Perhaps the focal hemorrhagic lesions were most frequent in the adrenal gland. Generally, they were located in the cortex, although medullary hemorrhages were encountered. The extent of the process varied from minute hemorrhages, associated with necrosis of only a few cells, to extensive ones involving half of the adrenal. The microscopic examination of the exudate revealed the same elements and in approximately the same proportions as described for the similar process in the muscles. Not infrequently, mitotic figures in the adrenal cells indicated an attempt at repair of a minute damage.
Hemorrhages in the mucosa of the alimentary canal, including the stomach and intestines, similar to those so common at the post-mortem table in many different types of acute infectious disease, are, of course, common in influenza; but, in one case especially, a lesion was encountered which adds significance to these hemorrhages (47). Here areas of mucosa, usually round or oval and varying from one-half to two centimeters in diameter, often with ulceration in their centers, show, microscopically, bacterial emboli in the vessels of the mucosa with a hemorrhagic effusion which obliterates the architecture of this coat and extends at some points into the submucosal and muscular layers (Fig. [LVI]). Here, the occurrence of bacterial emboli in association with the lesion suggests that they may be etiologically related to similar processes in other parts of the body.
The above example of hemorrhage in the mucosa of the alimentary canal has seemed of especial interest, not only for its possible value in explaining the etiology of the lesion here and elsewhere, but as an interpretation of the findings in Autopsy No. 185, an abstract of which is appended below. There a hemorrhagic lesion in the wall of the urinary bladder led to rupture and brought the patient to the surgical clinic of the hospital.
Autopsy No. 185.
A white female, aged 46 years, was admitted to the New Haven Hospital on January 4, 1919, complaining of “cough and headache.” Five days previously she had a “cold” that she was able to “break up” with quinine and aspirin. The “cold” recurred two days ago, and since then she has had “frequent chills, aches all over, and feels weak.” Her family and past histories were unimportant.
Physical examination on admission showed congestion of the pharynx. Below the inferior angle of the scapula on the right, there was dullness, bronchovesicular breath sounds, and a few fine râles. The examination was otherwise negative. Three days later the signs in the lungs disappeared. The next day, after an attack of coughing, she complained of something having “burst” within her abdomen and of generalized abdominal pain. A diagnosis of ruptured bladder was made and 1,400 cubic centimeters of bloody urine were withdrawn by catheter. Immediate operation was decided upon and the bladder was found a hand’s breadth above the symphysis pubis; the posterior wall was very thin and presented a tear extending from the trigone upward in the mid line for 7 centimeters. Fully 500 cubic centimeters of clotted blood and urine were removed from the pelvis, but there was no marked evidence of peritonitis. A permanent mushroom catheter was placed in the urethra, and the tear was sutured. The abdomen was closed with provision for drainage. The patient was returned to the ward in doubtful condition.
Her temperature at entrance was 104°F., and it fell by lysis to 99°F. just before operation. After the operation it fell to 97°F., and in a few hours rose to 99°F. Thirty-six hours after operation she had a chill lasting ten minutes, and her temperature rose to 105°F. in eight hours, when death occurred. The respirations were thirty per minute until the rupture of the bladder when they rose to forty per minute and corresponding to the final rise in temperature rose to 60 per minute. The pulse ran a parallel curve to the temperature, ranging from 100 to 160 per minute.
The autopsy was held two hours after death, and the essential findings were as follows:—
The body was that of a moderately obese woman. Rigor mortis had not developed, but there was a distinct heliotropic hue of the face and neck. The recent surgical wound between the symphysis pubis and umbilicus was in good condition. The peritoneum was slightly dulled in the lower half of the abdomen, and there was about 100 cubic centimeters of faintly cloudy, blood-tinged, thin fluid in the pelvis. The left pleural cavity contained about 200 cubic centimeters of slightly turbid, amber fluid, but the right side was free from fluid. While the pneumonia had not been prominent clinically, both lungs were found extensively involved by a necrotizing and organizing bronchopneumonia with purulent bronchitis similar to what has already been described. As the lesion of the bladder is the distinctive one in this case, and as the other organs show nothing that has not been described elsewhere, further description will be confined to it.
The wall of the bladder was thin and soft, and grossly the sutured wound appeared in good condition. Posteriorly there was a hemorrhagic zone about 3 centimeters in width most marked beneath the mucosa, but involving all of the coats. The mucosa was superficially ulcerated along this area, and was covered by a thin, patchy, fibrinous exudate. In addition, there were scattered beneath the mucosa several smaller hemorrhagic foci, quite distinct from the larger one.