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Bacteriological examination.- Cultures of trachea show streptococcus and colon group organisms. Smear shows Gram-positive and negative cocci and Gram-negative bacilli in trachea. Gelatinous and consolidated lung, numerous streptococci, single cocci, and Gram-positive bacilli.
NOTE.- Mustard-gas case, dying nine days after exposure, and presenting typical lesions at autopsy. In the trachea there was beginning regeneration. Many of the medium-sized bronchi showed a very severe injury, and the terminal bronchioles were transformed into abscesses with a reactionary zone of organizing pneumonia about them.
CASE 65.- S. R., 2299831, Pvt., Co. H., 112th Inf. Died, November 9, 1918, 3.30 p. m., at Base Hospital No. 87. Autopsy, November 10, 24 hours after death, by Lieut. H. H. Robinson, M. C.
Clinical data.- Gassed on October 31, 1918; 1,000 yellow cross and 400 blue cross and green cross shells used in bombardment, northeast of Xammes. On admission to base hospital, eyelids were red and swollen, photophobia, coughing, slight dyspnea, rapid pulse. Venesection performed on November 3 and 5. Before death pulse became rapid. Whistling rales were heard through the entire left chest.
Anatomical diagnoses.- Pigmentation and superficial burns of skin, neck, scalp about eyelids and lips. Small erosion in fold of skin on right side of scrotum.
Gross findings.- Pleural cavities: There is no free fluid. Easily separated pleural adhesions over both lungs. Organs of neck: Trachea: In its upper portion is covered with thick necrotic membrane, which is absent in places exposing the deeply eroded surface. The lining of the lower portion of the trachea and the larger bronchi is smooth but bluish in color, as if mucosa had been exfoliated. Lungs are voluminous and heavy. On pressure a large amount of frothy blood exudes from the cut bronchi. On section the anterior portions of the lung are air containing. Elsewhere all lobes are full of small firm closely set, but irregularly outlined, patches of consolidation. Cut surface is very moist, and mottled pink arid dark red. Blood flows freely form the congested vessels. Smaller bronchi contain thick yellow pus. Heart is normal. Kidneys show moderate chronic nephritis. Remaining organs show nothing of interest. Gastrointestinal tract is normal throughout.
Microscopic examination.- Trachea: No pseudomembrane remains. Epithelium is completely destroyed. The submucosa is edematous, congested, and infiltrated with poly- morphonuclears and other types of wandering cells. Lungs: Two of the blocks show gangrenous necrosis of the walls of the bronchi. Other lumina are completely filled with plugs of fibrino-purulent exudate and bacteria. There is intense edema of the surrounding lung tissue, leading to rupture of the alveolar walls. Interlobular and subpleural lymphatics are greatly distended. Another block shows diffuse lobular pneumonia, with many swollen alveolar cells amongst the exudate. Several other sections show no additional features.
NOTE.-A case presumably of mustard-gas poisoningof nine days' duration. Skin lesions were of moderate severity, but there was very intense necrosis of the respiratory passages, with peribronchial consolidation and widespread edema. Probably because of the complete epithelial destruction, there were no reparative changes.
CASE 66.- P. J. C., 482258, Pvt., Co. L, 54th Inf. Died, November 14, 1918, at 9.45 a. m., at Base Hospital No. 87. Autopsy, November 15, 23 hours after death, by Lieut. H. H. Robinson, M. C.
Clinical data.- Gassed on November 5, 1918, by mustard-gas shell. On admission, difficulty in breathing and many rȃles in chest. Burns about eves, face, scrotum, and knees. Epistaxis.
Anatomical diagnosis.- Mustard-gas burns of lips, eyelids, face, penis, scrotum, and knees. Brownish-purple pigmentation on the anterior surface of thighs. Diphtheritic tracheitis and bronchitis. Peribronchial hemorrhages. Remaining viscera, normal. Gastrointestinal tract not recorded.
Microscopic examination.- Trachea is covered with several layers of nonciliated epithelium showing occasional mitoses. Some of the ducts of the mucous glands contain actively
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regenerating cells and are filled with more or less solid plugs. The submucosa is moderately edematous. There is a loose infiltration of mononucelears and many of the connective tissue cells have the character of fibroblasts. The blood vessels are hvperemic and their endothelium is swollen. Lungs: There are extensive fresh hemorrhages in the alveoli and septa, with edema in the surrounding tissue. Some of the small bronchi show purulent exudate and exfoliation of the epithelium. A second, very interesting, but poorly stained section showsa fibroblastic thickening of the septa, with early organization of the alveolar exudate.
NOTE.- Mustard-gas poisoning, with death on the ninth day after gassing. There was well defined regeneration of the tracheal epithelium with beginning fibrosis of the subepithelial connective tissue. There was extensive hemorrhagic edema of the lungs with interstitial fibrosis. This may have been associated with a secondary influenzal infection.
CASE 67.- A. W., 127455, 1 A. M., R. A. F. 3 Kite Balloon Section. Died, October 30, 1918, at 12.50 p. m., at Base Hospital No. 2. Autopsy, two hours after death, by Capt. B. F. Weems, M. C.
Clinical data.- October 21, admitted to No. 5 Casualty Clearing Station. Gas-shell wound of head. October 22, admitted to Base Hospital No. 2. Sore eyes, throat, chest; no vomiting; coughing. Slightly cyanosed; eyelids swollen, eyes congested. Heart normal. Lungs: Tracheal and bronchial rȃles, few fine rȃles at left base. No burns. October 24, coarse rȃles have disappeared; fine moist rȃles at both bases. October 25, foul breath; fine rȃles generally over anterior chest; expiration prolonged; still slightly cyanotic. October 26, same signs as yesterday. Profuse purulent sputum. No improvement in general condition. Sputum-direct smear-Gram-positive laneeolate diplococci, spirilla, staphylococci. Culture-pneumococcus, Type IV. October 27, feels better. Slight cyanosis. October 29, holding his own, breathing quietly. Generalized fine and coarse rȃles. Unable to localize consolidation. October 30, marked cyanosis, respiration rapid and feeble, chest filled with moisture. Died at 12.50 p. m.
Anatomical diagnosis.- Membranous pharyngitis, tracheitis, and bronchitis, broncho-pneumonia; old pleural adhesions; congestion of abdominal viscera; status lymphaticus; inhalation of irritant gas, presumably mustard.
External appearance.- Stigmata of status lymphaticus. Skin is dusky yellowish-brown, quite soft and smooth. Very little hair over thighs and trunk, feminine distribution of pubic hair. Sparse beard, adenoid facies; teeth carious, many missing; high arched palate. Desquamation of epidermis, dusky pigmentation and congestion about the eyes; dried exudate in the corners; deeply injected conjunetive, evidences of recent inflammation. Nasal mucosa injected, external orifices otherwise negative.
Gross findings.- Pleural cavities: Obliterated by fibrous adhesions. Left lung: Covered by fibrous tags; moderately distended; apex and anterior portion of upper lobe are normal in consistence, posterior portion somewhat firmer, slightly lumpy, lower lobe evidently partly consolidated. Lymph nodes at the hilum are congested. Bronchi display a marked injection, mucous membrane is covered by grayish-yellow, necrotic-looking exudate, which extends down into the smallest radicles; there is a slight amount of bronchiectasis. Upon cut surface, the lung is grayish red, rather irregular, numerous points of grayish color representing the plugged bronchioles. Around most of these is a zone of deep injection or hemorrhage, varying in width. There are several large, almost wedge-shaped areas of deep purple with yellowish patches about the bronchi; small abscesses are present in some of these. There is considerable edema in all of this diseased tissue. There are many yellowish-gray plugs in the small bronchi. Right lung: Lymph nodes at hilum are markedly enlarged, deeply congested, slightly spotted, but showing no frank suppuration. The lung is covered by fibrous adhesions and very much lacerated in removal. Bronchi contain the same inflammatory products as on the left side. The lung is less voluminous and shows less evidence of consolidation. The cut surface, however, presents almost the same picture as on the left side; the lower lobe is pale in color, except for the peribronchial changes. There is practically no anthracosis present in the lower lobe, although there is considerable amount in all other parts of the lung. There are many areas of hemorrhagic softening. Organs of leck: Tonsils are very small, slightly scarred. Pharynx: Reveals a coarse membranous inflammation, the membrane being thick and yellow and rather hard to peel. Very slight injection
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is noted, the healing process having evidently begun. Larynx: Contains the same sort of membranous exudate, but there is the appearance of regeneration in the mucous membrane. Trachea: Is not greatly altered in its upper half, but becomes more congested toward the bifurcation; patches of yellowish-gray membrane are present in the lowest third. Esophagus is normal. Heart: Left chambers contracted, right flaccid. No abnormalities. Liver, spleen, kidneys, adrenals, and pancreas congested. Stomach: Post-mortem digestion. Intestine not recorded.
Microscopic examination.- Trachea and primary bronchus, no sections. Lung: A medium- sized bronchus is cut longitudinally. It is completely filled with a fibrinopurulent plug,
FIG. 32.- Case 67. Mustard-gas burn, 9 days' duration. Section through bronchus, showing regeneration of metaplastic epithelium, fibroblastic thickening of bronchial wall, epithelial proliferation, edema of adjacent alveoli
which in a few places is becoming organized at the point of attachment by the ingrowth of fibroblasts. The outer portion of the plug shows here and there coarse interwoven lamellae of fibrin. The bronchial wall is represented by a loose vascular granulation tissue, which is covered in places by epithelium, either a single row of flattened cells or several layers of laminated, nonciliated squamous cells. (Fig. 32.) An interesting feature is the presence of sharply outlined areolar spaces within the epithelial cells, containing groups of three or four wandering cells, chiefly small mononuclears. These spaces appear to be formed within the protoplasm of the epithelial cells. Mitotic figures are quite numerous. In the vicinity of the bronchi the alveoli are filled with a hemorrhagic exudate which becomes serofibrinous and finally serous at a distance from the bronchus. The alveolar epithelium, especially in
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the neighborhood of the bronchus, appears to be regenerated, and is frequently columnar. In some areas there is epithelialization of the alveolar plugs in progress, as well as fibroblastic growth. Groups of pigment-containing exfoliated cells are present. In addition to these lesions the section shows several circumscribed abscesses, surrounded by a zone of hemorrhage. The purulent center contains large masses of bacteria. The bacterial stain shows great numbers of Gram-negative bacilli and a few Gram-negative coccoid forms in the bronchial exudate, where the staining of the fibrin shows that the decolorization has not been carried too far. Elsewhere bacteria are difficult to demonstrate. Additional blocks show no features beyond those noted. The epithelial proliferation in some of the bronchioles is remarkable, and there are many large atypical cells. Liver: The cells in the center of the lobules are atrophic; there is elema between the liver cells and the capillary walls. No other striking change. Spleen and myocardium normal. Adrenals intensely congested; cortex contains very little lipoid. There is fair chromaffin staining of the medullary tissue.
Bacteriological examination.- Blood culture: Sterile. Lung culture (blood plate): Staphylococcusaureus, pure. Spleen culture: Staphylococcusaureus and pneumococcus, type?
NOTE.-Death occurred nine days after definite history of inhalation of irritant shell gas. There was conjunctivitis, but the absence of skin burns is specifically recorded in the clinical history, and none were present at autopsy. The lesions of the upper respiratory passages appear to have been fairly characteristic of mustard gas, although the necrosis was less extreme than in many of the cases and not more severe than may occur in the influenzal cases which developed independently of previous gassing. The pulmonary lesions were those of an influenzal pneumonia, with hemorrhagic edema and typical bronchiolitis. There were also localized suppurative lesions, probably associated with a secondary staphylococcus aureus infection. There were interesting early reparative changes in bronchi and lung.
CASE 68.- H. A., 3131135, Pvt., Co. G, 109th Inf. Died, October 15, 1918, 7 p. m., at Base Hospital No. 18. Autopsy No. 143. Autopsy, October 16, 16 hours after death, by Maj. C. B. Farr, M. C.
Clinical data.- Gassed on October 5, 1918. Exposed to yellow cross, green cross, and blue cross shells (1,000 77 and 105 mm. shell). Admitted to Base Hospital No. 18 on October 8 with severe conjunctivitis and cough. Developed cyanosis and signs of consolidation at base of left lung. Leucocytes 9200. October 14, sputum culture negative or pneumo- coccus. There are many Gram-negative cocci.
Anatomical diagnosis.- Second degree burns about the eyes, and inside of nose, nostrils, mouth, and chin. Acute laryngitis, tracheitis, and bronchitis. Coalescing bronchopneumonia. Emphysema. Subpleural emphysema, right middle lobe. Fibrinous pleurisy. Fatty infiltration of liver.
External appearance.- The eyelids, periorbital skin, and adjoining areas of the nose, as well as the nares, left angle of the mouth, and folds of the chin are of a rough, dull red color, and covered by yellow crusts. There are numerous areas of localized desquamation of the skin.
Gross Findings.- Pleural cavities: There are fibrinous adhesions. Heart normal. Left lung is voluminous. The surface of the visceral pleura dotted and rough posteriorly, with tags of fibrin. The lower lobe is firm and airless. On section, the tissue is friable, the excised portions sink in water. The cut surface shows innumerable pinhead to pea sized firm yellowish-red areas surrounded by depressed purplish tissue. There is a moderate amount of moisture present. The upper lobe in the posterior portion is similar to the lower lobe. The anterior portion is soft, cottony, and on section, pale pink. Right lung: In the upper and lower lobes is similar to the left. The middle lobe is soft and cottony, except for a small tongue posteriorly, which is firm. There is slight subpleural emphysema. The general surface of the solid portion of the left, as well as the right lung, is rough, due to projections beneath the pleura of numerous small yellowish nodules. Organs of neck: The mucosa of the pharynx is pale. Tonsils are small. No lesions noted. Epiglottis and larynx slightly pinker than normal. The trachea in the lower portion, shows a thin whitish film, with pink strips corresponding to the areas between the rings. The larger bronchi are of a deep red color, show submucous hemorrhages and intense redness in general. The bronchi and the lower trachea contain gummy blood-tinged fluid.
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Alimentary tract.- Stomach, large and small intestine: On external examination apparently normal. Liver shows moderate fat infiltration. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: There is intense hemorrhagic necrosis which extends to the smooth muscle bundles overlying the mucous glands. There are very few leucocyte in the necrotic zone. The superficial epithelium, as well as that of the ducts of the mucous glands, is destroyed in its entirety, so that there is no trace of regenerative activity. Beneath the zone of necrosis, the vessels arc engorged with blood. There is some fibroblastic growth, individual cells penetrating the overlying dead tissue. The mucous glands are preserved, their lumina choked with mucous secretion, and their stroma infiltrated with lymphoid and plasma cells. There is sequestration of the necrotic zone from the living tissue, although the line of demarcation is distinct. Lung: There are only two blocks of tissue but these show very varied lesions. There are widespread areas of loose consolidation, the composition of the exudate differing in different alveoli. The leucocytes are chiefly polymorphonuclear and are well preserved. There is a variable amount of fibrin, sometimes in the form of dense plugs, sometimes as a delicate network. Red blood cells are abundant and there are hemorrhagic areas with actual necrosis of the alveolar framework. The capillaries are engorged. The alveolar cells are frequently desquamated, but there is no epithelial proliferation. There is no hyaline necrosis of the infundibular walls. The atrial epithelium is desquamated and their lumina filled with pus. In the second block of lung, the bronchial lesions are most interesting. The wall of the bronchus is formed by a clean, highly vascular granulation tissue devoid of epithelium, and in many places infiltrated with hemorrhage. The wandering cells are almost exclusively of the mononuclear types the majority being plasma cells. There is dense fibrinous exudate into the surrounding alveoli, and a diffuse pneumonia, poor in cells, and of the hemorrhagic edema type. Some of the atria in this block show hyaline necrosis of their walls. A well stained safranine preparation shows practically no bacteria aside from occasional plump Gram-positive rods.
NOTE.-Gas poisoning of ten days' duration with a history of exposure to mixed bombardment. The cutaneous and ocular lesions are characteristic of mustard gas. The necrosis of the respiratory tract was very deep and the destruction of the duct epithelium as well as the superficial layer accounts for the absence of regeneration. The pulmonary lesions were those of an influenzal pneumonia in all respects and the case illustrates the difficulty in differential diagnosis.
CASE 69.- C. I., 3509356, Pvt., Co. C, 20th Bat. Died, November 16, 1918, 4 a. m., at Base Hospital No. 87. Autopsy, six hours after death, by Lieut. H. H. Robinson, M. C.
Clinical data.- Said to have been gassed on November 5, 1918, but reports based on examination of Chemical Warfare Service records gives date of gassing as October 13; 2,000 77 and 105 mm. mustard shell in attack. Chief symptoms, sore throat and dyspnea.
Summary of anatomical findings.- Conjunctivve rough and sticky. Scaly desquamation of right side of scrotum. No crusts.
Gross findings.- Respiratory tract: Deep injection of tracheal and bronchial mucosa, with flakes of necrotic membrane. Crumbly exudate in lumen. Left lung: Is light pink in color, voluminous, and emphysematous. The base of the upper lobe is studded with pinhead size abscesses surrounding bronchi. Right lung: Shows some areas of consolidation in the right upper lobe. Diffuse bronchiopreumonia, with necrosis in right lower lobe.
Microscopic examination.- Trachea: The epithelium is missing. There is no exudate on the surface. Wall of the trachea is composed of granulation tissue, elsewhere infiltrated with wandering cells, chiefly small mononuclears. In places this is surmounted by wavy delicate membrane, possibly the remains of the original membrana propria. There is no marked hyperemia. Lungs: Four blocks were examined, (a) shows diffuse pneumonic consolidation with definite abscesses, (b and c) show larger abscesses surrounded by hemorrhage and edema, (d) shows marked emphysematous dilatation of the atria, peribronchiolitis, irregular areas of edema and edema of the interlobular septa.
NOTE.- Mustard-gas case of probably 11 days' duration. The cutaneous and ocular lesions were very slight. Neither the tracheal nor bronchial lesions
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were very characteristic. There was extensive bronchopneumonia with abscesses, not of the influenzal type, and apparently limited to the right lower lobe.
CASE 70.- W. K., 48564, Pvt., Co. M., 18th Inf. Died, October 12,1918, Gas Hospital, Julvécourt. Autopsy No. 51. Autopsy, October 12, - hours after death, by Capt. James F. Coupal, M. C.
Clinical data.- Exposed to mustard gas on October 1, 1918, passing over an area previously shelled.
Anatomical diagnosis.-Superficial burns of body (mustard gas). Bronchopneumonia. Ulcerative tracheitis. Acute fibrinous pleurisy.
External appearance.- Superficial burns of eyelids, conjunctivae, corneae, bends of elbows, scrotum, and buttocks. Scattered areas of brown pigmentation about elbows.
Gross findings.- Pleural cavities: Fresh fibrinous adhesions over both lungs. No fluid. Heart: Right heart dilated, otherwise normal. Left lung: Is voluminous. On section, scattered areas of consolidation with edema in the intervening portion and emphysema anteriorly. The small bronchi are filled with pus. Right lung: Presents the same picture. Organs of neck: Base of tongue and fauces are markedly injected. Trachea and bronchi are denuded of mucous membrane and contain purulent exudate. Alimentary tract not recorded. The remaining organs show nothing of interest.
Microscopic examination.- Trachea: The epithelium is absent. There is no pseudo-membrane. Submucous layers are somewhat edematous and infiltrated with polymorphonuclears and mononuclear leucocytes. Capillaries are congested. Some of the mucous glands contain normal epithelial cells; others show mucous secretion, are surrounded by lymphocytes and other inflammatory cells. The large bronchi are the same as above. Clumps of bacteria are present in the superficial submucous layers. Lungs: The smaller bronchi contain pus cells and granular detritus. Submucous layers are infiltrated with polymorphonuclear leucocytes and a few red blood cells. There is marked peribronchial congestion. There is an area of typical lobular pneumonia with clumps of cocci distributed amongst the leucocytes in the alveoli. The unconsolidated portion of this section shows emphysema. The remaining organs show nothing of interest.
NOTE.-Mustard-gas case of 11 days' duration. There were no special features except the absence of reparative changes of the epithelium of the bronchi of the lung.
CASE 71.- H. G., 113263, rank ?, Co. B, 150th M. G. Bat. Died, April 1, 1918, at Base Hospital No. 18. Autopsy No. 55. Autopsy, four hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on March 21, 1918, while attending to mules back of the trenches. Four hours later developed severe cough and conjunctivitis. On the following day, burns about the penis. On admission, marked conjunctivitis, throat deeply injected. Right middle lobe, dull to percussion, tubular breathing and rules. March 28, both lungs involved, bronchitis, laryngitis, and delirium. April 1, unconsciousness, cyanotic. Temperature 101° to 105?.
Anatomical diagnosis.- First degree healing burns of skin, conjunctive, posterior pharynx, upper esophagus. Diffuse patchy pigmentation of skin. Acute diphtheritic esophagitis, laryngitis, bronchitis, and tracheitis. Extensive bronchopneumonia. Acute fibrinous pleurisy. Pulmonary edema. Obsolete tuberculosis of peribronchial lymph nodes. Dilatation of right auricle.
External appearance.- There are extensive areas of desquamation of the skin over inner surfaces of the thighs. Areas showing innumerable tiny vesicles over the upper chest, upper forearms, and axille. There are good-sized vesicles on the backs of the hands, and on the back of the left hand there is a large bulla, 4 cm. in diameter, containing a considerable amount of clear fluid. There are areas of practically healed superficial ulceration about both knees, wrists, bend of right elbow, right buttock, scrotum, penis, and lips. These are, in places, healed completely, and in places covered by brown scabs. The skin everywhere shows a striking muddy pigmentation. In addition, there are large irregular dark brown areas of pigmentation, in places, associated with the skin lesions mentioned above, in places, especially over the abdomen unassociated with any skin lesions. The distal portion of the
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extremities quite free from the intenser pigmentation. Eyes: Eyelids puffy, lids glued to- gether by caked exudate. Conjunctivae swollen, injected; there are small hemorrhages. Both cornea everywhere transparent. Pupils are about equal, 3 mm. Nose: No abnormalities. Mouth: A few areas of superficial ulceration with scab formation about the lips.
Gross findings.- Pleural cavities are free of fluid and adhesions. Heart: Normal, in position and shows no significant lesions. Right lung: Weighs 900 grams. Left lung: Weighs 710 grams. All lobes are voluminous, cushiony, soggy. Both upper and lower contain solid areas. The pleura in general is thin and glistening, but over the posterior surfaces of the right upper and lower and median anterior surface of the upper it is somewhat glazed, and there is a small amount of fibrinous exudate which peels readily. There is also a moderate amount of fibrinous exudate between the lobes, and here and posteriorly there is a moderate number of red subpleural hemorrhages. Organs of neck: The glands of the neck and mediastinum moderately enlarged, pulpy, and injected. Thyroid of good size, Tissue pale, acini filled with colloid. Trachea: The lower one-third shows necrosis of the epithelium, with ulceration. The process extends into the submucosa. There is a considerable amount of necrotic and fibrinous membrane, below which the tissue is greatly injected and somewhat swollen. In the upper one-half of the trachea there is some necrosis of the epithelium. In the larynx the epithelium is practically necrotic, below it the tissue is greatly injected. The dead epithelium strips readily. In places the necrotic epithelium is associated with considerable coherent fibrinous and fibrinopurulent exudate. This is especially true of the true vocal cords. There is an extension of the process into the esophagus and the base of the tongue. Tonsils: In part are scarred, in part pulpy. A few of the crypts contain dry, yellow, opaque material. Alimentary tract: No abnormalities, except that the lymphoid tissue is slightly more prominent than normal, especially in the lower ileum. The mesenteric glands are small and pulpy. The remaining organs show nothing of interest.
Microscopic examination.- Trachea: No specimens. Lungs: Only a single section showing massive alveolar edema, no fibrin. Liver, spleen, and kidneys: Show no significant lesions.
NOTE.-Typical mustard-gas case of 11 days' duration, but the histological material was inadequate for study.
CASE 72.- V. P. T., 1588715, Pvt., Co. G, 30th Inf. Died, August 28th at 6 p.m., at Base Hospital No. 27. Autopsy 1No. 42, performed 1 hour after death, by Capt. H. H. Permar, M. C.
Clinical data.- August 10, admitted to Field Hospital No. 7, suffering from mustard-gas contact and inhalation. August 12, admitted to Base Hospital No. 27. Severe burns of eyes back, thighs, legs, and arms. Pain in throat, cough and tightness in chest. Heart negative. Many sonorous rales over both sides of chest. Extensive exudate in throat from burns.
Anatomical diagnosis.- Brown pigmentation of skin of body; third-degree burns on but- tocks, hips, and calves of legs, conjunctivitis, acute healing; tracheitis, acute healing; bron- chitis, acute purulent; bilateral; bronchopneumonia, early; bilateral; pulmonary emphysema; atelectasis of left Lipper lobe; acute fibrinous pleurisy; old pleural adhesions, bilateral; hydrothorax, bilateral; cardiac dilatation, right side; acute lymphadenitis, and tuberculosis of peribronchial lymph nodes; congestion and cloudy swelling of liver and kidneys.
Microscopic examination.- (Four blocks taken for examination.) Marked thickening of the bronchi, the walls of which are composed of opaque whitish tissue, 2 to 3 mm. in thickness, is noted in the fragment of preserved lung tissue. (a) The largest bronchus in the section is almost filled with purulent exudate, in which are masses of bacteria, and which toward the periphery has the character of a partially adherent fibrinopurtulent membrane. Over roughly one-half of the circumference the epithelium is entirely defective; over the remainder there is a loosely attached strip of laminated, pale nonciliated cells, several rows in depth. The individual epithelial cells, expecially those near the surface, are vacuolated, their nuclei shrunken and distorted, and there are many leucocytes passing between them. In one place, the epithelium is lifted up by a bleblike accumulation of fluid, appearing as a shreddy coagulum in the section. The bronchial wall is at least 2 mm. thick, and is composed of a fairly vascular granulation tissue, infiltrated near the surface with polymorphommuclears, and in its deeper portion with lymphoid and plasma cells. The mucous glands are partly preserved but mxiauliv of the acini are atrophic. The cartilages are small in comparison to the size of
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the bronchus; the matrix stains with eosin, and the nuclei appear degenerated. Small nerve trunks, embedded in the granulation tissue, show a proliferation of the endo- and perineurium, and are invaded by wandering cells. Another bronchus of about the same caliber shows similar changes, but there is less inflammation, and the reinvestment with metaplastic epithelium is more extensive. It is interesting that the new epithelium shows vacuolization of the epithelial cells, like that seen in the original burns. At the same time there are numerous mitotic figures. The arteries are surrounded by a broad zone of edematous granulation tissue. The lung tissue in the section shows a patchy edema, with some exfoliation of epithelial cells. (b) The section includes several bronchi of medium size. One of these is completely occluded with a fibrinous plug, loosely infiltrated with wandering cells; another is filled with pus and bacteria. In both, epithelium is entirely destroyed and the bronchial wall replaced by thick granulation tissue. The parenchyma shows emphysematous vesicles interposed between small areas of collapse and lobular pneumonia. An interesting feature is a marked stenosis of some of the smallest bronchi, the lumen of which is reduced to an irregular split, and the wall proportionately thickened. (c) The changes in the larger bronchi are like those described, some being completely reinvested with squamous epithelium, others still showing a severe diphtheritic inflammation with adherent laminated fibrinous membrane. The lung tissue is the seat of a hemorrhagic and fibrinous edema, which in the neighborhood of the bronchi is becoming organized by the ingrowth of fibroblasts. The alveolar septa are thick and infiltrated with wandering cells, chiefly lymphoid. There is an obliterating bronchiolitis in some areas. This is not associated with organization of the bronchial exudate, the lumen being free, and the epithelium normally ciliated. It appears to be caused rather by the contraction of the granulation tissue in the wall of the bronchiole. (d) The bronchial changes are like those in the previously described sections. The lung tissue itself shows an extensive edema. Many of the alveoli also are packed with well-preserved desquamated epithelial cells, amongst which are large multinucleated forms.
NOTE.-A case of severe mustard-gas poisoning, dying 11 days after exposure with typical cutaneous and respiratory lesions. The permanent changes which resulted from the intense bronchial injury are already indicated, and cicatrization and repair were seen, together with the destructive effects of the original injury.
CASE 73.- W. H. T., 2414146, Pvt., Hdqrs. Co., 312th Inf. Died, November 1. 1918, at 5.10 p. m., at Base Hospital No. 41. Autopsy No. 41, performed two hours after death, by Lieut. L. G. Gage, M. C.
Clinical data.- Gassed with mustard shell gas on October 21. Admitted to Mobile Hospital No. 4 on October 25, with diagnosis of mustard-gas burns, multiple shrapnel wounds. and fracture of right fibula. October 27, admitted to Base Hospital No. 41. Diffuse bronchitis.
Anatomical diagnosis.- Mustard-gas burns of skin; acute conjunctivitis; membranous laryngitis, tracheitis and bronchitis; acute bronchopneumonia; anomalous left kidney; multiple shrapnel wounds.
External appearance.- There is a dermatitis of eyelids, corner of mouth, lips, and nostrils. The epithelium is sloughing on inner surface of the thighs. The prepuce and glans penis are very edematous. There are multiple superficial shrapnel wounds over both legs. There is a penetrating wound just to the outer side of the right tibia.
Gross findings.- Left lung: Weighs 720 grams. It does not collapse readily after removal. The lower posterior portion of the upper lobe and the lower lobe are dark blue in color, firm in consistence. On section, the upper lobe has a pink color, but scattered through it are small dark red areas which surround the bronchioles. These contain a fibrinomucoid secretion. The main bronchus contains a fibrinous membrane beneath which the mucosa is congested, hemorrhagic and eroded. The lower lobe is solid, of beefy consistence, and dark red in color. The bronchioles are surrounded by patches of grayish consolidation. Right lung: Weighs 920 grams and presents lesions similar in character to those on the left side. (Additional note dictated from preserved Army Medical Museum specimen.) The specimen includes half of uIpper and lower lobes of right lung. The pleura is covered by a delicate fibrinous exudate. The surface of the lung is smooth, and the lobular structure obliterated.
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On section, the lower portion of the upper lobe, and the entire lower are solid, airless, dark red. The large bronchi show erosions of the inucosa with grayish membranous deposits. The small bronchi are more or less filled with yellow fibrinopurulent exudate. Larynx is covered with fibrinous exudate under which the mucous membrane is congested, hemorrhagic, and eroded. Trachea shows a similar membrane. The congestion increases toward the bifurcation. Gastrointestinal tract: Not recorded. The remaining viscera show no lesions of special interest.
Bacteriological examination.- Culture from lung (post-mortem) hemolytic streptococcus.
Microscopic examination- Large bronchus: The epithelium is in large part preserved, and is normally ciliated. Where exfoliation has occurred, this appears to have been post mortal. The submucosa is not markedly edematous and there is no acute inflammatory infiltration. The capillaries are engorged, and there are small hemorrhages. The picture does not correspond closely to the description of the gross lesions. Lungs: The picture is an unusual one. The bronchioles and infundibula are filled with masses of bacteria and muculs, with a variable number of leucocytes. The epithelium in most of them is wholly destroyed. The parenchyma shows practically no aerated alveoli, the alveolar spaces being filled with homogeneous coagulumn, or in places a fibrinoums plug, in which are numbers of red cells and alveolar epithelium. The hemorrhage in some portions of the sections is very abundant. Into the plugs are seen growing pale fibroblasts, but the organization is very early and limited to comparatively few alveoli. The exudate is practically free from leucocytes, but there is an increased number in the alveolar septa.
NOTE.-The duration of life after gassing in this case was eleven days. The skin burns bore out the clinical diagnosis of mustard-gas poisoning, but the respiratory lesions were less clear-cut. A membranous tracheobronchitis was described in the gross, but sections of a large bronchus failed to confirm this. The pulmonary lesions conformed to the acute influenzal type. with abundant hemorrhagic edema and an aplastic exudate. It is to be noted that the case occurred during the period when the influenzal epidemic was at its height. The case illustrates the difficulty in differential diagnosis.
CASE 74.-T. B., 124463, Pvt., Labor Corps, 204 Emp. Co. Died, November 1, 1918, at 4.40 a. m., at Base Hospital No. 2. Autopsy, five hours after death, by Lieut. J. H. Mueller, San. Corps.
Clinical data.- October 20, admitted to No. 47 Casualty Clearing Station. Irritant shell gas poisoning. October 22, admitted to Base Hospital No. 2. Nauseated; pain in abdomen; eyes and throat irritated and sore. Temperature 104.4?. Pulse 110. October 23, conjunctivitis; pharyngitis; chest clear; heart normal; pulse 80; abdomen, slight tenderness. October 24, temperature 104. Respirations normal; very drowsy; chest shows a few coarse râles in right axilla and under right scapula; coughing. No diarrhea; nauseated during night. Sputum smear shows mixed flora, Gram-positive diplococci, bacilli, etc. Plate staphylococcus, streptococcus viridans. Blood count, white blood cells, 9,150. Polymor-phonuclears, 84 per cent. Small lymphocytes, 10 per cent. Large lymphocytes, 5 per cent. Transitionals, 1 percent. October 25, temperature 103°. Small patch of relative dullness over right back in posterior axillary line near axilla. Bronchovesicular breathing and a few rȃles in this area. Urine, heavy trace of albumin; many finely granular casts. No cells. October 26, temperature 102°. Chest shows very slight change. Slight impairment at bases, also over right subscapular region; moist rȃles in these areas. Cyanotic, labored respiration; complains of pain in chest and lower lumbar region. October 30, condition worse, jaundice; many fine and coarse rȃles over entire chest; suppressed breathing. Blood culture sterile. October 31, marked jaundice; gasping; pulse rapid and weak. November 1, died at 4.40 a. m.
Anatomical diagnosis.-Acute purulent tracheobronchitis; bronchopneumonia; localized empyema; acute perihepatitis; icterus; poisoning by inhalation of irritant gas.
External appearance.- Moderate emaciation. Fairly marked jaundice evident over the whole cutaneous surfaces and particularly marked in the sclerie. There is all erythematous rash over the back. No other cutammeous lesions.
Gross findings.- Pleural Cavities: Free from fluid. Left lung: Lightly adherent along its posterior surface by thick fibrinous adhesions. The pleura is smooth except for this
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area, which is slightly dulled. The bronchi contain thick bloody pus, and their surfaces are red and eroded. The larger vessels are normal. On section, the upper lobe is practically normal, being air containing throughout except for some small areas of broncho-pneumonia at the base. The lower lobe is largely affected; it is very edematous and bloody. The consolidation is lobular, the consolidated areas being in places hemorrhagic, in others flesh-colored and translucent. The bronchi are not noticeably prominent. Right lung: Shows a rather more extensive exudate over the lower lobe. In addition, the lower portion of the upper lobe, on its anterior surface, and also on its mesial surface, shows a thick yellow exudate of purulent material. On section, all lobes are heavily involved in a lobular consolidation resembling that of the opposite lung. In one place in the lower lobe there are a number of small grayish-white areas, cutting with a fairly flat surface, perhaps slightly projecting, each about 0.5 cm. in diameter. These are dry, opaque, and granular in distinction to the surrounding lung. Bronchi show the same bloody exudate as on the left side, the smaller bronchioles not being prominent. Organs of neck.-Trachea: Shows an intense congestion with deep ulceration of the entire mucosa; glottis is similarly affected. Heart normal. Liver: Bile passages patent. Gall bladder contains a small amount of dark green fluid bile. There are no stones. Over the portion of the liver adjoining the diaphragm, there are partly organized fibrinous adhesions uniting the two. Stomach and intestines: Normal except for slight congestion of the lower portion of the ileum. Remaining viscera show no significant lesions.
Microscopic examination.- Trachea and large bronchus: No sections. Lungs: Four blocks showing similar pictures. No larger bronchi are included in the sections. The bronchioles and infundibula contain dense plugs of fibrinopurulent exudate; the epithelium shows in places early regeneration, and is frequently in the form of a single flat layer. Elsewhere there is an intense confluent hemorrhagic pneumonia. The exudate in some of the air spaces is composed predominantly of polymorphonuclears, pycnotic and distended with bluish granular material, which in Gram-stained sections are disclosed as a variety of Gram-positive and negative bacteria. Many of the Gram-negative organisms are cocci. There is practically no fibrin in the exudate. There are several areas of necrosis in which the alveolar walls are involved. In some areas there is profuse fresh hemorrhage, completely filling the alveoli. Mixed with the blood cells are pigment containing alveolar cells. Near the pleura there is active epithelial proliferation, new cells investing the alveolar wall and covering over the plugs of exudate. (See fig. 26.) Spleen, kidney, and myocardium: No significant changes.
NOTE.-Death 12 days after definite exposure to irritant shell gas. No cutaneous lesions, but there was conjunctivitis and marked icterus. There was an ulcerative tracheobronchitis, without definite membrane formation. The lungs showed a hemorrhagic lobular pneumonia with edema, of the influenzal type, with epithelial proliferation.
It is not possible from the data at hand to make a definite diagnosis of mustard-gas poisoning, nor indeed, aside from the clinical history, is there any convincing evidence of previous gassing. The lesions present might all be attributed to an influenzal infection with pneumonia.
CASE 75.- T. M., 561720 (rank not given), Hdqrs. Co., 59th Inf. Died, August 18,1918, at 8.25 a. m., at Base Hospital No. 17. Autopsy, performed ? hours after death. (Name of pathologist not stated.)
Clinical data.- Gassed on August 8. No further details available. The records include no other fatalities from gassing in the same company on or about this date, but soldiers from Companies D and H of the 59th Infantry were gassed on August 5 and 6 with yellow, blue, and green cross shells. It is possible that T. M. was exposed on the same date. August 8, admitted to Field Hospital No. 28. Exhausted. Blisters on scalp. Bath. Blisters dressed. Transferred to Evacuation Hospital No. 5, and on August 9, to Base Hospital No. 17. Cyanosis, marked dyspnea, air hunger, tachveardia, heaving displaced apex. Lungs showed typical physical signs of edema. August 10, cyanosis and dyspnea not improved. Pulse rapid and thready but regular. No dullness, but large and smallrȃles with prolonged blow at end of each respiration. Oxygen administered. Died on August 18. Autopsy protocol not received.
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The following note was dictated from the preserved Army Medical Museum specimen, which consists of the neck organs, with left lung attached, in formalin:
The base of the tongue and pharynx are normal. The inferior surface of the epiglottis and false cords of the larynx are covered by grayish flakes of exudate which are easily detached. The trachea is pale throughout. The lining is a little rough and granular, and largely denuded of mucosa. Beginning about the middle, however, there are islands of a grayish white adherent membrane which resembles patches of regenerated epithelium rather than a diphtheritic exudate. The large bronchi, especially after the first division, still contain much fibrinopurulent exudate. On section, both lobes of the left lung are air containing except for scattered patches of edema and partial atelectasis. The bronchi on cross section have opaque thick walls; many of them are completely occluded by membrane or exudate. The anterior portion of the upper lobe shows a group of small bronchiectases lined with necrotic material.
Microscopic examination.- Trachea: The surface is in part denuded of epithelium, in part covered with islands of stratified squamous cells, often six or more layers deep. The ulcerated regions are surmounted by a loose exudate composed of red blood cells, polymorphonuclears and detritus. There is very little fibrin and no formed pseudomembrane. The mucous ducts show the usual epithelial proliferation. The subepithelial tissue is the seat of a dense inflammatory infiltration, both polymorphonuclears and of lymphoid cells. There are very dense accumulations of lymphocytes about the otherwise normal mucous glands. Lungs: Section includes a group of medium-sized bronchi greatly distended with purulent exudate. The epithelium and glands are destroyed but the cartilages about the larger branches are still intact. The alveoli about these bronchiectases are compressed and the septa thickened and infiltrated. Some of them contain fibrinous exudate, others fresh blood. In many, organization is in progress. The connective tissue about the bronchi and blood vessels is edematous and contains many fibroblasts. (Fig. 33.) A second block of lung shows an acute suppurative bronchitis with moderate dilatation and inflammatory thickening of bronchial wall, leading in one place to necrosis of the bronchial cartilage. In many places the alveolar septa are condensed and infiltrated with dense collections of leucocytes, largely mononuclear. Practically no exudate in alveolar spaces.
NOTE.-An incompletely studied case; death 10 to 12 days after gassing. The nature of the gas to which the soldier had been exposed is uncertain, but the clinical history suggests an admixture of suffocative gas in addition to the vesicant. The regenerative changes in the tracheal epithelium are of interest.
CASE 76. T. M., 2849228, Pvt., Co. H, 359th Inf. Died, October 11, 1918, at 2 a. m., at Base Hospital No. 45. Autopsy No. 52. Autopsy, October 12, 31 hours after death, by Capt. Jean Oliver, M. C.
Clinical data.- Gassed on September 28, 1918. The following extract is taken from field card: "Was sleeping in dugout when gassed, also got some gas after leaving dugout, burned eyes, throat, and lungs; got sick at stomach and vomited, coughed good deal since. Physical examination: Eyes red, lids swollen, lacrymation and photophobia. Coughing some and spitting up mucopurulent sputum. Hoarse. Diagnosis: Mustard and diphosgene." On admission to Base Hospital No. 45 on October 5 complained of intense pain in throat and on swallowing. Face cyanotic, pulse rapid, temperature 102°. Dullness over right lower lobe. Fine crepitant rȃles.
Anatomical diagnosis.- Mustard-gas burns, on lips, eyes, nose, and over scrotum. Diphtheritic laryngitis, bronchitis, and tracheitis. Diffuse bronchopneumonia of all lobes of both lungs.
Following abstract was dictated upon the receipt of specimens at the pathological laboratory, Experimental Gas Field:
The posterior wall of the pharynx shows a superficial necrosis with a grayish membrane. The epiglottis and trachea present a worm-eaten appearance (erosions) and are covered in places with a sandy grayish deposit. The bronchi, larger branches, show intense purplish- red discoloration. There are patches of flaky exudate on the surface. After the second or third branching, the mucous membrane becomes smooth. The lumina contain very little exudate. The left lung is moderately heavy and voluminous. There is fresh fibrin in spots
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over the posterior portion of the lower lobe. The color is mottled bluish purple. On section is generally air containing. There are, however, a few shotty elevated areas of consolidation. These are not over 1 cm. in size. The bronchi are surrounded by a zone of hemorrhage 2 to 3 mm. broad. Elsewhere the lung tissue presents a marbled appearance because of irregular, uniform, darker areas, slightly prominent above the surface, which are partly consolidated. The lower lobe is very dark in color and poorly aerated. It contains a number of small shotty pneumonic patches. The right lung shows fresh fibrin over all lobes. On section there are numerous areas of lobular pneumonia, rather discreet and small for the most part, and distributed throughout all lobes.
FIG. 33.- Case 75. Death probably 10-12 days after exposure to mixed gases. Bronchiectases filled with purulent exudate. Peribronchial and periarterial edema and beginning fibrosis
Microscopic examination.- Trachea: The mucous membrane is of the stratified squamous type. In places it is partly exfoliated and there is false membrane. The submucous tissue shows, engorged vessels, edema, and a slight infiltration with mononuclear cells, large and small. This is especially marked about the mucous glands . A few bacteria are seen on the surface of the mucous membrane. Medium-sized bronchus: In places there are patches of adherent membrane composed of swollen reticulated fibrin. The wall of the bronchus is completely necrotic and there is no beginning of regeneration. Beneath the necrotic lining there is edematous tissue, poor in cells. About the bronchus there is the usual zone of intense hemorrhage. Lungs: The small bronchi show desquamated columnar epithelium. The lumina are filled with polymorphonuclear leucocytes. The walls are
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congested and acutely inflamed. The parenchyma is the seat of a bronchopneumonia of wide but patchy distribution. The exudate varies in its contents of edematous fluid, red-blood cells, polymorphonuclear leucocytes and fibrin. Usually there are well-defiled areas in which one or more of these elements predominates. Bacteria are numerous both in the bronchi and the pneumonic areas, almost extensively Gram-positive cocci, some in large masses, others in swollen groups and chains. It is evident from the naked-eye inspection of the lung section that many of the bronchi are both dilated and thickened. The dilatation is shown by the flattening of the adjacent alveoli. The thickening is produced by edema and peribronchial organization of the connective tissue. The periarterial tissue is also thickened. Liver, spleen, kidneys, pancreas, and intestines show no significant lesions.
NOTE.-Mustard-gas poisoning: death on the thirteenth day after exposure. There was no anatomical reason to support the clinical diagnosis of mustard-gas and diphosgene poisoning, the lesions differing in no respects from other mustard-gas cases. It must be said, however, that it would probably not be possible to recognize the effects of an admixture of suffocant gas after this time had elapsed. The trachea and large bronchi showed well-established epithelial regeneration, and it is possible that the necrosis was superficial. The smaller bronchi, on the other hand, showed extensive necrosis with beginning fibrosis of their walls, and dilatation. There was the usual peribronchitis with fresh hemorrhagic pneumonia. The consolidation was distinctly in relation to the bronchi.
CASE 77.- J. C., 2706880, Pvt., Co. H, 136th M. G. Bat. Died, October 28, 1918, 3.40 a. m., Base Hospital No. 45. Autopsy No. A 18-67. Autopsy, 10 hours after death, bv Lieut. Perry J. Manheims, M. C.
Clinical data.- Gassed about 6 a. m. October 14, 1918, in action, 2,000 150-mm. shells. Ciinical diagnosis: Bronchopneumonia following inhalation of mustard gas.
Anatomical diagnosis.- Multiple superficial mnustard-gas burns. Diphtheritic tracheo-bronchitis. Bronchopneumonia. Hemorrhagic erosions of stomach.
External appearance.- Superficial burns about mouth, nose, and right cheek, covered with thick brownish red scabs. Skin on inner surface of both thighs shows small dry blisters, confluent in places, extending from 3 cm. above knees to level with scrotum. Few drv scabs on under surface of scrotum and prepuce. Skin about the axillae shows the same condition as the thighs.
Gross findings.- Respiratory organs: Sent to Chernical Warfare Service. Stomach: Shows a few hemorrhagic erosions. The remaining organs show no significant lesions.
The following note on the gross appearance of the respiratory organs was made upon the receipt of the specimens at the pathological laboratory, experimental gas field:
The posterior wall of the pharynx shows necrosis and is covered with patches of gray membrane. The tonsils are smaller than usual, with deep crypts containing cheesy plugs. The inferior surface of the epiglottis, vocal cords, and trachea show complete necrosis of the mucous membrane, which is replaced by a soft slough. The bronchi are filled with a thin purulent fluid. The mucosa is necrotic and desquamated. There is no definite membrane. Left lung: Weighs 525 grams. The pleura is smooth. Firm nodular areas can be felt through the upper lobe. On sections these correspond to elevated I to 2 mm. sized areas of consolidation scattered about the bronchi. The latter are filled with pus. There is the same appearance in the lower lobe. The bronchi seem rather thick and project above the surface. Right lung: Weighs 700 grams. There are large areas which show a grayish-blue color through the pleura, which are quite soft and have lost their elasticity. These areas occupy the posterior two-thirds of the upper and middle lobes and the upper and posterior parts of the lower lobe. On section, the lung tissue is broken down, exuding a large amount of thin bloody fluid. There is no gangrenous odor. The anterior portion of the lobes contain numerous small greenish areas of consolidation, apparently peribronchial.
Microscopic examination.- Skin: Illustrates the late effect of a mild burn. There is hyperkeratosis; many of the epidermal cells show pycnotic nuclei and contain vacuoles, and the papillary layer of the corium shows edema. There are occasional pigment cells, but no
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marked increase. Inflammatory changes are absent. Primary bronchus: The membrane has been cleared away. The surface is formed by continuous membrana propria which is uncovered by epithelium. Immediately beneath it are fairly dense accumulations of leucocytes (pycnotic). The submucous tissue is very loose and edematous. Many of the venules contain dense hyaline thrombi, some of which are being covered with endothelium. In the deeper submucosa there is a proliferation of fibroblasts. The mucous glands are in active secretion and are not abnormal. The section includes no submucous ducts. Lungs: The most interesting changes are found in some of the bronchi, which, with the low power, are slightly thick walled, and under the high magnification show clearly an active hyperplastic growth with numerous plasma cells. The bronchi are relined with flattened epithelium. The parenchyma is the seat of irregular patches of bronchopneumonia, some of which are in definite relation to bronchi which are filled with purulent exudate. There are no special features to the exudate. In a few areas where fibrin is abundant organization is in progress. Bacteria are difficult to demonstrate. A few Grain-positive cocci are found in the bronchial exudate. Cultures at autopsy from lung show hemolytic streptococcus.
NOTE.-Mustard-gas poisoning; death 14 days after exposure. Charac- teristic burns. Atria and bronchi showed a cleaning up of the tissue with subsidence of the acute inflammatory process, but no epithelial regeneration. The small bronchi were already thickened and dilated. Some of them were relined with new epithelium, though incompletely. There was still an acute lobular pneumonia distributed about the infected atria. The usual organization of the exudate was in progress in certain places. The gangrenous areas in the right lung were, unfortunately, not examined histologically.
CASE 78.- P. C., 61723, Pvt., Co. ?, 101 Inf. Died, June 14, 1918, at Base Hospital No. 18. Autopsy No. 63. Autopsy, one and one-half hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Said to have been gassed with phosgene on May 31, 1918, while on raid on enemy's trenches. On return to own trenches developed cough; was carried to Field Hospital No. 103. Transferred to Base Hospital No. 18 on June 2. On admission temperature 1020, comfortable. Rȃles in both lower lobes. June 4, temperature 105°, moderate cyanosis, rapid respiration. Signs of bilateral bronchopneumonia, most extensive in lower lobe. Blood pressure 95/50. Heart not dilated. On June 5, temperature 105°, respiration 34, cyanosis, feeble pulse. June 6, consolidation of entire left lung. General condition better, apparent crisis. June 9, temperature again elevated. Delirium, Cheyne-Stokes; profound prostration. Irregular consolidation, right upper lobe. Stupor. Leucocytes, June 5, 13,800; June 10, 16,300; three blood cultures negative.
Anatomical diagnosis.- Acute tracheitis and bronchitis, following phosgene inhalation. Extensive bronchopneumonia, discrete and conglomerate with areas of organization. Acute bronchial lymphadenitis. Moderate fat infiltration of liver. Acute colitis. Few small healed infarcts of right kidney. Acute dilatation of right ventricle. Healed tuberculous foci of bronchial and tracheal lymph nodes.
External appearance.- Skin is sallow in appearance. About the right shoulder and forearm there are a number of flat, irregular, pearly white blotches in the skin, suggesting old burns. In the skin of both legs there are small excoriated areas suggesting pediculosis, also a number over. Mouth: Some sordes covering the lips and gums. Also a moderate amount of mucus.
Gross findings.- Pleural cavities: Opening the thorax, the median portions of the upper lobes almost meet in the midline. The pleural sac is free of adhesions and fluid. The heart is enlarged slightly to the right. No abnormalities in the sac. Heart: Weighs 290 grams. Moderate dilatation of the right ventricle. Otherwise negative. Right lung: Weighs 600 grams. All lobes are voluminous. The posterior and lateral portions of the upper and lower lobes soggy, solid, the median portions cushiony. The middle lobe cushiony, pink. The glands at the hilum are considerably enlarged, pulpy, somewhat edematous, pale. Some
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of the glands at the hilum have small scarred gray areas, plus anthracosis. The bronchi are filled with thin, viscid yellow pus. On section of the upper lobe, the posterior and lateral one-half dull gray-red and red, solid in great part, mottled with small grayish and yellowish pinhead sized areas. The median one-half is pink, aerated. Through it there is a moderate amount of discrete and conglomerate small gray nodules, quite firm in consistence. On section of the middle lobe, the tissue crackles, is well aerated, pink; scattered throughout, there is a moderate number of discrete and conglomerate pinhead sized yellowish-gray solid areas. Some of these more firm in consistence than others. In the lateral portion of the lobe there is some grayish consolidation about these conglomerations. The lower lobe, on section, shows in the posterior and lateral portions collapsed deep red long tissue mottled with a large number of discrete and conglomerate grayish and yellowish nodules, mostly gray with fairly firm consistence. About these conglomerations, more medially, there are discrete hemorrhages. About these medially the tissue is well aerated, pink, shows a moderate number of discrete and conglomerate solid gray areas, quite firm in consistence. In this lobe there is a little uniform consolidation and that present is found in the posterior and lateral portions of the lobe. Left lung: Weighs 800 grains. Both lobes voluminous, soggy, solid. The median portions, especially, show well-aerated tissue in which are felt numerous small nodules. The pleura over the lobes on this side and over the lobes on the right is thin, delicate and pale. The glands at the hilum and bronchi are similar to those on the right. On section, the upper lobe is mottled reddish and yellowish, surface presents with, here and there, areas of pink. The yellowish areas are discrete and conglomerate. The solid areas are associated with bronchial branches. The peripheral portions of greater consistence than the central portions. In places there are more firm solid areas. The dull reddish-gray areas are large consolidated patches, in places confluent. The surface is relatively dry, slightly granular, surrounding the numerous groups of yellow conglomerations mentioned above. The lower lobe, on section, shows a picture quite similar to the right lower lobe, except that the hemorrhage about the conglomerate yellow areas is much more marked. Associated on this side there is present some diffuse consolidation. The nodules, likewise, in this lobe are more numerous and of less consistence than those in the right lower lobe. Organs of neck: Lower tracheal and cervical glands are quite similar to the glands about the hilum. In addition some show calcified nodules. The thyroid is small and tissue pale. Acini contain some colloid. The larynx and trachea contain a considerable amount of viscid yellow pus. The mucosa is pale, thin, except in the lower portion of the trachea, where it is somewhat swollen and somewhat injected diffusely. Tonsils: Small, scarred, and crypts clean. Alimentary tract: Stomach is small. The walls are moderately contracted. There are a few 100 c. c. of thin bile tinged mucus in it. The duodenum and the jejunum contain bile tinged contents. The lymphoid tissue in the tract is slightly more prominent than normal. Throughout the large intestines there are large patches of injection of the mucosa with small hemorrhages. In these areas the lymphatic follicles are very prominent, and covering the mucosa there is adherent tenacious mucus. The rectum is similar in appearance. The injection here is more marked. The mesenteric glands are somewhat enlarged, pulpy, pale. Liver: Weighs 1,530 grams. Shows slight fat infiltration. Kidneys show focal scars.
Microscopic examination- Trachea: No sections. Large bronchus: The epithelium is continuous and very orderly in arrangement. The superficial layer is beautifully ciliated. There are occasional mitoses. Leucocytes, polymorphonuclears and mononuclears are wandering between the epithelial cells. The submucosa is not edematous nor extremely congested. There are numerous lymphoid and plasma cells but very few polynuclears. The mucous glands are in active secretion, otherwise normal. Lungs: There is an intense bronchiolitis and infundibulitis. The lumina are filled with pus, their epithelium is largely preserved, and in many cases regenerated, multiple-layered and nonciliated. There is an early organization of the bronchiolar exudate in places. The bronchial walls are thickened, partly by edema and inflammatory changes, and partly by new growth of connective tissue which extends into the septa of the neighboring alveoli. There is a marked peribronchitis, the alveolar exudate consisting often of dense plugs with few leucocytes. There is an early ingrowth of fibroblasts, and an epithelial proliferation. Epithelial cells are relining the alveoli and in the form of syncytial masses growing over and into the fibrin plugs. Another block shows a slightly different picture. Many of the infected atria, which have completely lost their epithelium, appear as abscesses and are surrounded by confluent areas of hemor-
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rhagic and fibrinous pneumonia, in which organization, interstitial fibrosis, and regeneration of the alveolar epithelium are conspicuous features. A study of the sections stained with Gram-Weigert-safranine under the low power magnification with a binocular microscope shows in a very interesting way the distribution of the lesions. There is an acute suppurative bronchitis and bronchiolitis, but the epithelium in the bronichli is in large part preserved. The bronchioles and atria are surrounded by pneumonic areas in which the exudate consists almost wholely of well preserved polynuclears. Outside of this the alveoli contain beautiful fibrin nets and the cells are largely desquamated epithelial cells. It is in this zone that reinvestment of the alveoli with new growth of proliferating epithelial cells and occasional organization is encountered. Large intestine shows congestion and hypersecretion of mucus. Testis: There is an absence of spermatogenesis, and interstitial edema and fibrosis. Liver, spleen, pancreas, kidney, and myocardium show no significant lesions.
Bacteriological examination.- Smears: Trachea shows innumerable small Gram-negative bacilli, a considerable number of Gram-positive diplococci, and a moderate number of fair-sized Gram-negative bacilli. The predominating organism is a small Gram-negative bacillus. Lung: Large consolidated portion shows a considerable number of Gram-negative bacilli, a few good sized Gram-negative bacilli. Small consolidation shows very few organisms, small clumps of Grain-positive cocci and a few small Gram-negative bacilli.
NOTE.-Death 14 days after alleged exposure to phosgene. There were no recent mustard-gas burns and the inflammatory changes observed in the trachea and larger bronchi had not the necrotizing character observed in mustard-gas cases. At this stage, it is not possible to make a definite anatomical liagnosis of previous poisoning by asphyxiating gas, although it is quite probable that the extensive bronchopneumonia present may have followed the inhalation of gas. The reparative changes in the bronchi and alveoli were those which might be seen in any type of bronchopneumonia at this stage.
CASE 79.- D. F., 1319851, Corpl., 120 Inf. H. Q. Died, November 2, 1918, at 1.25 p. m., at Base Hospital No. 2. Autopsy, one and one-half hours after death, by Lieut. J. H. Mueller, San. Corps.
Clinical data.- October 20, admitted to No. 61, Casualty Clearing Station. Poisoning by irritant gas, having been exposed October 19 to blue, green, and yellow cross shelling. October 22, admitted to Base Hospital No. 2. Gassed three days ago. Sore eyes and throat. Vomiting. Cough. No burns. Bleeding from nose. Heart normal. Lungs: A few coarse bronchial rȃles. Sputum, mucopurulent. October 25, feels much better. No localization of signs of consolidation; coarse rȃles and very harsh breath sounds at left base. October 27, fine moist rȃles over right lower lobe; harsh breath sounds over entire posterior chest. Condition worse, slightly irrational. Sputum culture-pneumococci and micrococcus catarrhalis. October 29, marked dulluess with diminished breath sounds over right lower lobe. Fine and coarse rȃles over left lower lobe. Holding his own. Good pulse. October 31, temperature falling by lysis. Consolidation of both bases. Doing well. November 1, harsh breath sounds with scattered areas of fine rȃles anteriorly. Respirations 60. Diarrhea. November 2, lemon yellow tint to conjnnctivle and skin. Acute tenderness in right upper quadrant, with rigidity of right abdominal wall. Diarrhea has ceased. No particular change in lungs. Few bronchial rȃles. Died at 1.25 p. m.
Anatomical diagnosis.- Acute laryngitis; acute purulent bronchitis, confluent double lobular pneumonia; acute fibrinous pleurisy; acute enteritis; hemorrhages into rectus abdominis muscle; icterus. Poisoning with irritant gas.
External appearance.- Slight icterus. No ocular or cutaneous lesions described. Extensive hemorrhages into rectus abdominis muscle.
Gross findings.- Pleural cavities: Partially organized adhesions over posterior portions of right and left lower lobe. No fluid. Left lung: Covered over entire lower lobe by partially organized layer of fibrin. The bronchi contain much frothy purulent fluid. On section, the greater part of lower lobe presents a very uniform consolidation; the lower portion however, is still free and air containing. The consolidated portion is grayish-red and rather moist. In the tipper lobe are a few small areas of bronchopneumnonia. Right lung: Shows a similar fibrinous exudate over the lower lobe. Bronchi contain rather more
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pus than those of the opposite lung, but their mucosa is neither eroded nor hemorrhagic. The lower lobe is completely consolidated, fairly uniform, grayish-red in color; at lower portion, there is a fairly large area made up apparently of small abscesses set closely together; whitish pus may be squeezed from some of these. The upper lobe contains a good many scattered areas of bronchopneumonia, some of them infarct-like in distribution. The middle lobe shows a few areas of hemorrhagic bronchopneumonia. Organs of neck: There is very slight ulceration of the glottis, and injection of the vessels near the bifurcation of the trachea; no other changes. Heart is normal. Liver and bile passages normal. Spleen enlarged to about twice normal size, firm, dark purple, follicles prominent. Adrenals, kidneys, stomach are normal. Intestines: Beginning about half way down the ileum, there is marked congestion of the mucosa without definite ulceration. This continues down to the colon. The solitary lymph follicles are prominent, but not the Peyer's patches. Large intestine normal.
Microscopic examination.- Trachea and large bronchus: No section. Lungs: The terminal bronchioles are distended with solid masses of purulent exudate in which are bacterial colonies. The epithelium is represented only here and there by proliferating flat cells. There is slight compression of the adjacent alveoli. Between the abscess-like cavities of the dilated atria there is hemorrhagic and fibrinous pneumonia distributed through all portions of the section. The alveoli are being lined actively with new epithelial cells, and here and there are sprouts of fibroblasts and epithelial cells growing into the exudate. There are fair numbers of fibroblasts in the thickened septa also, and occasional large mononuclears. Bacterial stains show large masses of cocci in the purulent exudate which fills the atria. They are chiefly Gram-positive. Elsewhere there are practically no bacteria. Another section of lung shows a uniform, almost lobar type of pneumonic consolidation, without unusual features. Liver, spleen, kidney: Marked congestion. Adrenal: Loss of chromaffin staining and depletion of cortical lipoids. Rectus muscle: Interstitial hemorrhage, without degeneration of fibers. Small intestine: Hemorrhages into tips of villi.
NOTE.- Death occurred 14 days after definite history of exposure to irritant gas. When first seen 3 days after gassing, there was slight conjunctivitis, but skin burns were lacking. The patient developed an extensive pneumonia, pathologically in all respects of the influenzal type, and associated with terminal icterus. The upper respiratory passages at autopsy did not show severe and characteristic lesions of mustard gas. There are not sufficient data, therefore, from which to draw conclusions as to the nature of the gas to which the patient had been exposed. It is of interest to note that Case 43, L. K. J., a member of the same organization, gassed on the same day, likewise showed at autopsy lesions which were not typical of mustard gas. It is probable that these patients developed an influenzal pneumonia following a very light exposure to the gas; or else that the lesions followed exposure to a mixture of other irritant and asphyxiating gases. The reparative changes which are a conspicuous feature of the histological picture are also commonly found in the lungs of the primary influenzal cases at this stage.
CASE 80.- M. McM., 1464462, Pvt., Co. B, 129th Field Artillery. Died, October It, 1918, at 10 a. m., at Base Hospital No. 15. Autopsy, five hours after death, by Maj. Daniel J. Glomset, M. C.
Clinical data.- Mustard-gas inhalation and contact, received in action on October 3, 1918. Second degree burns of legs and right foot. Acute gastritis. Lobular pneumonia.
Anatomical diagnosis.- Lobar pneumonia, red hepatization of entire right lower lobe and parts of the right middle and left lower lobes. Diphtheritic tracheitis and bronchitis. Fibrinous pleurisy.
External appearance.- The face is purplish in color and a large amount of bloody fluid runs from the nostrils. There are deeply pigmented areas over the shoulders posteriorly and the back is black in color. These areas are confluent in places. The sclerae are clear. The pupils are 3 m.m. in diameter. There are discrete black patches on the posterior part
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of the right shoulder. Body heat is present. Post-mortem lividity is marked. The scrotum is unchanged. On the left leg there is a belt of marked pigmentation of the upper and middle thirds and extends down for 4 or 5 cm.
Gross findings.- Body cavities: The liver extends 7 cm. below the xiphoid. The diaphragm extends to the 6th rib on the right and to the 5th rib on the left. The pericardial cavity is unchanged. The pleural cavities are unchanged. Cervical and thoracic organs: There is a small remnant of thymus left. The lungs are poorly collapsed. The lymph follicles at the base of the tongue are markedly enlarged and almost form two tonsils. The tonsils are large and purplish. There are patches of very adherent membrane in the trachea. These are whitish areas and extend throughout the tracheal wall and also cover the vocal cords. Left lung is partly collapsed. The posterior part has a downy feel. Anteriorly there are numerous poorly circumscribed solid areas. In the middle of the lower lobe there is another solid area. The edges of the lobe crepitate. The area in the lower lobe occupies about one-half of the lobe. The surface made by section is purplislh-pink in color and rather granular. From the cut surface a bloody tenacious fluid exudes. Right lung: The upper lobe crepitates throughout. The middle lobe crepitates posteriorly and the rest is solid. The same large and firm area is in the lower lobe and the lobe contains air at the posterior apex. The surface made by section is mottled and has a purplish-pink color and exudes the same tenacious fluid. Heart is normal in size. The myocardium and valves are unchanged. Abdominal organs: The spleen is normal in size. The Malpighian corpuscles are fairly distinct. The pulp scrapes off easily. The pancreas is unchanged. The left kidney is soft. The kidneys are markedly swollen and pale. The cortex measures 12 mm. The capsule strips easily. The stomach and small intestines are unchanged. The bladder is unchanged, also the testicles.
Microscopic examination.- Trachea: The epithelium is desquamated, save for a few adherent basement cells. There is marked submucous edema without cellular reaction. In the edematous tissue there are great numbers of bacteria. In Gram preparations these are in part Gram-positive coccoid bodies surrounded by a red staining veil or rod-shaped capsule. Lungs: In the smaller bronchi, the epithelium is either completely desquamated or the cells are deformed or degenerated. The submucous layer is edematous and infiltrated with polymorphonuclear leucocytes, and other inflammatory cells. The vessels about the bronchi are engorged with blood. Pulmonary capillaries are congested and contain polymorphonuclear leucocytes. The alveoli display pronounced bronchopneumonic process. There are definite groups of alveoli filled with pycnotic polymorphonuclear leucocytes alone and surrounding them are alveoli containing granular débris and red blood cells. Very little fibrin is present. Lymphatic vessels about some of the smaller arteries are filled with pyenotic and fragmented leucocytes. Bacteria are extremely numerous, the predominating type being Gram-positive cocci, sometimes in chains. Spleen contains hyaline, pink-staining material in the follicles. No other organs examined.
Bacteriological examination.- Lung exudate: Streptococcus hemolyticus, staphylococcus aureus, pneumococcus.
NOTE.-There is a definite history of mustard-gas exposure, 15 days before death, with typical burns. The respiratory lesions, however, were not altogether characteristic of mustard-gas inhalation. There was desquamation of the tracheal epithelium with erosions and massive bacterial infection of the submucous connective tissue. Where, however, the epithelium was preserved it was normally ciliated and showed neither a coagulative necrosis nor the metaplasia commonly found after regeneration. The pulmonary lesions are altogether typical, both grossly and histologically of the pneumonia of the pseudolobar type, which was so prevalent at that time. There was a hemorrhagic, nonfibrinous exudate in which the leucocytes were fragmented and pycnotic; dilatation of the atria with hyaline necrosis of the walls and of the alveolar lining, fibrinous thrombi, and the occasional necrosis of the alveolar capillaries. On the other hand, the customary regeneration and organization which one would expect in mustard gas of this stage were lacking. The lesions
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seem too acute for 15 days' duration. It seems probable in summing up the evidence that this patient contracted influenzal pneumonia while in the hospital, and that the initial gas injury of the respiratory tract was negligible except in so far as it may have predisposed to the secondary influenzal infection. It is unfortunate that the clinical history is too incomplete to give further evidence on this point.
CASE 81.- R. J. S., 1426189, Pvt., Co. F, 59th Inf. Died, August 12, 1918, at Base Hospital No. 46. Autopsy No. 3. Autopsy, 11 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on July 28, 1918. Burns of forehead and knees. Evidences of gas inhalation complicated with bronchopneumonia caused by staphylococcus albus and nonhemolytic streptococcus. Died with signs of pulmonary edema and symptoms of acute colitis.
Anatomical diagnosis.- Extensive gas burns of conjunctivae skin, buttocks, elbows, knees, penis, and scrotum. Acute ulcerative and membranous laryngitis, tracheitis and bronchitis. Bronchopneumonia. Moderate pulmonary edema. Acute laryngitis and esophagitis. Acute ulcerative colitis. Slight cardiac dilatation.
External appearance.- Over both buttocks, both knees and the backs of both elbows, the dorsal surface of the penis, the ventral surface of the scrotum, there are characteristic superficial gas burns, extending into the dermis. Those about the knees show near the margin large blebs filled with clear fluid. Elsewhere the base is covered with a thin dry scab. The skin of the backs of the hands and the face has diffuse light brown pigmentation. At the bend of the right elbow there is a small recent surgical incision 2.5 cm. long and gaping somewhat in its midportion. The base covered by an adherent red-brown scab. The superficial glands are somewhat enlarged. The mucous membranes pale. Eyes: The eyelids are slightly swollen. The conjunctivae somewhat edematous and the bulbar portions considerably injected. On the left there are in addition numerous scattered small red hemorrhages. The pupils 5 mm. in diameter. Ears and nose: No abnormalities.
Gross findings.- Pleural cavities: On opening the thorax, a few thin fibrous bands found binding the apex of the upper lobe to the chest wall on the right side. There is no excess of fluid and no adhesions of the left. The heart lies in normal position. On incising the pericardial sac, no abnormalities of or in the sac noted. Heart: Weighs 370 grams. Somewhat enlarged. The right auricle and ventricle slightly dilated. The tricuspid ring admitted three fingers. The valvular endocardium throughout is thin. The coronaries and bases of large vessels, no abnormalities. The left myocardium on section, the architecture regular, the bundles coarser than normal and the tissue pale, boiled. Right lung: All lobes voluminous, cushiony and somewhat soggy, especially the upper and lower lobes. The pleura over the lateral and posterior surface, especially of the lower lobe, is somewhat injected and covered by a small amount of tenacious fibrinous exudate. There are a few thin fibrous bands binding the middle lobe to the lower lobe. The glands at the hilum moderately enlarged, pulpy and injected. The vessels at the hilum show no abnormalities. Bronchi: There is extensive ulceration of the mucosa and considerable edema and injection of the mucosa. Tightly adherent to the submucosa there is a castlike membrane of friable fibrinopurulent exudate. On section of the upper lobe a moist pink-red surface presents. The air sacs contain a moderate amount of thin frothy fluid. Scattered throughout there are several small solid deep red areas associated with the bronchioles. On repeated section of this lobe the consolidation immediately adjoins not only the small bronchioles but also the good sized ones. The bronchioles throughout show considerable injection of the walls. Attached to the mucosa and submucosa there is an adherent fibrinous and fibrinopurulent exudate. The consolidation about the bronchioles is most marked in the posterior portion of the lobe. The middle lobe, on section, presents a pink surface. The air sacs contain a small amount of thin frothy fluid. The bronchioles show injection of the mucosa. The exudate in this lobe is much less than in the upper lobe. About the bronchioles there is no hemorrhage or consolidation visible anywhere. The lower lobe on section presents a similar picture to that in the upper. There are areas of peribronchial consolidation here, verystriking. There is a moderate to considerable amount of fluid in the air sacs. Toward the periphery the lung, especially in the lower portion, shows much more marked areas of peri-
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bronchial consolidation, which extends in some places into the lung for a distance of 1 cm. These deep red consolidated areas are more numerous near the pleura in the lower portion of the lobe. Left lung: Both lobes are voluminous, cushiony, soggy, especially in the lower. In the lower, scattered solid patches are palpable. The vessels, bronchi, similar to those on the right in appearance. The lymph glands on this side moderately enlarged, pulpy, pigmented, and injected. A number of them show pinhead to small lemon-seed sized firm yellow opaque nodules, encapsulated by firm gray tissue. The left upper lobe similar to the right side, upper, in appearance. The pleura on this side over both lobes especially posteriorly shows a small amount of adherent fibrinous exudate. The lower lobe on section similar to the right lower lobe. The peribronchial consolidation is present to about the same extent. Liver: Slight fat infiltration; weighs 2,000 grams. Organs of neck: The glands throughout the neck are moderately enlarged, pulpy, and considerably injected. Thyroid: Of average size and the tissue, pale, spongy. The acini contain a moderate amount of colloid. Larynx and trachea: Show considerable diffuse ulceration of the mucosa, with edema and injection of the submucosa. Overlying intact and ulcerated mucosa there is a considerable amount of friable, tightly adherent fibrinous and fibrinopurulent exudate. The exudate is most marked in the larynx. The folds behind the true vocal cords filled with exudate. The process is present likewise in the upper portion of the esophagus as far down as the pouch at the level of the thyroid cartilage. The mucosa, however, intact, injected and covered by a moderate amount of fibrinous and fibrinopurulent exudate. There is likewise injection of mucosa of the base of the tongue and pharynx with a small amount of exudate. Tonsils: Small, buried and scarred. The crypts are clean. Alimentary tract: Stomach and small intestines: Show no significant lesions. In the transverse colon there are areas of patchy injection of mucosa, and in places there are small erosions in the mucosa, and in the neighborhood there is an adherent mucopurulent exudate. This mucopurulent exudate peels readily in general. Toward the rectum there are a few small eroded areas above which a friable exudate is quite tightly adherent. The mesenteric glands are somewhat enlarged, pulpy, pale. About the colon, the mesenteric glands show some injection. The remaining organs show no significant lesions.
Microscopic examination.- Trachea has a thick partly adherent membrane composed of dense interlacing fibrin strands with pycnotic nuclear fragments. The surface of the trachea is formed in places by swollen membrana propria which in some areas is reinvested with a single layer of flattened epithelial cells derived from the mucous ducts. Some of these flattened cells appear to be regenerating. In another section, the necrosis of the subepithelial tissue extends about halfway to the cartilage. There are fibrin, hemorrhage, and occasionally small suppurative foci near the surface. In the deeper tissues there are in places proliferating fibroblasts. Lungs: Sections show dilatation of the small bronchioles and atria with necrosis of the lining epithelium (see fig. 22), or in some places partial reinvestment with regenerating cells. About these there are extensive hemorrhages with areas of bacterial. necrosis. Medium-sized bronchus (2-3 cm.): Completely plugged with exudate and membraner The bronchial wall is entirely necrotic. Colon: Section of colon shows no ulceration of inflammatory change. Kidney, spleen, and liver show no significant change.
Bacteriological examination.- Smear from the exudate in the trachea shows innumerable organisms, Gram-positive rounded cocci predominating, some in chains, some in diplococcus forms. There are also some Gram-negative cocci and bacilli. Smear from consolidated lung shows a moderate number of Gram-positive cocci in diplococcus formation and small chains. Cultures from consolidated lung shows staphylococcus albus, streptococcus nonhemolytic. Culture from trachea shows staphylococcus aureus, streptococcus, nonhemolytic.
NOTE.- Mustard-gas case of 15 days' duration. Severe and typical lesions of the upper respiratory tract, with peribronchial hemorrhagic pneumonia. There was practically no reparative change or organization, probably because of the deep seated character of the initial injury. The acute colitis mentioned in the "anatomical diagnosis" is not in evidence in the sections.
CASE 82.- W. J., Corpl., 58th Inf. Died, August 6, 1918, at 6.25 P. M., at Base Hospital No. 18. Autopsy by Lieut. B. S. Kline, M. C.
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Anatomical diagnosis.- Shrapnel wound, interscapular region; fracture of spine of two upper dorsal vertebra, with subsequent infection of wound; septicemia (streptococcus hemolyticus); purulent otitis media, right; anemia and emaciation; general lymphatic hyperplasia; contused wounds of lower extremities and back; remains of old gas burns of pellis, scrotum, larynx, trachea, and bronchi; bronchopneumonia (streptococcus and gas bacillus); terminal gas bacillus (?) and streptococcus septicemia.
NOTE.-This case is not reported in detail, inasmuch as the gas burns. incurred at least 15 days before death, were of trivial importance in comparison with the surgical injuries and the ensuing general infection. Although there was no history of exposure to gas, there were characteristic mustard-gas burns noted during life and at autopsy. Histologically, the examination of the respiratory organs was unsatisfactory because of the poor preservation of the tissues and the terminal gas bacillus infection. Nothing was found to indicate previous inhalation of irritant gas. No material from the skin lesions was preserved.
CASE 83.- W. B. P., Pvt., Hdqrs. Co. 6th Marine Corps. Died, June 28, 1918, at 5.30 p. in., at Base Hospital :No. 18. Autopsy No. 66, performed 15 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.-None available, and the date of gassing is not recorded. The records of the Chemical Warfare Service show that there were casualties on June 13 in the 78th and 96th Companies of the 6th Marine Corps, which were in action at Belleau Wood and Chateau Thierry. Yellow cross and blue cross gas shells were employed against these detachments.
Anatomical diagnosis.- Bullet wound through right kidney; surgical excision of right kidney; extensive renal hemorrhage (800 c. c.); shock (clinical) and anemia; pulmonary edema (considerable) and slight general anasarca; old gas burns of skin, scrotum, and respiratory tract; purulent bronchitis of left lower lobe, associated with moderate atelectasis, following exposure to gas; old tuberculous foci of bronchial and pulmonary lymph nodes.
External appearance.- The skin is pale and slightly sallow. The skin of the neck. upper chest, axillae , upper and inner portions of the thighs, and the bend of the right elbow shows numerous dull light brown splotches, with here and there areas of superficial desquamation. There is slight edema of the ankles. The scrotum on its anterior aspect shows a flat smooth surface. The epithelium here appears to be almost entirely gone in a uniform sheet (?); the region is dry. Eyes, nose, and mouth normal. (Description of traumatic and surgical lesions is omitted.)
Gross findings.- Pleural cavities: In the right pleural sac there are about 20 c. c. of thin blood-stained fluid; a smaller amount on the left side. No adhesions are present. Right lung: Weighs 580 grams. The upper and middle lobes are fairly voluminous, cushiony, slightly soggy. The lower lobe is relatively more voluminous than the others. The pleura is delicate and glistening throughout. There are three small chalky nodules beneath the pleura of the lower lobe on the anterior aspect. The glands at the hilum are considerably enlarged and edematous and show scarred areas. The mucosa of the bronchi is pale; in their lumina is thin frothy fluid and mucus. On section no abnormalities are found except a moderate edema of the upper and middle lobes, and a more marked edema of the lower. Left lung: Weighs 630 grams. Both lobes are voluminous; the median portion of the lower lobe feels rubbery. The pleura is thin and delicate. The glands and blood vessels are like those on the right side. The bronchi, however, show a patchy injection of the mucosa, and contain a small amount of viscid purulent material, also thin frothy fluid and mucus. On section, except for edema, the lung is normal with the exception of the mesial third of the lower lobe, where the lung tissue is collapsed, rubbery, dull red, and moist. The bronchial branches in this region contain a considerable amount of viscid mucopurulent material. On squeezing the lung tissue in this region a somewhat translucent viscid fluid exudes. The tissue here is not friable and not more voluminous than the surrounding lung. Examination of the veins and arteries in this region shows no thrombi, the overlying pleura is thin and pale. Organs of neck, Larynx, and trachea: Show no abnormalities, except slight diffuse injection in the lower portion of the trachea. In the lumen is a moderate amount of thin
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frothy fluid and a small amount of muco-pus. Thyroid, enlarged symmetrically. Tonsils: Small and scarred. Heart: Weighs 335 grams. There is moderate dilatation of all chambers. No other significant changes. Gastrointestinal tract shows no significant changes. Remaining viscera show no lesions, except those related to the surgical condition.
Microscopic examination.- Skin: There is a thick horny layer. The remainder of the epidermis appears normal and is regularly disposed. There is little or no pigment in the rete mucosum. The papillae are rather loose and show young connective tissue cells and a moderate number of chromatophores filled with golden yellow pigment. The small blood vessels are collapsed and surrounded by loose aggregations of lymphoid cells. The endothelium shows no changes, and there are no thrombi. The deeper layer of the corium and the epidermal appendages are normal. In another block examined, the keratin layer is thin and partly exfoliated. The remaining strata of the epidermis are condensed into a thin densely stained layer in which outlines of individual cells are lost, and the tissue appears mummified or desiccated. There is an apparent increase of pigment in the basal layer. The papilae are flattened out, the corium is very dense and sclerotic, the nuclei pycnotic or caryorrhectic. All superficial vessels are filled with dense hyaline thrombi, having a peculiar refractile appearance. Trachea and primary bronchus: The mucosa is largely exfoliated, but detached strips still lying on the surface show excellent preservation of the ciliated cells. The subepithelial connective tissue is edematous in places and moderately congested, but there is no inflammatory infiltration, except for a few round cells. There is therefore no positive evidence of previous gassing. Lungs: (a) The lesions are not marked. The septa are stout, and show frequently an accumulation of polymorphonuelear leucocytes in and about the capillaries. Few have emigrated into the alveolar spaces, which contain only desquamated (postmortal?) alveolar cells, either single or in coherent strips, and a little shreddy coagulum. The epithelium of the small bronchi is detached, but shows no degen- erative change. There is no exudate in the lumina. There is moderate emphysema. No bacteria are found in Gram-stained sections. (b) Same picture, save that there is partial atelectasis. No evidence of old bronchial lesions. Liver, myocardium, kidney, and testis show no significant lesions.
NOTE.-The gas burns, probably inflicted on June 13, 15 days before death, were of minor importance in the case. Death probably resulted from the bullet wound of the kidney, with the accompanying hemorrhage and shock. There is little clear evidence of previous respiratory injury due to the gas, either grossly or in the sections.
CASE 84.- H. G., 2058794, Corpl., Co. G, 47th Inf. Died, October 28, 1918, at Base Hospital No. 42. Autopsy No. 92. Autopsy, 2 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Patient was gassed on October 12, 1918, having been exposed to blue, green, and yellow cross shells. Admitted to Base Hospital No. 42 on October 25, with burns of skin, conjunctive, respiratory tract. Signs of bronchopneumonia in both lower lobes, especially the left. October 27, patient delirious.
Anatomical diagnosis.- Superficial mustard-gas burns of conjunctive, scalp, body, scrotum, and penis. Few small vesicles with local brown pigmentation. Acute fibrinopurulent esophagitis extending as far as the cricoid cartilage. Acute fibrinopurulent laryngitis, tracheitis, and bronchitis (left side). Acute purulent bronchitis (right side). Extensive coalescing lobular pneumonia. Acute bronchial lymphadenitis. Cloudy swelling of parenchymatous organs. Autopsy report.-No detailed protocol.
Microscopic examination.- Trachea (2 blocks): The epithelium is not only preserved, but shows remarkably little change. The cells in the superficial layer are cylindrical and here and there distinctly ciliated, although in general they are stained rather poorly. There are a few leucocytes wandering between them. The submucous tissue contains lymphoid and plasma cells in normal numbers, but there is no clear evidence of previous inflammation. Mucous glands are in hypersecretion but otherwise normal. Primary bronchus: contains a detached fibrinopurulenit membrane about 1 mm. in thickness. The lining is constituted by the exposed membrana propria resting upon edematous and infiltrated granulation tissue. There are a few strips of regenerated, highly atypical epithelial cells interposed between false membrane and membrane propria. The glands are preserved, although they
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are separated by edema and inflammatory cells, chiefly of the plasma cell type. Lungs: (a) Block, which was apparently taken near the hilus, passes through a group of thick-walled and distinctly dilated bronchi. These are lined for the most part with dense adherent membrane, although, in some places they are reinvested with layers of squamous epithelium. The deeper portion of the bronchial wall, the peribronchial tissue and the original edematous cellular tissue about the blood vessels are the seat of active fibrosis, so that the structures are virtually embedded in a mass of connective tissue. This is rather avascular, the formation of new blood vessels appearing to lag behind the growth of fibroblasts. The adjoining alveoli show the effects of the compression due to the fibrosis of the peribronchial and periarterial tissue. The alveoli contain a serous coagulum with more or less fibrin, showing in places the usual organization. The septa are thickened with new formed fibroblasts and wandering cells, chiefly of the mononuclear type, and are distinctly edematous. The alveolar epithelium projects into the lumina and is probably largely new formed. (b) The smallest bronchioles and atria contain well-preserved epithelium. Some of them show beautiful vascularized organized plugs. A most striking picture is afforded by the organization of fibrin in the interlobular septa, which are already in large part converted into loose vascular scars. The same picture is seen in the loose tissue about the blood vessels. The parenchyma shows a marked diffuse edema of the alveoli with abundant fibrin. This seems to be a recent process. (c) There are several longitudinally cut bronchi completely filled with an exudate, in places purulent, in others purely fibrinous. There is the usual regeneration of epithelium with metaplasia and fibrosis of the wall of the bronchus. The adjoining lung tissue is completely atelectatic. Skin: (a) Section passes through an ulcer the base of which is formed by a slough densely infiltrated by masses of leucocytes. The corium is extremely thickened, partly by edema and partly by a new growth of connective tissue and blood vessels. There is not the typical appearance of granulation tissue. The endothelium of the blood vessels is swollen and deeply stained. Mitotic figures are distorted and multinuclear cells arc common. There are many small nerve trunks in the section.
The epidermis at the margin of the ulcer is much thickened, especially about the hair follicles. It stops short at the edge of the ulcer and does not seem to be actively proliferating, growing only a short distance between the slough. The epithelial cells at the base are free from pigment. Their arrangement is atypical and they appear to have developed from the sheaths of the hair follicles. (b) Section of skin showing hyperkeratosis and hyperpigmentation with chromatophores in the superficial corium. Pharynx: Section shows acute membranous inflammation with separation of the muscle fibres by inflammatory exudate. Spleen: Very cellular with excess of polymorphonuclears in the pulp. Appearance is that of the usual acute splenic tumor.
NOTE.-After alleged exposure to yellow, green, and blue cross shells 16 days before death there was found a severe membranous necrosis of the bronchi with partial epithelial regeneration and very extensive early fibrosis of the bronchial walls, periarterial tissue, interlobular septa, etc. The pulmonary lesions were confined to the vicinity except for a diffuse edema, which was probably terminal, or at least of much later date than the bronchial lesions. A peculiar feature of the case was the exemption of the trachea from necrosis, which was so evident in the larger and smaller bronchi. This is difficult to understand and highly exceptional. It is evidently not to be explained by the earlier repair, inasmuch as it is not shown by metaplasia of the usual type which is the rule during the earlier stages of regeneration. There is always the possi- bility that the blocks may have been confused, but this is unlikely in this case, since tissue examined from different blocks and preserved in different fixative show an identical picture.
CASE 85.- A. A., 1822508, Pvt., Co. C, 321st M. G. Bn. Died, August 27, 1918, at Base Hospital No. 46. Autopsy No. 9. Autopsy, one and three-fourths hours after death, by Lient. B. S. Kline, M. C.
Clinical data.- Exposed August 10 at night to heavy shelling with yellow, blue, and green cross gas. On admission to Base Hospital No. 46 on August 11, complained of pain
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in chest; respiration was labored; cyanosis and restlessness. Eyelids swollen and edema- tous. Generalized rhles. Patchy fine crackling rales with exaggerated voice sounds at right base. Diagnosis: Gas inhalation, lobar pneumonia. August 14, double lobar pneumonia. Condition fair. August 19, respiration more labored. Signs suggesting fluid at right base, not shown by X ray or aspiration. August 25, no change in symptoms. Signs persist. August 26, pleural friction left base with pains over this region. Signs of patchy bronchopneumonia.
Anatomical diagnosis.- Mustard-gas burns of skin and superficial mucous membranes, healed or healing lesions. Acute ulcerative tracheitis and bronchitis. Fibrinopurulent bronchiolitis. Bronchopneumonia, both lower lobes, in part organized. Extensive fibrinous and fibrinopurulent pleurisy, with effusion and associated atelectasis in both lower lobes. Acute bronchial lymphadenitis. Cardiac dilatation, slight.
External appearance.- Skin in general pale, face and hands tanned. Skin of scrotum and base of penis show considerable desquamation; no ulceration, however. There is some desquamation of the skin of the lower abdominal and pubic region and also in the lower right axilla. The superficial mucous membranes, excepting the conjunctivn, are pale and cyanotic. The superficial lymph glands somewhat enlarged. Eyes: Conjunctivae somewhat edematous, considerably injected. There is a small amount of viscid exudate present between the lids. The pupils, 5 mm. in diameter. Nose and ears show no abnormalities.
Gross findings.- Pleural cavities: On opening the thorax a small amount of coherent fibrinopurulent exudate found over the right lower lobe. The left chest contains from 1,500 to 2,000 c. c. of turbid yellow fluid, in which flakes of fibrinous exudate are suspended. Both lobes on this side collapsed toward the spine. There is moderate amount of fibrinous exudate binding the median portions of these lobes to the pericardium. On incising the pericardium no abnormalities of the sac are seen. After removing the thoracic viscera the parietal pleura on the left is everywhere glazed, edematous, covered by a considerable amount of shaggy fibrinous exudate. The exudate is most marked over the diaphragm. Heart: Weighs 360 grams. Moderate dilatation of both auricles and right ventricle. Myocardium is pale, soft, and moist. Right lung: Lobes less voluminous than normal, especially the lower. Upper and middle are cushiony, well aerated. Lower, rubbery. Glands at the hilum considerably enlarged, pulpy, edematous, pigmented. Some show areas of gray scarring. Vessels show no abnormalities. Bronchi somewhat swollen, show areas of injection. In the lumen there is some mucopurulent exudate. On section of the upper and middle lobes a light pink surface presents. Tissues well aerated. In the bronchial branches there is some mucopurulent exudate. In the lower lobe, on section, the tissue is collapsed, rubbery, dull reddish brown, poorly aerated. Scattered throughout the lobe there are large numbers of grape seed to lemon seed sized rather firm areas of consolidation. On pressure no exudate is expressed. These areas have a dull grayish-pink surface. Bronchial branches in this lobe contain a small amount of viscid mucopurulent secretion (no organization, apparently). Left lung: Both lobes much less voluminous than normal. The pleura is somewhat swollen; covering it, there is a layer of tenacious fibrinous exudate, in places at least 1 mm. in thickness. Between this and the pleura there is a thin zone, which contains many tiny vessels. On section of the upper lobe a well aerated pink surface presents, except posteriorly, where there is an egg-sized dull reddish brown poorly aerated portion. Lower lobe, on section, is similar in appearance to the right lobe. Organs of neck: Glands in the lower part of the neck similar in appearance to those at the hilum. Thyroid: Of average size and consistence. On section the tissue is pale, spongy. There is moderate amount of colloid in the acini. Larynx: Shows a moderate edema of the mucosa. About the left vocal cord there is considerable injection. Trachea: Shows patchy injection toward the bifurcation. In the lumen there is some blood tinged mucopurulent exudate. Tonsils. Somewhat enlarged, pulpy. Crypts are clean, in general. There is apparently considerable lymphoid tissue present. Alimentary tract: No abnormalities except that the lymphoid tissue in the lower ileum is somewhat more prominent than normal. Mesenteric glands pulpy, pale. The remaining organs show no significant lesions.
Microscopic examination.- Trachea: No sections preserved. Lungs: A. A number of small bronchi included in the section are lined with a very well-preserved layer of ciliated epithelium. Lumina are free from exudate. There is no thickening of the bronchial wall. Parenchyma shows irregular small areas of lobular pneumonia, which appear to center about
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the infundibula. Exudate is poor in fibrin. Predominant cell type is polynuclear. About these areas there is some edema and epithelial desquamation. B. This block passes through an infarctlike area of hemorrhage. In certain areas the alveolar structure is destroyed, and there is necrosis with partial decolorization of the red cells. No thromnbosed vessels are in- cluded in this section. C. Section passes through completely collapsed lung, and includes also large encapsulated areas of caseation with typical giant cells at the periphery. Liver, spleen, and kidney show no significant lesions.
Bacteriological examination.- Smears of the exudate in the larynx show innumerable Gram-positive rounded cocci in pairs and in small chains. There are also moderate numbers of Gram-negative cocci. The predominating organism is streptococcus. Culture shows staphylococcus, streptococcus, and small Gram-negative bacillus.
NOTE.-Death occurred 17 days after exposure to mixed gases, but it is not clear either from the clinical historv or from the autopsy protocol that this is a late mustard-gas case. There were no typical burns or pigmentation. The eve lesions were no more severe than those frequently seen in influenza. The walls of the trachea and bronchi do not suggest inhalation burns. The patient evidently died from the seropurulent pleurisy complicating the pneumonia. Unfortunately the histological material is inadequate, no tissue from the trachea or large bronchi having been preserved. The excellent preservation of the bronchial epithelium in the small branches is not in common with the usual findings of mustard gas.
CASE 86.- O. F., 1696236, Pvt., Co. D, 305th M. G. Bat. Died, October 13, 1918, 3 p. m., at Base Hospital No. 18. Autopsy No. 135. Autopsy, - hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Mustard-gas inhalation on September 25, 1918, incurred in action. Admitted to Field Hospital No. 306, developed acute bronchopneumonia, of epidemic coalescing type. Mild conjunctivitis, photophobia, and vomiting. September 29, admitted to Base Hospital No. 18, conjunctivitis and scrotal burns, few signs of bronchlopneumonia October 10, rAles at bases of both lungs, tubular breathing, etc., at left base, bronchopneumonia. October 13, both lungs filled with crackling rAtes. October 11, blood count, leucocytes 7,800; October 12, leucocytes 8,000. Blood culture sterile; sputum culture, pneumococcus, Type IV.
Anatomical diagnosis.- Healed gas burns of skin. Infected burn of scrotum. Acute laryngitis, tracheitis, and bronchitis. Peribronchial pneumonia, in part suppurative, in part organizing. Coalescing lobular pneumonia, right lower lobe. Fibrinous pleurisy, slight. Acute peribronchial lymphadenitis. Cardiac dilatation, right. Parenchymatous degeneration of liver and spleen.
External appearance.- No abnormalities, externally, except moderate diffuse brown pigmentation, with deeper brown pigmentation about the healed superficial ulcerated areas of axillae and upper portion of left thigh. There are areas of ulceration of the scrotum about 4 cm. long, and from a few millimeters to 1 cm. in width extending into the dermis. About these regions the epidermis is thickened for several centimeters and covered by matted serum. There are superficial ulcerated areas about the left nostril, covered by scabs. Con junctiv ae are dry and pale.
Gross findings.- Pleural cavities: There is a small amount of fibrinous exudate in the right pleural sac. Left pleural cavity is normal. Pericardium is normal. Heart: Weighs 450 grams and is considerably enlarged, the right auricle and ventricle being especially di- lated. The myocardium is soft and appears somewhat greasy. Right lung: All lobes are voluminous, cushionly, soggy, and solid. The pleura is thin, posteriorly covered by a small amount of fibrinous exudate. The glands at the hilum are greatly enlarged, pulpy, injected. Bronchus: The epithelium of the mucosa in general has a whitish appearance. In places there is a patchy ulceration covered by fibrinous exudate. There is considerable diffuse injection with some extravasation of the blood. In the lumen, there is thin and somewhat viscid fluid. In the upper lobe on section, the tissue in general is fairly well aerated. In the posterior half there is a moderate amount of thin, frothy fluid in the air sacs. Throughout the lobe, the striking thing is the involvement of the bronchi, the inucosa having a dull,
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ragged, grayish appearance and surrounding the walls there is an area of grayish and red consolidation, a few millimeters in thickness. In places the peribronchial consolidation is depressed grayish, suggesting organization. The middle lobe on section is well aerated and pink. The appearance is quite similar to the upper lobe, but here some of the patches have reached the surface and are bronchopneumonic in type, finely granular, and yellowish gray. On section of the lower lobe the picture is that of extensive involvement of the bronchial mucosa and walls and adjoining lung tissue. There are depressed, firm, grayish streaks. Toward the pleura posteriorly there is a finely granular, gray-red consolidation, coalescing lobular in type. The process, however, is not very extensive. The fibrinous exudate over the pleura is perhaps most marked in this region. The smaller bronchioles in many places contain thin viscid purulent exudate. Left lung: Both lobes are voluminous, cushiony, and soggy solid. The posterior portion is most involved. The bronchi andglands similar to those on the right. On section of the upper lobe, the smaller bronchioles show a dull whitish, in places granular, membrane. In the lumen there is thin viscid pus. In places, there is considerable destruction of the bronchial walls with dilatation. There is old peribronchial consolidation, coarsely granular in some places, softened in others. The consolidation is practically limited to the posterior half. Medially, the tissue is well-aerated pink. The lower lobe, on section, shows quite uniform involvement of the smaller bronchial branches and the lung tissue about them for a small distance. There is a moderate amount of thin, frothy fluid in the air sacs. Organs of neck: The larynx shows considerable injection of the mucosa. The epithelium in considerable part is dull, whitish, apparently necrotic. There is mucopurulent exudate present in considerable amount, especially about the true vocal cords, where the ulceration seems to extend deeper into the mucosa in places. Throughout the trachea the membrane in considerable part has a dull grayish appearance. There are areas of desquamation. There is patchy injection, and in places, the mucosa shows puruleist ulceration. The process involves the base of the tongue, posterior pharynx, and upper esophagus as far as the level of the cricoid cartilage. Thyroid: Moderately enlarged, the acini distended with colloid. Liver: Weighs 2,000 grams. There is slight fatty infiltration. Spleen: Weighs 400 grams, somewhat enlarged. Malpighian bodies increased in number and size. Alimentary tract: Not recorded. The remaining organs show nothing of interest.
Microscopic examination.- Trachea: Section is not instructive. Submucous layer is thin and intact and stains poorly but does not seem to be necrotic. The membrana propria is preserved. A few faintly-staining vertically arranged epithelial cells are still adherent but the greater part of the epithelium has been desquamated. Large bronchus: The surface epithelium is largely lost. A few small strips of stratified, nonciliated epithelium are still adherent, but in most places the membrana propria lies exposed. The striking feature is the presence of solid masses of epithelial cells, of concentric arrangement and highly atypical character. These are situated in the ducts and acini of the mucous glands. (See fig. 19.) In some places the intercellular fibrils complete the resemblance to epidermal cells. This atypical epidermis elsewhere surrounds or penetrates masses of mucus and the remains of the original gland cells. There is marked congestion of the epithelial tissue, but no polynuclear infiltration. Lungs: Section includes a medium-sized bronchus, the wall of which is lined with necrotic tissue, adherent to which are shreds of atypical layered epithelium. The bronchial wall is formed by granulation tissue, very loose, vascular and hyperemic with fibroblasts and plasma cells. About the bronchus, the alveoli con- tain plugs of dense poorly-staining fibrin which in a few areas show early organization. The alveolar epithelium, is swollen, atypical and hyperplastic. Mitotic figures are found in a few of the cells. Plasma cells are numerous. Other areas in the section show nonfibrinous homogeneous coagulum and in still other areas there is an acute pneumonic exudate. The interlobular septa are edematous. Skin: Probably of scrotum. There is a slight hyperkeratosis, hyperpigmentation of the rete mucosum and numerous melanophores in the superficial layers of the corium. (See Pi. V.) Myocardium, liver, and kidney show no significant lesions.
NOTE.-Mustard-gas poisoning of 18 days' duration. There are the usual remains of an acute destruction of the upper air passages, with extensive complicating pneumonia showing early regeneration in the vicinity of the bronchi. The most interesting histological features are the nests of carcinoma-like epithelial cells in the bronchial ducts and glands.
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CASE 87.- W. S., 1821307, Corpl., 318th Inf. Died, October 24, at 8.12 P. in., at Base Hospital No. 81. Autopsy, 15 hours after death, by Capt. B. S. Kline, M. C.
Clinical data.- October 5, 1918, patient admitted to Gas Hospital No. 1. October 7, admitted to Base Hospital No. 81. Diagnosis: Gas inhalation, marked. While in the hospital, developed signs of influenza (October 15) and of bronchopneumonia (October 17). Acute temporary dilatation of heart. Leucocytes (October 10) 5,700. Leucocytes (October 15) 6,600. Patient apparently convalescing. October 24, at 8.12 p. m., suddenly began gasping for breath and died a few minutes after.
Anatomical diagnosis.- Healing acute tracheitis and bronchitis; stenosis of right bronchus due to scarring (old infected mustard-gas lesion); healing acute lymphadenitis of mediastinal and tracheal lymph glands; fat infiltration of myocardium; cardiac dilatation, most marked on right side, with possible slight hypertrophy of right ventricle; chronic passive congestion of short duration, of abdominal viscera; thrombosis of left iliac vein; large emboli occluding pulmonary artery; old tuberculous foci of bronchial lymph glands and spleen.
Microscopic examination.- Pharynx or upper esophagus: Stratified squamous epithelium, showing nothing atypical. Subepithelial tissue free from inflammatory changes. No lesions suggesting previous injury. Primary bronchus: Lined with regenerated squamous epithelium, the superficial cells of which are flattened and deeply stained, with indistinct nuclei, appearing almost as if keratinized. Mitoses are very numerous at all levels. The subepithelial tissue is loose and vascular, loosely infiltrated with mononuclear lymphoid and plasma cells. The mucous glands are not much altered; some acini seem to be choked with retained mucus. Lungs: Many of the bronchioles contain still a purulent exudate. Their lumina are narrow in proportion to the thickness of the wall, which is formed by granulation tissue, thickly infiltrated by lymphoid and plasma cells. The surrounding alveoli are thick-walled, often collapsed, and frequently lined with high columnar or atypical epithelium and filled with plugs of organizing exudate. Outside is a zone of edematous lung tissue and between these areas of peribronchiolitis, there are areas of emphysema. The periarterial tissue is tremendously thickened with young fibroblasts in abundance, and the interlobular septa are also. There are in some of the sections, large patches of granulation tissue in which the original lung structure is completely lost. The epithelium in bronchioles and alveolar ducts is wholly missing in some cases, in others there is regenerating epithelium, more or less atypical in character. No bronchi relined with well-ciliated epithelium are found. Bronchial lymph nodes: Contains a large calcified encapsulated mass, probably a healed tuberculous lesion. The lymph sinuses in the intact portion of the gland are filled with phagocytic cells. Spleen: Congested; no features of special interest.
NOTE.-The interpretation of this case is difficult. The healing lesions of the bronchi, found at autopsy and confirmed by microscopic examination, were ascribed by the pathologist to the late effects of mustard-gas inhalation. However, there is no record in the history of mustard-gas burns or eye lesions, and none are included in the very detailed anatomical diagnosis. On the other hand, there is a clinical history of influenzal pneumonia, the onset of which dates from October 15, approximately 10 days after the alleged exposure to gas, and nine days before death. The patient was convalescing from this, but died suddenly from pulmonary embolism, following thrombosis of the iliac vein, a not uncommon influenzal complication. The question arises, therefore, whether the bronchial and pulmonary lesions were late sequels of the influenzal pneumonia, or were attributable rather to the previous gassing. While it is hardly possible to be certain, it seems more probable that the gassing was responsible, at least in large measure, since the thickening of the bronchi and the extensive fibrosis in some areas of the lung tissue itself were beyond what might ordinarily be expected to develop within nine days of an influenzal pneumonia.
CASE 88.- W. C. D., 2178762, Corpl., Co. B, 354th Inf. Died. August 28, 1918, at Base Hospital No. 42. Autopsy No. 2. Autopsy, eight hours after death, by Lieut. B. S. Kline, M. C.
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Clinical data.- Exposed to yellow, blue, and green cross shell from 10.30 p. m., August 7, to 3.30 a. m., August 8. Ten thousand 77 and 105 mm. shells. August 9, admitted to Field Hospital No. 327, with temperature of 104?. August 11, admitted to Base Hospital No. 42. August 13, temperature 104?. Diffuse rales in both lower lobes. Impairment of resonance in lower loft. No tubular breathing. On following day, rȃles over upper lobes also. Two days later, bronchovesicular breathing in both. This persisted for five days. August 26, signs of consolidation in right, middle, and lower lobes. Death with signs of cardiac dilatation. Anatomical diagnosis. First-degree mustard-gas burns of skin. Healing lesions with areas of vesiculation and brown pigmentation. Ulceration of upper esophagus, larynx, trachea, and bronchi. Fibrinopurulent esophagitis, laryngitis, tracheitis, and bronchitis. Bronchopneumonia in part organized. Acute fibrinous pleurisy. Acute bronchial Lymphadenitis. Slight pulmonary edema. Cardiac dilatation.
External appearance.- Skin in general has a muddy appearance. The ventral surface of the scrotum and the head of the penis show an ulceration of the epidermis. There is considerable desquamation. A small area of the scrotum shows some matted seropurulent exudate. There is considerable exudate covering the ulcerations of the head of the penis. Over the right greater trochanter there are some pustules and small areas of superficial ulcerations covered by brown scabs. In the genital folds, the popliteal regions, both buttocks, the bends of the elbows, both axilli, upper chest and neck, there is well defined, splotchy, brown pigmentation. Associated with all of these areas there are tiny vesicles. The superficial lymph glands are somewhat enlarged. Superficial mucous membranes are pale. Eyes: Conjunctivae in general pale, delicate. There is some swelling of the bulbar conjunctivae , and there is a small amount of caked exudate present. Pupils equal 3 mm. Ears: In the skin of the right ear, near the concha, there is a small superficial ulcerated area about 2 mm. in diameter, covered by a dry scab. There is also a small ulcerated area at the junction of the upper and lower lips. In the nasal cavity there is some mucopurulent exudate.
Gross findings.- Pleural cavities: On opening the thorax, a few organizing adhesions are found over the upper lobe. In the cavity there are about 40 c. c. of turbid yellow fluid in which some flecks of exudate are visible. A similar picture is present on the left, except that there are no firm adhesions. Heart lies in normal position. On incising the pericardium no abnormalities of or in the sac are seen. Heart: Weighs 380 grams. There is slight dilatation of both right and left ventricles. Right lung: All lobes are much more voluminous than normal. Feel cushiony, slightly soggy, and numerous small solid patches are palpable. Pleura, except medially, glazed, covered by a small amount of fibrinous exudate. Glands at the hilum are greatly enlarged, pulpy, injected, pigmented. A number of them show firm and calcified nodules, surrounded by firm gray tissue. Vessels at the hilum, no abnormalities. Bronchus: Shows considerable swelling, injection, and in places ulceration of the mucosa. The membrane is infiltrated and covered by tenacious fibrinopurulent exudate in considerable amount. The upper lobe on section shows innumerable solid patches, varying in size from pinhead to a few centimeters in diameter. Some of the smaller areas are coherent, dry, granular, grayish, or yellowish; some have soft yellow centers. Others are much more firm, gray, and show a greenish pigmentation about them. The larger patches are dull pinkish gray. The surface is relatively dry, finely granular. The remainder of the lung tissue is fairly well aerated, pink, and contains a small amount of fluid in the air sacs. Middle lobe, picture in general similar, especially posteriorly. Medially, there is much less involvement. Lower lobe, the picture is quite uniform throughout. Tissue in general fairly well aerated, pinkish red, contains a small amount of thin frothy fluid in the air sacs. Here, quite thickly throughout, there are pinhead to grape seed sized firm patches of consolidation, some gray, others showing considerable greenish pink pigmentation. In a few places, especially inferiorly, there are larger dull pinkish-gray consolidated areas. Some of the bronchial branches show intense injection of the mucosa and walls. Left lung: Both lobes are much more voluminous than normal. On inspection, palpation, and section the upper lobe shows changes similar to the right upper; here, however, there are but few large patches of recent consolidation. In great part the lesion consists in a moderate number of firm solid patches. Left lower lobe, in general similar to the right lower. There is more fluid in the air sacs on the left. The glands at the hilum similar in appearance to those on the right. The tuberculous foci here, however, less prominent. The bronchi show very much less involvement than the bronchi and larger branches on the right.
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Organs of neck: Glands in the lower portion of the neck, similar in aispearance to those about the hilum on the right. Some show old tuberculous foci. Thyroid: Somewhat smaller than normal. Tissues, spongy and pale. There is but a moderate amount of colloid in the acini. Larynx: Shows small ulcerated areas of the epiglottis, ulceration extending down into the submucosa. Vocal cords show ulceration of the epithelium. The epithelium in general is infiltrated or ulcerated. Everywhere below the true cords there is a large amount of tenacious fibrinopurulent exudate. Picture the same in the trachea. The process Continues over into the upper esophagus, where there is a large patch of ulceration of the epithelium, and a considerable amount of tenacious fibrinopurulent exudate attached to submucosa
FIG. 34.- Case 88. Exposure to yellow, blue, and green cross shell gas. Death after 20 days. Lung. Section passes through interlobular septum, which is edematous and in which there is active growth of fibroblasts, and plasma cell infiltration. There are organizing plugs in the septal lymphatics
tissue. Tonsils: Fair size, contain a considerable amount of lymphoid tissue. Crypts contain inspissated material. Alimentary tract: No abnormalities, except that the stomach contains a small amount of bile-tinged mucus. Lymphoid tissue throughout the trachea slightly more prominent than normal. Mesenteric glands are small, pulpy, and pale. Liver: Weighs 2,000 grams. Slight fat infiltration. The remaining organs show no significant lesions.
Microscopic examination.- Trachea: No sections. Bronchi: Section through medium-sized bronchus shows massive necrosis of the lining without definite membrane formation. Through the necrotic tissue there is a great amount of detritus. The epithelial layer is
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totally destroyed, although the mucous glands are still intact. In the deeper part of the bronchial wall, there is active proliferation of fibroblasts and great numbers of plasma cells. There is much fibrinous edema in the peribronchial tissue external to the cartilage, and in these areas are many fibroblasts. One of the small veins contains a well formed thrombus which is beginning to organize. Lung: The lesions in the smaller bronchi are very interesting. Some of the bronchi are lined with a clean vascular granulation tissue, uncovered by epithelium. There is no exudate in the lumen. Between the congested vessels are numerous lymphoid and plasma cells, but practically no polynuclears. About these bronchi, the septal tissue of the alveoli is thickened. Many of the air spaces are filled with dense fibrin plugs which are being invaded by fibroblasts and recovered in many places by alveolar cells, probably regenerated epithelium. (Fig. 34). Other bronchi are clothed with regenerated epithelial lining, continuous with solid plugs of epithelial cells in a neighboring alveoli. New formed epithelium is highly atypical, stratified, and nonciliated. The lumen contains well-preserved polymorphonuclears. There is a new formed epithelial lining resting upon a layer of clean granulation tissue, in which are only occasional Gram-positive cocci. Still other bronchi show early and very acute lesions. Lumen is filled with fragmented polymorphonuclears and the walls are invaded by them. There are small areas of bronchopneumonia in the adjoining alveoli. The grayish-yellow nodular areas described in the gross resolve themselves into bronchioles or infundibula, the center of which is occupied by exudate with numerous fragmented leucocytes. The wall is greatly thickened, partly by inflammatory infiltration, but also by an active growth of granulation tissue with strikingly numerous plasma cells. The adjoining alveoli are solid with fibrin plugs becoming organized and covered with new alveolar epithelium. External to these peribronchial nodules, the lung tissue shows a patchy edema. In some areas, the alveolar septa are greatly thickened by the growth of fibroblasts along the collapsed capillaries, and the accumulation of mono- nuclear cells. The cavities are being relined with new epithelium. The interlobular septa are broad and there are numerous fibroblasts invading the edematous tissue. An interesting feature is the organization of plugs of exudate in the dilated septal lymphatics. (Fig. 34.) The remaining organs show no significant lesions.
Bacteriological examination.- Smears of the trachea show innumerable Gram-positive cocci, some lancet-shaped, others rounded and in chains. The lancet-shaped ones encapsulated. There are also a moderate number of Gram-negative bacilli. The predominating organism, Gram-positive. Smear of consolidated lung shows a very few diplococci (Gram-positive) and no Gram-negative organisms are seen.
NOTE.-A very characteristic case of mustard-gas poisoning dying after 20 days. The respiratory lesions were largely limited to the trachea and the bronchial and peribronchial tract. Although many of the bronchi still showed evidence of the original chemical injury in the form of a deep-seated necrosis, attempts at repair were well under way. In some of the tubes, there was partial reepithelization and the walls of the bronchi as well as the perivascular tissue and the edematous interlobular septa were becoming thickened by a new growth of fibrous tissue. The case illustrates clearly the probable nature of the permanent injury which may follow this type of gassing. It is worth recording also that the lesions do not suggest a complicating influenzal pneu- monia, such as was so frequently encountered in the October and November cases.
CASE 89.- W. K., 1779786, Wagoner, 308th Inf. Died, October 28, 1918, at 2 a. m., at Base Hospital No. 42. Autopsy No. 91. Autopsy, seven hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- Gassed on October 8, 1918. Admitted to infirmary on October 10. Diagnosis: "Mustard-gas inhalation." On admission to Base Hospital No. 42 on October 18 complained of cough and fever. Symptoms of laryngitis, bronchitis, and bronchopneumonia; signs of consolidation of both lungs.
Anatomical diagnosis.- Superficial gas burns of conjunctive and skin with vesiculation and local brown pigmentation. Infected scrotal burns. Acute fibrinous and gangrenous laryngitis with marked ulceration of vocal cords. Gangrenous tracheitis and bronchitis.
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Extensive peribronchial pneumonia of all lobes except right middle, associated with ulceration of bronchi and adjoining lung tissue. Gangrenous exudate in cavities. Acute bronchial lymphadenitis. Parenchynmatous degeneration of liver and kidneys. Moderate anemia and emaciation. Dental caries marked.
No detailed autopsy protocol received.
Microscopic examination.- Skin: Section passes through an area in which the epithelium is denuded; the exposed corium appears dense as if dessicated. Adjacent to it, theepitlielitim is greatly thinned out; there is a homogeneous pink-staining material beneath the thin layer of epithelium, which is apparently regenerating. There are still in places, adherent crusts of
FIG. 35.– Case 89. Mustard-gas burn, 20 days’ duration. Lung. Area of bacterial necrosis with fibrinopurulent material in the adjacent alveoli.
completely necrotic tissue. There is marked hyperemia of all the vessels, little leucocytic reaction. (See fig. 5) Trachea: Is denuded of epithelium over large areas, where the lining consists of necrotic tissue chiefly infiltrated with leucocytes, the nuclei of which are much fragmented. There are adherent shreds of fibrinous slough and masses of bacteria. Where the epithelium is preserved, it consists usually of a single row of cuboidal cells resting upon a swollen hyaline membrane. In a few places the cells are heaped up into several layers, suggesting proliferation (mitosis). An interesting feature is noted in one section where the regenerating epithelium has interpolated itself beneath the still preserved, swollen, original membrana propria and a new basement membrane seems to be in process of formation. (See fig. 18.) There is an active growth of cells from the mucous ducts, forming solid
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sheets of large polygonal, nonciliated cells. The mucous glands are in hypersecretion. In oIne duct, the cavity or widened lumen is filled with a mass of desquamated mucous cells. Lungs: The infundibula and terminal bronchi show gangrene of their walls including often the neighboring alveoli. The nuclei have lost their staining, and there are large masses of bacteria. (Fig. 35.) There is much brownish-black pigment, both extra and intracellular. Elsewhere there is a loose pneumonic exudate, more or less hemorrhagic or fibrinous. Some alveoli are filled with fragmented vacuolated cytoplasm. (Fig. 36.) There is little or no regeneration or organization evident. A very interesting appearance is afforded by the lifting up of the alveolar epithelium in continuous sheets, with accumulations of leucocytes underneath. Adrenals: There is marked congestion with capillary extravasation. Spleen: Presents the usual picture of an acute splenic tumor.
FIG. 36.- Same as Fig. 35. Larger area of gangrene in lung
NOTE.-Case of mustard-gas poisoning of 20 days' duration. Although certain of the bronchi showed regeneration of the epithelium with metaplasia, the majority of them, as well as the trachea itself, were the seat of a gangrenous necrosis, associated with the presence of great masses of bacteria. There was a gangrenous infection of many of the infundibula extending into the adjacent lung tissue. About these necrotic areas there was a fibrinous pneumonia with organization. The presence of marked dental caries is specifically recorded and may have some relation to the gangrene.
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The following points of special histological interest may be noted: In the skin, the regeneration of the nonpigmented, atypical epithelium beneath the vesiculated crust of the original epithelium, absence of hair follicles, and marked vascular dilatation. The regeneration, in the bronchus, of the epithelium beneath the still preserved hyaline basement membrane. The gan- grenous bronchitis and bronchiolitis in the lung.
CASE 90.- L. M., 1202584, Pvt., 102d Engineers. Died, November 4, 1918, at 12.55 a. m., at Base Hospital No. 2. Autopsy, 10 hours after death, by Lieut. J. H. Mueller, San. Corps.
Clinical data.- October 29, admitted to General Hospital No. 1. Gassed on October 8; in hospital for mustard-gas burns. While in hospital, suddenly developed chills, fever, pains, sore throat, and cough. On admission, general condition excellent. Slight conjunctivitis. Heart normal. Lungs: No dullness, breath sounds normal. Tenderness in patelle, shins, and back. October 30, seem to be worse. Temperature up last night. Lungs show areas of dullness, more on right side posteriorly; many moist rȃles over both lungs. November 2, has been growing progressively worse, with more and more involvement of lungs. Heart action rapid, cyanosis marked. November 3, has become more cyanotic, with grayish pallor; respirations weak, shallow, and rapid. Heart action poor; edematous breathing. November 4, died at 12.55 a. m.
Anatomical diagnosis.- Acute tracheobronchitis; confluent lobular pneumonia; edema of lungs; hemorrhages into pleura.
External appearance.- No cutaneous lesions.
Gross findings.- Pleural activities: No fluid. Left lung: Pleura smooth; there are punctate hemorrhages over the lateral surfaces of the upper and lower lobes. Bronchi: Contain abundant thin frothy fluid. The larger vessels are normal. On section, the lung tissue is very wet; there is a confluent lobular consolidation throughout the greater part of the lower lobe and the base of the upper lobe; the consolidated portion is red, with mottled lighter areas. The smaller bronchioles do not contain pus. Right lung: Covered with smooth pleura. Bronchi also contain frothy fluid; their mucosa is intensely injected. On section, the same type of consolidation described in the opposite lung is found throughout the lower lobe, the base of the upper, and about half of the middle lobe. Organs of neck: Larynx normal. Trachea: Shows a rapidly increasing injection of the mucosa without ulceration, as it descends. Heart normal. Remaining viscera show no significant lesions. Stomach and intestines normal.
Microscopic examination.- Trachea and primary bronchus: No sections. Lungs: The small bronchi show partial exfoliation of the epithelium in long strips. The individual celli are not necrotic. The lumina contain polymorphonuclear leucocytes, red blood cells, and granular coagulum. The bronchial walls are infiltrated with leucocytes. The parenchyma shows a most intense congestion of the alveolar capillaries, with widespread hemorrhagic edema. The alveolar spaces contain a varying number of rather pycnotic and fragmented polymorphonuclears, and occasional pigmented alveolar cells. Some areas show only hemorrhage and edema. There is much destruction and caryorrhexis of the capillary endothelial nuclei, the nuclear material being drawn into long wisps and threads. The infundibula are dilated, and the walls show, not infrequently, hyaline necrosis. The pleura is normal. The interlobular and periarterial lymphatics are distended; some contain masses of inflammatory cells. Sections stained for bacteria show minute Gram-negative bacilli within the leucocvtes, in considerable numbers. No other bacteria found in careful search. Liver, spleen, and kidneys: No significant lesions other than congestion. Adrenal: Impoverishment of lipoids in cortex, with degeneration of individual cells. Poor chromaffin staining.
NOTE.-The case is of interest, since it illustrates the occurrence of an influenzal pneumonia in a gassed patient, 21 days after the gassing. A study of the gross and histological lesions indicates that the influenzal pneumonia is probably a primary infection, not related to the gassing. The bronchi fail to show the usual epithelial necrosis, followed by metaplasia, and there are not
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the customary peribronchial lesions of mustard gas. The lesions, on the other hand, are in all respects typical of the influenzal pneumonia which was raging at that time.
Another point of interest in the case is the presence, apparently in pure culture, so far as can be judged by the section, of a minute Gram-negative influenza-like bacillus.
CASE 91.- J. W., 1910957, Sergt., 328th Inf. Died, October 26, at 8.25 p. m., at Base Hospital No. 46. Autopsy, 13 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- October 3, admitted to Field Hospital No. 325; diagnosis; acute bronchitis. Admitted to Base Hospital No. 46 on October 5. Onset of illness October 1, with cough and aching of body. Breathing shallow, rapid, and labored; cyanotic. Lungs negative except in left axilla, where there is bronchial breathing, and showers of rfiles in left upper lobe posteriorly. The right and left lower lobes are consolidated. October 14, very nervous, cyanotic, delirious, pulse weak and thready. Died, October 26. Leucoeytes on October 7, 3,900.
Anatomical diagnosis.- Vesiculation of skin in folds of flanks (old gas burns ?); healed ulcers of vocal cords; acute tracheobronchitis; extensive peribronchial pneumonia, all lobes showing areas of resolution and organization; bronchiectasis; left lower lobe; coalescing lobular pneumonia, left upper lobe; fibrinous pleurisy with effusion (400 c. c.); pulmonary edema, moderate; cardiac dilatation, right; abscess of right arm, following hypodermic injection. A detailed autopsy protocol of this case was not made, owing to stress of other work (personal communication from Lieutenant Kline).
Microscopic examination.
Trachea: Epithelium desquamated, either superficially or completely, exposing the membrana propria. Where the superficial cells are still present they are normally ciliated and appear uninjured. It is probable that the loss of epithelium is a postmortal affair. The subepithelial tissue is normal save for congestion. Lungs: (a) The picture is complicated. Some of the bronchioles are dilated, but lined with well-preserved ciliated epithelium. The walls are thickened, congested, and densely infiltrated with lymphoid and plasma cells, but there is no exudate in the lumen. Other bronchioles show acute inflammatory changes. The epithelium is more or less completely detached, the lumen filled with pus and exfoliated cells; there is intense congestion and in some cases free hemorrhage beneath the epithelium, and a dense infiltration of the wall with polymorphonuclears. About these infected bronchi are patches of pneumonia, at the periphery, of which, organization of the exudate, which is here more purely fibrinous, is in progress. Between the pneumonic patches, there is intense congestion, with partial collapse. There are many pigmented cells in the alveoli, and a general stasis of leucoeytes in the capillaries. (b) Pleura shows a fibrinous exudate, with beginning ingrowth of fibroblasts at the base. The subpleural lymphatics are filled with purulent exudate. There are no larger bronchi in the section, but the bronchioli and the ductus alveolares are dilated with pus, and show necrosis and partial degeneration of their epithelium. The parenchyma shows diffuse fibrous and edematous thickening of the alveolar septa, with round cells and polymorphonuclears between the epithelium and capillary walls; extensive relining of the alveoli with columnar, probably regenerated epithelium; plugs of freshly organizing exudate in the alveolar spaces, or more recent fibrinous exudate with numerous exfoliated alveolar cells. (c) Some of the small bronchi show complete necrosis of their wall, and their somewhat narrowed lumina are filled with pus. The adjoining lung tissue is atelectatic, and shows extensive septal fibrosis and organization. The predominating types of wandering cells are the lymphoid and plasma cells. There is marked periarterial fibrosis. The section includes several bronehiectases, lined with ciliated epithelium. The prevailing bacteria in Gram-stained sections are Gram- positive cocci in pairs and chains. Bronchial lymph nodes: Contain masses of resorbing exudate in the sinuses.
NOTE.- Presumably a late case of mustard-gas poisoning, dying 23 days after exposure. The skin lesions were suggestive of old mustard-gas burns. The trachea gave no positive indication of gas injury, but the lung showed lesions of the bronchioles (necrosis, thickening, stenosis, bronchiectasis) which pointed strongly to previous gas injury. The marked leucopenia (3,900) on the fourth
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or fifth day after the supposed gassing was confirmatory evidence. The lesions were not quite those following in the wake of influenzal pneumonia, although the case occurred during the period when the epidemic was at its height, and a primary influenzal infection can not be entirely ruled out. The case illustrates the difficulty in arriving at a positive conclusion, when definite data as to the gas exposure are lacking.
CASE 92.- H. R., 489127, Pvt., 34th Inf. Died, November 7, 1918, at 10.30 p. m., at Base Hospital No. 81. Autopsy, 112 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data..- Exposed on October 14 to yellow and blue cross shells. October 17, admitted to Base Hospital No. 78 with diagnosis of bronchitis. Diagnosis had been made at Infirmary No. ? of influenza and gas burns about eyes. October 23, admitted to Base Hospital No. 81. Complains of pains across chest and cough; has been somewhat deaf for about two weeks. There is some impairment of resonance over right chest posteriorly below the angle of the scapula; also in right lower axilla. Over right base and lower axilla, there are many fine moist râles; scattered dry râles throughout the chest. October 23, leucocytes 15,600; November 2, leucocytes 15,400; November 6, leucocytes 13,600. Clinical diagnosis: Bronchopneumonia.
Anatomical diagnosis.- Gas burns of respiratory tract; healing ulcerative tracheitis and bronchitis; acute and organizing bronchopneumonia, all lobes; fibrinopurulent pleurisy, right; cardiac dilatation, right; terminal pulmonary edema, moderate; acute splenic tumor.
No detailed autopsy protocol was made in this case, owing to stress of other work (personal communication from Lieutenant Kline).
Microscopic examination.- Primary bronchus: There are adherent strips of stratified, but ciliated epithelium, showing no necrosis. There is an acute inflammation with leucocytic infiltration and congestion and edema of subepithelial tissue. The wandering cells are chiefly lymphocytes. Lungs: The larger bronchi are completely lined with ciliated epithelium, which, however, is composed of several layers like that of the trachea. There is mucopurulent exudate in the lumina. The wall is replaced by granulation tissue, densely infiltrated with lymphocytes. Most interesting changes are found in the smallest bronchioles and atria. Many of them are obliterated in part by purulent exudate, in part by ingrowing vascularized plugs of organized tissue. Their walls are thickened by granulation tissue. The surrounding alveoli are collapsed and show the usual epithelial changes and organization of contained exudate. Between these foci of bronchitis and peribronchitis, the lung tissue is emphysematous, and the air spaces free from exudate. In another block, the pleura is included. It is covered with a thick layer of fibrinous exudate, which shows only beginning organization. The underlying lung tissue, including also the bronchioli, is collapsed. The bronchi are lined with well-preserved ciliated epithelium; they contain mucopus, and in places there is beginning organization of the exudate. The walls are thickened by newly formed granulation tissue, but the lesions are less pronounced than in the former block. The collapsed alveoli have thickened walls and in places there are also organizing fibrinous plugs. A few infundibula filled with pus and showing necrosis of their walls, are present. Myocardium and kidney: Normal. Testis: Interstitial fibrosis, and absence of spermatogenesis.
NOTE.-There is beautiful organizing bronchiolitis and peribronchiolitis, which may or may not be the late result of gassing. There is an indefinite history of "gas burns about eyes," and subsequent information indicates an exposure to yellow and blue cross shell, three and one half weeks before death. The data are too incomplete to warrant extended discussion and it is not altogether certain that the respiratory lesions are effects of the gassing.
CASE 93.- E. K., 2397299, Pvt., Co. G, 30th Inf. Died, September 4, 1918, at 9 p. m., at Base Hospital No. 27. Autopsy No. 46, performed on following day, by Capt. HI. H. Permar, M. C.
Clinical data.- Gassed with mustard gas on August 10. Admitted to Field Hospital No. 110 on same day, and to Base Hospital No. 27 on August 12. Placed in diphtheria ward as suspect. Throat covered with gray exudate. September 4, throat culture positive for diphtheria bacilli. Extensive burns about whole body. General condition very bad.
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Anatomical diagnosis.- Healing burns of skin of legs, thighs, buttocks, arms, genitals and axillae, with pigmentation; diphtheritic pharyngitis, laryngitis, tracheitis and bronchitis; bronchopneumonia, acute, bilateral; edema and congestion of lungs; acute toxic myocarditis; acute lymphadenitis or peribronchial lymph nodes.
Microscopic examination.- There is an acute suppurative bronchitis, with complete necrosis of the mucosa, and acute inflammatory infiltration of the wall. Some of the smaller bronchi are completely plugged with fibrinopurulent exudate. There is no regeneration. The parenchyma shows patches of lobular pneumonia, emphysema and extreme alveolar edema in unconsolidated areas.
Bacteriological examination.- Smears of membrane taken post mortem shows diphtheria bacilli.
NOTE.-A case of mustard-gas poisoning, dying 25 days after exposure, with intense diphtheritic lesions of the upper respiratory passages, from which the diphtheria bacillus was cultured during life. The most unusual feature of the case is the absence of reparative changes in the bronchi and lungs.
CASE 94 - S. T., 490034, Pvt., Co. L. 47th Inf. Died, November 8, at 5 a. m., at Base Hospital No. 19. Autopsy No. 112, performed six and one-half hours after death, by Capt. H. H. Martland, M. C.
Clinical data. - Exposed to blue, green, and yellow cross shelling on October 13, near Verdun. Admitted to Gas Hospital No. 3 on same day, October 20, admitted to Base Hospital No. 76, with conjunctivitis, dermatitis of face and chest, laryngitis, and bronchopneumonia. October 24, patient very weak. Pulse 156. Temperature 99.8°. Respirations 28. Cough with large amount of expectoration. Severe conjunctivitis. Mucous rȃles over both sides of chest, especially left. October 24, admitted to Base Hospital No. 1. Severe bronchitis; no areas of consolidation found. October 27, membrane over uvula and soft palate. Culture positive for diphtheria bacilli. Diphtheria antitoxin, 6,000 units, given. October 28, admitted to Base Hospital No. 19. October 31, pulse rapid and weak. Eats very little. Dry skin. Raises large amount of purulent sputum. Moist rȃles, more numerous over left chest. Throat improving; 15,000 more units of antitoxin administered. Gradually growing weaker.
Summary of gross lesions.- No skin burns. There is extensive ulceration of the larynx, vocal cords, and trachea, which are covered with thick grayish membrane; this extends down to the finest bronchioles and is diffuse through both lungs. All lobes show a confluent bronchopneumonia. There is moderate distention of the chambers of the right heart.
Microscopic examination.- (a) There is gangrenous bronchitis which involves the entire bronchial wall and a zone of neighboring lung tissue. In the center of the gangrenous areas are large masses of bacteria. Elsewhere, the parenchyma shows a very widespread acute pneumonia, the exudate being rich in cells and fibrin. In some alveoli, there is beginning ingrowth of fibroblasts. Scattered through the consolidated lung are patches of necrosis with great numbers of bacteria. These are not always clearly related to the bronchi. (b) There is an organizing fibrinous pleurisy. In the lung tissue itself some of the bronchioles show a suppurative inflammation, with preservation of the epithelium; others gangrenous necrosis. There are emphysema and small patches of atelectasis. (c) The picture is a somewhat different one. There is almost complete collapse of the lung tissue, with extensive early organization in some areas, fibroblastic thickening of the alveolar septa, and edema. The bronchi are lined with regenerated metaplastic epithelium, resting upon a wall of highly vascular granulation tissue. In places the bronchi also are collapsed, the walls being practically intact, as seen in longitudinal sections. The arteries are surrounded by broad bands of edematous granulation tissue. (d) The section shows irregular areas of edema, emphysema. and moderate epithelial exfoliation. A small bronchus in the section shows an extraordinary obliterating process leading to practical closure of the lumen. The lining epithelial cells are curiously altered, and the basement membrane is hyalinized and thickened. There is a layer of granulation tissue between the mucosa and the circular muscle. (Fig. 37.) The process seems to be very like an obliterating endarteritis. That the stenosis of the terminal bronchi is the cause of the associated emphysema and atelectasis seems very probable.
NOTE.- Death 26 days after exposure to a mixture of suffocative and vesicant gases. The noteworthy features in the case are the gangrenous
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bronchitis, with areas of necrosis in the parenchyma of the lung; the very extensive lobular pneumonia, showing in places, early organization; and the obliterating bronchiolitis in the nonpneumonic areas, associated with emphysema and areas of collapse. The recovery of the diphtheria bacillus from the membranous pharyngeal lesions is also of interest.
CASE 95.- E. S., 62768, Corpl., Co. ?, 101st Inf. Died, September 13, 1918, at Base Hospital No. 116. Autopsy No. 13. Autopsy, five hours after death, by Lieut. B. S. Kline, M. C.
FIG. 37.– Death, 26 days after exposure to mixture of suffocant and vesicant gases. Obliterative bronchiolitis.
Clinical data. – Date of gassing, August 15. The patient was burned by the explosion of a mustard-gas shell above him while sleeping in a hayloft. Liquid covered his body. Admitted to Base Hospital No. 116 on July 24 with severe secondary burns involving entire back from neck down and including the buttocks and posterior surface of both thighs and back of legs. Burns also present on both arms, scrotum, penis, forehead, chest. Progressed fairly well with only moderate infection and superficial sloughing. Developed pressure necrosis over sacrum and both elbows, which grew steadily worse until death.
Anatomical diagnosis. – Extensive gas burns of skin of first and second degree, with secondary infection and moderate general brown pigmentation. Small areas of organized bronchopenumonia. Anemia and emaciation. Cloudy swelling of parenchymatous organs. Old vegetative endocarditis of mitral valve. Pulmonary edema.
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External appearance.- The skin shows a striking picture. Beginning over the scapula above, there is complete ulceration of the skin of the back as far down as the buttocks, where the posterior portion is likewise ulcerated. The ulceration continues down to the mid-portion of the thighs. Over the sacrum there is a large deep ulcerated area, in the base of which the sacrum and coccyx are visible. There is a moderate amount of viscid and caked exudate here. Above this deep wound there is a similar smaller wound over the crest of the ilium. The ulceration of the skin of the back, buttocks, and thighs extends well into the subcutaneous tissue. The base is covered by a moderate amount of foul-smelling seropurulent exudate. In places there is dry scabbing. Ulcerations, similar in character but less extensive, are present over the posterior aspects of the legs, about the elbows and the knees, the right ear, crest of the ilium anteriorly. There is also an extensive deep ulceration of the scrotum and the base of the penis. Here the infection is most marked. The skin in general has a dull grayish-brown cast. Associated with the burns there is a moderate desquamation. There is also desquamation at some distance from the ulcerated areas. In places the burns show considerable healing. This is especially true of the small burns over the right hip, lower abdomen, upper arms, and chest. The superficial glands moderately enlarged. Scalp: Over the vertex there is some thick matted desquamation. The skin at one place shows a contusion. Eyes: The eyeballs are sunken in the sockets. The left upper eyelid shows a large area of ecchymosis. The conjunctive, however, and the mucous membranes are pale. At the right corner of the mouth there is a small superficial ulcerated area, base clean.
Gross findings.- Pleural cavities: On opening the thorax a number of fairly dense fibrous adhesions are found in the right sac, binding the posterior portion of the upper and lower lobes to the chest wail. In the left chest likewise a number of fibrous bands found binding the lateral portions of the upper and lower lobes to the chest wall. On incising the pericardial sac there is considerably less fluid than average. The pericardium is delicate and pale. Heart: Weighs about 330 grams. The right auricle considerably dilated. The tricuspid ring admits three fingers. There is slight dilatation of the conus. The valvular endocardium, thin and delicate, except the mitral valve, which shows along the line of closure several vegetations tightly adherent to the underlying endocardium. In part the vegetations are covered by endocardium. The chorda e, however, are thin and delicate. The base of the aorta shows small soft yellow opaque patches in the intima. The coronary vessels, no abnormalities, except that the right one opens by two mouths. The left myocardium on section is paler than normal. The architecture not altogether regular. There are scattered grayish flecks here and there. The tissue has a boiled and slightly greasy appearance. Right lung: All lobes fairly voluminous, cushiony, and inelastic. The lower lobe slightly soggy in addition. The glands at the hilum somewhat enlarged, edematous, pulpy, and not injected. The vessels, no abnormalities. Bronchi: The mucosa is pale and smooth. In the lumen there is a small amount of frothy fluid. The upper lobe on section presents a pink surface. The air sacs contain a small amount of fluid. In the posterior portion there are numbers of grape seed-sized to pea-sized firm consolidated areas, grayish-red in color. The middle lobe is well aerated and pink throughout. There is extremely little fluid in the air sacs. The lower lobe on section presents a pink surface. There is a small amount of thin, frothy fluid in the air sacs. In this lobe also there are numerous reddish patches, associated with some of which there are firm reddish-gray small consolidated areas. Left lung: Both lobes voluminous, cushiony, and inelastic. The glands at the hilus, vessels, and bronchi similar to those on the right. On close inspection of the bronchi the mucosa appears exceedingly thin. On section the upper lobe in general similar to the right upper. The lower lobe in general similar to the right lower lobe. Organs of neck: Glands in the lower portion of the neck are not appreciably enlarged. Thyroid: Considerably smaller than normal. The tissue coherent, pale. There is little colloid in the acini. Larynx and trachea: Present an interesting picture. The mucosa is exceedingly thin, pale, except in the region of the epiglottis, where it is somewhat diffusely thickened, pale with injection of the vessels here and there. The lymphatic tissue in the pharynx and the upper esophagus adjoining the glottis somewhat enlarged, injected. Tonsils: Enlarged, but scarred. Crypts clean. Liver: Weighs 1,400 grams. Adrenals: Right adrenal shows digestion of the medulla in one portion, with considerable extravasation of the blood here. There is moderate loss of the yellow pigment. The left shows no digestion of the medulla, some diminution in the yellow
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pigment. In places there are fine gray streaks in the cortex. Kidneys: Normal. Alimentary tract: There is perhaps slight thickening of the mucosa of the upper esophagus, pharynx, and base of tongue. The stomach contains about 75 c. c. of thin, bile-tinged contents. The mucosa pale. Duodenum, ileum, the mucosa somewhat bile-tinged. In the lower ileum there are scattered patches of injection of the mucosa. The Peyer's patches arc flat here, somewhat pigmented. The solitary follicles in the cecum are flat, pigmented. There is some patchy injection of the mucosa of the cecum and ascending colon. In the rectum there is quite diffuse moderate injection of the mucosa. The tissue about the rectum is somewhat edematous. The mesenteric lymph glands are not appreciably enlarged.
Microscopic examination.- Skin: Section passes through ulcer covered by infected slough. There is no healing at the margin and very little granulation tissue at the base. The adjacent epithelium contains little pigment, but there are beautiful melanophores in the superficial layer of corium sending processes between the basal epidermal cells. Another block shows thinning of epidermis with hyperpigmentation. Trachea: Epithelium is intact and normal save for post-mortem desquamation. Epithelium is ciliated. There is no edema, congestion, or inflammatory infiltration of submucosa. No bacteria found in section. Lungs: Bronchi still have intact epithelium, but are filled with pus. Atria are dilated and their epithelium necrotic. There are patches of lobular pneumonia and interstitial infiltration. The exudate is cellular, not fibrinous. No organization. There are many pigmented exfoliated epithelial cells. Section stained with Gram-Weigert shows practically no bacteria or fibrin. Kidneys: A few of the glomerular tufts contain hvaline thrombi. No other changes. Myocardium, spleen, and pancreas: No abnormalities.
NOTE.- Mustard-gas case of 29 days' duration, with very extensive contact burns of skin. The respiratory lesions do not indicate gas inhalation. There was a terminal pneumonia in the lung which also showed signs of chronic passive congestion associated with the mitral lesions. Death in this case was primarily the result of very extensive skin burns associated with infection or toxemia.
CASE 96.- W. A. H., 2182677, Pvt., 354th Inf. Died, on September 7, at 7 a. m., at Base Hospital No. 42. Autopsy No. 3, performed three hours after death, by Capt. F. A. Evans, M. C.
Clinical data:- Gassed on August 8, near Toul, with mustard-gas shells. August 10, admitted to Base Hospital No. 42. August 20, the patient began to have a temperature of 100 ° to l01 °, followed a few days later bv areas of bronchovesicular breathing front and back. There was a definite area of consolidation, especially marked in the angle of the right scapula. For a few days the patient improved and did very well. August 28, scattered râles over upper front on both sides, with bronchovesicular breathing over lower right anterior chest. There was a click on expiration and inspiration over this area. In the back, various kinds of râles were heard on both sides; impairment of resonance over lower right side, beginning about 5 cm. below the angle of the scapula. September 4, signs of irregular consolidation over entire right lower lobe, and also over right upper chest anteriorly. The patient, from this time on, became more intoxicated; breathing became labored; there was very abundant purulent sputum. September 6, condition very bad. Laryngoscopy on August 30 showed the vocal cords covered with a film of mucopurulent exudate. Died on September 7, at 7 a. m.
Anatomical diagnosis.- Acute tracheitis and bronchitis; bronchopneumonia of all lobes; acute fibrinous pleurisy; healed mustard-gas burns of axillae; perineal region, buttocks, and popliteal spaces.
External appearance.- Few superficial excoriations under the lower lip. There is pigmentation of healing gas burns in the perineal region over the inner and posterior aspects of the thighs, over the buttocks, and popliteal spaces. Similar but less pronounced pigmentation is seen in the axillae. There is purulent exudate in both eyes.
Gross findings.- Right lung: Floats in water and is voluminous. In certain areas, notably at the extreme apex of the upper lobe and the extreme base of the lower, posteriorly, the lung tissue appears normal. There is fibrinous deposit over the lower surface of the upper lobe, over the middle lobe posteriorly, and over the uipper part of the lower lobe. There is also a heavy deposit of fibrin in the initerlobar fissures. Those places that have not been
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described as normal have a pinkish-purple color and on palpation are in part air containing, in part consolidated. There is an isolated area of dark color in the posterior part of the upper lobe extending from the fissure to the apex, which has a nodular feel. On section, there is an irregular and patchy bronchopneumonia. The lung tissue is everywhere moist and, where not consolidated, of a salmon-pink color, from which the small bronchopneumonic nodules stand out. The larger bronchi of the right lung are injected, and pus exudes from them on cutting. Left lung: Also is voluminous. There is a fine fibrinous pleural exudate most marked posteriorly. On section, the lung tissue is less moist than that of the right lung; it is spotted with areas of bronchopneumonia, varying in size from miliary to that of a bean. The pneumonic consolidation is most extensive in the posterior part of the lower lobe. The larger bronchi are injected, but their mucosa appears to be intact. Organs of neck: Larynx and pharynx are normal. Trachea: Shows a fibrinomucopurulent exudate, which when stripped off shows the underlying mucosa intact and only moderately congested. No scarring is apparent. Heart normal. Intestines not reinoved. Remaining organs show no significant changes.
Microscopic examination.- Trachea: Epithelium is everywhere intact, but resembles esophageal epithelium, being squamous and nonciliated. The same alteration is present in the epithelium lining the mucous ducts. The glandular acini are distended with mucus. The submucous tissue is evenly infiltrated with wandering cells having stained distorted nuclei. The preservation of the tissue is too poor to identify these with certainty. Most of them appear to be lymphoid cells. The capillaries are wide, but contain no preserved red blood cells. Lungs: The smaller bronchi are wide, their walls thickened by granulation tissue and closely invaded by leucocytes. Some are lined by a thin layer of flattened epithelial cells; in others the rough granulation tissue lies exposed. Many of them contain purulent exudate, and most of the terminal bronchioles and infundibula are filled with it. The adjacent lung tissue over a narrow zone shows all organizing pneumonia. A second block shows all extensive bronchopneumonia. which is not of the usual influenzal type, inasmuch as the exudate is very cellular. The leucocytes are well preserved, and the process seems of recent date. A third block shows all organizing bronchiolitis, with plugs of vascularized tissue growing from the walls. The smaller bronchi are greatly thickened by new formed granulation tissue and surrounded by zones of edema. Liver, spleen, myocardium, and adrenal show no features of special interest.
NOTE.- A case of mustard-gas poisoning, dying 30 days after exposure. There were healing burns in characteristic situations at autopsy, and histological examination shows the typical metaplasia of the tracheal epithelium and subacute bronchitis and peribronchitis similar to that seen in other mustard-gas cases after the lapse of several weeks. In addition, however, there appeatrs to have been a lobular pneumonia of more recent date.
CASE 97.- T. F. (Cherokee Indian), 48537, Ivt., Co. M, 18th Inf. Died, Novembler 6, 1918, 9.20 a. m., at Base Hospital No. 58. Autopsy No. 17. Autopsy, four hours after death. by Capt. M. Flexner, M. C.
Clinical data.- Exposed to phosgene and mustard-gas shells on October 1, near Charpenterey. Admitted to Base Hospital No. 58, October 15, with severe cough and pain in chest. Diagnosis: Bronchopneumonia, with suspicion of lung abscesses.
Anatomical diagnosis.- Mustard-gas burns, healing at left wrist, hemorragic and gangrenous tracheitis, bronchitis, and bronchiolitis. Extensive peribronchial pneumonia. Chronic fibrous pleurisy. Parenchymatous degeneration of liver and spleen.
External appearance.- Body is that of an Indian. The skin is brownish-tan in color with darker pigmentation over abdomen and thighs, almost white over lower legs and feet. Over end of radius on left wrist is a healing burnt circular in shape, with slight scab formation at lower edge. Over coccyx is a beginning ulcer.
Gross findings.- Pleural cavities: The left is obliterated by old adhesions. The right is free from fluid or adhesions. Heart: Normal. (Note dictated upon receipt of organs at pathological laboratory, experimental gas field.) Right lung: Pleura over upper and lower lobes is normal. Over the lower 1obe are the remains of old fibrinous adhesions. Posterior half of lung is dark with sunken patches of collapse. The anterior portion is pale and
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emphysematous. Bronchi: As far as call be followed, are lined with dark greenish-brown mucosa, contain a little dark, fool-smelling exudate. No diphtheritic membrane. On section, the upper lobe, in the posterior portion shows numerous discrete yellow foci surrounded by irregular patches of hemorrhagic consolidation. These areas correspond to the cross section of small bronchi dilated with plugs of exudate. Same condition throughout the lower lobe, with exception of small patches anteriorly. The consolidation, however, is more widespread and the intervening lung tissue less well aerated. The middle lobe, with the exception of the extreme anterior strip, is air-containing and dry. The bronchial lymph nodes are small and pigmented. Large branches of the pulmonary artery are normal. Left lung: Both lobes are covered with sheetlike adhesions. The apex is deformed by old scars. Several calcified nodules in the substance of the lung can be felt about one inch below the extreme apex. Upper lobe on section is air-containing. Along the posterior border the walls of the bronchi show greenish-brown discoloration. The lower lobe is very dark ill color, firm and nodular. Numerous foci of grayish-yellow project upon a background of dark red, uniformly consolidated. On pressure plugs of dense exudate can be expressed. Section shows also small irregular cavities with necrotic walls, and representing small dilated bronchioles. The bronchi show the same intense hemorrhagic condition as in the right lung. The fetid odor is apparently not due to post-mortem change. Trachea and bronchi: Are markedly injected with blackish-gray discoloration of the wall. There are small yellow flecks in the contained secretion. Gastrointestinal tract is grossly normal. Remaining organs show no significant lesions.
Microscopic examination.- Trachea: The mucous membrane in places is preserved, and the lining epithelium is not atypical, showing well preserved cilia. Desquamation is probably post mortem, since there is no edema of the corium, no membrane formation, no inflammatory infiltration and no evidence of regeneration. Lungs: Bronchioles show necrosis. There is complete loss of epithelium without formation of membrane or exudation of leucocytes into the lumina. In many places the peribronchiolar tissue is involved in the necrosis. Only faint indications of alveolar outlines persist. Detritus, which lines these gangrenous cavities, is very rich in organisms. The necrotic areas are surrounded by a zone of bronchopneumonia with many polymorphonuelear leucocytes in the exudate. External to these the alveoli contain much fibrin. In some areas these peribronchial pneumonic patches are undergoing organization. There is much edema about the large vessels with formation of abundant young connective tissue. Septa also are edematous and in places organized and contain many lymphoid and plasma cells. Skin:. Superficial desquamation of the keratin layer, slight edema of corium with a few wandering cells. No other significant lesions. Section of kidney, pancreas, spleen, and myocardium show no changes of interest. Liver: Shows rather marked periportal fat infiltration.
NOTE.- Exposed to phosgene and mustard gas 37 days before death There was a healing mustard-gas (?) burn of the left wrist, but no other cutaneous lesions suggestive of previous gassing. Findings in the trachea were not indicative, but there was a gangrenous bronchiolitis associated with a widespread hemorrhagic bronchopneumonia, which was becoming organized. While it is probably a late mustard-gas case, it is difficult to make a differential diagnosis from influenzal pneumonia complicated by a gangrenous bronchiolitis. A point of interest in this case is the presence of obsolete apical tubercles which after 35 days have not become activated.
CASE 98.- C. M., 17004, Pvt., 2 Northumberland Fusileers. Died, November 12, 1918, at 1 p. m., at Base Hospital No. 2. Autopsy, five hours after death, by Capt. 1B. F. Weems, M. C.
Clinical data.- October 5, admitted to No. 20 Casualty Clearing Station. Diagnosis: Gas-shell wound of left thigh, right foot, left hand; gassed. Operation: Amputation of left thigh, right foot. Left hand cleaned tip. Patient's condition very poor. Blood transfusion. October 7, admitted to Base Hospital No. 2. Stump of left thigh fairly clean, right foot very dirty, completely excised and part of first and second metatarsals removed; posterior tibial vessels tied; not amputated because of amputation of opposite thigh. Wound of left hand very dirty. Fifth finger amputated. Corneal ulcer of left eve. October 28. has
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been doing only fairly well; foot still badly infected. Incision on dorsum today; abscess apparently arising from tarsal joints. November 5, patient doing poorly; running temperature of 103?and 104?. Blood culture sterile; moderate generalized bronchitis; has apparently an infection of most of the tarsal joints. Amputation through junction of middle and lower third of right leg under stovaine intraspinally. Transfusion 700 c. c. Stood operation well. November 12, condition has grown steadily worse. All wounds appear clean. Many fine râles at both bases with much cough. Died at 1 p. m.
Anatomical diagnosis.- Acute membranoulcerative laryngitis, tracheitis and bronchitis; bronchopneumonia; edema and congestion of both lungs; multiple abscesses, both lungs; acute fibrinous pleurisy, amputation wounds of both legs, and finger of left hand; emaciation; poisoning with irritant gas.
External appearance.- Much emaciated; adenoid facies; many teeth missing. Skin and external genitals normal. Wounds as follows: Left-hand middle finger missing; ulcerated, partially healed wound over area of amputation; left leg amputated in midthigh; stump apparently clean; right leg amputated just above foot; upon removing sutures, tissues are found to be clean and apparently healing.
Gross findings.- Pleural cavities: Lungs are collapsed to some extent; there are about 100 c. c. of fluid in the left pleural space; loose fibrinous exudate and fluid over the entire posterior surface and base of right lung. Left lung: Moderately voluminous; there is a slight amount of fibrinous exudate over posterior surface; lower portion of upper lobe, as well as greater portion of lower lobe, is consolidated. Bronchi: Contain slightly purulent and sanguineous exudate; mucous membrane is much eroded and covered by exudate. Upon section, the lung presents a dark grayish-red color; the surface is moderately smooth, exuding a large quantity of serum and blood; there are numerous small points of pus over the surface. It is rather a diffuse type of lobular pneumonia combined with edema. Right lung: Covered with thick fibrinous exudate. The lower lobe and a large part of the upper and middle lobes are of rather firm and lumpy consistence. The lung upon section reveals much the same picture as the left. There is a diffuse partial consolidation, roughly lobular in type. The bronchi are filled with pus and necrotic membrane; many small abscesses are present at the end of the bronchi. Edema is pronounced. The glands at the hilum are much enlarged. Organs of neck: Tonsils normal. Epiglottis: Tremendously thickened and covered by a yellowish-gray membrane; the mucosa is eroded. The arytenoepiglottic folds are also much thickened and ulcerated. Trachea: Is covered over its entire length by a thick cheesy membrane, beneath which the mucous membrane is deeply ulcerated. Heart normal. Gastrointestinal tract: Not recorded. Remaining viscera show no significant changes.
Microscopic examination.- Epiglottis: On both sides a diphtheritic necrosis extending almost to cartilage. Much fibrin is present, both on the surface and in the edematous sub- mucous tissue. There is hyperernia and hemorrhage. Many of the small vessels contain thrombi, some of which are becoming organized. There are many mononuclear and polymorphonuclear leucocytes loosely scattered through the tissues; they appear pycnotic. The cartilage also is affected, showing in places fibrillary degeneration of the ground substance, with swelling and loss of definition of the cartilage cells themselves. Trachea: There is a thick adherent membrane, densely crowded in places with fragmented and pycnotic leucocytes; on the surface of this is a loose purulent exudate containing masses of Gram-positive cocci. There is no epithelium remaining. The submucosa shows numerous fibroblasts, pycnotic leucocytes, and congested vessels. The mucous ducts are wide and filled with exfoliated cells. Lungs: A bronchus cut longitudinally is practically filled with a thick fibrinous plug in which are many pigment-containing cells, and a few ingrowing fibroblasts. The alveoli everywhere contain plugs of loose fibrinous exudate, poor in cells, which are continuous with similar plugs in the distended atria. Few large mononruclear cells and polymorphonuticlears and isolated spindle cells are present in the fibrin. The septa are thickened and loose in texture and under the high power the epithelium is frequently found elevated from the capillaries in a continuous sheet, presumably by edema. There are occasional hemorrhagic extravasations between epitlielium and blood vesssel, or into the alveolus itself. The epithelial cells, judging by their swollen contours and dark staining protoplasm, are probably in large part new formed, although no mitoses are found. Another block of lung tissue shows in general the same picture. There is fibrin upon the surface of the pleura, which is exceedingly edematous. In its basal portion are many congested blood vessels with fresh hemor-
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rhages. Beneath the pleura in one place is an abscess about 2 mm. in diameter. The lymphatics in the interlobular septa are distended with masses of degenerating leucocytes. Liver, spleen, adrenal, and kidney show nothing abnormal.
Bacteriological examination.- Blood culture (post-mortem) staphylococcus albus. Culture from bronchus: B. influenzae, streptococcus hemolyticus, staphylococcus aureus, Gram-positive diphtheroid bacillus. Culture from bronchiole, staphylococcus aureus. Culture from pleura: Staphylococcus aureus. Culture from lung: B. influenzae, diphtheroid bacillus.
NOTE.- History of gassing, 38 days before death, with severe wounds of lower extremities, later necessitating double amputation. There is no record of skin burns, and none are described in the autopsy protocol. There is said to have been a corneal ulcer, but there is no mention of conjunctivitis. The upper respiratory tract showed a membranous necrosis of great severity, with complete epithelial destruction. Repair was therefore limited to attempted organization in the deeper tissue, but was very imperfect. The small bronchi still contained plugs of dense exudate, which was undergoing early organization. There was a lobular pneumonia which also showed evidence of organization and epithelial repair. There were a few suppurative foci. Presumably, the case is one of mustard gas inhalation, in which, as in other autopsies at this hospital during the same period, the cutaneous lesions are slight or absent. The surgical complications, in this case, though very grave, can not be regarded as the cause of death.
CASE 99.- J. Y., 105587, 16th Inf. Died, November 10, 1918, at 7 p. m. Autopsy, 141 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- October 2, admitted to Field Hospital No. 12 with shell wound of right side. Foreign body about 6 mm. long beneath superficial muscles of right chest. October 4, multiple burns of skin, dressed with vaseline each day. October 24, incision and drainage of large abscess of right buttock. October 25, patient complained of difficulty in opening jaw; no stiffness of neck. November 1, incision of gluteal abscess and inguinal glands. Antitetanic serum 5,000 units intraspinally, 10,000 intramuscularly. November 2, fluoroscopic examination showed foreign body, 1 by 1 cm. lying 10 cm. under skin apparently in the body of the liver. November 3, subdiaphragmatic abscess; operation; resection of rib and evacuation of abscess. Culture of pus showed anaerobic Gram-positive bacilli and Gram-positive diplococci. Forty thousand units of antitetanic serum intramuscularly. November 10, the patient grew rapidly worse, although tetanus was cured. Frequent vomiting, incontinence of feces, much thick sputum, and definite signs of peritonitis. The patient died, Novemper 10 at 7 p. m.
Anatomical diagnosis.- Gunshot wound of abdomen, with perforation and laceration of liver (encapsulated bit of shrapnel, with clothing fragments and small spicules of bone), subsequent infection, abscess formation; thrombosis, local hepatic veins; small infarct, left upper lobe; subdiaphragmatic abscess; local organizing peritonitis; resection of seventh rib, right; drainage of liver abscess and abscess of right buttock; surgical incisions and drainage; decubital ulcer over sacrum, beginning healing; healing extensive superficial gas burns of skin, with moderate general brown pigmentation, and considerable local brown pigmentation of trunk, extremities, and scalp; anemia and marked emaciation; healing and acute purulent bronchitis; areas of bronchiectasis; old peribronchial and peribronchiolar pneumonia of all lobes except right middle; recent bronchopneumonia, right upper and lower lobes; fibrinopurulent pleurisy, right; acute splenic tumor; cardiac dilatation, right (slight); pulmonary edema (slight). A detailed autopsy protocol of this case was not made, owing to stress of other work (personal communication from Lieut. B. S. Kline).
Microscopic examination.- Large bronchus: Presents no clear evidence of previous gas injury. The epithelium is defective in places, but this is probably due to postmortal desquamation. Where it is still intact, it is ciliated, and in no wise abnormal. The subepithelial tissue contains pink-staining hyaline material, which is probably old fibrin. The blood
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vessels are congested. There are moderate numbers of lymphoid cells. The mucous glands are normal. Lungs: (a) Section shows an acute confluent bronchopneumonia, presenting no special features. There are no other lesions indicative of previous gassing. (b) In addition to patches of acute bronchopneumonia, the bronchioles show changes which are probably of older date, and may be referable to gas inhalation. Some are dilated and contain fibrinopurulert exudate which in places is becoming organized; the walls are formed by a hyperemic granulation tissue, densely infiltrated with round cells and plasma cells. The epithelium in some is ciliated; in others, flat and atypical; in still others, lost. The adjacent alveoli are collapsed and compressed, and there is hemorrhage and fibrinous exudate, showing early organization. Irregular nests of proliferated epithelium fill up some of the alveoli. (c) The section shows an old infarct, at the apex of which is an organizing thrombus, already well canalized. In the noninfarcted area the bronchioles and infundibula show lesions similar to those in (b) and probably due to the original gassing. Liver: Section shows healing scars with granulation tissue and much foreign material on surface. Spleen: Fragmentation of cells in centers of follicles, marked congestion of pull), and much pigment deposit. Kidney: Acute degenerative changes in epithelium of convoluted tubules
NOTE.-There is a definite clinical history of old mustard-gas burns, and healing and pigmented burns were present at the autopsy 39 days after the injury was incurred. The pulmonary lesions were complicated by the presence of an infarct, doubtless due to an embolus from the hepatic veins, and by a terminal bronchopneumonia complicating the abdominal injuries. There were, nevertheless, traces of old respiratory burns in the small bronchi and infundibula, although the larger bronchi showed restitution of the epithelium.
CASE 100.- R. A. B., 2181649, Corpi., 355th Inf. Died, September 28, 1918, at 12.40 p. m., at Base Hospital No. 116. Autopsy, three hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.- August 10, admitted to Base Hospital No. 116, suffering from mustard-gas inhalation and contact received in action on August S. Said to have been exposed to yellow and green and blue cross shells for six hours. There were on admission extensive body burns, conjunctivitis, laryngitis, and bronchitis. August 12, consolidation of right lower lobe. August 20, scattered areas of consolidation over both lungs, with complete consolidation of left lower. September 10, diarrhea. September 15, signs of fluid at the base of the left lung. Aspiration showed pus. September 16, operation for empyema. Since admission there has been gradual emaciation which is now very marked. The gas burn of the lower back has never healed, and has become a bed sore. The right lung presents harsh breathing and many coarse, moist, bubbling rales. Diagnosis: Bronchiectasis, with purulent expectoration. Died, September 28 at 12.40 p. m.
Anatomical diagnosis.- Healed gas burns, upper respiratory tract and skin; diffuse and local brown pigmentation of skin; organized bronchopneumonia, left lower lobe; empyema, left; resection of portion of ninth rib; extensive organizing fibrinopurulent pleurisy, left; dilatation of bronchial branches, slight; purulent bronchitis, slight atelectasis of left lung, moderate; compensatory emphysema, right lung; rupture of thoracic aorta, false aneurysmal sac; old tuberculosis foci, right lower lobe; healed pleural adhesions, right; decubital ulcer of sacrum, healing; anemia and emaciation, marked.
External appearance.- Body markedly emaciated and anemic; slight hypostasis. The skin in general has a slight brownish tint. Scattered over the thighs, genital folds, lower abdomen, elbows and upper arms, there are irregular blotchy areas of deeper brown pigmentation. In some of these, the epidermis is desquamnated in the inner portion. The outer surfaces of both thighs and the scrotum show thin pearly areas several centimeters in diameter. Over the sacrum posteriorly, there is an area of ulceration 4.5 cm. extending into the muscles; the base clean, showing healing. The skin edges show new epidermis. Operative wound below angle of left scapula, with drainage into pleural cavity.
Gross findings.- Pleural cavities: On opening the thorax, a small number of fibrous hands found in the posterior andl inferior portions of the sac on the right side. On the left both lobes collapsed against the spine. There is a large air space present, with firm adhesions over the upper and lower loibes posteriorly. In the sac are a few pockets of viscid pus. The heart is displa ed somewhat to the right. Its long axis is parallel to the long axis of the
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body. The pericardial sac on the left is bound to the lung by firm bands; otherwise pericardium is normal. Right lung: All lobes fairly voluminous, cushiony, inelastic. The pleura thin; the vessels present no abnormalities. The glands at the hilum are intensely pigmented and scarred. The bronchial mucosa is pale, perhaps slightly thickened. On section of all lobes, a light pink very well aerated surface presents. The upper portion of the lower lobe shows a scarred pigmented patch 2 by 1.5 cm., embedded in which there are firm whitish-yellow nodules. On this side, some of the bronchial branches contain viscid mucopurulent secretion; and in addition in places peripherally are moderately dilated. Left lung: Both lobes considerably collapsed. The pleura diffusely thickened, covered by tenacious fibrinopurulent exudate, which when stripped shows tiny vessels between it and the pleura. The pleura itself is diffusely injected. The vessels and glands are similar to those on the right side. The bronchi show slight patchy injection of the mucosa. In the lumen there is thin viscid fluid. On section of the upper lobe, a light pink well aerated surface presents. In the posterior portion, there is a firm gray area 1.5 cm. in diameter, suggesting organizing pneumonia. No consolidation elsewhere. The lower lobe on section presents a similar picture to the upper, except that it is not consolidated. In both lobes some of the peripheral bronchial branches show moderate dilatation. In the lumen, there is viscid mucopurulent material. Between upper and lower lobes posteriorly there is a mass of soft purulent exudate. Encapsulated in the inferior portion of the lower lobe, there is a small amount of viscid pus similar to that in the surgical wound described above. Scattered through the left lower lobe are numerous tiny nodules suggesting organizing pneumonia. In this lobe also a number of the medium-sized bronchioles are somewhat dilated. Organs of neck.-Trachea and larynx: Mucosa pale, perhaps slightly thickened. There is no outspoken evidence of former inflammation. Tonsils: Small and scarred. Heart: Brown atrophy, not otherwise abnormal. Aorta: Moderate atherosclerosis with rupture at junction of transverse and descending portions of arch, and false aneurysm formation. Gastrointestinal tract: Patchy injection, but no other significant changes. Remaining viscera show no lesions of interest.
Microscopic examination.- Skin: Area from which specimen was taken is not known, possibly scrotum, because of abundant large sebaceous glands and corrugated surface. There are few definite alterations. The stratum corneum is loose and partially exfoliated. There is an excessive amount of pigment in some areas of the stratum mucosum, and rather numerous branching chromatophores in the superficial laver of the corium. There are no inflammatory changes, and the appendages are normal. The superficial vessels are collapsed and not thrombosed. In a few areas there is irregular arrangement of the epidermal cells with considerable hyperkeratosis. Trachea: Epithelium over the greater portion of the section is of the normal stratified ciliated type. The arrangement of the cells is orderly and there is nothing to indicate a previous injury. In one area, however, there is a superficial ulcer, where the epithelium is defective, and the base formed by dense scar tissue, in which the connective tissue cells have dense distorted nuclei. The subepithelial tissue is loose and contains many scattered wandering cells, predominently plasma cells. There are also large mononuclear elements, fibroblasts, and phagocytes filled with hemosiderin pigment. These cells, especially lymphoid and plasma cells, are present in numbers between the acini of the mucous glands. Lungs: There is dense organizing fibrinous exudate on the pleura, 2 mm. in thickness. The underlying tissue is collapsed, the septa thickened. There are well-organized plugs, with new-formed blood vessels and many pigment cells in some of the bronchi (see fig. 25) and alveoli. Here and there are dense masses of fibrin still present in the alveoli. These are invaded by scattered connective tissue cells, and covered often by flattened epithelium. Others are filled with vacuolated fat-containing epithelial cells. The interlobular septa are edematous, but organization is in progress. Myocardium, spleen, liver, and adrenals: No significant changes.
NOTE.- Death 51 days after exposure to mixed suffocant and vesicant geases. Death probably due to empyema, complicating the gas pneumonia. The trachea showed localized ulcers, but over large areas there is complete regeneration of ciliated epithelium, a point of great interest since it indicates that the squamous metaplasia is not a permanent nor inevitable effect of the gassing. The organizing bronchiolitis is also of interest.
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CASE 101.- C. D., No.- Pvt., 28th Inf. Died, November 21 at 5 p. m., at Base Hospital No. 116. Autopsy, 16l hours after death, by Lieut. E. S. Maxwell, M. C.
Clinical data.- October 2, admitted to Base Hospital No. 23. Diagnosis: Mustard-gas poisoning. Held for mental observation. October 27 transferred to Base Hospital No. 116. Eyes and head generally burned. Scattered râles in lungs. The patient is extremely active with intent of destruction, and requires restraint. Apparent mania due to toxic and exhausted state. November 5, leucocytes 18,200. The patient's condition mentally and physically is worse. Irregular temperature, at times reaching 104°. An area of dullness has developed over left lower and lower part of left upper lobes. No fluid obtained on tapping chest. November 21, respirations rapid and shallow, pulse feeble and irregular. Pulmonary edema and cardiac exhaustion. Died at 5 p. m.
Anatomical diagnosis.- Gas burns, mustard gas (slight): Healed tracheitis and suppurative bronchitis; organizing coalescing lobular pneumonia, left upper and lower lobes; peribronchial pneumonia, right upper lobe; fibrinopurulent pleurisy, bilateral (600 c. c. left, 200 c. c. right); acute lymphadenitis; regional lymph nodes; pulmonary edema, moderate; cardiac dilatation, right (moderate).
Detailed autopsy protocol not received.
Microscopic examination.- Trachea and large bronchus: No material preserved. Lungs: Pleura covered with thick fibrinopurulent exudate, which is evidently very recent since there is no organization in progress. There are no larger bronchi included in the section. The bronchioli are filled with purulent exudate, and their epithelia invaded by leucocytes. There is no necrosis or membrane formation. The most striking feature is a diffuse alveolar edema, partly fibrinous, in which are seen a few pigmented epithelial cells but very few leucocytes. Occasionally there are some spindle-shaped fibroblasts, but the organization is not wide-spread and is extremely early. There is edema also about the arteries and veins; the lymphatic spaces are widely distended with plugs of purulent exudate, which in places simulate small abscesses. Bronchial lymph nodes: Show no features of special interest.
NOTE.-There is a definite history of mustard-gas intoxication, with typical burns and very severe mental symptoms. The injury was received approximately 52 days before death. The pulmonary symptoms appear to have been of later development, and it is difficult to ascribe the histological lesions found in the lungs to the initial injury. The material is defective, no tissue from the trachea or larger bronchi having been preserved.
CASE 102.-A. K., 2181274, Corpl., Co. A, 355th Inf. Died, October 1, 1918, at 7.45 a. m., at Base Hospital No. 18. Autopsy No. 100, performed eight hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.-None available. There were numerous casualties from gas on August 7 and 8, on which days Co. A of the 355th Infantry was exposed to severe shelling with yellow, blue, and green cross shells. In all probability this is the correct date of gassing.
Anatomical diagnosis.- Gas burns of respiratory tract, with healing in larynx and trachea; intense bronchitis; extensive peribronchial pneumonia of all lobes except right middle, in large part organizing; multiple abscess formation, left lower lobe; localized areas of gangrene, left lower lobe; extensive recent lobular pneumonia; organizing fibrinous pleurisy, left lower lobe, slight; acute lymphadenitis of regional lymph nodes; slight general brown pigmentation of skin; anemia and emaciation marked.
External appearance.- The skin in general has a dull light brownish cast, most marked in the folds and over the lower abdomen. Eyes normal. External genitalia normal.
Gross findings.- Pleural cavities: Fibrous bands over the upper lobe on the right side, and a small amount of fibrinous exudate on the left. Right lung: Is voluminous and cushiony; the upper lobe shows solid patches posteriorly; the middle lobe is well aerated; the lower lobe is like the upper. The glands at the hilus are greatly enlarged, pulpy, edematous, somewhat injected. The vessels are normal. The bronchus shows marked injection and hemorrhage into the mucosa. In the lumen there is thin, viscid, green-tinged fluid. The bronchial cartilages cut with more than usual resistance. On section of the upper lobe, the posterior half shows patchy consolidation, the cut surface in the pneumonic areas being pinkish-gray to yellow. In places the consolidation is soft, coherent, pulpy, and yellowish.
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The finer bronchioles contain viscid pus. The larger bronchi show considerable thickening of their mucosa. Mesially, the tissue is well aerated and pink. The consolidation is in great part peribronchial; in places it is firm and gray, suggesting organization. The middle lobe on section is pink and air-containing. The bronchioles contain viscid purulent material. About some of them there is a small amount of pinkish-gray consolidation. The lower lobe is strikingly less affected than the upper, but presents in general a similar picture. The bronchial thickening and peribronchial consolidation are even more conspicuous. In addition, the bronchioli show slight but definite diffuse dilatation. This is especially marked at the periphery of the lobe, where the bronchioles are equal in size to ordinary good-sized bronchial branches. Left lung: The lower lobe is much more voluminous than average and in great part soggy. The upper lobe is of average volume. Over the lower lobe, tightly adherent, apparently organizing fibrinous exudate in small amount is present. The glands at the hilum, vessels, and bronchi similar to those on the right side. On section the upper lobe is aerated and pink in its upper portion; in the lower portion, especially posteriorly, there are numerous areas of consolidation similar in appearance to those on the right and associated with the bronchial branches. The lower lobe on section presents a striking picture. The consolidation involves the greater portion of the lobe. There are softened areas in the consolidated regions in many places. There is a dull-grayish appearance in the cavities and neighboring edematous lung. The odor is characteristically gastric. In the relatively uninvolved portions of the lobe there is considerable edema. In places, this has a yellowish tinge, suggesting much fat. The picture in this lobe is that of extensive peribronchial and lobular consolidation, with multiple areas of softening and abscess for- mation and considerable edema. Organs of neck-Larynx: Shows prominent streaky gray thickening of the mucosa. Trachea: Shows similar gray streaking and uniform thickening of the mucosa, also considerable old diffuse hemorrhage. Tonsils: Slightly enlarged and on the right there is a large crypt containing milky fluid. Heart: Normal, except for brown atrophy. Gastrointestinal tract: No significant changes. Remaining viscera show no lesions of interest.
Microscopic examination- Trachea: The lining is constituted by a rather dense granulation tissue which is devoid of epithelial covering, save for a few small islands of layered, nonciliated cells. There is a fairly profuse inflammatory infiltration; many of the cells show distorted nuclei and are difficult to identify. The mucous glands are atrophic, the few remaining acini being surrounded by dense accumulations of lymphoid and plasma cells. Some of the glandular cells show an interesting metaplasia into solid nests of squamous cells, like islands of carcinoma cells. The adjacent lymph nodes show areas of fibrosis. There is much scar tissue about the cartilage. Large bronchus: The epithelial lining is desquamated, save for a single row of adherent cells. In a few places, where the cells are still attached, they are seen to be arranged in an orderly way and to be distinctly ciliated. The submucous tissue has the character of a loose granulation tissue with many wide, thin-walled, blood vessels. There is dense cellular infiltration, composed largely of plasma cells. The mucous glands are atrophic and surrounded by fibrous tissue and inflammatory cells. The lumen of the bronchus contains bacteria and leucocytes, with exfoliated epithelial cells. Lungs: (a) The bronchi are represented by abscesslike masses of pus and bacteria, surrounded by granulation tissue which is very vascular and thickly infiltrated with lymphoid and plasma cells. Very few of these suppurative bronchi show remains of an epithelial lining, but in a few of them shreds of adherent, flattened, regenerating cells serve to identify these structures as dilated and infected bronchi. The dilatation is proven by compression of the adjoining alveolar spaces. The parenchyma is almost uniformly consolidated, but the alveolar contents vary. Many of the alveoli are filled with a homogeneous, granular or fibrinous coagulum; others contain in addition large, rounded, foamy, and apparently fat or lipoid containing epithelial cells. In some areas, especially about the bronchiolar abscesses, the alveolar exudate is undergoing organization; pale spindle cells invade the coagulum. The septa are cellular and thickened; there is an increased number of nuclei belonging chiefly to lymphoid cells. The alveolar capillaries are not congested. The alveolar epithelium in many places is actively regenerating, as shown by the deep staining and cylindrical shape of the cells. The pleura is smooth; the subpleural capillaries are wide and congested. The lymphatics also are dilated and filled with homogeneous coagulum. (b) In general, a similar picture. One bronchus shows exquisite epithelial metaplasia. It is surrounded by a thick wall of vascular, in places, hemorrhagic granulation tissue, and there is active organization of the exudate in the neighboring alveoli.
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(c) The section shows the same lesions as described above, but confined to the bronchi and peribronchial tissue. There is no generalized edema as in block (a). The dilatation of the pus-filled bronchi is very distinct. (d) There is a suppurative and necrotizing bronchitis, and an organizing peribronchial exudate as described in (a) and (b). In another portion of the slide the bronchioles are lined with intact ciliated epithelium, but there are local thickenings composed of vascular granulation tissue. There is also marked perivascular fibrosis. (e) The section shows an additional feature of interest, namely, several areas of gangrene, in which there is complete loss of nuclear staining, and all structures are involved. Another striking feature is an area in which the alveolar walls are greatly thickened by the accumulation of numberless lymphoid and plasma cells in the spaces between the alveolar epithelium and the e apillarv wall. In some there is extensive organizing pneumonia, the plugs being well vascularized. Skin: Two blocks, showing a thin epidermis composed of only two or three rows of cells, covered by a relatively thick loose keratin layer. The basal row of cells shows an excessive melanin production. There are many chromatophores in the superficial corium, and some granules of extracellular pigment. The subepithelial portion of the corium shows a hyaline edema. There is no inflammation. The capillaries are collapsed and empty. The sweat glands and hair follicles show no lesions.
NOTE.-The case illustrates admirably the late effects of severe mustard-gas lesions of the respiratory tract. The injury was quite certainly incurred n on August 7 or 8, so that the duration of life after gassing may be taken as 53 days. While the records of the Chemical Warfare Service show that the organization to which A. K. belonged was exposed to indiscriminate shelling on those days with yellow, blue, and green cross shells, it is probable that mustard gas was the principal agent concerned.
The skin lesions illustrate the persistent pigmentation. The lesions of the trachea were evidently very severe, the destruction even involving some of the mucous glands. There was little epithelial regeneration: what epitheliurn there was showed the customary metaplasia. There was a widespread suppurative and necrotizing bronchitis, which led to marked cicatricial thickening of the bronchi. In places there were abscesslike bronchiectases. The parenchyma about the bronchi showed an organizing pneumonia. but in some blocks there was an interesting chronic edema, with epithelial exfoliation and proliferation, and interstitial changes--lymphoid and plasma cell accumulation-in the alveolar septa. The picture in these regions resembles in many respects the pneumonia alba of congenital syphilis. Worth noting are the areas of gangrene.
CASE 103.- A. M., 2187370, Pvt., Co. F, 340th Inf. Died, on December 20, 1918, at 1.20 p. m., at Base Hospital No. 87. Autopsy No. 47, performed one and one-half hours after death, by Lieut. H. H. Robinson, M. C.
Clinical data.- October 23, gassed with mustard gas. No further details recorded. October 25, admitted to Base Hospital No. 87. On November 7, two weeks after gassing (?),developed bronchopneumonia, vhich never entirely cleared up. Illness marked by profuse mucopurumlent expectoration. Died in collapse on December 20, a few minutes after aspiration of the chest.
Summary of gross lesions.- There is brown pigmentation of skin of knees and thighs and of scrotum. Both pleural cavities show firm adhesions. The lungs are voluminous and pink. Scattered through all lobes are numerous areas of grayish consolidation. In the left lung, in both lobes, there are numerous smooth cavities, varying from a pea to a walnut in size. Circulatory organs: Normal.
Additional note, dictated from preserved Army Medical Museum specimen of left lung:
"Upper lobe: The pleura over a localized area in lower portion of the lobe is thickened with organizing fibrinous exudate; elsewhere smooth. Over the lower lobe there are a few delieate fibrous tabs. On section, the lung is generally dry and air-containing. About the bronchi and vessels, however, there are firm, yellowish-white zones of consolidation, becoming
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more translucent at the periphery. About these again, there are irregular patches darker in color, which appear to be areas of organizing pneumonia. Beneath the thickened pleural patch in the upper lobe there is a group of large bronchiectasis with smooth walls. These are surrounded by opaque, grayish-yellow patches. The larger bronchi are lined with smooth, pale mucosa which in places has a scarred appearance."
Microscopic examination- Lung: A block taken through wall of the bronchiectasis shows that the cavity is bounded by granulation tissue, remarkable because of the great number of large foamy (lipoid containing?) cells included in it. Adherent or lying loosely upon the surface of the granulation tissue are many large multinucleated giant cells. Whether these have arisen from remains of the epithelium or are of the nature of foreign body giant
FIG. 38.- Case 103. Mustard-gas burn, 58 days' duration. Lung. Low-power drawing through bronchiectatic cavity. Peribronchial and periarterial fibrosis.
cells can not he made out. The lung tissue about the cavities is collapsed and shows the usual interstitial fibrosis, with occasional alveoli lined by cylindrical cells. (Fig. 38.) There is much epithelial desquaination, and fibrous thickening of the septa in the better aerated regions. Some of the air spaces contain organized vascular plugs. Another section was taken through a patch of organizing pneumonia. There is histologically an exquisite interstitial and organizing process. (See fig. 21.) Especially interesting are the changes in the apparently regenerated epithelium. The band of hyaline necrosis, so frequently found lining ductus alveolares and alveoli in the acute cases, as well as in the primary influezal pneumounias, is still very distinctly to be recognized; it is, however condensed hyaline, and stains very intensely with eosin. In many places it is being invaded and replaced with connective tissue, the nuclei of the cells tending to range themselves parallel to the wall of the
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air space. The bronchioli in this section are for the most part lined with ciliated epithelium, but this is thrown up into corrugated folds, and many of the small bronchi are collapsed, and their lumen reduced to a narrow cleft. Acute inflammatory changes are still present in places.
NOTE.- A case of mustard-gas poisoning in which death occurred on the 58th day after exposure. The interpretation of the case is complicated by the fact that pneumonia, according to the brief clinical note, did not develop until two weeks after the gassing; there is no reference to previous respiratory symptoms. It is conceivable, therefore, that the interesting residual lesions in the lungs-interstitial and organizing peribronchial pneumonia, bronchiectasis, etc.--may have resulted from a primary influenzal pneumonia rather than from the direct gas injury. It is unfortunate that there is neither a description of nor material from the trachea available.
CASE 104.- M. L. A., Number-, Pvt., Co. L, 101st Inf. Died, June 11, 1918, at 11.15 p. m., at Base Hospital No. 18. Autopsy, 10 hours after death, by Lieut. B. S. Kline, M. C.
Clinical data.-March 31, gassed with phosgene at 2 a. m. Following this, shortness of breath and headache with vomiting. June 2, admitted to Base Hospital No. 18. Patient conscious, but stuporous and cyanotic. June 3, oxygen therapy begun and he was bled 325 c. c. The heart sounds at this time were clear and regular; tubular breathing was present over a small area at the left base. On June 4 and 5, his general condition seemed to improve. On the 6th, however, diffuse areas of consolidation were made out over the left lower chest. He also developed diarrhea on this day. June 8, patient was definitely weaker and very dull. Pulse full and fast. June 10, Cheyne-Stokes respiration, with long pauses. Pulse irregular and weaker. June 11, small area of consolidation in the right lung. Patient very restless, rapidly became weaker. Venesection, 600 c. c. Died at 11.15 p. m. Temperature, from admission on June 2 to his death, was never below 100.2 ?. Maximum, 104.8 ?, on afternoon of June 4. Pulse, 100 to 128. Respirations, 28 to 44.
Anatomical diagnosis.- Acute pharyngitis, esophagitis, laryngitis, and bronchitis, following phosgene (?) inhalation; extensive bronchopneumonia, involving all lobes; acute lymphadenitis of regional lymph nodes; acute colitis; pulmonary edema, terminal; cardiac dilatation, more marked on the right side.
External appearance.-No cutaneous lesions. Skin has a muddy color, but there is no pigmentation recorded. Conjunctiv ae and other mucous membranes pale. Slight clubbing of fingers and toes.
Gross findings.- Pleural cavities: Fibrous adhesions are found over the lateral and pos- terior surfaces of all lobes, especially the middle and lower on the right side. In the left pleural cavity are a few cubic centimeters of clear fluid, and a few adhesions binding the under surface of the lobe to the diaphragm. Right lung: Weighs 840 grams. Left lung, 1,020 grams. All lobes are voluminous, cushiony, soggy, and solid. The pleura is thickened in the regions showing the fibrous adhesions mentioned above; elsewhere it is thin and delicate. The glands at the hilum considerably enlarged, pulpy, edematous and injected. The bronchi show marked diffuse injection, with suggestion of ulceration of the epithelium. In the lumina there is blood-tinged thin viscid fluid. On section of all lobes a dull gray red surface presents mottled with pinhead to grape-seed sized dull reddish-yellow areas. The surface is moist, and on pressure, a considerable amount of thin blood-tinged fluid exudes. When this is wiped off on the knife, a considerable portion of each lobe shows a dull, slightly granular, reddish-gray consolidation, which at first suggests a lobar type, but on close inspection, relatively few alveoli here and there are found to be involved. Although the tissue floats in water, the pseudo-lobar consolidation is very extensive and the tissue is friable. In the finer bronchioles, the exudate is perhaps slightly more viscid than in the larger branches. The two types of consolidation are more marked on the left side, and particularly in the left lower lobe. where some of the smaller areas are firm and look quite like miliary tubercles. In the other lobes, some of the smaller solid areas have a similar appearance. There is little hemorrhage anywhere. The blood vessels contain large currant-jelly clots. Organs of neck: Larynx and trachea show moderate diffuse injection of the muscosa, with adherent fibrino- purtilent exudate here and there in small amount, especially in the region of the true vocal
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cords. The process continues over the brim and involves the upper portion of the esophagus, pharynx, and base of the tongue. The trachael and cervical lymph nodes are moderately to considerably enlarged, injected, pulpy. Tonsils: Small and scarred. Heart: Weighs 360 grams; right auricle and ventricle moderately dilated and the tricuspid and pulmonary rings considerably stretched. Myocardium of left ventricle pale, moist, and greasy. Gastrointestinal tract: Stomach normal. In the cecum there is patchy injection of mucosa, and in the transverse and descending colon there is, in addition to the injection, a small amount of adherent exudate on the surface of the mucosa. The mesenteric glands are slightly enlarged, soft, and pale. Remaining viscera show no significant changes.
Microscopic examination: Pharynx or upper esophagus: The mucosa is continuous except over a small area where there is superficial ulceration, with a little adherent exudate and localized edema and inflammatory infiltration. Trachea: No section. Lung: (a) Bronchi are lined with multiple layers of epithelial cells, the superficial layer of which is composed of flattened nonciliated cells. The mucosa is thrown into rugae , there being a granular coagulum beneath it. The lumen contains blood and granular material, with very few leucocytes. Throughout the parenchyma the alveoli are filled with red blood cells, granular coagulum, and only here and there are there denser collections of leucocytes, polymorphonuclears, and mononuclears. In some air spaces are numerous foamy exfoliated epithelial cells. The most striking feature is the almost universal regeneration of alveolar epitholium; in places the proliferating cells form solid nests or sprouts almost completely filling the air spaces. Individual hypertrophic cells are found, and mitoses are fairly numerous. The septa are edematous, contain more than the normal number of leucocytes, chiefly large and small mononuclears. There are stout fibrin threads in the capillaries. A small artery in the section contains a well-formed recent thrombus. (b) There is a somewhat more acute process, with purulent bronchiolitis and inflammation of the ductus alveolares, and hemorrhagic edema in the surrounding lung. Epithelial regeneration is less marked than in the previously described section. (c) In addition to the features above described, there is a striking hyaline necrosis of the alveolar walls. Where the epithelium is being regenerated, it is often separated from the alveolar capillary by edematous tissue in which are proliferating fibroblasts and large and small mononuclear cells. No bacteria are found in Gram-stained sections. Liver, spleen, myocardium, adrenals, and kidneys show no lesions of special interest.
Bacteriological examination.- Smears made of the exudate from the larynx show numerous lanceolate diplococci, Gram-positive; also numerous biscuit and rounded cocci in groups. Gram-positive and a moderate number of intracellular and extracellular Gram-negative bacilli of small size. Smear from the bronchus shows moderate numbers of intracellular Gram-positive and negative cocci and diplococci, and groups of small Gram-negative bacilli. Smear from a small consolidated area shows numerous intracellular Gram-negative baccilli. Smear from the large consolidated area shows a small number of Gram-positive diplococci and a few groups of Gram-negative small bacilli. Cultures from the larynx shows innumerable staphylococci. Cultures from bronchus: Staphylococci and Gram-negative bacilli, tiny and of good size. Culture from small consolidated area shows predominating organism a staphylococcus. From the large consolidated area, minute Gram-negative bacilli and a few staphylococcus colonies.
NOTE.- Aside from the superficial erosions of the pharynx and larynx, there is nothing to suggest that the lesions are due to the toxic effect of gas, either mustard or, still less, to a suffocative gas such as phosgene. The history does not state whether symptoms persisted after gassing until admission to Base Hospital No. 18, two months later, nor are additional data as to the character of the gas available. The pulmonary lesions are those of influenzal pneumonia as seen in the fall and winter pandemic, and would coincide with an onset about June 2. Whether a previous gassing determined the severity of the pulmonary lesions at a time when the prevailing type of the disease was mild and rarely followed by pneumonia, remains uncertain.
CASE 105.- W. K., 2566932, Corpl., Co. A, 107th Engineers. Died, October 21, 1918, at 3 a. m., at A. R. C. M. Hospital No. 5. Autopsy No. 92, performed six hours after death, by Lieut. H. W. Hundling, M. C.
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Clinical data.- On August 5, patient was exposed to shelling with yellow, blue, and green cross shells, while his detachment was advancing through valleys in rolling country (sector of 64th Brigade). On August 12, there was bleeding from the nose and lungs. September 15, admitted to A. R. C. M. H. No. 5. September 19, pulse bad. Chest full of râles; profuse expectoration; sputum negative for tubercle bacilli; streptococci and pneumococci in cultures. Daily temperature of 101°, respirations 24, pulse 104. Marked emaciation.
Summary of gross lesions.- No external lesions. Marked emaciation. Pleural cavities show friable adhesions. Lungs firm posteriorly, crepitant anteriorly. Cut surface moist; scattered through all lobes are areas of peribronchial thickening, coalescing to form broad areas of consolidation. Circulatory organs normal. Organs of neck. (Note dictated from preserved Army Medical Museum specimen). The specimen consists of tongue, trachea, and larynx preserved in formalin. The tongue and pharynx show no changes. The inferior surface of the epiglottis shows a large depressed brown patch, which is present also along the tracheal surface of the cords. It is not clear whether this may not be an artefact due to drying. The upper part of the larynx shows a thin, smooth lining, with irregular pearly scarred areas. Further down, the tracheal wall becomes rough, sandy and congested, and covered here and there with little flakes of necrotic exudate. Along the right border, about 2 cm. above the bifurcation, are two punched-out ulcers which extend through the eroded cartilages. They are from 2 to 3 mm. in diameter.
Microscopic examination.- Blocks were taken from preserved Army Medical Museum specimen. Epiglottis: The cartilage is covered on both sides by dense layered squamous epithelium, like that of the pharynx or esophagus. There is no pigmentation, and the brown color noted in the specimen was probably due to drying. The subepithelial tissue contains dense collections of lymphoid cells, but there are no other evidences of inflammation. The glands are normal. Trachea: Section taken at level of thyroid. Here too the epithelium is squamous and devoid of cilia. It is quite thin, consisting of only three or four rows of cells. There is no keratinization of the superficial cells. The subepithelial tissue is very dense and scarlike, and contains few blood vessels. Some of the glands are normal, others are atrophic, still others are distended with secretion. The glands are entirely missing over large areas. Section taken through small ulcers shows the following: At the margin, the epithelium is thickened and squamous. The ulcer is quite sharply defined, and extends clown to the cartilage, and even undermines it. The base is composed of dense scar tissue infiltrated with lymphoid cells. Large bronchus: Completely filled with a fibrinopuruilent plug. The lining consists of loose granulation tissue. There is much edema, hemorrhage, and inflammatory infiltration of the bronchial wall.
Bacteriological examination.- B. influenzal in culture from lung after death.
NOTE.- After 77 days, marked changes were found in the trachea. The epithelium was converted permanently into a dense stratified layer composed exclusively of squamous cells, watch, however, had not become keratinized. The subepithelial tissue was dense and scarred, the mucous glands atrophic or wholly lost, and the smooth muscle fibers had disappeared. There were also several deep localized ulcers in the lower portion of the trachea. In the large bronchus taken for examination, there was no regeneration of the epithelium, and the lining granulation tissue lay exposed.
It is probable that these lesions of the upper respiratory tract are the late results of exposure to mustard gas. although there is no reference to cutaneous burns in the history, and the records of the Chemical Warfare Service show that the patient had been subjected to shelling with mixed types of gas.
CASE 106.-C. M., No.-, organization (?), rank (?). Died, December 8, 1918, at U. S. A. General Hospital No. 19, Oteen, N. C. Autopsy by (?).
Clinical data.-The following is a verbatim transcript of the history which accompanied the preserved museum specimen. No further information in regard to the case is available. "Enlisted September 10, 1917. June 20, 1918, to trenches. June 24, hit with mustard gas and blinded for four days. He had black spots all over and could not see well for six weeks. Throat quite sore. Has been in hospital ever since. Pleurisy August 15.
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Walked into U. S. A. General Hospital No. 19, Oteen, N. C. with slight cough and expectoration, dyspnea, and occasional pains in left lumbar region. Looked well. Right side, dullness above third rib, and practically throughout posteriorly. Moist r ales from fifth rib and sixth dorsal spine down. Left side, markedly diminished expansion; dullness above fourth rib from eighth dorsal spine up. Moist subcrepitant râles ninth to fourth dorsal spine. Slight pretibial edema. Cardiac fibrillation and pulse deficit. Fluoroscopy, apices cloudy and do not clear on coughing. Right hilus shows very dense shadow to diaphragm. Tuberculosis, pulmonary, chronic, oldest and most extensive in upper left lobe. Abnormal densities at both bases.
"Autopsy.-Fairly well nourished. Pink adhesions which completely obliterate right pleural cavity. Dilatation of right heart, slight. Liver, hypertrophied, 12 cm. below costal margin in midline. Pleural adhesions on left at base and posteriorly. Greenish pus in trachea. No gross changes in kidneys. In small bowel are a number of dark areas several feet in length, and slight ulcerations are noticed in several parts, In the neighborhood of the cecum these areas are more marked. Appendix slightly inflamed. Urinary bladder, slightly ulcerated on the superior surface."
The following additional note was dictated upon receipt of the Army Medical Museum specimen:
The specimen consists of formalin fixed slabs of the right lung passing through the three lobes. The pleura is covered with tabs of fibrous adhesions. The upper lobe, in its posterior two-thirds, is of translucent texture, very slightly air-containing; only here and there a few well-aerated patches. Near the hilum there is a cross section of a bronchus 3 mm. in diameter, completely filled with a fibrinous plug. This is surrounded by opaque creamy white airless tissue from which radiate fibrous strands to join the small interlobular septa. The section passes also through a number of smaller bronchi plugged with exudate, and with thickened walls composed of dense opaque white tissue. Lower lobe: A large portion consists of very firm white or yellowish-white opaque tissue, absolutely airless, in which bronchi and blood vessels seem to be largely obliterated. Between these patches, the architecture of the lung is still recognizable, but the alveolar walls are thick and the air content much diminished. The smaller and larger bronchi are extremely thick-walled. The lumina are narrowed and their mucosa appears rough and eroded. Near the posterior border, there is an irregular, but smooth-walled cavity, the lining of which is blood stained. The communication of this with a bronchus can not be demonstrated because of the thinness of the specimen. The middle lobe shows only moderate bronchial thickening and is air-containing. A group of lymph glands at the hilum appears to be completely caseated, although they are firmer than ordinary tuberculous glands. In no portion of the lung are there seen definite tubercles, although the gross resemblance of certain areas to diffuse tuberculous caseation is very close. (Fig. 39.)
Microscopic examination.-Lung: (a) The block is taken through the area of gelatinous edema at the base of the upper lobe, and includes the edematous interlobar septum. (Fig. 40.) The alveoli are wide and almost without exception, distended with a homogeneous coagulum, in which are scattered large rounded alveolar cells containing black pigment. The alveolar septa are compressed and there is very little blood in the capillaries. Such attached alveolar cells as can be recognized seem hydropic and project into the alveolus. There are many cells with pale distorted nuclei, probably fibroblasts. The section includes two small bronchi. The larger of these has an irregular slit-like lumen like that of an intracanalicular fibroma, which is filled with pus. The epithelium is beautifully ciliated, showing no metaplasia. The wall is tremendously thickened by a rather dense and not very vascular granulation tissue in which are numerous lymphoid and plasma cells. These cellular infiltrations extend into the adjacent alveolar septa. The interlobar septum is edematous forming a broad pink-staining band. Under the high power, a delicate thready reticulum can be distinguished. From the margin, there is an ingrowth of delicate blood vessels with pale swollen endothelium. Scattered through the edematous zone, there are groups or little colonies of large rounded cells with very pale nuclei, which are identical with the proliferating pleural mesothelium, and are probably derived from it, having migrated into the plasma clot after the fashion of a tissue culture. Here and there these cells are multinucleated. There are also scattered small lymphoid cells, but very few fibroblasts and it
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can not be said that the edematous tissue is becoming organized. (b) The block is taken from the anterior and lower portion of the upper lobe, passing through the bronchus described in the gross. (Fig. 41.) The exudate which fills the lumen with a complete plug is composed chiefly of polymorphonuclears, well preserved at the periphery, fragmented at the center. The bronchus is lined by a very thick wall of granulation tissue, the epithelium having been quite destroyed. This granulation tissue is remarkable because of the very dense plasma cell infiltration. In many fields, the plasma cells completely fill the interstices
FIG. 40.- Case 106. Lung. Section (a) Edema of alveoli and interlobular septum
between the sprouting capillaries. Further out, the granulation takes on rather the character of scar tissue, and extends in the form of radiating strands into the neighboring parenchyma. Here the alveoli are widely separated, and their lumina irregularly distorted. They are lined with columnar epithelium, and contain exfoliated cells. Often the wall of the alveolus is thrown up in papillary folds. Although the bronchus is fully 5 or 6 mm. in diameter, there are no remains of cartilage, muscular wall or mucous glands, all of these structures having apparently been replaced by granulation and scar tissue. Between the fibrous
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strands radiating from the bronchus, the alveoli are very large, and filled with edematous coagulum and exfoliated epithelial cells. The septa are infiltrated with lymphoid and plasma cells. Smaller bronchi in the section are lined with intact epithelium, but they appear collapsed into irregular slits. The small pulmonary arteries are surrounded by broad bands of scar tissue, from which, also, strands extend into the neighboring parenchyma. (c) The block is taken from the opaque whitish tissue in the anterior portion of the lower lobe, which grossly resembled tuberculous caseation. Microscopically, the tissue proves to be a rather avascular granulation tissue which, over large areas, has completely obliterated the normal lung structure. There is a remarkably dense plasma cell infiltration, these comprising practically the only type of wandering cell in many fields. In areas where the alveolar
FIG. 41.- Case 106. Lung. Section (b) through cavity in the upper lobe
structure is still discernible, the septa are thickened and infiltrated. As in the other section, the arteries are surrounded by broad bands of connective tissue, and there is marked interlobular fibrosis. (Fig. 42.) (d) Block taken through a group of greatly thickened bronchi, surrounded by scar tissue, near the hilum of the lower lobe. The lumina are narrowed and their wall thrown up into corrugations. The epithelium is high, stratified and beautifully ciliated, showing no squamous cell metaplasia. The walls of the bronchi are enormously thickened by dense scar tissue, thickly infiltrated with plasma cells. (Fig. 43.) The mucous glands are preserved, and are in hypersecretion. The cartilages likewise are still present and show no degeneration. The surrounding pulmonary tissue shows the same changes
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that have been described in previous section. A large branch of a pulmonary artery presents interesting lesions. There is marked intimal thickening by a loose edematous (fatty?) fibrous tissue, with corresponding thinning of the muscular coats. The adventitia of this and of all the smaller arterial branches is tremendously thickened. (e) Block taken through the wall of the supposed bronchiectatic cavity in the posterior portion of the lower lobe. Microscopically, there is no certain evidence that this cavity is a bronchiectasis, since there are no remains of the normal bronchial structures. The wall is formed simply by the irregularly thickened septa of the adjacent lung tissue, the rounded walls projecting freely into the cavity, which therefore has neither a continuous epithelial lining, nor one composed of
FIG. 42.- Case 106. Lung. Section (c) taken from opaque whitish tissue in anterior portion of lower lobe. Lung structure over large areas obliterated by poorly vascularized granulation tissue, tensely infiltrated with plasma cells
granulation tissue. The cavity appears to he simply a defect in the lung substance, in all area which shows an extreme interstitial fibrosis of the type described. The exact way in which this cavity has been formed is not clear. In only one portion is there a definite lining of granulation tissue with tangential compression of the neighboring alveoli. (f) A section taken from the upper lobe, in an area of relatively normal lung tissue, ill which, however, there were a few thickened bronchi and blood vessels. Microscopically, the lesions resemble those in block (a), save that there is less alveolar edema. The only new feature is a rather marked emphysema. Worth noting also are the lymphoid follicles with definite germinal centers, which are seen in the scar tissue about the bronchi. Primary bronchus: The
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epithelial lining is intact over most of the circumference, and is composed of several layers of cells, the superficial row normally ciliated. The section, however, passes through a small patch of squamous epithelium, continuous on either side with the ciliated epithelium, but somewhat thicker. In this area there are numerous mitotic figures. There is persistent metaplasia in some of the ducts of the mucous glands, while others are invested with normal cylindrical epithelium. The submucosa is thick and dense, and filled with lymphoid and plasma cells in great numbers. The acute inflammatory process has disappeared, and polymorphonuclears are found only on the surface, or between epithelial cells. The mucous glands are in active secretion, and in no wise abnormal. The cartilages also are unchanged.
FIG. 43.- Case 106. Lung. Section (d), through thickened bronchi at hilum of lower lobe
The adjoining lung tissue appears compressed. Secondary bronchus: In places denuded of epithelium, the wall being formed by a dense cellular and not very vascular granulation tissue. Where epithelium is present, it is for the most part quite normal in structure, the cilia being very distinct. Here and there, and especially about the openings of the mucous ducts, the epithelial cells are heaped up irregularly and the superficial cells are not differentiated. That the denuded areas are really ulcerated, and not merely exposed by the post- mortal exfoliation of cells, is indicated by dense plasma cell infiltration. Bronchial lymph node: The changes are surprisingly slight, although the gland as a whole appears hyper- plastic, and is strikingly free from pigment. There is much periglandular fibrosis, and a branch of the pulmonary artery included in the section shows a marked intimal fibrosis.
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NOTE.- The case is one of particular interest. Death occurred 167 days, or approximately five and one-half months, after gassing with mustard-gas. The respiratory lesions found at autopsy maybe regarded without qualification as the late results of this injury. Clinically, the patient presented pulmonary symptoms and physical signs closely simulating those of chronic pulmonary tuberculosis, and this diagnosis was made during life on the basis of the fluoroscopic findings, although there is no record of tubercle bacilli having been found in the sputum
CASE 107.- F. S., Pvt., Co. A., 126th M. G. Bat. Died, May 16, 1919, at base hospital, Camp Lee, Va. Autopsy No. 49, eight hours after death, by Lieut. Charles H. Manlove, M. C.
Clinical data.- Patient was gassed October 14, 1918, on the Toul sector, with mustard gas. He was not burned much on the skin, but was rendered unconscious for a short time. Taken to the field hospital and from there transferred to Base Hospital No. 45, then to Base No. 210, and then to Base No. 87. Later sent to Camp Lee, where he arrived about April 6, 1919. At the time of the gas attack, the gas mask was rendered useless as the can was broken from the contact. As gas entered the mask, he began to vomit and then the mask came off entirely, and he inhaled the pure gas. The patient was very much emaciated, cyanotic, and markedly dyspneic. His breathing was better at night, allowing him to sleep very well. He coughed continuously and expectorated considerably. Had sense of constriction in the larynx. Physical examination of the chest showed harsh breath sounds, showers of moist râles, vocal fremitus decreased over left base. Heart rate was regular.
Anatomical diagnosis.- Stricture of trachea, following gas injury. Tracheotomy. Chronic tracheitis. Subcutaneous emphysema. Chronic bronchitis. Passive congestion of viscera
External appearance.- Well developed, poorly nourished. No ocular or cutaneous lesions. Subcutaneous tissue of the entire neck and upper third of sternum are emphysematous. In the midline of the neck, over the thyroid there is a recent operative wound, measuring about 3.5 cm. in length, with a central opening, which extends into the trachea, from which a mucopurulent material exudes.
Gross findings.- Trachea: Vocal cords and mucous membrane above the trachea normal. Mucous membrane just below the vocal cords show marked thickening, which extends to the bifurcation of the trachea, the lumen throughout being markedly diminished in diameter. This is especially evident over an area of 3 to 4 cm. in length, beginning about 3 cm. below the stricture. Mucous membranes of trachea and bronchi are reddened and coated with a thick mucopurulent material. Lungs: Are rather large, and crepitate throughout, and crackling is present in some places. The pleura covering the lungs is spotted with black pigment over its entire surface, giving the surface a blackish gray appearance. After preservation in Kaiserling, section shows lung tissue to have been air containing throughout. Bronchi contain plugs of mucopurulent material. Apices appear slightly more compact than the remaining portion of lungs. Heart and the remaining viscera are normal. (Fig. 44.)
Microscopic examination.- Block 1. Trachea: The section is taken longitudinally through the scarred stenotic tissue below the thyroid. There is a thin layer of stratified nonciliated epithelium in places, but the greater part of the submucosa lies exposed. It is converted into dense scar tissue, 2 to 3 mm. in width. In the depths are groups of mucous glands and ducts, some dilated, other atrophic, and surrounded by lymphoid and plasma cells. There is intracellular hemosiderin in the more superficial portion of the tissue. The cartilages are intact. Secondary bronchus: Block 2. The epithelium is partially exfoliated, but normally ciliated, where still preserved. There is congestion of the bronchial wall, but little or no inflammatory change or scarring. The mucous glands are numerous and in active secretion. Lung: Block 3. Some of the alveoli are collapsed, others filled with edema fluid, still others emphysematous. There is excessive deposit of anthracotic pigment with small areas of fibrosis where the pigment is most abundant. The septa are a little thickened, and there is definite fibrosis of the perivascular connective tissue and of the interlobular septa. The small bronchioles are filled with columnar ciliated epithelium and contain no exudate. Many are corrugated and appear contracted or collapsed, others are slightly dilated. Block 4. Emphysema and anthracosis. Block 5. Somewhat more congested. No other significant changes.
Bacteriological examination.- Cultures from bronchial contents show staphylococcus.
NOTE.- Death six months after exposure to concentrated mustard-gas. This resulted in little permanent damage to the lower respiratory passages,
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FIG. 44.- Case 107. Late stricture of trachea showing mustard-gas inhalation
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but produced a marked cicatricial stenosis of the trachea requiring tracheotomy. Epithelium still present in these scarred areas is of the squamous nonciliated type.
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(1) McNeal, W. J.: The Influenza Epidemic of 1918 in the American Expeditionary Forces in France and England. Archives of Internal Medicine, Chicago, III., 1919, xxiii, No. 6, 657.
(2) Report: Fifty Necropsies of Phosgene Cases, by Maj. R. H. Wilder, M. C. On file, Historical Division, S. G. O.
(3) Ricker, G.: Beitrage zur Kenntnis der Toxischen Wirkung des Chlorkohlenoxydgases (Phosgens). Sammlung Klinischer Vortr age, Leipzig, 1919, xiii, n. F., No. 226-260, 727.
(4) Dunn, J. S.: Report on Histological Examination of Human Tissues from Cases of Poisoning by Dichlorethylsulphide. Reports of the Chemical Warfare Medical Committee (British), April, 1918, No. 2, 40.
(5) Meek, W. J., and Eyster, J. A. E.: Experiments on the Pathological Physiology of Acute Phosgene Poisoning. American Journal of Physiology, Baltimore, Md., 1920, xxxi, No. 2, 303. (6) Pappenheimer, A. M., and Vance, M.: The Effects of Intravenous Injections of Dichlor-ethylsulphide in Rabbits, with Special Reference to its Leucotoxic Action. Journal of Experimental Medicine, New York, 1920, xxxi, No. 1, 71.
(7) Lynch, V., Smith, H. W., and Marshall, E. K.: On Dichlorethylsulphide (Mustard Gas). The Systemic Effects and Mechanism of Action. Journal of Pharmacology and Experimental Therapeutics, Baltimore, Md., 1918, xii, No. 5, 265.
(8) Le Count, E. R.: Disseminated Necrosis of the Pulmonary Capillaries in Influenzal Pneumonia. Journal of the American Medical Association, Chicago, Ill., 1919, lxxii, No. 21, 1519.
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