaps but 30 c. c. of fluid here. Heart: Enlarged somewhat to
the right. Shows no significant lesions. Right lung:
All lobes of the right lung are very much more voluminous than normal.
The upper is cushiony, soggy, many large
solid patches felt. Middle and lower lobes
similar, with apparently more consolidation in the upper portion.
everywhere glazed, covered by tightly adherent fibrinous exudate. On
stripping this posteriorly, tiny vessels are seen
in the pleura below in places only. The vessels at the hilum show no
abnormalities. Glands are greatly enlarged,
pulpy, edematous, injected and pigmented. Bronchus shows considerable
swelling and intense injection of the
mucosa. In places there is desquaination of the nitucosa. Everywhere
there is considerable mucopurulent and
fibrinopurulent fluid, blood tinged. On section, the upper lobe, a
moist mottled pink, whitish-yellow and yellowish
grayish-red surface presents. Air sacs in general contain a
considerable amount of thin frothy fluid. Scattered
throughout the lobe there is much dull grayish-red consolidation.
Patches vary in size from a few millimeters to one
large patch having a surface area 6 cm. Associated with these solid
patches the bronchioles in places contain viscid
purulent matter. The walls of these smaller bronchioles merge with the
surrounding consolidation. Middle lobe on
section, presents a picture in general similar to the upper lobe. There
are numerous areas of consolidation associated
with bronchial branches which contain viscid purulent material. There
is moderate amount of fluid in the air sacs
elsewhere, in this lobe. In places there are dilatations of the bronchi towards the
periphery. Lower lobe, on section
presents a picture in general similar to the other lobes. Here the
peribronchial consolidation is much more distinct.
There is considerably more injection present. Lower portion of the
lobe, on repeated section, the bronchial branches
in greater numbers show viscid purulent fluid. The peribronchial
consolidation is much more extensive here. The
bronchi throughout have a larger diameter than normal. Left lung:
Both lobes are very much more voluminous than
normal, especially the upper, and are quite solid. The lower in the
median portion is cushiony. The pleura, vessels,
lymph glands, and bronchi similar in appearance to those of the right.
On this side the necrotic desquamating mucosa
is more conspicuous than on the right side. The upper lobe on section,
in general similar to the right upper lobe.
Consolidation, however, is much more marked; in places the patches are
almost confluent. Associated with the
gelatinous areas of consolidation there are also numerous small yellow
opaque areas. On section of this lobe towards
the hilus, there is an enlarged bronchial lymph gland, showing a
pea-sized chalky and calcified mass, encapsulated
by firm gray tissue. Left upper lobe, bronchi, and areas of
peribronchiial consolidation have a greenish color. This is
especially true in the centre and the upper portion of the lobe. In
places, especially in these areas, the bronchial
branches show moderate dilatation. In this lobe, on further inspection
there are seen yellowish opaque nodules much
firmer in consistence than the consolidation mentioned above. These are
especially prominent medially. The left
lower lobe on section, in general presents a picture similar to that in
the other parts, except that the process medially
is less marked. Scattered throughout this relatively well areated
portion considerable numbers of discrete pinhead
sized and smaller firm gray nodules. Organs of neck: Glands
throughout the neck, especially below, greatly
enlarged, pulpy, edematous, and injected. Those in the mediastinum
show areas of gray scarring, moderately
pigmented. Thyroid: Marked amount of colloid in the acini. Larynx:
Shows several areas of ulceration of the
mucosa, both of the epiglottis and true vocal cords. The largest patch
is 1 cm. in diameter. These ulcerations extend
into the cartilage. Elsewhere the mucosa is injected, swollen and
covered by loose mucopurulent exudate. Trachea:
Mucosa is somewhat swollen, and injected, especially towards the
bifurcation, where in addition there is
considerable desquamation of the epithelium of the mucosa, and
associated with these areas there is a moderate
amount of adherent fibrinous and fibrinopurulent exudate. In the lumen
there is a considerable amount of
mucopurulent secretion. Tonsils: Are almost gone on the left.
On section, however, one crypt filled with viscid
purulent material On the right, the tonsil is buried and crypts are
clean. Alimentary tract: Mucosa of the pharynx and
upper esophagus is slightly swollen, moderately injected. Stomach: No
abnormalities. Cecum: Some patchy injection of the
mucosa. Mesenteric glands are slightly enlarged, and pulpy. Liver: There
are a few minute, encapsulated, caseous
areas and focal fat infiltration. No other significant lesions. Spleen:
Also contains small yellowish nodules, otherwise
the appearance of an acute splenic tumor. Adrenals: Slight
cortical edema, moderate lipoid depletion.
examination.- Skin: There are two blocks, showing hyperkeratosis
thinning of the remaining
layers of epidermis. There is marked hyperpigmentation with
chromatophores in the superficial layers of the corium.
The smaller vessels are collapsed
and empty, surrounded by a loose aggregation
of pycnotic lymphocytes and occasional polymorphonuclear cells
with distorted nuclei. The section evidently represents a healed
pigmented lesion. Trachea: There are patches of
regenerated stratified non-ciliated epithelium alternating with
ulcerated areas to which necrotic membrane is
adherent. The ducts frequently contain
solid plugs of epithelial cells. Submucosa is edematous and in the
regions is infiltrated with both polymorphonuclear and mononuclear
cells. Where the epithelial regeneration has
occurred, the underlying tissue has rather the character of clean
granulation tissue. Lungs: The bronchi all contain
exudate which is chiefly purulent but in some instances is undergoing
early organization. Lining epithelium of some
of the bronchi is intact, in others necrotic, and still others
regenerative and metaplastic. There are the usual
peribronchial lesions; areas of extensive peribronchial pneumonia with
fibrinous exudate often showing early
organization. Alveolar wall in many places is thickened by the presence
of numerous large pale epithelial cells
having in general the character of fibroblasts, but possibly derived in
part from the endothelial cells of the
capillaries. One block of lung tissue shows in addition to the
thickening, diffuse edema, hemorrhage, and focal areas
of suppuration. Rectus muscle:
There is hvaline necrosis of the fibres
with hemorrhage and acute inflammatory
reaction. Liver, spleen, kidney
show no striking changes.
examination: Culture of
lung: Staphylococcus aureus,
large number. Culture of vocal cords:
Streptococcus, nonhemolytic, non-green-producing.
case is a typical one of mustard-gas poisoning. The exact duration is
established, but was over nine days. The destruction of the mucosa of
the upper respiratory
passages was less severe than in many cases, and does not involve the
smallest branches, in
which, generally speaking, the epithelium appeared to be preserved.
Early regeneration occurred.
Broncho-pneumonia was extensive but does not appear to be of the
typical influenzal type,
associated with extreme and widespread hemorrhagic edema.
CASE 64.- F. M., 2209877, Pvt., Hdqrs. Co.,
355th Inf. Died, August 18, 1918, 9.45 p.m, at Base Hospital
No. 46. Autopsy No. 8. Autopsy, 19 hours after death, by Lieut. B. S.
Mline, M. C.
data.- Patient was gassed on August 7 to 8, having been exposed to
yellow, green, and blue cross
shell. On August 15, patient was weak and a little delirious. There was
a cough without sputum. Throat was red and
edematous. Painful burns of scrotum and face. Rȃles at
posteriorly. August 18, patient became weaker,
apprehensive, and at times delirious.
diagnosis.- Extensive gas burns of skin and mucous
membranes. Acute laryngitis, tracheitis, and bronchitis. Purulent
bronchiolitis. Acute peribronchitis. Extensive
bronchopneumonia. Acute fibrinous pleurisy. Marked pulmonary edema.
Dilatation of right auricle. Obsolete
tuberculosis of bronchial lymph nodes. Terminal gas bacillus infection.
appearance: There is a marked gas burn about the lips, over the
left eye, scrotum and penis.
of the face extend into the subcutaneous tissues and are covered by a
dry red brown scab. The scrotum and penis
show in addition to the ulcerated epidermis, moderate amount of
matted serum and purulent exudate. There is a
small area of ulceration covered by a scab toward the inner canthus of
the right eye. There are areas of desquamation
of the epidermis over the scalp, about the ears, and in the genital
fold. Axilllae, clear. Superficial lymph glands,
somewhat enlarged. Conjunctivae slightly edematous, show patchy
injection. There is some mucopurulent secretion
present. The corne slightly cloudy. Pupils, dilated 6 mm. in diameter.
Ears: No abnormalties except as above
mentioned. Nose: In the left nostril there is an area of
superficial ulceration covered by a red brown scab. Mucosa is
somewhat injected. There is some bloody mucopurulent secretion present.
Mouth: Lips show ulceration mentioned
above. Teeth poorly formed. In the upper jaw, there are several milk
teeth present. There is considerable erosion of
the cutting edges. A few teeth gone from the lower jaw.
finding.- Pleural cavities: On opening the thorax about 60 c. c. of
thin blood-tinged turbid fluid
found in the right sac. In the left there are a number of delicate
fibrous adhesions between the lungs and the chest
wall. In this cavity also there are about 40 c. c.
of blood-tinged fluid. Heart is normally
disposed. Pericardium is normal. Heart
is normal except for dilatation
right auricle. Right lung: Upper and lower lobes are very much
more voluminous than normal, cushiony, soggy.
Middle lobe is fairly voluminous, slightly soggy. Pleura, especially
posteriorly, glazed, covered by small amount of
fibrinous exudate. There is considerable reddish-purple discoloration
of the pleura, and in addition there are scattered
small hemorrhages posteriorly. Vessels: No abnormalities,
except the pulmonary artery somewhat dilated. Glands are
moderately enlarged, pulpy, edematous, injected, pigmented, scarred. Bronchi:
There is considerable swelling,
injection and hemorrhage of the mucosa. There is much greenish-black
discoloration. In the lumen there is a large
amount of thin frothy fluid. On section of upper lobe a strikingly
moist deep red surface presents. Air sacs are
moderately distended with thin fluid. The smaller bronchial branches
contain fibrinous and fibrinopurulent exudate;
their walls are injected, the surrounding lung tissue consolidated.
Posteriorly there is some gelatinous reddish lung
tissue, and in addition there are fair-sized areas of granular deep red
consolidation. Middle lobe on section shows
little involvement, and there are but a few areas of consolidation in
this lobe. Lower lobe on section quite similar to
the upper, however, the bronchial branches are filled with purulent
exudate. Walls are deeply injected. There is
much consolidation. In the air sacs there is a striking amount of thin
frothy fluid. In addition there is considerable
extravasation of blood throughout the tissue and near the apex of this
lobe there is an egg-sized solid slightly
granular deep red consolidated patch. Left lung: Both lobes are
more voluminous than normal, especially the lower.
The upper, cushiony, soggy. The lower, soggy. Pleura: Vessels,
bronchi, lymph glands, similar to those on the right
in appearance. In addition, lymph glands show numerous yellow opaque
nodules. Upper lobe on section is similar in
general to the right upper. The lower, in general similar to the right
lower. Liver: Fatty infiltration and small cystic
spaces apparently due to gas-bacillus infection Adrenals:
Cortical edema with injection of inner cortical zone.
Organs of neck: Glands in the lower portion of the neck are
moderately enlarged, edematous, pulpy, injected,
pigmented, show some scarring. Thyroid: Average size. The right
lobe is bifurcated. Tissue is pale and spongy. The
acini contain a moderate amount
of colloid. Larynx: There is considerable swelling of the
mucosa with patchy
injection. There are small areas of ulceration in the epiglottis. There
is also some ulceration of the true vocal cords.
From the true vocal cords downward the ulcerated and intact mucosa is
covered by a considerable amount of slimy,
dirty brown exudate. Within and below the mucosa there are numerous
deep red hemorrhages, especially toward the
bifurcation of the trachea. The greater portion of the brownish exudate is
present in the lower portion of the
pharynx and the upper portion of the trachea. The adjoining mucous
membrane of the base of the tongue and larynx
moderately injected. Tonsils:
Show a small amount of lymphoid tissue.
There is considerable scarring of each.
shows some injection of the mucosa as far as its mid- portion. Stomach:
abnormalities. Jejunum: Upper
portion shows some patchy edema of the
mucosa. Ileum: Shows areas of
injection of the mnucosa with which there is associated some
extravasation of the blood. The lymphatic tissue
throughout is somewhat more prominent than normal. Appendix, cecum,
colon, and rectum, no
about the rectum and in the bladder wall posteriorly shows numerous
dilated, engorged, and in places, thromnbosed
veins. The mesenteric glands are slightly enlarged, pulpy, and
is no pseudomembrane present. Normal epithelium is replaced by layers
of polygonal squamous cells resting upon
basement membrane. Mucous glands have disappeared. Large bronchi:
Many show gangrenous lining. and hyaline
necrosis, not extending very deeply into the bronchial wall. There is
abundant hemorrhage both of mucosa and
adjacent lung tissue. Some bronchi show regeneration of squamous stratified epithelium. Lung: Tissue
at a distance
from the bronchi shows emphyserma and moderate hemorrhagic edema. In
the second block numerous sections
were taken at different levels and mounted in series. In this way there
are demonstrated suppurating cavities directly
in connection with bronchi. These suppurative foci are surrounded by
areas of organizing pneumonia. In some of the
alveoli there is exfoliated ciliated epithelium, probably aspirated
from the bronchi. The third block shows complete
atelectasis. Kidney, spleen, liver,
and bronchial lymph nodes
features of special interest.