The cases are arranged according to the period of survival after gassing. In the majority of the cases the date of gassing is accurately stated; in some it is inferred from the date of the first admission to field or evacuation hospital. Frequently additional data have been disclosed by the study of the reports of the gas officers of the Chemical Warfare Service, and the clinical records on file in the Office of the Surgeon General. Such information has been included in the autopsy record. In a few instances, where the date of gassing is not given, it may be reasonably surmised from the fact that other members of the same company, battalion, or regiment were gassed about the same time and showed lesions similar in character. In only two cases was it not possible to obtain data roughly estimated from the character of the lesions.
While the effort has been made to present the records of the gross lesions
as nearly as possible in the form and expressions used by the pathologist
who performed the autopsy, it has been thought desirable to omit detailed
descriptions of lesions irrelevant to the gassing and where necessary to
alter the arrangement for the sake of uniformity. The reports will naturally
be found to vary greatly in accuracy and completeness. Many of the autopsies
were done under conditions where there was neither time nor facility for
detailed observation and record. It seems hardly necessary to apologize
for these defects .
CASE 1.-M. L., 64329, Pvt. Co. L, 192d Inf. Died, October 28, 1918, 2 pm., Evacuation Hospital No. 7.
Autopsy- hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Date of gassing not recorded. October 28, men of company were exposed to shell which had little odour, produced marked sneezing, with casualties five hours later. Severe dyspnea.
Anatomical diagnosis.-Not recorded.
Gross findings.-(The following note upon the lesions of the respiratory tract was made in the pathological laboratory, experimental gas field). The pharynx larynx, and oesophagus are normal. The trachea also shows no gross lesions. The primary and secondary bronchi show a reddened mucosa, covered with loose shreds of tenacious mucus. Their mucosa is intact.
Right lung: Voluminous, weighs 735 grams. The pleura is smooth, mottled with darker patches which are slightly sunken. On section the lung is air containing in all lobes. There is a very
moderate general edema, somewhat more marked in the anterior portion of the lung.
Left lung: Weight, 705 grams; somewhat more voluminous than the right. The pleura is free from exudate. On section there is pretty marked general edema, with scattered patches of collapse. No pneumonic patches. The small bronchi are normal.
Microscopic examination.-Trachea: In some places the epithelium is definitely necrotic and replaced by a mucopurulent exudate, the membrana propria being interrupted in some of the eroded places. In other places the nuclei of the epithelial cells, which are reduced to a single row, are definitely pycnotic in comparison with the vesicular nuclei of the uninjured cells. The vessels of the submucosa are congested.
Lung: The epithelium of the smaller bronchi is uninjured; the lumina contain a small amount of coagulum, desquamated cells and a few leucocytes. Many of the alveoli contain homogeneous, pink-staining material which is practically cell free. The septa are thickened and edematous. There is a stasis of leucocytes in the capillaries. No bacteria are found in sections stained with Gram-saffranine.
Myocardium: There is distinct edema about the intermuscular vessels and of the connective tissue between the muscle bundles.
Liver, kidney, spleen, adrenal, and pancreas show no significant lesions.
NOTE.-The lesions suggest exposure to a mixture of the suffocant and irritant types of gas, possibly phosgene and arsene compounds. There was definite necrosis of the bronchial epithelium such as one would not expect to find after phosgene alone. The absence of bacterial growth and secondary pneumonic lesions may be taken as evidence of early death in this case, probably within 24 hours.
CASE 2.-A. D., 1429216, Pvt. Hdqrs. Co., 39th Inf. Died, October 11, 1918, 4.45 am., Evacuation Hospital No. 6.
Autopsy, five hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Gassed October 10, near Verdun, blue cross and green cross shells. Clinical diagnosis of phosgene poisoning.
Anatomical diagnosis.-Edema and congestion of lungs; emphysema; bronchopneumonia.
External appearance.-Marked post-mortem lividity. No burns of skin. Quantities of frothy fluid exude from mouth.
Pleural cavities: Very slight retraction of lungs after removal of sternum. Each cavity contains about 60 cc. of straw-coloured fluid.
Lungs: Voluminous and extremely mottled, dark red areas of congestion alternating with pink areas of emphysema. On section the left lung especially shows numerous miliary areas, apparently connected with the finest bronchi. On examination with a hand lens these are found to be composed of aerated alveoli surrounded by dark red edematous and congested lung tissue. This appearance is less pronounced in the right lung. The parenchyma in general shows intense congestion but relatively little edema.
Neck organs: Tonsils and Lymphoid tissue at the base of the tongue enlarged. The mucosa is smooth, velvety, much congested, but there is no ulceration or exudate.
The smaller bronchi appear normal.
Heart: Cavities of right side extremely dilated. Remaining organs show no distinctive changes.
Gastrointestinal tract: Not recorded.
Trachea and bronchi of larger calibre. Ciliated epithelium is lost. The superficial cells show pycnosis of their nuclei and a homogenization of the cytoplasm. In occasional cells are found hydropic vacuoles with crescentic compression of the nucleus. The membrana propria is thick and swollen. The blood vessels of the submucosa are congested, but there is no haemorrhage and little or no inflammatory reaction.
Lungs: The small bronchi show a normal epithelium which is often desquamated or elevated in strips from the underlying basement membrane by a collection of edematous fluid. The infundibula are dilated; they have no epithelial lining. The surrounding alveoli show marked changes consisting of edema, haemorrhage, desquamation of epithelium, and the presence of numerous pigment cells. There are excessive numbers of polynuclears in the capillaries, the nuclei of which, especially in the neighbourhood of the infundibula, show striking distortion and fragmentation. Elsewhere there is patchy edema, the coagulum being homogeneous and containing little fibrin. Gram-positive cocci are found both in the bronchi and in the alveolar coagulum.
Liver, spleen, and adrenals: No significant changes .
NOTE.-In spite of the clinical history of phosgene, and the gross appearance of the lung, the lesions suggested the admixture of an irritant gas, possibly an arsene compound, acting especially upon the infundibula and the adjoining lung tissue. There was no extensive bacterial infection of the lung, masses of bacteria being found only in the small bronchi.
CASE 3.-C. G., French soldier. Died, October 8, 1918, at 8 a. m., Gas Hospital, Julvecourt. Autopsy, six hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Gassed with phosgene on October 7. Died suddenly after sitting up, without great preceding dyspnea.
Anatomical diagnosis.-Massive pulmonary edema; dilatation of right heart; acute tracheitis.
External appearance.-The body shows marked lividity.
Gross findings.-Pleural cavities: Each contains about 300 c. cc of blood-stained fluid. Respiratory organs: (Note dictated upon receipt of specimens at the pathological laboratory, experimental gas field.)
Larynx: Shows no edema.
Trachea: Is discoloured dark purplish.
Bronchi: Contain frothy fluid and their mucosa is stained with blood.
Right Lung: Extremely large and dark purplish in colour; the surface is smooth, the lobular markings being entirely obliterated. On section the lung is dark, firm, and rubbery, but showing no evident pneumonic consolidation; there is most intense edema, bloody fluid dripping from the cut section. The smaller bronchi do not contain purulent exudate.
Left lung: Differs from the right in the appearance of the lower lobe, which, in its lower portion, is somewhat grayish, dryer, and more granular than elsewhere, suggesting early pneumonic consolidation.
Gastrointestinal tract and remaining abdominal viscera normal save for congestion.
Heart: Right side markedly dilated, left ventricle in extreme contraction.
Microscopic examination.-Trachea: There are definite lesions in certain areas. Where the epithelium is entirely defective the nuclei of the underlying connective tissue cells and Lymphoid cells show marked caryorrhexis, and there is superficial necrosis, with groups of Gram-positive cocci in the necrotic tissue and in the blood vessels. There is also superficial haemorrhage. Lesser injury to the epithelium is indicated by vacuolization of individual cells, or hyaline, pink staining of their cytoplasm. Where the epithelium is intact and composed of several layers, there is loss of cilia; but efforts at repair are suggested by the presence of numerous mitoses.
Lungs: Sections of various blocks show similar picture. The alveoli are widely distended. The alveolar capillaries are wide and crowded with decolourized red blood cells. In the larger vessels the red cells are better preserved. In some of the septa it is possible to make out extravasation of cells between the capillary and the somewhat swollen basement membrane upon which the alveolar cells should rest. There is slight diapedesis into the alveolar spaces. The capillaries contain moderate numbers of mononuclear and polymorphonuclear leucocytes, some in process of emigration. A few alveoli contain dense collections of pycnotic leucocytes and much granular coagulum. The alveolar epithelium is not distinguishable. There is no fibrin. In some sections the edema is more evident, as shown by the abundant pink-staining coagulum. Sections stained for bacteria show enormous numbers of Gram-positive cocci in chains, pairs, and groups. They are found in the connective tissue about the blood vessels, in the septa outside the capillaries, and within the polymorphonuclear leucocytes of the alveolar exudate. No other types of bacteria are present.
Liver, spleen, kidney, and adrenals show no significant changes.
NOTE.-A case of poisoning by suffocative gas, probably phosgene. There appears to have been complete death of alveolar epithelium, with massive invasion of bacteria (streptococci ?) and haemolysis. The bacterial growth was probably not postmortal, since the autopsy was performed within six hours after death. There was very little inflammatory reaction.
CASE 4.-H. R., 76213, Pvt. Co. B. 18th Inf. Died, August 8, 1918, Gas Hospital No. 4. Autopsy, 11 hours after death, by Lieut. Russell W. Wilder, M. C.
Clinical data.- October 7, exposed to bombardment of phosgene and mustard-gas shells (77.105.150 mm.). Clinical diagnosis: Phosgene poisoning.
Anatomical diagnosis.-Diffuse generalized edema of lungs; anthracosis; hydrothorax, bilateral; dilatation of the heart; hyperaemia of laryngeal and tracheal mucosa; cloudy swelling of liver and kidneys.
External appearance.-Marked cyanosis of ears, lips, and fingers, and extensive lividity of all dependent parts. Frothy serosanguineous discharge exudes from the mouth and nostrils. The skin shows no burns, scars, wounds, or abrasions. The eyes are clear, the lids edematous.
Gross findings.-Lymph glands are small.
Lungs: Do not collapse and completely fill the pleural cavities. They show the imprint of the ribs. Right pleural sac contains 200 cc. of serosanguineous watery exudate; the pleura is everywhere smooth and glistening. The left is like the right. The lungs are heavy and boggy, and when cut show an extremely wet surface. There is much anthracotic pigmentation. Several accumulations of air appear subpleurally over the surface, and the lung markings are emphysematous.
Neck organs: There is moderate hyperaemia of the mucosa of the pharynx and trachea, but no edema, tumefaction, exudation, or ulceration. The trachea shows slight hyperaemia but no further change. It is filled with frothy serosanguineous fluid, which exudes in quantity when the lungs are pressed.
Heart: Enormously dilated, especially the right auricle and ventricle, which are three times their normal size and filled with dark clotted blood.
Liver: Intense congestion and cloudy swelling.
Spleen: Four times normal size and very firm.
Kidneys: Congestion and cloudy swelling.
Gastrointestinal tract: Not recorded.
Microscopic examination.-Trachea: Lined with a single row of nonciliated cells, which are in some places completely exfoliated. The superficial cells have been desquamated. There is no edema or leucocytic infiltration of the submucosa, but the membrana propria unquestionably is thicker than normal.
Lungs: Sections show advanced post-mortem changes, and finer details can not be made out. There are scattered patchy areas of edema. In some of the alveoli are many polymorphonuclear leucocytes, in the majority, the cellular elements are scanty and composed chiefly of desquamated epithelial cells containing pigment, red blood cells, and occasional leucocytes. Gram-positive bacteria are fairly numerous. There is little fibrin. Interspersed amongst the edematous and pneumonic areas are patches of collapse and emphysema.
NOTE.-The gross findings are very typical of acute poisoning by phosgene or similar suffocant gas, and confirm the clinical diagnosis. The histological material is of little value for finer study.
CASE 5.-H. E. M. C.H. 3173285 Pvt. Co. H 16th Inf. Died ()ctober 4 1918 Evaeuation Hospital No. 6. Autopsy October 5 1918 -hours after death by Capt. James F. Coupal M. C.
Clinical data.-Mustard-gas burns and inhalation. Died while being evacuated.
Anatomical diagnosis.-Extensive superficial burns. Diphtheritic tracheobronchitis. Bronchopneumonia (bilateral).
External appearance.-Cloudiness of cornea and conjunctivae. Burns of face hands elbows and back.
Gross findings.-Pleural cavities: Left contains 40 cc. of cloudy fluid. Right negative.
Heart: Right ventricle and auricle dilated. Otherwise normal.
Lungs: Do not retract on opening chest cavity. Left: Early pleurisy over posterior portion. Lung on section is purple and yields quantity of blood and frothy mucus. Both lungs show areas of congestion and beginning consolidation scattered throughout.
Trachea: Contains a false membrane which hangs to the wall and is surrounded by a quantity of thick mucus.
Gastrointestinal tract: Negative except for injection of small intestine. The remaining organs are normal.
Microscopic examination.-Trachea and larger bronchi are covered by thick pseudomembrane which is made up of a fibrinous network in the interstices in which are numerous polymorphonuclear leucocytes. The mucous glands show epithelial degeneration possibly in part post mortem. The cartilages are normal.
Lungs: Marked injection of all blood vessels including the alveolar capillaries. In some areas the alveoli contain an eosinophilic granular debris and the exudate is frankly inflammatory the alveoli being filled with plugs of fibrin and leucocytes or merely leucocytes. Some alveoli contain large epithelioid cells which are filled with brown pigment. The smaller bronchi are acutely inflamed. Some contain a fine purulent pseudomembrane or a covering of leucocytes. Around one bronchus is an especially marked zone of congestion and even an infiltration of red blood cells into the adjacent alveoli.
Liver: Shows extensive fat infiltration. The remaining organs are free from significant changes.
NOTE.-The case is a typical one of early mustard-gas poisoning, with very extensive tracheobronchitis and early bronchopneumonia, dying on the second day after exposure.
CASE 6.-W. D. F. 3173197 Pvt. Co. H 16th Inf. Died October 4 1918 at 2.20 pm. Gas Hospital Julvecourt. Autopsy October 4 three and one half hours after death by Capt. James F. Coupal M. C..
Clinical data.-Mustard gas on the morning of October 2 1918.
Anatomical diagnosis.-Multiple burns of skin; necrosis of tracheal anal bronchial mucosa; bronchopneumonia; pulmonary edema.
External appearance.-Burns of face neck left hand elbows buttocks and scrotum.
Gross findings.-Pleural cavities: The right pleural cavity contains 50 cc. of clear fluid. Left negative.
Lungs: Contract only slightly.
Pericardium: Contains 40cc. of clear fluid. The right heart is markedly dilated; left in contraction. Otherwise negative.
Lungs: The parenchyma of both lungs is congested. In the right middle lobe near the anterior border are patchy areas of atelectasis and bronchopneumonia in a stage of gray hepatisation. Also a few areas of consolidation in right lower lobe. In the posterior portion of the left lung in both lobes are several deeply congested dark-red areas somewhat resembling infarcts. The unconsolidated portion of the lung yields a quantity of frothy fluid. Mucosa of trachea appears necrotic and when stripped leaves an injected wall. The smaller bronchi contain a rather thin purulent exudate.
Microscopic examination.-Trachea: The epithelium is lost save for a single row of colloidal cells here and there and the epithelium of the ducts of the mucous glands which tends to creep over the adjacent tissue. The submucosa is slightly edematous. The nuclei of the connective tissue cells and of the wandering cells (chiefly polymorphonuclear leucocytes) which infiltrate the tissue in moderate numbers are distorted and caryorrhectic. The blood vessels are rather wide and contain unaltered cells. Mucous glands normal.
Lungs: Areas of lobular pneumonia with foci of necrosis, patchy alveolar edema, and an excess of leucocytes in capillaries. ( There is marked congestion and haemorrhage. The alveolar epithelium appears to be largely desquamated. It can rarely be made out distinctly. Bacteria are quite numerous, predominantly Gram-positive diplococci in the alveolar exudate and walls. Long chained streptococci and Gram-negative cocci and bacilli are also found, especially in bronchi. Bacteria are particularly numerous in the areas of necrosis. Fibrin is not abundant in the exudate, but is often present in the walls of the alveoli, apparently outside the capillary walls. A very interesting feature of the section is that many of the atria and alveoli are lined with a hyaline, wavy, refractile band, which in Gram-Weigert-safranine preparation stains bluish but has not the definiteness of fibrin. No alveolar cells overlie this membrane. It is difficult to make out whether it is swollen fibrinous exudate, the membrana propria of the alveolar epithelium, or the hyaline necrotic alveolar epithelium itself. In favourable places it is seen to be raised up from the alveolar capillary, polymorphonuclear leucocytes and red blood cells being found beneath it, as well as in the alveolar space.
NOTE.-Definite history of mustard-gas poisoning, patient dying on second day. Typical mustard-gas burns. Lesions of the upper respiratory passages were rather superficial. Pneumonia was of the influenzal type, with haemorrhagic edema and hyaline necrosis of the alveolar and bronchial walls. Bacterial infection was already established.
CASE 7.-V. O., 134765, Pvt., Battery B. 2d Mass. F. A. Died, October 13, 1918, Julvecourt Gas Hospital. Autopsy, October 13, at 2 p. m., by Capt. James F. Coupal, M. C.
Clinical data.-Gassed with mustard gas 48 hours before death. Marked dyspnea.
Anatomical diagnosis.-Multiple superficial burns of skin; acute ulcerative tracheitis; purulent bronchitis; bronchopneumonia; acute fibrinous pleurisy; acute parenchymatous nephritis; mustard gas poisoning.
External appearance.-Marked post-mortem lividity. Burns of conjunctivae, cornea, axillae, elbows, and scrotum.
Gross findings.-Heart: Markedly enlarged, right heart dilated. Muscle pale.
Lungs: Retract only slightly upon opening the pleural cavity. Few fresh fibrinous adhesions over major portion of both lungs. Both lungs markedly edematous, especially in the posterior part, with the alternating areas of consolidation, congestion, and emphysema, the last especially along the anterior margins. Quantities of dark-red blood and frothy mucus can be scraped from the surface.
Neck organs: Base of tongue and larynx are markedly congested. Mucosa of trachea is necrotic. Lumen filled with purulent exudate. Same condition extends throughout bronchial tree. Gastrointestinal tract: Not recorded.
Liver, spleen, and kidneys show marked congestion.
Microscopic examination.-Trachea: Epithelium is desquamated over surface of mucosa except for a few flat epithelial cells in one area. Epithelium of gland ducts, however, though damaged, is more or less intact. A little fibrinous pseudomembrane is present. This is infiltrated with polymorphonuclear leucocytes and attached to the submucous layer. The latter is congested, edematous, and infiltrated with polymorphonuclear leucocytes, especially the superficial zone. The nuclei are caryorrhectic. The mucous glands and the deeper layers are not involved to the same extent. A few capillary thrombi are present.
Lungs: The sections show no large bronchi, but some branches show desquamated epithelium and contain detritus and leucocytes. The alveolar walls are everywhere congested. Capillaries are distended with blood and contain leucocytes in excess. In one section the alveoli contain granular debris in which are large epithelioid cells with relatively small spherical nucleus, often containing brown pigment in the cytoplasm, and are accompanied by mononuclear and polymorphonuclear leucocytes and little fibrin. There is also more definite bronchopneumonia. Gram-stained sections show great numbers of streptococci.
Skin: Entire layer of stratified squamous epithelium has been raised from the subcutaneous surface except for small areas near the mouths of the hair follicles. This portion of the epithelium is thin and the cells distorted and deeply pigmented. The subepithelial layer contains inflammatory cells of various types, some of which show abundant chestnut-brown pigment. Capillaries are congested, and elsewhere vessels are surrounded by small round cells. Sebaceous glands and hair follicles are not much affected. Sweat glands are normal.
Liver: Congested and atrophied with central fat infiltration.
Spleen and kidneys are negative.
NOTE.-Mustard-gas poisoning, death after 48 hours, with skin burns. There was necrosis of the epithelium of the trachea and bronchi, with very little membrane formation. There was early lobular pneumonia, probably streptococcal.
CASE 8.-O. K. M. C.D., 45325. Pvt., Co. L, 18th Inf. Died, October 5, 1918. Autopsy at Evacuation Hospital No. 7, on following day, by Capt. James F. Coupal, M. C.
Clinical data.-Gassed October 3, mustard-gas shell. No autopsy protocol.
Gross findings.-(The following note of lesions of the respiratory tract was made at the pathological laboratory of the experimental gas field.)
The epiglottis and larynx show no edema. Mucous membrane of trachea and large bronchi is reddened. There is no evident necrosis, exudate, or false membrane. The lymph nodes at the bifurcation are calcareous, showing obsolete tuberculosis.
Left lung: Over the upper lobe are organized apical adhesions. There is a small area of collapse near the anterior border. On section there is moderate general edema and congestion. At the base of the lower lobe there is a circumscribed dark red area of consolidation about 3 cm. in diameter. The lower lobe is somewhat more edematous, congested posteriorly, with small patches of collapse scattered throughout the lung. Near the base is an area of consolidation somewhat grayer than that in the upper lobe.
Right lung: The upper lobe shows edema and congestion, with a few small areas of consolidation near the hilus. The middle lobe is congested posteriorly, and anteriorly there are areas of atelectasis. There are a few small pneumonic areas in the base of the lower lobe. Some of the bronchi are found filled with thick mucopurulent exudate and surrounded by a narrow zone of collapse.
Microscopic examination.-Lung and trachea: There is a pseudomembrane present and the epithelium is destroyed. The submucous layers are edematous and infiltrated with polymorphonuclear leucocytes. The smaller bronchi are similarly inflamed but there is no pseudomembrane. The epithelium is intact in some bronchioles but the lumina contain masses of pus cells. The lung parenchyma is edematous and congested. The alveolar capillaries are infiltrated with leucocytes, some of which have wandered out into the alveolar spaces. In the alveoli are present also red blood cells, pigmented epithelial cells, and occasionally a small amount of fibrin. There is hyaline fibrinous material deposited in places in the alveolar septa.
Skin: The normal epithelial covering is destroyed except around the mouths of two hair follicles. Even here the basal cells are in the process of vacuolisation, elongation, and destruction, while the overlying layers are flattening out and disappearing. On the surface there is noncellular cornified membrane underneath which is a collection of red blood cells, leucocytes, and detritus, while the base of this blister is formed by the subcutaneous tissue, infiltrated by poly-morphonuclear leucocytes, and is edematous.
Liver, spleen, and kidneys show no significant lesions.
NOTE.-Mustard-gas poisoning, with typical skin lesions, death occurring on the second day after exposure. The respiratory lesions are rather indefinite and the histological description does not correspond with the gross findings, particularly as regards the presence of a membranous necrosis in the bronchi.
CASE 9.-C. H. W., 101135, Pvt., R. A. F., 3 Kite Balloon Section. Died, October 23, 1918, at 7.05 a. m., at Base Hospital No. 2. Autopsy, two hours after death, by Capt. B. F. Weems, M..C.
Clinical data.-October 21, 1918. Admitted to No. 47 Casualty Clearing Station, with gas-shell wound of right leg and groin. Gassed. October 22, admitted to Base Hospital No. 2. Face badly burned; eyelids edematous; slight cyanosis and dyspnea; rattle of moisture in trachea and bronchi; pulse 120. Chest: Good resonance, bronchial and tracheal rales. Heart: Cardiac dullness within normal limits. Abdomen: Superficial wound in epigastric region. Abdomen soft. Penetrating wound of left groin. Through and through wound of right thigh. October 23. No change in condition. Died suddenly at 7.05 a. m.
Anatomical diagnosis.-Extensive first and second degree burns of skin; acute conjunctivitis; membrano-ulcerative pharyngitis and tracheitis; laryngitis; membranous bronchitis; lobular pneumonia; congestion and edema of lungs; interstitial emphysema of lungs; acute fibrinous pleurisy, chronic fibrous pleurisy over right upper lobe; congestion of abdominal viscera; gas-shell wounds of both thighs.
External appearance.-Extensive burns over the trunk and extremities and large, pale yellow blebs upon the anterior surface of both thighs, about the left knee, upon both forearms, and upon the neck and face. Besides these clear bullae, there are large areas of a peculiar dusky, pinkish-purple colour, in most cases adjacent to the bullae and having approximately the same distribution. The face is swollen and covered over the bearded portions by scabby exudate; the skin about both eyes is swollen and discoloured; there is purulent conjunctivitis. A mucopurulent exudate issues from the nostrils. There is extensive gingivitis. Skin over scrotum and penis edematous and in part blistered. Wounds: There is a through-and-through wound of right thigh, external to femur; wound of entrance just beneath anterior superior spine .
Gross findings.-Lungs: Marked inflation, anterior edges overlapping to level of third rib. Fibrous adhesions over right apex, no fluid in pleural cavities. Right, voluminous, colour gray, becoming pink near posterior portion. The organ crepitates throughout. There are a few small slightly nodular areas in lower lobe. On section through upper lobe some small slightly sunken areas of a deep-red colour are revealed, and a few small, rather cheesy plugs in the small bronchi. The lower lobe presents the same picture, except that there are a few patches of incomplete consolidation in lower portion and somewhat more congestion. Left, likewise voluminous, rather heavier than right, pleural surface shows a very slight fibrinous exudate, especially over anterior part of upper and lower lobes. There is some interstitial emphysema, most marked upon the anterior flap of upper lobe. The organ is closely nodular. There are lobular elevations over the anterior and inferior portions of upper lobe as well as lower. Upon section, surface is very moist, exuding bloody serum. There is patchy and extensive but incomplete consolidation. There are sunken brownish-red areas about the smaller bronchi. The bronchi themselves stand out sharply from the surrounding tissue and appear almost occluded by fatty-looking plugs of exudate. Upon dissecting the larger bronchi these are found to contain large fatty looking casts coextensive with the tracheal membrane and extending downwards into the smallest bronchial tubes.
Organs of neck: Tongue and regions about tonsils appear normal. The uvula is edematous and mucous membrane slightly macerated. The posterior pharyngeal wall is inflamed with a slight fibrinous exudate. The laryngeal surface of the epiglottis and the epiglottis folds are edematous deeply injected and covered by a somewhat patchy grayish-yellow membrane. There is considerable erosion of the mucous membrane over both true and false vocal cords.
The trachea is covered by a yellowish-gray necrotic membrane. Upon lifting the edge of this and stripping it back one has the impression of separating the mucous coat. The underlying surface is finely granular with minute points of capillary haemorrhage. This membranous lesion extends down into the primary bronchi. The peribronchial glands are not enlarged.
Gastrointestinal tract normal. Remaining organs show no significant lesions.
Microscopic examination.-Skin: The section shows definite necrosis as evidenced by pink-staining cytoplasm pycnosis of nuclei vacuolisation separation of individual cells. There is loosening of the keratin lamellae. The section passes through the edge of a vesicle filled with shreddy fibrinous coagulum. The separation appears to have taken place within the epidermis and not between epidermis and corium. The superficial layer of the corium is moderately edematous and contains a few pycnotic wandering cells. There is no marked hyperaemia; no thrombosis and no striking alteration of the vascular endothelium.
Primary bronchus: Lined with a thick fibrinous membrane in places distinctly laminated and containing polynuclear leucocytes especially on the surface. The ciliated mucosa is still present beneath the membrane though largely detached from the basal layer of cells. The nuclei of these detached cells are perhaps somewhat pycnotic but there is no very evident necrosis. The membrane is attached at intervals by vertical fibrinous strands to the submucosa. The ciliated cells are separated from the basal row in places by fresh haemorrhage. The submucosa is very edematous fibrinous haemorrhagic with moderate cellular infiltration. The mucous glands are flattened and do not appear to be actively secreting.
Medium-sized bronchus: Shows similar changes except that the lumen is completely filled by a loose fibrinopurulent exudate. An attached bronchial lymph node shows the sinuses filled with pus and fibrin.
Lungs: There is marked subpleural and interlobular edema. The capillaries are universally congested. There is a patchy very loose exudate into the alveoli composed of well-preserved mononuclear and polymorphonuclear leucocytes few erythrocytes and occasional swollen and exfoliated epithelial cells. Two small bronchi in the section show an intact mucosa. There are scattered emphysematous vesicles.
Liver, spleen, kidney, pancreas, and adrenal show no significant lesion.
Bacteriological report.-Blood culture (post-mortem) anaerobic media streptococcus haemolyticus aerobic in second generation. Lung culture: Pneumococcus type(?); micrococcus catarrhalis.
NOTE.-A very characteristic case of poisoning with mustard gas, probably dying on the second day after exposure. There were extensive skin burns, and a severe membranous necrosis of the upper respiratory tract. The lung showed an early patchy lobular pneumonia, with areas of edema. There are no features deserving special comment except, perhaps, the preservation of the tracheal epithelium, which is included in the fibrinous membrane.
CASE 10.-B. B. 2252004 Pvt. Co. A 39th Inf. Died October 14 1918 10.45 a. m. Base Hospital No. 58. Autopsy October 15 23 hours after death by Capt. M. Flexner M. C.
Clinical data.-Gassed October 11 1918 admitted to Base Hospital No. 58 on same day. Semicomatose, no history obtainable. Tincture digitalis and oxygen inhalation.
Anatomical diagnosis.-Mustard-gas poisoning. Bronchopneumonia.
External appearance.-Cyanosis of face and ears. Two superficial blisters on forehead about 3 cm. in diameter. Superficial burn on bend of left elbow. No other cutaneous lesions.
Gross findings.-Pleural cavities: The right is free. The left is obliterated by old fibrous adhesions.
Pericardium: Contains about 20 cc. of clear fluid.
Heart: Left ventricle is contracted; the right is flabby; no other lesions.
Right lung: Has old fibrous adhesions between the upper and middle lobes.
Left lung: The pleura presents a shaggy appearance over both lobes. Lung feels cottony with the exception of a few calcified areas. In the upper lobe is a small patch of bronchopneumonia about 2 by 3 cm. In general the cut surface is dry, mottled pinkish red in colour. Purulent bronchitis, somewhat less marked than in right lung.
Larynx, trachea, and large bronchi are injected and contain thick yellow pus.
Gastrointestinal tract: Normal. The remaining organs show no significant lesions.
Microscopic examination.-Trachea: The epithelium for the most part is desquamated. (This may be largely post-mortem, autopsy 23 hours after death.) In places there is a layer of squamous epithelium which seems to originate from the glandular ducts. There is a moderate leucocytic infiltration of the submucous tissue, with congestion and edema. The leucocytes in the superficial zone are caryorrhectic. Section through medium-sized bronchus shows complete necrosis of epithelium and formation of definite membrane.
Lung: Terminal bronchioles and alveoli are filled with exudate composed of polynuclear cells. In some areas red cells predominate and moderate numbers of pigmented epithelial cells also are seen There are small areas of emphysema and atelectasis. Alveolar capillaries are also congested. In sections stained by Gram method very few bacteria are seen.
Skin: There is desquamation of the epidermis and remains of an old bleb. Slight leucocytic infiltration in subepithelial layer and some fibroblastic activity. There are a few polymorphic pigment cells.
NOTE.-A case of mustard-gas poisoning of three days' duration. Slight burns of skin; inflammatory changes of trachea and larger bronchi were rather superficial. NO membrane except in smaller bronchi. Parenchyma of lung was very little affected.
CASE 11.-J. L. J., 2388735, Pvt., Co. M, 4th Inf. Died, October 17, 1918, 7 a. m., at Evacuation Hospital No. 6. Autopsy, three hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Mustard-gas burns and inhalation. Gassed on October 14. Area shelled daily with Yellow, Blue, and Green Cross shells; prolonged stay in contaminated vegetation and shell holes.
Anatomical diagnosis.-Multiple superficial burns of body with mustard gas. Acute ulcerative tracheitis and bronchitis. Bronchopneumonia. Acute fibrinous pleurisy.
External appearance.-Burns of face, scalp, conjunctivae, left shoulder, arm, and axilla, scrotum, and buttocks.
Gross findings.-Pleural cavities: Contain each about 200 cc. of clear fluid. Few fresh fibrinous adhesions. Lungs: Both present a similar appearance, showing alternating areas of emphysema, edema, and congestion. On section they yield quantities of dark blood and frothy fluid. Posterior portions are especially edematous; anterior margins emphysematous. Organs of neck: Base of tongue, fauces, pharynx and larynx are markedly congested. Moderate edema of glottis. Trachea: Throughout is denuded of mucosa. Bronchi: There is a loose membrane which extends from the trachea into the larger bronchi. Secondary bronchi contain purulent exudate.
Microscopic examination.-Trachea: There is an adherent fibrinopurulent slough in which is incorporated a necrotic submucosa. Coarse network of fibrin, with many distorted and fragmented nuclei and superficial masses of bacteria, composes the exudate. Here and there the surface is covered by a layer of flattened cells, the connection of which with the proliferating cells of the mucous ducts does not appear in the section. The fibrinous edema and leucocytic infiltration of the fibrous tissue extends quite deeply. There is extensive congestion but little or no hemorrhage. Some of the glands show excessive mucous secretion; others are exhausted. Lung: Bronchi are filled with purulent exudate. Epithelium is largely preserved. Wall moderately congested and haemorrhagic. There is a fine fibrinous exudate in the surrounding alveoli. In these plugs of exudate are large wellpreserved epithelioid nuclei, probably derived from alveolar cells. The alveolar epithelium under the immersion shows interesting changes. It is swollen and vacuolated. In many places there is an active growth of epithelial cells which creep along the alveolar walls or follow fibrin strands to invade or cover the plugs of exudate. In these places one finds the remains of the original epithelial lining. This epithelial reaction is the most striking feature of the section. Liver and spleen show no lesions of interest.
NOTE.-Case of typical mustard-gas poisoning, with extensive diphtheritic necrosis of trachea and bronchi and characteristic peribronchial reaction. There were interesting regenerative changes in the alveolar epithelium.
CASE 12.-J. R., 134681, Pvt., Co. B. 102d F. A. Died, October 13, 1918, 3 p. m., Evacuation Hospital No. 6. Autopsy No. 54. Autopsy, October 14, 19 hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Exposed on 9th and 10th of October to gas shelling (mustard gas and chloropicrin) over a period of five and one-half hours, 2,000 105-mm. and 150-mm. shells used over small area. Masks were removed too soon and soldiers slept in a gassed area. Diagnosis sof mustard-gas poisoning.
Anatomical diagnosis.-Multiple mustard-gas burns of skin; acute ulcerative tracheitis; surulent bronchitis; bronchopneumonia; fibrinous pleurisy; acute parenchymatous nephritis.
External appearance.-Burns of face, neck, conjunctive corneEe, elbows, axille, and scrotum .
Gross findings.-Pleural cavities: Lungs retract very slightly on opening the thorax, The right contains 400 c. c. of fluid with many fresh fibrinous adhesions.
(The following note was dictated at the pathological laboratory, Experimental Gas Field.)
Respiratory organs.-Trachea and bronchi are intensely congested. There is no membrane. Right lung: The upper lobe is voluminous and congested and markedly edematous. Middle lobe shows confluent lobular consolidation, affecting the entire lobe, with much fibrinous exudate about the pleural surface. The lower lobe shows extensive pneumonic consolidation, confluent in the lower portion. Left lung: Both upper and lower lobes are moderately congested and edematous and are free from pneumonic consolidation.
Alimentary tract: Not examined.
Kidneys: Cortex is mottled, alternately pale and haemorrhagic. The capsule is somewhat adherent. Vessels engorged. The remaining organs show no significant changes.
Microscopic examination.-Trachea: Shows complete loss of epithelium, with necrosis of the superficial portion of the submucosa. Associated with the leucocytic invasion, there is a fibrinous exudate and capillary hemorrhage. Nuclei of leucocytes show marked caryorrhexis. There is no false membrane. Epithelium of the ducts is conserved and in part widened.
Bronchus: There are a few shreds of apparently proliferating epithelial cells beneath the fibrino-purulent membrane. Edema is intense. The bronchial wall is congested and there is early proliferation of the fibroblasts.
Lung: Alveoli are very large. Many are partially filled with dense leucocytic exudate. Some edema of the interlobular septa and about the bronchi. There is also patchy alveolar edema. In the nonconsolidated areas there is marked congestion, with extensive exfoliation of the alveolar epithelium. Gram-stained section shows many Gram-positive cocci, morphologically staphlyococci, occurring in groups in the alveolar exudate.
Kidney: Shows acute haemorrhagic nephritis. There are no inflammatory lesions in the glomeruli. There is considerable epithelial necrosis, some of which may be autolytic.
Liver and spleen show no significant lesions.
NOTE.-The lesions are sufficiently typical of early mustard-gas poisoning (duration 3 days) except for the presence of an acute haemorrhagic nephritis. It is interesting to note that Nee recorded one case of haemorrhagic nephritis in his series of 18 mustard-gas cases.
CASE 13.-A. J. L., 1426227, Cpl., Co. G. 30th Inf. Died, August 13, 1918, at 3.30 p. m. .at Base Hospital No.27. Autopsy, one and one-half hours after death, by Capt. H. H. Permar, M. C.
Clinical data.-August 10, admitted to Field Hospital No. 7. Diagnosis: Exposure to mustard gas. Eyes irrigated; soda bath. Transferred at 6.30 p. m. to Evacuation Hospital No. 6. August 12, admitted to Base Hospital No. 27. Surface burns of back and genitals, edema of lungs, rapid, weak heart. August 13, died at 3.30 p. m.
Clinical diagnosis: Inhalation of deleterious gas, mustard gas and phosgene.
Summary of gross lesions.- Excoriations and second-degree burns of skin back and genitals. Both pleural cavities empty. Left lung: Weighed 960 grams; upper lobe congested and edematous, lower lobe shows peribronchial consolidation. Right lung: Weighed 70 grams; areas of consolidation in all lobes, which are markedly congested. Completed destruction of mucosa of primary bronchi. Right side of heart dilated.
Microscopic examination.-Trachea and large bronchi: No material preserved.
Lung: The medium-sized bronchi show complete epithelial necrosis, with the formation of fibrinopurulent plugs, in some cases occluding the entire lumen. The epithelium in a few of the bronchi shows early regeneration. The bronchioli have an intact epithelium, normally ciliated, but contain purulent exudate. So also the atria. The lung tissue itself is the seat of confluent lobular pneumonia, the exudate in places being celhllar, in others more fibrinous There are no distinctive features.
NOTE. -An incompletely studied, but apparently typical case, of mustard gas poisoning of three days' duration. There is nothing in the findings at autopsy to confirm the clinical suspicion of exposure to phosgene in addition to mustard gas.
CASE 14.-J. M. P., 1630061, Pvt., Co. H. 30th Inf. Died, August 13, 1918, at 2 p.m. at Base Hospital No. 27. Autopsy No. 30, performed one and one-half hours after death by Capt. H. H. Permar, M. C.
Clinical data.-Gassed with mustard-gas shells at Chateau Thierry on August 10; admitted to Field Hospital No. 7 on same day. Eyes irrigated with novocaine; soda bath. August 12, admitted to Base Hospital No. 27. Extremely cyanotic and dyspneic; weak, rapid pulse; burns over entire body surface. Lungs: Moist rales throughout.
Summary of gross lesions.-Large blebs over back, chest, arms, face, and genitals. Few old adhesions in right pleura, left negative.
Left lung: Weight, 466 grams; scattered areas of emphysema, atelectasis and consolidation in lower lobe; upper lobe congested. Bronchi filled with crust-like yellow slough. Right lung weighs 530 grams; voluminous, emphysematous, areas of consolidation in lower lobe.
Trachea ulcerated and covered with pseudomembrane.
Right heart dilated. Old tuberculous lesions in peribronchial lymph node.
Microscopic examination.-Medium-sized bronchus: There is complete denudation of the epithelium; the wall is formed by a dense granulation tissue, with distorted nuclei of inflammatory cells. No membrane is included in the section. The mucous glands are atrophic.
Lungs: The smallest bronchi are filled with purulent exudate; their epithelium is intact. The alveoli contain a dense cellular exudate, the pneumonic process being diffuse and confluent. There are no special features.
NOTE.-An incompletely described case of early mustard-gas poisoning of three days' duration showing the usual findings at autopsy.
CASE 15.-A. L., 547297, Pvt., Co. H. 30th Inf. Died, August 13, 1918, at 5.30 a. m., at Base Hospital No. 27. Autopsy No. 29, performed three and one-half hours after death, by Capt. H. H. Permar, M. C.
Clinical data.-August 10, exposed to mustard-gas shelling. Admitted to Field Hospital No. 7. August 12, admitted to Base Hospital No. 27, with diagnosis of mustard-gas inhalation and contact burns of extremities, head and back. Cardiac failure.
Anatomical diagnosis.-Burns of face, shoulders, back, chest, arms, thighs, and knees; pigmentation of skin of scrotum; laryngitis, tracheitis, and bronchitis, mucopurulent, with sloughing of mucosal lining; bronchopneumonia, early bilateral; edema and congestion of lungs. Heart: Dilatation of right side.
Microscopic examination.-Trachea: There is complete destruction of the surface epithelium, but that of the ducts of the mucous glands is intact, and already actively proliferating. There are small shreds of false membrane adherent in places, but in general the trachea is lined by the necrotic submucous tissue. The zone of necrosis extends to the mucous glands, and the membrana propria is destroyed. In the necrotic tissue are many wandering cells, with pycnotic and distorted nuclei. The blood vessels are intensely congested. The glands appear somewhat compressed and flattened.
Medium-sized bronchus: About the same picture as in the trachea. In one area, the necrotic epithelium, the cells of which have completely lost their staining, is lifted up from the membrana propria by a collection of leucocytes, forming a sort of pustule. A smaller bronchus shows in addition very extensive haemorrhage into the deeper portion of the submucosa.
Lung: Bronchioli show a suppurative inflammation, but their epithelium is still intact. There is an extensive lobular pneumonia, without special features. The exudate is very cellular, and the leucocytes well preserved.
NOTE.-A very severe but typical case of mustard-gas poisoning of only three days' duration. An interesting point in the histological study of the trachea is the early proliferation of the epithelium of the mucous ducts.
CASE 16.-H. B., 2193795, Pvt., 314th F. S. B. Died, August 11, 1918, at Base Hospital No. 116. Autopsy by Lieut. B. S. Kline, M. C.
Clinical data.-Gassed with mustard-gas August 7; admitted to Base Hospital No. 116 on August 10, with cyanosis and extensive edema; severe burns all over body. Right heart dilated. Pulse rapid and weak. Treated with stimulants and venesection.
Anatomical diagnosis.-Extensive gas burns, upper respiratory tract. Superficial burns of skin, penis, and scotum. Acute seropurulent conjunctivitis. Pigmentation of skin of face and scalp. Ulceration of mucosa of larynx, trachea, and bronchi. Acute membranous laryngitis, tracheitis, and bronchitis. Bronchopneumonia. Acute lymphadenitis. C!oudy swelling of parenchymatous organs. Cardiac dilatation, right side, moderate. Pulmonary edema, slight.
External appearance.-Body is that of an adult male, 192 cm. in length, well developed. Rigor is present to a considerable degree in the voluntary muscles. There is a moderate amount of hypostasis. In the skin of the back, particularly over the left shoulder and left axilla and to a less extent over the right scapular region- above this and between the scapulae there are large superficial ulcerated areas. The base is clean and has a reddish-brown appearance. There is a similar smaller ulcerated area in the left lumbar region. There are others about the sacrum, the axilla on each side, the right upper arm, and over the chest anteriorly, particularly in the region of the ensiform. There is also superficial ulceration about the prepuce, the anterior surface of the scrotum showing a matted scab. These ulcerations are very superficial and extend into the dermis only. At the bend of the left elbow there is an area of vesiculation several centimeters in length and about 6 men. in width. There is also another area on the left greater trochanter, a few centimeters in diameter. At the bend of the right elbow there is a superficial ulcerated area similar to those described above, and in addition over the head of the ulna there is an area of contusion. The skin of the face and scalp have a brownish colour. There are beginning vesicles about the left side of the mouth. The inguinal glands are somewhat enlarged. The mucous membranes are pale.
Eyes: The eyelids are somewhat swollen, the lids glued together by tenacious mucopurulent material. The conjunctivae are edematous and there are patches of injection of the bulbar conjunctiva. There is a slight cloudiness of the cornea. The pupils, about 3 mm. in diameter, equal.
Nose: In the nose there is a moderate amount of mucopurulent material.
Mouth: No abnormalities.
Chest: Well formed, costal angle about 90°.
Abdomen and extremities: Natural looking.
Gross findings.-Pleural cavities: On opening the thorax the right pleural sac is free of fluid and adhesions. The left pleural sac is likewise free of fluid and adhesions. The heart lies in normal position. On incising the pericardial sac no abnormalities of or in the sac are visible. On the ventral surface of the right ventricle there is typical milky patch.
Heart: Right auricle and ventricle moderately dilated. Otherwise normal.
Right lung: All lobes voluminous, cushiony, somewhat soggy, palpable solid areas here and there, most marked in the upper and median portion of the upper and middle lobes. The glands at the hilus are somewhat enlarged, pulpy, pigmented, and somewhat injected.
Bronchus: The mucosa in the greater part ulcerated. Covering the denuded submucosa there is an elastic fibrinous membrane forming a cast of the bronchial tree. The vessels at the hilus show no abnormalities except perhaps some dilatation of the arteries. On section of the upper lobe a moist pinkish-red surface presents. The tissue is quite well aerated. In the air sacs there is a moderate amount of thin frothy fluid. Medially there are vaguely outlined grayish-red solid patches varying in size from a few millimeters to a few centimeters in diameter. Posteriorly the solid patches are fewer in number and the tissue is well aerated. The middle lobe on section crepitates.
Medially there is a large walnut-sized, solid, dull reddish-gray patch. Nearby there are other solid patches of similar appearance. In the smaller bronchioles in this lobe viscid purulent exudate is visible. There is one peribronchial lymph node, grape seed in size, surrounded by a firm pigmented zone. On section of the lower lobe the tissue crepitates. The tissue is well aerated. In the air sacs there is a small amount of thin frothy fluid. The tissue is somewhat congested. In the large bronchial branches there is an adherent mass of exudate. On repeated section no definite solid areas can be made out.
Left lung: The glands, vessels, and bronchi similar in appearance to those on the right. The pleura here, as on the right side, is thin and delicate. The lobes, as of the right, are very voluminous, cushiony. On section they crepitate. In the median portion there are good-sized reddish, dull gray areas of consolidation. In the left lower lobe the purulent exudate in the bronchioles is striking in amount.
Neck organs: The larynx is filled with tenacious viscid mucopurulent exudate, most marked in the epiglottis and about the true vocal cords. The pouch behind them likewise is filled with a viscid exudate. The trachea is similar in appearance except that the exudate lessens in amount toward the bifurcation. Here the patchy ulceration of the mucosa is very striking. Below it the submucosa is intensely injected. Attached to the tip of the epiglottis there is an adherent elastic, friable plug of exudate. Throughout the upper respiratory tract the submucosa and the muscular coats are considerably edematous. The thyroid of average size and consistency. On section the tissue is spongy. The acini contain but a small amount of colloid. The tonsils of fair size and project somewhat above the general level. On section the tissue in great part is scarred. There is but a small amount lymphoid tissue present. The crypts are clean.
Alimentary tract: The upper end of the oesophagus and the base of the tongue show considerable injection of the mucosa. There is no ulceration present, however, and no exudate. The stomach contains some intensely bilestained contents and a small amount of mucus. In the mucosa there are scatted areas of patchy injection. The duodenum shows no abnormalities. In the lower ileum there are patches of patchy injection of the mucosa. The solitary follicles are somewhat more prominent than normal in the lower ileum. Patchy injection of the caecum and of the transverse and descending colon. The appendix shows considerable patchy injection of the mucosa with tiny haemorrhages, especially marked in the tip.
Kidneys show cloudy swelling.
Microscopic examination.-Lungs: No large bronchi are included in the sections. There is dilatation and hyaline necrosis of the walls of the infundibula. Small bronchioles still retain their epithelium but their walls are infiltrated with inflammatory cells. Alveolar walls are congested and contain many leucocytes. There is typical bronchopneumonia, the exudate being composed chiefly of well-preserved polymorphonuclear leucocytes. There is very little fibrin.
Trachea: Well-formed laminated membrane invaded with leucocytes and containing in one area a large mass of mucus. Beneath the membrane in places a single row of epithelial cells with pycnotic distorted nuclei. Marked swelling of membrana propria. Edema, congestion,
haemorrhage, and leucocytic infiltration of submucosa. The ducts of the mucous glands are distended with thick plugs of mucus. The epithelium in the superficial portion is destroyed.
Bacteriological report.-Smears made from the exudate in larynx show innumerable organisms. The predominating one, a Gram-positive lancet-shaped diplococcus. In addition there are some rounded Gram-positive cocci, also a moderate number of small and large Gram-negative bacilli and a few Gram-negative cocci.
NOTE.-A typical case of mustard-gas poisoning of four days' duration. There was a diphtheritic tracheobronchitis, with patches of secondary bronchopneumonia. Histologically the lung lesions differ from the influenzal pneumonias in the absence of extensive haemorrhagic edema and in the presence of large numbers of leucocytes in the exudate. There was, however, hyaline necrosis of the walls of the dilated atria, such as was commonly observed in the influenzal pneumonias.
CASE 17.-A. H., 1940705, Pvt., Co. E, 20th Inf. Died, October 7, 1918, Gas Hospital A. Autopsy, October 8, four hours after death, by Lieut. Russell W. Wilder, M. C.
Clinical data.-Gassed on October 3, 1918. Burns of skin, eyes, and respiratory tract.
Anatomical diagnosis.-Hyperaemia of mucous membranes of larynx, pharynx, and trachea. Ulcerations of mucous membrane of bronchi. Emphysema and beginning atelectasis of lungs. Healed apical tuberculosis. Parenchymatous degeneration of liver and kidneys. Second-degree mustard-gas burns of face, arms, and trunk.
External appearance.-Moderate cyanosis and lividity. Large vesiculated burns of arms and trunk. Desquamation of skin of scrotum, leaving raw bloody surface. Purulent discharge from eyes.
Gross findings.-Lungs: Distended. No free fluid in pleural cavities. Pleura is smooth and glistening. Right, crepitates throughout. On section reveals small bronchi occluded with fibrinous exudate. Larger bronchi covered by membrane, which, when stripped away, reveals longitudinal muscle fibres. Extensive areas of emphysema and other areas of beginning atelectasis. Left, shows similar picture. There is a calcified scar 1 cm. in diameter in the apex of the upper lobe.
Heart: Right ventricle moderately dilated. Mitral orifice somewhat stenotic, showing old endocardial scars.
Abdomen: Adhesions about the site of old appendectomy.
Gastrointestinal tract not examined.
Pharynx intensely congested.
Larynx and tracheal mucosa hyperaemic, but not ulcerated or covered by exudate. Thin purulent material in tracheal lumen.
Microscopic examination.-Trachea: Tissue poorly preserved. Epithelium desquamated. Submucous layer is edematous, congested, and infiltrated with leucocytes. There is no pseudomembrane. Section of medium-sized bronchus shows complete destruction of mucosa, with formation of false membrane composed of laminated fibrin.
Lung: Sections unsatisfactory. Show only congestion of capillaries and desquamation of mononuclear epithelial cells.
NOTE.-A typical early case of mustard-gas poisoning, dying four days after exposure. There was a membranous inflammation involving the bronchi, more deep seated than that in the trachea and extending into the smallest branches. Parenchyma of the lung, aside from the emphysema and atelectasis, due to occlusion of the bronchi was very little affected.
CASE 18.-C. P., 3171057 (rank and organization not given). Died, October 13, 1918, 11 a. m.,
Evacuation Hospital No. 6. Autopsy No. 53. Autopsy, October 14, 27 hours after death, by Capt. James F. Coupal, M. C.
Clinical data.-Gassed October 7 or 8. Died while being evacuated. Diagnosis: Mustard-gas poisoning.
Anatomical diagnosis.-Multiple superficial burns. Acute ulcerative tracheitis; purulent bronchitis; bronchopneumonia; acute fibrinous pleurisy; acute parenchymatous nephritis.
External appearance.-Burns of face, neck, conjunctive, cornea, scrotum, buttock, and thighs. Multiple blisters. Marked subcutaneous emphysema at base of neck and extending down to first rib. Paraphimosis.
Gross findings.-Pleural cavities: Lungs retract very slightly. Left pleural cavity contains 100 cc. of sterile yellow fluid. Right, a similar amount, with few fibrinous adhesions over the diaphragm.
Heart: The right ventricle is dilated.
(Note dictated at the pathological laboratory, experimental gas field.)
Respiratory organs.-Trachea: Covered with tough continuous membrane extending into the smaller bronchi. The anterior portions of both lungs, including the right middle lobe, are emphysematous, while the posterior portions are congested and edematous. There are no gross pneumonic lesions.
Alimentary tract: Intestines injected throughout. The remaining organs show no significant lesions.
Microscopic examination.-Trachea: Has a well-formed pseudomembrane composed of fibrin infiltrated with polymorphonuclear leucocytes. Submucous layer is congested, edematous and infiltrated with wandering cells, showing beginning caryorrhexis. An interesting point is the presence over large areas of a single row of epithelial cells beneath the pseudomembrane and still attached to the swollen membrane propria. The leucocytic infiltration is not dense. There is beginning caryorrhexis and capillary extravasation. The mucous glands do not appear to be in active secretion.
Bronchus: section through a medium sized bronchus shows complete necrosis of the epithelium. The lumina are filled with purulent exudate.
Lungs: There are a few small bronchi in the section showing generally exfoliation of the epithelium, probably post-mortem. The alveolar capillaries are congested, tortuous, and contain an increased number of polymorphonuclear and large mononuclear cells. A few air spaces are collapsed, others contain pink coagulum. There is slight exfoliation of the alveolar cells. No pneumonia.
Skin: The epithelium is raised up from the corium in a continuous sheet, forming a blister, the contents of which consist of homogeneous, slightly fibrinous coagulum with a fair number of leucocytes, chiefly polymorphonuclears. The epithelial cells show varying degrees of necrosis. The underlying corium is moderately edematous and loosely invaded by wandering cells. The vessels are not extremely congested and are free from thrombi even in the superficial zone. Near the surface there are small irregular cells containing pigment, some of which seem to have been derived from the basal cells of the rete mucosum. Some of the brown pigment has been taken up by the polynuclears. At the margin of the blister the epidermal cells are in places detached from their neighbours, and there is considerable leucocytic infiltration, especially in the zone just above the pigment layer. Papillary processes are edematous.
NOTE.-Mustard gas case, five or six days' duration. There was a typical membranous tracheobronchitis, in addition to the typical cutaneous lesions. The pulmonary parenchyma, according to the gross description and the single histological block available, showed only emphysema, edema, and congestion. There was no pneumonia.
CASE 19.-D. B., 187, Pvt., 1/4 Highlanders R. Died, October 23, 1918, at 5.10 a. m., at Base Hospital No. 2. Autopsy, four and one-half hours after death, by Maj. A. M. Pappenheimer, M. C.
Clinical data.-October 20, admitted to No. 5 Casualty Clearing Station, with diagnosis of shell-gas poisoning (irritant). October 22 admitted to Base Hospital No. 2. Patient is pale; breathing with much difficulty; edematous; pulse 140, very weak; blood pressure 120-100. No sounds during respiration. Sputum mucopurulent. Chest: Good resonance, tracheal and bronchial rates. Heart: Cardiac dullness within normal limits. Patient received an intravenous dose of strophanthin at 7 p. m. Oxygen administered, October 23, 4 am. Pulse very weak; pale; thirsty. Died at 5.10 am.
Anatomical diagnosis.-Membranous tracheobronchitis; lobular pneumonia; congestion and edema of lungs; pleural adhesions; acute conjunctivitis; congestion of viscera.
External appearance.-conjunctivae are injected, slightly more so on left side. Abundant thin watery fluid flowing from mouth. The mucous membrane over the lower lip is a little macerated. There are no burns or other cutaneous lesions.
Gross findings.-Pleural cavities: On both sides obliterated by organized adhesions. Lungs meet in median line to third interspace.
Lungs: Voluminous and heavy covered everywhere with edematous sheet-like adhesions. In all lobes there can be felt firm areas which are quite extensive. Right lung: On section upper lobe shows very widespread areas of consolidation which are grayish red and granular forming patches 2 or 3 cm. in size between which the lung tissue is very edematous and congested. The bronchi are thick the larger ones lined with a continuation of the gray membrane present in the upper respiratory passages the smaller ones completely filled with purulent fluid. In the lower and middle lobes the consolidation is less extensive but of the same character. The bronchi are surrounded by a sunken red zone. Left lung: Presents a similar picture. The most extensive consolidation is in the lower lobe about two-thirds of which are completely consolidated.
Organs of neck: Tongue normal. Tonsils small normal on section. The pharynx congested slight thickening of the arytenoepiglottidean folds. On the laryngeal surface of the epiglottis the mucous membrane in places is denuded and covered by a thin grayish membrane. The vocal cords and the entire lining of the trachea and primary bronchi are covered with a coherent rather moist yellowish-gray membrane. This is readily detached leaving a swollen red velvety surface apparently covered by epithelium.
Remaining viscera including gastrointestinal tract show no significant changes.
Microscopic examination.-Trachea: There is no membrane preserved in the section. The epithelium is reduced to occasional small groups of flattened cells with pycnotic nuclei. The membrana propria is swollen. The submucous tissue is the seat of fibrinous edema. There is congestion scattered haemorrhage and loose inflammatory infiltration. The leucocytes as they approach the surface show pycnosis and caryorrhexis. The edema extends through the wall of the trachea to the neighbouring fat and areolar tissue.
Primary bronchus: The section shows a loose fibrinous membrane to the base of which are attached strips of exfoliated epithelium. There is a curious arrangement of the fibrin. To the swollen membrana propria are still adherent in places flattened deeply staining epithelial cells. The openings of the mucous ducts are dilated with mucus and exfoliated cells. The edema congestion haemorrhage and leucocytic infiltration of the bronchial wall are like that in the trachea.
Tonsils: No epithelial necrosis.
Lungs: Bronchi filled with purulent exudate which in the terminal infundibula are in the form of fibrinopurulent plugs completely filling them. The epithelium is preserved in part. There is diffuse pneumonia showing no special features. The exudate is rich in polymorphonuclear leucocytes showing early pycnosis. The capillaries are extremely congested and there is moderate diapedesis. There is rather marked periarterial edema. Another block shows a medium-sized bronchus cut longitudinally and completely occluded by a fibrinopurulent plug. A few flattened epithelial cells persist here and there where the plug is less firmly attached. The wall is edematous and loosely invaded by wandering cells. The rest of the section shows edema patchy in distribution emphysema and congestion.
Liver, spleen, pancreas, and adrenals: Show no special features.
Bacteriological report.-Blood culture (post-mortem) anaerobic streptococcus dying on transplant. Staphylococcus aureus. Lung culture: B. influenzae and pneumococcus Type IV.
NOTE.-This case, probably one of mustard-gas poisoning of three or four days' duration, is interesting and unusual because of the absence of cutaneous lesions. The diphtheritic necrosis of the trachea and bronchi were very severe and extensive and could hardly be ascribed to an influenzal infection alone. There was, moreover, a definite history of shell-gas inhalation. The eye lesions appear to have been very mild.
CASE 20.-J. A. A. 1681974 Pvt. (Co. not given) 306th Inf. Died September 29 1918 at Base Hospital No. 18. Autopsy No. 99 performed 16~ hours after death by Lieut. 13. S. Kline M. C.
Clinical data.-Gassed on the night of September 25. Died shortly after admission to Base Hospital No. 18. No further data are available. The records at hand show four other casualties from gas on the night of September 25 in the 306th Infantry. One thousand five hundred 77 and 105 mm. Yellow Cross shells were used in the bombardment which lasted one hour.
Anatomical diagnosis.-Gas burns of scrotum conjunctivae and respiratory tract; infected scrotal burn; acute conjunctivitis; acute oesophagitis; laryngitis, tracheitis and bronchitis; peribronchial and bronchopneumonia; acute lymphadenitis regional lymph nodes; healed pleural adhesions; pulmonary edema slight to moderate; chronic diffuse nephritis; myocardial scars left; hypertrophy of left ventricle considerable; anaemia and emaciation slight to moderate.
External appearance.-The skin is thin and sallow. The scrotum shows an area of superficial necrosis of the epidermis over each testis also in the midline several centimeters in diameter. Over this there is matted serum and a small amount of purulent exudate. The superficial lymph glands are palpable. The conjunctivae are diffusely injected. There is a. small amount of fibrinopurulent secretion present; both corneas are cloudy. There is superficial ulceration of the mucosa of the lips covered with sores; many teeth poorly formed.
Gross findings.-Pleural cavities: Right pleural sac obliterated by sheetlike adhesions. On the left side no abnormalities.
Right lung: All lobes are voluminous except the middle lobe which is smaller than the average. The pleura in general is thickened. The lobes are bound to each other and to the pericardium by fibrous bands. Vessels at the hilum are normal. The lymph glands are enlarged, pulpy, injected and edematous. The bronchus shows a striking picture; there is injection of the mucosa with patches of ulceration; in many places fibrinous and fibrinopurulent exudate adheres to the walls. On section of the upper lobe the tissue in the posterior part shows slight congestion and moderate edema. Throughout the lobe there are scattered areas of peribronchial consolidation varying in size up to a few centimeters in diameter. In general they average only several millimeters. The middle lobe in its greater portion shows a patchy grayish-pink consolidation; about two thirds of the lobes are involved. The right lower lobe on section resembles the upper. There is more uniform congestion and the consolidation is more distinctly peribronchial. The bronchial branches throughout this side contain tightly adherent fibrinopurulent exudate.
Left lung: Also voluminous in both lobes. The entire lung except the apex of the upper lobe feels soggy and solid. Over the lower lobe posteriorly there is a small amount of fibrinous exudate. Glands at the hilum vessels and bronchi are similar to those on the right side. On section of the upper lobe the upper part is well aerated and pink but contains a few bronchopneumonic areas. In the lower portion there is considerable edema slight congestion and scattered areas of grayish consolidation peribronchial and pneumonic. In the median portion of the lobe there is an area of consolidation several centimeters in diameter; the consolidation here is almost uniform grayish and red finely granular. The lower lobe on section presents a picture similar to the lower portion of the upper but is more extensive. The smaller bronchial branches are like those on the right side.
Organs of neck: The larynx is. lined with a necrotic white mucosa covered in great part with tenacious yellowish slightly green tinged coherent exudate. The true vocal cords and lower portion of the larynx are especially affected. A similar condition is present throughout the trachea although the exudate is somewhat less abundant. Patchy injection and superficial ulceration of the mucosa is visible here and there. The posterior wall of the pharynx and the upper esophagus present a picture like that in the upper part of the larynx. The tonsils are slightly enlarged edematous pale and scarred.
Heart: Weighs 320 grams the left ventricle about twice the average thickness. There are myocardial scars and the muscle is coarse in texture. Sclerotic patches are seen in the coronaries and at the base of the aorta.
Kidneys: Reduced in size and show irregular atrophy of the cortex and indistinct markings.
Gastrointestinal tract: Not described. Remaining viscera show no changes of interest.
Microscopic examination.-Trachea: Longitudinal section cut. There is complete epithelial necrosis. Masses of tightly adherent fibrinopurulent exudate in which are many bacterial colonies cover the surface. The submucous tissue is only superficially infiltrated with inflammatory cells. The tissue is poorly preserved and the red cells in the vessels are not stained.
Pharynx: On the surface is an adherent fibrinopurulent slough; there is edema intense congestion and inflammatory infiltration of the submucous tissue.
Lungs: the smaller bronchi are lined with adherent fibrinopurulent exudate which is incorporated in the wall and does not form a distinct membrane. The terminal bronchioles and infundibula are filled with pus; their epithelium is still partially preserved. The parenchyma shows a diffuse pneumonia; the exudate is of varying composition in places almost fibrinous in others containing dense aggregations of leucocytes. There are no features of special interest
The finer details are somewhat obscured by formalin pigment. Another section shows circumscribed areas of pneumonia in which there is great fragmentation of leucocytes and abundant bacterial growth. The appearance suggests beginning gangrene. Some of these consolidated foci are surrounded by zones of haemorrhagic edema. There is marked perivascular edema in some sections.
NOTE.-Typical early case of mustard-gas poisoning of four days durations with severe diphtheritic necrosis of the upper respiratory passages.
CASE 21.-A. B. 240806 Pvt. Co. L 309th Inf. Died October 22 1918 at 2.20 p. m.? at Base Hospital No. 15. Autopsy (time not given) by Maj. Daniel Glomset M. C.
Clinical data.-Gassed (inhalation and contact) October 17 1918. October 20 diagnosis of lobar pneumonia right lower lobe was made.
Anatomical diagnosis.-Bronchopneumonia all lobes pseudomembranous tracheitis and bronchitis. Parenchymatous degeneration of liver and kidneys. Second-degree burns of skin. No detailed description of gross lesions available.
Microscopic examination- Trachea: The membrane only shreds of which are present consists of coarse fibrin network in which are scattered pycnotic leucocytes. Surface is formed by the slightly swollen basement membrane. The outer half of the submucosa is necrotic There is a coarse fibrinous exudate in the edematous tissue with deeply staining nuclei. Vessels are congested but there is no haemorrhage. The mucous ducts are apparently obstructed at their orifices. They are dilated as are many of the mucous glands and the epithelium is metaplastic in places showing regenerative changes.
Lungs: There are small patches of pneumonia definitely grouped about the bronchioles and atria in which are found the usual lesions. Uninvolved lung is emphysematous.
Kidney, myocardium, and adrenals show no lesions of interest.
NOTE.-Typical case of mustard-gas poisoning of five days duration with membranous tracheobronchitis. Lesions of the lung parenchyma are sharply limited to the peribronchial regions. It is of interest to note that regenerative changes in the epithelium of the mucous ducts are already in progress.
CASE 22.-S. D. 2250618 Pvt. Co. I 39th Inf. Died October 16 1918 8.30 a. m. at Base Hospital No. 59. Autopsy No. 7. Autopsy four and one-half hours after death by Capt. M. Flexner M. C.
Clinical data.-Gassed October 11 1918. Exposed to blue green and yellow cross shells. Admitted to Field Hospital the same day. Base Hospital No. 59 on October 13. On admission conjunctivitis sore throat pain in chest rales of all types throughout chest. Diagnosis of gas inhalation and bronchopneumonia.
Anatomical diagnosis.-Mustard-gas burns. Fibrinopurulent tracheo-bronchopneumonia. Acute fibrinous pleurisy. Emphysema.
External appearance.-Skin about eyes nose and mouth shows crusts from gas burns. Scrotum shows dense scab formation frown old burns and other severe superficial burns on the elbows. Eyes show conjunctivitis bilateral keratitis. Cornea have steamed appearance.
Gross findings.-Pleural cavities: Right lung: Pleural surface is shaggy anteriorly due to fibrous adhesions. There are more recent adhesions between the visceral pleura and the pericardial sac. Upper lobe is grayish white in colour with a few darker patches especially at the apex and the lobe has a cottony feeling. On section it is a pinkish-gray colour with scattered flesh-coloured areas from one-half to 3 cm. in diameter. On pressure bloody frothy fluid escapes. The base of lower lobe is firm and darker in colour. Excised piece of darker tissue sinks when placed in water. Left lung: Pleura over lower lobe is covered with fibrous tags. Upper lobe on section is pinkish gray in colour. Contains scattered flesh coloured areas. Around smaller bronchioles are narrow dark coloured zones. The upper two-thirds of the lower lobe are reddish brown with a few scattered purplish areas which are dry and granular and apparently contain no air. Lower lobe is pinkish gray in colour with few scattered elevations.
Trachea and larger bronchi show erosions of mucous membrane with fibrin. The remaining viscera show nothing of interest.
Microscopic examination.-Trachea: In the trachea is deep-seated necrosis which involves the epithelium and underlying tissue to a considerable depth. Incorporated in this necrotic area is a dense fibrinous membrane infiltrated with many pycnotic leucocytes and in a few places there are clefts which separate the membrane of dead tissue from the underlying living tissue and these are lined with flattened cells possibly derived from the remains of the epithelium. There is extreme distension of all the blood vessels which form wide sinuses almost like a cavernous angioma. The mucous glands are compressed and distorted.
Lungs: The picture is unusual. There is an extensive haemorrhagic and fibrinopurulent exudate in the alveoli the arteries of which are rendered indistinct by the fragmentation of the nuclei and the abundance of chromatin debris in the septa. The elastic framework is torn and disrupted as can be seen in appropriately stained sections. There is great edema of the interstitial tissue and the interlobular septa. There are masses of Gram-positive bacteria scattered through the section.
NOTE.-Case of mustard-gas poisoning of five days' duration. There was the usual diphtheritic necrosis of the upper respiratory passages. Pneumonic lesions of the haemorrhagic "influenzal" type, with infarct-like areas of necrosis.
CASE 23.-J. B. 2810342 Pvt. Co. C 344th M. G. Bn. Died at 6 p. m. October 7 1918 Justice Hospital Group Toul. Autopsy No. A9. Autopsy performed 19 hours after death by Capt. Jean Oliver M. C.
Clinical data.-Severe mustard-gas intoxication incurred October 2 1918.
Anatomical diagnosis.-Pigmentation of skin of face; suppurative and haemorrhagic tracheobronchitis; congestion and edema of lungs; interstitial emphysema.
External appearance.-The skin over face is brown. The epithelium is excoriated in small areas and can be rubbed off on pressure. No typical mustard-gas burns. Skin of scrotum shows similar changes. No other cutaneous lesions.
Gross findings.-On removing sternum there is found interstitial emphysema which extends over upper portion of pharynx and lower portion of neck. Marked hyperaemia and edema of all lobes of both lungs posteriorly. Anteriorly lungs are emphysematous. Larynx trachea and primary bronchi contain purulent exudate. Mucosa is slightly roughened but there is no definite false membrane. There are many small haemorrhages. There is a necrosis of the mucosa of certain bronchi only in the upper lobes of both lungs. Some of them are lined with a definite grayish-green membrane. There is little fibrinous pleural exudate.
Microscopic examination-Trachea: The epithelium of trachea is completely necrotic and desquamated. Exudate consists principally of pus cells and necrotic material without definite fibrin. Corium is edematous congested and infiltrated with leucocytes. Bronchi are similar but some of them contain an edematous exudate in addition to their other components. Terminal bronchioles are also denuded of epithelium. Many of them are lined with distinct diphtheritic membrane.
Lungs: Capillaries and alveoli contain an excessive member of polynuclears. There is a granular coagulum in the alveolar spaces and exfoliated pigment-containing alveolar cells. Polynuclears are not numerous. In Gram-Weigert preparations a wavy bluish-staining network is seen lying against the alveolar wall in many of the air spaces. Bacteria are not numerous. Predominating type are Gram-positive cocci arranged in groups.
Kidneys: There is marked cloudy swelling especially in the cells of the convoluted tubules. Some tubules contain a pink-staining coagulum others red blood cells and still others desquamated epithelial cells. Liver: Capillaries are congested. There is a moderate diffuse fat infiltration.
Adrenals: Are edematous and congested.
NOTE.-Duration of life after gassing was 5 days. The interesting points in the case are:
1. Very slight cutaneous lesions and apparent absence of ocular lesions.
2. Trachea and large bronchi showed a necrosis and purulent exudate, but no membrane formation.
3. Smaller bronchi were the seat of a typical membranous inflammation, but this was marked only in the upper lobes. 4. Absence of definite pneumonic lesions after five days is unusual. There was, however, a hyaline necrosis of atrial and alveolar epithelium, which in absence of general lung infection, may be ascribed to the direct action of the gas.
CASE 24.-W. D. 238318 Pvt. Co. I 103d Inf. Died 7.30 a. m. October 3 1918 Base Hospital 15 Autopsy No. 214. Autopsy October 3 three and one-half hours after death by Maj. Daniel J. Glomset M. C.
Clinical data.-Mustard-gas burns and inhalation received in action September 28 1918. Clinical diagnosis gas inhalation complicated by lobar pneumonia.
Anatomical diagnosis.-Superficial ulcers of lips; acute conjunctivitis; first-degree burns of scrotum; pseudomembranous and haemorrhagic laryngitis, tracheitis and bronchitis; peribronchial haemorrhages; confluent lobular pneumonia left and right upper lobes; haemorrhage into gastric mucosa.
External appearance.-The epidermis about the eyes and conjunctivae is rough and reddened and covered on the left side by an exudate. Lower lip is swollen and ulcerated. There is a purplish blotch over thorax and abdomen. Skin over penis is swollen while that over scrotum is swollen and purplish. Blood is caked and black.
Gross findings.-Pleural cavities: There are a few fibrous pleural adhesions on the left side but no fluid.
Lungs: Do not collapse readily. Left lung: Anteriorly is crepitant. Posteriorly it is partially consolidated. On section there are solid areas in lower lobe posteriorly and few discrete nodules anteriorly. These are dark red in colour and vary from pinhead in size to several millimeters across and have grayish centres. In one case outside this dark-red area is a slightly raised granular pink zone. In the upper lobe in addition to similar dark areas there is a distinct well-defined consolidation involving one-third of the lobe. Right lung: Shows a similar picture. The mucosa of larynx is swollen and roughened. The trachea and bronchi contain greenish thick flocculent material. Mucosa is thick and peels off leaving a haemorrhagic surface. Bronchi show similar changes.
Heart: Is normal.
Stomach: Shows small erosions in the region of the fundus.
Small and large intestines are injected.
Kidneys: Are pale swollen and opaque. Remaining viscera seem normal.
Microscopic examination.-The trachea is covered with an exudate composed of mucus and desquamated and degenerating epithelial cells. There is practically no fibrin and very few leucocytes are present. The epithelium is conserved except at openings of ducts of the glands. It shows striking metaplasia into cells of the squamous-cell type. Submucosa is slightly edematous and vessels are injected. There is very little leucocytic reaction. In the small and medium-sized bronchi the epithelium is partially intact and ciliated. The lumina are filled with purulent exudate. A few of the large bronchi show complete epithelial necrosis with false membrane formation and contain laminated fibrin. The bacteria in the exudate are chiefly Gram-positive diplococci. The blood vessels of the bronchial walls are engorged and there are haemorrhages in the surrounding alveoli. The lung shows widespread pneumonic areas. There is an exudate of fibrin and in other places haemorrhage. Leucocytes and red blood cells are well preserved. The process is apparently quite recent. Bacteria are not numerous in the pneumonic patches; in the bronchioles they are quite abundant. There is capillary thrombosis. Interlobular septa are edematous and show an inflammatory infiltration. The unconsolidated portions of the lungs are the seat of patchy nonfibrinous edema and there is exfoliation of the alveolar epithelium with many of the cells containing pigment. Capillary congestion is marked.
Stomach: Fresh haemorrhages into the mucosa without necrosis or inflammatory reaction.
Kidneys: Capsular spaces contain a granular coagulum. There are numerous hyaline casts in Henle s tubules and tubuli recti.
Penis: The skin over the glans penis is in part denuded. Where it is conserved there is a marked increase in the pigment of the rete mucosum. There is slight papillary edema. Corium contains numerous chromatophores.
NOTE.-Duration of life after gassing was five days. The skin lesions were slight but typical of mustard gas in their character and distribution. The tracheal lesions were slight and regeneration of the epithelium, with the usual metaplasia into the squamous-cell type, had already occurred. Some of the smaller bronchi showed a simple purulent inflammation with intact ciliated epithelium; others showed characteristic diphtheritic necrosis. There were patches of bronchopneumonia which were not of the influenzal type. On the whole the respiratory lesions were not intense, and in conjunction with the mildness of the cutaneous lesions, imply a short exposure or a low concentration of the gas.
CASE 25.-A. W. G. 2088223 Pvt. Co. A 355th Inf. Died August 13 1918 Base Hospital 116 autopsy No. 12. Autopsy four hours after death by Lieut. B. S. Kline M. C.
Clinical data.-Mustard-gas inhalation. Date of gassing not recorded. Co. A 255th Infantry was exposed to yellow blue and green cross shell on August 7 and 8. Autopsy protocols of 9 fatal cases from this gas attack are on file. Admitted in severe condition with burns of face chest neck scrotum and penis. Temperature and pulse rather high. Respiration short and laboured.
Anatomical diagnosis.-Extensive mustard-gas burns of scalp, face, conjunctivae, neck, buttocks, scrotum and penis. Acute membranous and ulcerative pharyngitis laryngitis oesophagitis tracheitis and bronchitis. Bronchopneumonia. Marked pulmonary edema. Acute bronchial lymphadenitis. Slight cardiac dilatation. Parenchymatous degeneration of liver and spleen.
External appearance.-The skin has a slight sallow brown appearance. There are extensive superficial burns of the scalp, face, neck, bend of each elbow, the scrotum, penis, the skin of the genital folds and lower buttocks and in the undersurface of the right knee. There is considerable desquamation of the skin in these areas. There is some brownish pigmentation of the dermis which is most marked on the inner aspect of both thighs. Superficial glands are somewhat enlarged. Eyelids puffy and glued together by tenacious viscid exudate. The conjunctivae are edematous and injected. The pupils dilated 5 mm. in diameter.
Ears: No abnormalities except the superficial burn of the skin.
Nose: In the nostrils there is some mucopurulent material.
Mouth: Shows superficial ulcerated areas of the lips covered with sordes and viscid exudate. A number of the teeth show gold filling. There is a viscid material over the gums.
Gross findings.-Pleural cavities: On opening the thorax a small amount of fibrinopurulent exudate found free over the pleura of the lower lobe on the right side. On the left there is likewise a small amount of fibrinopurulent exudate especially marked over the lower portion of the upper and upper portion of the lower lobe. Heart is somewhat enlarged to the right. On incising the pericardium no abnormalities of or in the sac.
Heart: Weighs 380 grams the right auricle is moderately dilated. Other vise normal.
Right lung: All lobes are voluminous. Upper and middle lobes in great part cushiony inelastic. In the middle lobe there is a large solid area palpable. Binding the middle lobe to the upper lobe just above the solid patch there are a number of sheet-like fibrous bands. The pleura shows laterally and posteriorly a considerable amount of fibrinous exudate below which the pleura is considerably injected and shows numerous small discrete and confluent red haemorrhages. Medially over the upper and middle lobes the pleura is thin and delicate. The glands at the hilum considerably enlarged pigmented pulpy and injected; there is no scarring. Vessels at the hilum show no abnormalities. The bronchi show considerable ulceration of the mucosa; submucosa swollen and injected. Overlying it and the small amount of intact mucosa there is a cast-like friable gray membrane about 0.5 mm. in thickness. On section of the upper lobe a moist pink surface presents medially. Posteriorly a pinkish-red surface presents. There is a small amount of thin frothy fluid in the air sacs. Scattered throughout this lobe there are several vaguely outlined dull grayish-red solid patches varying in size from 1 cm. in diameter to several centimeters. The largest patch is present posteriorly. On pressure here viscid fluid exudes from the air spaces. The finer bronchioles are filled with viscid purulent material. The larger bronchial branches show a tenacious fibrinopurulent membrane. The middle lobe on section is in great parts pink and well aerated. There is a small amount of thin frothy fluid in the air sacs. The large solid area is found to be a patch 6 by 4 by 3 cm. uniformly consolidated dull and reddish. This portion of the lung is apparently less ventilated than the rest. In the centre of the lobe there is a small patch similar in appearance 1 cm. in diameter. The lower lobe on section presents a moist pinkish-red surface. The air sacs contain a moderate to considerable amount of thin frothy fluid. The bronchial branches show ulceration of the mucosa with adherent friable gray membrane. About the bronchial branches small and large there is deep red consolidation extending for a small distance into the lung. At the periphery of the lung the consolidation about the bronchioles is most marked. Left lung: Both lobes are much more voluminous than normal. In the median portion of the lower lobe the tissue is well aerated cushiony; posteriorly it is soggy. The lower lobe in great part is soggy and covering the pleura of practically the entire lobe there is a considerable amount of tenacious fibrinous exudate. There is some fibrinous exudate over the lower portion of the upper lobe especially posteriorly. The glands at the hilum are some what enlarged pulpy and deeply injected. The vessels and bronchi are similar in appearance to those on the right. On section of the upper lobe it is similar in appearance to the right upper lobe. There is a walnut-sized solid patch posteriorly and a few smaller patches more medially. The lower lobe on section in general is similar in appearance to the right lower lobe except that here the bronchopneumonic patches are much more numerous and extensive. The edema is most marked in the left lower lobe.
Neck organs: The glands in the lower portion of the neck are swollen pulpy edematous injected and pigmented. In the upper portion of the neck the glands likewise are swollen and injected. The thyroid much larger than normal. Each lobe measures 6.5 by 4 by 3.25 cm. There is a prominent isthmus. On section the acini are distended with colloid the tissue gelatinous and pale. In the left lobe there is a hazel-nut sized large cyst filled with gelatinous blood-tinged fluid. The larynx shows marked swelling of the mucosa and deeper tissue. In places the epithelium is gone. In these areas the injection of that tissue below is prominent. Covering the membrane there is a tenacious fibrinous and fibrinopurulent membrane. The process is quite uniform throughout the larynx and trachea and is present likewise in the upper esophagus and the base of the tongue. The tonsils are small and buried. On section there is little lymphoid tissue visible and there is much scarring. In the crypts of the right tonsil there is caked and viscid yellow opaque material.
Alimentary tract: The stomach cardiac end shows moderate patchy injection of the mucosa and there are tiny haemorrhages here and there in this region.
Duodenum: No abnormalities. Throughout the tract the lymphoid tissue is somewhat more prominent than normal especially so in the lower ileum.
Appendix: No abnormalities.
Caecum: No abnormalities. The mucosa of the colon pale the walls thinned. Mesenteric lymph glands are slightly enlarged pulpy and pale.
Liver: Weighs 1 800 grams slight fat infiltration. Remaining organs show no significant lesions.
Microscopic examination-Trachea: Lined with well-formed laminated fibrinous pseudomembrane invaded with leucocytes and containing in one area in its meshes a large mass of mucus. Beneath the membrane in places is preserved a single row of epithelial cells with pycnotic distorted nuclei cilia of which are intact. There is marked swelling of membrana propria. Subepithelial tissue edema intense congestion and haemorrhage. Marked leucocytic infiltration. Ducts of the mucous glands are distended with thick plugs of mucus. Epithelium in the superficial portions is destroyed. Additional sections cut from fresh block shows a slightly different picture. Mucosa is partly ulcerated down to perichondrium the submucosa being in these areas very dense and showing great distortion of nuclei in inflammatory infiltration with pycnotic leucocytes. In other places the epithelium is regenerating pale flattened cells covering the denuded surface. These are continuous with the proliferating epithelial cells of the mucous ducts. The sub-epithelial tissue here has the character of very vascular granulation tissue and the predominating cells are lymphoid. There are capillary extravasations and in places much edema. Mucous glands are edematous but the epithelium is preserved.
Lung: In the terminal bronchioles the epithelium is still present but shows degenerative changes. There is marked leucocytic exudate in the lumina. Consolidation is almost entirely peribronchial. There is a recent pneumonic exudate in which polymorphonuclear cells are predominating. Infundibula are dilated. Another section contains a medium-sized bronchus lined by thickened laminated fibrinopurulent membrane which together with the looser more purulent exudate practically occludes the lumen. The epithelium is destroyed and invaded with wandering cells. There is early fibroblastic proliferation. The smaller bronchi on the other hand are free from exudate and show an intact epithelium. Lung tissue itself is emphysematous and atria are dilated. There is practically no pneumonia although there is a little epithelial desquamation and masses of leucocytes in the capillaries. Still another block shows marked dilatation of the atria with some hyaline necrosis of the wall and lobular pneumonia surrounded by areas of patchy edema. Exudate consists chiefly of polymorphonuclears red blood cells