The pathology of influenza

by M. C. Winternitz; Frank P. McNamara; Isabel M. Wason

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

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

Autopsy No. 194.

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

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

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

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

FIG. XXXIII. GANGRENE OF THE LUNG.

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

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

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

Summary.

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