Part 8

Twelve hundred cubic centimeters of fibrinopurulent fluid were found in the right pleural cavity and the visceral and parietal pleura had a thick, yellow coat of fibrin. The right lung was voluminous, retained its shape on removal, and weighed 1,800 grams. The lower two lobes were consolidated and the upper lobe was atelectatic. On section the latter was slightly congested, but not consolidated. The lower two lobes were fairly smooth and grey, mixed with red areas, and exuded thick, sanguinous pus. They also showed several necrotic areas in the central portion and, in some instances, cavities 1 centimeter in diameter filled with sanguinous pus had formed. The bronchi contained the same material, and on its removal a deep red mucosa was exposed. The left lung showed some fibrous pleurisy over its lateral, posterior, and diaphragmatic surfaces. There was a firm, puckered scar at the apex. The lung crepitated throughout, and on section was essentially normal except for moderately intense injection of the bronchi. The hilic nodes were enlarged, soft, succulent, moderately injected, and pigmented. The trachea was pale, but was covered by a mucopurulent exudate. The right side of the heart was moderately dilated. The spleen was not enlarged, but was softened and congested. The liver was pale, slightly decreased in consistency, and congested. The kidneys and adrenals showed cloudy swelling. The gall-bladder contained several stones, had a thickened wall, and was bound to the pylorus by firm, fibrous adhesions.

Microscopic examination of the lung showed the alveoli filled with an acute inflammatory exudate in many stages of degeneration and hyalinization (Fig. XLII). Abscesses were frequent, but were for the most part small. A similar necrotic mass was contained in the bronchi. There were, however, features of the microscopic picture that outweighed those already described. The alveolar and bronchiolar exudates were everywhere being invaded by a young granulation tissue, rich in fibroblasts and capillaries. Mononuclear cells abounded in the new tissue. Even more striking than the mesodermal new growth was the epithelial proliferation which could be seen in many areas. It not only attempted to cover the denuded bronchial surfaces, but stretched over masses of exudate and granulation in the lumina and extended in tongue-like projections for a considerable distance into the surrounding lung tissue (Fig. XLVIII).

FIG. XXVII. AUTOPSY NO. 115. HERE THE HEMORRHAGIC CONSOLIDATION INVOLVES THE DEPENDENT PORTION OF THE LUNG; CONTRAST THIS WITH THE EDEMATOUS AND EMPHYSEMATOUS UPPER LOBE. ]

FIG. XXVIII. AUTOPSY NO. 118. THE CONSOLIDATION IS GREY IN COLOR AND LOBAR IN TYPE. IN THE CENTER OF THE HEPATIZED LOBE THERE IS A LARGE HEMORRHAGE. THE UPPER LOBE IS CONGESTED AND EDEMATOUS. ]

Cultures of the blood, lung, and pleural fluid showed gram-positive, bile insoluble diplococci which formed chains, and morphologically and culturally were Streptococcus mucosus capsulatus.

These two examples differ widely in the distribution of the pulmonary involvement. They show the acute inflammatory process persisting and complicating the attempt at repair, which manifests itself, not only by the formation of granulation tissue, but also by extensive epithelial proliferation.

Still a third type of chronic lesion is manifested in Autopsy No. 209, where the necrotizing and organizing process in the pulmonary parenchyma is associated with typical saccular bronchiectatic cavities.

Autopsy No. 209.

A white woman, aged 55 years, was admitted to the New Haven Hospital complaining of weakness and ill health following pleurisy. For the past seventeen years she had suffered from a gradually progressing arthritis, which had resulted in marked deformity and disability. Five weeks before admission she became ill with chills, fever, cough, and pain on both sides of the chest. Thereafter, her general condition had gradually grown worse.

Physical examination showed a markedly emaciated white woman with a high degree of arthritis deformans. Dullness and fine râles were present at the left apex. The temperature was but slightly elevated until three days before death, when it rose to 101°F. and slight dullness developed at the right base with bronchial breathing and fine râles. The white blood count, which on admission had been 9,200 cells per cubic millimeter, rose to 15,000 per cubic millimeter. She died after a seven-weeks’ illness.

At necropsy, with the exception of the joints, little of interest was found outside the thoracic cavity. On the posterior and diaphragmatic surfaces of both lungs fibrous adhesions were present binding the visceral to the parietal pleura. The right lung was moderately voluminous and grey in color over the upper lobe, but had darker red areas over the surface of the lower lobes. Patches of increased consistency were found in the lower part of the upper lobe, in the middle lobe, and at the base. On section there was a slight, red, serous exudate. The surface over the more solid areas was somewhat translucent, grey or light red, and was firm and not friable. The bronchi of the lower lobes were conspicuous, and at the extreme base so dilated as to give almost a honeycombed appearance. From them yellow pus exuded. The left lung was less voluminous and showed some increase in consistency throughout. In the lower lobe this was more uniform, but the upper had a shotty feeling. On section the upper lobe showed many hard or caseous nodules, with occasional patches of grey, gelatinous pneumonia. One small cavity was present about 3 centimeters from the apex. The lower lobe showed no gross evidence of any tuberculous process. Many pseudotubercles projected from the red surface, but from each pus could be expressed exposing the slightly congested wall of a bronchiole. At the extreme base two small cavities filled with yellow pus were present (Fig. L).

Sections from the left upper lobe showed, microscopically, both a chronic and acute tuberculous process. Tubercles with a definite wall were present, but there were also large areas of caseation. The tissue between showed interstitial organization with mononuclear infiltration and occasional groups of leucocytes. The bronchial epithelium exhibited no marked change, but the bronchi were filled with pus cells.

Sections from the left lower lobe and from the right lung showed both necrotization and organization. The alveoli contained an exudate, fibrinous, serous, and hemorrhagic, but predominantly leucocytic. There was slight necrotization of alveolar walls in some areas with infiltration of leucocytes in them and in the interstitial tissue. Several sections showed a marked degree of interstitial organization (Fig. XLVI). The bronchi were filled with a purulent exudate which sometimes involved the walls to form a peribronchial abscess. The walls of other bronchi showed great thickening with infiltration of both mononuclear cells and leucocytes, and many saccular dilatations were found (Fig. XII).

The post-mortem blood culture showed a small, gram-negative, hemoglobinophilic bacillus (B. influenzæ). Cultures from lungs and bronchi yielded hemolytic streptococci, and Staphylococcus aureus was also present in the lung.

Summary.

Of the ninety-five cases included in this report, twelve showed the reparative process in a more or less marked degree. Furthermore, the twelve showing organization had an illness averaging twenty-seven days in duration, whereas for the eighty-three cases in which there was no organization, the period of illness averaged nine days. Thus, it appears that the early fatal termination of the disease in the latter group is responsible for the absence of organization.

With one exception, when organization was encountered, the disease had run a relatively acute course without marked remission until death. In this instance, the fatal outcome was the result of an accident at a time when all the clinical evidence pointed toward a subsidence of the acute disease. The history of this patient is abstracted below, for it may throw light upon possible relapse and upon late, chronic, respiratory changes.

Autopsy No. 163.

A white male, aged 35 years, was admitted to the New Haven Hospital on December 5, 1918, complaining of “cough, pain in the chest, and headache.” For six days he had had fever, chills, and severe frontal headache, and for three days pains in the chest. He had also had “coryza” and epistaxis. The family and past histories were unimportant.

The physical examination showed a well developed and well nourished male, who was slightly jaundiced and markedly prostrated. The conjunctivæ were injected. The heart, abdomen, extremities, and right lung were negative. In a small area outside the left nipple and extending into the axilla, tubular breathing and subcrepitant râles were heard, but no definite signs of consolidation were made out. The physical signs remained the same during the eight-day stay in the hospital. At entrance his temperature was 102.8°F. In twelve hours it fell to 100°F., then rose to 103°F., where it stayed for twenty-four hours, falling by lysis and remaining normal for the three last days. On his eighth day in the hospital, the patient suddenly collapsed and died within fifteen minutes.

The autopsy was held one hour after death and the essential findings were as follows:—

The peritoneal cavity contained 100 cubic centimeters of clear, straw-colored fluid and the viscera, particularly the liver, were acutely congested. The right side of the heart was greatly dilated; and on opening the pulmonary artery in situ considerable blood gushed forth under pressure and a huge, tortuous embolus completely filled the vessel and its branches (Fig. LIII). The veins of the vesicoprostatic plexus on the right, and the right internal and external iliac veins contained thrombi, and it was evidently from this region that the embolus had been set free. The pleura of the lower third of the left lung over an oval area about 13 × 5 centimeters was bound to the parietal pleura by pinkish-grey, translucent adhesions which were evidently of comparatively recent origin. Here the lung was firmly consolidated, but it was apparently normal elsewhere. On section the consolidated area was silvery grey, with a pink tinge, comparatively dry and smooth. In some areas, especially about the bronchi, delicate, silvery grey, translucent strands could be seen sweeping out into the surrounding lung, which contained no air. The remainder of the lung was air-containing. The trachea showed moderate congestion most marked near the bifurcation. The hilic lymph nodes were enlarged, soft, congested, and succulent, as well as anthracotic.

FIG. XXIX. THE VESSELS OF THE ALVEOLAR WALLS ARE CONGESTED AND CONTAIN A LARGE NUMBER OF LEUCOCYTES. THE EXUDATE IS COMPOSED ALMOST ENTIRELY OF WHITE BLOOD CELLS, IN THE BODIES OF WHICH INNUMERABLE BACTERIA MAY BE SEEN. COMPARE FIGURES XXI, AND XXXII. ]

Microscopic examination of the viscera showed acute congestion and some degree of cloudy swelling in the liver and kidneys. The sections of the lung through the consolidated area showed the pleura replaced by a thick layer composed of large and small mononuclear cells, some red blood cells, a rare polymorphonuclear cell, and great numbers of fibroblasts and budding capillaries. Some of the alveoli contained many red blood cells, a few polymorphonuclear and mononuclear cells, some fibrin, and in many areas fibroblasts were organizing this exudate (Fig. XLV). Organization was also present around the bronchi and these contained mucus, pus, and desquamated epithelium. Frequently strands of fibroblasts were seen sweeping through the bronchiolar exudates, and in a few instances they had completely filled the lumina.

II. INFLUENCE OF THE RESPIRATORY COMPLICATION OF INFLUENZA UPON TUBERCULOSIS OF THE LUNG

Thirteen of the ninety-five cases included in this report occurred at the United States General Hospital No. 16, one of the large tuberculosis camps. In five instances the patients had active pulmonary tuberculosis. The remaining eight were members of the detachment and may be added to the eighty-two from the New Haven Hospital, making a total of ninety cases in which there was no clinical evidence of active pulmonary tuberculosis at the onset of the acute respiratory disease. When these ninety cases are analyzed, it is found that only two of them show definite activation of an old tuberculous focus (82). One has already been referred to (Autopsy No. 209); the other, presenting a much more acute exudative and ulcerative tuberculosis, deserves special consideration.

Autopsy No. 194.

A white female, aged 27 years, was admitted to the New Haven Hospital on November 8, 1918, complaining of “cold on the chest, fever, cough, and prostration.”