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Microscopic examination.- Trachea: It the trachea is deep-seated necrosis, which involves the epithelium and underlying tissue to a considerable depth. Incorporated in this necrotic area is a dense fibrinous membrane infiltrated with many pycnotic leucocytes, and in a few places there are clefts which separate the membrane of dead tissue from the underlying living tissue, and these are lined with flattened cells, possibly derived from the remains of the epithelium. There is extreme distension of all the blood vessels which form wide sinuses almost like a cavernous angioma. The mucous glands are compressed and distorted. (See fig. 13.) Lungs: The picture is unusual. There is an extensive hemorrhagic and fibrinopurulent exudate in the alveoli, the arteries of which are rendered indistinct by the fragmentation of the nuclei and the abundance of chromatin debris in the septa. (See fig. 23.) The elastic framework is torn and disrupted, as can be seen in appropriately stained sections. There is great edema of the interstitial tissue and the interlobular septa. There are masses of Gram-positive bacteria scattered through the section.
NOTE.- Case of mustard-gas poisoning of five days' duration. There was the usual diphtheritic necrosis of the upper respiratory passages. Pneumonic lesions of the hemorrhagic "influenzal" type, with infarct-like areas of necrosis.
CASE 23.- J. B., 2810342, Pvt., Co. C, 344th M. G. Bn. Died at 6 p. m., October 7, 1918, Justice Hospital Group, Toul. Autopsy No. A9. Autopsy performed, 19 hours after death, by Capt. Jean Oliver, M. C. Clinical data.-Severe mustard-gas intoxication, incurred October 2, 1918.
Anatomical diagnosis.- Pigmentation of skin of face; suppurative and hemorrhagic tracheobronchitis; congestion and edema of lungs; interstitial emphysema.
External appearance.- The skin over face is brown. The epithelium is excoriated in small areas and can be rubbed off on pressure. No typical mustard-gas burns. Skin of scrotum shows similar changes. No other cutaneous lesions.
Grossfindings.- On removing sternum there is found interstitial emphysema which extends over upper portion of pharynx and lower portion of neck. Marked hyperemia and edema of all lobes of both lungs posteriorly. Anteriorly, lungs are emphysematous. Larynx, trachea, and primary bronchi contain purulent exudate. Mucosa is slightly roughened, but there is no definite false membrane. There are many small hemorrhages. There is a necrosis of the mucosa of certain bronchi, only in the upper lobes of both lungs. Some of them are lined with a definite grayish-green membrane. There is little fibrinous pleural exudate.
Microscopic examination.- Trachea: The epithelium of trachea is completely necrotic and desquamated. Exudate consists principally of pus cells and necrotic material without definite fibrin. Corium is edematous, congested, and infiltrated with leucocytes. Bronchi are similar, but some of them contain an edematous exudate in addition to their other components. Terminal bronchioles are also denuded of epithelium. Many of them are lined with distinct diphtheritic membrane. Lungs: Capillaries and alveoli contain an excessive lumber of polynuclears. There is a granular coagulum in the alveolar spaces and exfoliated, pigment-containing alveolar cells. Polynuclears are not numerous. In Gram-Weigert preparations a wavy, bluish-staining network is seen lying against the alveolar wall in many of the air spaces. Bacteria are not numerous. Predominating type are Gram-positive cocci, arranged in groups. Kidneys: There is marked cloudy swelling, especially in the cells of the convoluted tubules. Some tubules contain a pink-staining coagulum, others red blood cells, and still others, desquamated epithelial cells. Liver: Capillaries are congested. There is a moderate diffuse fat infiltration. Adrenals: Are edematous and congested.
NOTE.- Duration of life after gassing was 5 days. The interesting points in the case are: 1. Very slight cutaneous lesions and apparent absence of ocular lesions. 2. Trachea and large bronchi showed a necrosis and purulent exudate, but no membrane formation. 3. Smaller bronchi were the seat of a typical membranous inflammation, but this was marked only in the upper lobes. 4. Absence of definite pneumotic lesions after five days is unusual. There was, however, a hyaline necrosis of atrial and alveolar epithelium,
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which in absence of general lung infection, may be ascribed to the direct action of the gas.
CASE 24.- W. D., 238318, Pvt., Co. I, 103d lnf. Died, 7.30 a.m., October 3,1918 Base Hospital 15, Autopsy No. 214. Autopsy, October 3, three and one-half hours after death, by Maj. Daniel J. Glomset, M. C.
Clinical data.- Mustard-gas burns and inhalation received in action September 28, 1918. Clinical diagnosis, gas inhalation complicated by lobar pneumonia.
Anatomical diagnosis.- Superficial ulcers of lips; acute conjunctivitis; first-degree burns of scrotum; pseudomembranous and hemorrhagic laryngitis, tracheitis, and bronchitis; peribronchial hemorrhages; confluent lobular pneumonia, left and right upper lobes; hemorrhage into gastric mucosa.
External appearance.- The epidermis about the eyes and conjunctive is rough and reddened and covered on the left side by an exudate. Lower lip is swollen and ulcerated. There is a purplish blotch over thorax and abdomen. Skin over penis is swollen, while that over scrotum is swollen and purplish. Blood is laked and black.
Gross findings.- Pleural cavities: There are a few fibrous pleural adhesions on the left side, but no fluid. Lungs: Do not collapse readily. Left lung: Anteriorly is crepitant. Posteriorly it is partially consolidated. On section there are solid areas in lower lobe posteriorly and few discrete nodules anteriorly. These are dark red in color and vary from pinhead in size to several millimeters across and have grayish centers. In one case outside this dark-red area is a slightly raised granular pink zone. In the upper lobe in addition to similar dark areas there is a distinct well-defined consolidation involving one-third of the lobe. Right lung: Shows a similar picture. The mucosa of larynx is swollen and roughened. The trachea and bronchi contain greenish thick flocculent material. Mucosa is thick and peels off, leaving a hemorrhagic surface. Bronchi show similar changes. Heart: Is normal. Stomach: Shows small erosions in the region of the fundus. Small and large intestines are injected. Kidneys: Are pale, swollen, and opaque. Remaining viscera seem normal.
Microscopic examination.- The trachea is covered with an exudate, composed of mucus and desquamated and degenerating epithelial cells. There is practically no fibrin and very few leucocytes are present. The epithelium is conserved except at openings of ducts of the glands. It shows striking metaplasia into cells of the squamous-cell type. (See fig. 17.) Submucosa is slightly edematous and vessels are injected. There is very little leucocytic reaction. In the small and medium-sized bronchi the epithelium is partially intact and ciliated. The lumina are filled with purulent exudate. A few of the large bronchi show complete epithelial necrosis with false membrane formation and contain laminated fibrin. The bacteria in the exudate are chiefly Grain-positive diplococci. The blood vessels of the bronchial walls are engorged, and there are hemorrhages in the surrounding alveoli. (See Pl. IX.) The lung shows widespread pneumonic areas. There is an exudate of fibrin and in other places hemorrhage. Leucocytes and red blood cells are well preserved. The process is apparently quite recent. Bacteria are not numerous in the pneumonic patches; in the bronchioles they are quite abundant. There is capillary thrombosis. Interlobular septa are edematous and show an inflammatory infiltration. The unconsolidated portions of the lungs are the seat of patchy nonfibrinous edema, and there is exfoliation of the alveolar epithelium with many of the cells containing pigment. Capillary congestion is marked. Stomach: Fresh hemorrhages into the mucosa without necrosis or inflammatory reaction. Kidneys: Capsular spaces contain a granular coagulum. There are numerous hyaline casts in Henle's tubules and tubuli recti. Penis: The skin over the glans penis is in part denuded. Where it is conserved there is a marked increase in the pigment of the rete mucosum. There is slight papillary edema. Corium contains numerous chronmatophores.
NOTE.- Duration of life after gassing was five days. The skin lesions were slight but typical of mustard gas in their character and distribution. The tracheal lesions were slight and regeneration of the epithelium, with the usual metaplasia into the squamous-cell type, had already occurred. Some of the smaller bronchi showed a simple purulent inflammation with intact ciliated epithelium; others showed characteristic diphtheritic necrosis. There were
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patches of bronchopneumonia which were not of the influenzal type. On the whole the respiratory lesions were not intense, and in conjunction with the mildness of the cutaneous lesions, imply a short exposure or a low concentration of the gas.
CASE 25.- A. W. G., 2088223, Pvt., Co. A, 355th Inf. Died, August 13, 1918, Base Hospital 116, autopsy No. 12. Autopsy, four hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Mustard-gas inhalation. Date of gassing not recorded. Co. A, 255th Infantry, was exposed to yellow, blue, and green cross shell on August 7 and 8. Autopsy protocols of 9 fatal cases from this gas attack are on file. Admitted in severe condition with burns of face, chest, neck, scrotum, and penis. Temperature and pulse rather high. Respiration short and labored.
Anatomical diagnosis.- Extensive mustard-gas burns of scalp, face, conjunctiv , neck, buttocks, scrotum, and penis. Acute membranous and ulcerative pharyngitis, laryngitis, esophagitis, tracheitis, and bronchitis. Bronchopneumonia. Marked pulmonary edema. Acute bronchial lymphadenitis. Slight cardiac dilitation. Parenchyymatous degeneration of liver and spleen.
External appearance.- The skin has a slight sallow brown appearance. There are extensive superficial burns of the scalp, face, neck, bend of each elbow, the scrotum, penis, the skin of the genital folds and lower buttocks, and in the undersurface of the right knee. There is considerable desquamation of the skin in these areas. There is some brownish pigmentation of the dermis, which is most marked on the inner aspect of both thighs. Superficial glands are somewhat enlarged. Eyelids puffy and glued together by tenacious viscid exudate. The conjunctivae are edematous and injected. The pupils dilated 5 mm. in diameter. Ears: No abnormalities, except the superficial burn of the skin. Nose: In the nostrils there is some mucopurulent material. Mouth: Shows superficial ulcerated areas of the lips, covered with sordes and viscid exudate. A number of the teeth show gold filling. There is a viscid material over the gums.
Gross findings.- Pleural cavities: On opening the thorax, a small amount of fibrino-purulent exudate found free over the pleura of the lower lobe on the right side. On the left there is likewise a small amount of fibrinopurulent exudate, especially marked over the lower portion of the upper and upper portion of the lower lobe. Heart is somewhat enlarged to the right. On incising the pericardium no abnormalities of or in the sac. Heart: Weighs 380 grams, the right auricle is moderately dilated. Otherwise normal. Right lung: All lobes are voluminous. Upper and middle lobes in great part cushiony, inelastic. In the middle lobe there is a large solid area palpable. Binding the middle lobe to the upper lobe, just above the solid patch there are a number of sheetlike fibrous bands. The pleura shows laterally and posteriorly a considerable amount of fibrinous exudate, below which the pleura is considerably injected and shows numerous small discrete and confluent red hemorrhages. Medially over the upper and middle lobes the pleura is thin and delicate. The glands at the hilum considerably enlarged, pigmented, pulpy, and injected; there is no scarring. Vessels at the hilum show no abnormalities. The bronchi show considerable ulceration of the mucosa; submucosa swollen and injected. Overlying it and the small amount of intact mucosa, there is a cast-like friable gray membrane about 0.5 mm. in thickness. On section of the upper lobe, a moist pink surface presents medially. Posteriorly a pinkish-red surface presents. There is a small amount of thin frothy fluid in the air sacs. Scattered throughout this lobe there are several vaguely outlined dull grayish-red solid patches varying in size from 1 cm. in diameter to several centimeters. The largest patch is present posteriorly. On pressure here viscid fluid exudes from the air spaces. The finer bronchioles are filled with viscid purulent material. The larger bronchial branches show a tenacious fibrino-purulent membrane. The middle lobe on section is in great parts pink and well aerated. There is a small amount of thin frothy fluid in the air sacs. The large solid area is found to be a patch 6 by 4 by 3 cm. uniformly consolidated, dull, and reddish. This portion of the lung is apparently less ventilated than the rest. In the center of the lobe there is a small patch similar in appearance, 1 cm. in diameter. The lower lobe on section presents a moist pinkish-red surface. The air sacs contain a moderate to considerable amount of thin frothy fluid. The bronchial branches show ulceration of the mucosa, with adherent friable gray membrane. About the bronchial branches small and large, there is deep red consolidation
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extending for a small distance into the lung. At the periphery of the lung the consolidation about the bronchioles is most marked. Left lung: Both lobes are much more voluminous than normal. In the median portion of the lower lobe the tissue is well aerated, cushiony; posteriorly, it is soggy. The lower lobe in great part is soggy, and covering the pleura of practically the entire lobe there is a considerable amount of tenacious fibrinous exudate. There is some fibrinous exudate over the lower portion of the upper lobe, especially posteriorly. The glands at the hilum are somewhat enlarged, pulpy, and deeply injected. The vessels and bronchi arc similar in appearance to those on the right. On section of the upper lobe it is similar in appearance to the right upper lobe. There is a walnut-sized solid patch posteriorly and a few smaller patches more medially. The lower lobe on section in general is similar in appearance to the right lower lobe, except that here the bronchopneumonic patches are much more numerous and extensive. The edema is most marked in the left lower lobe. Neck organs: The glands in the lower portion of the neck are swollen pulpy, edematous injected, and pigmented. In the upper portion of the neck the glands likewise are swollen and injected. The thyroid much larger than normal. Each lobe measures 6.5 by 4 by 3.25 cm. There is a prominent isthmus. On section, the acini are distended with colloid, the tissue gelatinous and pale. In the left lobe there is a hazel-nut sized large cyst filled with gelatinous blood-tinged fluid. The larynx shows marked swelling of the mucosa and deeper tissue. In places the epithelium is gone. In these areas the injection of that tissue below is prominent. Covering the membrane there is a tenacious fibrinous and fibrinopurulent membrane. The process is quite uniform throughout the larynx and trachea and is present likewise in the upper esophagus and the base of the tongue. The tonsils are small and buried. On section there is little lymphoid tissue visible and there is much scarring. In the crypts of the right tonsil there is caked and viscid yellow opaque material. Alimentary tract: The stomach, cardiac end, shows moderate patchy injection of the mucosa and there are tiny hemorrhages here and there in this region. Duodenum: No abnormalities. Throughout the tract the lymphoid tissue is somewhat more prominent than normal, especially so in the lower ileum. Appendix: No abnormalities. Cecum: No abnormalities. The mucosa of the colon pale, the walls thinned. Mesenteric lymph glands are slightly enlarged, pulpy, and pale. Liver: Weighs 1,800 grams, slight fat infiltration. Remaining organs show no significant lesions.
Microscopic examination - Treachea: Lined with well-formed laminated fibrinous pseudo- membrane invaded with leucocytes and containing in one area in its meshes a large mass of mucus. Beneath the membrane in places is preserved a single row of epithelial cells with pyenotic distorted nuclei, cilia of which are intact. There is marked swelling of membrana propria. Subepithelial tissue, edema, intense congestion, and hemorrhage. Marked leucocytic infiltration. Ducts of the mucous glands are distended with thick plugs of mucus. Epithelium in the superficial portions is destroyed. Additional sections cut from fresh block shows a slightly different picture. Mucosa is partly ulcerated down to perichondritum, the submucosa being in these areas very dense and showing great distortion of nuclei in inflammatory infiltration with pycnotic leucocytes. In other places the epithelium is regenerating, pale, flattened cells covering the denuded surface. These are continuous with the proliferating epithelial cells of the mucous ducts. The subepithelial tissue here has the character of very vascular granulation tissue and the predominating cells are lymphoid. There are capillary extravasations and in places much edema. Mucous glands are edematous but the epithelium is preserved. Lung: In the terminal bronchioles the epithelium is still present but shows degenerative changes. There is marked leucocytic exudate in the lumina. Consolidation is almost entirely peribronchial. There is a recent pneumonic exudate in which polymorphonuclear cells are predominating. Infundibula are dilated. Another section contains a medium-sized bronchus lined by thickened laminated fibrinopurulent membrane which, together with the looser more purulent exudate, practically occludes the lumen. (Fig. 29.) The epithelium is destroyed and invaded with wandering cells. There is early fibroblastic proliferation. The smaller bronchi on the other hand are free from exudate and show an intact epithelium. Lung tissue itself is emphysematous and atria are dilated. There is practically no pneumonia although there is a little epithelial desquamation and masses of leucocytes in the capillaries. Still another block shows marked dilatation of the atria with some hyaline necrosis of the wall and lobular pneumonia surrounded by areas of patchy edema. Exudate consists chiefly of polymorphonuclears, red blood cells,
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and desquamated alveolar epithelium, very little fibrin. There is a purulent bronchiolitis. Gram-positive diplococci, very few Gram-negative bacteria. Remaining organs show no interesting lesions.
Bacteriological report.- Smears of exudate in larynx, Grain stain, show innumerable Grain-positive cocci in pairs and some in small chains. Those in pairs, lancet shape, others rounded. There are also Gram-negative cocci and bacilli. Smears of the consolidated lung show a small number of Gram-positive cocci, most in diplococcus form. No Gram-negative organisms seen. Cultures: Trachea, staphylococcus aureus, streptococcus nonhemolyticus.
Fig. 29.- Case 25. Yellow, blue, and green cross shell, exposure 5 or 6 days before death. Dilated bronchiole lined with laminated fibrinopurulent membrane. Complete loss of epithelium
NOTE.- Typical early case of mustard-gas poisoning. There are no precise data given as to exact date of gassing. Since, however, other soldiers of Co. A, 355th Infantry, were gassed on August 7 and 8, 1918, duration of life after gassing may be estimated as 5 or 6 days which corresponds with the anatomical findings.
Points of interest are: The early epithelial regeneration of the trachea, the intense diphtheritic necrosis of the medium sized bronchi, and relatively slight lesions in the bronchioles which seem to have escaped the direct action of the irritant. There was the early lobular pneumonia which presented Some of the features of influenzal pneumonia, namely, dilatation and hyaline
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necrosis of the atrial walls. There was less hemorrhage and edema and more marked cellular exudation than in the typical case of early influenzal pneumonia.
CASE 26.- I. G.,48449, Pvt., Co. M, 18th Inf. Died, October 6, 1918, 8 p. m., Gas Hospital, Julvecourt. Autopsy, October 7, 20 hours after death, by Capt. James F. Coupal, M. C. Clinical data.- Gassed with mustard shell on October 1, near Verdum. Diagnosis of mustard-gas poisioning.
Anatomical diagnosis.- Inhalation of mustard gas. Purulent bronchitis and tracheitis. Bronchial pneumonia.
External appearance.- Extensive burns of face, conjunctive and cornea. Slight burn scrotum.
Gross findings.- Pleural cavities: Lungs do not retract on opening the chest. There are a few fresh fibrinous adhesions in the left sac. The right is free. Right lung is large. Entire middle, lower, and greater portion of the upper lobes are inflated. There are dark sunken patches along the posterior part of the lower lobe. Firm nodular masses up to 3 or 4 cm. in diameter can be felt through the pleura. Section shows these to consist of areas of peribronchial consolidation. In the center of these areas bronchi appear to be somewhat dilated and filled with pus. The middle lobe shows bronchial lesions, but somewhat less intense than in the remaining lobes. The lower lobe is somewhat edematous, with a few irregular areas of consolidation about the bronchi. Left lung: Is very large and heavy, especially about the upper lobe. There is diffuse edema and marked congestion in the posterior portions. The bronchi exude pus and are surrounded by dark-red areas of collapse and hemorrhagic infiltration. The bronchial lymph nodes are dark red, succulent and hyperemic. Trachea, as well as the larnyx and epiglottis, show intense congestion and numerous superficial erosions covered in places by shreds of fibrin. This condition becomes more marked in the larger bronchi, where the wall is completely covered by necrotic gray slough. In the smaller branches there is hemorrhagic exudate. Heart: Is dilated on the right side. Valves are normal. Alimentary tract: Injection of small intestines and stomach; otherwise negative. Liver, spleen, kidneys: Show no significant lesions.
Microscopic examination.- Trachea: No section preserved. Bronchi: The epithelium is desquamated. Lumen filled with pus cells. There is marked peribronchial congestion. Lungs: There is general capillary congestion. Alveoli contain polymorphonuclear leucocytes, red blood cells, and edematous fluid and fibrin. The most striking lesion is the marked dilatation of the infundibula with hyaline necrosis of their lining. Liver and kidneys negative.
NOTE.- Typical mustard-gas case of five days' duration, with moderately severe tracheal and bronchial lesions. There are no unusual features.
CASE 27.- E. S., 2915502, Pvt., Co. A, 355th Inf. Died, August 13, 1918, Base Hospital No. 46. Autopsy No. 4. Autopsy, 10 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on August 8, 1918. Exposed to yellow, blue, and green cross shell. Admitted to Base Hospital No. 46 on August 10 with extensive gas burns of face, neck, trunk, back, and scrotum. Severe burns of eyes. Short of breath. Cyanosis. Pulse rapid. Temperature high. Loud moist rales over both chests. Complete aphonia. August 12, slight dullness over both lower lobes posteriorly.
Anatomical diagnosis.- Mustard-gas burns of conjunctiv ae, right ear, mouth, chin, genital folds, scrotum, and penis. Ulcerative and membranous esoplhagitis, laryngitis, tracheitis, and bronchitis. Purulent bronchiolitis. Bronchopneumonia. Acute lymphadenitis of bronchial nodes. Pulmonary edema. Gastric and intestinal erosions.
External appearance.- The skin in general is sallow. There are areas of superficial ulceration of the skin about the mouth and chin, back of right car, in the genital folds, scrotum and prepuce. These superficial ulcerated areas extend into the dermis. Those about the mouth are covered with dry scabs; those about the right ear and over the scrotum and penis covered by a moderate amount of seropurulent exudate. The eyelids are matted together by a small amount of mucopurulent exudate. The conjunctiva are edematous, injected. There are small hemorrhages below the bulbar conjunctive. The corneae are slightly cloudy. Pupils 2.5 mm. in diameter. Superficial lymph glands are somewhat enlarged. Nose: In the nostrils there is considerable tenacious mucopurulent secretion. The mucosa is injected.
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Gross findings.- Pleural cavities: On opening the thorax the right pleural cavity is free of fluid and adhesions. The left pleural cavity contains about 10 c. c. of slightly turbid fluid. The heart lies in normal position. On incising the pericardial sac, no abnormalities of or in the sac. Heart: The right auricle and ventricle are slightly dilated. Otherwise normal, except for small grayish flecks in the myocardium. Right lung: All lobes are voluminous. The upper lobe is cushiony, inelastic in the upper portion. In the median and lower portion there are solid masses palpable. The middle lobe is cushiony and inelastic. Lower lobe is cushiony and soggy. Near the pleura posteriorly solid masses are palpable. The pleura in general is thin and delicate. Below it, especially posteriorly over the lower lobe, there are scattered and confluent deep red hemorrhages; the small ones pinhead in size and the large ones having an area of a few square centimeters. The glands at the hilum are greatly enlarged, pulpy, edematous, injected, and pigmented; some contain firm gray areas. Vessels at the hilum, no abnormalities. The bronchi show considerable ulceration of the mucosa and covering the ulcerated and intact membrane there is a thin tightly adherent yellowish-gray membrane. Upper lobe on section is pink; in the median portion posteriorly it is red. The bronchi contain fibrinous casts; there is no consolidation about the walls. The air sacs posteriorly contain a considerable amount of thin frothy fluid. The vessels here are somewhat congested. In the median portion there are vaguely outlined dull grayish-red consolidated patches 1 to 2 cm. in diameter. The middle lobe on section presents a very moist red surface. There is a very large amount of thin frothy fluid in the air sacs. Mottling the surface there are large, deep-red, solid, non-air-containing areas varying in size up to 2.5 cm. in diameter. There are larger bronchial branches showing a tenacious fibrinous membrane. The smaller likewise show a fibrinous membrane which in places practically occludes the lumen. At the very periphery of the lobe the bronchi contain a purulent exudate in considerable amount. Left lung: Both lobes are much more voluminous than normal. Upper lobe is cushiony, inelastic. The lower lobe is soggy. There are few small solid patches palpable. The pleura is thin and delicate, except posteriorly, where there is some fibrinous and a small amount of fibrinopurulent exudate. Below the pleura here, as on the right side, there are numerous scattered discrete and confluent hemorrhages. The vessels and glands at the hilum similar to those on the right. The bronchi show patchy injection of the mucosa. Everywhere there is considerable tenacious fibrinous exudate. Deep in the smaller bronchial branches there is viscid purulent material in the lumen. The tipper lobe on section, a moist red surface presents. The air sacs contain a moderate amount of thin frothy fluid. Posteriorly a few small, solid, non-air-containing, discrete gray consolidated areas observed. Medially there is a small, walnut-sized, solid, dull, pinkish-gray patch. In the lower lobe on section, a deep-red surface presents. The air sacs contain a moderate amount of thin, frothy fluid. Scattered throughout there are deep-red, solid, and non-air-containing solid patches varying in size up to 2.5 cm. in diameter. In addition in this lobe there is some consolidation in the neighborhood of the small bronchioles which are filled with viscid pus. Neck organs: Glands in the lower portion of the neck are considerably enlarged, pulpy, and edematous and injected. Some show scarred areas. The glands in the upper portion of the neck moderately enlarged, pulpy, and infected. The thyroid is of average size. On section the tissue is spongy. The acini contain a moderate amount of colloid. Larynx: Mucosa is swollen and injected. In places, especially in the region of the true and false vocal cords, the mucosa is ulcerated. The process is similar throughout the trachea, where there are areas of ulceration of the mucosa with injection of the submucosa. Over the intact mucosa and covering the ulcerated portion there is tenacious purulent exudate. The process is present also in the upper portion of the esophagus and base of the tongue, in the region of the glottis Here, however, there is intense injection of the mucosa and but a few areas of ulceration and fibrinous exudate. The tonsils are buried, scarred, but the crypts are clean. Alimentary tract: No other abnormalities of the esophagus. Stomach: In the pyloric region shows some 12 or 14 erosions of the mucosa a few millimeters in diameter. In the base of some of these there is a deep-red hemorrhage. Others show a small injected zone about them. The edges somewhat thickened. There is similar eroded area a few millimeters in diameter just beyond the pylorus. The duodenojejunal mucosa is bile stained. Ileum: There are scattered patches of injection of the mucosa. The mucosa here, likewise stained with bile. In the lower ileum the lymphnoid tissue is somewhat more prominent than normal. There is some injection of the mucosa of the appendix.
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There is some patchy injection of the cecum. There is slight diffuse injection of the rectum for a distance of a few centimeters from the anus. The mesenteric lymph glands are slightly enlarged, pulpy, injected. Liver: Slight fat infiltration. Spleen: Shows moderate lymphoid hyperplasia and hemorrhages into the pulp. Adrenals: Show moderate lipoid depletion. Kidneys: Negative. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: Has a well-marked membrane consisting of fibrin, leucocytes, and necrotic cells. The epithelium is lost with the exception of a few squamous cells adherent here and there and a thickened basement membrane. Section of large bronchus also shows epithelial necrosis, the bronchus being lined with necrotic fibrinopurulent exudate which is firmly attached and does not form a loose membrane except in a few places. The wall of the bronchus shows marked inflammatory edema with leucocytic infiltration and intense congestion. Caryorrhexis of the nuclei is very striking. Much chromatin is drawn out into bizarre forms as if melted. Lungs: Two blocks of tissue show similar lesions. Very marked edema with little or no fibrin. Alveolar capillaries contain an excess of leucocytes, a few of which have emigrated. There are occasional epithelial cells in the alveoli and scattered hemorrhage. Bronchioles and atria show intact and relatively uninjured epithelium, but contain purulent exudate. There are a few small patches of lobular pneumonia. Stomach: Section passes through erosions described in the gross. Liver, spleen, kidneys show no significant lesions.
Bacteriological examination.- Smear of exudate from larynx shows Gram-positive and Gram-negative cocci and Gram-negative bacilli. The predominating organism is a Gram-positive coccus in diplococcus form. Smear from consolidated lung shows relatively few organisms. There are Gram-positive diplococci, some lancet shaped, others rounded. No Gram-negative organisms seen. Culture: Lung, staphylococcus albus, streptococcus nonheinolyticus. Trachea, streptococcus nonhemolyticus, Gram-positive bacilli.
NOTE.- A very typical early case of mustard-gas poisoning of five days, with necrosis of the tracheal and bronchial epithelium and marked edema. The small bronchioles and atria showed an intact epithelium, although there was a purulent inflammation. There was an early bronchopneumonia. The gastric and duodenal erosions should be noted.
CASE 28.- F. S., 14555, Cpl., 1/4 Highlanders. Died, October 24, 1918, at 6.30 p. m., at Base Hospital No. 2. Autopsy, five hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- October 20, admitted to No. 5, Casualty Clearing Station, with diagnosis of shell-gas poisoning (irritant). October 22, admitted to Base Hospital No. 2. Well nourished; breathes with marked exertion, rapid and fairly deep respirations. Lungs edematous; pale and also somewhat cyanotic. Heart: No increase of cardiac dullness beyond normal limits. Pulse 130. Blood pressure 120/85. Lungs: Tracheal and bronchial rȃles; also fine moist rȃles at both bases. Burn of scrotum. October 23 no improvement in condition. Digitalis and oxygen inhalations; pulse 130, weak and irregular. Chest filled with moisture. October 24, still bravely holding on, but getting tired. Breathing with increasing difficulty. Pale and slightly cyanotic. Becoming very restless. Fully conscious. Anterior chest shows good resonance. Harsh respiratory sound, expiratory sound suppressed. Pulse 140, weak but regular. Died at 6.30 p. m.
Anatomical diagnosis.- Acute conjunctivitis; acute ulcerative pharyngitis; membrano- ulcerative tracheobronchitis; peribronchial adenitis; massive congestion and edema of lungs; ulcerative bronchitis and extensive bronchopneumonia of both lungs; pleural adhesions, right; influenzal pneumonia, following inhalation of poisonous irritant gas (?).
External appearance.- Moderate post-mortem lividity. Conjunctiva markedly injected; corners of the eyes stuck together by dried exudate. Mucopurulent exudate in the nares, nasal mucosa inflamed. No certain evidence of burns upon the skin, but there is one scabbed-over ulceration on the left leg, of uncertain origin. External genitalia are apparently normal.
Gross Findings.- Pleural cavities: Lungs meet in almost full inflation. Right pleura free of fluid and adhesions; upon the left side there are soft fibrinous adhesions over a small region beneath the fifth rib in the mammary line and likewise over the dome of the diaphragm. Pericardial sac: Contains about 50 c. c. of a slightly turbid, lemon-colored fluid; the membrane
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appears quite normal. Right lung: Covered over posterior portions by fibrous adhesions. The lung is voluminous, rather heavy, especially in the posterior part; a blotchy gray and purple, very lumpy in consistence. The cut surface is, in general, deep purple, roughly nodular and exudes a large quantity of bloody serum. About the bronchi are grayish red elevated areas of firmer consistence. Upon pressure numerous fine points of pus appear over the surface. The necrosis of the mucous membrane of the bronchi extends into the smallest branches, becoming purulent near the terminal branches. Left lung: Early fibrinous pleurisy; quite voluminous; rather firmer in its lower lobe than the right; coarsely nodular throughout. Cut surface presents about the same characteristics as on the right side; there is a rather large area of consolidation in lower portion of upper lobe. Small bronchioles are universally involved and contain either fluid pus or fatty looking plugs of exudate. The edema is exceedingly pronounced. The glands at hilum are acutely inflamed, not frankly suppurative. There is a moderate amount of interstitial emphysema over both lungs. Organs of the neck: Pharynx is deeply congested and presents a marked membrano- ulcerative type of inflammation. Tonsils: Are quite small. The inflammatory exudate extends down to the lowest portion of the pharynx. Esophagus: Appears quite normal, but a necrotic membrane extends downward into the glottis. Trachea is filled with a grumous purulent exudate, very foul in odor; the mucous membrane over the vocal cords is entirely sloughed away, and the necrosis extends down the entire trachea into the primary bronchi; beneath the necrotic mucous layer, a roughly granular hemorrhagic surface is revealed. Heart: Both ventricles in fair contraction, no lesions. Remaining viscera normal, save for congestion. Stomach shows advanced autolysis. Intestines are not recorded.
Microscopic examination.- Pharynx: In some areas the epithelium is still adherent, but dense and shrunken; in other places, the cells show marked vacuolization; in still others, the epithelial cells are vacuolated, but still fairly preserved and probably viable. Where the corium is exposed, it is densely infiltrated with pyonotic leucocytes, and there is fibrin and hemorrhage. The small superficial vessels are thrombosed. Elsewhere, that is in the non-ulcerated areas, there is merely edema with very little inflammatory reaction. The vessels are much congested. The deeper glands are not affected. Trachea: No section. Lungs: There are extensive patches of pneumonia. The exudate is composed largely of leucocytes which are probably polymorphonuclears, but are remarkable for the fact that the nucleus is displaced to the periphery of the cell, taking a more or less crescentic form. This seems to be due to the ingestion within the cytoplasm of one or more red blood cells and enormous numbers of minute Gram-negative bacilli (B. influenzae ?), and lesser numbers of Gram-positive cocci. The same leucocyte not infrequently contains a red blood corpuscle and masses of bacteria. Fibrin is present to a variable extent. The capillaries are engorged with red blood cells, and occasionally contain fibrin thrombi. (See Fig. 20.) There are no larger bronchi in the sections. A medium-sized bronchus shows complete necrosis of the wall, with an adherent fibrin network. The smaller bronchioles contain purulent exudate; and show an epithelial lining which is more or less exfoliated, but not necrotic. Bronchial lymphnodes contain a circumscribed area of fibrinopurulent exudate. Liver, myocardium, spleen, and pancreas show no significant changes. Adrenal shows marked edema of cortex, with dilatation of cortical capillaries. Areas of focal necrosis (?) in glomerular zone.
Bacteriological report.- Blood culture (post-mortem) sterile.
NOTE.- Presumably an early mustard-gas case, the estimated duration of life after gassing being four to five days. Like a previous case (Case 19), there was slight conjunctivitis, but the cutaneous lesions clinically and at autopsy were insignificant. There was, however, a characteristic diphtheritic necrosis of the upper respiratory passages, in all respects like that of other severe mustard cases. The lung lesions were those of an influenzal pneumonia.
CASE 29.- J. F., 22221, 1/4 Highlanders R. Died, October 25, 1918, at 10.30 a. m., at Base Hospital No. 2. Autopsy, four hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- October 20, admitted to No. 5 Casualty Clearing Station, with diagnosis of shell-gas poisoning (irritant). October 22, admitted to Base Hospital No. 2. Gassed three days ago. Now feels worse. Slight burns of face; eyelids edematous; slight cyanosis; breathes with difficulty; tracheal rales; mucopurulent sputum. Chest: Good resonance; coarse and fine rales. Roughened inspiration; expiration markedly reduced. Heart: No dilatation ascertainahle. Died at 10.30 a. m. Sputum contained pneumococcus, Type III.
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Anatomical diagnosis.- Ulceration of upper respiratory passages; acute purulent bronchitis; bronchopneumonia, following inhalation of poisonous irritant gas (?).
External appearance- Eyelids are edematous and discolored; left ear and left side of face are purple.
Gross findings.- Pleural cavities: No fluid or adhesions. The lungs do not collapse and are greatly inflated. Left lung: Covered with smooth pleura; larger branches of the bronchi contain thick yellow pus, and their surfaces are in places eroded. On section, droplets of pus exude from each cut bronchiole, and the lung soon collapses markedly. No definite areas of consolidation. Right lung: In every way similar to the left, except that there are some small areas of consolidation in the lower lobe. Organs of neck: Marked ulceration of the epiglottis and trachea, without a definite membrane. Heart: Normal. Spleen: Enlarged to about three times normal size. On section, pulp is dark red, moderately firm, follicles small and distinct. Remaining viscera show no noteworthy changes. Gastrointestinal tract not described.
Microscopic examination.- Large bronchi: The surface is formed by the wavy membrana propria, loosely attached to which are shreds and flakes of very well preserved epithelial cells, in a single flattened row, or in a partly exfoliated layer several cells deep. The cilia are lost, and the cells are partially dissociated by hydropic swelling and leucocytic invasion. The subepithelial tissue is loose and edematous. There is marked congestion and a moderate leucocytic accumulation, chiefly of polymorphonuclears. In the deeper layers the connective tissue cells have the character of fibroblasts and appear to be proliferating. The glands are not affected. There is no membrane or surface exudate. Very few bacteria are present; they are limited to the surface. Lungs: There are discrete 2 or 3 cm. sized areas of consolidation between which the parenchyma is relatively normal. These areas are definitely peribronchial. The small bronchioles show a fairly intact ciliated epithelium, but contain a dense purulent exudate with little or no fibrin. The peribronchiolitis shows no special features, apart from the number of large pigment containing alveolar cells. The leucocytes, almost wholly polymorphonuclear, are well preserved. In some of the alveoli are loose masses of cylindrical epithelium, aspirated from the bronchi. Very few bacteria can be demonstrated in Gram-stained sections. Liver and kidneys: Show congestion. Spleen: Also greatly congested; very few leucocytes in pulp.
NOTE.- A case of poisoning by irritant gas, presumably mustard gas, of five days' duration. There was edema and discoloration about the eyes, but no definite conjunctivitis. The acute ulcerative tracheobronchitis was not membranous in character, and the smaller bronchi showed an acute inflammation, without evidence of chemical injury to the epithelium. The pulmonary lesions were limited to small peribronchial pneumonic areas, and did not have the character of the prevailing influenzal pneumonia. This and the two previous cases (Cases 19 and 28) are peculiar because of the minimal cutaneous lesions. Since the individuals were members of the same organization and were admitted on the same day to the same casualty clearing station, it is very probable that they were exposed to the same gas.
CASE 30.- C. M. S., 134772, Pvt., Battery B, 102d F. A. Died, 1.30 a. m., October 16, 1918, at Base Hospital No. 58. Autopsy No. 5. Autopsy, October 16, 1918, 7 hours after death, by Lieut. H. E. Schoonover, M. C.
Clinical data.- Exposed on night of October 9-10 to bombardment of 2,000 105-mm., and 1.50-mm. shells of mustard gas and chloropicrin. Masks removed prematurely, and soldiers slept in gassed area. Small area attacked, and current kept bringing over the persistent gas. Admitted to Base Hospital No. 58 on October 14. Temperature 103 . Definite signs of lobar pneumonia.
Anatomical diagnosis.- Multiple superficial gas burns. Fibrinopurulent tracheobron- chitis. Bronchopneumonia. Emphysema. Chronic fibrinous pleurisy.
External appearances.- Superfieial burns over right subclavicular region and both axillary spaces. Rather severe burns about scrotum. Superficial burns on inner aspect of both thighs. Slight burns on both upper eyelids.
Gross findings.- Pleural cavities: There are fibrous adhesions at the right apex anmd over the entire left lung. Left htug: There are large extensive subpleural hemorrhages posteriorly
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and a little fresh fibrinous exudate. In the upper lobe the bronchi are thick and surrounded by a narrow, sunken red zone. No consolidation. A few small patches of hemorrhagic pneumonia. The smaller bronchi contain pus. Right lung: The posterior portion of the upper lobe is congested and edematous. There are ill-defined areas of consolidation. Middle lobe, posterior portion presents the same picture. Lower lobe, extreme base posteriorly shows an area about 3 cm. wide that is definitely consolidated, the cut surface being dark red and granular. The main bronchus to this area shows a moderate diffuse dilatation. Trachea and bronchi show intense congestion and multiple small hemorrhages. Mucosa is opaque and smooth like that of the esophagus and is covered in places by shreds of fibrinous exudate. Mucosa of the bronchi is definitely necrotic and their lumina are filled with exudate.
Microscopic examination.- Trachea: On section, shows complete desquamation of the epithelium, which is replaced by thick adherent membrane composed of leucocytes, fibrinous detritus,and masses of Gram-positive organisms. Subepithelial tissue is edematous. The bronchi show no membrane, but the epithelium is necrotic and the lumnina are filled with leucocytes. There are many Gram-positive bacteria. Lungs: Are slightly edematous with a patchy peribronchial and alveolar exudate of leucocytes with very little fibrin and few red blood cells. The lung lesions, on the whole, are insignificant in the sections examined.
NOTE.- Typical mustard-gas case of six days' duration with early mem- branous tracheobronchitis and few small areas of lobular pneumonia. There are no features of special interest. Regenerative changes were not present.
CASE 31.- F. J. M., 2280979, Pvt., Co. L, 147th (47th) Inf. Died, August 14, 1918. Base Hospital No. 18. Autopsy No. 79. Autopsy, August 15, 26 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed August 8, 1918, with mustard-gas shell. Marked erythema over the entire body, particularly marked over chest and about genitals. Marked conjunctivitis, dyspnea, bronchitis, no evidence of consolidation. Frothy, bloody sputum. Burns im- proved but respiratory symptoms persisted. Pulse rapid and thready.
Anatomical diagnosis.- Extensive burns of respiratory tract, skin, and conjunctiva. Purulent conjunctivitis. Acute pharyngitis and esophagitis. Acute fibrinopurulent tracheo-bronchitis. Purulent bronchiolitis. Extensive bronchopneumonia. Pulmonary edema. Acute fibrinous pleurisy. Fatty infiltration of liver. Tuberculous epididymitis
External appearances.-There is a moderate hypostasis. The skin in general has a muddy sallow-brown appearance. There are in addition scattered areas of deeper brownish pigmentation, especially marked on the inner surface of the thighs, about the knees. The skin shows numerous superficial burns. The burns are most marked in the skin of the back, commencing in the axilla, extending down the sides, the greater portion of both buttocks being involved. The skin about both shoulders and neck likewise shows superficial ulceration and desquamation. There are large burns on the upper arms, at the bends of both elbows, and on the left forearm. There are scattered superficial burns over the chest and abdomen anteriorly, the skin of the neck and greater portion of the face is desquamated, and in places there are superficial ulcerated areas. The scrotum and penis show superficial ulceration. The base is covered by dry serum. Genital folds show considerable superficial ulceration and desquamnation. There are also burns on the under surface of each knee. Above and below the knee oil both sides there are areas of clear vesicles, one large bleb. Nowhere does the burn extend deeper than the dermis. Most of the areas are covered by dry serum, below which injected dermis is visible. Eyes: Eyelids puffy, matted together bv tenacious mucopurulent secretion. The conjunctivie somewhat injected, and there are small hemorrhages. The corneae are somewhat cloudy, especially the left. The pupils, 3 mm. in diameter. Nose: Tissues puffy. Considerable amount of mucopurulent material in the nostrils. Ears: Tissues of the ears are puffy. There are superficial burns about them, covered by desquamated skin and dry serum. Mouth: There are superficial ulcerated areas of the lips. The teeth show considerable erosion of the cutting edges. The mucous membrane is cyanotic.
Gross findings.- Pleural cavities: The right pleural cavity contains a small amount of fibrinous exudate, lying over the posterior portions of the lower lobe. The left pleural cavity is obliterated in great part by sheetlike fibrous bands. Pericardiun normal. On
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removing the left lung a small amount of fibrinous exudate is visible over the posterior portion of the lower lobe. Right lung: Weighs 1,025 grams. The lower lobe shows a large, deep, congenital fissure dividing it imperfectly in two. The fold is covered by norml pleura. All lobes very voluminous, cushiony, slightly soggy. The pleura over the lower lobe is somewhat glazed posteriorly and laterally, covered by a moderate amount of fibrinous exudate. Below the pleura of all lobes there are scattered small hemorrhages. The vessels at the hilum show no abnormalities. Lymph glands are greatly enlarged, pulpy, edematous, pigmented, injected. Bronchi show considerable ulceration of the mucosa, the underlying submucosa injected. Covering intact and ulcerated mucosa there is a tenacious fibrinous and fibrinopurulent membrane, yellowish in color. On section of the upper lobe a moist pink surface presents medially; posteriorly the surface is a moist red. The air sacs contain a moderate amount of thin frothy fluid. The smaller bronchioles contain a viscid blood-tinged material, the walls are deeply injected, and immediately about the walls the adjoining alveoli are consolidated and deep red. There are a few grayish-red consolidated areas from a few millimeters to 12 cm. in diameter in the posterior portion of this lobe. The middle lobe on section presents a pink surface. There is a injected, the adjoining lung tissue consolidated for a small distance, deep red. In addition there are a number of vaguely outlined, dull, pinkish-gray, consolidated areas,small amount of fluid in the air sacs. The filler bronchioles, similar in appearances to those in the upper lobe, contain fibrinous and purulent exudate. There is but little peribronchial involvement. On section of the lower lobe a moist pink surface mottled with deep red is presented. There is abundant thin, frothy, purulent exudate in places. The walls are varying in size from a few millimeters to a few centimeters in diameter. These areas are associated with the inflamed bronchioles. Left lung: Weighs 1,270 grams. Vessels, glands, and bronchi are similar to those on the right. The pleura over the median portion of the upper lobe is thickened, bound tightly to the parietal pleura by sheetlike fibrous bands. Over the posterior portion of this lobe and the lower lobe thepleura is thin and covered by moderate amount of fibrinous exudate. On section, the left upper lobe is similar to the right upper in appearance. The left lower in general similar to the right lower, but here the consolidation extending from the small bronchioles is much more extensive; reddish gray, involving about one-third of the lobe. In places in the dull, reddish-gray, consolidated portion there are small yellowish areas. Heart: There is moderate dilatation of the right auricles and ventricles. Muscle is pale and opaque. Neck organs: The lymph glands of the neck and especially those in the lower portion are considerably enlarged, pigmented, pulpy, injected. Thyroid is of average size, tissue spongy, gelatinous. The acini contain a moderate amount of colloid. Larynx: There is considerable swelling due to edema of the mucosa; membrane is injected, infiltrated, and covered in places by fibrinous and fibrinopurulent exudate. There are areas of ulceration, especially marked over the true vocal cords. The submucosa is intensely injected throughout lower larynx and trachea. There are small hemorrhages present likewise in this coat. Throughout the lower larynx and trachea there is considerable tightly adherent fibrinous exudate, also a small amount of fibrinopurulent exudate. The injection of the mucosa continues over the glottis into the adjoining esophagus and base of tongue; attached to the injected mucosa in these situations there is a small amount of fibrinous exudate. Tonsils somewhat enlarged, pulpy, and injected. Lymphoid tissue present in moderate amount. There is some scarring. On the left the tonsils show several crypts filled with viscid purulent material. Liver: Weighs 2,710 grams. Irregular fat infiltration. Alimentary tract: Injected. Stomach and duodenal mucosa injected. Jejunum and ileum edematous. The remaining organs show no significant changes except for the left epididymis, which is thick and on section shows areas of caseation and fibrosis.
Microscopic examination.- Bronchus: There is a complete necrosis of the epithelium, limited in places by the membrana propria, but in other places involving the connective tissue as far down as the glands. There is edema, intense congestion, hemorrhage, and localized collections of polynuclears, all more or less fragmented. The epithelium of the mucous ducts is also completely destroyed. The glands are edematous but still intact. Small bronchus: Shows a similar picture except that there is a portion of thick fibrinous membrane still adherent. Masses of bacteria are present on the surface. Lung: The bronchioles and atria show complete necrosis of the entire wall; the lumen is filled with detritus and masses of bacteria. The parenchyma throughout shows alveoli filled with
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exudate, serous, fibrinous, or hemorrhagic. There are few cells, and these chiefly degenerating and exfoliating epithelium and mononuiclears. The relatively few polynuclears show nuclear pycnosis and fragmentation. The alveolar walls are infiltrated with leucocytes, edematous, and often indistinct.
Bacteriological examination.- Smears of trachea show innumerable Gram-positive bacilli and cocci. Smears of consolidated lungs show many Gram-positive lancet-shaped diplococci and rounded Gram-positive cocci. Cultures of tracheal exudate show staphylococcus, nonhemolytic streptococcus, B. coli and Gram-positive bacillus. Cultures of consolidated lung show staphylococcus and nonhemolytic streptococcus.
NOTE.- Case of mustard-gas poisoning of six days' duration with typical skin and eye lesions and a severe necrotizing inflammation of the entire upper respiratory tract and extending into the smallest bronchi. The complete destruction of the epithelium would have made repair impossible. The parenchyma of the lung showed a hemorrhagic and fibrinous inflammation like that commonly seen in the influenzal pneumonias. The case illustrates the difficulty in estimating the part played by the original injury and by the supervening infection, respectively.
CASE 32.- R. A., 91283, Pvt., Co. K, 165th Inf. Died, March 28, 1918, 7 a. in., at Base Hospital No. 18. Autopsy, performed nine hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on March 20 and 21, 1918. On admission, cyanosis, accelerated breathing, irrational. Bronchial fremitus, no signs of consolidation. Dypnea and polypnea. Pulse rapid and of bad quality. Lungs, hyperresonant and movements limited (inflation). Moist and bubbling rales front and back. At bases are areas of relative impairment.
Anatomical diagnosis.- Superficial burns on eyes, lips, scrotum, and penis. Ulcerative laryngitis, tracheitis, and bronchitis. Bronchopneumonia. Acute fibrinous pleurisy. Obsolete tuberculous bronchial lymph nodes. Healed chronic epididymitis. Fibrosis of myocardium. Dilatation of right ventricle and auricle.
External appearance.- Eyes, bulbar and palpebral conjunctive, irregularly injected with small hemorrhages here and there. Gluing the eyelids together is considerable caked exudate. About the eyes a few scabs, especially near the inner canthus on each side. There are similar scabs at the junction of the mucous membrane and skin of the lips. External genitals: A portion of the glans penis and greater portion of the scrotum show superficial ulceration, apparently just through the epidermis. The area is dry. In the scrotum at the periphery of the dry area there is an area of moist, very superficial ulceration limited to the epidermis and tissue immediately below. There is a small amount of grayish exudate here and there covering the skin and denuded areas. In the affected parts there is moderate injection of the vessels.
Gross findings.- Cavities: On opening the thorax a number of fibrous adhesions are seen between the right middle lobe and chest wall. In the left pleural sac there are a few centimeters of turbid fluid. Heart is displaced slightly to the right. Right lung: Weighs 800 grams. All lobes are voluminous. The pleura over the middle lobe is considerably thickened and there are numerous fibrous tags here. Below the pleura in the interlobar region there are numerous discrete pinpoint to pinhead sized hemorrhages. They are present also below the pleura posteriorly. In addition over the posterior portion of the upper and lower lobes there are areas of fibrinous exudate overlying the pleura. The glands at the hilum are strikingly enlarged, pulpy, edematous, and somewhat injected. Some of them contain grayish and yellowish nodules, pinhead to grapeseed in size. On section of the tipper and middle lobes a moist pink surface presents. On the section of the lower a moist red surface presents. The bronchial branches are everywhere prominent. They are filled with viscid pus. The mucosa is swollen and injected. In places the mucosa is ulcerated. In all three lobes the air sacs contain a moderate amount of thin fluid, and in places about the finer bronchioles there are small areas of dull grayish-pink consolidation. The consolidation in the lobes on the right is not marked. In most places the consolidation is limited to the area immediately about the bronchial branches. Left lung: Weighs 770 grams. All lobes voluminous, soggy in great part. In the lower lobe large solid patches
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are palpable. The pleura, especially posterially, over both lobes, covered in places by fibrinous exudate. Below the pleura between the lobes there are innumerable pinhead in size hemorrhages. Here, also, there is much fibrinous exudate. Glands at the hiljum are similar to the one on the right. On section of the upper lobe a dull pinkish-red surface presents; moist. Air sacs contain a considerable amount of thin, frothy fluid. The bronchial tree throughout filled vith viscid pus. The mucosa is injected. The swelling, injection, and ulceration of the bronchial tree is very striking near the roots of both lungs. In the left upper lobe there are scattered small pinkish-gray areas of consolidation associated with the bronchi. In the lower lobe there are scattered throughout a considerable mumber of grape-seed to hen's-egg sized areas of pinkish-gray consolidation. In addition there is much fluid in the air sacs. Heart: Weighs 380 grams. There are small subpericardial hemorrhages. Right ventricle and auricle dilated. Muscle pale with few small scars in left ventricle. Slight chronic aortic valvular disease. Neck organs: The larynx and trachea present a striking appearance. The mucosa is swollen, intensely injected, especially in the lower portion of the trachea. There are in places numerous small hemorrhages in this portion. In the lumen there is a considerable amount of viscid mucopurulent material. Tonsils are somewhat buried and small, overlying them there is some desquamation of the epithelium. Tonsils scarred, crypts in general clean. Liver: Weighs 2,110 grams. Local areas of fat infiltration. The remaining organs, including the alimentary tract, are normal except for fibrosis of right epididymis.
Microscopic examination.- Trachea: There are shreds of epithelium still adherent, but in most places the denuded and swollen membrana propria lies exposed. There is active proliferation of the duct epithelium. In a few places there is necrosis of the superficial portion of the subepithelial connective tissue, which generally is edematous and infiltrated with leucocytes. Bronchus: Practically the same picture as the trachea. There is no membrane and the lumen is free from exudate. Lung: Two blocks showing similar lesions. The picture is not that of the usual "mustard lung." There is marked and diffuse edema, in places homogeneous, in places distinctly fibrinous. The atria are filled and lined often with a hyaline band. There are dense plugs of exudate in many of the alveoli, the cells differing from normal polynuclears in the shape of their nuclei, which are reniform rather than lobulated. There are many exfoliated epithelial cells, some of which contain pigment, also moderate number of red blood cells. It is hard to make out the walls of the alveoli distinctly. The capillaries are empty, and some appear to contain fibrin thrombi. A small bronchus is filled with pus, but the epithelium is still largely intact. Sections stained with Gram-safranine show innumerable bacteria in the exudate; the predominating organisms are Gram-positive cocci in pairs; and short chains. A few Gram-negative cocci and minute influenza bacillus-like rods are also seen.
Bacteriological examination.- Smears from bronchus show innumerable intracellular and extracellular mouth organisms (Gram-positive diplococci), Gram-negative and positive diplococci, tiny Gram-negative bacilli and diplobacilli. Culture from consolidated lung lost by accident.
NOTE.- Duration of life after gassing, six days. The nature of the gas to which soldier was exposed is not established, but there were characteristic mustard-gas lesions of skin with the usual changes in the trachea and bronchi. There was extensive bronchopneumonia resembling the "influenzal" type. No other special features.
CASE 33.- J. G., 485952, Pvt., Co. B, 47th Inf. Died, 11.30 p. m., October 18, 1918, at Evacuation Hospital No. 7. Autopsy No. 61. Autopsy, October 19, 1918, nine and one-half hours after death, by Capt. James F. Coupal, M. C.
Clinical data.- Gassed on October 12 near Verdun, exposed to blue, green, and yellow cross shells.
Anatomical diagnosis.- Multiple superficial burns. Necrotic inflammation of larynx, pharynx, trachea, and bronchi. Bronchopneumonia (bilateral).
External appearance.- Superficial burns of face, neck, axillae, hands, scrotum, and conjunctiva .
Gross findings.- Pleural cavities: Left contains many fresh fibrinous adhesions, about 100 c. c. of serosanguineous fluid. The right is obliterated by fresh dense adhesions. Heart:
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Moderate mitral stenosis. Left lung: Is alternately consolidated and congested. Emphysematous along the anterior margins and edematous in dependent portions. The smaller bronchi contain pus. Right lung: Same as the left. Larynx and pharynx: Markedly injected. Trachea and larger bronchi are denuded of mucosa throughout and are lined with a purulent exudate.
Microscopic examination.- Trachea: A few deeply-staining cells are still adherent to the basement membrane. The duct epithelium is also preserved. There is no membrane or exudate on the smooth surface formed by the membrana propria. The subcutaneous tissue is moderately edematous. There is probably a little fibrinous exudate. Very few wandering cells. The congestion of all vessels is marked. Lung: (a) Sections show the alveoli lined with coagulum, partly homogeneous, partly hemorrhagic and fibrinous. Leucocytes, mostly polymorphonuclears, are present in variable numbers. Occasional exfolitated alveolar cells are found, but in general they are not distinct. There is marked edema of the interlobular septa, fibrinous and hemorrhagic. No bronchi in section. (b) This block shows a diffuse edema, not intense. A small bronchus is filled with debris of fibrin, fragmenting leucocytes, necrotic epithelial cells. There arc fibrin plugs in the adjacent alveoli. In a few places the regenerating epithelium forms a single layer of low cuboidal cells. Liver: Central congestion with fatty infiltration and degeneration of cells in center of lobules.
NOTE.- The case illustrates the usual lesion at this stage (six days) following a not too severe injury. There was beginning organization of the tracheal and bronchial epithelium and also the alveolar epithelium in the less damaged regions of the lung. The widespread hemorrhagic edema suggests the prevailing "influenzal" type of infection. The lesions may be ascribed to mustard gas, although there is a history of mixed exposure.
CASE 34.- H. S., 1565196, Pvt., Hdqrs. Co., 18th Inf. Died, October 7, 1918, 3 p. m., Gas hospital, Julvecourt. Autopsy, two hours after death, by Capt. James F. Coupal, M. C.
Clinical data.- Gassed, October 1, near Verdun. While digging into old gas-shelled hilltop a second gas attack was launched upon the detachment to which the soldier belongs. Nature of gassing not recorded. Clinical diagnosis of mustard-gas poisoning.
Anatomical diagnosis.- Inhalation of mustard gas. Purulent tracheobrolnchitis. Bron- chopneuemonia.
External appearance.- Marked burns of face, neck, axillae, buttock, scrotum, upper arms, conjunctivie, and cornae.
Gross findings.- Pleural cavities normal. Heart normal. Lungs: Voluminous. Markedly edematous on section with central areas of bronchopneuumonia. Bronchi yield plugs of pus. The remaining organs show no significant lesions.
(The following note upon the lesions of the respiratory tract was made at the pathological laboratory, Experimental Gas Field.)
Pharynx normal. The under surface of the trachea and epiglottis rough and covered with bloody mucus, not definitely ulcerated. Bronchi are filled with very abundant blood-stained purulent exudate. No membrane. Right lung: Is very fluffy and voluminous, especially the middle lobe, which shows maximum inflation. The pleura is everywhere smooth. On section the upper lobe is dry and air containing. The middle lobe is pale, emphysematous, and dry. Lower lobe is also free from consolidation. No edema. All bronchi exude pus on pressure and show swollen mucous membrane. A small nodular focus of bronchopneumonia about the size of a bean is found on the mesial surface just below the main branch of the pulmonary vein. Left lung: Is also large and emphysematous, and there are a few irregular areas of atelectasis which extend a millimeter or so into the lung substance. On section, the lobes are dry, free from edema and consolidation. The bronchi are filled with purulent blood.
Microscopic examination.- The lung is slightly emphysematous in one section. The smaller bronchi are filled with pus cells, there being a general capillary bronchitis. There are a few patchy areas of pneumonia where the groups of alveoli contain polymorphonuclear leucocytes and large cells filled with anthracotic pigment. Capillary vessels are congested.
NOTE.- The case is one of six days' duration. The pulmonary lesions were practically confined to the small bronchi and infundibula, and the emphysema and atelectasis resulting from their partial occlusion. There were typical skin burns, so that the diagnosis of mustard-gas poisoning is unquestioned.
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CASE 35.- S. 2108. L/Cpl. 1/Gloucester R. Died, September 24, 1918, at 5.30 p. m., at Base Hospital No. 2. Autopsy, three and one-half hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- September 18 admitted to No. 47 Casualty Clearing Station. Poisoned by shell gas (irritant). September 19 admitted to Base Hospital No. 2. Markedly cyanotic and breathing with much difficulty; profuse mucoid sputum. Burns of lips and nose; congested conjunctivae. Lungs: Moisture generally; pulse, 116; heart, dullness 2 cm. to right of right sternal margin, left to nipple line. Oxygen administered. 1 p. m., pulse 150, marked cyanosis. Venesection 400 c. c. Strophanthin 1/500 gr. intravenously. At 2 p. m., much improved. September 20, doing nicely. Has been getting digitalis. Blood culture sterile. Sputum: Hemolytic streptococci predominating. No tubercle bacilli. September 22, feels much improved; still cyanotic; mucoid sputum. Heart: No enlargement. Lungs: Marked prolongation of expiratory sounds, few squeaks and coarse rales. September 24, still cyanotic, respiratory difficulty. Lungs: No signs of consolidation. Expiration prolonged. Pulse good. 2 p. in., acute attack of severe dyspnea and cyanosis. Pulse rapid and weaker; died at 5.30 p. in.
Anatomical diagnosis.- Acute pharyngitis and laryngitis; intense purulent and ulcerative inflammation of trachea and bronchi; diffuse bronchopneumonia and multiple abscesses of both lungs; pulmonary edema; interstitial emphysema; acute fibrinous pleurisy; old pleural adhesions; healed tuberculosis of right apex; acute suppurative adenitis of peribronchial glands; healed tuberculosis of bronchial glands; congestion of abdominal viscera.
External appearance.- Herpetic eruption on lips (burns?); teeth in very poor condition, many missing, others carious. Dried blood-tinged exudate in the corners of the eyelids, evidence of recent conjunctival inflammation; several small ecchymoses in the bulbar and palpebral conjunctivn. Dusky cyanosis about ears, cheeks, and posterior part of neck. Mucous membrane over nasal septum much injected; external orifices negative.
Gross findings.- Pleural cavities: Lungs are fully inflated and pale. No fluid in pleural sacs. Left lung: Exceeding voluminous and does not collapse in the least after severing the bron- chus. There are a few fibrous adhesions between the lobes, and several bands near the apex, in which there is a firm calcified nodule. There are a few soft adhesions at the tipper portion of the interlobar fissure, which reveals a congested and roughened pleural surface; there is fresh fibrinous exudate along the posterior surface of the lower lobe. The tipper and lower branches of the primary bronchus appear very much smaller than usual and are almost entirely occluded by a yellowish-gray, fatty-looking material, and some thinner, almost clear fluid. An occasional bubble of air escapes as the lung slowly collapses. A portion of this occluding material separates readily from the bronchial wall and suggests a fibrino-purulent exudate. A quantity of deep-yellow pus entirely occludes the branches of the bronchi immediately distal. Upon dissection, the mucous membrane of the bronchus appears very considerably thickened, congested at its base, extensively ulcerated superficially, covered by a rather dense, shaggy exudate. Upon section, a striking condition was revealed, bright-yellow points of pus appeared immediately in large numbers, standing out sharply against the bright-red background. There is a deep red areola surrounding each of these purulent points. There are a few small abscesses about the terminal bronchioles. In some areas the inflammation has extended several millimeters about the bronchioles. Right lung: Also exceedingly voluminous; heavier in posterior portion than left and has an almost drum-like tightness over the middle and upper lobes, which seem homogeneous and air containing. The lower lobe is firmer, of a peculiar soft doughy consistence. Although there is a great deal of air in the lung, almost no crepitation is felt. The pleural membrane has a glassy appearance and is definitely edematous. Over the lower lobe there is a striking milky opacity of the pleura and a conspicuous edema of the interlobular connective tissue. The superficial blood vessels in the pleura at the base are very much congested; there are a few minute subpleural hemorrhages. The bronchi at the root present a deep congestion with hemorrhages. The glands at the hilum are enlarged and extensively calcified. Upon longitudinal section, a picture similar to that in the left lung is observed. The tissue, however, is somewhat firmer; the surface is more moist and in consistence is firmly nodular. A considerable amount of clear fluid issues from the surface, which has a rather translucent appearance. The general pulmonary inflammation appears more diffuse; otherwise there is little difference from the condition in the left lung. Heart: Left ventricle contracted, right rather flabby. No other lesions. Organs of neck: The base of the tongue and entire
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pharynx are deeply congested and granular. There is a large amount of muco-pus about the epiglottis and the larynx. The larynx itself and the entire trachea are filled with a foul mucopurulent exudate. The epiglottis is markedly inflamed and covered over its lower portion by a diphtheroid membrane; this extends over the false and true vocal cords, which are congested and swollen. The trachea is inflamed and covered with patches of the whitish membrane. The esophagus is normal. The lymph glands above the bifurcation of the trachea are much enlarged and contain some calcified nodules. Stomach and duodenum: Mucous membrane normal. Intestine: Not recorded. Other viscera: No significant changes.
Microscopic examination.- Trachea: Patches of necrotic membrane between which the edematous and infiltrated submucosa is covered by a single layer of regenerated epithelial cells, proceeding from the duct epithelium. The new cells are flattened. There is much fibrin and many polymorphonuclears in submucous tissues. Also marked congestion but no hemorrhage. Large bronchus: Filled with fibrinopurulent exudate. There is an acute inflammation of the wall which extends to the cartilages. The mucous glands are in hypersecretion. Lung: The section includes a medium-sized bronchus entirely filled with purulent exudate, with practically no fibrin. Epithelium is in the form of a single layer of flattened nonciliated cells. Bronchial wall, edematous, hyperemic and infiltrated with leucocytes. There is no peribronchial abscess formation, as was indicated by the gross appearance, but the bronchus is surrounded by a zone of pneumonia in which the exudate is largely fibrinous and beginning to be covered by proliferating alveolar epithelium. In some alveoli there is hemorrhage. Where the pleura is included in the section, it is found to be thickened by edema; the vessels of the deeper tissue are congested. Sections of myocardium, liver, spleen, adrenals, and pancreas show nothing interesting.
Bacteriological report.- Blood culture, aerobic and anaerobic media, no growth. Pus from bronchiole: Smear shows a preponderance of short Gram-negative rods, probably B. influenza , also pneumococci and a few streptococci. Culture on agar slant shows only streptococci, which prove to be hemolytic.
NOTE.- Case of six days' duration, probably mustard gas. The burns appear to have been insignificant, being limited to the region of the eyes, lips, and nose. There was a necrotic inflammation of the larynx, trachea, and large bronchi, without the formation of a definite coherent membrane. Epithelial regeneration had begun. There was purulent bronchitis and infundibulitis, with exudate into the surrounding parenchyma, largely fibrinous or hemorrhagic. The alveoli in these peribronchial areas showed beginning epithelial proliferation. Elsewhere there was emphysema and alveolar and interstitial edema.
CASE 36.- E. P. 569343, (?); Sgt., Co. H, 59th Inf. Died, August 14, 1918, at 2.35 p. m.. at Base Hospital No. 27. Autopsy, No. 32, performed one and one-half hours after death, by Capt. H. H. Permar, M. C.
Clinical data.- Exposed to mustard-gas shelling on August 8. Extensive skin burns. Gunshot wounds of both feet and left knee; also compound comminuted fracture of first left metatarsal. Admitted to Base Hospital No. 27 on August 12, in a critical condition. Died in delirium.
Summary of gross lesions.- Extensive second-degree burns of face, neck, back, shoulders. arms, and genitals. Left lung weighed 298 grams, right lung 299 grams. All lobes crepitant; no edema or consolidation. Bronchi and trachea negative. Heart muscle flabby; marked dilatation of right ventricle.
Microscopic examination.- Large bronchus and adjacent lung: The bronchus is lined with a single row of ciliated epithelium. There is no exudate and the bronchial wall is free from inflammatory changes. The adjoining lung tissue is moderately emphysematous, but not otherwise abnormal. The smallest bronchioles are normal. A medium-sized branch of pulmonary artery shows some adventitial thickening, but is otherwise unchanged. Lung (two blocks examined): There is marked emphysema, but no other changes are seen. All bronchioles and infundibula are normal.
NOTE.- Severe and extensive mustard-gas burns of skin, without involvement of the respiratory tract. Death probably due to traumatic injuries six days after exposure to gas.
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CASE 37.- J. B., 546888. Cpl., Co. G, 30th Inf. Died, August 16, 1918, at 9 p. m., at Base Hospital No. 27. Autopsy No. 37, performed 28 hours after death, by Capt. H. 11. Permar, M. C. (Lieut. F. M. Jacob, M. C.?)
Clinical data.- Exposed to Yellow and Blue Cross shelling on August 10, at Fismes, 75, 77, and 105 mm. shells in attack. Admitted on same day to Field Hospital No. 7 with diagnosis of mustard-gas contact and shrapnel wound of left index finger. August 11 transferred to Evacuation Hospital No. 6. August 12 admitted to Base Hospital No. 27. Severe burns. August 14 crepitant rȃles and bronchial breathing over both tipper lobes. August 15 diffuse crepitant, moist, and bubbling rȃles at various points over right chest; harsh expiration with loud sibilant rhonchi over lower left lobe. Moderate cyanosis. Bronchial breathing at angle of left scapula. August 16, bronchial breathing over right middle lobe. Breath sounds emphysematous; no signs of edema.
Anatomical diagnosis. - Burns of abdomen, left thigh, and genitals; acute tracheitis and bronchitis, purulent; beginning lobar (?) pneumonia of both tipper lobes; emphysenma; dilatation of right side of heart.
Microscopic examination.- Small bronchus: Purulent exudate fills the lumen. The epithelium is reduced to a few flattened and degenerating cells between the membrana propria and the exudate. There is intense congestion and abundant fresh hemorrhage into the bronchial wall. Lung: A medium-sized bronchus shows a partially attached fibrinous membrane. Flattened and highly atypical epithelial cells in a single row are insinuating themselves between the false membrane and the membrana propria. The wall of the bronchus is thick, edematous, and shows fibroblastic proliferation. There is little infiltration with inflammatory cells. The same edematous tissue surrounds the blood vessels. The parenchyma is the seat of confluent lobular pneumonia. The exudate is rich in laucocytes and fibrin. The most striking feature is the regeneration of the alveolar epithelum, the new cells standing out because of their deeper staining. Some of the atria show hyaline necrosis. In another section a large bronchus is completely plugged with a fibrinoums mass. Attached to this at the periphery are strips of the original epithelium surprisingly little altered. A single layer of flattened cells, many of them degenerated, line the bronchus. The lung tissue shows an extensive fibrinous and hemorrhagic edema very poor in cells. The consolidation produced in this way, though incomplete, is uniform and diffuse. The interlobular lymphatics are distended and contain fibrin clots.
NOTE.- A case of mustard-gas poisoning of six days' duration presenting the usual picture at autopsy. There was beginning epithelial regeneration in bronchi and alveoli.
CASE 38.- C. E. F., 2105082, Pvt., Co. H, 59th Inf. Died, August 15, 1918, 4.45 p. m., at Base Hospital No. 46. Autopsy No. 5, August 15, 11 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed with mustard gas August 8, receiving severe burns of face, eyes, chest, back, scrotum, penis, and extremities. Unable to talk above a whisper. Eyelids matted together. Foul, purulent discharge from nose. Blood pressure 160/85. Respiration 26, temperature 101, pulse 90, labored respiration. General large moist rales which began on right. Excursion greater on left. Slight flatness over both lower lobes. August 11, diarrhea with bloody involuntary stools, persisting until death.
Anatomical diagnosis.- Extensive burns (gas) of respiratory tract, skin, conjunctiva. Seropurulent conjunctivitis. Acute fibrinous and fibrinopurulent pharyngitis, esophagitis, laryngitis, tracheitis, bronchitis, larynx most marked. Bronchopneumonia both upper lobes. Acute fibrinous pleurisy, left. Acute lymphadenitis regional lymph nodes. Proctitis and colitis, ulcerative. Replacement fibrosis of testes. Cardiac dilatation slight. Pulmonary edema, considerable.
External appearance.- The body is that of a well-built adult male, 168 cm. long. Rigor present to a considerable degree in voluntary muscles. There is considerable hypostasis. The skin in general pale, slightly lemon tinged. There are large areas of ulceration of the epidermis over both buttocks, in the genital fold, backs of both elbows, right shoulder, right upper arm, both forearms, right and left hands. There is considerable ulceration of the epidermis of the scrotum and penis, and there is some matted seropurulent material there. A similar exudate is present over the ulcerated areas of the buttocks and the genital fold;
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elsewhere the ulcerated areas are covered by small amount of clotted serum. In the neighborhood of the ulcerated areas there is considerable desquamation of the epidermis. Eyes: The eyelids somewhat puffy, conjunctive edematous, deeply injected. There are small hemorrhages. Between the lids there is a small amount of caked mucopurulent secretion. Nose: Mucous membrane somewhat injected. In the nostrils there is mucopurulenit material. Mouth: There is some superficial ulceration of the membrane of the lips with slimy material covering the gums. Teeth: Show considerable erosion of the cutting edges. Neck: Somewhat full in thyroid region. Chest: Slightly flattened anteriorly; costal angle about 90 Abdomen: Contour normal.
Gross findings.- On opening thorax, no fluid, no adhesions in right sac. In left sac about 100 c. c. of slightly turbid yellow fluid. Heart enlarged somewhat to right, and on incision no abnormalities, except that there is less fluid present than normal. Heart: Normal. Right lung: Upper, voluminous; upper portion cushiony; inelastic; lower portion cushiony, soggy, solid. The middle lobe cushiony throughout. The lower lobe cushiony, soggy in addition; small solid patches palpable. Pleura thin and delicate everywhere; below it posteriorly a moderate number of small red hemorrhages. Pulmonary vessels, no abnormalities. Glands greatly enlarged, pulpy, edematous; most of them contain large coherent yellow opaque nodules encapsulated by firm, gray tissue. Bronchi show swelling and intense injection of the mucosa. There is a small amount of fibrinous and fibrinopurulent exudate in places. Upper lobe, on section, upper portion moist, pink; tissue contains a small amount of thin frothy fluid. Section of the lower portion of the lobe shows a very moist, pink and red surface. Air sacs contain a considerable amount of thin frothy fluid. In addition there are good-sized, solid, somewhat granular, dry, nonaerated, deep-red patches, varying in size up to 3 cm. in diameter; associated with these solid areas the bronchioles contain a considerable amount of fibrinous and tenacious fibrinopuruleiit exudate. These areas are just below the pleura. Middle lobe on section is well aerated. Air sacs contain a small amount of thin, frothy fluid. Lower lobe, on section, tissue in the upper portion pink medially, red posteriorly. There is a moderate amount of thin, frothy fluid in the air sacs. Posteriorly in the upper portion there are numerous deep-red hemorrhages, each several millimeters in diameter. Toward the lower portion of the lobe, the deep-red hemorrhages are more numerous. The tissue contains a moderate amount of thin, frothy fluid. Left lung: Both lobes are much more voluminous than normal, especially the upper. Pleura in great part glazed and covered by small amount of tightly adherent fibrinous exudate. The upper lobe cushiony medially, elsewhere soggy. In the mid portion there is an orange-sized, solid, deep-red patch, reaching to and involving the pleura; lower, cushiony soggy. The vessels and bronchi are similar to those in the right. Lymph gland considerably swollen, edematous, injected, and somewhat scarred. On section of the upper lobe, tissue is pinkish red. The air sacs contain a large amount of thin, frothy fluid. In the upper central portion of the lobe there is large, egg-sized, solid, patch relatively dry, granular, and airless. The bronchioles in this lobe toward the periphery show a considerable amount of fibrinous exudate within them. The lower lobe on section similar to the right lower lobe. No distinct, solid, patches; numerous hemorrhages. In this lobe the bronchi show intensely injected, swollen mucosa, with, however, very little exudate. Neck organs: The structures of the lower portion of the neck particularly, somewhat edematous. The glands throughout are considerably enlarged, pulpy, injected. Thyroids much smaller than normal. Tissue, spongy and pale. The acini contain but a small amount of colloid. The larynx presents a striking picture; almost completely filling the lumen, there is a large amount of gelatinous fibrinopurulent exudate. The mucous membrane greatly swollen, intensely injected, and covered by tightly adherent, gelatinous, fibrinopurulent exudate. The process is perhaps more marked over the true cords. The mucosa of the trachea is considerably swollen, intensely injected, covered in places by tightly adherent fibrinous and fibrinopurulent exudate. The upper portion of the esophagus and base of tongue show considerable edema of mucous membrane, with scattered patches of injection, in the neighborhood of which there is a moderate amount of tightly adherent, fibrinous, and fibrinopurulent exudate. Tonsils: Good size, show considerable amount of lymphoid tissue. There is some injection throughout. Alimentary tract: Lower portion of the esophagus, no abnormalities. Stomach shows considerable post-mortem change. Jejunum, ileum, and appendix: No abnormalities. Cecum and ascending colon show considerable diffuse edema of walls, especially of the mucosa. Beginninig in the hepatic
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flexure and continuing throughout the large intestines and rectum there is marked edema of the mucosa, with innumerable areas of ulceration, about which there is considerable injection, giving the gut a moth-eaten appearance. The ulceration extends into the submucosa. Overlying the ulcerated areas in most places there is an adherent fibrinous and fibrinopurulent exudate in considerable amount. The retroperitoneal and mesenteric glands are considerablh enlarged, edematous and pulpy, and injected. The remaining organs show no significant lesions.
Microscopic examination.- Trachea: Desquamation of the mucosa; islands of regenerating epithelium still attached here and there. Sections show no membrane or exudate and no inflammatory infiltration of submnucosa, which is intact. Lungs: (a) The greater portion of the slide presents the picture of an infected hemorrhagic infarct. There is necrosis of the alveolar walls, blood vessels, and bronchi, with much nuclear fragmentation and scattered colonies of bacteria. The blood cells in some areas are partially decolorized. Thrombi are not found, however. (b) The appearance is that of lung following suffocant-gas inhalation. There is intense alveolar and interstitial edema, partly fibrinous or hemorrhagic, alternating with areas of acute emphysema, in which the dilatation of the bronchioles and infundibula is a striking feature. The epithelium of the bronchioles is perfectly preserved; and there is no pneumonic exudate, although the alveolar capillaries show an increased number of leucocytes. Large intestine: Complete necrosis of mucosa, involving the subjacent tissue to a variable depth. The superficial vessels are plugged with hyaline and fibrinous thrombi. The deeper layers of the submucosa show an intense hemorrhagic and fibrinous edema, with a moderate lymphoid inflammatory reaction. The muscular coats are not involved. Testis: Coarse interstitial fibrosis, with groups of atrophic hyalinized tubules.
Bacteriological description.- Smears.--Trachea: Innumerable Grain-positive and negative bacilli and cocci. Lung: Very few organisms, rounded Gram-positive cocci. Cultures.- Trachea: Staphylococcus aureus, streptococcus nonhemolytic. Gram-positive and negative bacilli (few), aerobe. Lung: Staphylococcus aureus, streptococcus, Gram-negative bacilli (few), aerobe.
NOTE.-Death occurred seven days after gassing. The history and typical skin burns confirm the diagnosis of mustard-gas poisoning. The lesions of the upper respiratory tract were also typical. The lung lesion, however, differed in some respects from the usual picture. The intense hemorrhage, with infarct-like areas of bacterial necrosis were more like those of the later stages of influenzal pneumonia, although the case occurred at a time when there were few fatal influenzal cases coming to autopsy. Blocks from other portions of the lung showed only an intense edema and congestion, with intact bronchiolar epithelium, and taken by themselves would suggest a diagnosis of phosgene or other gas of the suffocative, rather than irritant or vesicant type. Another interesting feature in the case is the intense hemorrhagic and necrotic colitis, evidently an acute lesion developing after the gassing, and possibly referable to it.
CASE 39.- W. F., 3113960, Pvt., Co. E, 316th Inf. Died, October 16, 1918, 1.45 p. m., at Evacuation Hospital No. 6. Autopsy, October 17, 1918, 20 hours after death, by Capt. James F. Coupal, M. C.
Clinical data.- Mustard-gas burns and inhalation, incurred October 9.
Anatomical diagnosis.- Multiple superficial burns of body. Ulcerative tracheitis (acute). Bronchopneumonia. Acute fibrinous pleurisy.
External appearance.-Marked lividity and diffuse pigmentation over entire body. Burns of cornea, conjunctiva, face, scalp, penis, scrotum, buttocks, wrists, thighs, and knees.
Gross findings.- Heart normal. Pleural cavities: The left contains 100 c. c. of serosanguineous fluid. Right is negative. Lungs: Both are voluminous, alternately consolidated, edematous and congested, and yield, on section, quantities of dark blood and frothy mucus. Emphysema along the anterior margin. Base of tongue, pharynx, and larynx: Show beginning ulcerative inflamation extending into whole bronchial tree, with plugs of pus in finer bronchi. Trachea: Is denuded of mucosa, which lies in lumen as membrane. Abdominal viscera: Congested.
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Microscopic examination.- Tracheal epithelium is desquamated to the basement mem- brane. Here and there a single layer of squamous cells remain. No false membrane is included in the specimen. Corium shows edema, congested capillaries, and round cell infiltration, particularly near the congested capillaries. Lungs: Only one block preserved. There is practical occlusion of the small bronchi with dense fibrinopurulent exudate, the epithelium of which shows complete necrosis. There is a zone of fresh hemorrhage about the affected bronchi. Elsewhere no pneumonic exudation or edema except for thready coagulum in a few alveolar spaces. There is a diapedesis of red blood cells throughout the section. Skin: Probably of scrotum. The stratum corneum is desquamated. Cells in deeper portion of the epidermis are vacuolated. There is a slight edema of the corium. Section taken from skin of eyelid shows similar changes, the edema being more marked. Cornea: There is a desquamation of the epithelium of the anterior limiting membrane. Corneal cells and fibrils near the surface are separated, giving a reticulated appearance. Small intestine, liver, and kidneys show no significant lesions.
NOTE.- Typical case of mustard-gas poisoning dying on the seventh day after gassing. Although the protocol is not given in great detail and the histological material is inadequate, the case seems to have shown tracheo-bronchitis with membrane formation. The lung lesions appear to be limited to the vicinity of the bronchi, but only one block of tissue was available for study.
CASE 40.- W. B., 1430805, Pvt., Battery B, 102d F. A. Died, October 17, 1918, at 10.30 p. m., at Base Hospital No. 59. Autopsy No. 9. Autopsy, October 18, 11 hours after death, by Capt. M. Flexner, M. C.
Clinical data.- Exposed on night of October 9-10 to bombardment of 2,000 105-mm. and 150-mm. shells of mustard gas and chloropicrin. Masks removed prematurely, and soldiers slept in gassed area. Admitted to Evacuation Hospital No. 10 on October 12 with diagnosis of gas inhalation severe, conjunctivitis, scrotal burns.
Anatomical diagnosis.- Mustard-gas burns of eyes, nose, mouth, and genitals. Acute fibrinous pleurisy. Emphysema. Bronchopneumonia with miliary abscesses. Membranous and ulcerative tracheobronchitis.
External appearance.- Scabs of mustard-gas burns about eyelids, nares, mouth, and chin. Prepuce and scrotum badly burned. No other severe lesions.
Gross findings.- Pleural cavities: No fluid. Right lung: Shows a fibrinous pleurisy over the lower two-thirds of the upper, the entire middle, and lower lobes. On section there are scattered elevated flesh-colored and reddened areas of consolidation tending to become confluent at the base of the upper lobe. Thick yellow pius exudes from the bronchi and smaller bronchioles. Left lung: Also shows fibrinous pleurisy. On section there are similar areas of consolidation, in addition to which at the base of the upper lobe many rnilitary abscesses, from which a thick yellow pus exudes on pressure. These are from 3 to 6 mm. in diameter. Walls are roughened. Consolidated portions of the lung are dark red in color. The entire trachea, from the epiglottis down to the bronchial tubes, as well as the smallest visible branches are reddened and covered to a greater or lesser extent with a fibrino-purulent exudate, which varies in amount very markedly in different bronchi. In the pharynx is a slight redness and delicate white film. Same in the upper portion of larynx. Below the vocal cords is a heavy scaly membrane, white in color, which merges in the trachea into a mucopurulent exudate, which is less adherent. Mucosa is eroded. Peribronchial lymph nodes are swollen and edematous. The remaining organs show no lesions of interest.
Microscopic examination.- Large bronchus: Shows the entire bronchial wall edematous, congested and infiltrated with polynuclear leucocytes. Some of the epithelial cells persist or are in various stages of degeneration. Lungs: The alveolar capillaries are congested and contain an excess of polynuclears. The contents of the alveoli are a collection of fibrin and granular coagulum, in which there are large pigmented alveolar cells; some of them containing several nuclei, and moderate numbers of polymorphonuclear leucocytes. Pleura is covered with a recent fibrinopurulent exudate. The smaller bronchi are filled with pus. A second section of lung shows definite abscesses, possibly occupying the distended atria and surrounded by ecompressed alveoli filled with coagulated blood and serum. Liver: In some lobules the liver cells about the central veins are atrophic. Protoplasm shows fatty infiltration. A few cells are necrotic. Capillaries in these areas are congested.
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NOTE.- The duration of life after gassing was seven days. Although there is a history of exposure to both mustard gas and chloropicrin, the lesions do not differ from those found at this stage in cases exposed to mustard alone. There was no definite membrane formation in the upper respiratory passages, but much necrosis, hemorrhage, and fibrinopurulent exudate. The miliary abscesses in the lungs were probably an extension of the suppurative inflammation of the atria.
CASE 41.- J. T. A., 3106661, Mech., Co. D, 313th Inf. Died, October 18,1918,12.15 p. m., Base Hospital No. 15. Autopsy, October, 18,--hours after death, by Maj. Daniel J. Glomset, M. C.
Clinical data.- Gassed with mustard gas October 9 to 10, near Fresnes; 1,000 77-mm. shells used; exposed five and one-half hours; acute conjunctivitis and bronchopneumonia.
Anatomical diagnosis.- First-degree burns of head, neck, and scrotum. Membranous pharyngitis, tracheitis, and bronchitis. Focal pneumonia in left lower lobe, with patchy hemorrhages in both lungs. Marked congestion of abdominal viscera. There is no detailed description of the gross organs available.
Microscopic examination.- Trachea: Is lined with stratified epithelium, showing numerous mitoses (See fig. 30). Superficial layer is flattened and devoid of cilia. Subepithelial layer is not edematous and shows no leucocytic infiltration. There is marked congestion. Mucous glands are normal. Lungs: Some of the bronchioles are completely filled with loose fibrin plugs, in which are few polynuclears. Epithelium in places is flattened and evidently regenerating; in other places it is destroyed. The bronchial wall is thickened by marked fibroblastic growth. The parenchyma shows a patchy edema, which about the bronchioles is fibrinous and in some places hemorrhagic. There are desquamated pigmented epithelial cells in many of the alveoli. Another section, evidently taken from the "patchy hemorrhages" mentioned in the anatomical diagnosis, shows a very different picture. The alveoli are everywhere filled with a granular coagulum, more or less decolorized, red blood cells, and pyenotic leucocytes in small numbers, exfoliated and degenerating alveolar cells. The capillaries are filled with poorly staining red cells. There are many bacteria. Not only the alveolar epithelial cells but the endothelial and connective tissue cells showv degenerative changes, whether from the infection or the direct action of the irritant it is impossible to say. The changes are evidently not post-mortem because of the excellent preservation of the trachea and other portions of the lung. Probably an overwhelming streptococcal infection on the basis of local gas lesions.
NOTE.- After seven days there was a relining of the trachea with epithelium, which was nonciliated. The initial destruction of the epithelium was probably superficial. The lungs showed areas of hemorrhagic pneumonia, in which there was evidently intense infection and damage to the framework of the alveoli. In other areas the lesions were milder in type and regeneration of the alveolar epithelium was in progress. The walls of the small bronchioles were becoming thickened.
CASE 42.- H. B. M., 1786923, Pvt., Co. F, 316th Inf. Died, October 16, 1918, 7.30 p. m., at Base Hospital No. 59. Autopsy No. 8. Autopsy, 1012 hours after death.
Clinical data.- Gassed on October 9, 1918; inhalation and contact. Conjunctivitis. Signs of bronchopneumonia.
Anatomical diagnosis.- Superficial burns about the eyes and scrotum. Extensive hemorrhagic lobular pneumonia with infarct-like areas. Acute membranous tracheobronchitis.
External appearances.- Conjunctivitis with keratitis of both eves. Burns of lower eyelids. Healing burns about the scrotum. Large amount of reddish-brown fluid escapes from the mouth.
Gross findings.- Pleural cavities.-There is no fluid. There are a few adhesions between the visceral and diaphragmatic pleurae of the lower lobe. Heart: Right auricle and ventricle dilated and flabby; otherwise normal. Right lung: Shows a fine fibrinous deposit confined
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to the middle lobe. The lung is purplish or bluish-red in color with localized dark, reddish-black areas in the middle and lower lobe. On section, these are rather friable and firm. Some of them resemble infarcts. The remaining lung tissue exudes blood-tinged, frothy fluid. Left lung: Shows an even more intense edema. Otherwise is the same as the right except for older, more pinkish, patches of consolidation in the lower lobe. Larynx: In the region of the piriform sinuses shows a grayish necrotic membrane. The mucosa of the trachea is entirely necrotic, replaced by adherent grayish-yellow membrane. The underlying tissue is blotched with hemorrhages. Same condition obtains in larger bronchi. Lumina are filled with large amount of frothy, blood-tinged, purulent material.
Microscopic examination.- Trachea: There is a complete epithelial necrosis, involving the duct epithelium as well as that on the surface. There is no regeneration. There are shreds of adherent false membrane containing colonies of bacteria. There is intense filling of blood vessels of submucosa and deeper layers of connective tissue, with capillary hemorrhages. In places there is a beginning sequestration of the edematous and partially necrotic layer from the deeper tissue beneath. Mucous glands are flattened, atrophied, and in some places necrotic. There is very little cellular inflammatory reaction. Lungs: In some of the bronchioles, at least, the epithelium is well preserved. In other lumina there is an exudate; in some places serous and in others purulent and more hemorrhagic. Lung parenchyma shows areas in which alveoli are filled with exudate of leucocytes, red blood cells, and well-marked fibrin network, the adjacent regions showing edema or simply hemorrhage. Capillaries and veins are distended with blood. Many of the atria and alveoli are lined with a pink-staining hyaline band, which appears to be partly formed from the swollen basement membrane. Epithelium is not present. In some of the capillaries there are hvaline thrombi, apparently originating from the fused red blood cells. Another striking feature is the pyenosis of the leucocytes in the exudate and the relatively large percentage of mononuclear cells. Gram-safranine stain shows large number of Gram-positive streptococci.
NOTE.- Mustard-gas poisoning of seven days' duration. There was a complete necrosis of the bronchial epithelium involving the ducts of the mucous glands. There were therefore no reparative changes. There was an extensive hemorrhagic lobular pneumonia, more cellular and fibrinous than the usual influenzal type.
CASE 43.- L. K. J., Lieut., 120th Inf. Died, October 26, 1918, at Base Hospital No. 2, at 9 p. m. Autopsy, 13 hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- Exposed on October 19 to blue, green, and yellow cross shells. October 20, admitted to No. 47 Casualty Clearing Station. October 22, admitted to Base Hospital No. 2. Pyrexia of unknown origin in May, 1918. In hospital two months; has been well since. Now suffering from sore eyes, cough, pain in throat and chest; vomiting; has not eaten for three days. Physical examination: Well nourished; slight cyanosis; breathing with slight difficulty; eyes congested, lids swollen; nares discharging; pharynx congested. Heart normal. Lungs: Few bronchial rales, heard generally; fine moist rales at left base; resonance normal. Slight first-degree burns of axilla and thighs. October 24, condition unchanged. Profuse mucopurulent sputum. Fine moist rales at left base, no localized signs of consolidation. Sputum shows M. catarrhalis and pneumococcus, not typed. October 25, no improvement in general condition. October 26, much worse this morning. Cyanosis deeper. Respiration rapid, bloody sputum. Dullness marked in left axilla, extending posteriorly to left base. Distant bronchial breathing. Moist rales over both lower lobes. Pulse, 150. Died at 9 p. m.
Anatomical diagnosis.- Acute tracheolaryngitis and hemorrhagic bronchitis; diffuse lobular pneumonia, with marked edema and congestion; acute serous pleurisy; old pleural adhesions; poisoning by irritant gas, nature undetermined.
External appearance.- Quantity of blood is issuing from nostrils and a sanguineous froth from mouth. External genitalia apparently normal. No cutaneous burns. Slight pigmentation and dried exudate about corners of eyelids; conjunctive are normal.
Gross findings.- Pleural cavities: Right contains about 100 c. c. of blood-tinged fluid, left about the same quantity. There are fibrous adhesions over entire posterior and lateral surfaces of left upper lobe. Right lung: Moderately voluminous; grayish-red and purple
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color; pleura over middle and greater part of lower lobes shows fresh fibrinous exudate. Bronchi contain a quantity of bloody froth; their mucous membrane is deeply injected and hemor- rhagic. Blood vessels and glands at the hilum are normal. The lung has a lumpy consistence; all three lobes contain extensive areas of incomplete consolidation. The cut surface presents a blotchy reddish-gray and purple appearance, with some areas of a deep-reddish brown; the darker areas stand out somewhat from the surface, are of firmer consistence and almost airless. No evidence of infarction is present. Left lung: Is moderately voluminous, rather heavy; the upper lobe is covered with fibrous adhesions; the lower lobe presents a mottled appearance, the light-grayish areas being somewhat elevated but not firm, apparently emphysematous. The lower lobe is pretty diffusely consolidated, but contains a small quantity of air throughout and is flabby. The upper lobe on section presents the same characteristics over the lower half; the anterior and upper half are only slightly involved. There is a group of enlarged firmly calcified glands at the hilum. No acute pleurisy. Blood vessels normal. The bronchi display the same injection and diffuse hemorrhagic inflammation with very little exudate. The cut surface of the lung also has the same general appearance as that of the right, a mottled grayish-red and purple and deep red color with diffuse irregular and firmer areas of partial consolidation. There is a large quantity of sanguineous and serous exudate upon the surface. The smaller bronchi are microscopically normal. No exudate or plugs within their lumina are demonstrable. Organs of neck: Pharynx is rather deeply congested. Tonsils are small and scarred. Laryngeal surface of epiglottis reveals an acute membranoulcerative inflammation. There is considerable erosion of mucous membrane over vocal cords and a slight superficial necrosis of the mucous coat along the entire trachea, with a slightly granular looking exudate. A deep fiery injection extends down the trachea, becoming more intense at the bifurcation. Esophagus is normal. Thyroid gland is somewhat enlarged. Stomach normal. Intestines not recorded. Other viscera show no significant lesions.
Microscopic examination.- Trachea: Epithelium defective, save for a few unattached strips in which the cells are not much altered. The somewhat thickened basement membrane lies exposed, uncovered by inflammatory exudate. There is much hyperemia of the cerium, with slight diapedesis and a moderate accumulation of wandering cells, principally small mononuclears. The picture is not that of a severe necrotizing inflammation. Very few bacteria are found on the surface, none in the substance of the trachea. Lung: The capillaries throughout are filled with well-stained cells, and there are in places profuse alveolar hemorrhages. In addition the alveoli contain a faintly-stained shreddy coagulum, occasional pigment cells and lelcocytes, many of which are pycnotic and fragmented. The most interesting feature of the section is the lining of the walls of the alveoli and of the alveolar ducts, with a pink-staining, fibrinoid membrane, representing probably the hyaline necrosis of the alveolar epithelium plus the basement membrane. The remaining blocks of lung show in sections a similar picture, with one exception, in which there is an area resembling a hemorrhagic infarct, with beginning decolorization of the red cells and massive bacterial growth. The alveolar septa in these areas are necrotic. Sections stained with Gram-Weigert-safranine show practically but one type of organism, Gram-positive cocci, occurring in pairs, or more commonly groups, rarely in short chains, rounded and morphologically resembling a staphylococcus. Many of them are intracellular and partially decolorized. They are irregularly distributed, being more abundant where there is a leucocytic reaction, and very sparse or absent in the areas of simple hemorrhagic edema. Myocardium, liver, spleen, adrenals, thyroid, and pancreas show no significant changes.
NOTE.- A case dying seven days after a definite history of being exposed to a mixture of irritant and suffocant shell gases. The ocular lesions appear to have been very trifling, and no note was made at the autopsy of the "slight burns of thigh and axilla" recorded in the clinical history. The lesions of the upper respiratory tract were not sufficiently destructive, and their superficial character after seven days argues against exposure to mustard gas. The smaller bronchi showed only hemorrhage. There was widespread congestion, hemorrhage, and edema of the lungs, but no peribronchiolitis of the type so commonly associated with mustard gas. The inflammatory changes .were early and appeared to be associated with a staphylococcus, or mixed staphylococcus and streptococcus, infection.
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The case is certainly not characteristic of mustard gas, and the lesions are either to be attributed to a mixture of other irritant and asphyxiating gases or to the development of a severe influenzal pneumonia in an individual who had received very light mustard-gas injuries. The case illustrates very well the difficulties in interpretation which may arise.
CASE 44.- H. W. T. L., 88715, Pvt., R. A. F. 3 K. B. S. Died, October 28, 1918, at 4.30 p. m., at Base Hospital No. 2. Autopsy, four and one-half hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- October 21, admitted to No. 47 Casualty Clearing Station. Gassed and wound of right foot. October 22, admitted to Base Hospital No. 2. Generalized inflammation of the bronchi with signs most marked at left base; also many rȃles at right base. Severe scrotal burn. October 26, doing very poorly; right lower lobe practically useless; stifling inspiration sound; short and faint gurgle as expiratory sound. Outlook bad. Left chest filled with coarse and fine rates. Sputum: Direct smear-short Gram-negative bacillus is predominating organism. October 28, much more rattling in chest. Pulse, 120. Died at 5 p. m.
Anatomical diagnosis.- Extensive burns of skin; acute conjunctivitis; acute membranoulcerative pharyngitis, laryngitis, and tracheobronchitis; diffuse peribronchiolitis and bronchopneumonia; emphysema; acute fibrinous pleurisy; old pleural adhesions; acute peritracheal and peribronchial adenitis; congestion of abdominal viscera.
External appearance.- The skin has a dusky discoloration and is extensively desquamating; large areas of maceration and peeling of the epidermal layer over abdomen, chest, and thighs. There is much edema and erosion of the skin over the penis and scrotum and a good deal of moist exudate about the groins and inner aspects of the thighs. There is considerable pigmentation of the skin over the neck and face, a dusky purple discoloration about the eyes, the lids of which show some desquamation of the epidermis and rather marked injection and hemorrhagic inflammation of the conjunctive. There is bloody dried exudate in the nares; there are extensive erosions over the buttocks and back. Typically adenoid facies.
Gross findings.- Pleural cavities: Lungs in full inflation; there is fresh fibrinous pleurisy over a large part of the posterior surface of the right lung and a few chronic adhesions over base. There is a fresh adhesive pleurisy over lower portion of the lung and old adhesions at base. No free fluid in pleural sacs. Pericardium normal. Right lung: Quite voluminous, rather light, somewhat denser in posterior portion; does not collapse in the least after severing bronchi, and has a peculiar fluffy feel; grayish white in color anteriorly, blotchy red posteriorly. Almost the entire pleural surface is covered by very thin fibrinous exudate and the pleural vessels are injected. The apex and posterior half of the lung is perfectly aerated and soft; the tissue is air-containing throughout and of an almost homogenous consistence. The bronchi display considerable tightly adherent, rather elastic, semimucous exudate, which is purulent and slightly blood-streaked; the membrane is deeply injected and covered by an ulcerating, partly necrotic layer. There is comparatively small content of fluid in the larger bronchi. Blood vessels normal. Lymph nodes are slightly enlarged and acutely inflamed. On cut surface the lung presents a grayish-pink color with deep reddish-brown spots; surface is moderately moist but not in the least bloody; the dark areas are slightly elevated and somewhat firm; they surround small bronchi, which appear to contain small yellowish-gray plugs of exudate. Left lung: Presents the same general appearance as right, and is equally voluminous; bronchi contain the same kind of exudate. Upon cut section exactly the same picture is seem. The tissue is everywhere spotted by small dark areas of bronchopneumonia, surrounded by emphysema. Organs of neck.- Pharynx: Shows an acute ulcerative and membranous inflammation; the arytenoepiglotti-dean folds are considerably thickened and covered by a yellowish-gray membrane. Larynx: Is covered by membrane and froth; its mucous surface is considerably eroded. The upper portion of the trachea is pale in color; the mucous membrane is in a fair state of preservation; the lower half is deeply injected and covered by a patchy necrotic membrane. The peritracheal lymph nodes are somewhat enlarged and considerable congested. Esophagus: Normal. Thyroid appears normal. Intestines not recorded. Stomach and duodenum normal. Heart: Left chamber contracted, right flaccid. Remaining viscera show congestion, but no other significant changes.
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Microscopic examination.-No blocks of trachea and large bronchi. Lungs: The largest bronchus in the section is lined with normal epithelium showing hypersecretion of mucus. The lumen is filled with blood cells and leucocytes. Several smaller bronchi also contain blood and show an intact epithelial lining. The parenchyma shows very intense congestion, with areas of alveolar hemorrhage and emphysema. There is a little shreddy coagulum in some of the air spaces and a very moderate stasis of leucocytes in the capillaries and the interstices of the septal tissue. Very few have emigrated into the alveolar spaces. Another block shows a large infected thrombus filling a vessel, which is probably a distended artery; the wall, however, is thinned and infiltrated with leucocytes, so that it is difficult to be certain. The center of the thrombus shows suppurative softening and contains large masses of cocci (Gram-positive), which in some places line the necrotic wall of the vessel. The adjoining lung tissue for a distance of several millimeters is profusely infiltrated with hemorrhage. In this hemorrhagic zone are scattered bacteral masses about which the lung tissue is necrotic. A small bronchus included in this area contains a hemorrhagic purulent exudate, hut the epithelium is intact. The predominant organisms in the thrombus are: Grain-positive cocci, 1; in tetrads and groups, 2; in chains, probably staphylococci and streptococci. Myocardium: In the adventitia of a small artery is a loose collection of leucocytes, chiefly polymorphonuclear. No other lesions noted. Liver: Moderate fat infiltration. Adrenal: There are some interesting features. The cortical tissue is very edematous, the capillaries of the reticular zone congested. The cortical cells are not vacuolated. Many of them are in various stages of necrosis; others are deeply stained and give the appearance of regenerated cells. This is supported by the finding of numerous mitotic figures, especially in the deeper layers of the fascicularis and reticularis. The chromaffin staining of the medullary tissue is faint or absent in many cells. There are small groups of lymphoid and plasma cells in the medulla. In some areas of the cortex the cells have disappeared, being replaced by the edematous stroma; about the degenerating remains are leucocytes. Spleen: Pulp shows hemorrhages, is cellular, and contains a slightly increased number of polymorphonuclear leucocytes. Kidney: Intense congestion. In one block there are suppurative foci surrounding bacterial emboli in the pyramidal capillaries. There is hemosiderin deposit in the epithelial cells of the loops of Henle, such as is seen in chronic passive congestion. Small intestine: There is hemorrhage into the tips of the villi, with exfoliation (post-mortem ?) of the overlying epithelium. No thrombi, no inflammatory reaction.
Bacteriological report.- Blood culture (post-mortem): Pneumococcus, not typed. Lung culture (post-mortem) on blood agar plate, B. influenzae greatly predominates; few hemolytic streptococci, few staphylococcus aureus, few M. catarrhalis, Gram-positive and negative bacilli, undetermined.
NOTE.- Mustard-gas case of seven days' duration. The diagnosis is evident from the gross cutaneous lesions and the intense diphtheritic inflammation of the upper respiratory passages. The presence of an infected thrombus in one of the lung arteries and a suppurative lesion in the kidney suggest a generalized bacterial infection; the acute focal myocarditis further supports this view. Although pneumococci were recovered from the heart's blood at autopsy, it is doubtful whether these were responsible for the metastatic lesions. The source of the generalized sepsis is also uncertain. It may have been in the infected wound of the foot, which is recorded in the clinical history, though not described in the autopsy protocol. The lesions in the adrenal cortex are interesting and suggest a severe injury, with early regeneration. The hemorrhages in the intestine may be comparable to those produced by the intravenous injection of dichlorethysulphide in animals, or they may be associated with the very extensive skin burns.
CASE 45.- J. T., 552741, Pvt., Co. M., 38th Inf. Died, August 15, 1918, at 10.30 a. m. at Base Hospital No. 27. Autopsy No. 33, performed two and one-half hours after death, by Capt. H. H. Permar, M. C.
Clinical data.- Exposed to mustard-gas shelling on August 8. After passing through Field Hospital No. 6 and Evacuation Hospital No. 7, was admitted on August 12 to Base
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Hospital No. 27. August 14, diffuse large moist rȃles, especially on left side. Pulse, 132. August 15, many areas of high-pitched percussion noted; prolonged harsh respiration. Died at 10.30 a. m.
Summary of gross lesions.- Excoriations of skin of face, arms, buttocks, and genitals. Pleural cavities: Clear. Both lungs voluminous, weight (of each) 750 grams. Cut section shows marked edema with areas of peribronchial consolidation. The bronchi are filled with fibrinous exudate; there is loose membrane in the larger branches. Trachea and larynx: Ulcerated, partially covered with exudate. Circulatory organs: Negative. Old tuberculosis of peribronchial glands.
Microscopic examination.- Trachea: There is a continuous false membrane. In the areas where this is unattached, a single row of flattened epithelial cells is interposed. The submucosa is edematous but not congested. There is a striking paucity of leucocytes; the few that are present are fragmented and pycnotic. The epithelium of the mucous ducts is in active proliferation. Medium-sized bronchus: There is diphtheritic necrosis, with masses of bacteria in the lumen, and here and there early regeneration of epithelium. The outstanding feature is the copious hemorrhage in the walls of the bronchi and the adjacent alveoli. Lungs: Bronchioles are filled with plugs of fibrin, in which are masses of bacteria and nuclear detritus. There is profuse alveolar hemorrhage in the neighborhood of the bronchi. In other areas the exudate is rather fibrinous. There are very few leucocytes. Another block shows similar changes in the bronchi and peribronchial tissues. The rest of the lung is markedly emphysematous and anthracotic.
NOTE.- A case of mustard-gas poisoning of seven days' duration. There was the typical diphtheritic necrosis of trachea and bronchi. The pulmonary lesions were chiefly a fibrinous and hemorrhagic edema and appear to have been confined to the vicinity of the bronchi.
CASE 46.- H. S., 310789, Pvt., Co. E, 304th Eng. Died, 7.10 a. m., October 14,1918, at Base Hospital No. 52. Autopsy six hours after death, by Capt. M. Flexner, M. C.
Clinical data.- Gassed with mustard gas shells October 6. Admitted to Base Hospital No. 52 on October 8. For six days fever, rapid pulse, and respiration. Severe mustard-gas burns over face and upper part of body.
Anatomical diagnosis.- Mustard-gas burns on left side of face, neck, and scalp. Acute tracheobronchitis. Bronchopneumonia. Disseminated tuberculosis, both lungs with cavity formation at both apices. Cloudy swelling of kidney.
External appearances.- Burns over entire left side of face, ear, and neck, extending up to scalp. Scab formation with beginning healing in deeper areas, left ear particularly involved. Burns of first degree with vesicles on right hand. Occasional small vesicles on abdominal wall. No burns of penis or scrotum.
Gross findings.- Pleural cavities: There are a few old fibrous adhesions on both sides but no fluid. Right lung: At the apex there is a small calcified nodule one-half centimeter in diameter. At the base of the upper lobe is an area 3 to 4 cm. in diameter, grayish purple in color. The remainder of the lobe is mottled pinkish gray. Much fluid can be expressed. Middle lobe is normal. Pleura over the lower lobe is covered with a fine yellow layer of fibrin. Upper pole of the lobe is firm with scattered grayish areas varying in consistency from smooth caseous material to that undergoing purulent degeneration. Left lung: The pleural surface is dull. At the apex of the upper lobe is an old dimpled scar 4 cm. in diameter, beneath which on section is a cavity 2 by 3 cm. with fibrous thickened wall. Throughout the entire lower lobe are small calcified nodules. Lung tissue is purplish red in color with scattered irregular yellowish areas 2 to 5 mm. in diameter. A moderate amount of blood-stained fluid. Trachea appears red and congested. Peribronchial lymph glands are injected and pigmented. Heart: Normal. Stomach and intestines are "grossly normal." Kidneys show cloudy swelling. Remaining organs present nothing of interest.
Microscopic examination.- Trachea: On section, the epithelium is stratified, the lower layer of cells being columnar, the upper layers being polymorphous and generally polygonal. In another section, presumably a main bronchus, epithelimm is largely desquamated; it is composed of a single layer of polygonal or columnar cells, very ragged and irregular in their arrangement. Submucous layer is congested, somewhat edematous, and infiltrated with
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various mononuclear inflammatory cells, especially about the submucous glands. Lung: The parenchyma is the seat of an extensive pneumonic process, showing red cells, leucocytes, fibrin, and large mononuclear cells with pigment, etc. Capillaries are congested. In some areas there are large clumps of bacteria in the alveoli and the surrounding tissue is necrotic. One very extensive area of necrosis is associated with a thrombus in a branch of the pulmonary artery. There is no suggestion of tuberculosis in the three blocks taken. Skin: Under the intact epithelial layer there are pigment cells in the corium. Vessels are congested. In another part epithelium is congested and composed of two layers of polymorphous cells with layer of keratin above them.
NOTE.- So far as can be judged from the gross lesions and section, the injury to the upper air passages was slight and repair almost complete. There was an extensive hemorrhagic lobular pneumonia with areas of definite necrosis, in part associated with thrombosis of the vessels. Although from the gross description there were obviously a few obsolete tuberculous lesions at the apex, the histological studies show that there was no disseminated tuberculosis. The occasional areas described might correspond to the areas of definite necrosis. The extensive cutaneous burns confirm the diagnosis of poisoning by mustard gas. The duration of life was eight days.
CASE 47.- R. T., 113314, Pvt., Co. B, 150th M. G. Bat. Died, March 29, 1918, at Base Hospital No. 18. Autopsy No. 52. Autopsy, 21 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed in front-line trenches, March 21, 1918. Thirty minutes later his eyes became sore; after one hour vomited. At hospital at Luneville developed dry cough. On admission to Base Hospital No. 18 eyes closed, purulent discharge; pharynx much injected. Blisters on face, neck, and legs. Slight general glandular enlargement; harsh breathing and moist general riles. On March 26, signs of consolidation in left chest, dullness, tubular breathing, and rȃles. March 27, much tenacious sputum. General rȃles, harsh breathing with dullness, bronchophony, etc., below right scapula. Dyspnea and cyanosis. Temperature, 103; pulse, 120; respiration, 20 to 36.
Anatomical diagnosis.- First-degree mustard-gas burns of conjunctum, eyelids, nose, lips, wrists, axillae, buttocks, penis, scrotum. Membranous laryngitis, esophagitis, pharyngitis, tracheitis, and bronchitis. Purulent bronchiolitis. Bronchopneumonia. Pulmonary edema. Acute lymphadenitis of regional lymph nodes. Cardiac dilatation. Cloudy swelling of liver and spleen.
External appearance.- Cyanosis of face and scalp. There is considerable desquamation of the skin over the buttocks, to a less extent in the neighborhood of the armpits. Also some on the undersurface of both wrists, about both knees, and in both popliteal areas. There is extensive necrosis of the superficial layers of the epidermis with sheetlike shedding of this necrotic skin. Underlying base, quite clean and moist. A similar picture is seen over the central surface of the scrotum and under surface of the penis. There are also superficial burns about the nostrils, lips, and eyes. In these areas necrotic skin is covered by brown scabs. The necrosis extends a small way into both nostrils and a little beyond the line of closure of the lips. Both conjunctivai considerably injected, and over the left cornea there is a wedge-shaped area of grayish thickening a few millimeters in diameter. The eyelids are somewhat puffy. The pupils about equal, dilated 5 mm. The greater portion of the nasal and buccal mucosa is pale. Teeth and gums in fair condition. Chest, abdomen, and extremities, except for burns, natural looking. Over the buttocks and wrists there are areas of superficial ulceration. The bases clear. In the left lumbar region behind there is an area of superficial ulceration about 2.1 by 1.5 cm. covered by a dense brown-black scab. About this area there is a zone of desquamated superficial epidermis. There is considerable desquamation of the superficial epitheliuni of the scalp. No definite ulceration, however.
Gross findings.- Pleural cavities: On opening thorax pleural cavities show no abnormalitics. Heart: Is enlarged somewhat to the right. Weighs 400 grams. All chambers, particularly the left ventricle, moderately dilated. Dilatation most marked in the conus. No abnormalities except endocardium of the left ventricle diffusely thicker than normal. The myocardium is boiled in appearance. Right lung: Weighs 650 grams; left lung, 530 grains. All lobes voluminous and soggy. In addition in the right upper lobe a number of
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solid patches of good size are felt. Over one of these the pleura is slightly glazed, glistening everywhere else. The glands at the hilum greatly enlarged, pulpy, edematous, injected. The bronchial tree throughout shows almost complete necrosis of the epithelium. Only here and there are islands of intact mucosa observed. The underlying tissue is intensely injected, and in the smaller branches there are almost occluding fibrinous casts. In places the finer bronchioles contain viscid pus. This picture is present in all lobes. In addition there are scattered areas of whitish-yellow consolidation. In some places these solid patches are associated with atelectatic lung, in others there is no associated atelectasis. The solid areas, varying in size from grape seed to walnut, are most numerous in the right upper lobe. Some are present in the right lower. A few small patches only in the left lower and upper lobes. In addition all lobes contain a moderate to considerable amount of thin frothy fluid in the air sacs. The edema is most marked in the upper lobes. Between the lobes on the right there is a very small amount of fibrinous exudate. Here also there are a few small discrete red hemorrhages below the pleura. There is a moderate number of discrete recent sub- pleural hemorrhages between the left upper and lower lobes. Organs of neck: The anterior mediastinal, tracheal, and cervical glands, especially those in the lower portion of the neck, greatly swollen, edematous, injected. Thyroid, no abnormalities. Acini contain considerable colloid. The trachea and larynx show practically complete necrosis of the epithelium. In places the necrotic epithelium is gone, and in places it is present and readily strips. The underlying tissue intensely injected, especially marked lower down in the trachea. In the lumen there is some fibrinopurulent exudate. In the larynx, affecting the epiglottis and vocal cords true and false, in addition to the necrotic epithelium there is a considerable amount of caked fibrinous exudate. Epithelium and exudate strip fairly readily. The upper portion of the esophagus presents picture similar to that of the larynx. The posterior pharynx, especially about the uvula, similar in appearance. Tonsils are somewhat enlarged, buried, in part, scarred, in part pulpy. Many of the crypts contain viscid or caked purulent and necrotic material. Alimentary tract: In addition to the lesions in the upper esophagus there is considerable digestion of the mucosa of the lower portion and of the gastric mucosa. The lymphoid tissue of the tract slightly more prominent than usual. The large intestines considerably distended with gas as far as the splenic flexure. Adrenals: There is some diminution of the lipoid material in the cortex and in addition the vessels in the deeper layer of the cortex injected. In places there appear to be small hemorrhages. The meseteric glands are slightly enlarged, pulpy, pale. The remaining organs show no lesions of interest.
Microscopic examination.- Trachea: No preserved epithelium; surface formed by a wavy hyaline band. No exudate or membrane. Submucosa moderately edematous. Loose infiltration of polymorphonuclears, lymphocytes, and plasma cells. Glands show little alteration. Vessels dilated, few capillary hemorrhages. Very few bacteria on surface. Lungs: Bronchi present a variable picture. One shows in one place a thick adherent fibrino-purulent membrane, beneath which the epithelium is necrotic. On the opposite wall the bronchus is lined with a single layer of flattened nonciliated epithelium. (Fig. 30.) The picture in the alveoli is a complicated one. There are areas of lobular pneumonia, hemorrhagic in the periphery, which arc not especially distinctive. The leucocytes are fragmented. In the unconsolidated areas the alveolar septa are thick and cellular. The cells include relatively few polynuclears, but many large and small mononuclears, plasma cells, and a fair number of eosinophiles. In the alveoli are desquamated epithelial cells, entangled in a fibrinous matrix, over which the regenerated cylindrical epithelium is often growing. In some alveoli are sheets of cells with pale nuclei and indefinite outline, probably actively growing masses of epithelium. Some of the new cells are multinucleated. In other alveoli there is a structureless coagulum incompletely filling the space. A few cocci are present in the pneumonic areas, especially the somewhat dilated infundibuli. Elsewhere they are not found.
Bacteriological examination.- Smears of the bronchus show a large number of Gram- positive and negative diplococci; many tiny Gram-negative bacilli. Smears of the lung show a few Gram-positive diplococci. Cultures from the bronchus show Gram-positive cocci and numerous Grain-negative diplobacilli (influenza). Cultures from the lung show Gram-positive cocci, suggesting pneumococci.
NOTE.- Mustard-gas poisoning of eight days' duration. Typical lesions of skin and respiratory passages. Trachea had been cleaned of exudate.
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No epithelial regeneration in section examined. Bronchi showed early regenerative changes along with the remains of the injury and the supervening infection. Lung showed in some areas active bronchopneumonic lesions; in others, as in previous case, epithelium in the alveoli was being restored and the subsidence of the process is shown by the presence of lymphoid and plasma cells in numbers. Eosinophilic polynuclears were also found, with an edema which is apparently not related to the pneumonic infection.
FIG. 30.- Case 47. Mustard-gas burn, 8 days' duration. Longitudinal section of bronchiole, completely occluded by fibrinopurulent exudate. A few shreds of epithelium are still present
CASE 48.- W. G., 3322314, Pvt., Co. C, 109th M. G. Bat. Died, November 8, 1919. 9 p. m., at Base Hospital No. 87. Autopsy, November 9, 13 hours after death, by Lieut. H. H. Robinson, M. C.
Clinical data.- Detachment exposed to 1,000 mustard-gas shells and 400 blue and greet] cross shells on night of October 31, northeast of Xammes. Went to sleep in headquarters' dugout, 4 a. in., October 31. When he awoke the place was full of gas. Severe pain in eyes and chest; vomiting. Admitted to Base Hospital No. 87 the same day. Increasing bronchitis.
Anatomical diagnosis.- Conjunctivitis. Acute tracheobronchitis. Suppurative bronchiolitis.
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External appearance.- No cutaneous lesions. Edema of eyelids with crusts. Slight reddening of scrotum.
Gross findings.-Trachea: From epiglottis down, reddened and granular. Lungs: Minute foci of consolidation, with small areas of atelectasis and marked emphysema. Lumen of trachea and bronchi filled with greenish pus.
Microscopic examination.- Bronchi: The epithelium is intact; there is an albuminous exudate with leucocytes in lumen. Wall inflamed and infiltrated with polynuclear leucocytes. Lung: Small patch of beginning bronchopneumonia. Alveoli are air containing. Alveolar capillaries are congested and infiltrated with leucocytes (polvnuelear). Liver and kidney: Cloudy swelling.
Bacteriological examination.- Staphylococcus and streptococcus in cultures from lung.
NOTE.- Death occurred eight days after gassing. Nature of gas was somewhat uncertain. Conjunctivitis and reddening of scrotum suggest mustard gas, but there were no typical cutaneous lesions and the bronchi did not show the usual diphtheritic necrosis. The material and records of this case are incomplete.
CASE 49.- A. H. P., 2214110, Pvt., Co. G, 4th Inf. Died, August 4, 1918, 12.30 p. m., at Base Hospital No. 46. Autopsy No. 2. Autopsy, August 4, four hours after death, by Capt. Robert Benson, M. C.
Clinical data.- Patient's burns confined to lower extremities and scrotum. Considerable irritative effects of gas could be seen over entire body. Prognosis seemed favorable until 24 hours before death, when patient became delirious and finally toxic. The heart showed the effects of the toxemia and became definitely rapid and weak. Twenty-four hours before death patient had numerous illusions in which he imagined himself in the trenches performing very difficult tasks. At all times he was very restless and complained a great deal of pain about the various parts affected by the gas. Twelve hours before death patient's pulse became almost imperceptible and patient entered a state of coma from which it was almost impossible to arouse him. Restlessness continued until death.
Anatomical diagnosis.- Extensive first and second-degree burns of trunk, extremities and genitalia. Edema and congestion of lungs. Pericardial effusion. Cloudy swelling of liver and kidney.
External appearance.- Surface layers of epidermis denuded and underlying skin of deep red color over greater portion of right arm, upper three-fifths of left arm, greater part of back, nearly whole left flank of trunk, both buttocks, about half of each thigh, greater portion of right leg, portion of left leg, and over penis and scrotum.
Gross findings.- Pericardial cavity: Contains 75 c. c. of clear fluid. Both pleural and parietal surfaces show petechiam. Lungs: The anterior portion is normal; posteriorly, are dark reddish blue in color with many petechize. Bloody fluid exudes on section. Heart normal. Alimentary tract normal except for reddened duodenal mucosa. Left adrenal, dark red in color, almost black in places. Right adrenal, somewhat enlarged but normal in appearance. Trachea and bronchi, apparently were not examined.
Microscopic examination.- Lungs: Bronchial epithelium is intact. There is no exudate in the lumen. Alveolar capillaries are tortuous and congested. Slight epithelial congestion and hemorrhage, but no pneumonia. (Two blocks examined.) Adrenals: Show excellent preservation. There is no chromaffin staining of the medullary tissue (Zenker's fixation).
NOTE.- No precise data are given as to the date of gassing. Since he was admitted to base hospital on July 27, the duration of life after gassing must have been over eight days.
There are important omissions in the protocol and material for histological examination, since no mention is made of lesions found in the trachea and bronchi, and no sections of these tissues are available. The smaller bronchi showed an intact mucosa and no inflammatory or degenerative changes. The lung tissue itself was congested and edematous, but there was no pneumonia. So far as these findings go, they argue against mustard gas inhalation in lethal
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concentration, and this is borne out by the clinical history, which emphasized the mental symptoms, but does not record any respiratory complications. The cause of death in this case is therefore obscure, although the extensive skip lesions with characteristic distribution make it certain that the soldier had been exposed to mustard gas.
CASE 50.- R. P., 2214109, Pvt., Co.--, 4th Inf. Died, August 4, 1918, 10.15 a. m., at Base Hospital No. 46. Autopsy No. 1. Autopsy, August 4, three hours after death, by Capt. Robert Benson, M. C.
Clinical data.- On admission patient was found to have extensive burns over entire back and legs, involving both anterior and posterior surfaces of legs and scrotum. At first patient's appetite was fairly good and he was mentally rational, but patient was seen to be suffering from considerable toxemia. Later as toxemia advanced patient became irrational, stuporous. Temperature remained fairly high; heart action fairly good until 10 hours before death, when it became rapid and irregular. At this time patient became comatose and remained so until death.
Anatomical diagnosis.- First and second degree burns from chemical irritant. Pulmonary edema. Bronchopneumonia, left lower lobe. Pericarditis with effusion.
External appearance.- The skin is denuded over large portion of the body, namely, over left arm from wrist to shoulder, right forearm, whole of left flank, back of trunk. Surface epithelium in these areas is denuded and underlying skin of a deep crimson color. There are a few areas 6 to 8 mm. in diameter in which the deeper tissue is destroyed. Right lower leg and both buttocks are also affected. Skin over penis and scrotum is deep red and swollen but not denuded. Foreskin is greatly swollen but completely covers the glans.
Gross findings.- Pleural cavities: Lungs show no adhesions. There is no fluid in the ravities. Left lung: Is somewhat firm; over both lobes are areas of annular deep red spots 4 to 8 mm. Cut surface of lower lobe is reddish gray in color and large amount of fluid exudes. The upper lobe is similar but contains more air and is less firm. The pleura, especially in the areas between the lobes, is greenish and edematous. Right lung: Lobes on section, are reddish gray and exude a large amount of blood. Pericardial cavity: Contains fully 50 c. c. of thin watery fluid. A peculiar pungent odor is observed. Heart: Normal. Remaining organs show no significant lesions. Trachea apparently was not examined.
Microscopic examination.- Lung: Largest bronchus, in section shows practically coIn- plete necrosis of epithelium. Membrana propria is swollen and hyaline, resting upon a layer of new formed granulation tissue, infiltrated with polvmorphonuclear leucocytes and mononuclear leucocytes. In the lumen is an exudate containing numerous Gram-positive and negative cocci. Other bronchi contain an exudate but show a normal epithelium. Infundibula are somewhat distended and surrounded by areas of lobular pneumonia, with very little fibrin and cellular exudate of predominately polymorphonuclear leucocytes. There is marked congestion and patchy edema. Liver shows caryolytic changes in many of the cell nuclei.
NOTE.- A case similar in many respects to the preceding, and since the patient belonged to the same company, was admitted to hospital the same day and died on the same day, the duration of life after gassing was probably the same, namely, over eight days. The skin burns were very extensive, but no mention is made of ocular lesions. The findings in the trachea and bronchi are not given in the protocol and no histological material was preserved. Lung sections showed a bronchiolitis and a peribronchiolitis, the injury to the epithelium varying. Complete necrosis with membrane formation, such as one would expect to find at this stage of mustard-gas poisoning, was nowhere present. These two cases therefore differ somewhat from the usual picture: (1) Clinically, in the marked mental disturbance. (2) In the absence of ocular lesions. (3) In the relatively slight lesions of the lower respiratory tract. It is unfortunate that the records and material are incomplete. It is possible that in these cases the toxemia was comparable to that seen in burns involving
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a large part of the body surfaces. It is possible also that the patients were poisoned by some other irritant gas, possibly an arsene compound, and that the divergence from the usual picture is due to this. No evidence is at hand to decide the question.
CASE 51.- J. M., 2181256, Corpl., Co. A, 355th Eng. Died, August 16, 1918, Base Hospital No. 116. Autopsy No. 16. Autopsy, 10 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Mustard-gas inhalation and contact, incurred August 8, 1918. First degree burns of face, neck, scrotum, penis, and conjunctiva. On August 12, auricular fibrillations; coarse râles on both sides; labored respiration. August 14, restless and delirious. Last three days signs of bronchopneumonia; purulent sputum; pus and blood from nostrils; edema of face and eyelids.
Anatomical diagnosis.- Gas burns of skin, conjunctivae, lips. Acute fibrinous pharyngitis, esophagitis, laryngitis, tracheitis, and bronchitis. Acute peribronlchitis. Broncho- pneumonia. Pulmonary edema. Serofibrinous pleurisy. Acute fibrinous pericarditis.
External appearance.- Skin in general has a slightly bluish tinge, backs of hands, face to a slightly less extent, thighs and upper legs show a diffuse brownish pigmentation. Superficial areas of ulceration of epidermis of genital folds of scrotum and penis, about both lips, right nostril, over left eye, and under surface of both knees, where there is desquamation of the skin with apparently new epidermis belovw. There is considerable caked desquamation of the scalp, about the ears, chin, and also in the region of the superficial ulcerated areas mentioned above. Along the inner aspect of both thighs, at some distance from the ulcerated areas, there are numerous pinpoint to pinhead sized vesicles. Eyelids are edematous; there is a moderate amount of mucopurulent exudate between the lids. Conjunctiv e are injected with small dark-red hemorrhages. Moderate amount of mucopurulent exudate in nostrils.
Gross findings.- Thorax: Left pleural cavity contains 700 c. c. of slightly turbid yellow fluid in which are flecks of fibrinous exudate suspended. Pleural and pericardial adhesions on both sides. Pericardium: Both visceral and parietal layers swollen, diffusely injected, and covered by moderate amount of fibrinous exudate, binding the two layers together. Heart: Right side is dilated. Myocardium is opaque and flabby. Lungs: Right upper and lower lobes are much more voluminous than normal, cushiony, and soggy. In the lower lobe solid patches are palpable. The middle lobe more voluminous than normal, cushiony, slightly soggy. The lower lobe shows a congenital fissure 7 cm. long from the interlobar septum. Pleura posteriorly and between the lobes shows a small amount of fibrinous exudate. The glands at the hilum moderately enlarged, pulpy, edematous, injected, pigmented, show in places old scars. Bronchi: Mucosa is moderately swollen and intensely injected, covered in places by fibrinous and fibrinopurulent exudate. There is mucopurulent exudate and thin frothy blood-tinged fluid. On section, upper lobe, a moist pink surface presents. The air sacs contain a moderate amount of thin frothy fluid. The smaller bronchial branches contain a considerable amount of fibrinous and fibrinopurulent exudate, friable in places, and practically occluding the lumen. The walls of these small bronchioles show considerable injection, and the lung tissue about them likewise deeply injected for a small distance. In places in this lobe there is a small amount of peribronchial consolidation. The middle lobe on section presents a mottled pink and red surface. The air sacs contain a small amount of thin frothy fluid. The bronchi are similar to those in upper lobe in appearance. The changes, however, are not quite so marked. In the median portion there is an area of atelectasis. Lower lobe on section presents a mottled pinkish red and reddish purple surface. The bronchial changes are similar to those described above. About the bronchial branches there is considerable injection of the tissue, and toward the periphery there are numerous extensive areas of dull reddish-gray consolidation. Left lung: Upper lobe is much more voluminous than normal. Lower lobe somewhat collapsed. The vessels, glands, and bronchi similar in appearance to those on the right. On section of the upper lobe a pink and red surface presents. The air sacs contain a moderate amount of thin frothy fluid. The picture is quite similar to that of the right upper lobe. In this lobe, however, there are a few consolidated patches toward the periphery. The cut section passes through a large pulpy injected lymph gland with numerous soft and firm yellow opaque nodules, varying in size from less than a pinhead to a grape seed.
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The consolidation in this lobe is more marked in the lower portion. On section of the lower lobe the tissue is rubbery in consistency, poorly aerated, deep red. Bronchial tree shows a picture similar in general to those elsewhere. The pleura everywhere is glazed and covered by a large amount of fibrinous exudate. On stripping this exudate in places numerous injected vessels can be seen in the pleura. Neck organs: Glands through neck considerably enlarged, pulpy, edematous, deeply injected, especially those in the lower portion. Thyroid: Of good size, spongy, and gelatinous. There is a moderate amount of colloid in the acini. Larynx: There is marked swelling and injection of the mucosa, with small areas of ulceration, especially about the true vocal cords. Within and adherent to the mucosa there is consider- able amount of fibrinous and fibrinopurulent exudate. In the trachea the change is less marked. The mucosa is swollen, intensely injected. There are scattered small flecks of yellow opaque exudate. In the lumen there is much mucopurulent and some thin frothy blood-tinged fluid. The posterior plharyngeal wall and upper esophagus adjoining the glottis shows considerable edema and injection of the mucosa; covering the mucosa in several places there is a moderate amount of adherent fibrinous and a small amount of fibrinopurulent exudate. Tonsils: Right tonsil not removed. Left tonsil somewhat swollen. On section considerable pulpy, edematous, injected, lymphatic tissue present. Crypts, clean. Alimentary tract: No abnormalities of esophagus other than those mentioned above. Stomach contains a small amount of mucus. The mucosa in the fundus is somewhat swollen. The duodenum, the jejunum, and the ileum, no abnormalities, except that the lymphoid tissue is more prominent than normal. Appendix, cecum, colon, rectum, no abnormalities. The remaining viscera show no significant lesions.
Microscopic examination.- Trachea and large bronchi: No material preserved. Lung: (Block A) Picture is that of late lobar pneumonia. Alveoli are filled with exudate in which there are many fragmented leucocytes and fibrin. Capillaries are thin, collapsed, and empty. Some alveoli are being relined with irregular syncytial growth of epithelium, amongst which are large cells with pale nuclei. (Block B) Intense hemorrhagic edema and epithelial desquamation. Bronchi are distended with solid plugs of exudate. Epithelium completely necrotic. (Block C) Smaller bronchi are the seat of an intense necrosis, often with fibrinous membrane formation. Peribronchial exudate with much fibroblastic activity, especially in the thickened septa. Alveoli contain an exudate which in places is fibrinous, in others hemorrhagic, and others serous. There is not much epithelial proliferation. Atria are filled with purulent plugs. There is an edema of the interlobular septa. (Block D) Evidently taken from the left collapsed lobe, showing usual picture of atelectasis. It is interesting that the bronchi in section show very slight changes, their epithelium being preserved and their lumina free from exudate. Myocardium: Recent acute fibrinous pericarditis. Liver, spleen, and kidneys normal.
Bacteriological examination.- Smears from exudate on right side of larynx show innumerable Gram-positive and Gram-negative cocci. Smear from consolidated lung show few Gram-positive cocci, most in diplococcus formation.
NOTE.-Typical mustard-gas case, of eight days' duration, with multiple skin burns and diphtheritic necrosis of the larynx, trachea, and bronchi. There was complicating serofibrinous pleurisy and percarditis. It is worthy of note that the bronchial lesions in the atelectatic lobe were less severe than elsewhere. The focal areas of pneumonia were not of the influenzal type.
CASE 52.-P. B., 113251, Pvt., Co. B, 150th M. G. Bat. Died, March 29, 1918, at Base Hospital No. 18. Autopsy No. 53. Autopsy, 20 hours after death, by Lieut. B. S. Kline, M1. C.
Clinical data.- Gassed on March 21, 1918. On same day, smarting of eyes, burning and blistering of scrotum, and following morning vomiting. Night of 22d, pain in chest and coughing. On admission, severe conjunctivitis. First degree burns of buttocks, thighs, and legs 5 cm. below knee. Anteriorly from patella up to scrotum and perineum. Severe burns of hands and fingers and forearms. March 28, burns healing nicely, but patient appears intoxicated. Acetonuria, March 29, semidelirious.
Anatomical diagnosis.- Second-degree mustard-gas burns of skin over thighs, buttocks, hands. Conjunctivitis. Acute pharyngitis, esophagitis, laryngitis, tracheitis, and bronchitis. Bronchopneumomia. Marked pulmonary edema.
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External appearance.- There is considerable hypostasis, with, cyanosis of the face and extremities. From the level of the symphysis downward anteriorly and posteriorly the greater portion of the skin of the thighs shows almost sheetlike necrosis, desquamation, and ulceration, which extends in places a small way into the subcutaneous tissue. The base shows patchy injection, and especially toward the genital fold there is a moderate mount of moist, foul-smelling exudate. The penis and the scrotum show necrosis of the epithelium with superficial ulceration. There are well-marked areas of ulceration over both buttocks. The burn continues down and involves the popliteal area. The most extensive ulceration is present over the backs of the hands and undersurface of the wrists, where the subcutaneous tissue is involved. The epithelium over the dorsal surface of the wrists, hands, and to a less extent left forearm is gone entirely. The base of the denuded tissue shows considerable injection. There is a moderate amount of exudate over the wrists. On the left the base is quite dry, brown. There is some desquamation and superficial ulceration of the left forearm. No involvement in the axillae . Slight involvement of the eyes, especially the left. Conjunctiva on this side moderately injected. Corneae show slight milky thickening. There is a small burn at the left angle of the mouth. There is some desquamation of the epidermis over the abdomen, but no ulceration. Left leg and left foot show few areas of necrosis of the epidermis without ulceration, however. Nose: The mucosa is somewhat swollen, slightlv injected. Mouth: There is superficial ulceration of the lips along the line of closure. The buccal mucosa beyond, however, pale, apparently uninvolved. Gums in fair condition. A number of teeth poorly formed.
Gross findings.- Both pleural cavities: Free from adhesions. Each contains a few centimeters of fluid. The heart is enlarged somewhat to the right. Heart: The right auricle and ventricle moderately dilated. Myocardium is boiled, slightly greasy. No valvular lesions. Right lung weighs 655 grams. Pleura thin and glistening in great part. Over the posterior portion of the left lower lobe, however, it is dull gray, and there is a very small amount of fibrinous exudate. Below the pleura, especially posteriorly, there are innumerable discrete and in places confluent hemorrhages varying in size from one to several millimeters. All lobes are quite voluminous, especially both lowers and the posterior portion of the uppers. These areas are soggy in great part. Glands at the hilum are moderately enlarged, pulpy, edematous, injected. The bronchial tree toward the hilum shows considerable diffuse injection of the mucosa without outspoken ulceration. In the lumen there is some frothy blood-tinged fluid and some mucopurulent material. In the smaller bronchial branches, especially in the posterior portion of both lower lobes, there is a fibrinopurulent exudate present, and in the posterior portion of both upper lobes to a less extent. In the tipper lobes there are numerous patches of consolidation, deep red, dry, granular, varying in size from pinhead to walnut. In addition both lower lobes and the posterior portion of both uppers show a large amount of thin, frothy fluid in the air sacs. The right middle lobe is relatively uninvolved. The cut surface is pink. Organs of neck: The mediastinal and tracheal glands are moderately enlarged, pulpy, and edematous. Thyroid: Of average size, pale. Acini contain a moderate amount of colloid. The neck organs present a striking picture. There is moderate necrosis of the epithelium of the posterior pharynx, upper portion of the esophagus, larynx, and tipper portion of the trachea. Associated with the necrosis there is a membranous exudate having a necrotic greenish appearance. Throughout the larynx and trachea there is considerable injection and swelling of the mucosa with no ulceration. In the ulcerated area the base is well in the mucosa. Tonsils fair size, buried, in part scarred. The crypts in general are clean. Alimentary tract: There is pigmentation of the solitary follicles and Peyer's patches. No ulceration or hemorrhage. Liver enlarged and fatty. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: Epithelium is lost and no pseudomembrane is present. Submucous layers are congested, edematous, and infiltrated with round cells. Lungs: Parenchyma is very much congested. There are areas where the alveoli are filled with red blood cells, and the alveolar walls are necrotic. There is no inflammatory exudate. Bronchial epithelium is preserved. No exudate in the lumina. Liver and kidneys show parenchymatous degeneration.
Bacteriological examination.- Smears of exudate from the trachea show innumerable mouth organisms. Smears of the exudate from the lung show large numbers of Gram-positive diplococci, lancet-shaped. Culture of exudate from trachea shows Gram-positive diplococci and tiny Gram-negative influenza bacilli.
NOTE.- Duration of life after gassing was eight days. Lesions of the respiratory tract were not typical of mustard-gas inhalation. Absence of
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necrosis in trachea and large bronchi, and simple congestion and hemorrhagic edema of lungs without inflammatory changes did not conform to the usual pictures. Histological material was inadequate, but the clinical and gross findings were sufficiently characteristic to justify a diagnosis of mustard-gas poisoning. The marked post-mortem changes in the adrenal and kidney, and other organs made the interpretation of the findings in these organs difficult.
CASE 53.- L. P. G., 91249, Pvt., Co. K, 165th Inf. Died, March 29, 1918, at Base Hospital No. 18. Autopsy No. 50. Autopsy, four hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on March 20 and 21. On admission severe conjunctivitis (blindness). Many small blisters on wrists and hands. Forehead hyperemic. Superficial burns of scrotum and inner aspect of thighs. Generalized coarse râles. March 25, eyes better. Temperature elevated. Increased râles, cyanosis. March 27 and 28, bloody sputum, bronchovesicular respiration left axillae, dyspnea, and increasing rales.
Anatomical diagnosis.- Mustard gas burns of conjunctivse and scrotum. Fibrinous and fibrinopurulent esophagitis, laryngitis, tracheitis, and bronchitis. Purulent bronchiolitis. Extensive bronchopneumonia. Acute fibrinous pleurisy. Pulmonary edema.
External appearance.- There is considerable hypostasis; marked cyanosis of left side of face and scalp, less marked in lips and right side of face. Over the proximal portion of the upper and lower extremities, especially in the folds, there is much scaling of the epidermis and numerous groups of pinpoint to pinhead sized vesicles, filled with transparent fluid. This condition is present also over the upper and lower back and is most marked on the backs of the hands, scrotum, and penis, where there are outspoken first-degree burns. There are several superficial ulcerated areas covered by scabs about the lips. Superficial glands are palpable. Eyes: The right pupil is larger than the left, 4.5 mm.; left, 3 mm. Bulbar and palpebral conjunctive somewhat swollen, show extensive patchy injection, and on the left side particularly there are good-sized deep red hemorrhages below the conjunctivae. The lids are somewhat puffy and glued together by caked exudate. Nose: Both nostrils contain clotted blood. Mucosa not appreciably swollen, but pale. Mouth: Teeth in fair condition. Gums quite clean. Buccal mucous membrane pale, apparently uninvolved.
Gross findings.- Pleural cavities: A few cubic centimeters of fluid in each pleural sac. No fibrous adhesions. Heart enlarged somewhat to the right. Heart: Weighs 375 grams. The heart is somewhat enlarged. The tricuspid and pulmonary rings moderately stretched. The conus is greatly dilated. Left ventricle moderately dilated. Valvular endocardium, no abnormalities. Chambers contain large elastic clots. Lungs: Right, weighs 630 grams. Left, weighs 475 grams. All lobes are moderately voluminous. Upper and middle lobes cushiony, somewhat soggy. The lower lobes soggy and solid. Covering both lower lobes posteriorly there is a moderate amount of fibrinous exudate. In these regions and also in the interlobar areas there are numerous subpleural pinhead sized red hemorrhages. Glands at the hilus on each side greatly enlarged, pulpy, edematous, moderately injected, some areas show scarring. The bronchial tree throughout presents a striking picture. There is practically complete desquaination of the epithelium. The submucosa is apparently injected and covered by a layer of friable to elastic coherent light whitish-yellow exudate, in the larger bronchi over 1 mm. in thickness. These fibrinous masses form a large cast of the bronchi and are readily stripped from the walls. The process is most marked in the lower lobes, is present also in the right upper and middle, and less marked in the left tipper lobe. In the finer bronchioles of all lobes, but most marked in both lowers and the right upper, the exudate is viscid purulent, rather than fibrinous. Associated with some of these areas of purulent bronchitis there are patches of gravish red consolidation of the lungs. These areas of consolidation are most numerous in the lower lobes, perhaps more numerous in the left than the right, and here they vary considerably in size up to large walnuts. In addition all lobes, especially the lower, show a moderate amount of thin frothy fluid in the air sacs. Organs of neck: The cervical and tracheal glands are considerably swollen, pulpy, edematous, apparently injected. Thyroid, no abnormalities. Larynx and trachea present a striking picture, the edematous, practically entirely gone. Attached to the underlying submucosa which lines the considerably injected lower portion of the trachea there is a layer of exudate,
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riable and elastic, like that in the bronchi and about 1.5 mm. in thickness. This exudate practically forms a cast of the trachea and of the greater portion of the larynx. Both vocal cords are covered. There are, however, several islands uncovered by exudate in the larynx. The exudate is coherent and strips quite readily in one mass from the walls. The process is quite similar at the base of the tongue and at the upper portion of the esophagus down to the level of the mid-portion of the thyroid cartilage. Tonsils, buried, cryptic, and somewhat scarred, in part pulpy. Crypts in general clean. Alimentary tract: There is some suggestion of pigmentation of the pharyngeal epithelium in patches in the mid-portion. There is considerable digestion of the gastric mucosa and toward the pylorus, apparently ante-mortem, small hemorrhages below the mucosa. No other abnormalities in the tract. Mesenteric glands are somewhat swollen. The remaining organs show no significant lesions.
Microscopic examination.- Trachea: There are patches of a very thick fibrinopurulent membrane still adherent. The injury to the subepithelial connective tissue has been very deep in some places extending almost to the cartilage. In other places, the preserved tissue is thicker, but edematous, and hemorrhagic, with exudate of fibrin and polynuclears. In those areas where the destruction was greatest, the mucous glands have practically disappeared, only a few atrophic acini remaining. The original epithelium has doubtless been destroyed, buta new layer of flattened and highly atypical cells, apparently derived from the mucous ducts, is interposed in places between the edematous subepithelial connective tissue and the overlying membrane. The new cells are pale and hydropic; many of them have pale nuclei of excessive size. Bronchi: The changes are like those in the trachea. The lumen of one of the larger branches is almost obstructed by the thick partly detached membrane. The wall of the bronchus is thickened by inflammatory changes, but in the deeper portions between the cartilage rings there is active growth of new connective tissue. There is almost complete reinvestment with atypical flattened epithelial cells like those in the trachea, but they seem to be leading a precarious existence, many of them showing evidence of degeneration. Some of the medium sized bronchi are greatly thickened by an active growth of granulation tissue about them. This fuses into the organizing tissue about the arteries, where they are juxtaposed. There is no obvious dilatation. Organization of the fibrinous exudate in the edematous interlobular septa is also in progress, many fibroblasts and occasional new forming vessels being found. Parenchyma: There are confluent areas of lobular pneumonia. The exudate contains many well preserved polynuclears in places mixed with fibrin or coagulated serum. It is not hemorrhagic. There is no organization and no obvious epithelial proliferation. The bronchioles and atria are lined with well preserved, though often desquamated, ciliated cells. They are filled with purulent exudate.
CASE 54.- R. G., 93377, Corpl., Co. D, 166th Inf. Died, October 8, 1918, at Justice Hospital, Toul. Autopsy No. A-8. Autopsy, October 8, - hours after death, by Capt. Jean Oliver, M. C.
Clinical data.- Gas intoxication, mustard-gas, severe, incurred October 1.
Anatomical diagnosis.- Second degree burns of eyes, mouth, and scrotum. Fibrinopurulent tracheitis, bronchitis, and bronchopneumonia. Marked hyperemia and edema of the lungs.
A full autopsy report is not available. The following is a description of the gross specimens received at the experimental gas field.
Gross findings.- Left lung: In the upper lobe there are small groups of abscesses beneath the pleura with overlying fibrinous pleurisy. Bronchi to these areas show slightly dilated lumina and in the terminal portions are less severely injured than the larger bronchi. There is no extensive false membrane. Lower lobe shows lobular pneumonia with beginning pleurisy. One bronchus shows thickened opaque mucosa (squamous epithelium ?). Right lung: Shows scattered areas of fibrinous pleuritis. Necrosis of bronchial epithelium and false membrane do not extend beyond the second branching, outside of which the mucosa is both hyperemic and smooth. Lumina contain fibrin plugs. There is marked patchy edema, and hemorrhage and atelectasis about the smaller bronchi.
Microscopic examination.- Trachea: The epithelium is desquamated and necrotic. The denuded surface is covered with necrotic pus cells and fibrin. Larger bronchi: The surface epithelium is wholly lost. Bronchus is lined with necrotic material upon which are flakes of adherent slough. Superficial tissue is elsewhere invaded with polynuclears, the nuclei of which become progressively fragmented as they approach the surface. Bacteria are
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chiefly Gram-positive cocci, which are plentiful on the surface and in the adherent slough. The submucosa is edematous and infiltrated with wandering cells, among them many polynuclears and many fibroblasts. Vessels are intensely congested, not thrombosed. Mouths of the ducts of the mucous glands contain exfoliated cells. Cells lining the ducts are of the flat squamous type and tend to creep over the adjacent tissue. Adherent lymph node shows caseous foci. Inflammation of submucosa extends between the cartilages to involve the periglandular areolar tissue. There is much inflammatory exudation, fibrin, etc., and a focal area of suppuration in which no bacteria are demonstrable. Medium-sized bronchus: Is lines with membrance composed of dense layers of leucocytes enmeshed in a fibrin network. Bacteria, chiefly Gram-positive cocci, in small groups (staphylococcus) are abundant throughout this layer. The bronchial wall itself is edematous and shows inflammatory infiltration. The adjoining alveoli are filled with dense plugs of fibrin, passing over from one alveolus to another. In it are a few desquamated alveolar cells and leucocytes. External to this, the alveoli are collapsed and there is abundant hemorrhage. Lung: The epithelium of the terminal bronchioles and infundibula is well preserved. There is a great variety in the contents, as in the alveoli. In some alveoli, the exudate is more or less homogeneous. In others the coagulum is mixed with fibrin, red blood cell, etc. Some alveoli are filled with desquamated pigment-containing cells. Capillaries are congested. There is no periarterial edema. Section through eyelid: There is a superficial desquamation of the epidermis at the junction of the epidermis and mucous membrane. There is partial necrosis with edema, hemorrhage, and leucocytic infitration of the underlying corium. The hair follicles show varying degrees of necrosis.
NOTE.- The duration of life after gassing was eight days. Findings were typical of severe mustard-gas burns of skin and respiratory passages. There were very early attempts at regeneration in the trachea and lungs. The lungs showed suppurative foci and in one area there was slight bronchiectatic dilatation.
CASE 55.- W. B., 1025112, Corporal, Co. G, 34th Inf. Died, November 8, 1918, at Base Hospital No. 87. Autopsy No. 5. Autopsy, November 9,--hours after death, by Maj. M. C. Farr, M. C., and Lieut. H. H. Robinson, M. C.
Clinical data.- Severely gassed with mustard gas on October 31, 1918. Symptoms began with dyspnea and vomiting. Later, moist bubbling rȃles throughout.
Anatomical diagnosis.- Slight mustard-gas burns of scrotum. Estensive pigmentation. Fibrinous and necrotic pharyngitis, laryngitis, and tracheitis. Purulent bronchitis. Peribronchial pneumonia. Acute fibrinous pleurisy. Intense edema and congestion of lungs.
External appearance.- There is deep brownish pigmentation of skin of face, neck, scalp, shoulders, back, and flexor surface of arms. There is an apronlike patch over the abdomen and a triangular area with apex downward at pubis, extending over genitalia and anterior aspects of the thighs. There are some slight erosions and thickening of the skin over scrotum.
Gross findings.- Pleural cavities: There is no free fluid. There are a few fresh adhesions over the right lower lobe. Heart normal. Lungs: Are voluminous and heavy, and do not col- lapse. Firm and elastic on palpation, especiaUy at the bases. On section, of a uniform appearance. Diffuse copious edema. No definite pneumonic areas. Drops of pus can be expressed from the bronchioles. There are patches of fibrin over the posterior surface of both upper lobes and over the entire right lower lobe. Organs of neck: Tonsils are scarred and fibrous. Pharynx is reddened and there are a few small necrotic membranous patches. Epiglottis, larynx, trachea, and bronchi are covered with an adherent necrotic membrane, somewhat patchy in its distribution. Alimentary tract normal. The remaining organs show no lesions of interest.
Microscopic examination.- Trachea: The epithelium is completely destroyed. There is a pseudomembrane consisting of fibrin network in which are numbers of polynuclear leucocytes and in some areas numerous bacteria. Submucous layers are edematous, vessels are congested, and there is infiltration by polymorphonuclear leucocytes and a few lymphoid cells, even as deep as the submucous glands. No metaplasia, regeneration, or fibrosis. Larger bronchi: Show the same lesions as the trachea. There is marked peribronchial inflammation with hemorrhage and fibrinous exudate in the alveoli. Terminal bronchioles
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show an intact epithelium, which, however, is invaded by leucocytes. There is pus in the lumina. Lungs: Show marked dilatation of the terminal bronchioles and infundibula, many of which are completely filled with loose fibrinopurulent exudate. There are strips of apparently well-preserved epithelium lying detached in the exudate or partially investing the walls of the bronchioles. In some bronchi, the necrotic lining is replaced by vascular granulation tissue. The alveolar exudate is of varying composition. There are areas which are emphysematous but entirely free from pneumonic changes. The peribronchial character of the consolidation is very evident. There is no periarterial or perivascular edema.
Bacteriological report.- Cultures from trachea and lungs yield staphylococci and unidentified bacillus.
NOTE.-Typical mustard-gas case of eight days' duration. Extensive diphtheritic necrosis of trachea and bronchi. Characteristic peribronchial lesions, and rather widespread edema. There was an early fibrosis of the bronchial walls and no epithelial regeneration.
CASE 56.- R. L., Pvt., 2088261, Co. A, 355th Inf. Died, August 17, 1918, at Base Hospital No. 42. Autopsy No. 1. Autopsy, August 18, 24 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Exposed to heavy shelling for 6 hours with yellow, blue, and green cross shells on August 8. Admitted to Field Hospital No. 325, with diagnosis "Gas inhalation, delirious, burns of eyes and genitals." On admission to Base Hospital No. 42, diagnosis of diffuse bronchitis, followed by bronchopneumonia. Respiration labored, inspiration and expiration prolonged. Temperature 103.6°
Anatomical diagnosis.- Extensive gas burns of skin and superficial mucous membranes, conjunctive, lips, and respiratory tract. Membranous and fibrinopurulent pharyngitis, esophagitis, laryngitis, tracheitis, and purulent bronchiolitis. Extensive peribronchial pneumonia. Acute fibrinous pleurisy. Pulmonary edema, marked. Cloudy swelling of liver and kidney. Lymphoid hyperplasia of spleen, intestines, and lymph nodes. Adenomata of thyroid gland.
External appearance.- The skin of the penis and scrotum shows considerable ulceration of the epidermis, associated with desquamation in the neighborhood. The base of the ulcers covered with some soropurulent exudate. The skin about the nose and lips shows considerable ulceration, the base covered by a thick brown scab. There is a similar burn of the mucous membrane of the lips, especially the lower, covered with a thick brown scab. At the bend of both elbows and on the inner aspects of both thighs there are many pinpoint to pinhead sized vesicles filled with clear fluid. No ulceration of these areas. There is a however, some desquamation of the skin. A similar picture presents in both axillae. Eyes: In the skin of both upper lids there are a few superficial ulcerated areas covered by red-brown scabs. The bulbar conjunctivae are somewhat edematous, considerably injected. There are scattered small deep red hemorrhages. Over the cornea there is a small amount of muco-purulent exudate. Pupils: 4 mm. in diameter. Ears: No abnormalities. Nose: The superficial ulceration extends into both nostrils, affecting the mucous membrane for a distance of 1 cm. on each side. The ulceration is covered by a brown scab. Mouth: Teeth in fair condition. Some slimy, cheesy material over the gums.
Gross findings.- Pleural cavities: On opening the thorax, the right pleural cavity contains about 30 c. c. of slightly turbid yellow fluid. There is a small amount of fibrinous exudate over all lobes. In the left pleural cavity about 15 to 20 c. c. of similar fluid. Heart enlarged slightly to the right, right border reaching almost to the costochondral line. On incising the pericardium there are no abnormalities in sac. The parietal pericardium toward the right lung shows a number of tiny deep-red hemorrhages. Heart: Weighs 325 grams. Right auricle and ventricle dilated. Left ventricle and auricle contracted. Otherwise, normal. Right lung: Middle lobe is imperfectly formed. There is no fissure medially separating it from the upper lobe. All lobes are voluminous. The upper lobe and upper portion of the middle are cushiony and inelastic. The lower portion of the upper lobe and the lower lobe are soggy and solid. The pleura everywhere except medially, and here also, in places, is glazed and covered by small amount of fibrinous exudate. Vessels at the hilum; no abnormalities. The bronchial lymph nodes are greatly swollen, pulpy, edematous, deeply injected. pigmnented. Bronchi: The mucosa shows considerable ulceration. The underlying sub-
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mucosa is intensely injected, somewhat swollen. Covering intact and ulcerated mucosa; there is a large amount of fibrinous and fibrinopurulent exudate, which in places forms a membrane. In the smaller branches the lumen is almost occluded. Upper lobe on section presents mottled moist pink and red surface. Air sacs contain a moderate amount of thin frothy fluid. Medially there is a small egg-sized dull reddish-gray patch of consolidation. The tissue is relatively dry and slightly granular. In the posterior and inferior portions of the lobes the smaller bronchi show considerable amount of fibrinopurulent, and more peripherally purulent, exudate. The walls of the bronchioles are injected throughout, and the lung tissue adjoining for a distance of a few centimeters in places is consolidated, grayish red, dry and granular. On section of the lower lobe a moist pinkish-red and deep-red surface presents. Air sacs contain a moderate amount of thin frothy fluid. Left lung: Both lobes are more voluminous than normal. The upper lobe, upper portion, cushiony, inelastic. Lower portion, soggy and solid. Lower lobe, soggy, solid patches flat in places. The pleura, vessels, bronchi, and lymph glands similar in appearance to those on the right. The left upper lobe on section presents a mottled pink and red surface. The air sacs contain a considerable amount of thin, frothy fluid. Medially there is a large uniform consolidated area about the size of a large orange. The consolidation resembles gray hepatization. There are no intervening aerated areas. In the mid-inferior and posterior portions there are areas of peribronchial consolidation and larger bronchopneumonic patches. The lower lobe on section presents a red and mottled reddish-purple surface. The changes are similar to those in the right lower lobe. Organs of neck: The glands throughout, especially marked in the lower portion, considerably swollen, pulpy, injected. Thyroid: Average size, tissue spongy. The acini contain but a moderate amount of colloid. In the right lobe there is a large filbert-sized, sharply circumscribed area, the tissue at the periphery resembling the neighboring tissue somewhat. The architecture is finer, however. The greater portion of the tumor has an almost uniform gelatinous translucent, faintly green-tinged appearance. Near by there is a grape-seed sized mass similar in appearance. Larynx: Shows considerable swelling of the mucosa. In places, especially about the true vocal cords, there is some ulceration of the mucosa. The picture throughout the trachea is similar. Covering intact and ulcerated mucosa, there is an adherent membranous mass of fibrinous and tenacious fibrinopurulent exudate. The process is similar in character and almost as extensive in the upper esophagus, posterior pharynx, and base of tongue. The mucosa and deeper tissues here are considerally swollen, mucosa greatly injected. In places there is some ulceration, and covering it there is fibrinous and fibrinopurulent exudate. Tonsils: Somewhat enlarged, buried. On section there is a small amount of lymphoid tissue present. There is some scarring. Some of the crypts contain inspissated material. Alimentary tract: Esophagus below the area mentioned above shows no abnormalities. Stomach shows considerable post-mortem change. Duodenum, jejunum, and ileum: No abnormalities, except that the lymph tissue is somewhat more prominent than normal. Toward the lower end of the ileum the Peyer's patches have a shaven-beard appearance. Mucosa everywhere intact. Appendix shows some injection of the mucosa toward the distal end. The eccum is considerably dilated. The lymphoid tissue in the cecum and large intestine is somewhat more prominent than normal. No other abnormalities of the colon or rectum. Mesenteric glands are somewhat enlarged, pulpy Some show moderate injection. Liver: There are focal areas of fat infiltration. The remaining organs show no significant changes.
Microscopic examination.- Trachea: Shows a thick fibrinous membrane still adherent in places. Fibrin threads ramify in the superficial portion of the submucosa. Bacteria, chiefly Gram-positive cocci, on surface. Polynuclear infiltration with mononuclears predominating in deeper tissues. Congestion is marked, but there is little hemorrhage. Epithelitim is destroyed even in the duets of the mucous glands. Lung: There is an infarct-like area at the margin of which the lung tissue shows merely intense congestion and slight alveolar hemorrhage. In the infarcted area, the medium sized bronchi show a necrosis of the bronchial wall down to the cartilage. They are found with thick membranes, composed of meshwork of coarse fibrin, including nuclear fragments and bacterial masses. What remains of the lumen is filled with masses of degenerating leucocytes-bacteria, and the necrotic wall of the bronchus is infiltrated with pycnotic leucocytes. One dilated infundibulum is filled with i a plug of fibrinotis material, of loose mesh, with leucocytes. About the necrotic bronchi there
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is intense hemorrhage, in places with necrosis of the alveolar septa and decolorization of blood cells. At the periphery of the infarct are groups of alveoli filled with pneumonic exudate; many bacteria, cocci predominating.
Bacteriological examination.- Cultures of trachea: Staphylococcus aureus, streptococcus nonhemolyticus. Gram-negative bacilli. Lung same flora as trachea.
NOTE.-The duration of life after gassing was nine days. The case illustrates a very severe type of mustard-gas injury with necrosis in many of the bronchi, involving the entire wall, and leading to extensive hemorrhage in the adjoining tissue. It is by the confluence of such adjacent hemorrhagic areas with subsequent necrosis of the more central portions, and a reaction of the fixed elements at the periphery, that the infarct-like areas described, are formed. There was a massive bacterial infection in the walls of the necrotic bronchi. The injury was so intense that even the cartilages in some of the bronchi were destroyed. Because of the complete loss of all of the epithelial elements, including the ducts of the mucous glands, no regeneration took place.
CASE 57.- W. J. B., 91290, Pvt., Co. K, 165th Inf. Died, March 29, 1918, at 6.45 a. m., at Base Hospital No. 18. Autopsy No. 51. Autopsy, 10 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on March 20. On admission, severe conjunctivitis, second degree burns of right eye, nose, forehead, nasal mucosa. Pulse rapid. General rales. March 24, elevated temperature. No definite consolidation. Pain in chest. Respiration difficult. From this time until death temperature remained above 102°.
Anatomical diagnosis.- Mustard-gas burns of skin, conjunctive, nasal and buccal mucosa, scrotum. Membranous esophagitis, laryngitis, tracheitis, and bronchitis. Purulent bronchiolitis. Extensive bronchopneunionia. Acute fibrinous pleurisy. Marked pulmonary edema. Cloudy swelling of liver and kidneys.
External appearance.- There are superficial gas burns of the forehead and face, particularly marked over both upper and lower eyelids on the right side. Also present about the left eve and nostrils and lips. There is also a first degree burn of the scrotum. All burns are covered with thick brownish dry scabs. At the bend of the left elbow there is a small recent incision closed with sutures. Superficial glands palpable. Eyes: The conjunctive on both sides bulbar and palpebral, injected, especially marked on the right. Eyelids on both sides glued together by viscid and caked exudate, most marked on the right side. There are small hemorrhages below the conjunctiva on the right. Right pupil 4 mm. in diameter, left 2.5 mm. The ulceration and scabbing continues about 1 cm. into each nostril. Along the line of closure of the lips, especially the upper, there are small superficial ulcerated areas covered by dry brown scabs. Internal to this, however, the buccal mucosa is pale and delicate.
Gross findings.- Pleural cavities: On opening the thorax a number of fibrous adhesions found over the posterior portion of the right lower lobe. Somewhat more numerous at the apex. Also a number of fibrous adhesions over the posterior portion of the lower left lobe, binding the left to the diaphragm. The heart is enlarged somewhat to the right. Heart: Weighs 335 grams. The right auricle and ventricle somewhat dilated. Myocardium is of good color, somewhat boiled in appearance. Lungs: Right weighs 715 grams. Left weighs 660 grams. All lobes quite voluminous, cushiony and soggy. In all but the middle lobe solid patches are palpable. The pleura over the posterior and interlobar portions of all lobes glazed and covered by a thin layer of fibrinous exudate. Glands at the hilum enlarged, edematous, injected. The bronchial tree throughout shows extensive necrosis of the epithelium. Islands of intact mucosa are present only here and there. The underlying tissue is considerably injected. There is considerable diffuse extravasation of blood. In some of the larger bronchial branches there is associated with the necrotic epithelium a moderate amount of fibrin. The exudate is membranous. In the finer bronchioles the lumen contains viscid pus. About some of the finer bronchioles, especially in the right lower lobe, there is considerable hemorrhage. Scattered throughout all lobes, most marked in the lower and left upper, there are numerous irregular areas of dull reddish gray and in
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places deep-red consolidation. In addition there is much thin frothy fluid in both upper lobes and the left lower. Organs of neck: The anterior rnediastinal, cervical, and tracheal glands, especially those low down in the neck, greatly enlarged, pulpy, edematous, injected. Thyroid, no abnormalities. Acini contain a considerable amount of colloid. In the trachea there is some swelling of the mucosa, with considerable diffuse necrosis of the epithelium. In the lower portion the appearance is moth-eaten. The underlying tissue is intensely injected. Towards the larynx the desquamation and injection is less marked. In the larynx, although the underlying tissue is relatively pale, there is considerable desquamation of the epithelium, and in places associated with this desquamation there is fibrinous exudate. The appearance is that of a true membranous exudate. This is well marked on both true and, to a less extent, on the false vocal cords. A similar appearance is seen in the pockets at the upper end of the esophagus. The pharyngeal tissue about the tonsils is boggy. Tonsils: Somewhat buried, show large crypts, most of them filled with viscid or dry purulent necrotic material. Alimentary tract: The lymphoid tissue is somewhat more prominent than normal. There is patchy injection of the mucosa of the rectum. The mesenteric glands are somewhat enlarged. There is some injection of the distal one-third of the mucosa of the appendix. Liver: Shows focal areas of fat infiltration. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: In places ulcerated, in others reinvested with stratfied squamous epithelium showing numerous mitotic figures. The epithelium in places is elevated from the basement membrane by a foamy coagulum as if blistered. The subepithelial connectivetissue contains lymphocytes in moderate numbers, no polynuclears. It is edematous and all the vessels are very congested. Large bronchus shows a very similar picture. There is a metaplasia of the epithelium where present, but a large portion of the connective tissue is bare. There is no membrane or exudate upon the surface. The ducts of the mucous glands are proliferating. A Gram stain shows no fibrin, and only occasional bacteria (Gram- positive rods) on the surface. Lung: The bronchioles and atria contain purulent exudate, in which are groups of Gram-positive cocci. They are relined, for the most part with flattened epithelial cells. The alveolar septa appear stout and cellular with the low power. Microscopically, there are numerous round cells and plasma cells in the walls, and occasionally a new growth of fibroblasts. Stout filaments of fibrin are seen, both within the capillaries and between the capillary wall and the epithelium. There are, however, no thrombi. The alveolar epithelium shows widespread changes which are interpreted as regenerative. The cells are elevated, rounded or cuboidal, with deeply staining, sometimes vacuolated, cytoplasm. The epithelium is sometimes elevated by the accumulation of edematous fluid, appearing as granular coagulum. There are multinucleated flattened cells. The alveolar spaces are largely filled with pink-staining homogeneous material, but in spaces this is definitely fibrinous. The fibrin is swollen and stains poorly. In addition there are exfoliated epithelial cells, small and large mnononuclears, occasional plasma cells, numerous polynuclear eosinophiles, but rarely a polymorphonuclear neutrophile. Careful search in well-stained Gram section fails to show bacteria in these areas. Here and there are strands of fibroblasts growing into the fibrinous exudate. Spleen shows nothing of interest except irregular hem- orrhage. Liver: The cells are swollen and very homogeneous, the capillaries narrowed.
NOTE.-Case of mustard-gas poisoning, dying nine days after gassing. There were well-advanced reparative changes. Trachea and bronchi were lined with stratified epithelium. Small bronchioles and atria still showed suppurative inflammation. There was a widespread regeneration of the alveolar epitheliurn and a subsidence of the inflammation in the lung, as shown by the large proportion of plasma and mononuclear cells in the septa. An interesting and unusual finding was the presence in some areas of great numbers of eosinophilic polymorphonuclear leucocytes. There was extensive edema. largely fibrinous, and, so far as could be ascertained from a Gram-stained section, unassociated with the presence of bacteria. Aside from the lesions in the trachea and large bronchi, the picture resembled very closely that seen at a corresponding stage of "influenzal" pneumonia. In this particular instance, however, the possi-
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bility that a secondary influenzal infection had supervened upon the gassing can be excluded by the fact that the case occurred in March at a time when "influenzal " pneumonia was not prevalent among the troops.
CASE 58.- W. G. S., 107837, Corpl., 5th M. G. Bat., Battery D. Died, June 30, 1918, at Base Hospital No. 15. Autopsy, three hours after death, by Maj. A. M. Pappenheimer, M. C.
Clinical data.- Gassed on June 21, 1918. Admitted to Base Hospital No. 15 on June 26. Diagnosis: Mustard gas. Dyspnea, cyanosis, conjunctivitis, large blebs on back and arms. Temperature, 101°.
Anatomical diagnosis.- Superficial burns on back, shoulders, neck, and scrotum. Conjunctivitis, diphtheritic tracheobronchitis, lobular pneumonia. Pulmonary edema. Fibrinous pleurisy.
External appearance.- There is marked lividity of the head and dependent portions of the body. Eyes show intense conjunctival edema with several fresh hemorrhages beneath the bulbar conjunctiva. There is a bloody discharge from the nares, and a large amount of thin greenish fluid issues from the mouth. Over the neck, shoulder, and upper portion of the thorax there are very numerous superficial elevated blebs, filled with clear fluid. Over the back these have become confluent and the epidermis macerated and lifted up in large sheets, exposing the wet corium. There is no edema of the penis, but the anterior surface of the scrotal sacs shows loss of hair, pigmentation, and superficial desquamation, and was evidently slightly burned. There are no other cutaneous changes.
Gross findings.- Pleural cavities: Lungs: The right and left lungs present almost the same changes and can be described together. They are voluminous and heavy, but not extremely so. There are patches of fresh, very delicate, fibrinous exudate, and a few larger sheets of edematous fibrin over the posterior surface of the lower lobe of the right lung. The interlobular septa appear as a translucent grayish network and are obviously edematous. There are a few small areas of interstitial emphysema in the region of the lingula of the left lower lobe. On section there is a very marked edema of all the lobes. A large amount of thin frothy fluid exudes from the cut surface. Here and there are small partially atelectatic patches of a dark red color scattered through the substance of the lung, but there are no extensive areas of collapse. The bronchi appear on section to be filled with purulent exudate and their mucosa in the case of the larger branches covered with slough. They show no obvious dilatation or contraction. Very striking is the surrounding zone, several millimeters in extent, which is darker in color, very translucent and apparently airless and slightly sunken below the adjacent aerated tissue. There are a very few small pneumonic patches scattered through both lungs. These are dry, grayish, granular, and have not undergone suppurative softening. Some of them are surrounded by irregular darker areas of partial atelectasis. In general, there is strikingly little consolidation, the changes being limited to the bronchi.
Heart normal. Alimentary tract: Normal. Histological material lost.
NOTE.- Mustard-gas case of nine days' duration. Gross lesions are very typical. There were the usual cutaneous lesions, and a very intense diphtheritic necrosis of the upper respiratory passages. Lung lesions aside from the widespread edema were almost wholly limited to the peribronchial regions. There were only a few small patches of focal pneumonia.
CASE 59.- F. C., 1526296, Pvt., Co. H., 147th Inf. Died, October 23, 1919, 11 p. m. at Base Hospital No. 45. Autopsy, 28 hours after death, by Lieut. Perry J. Manheims, M. C.
Clinical data.- Gassed with mustard gas at 6 a. m. on October 14. Subsequent informa- tion based on Chemical Warfare Service reports. Co. H, 147th Infantry, was exposed on October 12 to mustard-gas bombardment of 2,000 150-mm. shells. October 18, developed bronchopneumnonia. Condition serious. Clinical diagnosis: Bronchopneumonia, following inhalation of mustard gas.
Abstract of anatomical findings.- Small hemorrhages in both conjunctiva. Characteristic burn of scrotum. Pigmentation of skin of inner side of thighs. Heart normal.
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Gross findings.- Pleural cavities: Left contains no fluid or adhesions. Right shows fresh fibrinous adhesions between the lobes. Left lung: Is reddish grey in color. On section, it is hyperemic with areas of consolidation. Right lung: There is a small sear with three small partly calcified nodules. The upper lobe in general is grey in color, generally crepitant with a few small areas of consolidation. The middle and lower lobes are the same. Stomach and small intestines contain a few hemorrhagic areas. Large intestine normal. Larynx and trachea: Erosions of the mucosa with general hyperemic color and hemorrhagic areas. The remaining organs show nothing of interest.
Microscopic examination.- No section of trachea preserved. Large bronchi: Desquamation or complete necrosis of the epithelium. Exudate of polymorphonuclears, epithelial cells and bacteria in the lumen. Extensive congestion of bronchial vessels. Edema of walls and of peribronchial tissue. There is a loose leucocytic infiltration. Lungs: Show intense congestion of all capillaries, hemorrhages into alveoli, numerous pigment containing cells, very little fibrin. Fresh fibrinous exudate on pleura. Another section shows a definite suppurative focus with necrosis and masses of bacteria, destruction of alveolar septa, etc. There is marked periarterial edema. Section stained for bacteria shows numerous Gram-positive cocci, some in long chains, but chiefly confined to bronchial exudate.
Bacteriological examination.- Heart's blood at autopsy showed long chained hemolytic streptococcus. Culture from lung showed hemolytic streptococcus.
NOTE.-Mustard-gas case of nine days' duration. No special features of interest. No reparative changes noted in section. There was an obsolete apical tuberculosis, which did not appear to have been activated by the gassing.
CASE 60.- J. L., 44533, Corpl.. Co. M, 16th Inf. Died, October 10, 1918, 9.45 a. m., at Base Hospital No. 15. Autopsy, six hours after death, bv Maj. Rolfe Floyd, M. C.
Clinical data.- Mustard-gas inhalation and contact, received in action October 1, 1918. Anatomical diagnosis.- Extensive mustard-gas burns of skin. Diphtheritic laryngitis, pharyngitis, and bronchitis. Edema and congestion of lungs. Peritoneal and pleural adhesions.
External appearance.- Extensive first degree burns and desquamation of epidermis over upper part of chest and almost whole of back. Burns of first and second degree about lips, nostrils, and eyelids. No burns of scrotum or buttocks.
Gross findings.- Peritoneal cavity: There are extensive old organized adhesions, binding together the abdominal viscera. Pleural cavities: The left is obliterated by fibrous adhesions. The right also shows fibrous adhesions less dense than on the left side. Left lung: There is extensive bronchopneumonia in the lower lobe with areas of intense hemorrhagic exudate. Consolidated areas are numerous but not confluent. Small bronchi contain pus. The unconsolidated lung is very edematous and congested. Larger bronchi show extensive diphtheritic necrosis extending down through the medium-sized tubes. In the lower lobe there are small calcified and fibrous nodules surrounded by scar tissue. Lymph nodes at hilus contain small caseous nodules. Right lung: Shows extensive edema and congestion with areas of diffuse consolidation. No tuberculous foci. Organs of neck.--Pharynx, uvula, and tonsils: Show a diphtheritic membrane which extends down the entire length beyond the trachea into the bronchi. False membrane is yellow in color and fairly tenacious, still adherent. Esophagus beyond the pharynx is normal. Stomach and intestines: Areas of acute congestion. Abdominal vessels are congested. Kidneys show old infarcts. The remaining organs are normal.
Microscopic examination.- Trachea: No sections. Medium-sized bronchi: Are lined with a thick fibrinopuruilent membrane. Entire bronchial wall is infiltrated with leuceocytes, the nuclei of which are pycnotic. Lungs: The terminal bronchioles contain an exudate which in some is composed almost entirely of polvnuclears, in others of a granular coagulum. The lining epithelium is in general well preserved, though the desquamation in places is probably the result of post-mortem change. The exudate about bronchus is largely fibrinous and hemorrhagic. There is no organization in progress. Elsewhere there are patches of lobular pneumonia, not definitely in relation to bronchi, and surrounded by an edematous zone. An interesting histological feature is the lifting up of the pleura, with its intact
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mesothelial cells, by a layer of edema. Section stained for bacteria shows few cocci in bronchial exudate, and practically none in the parenchyma. Liver, spleen, and kidney show no significant lesions.
NOTE.-Typical mustard-gas case of nine days' duration with extensive diphtheritic necrosis of trachea and bronchi, large areas of bronchopneumonia and pulmonary edema. No special features except perhaps the absence of reparative changes.
CASE 61.- M. M., 3105447, Pvt., Co. C, 109th Inf. Died, October 11, 1918, 8.55 a. m., at Base Hospital No. 42. Autopsy No. 53. Autopsy, six hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed October 2, 1918, bled at Field Hospital No. 110. Contact burns of face, scrotum, penis, and thighs. Conjunctivitis and laryngitis. On admission, respiratory distress, general râles, heart enlarged to right. Accessory muscles of respiration active, chest hyperresonant, expiration prolonged. Clinical diagnosis:Gas inhalation and contact burns, emphysema, cardiac dilatation, and bronchopneumonia.
Anatomical diagnosis.- Superficial gas burns of conjunctivae and skin. Acute pharyngitis, laryngitis and esophagitis, tracheitis and bronchitis. Peribronchial pneumonia of all lobes. Pulmonary edema. Cardiac dilatation of right side. Cloudy swelling of liver and spleen. Detailed protocol not received.
Microscopic examination.- Trachea: There is a dense membrane firmly attached to the adjacent tissue. Epithelium in general is wanting, in places there is a single row of flattened cells beneath the slough. Leucocytic infiltration is moderate and accompanied by pycnosis and fragmentation of the nuclei. There is marked hyerpemia and hemorrhage. Epithelium of mucous glands is desquamated, and the cells of the duets show proliferation and mitotic figures. (See fig. 15.) There are numerous bacteria on the surface. Bronchi: There is complete epithelial necrosis. Many bronchi are filled with purulent exudate and bacteria. In many places the entire bronchial wall is involved as well as the adjacent alveoli, so that these are practically small abscesses. About these gangrenous zones there is hemorrhage. A few of the bronchi show regenerating new epithelial cells being interlaid between the still adherent membrane and the granulating submucous tissue. Lungs: Edema is marked and diffuse in two of the blocks. A third block shows no edema but marked emphysema and dilatation of the infundibula together with bronchopneumonia of the usual type. In some places, especially in the vicinity of the inflamed bronchi, the exudate is fibrinous, in others a uniform coagulum. In places there are definite abscesses with masses of bacteria, which appear to have originated in the distended atria, but involve the adjoining tissue. Pharynx: The section passes through localized areas in which the epithelium is replaced by an adherent superficial slough, the base of which shows an acute leucocytic infiltration. (Fig. 31.) A section of skin, probably from the scrotum, shows a partial desquamation of the superficial squamous cells with vacuolar degeneration of the upper layers. There are some areas in which there is total necrosis of the entire epithelium, with edema and leucocytic infiltration of the corium. In the ulcerated areas the pigment in the rete mucosum is clumped and there are numerous chromatophores. There is no evidence of regeneration at the margins of the ulcerated areas. Kidney and liver show cloudy swelling. Adrenals are congested.
NOTE.-Mustard-gas case, dying nine days after exposure. Severe destructive lesions of the upper respiratory tract extending into the smaller bronchioles. There was widespread hemorrhagic edema, lobular pnuemonia, and suppurative foci, probably originating in the smallest bronchioles or atria. The evidences of repair were very slight, being limited to the earliest proliferation of the epithelium in the larger bronchi.
CASE 62.- O.H., Corpl.,45273,Hdqrs.Co.,18th. Inf. Died October,1918, at 4 a.m., at Base Hospital No. 18. Autopsy No. 128. Autopsy, October 11, 14 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gunshot wounds of right arm and hip, with subsequent gas bacillus infection. Gas inhalation incurred in action October 2.
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Anatomical diagnosis.- Extensive gunshot wounds of upper right arm, with infection. Gunshot wounds of right buttock. Healing conjunctivitis and superficial burns of skin. Infected burn of scrotum. Healing gas burns of upper respiratory tract. Small areas of organized pneumonia especially marked in right upper and lower lobes. Few small bronchiectatic cavities, filled with exudate. Ascaris lumbricoides. Healed and recent ulcerations of lower ileum and cecum, possibly due to worm. Localized fibrinous peritonitis.
External appearance.- Externally there is a large wound of the right upper arm 15 by 8 cm. The shoulder and anterior chest in the neighborhood are puffy. On palpation a considerable amount of gas is felt. The wound shows necrotic injected muscle in the base. A thin watery grayish-black exudate in small amount in places. On pressure of the wound crepitation is made out. The neck, axillary folds, and abdomen show numerous tiny vesicles filled with clear fluid. In the axillary folds there is some bloody pigmentation of the skin.
FIG. 31.- Case 61. Mustard-gas burn, 9 days' duration. Pharynx. Localized superficial necrosis of epithelium with inflammatory reaction
The scrotum, penis, toward the head, show superficial ulceration of the epidermis and some matted seropurtilent exudate. Eyes: The outer corners are glued together with matted exiu- date. Over the right buttock, upper portion laterally, there is a wound in the skin about 6 by 4 cm. extending into the muscle. In the skin of the left ankle there is a large irregular bleb filled with thin fluid.
Gross findings.- Peritoneal surfaces: In the right hypochrondrium show patchy injection and small hemorrhages. The hepatic flexure of the colon glued to the liver by fibrinuos exudate. There is considerable post-mortem discoloration, greenish black in the neighborhood. The stomach is considerably distended with gas. Pleural cavities.-Right lung: The lobes are voluminous and cushiony in great part. The pleura is thin. The glands at the hilum are somewhat enlarged, pulpy, and scarred. There is slight to moderate diffuse injection of the mucosa. In the lumen there is thin fluid. The upper lobe, on section, in great part is well aerated and pink. Toward the apex there is considerable scarring. There are strands
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and small nodules of firm gray tissue. In one place there is a small pea-sized calcified nodule. Toward the apex there is a bronchus showing considerable dilatation, filled with coherent mucopurulent fluid. On tracing the bronchi from the hilum they are found to become stenotic quite quickly. At one place near the pleura there is a pea-sized yellow, opaque, cheesy mass involving the bronchial lumen and wall. On repeated section, dilated and stenotic bronchi, with small pigmented firm gray streaks and nodules are found, in the posterior portion of this lobe, suggesting the end result of gas inhalation. The middle lobe on section fairly well aerated, pink-red. Throughout the lobe there are firm gray strands and flat nodular areas, a few millimeters in diameter. The picture suggested tiny organized areas following rather extensive peribronchial consolidation. The walls of the bronchi themselves are not appreciably thickened. In general the lumen is considerably smaller than the average. In this lobe, the air sacs contain a moderate amount of thin frothy fluid. Left lung: Both lobes fairly voluminous and cushiony. The artery at the hilum shows no abnormalities of its larger branches. The bronchi and glands are similar to those on the right. On section of the upper lobe toward the apex and elsewhere, firm gray streaks and small nodules suggesting organized pneumonia are seen and peribronchial thickening. The lower lobe on section, in general similar to the upper. Liver weighs 2,000 grams and shows marked fatty infiltration. Spleen, kidneys, adrenals, and bladder normal. Organs of neck.-Thyroid: Average size and presents no abnormalities. There is considerable colloid present. Larynx and trachea: There is much viscid exudate in the lumen. Toward the bifurcation there is patchy injection of the mucosa. The base of the tongue, posterior pharynx and upper esophagus as far as the level of the cricoid cartilage show a uniform thickening of the mucosa. Tonsils: Show a moderate amount of pulpy pale lymphoid tissue, somewhat scarred. Alimentary tract: The esophagus shows some dilatation. The stomach is considerably distended with gas and contains about 200 to 300 c. c. of bile-tinged contents, partially digested. In the lower ileum there are several apparently healed ulcerated areas in the neighborhood of the valve. The cecum and ascending colon show a number of ragged perforations of the mucosa. In one place the ulceration is about 1 cm. in diameter, the edge heaped upon the base formed by the muscle. Just beyond the ileocecal valve there is a ragged perforation of the mucosa. The scrosa and outer muscular coats dissected up for a considerable distance forming a cavity about 3 cm. in diameter, communicating with the interior of the gut by the perforation mentioned above. The walls are moth-eaten in appearance, apparently the habitat of the ascaris mentioned above. It is over this region that the fibrinous exudate mentioned above is found. The remainder of the tract shows no abnormalities.
Microscopic examination.- Large bronchus: Covered for the most part with one or two layers of flattened cells, very pale and large wvith distinct cell membrane. Individual cells show pycnosis of nuclei and hyaline condensation of cytoplasm. The superficial portion of the subepithelial tissue is very dense, the membrana propria and collagen fibres are swollen and indistinct. There are very few wandering cells in this zone; the connective tissue and endothelial nuclei are large and succulent. Deeper clown there is a rather dense infiltration of lymphoid and plasma cells, especially about the mucous glands. The ducts show the usual epithelial proliferation, with occasional mitotic figures. Lungs: Two blocks examined. In one there are definite encapsulated areas with smaller tubercles at the periphery. The granulation tissue at time margin of the tuberculous area is intensely injected, and in one place there is an extensive fresh hemorrhage. The caseation involves the wall of an adjacent pulmonary artery. The section passes through a small bronchiectasis which is situated in the scarred tuberculous area. Elsewhere there is a suppurative bronchiolitis and infundibulitis, with involvement of the adjacent alveoli. The smallest bronchioles are filled with pus and have lost their epithelium. Their wall shows a good deal of fibrous thickening, and the lumina appear narrowed. The remaining part of the lung tissue shows nothing of special interest. The capillaries are congested; there is moderate diapedesis and edema, and here and there alveoli containing leucocytes and fibrin. There are various types of bacteria in the bronchial exudate. Gram-positive cocci predominating.
NOTE.- Mustard-gas poisoning of nine days' duration, complicated with multiple gunshot wounds. The cutaneous lesions tire typical, and the trachea and bronchi showed unmistakable evidence of previous gassing with very early reparative changes. There were associated obsolescent tuberculous
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lesions in the lung, to which were probably due the small bronchiectases and scars described in the protocol. It is not probable that the gas bronchitis after nine days could lead to the formation of bronchiectasis, and in support of this idea is given the histological study, which shows at least one dilated bronchiole in definite relation to the tuberculous focus. Of interest, in view of the possible activation of old tuberculous foci by exposure to gas, is the intense congestion and hemorrhage about the tuberculous areas. It is conceivable that such a hemorrhage might favor the extension of the tuberculous foci.
CASE 63.- J. W. H., 1627698, Corpl., Co. M., 109th Inf. Died, August 19, 1918, at Base Hospital No. 46. Autopsy No. 7. Autopsy, two hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Date of gassing not known. Admitted to hospital August 10. Cyanosis, air hunger, cough, abundant mucopurulent sputum. Somewhat relieved by venesection. On fifth day, temperature 104°. Dullness, and bronchial breathing. From then until death, periods of improvement; temperature up to 106°.
Anatomical diagnosis.- Extensive gas burns of skin, in part infected, in part healed, associated with local pigmentation. Acute ulcerative laryngitis, tracheitis, bronchitis. Purulent bronchiolitis. Extensive bronchopneumonia. Fibrinous pleurisy. Pulmonary edema. Miliary tuberculosis (obsolete) of bronchial lymph nodes, lung, liver, and spleen. Rupture of right rectus muscle with hemorrhage.
External appearance.- The skin in general has a sallow appearance. In addition, the face, neck, and upper portion of the body has a somewhat bluish cast. The skin of both arms almost to the wrists show extensive areas of superficial ulceration and desquaination. In places there is a small amount of matted skin and purulent exudate over the ulcerated areas. The ulceration extends only into the dermis. There is similar ulceration and desquamation of the skin in both axillae and upper backs. The head of the penis and body show similar ulceration, with some puruilent exudate. Over both buttocks, in the right axillw, the outer aspect of the right thigh, there are a number of old ulcerated areas varying in size from a few millimeters to several centimeters in diameter, practically healed, showing new epidermis with brownish pigmentation about them. There are large blotches of brown pigmentation of the skin over the chest and thighs. Associated with all these there are innumeral)le tiny vescieles filled with clear fluid. The skin of the neck and a portion of the face and scalp shows considerable desquamation. The superficial lymph glands are somewhat enlarged. Eyes: Eyelids are somewhat edematous toward the inner canthus. On each side there is a small superficial ulcerated area covered by a reddish-brown scab. There is some desquamation of the skin of the lids. Conjunctive are pale. The pupils a few millimeters in diameter. Nose: In both nostrils there are superficial ulcerated areas, covered by scabs. In the nose there is a moderate amount of mucopurulent secretion. External genitalia: No addition to the note above. The skin of the scrotum in two places shows healed superficial areas. Attached to the new epidermis there is some desquamated epithelium.
Gross findings.- Abdomen: On opening the abdomen, the peritoneal surfaces in general are delicate and pale. In the region of the attachment of the internal rectus on the left, the peritoneal surface shows extensive deep red hemorrhage. In the pelvis there is about 30 c. c. of clear yellow fluid. Binding the lateral portion of the right lobe of the liver to the abdominal wall there is a small amount of apparently organizing gelatinous fibrinous exudate. On incising the rectus muscle on the left, a small egg-sized mass of fluid and clotted blood is found. There appears to be a loss of continuity in the rectus muscle about 6 cm. from the attachment to the pubic bone. There is some apparent scarring of the musculature at the point of rupture. The diaphragm reaches to the fifth rib right, fifth space left. Thorax: On opening the thorax about 50 c. c. of turbid yellow fluid found in the right pleural sac. There is some fibrinous exudate posteriorly between the lobes and the chest wall. A similar picture presents on the left. There is perhaps but 30 c. c. of fluid here. Heart: Enlarged somewhat to the right. Shows no significant lesions. Right lung: All lobes of the right lung are very much more voluminous than normal. The upper is cushiony, soggy, many large
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solid patches felt. Middle and lower lobes similar, with apparently more consolidation in the upper portion. Pleura everywhere glazed, covered by tightly adherent fibrinous exudate. On stripping this posteriorly, tiny vessels are seen in the pleura below in places only. The vessels at the hilum show no abnormalities. Glands are greatly enlarged, pulpy, edematous, injected and pigmented. Bronchus shows considerable swelling and intense injection of the mucosa. In places there is desquaination of the nitucosa. Everywhere there is considerable mucopurulent and fibrinopurulent fluid, blood tinged. On section, the upper lobe, a moist mottled pink, whitish-yellow and yellowish grayish-red surface presents. Air sacs in general contain a considerable amount of thin frothy fluid. Scattered throughout the lobe there is much dull grayish-red consolidation. Patches vary in size from a few millimeters to one large patch having a surface area 6 cm. Associated with these solid patches the bronchioles in places contain viscid purulent matter. The walls of these smaller bronchioles merge with the surrounding consolidation. Middle lobe on section, presents a picture in general similar to the upper lobe. There are numerous areas of consolidation associated with bronchial branches which contain viscid purulent material. There is moderate amount of fluid in the air sacs elsewhere, in this lobe. In places there are dilatations of the bronchi towards the periphery. Lower lobe, on section presents a picture in general similar to the other lobes. Here the peribronchial consolidation is much more distinct. There is considerably more injection present. Lower portion of the lobe, on repeated section, the bronchial branches in greater numbers show viscid purulent fluid. The peribronchial consolidation is much more extensive here. The bronchi throughout have a larger diameter than normal. Left lung: Both lobes are very much more voluminous than normal, especially the upper, and are quite solid. The lower in the median portion is cushiony. The pleura, vessels, lymph glands, and bronchi similar in appearance to those of the right. On this side the necrotic desquamating mucosa is more conspicuous than on the right side. The upper lobe on section, in general similar to the right upper lobe. Consolidation, however, is much more marked; in places the patches are almost confluent. Associated with the gelatinous areas of consolidation there are also numerous small yellow opaque areas. On section of this lobe towards the hilus, there is an enlarged bronchial lymph gland, showing a pea-sized chalky and calcified mass, encapsulated by firm gray tissue. Left upper lobe, bronchi, and areas of peribronchiial consolidation have a greenish color. This is especially true in the centre and the upper portion of the lobe. In places, especially in these areas, the bronchial branches show moderate dilatation. In this lobe, on further inspection there are seen yellowish opaque nodules much firmer in consistence than the consolidation mentioned above. These are especially prominent medially. The left lower lobe on section, in general presents a picture similar to that in the other parts, except that the process medially is less marked. Scattered throughout this relatively well areated portion considerable numbers of discrete pinhead sized and smaller firm gray nodules. Organs of neck: Glands throughout the neck, especially below, greatly enlarged, pulpy, edematous, and injected. Those in the mediastinum show areas of gray scarring, moderately pigmented. Thyroid: Marked amount of colloid in the acini. Larynx: Shows several areas of ulceration of the mucosa, both of the epiglottis and true vocal cords. The largest patch is 1 cm. in diameter. These ulcerations extend into the cartilage. Elsewhere the mucosa is injected, swollen and covered by loose mucopurulent exudate. Trachea: Mucosa is somewhat swollen, and injected, especially towards the bifurcation, where in addition there is considerable desquamation of the epithelium of the mucosa, and associated with these areas there is a moderate amount of adherent fibrinous and fibrinopurulent exudate. In the lumen there is a considerable amount of mucopurulent secretion. Tonsils: Are almost gone on the left. On section, however, one crypt filled with viscid purulent material On the right, the tonsil is buried and crypts are clean. Alimentary tract: Mucosa of the pharynx and upper esophagus is slightly swollen, moderately injected. Stomach: No abnormalities. Cecum: Some patchy injection of the mucosa. Mesenteric glands are slightly enlarged, and pulpy. Liver: There are a few minute, encapsulated, caseous areas and focal fat infiltration. No other significant lesions. Spleen: Also contains small yellowish nodules, otherwise the appearance of an acute splenic tumor. Adrenals: Slight cortical edema, moderate lipoid depletion.
Microscopic examination.- Skin: There are two blocks, showing hyperkeratosis and thinning of the remaining layers of epidermis. There is marked hyperpigmentation with chromatophores in the superficial layers of the corium. The smaller vessels are collapsed
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and empty, surrounded by a loose aggregation of pycnotic lymphocytes and occasional polymorphonuclear cells with distorted nuclei. The section evidently represents a healed pigmented lesion. Trachea: There are patches of regenerated stratified non-ciliated epithelium alternating with ulcerated areas to which necrotic membrane is adherent. The ducts frequently contain solid plugs of epithelial cells. Submucosa is edematous and in the ulcerated regions is infiltrated with both polymorphonuclear and mononuclear cells. Where the epithelial regeneration has occurred, the underlying tissue has rather the character of clean granulation tissue. Lungs: The bronchi all contain exudate which is chiefly purulent but in some instances is undergoing early organization. Lining epithelium of some of the bronchi is intact, in others necrotic, and still others regenerative and metaplastic. There are the usual peribronchial lesions; areas of extensive peribronchial pneumonia with fibrinous exudate often showing early organization. Alveolar wall in many places is thickened by the presence of numerous large pale epithelial cells having in general the character of fibroblasts, but possibly derived in part from the endothelial cells of the capillaries. One block of lung tissue shows in addition to the thickening, diffuse edema, hemorrhage, and focal areas of suppuration. Rectus muscle: There is hvaline necrosis of the fibres with hemorrhage and acute inflammatory reaction. Liver, spleen, kidney show no striking changes.
Bacteriological examination: Culture of lung: Staphylococcus aureus, large number. Culture of vocal cords: Streptococcus, nonhemolytic, non-green-producing.
NOTE.-The case is a typical one of mustard-gas poisoning. The exact duration is not established, but was over nine days. The destruction of the mucosa of the upper respiratory passages was less severe than in many cases, and does not involve the smallest branches, in which, generally speaking, the epithelium appeared to be preserved. Early regeneration occurred. Broncho-pneumonia was extensive but does not appear to be of the typical influenzal type, associated with extreme and widespread hemorrhagic edema.
CASE 64.- F. M., 2209877, Pvt., Hdqrs. Co., 355th Inf. Died, August 18, 1918, 9.45 p.m, at Base Hospital No. 46. Autopsy No. 8. Autopsy, 19 hours after death, by Lieut. B. S. Mline, M. C.
Clinical data.- Patient was gassed on August 7 to 8, having been exposed to yellow, green, and blue cross shell. On August 15, patient was weak and a little delirious. There was a cough without sputum. Throat was red and edematous. Painful burns of scrotum and face. Rȃles at the bases posteriorly. August 18, patient became weaker, apprehensive, and at times delirious. Anatomical diagnosis.- Extensive gas burns of skin and mucous membranes. Acute laryngitis, tracheitis, and bronchitis. Purulent bronchiolitis. Acute peribronchitis. Extensive bronchopneumonia. Acute fibrinous pleurisy. Marked pulmonary edema. Dilatation of right auricle. Obsolete tuberculosis of bronchial lymph nodes. Terminal gas bacillus infection.
External appearance: There is a marked gas burn about the lips, over the left eye, scrotum and penis. Burns of the face extend into the subcutaneous tissues and are covered by a dry red brown scab. The scrotum and penis show in addition to the ulcerated epidermis, moderate amount of matted serum and purulent exudate. There is a small area of ulceration covered by a scab toward the inner canthus of the right eye. There are areas of desquamation of the epidermis over the scalp, about the ears, and in the genital fold. Axilllae, clear. Superficial lymph glands, somewhat enlarged. Conjunctivae slightly edematous, show patchy injection. There is some mucopurulent secretion present. The corne slightly cloudy. Pupils, dilated 6 mm. in diameter. Ears: No abnormalties except as above mentioned. Nose: In the left nostril there is an area of superficial ulceration covered by a red brown scab. Mucosa is somewhat injected. There is some bloody mucopurulent secretion present. Mouth: Lips show ulceration mentioned above. Teeth poorly formed. In the upper jaw, there are several milk teeth present. There is considerable erosion of the cutting edges. A few teeth gone from the lower jaw.
Gross finding.- Pleural cavities: On opening the thorax about 60 c. c. of thin blood-tinged turbid fluid found in the right sac. In the left there are a number of delicate fibrous adhesions between the lungs and the chest wall. In this cavity also there are about 40 c. c.
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of blood-tinged fluid. Heart is normally disposed. Pericardium is normal. Heart is normal except for dilatation of right auricle. Right lung: Upper and lower lobes are very much more voluminous than normal, cushiony, soggy. Middle lobe is fairly voluminous, slightly soggy. Pleura, especially posteriorly, glazed, covered by small amount of fibrinous exudate. There is considerable reddish-purple discoloration of the pleura, and in addition there are scattered small hemorrhages posteriorly. Vessels: No abnormalities, except the pulmonary artery somewhat dilated. Glands are moderately enlarged, pulpy, edematous, injected, pigmented, scarred. Bronchi: There is considerable swelling, injection and hemorrhage of the mucosa. There is much greenish-black discoloration. In the lumen there is a large amount of thin frothy fluid. On section of upper lobe a strikingly moist deep red surface presents. Air sacs are moderately distended with thin fluid. The smaller bronchial branches contain fibrinous and fibrinopurulent exudate; their walls are injected, the surrounding lung tissue consolidated. Posteriorly there is some gelatinous reddish lung tissue, and in addition there are fair-sized areas of granular deep red consolidation. Middle lobe on section shows little involvement, and there are but a few areas of consolidation in this lobe. Lower lobe on section quite similar to the upper, however, the bronchial branches are filled with purulent exudate. Walls are deeply injected. There is much consolidation. In the air sacs there is a striking amount of thin frothy fluid. In addition there is considerable extravasation of blood throughout the tissue and near the apex of this lobe there is an egg-sized solid slightly granular deep red consolidated patch. Left lung: Both lobes are more voluminous than normal, especially the lower. The upper, cushiony, soggy. The lower, soggy. Pleura: Vessels, bronchi, lymph glands, similar to those on the right in appearance. In addition, lymph glands show numerous yellow opaque nodules. Upper lobe on section is similar in general to the right upper. The lower, in general similar to the right lower. Liver: Fatty infiltration and small cystic spaces apparently due to gas-bacillus infection Adrenals: Cortical edema with injection of inner cortical zone. Organs of neck: Glands in the lower portion of the neck are moderately enlarged, edematous, pulpy, injected, pigmented, show some scarring. Thyroid: Average size. The right lobe is bifurcated. Tissue is pale and spongy. The acini contain a moderate amount of colloid. Larynx: There is considerable swelling of the mucosa with patchy injection. There are small areas of ulceration in the epiglottis. There is also some ulceration of the true vocal cords. From the true vocal cords downward the ulcerated and intact mucosa is covered by a considerable amount of slimy, dirty brown exudate. Within and below the mucosa there are numerous deep red hemorrhages, especially toward the bifurcation of the trachea. The greater portion of the brownish exudate is present in the lower portion of the pharynx and the upper portion of the trachea. The adjoining mucous membrane of the base of the tongue and larynx moderately injected. Tonsils: Show a small amount of lymphoid tissue. There is considerable scarring of each.
Alimentary tract: Esophagus shows some injection of the mucosa as far as its mid- portion. Stomach: No abnormalities. Jejunum: Upper portion shows some patchy edema of the mucosa. Ileum: Shows areas of patchy injection of the mnucosa with which there is associated some extravasation of the blood. The lymphatic tissue throughout is somewhat more prominent than normal. Appendix, cecum, colon, and rectum, no abnormalities. Tissue about the rectum and in the bladder wall posteriorly shows numerous dilated, engorged, and in places, thromnbosed veins. The mesenteric glands are slightly enlarged, pulpy, and injected.
Microscopic examination.-Trachea: There is no pseudomembrane present. Normal epithelium is replaced by layers of polygonal squamous cells resting upon basement membrane. Mucous glands have disappeared. Large bronchi: Many show gangrenous lining. and hyaline necrosis, not extending very deeply into the bronchial wall. There is abundant hemorrhage both of mucosa and adjacent lung tissue. Some bronchi show regeneration of squamous stratified epithelium. Lung: Tissue at a distance from the bronchi shows emphyserma and moderate hemorrhagic edema. In the second block numerous sections were taken at different levels and mounted in series. In this way there are demonstrated suppurating cavities directly in connection with bronchi. These suppurative foci are surrounded by areas of organizing pneumonia. In some of the alveoli there is exfoliated ciliated epithelium, probably aspirated from the bronchi. The third block shows complete atelectasis. Kidney, spleen, liver, and bronchial lymph nodes show no features of special interest.
