Part 9

The past and family histories were unimportant. Her illness began one week before admission with dizziness, headache, vomiting, cough, pains in back and legs, chilly sensations, and fever. She went to bed the day after. The acute onset became definitely worse and pains developed in her chest. On admission she was very weak, had a temperature of 101.4°F., a pulse of 120, and respirations of 40 per minute. The physical examination showed a very well developed and nourished woman who was cyanotic but not dyspnœic. The pharynx and tonsils were definitely injected. There were signs of consolidation at the base of the left lung. The pneumonic process gradually increased in the left, spread to the right, and involved the greater portion of both lungs. Otherwise the physical signs did not change greatly during her stay of thirteen weeks in the hospital. Thrombosis of the left femoral vein was diagnosed about two days before her death. The temperature curve was of interest. During the first two days in the hospital it remained at 104°F. For two weeks it was septic in character, being 102°F. in the morning and 104°F. in the afternoon. Then for thirty days it was practically constant at 102°F., only to become septic again, 98.6°F. in the morning and 103.4°F. in the afternoon, and it remained so until death. The pulse curve ran essentially parallel to the temperature curve, varying from 100 to 140 per minute. The respirations varied between 46 and 64 per minute.

The sputum showed Type IV pneumococcus. The blood culture was negative.

FIG. XXX. AUTOPSY NO. 169 (LEFT) AND AUTOPSY NO. 97 (RIGHT). THIS CONTRAST IN THE EXTENT OF INFLAMMATORY INVOLVEMENT BETWEEN NEIGHBORING LOBULES IS FREQUENTLY ENCOUNTERED. ]

FIG. XXXIII. GANGRENE OF THE LUNG. ]

The autopsy was held four hours after death. The body was markedly emaciated. The peritoneal cavity and its contents appeared normal, though the liver was low. The right pleural cavity contained 150 c.c. of slightly cloudy, yellow fluid. The left was free from fluid. Both lungs were bound to the chest wall by silvery grey, translucent adhesions which were broken with slight difficulty. The right lung was heavy, voluminous, retained its shape on removal, and was consolidated throughout. Thick, creamy pus exuded from the cut trachea. For the most part, the lung was covered by a recently organized exudate several millimeters thick in which delicate blood vessels could sometimes be made out. Beneath the pleura of the lower three-fourths of the lung, were numerous, irregularly rounded, slightly elevated, opaque, greenish-yellow areas resembling conglomerate tubercles. These gave the lung a shotty or nodular feeling. In the lowest lobe several of these areas had fused and softened to form semifluctuant areas several centimeters in diameter. On section the lower two-thirds of the lung was studded with areas corresponding to those seen on the surface, which in many instances had broken down and formed irregular cavities filled by thick, green pus (Fig. LI). Between the green areas delicate strands of new-formed fibrous tissue could be made out in all parts of the lung. The bronchial mucosa was injected, the walls were irregularly thickened and dilated and they opened into the ragged cavities noted above. New-formed fibrous tissue was prominent along the bronchi. One chalky white, old, encapsulated, tuberculous focus was found near the apex of the left lung.

Microscopically, there were two distinct processes found in the sections taken from various parts of the lung: an early miliary and exudative tuberculosis, and a necrotizing and organizing bronchopneumonia. Often the two processes were side by side, but sharply demarcated, in the same section. In others, they might be so intermingled that they could not be differentiated. The bronchi were filled with pus and often could be seen opening into large abscess cavities. The proliferation of the bronchial epithelium, as noted elsewhere, also was a striking feature in these sections. The pleural exudate was undergoing organization.

Streptococcus hemolyticus was found in the cultures of the lung, blood, pleural fluid, and bronchi. In addition, the bronchi and abscess cavities also showed Type IV pneumococcus and Staphylococcus albus.

Summary.

In this series of ninety-five cases, two examples of activation of an old tuberculous focus by the acute respiratory process were encountered. In both the pulmonary tubercular process was acute and played an important rôle in the fatal outcome.

III. EXTRARESPIRATORY LESIONS IN INFLUENZA

In all the fatal cases of influenza which came to autopsy, and this has been the experience of others, the respiratory lesions, as indicated above, occupy the foreground. Indeed, compared with other types of respiratory disease, the lung involvement is so great that expression of the disease need not be sought elsewhere to explain the cause of death. However, there are general systemic changes which, even though quantitatively inconstant, are sufficiently common and widespread to support the view that the disease is a systemic one. The lesions of the hematopoietic organs and those of the vascular system are the most important and will now be taken up.

A. LESIONS OF THE HEMATOPOIETIC SYSTEM

There is ample evidence that both the lymphadenoid and myeloid tissues of the body are affected. The lymph glands at the hilum of the lung naturally are involved with the extensive pulmonary changes. Also, a similar change may be found in distant nodes, perhaps associated with drainage from focal lesions or perhaps brought about by general intoxication.

The myeloid involvement is unassociated with focal lesions and finds its early expression in the equation of the white blood cells of the peripheral blood. The two groups of changes, those involving the lymphadenoid and those of the myeloid structures, should be discussed separately.

Lymphadenoid Tissues.

By far the most extensive lesions are encountered in the lymph glands of the lung and its hilum, and from here the mediastinal and deep nodes along the trachea are affected to a greater or lesser extent. The glands are very large and succulent (2, 157, 162, etc.). Very frequently, indeed, they are hemorrhagic on cross section (34, 108) (Fig. XXXVII), and there exudes a sanguinous fluid, usually thin and syrupy in character. The cut surface projects slightly, and the edge of the gland everts. The architecture is often obscured by hemorrhage—a diffuse red color—but very frequently near the periphery, translucent or more opaque, yellowish points are visible. Rarely, larger, opaque, yellow foci are found in the gland; these may be softened and purulent in exceptional cases (2, 47, 157).

Microscopically, the picture presented by the gland is that of a non-suppurative lymphadenitis. The peripheral sinuses are markedly distended and the channels through the gland share in the change (66). The sinuses contain serum, red blood cells, and mononuclear cells for the most part, but occasionally polymorphonuclear leucocytes are also encountered. More rarely still, a megalokaryocyte finds its way into the sinus. The most characteristic feature is the presence of phagocytosed cells,—a picture comparable with that found in the typhoid lymph node. The nuclei of the phagocytic cells are vesicular and usually stand out sharply in contrast with the pyknotic nuclei of the included cells. There is conclusive evidence that the phagocytes arise from the lining cells of the channel wall, as in typhoid fever, for these cells are frequently in process of division (Fig. LIV). The blood vessels of the lymph gland, greatly congested, contain almost exclusively red blood cells. As a rule, the lymph follicles and the lymph cords take little part in the process. If there is any change in these structures, it is a rarefication. Occasionally, hemorrhage is encountered in a follicle or even in a cord, and this hemorrhage may involve not only the cells of the cord, but its supporting reticular structure, and may form the nucleus of a subsequent necrotizing or suppurative focus.

FIG. XXXI. AUTOPSY NO. 100. ACUTE FULMINATING BRONCHIOLITIS AND BRONCHOPNEUMONIA. NOTE THE NECROTIC ALVEOLAR WALLS AND THE MASSES OF BACTERIA IN THE EXUDATE. COMPARE FIGURES VIII, XVII, AND XXXII. ]

The picture that has been detailed is subject to modification in those cases particularly where a leucocytic reaction is associated. Then, there may be more polymorphonuclear leucocytes in the sinuses, and necrotizing foci may be converted into miliary abscesses.

The change in the bronchial lymph glands cannot be considered other than an expression of an aplastic, inflammatory reaction. It finds an analogue especially in diseases like typhoid fever. The most constant picture includes an edematous, hemorrhagic reaction in which there is phagocytosis of sieved-out cells by the scavengers generated within the gland. Where necrosis or suppuration occurs, and this is rare, it may be considered as a complication.

Elsewhere in the body, the lymph glands rarely show the same degree of change as those of the thorax. The same general picture, however, is present to a greater or lesser extent, except that extensive necrosis and suppuration have not been encountered.

The lymphadenoid tissues of the alimentary canal share in the process only to a minor extent. In a number of cases, there is no question that the Peyer’s patches and solitary follicles are hyperplastic. Grossly, they stand out prominently, and are pale pinkish-grey in color. Histologically, there is hyperplasia, chiefly apparent from the large germinal centers in the follicles, and a slight distention of the lymph channels. This picture, so commonly found in every type of general infection, is in no way characteristic of influenza.

Spleen.

The spleen is the seat of the usual manifestations in generalized acute infections. In no case is the organ markedly involved, although considerable increases in its size may occur (2, 108, 141, 157, 162). It is not feasible to introduce a detailed discussion of this mild grade of splenic tumor, for there are natural variations in the size of the spleen and frequently it is modified in this respect by subsidiary conditions. In every instance the capsule of the spleen is smooth and there is no acute or chronic perisplenitis attributable to influenza. The capsule usually retracts slightly and the splenic pulp, in slight excess, is much more frequently red or garnet than grey in color. Occasionally, the splenic tumor is grey as in pneumonia. The more minute changes in the organ consist of congestion of the sinuses, increase of the mononuclear cells of the pulp, and prominence of the germinal centers of the Malpighian corpuscles (140). Hemorrhages, found occasionally (47), are more frequent in the pulp, but also occur in the corpuscles.

Bone Marrow.

One of the clinical features of influenza is a leukopenia, which persists often in the face of acute pyogenic pulmonary infection (12, 138, 143, etc.). In this series of ninety-five cases, the vast majority had this type of blood picture, but occasionally a leucocytosis (14) was demonstrable even during the early part of the disease and in those cases which terminated fatally within a period that may be called acute. In almost all instances where fatal termination was delayed, the leucocyte count ultimately was elevated either with remission or to a constant high level. The blood studies have not been sufficiently complete to allow further discussion, though there is reason to believe that these might have yielded interesting results. The blood changes in this series are similar to those presented in the reports of the epidemic from other sources.

In the majority of cases where the marrow was studied, it was aplastic (12). Occasional, focal, hemorrhagic lesions of the marrow (47) similar to those discussed below in the skeletal and parenchymatous systems were encountered and there was an apparent increase in the number of megalokaryocytes. The usual hyperplasia of the myeloid elements of the marrow associated with pyogenic change was not present.

B. LESIONS OF THE BLOOD VESSELS AND ELSEWHERE IN THE BODY