189
Bacteriological examination.- Cultures of trachea show streptococcus and
colon group organisms. Smear shows
Gram-positive and negative cocci and Gram-negative bacilli in trachea.
Gelatinous and consolidated lung, numerous
streptococci, single cocci, and Gram-positive bacilli.
NOTE.-
Mustard-gas
case, dying nine days after exposure, and presenting typical lesions
at autopsy. In the trachea there was beginning regeneration. Many of
the medium-sized bronchi
showed a very severe injury, and the terminal bronchioles were
transformed into abscesses with
a reactionary zone of organizing pneumonia about them.
CASE 65.- S. R., 2299831, Pvt., Co. H., 112th
Inf. Died, November 9, 1918, 3.30 p. m., at Base Hospital
No. 87. Autopsy, November 10, 24 hours after death, by Lieut. H. H.
Robinson, M. C.
Clinical
data.- Gassed on October 31, 1918; 1,000 yellow cross and 400 blue
cross and green cross shells
used in bombardment, northeast of Xammes. On admission to base
hospital, eyelids were red and swollen,
photophobia, coughing, slight dyspnea, rapid pulse. Venesection
performed on November 3 and 5. Before death
pulse became rapid. Whistling rales were heard through the entire left
chest.
Anatomical
diagnoses.- Pigmentation and superficial burns of skin, neck, scalp
about eyelids and lips. Small
erosion in fold of skin on right side of scrotum.
Gross
findings.- Pleural cavities: There is no free fluid. Easily
separated pleural adhesions over both lungs.
Organs of neck: Trachea: In its upper portion is covered
with thick necrotic membrane, which is absent in places
exposing the deeply eroded surface. The lining of the lower portion of
the trachea and the larger bronchi is smooth
but bluish in color, as if mucosa had been exfoliated. Lungs are
voluminous and heavy. On pressure a large amount
of frothy blood exudes from the cut bronchi. On section the anterior
portions of the lung are air containing.
Elsewhere all lobes are full of small firm closely set, but irregularly
outlined, patches of consolidation. Cut surface is
very moist, and mottled pink arid dark red. Blood flows freely form the
congested vessels. Smaller bronchi contain
thick yellow pus. Heart is
normal. Kidneys show moderate
chronic
nephritis. Remaining organs show nothing of
interest. Gastrointestinal tract is
normal throughout.
Microscopic
examination.- Trachea: No pseudomembrane remains. Epithelium is
completely destroyed.
The submucosa is edematous, congested, and infiltrated with poly-
morphonuclears and other types of wandering
cells. Lungs: Two of the blocks show gangrenous necrosis of
the walls of the bronchi. Other lumina are completely
filled with plugs of fibrino-purulent exudate and bacteria. There is
intense edema of the surrounding lung tissue,
leading to rupture of the alveolar walls. Interlobular and subpleural
lymphatics are greatly distended. Another block
shows diffuse lobular pneumonia, with many swollen alveolar cells
amongst the exudate. Several other sections
show no additional features.
NOTE.-A
case presumably of mustard-gas poisoningof nine days' duration. Skin
lesions were of moderate
severity, but there was very intense necrosis of the respiratory
passages, with peribronchial consolidation and
widespread edema. Probably because of the complete epithelial
destruction, there were no reparative changes.
CASE
66.- P. J. C., 482258, Pvt., Co. L, 54th Inf. Died, November 14, 1918,
at 9.45 a. m., at Base Hospital
No. 87. Autopsy, November 15, 23 hours after death, by Lieut. H. H.
Robinson, M. C.
Clinical
data.- Gassed on November 5, 1918, by mustard-gas shell. On
admission, difficulty in breathing
and many rȃles in chest. Burns about eves, face,
scrotum, and knees.
Epistaxis.
Anatomical
diagnosis.- Mustard-gas burns of lips, eyelids, face, penis,
scrotum, and knees. Brownish-purple
pigmentation on the anterior surface of thighs. Diphtheritic tracheitis
and bronchitis. Peribronchial hemorrhages.
Remaining viscera, normal. Gastrointestinal tract not recorded.
Microscopic
examination.- Trachea is covered with several layers of
nonciliated epithelium showing
occasional mitoses. Some of the ducts of the mucous glands contain
actively
190
regenerating cells and are filled with more
or less solid plugs. The submucosa is moderately edematous. There is a
loose infiltration of mononucelears and many of the connective tissue
cells have the character of fibroblasts. The
blood vessels are hvperemic and their endothelium is swollen. Lungs:
There are extensive fresh hemorrhages in the
alveoli and septa, with edema in the surrounding tissue. Some of the
small bronchi show purulent exudate and
exfoliation of the epithelium. A second, very interesting, but poorly
stained section showsa fibroblastic thickening of
the septa, with early organization of the alveolar exudate.
NOTE.- Mustard-gas
poisoning, with death on the ninth day after gassing. There was well
defined regeneration of the tracheal epithelium with beginning fibrosis
of the subepithelial
connective tissue. There was extensive hemorrhagic edema of the lungs
with interstitial
fibrosis. This may have been associated with a secondary influenzal
infection.
CASE
67.- A. W., 127455, 1 A. M., R. A. F. 3 Kite Balloon Section. Died,
October 30, 1918, at 12.50 p. m.,
at Base Hospital No. 2. Autopsy, two hours after death, by Capt. B. F.
Weems, M. C.
Clinical
data.- October 21, admitted to No. 5 Casualty Clearing Station.
Gas-shell wound of head. October
22, admitted to Base Hospital No. 2. Sore eyes, throat, chest; no
vomiting; coughing. Slightly cyanosed; eyelids
swollen, eyes congested. Heart normal. Lungs: Tracheal and
bronchial rȃles, few fine rȃles at left
base. No burns.
October 24, coarse rȃles have disappeared; fine moist rȃles
at both
bases. October 25, foul breath; fine rȃles
generally over anterior chest; expiration prolonged; still slightly
cyanotic. October 26, same signs as yesterday.
Profuse purulent sputum. No improvement in general condition.
Sputum-direct smear-Gram-positive laneeolate
diplococci, spirilla, staphylococci. Culture-pneumococcus, Type IV.
October 27, feels better. Slight cyanosis.
October 29, holding his own, breathing quietly. Generalized fine and
coarse rȃles. Unable to localize consolidation.
October 30, marked cyanosis, respiration rapid and feeble, chest filled
with moisture. Died at 12.50 p. m.
Anatomical
diagnosis.- Membranous pharyngitis, tracheitis, and bronchitis,
broncho-pneumonia; old pleural
adhesions; congestion of abdominal viscera; status lymphaticus;
inhalation of irritant gas, presumably mustard.
External
appearance.- Stigmata of status lymphaticus. Skin is dusky
yellowish-brown, quite soft and
smooth. Very little hair over thighs and trunk, feminine distribution
of pubic hair. Sparse beard, adenoid facies; teeth
carious, many missing; high arched palate. Desquamation of epidermis,
dusky pigmentation and congestion about
the eyes; dried exudate in the corners; deeply injected conjunetive,
evidences of recent inflammation. Nasal mucosa
injected, external orifices otherwise negative.
Gross
findings.- Pleural cavities: Obliterated by fibrous adhesions. Left
lung: Covered by fibrous tags;
moderately distended; apex and anterior portion of upper lobe are
normal in consistence, posterior portion somewhat
firmer, slightly lumpy, lower lobe evidently partly consolidated. Lymph
nodes at the hilum are congested. Bronchi
display a marked injection, mucous membrane is covered by
grayish-yellow, necrotic-looking exudate, which
extends down into the smallest radicles; there is a slight amount of
bronchiectasis. Upon cut surface, the lung is
grayish red, rather irregular, numerous points of grayish color
representing the plugged bronchioles. Around most of
these is a zone of deep injection or hemorrhage, varying in width.
There are several large, almost wedge-shaped
areas of deep purple with yellowish patches about the bronchi; small
abscesses are present in some of these. There is
considerable edema in all of this diseased tissue. There are many
yellowish-gray plugs in the small bronchi. Right
lung: Lymph nodes at hilum are markedly enlarged, deeply
congested, slightly spotted, but showing no frank
suppuration. The lung is covered by fibrous adhesions and very much
lacerated in removal. Bronchi contain the
same inflammatory products as on the left side. The lung is less
voluminous and shows less evidence of
consolidation. The cut surface, however, presents almost the same
picture as on the left side; the lower lobe is pale in
color, except for the peribronchial changes. There is practically no
anthracosis present in the lower lobe, although
there is considerable amount in all other parts of the lung. There are
many areas of hemorrhagic softening. Organs of
leck: Tonsils are very small, slightly scarred. Pharynx:
Reveals a coarse membranous inflammation, the membrane
being thick and yellow and rather hard to peel. Very slight injection
191
is noted, the healing process having
evidently begun. Larynx: Contains the same sort of membranous
exudate, but
there is the appearance of regeneration in the mucous membrane. Trachea:
Is not greatly altered in its upper half, but
becomes more congested toward the bifurcation; patches of
yellowish-gray membrane are present in the lowest third.
Esophagus is normal. Heart: Left chambers contracted, right
flaccid. No abnormalities. Liver, spleen, kidneys,
adrenals, and pancreas congested. Stomach: Post-mortem
digestion. Intestine not recorded.
Microscopic
examination.- Trachea and
primary bronchus, no sections.
Lung:
A medium- sized bronchus is
cut longitudinally. It is completely filled with a fibrinopurulent
plug,
FIG. 32.- Case 67.
Mustard-gas burn, 9 days' duration. Section through bronchus, showing
regeneration of metaplastic epithelium, fibroblastic
thickening of
bronchial wall, epithelial
proliferation, edema of adjacent alveoli
which in a few places is becoming organized
at the point of attachment by the ingrowth of fibroblasts. The outer
portion of the plug shows here and there coarse interwoven lamellae of
fibrin. The bronchial wall is represented
by a loose vascular granulation tissue, which is covered in places by
epithelium, either a single row of flattened cells
or several layers of laminated, nonciliated squamous cells. (Fig. 32.)
An interesting feature is the presence of sharply
outlined areolar spaces within the epithelial cells, containing groups
of three or four wandering cells, chiefly small
mononuclears. These spaces appear to be formed within the protoplasm of
the epithelial cells. Mitotic figures are
quite numerous. In the vicinity of the bronchi the alveoli are filled
with a hemorrhagic exudate which becomes
serofibrinous and finally serous at a distance from the bronchus. The
alveolar epithelium, especially in
192
the neighborhood of the bronchus, appears to
be regenerated, and is frequently columnar. In some areas there is
epithelialization of the alveolar plugs in progress, as well as
fibroblastic growth. Groups of pigment-containing
exfoliated cells are present. In addition to these lesions the section
shows several circumscribed abscesses,
surrounded by a zone of hemorrhage. The purulent center contains large
masses of bacteria. The bacterial stain
shows great numbers of Gram-negative bacilli and a few Gram-negative
coccoid forms in the bronchial exudate,
where the staining of the fibrin shows that the decolorization has not
been carried too far. Elsewhere bacteria are
difficult to demonstrate. Additional blocks show no features beyond
those noted. The epithelial proliferation in some
of the bronchioles is remarkable, and there are many large atypical
cells. Liver: The cells in
the center of the lobules
are atrophic; there is elema between the liver cells and the capillary
walls. No other striking change. Spleen
and
myocardium normal. Adrenals
intensely congested; cortex contains
very little lipoid. There is fair chromaffin
staining of the medullary tissue.
Bacteriological
examination.- Blood culture: Sterile. Lung culture (blood plate):
Staphylococcusaureus,
pure. Spleen culture: Staphylococcusaureus and pneumococcus, type?
NOTE.-Death
occurred nine days after definite history of inhalation of irritant
shell gas.
There was conjunctivitis, but the absence of skin burns is specifically
recorded in the clinical
history, and none were present at autopsy. The lesions of the upper
respiratory passages appear
to have been fairly characteristic of mustard gas, although the
necrosis was less extreme than in
many of the cases and not more severe than may occur in the influenzal
cases which developed
independently of previous gassing. The pulmonary lesions were those of
an influenzal
pneumonia, with hemorrhagic edema and typical bronchiolitis. There were
also localized
suppurative lesions, probably associated with a secondary
staphylococcus aureus infection.
There were interesting early reparative changes in bronchi and lung.
CASE 68.- H. A., 3131135, Pvt., Co. G, 109th
Inf. Died, October 15, 1918, 7 p. m., at Base Hospital No. 18.
Autopsy No. 143. Autopsy, October 16, 16 hours after death, by Maj. C.
B. Farr, M. C.
Clinical
data.- Gassed on October 5, 1918. Exposed to yellow cross, green
cross,
and blue cross shells
(1,000 77 and 105 mm. shell). Admitted to Base Hospital No. 18 on
October 8 with severe conjunctivitis and cough.
Developed cyanosis and signs of consolidation at base of left lung.
Leucocytes 9200. October 14, sputum culture
negative or pneumo- coccus. There are many Gram-negative cocci.
Anatomical
diagnosis.- Second degree burns about the eyes, and inside of nose,
nostrils, mouth, and chin.
Acute laryngitis, tracheitis, and bronchitis. Coalescing
bronchopneumonia. Emphysema.
Subpleural emphysema,
right middle lobe. Fibrinous pleurisy. Fatty infiltration of liver.
External
appearance.- The eyelids, periorbital skin, and adjoining areas of
the nose, as well as the nares, left
angle of the mouth, and folds of the chin are of a rough, dull red
color, and covered by yellow crusts. There are
numerous areas of localized desquamation of the skin.
Gross
Findings.- Pleural cavities: There are fibrinous adhesions. Heart
normal. Left lung is voluminous.
The surface of the visceral pleura dotted and rough posteriorly, with
tags of fibrin. The lower lobe is firm and airless.
On section, the tissue is friable, the excised portions sink in water.
The cut surface shows innumerable pinhead to
pea sized firm yellowish-red areas surrounded by depressed purplish
tissue. There is a moderate amount of moisture
present. The upper lobe in the posterior portion is similar to the
lower lobe. The anterior portion is soft, cottony, and
on section, pale pink. Right lung: In the upper and lower lobes
is similar to the left. The middle lobe is soft and
cottony, except for a small tongue posteriorly, which is firm. There is
slight subpleural emphysema. The general
surface of the solid portion of the left, as well as the right lung, is
rough, due to projections beneath the pleura of
numerous small yellowish nodules. Organs of neck: The mucosa of
the pharynx is pale. Tonsils
are small. No lesions
noted. Epiglottis and larynx slightly pinker than normal.
The trachea
in the lower portion, shows a thin whitish film,
with pink strips corresponding to the areas between the rings. The
larger bronchi are of a deep
red color, show
submucous hemorrhages and intense redness in general. The bronchi and
the lower trachea contain gummy blood-tinged fluid.
193
Alimentary
tract.- Stomach, large
and small intestine: On
external examination
apparently normal. Liver
shows moderate fat infiltration. Remaining organs show no significant
lesions.
Microscopic
examination.- Trachea: There is intense hemorrhagic necrosis which
extends to the smooth
muscle bundles overlying the mucous glands. There are very few
leucocyte in the necrotic zone. The superficial
epithelium, as well as that of the ducts of the mucous glands, is
destroyed in its entirety, so that there is no trace of
regenerative activity. Beneath the zone of necrosis, the vessels arc
engorged with blood. There is some fibroblastic
growth, individual cells penetrating the overlying dead tissue. The
mucous glands are preserved, their lumina choked
with mucous secretion, and their stroma infiltrated with lymphoid and
plasma cells. There is sequestration of the
necrotic zone from the living tissue, although the line of demarcation
is distinct. Lung: There are only two blocks of
tissue but these show very varied lesions. There are widespread areas
of loose consolidation, the composition of the
exudate differing in different alveoli. The leucocytes are chiefly
polymorphonuclear and are well preserved. There is
a variable amount of fibrin, sometimes in the form of dense plugs,
sometimes as a delicate network. Red blood cells
are abundant and there are hemorrhagic areas with actual necrosis of
the alveolar framework. The capillaries are
engorged. The alveolar cells are frequently desquamated, but there is
no epithelial proliferation. There is no hyaline
necrosis of the infundibular walls. The atrial epithelium is
desquamated and their lumina filled with pus. In the
second block of lung, the bronchial lesions are most interesting. The
wall of the bronchus is formed by a clean,
highly vascular granulation tissue devoid of epithelium, and in many
places infiltrated with hemorrhage. The
wandering cells are almost exclusively of the mononuclear types the
majority being plasma cells. There is dense
fibrinous exudate into the surrounding alveoli, and a diffuse
pneumonia, poor in cells, and of the hemorrhagic edema
type. Some of the atria in this block show hyaline necrosis of their
walls. A well stained safranine preparation shows
practically no bacteria aside from occasional plump Gram-positive rods.
NOTE.-Gas
poisoning of ten days' duration with a history of exposure to mixed
bombardment. The cutaneous and ocular lesions are characteristic of
mustard gas. The necrosis
of the respiratory tract was very deep and the destruction of the duct
epithelium as well as the
superficial layer accounts for the absence of regeneration. The
pulmonary lesions were those of
an influenzal pneumonia in all respects and the case illustrates the
difficulty in differential
diagnosis.
CASE
69.- C. I., 3509356, Pvt., Co. C, 20th Bat. Died, November 16, 1918, 4
a. m., at Base Hospital No.
87. Autopsy, six hours after death, by Lieut. H. H. Robinson, M. C.
Clinical
data.- Said to have been gassed on November 5, 1918, but reports
based on examination of
Chemical Warfare Service records gives date of gassing as October 13;
2,000 77 and 105 mm. mustard shell in
attack. Chief symptoms, sore throat and dyspnea.
Summary
of anatomical findings.- Conjunctivve rough and sticky. Scaly
desquamation of right side of
scrotum. No crusts.
Gross
findings.- Respiratory tract: Deep injection of tracheal and
bronchial mucosa, with flakes of necrotic
membrane. Crumbly exudate in lumen. Left lung: Is light pink in
color, voluminous, and emphysematous. The base
of the upper lobe is studded with pinhead size abscesses surrounding
bronchi. Right lung: Shows some areas of
consolidation in the right upper lobe. Diffuse bronchiopreumonia, with
necrosis in right lower lobe.
Microscopic
examination.- Trachea: The epithelium is missing. There is no
exudate on the surface. Wall of
the trachea is composed of granulation tissue, elsewhere infiltrated
with wandering cells, chiefly small
mononuclears. In places this is surmounted by wavy delicate membrane,
possibly the remains of the original
membrana propria. There is no marked hyperemia. Lungs: Four
blocks were examined, (a) shows diffuse
pneumonic consolidation with definite abscesses, (b and c) show larger
abscesses surrounded by hemorrhage and
edema, (d) shows marked emphysematous dilatation of the atria,
peribronchiolitis, irregular areas of edema and
edema of the interlobular septa.
NOTE.-
Mustard-gas case of probably 11 days' duration. The cutaneous and
ocular
lesions were very slight. Neither the tracheal nor bronchial lesions
194
were very characteristic. There was
extensive
bronchopneumonia with abscesses, not of the influenzal
type, and
apparently limited to the right lower lobe.
CASE
70.- W. K., 48564, Pvt., Co. M., 18th Inf. Died, October 12,1918, Gas
Hospital, Julvécourt. Autopsy
No. 51. Autopsy, October 12, - hours after death, by Capt. James F.
Coupal, M. C.
Clinical
data.- Exposed to mustard gas on October 1, 1918, passing over an
area previously shelled.
Anatomical
diagnosis.-Superficial burns of body (mustard gas).
Bronchopneumonia. Ulcerative tracheitis.
Acute fibrinous pleurisy.
External
appearance.- Superficial burns of eyelids, conjunctivae, corneae,
bends of elbows, scrotum, and
buttocks. Scattered areas of brown pigmentation about elbows.
Gross
findings.- Pleural cavities: Fresh fibrinous adhesions over both
lungs. No fluid. Heart: Right heart
dilated, otherwise normal. Left lung: Is voluminous. On
section, scattered areas of consolidation with edema in the
intervening portion and emphysema anteriorly. The small bronchi are
filled with pus. Right lung: Presents the same
picture. Organs of neck: Base of tongue and fauces are markedly
injected. Trachea and bronchi are denuded of
mucous membrane and contain purulent exudate. Alimentary tract not
recorded. The remaining organs show nothing
of interest.
Microscopic
examination.- Trachea: The epithelium is absent. There is no
pseudo-membrane. Submucous
layers are somewhat edematous and infiltrated with polymorphonuclears
and mononuclear leucocytes. Capillaries
are congested. Some of the mucous glands contain normal epithelial
cells; others show mucous secretion, are
surrounded by lymphocytes and other inflammatory cells. The large
bronchi are the same as above. Clumps of
bacteria are present in the superficial submucous layers. Lungs:
The smaller bronchi contain pus cells and granular
detritus. Submucous layers are infiltrated with polymorphonuclear
leucocytes and a few red blood cells. There is
marked peribronchial congestion. There is an area of typical lobular
pneumonia with clumps of cocci distributed
amongst the leucocytes in the alveoli. The unconsolidated portion of
this section shows emphysema. The remaining
organs show nothing of interest.
NOTE.-Mustard-gas
case of 11 days' duration. There were no special features except the
absence of reparative changes of the epithelium of the bronchi of the
lung.
CASE
71.- H. G., 113263, rank ?, Co. B, 150th M. G. Bat. Died, April 1,
1918,
at Base Hospital No. 18.
Autopsy No. 55. Autopsy, four hours after death, by Lieut. B. S. Kline,
M. C.
Clinical
data.- Gassed on
March 21, 1918, while attending to mules back of the trenches. Four
hours later developed severe cough and
conjunctivitis. On the following day, burns about the penis. On
admission, marked conjunctivitis, throat deeply
injected. Right middle lobe, dull to percussion, tubular breathing and
rules. March 28, both lungs involved,
bronchitis, laryngitis, and delirium. April 1, unconsciousness,
cyanotic. Temperature 101° to 105°.
Anatomical
diagnosis.- First degree healing burns of skin, conjunctive,
posterior pharynx, upper esophagus.
Diffuse patchy pigmentation of skin. Acute diphtheritic esophagitis,
laryngitis, bronchitis, and tracheitis. Extensive
bronchopneumonia. Acute fibrinous pleurisy. Pulmonary edema. Obsolete
tuberculosis of peribronchial lymph
nodes. Dilatation of right auricle.
External
appearance.- There are extensive areas of desquamation of the skin
over inner surfaces of the
thighs. Areas showing innumerable tiny vesicles over the upper chest,
upper forearms, and axille. There are good-sized vesicles on the backs
of the hands, and on the back of the left hand there is a large bulla,
4 cm. in diameter,
containing a considerable amount of clear fluid. There are areas of
practically healed superficial ulceration about
both knees, wrists, bend of right elbow, right buttock, scrotum, penis,
and lips. These are, in places, healed
completely, and in places covered by brown scabs. The skin everywhere
shows a striking muddy pigmentation. In
addition, there are large irregular dark brown areas of pigmentation,
in places, associated with the skin lesions
mentioned above, in places, especially over the abdomen unassociated
with any skin lesions. The distal portion of
the
195
extremities quite free from the intenser
pigmentation. Eyes: Eyelids puffy, lids glued to- gether by
caked exudate.
Conjunctivae swollen, injected; there are small hemorrhages. Both
cornea
everywhere transparent. Pupils are about
equal, 3 mm. Nose: No abnormalities. Mouth: A few areas of
superficial ulceration with scab formation about the
lips.
Gross
findings.- Pleural cavities are free of fluid and adhesions. Heart:
Normal, in position and shows no
significant lesions. Right lung: Weighs 900 grams. Left lung:
Weighs 710 grams. All lobes are voluminous,
cushiony, soggy. Both upper and lower contain solid areas. The pleura
in general is thin and glistening, but over the
posterior surfaces of the right upper and lower and median anterior
surface of the upper it is somewhat glazed, and
there is a small amount of fibrinous exudate which peels readily. There
is also a moderate amount of fibrinous
exudate between the lobes, and here and posteriorly there is a moderate
number of red subpleural hemorrhages.
Organs of neck: The glands of the neck and mediastinum
moderately enlarged, pulpy, and injected. Thyroid of good
size, Tissue pale, acini filled with colloid. Trachea: The
lower one-third shows necrosis of the epithelium, with
ulceration. The process extends into the submucosa. There is a
considerable amount of necrotic and fibrinous
membrane, below which the tissue is greatly injected and somewhat
swollen. In the upper one-half of the trachea
there is some necrosis of the epithelium. In the larynx the epithelium
is practically necrotic, below it the tissue is
greatly injected. The dead epithelium strips readily. In places the
necrotic epithelium is associated with considerable
coherent fibrinous and fibrinopurulent exudate. This is especially true
of the true vocal cords. There is an extension
of the process into the esophagus and the base of the tongue. Tonsils:
In part are scarred, in part pulpy. A few of the
crypts contain dry, yellow, opaque material. Alimentary tract: No
abnormalities, except that the lymphoid tissue is
slightly more prominent than normal, especially in the lower ileum. The
mesenteric glands are small and pulpy. The
remaining organs show nothing of interest.
Microscopic
examination.- Trachea: No specimens. Lungs: Only a single
section showing massive
alveolar edema, no fibrin. Liver, spleen, and kidneys: Show no
significant lesions.
NOTE.-Typical mustard-gas
case of 11 days' duration, but the histological material was
inadequate for study.
CASE
72.- V. P. T., 1588715, Pvt., Co. G, 30th Inf. Died, August 28th at 6
p.m., at Base Hospital No. 27.
Autopsy 1No. 42, performed 1 hour after death, by Capt. H. H. Permar,
M. C.
Clinical
data.- August 10, admitted to Field Hospital No. 7, suffering from
mustard-gas contact and
inhalation. August 12, admitted to Base Hospital No. 27. Severe burns
of eyes back, thighs, legs, and arms. Pain in
throat, cough and tightness in chest. Heart negative. Many sonorous
rales over both sides of chest. Extensive exudate
in throat from burns.
Anatomical
diagnosis.- Brown pigmentation of skin of body; third-degree burns
on but- tocks, hips, and
calves of legs, conjunctivitis, acute healing; tracheitis, acute
healing; bron- chitis, acute purulent; bilateral;
bronchopneumonia, early; bilateral; pulmonary emphysema; atelectasis of
left Lipper lobe; acute fibrinous pleurisy;
old pleural adhesions, bilateral; hydrothorax, bilateral; cardiac
dilatation, right side; acute lymphadenitis, and
tuberculosis of peribronchial lymph nodes; congestion and cloudy
swelling of liver and kidneys.
Microscopic
examination.- (Four blocks taken for examination.) Marked
thickening
of the bronchi, the
walls of which are composed of opaque whitish tissue, 2 to 3 mm. in
thickness, is noted in the fragment of
preserved lung tissue. (a) The largest bronchus in the section is
almost filled with purulent exudate, in which are
masses of bacteria, and which toward the periphery has the character of
a partially adherent fibrinopurtulent
membrane. Over roughly one-half of the circumference the epithelium is
entirely defective; over the remainder there is a loosely attached
strip of laminated, pale nonciliated cells, several rows in depth. The
individual epithelial cells,
expecially those near the surface, are vacuolated, their nuclei
shrunken and distorted, and there are many leucocytes
passing between them. In one place, the epithelium is lifted up by a
bleblike accumulation of fluid, appearing as a
shreddy coagulum in the section. The bronchial wall is at least 2 mm.
thick, and is composed of a fairly vascular
granulation tissue, infiltrated near the surface with
polymorphommuclears, and in its deeper portion with lymphoid
and plasma cells. The mucous glands are partly preserved but mxiauliv
of the acini are atrophic. The cartilages are
small in comparison to the size of
196
the bronchus; the matrix stains with eosin,
and the nuclei appear degenerated. Small nerve trunks, embedded in the
granulation tissue, show a proliferation of the endo- and perineurium,
and are invaded by wandering cells. Another
bronchus of about the same caliber shows similar changes, but there is
less inflammation, and the reinvestment with
metaplastic epithelium is more extensive. It is interesting that the
new epithelium shows vacuolization of the
epithelial cells, like that seen in the original burns. At the same
time there are numerous mitotic figures. The arteries
are surrounded by a broad zone of edematous granulation tissue. The
lung tissue in the section shows a patchy
edema, with some exfoliation of epithelial cells. (b) The section
includes several bronchi of medium size. One of
these is completely occluded with a fibrinous plug, loosely infiltrated
with wandering cells; another is filled with pus
and bacteria. In both, epithelium is entirely destroyed and the
bronchial wall replaced by thick granulation tissue.
The parenchyma shows emphysematous vesicles interposed between small
areas of collapse and lobular pneumonia.
An interesting feature is a marked stenosis of some of the smallest
bronchi, the lumen of which is reduced to an
irregular split, and the wall proportionately thickened. (c) The
changes in the larger bronchi are like those described,
some being completely reinvested with squamous epithelium, others still
showing a severe diphtheritic inflammation
with adherent laminated fibrinous membrane. The lung tissue is the seat
of a hemorrhagic and fibrinous edema,
which in the neighborhood of the bronchi is becoming organized by the
ingrowth of fibroblasts. The alveolar septa
are thick and infiltrated with wandering cells, chiefly lymphoid. There
is an obliterating bronchiolitis in some areas.
This is not associated with organization of the bronchial exudate, the
lumen being free, and the epithelium normally
ciliated. It appears to be caused rather by the contraction of the
granulation tissue in the wall of the bronchiole. (d)
The bronchial changes are like those in the previously described
sections. The lung tissue itself shows an extensive
edema. Many of the alveoli also are packed with well-preserved
desquamated epithelial cells, amongst which are
large multinucleated forms.
NOTE.-A
case of severe mustard-gas poisoning, dying 11 days after exposure with
typical cutaneous and respiratory lesions. The permanent changes which
resulted from the
intense bronchial injury are already indicated, and cicatrization and
repair were seen, together
with the destructive effects of the original injury.
CASE 73.- W. H. T., 2414146, Pvt.,
Hdqrs. Co., 312th Inf. Died, November 1. 1918, at 5.10 p. m., at Base
Hospital No. 41. Autopsy No. 41, performed two hours after death, by
Lieut. L. G. Gage, M. C.
Clinical data.- Gassed with mustard shell gas on
October
21. Admitted to Mobile Hospital No. 4 on October
25, with diagnosis of mustard-gas burns, multiple shrapnel wounds. and
fracture of right fibula. October 27, admitted
to Base Hospital No. 41. Diffuse bronchitis.
Anatomical
diagnosis.- Mustard-gas burns of skin; acute conjunctivitis;
membranous laryngitis, tracheitis
and bronchitis; acute bronchopneumonia; anomalous left kidney; multiple
shrapnel wounds.
External
appearance.- There is a dermatitis of eyelids, corner of mouth,
lips, and nostrils. The epithelium is
sloughing on inner surface of the thighs. The prepuce and glans penis
are very edematous. There are multiple
superficial shrapnel wounds over both legs. There is a penetrating
wound just to the outer side of the right tibia.
Gross findings.- Left lung: Weighs 720 grams. It
does not
collapse readily after removal. The lower
posterior portion of the upper lobe and the lower lobe are dark blue in
color, firm in consistence. On section, the
upper lobe has a pink color, but scattered through it are small dark
red areas which surround the bronchioles. These
contain a fibrinomucoid secretion. The main bronchus contains a
fibrinous membrane beneath which the mucosa is
congested, hemorrhagic and eroded. The lower lobe is solid, of beefy
consistence, and dark red in color. The
bronchioles are surrounded by patches of grayish consolidation. Right
lung: Weighs 920 grams and presents lesions
similar in character to those on the left side. (Additional note
dictated from preserved Army Medical Museum
specimen.) The specimen includes half of uIpper and lower lobes of
right lung. The pleura is covered by a delicate
fibrinous exudate. The surface of the lung is smooth, and the lobular
structure obliterated.
197
On section, the lower portion of the upper
lobe, and the entire lower are solid, airless, dark red. The large
bronchi
show erosions of the inucosa with grayish membranous deposits. The
small bronchi are more or less filled with
yellow fibrinopurulent exudate. Larynx is covered with fibrinous
exudate under which the mucous membrane is
congested, hemorrhagic, and eroded. Trachea
shows a similar membrane.
The congestion increases toward the
bifurcation. Gastrointestinal
tract: Not recorded. The remaining viscera show no lesions of
special interest.
Bacteriological
examination.- Culture from lung (post-mortem) hemolytic
streptococcus.
Microscopic
examination- Large bronchus: The epithelium is in large part
preserved, and is normally ciliated. Where
exfoliation has occurred, this appears to have been post mortal. The
submucosa is not markedly edematous and
there is no acute inflammatory infiltration. The capillaries are
engorged, and there are small hemorrhages. The
picture does not correspond closely to the description of the gross
lesions. Lungs: The picture is an unusual one. The
bronchioles and infundibula are filled with masses of bacteria and
muculs, with a variable number of leucocytes. The
epithelium in most of them is wholly destroyed. The parenchyma shows
practically no aerated alveoli, the alveolar
spaces being filled with homogeneous coagulumn, or in places a
fibrinoums plug, in which are numbers of red cells
and alveolar epithelium. The hemorrhage in some portions of the
sections is very abundant. Into the plugs are seen
growing pale fibroblasts, but the organization is very early and
limited to comparatively few alveoli. The exudate is
practically free from leucocytes, but there is an increased number in
the alveolar septa.
NOTE.-The
duration of life after gassing in this case was eleven days. The skin
burns
bore out the clinical diagnosis of mustard-gas poisoning, but the
respiratory lesions were less
clear-cut. A membranous tracheobronchitis was described in the gross,
but sections of a large
bronchus failed to confirm this. The pulmonary lesions conformed to the
acute influenzal type.
with abundant hemorrhagic edema and an aplastic exudate. It is to be
noted that the case
occurred during the period when the influenzal epidemic was at its
height. The case illustrates
the difficulty in differential diagnosis.
CASE 74.-T. B., 124463, Pvt., Labor Corps,
204 Emp. Co. Died, November 1, 1918, at 4.40 a. m., at Base
Hospital No. 2. Autopsy, five hours after death, by Lieut. J. H.
Mueller, San. Corps.
Clinical data.-
October 20, admitted to No. 47 Casualty Clearing
Station. Irritant shell gas poisoning.
October 22, admitted to Base Hospital No. 2. Nauseated; pain in
abdomen; eyes and throat irritated and sore.
Temperature 104.4°. Pulse 110. October 23,
conjunctivitis;
pharyngitis; chest clear; heart normal; pulse 80;
abdomen, slight tenderness. October 24, temperature 104. Respirations
normal; very drowsy; chest shows a few
coarse râles in right axilla and under right scapula; coughing. No
diarrhea; nauseated during night. Sputum smear
shows mixed flora, Gram-positive diplococci, bacilli, etc. Plate
staphylococcus, streptococcus viridans. Blood count,
white blood cells, 9,150. Polymor-phonuclears, 84 per cent. Small
lymphocytes, 10 per cent. Large lymphocytes, 5
per cent. Transitionals, 1 percent. October 25, temperature 103°.
Small patch of relative dullness over right back in
posterior axillary line near axilla. Bronchovesicular breathing and a
few rȃles in this area. Urine, heavy trace of
albumin; many finely granular casts. No cells. October 26, temperature
102°. Chest shows very slight change. Slight
impairment at bases, also over right subscapular region; moist rȃles
in
these areas. Cyanotic, labored respiration;
complains of pain in chest and lower lumbar region. October 30,
condition worse, jaundice; many fine and coarse
rȃles over entire chest; suppressed breathing. Blood
culture sterile.
October 31, marked jaundice; gasping; pulse
rapid and weak. November 1, died
at 4.40 a. m.
Anatomical
diagnosis.-Acute purulent tracheobronchitis; bronchopneumonia;
localized empyema; acute
perihepatitis; icterus; poisoning by inhalation of irritant gas.
External
appearance.- Moderate emaciation. Fairly marked jaundice evident
over the whole cutaneous
surfaces and particularly marked in the sclerie. There is all
erythematous rash over the back. No other cutammeous
lesions.
Gross
findings.- Pleural Cavities: Free from fluid. Left lung: Lightly adherent along
its posterior surface
by thick fibrinous adhesions. The pleura is smooth except for this
198
area, which is slightly dulled. The bronchi
contain thick bloody pus, and their surfaces are red and eroded. The
larger
vessels are normal. On section, the upper lobe is practically normal,
being air containing throughout except for some
small areas of broncho-pneumonia at the base. The lower lobe is largely
affected; it is very edematous and bloody.
The consolidation is lobular, the consolidated areas being in places
hemorrhagic, in others flesh-colored and
translucent. The bronchi are not noticeably prominent. Right lung:
Shows a rather more extensive exudate over the
lower lobe. In addition, the lower portion of the upper lobe, on its
anterior surface, and also on its mesial surface,
shows a thick yellow exudate of purulent material. On section, all
lobes are heavily involved in a lobular
consolidation resembling that of the opposite lung. In one place in the
lower lobe there are a number of small
grayish-white areas, cutting with a fairly flat surface, perhaps
slightly projecting, each about 0.5 cm. in diameter.
These are dry, opaque, and granular in distinction to the surrounding
lung. Bronchi show the same bloody exudate as
on the left side, the smaller bronchioles not being prominent. Organs
of neck.-Trachea: Shows an intense congestion
with deep ulceration of the entire mucosa; glottis is similarly
affected. Heart normal. Liver:
Bile passages patent.
Gall bladder contains a small
amount of dark green fluid bile. There
are no stones. Over the portion of the liver
adjoining the diaphragm, there are partly organized fibrinous adhesions
uniting the two. Stomach and intestines:
Normal except for slight congestion of the lower portion of the ileum.
Remaining viscera show no significant
lesions.
Microscopic
examination.- Trachea and large bronchus: No sections. Lungs:
Four blocks showing similar
pictures. No larger bronchi are included in the sections. The
bronchioles and infundibula contain dense plugs of
fibrinopurulent exudate; the epithelium shows in places early
regeneration, and is frequently in the form of a single
flat layer. Elsewhere there is an intense confluent hemorrhagic
pneumonia. The exudate in some of the air spaces is
composed predominantly of polymorphonuclears, pycnotic and distended
with bluish granular material, which in
Gram-stained sections are disclosed as a variety of Gram-positive and
negative bacteria. Many of the Gram-negative
organisms are cocci. There is practically no fibrin in the exudate.
There are several areas of necrosis in which the
alveolar walls are involved. In some areas there is profuse fresh
hemorrhage, completely filling the alveoli. Mixed
with the blood cells are pigment containing alveolar cells. Near the
pleura there is active epithelial proliferation, new
cells investing the alveolar wall and covering over the plugs of
exudate. (See fig. 26.) Spleen, kidney, and
myocardium: No significant changes.
NOTE.-Death
12 days after definite exposure to irritant shell gas. No cutaneous
lesions,
but there was conjunctivitis and marked icterus. There was an
ulcerative tracheobronchitis,
without definite membrane formation. The lungs showed a hemorrhagic
lobular pneumonia with
edema, of the influenzal type, with epithelial proliferation.
It
is not possible from the data at hand to make a definite diagnosis of
mustard-gas poisoning, nor indeed,
aside from the clinical history, is there any convincing evidence of
previous gassing. The lesions present might all be
attributed to an influenzal infection with pneumonia.
CASE
75.- T. M., 561720 (rank not given), Hdqrs. Co., 59th Inf. Died, August
18,1918, at 8.25 a. m., at
Base Hospital No. 17. Autopsy, performed ? hours after death. (Name of
pathologist not stated.)
Clinical
data.- Gassed on August 8. No further details available. The
records
include no other fatalities from
gassing in the same company on or about this date, but soldiers from
Companies D and H of the 59th Infantry were
gassed on August 5 and 6 with yellow, blue, and green cross shells. It
is possible that T. M. was exposed on the
same date. August 8, admitted to Field Hospital No. 28. Exhausted.
Blisters on scalp. Bath. Blisters dressed.
Transferred to Evacuation Hospital No. 5, and on August 9, to Base
Hospital No. 17. Cyanosis, marked dyspnea, air
hunger, tachveardia, heaving displaced apex. Lungs showed typical
physical signs of edema. August 10, cyanosis
and dyspnea not improved. Pulse rapid and thready but regular. No
dullness, but large and smallrȃles with
prolonged blow at end of each respiration. Oxygen administered. Died on
August 18. Autopsy protocol not received.
199
The following note was dictated from the
preserved Army Medical Museum specimen, which consists of
the neck organs, with left lung attached, in formalin:
The
base of the tongue and pharynx are normal. The inferior surface of the
epiglottis and false cords of the
larynx are covered by grayish flakes of exudate which are easily
detached. The trachea is pale throughout. The lining
is a little rough and granular, and largely denuded of mucosa.
Beginning about the middle, however, there are islands
of a grayish white adherent membrane which resembles patches of
regenerated epithelium rather than a diphtheritic
exudate. The large bronchi, especially after the first division, still
contain much fibrinopurulent exudate. On section,
both lobes of the left lung are air containing except for scattered
patches of edema and partial atelectasis. The
bronchi on cross section have opaque thick walls; many of them are
completely occluded by membrane or exudate.
The anterior portion of the upper lobe shows a group of small
bronchiectases lined with necrotic material.
Microscopic
examination.- Trachea: The surface is in part denuded of
epithelium,
in part covered with
islands of stratified squamous cells, often six or more layers deep.
The ulcerated regions are surmounted by a loose
exudate composed of red blood cells, polymorphonuclears and detritus.
There is very little fibrin and no formed
pseudomembrane. The mucous ducts show the usual epithelial
proliferation. The subepithelial tissue is the seat of a
dense inflammatory infiltration, both polymorphonuclears and of
lymphoid cells. There are very dense
accumulations of lymphocytes about the otherwise normal mucous glands. Lungs:
Section includes a group of
medium-sized bronchi greatly distended with purulent exudate. The
epithelium and glands are destroyed but the
cartilages about the larger branches are still intact. The alveoli
about these bronchiectases are compressed and the
septa thickened and infiltrated. Some of them contain fibrinous
exudate, others fresh blood. In many, organization is
in progress. The connective tissue about the bronchi and blood vessels
is edematous and contains many fibroblasts.
(Fig. 33.) A second block of lung shows an acute suppurative bronchitis
with moderate dilatation and inflammatory
thickening of bronchial wall, leading in one place to necrosis of the
bronchial cartilage. In many places the alveolar
septa are condensed and infiltrated with dense collections of
leucocytes, largely mononuclear. Practically no exudate
in alveolar spaces.
NOTE.-An
incompletely studied case; death 10 to 12 days after gassing. The
nature of
the gas to which the soldier had been exposed is uncertain, but the
clinical history suggests an
admixture of suffocative gas in addition to the vesicant. The
regenerative changes in the tracheal
epithelium are of interest.
CASE
76. T. M., 2849228, Pvt., Co. H, 359th Inf. Died, October 11, 1918, at
2 a. m., at Base Hospital No.
45. Autopsy No. 52. Autopsy, October 12, 31 hours after death, by Capt.
Jean Oliver, M. C.
Clinical
data.- Gassed on September 28, 1918. The following extract is taken
from field card: "Was sleeping
in dugout when gassed, also got some gas after leaving dugout, burned
eyes, throat, and lungs; got sick at stomach
and vomited, coughed good deal since. Physical examination: Eyes red,
lids swollen, lacrymation and photophobia.
Coughing some and spitting up mucopurulent sputum. Hoarse. Diagnosis:
Mustard and diphosgene." On admission
to Base Hospital No. 45 on October 5 complained of intense pain in
throat and on swallowing. Face cyanotic, pulse
rapid, temperature 102°. Dullness over right lower lobe. Fine crepitant
rȃles.
Anatomical
diagnosis.- Mustard-gas burns, on lips, eyes, nose, and over
scrotum. Diphtheritic laryngitis,
bronchitis, and tracheitis. Diffuse bronchopneumonia of all lobes of
both lungs.
Following
abstract was dictated upon the receipt of specimens at the pathological
laboratory, Experimental
Gas Field:
The
posterior wall of the pharynx shows a superficial necrosis with a
grayish membrane. The epiglottis and
trachea present a worm-eaten appearance (erosions) and are covered in
places with a sandy grayish deposit. The
bronchi, larger branches, show intense purplish- red discoloration.
There are patches of flaky exudate on the surface.
After the second or third branching, the mucous membrane becomes
smooth. The lumina contain very little exudate.
The left lung is moderately heavy and voluminous. There is fresh fibrin
in spots
200
over the posterior portion of the lower lobe.
The color is mottled bluish purple. On section is generally
air containing. There are, however, a few shotty elevated areas of
consolidation. These are not over 1 cm. in size. The
bronchi are surrounded by a zone of hemorrhage 2 to 3 mm. broad.
Elsewhere the lung tissue presents a marbled
appearance because of irregular, uniform, darker areas, slightly
prominent above the surface, which are partly
consolidated. The lower lobe is very dark in color and poorly aerated.
It contains a number of small shotty
pneumonic patches. The right lung shows fresh fibrin over all lobes. On
section there are numerous areas of lobular
pneumonia, rather discreet and small for the most part, and distributed
throughout all lobes.
FIG. 33.- Case 75. Death
probably 10-12 days
after exposure to mixed gases. Bronchiectases filled with purulent
exudate. Peribronchial and periarterial edema and beginning fibrosis
Microscopic
examination.- Trachea: The mucous membrane is of the stratified
squamous type. In places it
is partly exfoliated and there is false membrane. The submucous tissue
shows, engorged vessels, edema, and a slight
infiltration with mononuclear cells, large and small. This is
especially marked about the mucous glands . A few
bacteria are seen on the surface of the mucous membrane. Medium-sized
bronchus: In places there are patches of
adherent membrane composed of swollen reticulated fibrin. The wall of
the bronchus is completely necrotic and
there is no beginning of regeneration. Beneath the necrotic lining
there is edematous tissue, poor in cells. About the
bronchus there is the usual zone of intense hemorrhage. Lungs:
The small bronchi show desquamated columnar
epithelium. The lumina are filled with polymorphonuclear leucocytes.
The walls are
201
congested and acutely inflamed. The
parenchyma is the seat of a bronchopneumonia of wide but patchy
distribution.
The exudate varies in its contents of edematous fluid, red-blood cells,
polymorphonuclear leucocytes and fibrin.
Usually there are well-defiled areas in which one or more of these
elements predominates. Bacteria are numerous
both in the bronchi and the pneumonic areas, almost extensively
Gram-positive cocci, some in large masses, others
in swollen groups and chains. It is evident from the naked-eye
inspection of the lung section that many of the
bronchi are both dilated and thickened. The dilatation is shown by the
flattening of the adjacent alveoli. The
thickening is produced by edema and peribronchial organization of the
connective tissue. The periarterial tissue is
also thickened. Liver, spleen, kidneys, pancreas, and intestines
show no significant lesions.
NOTE.-Mustard-gas
poisoning: death on the thirteenth day after exposure. There was no
anatomical reason to support the clinical diagnosis of mustard-gas and
diphosgene poisoning, the
lesions differing in no respects from other mustard-gas cases. It must
be said, however, that it
would probably not be possible to recognize the effects of an admixture
of suffocant gas after
this time had elapsed. The trachea and large bronchi showed
well-established epithelial
regeneration, and it is possible that the necrosis was superficial. The
smaller bronchi, on the
other hand, showed extensive necrosis with beginning fibrosis of their
walls, and dilatation.
There was the usual peribronchitis with fresh hemorrhagic pneumonia.
The consolidation was
distinctly in relation to the bronchi.
CASE 77.- J. C., 2706880, Pvt., Co. H, 136th
M. G. Bat. Died, October 28, 1918, 3.40 a. m., Base Hospital
No. 45. Autopsy No. A 18-67. Autopsy, 10 hours after death, bv Lieut.
Perry J. Manheims, M. C.
Clinical
data.- Gassed about 6 a. m. October 14, 1918, in action, 2,000
150-mm. shells. Ciinical diagnosis:
Bronchopneumonia following inhalation of mustard gas.
Anatomical
diagnosis.- Multiple superficial mnustard-gas burns. Diphtheritic
tracheo-bronchitis.
Bronchopneumonia. Hemorrhagic erosions of stomach.
External
appearance.- Superficial burns about mouth, nose, and right cheek,
covered with thick brownish
red scabs. Skin on inner surface of both thighs shows small dry
blisters, confluent in places, extending from 3 cm.
above knees to level with scrotum. Few drv scabs on under surface of
scrotum and prepuce. Skin about the axillae
shows the same condition as the thighs.
Gross
findings.- Respiratory organs: Sent to Chernical Warfare Service.
Stomach: Shows a few
hemorrhagic erosions. The remaining organs show no significant lesions.
The
following note on the gross appearance of the respiratory organs was
made upon the receipt of the
specimens at the pathological laboratory, experimental gas field:
The posterior wall of the pharynx shows
necrosis and is covered with patches of gray membrane. The
tonsils are smaller than
usual, with deep crypts containing cheesy
plugs. The inferior surface of the epiglottis,
vocal
cords, and trachea show
complete necrosis of the mucous membrane, which
is replaced by a soft slough. The
bronchi are filled with a thin
purulent fluid. The mucosa is necrotic
and desquamated. There is no definite
membrane. Left lung: Weighs 525 grams. The pleura is smooth.
Firm nodular areas can be felt through the upper
lobe. On sections these correspond to elevated I to 2 mm. sized areas
of consolidation scattered about the bronchi.
The latter are filled with pus. There is the same appearance in the
lower lobe. The bronchi seem rather thick and
project above the surface. Right lung: Weighs 700 grams. There
are large areas which show a grayish-blue color
through the pleura, which are quite soft and have lost their
elasticity. These areas occupy the posterior two-thirds of
the upper and middle lobes and the upper and posterior parts of the
lower lobe. On section, the lung tissue is broken
down, exuding a large amount of thin bloody fluid. There is no
gangrenous odor. The anterior portion of the lobes
contain numerous small greenish areas of consolidation, apparently
peribronchial.
Microscopic
examination.- Skin: Illustrates the late effect of a mild
burn. There is hyperkeratosis; many of
the epidermal cells show pycnotic nuclei and contain vacuoles, and the
papillary layer of the corium shows edema.
There are occasional pigment cells, but no
202
marked increase. Inflammatory changes are
absent. Primary bronchus: The membrane has been cleared away. The
surface is formed by continuous membrana propria which is uncovered by
epithelium. Immediately beneath it are
fairly dense accumulations of leucocytes (pycnotic). The submucous
tissue is very loose and edematous. Many of the
venules contain dense hyaline thrombi, some of which are being covered
with endothelium. In the deeper submucosa
there is a proliferation of fibroblasts. The mucous glands are in
active secretion and are not abnormal. The section
includes no submucous ducts. Lungs: The most interesting
changes are found in some of the bronchi, which, with the
low power, are slightly thick walled, and under the high magnification
show clearly an active hyperplastic growth
with numerous plasma cells. The bronchi are relined with flattened
epithelium. The parenchyma is the seat of
irregular patches of bronchopneumonia, some of which are in definite
relation to bronchi which are filled with
purulent exudate. There are no special features to the exudate. In a
few areas where fibrin is abundant organization is
in progress. Bacteria are difficult to demonstrate. A few
Grain-positive cocci are found in the bronchial exudate.
Cultures at autopsy from lung show hemolytic streptococcus.
NOTE.-Mustard-gas
poisoning; death 14 days after exposure. Charac- teristic burns.
Atria and bronchi showed a cleaning up of the tissue with subsidence of
the acute inflammatory
process, but no epithelial regeneration. The small bronchi were already
thickened and dilated.
Some of them were relined with new epithelium, though incompletely.
There was still an acute lobular pneumonia distributed about the
infected atria. The usual organization of the exudate was
in progress in certain places. The gangrenous areas in the right lung
were, unfortunately, not
examined histologically.
CASE 78.- P. C.,
61723, Pvt., Co. ?, 101 Inf.
Died, June 14, 1918, at Base Hospital No. 18.
Autopsy No. 63. Autopsy, one and one-half hours after death, by Lieut.
B. S. Kline, M. C.
Clinical data.- Said to have been gassed with
phosgene on May 31, 1918, while on raid on enemy's trenches. On return
to own
trenches developed cough; was carried to Field Hospital No. 103.
Transferred to Base Hospital No. 18 on June 2. On
admission temperature 1020, comfortable. Rȃles in both
lower lobes.
June 4, temperature 105°, moderate
cyanosis, rapid respiration. Signs of bilateral bronchopneumonia, most
extensive in lower lobe. Blood pressure
95/50. Heart not dilated. On June 5, temperature 105°, respiration 34,
cyanosis, feeble pulse. June 6, consolidation
of entire left lung. General condition better, apparent crisis. June 9,
temperature again elevated. Delirium, Cheyne-Stokes; profound
prostration. Irregular consolidation, right upper lobe. Stupor.
Leucocytes, June 5, 13,800; June 10,
16,300; three blood cultures negative.
Anatomical
diagnosis.- Acute tracheitis and bronchitis, following phosgene
inhalation. Extensive
bronchopneumonia, discrete and conglomerate with areas of organization.
Acute bronchial lymphadenitis. Moderate
fat infiltration of liver. Acute colitis. Few small healed infarcts of
right kidney. Acute dilatation of right ventricle.
Healed tuberculous foci of bronchial and tracheal lymph nodes.
External
appearance.- Skin is sallow in appearance. About the right shoulder
and forearm there are a
number of flat, irregular, pearly white blotches in the skin,
suggesting old burns. In the skin of both legs there are
small excoriated areas suggesting pediculosis, also a number over.
Mouth: Some sordes covering the lips and gums.
Also a moderate amount of mucus.
Gross
findings.- Pleural cavities: Opening the thorax, the median
portions
of the upper lobes almost meet in
the midline. The pleural sac is free of adhesions and fluid. The heart
is enlarged slightly to the right. No
abnormalities in the sac. Heart: Weighs 290 grams. Moderate
dilatation of the right ventricle. Otherwise negative.
Right lung: Weighs 600 grams. All lobes are voluminous. The
posterior and lateral portions of the upper and lower
lobes soggy, solid, the median portions cushiony. The middle lobe
cushiony, pink. The glands at the hilum are
considerably enlarged, pulpy, somewhat edematous, pale. Some
203
of the glands at the hilum have small scarred
gray areas, plus anthracosis. The bronchi are filled with thin, viscid
yellow pus. On section of the upper lobe, the posterior and lateral
one-half dull gray-red and red, solid in great part,
mottled with small grayish and yellowish pinhead sized areas. The
median one-half is pink, aerated. Through it there
is a moderate amount of discrete and conglomerate small gray nodules,
quite firm in consistence. On section of the
middle lobe, the tissue crackles, is well aerated, pink; scattered
throughout, there is a moderate number of discrete
and conglomerate pinhead sized yellowish-gray solid areas. Some of
these more firm in consistence than others. In
the lateral portion of the lobe there is some grayish consolidation
about these conglomerations. The lower lobe, on
section, shows in the posterior and lateral portions collapsed deep red
long tissue mottled with a large number of
discrete and conglomerate grayish and yellowish nodules, mostly gray
with fairly firm consistence. About these
conglomerations, more medially, there are discrete hemorrhages. About
these medially the tissue is well aerated,
pink, shows a moderate number of discrete and conglomerate solid gray
areas, quite firm in consistence. In this lobe
there is a little uniform consolidation and that present is found in
the posterior and lateral portions of the lobe. Left
lung: Weighs 800 grains. Both lobes voluminous, soggy, solid.
The
median portions, especially, show well-aerated
tissue in which are felt numerous small nodules. The pleura over the
lobes on this side and over the lobes on the
right is thin, delicate and pale. The glands at the hilum and bronchi
are similar to those on the right. On section, the
upper lobe is mottled reddish and yellowish, surface presents with,
here and there, areas of pink. The yellowish areas
are discrete and conglomerate. The solid areas are associated with
bronchial branches. The peripheral portions of
greater consistence than the central portions. In places there are more
firm solid areas. The dull reddish-gray areas
are large consolidated patches, in places confluent. The surface is
relatively dry, slightly granular, surrounding the
numerous groups of yellow conglomerations mentioned above. The lower
lobe, on section, shows a picture quite
similar to the right lower lobe, except that the hemorrhage about the
conglomerate yellow areas is much more
marked. Associated on this side there is present some diffuse
consolidation. The nodules, likewise, in this lobe are
more numerous and of less consistence than those in the right lower
lobe. Organs of neck: Lower tracheal and
cervical glands are quite similar to the glands about the hilum. In
addition some show calcified nodules. The thyroid
is small and tissue pale. Acini contain some colloid. The larynx and
trachea contain a considerable amount of viscid
yellow pus. The mucosa is pale, thin, except in the lower portion of
the trachea, where it is somewhat swollen and
somewhat injected diffusely. Tonsils:
Small, scarred, and crypts clean.
Alimentary tract: Stomach is small. The walls
are moderately contracted. There are a few 100 c. c. of thin bile
tinged mucus in it. The duodenum and the jejunum
contain bile tinged contents. The lymphoid tissue in the tract is
slightly more prominent than normal. Throughout the
large intestines there are large patches of injection of the mucosa
with small hemorrhages. In these areas the
lymphatic follicles are very prominent, and covering the mucosa there
is adherent tenacious mucus. The rectum is
similar in appearance. The injection here is more marked. The
mesenteric glands are somewhat enlarged, pulpy,
pale. Liver: Weighs 1,530
grams. Shows slight fat infiltration. Kidneys
show focal scars.
Microscopic examination- Trachea: No
sections. Large bronchus: The epithelium is continuous and very
orderly in
arrangement. The superficial layer is beautifully ciliated. There are
occasional mitoses. Leucocytes,
polymorphonuclears and mononuclears are wandering between the
epithelial cells. The submucosa is not edematous
nor extremely congested. There are numerous lymphoid and plasma cells
but very few polynuclears. The mucous
glands are in active secretion, otherwise normal. Lungs: There
is an intense bronchiolitis and infundibulitis. The
lumina are filled with pus, their epithelium is largely preserved, and
in many cases regenerated, multiple-layered and
nonciliated. There is an early organization of the bronchiolar exudate
in places. The bronchial walls are thickened,
partly by edema and inflammatory changes, and partly by new growth of
connective tissue which extends into the
septa of the neighboring alveoli. There is a marked peribronchitis, the
alveolar exudate consisting often of dense
plugs with few leucocytes. There is an early ingrowth of fibroblasts,
and an epithelial proliferation. Epithelial cells
are relining the alveoli and in the form of syncytial masses growing
over and into the fibrin plugs. Another block
shows a slightly different picture. Many of the infected atria, which
have completely lost their epithelium, appear as
abscesses and are surrounded by confluent areas of hemor-
204
rhagic and fibrinous pneumonia, in which
organization, interstitial fibrosis, and regeneration of the alveolar
epithelium are conspicuous features. A study of the sections stained
with Gram-Weigert-safranine under the low
power magnification with a binocular microscope shows in a very
interesting way the distribution of the lesions.
There is an acute suppurative bronchitis and bronchiolitis, but the
epithelium in the bronichli is in large part
preserved. The bronchioles and atria are surrounded by pneumonic areas
in which the exudate consists almost
wholely of well preserved polynuclears. Outside of this the alveoli
contain beautiful fibrin nets and the cells are
largely desquamated epithelial cells. It is in this zone that
reinvestment of the alveoli with new growth of
proliferating epithelial cells and occasional organization is
encountered. Large intestine
shows congestion and
hypersecretion of mucus. Testis: There is an absence of
spermatogenesis, and interstitial edema and fibrosis. Liver,
spleen, pancreas, kidney, and myocardium show no significant
lesions.
Bacteriological
examination.- Smears: Trachea
shows innumerable small
Gram-negative bacilli, a
considerable number of Gram-positive diplococci, and a moderate number
of fair-sized Gram-negative bacilli. The
predominating organism is a small Gram-negative bacillus. Lung: Large
consolidated portion shows a considerable
number of Gram-negative bacilli, a few good sized Gram-negative
bacilli. Small consolidation shows very few
organisms, small clumps of Grain-positive cocci and a few small
Gram-negative bacilli.
NOTE.-Death
14 days after alleged exposure to phosgene. There were no recent
mustard-gas burns and the inflammatory changes observed in the trachea
and larger bronchi had not the
necrotizing character observed in mustard-gas cases. At this stage, it
is not possible to make a
definite anatomical liagnosis of previous poisoning by asphyxiating
gas, although it is quite
probable that the extensive bronchopneumonia present may have followed
the inhalation of gas.
The reparative changes in the bronchi and alveoli were those which
might be seen in any type of
bronchopneumonia at this stage.
CASE 79.- D. F., 1319851,
Corpl., 120 Inf. H.
Q. Died, November 2, 1918, at 1.25 p. m., at Base Hospital
No. 2. Autopsy, one and one-half hours after death, by Lieut. J. H.
Mueller, San. Corps.
Clinical
data.- October 20, admitted to No. 61, Casualty Clearing Station.
Poisoning by irritant gas, having
been exposed October 19 to blue, green, and yellow cross shelling.
October 22, admitted to Base Hospital No. 2.
Gassed three days ago. Sore eyes and throat. Vomiting. Cough. No burns.
Bleeding from nose. Heart normal. Lungs:
A few coarse bronchial rȃles. Sputum, mucopurulent.
October 25, feels
much better. No localization of signs of
consolidation; coarse rȃles and very harsh breath sounds
at left base.
October 27, fine moist rȃles over right lower
lobe; harsh breath sounds over entire posterior chest. Condition worse,
slightly irrational. Sputum culture-pneumococci and micrococcus
catarrhalis. October 29, marked dulluess with diminished breath sounds
over right
lower lobe. Fine and coarse rȃles over left lower lobe.
Holding his
own. Good pulse. October 31, temperature falling
by lysis. Consolidation
of both bases. Doing well. November 1, harsh breath sounds with
scattered areas of fine rȃles
anteriorly. Respirations 60. Diarrhea. November 2, lemon yellow tint
to conjnnctivle and skin. Acute tenderness in
right upper quadrant, with rigidity of right abdominal wall. Diarrhea
has ceased. No particular change in lungs. Few
bronchial rȃles. Died at 1.25 p. m.
Anatomical
diagnosis.- Acute laryngitis; acute purulent bronchitis, confluent
double lobular pneumonia;
acute fibrinous pleurisy; acute enteritis; hemorrhages into rectus
abdominis muscle; icterus. Poisoning with irritant
gas.
External appearance.- Slight icterus. No ocular or cutaneous
lesions described. Extensive hemorrhages
into rectus abdominis muscle.
Gross
findings.- Pleural cavities: Partially organized adhesions over
posterior portions of right and left
lower lobe. No fluid. Left lung:
Covered over entire lower lobe by
partially organized layer of fibrin. The bronchi
contain much frothy purulent fluid. On section, the greater part of
lower lobe presents a very uniform consolidation;
the lower portion however, is still free and air containing. The
consolidated portion is grayish-red and rather moist.
In the tipper lobe are a few small areas of bronchopneumnonia. Right
lung: Shows a similar fibrinous exudate over
the lower lobe. Bronchi contain rather more
205
pus than those of the opposite lung, but
their mucosa is neither eroded nor hemorrhagic. The lower lobe is
completely consolidated, fairly uniform, grayish-red in color; at lower
portion, there is a fairly large area made up
apparently of small abscesses set closely together; whitish pus may be
squeezed from some of these. The upper lobe
contains a good many scattered areas of bronchopneumonia, some of them
infarct-like in distribution. The middle
lobe shows a few areas of hemorrhagic bronchopneumonia. Organs of
neck: There is very slight ulceration of the
glottis, and injection of the vessels near the bifurcation of the
trachea; no other changes. Heart
is normal. Liver and
bile passages normal. Spleen enlarged to about twice
normal size, firm,
dark purple, follicles prominent. Adrenals,
kidneys, stomach are normal. Intestines: Beginning about half way
down the ileum, there is marked congestion of
the mucosa without definite ulceration. This continues down to the
colon. The solitary lymph follicles are
prominent, but not the Peyer's patches. Large intestine normal.
Microscopic
examination.- Trachea and large bronchus: No section. Lungs:
The terminal bronchioles are
distended with solid masses of purulent exudate in which are bacterial
colonies. The epithelium is represented only
here and there by proliferating flat cells. There is slight compression
of the adjacent alveoli. Between the abscess-like cavities of the
dilated atria there is hemorrhagic and fibrinous pneumonia distributed
through all portions of the
section. The alveoli are being lined actively with new epithelial
cells, and here and there are sprouts of fibroblasts
and epithelial cells growing into the exudate. There are fair numbers
of fibroblasts in the thickened septa also, and
occasional large mononuclears. Bacterial stains show large masses of
cocci in the purulent exudate which fills the
atria. They are chiefly Gram-positive. Elsewhere there are practically
no bacteria. Another section of lung shows a
uniform, almost lobar type of pneumonic consolidation, without unusual
features. Liver, spleen, kidney: Marked
congestion. Adrenal: Loss of chromaffin staining and depletion of cortical lipoids.
Rectus muscle: Interstitial
hemorrhage, without degeneration of fibers. Small intestine:
Hemorrhages into tips of villi.
NOTE.-
Death
occurred 14 days after definite history of exposure to irritant gas.
When
first seen 3 days after gassing, there was slight conjunctivitis, but
skin burns were lacking. The
patient developed an extensive pneumonia, pathologically in all
respects of the influenzal type,
and associated with terminal icterus. The upper respiratory passages at
autopsy did not show
severe and characteristic lesions of mustard gas. There are not
sufficient data, therefore, from
which to draw conclusions as to the nature of the gas to which the
patient had been exposed. It is
of interest to note that Case 43, L. K. J., a member of the same
organization, gassed on the same
day, likewise showed at autopsy lesions which were not typical of
mustard gas. It is probable
that these patients developed an influenzal pneumonia following a very
light exposure to the gas;
or else that the lesions followed exposure to a mixture of other
irritant and asphyxiating gases.
The reparative changes which are a conspicuous feature of the
histological picture are also
commonly found in the lungs of the primary influenzal cases at this
stage.
CASE 80.- M. McM., 1464462, Pvt., Co. B,
129th
Field Artillery. Died, October It, 1918, at 10 a. m., at
Base Hospital No. 15. Autopsy, five hours after death, by Maj. Daniel
J. Glomset, M. C.
Clinical data.- Mustard-gas inhalation and
contact,
received in action on October 3, 1918. Second degree
burns of legs and right foot. Acute gastritis. Lobular pneumonia.
Anatomical
diagnosis.- Lobar pneumonia, red hepatization of entire right lower
lobe and parts of the right
middle and left lower lobes. Diphtheritic tracheitis and bronchitis.
Fibrinous pleurisy.
External
appearance.- The face is purplish in color and a large amount of
bloody fluid runs from the
nostrils. There are deeply pigmented areas over the shoulders
posteriorly and the back is black in color. These areas
are confluent in places. The sclerae are clear. The pupils are 3 m.m.
in diameter. There are discrete black patches
on the posterior part
206
of the right shoulder. Body heat is present.
Post-mortem lividity is marked. The scrotum is unchanged. On the left
leg there is a belt of marked pigmentation of the upper and middle
thirds and extends down for 4 or 5 cm.
Gross
findings.- Body cavities: The liver extends 7 cm. below the
xiphoid.
The diaphragm extends to the
6th rib on the right and to the 5th rib on the left. The pericardial
cavity is unchanged. The pleural cavities are
unchanged. Cervical and thoracic organs: There is a small
remnant of
thymus left. The lungs are poorly collapsed.
The lymph follicles at the base of the tongue are markedly enlarged and
almost form two tonsils. The tonsils are
large and purplish. There are patches of very adherent membrane in the
trachea. These are whitish areas and extend
throughout the tracheal wall and also cover the vocal cords. Left lung
is partly collapsed. The posterior part has a
downy feel. Anteriorly there are numerous poorly circumscribed solid
areas. In the middle of the lower lobe there is
another solid area. The edges of the lobe crepitate. The area in the
lower lobe occupies about one-half of the lobe.
The surface made by section is purplislh-pink in color and rather
granular. From the cut surface a bloody tenacious
fluid exudes. Right lung: The upper lobe crepitates
throughout. The middle lobe crepitates posteriorly and the rest is
solid. The same large and firm area is in the lower lobe and the lobe
contains air at the posterior apex. The surface
made by section is mottled and has a purplish-pink color and exudes the
same tenacious fluid. Heart is
normal in
size. The myocardium and valves are unchanged. Abdominal organs:
The spleen is normal in size. The Malpighian
corpuscles are fairly distinct. The pulp scrapes off easily. The
pancreas is unchanged. The left kidney is soft. The
kidneys are markedly swollen and pale. The cortex measures 12 mm. The
capsule strips easily. The stomach and
small intestines are unchanged. The bladder is unchanged, also the
testicles.
Microscopic
examination.- Trachea: The epithelium is desquamated, save
for a few adherent basement
cells. There is marked submucous edema without cellular reaction. In
the edematous tissue there are great numbers
of bacteria. In Gram preparations these are in part Gram-positive
coccoid bodies surrounded by a red staining veil or
rod-shaped capsule. Lungs: In the smaller bronchi, the
epithelium is either completely desquamated or the cells are
deformed or degenerated. The submucous layer is edematous and
infiltrated with polymorphonuclear leucocytes, and
other inflammatory cells. The vessels about the bronchi are engorged
with blood. Pulmonary capillaries are
congested and contain polymorphonuclear leucocytes. The alveoli display
pronounced bronchopneumonic process.
There are definite groups of alveoli filled with pycnotic
polymorphonuclear leucocytes alone and surrounding them
are alveoli containing granular débris and red blood cells. Very
little fibrin is present. Lymphatic vessels about
some of the smaller arteries are filled with pyenotic and fragmented
leucocytes. Bacteria are extremely numerous,
the predominating type being Gram-positive cocci, sometimes in chains.
Spleen contains hyaline, pink-staining
material in the follicles. No other organs examined.
Bacteriological
examination.- Lung exudate: Streptococcus hemolyticus,
staphylococcus aureus,
pneumococcus.
NOTE.-There
is a definite history of mustard-gas exposure, 15 days before death,
with
typical burns. The respiratory lesions, however, were not altogether
characteristic of mustard-gas
inhalation. There was desquamation of the tracheal epithelium with
erosions and massive
bacterial infection of the submucous connective tissue. Where, however,
the epithelium was
preserved it was normally ciliated and showed neither a coagulative
necrosis nor the metaplasia
commonly found after regeneration. The pulmonary lesions are altogether
typical, both grossly
and histologically of the pneumonia of the pseudolobar type, which was
so prevalent at that time.
There was a hemorrhagic, nonfibrinous exudate in which the leucocytes
were fragmented and
pycnotic; dilatation of the atria with hyaline necrosis of the walls
and of the alveolar lining,
fibrinous thrombi, and the occasional necrosis of the alveolar
capillaries. On the other hand, the
customary regeneration and organization which one would expect in
mustard gas of this stage
were lacking. The lesions
207
seem too acute for 15 days' duration. It
seems probable in summing up the evidence that this patient contracted
influenzal pneumonia while in the hospital, and that the
initial gas
injury of the respiratory tract was negligible
except in so far as it may have predisposed to the secondary influenzal
infection. It is unfortunate that the clinical
history is too incomplete to give further evidence on this point.
CASE
81.- R. J. S., 1426189, Pvt., Co. F, 59th Inf. Died, August 12, 1918,
at
Base Hospital No. 46. Autopsy
No. 3. Autopsy, 11 hours after death, by Lieut. B. S. Kline, M. C.
Clinical
data.- Gassed on July 28, 1918. Burns of forehead and knees.
Evidences of gas inhalation
complicated with bronchopneumonia caused by staphylococcus albus and
nonhemolytic streptococcus. Died with
signs of pulmonary edema and symptoms of acute colitis.
Anatomical
diagnosis.- Extensive gas burns of conjunctivae skin, buttocks,
elbows, knees, penis, and
scrotum. Acute ulcerative and membranous laryngitis, tracheitis and
bronchitis. Bronchopneumonia. Moderate
pulmonary edema. Acute laryngitis and esophagitis. Acute ulcerative
colitis. Slight cardiac dilatation.
External appearance.- Over both buttocks, both knees and the backs of
both elbows, the dorsal surface of the
penis, the ventral surface of the scrotum, there are characteristic
superficial gas burns, extending into the dermis.
Those about the knees show near the margin large blebs filled with
clear fluid. Elsewhere the base is covered with a
thin dry scab. The skin of the backs of the hands and the face has
diffuse light brown pigmentation. At the bend of
the right elbow there is a small recent surgical incision 2.5 cm. long
and gaping somewhat in its midportion. The
base covered by an adherent red-brown scab. The superficial glands are
somewhat enlarged. The mucous
membranes pale. Eyes: The eyelids are slightly swollen. The
conjunctivae somewhat edematous and the bulbar
portions considerably injected. On the left there are in addition
numerous scattered small red hemorrhages. The
pupils 5 mm. in diameter. Ears and nose: No abnormalities.
Gross
findings.- Pleural cavities: On opening the thorax, a few thin
fibrous bands found binding the apex of
the upper lobe to the chest wall on the right side. There is no excess
of fluid and no adhesions of the left. The heart
lies in normal position. On incising the pericardial sac, no
abnormalities of or in the sac noted. Heart: Weighs 370
grams. Somewhat enlarged. The right auricle and ventricle slightly
dilated. The tricuspid ring admitted three fingers.
The valvular endocardium throughout is thin. The coronaries and bases
of large vessels, no abnormalities. The left
myocardium on section, the architecture regular, the bundles coarser
than normal and the tissue pale, boiled. Right
lung: All lobes voluminous, cushiony and somewhat soggy, especially
the upper and lower lobes. The pleura over
the lateral and posterior surface, especially of the lower lobe, is
somewhat injected and covered by a small amount
of tenacious fibrinous exudate. There are a few thin fibrous bands
binding the middle lobe to the lower lobe. The
glands at the hilum moderately enlarged, pulpy and injected. The
vessels at the hilum show no abnormalities. Bronchi: There is
extensive ulceration of the mucosa and considerable edema and injection
of the mucosa. Tightly
adherent to the submucosa there is a castlike membrane of friable
fibrinopurulent exudate. On section of the upper
lobe a moist pink-red surface presents. The air sacs contain a moderate
amount of thin frothy fluid. Scattered
throughout there are several small solid deep red areas associated with
the bronchioles. On repeated section of this
lobe the consolidation immediately adjoins not only the small
bronchioles but also the good sized ones. The
bronchioles throughout show considerable injection of the walls.
Attached to the mucosa and submucosa there is an
adherent fibrinous and fibrinopurulent exudate. The consolidation about
the bronchioles is most marked in the
posterior portion of the lobe. The middle lobe, on section, presents a
pink surface. The air sacs contain a small
amount of thin frothy fluid. The bronchioles show injection of the
mucosa. The exudate in this lobe is much less
than in the upper lobe. About the bronchioles there is no hemorrhage or
consolidation visible anywhere. The lower
lobe on section presents a similar picture to that in the upper. There
are areas of peribronchial consolidation here,
verystriking. There is a moderate to considerable amount of fluid in
the air sacs. Toward the periphery the lung,
especially in the lower portion, shows much more marked areas of peri-
208
bronchial consolidation, which extends in
some places into the lung for a distance of 1 cm. These deep red
consolidated areas are more numerous near the pleura in the lower
portion of the lobe. Left lung:
Both lobes are
voluminous, cushiony, soggy, especially in the lower. In the lower,
scattered solid patches are palpable. The vessels,
bronchi, similar to those on the right in appearance. The lymph glands
on this side moderately enlarged, pulpy, pigmented, and injected. A
number of them show pinhead to small lemon-seed
sized firm yellow opaque nodules,
encapsulated by firm gray tissue. The left upper lobe similar to the
right side, upper, in appearance. The pleura on
this side over both lobes especially posteriorly shows a small amount
of adherent fibrinous exudate. The lower lobe
on section similar to the right lower lobe. The peribronchial
consolidation is present to about the same extent. Liver:
Slight fat infiltration; weighs 2,000 grams. Organs of neck: The glands
throughout the neck are moderately enlarged,
pulpy, and considerably injected. Thyroid:
Of average size and the
tissue, pale, spongy. The acini contain a moderate
amount of colloid. Larynx and
trachea: Show considerable
diffuse
ulceration of the mucosa, with edema and
injection of the submucosa. Overlying intact and ulcerated mucosa there
is a considerable amount of friable, tightly
adherent fibrinous and fibrinopurulent exudate. The exudate is most
marked in the larynx. The folds behind the true
vocal cords filled with exudate. The process is present likewise in the
upper portion of the esophagus as far down as
the pouch at the level of the thyroid cartilage. The mucosa, however,
intact, injected and covered by a moderate
amount of fibrinous and fibrinopurulent exudate. There is likewise
injection of mucosa of the base of the tongue
and pharynx with a small amount of exudate. Tonsils: Small,
buried and scarred. The crypts are clean. Alimentary
tract: Stomach and small intestines: Show no significant
lesions. In
the transverse colon there are areas of patchy
injection of mucosa, and in places there are small erosions in the
mucosa, and in the neighborhood there is an
adherent mucopurulent exudate. This mucopurulent exudate peels readily
in general. Toward the rectum there are a
few small eroded areas above which a friable exudate is quite tightly
adherent. The mesenteric glands are somewhat enlarged, pulpy, pale.
About the colon, the mesenteric glands show
some injection. The remaining organs show
no significant lesions.
Microscopic
examination.- Trachea has a thick partly adherent membrane composed
of dense interlacing
fibrin strands with pycnotic nuclear fragments. The surface of the
trachea is formed in places by swollen membrana
propria which in some areas is reinvested with a single layer of
flattened epithelial cells derived from the mucous
ducts. Some of these flattened cells appear to be regenerating. In
another section, the necrosis of the subepithelial
tissue extends about halfway to the cartilage. There are fibrin,
hemorrhage, and occasionally small suppurative foci
near the surface. In the deeper tissues there are in places
proliferating fibroblasts. Lungs: Sections show dilatation of
the small bronchioles and atria with necrosis of the lining epithelium
(see fig. 22), or in some places partial
reinvestment with regenerating cells. About these there are extensive
hemorrhages with areas of bacterial. necrosis.
Medium-sized bronchus (2-3
cm.): Completely plugged with exudate and
membraner The bronchial wall is entirely
necrotic. Colon: Section of colon shows no ulceration of
inflammatory change. Kidney, spleen,
and liver show no
significant change.
Bacteriological
examination.- Smear from the exudate in the trachea shows
innumerable organisms, Gram-positive rounded cocci predominating, some
in chains, some in diplococcus forms. There are also some Gram-negative
cocci and bacilli. Smear from consolidated lung shows a moderate number
of Gram-positive cocci in
diplococcus formation and small chains. Cultures from consolidated lung
shows staphylococcus albus, streptococcus
nonhemolytic. Culture from trachea shows staphylococcus aureus,
streptococcus, nonhemolytic.
NOTE.- Mustard-gas
case of 15 days' duration. Severe and typical lesions of the upper
respiratory tract, with
peribronchial hemorrhagic pneumonia. There was practically no
reparative change or organization, probably because
of the deep seated character of the initial injury. The acute colitis
mentioned in the "anatomical diagnosis" is not in
evidence in the sections.
CASE
82.- W. J., Corpl., 58th Inf. Died, August 6, 1918, at 6.25 P. M., at
Base Hospital No. 18. Autopsy by
Lieut. B. S. Kline, M. C.
209
Anatomical diagnosis.- Shrapnel wound, interscapular region;
fracture of spine of two upper dorsal vertebra,
with subsequent infection of wound; septicemia (streptococcus
hemolyticus); purulent otitis media, right; anemia
and emaciation; general lymphatic hyperplasia; contused wounds of
lower extremities and back; remains of old gas
burns of pellis, scrotum, larynx, trachea, and bronchi;
bronchopneumonia (streptococcus and gas bacillus); terminal
gas bacillus (?) and streptococcus septicemia.
NOTE.-This
case is not reported in detail, inasmuch as the gas burns. incurred at
least 15
days before death, were of trivial importance in comparison with the
surgical injuries and the
ensuing general infection. Although there was no history of exposure to
gas, there were
characteristic mustard-gas burns noted during life and at autopsy.
Histologically, the
examination of the respiratory organs was unsatisfactory because of the
poor preservation of the
tissues and the terminal gas bacillus infection. Nothing was found to
indicate previous inhalation
of irritant gas. No material from the skin lesions was preserved.
CASE 83.- W. B. P., Pvt., Hdqrs. Co. 6th
Marine Corps. Died, June 28, 1918, at 5.30 p. in., at Base Hospital
:No. 18. Autopsy No. 66, performed 15 hours after death, by Lieut. B.
S. Kline, M. C.
Clinical
data.-None available, and the date of gassing is not recorded. The
records of the Chemical Warfare
Service show that there were casualties on June 13 in the 78th and 96th
Companies of the 6th Marine Corps, which
were in action at Belleau Wood and Chateau Thierry. Yellow cross and
blue cross gas shells were employed against
these detachments.
Anatomical
diagnosis.- Bullet wound through right kidney; surgical excision of
right kidney; extensive renal
hemorrhage (800 c. c.); shock (clinical) and anemia; pulmonary edema
(considerable) and slight general anasarca;
old gas burns of skin, scrotum, and respiratory tract; purulent
bronchitis of left lower lobe, associated with moderate
atelectasis, following exposure to gas; old tuberculous foci of
bronchial and pulmonary lymph nodes.
External
appearance.- The skin is pale and slightly sallow. The skin of the
neck. upper chest, axillae ,
upper and inner portions of the thighs, and the bend of the right elbow
shows numerous dull light brown splotches,
with here and there areas of superficial desquamation. There is slight
edema of the ankles. The scrotum on its
anterior aspect shows a flat smooth surface. The epithelium here
appears to be almost entirely gone in a uniform
sheet (?); the region is dry. Eyes, nose, and mouth normal.
(Description of traumatic and surgical lesions is omitted.)
Gross
findings.- Pleural cavities: In the right pleural sac there are
about 20 c. c. of thin blood-stained fluid;
a smaller amount on the left side. No adhesions are present. Right
lung: Weighs 580 grams. The upper and middle
lobes are fairly voluminous, cushiony, slightly soggy. The lower lobe
is relatively more voluminous than the others.
The pleura is delicate and glistening throughout. There are three small
chalky nodules beneath the pleura of the
lower lobe on the anterior aspect. The glands at the hilum are
considerably enlarged and edematous and show
scarred areas. The mucosa of the bronchi is pale; in their lumina is
thin frothy fluid and mucus. On section no
abnormalities are found except a moderate edema of the upper and middle
lobes, and a more marked edema of the
lower. Left lung: Weighs 630 grams. Both lobes are voluminous;
the median portion of the lower lobe feels rubbery.
The pleura is thin and delicate. The glands and blood vessels are like
those on the right side. The bronchi, however,
show a patchy injection of the mucosa, and contain a small amount of
viscid purulent material, also thin frothy fluid
and mucus. On section, except for edema, the lung is normal with the
exception of the mesial third of the lower lobe,
where the lung tissue is collapsed, rubbery, dull red, and moist. The
bronchial branches in this region contain a
considerable amount of viscid mucopurulent material. On squeezing the
lung tissue in this region a somewhat
translucent viscid fluid exudes. The tissue here is not friable and not
more voluminous than the surrounding lung.
Examination of the veins and arteries in this region shows no thrombi,
the overlying pleura is thin and pale. Organs
of neck, Larynx, and trachea: Show no abnormalities, except slight
diffuse injection in the lower portion of the
trachea. In the lumen is a moderate amount of thin
210
frothy fluid and a small amount of muco-pus.
Thyroid, enlarged
symmetrically. Tonsils: Small and scarred. Heart:
Weighs 335 grams. There is moderate dilatation of all chambers. No
other significant changes. Gastrointestinal
tract
shows no significant changes. Remaining viscera show no lesions, except
those related to the surgical condition.
Microscopic
examination.- Skin: There is a thick horny layer. The remainder of
the epidermis appears
normal and is regularly disposed. There is little or no pigment in the
rete mucosum. The papillae are rather loose and
show young connective tissue cells and a moderate number of
chromatophores filled with golden yellow pigment.
The small blood vessels are collapsed and surrounded by loose
aggregations of lymphoid cells. The endothelium
shows no changes, and there are no thrombi. The deeper layer of the
corium and the epidermal appendages are
normal. In another block examined, the keratin layer is thin and partly
exfoliated. The remaining strata of the
epidermis are condensed into a thin densely stained layer in which
outlines of individual cells are lost, and the tissue
appears mummified or desiccated. There is an apparent increase of
pigment in the basal layer. The papilae are
flattened out, the corium is very dense and sclerotic, the nuclei
pycnotic or caryorrhectic. All superficial vessels are
filled with dense hyaline thrombi, having a peculiar refractile
appearance. Trachea and primary
bronchus: The
mucosa is largely exfoliated, but detached strips still lying on the
surface show excellent preservation of the ciliated
cells. The subepithelial connective tissue is edematous in places and
moderately congested, but there is no
inflammatory infiltration, except for a few round cells. There is
therefore no positive evidence of previous gassing.
Lungs: (a) The lesions are not marked. The septa are stout, and
show frequently an accumulation of
polymorphonuelear leucocytes in and about the capillaries. Few have
emigrated into the alveolar spaces, which
contain only desquamated (postmortal?) alveolar cells, either single or
in coherent strips, and a little shreddy
coagulum. The epithelium of the small bronchi is detached, but shows no
degen- erative change. There is no exudate
in the lumina. There is moderate emphysema. No bacteria are found in
Gram-stained sections. (b) Same picture, save
that there is partial atelectasis. No evidence of old bronchial
lesions. Liver, myocardium, kidney,
and testis show no
significant lesions.
NOTE.-The
gas burns, probably inflicted on June 13, 15 days before death, were of
minor importance in the case. Death probably resulted from the bullet
wound of the kidney,
with the accompanying hemorrhage and shock. There is little clear
evidence of previous
respiratory injury due to the gas, either grossly or in the sections.
CASE
84.- H. G., 2058794, Corpl., Co. G, 47th Inf. Died, October 28, 1918,
at
Base Hospital No. 42.
Autopsy No. 92. Autopsy, 2 hours after death, by Lieut. B. S. Kline, M.
C.
Clinical
data.- Patient was gassed on October 12, 1918, having been exposed
to blue, green, and yellow
cross shells. Admitted to Base Hospital No. 42 on October 25, with
burns of skin, conjunctive, respiratory tract.
Signs of bronchopneumonia in both lower lobes, especially the left.
October 27, patient delirious.
Anatomical
diagnosis.- Superficial mustard-gas burns of conjunctive, scalp,
body, scrotum, and penis. Few
small vesicles with local brown pigmentation. Acute fibrinopurulent
esophagitis extending as far as the cricoid
cartilage. Acute fibrinopurulent laryngitis, tracheitis, and bronchitis
(left side). Acute purulent bronchitis (right side).
Extensive coalescing lobular pneumonia. Acute bronchial lymphadenitis.
Cloudy swelling of parenchymatous
organs. Autopsy report.-No detailed protocol.
Microscopic
examination.- Trachea (2 blocks): The epithelium is not only
preserved, but shows remarkably
little change. The cells in the superficial layer are cylindrical and
here and there distinctly ciliated, although in
general they are stained rather poorly. There are a few leucocytes
wandering between them. The submucous tissue
contains lymphoid and plasma cells in normal numbers, but there is no
clear evidence of previous inflammation.
Mucous glands are in hypersecretion but otherwise normal. Primary
bronchus: contains a detached fibrinopurulenit
membrane about 1 mm. in thickness. The lining is constituted by the
exposed membrana propria resting upon
edematous and infiltrated granulation tissue. There are a few strips of
regenerated, highly atypical epithelial cells
interposed between false membrane and membrane propria. The glands are
preserved, although they
211
are separated by edema and inflammatory
cells, chiefly of the plasma cell type. Lungs: (a) Block, which
was
apparently taken near the hilus, passes through a group of thick-walled
and distinctly dilated bronchi. These are lined
for the most part with dense adherent membrane, although, in some
places they are reinvested with layers of
squamous epithelium. The deeper portion of the bronchial wall, the
peribronchial tissue and the original edematous
cellular tissue about the blood vessels are the seat of active
fibrosis, so that the structures are virtually embedded in a
mass of connective tissue. This is rather avascular, the formation of
new blood vessels appearing to lag behind the
growth of fibroblasts. The adjoining alveoli show the effects of the
compression due to the fibrosis of the
peribronchial and periarterial tissue. The alveoli contain a serous
coagulum with more or less fibrin, showing in
places the usual organization. The septa are thickened with new formed
fibroblasts and wandering cells, chiefly of
the mononuclear type, and are distinctly edematous. The alveolar
epithelium projects into the lumina and is probably
largely new formed. (b) The smallest bronchioles and atria contain
well-preserved epithelium. Some of them show
beautiful vascularized organized plugs. A most striking picture is
afforded by the organization of fibrin in the
interlobular septa, which are already in large part converted into
loose vascular scars. The same picture is seen in the
loose tissue about the blood vessels. The parenchyma shows a marked
diffuse edema of the alveoli with abundant
fibrin. This seems to be a recent process. (c) There are several
longitudinally cut bronchi completely filled with an
exudate, in places purulent, in others purely fibrinous. There is the
usual regeneration of epithelium with metaplasia
and fibrosis of the wall of the bronchus. The adjoining lung tissue is
completely atelectatic. Skin: (a) Section passes
through an ulcer the base of which is formed by a slough densely
infiltrated by masses of leucocytes. The corium is
extremely thickened, partly by edema and partly by a new growth of
connective tissue and blood vessels. There is
not the typical appearance of granulation tissue. The endothelium of
the blood vessels is swollen and deeply stained.
Mitotic figures are distorted and multinuclear cells arc common. There
are many small nerve trunks in the section.
The epidermis at the margin of the ulcer is much
thickened,
especially about the hair follicles. It stops short
at the edge of the ulcer and does not seem to be actively
proliferating, growing only a short distance between the
slough. The epithelial cells at the base are free from pigment. Their
arrangement is atypical and they appear to have
developed from the sheaths of the hair follicles. (b) Section of skin
showing hyperkeratosis and hyperpigmentation
with chromatophores in the superficial corium. Pharynx: Section
shows acute membranous inflammation with
separation of the muscle fibres by inflammatory exudate. Spleen:
Very cellular with excess of polymorphonuclears
in the pulp. Appearance is that of the usual acute splenic tumor.
NOTE.-After alleged exposure to
yellow, green, and blue
cross shells 16 days before death there was found
a severe membranous necrosis of the bronchi with partial epithelial
regeneration and very extensive early fibrosis of
the bronchial walls, periarterial tissue, interlobular septa, etc. The
pulmonary lesions were confined to the vicinity
except for a diffuse edema, which was probably terminal, or at least of
much later date than the bronchial lesions. A
peculiar feature of the case was the exemption of the trachea from
necrosis, which was so evident in the larger and
smaller bronchi. This is difficult to understand and highly
exceptional. It is evidently not to be explained by the
earlier repair, inasmuch as it is not shown by metaplasia of the usual
type which is the rule during the earlier stages
of regeneration. There is always the possi- bility that the blocks may
have been confused, but this is unlikely in this
case, since tissue examined from different blocks and preserved in
different fixative show an identical picture.
CASE
85.- A. A., 1822508, Pvt., Co. C, 321st M. G. Bn. Died, August 27,
1918,
at Base Hospital No. 46.
Autopsy No. 9. Autopsy, one and three-fourths hours after death, by
Lient. B. S. Kline, M. C.
Clinical
data.- Exposed August 10 at night to heavy shelling with yellow,
blue, and green cross gas. On
admission to Base Hospital No. 46 on August 11, complained of pain
212
in chest; respiration was labored; cyanosis
and restlessness. Eyelids swollen and edema- tous. Generalized rhles.
Patchy fine crackling rales with exaggerated voice sounds at right
base. Diagnosis: Gas inhalation, lobar pneumonia.
August 14, double lobar pneumonia. Condition fair. August 19,
respiration more labored. Signs suggesting fluid at
right base, not shown by X ray or aspiration. August 25, no change in
symptoms. Signs persist. August 26, pleural
friction left base with pains over this region. Signs of patchy
bronchopneumonia.
Anatomical
diagnosis.- Mustard-gas burns of skin and superficial mucous
membranes, healed or healing
lesions. Acute ulcerative tracheitis and bronchitis. Fibrinopurulent
bronchiolitis. Bronchopneumonia, both lower
lobes, in part organized. Extensive fibrinous and fibrinopurulent
pleurisy, with effusion and associated atelectasis in
both lower lobes. Acute bronchial lymphadenitis. Cardiac dilatation,
slight.
External
appearance.- Skin in general pale, face and hands tanned. Skin of
scrotum and base of penis show
considerable desquamation; no ulceration, however. There is some
desquamation of the skin of the lower abdominal
and pubic region and also in the lower right axilla. The superficial
mucous membranes, excepting the conjunctivn,
are pale and cyanotic. The superficial lymph glands somewhat enlarged. Eyes:
Conjunctivae somewhat edematous,
considerably injected. There is a small amount of viscid exudate
present between the lids. The pupils, 5 mm. in
diameter. Nose and ears show no abnormalities.
Gross
findings.- Pleural cavities: On opening the thorax a small amount
of
coherent fibrinopurulent exudate
found over the right lower lobe. The left chest contains from 1,500 to
2,000 c. c. of turbid yellow fluid, in which
flakes of fibrinous exudate are suspended. Both lobes on this side
collapsed toward the spine. There is moderate
amount of fibrinous exudate binding the median portions of these lobes
to the pericardium. On incising the
pericardium no abnormalities of the sac are seen. After removing the
thoracic viscera the parietal pleura on the left is
everywhere glazed, edematous, covered by a considerable amount of
shaggy fibrinous exudate. The exudate is most
marked over the diaphragm. Heart: Weighs 360 grams. Moderate
dilatation of both auricles and right ventricle.
Myocardium is pale, soft, and moist. Right lung: Lobes less
voluminous than normal, especially the lower. Upper
and middle are cushiony, well aerated. Lower, rubbery. Glands at the
hilum considerably enlarged, pulpy,
edematous, pigmented. Some show areas of gray scarring. Vessels show no
abnormalities. Bronchi somewhat
swollen, show areas of injection. In the lumen there is some
mucopurulent exudate. On section of the upper and
middle lobes a light pink surface presents. Tissues well aerated. In
the bronchial branches there is some
mucopurulent exudate. In the lower lobe, on section, the tissue is
collapsed, rubbery, dull reddish brown, poorly
aerated. Scattered throughout the lobe there are large numbers of
grape seed to lemon seed sized rather firm areas of
consolidation. On pressure no exudate is expressed. These areas have a
dull grayish-pink surface. Bronchial
branches in this lobe contain a small amount of viscid mucopurulent
secretion (no organization, apparently). Left
lung: Both lobes much less voluminous than normal. The pleura
is somewhat swollen; covering it, there is a layer of
tenacious fibrinous exudate, in places at least 1 mm. in thickness.
Between this and the pleura there is a thin zone,
which contains many tiny vessels. On section of the upper lobe a well
aerated pink surface presents, except
posteriorly, where there is an egg-sized dull reddish brown poorly
aerated portion. Lower lobe, on section, is similar
in appearance to the right lobe. Organs of neck: Glands in the
lower part of the neck similar in appearance to those at
the hilum. Thyroid: Of average size and consistence. On section
the tissue is pale, spongy. There is moderate amount
of colloid in the acini. Larynx: Shows a moderate edema of the
mucosa. About the left vocal cord there is
considerable injection. Trachea: Shows patchy injection toward
the bifurcation. In the lumen there is some blood
tinged mucopurulent exudate. Tonsils. Somewhat enlarged, pulpy.
Crypts are clean, in general. There is apparently
considerable lymphoid tissue present. Alimentary tract: No
abnormalities except that the lymphoid tissue in the
lower ileum is somewhat more prominent than normal. Mesenteric glands
pulpy, pale. The remaining organs show
no significant lesions.
Microscopic
examination.- Trachea: No sections preserved. Lungs: A. A number of
small bronchi included
in the section are lined with a very well-preserved layer of ciliated
epithelium. Lumina are free from exudate. There
is no thickening of the bronchial wall. Parenchyma shows irregular
small areas of lobular pneumonia, which appear
to center about
213
the infundibula. Exudate is poor in fibrin.
Predominant cell type is polynuclear. About these areas there is some
edema and epithelial desquamation. B. This block passes through an
infarctlike area of hemorrhage. In certain areas
the alveolar structure is destroyed, and there is necrosis with partial
decolorization of the red cells. No thromnbosed
vessels are in- cluded in this section. C. Section passes through
completely collapsed lung, and includes also large
encapsulated areas of caseation with typical giant cells at the
periphery. Liver, spleen, and kidney show no
significant lesions.
Bacteriological
examination.- Smears of the exudate in the larynx show innumerable
Gram-positive rounded
cocci in pairs and in small chains. There are also moderate numbers of
Gram-negative cocci. The predominating
organism is streptococcus. Culture shows staphylococcus, streptococcus,
and small Gram-negative bacillus.
NOTE.-Death
occurred 17 days after exposure to mixed gases, but it is not clear
either from the clinical
historv or from the autopsy protocol that this is a late mustard-gas
case. There were no typical burns or pigmentation.
The eve lesions were no more severe than those frequently seen in
influenza. The walls of the trachea and bronchi do
not suggest inhalation burns. The patient evidently died from the
seropurulent pleurisy complicating the pneumonia.
Unfortunately the histological material is inadequate, no tissue from
the trachea or large bronchi having been
preserved. The excellent preservation of the bronchial epithelium in
the small branches is not in common with the
usual findings of mustard gas.
CASE
86.- O. F., 1696236, Pvt., Co. D, 305th M. G. Bat. Died, October 13,
1918, 3 p. m., at Base Hospital
No. 18. Autopsy No. 135. Autopsy, - hours after death, by Lieut. B. S.
Kline, M. C.
Clinical
data.- Mustard-gas inhalation on September 25, 1918, incurred in
action. Admitted to Field
Hospital No. 306, developed acute bronchopneumonia, of epidemic
coalescing type. Mild conjunctivitis,
photophobia, and vomiting. September 29, admitted to Base Hospital No.
18, conjunctivitis and scrotal burns, few
signs of bronchlopneumonia October 10, rAles at bases of both lungs,
tubular breathing, etc., at left base, bronchopneumonia. October 13,
both lungs filled with crackling rAtes. October
11, blood count, leucocytes 7,800; October
12, leucocytes 8,000. Blood culture sterile; sputum culture,
pneumococcus, Type IV.
Anatomical
diagnosis.- Healed gas burns of skin. Infected burn of scrotum.
Acute laryngitis, tracheitis, and
bronchitis. Peribronchial pneumonia, in part suppurative, in part
organizing. Coalescing lobular pneumonia, right
lower lobe. Fibrinous pleurisy, slight. Acute peribronchial
lymphadenitis. Cardiac dilatation, right. Parenchymatous
degeneration of liver and spleen.
External
appearance.- No abnormalities, externally, except moderate diffuse
brown pigmentation, with
deeper brown pigmentation about the healed superficial ulcerated areas
of axillae and upper portion of left thigh.
There are areas of ulceration of the scrotum about 4 cm. long, and from
a few millimeters to 1 cm. in width
extending into the dermis. About these regions the epidermis is
thickened for several centimeters and covered by
matted serum. There are superficial ulcerated areas about the left
nostril, covered by scabs. Con junctiv ae are dry
and pale.
Gross
findings.- Pleural cavities: There is a small amount of fibrinous
exudate in the right pleural sac. Left
pleural cavity is normal. Pericardium is normal. Heart: Weighs
450 grams and is considerably enlarged, the right
auricle and ventricle being especially di- lated. The myocardium is
soft and appears somewhat greasy. Right lung:
All lobes are voluminous, cushionly, soggy, and solid. The pleura is
thin, posteriorly covered by a small amount of
fibrinous exudate. The glands at the hilum are greatly enlarged, pulpy,
injected. Bronchus: The epithelium of the
mucosa in general has a whitish appearance. In places there is a patchy
ulceration covered by fibrinous exudate.
There is considerable diffuse injection with some extravasation of the
blood. In the lumen, there is thin and
somewhat viscid fluid. In the upper lobe on section, the tissue in
general is fairly well aerated. In the posterior half
there is a moderate amount of thin, frothy fluid in the air sacs.
Throughout the lobe, the striking thing is the
involvement of the bronchi, the inucosa having a dull,
214
ragged, grayish appearance and surrounding
the walls there is an area of grayish and red consolidation, a few
millimeters in thickness. In places the peribronchial consolidation is
depressed grayish, suggesting organization. The
middle lobe on section is well aerated and pink. The appearance is
quite similar to the upper lobe, but here some of
the patches have reached the surface and are bronchopneumonic in type,
finely granular, and yellowish gray. On
section of the lower lobe the picture is that of extensive involvement
of the bronchial mucosa and walls and
adjoining lung tissue. There are depressed, firm, grayish streaks.
Toward the pleura posteriorly there is a finely
granular, gray-red consolidation, coalescing lobular in type. The
process, however, is not very extensive. The
fibrinous exudate over the pleura is perhaps most marked in this
region. The smaller bronchioles in many places
contain thin viscid purulent exudate. Left
lung: Both lobes are voluminous, cushiony, and soggy solid. The
posterior
portion is most involved. The bronchi andglands similar to those on the
right. On section of the upper lobe, the
smaller bronchioles show a dull whitish, in places granular, membrane.
In the lumen there is thin viscid pus. In
places, there is considerable destruction of the bronchial walls with
dilatation. There is old peribronchial
consolidation, coarsely granular in some places, softened in others.
The consolidation is practically limited to the
posterior half. Medially, the tissue is well-aerated pink. The lower
lobe, on section, shows quite uniform
involvement of the smaller bronchial branches and the lung tissue about
them for a small distance. There is a
moderate amount of thin, frothy fluid in the air sacs. Organs of
neck: The larynx shows considerable injection of the
mucosa. The epithelium in considerable part is dull, whitish,
apparently necrotic. There is mucopurulent exudate
present in considerable amount, especially about the true vocal cords,
where the ulceration seems to extend deeper
into the mucosa in places. Throughout the trachea the membrane in
considerable part has a dull grayish appearance.
There are areas of desquamation. There is patchy injection, and in
places, the mucosa shows puruleist ulceration.
The process involves the base of the tongue, posterior pharynx, and
upper esophagus as far as the level of the cricoid
cartilage. Thyroid: Moderately enlarged, the acini distended
with colloid. Liver: Weighs 2,000 grams. There is slight
fatty infiltration. Spleen:
Weighs 400 grams, somewhat enlarged.
Malpighian bodies increased in number and size.
Alimentary tract: Not recorded. The remaining organs show
nothing of interest.
Microscopic
examination.- Trachea: Section is not instructive. Submucous layer
is thin and intact and stains
poorly but does not seem to be necrotic. The membrana propria is
preserved. A few faintly-staining vertically
arranged epithelial cells are still adherent but the greater part of
the epithelium has been desquamated. Large
bronchus: The surface epithelium is largely lost. A few small
strips of stratified, nonciliated epithelium are still
adherent, but in most places the membrana propria lies exposed. The
striking feature is the presence of solid masses
of epithelial cells, of concentric arrangement and highly atypical
character. These are situated in the ducts and acini
of the mucous glands. (See fig. 19.) In some places the intercellular
fibrils complete the resemblance to epidermal
cells. This atypical epidermis elsewhere surrounds or penetrates masses
of mucus and the remains of the original
gland cells. There is marked congestion of the epithelial tissue, but
no polynuclear infiltration. Lungs: Section
includes a medium-sized bronchus, the wall of which is lined with
necrotic tissue, adherent to which are shreds of
atypical layered epithelium. The bronchial wall is formed by
granulation tissue, very loose, vascular and hyperemic
with fibroblasts and plasma cells. About the bronchus, the alveoli con-
tain plugs of dense poorly-staining fibrin
which in a few areas show early organization. The alveolar
epithelium, is swollen, atypical and hyperplastic.
Mitotic figures are found in a few of the cells. Plasma cells are
numerous. Other areas in the section show
nonfibrinous homogeneous coagulum and in still other areas there is an
acute pneumonic exudate. The interlobular
septa are edematous. Skin: Probably of scrotum. There is a
slight hyperkeratosis, hyperpigmentation of the rete
mucosum and numerous melanophores in the superficial layers of the
corium. (See Pi. V.) Myocardium, liver, and
kidney show no significant lesions.
NOTE.-Mustard-gas
poisoning of 18 days' duration. There are the usual remains of an
acute destruction of the upper air passages, with extensive
complicating pneumonia showing
early regeneration in the vicinity of the bronchi. The most interesting
histological features are the
nests of carcinoma-like epithelial cells in the bronchial ducts and
glands.
215
CASE
87.- W. S., 1821307, Corpl., 318th Inf. Died, October 24, at 8.12 P.
in., at Base Hospital No. 81.
Autopsy, 15 hours after death, by Capt. B. S. Kline, M. C.
Clinical data.- October 5, 1918, patient
admitted to Gas
Hospital No. 1. October 7, admitted to Base
Hospital No. 81. Diagnosis: Gas inhalation, marked. While in
the hospital, developed signs of influenza (October
15) and of bronchopneumonia (October 17). Acute temporary dilatation
of heart. Leucocytes (October 10) 5,700.
Leucocytes (October 15) 6,600. Patient apparently convalescing.
October 24, at 8.12 p. m., suddenly began gasping
for breath and died a few minutes after.
Anatomical
diagnosis.- Healing acute tracheitis and bronchitis; stenosis of
right bronchus due to scarring
(old infected mustard-gas lesion); healing acute lymphadenitis of
mediastinal and tracheal lymph glands; fat
infiltration of myocardium; cardiac dilatation, most marked on right
side, with possible slight hypertrophy of right
ventricle; chronic passive congestion of short duration, of abdominal
viscera; thrombosis of left iliac vein; large
emboli occluding pulmonary artery; old tuberculous foci of bronchial
lymph glands and spleen.
Microscopic
examination.- Pharynx or upper esophagus: Stratified squamous
epithelium, showing nothing
atypical. Subepithelial tissue free from inflammatory changes. No
lesions suggesting previous injury. Primary
bronchus: Lined with regenerated squamous epithelium, the
superficial
cells of which are flattened and deeply
stained, with indistinct nuclei, appearing almost as if keratinized.
Mitoses are very numerous at all levels. The
subepithelial tissue is loose and vascular, loosely infiltrated with
mononuclear lymphoid and plasma cells. The
mucous glands are not much altered; some acini seem to be choked with
retained mucus. Lungs: Many of the
bronchioles contain still a purulent exudate. Their lumina are narrow
in proportion to the thickness of the wall,
which is formed by granulation tissue, thickly infiltrated by lymphoid
and plasma cells. The surrounding alveoli are
thick-walled, often collapsed, and frequently lined with high columnar
or atypical epithelium and filled with plugs of
organizing exudate. Outside is a zone of edematous lung tissue and
between these areas of peribronchiolitis, there
are areas of emphysema. The periarterial tissue is tremendously
thickened with young fibroblasts in abundance, and
the interlobular septa are also. There are in some of the sections,
large patches of granulation tissue in which the
original lung structure is completely lost. The epithelium in
bronchioles and alveolar ducts is wholly missing in
some cases, in others there is regenerating epithelium, more or less
atypical in character. No bronchi relined with
well-ciliated epithelium are found. Bronchial lymph nodes:
Contains a large calcified encapsulated mass, probably a
healed tuberculous lesion. The lymph sinuses in the intact portion of
the gland are filled with phagocytic
cells.
Spleen: Congested; no features
of special interest.
NOTE.-The
interpretation of this case is difficult. The healing lesions of the
bronchi,
found at autopsy and confirmed by microscopic examination, were
ascribed by the pathologist to
the late effects of mustard-gas inhalation. However, there is no record
in the history of mustard-gas burns or eye lesions, and none are
included in the very detailed anatomical diagnosis. On the
other hand, there is a clinical history of influenzal pneumonia, the
onset of which dates from
October 15, approximately 10 days after the alleged exposure to gas,
and nine days before death.
The patient was convalescing from this, but died suddenly from
pulmonary embolism, following
thrombosis of the iliac vein, a not uncommon influenzal complication.
The question arises,
therefore, whether the bronchial and pulmonary lesions were late
sequels of the influenzal
pneumonia, or were attributable rather to the previous gassing. While
it is hardly possible to be
certain, it seems more probable that the gassing was responsible, at
least in large measure, since
the thickening of the bronchi and the extensive fibrosis in some areas
of the lung tissue itself
were beyond what might ordinarily be expected to develop within nine
days of an influenzal
pneumonia.
CASE 88.- W. C. D., 2178762, Corpl., Co. B,
354th Inf. Died. August 28, 1918, at Base Hospital No. 42.
Autopsy No. 2. Autopsy, eight hours after death, by Lieut. B. S. Kline,
M. C.
216
Clinical data.- Exposed to yellow, blue, and green cross
shell from 10.30 p. m., August 7, to 3.30 a. m.,
August 8. Ten thousand 77 and 105 mm. shells. August 9, admitted to
Field Hospital No. 327, with temperature of
104°. August 11, admitted to Base Hospital No.
42. August
13, temperature 104°. Diffuse rales in both lower
lobes.
Impairment of resonance in lower loft. No tubular breathing. On
following day, rȃles over upper lobes also. Two
days later, bronchovesicular breathing in both. This persisted for five
days. August 26, signs of consolidation in
right, middle, and lower lobes. Death with signs of cardiac dilatation.
Anatomical diagnosis. First-degree
mustard-gas burns of skin. Healing lesions with areas of vesiculation
and brown pigmentation. Ulceration of upper
esophagus, larynx, trachea, and bronchi. Fibrinopurulent esophagitis,
laryngitis, tracheitis, and bronchitis.
Bronchopneumonia in part organized. Acute fibrinous pleurisy. Acute
bronchial Lymphadenitis. Slight pulmonary
edema. Cardiac dilatation.
External
appearance.- Skin in
general has a muddy appearance. The ventral surface of the scrotum and
the
head of the penis show an ulceration of the epidermis. There is
considerable desquamation. A small area of the
scrotum shows some matted seropurulent exudate. There is considerable
exudate covering the ulcerations of the head
of the penis. Over the right greater trochanter there are some pustules
and small areas of superficial ulcerations
covered by brown scabs. In the genital folds, the popliteal regions,
both buttocks, the bends of the elbows, both
axilli, upper chest and neck, there is well defined, splotchy, brown
pigmentation. Associated with all of these areas
there are tiny vesicles. The superficial lymph glands are somewhat
enlarged. Superficial mucous membranes are
pale. Eyes: Conjunctivae in general pale, delicate. There is
some swelling of the bulbar conjunctivae , and there is
a small amount of caked exudate present. Pupils equal 3 mm. Ears: In
the skin of the right ear, near the concha, there
is a small superficial ulcerated area about 2 mm. in diameter, covered
by a dry scab. There is also a small ulcerated
area at the junction of the upper and lower lips. In the nasal cavity
there is some mucopurulent exudate.
Gross
findings.- Pleural cavities: On opening the thorax, a few
organizing
adhesions are found over the
upper lobe. In the cavity there are about 40 c. c. of turbid yellow
fluid in which some flecks of exudate are visible. A
similar picture is present on the left, except that there are no firm
adhesions. Heart lies in normal position. On
incising the pericardium no abnormalities of or in the sac are seen. Heart:
Weighs 380 grams. There is slight dilatation of both right and left
ventricles. Right lung: All
lobes are much more voluminous than normal.
Feel cushiony,
slightly soggy, and numerous small solid patches are palpable. Pleura,
except medially, glazed, covered by a small
amount of fibrinous exudate. Glands at the hilum are greatly enlarged,
pulpy, injected, pigmented. A number of them
show firm and calcified nodules, surrounded by firm gray tissue.
Vessels at the hilum, no abnormalities. Bronchus:
Shows considerable swelling, injection, and in places ulceration of the
mucosa. The membrane is infiltrated and
covered by tenacious fibrinopurulent exudate in considerable amount.
The upper lobe on section shows innumerable
solid patches, varying in size from pinhead to a few centimeters in
diameter. Some of the smaller areas are coherent,
dry, granular, grayish, or yellowish; some have soft yellow centers.
Others are much more firm, gray, and show a
greenish pigmentation about them. The larger patches are dull pinkish
gray. The surface is relatively dry, finely
granular. The remainder of the lung tissue is fairly well aerated,
pink, and contains a small amount of fluid in the air
sacs. Middle lobe, picture in general similar, especially posteriorly.
Medially, there is much less involvement. Lower
lobe, the picture is quite uniform throughout. Tissue in general fairly
well aerated, pinkish red, contains a small
amount of thin frothy fluid in the air sacs. Here, quite thickly
throughout, there are pinhead to grape seed sized firm
patches of consolidation, some gray, others showing considerable
greenish pink pigmentation. In a few places,
especially inferiorly, there are larger dull pinkish-gray consolidated
areas. Some of the bronchial branches show
intense injection of the mucosa and walls. Left lung: Both
lobes are much more voluminous than normal. On
inspection, palpation, and section the upper lobe shows changes similar
to the right upper; here, however, there are
but few large patches of recent consolidation. In great part the lesion
consists in a moderate number of firm solid
patches. Left lower lobe, in general similar to the right lower. There
is more fluid in the air sacs on the left. The
glands at the hilum similar in appearance to those on the right. The
tuberculous foci here, however, less prominent.
The bronchi show very much less involvement than the bronchi and larger
branches on the right.
217
Organs of neck: Glands in
the lower portion of the neck, similar in aispearance to those about
the hilum on the right. Some show old tuberculous foci. Thyroid:
Somewhat smaller than normal. Tissues, spongy and pale. There is but
a moderate amount of colloid in the acini. Larynx: Shows small
ulcerated areas of the epiglottis, ulceration extending
down into the submucosa. Vocal cords show ulceration of the epithelium.
The epithelium in general is infiltrated or
ulcerated. Everywhere below the true cords there is a large amount of
tenacious fibrinopurulent exudate. Picture the
same in the trachea. The process Continues over into the upper
esophagus, where there is a large patch of
ulceration of the epithelium, and a considerable amount of tenacious
fibrinopurulent exudate attached to submucosa
FIG. 34.- Case 88. Exposure to yellow,
blue,
and green cross shell gas. Death after 20 days. Lung. Section passes
through interlobular septum, which is edematous and in which there is
active growth of fibroblasts, and plasma cell
infiltration. There are organizing plugs in the septal
lymphatics
tissue. Tonsils: Fair size, contain a
considerable amount of lymphoid tissue. Crypts contain inspissated
material.
Alimentary tract: No abnormalities, except that the stomach contains a
small amount of bile-tinged mucus. Lymphoid tissue throughout the
trachea slightly more prominent than normal. Mesenteric glands are
small, pulpy,
and pale. Liver: Weighs 2,000 grams. Slight fat infiltration.
The remaining organs show no significant lesions.
Microscopic
examination.- Trachea: No sections. Bronchi: Section
through
medium-sized bronchus shows
massive necrosis of the lining without definite membrane formation.
Through the necrotic tissue there is a great
amount of detritus. The epithelial layer is
218
totally destroyed, although the mucous glands
are still intact. In the deeper part of the bronchial wall, there is
active
proliferation of fibroblasts and great numbers of plasma cells. There
is much fibrinous edema in the peribronchial
tissue external to the cartilage, and in these areas are many
fibroblasts. One of the small veins contains a well formed
thrombus which is beginning to organize. Lung: The lesions in
the smaller bronchi are very interesting. Some of the
bronchi are lined with a clean vascular granulation tissue, uncovered
by epithelium. There is no exudate in the
lumen. Between the congested vessels are numerous lymphoid and plasma
cells, but practically no polynuclears.
About these bronchi, the septal tissue of the alveoli is thickened.
Many of the air spaces are filled with dense fibrin
plugs which are being invaded by fibroblasts and recovered in many
places by alveolar cells, probably regenerated
epithelium. (Fig. 34). Other bronchi are clothed with regenerated
epithelial lining, continuous with solid plugs of
epithelial cells in a neighboring alveoli. New formed epithelium is
highly atypical, stratified, and nonciliated. The
lumen contains well-preserved polymorphonuclears. There is a new formed
epithelial lining resting upon a layer of
clean granulation tissue, in which are only occasional Gram-positive
cocci. Still other bronchi show early and very
acute lesions. Lumen is filled with fragmented polymorphonuclears and
the walls are invaded by them. There are
small areas of bronchopneumonia in the adjoining alveoli. The
grayish-yellow nodular areas described in the gross
resolve themselves into bronchioles or infundibula, the center of which
is occupied by exudate with numerous
fragmented leucocytes. The wall is greatly thickened, partly by
inflammatory infiltration, but also by an active
growth of granulation tissue with strikingly numerous plasma cells. The adjoining alveoli are solid
with fibrin plugs
becoming organized and covered with new alveolar epithelium. External
to these peribronchial nodules, the lung
tissue shows a patchy edema. In some areas, the alveolar septa are
greatly thickened by the growth of fibroblasts
along the collapsed capillaries, and the accumulation of mono- nuclear
cells. The cavities are being relined with new
epithelium. The interlobular septa are broad and there are numerous
fibroblasts invading the edematous tissue. An
interesting feature is the organization of plugs of exudate in the
dilated septal lymphatics. (Fig. 34.) The remaining
organs show no significant lesions.
Bacteriological examination.- Smears of the trachea show innumerable
Gram-positive cocci, some lancet-shaped, others rounded and in chains.
The lancet-shaped ones encapsulated. There are also a moderate number
of
Gram-negative bacilli. The predominating organism, Gram-positive. Smear
of consolidated lung shows a very few
diplococci (Gram-positive) and no Gram-negative organisms are seen.
NOTE.-A very
characteristic case of mustard-gas poisoning dying after 20 days. The
respiratory lesions were largely limited to the trachea and the
bronchial and peribronchial tract.
Although many of the bronchi still showed evidence of the original
chemical injury in the form
of a deep-seated necrosis, attempts at repair were well under way. In
some of the tubes, there
was partial reepithelization and the walls of the bronchi as well as
the perivascular tissue and the
edematous interlobular septa were becoming thickened by a new growth of
fibrous tissue. The
case illustrates clearly the probable nature of the permanent injury
which may follow this type of
gassing. It is worth recording also that the lesions do not suggest a
complicating influenzal pneu-
monia, such as was so frequently encountered in the October and
November cases.
CASE 89.- W. K., 1779786, Wagoner, 308th Inf. Died,
October 28, 1918, at 2 a. m., at
Base Hospital No. 42. Autopsy No. 91. Autopsy, seven hours after death,
by Lieut. B. S. Kline,
M. C.
Clinical data.- Gassed on October 8, 1918. Admitted to
infirmary on October 10. Diagnosis: "Mustard-gas
inhalation." On admission to Base Hospital No. 42 on October 18
complained of cough and fever. Symptoms of
laryngitis, bronchitis, and bronchopneumonia; signs of consolidation of
both lungs.
Anatomical
diagnosis.- Superficial gas burns of conjunctive and skin with
vesiculation and local brown
pigmentation. Infected scrotal burns. Acute fibrinous and gangrenous
laryngitis with marked ulceration of vocal
cords. Gangrenous tracheitis and bronchitis.
219
Extensive peribronchial pneumonia of all
lobes except right middle, associated with ulceration of bronchi and
adjoining lung tissue. Gangrenous exudate in cavities. Acute bronchial
lymphadenitis. Parenchynmatous
degeneration of liver and kidneys. Moderate anemia and emaciation.
Dental caries marked.
No
detailed autopsy protocol received.
Microscopic
examination.- Skin: Section passes through an area in which the
epithelium is denuded; the
exposed corium appears dense as if dessicated. Adjacent to it,
theepitlielitim is greatly thinned out; there is a
homogeneous pink-staining material beneath the thin layer of
epithelium, which is apparently regenerating. There
are still in places, adherent crusts of
FIG. 35.– Case
89.
Mustard-gas burn, 20 days’
duration. Lung. Area of
bacterial necrosis with fibrinopurulent
material in the adjacent alveoli.
completely necrotic tissue. There is marked
hyperemia of all the vessels, little leucocytic reaction. (See fig. 5)
Trachea: Is denuded of
epithelium over large areas, where the lining consists of necrotic
tissue chiefly infiltrated
with leucocytes, the nuclei of which are much fragmented. There are
adherent shreds of fibrinous slough and masses
of bacteria. Where the epithelium is preserved, it consists usually of
a single row of cuboidal cells resting upon a
swollen hyaline membrane. In a few places the cells are heaped up into
several layers, suggesting proliferation
(mitosis). An interesting feature is noted in one section where the
regenerating epithelium has interpolated itself
beneath the still preserved, swollen, original membrana propria and a
new basement membrane seems to be in
process of formation. (See fig. 18.) There is an active growth of cells
from the mucous ducts, forming solid
220
sheets of large polygonal, nonciliated cells.
The mucous glands are in hypersecretion. In oIne duct, the cavity or
widened lumen is filled with a mass of desquamated mucous cells. Lungs:
The infundibula and terminal bronchi
show gangrene of their walls including often the neighboring alveoli.
The nuclei have lost their staining, and there
are large masses of bacteria. (Fig. 35.) There is much brownish-black
pigment, both extra and intracellular.
Elsewhere there is a loose pneumonic exudate, more or less hemorrhagic
or fibrinous. Some alveoli are filled with
fragmented vacuolated cytoplasm. (Fig. 36.) There is little or no
regeneration or organization evident. A very
interesting appearance is afforded by the lifting up of the alveolar
epithelium in continuous sheets, with
accumulations of leucocytes underneath. Adrenals: There is marked
congestion with capillary extravasation. Spleen:
Presents the usual picture of an acute splenic tumor.
FIG. 36.-
Same
as Fig. 35. Larger area of gangrene in lung
NOTE.-Case of
mustard-gas
poisoning of 20 days' duration. Although certain of the bronchi
showed regeneration of the epithelium with metaplasia, the majority of
them, as well as the
trachea itself, were the seat of a gangrenous necrosis, associated with
the presence of great
masses of bacteria. There was a gangrenous infection of many of the
infundibula extending into
the adjacent lung tissue. About these necrotic areas there was a
fibrinous pneumonia with
organization. The presence of marked dental caries is specifically
recorded and may have some
relation to the gangrene.
221
The following points of
special
histological interest may be noted: In the skin, the regeneration
of the nonpigmented, atypical epithelium beneath the vesiculated crust
of the original
epithelium, absence of hair follicles, and marked vascular dilatation.
The regeneration, in the
bronchus, of the epithelium beneath the still preserved hyaline
basement membrane. The gan-
grenous bronchitis and bronchiolitis in the lung.
CASE 90.- L. M., 1202584, Pvt., 102d
Engineers. Died, November 4, 1918, at 12.55 a. m., at Base Hospital
No. 2. Autopsy, 10 hours after death, by Lieut. J. H. Mueller, San.
Corps.
Clinical
data.- October 29, admitted to General Hospital No. 1. Gassed on
October 8; in hospital for
mustard-gas burns. While in hospital, suddenly developed chills, fever,
pains, sore throat, and cough. On admission,
general condition excellent. Slight conjunctivitis. Heart normal. Lungs:
No dullness, breath sounds normal.
Tenderness in patelle, shins, and back. October 30, seem to be worse.
Temperature up last night. Lungs show areas
of dullness, more on right side posteriorly; many moist rȃles
over
both lungs. November 2, has been growing
progressively worse, with more and more involvement of lungs. Heart
action rapid, cyanosis marked. November 3,
has become more cyanotic, with grayish pallor; respirations weak,
shallow, and rapid. Heart action poor; edematous
breathing. November 4, died at 12.55 a. m.
Anatomical
diagnosis.- Acute
tracheobronchitis; confluent lobular
pneumonia; edema of lungs; hemorrhages into pleura.
External
appearance.- No cutaneous lesions.
Gross
findings.- Pleural activities: No fluid. Left lung: Pleura
smooth; there are punctate hemorrhages over
the lateral surfaces of the upper and lower lobes. Bronchi:
Contain abundant thin frothy fluid. The larger vessels are
normal. On section, the lung tissue is very wet; there is a confluent
lobular consolidation throughout the greater part
of the lower lobe and the base of the upper lobe; the consolidated
portion is red, with mottled lighter areas. The
smaller bronchioles do not contain pus. Right lung: Covered
with smooth pleura. Bronchi also contain frothy fluid;
their mucosa is intensely injected. On section, the same type of
consolidation described in the opposite lung is found
throughout the lower lobe, the base of the upper, and about half of the
middle lobe. Organs of neck: Larynx normal.
Trachea: Shows a rapidly increasing injection of the mucosa
without ulceration, as it descends. Heart normal.
Remaining viscera show no significant lesions. Stomach and intestines
normal.
Microscopic
examination.- Trachea and primary bronchus: No sections. Lungs:
The small bronchi show
partial exfoliation of the epithelium in long strips. The individual
celli are not necrotic. The lumina contain
polymorphonuclear leucocytes, red blood cells, and granular coagulum.
The bronchial walls are infiltrated with
leucocytes. The parenchyma shows a most intense congestion of the
alveolar capillaries, with widespread
hemorrhagic edema. The alveolar spaces contain a varying number of
rather pycnotic and fragmented
polymorphonuclears, and occasional pigmented alveolar cells. Some areas
show only hemorrhage and edema. There
is much destruction and caryorrhexis of the capillary endothelial
nuclei, the nuclear material being drawn into long
wisps and threads. The infundibula are dilated, and the walls show, not
infrequently, hyaline necrosis. The pleura is
normal. The interlobular and periarterial lymphatics are distended;
some contain masses of inflammatory cells.
Sections stained for bacteria show minute Gram-negative bacilli within
the leucocvtes, in considerable numbers. No
other bacteria found in careful search. Liver, spleen, and kidneys:
No significant lesions other than congestion.
Adrenal: Impoverishment of lipoids in cortex, with degeneration
of individual cells. Poor chromaffin staining.
NOTE.-The
case is of interest, since it illustrates the occurrence of an
influenzal
pneumonia in a gassed patient, 21 days after the gassing. A study of
the gross and histological
lesions indicates that the influenzal pneumonia is probably a primary
infection, not related to the
gassing. The bronchi fail to show the usual epithelial necrosis,
followed by metaplasia, and there
are not
222
the customary
peribronchial lesions of mustard gas. The lesions, on the other hand,
are in all
respects typical of the influenzal pneumonia which was raging at that
time.
Another
point of interest in the case is the presence, apparently in pure
culture, so far as
can be judged by the section, of a minute Gram-negative influenza-like
bacillus.
CASE 91.- J. W., 1910957, Sergt., 328th Inf.
Died, October 26, at 8.25 p. m., at Base Hospital No. 46.
Autopsy, 13 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- October 3, admitted to Field
Hospital No.
325; diagnosis; acute bronchitis. Admitted to
Base Hospital No. 46 on October 5. Onset of illness October 1, with
cough and aching of body. Breathing shallow,
rapid, and labored; cyanotic. Lungs negative except in left axilla,
where there is bronchial breathing, and showers
of rfiles in left upper lobe posteriorly. The right and left lower
lobes are consolidated. October 14, very nervous,
cyanotic, delirious, pulse weak and thready. Died, October 26.
Leucoeytes on October 7, 3,900.
Anatomical diagnosis.- Vesiculation of skin in folds of flanks
(old gas burns ?); healed ulcers of vocal cords;
acute tracheobronchitis; extensive peribronchial pneumonia, all lobes
showing areas of resolution and organization;
bronchiectasis; left lower lobe; coalescing lobular pneumonia, left
upper lobe; fibrinous pleurisy with effusion (400
c. c.); pulmonary edema, moderate; cardiac dilatation, right; abscess
of right arm, following hypodermic injection.
A detailed autopsy protocol of this case was not made, owing to stress
of other work (personal communication from
Lieutenant Kline).
Microscopic
examination.
Trachea: Epithelium desquamated, either superficially
or completely, exposing
the membrana propria. Where the superficial cells are still present
they are normally ciliated and appear uninjured. It
is probable that the loss of epithelium is a postmortal affair. The
subepithelial tissue is normal save for congestion.
Lungs: (a) The picture is complicated. Some of the bronchioles
are dilated, but lined with well-preserved ciliated
epithelium. The walls are thickened, congested, and densely infiltrated
with lymphoid and plasma cells, but there is
no exudate in the lumen. Other bronchioles show acute inflammatory
changes. The epithelium is more or less
completely detached, the lumen filled with pus and exfoliated cells;
there is intense congestion and in some cases
free hemorrhage beneath the epithelium, and a dense infiltration of the
wall with polymorphonuclears. About these
infected bronchi are patches of
pneumonia, at the periphery, of which, organization of the exudate,
which is here
more purely fibrinous, is in progress. Between the pneumonic patches,
there is intense congestion, with partial
collapse. There are many pigmented cells in the alveoli, and a general
stasis of leucoeytes in the capillaries. (b)
Pleura shows a fibrinous exudate, with beginning ingrowth of
fibroblasts at the base. The subpleural lymphatics are
filled with purulent exudate. There are no larger bronchi in the
section, but the bronchioli and the ductus alveolares
are dilated with pus, and show necrosis and partial degeneration of
their epithelium. The parenchyma shows diffuse
fibrous and edematous thickening of the alveolar septa, with round
cells and polymorphonuclears between the
epithelium and capillary walls; extensive relining of the alveoli with
columnar, probably regenerated epithelium;
plugs of freshly organizing exudate in the alveolar spaces, or more
recent fibrinous exudate with numerous
exfoliated alveolar cells. (c) Some of the small bronchi show complete
necrosis of their wall, and their somewhat
narrowed lumina are filled with pus. The adjoining lung tissue is
atelectatic, and shows extensive septal fibrosis and
organization. The predominating types of wandering cells are the
lymphoid and plasma cells. There is marked
periarterial fibrosis. The section includes several bronehiectases,
lined with ciliated epithelium. The prevailing
bacteria in Gram-stained sections are Gram- positive cocci in pairs and
chains. Bronchial lymph nodes: Contain
masses of resorbing exudate in the sinuses.
NOTE.- Presumably
a late case of mustard-gas poisoning, dying 23 days after exposure.
The skin lesions were suggestive of old mustard-gas burns. The trachea
gave no positive
indication of gas injury, but the lung showed lesions of the
bronchioles (necrosis, thickening,
stenosis, bronchiectasis) which pointed strongly to previous gas
injury. The marked leucopenia
(3,900) on the fourth
223
or fifth day after the
supposed gassing was confirmatory evidence. The lesions were not quite
those following in the wake of influenzal pneumonia, although the case
occurred during the
period when the epidemic was at its height, and a primary influenzal
infection can not be entirely
ruled out. The case illustrates the difficulty in arriving at a
positive conclusion, when definite
data as to the gas exposure are lacking.
CASE 92.- H.
R., 489127, Pvt., 34th Inf. Died,
November 7, 1918, at 10.30 p. m., at Base Hospital No. 81.
Autopsy, 112 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data..- Exposed on October
14 to yellow and blue cross shells. October 17, admitted to Base
Hospital No. 78 with diagnosis of bronchitis. Diagnosis had been made
at Infirmary No. ? of influenza and gas burns
about eyes. October 23, admitted to Base Hospital No. 81. Complains of
pains across chest and cough; has been
somewhat deaf for about two weeks. There is some impairment of
resonance over right chest posteriorly below the
angle of the scapula; also in right lower axilla. Over right base and
lower axilla, there are many fine moist râles;
scattered dry râles throughout the chest. October 23,
leucocytes
15,600; November 2, leucocytes 15,400;
November 6, leucocytes 13,600. Clinical
diagnosis: Bronchopneumonia.
Anatomical diagnosis.- Gas burns of respiratory tract; healing
ulcerative tracheitis and bronchitis; acute and
organizing bronchopneumonia, all lobes; fibrinopurulent pleurisy,
right; cardiac dilatation, right; terminal pulmonary
edema, moderate; acute splenic tumor.
No
detailed autopsy protocol was made in this case, owing to stress of
other work (personal
communication from Lieutenant Kline).
Microscopic
examination.- Primary bronchus: There are adherent strips of
stratified, but ciliated epithelium,
showing no necrosis. There is an acute inflammation with leucocytic
infiltration and congestion and edema of
subepithelial tissue. The wandering cells are chiefly lymphocytes. Lungs:
The larger bronchi are completely lined
with ciliated epithelium, which, however, is composed of several layers
like that of the trachea. There is mucopurulent exudate in the lumina.
The wall is replaced by granulation
tissue, densely infiltrated with lymphocytes.
Most interesting changes are found in the smallest bronchioles and
atria. Many of them are obliterated in part by
purulent exudate, in part by ingrowing vascularized plugs of organized
tissue. Their walls are thickened by
granulation tissue. The surrounding alveoli are collapsed and show the
usual epithelial changes and organization of
contained exudate. Between these foci of bronchitis and peribronchitis,
the lung tissue is emphysematous, and the air
spaces free from exudate. In another block, the pleura is included. It
is covered with a thick layer of fibrinous
exudate, which shows only beginning organization. The underlying lung
tissue, including also the bronchioli, is
collapsed. The bronchi are lined with well-preserved ciliated
epithelium; they contain mucopus, and in places there
is beginning organization of the exudate. The walls are thickened by
newly formed granulation tissue, but the lesions
are less pronounced than in the former block. The collapsed alveoli
have thickened walls and in places there are also
organizing fibrinous plugs. A few infundibula filled with pus and
showing necrosis of their walls, are present.
Myocardium and kidney: Normal. Testis: Interstitial
fibrosis, and absence of spermatogenesis.
NOTE.-There is
beautiful organizing bronchiolitis and peribronchiolitis, which may or
may not be the late result of gassing. There is an indefinite history
of "gas burns about eyes," and
subsequent information indicates an exposure to yellow and blue cross
shell, three and one half
weeks before death. The data are too incomplete to warrant extended
discussion and it is not
altogether certain that the respiratory lesions are effects of the
gassing.
CASE 93.- E. K., 2397299, Pvt., Co. G, 30th
Inf. Died, September
4, 1918, at 9 p. m., at Base Hospital No.
27. Autopsy No. 46, performed on following day, by Capt. HI. H. Permar,
M. C.
Clinical
data.- Gassed with mustard gas on August 10. Admitted to Field
Hospital No. 110 on same day,
and to Base Hospital No. 27 on August 12. Placed in diphtheria ward as
suspect. Throat covered with gray exudate.
September 4, throat culture positive for diphtheria bacilli. Extensive
burns about whole body. General condition very
bad.
224
Anatomical
diagnosis.- Healing
burns of skin of legs, thighs, buttocks, arms, genitals and axillae,
with pigmentation; diphtheritic pharyngitis, laryngitis, tracheitis and
bronchitis;
bronchopneumonia, acute, bilateral; edema and congestion of lungs;
acute toxic myocarditis;
acute lymphadenitis or peribronchial lymph nodes.
Microscopic
examination.- There is an acute suppurative bronchitis, with
complete
necrosis of the mucosa, and acute inflammatory infiltration of the
wall. Some of the smaller
bronchi are completely plugged with fibrinopurulent exudate. There is
no regeneration. The
parenchyma shows patches of lobular pneumonia, emphysema and extreme
alveolar edema in
unconsolidated areas.
Bacteriological
examination.- Smears of membrane taken post mortem shows diphtheria
bacilli.
NOTE.-A case
of mustard-gas poisoning, dying 25 days after exposure, with intense
diphtheritic lesions of the upper respiratory passages, from which the
diphtheria bacillus was
cultured during life. The most unusual feature of the case is the
absence of reparative changes in
the bronchi and lungs.
CASE 94 - S. T., 490034, Pvt., Co. L. 47th Inf.
Died, November 8, at 5 a. m., at Base Hospital No. 19. Autopsy No. 112,
performed six and one-half hours after death, by Capt. H. H. Martland,
M. C.
Clinical
data. - Exposed to blue, green, and yellow cross shelling on
October
13, near Verdun. Admitted to
Gas Hospital No. 3 on same day, October 20, admitted to Base Hospital
No. 76, with conjunctivitis, dermatitis of
face and chest, laryngitis, and bronchopneumonia. October 24, patient
very weak. Pulse 156. Temperature 99.8°.
Respirations 28. Cough with large amount of expectoration. Severe
conjunctivitis. Mucous rȃles over both sides of
chest, especially left. October 24, admitted to Base Hospital No. 1.
Severe bronchitis; no areas of consolidation
found. October 27, membrane over uvula and soft palate. Culture
positive for diphtheria bacilli. Diphtheria antitoxin,
6,000 units, given. October 28, admitted to Base Hospital No. 19.
October 31, pulse rapid and weak. Eats very little.
Dry skin. Raises large amount of purulent sputum. Moist rȃles,
more
numerous over left chest. Throat improving;
15,000 more units of antitoxin administered. Gradually growing weaker.
Summary of gross
lesions.- No skin burns.
There is extensive
ulceration of the larynx, vocal cords, and
trachea, which are covered with thick grayish membrane; this extends
down to the finest bronchioles and is diffuse
through both lungs. All lobes show a confluent bronchopneumonia. There
is moderate distention of the chambers of
the right heart.
Microscopic
examination.- (a) There is gangrenous bronchitis which involves the
entire bronchial wall and a
zone of neighboring lung tissue. In the center of the gangrenous areas
are large masses of bacteria. Elsewhere, the
parenchyma shows a very widespread acute pneumonia, the exudate being
rich in cells and fibrin. In some alveoli,
there is beginning ingrowth of fibroblasts. Scattered through the
consolidated lung are patches of necrosis with great
numbers of bacteria. These are not always clearly related to the
bronchi. (b) There is an organizing fibrinous
pleurisy. In the lung tissue itself some of the bronchioles show a
suppurative inflammation, with preservation of the
epithelium; others gangrenous necrosis. There are emphysema and small
patches of atelectasis. (c) The picture is a
somewhat different one. There is almost complete collapse of the lung
tissue, with extensive early organization in
some areas, fibroblastic thickening of the alveolar septa, and edema.
The bronchi are lined with regenerated
metaplastic epithelium, resting upon a wall of highly vascular
granulation tissue. In places the bronchi also are
collapsed, the walls being practically intact, as seen in longitudinal
sections. The arteries are surrounded by broad
bands of edematous granulation tissue. (d) The section shows irregular
areas of edema, emphysema. and moderate
epithelial exfoliation. A small bronchus in the section shows an
extraordinary obliterating process leading to
practical closure of the lumen. The lining epithelial cells are
curiously altered, and the basement membrane is
hyalinized and thickened. There is a layer of granulation tissue
between the mucosa and the circular muscle. (Fig.
37.) The process seems to be very like an obliterating endarteritis.
That the stenosis of the terminal bronchi is the
cause of the associated emphysema and atelectasis seems very probable.
NOTE.- Death 26 days after
exposure to a mixture of suffocative and vesicant gases. The
noteworthy features in the case are the gangrenous
225
bronchitis, with areas
of necrosis in the parenchyma of the lung; the very extensive lobular
pneumonia, showing in places, early organization; and the obliterating
bronchiolitis in the
nonpneumonic areas, associated with emphysema and areas of collapse.
The recovery of the
diphtheria bacillus from the membranous pharyngeal lesions is also of
interest.
CASE
95.- E. S., 62768, Corpl., Co. ?, 101st Inf. Died, September 13, 1918,
at Base Hospital No. 116.
Autopsy No. 13. Autopsy, five hours after death, by Lieut. B. S.
Kline, M. C.
FIG. 37.–
Death, 26 days
after exposure to mixture of suffocant and vesicant gases. Obliterative
bronchiolitis.
Clinical data. – Date of
gassing, August 15. The patient was burned by the explosion of a
mustard-gas shell above
him while sleeping in a hayloft. Liquid covered his body. Admitted to
Base Hospital No. 116 on July 24 with
severe secondary burns involving entire back from neck down and
including the buttocks and posterior surface of
both thighs and back of legs. Burns also present on both arms, scrotum,
penis, forehead, chest. Progressed fairly
well with only moderate infection and superficial sloughing. Developed
pressure necrosis over sacrum and both
elbows, which grew steadily worse until death.
Anatomical
diagnosis. –
Extensive gas burns of skin of first and second degree, with secondary
infection and
moderate general brown pigmentation. Small areas of organized
bronchopenumonia. Anemia and emaciation. Cloudy swelling of
parenchymatous organs. Old vegetative endocarditis of mitral valve.
Pulmonary edema.
226
External appearance.- The skin shows a striking picture.
Beginning over the scapula above, there is complete
ulceration of the skin of the back as far down as the buttocks, where
the posterior portion is likewise ulcerated. The
ulceration continues down to the mid-portion of the thighs. Over the
sacrum there is a large deep ulcerated area, in
the base of which the sacrum and coccyx are visible. There is a
moderate amount of viscid and caked exudate here.
Above this deep wound there is a similar smaller wound over the crest
of the ilium. The ulceration of the skin of the
back, buttocks, and thighs extends well into the subcutaneous tissue.
The base is covered by a moderate amount of
foul-smelling seropurulent exudate. In places there is dry scabbing.
Ulcerations, similar in character but less
extensive, are present over the posterior aspects of the legs, about
the elbows and the knees, the right ear, crest of the
ilium anteriorly. There is also an extensive deep ulceration of the
scrotum and the base of the penis. Here the
infection is most marked. The skin in general has a dull grayish-brown
cast. Associated with the burns there is a
moderate desquamation. There is also desquamation at some distance from
the ulcerated areas. In places the burns
show considerable healing. This is especially true of the small burns
over the right hip, lower abdomen, upper arms,
and chest. The superficial glands moderately enlarged. Scalp:
Over the vertex there is some thick matted
desquamation. The skin at one place shows a contusion. Eyes:
The eyeballs are sunken in the sockets. The left upper
eyelid shows a large area of ecchymosis. The conjunctive, however, and
the mucous membranes are pale. At the
right corner of the mouth there is a small superficial ulcerated area,
base clean.
Gross findings.- Pleural cavities: On opening the thorax a number of fairly
dense fibrous adhesions are
found in the right sac, binding the posterior portion of the upper and
lower lobes to the chest wail. In the left chest
likewise a number of fibrous bands found binding the lateral portions
of the upper and lower lobes to the chest wall.
On incising the pericardial sac there is considerably less fluid than
average. The pericardium is delicate and pale.
Heart: Weighs about 330 grams. The right auricle considerably
dilated. The tricuspid ring admits three fingers.
There is slight dilatation of the conus. The valvular endocardium, thin
and delicate, except the mitral valve, which
shows along the line of closure several vegetations tightly adherent to
the underlying endocardium. In part the
vegetations are covered by endocardium. The chorda e, however, are thin
and delicate. The base of the aorta shows
small soft yellow opaque patches in the intima. The coronary vessels,
no abnormalities, except that the right one
opens by two mouths. The left myocardium on section is paler than
normal. The architecture not altogether regular.
There are scattered grayish flecks here and there. The tissue has a
boiled and slightly greasy appearance. Right lung:
All lobes fairly voluminous, cushiony, and inelastic. The lower lobe
slightly soggy in addition. The glands at the
hilum somewhat enlarged, edematous, pulpy, and not injected. The
vessels, no abnormalities. Bronchi: The mucosa
is pale and smooth. In the lumen there is a small amount of frothy
fluid. The upper lobe on section presents a pink
surface. The air sacs contain a small amount of fluid. In the posterior
portion there are numbers of grape seed-sized
to pea-sized firm consolidated areas, grayish-red in color. The middle
lobe is well aerated and pink throughout.
There is extremely little fluid in the air sacs. The lower lobe on
section presents a pink surface. There is a small
amount of thin, frothy fluid in the air sacs. In this lobe also there
are numerous reddish patches, associated with
some of which there are firm reddish-gray small consolidated areas. Left
lung: Both lobes voluminous, cushiony, and
inelastic. The glands at the
hilus, vessels, and bronchi similar to those on the right. On close
inspection of the
bronchi the mucosa appears exceedingly thin. On section the upper lobe
in general similar to the right upper. The
lower lobe in general similar to the right lower lobe. Organs of
neck: Glands in the lower portion of the neck are not
appreciably enlarged. Thyroid: Considerably smaller than
normal. The tissue coherent, pale. There is little colloid in
the acini. Larynx and trachea: Present an interesting picture.
The mucosa is exceedingly thin, pale, except in the
region of the epiglottis, where it is somewhat diffusely thickened,
pale with injection of the vessels here and there.
The lymphatic tissue in the pharynx and the upper esophagus adjoining
the glottis somewhat enlarged, injected.
Tonsils: Enlarged, but scarred. Crypts clean. Liver:
Weighs 1,400 grams. Adrenals: Right adrenal shows digestion of
the medulla in one portion, with
considerable extravasation of the blood here. There is moderate loss of
the yellow
pigment. The left shows no digestion of the medulla, some diminution in
the yellow
227
pigment. In places there are fine gray
streaks in the cortex. Kidneys:
Normal. Alimentary tract:
There is
perhaps
slight thickening of the mucosa of the upper esophagus, pharynx, and
base of tongue. The stomach contains about 75
c. c. of thin, bile-tinged contents. The mucosa pale. Duodenum, ileum,
the mucosa somewhat bile-tinged. In the
lower ileum there are scattered patches of injection of the mucosa. The
Peyer's patches arc flat here, somewhat
pigmented. The solitary follicles in the cecum are flat, pigmented.
There is some patchy injection of the mucosa of
the cecum and ascending colon. In the rectum there is quite diffuse
moderate injection of the mucosa. The tissue
about the rectum is somewhat edematous. The mesenteric lymph glands are
not appreciably enlarged.
Microscopic
examination.- Skin: Section passes through ulcer covered by
infected
slough. There is no
healing at the margin and very little granulation tissue at the base.
The adjacent epithelium contains little pigment,
but there are beautiful melanophores in the superficial layer of corium
sending processes between the basal
epidermal cells. Another block shows thinning of epidermis with
hyperpigmentation. Trachea: Epithelium is intact
and normal save for post-mortem desquamation. Epithelium is ciliated.
There is no edema, congestion, or
inflammatory infiltration of submucosa. No bacteria found in section.
Lungs: Bronchi still have
intact epithelium,
but are filled with pus. Atria are dilated and their epithelium
necrotic. There are patches of lobular pneumonia and
interstitial infiltration. The exudate is cellular, not fibrinous. No
organization. There are many pigmented exfoliated
epithelial cells. Section stained with Gram-Weigert shows practically
no bacteria or fibrin. Kidneys: A few of the
glomerular tufts contain hvaline thrombi. No other changes. Myocardium,
spleen, and pancreas:
No abnormalities.
NOTE.- Mustard-gas case of 29 days' duration, with very
extensive contact burns of skin. The respiratory
lesions do not indicate gas inhalation. There was a terminal pneumonia
in the lung which also showed signs of
chronic passive congestion associated with the mitral lesions. Death in
this case was primarily the result of very
extensive skin burns associated with infection or toxemia.
CASE
96.- W. A. H., 2182677, Pvt., 354th Inf. Died, on September 7, at 7 a.
m., at Base Hospital No. 42.
Autopsy No. 3, performed three hours after death, by Capt. F. A. Evans,
M. C.
Clinical data:-
Gassed on August 8,
near Toul, with mustard-gas shells. August 10, admitted to Base
Hospital No. 42. August 20, the patient began to
have a temperature of 100 ° to l01 °, followed
a few days later bv areas of bronchovesicular breathing front and back.
There was a definite area of consolidation, especially marked in the
angle of the right scapula. For a few days the
patient improved and did very well. August 28, scattered râles over
upper front on both sides, with
bronchovesicular breathing over lower right anterior chest. There was a
click on expiration and inspiration over this
area. In the back, various kinds of râles were heard on both sides;
impairment of resonance over lower right side,
beginning about 5 cm. below the angle of the scapula. September 4,
signs of irregular consolidation over entire right
lower lobe, and also over right upper chest anteriorly. The patient,
from this time on, became more intoxicated;
breathing became labored; there was very abundant purulent sputum.
September 6, condition very bad.
Laryngoscopy on August 30 showed the vocal cords covered with a film of
mucopurulent exudate. Died on
September 7, at 7 a. m.
Anatomical
diagnosis.- Acute tracheitis and bronchitis; bronchopneumonia of
all
lobes; acute fibrinous
pleurisy; healed mustard-gas burns of axillae; perineal region,
buttocks, and popliteal spaces.
External appearance.- Few superficial excoriations under the
lower lip. There is pigmentation of healing
gas burns in the perineal region over the inner and posterior aspects
of the thighs, over the buttocks, and popliteal
spaces. Similar but less pronounced pigmentation is seen in the
axillae.
There is purulent exudate in both eyes.
Gross
findings.- Right lung: Floats in water and is voluminous. In
certain
areas, notably at the extreme apex
of the upper lobe and the extreme base of the lower, posteriorly, the
lung tissue appears normal. There is fibrinous
deposit over the lower surface of the upper lobe, over the middle lobe
posteriorly, and over the uipper part of the
lower lobe. There is also a heavy deposit of fibrin in the initerlobar
fissures. Those places that have not been
228
described as normal have a pinkish-purple
color and on palpation are in part air containing, in part
consolidated.
There is an isolated area of dark color in the posterior part of the
upper lobe extending from the fissure to the apex,
which has a nodular feel. On section, there is an irregular and patchy
bronchopneumonia. The lung tissue is
everywhere moist and, where not consolidated, of a salmon-pink color,
from which the small bronchopneumonic
nodules stand out. The larger bronchi of the right lung are injected,
and pus exudes from them on cutting. Left lung:
Also is voluminous. There is a fine fibrinous pleural exudate most
marked posteriorly. On section, the lung tissue is
less moist than that of the right lung; it is spotted with areas of
bronchopneumonia, varying in size from miliary to
that of a bean. The pneumonic consolidation is most extensive in the
posterior part of the lower lobe. The larger
bronchi are injected, but their mucosa appears to be intact. Organs
of neck: Larynx and pharynx are normal. Trachea: Shows a
fibrinomucopurulent exudate, which when stripped off shows the
underlying mucosa intact and
only moderately congested. No scarring is apparent. Heart normal.
Intestines not reinoved. Remaining organs
show no significant changes.
Microscopic
examination.- Trachea: Epithelium is everywhere intact, but
resembles esophageal epithelium,
being squamous and nonciliated. The same alteration is present in the
epithelium lining the mucous ducts. The
glandular acini are distended with mucus. The submucous tissue is
evenly infiltrated with wandering cells having
stained distorted nuclei. The preservation of the tissue is too poor to
identify these with certainty. Most of them
appear to be lymphoid cells. The capillaries are wide, but contain no
preserved red blood cells. Lungs: The smaller
bronchi are wide, their walls thickened by granulation tissue and
closely invaded by leucocytes. Some are lined by a
thin layer of flattened epithelial cells; in others the rough
granulation tissue lies exposed. Many of them contain
purulent exudate, and most of the terminal bronchioles and infundibula
are filled with it. The adjacent lung tissue
over a narrow zone shows all organizing pneumonia. A second block shows
all extensive bronchopneumonia. which
is not of the usual influenzal type, inasmuch as the exudate is very
cellular. The leucocytes are well preserved, and
the process seems of recent date. A third block shows all organizing
bronchiolitis, with plugs of vascularized tissue
growing from the walls. The smaller bronchi are greatly thickened by
new formed granulation tissue and
surrounded by zones of edema. Liver, spleen, myocardium, and adrenal
show no features of special interest.
NOTE.- A
case of mustard-gas poisoning, dying 30 days after exposure. There were
healing burns in
characteristic situations at autopsy, and histological examination
shows the typical metaplasia of the tracheal
epithelium and subacute bronchitis and peribronchitis similar to that
seen in other mustard-gas cases after the lapse
of several weeks. In addition, however, there appeatrs to have been a
lobular pneumonia of more recent date.
CASE 97.- T. F. (Cherokee Indian),
48537, Ivt., Co. M, 18th Inf.
Died, Novembler 6, 1918, 9.20 a. m., at
Base Hospital No. 58. Autopsy No. 17. Autopsy, four hours after death.
by Capt. M. Flexner, M. C.
Clinical
data.- Exposed to phosgene and mustard-gas shells on October 1,
near
Charpenterey. Admitted to
Base Hospital No. 58, October 15, with severe cough and pain in chest. Diagnosis:
Bronchopneumonia, with
suspicion of lung abscesses.
Anatomical
diagnosis.- Mustard-gas burns, healing at left wrist, hemorragic
and
gangrenous tracheitis,
bronchitis, and bronchiolitis. Extensive peribronchial pneumonia.
Chronic fibrous pleurisy. Parenchymatous
degeneration of liver and spleen.
External
appearance.- Body is that of an Indian. The skin is brownish-tan in
color with darker pigmentation
over abdomen and thighs, almost white over lower legs and feet. Over
end of radius on left wrist is a healing burnt
circular in shape, with slight scab formation at lower edge. Over
coccyx is a beginning ulcer.
Gross
findings.- Pleural cavities: The left is obliterated by old
adhesions. The right is free from fluid or
adhesions. Heart: Normal. (Note dictated upon receipt of organs
at pathological laboratory, experimental gas field.) Right lung:
Pleura over upper and lower lobes is normal. Over the lower 1obe are
the remains of old fibrinous
adhesions. Posterior half of lung is dark with sunken patches of
collapse. The anterior portion is pale and
229
emphysematous. Bronchi: As far as
call be followed, are lined with dark greenish-brown mucosa, contain a
little
dark, fool-smelling exudate. No diphtheritic membrane. On section, the
upper lobe, in the posterior portion shows
numerous discrete yellow foci surrounded by irregular patches of
hemorrhagic consolidation. These areas
correspond to the cross section of small bronchi dilated with plugs of
exudate. Same condition throughout the lower
lobe, with exception of small patches anteriorly. The consolidation,
however, is more widespread and the intervening
lung tissue less well aerated. The middle lobe, with the exception of
the extreme anterior strip, is air-containing and
dry. The bronchial lymph nodes are small and pigmented. Large branches
of the pulmonary artery are normal. Left
lung: Both lobes are covered with sheetlike adhesions. The apex is
deformed by old scars. Several calcified nodules
in the substance of the lung can be felt about one inch below the
extreme apex. Upper lobe on section is air-containing. Along the
posterior border the walls of the bronchi show greenish-brown
discoloration. The lower lobe
is very dark ill color, firm and nodular. Numerous foci of
grayish-yellow project upon a background of dark red,
uniformly consolidated. On pressure plugs of dense exudate can be
expressed. Section shows also small irregular
cavities with necrotic walls, and representing small dilated
bronchioles. The bronchi show the same intense
hemorrhagic condition as in the right lung. The fetid odor is
apparently not due to post-mortem change. Trachea and
bronchi: Are markedly injected with blackish-gray discoloration of
the wall. There are small yellow flecks in the
contained secretion. Gastrointestinal tract is grossly normal.
Remaining organs show no significant lesions.
Microscopic
examination.- Trachea: The mucous membrane in places is preserved,
and the lining
epithelium is not atypical, showing well preserved cilia. Desquamation
is probably post mortem, since there is no
edema of the corium, no membrane formation, no inflammatory
infiltration and no evidence of regeneration.
Lungs: Bronchioles show necrosis. There is complete loss of
epithelium without formation of membrane or
exudation of leucocytes into the lumina. In many places the
peribronchiolar tissue is involved in the necrosis. Only
faint indications of alveolar outlines persist. Detritus, which lines
these gangrenous cavities, is very rich in
organisms. The necrotic areas are surrounded by a zone of
bronchopneumonia with many polymorphonuelear
leucocytes in the exudate. External to these the alveoli contain much
fibrin. In some areas these peribronchial
pneumonic patches are undergoing organization. There is much edema
about the large vessels with formation of
abundant young connective tissue. Septa also are edematous and in
places organized and contain many lymphoid
and plasma cells. Skin:. Superficial desquamation of the keratin layer, slight edema of corium
with a few wandering
cells. No other significant lesions. Section of kidney, pancreas,
spleen, and myocardium show no changes of interest.
Liver: Shows rather marked periportal fat infiltration.
NOTE.-
Exposed
to phosgene and mustard gas 37 days before death There was a healing
mustard-gas (?) burn of the left wrist, but no other cutaneous lesions
suggestive of previous
gassing. Findings in the trachea were not indicative, but there was a
gangrenous bronchiolitis
associated with a widespread hemorrhagic bronchopneumonia, which was
becoming organized. While it is probably a late mustard-gas case, it is
difficult to make a differential
diagnosis from influenzal pneumonia complicated by a gangrenous
bronchiolitis. A point of
interest in this case is the presence of obsolete apical tubercles
which after 35 days have not
become activated.
CASE 98.- C. M., 17004, Pvt., 2
Northumberland
Fusileers. Died, November 12, 1918, at 1 p. m., at Base
Hospital No. 2. Autopsy, five hours after death, by Capt. 1B. F. Weems,
M. C.
Clinical data.- October 5,
admitted to No. 20 Casualty Clearing Station. Diagnosis: Gas-shell
wound of left thigh, right foot, left hand; gassed.
Operation: Amputation of left thigh, right foot. Left hand cleaned tip.
Patient's condition very poor. Blood
transfusion. October 7, admitted to Base Hospital No. 2. Stump of left
thigh fairly clean, right foot very dirty,
completely excised and part of first and second metatarsals removed;
posterior tibial vessels tied; not amputated
because of amputation of opposite thigh. Wound of left hand very dirty.
Fifth finger amputated. Corneal ulcer of left
eve. October 28. has
230
been doing only fairly well; foot still badly
infected. Incision on dorsum today; abscess apparently arising from
tarsal joints. November 5, patient doing poorly; running temperature of
103°and 104°. Blood culture sterile;
moderate generalized bronchitis; has apparently an infection of most of
the tarsal joints. Amputation through
junction of middle and lower third of right leg under stovaine
intraspinally. Transfusion 700 c. c. Stood operation
well. November 12, condition has grown steadily worse. All wounds
appear clean. Many fine râles at both bases
with much cough. Died at 1 p. m.
Anatomical
diagnosis.- Acute membranoulcerative laryngitis, tracheitis and
bronchitis; bronchopneumonia;
edema and congestion of both lungs; multiple abscesses, both lungs;
acute fibrinous pleurisy, amputation wounds of
both legs, and finger of left hand; emaciation; poisoning with irritant
gas.
External
appearance.- Much emaciated; adenoid facies; many teeth missing.
Skin and external genitals
normal. Wounds as follows: Left-hand middle finger missing; ulcerated,
partially healed wound over area of
amputation; left leg amputated in midthigh; stump apparently clean;
right leg amputated just above foot; upon
removing sutures, tissues are found to be clean and apparently healing.
Gross
findings.- Pleural cavities: Lungs are collapsed to some extent;
there are about 100 c. c. of fluid in the
left pleural space; loose fibrinous exudate and fluid over the entire
posterior surface and base of right lung. Left lung:
Moderately voluminous; there is a slight amount of fibrinous exudate
over posterior surface; lower portion of upper
lobe, as well as greater portion of lower lobe, is consolidated.
Bronchi: Contain slightly purulent and sanguineous
exudate; mucous membrane is much eroded and covered by exudate. Upon
section, the lung presents a dark grayish-red color; the surface is
moderately smooth, exuding a large quantity of serum and blood; there
are numerous small
points of pus over the surface. It is rather a diffuse type of lobular
pneumonia combined with edema. Right lung:
Covered with thick fibrinous exudate. The lower lobe and a large part
of the upper and middle lobes are of rather
firm and lumpy consistence. The lung upon section reveals much the same
picture as the left. There is a diffuse
partial consolidation, roughly lobular in type. The bronchi are filled
with pus and necrotic membrane; many small
abscesses are present at the end of the bronchi. Edema is pronounced.
The glands at the hilum are much enlarged.
Organs of neck: Tonsils normal. Epiglottis: Tremendously
thickened and covered by a yellowish-gray membrane;
the mucosa is eroded. The arytenoepiglottic folds are also much
thickened and ulcerated. Trachea: Is covered over
its entire length by a thick cheesy membrane, beneath which the mucous
membrane is deeply ulcerated. Heart
normal. Gastrointestinal tract: Not recorded. Remaining viscera show no
significant changes.
Microscopic
examination.- Epiglottis: On both sides a diphtheritic
necrosis extending almost to cartilage.
Much fibrin is present, both on the surface and in the edematous sub-
mucous tissue. There is hyperernia and
hemorrhage. Many of the small vessels contain thrombi, some of which
are becoming organized. There are many
mononuclear and polymorphonuclear leucocytes loosely scattered through
the tissues; they appear pycnotic. The
cartilage also is affected, showing in places fibrillary degeneration
of the ground substance, with swelling and loss of
definition of the cartilage cells themselves. Trachea: There is
a thick adherent membrane, densely crowded in
places with fragmented and pycnotic leucocytes; on the surface of this
is a loose purulent exudate containing masses
of Gram-positive cocci. There is no epithelium remaining. The submucosa
shows numerous fibroblasts, pycnotic
leucocytes, and congested vessels. The mucous ducts are wide and filled
with exfoliated cells. Lungs: A bronchus
cut longitudinally is practically filled with a thick fibrinous plug in
which are many pigment-containing cells, and a
few ingrowing fibroblasts. The alveoli everywhere contain plugs of
loose fibrinous exudate, poor in cells, which are
continuous with similar plugs in the distended atria. Few large
mononruclear cells and polymorphonuticlears and
isolated spindle cells are present in the fibrin. The septa are
thickened and loose in texture and under the high power
the epithelium is frequently found elevated from the capillaries in a
continuous sheet, presumably by edema. There
are occasional hemorrhagic extravasations between epitlielium and
blood vesssel, or into the alveolus itself. The
epithelial cells, judging by their swollen contours and dark staining
protoplasm, are probably in large part new
formed, although no mitoses are found. Another block of lung tissue
shows in general the same picture. There is
fibrin upon the surface of the pleura, which is exceedingly edematous.
In its basal portion are many congested blood
vessels with fresh hemor-
231
rhages. Beneath the pleura in one place is an
abscess about 2 mm. in diameter. The lymphatics in the interlobular
septa are distended with masses of degenerating leucocytes. Liver,
spleen, adrenal, and kidney show nothing
abnormal.
Bacteriological
examination.- Blood culture (post-mortem) staphylococcus albus.
Culture from bronchus:
B. influenzae, streptococcus
hemolyticus, staphylococcus aureus,
Gram-positive diphtheroid bacillus. Culture from
bronchiole, staphylococcus aureus. Culture from pleura: Staphylococcus
aureus. Culture from lung: B.
influenzae, diphtheroid
bacillus.
NOTE.- History
of gassing, 38 days before death, with severe wounds of lower
extremities, later necessitating double amputation. There is no record
of skin burns, and none are
described in the autopsy protocol. There is said to have been a corneal
ulcer, but there is no
mention of conjunctivitis. The upper respiratory tract showed a
membranous necrosis of great
severity, with complete epithelial destruction. Repair was therefore
limited to attempted
organization in the deeper tissue, but was very imperfect. The small
bronchi still contained plugs
of dense exudate, which was undergoing early organization. There was a
lobular pneumonia
which also showed evidence of organization and epithelial repair. There
were a few suppurative
foci. Presumably, the case is one of mustard gas inhalation, in which,
as in other autopsies at this
hospital during the same period, the cutaneous lesions are slight or
absent. The surgical
complications, in this case, though very grave, can not be regarded as
the cause of death.
CASE
99.- J. Y., 105587, 16th Inf. Died,
November 10, 1918, at 7 p. m. Autopsy, 141 hours after death, by
Lieut. B. S. Kline, M. C.
Clinical
data.- October 2, admitted to Field Hospital No. 12 with shell
wound
of right side. Foreign body
about 6 mm. long beneath superficial muscles of right chest. October 4,
multiple burns of skin, dressed with vaseline
each day. October 24, incision and drainage of large abscess of right
buttock. October 25, patient complained of
difficulty in opening jaw; no stiffness of neck. November 1, incision
of gluteal abscess and inguinal glands.
Antitetanic serum 5,000 units intraspinally, 10,000 intramuscularly.
November 2, fluoroscopic examination showed
foreign body, 1 by 1 cm. lying 10 cm. under skin apparently in the body
of the liver. November 3, subdiaphragmatic
abscess; operation; resection of rib and evacuation of abscess. Culture
of pus showed anaerobic Gram-positive
bacilli and Gram-positive diplococci. Forty thousand units of
antitetanic serum intramuscularly. November 10, the
patient grew rapidly worse, although tetanus was cured. Frequent
vomiting, incontinence of feces, much thick
sputum, and definite signs of peritonitis. The patient died, Novemper
10 at 7 p. m.
Anatomical
diagnosis.- Gunshot wound of abdomen, with perforation and
laceration of liver (encapsulated
bit of shrapnel, with clothing fragments and small spicules of bone),
subsequent infection, abscess formation;
thrombosis, local hepatic veins; small infarct, left upper lobe;
subdiaphragmatic abscess; local organizing peritonitis;
resection of seventh rib, right; drainage of liver abscess and abscess
of right buttock; surgical incisions and drainage;
decubital ulcer over sacrum, beginning healing; healing extensive
superficial gas burns of skin, with moderate
general brown pigmentation, and considerable local brown pigmentation
of trunk, extremities, and scalp; anemia
and marked emaciation; healing and acute purulent bronchitis; areas of
bronchiectasis; old peribronchial and
peribronchiolar pneumonia of all lobes except right middle; recent
bronchopneumonia, right upper and lower lobes;
fibrinopurulent pleurisy, right; acute splenic tumor; cardiac
dilatation, right (slight); pulmonary edema (slight). A
detailed autopsy protocol of this case was not made, owing to stress of
other work (personal communication from
Lieut. B. S. Kline).
Microscopic
examination.- Large bronchus: Presents no clear evidence of
previous
gas injury. The
epithelium is defective in places, but this is probably due to
postmortal desquamation. Where it is still intact, it is
ciliated, and in no wise abnormal. The subepithelial tissue contains
pink-staining hyaline material, which is probably
old fibrin. The blood
232
vessels are congested. There are moderate
numbers of lymphoid cells. The mucous glands are normal. Lungs: (a)
Section shows an acute confluent bronchopneumonia, presenting no
special features. There are no other lesions
indicative of previous gassing. (b) In addition to patches of acute
bronchopneumonia, the bronchioles show changes
which are probably of older date, and may be referable to gas
inhalation. Some are dilated and contain
fibrinopurulert exudate which in places is becoming organized; the
walls are formed by a hyperemic granulation
tissue, densely infiltrated with round cells and plasma cells. The
epithelium in some is ciliated; in others, flat and
atypical; in still others, lost. The adjacent alveoli are collapsed and
compressed, and there is hemorrhage and
fibrinous exudate, showing early organization. Irregular nests of
proliferated epithelium fill up some of the alveoli.
(c) The section shows an old infarct, at the apex of which is an
organizing thrombus, already well canalized. In the
noninfarcted area the bronchioles and infundibula show lesions similar
to those in (b) and probably due to the
original gassing. Liver:
Section shows healing scars with granulation
tissue and much foreign material on surface.
Spleen: Fragmentation of cells in centers of follicles, marked
congestion of pull), and much pigment deposit. Kidney:
Acute degenerative changes in epithelium of convoluted tubules
NOTE.-There
is a definite clinical history of old mustard-gas burns, and healing
and
pigmented burns were present at the autopsy 39 days after the injury
was incurred. The
pulmonary lesions were complicated by the presence of an infarct,
doubtless due to an embolus
from the hepatic veins, and by a terminal bronchopneumonia complicating
the abdominal
injuries. There were, nevertheless, traces of old respiratory burns in
the small bronchi and infundibula, although the larger bronchi showed
restitution of the
epithelium.
CASE 100.- R.
A. B., 2181649, Corpi., 355th
Inf. Died, September 28, 1918, at 12.40 p. m., at Base
Hospital No. 116. Autopsy, three hours after death, by Lieut. B. S.
Kline, M. C.
Clinical
data.- August 10, admitted to Base Hospital No. 116, suffering
from
mustard-gas inhalation and
contact received in action on August S. Said to have been exposed to
yellow and green and blue cross shells for six
hours. There were on admission extensive body burns, conjunctivitis,
laryngitis, and bronchitis. August 12,
consolidation of right lower lobe. August 20, scattered areas of
consolidation over both lungs, with complete
consolidation of left lower. September 10, diarrhea. September 15,
signs of fluid at the base of the left lung.
Aspiration showed pus. September 16, operation for empyema. Since
admission there has been gradual emaciation
which is now very marked. The gas burn of the lower back has never
healed, and has become a bed sore. The right
lung presents harsh breathing and many coarse, moist, bubbling rales. Diagnosis:
Bronchiectasis, with purulent
expectoration. Died, September 28 at 12.40 p. m.
Anatomical
diagnosis.- Healed gas burns, upper respiratory tract and skin;
diffuse and local brown
pigmentation of skin; organized bronchopneumonia, left lower lobe;
empyema, left; resection of portion of ninth rib;
extensive organizing fibrinopurulent pleurisy, left; dilatation of
bronchial branches, slight; purulent bronchitis, slight
atelectasis of left lung, moderate; compensatory emphysema, right lung;
rupture of thoracic aorta, false aneurysmal
sac; old tuberculosis foci, right lower lobe; healed pleural adhesions,
right; decubital ulcer of sacrum, healing;
anemia and emaciation, marked.
External
appearance.- Body markedly emaciated and anemic; slight hypostasis.
The skin in general has a
slight brownish tint. Scattered over the thighs, genital folds, lower
abdomen, elbows and upper arms, there are
irregular blotchy areas of deeper brown pigmentation. In some of these,
the epidermis is desquamnated in the inner
portion. The outer surfaces of both thighs and the scrotum show thin
pearly areas several centimeters in diameter.
Over the sacrum posteriorly, there is an area of ulceration 4.5 cm.
extending into the muscles; the base clean,
showing healing. The skin edges show new epidermis. Operative wound
below angle of left scapula, with drainage
into pleural cavity.
Gross
findings.- Pleural cavities: On opening the thorax, a small number
of fibrous hands found in the
posterior andl inferior portions of the sac on the right side. On the
left both lobes collapsed against the spine. There
is a large air space present, with firm adhesions over the upper and
lower loibes posteriorly. In the sac are a few
pockets of viscid pus. The heart is displa ed somewhat to the right.
Its long axis is parallel to the long axis of the
233
body. The pericardial sac on the left is
bound to the lung by firm bands; otherwise pericardium is normal. Right
lung: All lobes fairly voluminous, cushiony, inelastic. The
pleura thin; the vessels present no abnormalities. The
glands at the hilum are intensely pigmented and scarred. The bronchial
mucosa is pale, perhaps slightly thickened.
On section of all lobes, a light pink very well aerated surface
presents. The upper portion of the lower lobe shows a
scarred pigmented patch 2 by 1.5 cm., embedded in which there are firm
whitish-yellow nodules. On this side, some
of the bronchial branches contain viscid mucopurulent secretion; and
in addition in places peripherally are
moderately dilated. Left lung: Both lobes considerably
collapsed. The pleura diffusely thickened, covered by
tenacious fibrinopurulent exudate, which when stripped shows tiny
vessels between it and the pleura. The pleura
itself is diffusely injected. The vessels and glands are similar to
those on the right side. The bronchi show slight
patchy injection of the mucosa. In the lumen there is thin viscid
fluid. On section of the upper lobe, a light pink
well aerated surface presents. In the posterior portion, there is a
firm gray area 1.5 cm. in diameter, suggesting
organizing pneumonia. No consolidation elsewhere. The lower lobe on
section presents a similar picture to the
upper, except that it is not consolidated. In both lobes some of the
peripheral bronchial branches show moderate
dilatation. In the lumen, there is viscid mucopurulent material.
Between upper and lower lobes posteriorly there is a
mass of soft purulent exudate. Encapsulated in the inferior portion of
the lower lobe, there is a small amount of
viscid pus similar to that in the surgical wound described above.
Scattered through the left lower lobe are numerous
tiny nodules suggesting organizing pneumonia. In this lobe also a
number of the medium-sized bronchioles are
somewhat dilated. Organs of neck.-Trachea and larynx: Mucosa
pale, perhaps slightly thickened. There is no outspoken evidence of
former inflammation. Tonsils: Small and scarred. Heart: Brown
atrophy, not otherwise
abnormal. Aorta: Moderate
atherosclerosis with rupture at junction of
transverse and descending portions of arch,
and false aneurysm formation. Gastrointestinal
tract: Patchy injection,
but no other significant changes. Remaining
viscera show no lesions of interest.
Microscopic
examination.- Skin: Area from which specimen was taken is not
known,
possibly scrotum,
because of abundant large sebaceous glands and corrugated surface.
There are few definite alterations. The stratum
corneum is loose and partially exfoliated. There is an excessive amount
of pigment in some areas of the stratum
mucosum, and rather numerous branching chromatophores in the
superficial laver of the corium. There are no
inflammatory changes, and the appendages are normal. The superficial
vessels are collapsed and not thrombosed. In
a few areas there is irregular arrangement of the epidermal cells with
considerable hyperkeratosis. Trachea:
Epithelium over the greater portion of the section is of the normal
stratified ciliated type. The arrangement of the
cells is orderly and there is nothing to indicate a previous injury. In
one area, however, there is a superficial ulcer,
where the epithelium is defective, and the base formed by dense scar
tissue, in which the connective tissue cells have
dense distorted nuclei. The subepithelial tissue is loose and contains
many scattered wandering cells, predominently
plasma cells. There are also large mononuclear elements, fibroblasts,
and phagocytes filled with hemosiderin
pigment. These cells, especially
lymphoid and plasma cells, are present in numbers between the acini of
the mucous
glands. Lungs: There is dense organizing fibrinous exudate on
the pleura, 2 mm. in thickness. The underlying tissue
is collapsed, the septa thickened. There are well-organized plugs, with
new-formed blood vessels and many pigment
cells in some of the bronchi (see fig. 25) and alveoli. Here and there
are dense masses of fibrin still present in the
alveoli. These are invaded by scattered connective tissue cells, and
covered often by flattened epithelium. Others are
filled with vacuolated fat-containing epithelial cells. The
interlobular septa are edematous, but organization is in
progress. Myocardium, spleen, liver, and adrenals: No significant
changes.
NOTE.- Death
51 days after exposure to mixed suffocant and vesicant geases. Death
probably due to empyema, complicating the gas pneumonia. The trachea
showed localized
ulcers, but over large areas there is complete regeneration of ciliated
epithelium, a point of great
interest since it indicates that the squamous metaplasia is not a
permanent nor inevitable effect of
the gassing. The organizing bronchiolitis is also of interest.
234
CASE 101.- C. D., No.- Pvt.,
28th Inf. Died, November 21 at 5 p. m., at Base Hospital No. 116.
Autopsy, 16l hours
after death, by Lieut. E. S. Maxwell, M. C.
Clinical data.- October 2, admitted to Base Hospital No.
23. Diagnosis: Mustard-gas poisoning. Held for
mental observation. October 27 transferred to Base Hospital No. 116.
Eyes and head generally burned. Scattered
râles in lungs. The patient is extremely active with intent of
destruction, and requires restraint. Apparent mania due
to toxic and exhausted state. November 5, leucocytes 18,200. The
patient's condition mentally and physically is
worse. Irregular temperature, at times reaching 104°. An area of
dullness has developed over left lower and lower
part of left upper lobes. No fluid obtained on tapping chest. November
21, respirations rapid and shallow, pulse
feeble and irregular. Pulmonary edema and cardiac exhaustion. Died at 5
p. m.
Anatomical
diagnosis.- Gas burns, mustard gas (slight): Healed tracheitis and
suppurative bronchitis;
organizing coalescing lobular pneumonia, left upper and lower lobes;
peribronchial pneumonia, right upper lobe;
fibrinopurulent pleurisy, bilateral (600 c. c. left, 200 c. c. right);
acute lymphadenitis; regional lymph nodes;
pulmonary edema, moderate; cardiac dilatation, right (moderate).
Detailed
autopsy protocol not received.
Microscopic
examination.- Trachea and large bronchus: No material preserved. Lungs:
Pleura covered with
thick fibrinopurulent exudate, which is evidently very recent since
there is no organization in progress. There are no
larger bronchi included in the section. The bronchioli are filled with
purulent exudate, and their epithelia invaded by
leucocytes. There is no necrosis or membrane formation. The most
striking feature is a diffuse alveolar edema, partly
fibrinous, in which are seen a few pigmented epithelial cells but very
few leucocytes. Occasionally there are some
spindle-shaped fibroblasts, but the organization is not wide-spread and
is extremely early. There is edema also about
the arteries and veins; the lymphatic spaces are widely distended with
plugs of purulent exudate, which in places
simulate small abscesses. Bronchial lymph nodes: Show
no features of special interest.
NOTE.-There is a definite history of mustard-gas
intoxication, with typical burns and very severe mental
symptoms. The injury was received approximately 52 days before death.
The pulmonary symptoms appear to have
been of later development, and it is difficult to ascribe the
histological lesions found in the lungs to the initial injury.
The material is defective, no tissue from the trachea or larger bronchi
having been preserved.
CASE 102.-A. K., 2181274, Corpl., Co.
A, 355th Inf. Died,
October 1, 1918, at 7.45 a. m., at Base Hospital
No. 18. Autopsy No. 100, performed eight hours after death, by Lieut.
B. S. Kline, M. C.
Clinical
data.-None available. There were numerous casualties from gas on
August 7 and 8, on which days
Co. A of the 355th Infantry was exposed to severe shelling with yellow,
blue, and green cross shells. In all
probability this is the correct date of gassing.
Anatomical
diagnosis.- Gas burns of respiratory tract, with healing in larynx
and trachea; intense bronchitis;
extensive peribronchial pneumonia of all lobes except right middle, in
large part organizing; multiple abscess
formation, left lower lobe; localized areas of gangrene, left lower
lobe; extensive recent lobular pneumonia;
organizing fibrinous pleurisy, left lower lobe, slight; acute
lymphadenitis of regional lymph nodes; slight general
brown pigmentation of skin; anemia and emaciation marked.
External
appearance.- The skin in general has a dull light brownish cast,
most marked in the folds and over
the lower abdomen. Eyes normal. External genitalia normal.
Gross
findings.- Pleural cavities: Fibrous bands over the upper lobe on
the right side, and a small amount of
fibrinous exudate on the left. Right lung: Is voluminous and
cushiony; the upper lobe shows solid patches
posteriorly; the middle lobe is well aerated; the lower lobe is like
the upper. The glands at the hilus are greatly
enlarged, pulpy, edematous, somewhat injected. The vessels are normal.
The bronchus shows marked injection and
hemorrhage into the mucosa. In the lumen there is thin, viscid,
green-tinged fluid. The bronchial cartilages cut with
more than usual resistance. On section of the upper lobe, the posterior
half shows patchy consolidation, the cut
surface in the pneumonic areas being pinkish-gray to yellow. In places
the consolidation is soft, coherent, pulpy,
and yellowish.
235
The finer bronchioles contain viscid pus. The
larger bronchi show considerable thickening of their mucosa. Mesially,
the tissue is well aerated and pink. The consolidation is in great part
peribronchial; in places it is firm and gray,
suggesting organization. The middle lobe on section is pink and
air-containing. The bronchioles contain viscid
purulent material. About some of them there is a small amount of
pinkish-gray consolidation. The lower lobe is
strikingly less affected than the upper, but presents in general a
similar picture. The bronchial thickening and
peribronchial consolidation are even more conspicuous. In addition, the
bronchioli show slight but definite diffuse
dilatation. This is especially marked at the periphery of the lobe,
where the bronchioles are equal in size to ordinary
good-sized bronchial branches. Left lung: The lower lobe is
much more voluminous than average and in great part
soggy. The upper lobe is of average volume. Over the lower lobe,
tightly adherent, apparently organizing fibrinous
exudate in small amount is present. The glands at the hilum, vessels,
and bronchi similar to those on the right side.
On section the upper lobe is aerated and pink in its upper portion; in
the lower portion, especially posteriorly, there
are numerous areas of consolidation similar in appearance to those on
the right and associated with the bronchial
branches. The lower lobe on section presents a striking picture. The
consolidation involves the greater portion of the
lobe. There are softened areas in the consolidated regions in many
places. There is a dull-grayish appearance in the
cavities and neighboring edematous lung. The odor is characteristically
gastric. In the relatively uninvolved portions
of the lobe there is considerable edema. In places, this has a
yellowish tinge, suggesting much fat. The picture in this
lobe is that of extensive peribronchial and lobular consolidation, with
multiple areas of softening and abscess for-
mation and considerable edema. Organs of neck-Larynx: Shows
prominent streaky gray thickening of the mucosa.
Trachea: Shows similar gray streaking and uniform thickening of
the mucosa, also considerable old diffuse
hemorrhage. Tonsils: Slightly
enlarged and on the right there is a
large crypt containing milky fluid. Heart:
Normal,
except for brown atrophy. Gastrointestinal tract: No
significant changes. Remaining viscera show no lesions of
interest.
Microscopic examination- Trachea:
The lining is constituted by a rather dense granulation tissue which
is
devoid of epithelial covering, save for a few small islands of layered,
nonciliated cells. There is a fairly profuse
inflammatory infiltration; many of the cells show distorted nuclei and
are difficult to identify. The mucous glands
are atrophic, the few remaining acini being surrounded by dense
accumulations of lymphoid and plasma cells. Some
of the glandular cells show an interesting metaplasia into solid nests
of squamous cells, like islands of carcinoma
cells. The adjacent lymph nodes show areas of fibrosis. There is much
scar tissue about the cartilage. Large
bronchus: The epithelial lining is desquamated, save for a
single row of adherent cells. In a few places, where the
cells are still attached, they are seen to be arranged in an orderly
way and to be distinctly ciliated. The submucous
tissue has the character of a loose granulation tissue with many wide,
thin-walled, blood vessels. There is dense
cellular infiltration, composed largely of plasma cells. The mucous
glands are atrophic and surrounded by fibrous
tissue and inflammatory cells. The lumen of the bronchus contains
bacteria and leucocytes, with exfoliated
epithelial cells. Lungs: (a) The bronchi are represented by
abscesslike masses of pus and bacteria, surrounded by
granulation tissue which is very vascular and thickly infiltrated with
lymphoid and plasma cells. Very few of these
suppurative bronchi show remains of an epithelial lining, but in a few
of them shreds of adherent, flattened,
regenerating cells serve to identify these structures as dilated and
infected bronchi. The dilatation is proven by
compression of the adjoining alveolar spaces. The parenchyma is almost
uniformly consolidated, but the alveolar
contents vary. Many of the alveoli are filled with a homogeneous,
granular or fibrinous coagulum; others contain in
addition large, rounded, foamy, and apparently fat or lipoid containing
epithelial cells. In some areas, especially
about the bronchiolar abscesses, the alveolar exudate is undergoing
organization; pale spindle cells invade the
coagulum. The septa are cellular and thickened; there is an increased
number of nuclei belonging chiefly to
lymphoid cells. The alveolar capillaries are not congested. The
alveolar epithelium in many places is actively
regenerating, as shown by the deep staining and cylindrical shape of
the cells. The pleura is smooth; the subpleural
capillaries are wide and congested. The lymphatics also are dilated and
filled with homogeneous coagulum. (b) In
general, a similar picture. One bronchus shows exquisite epithelial
metaplasia. It is surrounded by a thick wall of
vascular, in places, hemorrhagic granulation tissue, and there is
active organization of the exudate in the neighboring
alveoli.
236
(c) The section
shows the same lesions as described above, but confined to the bronchi
and
peribronchial tissue. There is no generalized edema as in block (a).
The dilatation of the pus-filled bronchi is very distinct. (d) There is
a suppurative and necrotizing bronchitis, and an
organizing peribronchial exudate as described in (a) and (b). In
another portion of the slide the
bronchioles are lined with intact ciliated epithelium, but there are
local thickenings composed of
vascular granulation tissue. There is also marked perivascular
fibrosis. (e) The section shows an
additional feature of interest, namely, several areas of gangrene, in
which there is complete loss
of nuclear staining, and all structures are involved. Another striking
feature is an area in which
the alveolar walls are greatly thickened by the accumulation of
numberless lymphoid and plasma
cells in the spaces between the alveolar epithelium and the e apillarv
wall. In some there is
extensive organizing pneumonia, the plugs being well vascularized. Skin:
Two blocks, showing a
thin epidermis composed of only two or three rows of cells, covered by
a relatively thick loose
keratin layer. The basal row of cells shows an excessive melanin
production. There are many
chromatophores in the superficial corium, and some granules of extracellular
pigment. The
subepithelial portion of the corium shows a hyaline edema. There is no
inflammation. The
capillaries are collapsed and empty. The sweat glands and hair
follicles show no lesions.
NOTE.-The
case illustrates admirably the late effects of severe mustard-gas
lesions of
the respiratory tract. The injury was quite certainly incurred n on
August 7 or 8, so that the
duration of life after gassing may be taken as 53 days. While the
records of the Chemical
Warfare Service show that the organization to which A. K. belonged was
exposed to
indiscriminate shelling on those days with yellow, blue, and green
cross shells, it is probable that
mustard gas was the principal agent concerned.
The
skin lesions illustrate the persistent pigmentation. The lesions of the
trachea were
evidently very severe, the destruction even involving some of the
mucous glands. There was
little epithelial regeneration: what epitheliurn there was showed the
customary metaplasia. There
was a widespread suppurative and necrotizing bronchitis, which led to
marked cicatricial
thickening of the bronchi. In places there were abscesslike
bronchiectases. The parenchyma
about the bronchi showed an organizing pneumonia. but in some blocks
there was an interesting
chronic edema, with epithelial exfoliation and proliferation, and
interstitial changes--lymphoid
and plasma cell accumulation-in the alveolar septa. The picture in
these regions resembles in
many respects the pneumonia alba of congenital syphilis. Worth noting
are the areas of
gangrene.
CASE
103.- A. M., 2187370, Pvt., Co. F, 340th Inf. Died, on December 20,
1918, at 1.20
p. m., at Base Hospital No. 87. Autopsy No. 47, performed one and
one-half hours after death,
by Lieut. H. H. Robinson, M. C.
Clinical data.- October 23, gassed with mustard
gas. No
further details recorded. October
25, admitted to Base Hospital No. 87. On November 7, two weeks after
gassing (?),developed
bronchopneumonia, vhich never entirely cleared up. Illness marked by
profuse mucopurumlent
expectoration. Died in collapse on December 20, a few minutes after
aspiration of the chest.
Summary
of gross lesions.- There is brown pigmentation of skin of knees and
thighs and
of scrotum. Both pleural cavities show firm adhesions. The lungs are
voluminous and pink. Scattered through all lobes are numerous areas of
grayish consolidation. In the left lung, in both
lobes, there are numerous smooth cavities, varying from a pea to a
walnut in size. Circulatory
organs: Normal.
Additional
note, dictated from preserved Army Medical Museum specimen of left
lung:
"Upper lobe:
The pleura over a localized area in lower portion of the lobe is
thickened
with organizing fibrinous exudate; elsewhere smooth. Over the lower
lobe there are a few
delieate fibrous tabs. On section, the lung is generally dry and
air-containing. About the bronchi
and vessels, however, there are firm, yellowish-white zones of
consolidation, becoming
237
more translucent
at the periphery. About these again, there are irregular patches darker
in color,
which appear to be areas of organizing pneumonia. Beneath the thickened
pleural patch in the
upper lobe there is a group of large bronchiectasis with smooth walls.
These are surrounded by
opaque, grayish-yellow patches. The larger bronchi are lined with
smooth, pale mucosa which in
places has a scarred appearance."
Microscopic
examination- Lung: A block taken through wall of the bronchiectasis
shows that the cavity is bounded by granulation tissue, remarkable
because of the great number
of large foamy (lipoid containing?) cells included in it. Adherent or
lying loosely upon the
surface of the granulation tissue are many large multinucleated giant
cells. Whether these have
arisen from remains of the epithelium or are of the nature of foreign
body giant
FIG. 38.- Case
103. Mustard-gas burn, 58 days' duration. Lung.
Low-power drawing through
bronchiectatic cavity. Peribronchial and periarterial fibrosis.
cells can not he
made out. The lung tissue about the cavities is collapsed and shows the
usual
interstitial fibrosis, with occasional alveoli lined by cylindrical
cells. (Fig. 38.) There is much
epithelial desquaination, and fibrous thickening of the septa in the
better aerated regions. Some
of the air spaces contain organized vascular plugs. Another section was
taken through a patch of
organizing pneumonia. There is histologically an exquisite interstitial
and organizing process.
(See fig. 21.) Especially interesting are the changes in the apparently
regenerated epithelium. The band of hyaline necrosis, so frequently
found lining ductus alveolares and alveoli in the
acute cases, as well as in the primary influezal pneumounias, is still
very distinctly to be
recognized; it is, however condensed hyaline, and stains very intensely
with eosin. In many
places it is being invaded and replaced with connective tissue, the
nuclei of the cells tending to
range themselves parallel to the wall of the
238
air space. The
bronchioli in this section are for the most part lined with ciliated
epithelium, but
this is thrown up into corrugated folds, and many of the small bronchi
are collapsed, and their
lumen reduced to a narrow cleft. Acute inflammatory changes are still
present in places.
NOTE.- A
case of mustard-gas poisoning in which death occurred on the 58th day
after
exposure. The interpretation of the case is complicated by the fact
that pneumonia, according to
the brief clinical note, did not develop until two weeks after the
gassing; there is no reference to
previous respiratory symptoms. It is conceivable, therefore, that the
interesting residual lesions
in the lungs-interstitial and organizing peribronchial pneumonia,
bronchiectasis, etc.--may have
resulted from a primary influenzal pneumonia rather than from the
direct gas injury. It is
unfortunate that there is neither a description of nor material from
the trachea available.
CASE
104.- M. L. A., Number-, Pvt., Co. L, 101st Inf. Died, June 11, 1918,
at
11.15 p.
m., at Base Hospital No. 18. Autopsy, 10 hours after death, by Lieut.
B. S. Kline, M. C.
Clinical
data.-March 31, gassed with phosgene at 2 a. m. Following this,
shortness of
breath and headache with vomiting. June 2, admitted to Base Hospital
No. 18. Patient conscious,
but stuporous and cyanotic. June 3, oxygen therapy begun and he was
bled 325 c. c. The heart
sounds at this time were clear and regular; tubular breathing was
present over a small area at the
left base. On June 4 and 5, his general condition seemed to improve. On
the 6th, however,
diffuse areas of consolidation were made out over the left lower chest.
He also developed
diarrhea on this day. June 8, patient was definitely weaker and very
dull. Pulse full and fast. June
10, Cheyne-Stokes respiration, with long pauses. Pulse irregular and
weaker. June 11, small area
of consolidation in the right lung. Patient very restless, rapidly
became weaker. Venesection, 600
c. c. Died at 11.15 p. m. Temperature, from admission on June 2 to his
death, was never below
100.2 °. Maximum, 104.8 °, on afternoon of June
4. Pulse, 100 to 128. Respirations, 28 to 44.
Anatomical
diagnosis.- Acute pharyngitis, esophagitis, laryngitis, and
bronchitis,
following phosgene (?) inhalation; extensive bronchopneumonia,
involving all lobes; acute
lymphadenitis of regional lymph nodes; acute colitis; pulmonary edema,
terminal; cardiac
dilatation, more marked on the right side.
External
appearance.-No cutaneous lesions. Skin has a muddy color, but there
is no
pigmentation recorded. Conjunctiv ae and other mucous membranes pale.
Slight clubbing of
fingers and toes.
Gross
findings.- Pleural cavities: Fibrous adhesions are found over the
lateral and pos-
terior surfaces of all lobes, especially the middle and lower on the
right side. In the left pleural
cavity are a few cubic centimeters of clear fluid, and a few adhesions
binding the under surface
of the lobe to the diaphragm. Right lung: Weighs 840 grams.
Left lung, 1,020 grams. All lobes
are voluminous, cushiony, soggy, and solid. The pleura is thickened in
the regions showing the
fibrous adhesions mentioned above; elsewhere it is thin and delicate.
The glands at the hilum
considerably enlarged, pulpy, edematous and injected. The bronchi show
marked diffuse
injection, with suggestion of ulceration of the epithelium. In the
lumina there is blood-tinged thin
viscid fluid. On section of all lobes a dull gray red surface presents
mottled with pinhead to
grape-seed sized dull reddish-yellow areas. The surface is moist, and
on pressure, a considerable
amount of thin blood-tinged fluid exudes. When this is wiped off on the
knife, a considerable
portion of each lobe shows a dull, slightly granular, reddish-gray
consolidation, which at first
suggests a lobar type, but on close inspection, relatively few alveoli
here and there are found to
be involved. Although the tissue floats in water, the pseudo-lobar
consolidation is very extensive
and the tissue is friable. In the finer bronchioles, the exudate is
perhaps slightly more viscid than
in the larger branches. The two types of consolidation are more marked
on the left side, and
particularly in the left lower lobe. where some of the smaller areas
are firm and look quite like
miliary tubercles. In the other lobes, some of the smaller solid areas
have a similar appearance.
There is little hemorrhage anywhere. The blood vessels contain large
currant-jelly clots. Organs
of neck: Larynx and trachea show moderate diffuse injection of the
muscosa, with adherent
fibrino- purtilent exudate here and there in small amount, especially
in the region of the true
vocal
239
cords. The
process continues over the brim and involves the upper portion of the
esophagus,
pharynx, and base of the tongue. The trachael and cervical lymph nodes
are moderately to
considerably enlarged, injected, pulpy. Tonsils: Small and
scarred. Heart: Weighs 360 grams;
right auricle and ventricle moderately dilated and the tricuspid and
pulmonary rings considerably
stretched. Myocardium of left ventricle pale, moist, and greasy. Gastrointestinal
tract: Stomach
normal. In the cecum there is patchy injection of mucosa, and in the
transverse and descending
colon there is, in addition to the injection, a small amount of
adherent exudate on the surface of
the mucosa. The mesenteric glands are slightly enlarged, soft, and
pale. Remaining viscera show
no significant changes.
Microscopic
examination: Pharynx or upper esophagus: The mucosa is continuous
except
over a small area where there is superficial ulceration, with a little
adherent exudate and
localized edema and inflammatory infiltration. Trachea: No
section. Lung: (a) Bronchi are lined
with multiple layers of epithelial cells, the superficial layer of
which is composed of flattened
nonciliated cells. The mucosa is thrown into rugae , there being a
granular coagulum beneath
it. The lumen contains blood and granular material, with very few
leucocytes. Throughout the
parenchyma the alveoli are filled with red blood cells, granular
coagulum, and only here and
there are there denser collections of leucocytes, polymorphonuclears,
and mononuclears. In
some air spaces are numerous foamy exfoliated epithelial cells. The
most striking feature is the
almost universal regeneration of alveolar epitholium; in places the
proliferating cells form solid
nests or sprouts almost completely filling the air spaces. Individual
hypertrophic cells are found,
and mitoses are fairly numerous. The septa are edematous, contain more
than the normal number
of leucocytes, chiefly large and small mononuclears. There are stout
fibrin threads in the
capillaries. A small artery in the section contains a well-formed
recent thrombus. (b) There is a
somewhat more acute process, with purulent bronchiolitis and
inflammation of the ductus
alveolares, and hemorrhagic edema in the surrounding lung. Epithelial
regeneration is less
marked than in the previously described section. (c) In addition to the
features above described,
there is a striking hyaline necrosis of the alveolar walls. Where the
epithelium is being
regenerated, it is often separated from the alveolar capillary by
edematous tissue in which are
proliferating fibroblasts and large and small mononuclear cells. No
bacteria are found in Gram-stained sections. Liver, spleen,
myocardium, adrenals, and kidneys show no lesions of special
interest.
Bacteriological
examination.- Smears made of the exudate from the larynx show
numerous lanceolate diplococci, Gram-positive; also numerous biscuit
and rounded cocci in groups.
Gram-positive and a moderate number of intracellular and extracellular
Gram-negative bacilli of
small size. Smear from the bronchus shows moderate numbers of
intracellular Gram-positive and
negative cocci and diplococci, and groups of small Gram-negative
bacilli. Smear from a small
consolidated area shows numerous intracellular Gram-negative baccilli.
Smear from the large
consolidated area shows a small number of Gram-positive diplococci and
a few groups of Gram-negative small bacilli. Cultures from the larynx
shows innumerable staphylococci. Cultures from
bronchus: Staphylococci and Gram-negative bacilli, tiny and of good
size. Culture from small
consolidated area shows predominating organism a staphylococcus. From
the large consolidated
area, minute Gram-negative bacilli and a few staphylococcus colonies.
NOTE.-
Aside
from the superficial erosions of the pharynx and larynx, there is
nothing to
suggest that the lesions are due to the toxic effect of gas, either
mustard or, still less, to a
suffocative gas such as phosgene. The history does not state whether
symptoms persisted after
gassing until admission to Base Hospital No. 18, two months later, nor
are additional data as to
the character of the gas available. The pulmonary lesions are those of
influenzal pneumonia as
seen in the fall and winter pandemic, and would coincide with an onset
about June 2. Whether a
previous gassing determined the severity of the pulmonary lesions at a
time when the prevailing
type of the disease was mild and rarely followed by pneumonia, remains
uncertain.
CASE
105.- W. K., 2566932, Corpl., Co. A, 107th Engineers. Died, October 21,
1918, at
3 a. m., at A. R. C. M. Hospital No. 5. Autopsy No. 92, performed six
hours after death, by
Lieut. H. W. Hundling, M. C.
240
Clinical
data.- On August 5, patient was exposed to shelling with yellow,
blue, and green
cross shells, while his detachment was advancing through valleys in
rolling country (sector of
64th Brigade). On August 12, there was bleeding from the nose and
lungs. September 15,
admitted to A. R. C. M. H. No. 5. September 19, pulse bad. Chest full
of râles; profuse
expectoration; sputum negative for tubercle bacilli; streptococci and
pneumococci in cultures.
Daily temperature of 101°, respirations 24, pulse 104. Marked
emaciation.
Summary
of gross lesions.- No external lesions. Marked emaciation. Pleural
cavities show
friable adhesions. Lungs firm posteriorly, crepitant anteriorly. Cut
surface moist; scattered
through all lobes are areas of peribronchial thickening, coalescing to
form broad areas of
consolidation. Circulatory organs normal. Organs of neck. (Note
dictated from preserved Army
Medical Museum specimen). The specimen consists of tongue, trachea, and
larynx preserved in
formalin. The tongue and pharynx show no changes. The inferior surface
of the epiglottis shows
a large depressed brown patch, which is present also along the tracheal
surface of the cords. It is
not clear whether this may not be an artefact due to drying. The upper
part of the larynx shows a
thin, smooth lining, with irregular pearly scarred areas. Further down,
the tracheal wall becomes
rough, sandy and congested, and covered here and there with little
flakes of necrotic exudate.
Along the right border, about 2 cm. above the bifurcation, are two
punched-out ulcers which
extend through the eroded cartilages. They are from 2 to 3 mm. in
diameter.
Microscopic
examination.- Blocks were taken from preserved Army Medical Museum
specimen. Epiglottis: The cartilage is covered on both sides by
dense layered squamous
epithelium, like that of the pharynx or esophagus. There is no
pigmentation, and the brown color
noted in the specimen was probably due to drying. The subepithelial
tissue contains dense
collections of lymphoid cells, but there are no other evidences of
inflammation. The glands are
normal. Trachea: Section taken at level of thyroid. Here too
the epithelium is squamous and
devoid of cilia. It is quite thin, consisting of only three or four
rows of cells. There is no
keratinization of the superficial cells. The subepithelial tissue is
very dense and scarlike, and
contains few blood vessels. Some of the glands are normal, others are
atrophic, still others are
distended with secretion. The glands are entirely missing over large
areas. Section taken through
small ulcers shows the following: At the margin, the epithelium is
thickened and squamous. The
ulcer is quite sharply defined, and extends clown to the cartilage, and
even undermines it. The
base is composed of dense scar tissue infiltrated with lymphoid cells. Large
bronchus:
Completely filled with a fibrinopuruilent plug. The lining consists of
loose granulation tissue.
There is much edema, hemorrhage, and inflammatory infiltration of the
bronchial wall.
Bacteriological
examination.- B. influenzal
in culture from lung after death.
NOTE.-
After
77 days, marked changes were found in the trachea. The epithelium was
converted permanently into a dense stratified layer composed
exclusively of squamous cells,
watch, however, had not become keratinized. The subepithelial tissue
was dense and scarred, the
mucous glands atrophic or wholly lost, and the smooth muscle fibers had
disappeared. There
were also several deep localized ulcers in the lower portion of the
trachea. In the large bronchus
taken for examination, there was no regeneration of the epithelium, and
the lining granulation
tissue lay exposed.
It is probable that these lesions of the upper
respiratory tract
are the late results of
exposure to mustard gas. although there is no reference to cutaneous
burns in the history, and the
records of the Chemical Warfare Service show that the patient had been
subjected to shelling
with mixed types of gas.
CASE
106.-C. M., No.-, organization (?), rank (?). Died, December 8, 1918,
at U. S. A.
General Hospital No. 19, Oteen, N. C. Autopsy by (?).
Clinical
data.-The following is a verbatim transcript of the
history which
accompanied
the preserved museum specimen. No further information in regard to the
case is available.
"Enlisted September 10, 1917. June 20, 1918, to trenches. June 24, hit
with mustard gas and
blinded for four days. He had black spots all over and
could not see
well for six weeks. Throat
quite sore. Has been in hospital ever since. Pleurisy August 15.
241
Walked
into U. S. A. General Hospital No. 19, Oteen, N. C. with slight cough
and expectoration, dyspnea, and occasional pains in left lumbar region.
Looked well. Right side, dullness
above third rib, and practically throughout posteriorly. Moist r ales
from fifth rib and sixth dorsal
spine down. Left side, markedly diminished expansion; dullness above
fourth rib from eighth
dorsal spine up. Moist subcrepitant râles ninth to fourth dorsal
spine. Slight pretibial edema.
Cardiac fibrillation and pulse deficit. Fluoroscopy, apices cloudy and
do not clear on coughing.
Right hilus shows very dense shadow to diaphragm. Tuberculosis,
pulmonary, chronic, oldest
and most extensive in upper left lobe. Abnormal densities at both
bases.
"Autopsy.-Fairly
well nourished. Pink adhesions which completely obliterate right
pleural
cavity. Dilatation of right heart, slight. Liver, hypertrophied, 12 cm.
below costal margin in
midline. Pleural adhesions on left at base and posteriorly. Greenish
pus in trachea. No gross
changes in kidneys. In small bowel are a number of dark areas several
feet in length, and slight
ulcerations are noticed in several parts, In the neighborhood of the
cecum these areas are more
marked. Appendix slightly inflamed. Urinary bladder, slightly ulcerated
on the superior surface."
The
following additional note was dictated upon receipt of the Army Medical
Museum
specimen:
The
specimen consists of formalin fixed slabs of the right lung passing
through the three
lobes. The pleura is covered with tabs of fibrous adhesions. The upper
lobe, in its posterior two-thirds, is of translucent texture, very
slightly air-containing; only here and there a few well-aerated
patches. Near the hilum there is a cross section of a bronchus 3 mm. in
diameter,
completely filled with a fibrinous plug. This is surrounded by opaque
creamy white airless tissue
from which radiate fibrous strands to join the small interlobular
septa. The section passes also
through a number of smaller bronchi plugged with exudate, and with
thickened walls composed
of dense opaque white tissue. Lower lobe: A large portion
consists of very firm white or
yellowish-white opaque tissue, absolutely airless, in which bronchi and
blood vessels seem to be
largely obliterated. Between these patches, the architecture of the
lung is still recognizable, but
the alveolar walls are thick and the air content much diminished. The
smaller and larger bronchi
are extremely thick-walled. The lumina are narrowed and their mucosa
appears rough and
eroded. Near the posterior border, there is an irregular, but
smooth-walled cavity, the lining of
which is blood stained. The communication of this with a bronchus can
not be demonstrated
because of the thinness of the specimen. The middle lobe shows only
moderate bronchial
thickening and is air-containing. A group of lymph glands at the hilum
appears to be completely
caseated, although they are firmer than ordinary tuberculous glands. In
no portion of the lung are
there seen definite tubercles, although the gross resemblance of
certain areas to diffuse
tuberculous caseation is very close. (Fig. 39.)
Microscopic
examination.-Lung: (a) The block is taken through the area
of gelatinous
edema at the base of the upper lobe, and includes the edematous
interlobar septum. (Fig. 40.)
The alveoli are wide and almost without exception, distended with a
homogeneous coagulum, in
which are scattered large rounded alveolar cells containing black
pigment. The alveolar septa are
compressed and there is very little blood in the capillaries. Such
attached alveolar cells as can be
recognized seem hydropic and project into the alveolus. There are many
cells with pale distorted
nuclei, probably fibroblasts. The section includes two small bronchi.
The larger of these has an
irregular slit-like lumen like that of an intracanalicular fibroma,
which is filled with pus. The
epithelium is beautifully ciliated, showing no metaplasia. The wall is
tremendously thickened by
a rather dense and not very vascular granulation tissue in which are
numerous lymphoid and
plasma cells. These cellular infiltrations extend into the adjacent
alveolar septa. The interlobar
septum is edematous forming a broad pink-staining band. Under the high
power, a delicate
thready reticulum can be distinguished. From the margin, there is an
ingrowth of delicate blood
vessels with pale swollen endothelium. Scattered through the edematous
zone, there are groups
or little colonies of large rounded cells with very pale nuclei, which
are identical with the proliferating pleural mesothelium, and are
probably derived from it, having migrated into the
plasma clot after the fashion of a tissue culture. Here and there these
cells are multinucleated.
There are also scattered small lymphoid cells, but very few fibroblasts
and it
242
FIG. 39.-
Case
106. Mustard-gas burn, 5½ months' duration. Lung, showing marked
peribronchial and perivascular fibrosis, interstitial fibrosis,
organizing pneumonia Chronic edema. bronchiectasis
243
can not be said
that the edematous tissue is becoming organized. (b) The block is taken
from the
anterior and lower portion of the upper lobe, passing through the
bronchus described in the
gross. (Fig. 41.) The exudate which fills the lumen with a complete
plug is composed chiefly of
polymorphonuclears, well preserved at the periphery, fragmented at the
center. The bronchus is
lined by a very thick wall of granulation tissue, the epithelium having
been quite destroyed. This
granulation tissue is remarkable because of the very dense plasma cell
infiltration. In many
fields, the plasma cells completely fill the interstices
FIG. 40.-
Case 106.
Lung. Section (a) Edema of alveoli and interlobular septum
between the
sprouting capillaries. Further out, the granulation takes on rather the
character of
scar tissue, and extends in the form of radiating strands into the
neighboring parenchyma. Here
the alveoli are widely separated, and their lumina irregularly
distorted. They are lined with
columnar epithelium, and contain exfoliated cells. Often the wall of
the alveolus is thrown up in
papillary folds. Although the bronchus is fully 5 or 6 mm. in diameter,
there are no remains of
cartilage, muscular wall or mucous glands, all of these structures
having apparently been
replaced by granulation and scar tissue. Between the fibrous
244
strands radiating
from the bronchus, the alveoli are very large, and filled with
edematous
coagulum and exfoliated epithelial cells. The septa are infiltrated
with lymphoid and plasma
cells. Smaller bronchi in the section are lined with intact epithelium,
but they appear collapsed
into irregular slits. The small pulmonary arteries are surrounded by
broad bands of scar tissue,
from which, also, strands extend into the neighboring parenchyma. (c)
The block is taken from
the opaque whitish tissue in the anterior portion of the lower lobe,
which grossly resembled
tuberculous caseation. Microscopically, the tissue proves to be a
rather avascular granulation
tissue which, over large areas, has completely obliterated the normal
lung structure. There is a
remarkably dense plasma cell infiltration, these comprising practically
the only type of
wandering cell in many fields. In areas where the alveolar
FIG.
41.- Case
106. Lung. Section (b) through cavity in the upper lobe
structure is
still discernible, the septa are thickened and infiltrated. As in the
other section, the
arteries are surrounded by broad bands of connective tissue, and there
is marked interlobular
fibrosis. (Fig. 42.) (d) Block taken through a group of greatly
thickened bronchi, surrounded by
scar tissue, near the hilum of the lower lobe. The lumina are narrowed
and their wall thrown up
into corrugations. The epithelium is high, stratified and beautifully
ciliated, showing no
squamous cell metaplasia. The walls of the bronchi are enormously
thickened by dense scar
tissue, thickly infiltrated with plasma cells. (Fig. 43.) The mucous
glands are preserved, and are
in hypersecretion. The cartilages likewise are still present and show
no degeneration. The
surrounding pulmonary tissue shows the same changes
245
that have been
described in previous section. A large branch of a pulmonary artery
presents
interesting lesions. There is marked intimal thickening by a loose
edematous (fatty?) fibrous
tissue, with corresponding thinning of the muscular coats. The
adventitia of this and of all the
smaller arterial branches is tremendously thickened. (e) Block taken
through the wall of the
supposed bronchiectatic cavity in the posterior portion of the lower
lobe. Microscopically, there
is no certain evidence that this cavity is a bronchiectasis, since
there are no remains of the
normal bronchial structures. The wall is formed simply by the
irregularly thickened septa of the
adjacent lung tissue, the rounded walls projecting freely into the
cavity, which therefore has
neither a continuous epithelial lining, nor one composed of
FIG. 42.-
Case
106. Lung. Section (c) taken from opaque whitish tissue in anterior
portion of
lower lobe. Lung structure over large areas obliterated by
poorly
vascularized granulation tissue,
tensely infiltrated with plasma cells
granulation
tissue. The cavity appears to he simply a defect in the lung substance,
in all area
which shows an extreme interstitial fibrosis of the type described. The
exact way in which this
cavity has been formed is not clear. In only one portion is there a
definite lining of granulation
tissue with tangential compression of the neighboring alveoli. (f) A
section taken from the upper
lobe, in an area of relatively normal lung tissue, ill which, however,
there were a few thickened
bronchi and blood vessels. Microscopically, the lesions resemble those
in block (a), save that
there is less alveolar edema. The only new feature is a rather marked
emphysema. Worth noting
also are the lymphoid follicles with definite germinal centers, which
are seen in the scar tissue
about the bronchi. Primary bronchus: The
246
epithelial lining
is intact over most of the circumference, and is composed of several
layers of
cells, the superficial row normally ciliated. The section, however,
passes through a small patch
of squamous epithelium, continuous on either side with the ciliated
epithelium, but somewhat
thicker. In this area there are numerous mitotic figures. There is
persistent metaplasia in some of
the ducts of the mucous glands, while others are invested with normal
cylindrical epithelium.
The submucosa is thick and dense, and filled with lymphoid and plasma
cells in great numbers.
The acute inflammatory process has disappeared, and
polymorphonuclears are found only on the
surface, or between epithelial cells. The mucous glands are in active
secretion, and in no wise
abnormal. The cartilages also are unchanged.
FIG. 43.- Case
106. Lung. Section (d), through thickened bronchi at
hilum of lower lobe
The adjoining
lung tissue appears compressed. Secondary bronchus: In places
denuded of
epithelium, the wall being formed by a dense cellular and not very
vascular granulation tissue.
Where epithelium is present, it is for the most part quite normal in
structure, the cilia being very
distinct. Here and there, and especially about the openings of the
mucous ducts, the epithelial
cells are heaped up irregularly and the superficial cells are not
differentiated. That the denuded
areas are really ulcerated, and not merely exposed by the post- mortal
exfoliation of cells, is
indicated by dense plasma cell infiltration. Bronchial lymph node:
The changes are surprisingly
slight, although the gland as a whole appears hyper- plastic, and is
strikingly free from pigment.
There is much periglandular fibrosis, and a branch of the pulmonary
artery included in the
section shows a marked intimal fibrosis.
247
NOTE.- The
case is one of particular interest. Death occurred 167 days, or
approximately
five and one-half months, after gassing with mustard-gas. The
respiratory lesions found at
autopsy maybe regarded without qualification as the late results of
this injury. Clinically, the
patient presented pulmonary symptoms and physical signs closely
simulating those of chronic
pulmonary tuberculosis, and this diagnosis was made during life on the
basis of the fluoroscopic
findings, although there is no record of tubercle bacilli having been
found in the sputum
CASE
107.- F. S., Pvt., Co. A., 126th M. G. Bat. Died, May 16, 1919, at base
hospital,
Camp Lee, Va. Autopsy No. 49, eight hours after death, by Lieut.
Charles H. Manlove, M. C.
Clinical
data.- Patient was gassed October 14, 1918, on the Toul sector,
with
mustard gas.
He was not burned much on the skin, but was rendered unconscious for a
short time. Taken to
the field hospital and from there transferred to Base Hospital No. 45,
then to Base No. 210, and
then to Base No. 87. Later sent to Camp Lee, where he arrived about
April 6, 1919. At the time
of the gas attack, the gas mask was rendered useless as the can was
broken from the contact. As
gas entered the mask, he began to vomit and then the mask came off
entirely, and he inhaled the
pure gas. The patient was very much emaciated, cyanotic, and markedly
dyspneic. His breathing
was better at night, allowing him to sleep very well. He coughed
continuously and expectorated
considerably. Had sense of constriction in the larynx. Physical
examination of the chest showed
harsh breath sounds, showers of moist râles, vocal fremitus decreased
over left base. Heart rate
was regular.
Anatomical
diagnosis.- Stricture of trachea, following gas injury.
Tracheotomy.
Chronic
tracheitis. Subcutaneous emphysema. Chronic bronchitis. Passive
congestion of viscera
External
appearance.- Well developed, poorly nourished. No ocular or
cutaneous lesions.
Subcutaneous tissue of the entire neck and upper third of sternum are
emphysematous. In the
midline of the neck, over the thyroid there is a recent operative
wound, measuring about 3.5 cm.
in length, with a central opening, which extends into the trachea, from
which a mucopurulent
material exudes.
Gross
findings.- Trachea: Vocal cords and mucous membrane above the
trachea normal. Mucous membrane just below the vocal cords show marked
thickening, which extends to the bifurcation of the trachea, the lumen
throughout being markedly diminished in diameter. This is
especially evident over an area of 3 to 4 cm. in length, beginning
about 3 cm. below the
stricture. Mucous membranes of trachea and bronchi are reddened and
coated with a thick
mucopurulent material. Lungs: Are rather large, and crepitate
throughout, and crackling is
present in some places. The pleura covering the lungs is spotted with
black pigment over its
entire surface, giving the surface a blackish gray appearance. After
preservation in Kaiserling,
section shows lung tissue to have been air containing throughout.
Bronchi contain plugs of
mucopurulent material. Apices appear slightly more compact than the
remaining portion of
lungs. Heart and the
remaining viscera are normal. (Fig. 44.)
Microscopic
examination.- Block 1. Trachea: The section is taken
longitudinally through the scarred stenotic tissue below the thyroid.
There is a thin layer of stratified nonciliated epithelium in places,
but the greater part of the submucosa lies exposed. It is converted
into dense scar tissue, 2 to 3 mm. in width. In the depths are groups
of mucous glands and ducts,
some dilated, other atrophic, and surrounded by lymphoid and plasma
cells. There is
intracellular hemosiderin in the more superficial portion
of the tissue. The cartilages are intact.
Secondary bronchus: Block 2.
The epithelium is partially exfoliated,
but normally ciliated, where
still preserved. There is congestion of the bronchial wall, but little
or no inflammatory change or
scarring. The mucous glands are numerous and in active secretion. Lung:
Block 3. Some of the
alveoli are collapsed, others filled with edema fluid, still others
emphysematous. There is
excessive deposit of anthracotic pigment with small areas of fibrosis
where the pigment is most
abundant. The septa are a little thickened, and there is definite
fibrosis of the perivascular
connective tissue and of the interlobular septa. The small bronchioles
are filled with columnar
ciliated epithelium and contain no exudate. Many are corrugated and
appear contracted or
collapsed, others are slightly dilated. Block 4. Emphysema and
anthracosis. Block 5. Somewhat
more congested. No other significant changes.
Bacteriological
examination.- Cultures from bronchial contents show staphylococcus.
NOTE.- Death
six months after exposure to concentrated mustard-gas. This resulted in
little permanent damage to the lower respiratory passages,
248
FIG. 44.- Case 107. Late stricture of trachea showing mustard-gas
inhalation
249
but produced a marked
cicatricial stenosis of the trachea requiring tracheotomy. Epithelium
still
present in these scarred areas is of the squamous nonciliated type.
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(2) Report: Fifty
Necropsies of Phosgene Cases, by Maj. R. H. Wilder, M. C. On file,
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(3) Ricker, G.:
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(6) Pappenheimer, A. M., and Vance, M.: The Effects of Intravenous
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(7) Lynch, V.,
Smith, H. W., and Marshall, E. K.: On Dichlorethylsulphide (Mustard
Gas). The Systemic Effects and Mechanism of Action. Journal of
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(8) Le Count, E.
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(9) Lynch, V.,
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