Part 2 — THE PATHOLOGY OF EPIDEMIC INFLUENZA
Reading edition
By Oskar Klotz, M. D., C. M.
The discussion to be entered into in this report will be limited to an experience dealing with epidemic influenza as it was met with in the emergency Military Hospital in Pittsburgh. We shall largely confine our attention to the observations which came directly under our supervision, and in as much as this investigation was continued during the epidemic as it swept over this district, the intensive study was limited to a time period of about five weeks. During this period much material was collected, which since then, has taken us a considerable time to analyze. We have thought it more valuable to restrict our discussion to this material in that it illustrates the pathological lesions as they occurred during the acute stage of the disease. We have not entered upon a discussion of the sequelæ or the chronic lesions which are not uncommonly found following in the wake of an acute epidemic nor do we deal with the lesions arising in cases of sporadic influenza, such as are always with us. As is so well illustrated in the literature, there is probably no disease which has so many late complications and sequelæ as influenza. The investigations upon the protean lesions have been fully reported in numerous papers during the intervals between epidemics. A comprehensive bibliography upon influenza will be found at the end of the extensive report by Leichtenstern (1905). There is very much less accurate information available upon the actual lesions present during the acute disease when present in epidemic or pandemic form, than upon the many clinical complications in various systems and organs. In fact, our knowledge of the pathology of influenza lies more largely in the field of associated lesions such as the late events in the bronchi, the sinuses of the head, abscesses, meningitis and other conditions, rather to be viewed as complications than as portions of the disease. There are relatively few thorough pathological analyses of the influenza lesions as they are found in the acute epidemic disease.
208A fair literature has already appeared upon epidemic influenza from the many countries and regions over which the present pandemic (1918) has swept. These reports by various authors are offered from different viewpoints, some investigators being impressed with certain features which they bring into marked prominence in their reports. It thus happens that up to the present there is a decided lack of uniformity in the opinions expressed upon different phases of the subject. The nature of the pathology of the past epidemic has given rise to many expressions of opinion as well as dogmatic statements, which are found to differ from those of others. It seems to us that this apparent confusion arises partly through the somewhat different characteristics of the disease as it has made its appearance in different centers. We hear it repeatedly stated that the types found in different military camps and urban communities were quite unlike those of other regions. It is evident that such differences in the clinical course actually did exist and that the epidemic though having a common foundation upon which the disease process was built differed in what might be looked upon as symbiotic complications during the early and acute stages. Differences in the nature of the findings in various communities also probably lay in the fact that the bacterial flora associated with the causative agent of influenza was quite different in different regions. We mention this here so that a full appreciation will be obtained for the differences in the pathological characters of the disease as they are found in one region or another. We appreciate, of course, that if the concomitant bacterial flora associated with the underlying cause of influenza, differs in different regions, so, too, will the bodily reactions differ within certain degrees. We are becoming more familiar with different types of bacteria, and the resulting inflammatory reaction which is often unique or at least particular, and that not uncommonly the nature of the inflammatory process suggests the type of bacterium involved. This argument, of course, must not be driven too far, for we well know that the same micro-organisms under different conditions can cause types of inflammatory reactions wholly divergent.
In as much as our observations are confined to a particular group of cases and the study of these was undertaken during the five weeks of the acute epidemic, these results are not to be compared with the collected statistics on influenza as they shall 209be made over a period beginning with the onset of the epidemic and ending with the last vestiges remaining after months or it may be years of time. Our observations are to be considered only in the light of the events taking place during the height of an epidemic wave. In as much as influenza presents itself during an epidemic in different forms, we shall again mainly limit the report upon our investigations of those cases having respiratory lesions. Our acute observations were made upon the tissues of those who had died of this disease. It is impossible, or nearly so, to fully study the tissues of those with lesser lesions and who recover. Hence, if we divide the influenza cases into those (1) without pulmonary lesions and (2) those with pulmonary lesions, we must state that all of our cases coming to autopsy fall in the second group. It is true that one of these having pulmonary lesions was not brought to his fatal termination by them but by a septicæmia arising in the middle ear. He had distinct lesions in his lungs. In other words, our autopsy material represents epidemic influenza in which the lung was definitely involved in an inflammatory state. In all but one of these the pulmonary lesion was the cause of death.
No doubt, if opportunity had presented itself to follow a large epidemic through months of its progress, during which late complications in various portions of the body would make their appearance, our analysis would give a different picture and the pulmonary factor for the fatal termination would not be in such prominence.
Of the first group, those cases of epidemic influenza not showing pulmonary lesions, we will have very little to say, in as much as the pathological investigations of them is impossible, or nearly so, during the height of the disease.
Such cases apparently do not die at this period. I am willing to admit that individuals without pulmonary involvement may succumb, but I question whether their death has been due to the result of the influenzal lesions, be it in nose, pharynx, larynx or trachea, or be it in the intestine, but rather that the fatal termination occurred later in the course of this complex disease, when distant vital organs became involved or incapacitated in a toxemia or secondary bacterial invasion. We must clearly distinguish these cases from the clear-cut ones of epidemic influenza, looking upon the new circumstances as complications aside from 210the original disease. Such, for example, is the case we have mentioned where a fatal streptococcus bacteriæmia followed in the wake of an otitis media. In our experience we have not had a fatal case of the acute epidemic disease in which the lung was not involved.
In types of epidemic disease such as we have just had, where the epidemic wave has passed over in a period of four or five weeks, there is always much to be regretted which has been left undone. We tried as far as possible to gain all the information available at the time of collecting our materials and of laying aside such of the work which could be accomplished at a subsequent date. The materials were collected from divergent sources in the cadaver, and the more perishable substances were analyzed immediately. During the period of the epidemic 32 autopsies were performed and as much use as possible was made of each for a thorough comprehension of the lesions.
Materials
During the period of our work 639 patients were admitted to the hospital suffering from clinical influenza. The cases varied in type from the very mild to the extremely ill. The majority of the cases were of the type of “three-day fever.” Clinically 81 cases developed pneumonia, and of these, 35 died. It would, of course, be impossible to say how many other individuals had a pulmonary involvement which could not be recognized clinically. In fact, some of the cases which did come to autopsy were only recognized as having a pulmonary involvement when the lungs were examined outside of the body. The physicians freely admitted that the physical signs were quite unusual and unlike those of the ordinary forms of pneumonia. In fact, except for the fact that we were living in the midst of an epidemic of respiratory infections, there was nothing to make the clinician suspect that many of these cases had a pulmonary involvement. Obviously, when the recognized signs of different types of pneumonia made their appearance, the clinician did not fail to make proper interpretation of the lung involvement. This, as we shall discuss later, is an event superadded to a lung condition which pathologically must be recognized as pneumonia (inflammation) and which differs so decidedly from what we know of as croupous or lobar pneumonia, as well as ordinary broncho-pneumonia that 211it would be incorrect to include them under this heading, although the distribution of the lesion may have lobar, bronchial or lobular characters.
TABLE I
Date 1918 Patients Admitted Patients Discharged Cases in Hospital Deaths
October 5 65 0 65 0
〃 6 23 0 88 0
〃 7 61 0 149 0
〃 8 77 0 225 1
〃 9 42 1 266 0
〃 10 35 1 300 0
〃 11 9 0 307 2
〃 12 2 16 290 3
〃 13 10 0 298 2
〃 14 1 18 278 3
〃 15 4 13 266 3
〃 16 9 23 248 4
〃 17 10 19 235 4
〃 18 16 34 217 0
〃 19 38 29 225 1
〃 20 27 0 252 0
〃 21 37 43 245 1
〃 22 33 7 270 0
〃 23 14 20 263 2
〃 24 20 17 266 0
〃 25 27 21 272 0
〃 26 10 29 250 0
〃 27 18 3 265 1
〃 28 10 31 243 3
〃 29 6 16 231 0
〃 30 11 27 215 1
〃 31 2 15 202 2
November 1 2 18 185 0
〃 2 4 18 170 1
〃 3 5 1 174 0
〃 4 2 19 156 1
〃 5 5 0 161 0
〃 6 4 16 149 0
Admissions. 639 35
The individuals admitted to this hospital were obtained from the two military camps at the University of Pittsburgh and the Carnegie School of Technology. All of them were enrolled in 212the army service and ranged from the ages of 18 to 30. They were vigorous individuals, who had passed their physical examinations for the army. The epidemic made its appearance in these camps on October 2, rapidly ascending from a report of two ill on October 2, four on October 3, eight on October 4, to 65 on October 5. On October 11 there were 307 cases in the hospital.
Of these cases 35 died, the day of death being indicated in the following table.
TABLE II
Day of Disease on Which Death Occurred Number of Cases
Third 1
Fourth 3
Fifth 4
Sixth 4
Seventh 4
Eighth 5
Ninth 3
Tenth 4
Eleventh 3
Thirteenth 1
Fourteenth 1
Twentieth 1
Twenty-third 1
The time as indicated in the above table has no relation to the length of time that the patients were ill of pneumonia, but refer to the period of illness from the beginning of the influenza. The duration of the pneumonia is indicated in another table.
Of the 35 fatal cases 32 came to autopsy. Facilities were available to do the work very satisfactorily, in that the hospital was well provided with a modern post-mortem room and its accessories. The notes on the autopsies were taken immediately and fully, and the materials for subsequent study were collected in different types of preserving fluid. Portions of tissue were collected from all of the organs for microscopical study, while fluids from the chest, lungs, bronchi and heart were obtained for bacteriological investigations and for some chemical analyses.
Added to the above material we also had the opportunity of reviewing and studying the lesions of 18 autopsies performed by 213Dr. J. W. McMeans. These cases were very similar to our own series, in that they were cases of epidemic influenza amongst soldiers who were being cared for at the St. Francis Hospital. The disease processes were quite alike in the two series, and the analyses made by Dr. McMeans are comparable in our own and serve as a means of checking our results obtained in another institution. The similarity of the lesions in the lungs and other organs serve to indicate that what is reported in this paper is an index of the nature of the lesions of epidemic influenza as it occurred in the Pittsburgh district. In a few instances the autopsies performed by Dr. McMeans revealed more advanced pulmonary lesions with abscess and gangrene than were noted in the cases autopsied at the Military Hospital. The process, however, in the two series of autopsies was identical.
General External Features
There were no external characteristics of the bodies which were autopsied by us which were constant. Some features were more commonly present than others. Of these the cyanosis of the face, head, neck and shoulders, and in a few instances of the upper extremities, attracted our attention more than any other. This cyanosis was present in over one-half of the number of cases, and it was confined almost always to the upper part of the body. The face, ears and neck were always more affected than other parts. This cyanosis bore no relation to the length of time after death when the body was viewed, as we found that when it was present during life it maintained its prominent appearance for a long time after death.
The cyanosis differed from the bright hue or flush as it is at times observed in ordinary pneumonia, the color in these instances being of a dark purple, or better a purplish blue. The lips and ears showed the most intense color. The cyanosis was not associated with any evidence of œdema. The capillaries of the tissues were filled with blood which was of a very dark character. Cyanosis could also be seen in the finger tips about the nails. This was more marked in the upper extremities than in the lower. The skin of the body rarely showed any cyanosis, these tissues being quite pale, or at times showing a slightly yellowish tinge. In one instance the cyanosis of the head and 214neck was accompanied by a slight purplish rash upon the upper portion of the chest. This rash was of a petechial kind, there being slight hemorrhage into the tissues. The lesion, however, was not of the blotchy purpuric type which has been observed by others during this and past epidemics (Cole). This single case is the only one where we had evidence of superficial hemorrhages into the skin.
TABLE III
Cyanosis No Cyanosis
No. Degree Distribution
741 + Chest and upper extremities 747
743 + + Face, neck and ears 748
744 + + + Head and neck (upper portion of chest and thighs mottled and purple) 749
745 + + Head and neck and upper extremities 751
746 + + Ears, neck and shoulders 752
750 + + Face, ears and neck 764
756 + + Neck, jaw, shoulders and upper extremities 765
757 + Face, neck, shoulders, arms and chest 778
758 + + + Face, ears, neck and upper chest 782
761 + Face, ears, neck and upper chest 784
762 + Ears, neck and chest 786
763 + Head and neck 793
767 + Face, ears and neck
773 + + Neck, ears and cheeks, extending moderately to upper chest. Hemorrhage into conjunctiva
781 + + Eyes, lips, ears and neck
783 + + Face, lips, neck and fingers
787 + + + Ears, neck and shoulders
791 + + Ears, neck and upper chest
792 + + Ears and back of neck
19 + Blotchy or slight 6 12 or
or ++ Moderate 10 38.6%
61.4% +++ Well marked 3
770 Fine petechial rash over upper chest.
Occasionally we met with small hemorrhages lying in the upper layers of the subcutaneous tissue. These lesions were small and could not be seen from the external surface. Nevertheless, 215some of them seemed to have occurred in direct contact with the deep cutis and surrounded portions of the deep skin appendages. From an examination of our cases there was no reason at the time of autopsy to lay any particular stress upon the occurrence of these hemorrhages. Subsequently, it has come to mind, and since learning of the unusual frequency of boils and deep pustules making their appearance as post-influenzal sequelæ, that these minute lesions may have a bearing upon the localization of infection in the skin tissues. We must appreciate, of course, that other factors of a constitutional nature probably render the individual more susceptible to the invasion of the staphylococcus, and that such factors are all-important in allowing this organism to gain a foothold. Whether the decreased sugar-tolerance with hyperglycemia, which has been observed in the late stages of influenza, bears a relation to the increased susceptibility, as appears to be the case in diabetes mellitus, is an interesting point for further investigation. Other constitutional states are also undoubtedly involved in the increased susceptibility to the infection which the patient suffers. Elsewhere (Dr. Holman) it is shown that the natural complement content is considerably depressed during the height of the influenza. With such factors present and with the available infecting micro-organisms, it is possible that the minute deep skin hemorrhages bear a relation to the immediate localization of the infection.
In two instances slight hemorrhages were observed into the conjunctival tissues. In each case they were unilateral and occupied the tissues contiguous to the inner canthus. In one case there was well-marked icterus with yellow coloration of the scleræ and skin. In this case the icterus was associated with degenerative changes in the liver, there being no recognizable obstruction to the bile passages. The icterus had come on quite acutely and without any special clinical manifestations. In the epidemic of 1890 jaundice was present in a considerable number of cases (Medical Record, 1890, xxxvii, 473). Cole made similar observations in the epidemic of influenza amongst the Canadian soldiers. Œdema of the skin was not met with in any of our cases. This point is worthy of comment, inasmuch as some authors have been impressed with the serious damage taking place in the kidney and the resulting incapacity of these organs. 216Although, as we shall point out later, the kidney tissues in these cases showed a decided toxic degeneration, there was no evidence that a glomerular damage of serious degree ever occurred. The urinary excretion, as is pointed out in a report by Dr. Zeedick, varies considerably with the intensity of the disease. It is unusual to find derangement of kidney function to a degree to reflect seriously upon the general bodily state. At least this has been our experience in the present epidemic. Even where subsequently we were able to demonstrate a considerable tubular degeneration in the cortex of the kidney the change in the kidney function was not of sufficient magnitude to lead to a water-retention to be recognized in an anasarca. I wish to distinguish clearly at this point the difference in finding an œdema in certain involved tissue structures in various parts of the body and arising through an inflammatory reaction due to the presence of peculiar focal irritation, as compared with the accumulation of fluid in many and irregular situations as it occurs through retention and faulty excretion by the kidneys. Various organs as we have found—as, for instance, the lung, heart and liver—showed a condition of œdema which was not to be reconciled with an inadequate circulation because of a cardiac or renal incompetency. These œdemas, which we will discuss later, are local and are the result of damaging influences inducted in and upon the tissues where they are found.
Muscle
In all of our cases we have been struck with the excellent physique of the individuals succumbing to this epidemic. All were youths in the best of health, of good muscular build and strong bony frame-work. Post-mortem rigidity set in fairly rapidly after death. Where this rigidity had “set” for six or more hours it required much force to change the position of the muscles. The voluntary muscles of the thorax and abdomen were always carefully observed, and in a number of instances the muscles of the thigh were also examined. It was not possible routinely to dissect the muscles of the extremities, so that we are unable to give an accurate account of the occurrence of degenerations in these structures. We have, however, observed the reactions taking place in the pectorals, psoas and muscles of 217the abdominal parietes. Changes were observed with greatest frequency in the recti of the abdomen. Degeneration occurred in these muscles in 14 instances, while the same tissues suffered rupture, in part or completely with hemorrhage, in six instances. It was not uncommon to find marked degeneration in the lower segment of the rectus muscle on one side, while degeneration and hemorrhage had occurred in its fellow on the opposite side. In four cases rupture of the entire belly of the muscle had taken place, so that a considerable space had occurred between the broken ends and a large clot of blood filled the intervening space. This degeneration, which was seen only in the voluntary muscles, was quite interesting and in its milder degrees was rather difficult to detect. All gradations of loss of muscle color were seen. In some instances the muscle simply seemed to have lost its meaty lustre, while again in the more severe instances the muscle color had changed from the bright red to an insipid yellow or clay color. The most marked degeneration occurred in the midportions, while the ends of the muscle masses at the points of attachment were less involved. Complete rupture of the rectus always occurred in the lowermost segment, a short distance above the insertion into the pubic bone. At times the distribution of the degeneration within the muscle was quite patchy, and irregular islands of yellow about 2 cm. in diameter were splashed through the muscle masses, which in themselves were paler than normal. Where the muscle degeneration was advanced the tissue was soft and at times even buttery. It resembled the character of the degeneration observed in typhoid fever, although I have no recollection amongst many enteric cases of having seen the degeneration of the muscle occur so acutely. Recklinghausen claimed that these hemorrhages were most unusual in influenza. This is contrary to our findings.
Degenerations of a similar kind as those of the abdominal recti were found in both pectorals. In the chest region, however, the degeneration was less frequent and less severe. We observed it only twice, and in neither instance had the degeneration led to a rupture and hemorrhage of the muscle bundles. Kuskow observed a single case of degeneration and hemorrhage of the pectoral muscles. In the psoas muscle we observed degeneration on two occasions, in one of which the lesion was associated with a partial separation of the muscle fibers and hemorrhages into 218its substance. In one case clinically, but not coming to autopsy, a lesion, which from its character we presume to have been a degeneration, occurred in the sterno-mastoid, being accompanied by hemorrhage and the development of a firm clot the size of a hazel nut. In the subsequent history of this case the lesion passed through an aseptic process of organization with contracture so that the patient has recently been developing a “wryneck.” Kohts in 1890 reported the finding of muscle degeneration and abscesses in the arm. The condition arose as a late complication of influenza.
From our experience at the autopsy table in observing the relative frequency with which muscle degeneration occurs in the severe cases of epidemic influenza, we feel convinced that numerous cases which recover pass undiagnosed of this condition. Furthermore we have evidence, as illustrated in a case observed by Dr. McMeans, wherein a lesion which occurred in the gluteal muscles was followed by a localizing infection at this site that these muscle degenerations and hemorrhages may have serious consequences. There are a number of instances in which post-influenzal complications of the nature of deep-seated abscesses of the extremities, thorax, and abdomen may have their explanation for the localization in a primary muscle damage accompanied by hemorrhage and followed by an infection of variable type. Cole also comments upon the development of abscess in the deep muscles where degeneration had taken place. In illustrating some of our findings to Dr. J. Anderson he immediately recognized such a condition in the pectoral muscles of a patient in which he was unable to arrive at a conclusion of the pathological events which had taken place. It is one of the noteworthy features in this disease that the voluntary muscles of certain regions are apt to suffer severe damage, while the heart and the various unstriped muscular tissues are little if at all affected by a similar process. It would be interesting to know whether the lack of response and the delayed functional recovery on the part of the muscles of the extremities in so many patients who have suffered influenza is the result of the damaging influence of a peculiar intoxication present in this disease. One of the features in influenza is the prostration of the patient, and with it there is definite muscular weakness. We have been prone to lay the responsibility of this state entirely at the door of the nervous 219tissues. Here, however, we are able to offer evidence that quite aside from the lesions arising in the nervous tissue, there is definite muscle damage which, as we shall again discuss when describing the microscopic features, incapacitates even to the point of complete destruction the muscle elements in various fields of the body. Before, however, being able to state that the muscular weakness of the extremities is the result of such damage by toxins it is necessary to obtain more definite information regarding the frequency with which these degenerations occur in the limbs. In our own material we are unable to discuss the matter with adequate figures. We are, however, impressed with the changes observed in the muscles which were available to us. Naturally, too, a certain number of muscle degenerations have escaped our detection because of our unfamiliarity with the mildest grades. In fact, we have already discovered in our microscopic studies that certain cases, which in the macroscopic had escaped us, showed well-marked lesions under the microscope.
TABLE IV
MUSCLE DEGENERATION
Abdominal Recti Pectoral Psoas
Toxic Degeneration Hemorrhage Into Rectus Toxic Degeneration Toxic Degeneration
745 on 10th day 745 both on 10th day 756 on 8th day 756 on 8th day
749 on 4th 752 both on 13th 770 on 11th 792 on 6th
752 on 13th 756 both on 8th
756 on 8th 764 both on 9th
757 on 6th 765 both on 9th
762 on 10th 778 both on 23d
763 on 11th
764 on 9th Rupture of
765 on 9th Rectus
767 on 10th
770 on 11th 745 right on 10th day
778 on 23d 756 both on 8th day
783 on 8th 778 right on 23d day
791 on 6th
We have convinced ourselves that the marked hemorrhage taking place in the muscle tissue follows upon a primary degeneration of this tissue and its spontaneous rupture. The amount 220of hemorrhage is in proportion to the degeneration and fracture of the muscle elements. The hemorrhage does not precede the muscular change, nor does it have any antecedent relation to the actual tearing of the muscle fibers.
A much better appreciation of the muscle degeneration was obtained in the microscopic studies of these tissues. The various gradations of tissue change could be followed, which was not possible in the naked-eye examinations. Some points respecting this degeneration were quite noteworthy. Firstly, the process of degeneration in its early stages and advancing through the acute destructive periods was not accompanied by any inflammatory reaction. Evidence of inflammatory exudate was obtained only when the degeneration had proceeded to a degree permitting of rupture with hemorrhage, or in the late stages when the areas of marked muscle dissolution were undergoing repair. We have no evidence to indicate that bacteria were present during the beginning of the degenerative process. Bacteria could not be demonstrated in section. The appearance of the tissue suggested a purely toxic process which was selective in its action, picking out voluntary striped muscle tissue and attacking certain muscle groups in preference to others. It was also interesting to observe in the early stages of the degeneration that individual fibers lying amidst healthy and unchanged muscle elements would show degeneration in many of its stages. This appearance was often unique, particularly when in the early stages of the process the involved fiber would still retain its normal position and shape though markedly altered in its staining and chemical qualities.
The degeneration as observed in these cases showed many of the characters like that of waxy degeneration seen in typhoid fever. Similar appearances to these have also been described in connection with the toxic degenerations which occur in the vicinity of infections by the gas bacillus. In fact, all the stages observed in the one can be seen in the other. They differ, however, only in the degree to which final destruction takes place and in the speed with which the degeneration is accomplished. The character of the degeneration is well studied in sections stained with hematoxylin and eosin, eosin-methylene blue, and best of all in the phosphotungstic acid hematoxylin. By the latter method one is able to follow clearly the grade of degeneration as it effects the muscle striations. On the 221other hand, the peculiar waxy appearance of the early degenerating fibers is best seen in sections stained with eosin or fuchsin, where the striated muscle fibers are found to be changed to a more intensely staining red body of homogeneous character and devoid of all evidence of their original internal architecture. These bland waxy fibers were often of the size and shape like the normal. On the other hand, the fibers are also not uncommonly swollen, stretching the sarcolemma to almost the bursting point. Following this primary bland degeneration the fiber takes on irregular shapes, becoming constricted and collapsed at irregular intervals, so that islands of the waxy contents lie within the sarcolemma, being separated from each other by constricted areas in which the original myoplasm has undergone decomposition and sometimes complete absorption. This irregular destruction of the muscle contents often has a granular stage in which the original muscle substance has become disintegrated. The sarcolemma follows the condition within it, stretching when the fiber is swollen and shrinking, or even becoming collapsed when the inner substance is becoming liquified and absorbed. The sarcolemma does not suffer the degenerative changes of the inner fiber, nor can one observe nuclear changes in this sheath which are significant.
When first studying this process of degeneration it appeared to us that the earliest change was a loss of the transverse striations and the subsequent disappearance of the longitudinal fibrillæ. We have subsequently found that this is incorrect and that the changes observed in the markings of the fibers were not constant. At times the muscle substance would progress through stages of degeneration up to the point of disintegration and dissolution while the transverse striæ were still discernible in the altered fiber. The one constant change that we have observed in the degenerating fibers was the early loss of staining qualities as obtained by the phosphotungstic acid hematoxylin. In such preparations the earliest effect of the intoxication upon the muscle fiber was a change in reaction to this stain. Sometimes within a given fiber small irregular and poorly staining blotches could be observed, while the remaining portion of the fiber was normal in its appearance. Later these poorly staining areas became larger, occupying the entire width of the fiber and being distributed at irregular intervals in its length. Finally the characteristic 222staining quality was entirely lost, although in the poorly colored cell transverse striations were still discernible and a true waxy stage had not yet taken place.
At times the waxy degeneration advanced into the stage of disintegration by an irregular destruction within the fiber. When this occurred the fragments of waxy substance took on curious coiled and grotesque shapes, while a granular destruction was taking place in their periphery. Neither inflammation, œdema nor a vascular reaction could be determined in these tissues of mild or severe change. The reaction as is indicated in the table occurred quite acutely and was not accompanied by fatty products commonly seen in the slower forms of degeneration.
Gradually the debris of the degenerated fibers is absorbed and the sarcolemma shrinks and collapses upon itself. During this stage a reaction occurs in the sarcolemma with nuclear proliferation. At times the last vestiges of the muscle fiber are seen to be surrounded by a crown of nuclei and cells reminding one of the appearance of the degenerating nerve cells in the Gasserian ganglion in hydrophobia. The involved area becomes active in appearance, showing proliferation of fibroblasts and the appearance of occasional lymphocytes and plasma cells. Scar tissue continues to develop in proportion to the amount of damage done. In areas where hemorrhage had taken place the amount of scar tissue is exaggerated, owing to a process of organization which is taking place quite apart from the muscle degeneration. Thus not a few scars scattered through the voluntary striped muscles are the final outcome of this toxic degeneration occurring in epidemic influenza. Some of these lesions may account for the indefinite pains and symptoms of which the patient complains for so many months after his acute illness. I refer particularly to lesions occurring in the psoas and muscles of the back as possible explanations for the partial invaliding of some individuals.
In a certain number of cases of acute influenza the patients complain of severe abdominal pain, in the absence of any localizing symptoms or evidence of intestinal derangement. Such was the case with a number of the above cases coming to autopsy, and the sole evidence we could offer was muscle degeneration with or without massive hemorrhage. The abdominal pains complained of were more of the nature of dull aches with occasional exacerbations and shooting or lancinating “stitches.” Rarely was the 223patient able to define the position of the pain, not being able to state whether it was within the abdomen or in the parietes. Most frequently they claimed it was internal. We have on no occasion demonstrated an intra-abdominal lesion which could account for such pains. None of our cases was of the type of “intestinal influenza.” We are, therefore, led to the conclusion that the muscle degenerations of the various degrees, from the slight with few muscle elements involved to the severe with rupture and hemorrhage, account for a proportion of the clinical symptoms of (muscle) pains and aches as well as weakness. We cannot claim that coughing was a necessary factor in inducing rupture of the abdominal recti. In some of the cases with rupture severe coughing had not been observed during the illness.
Upper Respiratory Tract
The pathological changes found in the nose, pharynx and larynx were of relatively slight importance and most variable in their severity and incidence. The majority of individuals had few clinical manifestations of disease in these parts. Some, however, complained of dryness of the pharynx with slight feeling of fullness. An examination of these parts revealed some congestion, varying from a red injected mucosa to a bluish cyanosis. In the nose the reaction was rarely as acute as is seen in infectious coryza, but even where relatively little change was to be seen in the tissues hemorrhage from the erectile tissue was not uncommon during the acute stages. No particular lesion was to be found associated with nose bleed. There was an unusual absence of excessive secretion from nose and pharynx in the majority of cases. One was also struck with the infrequency with which the larynx was involved. A certain number of individuals complained of hoarseness, and in them injection of the vocal cords with some swelling was found. In many others, however, even where an intense infectious process was present in the lower respiratory tract the larynx was almost without change. It was from the level below the larynx that the acute reaction in the respiratory system was found.
In all of our cases the trachea showed definite inflammatory reaction. Of the 32 cases there were 26 having an acute tracheitis, 5 with an acute mucopurulent inflammation and 1 with a 224reaction in the subacute stage. In the majority of the cases with acute tracheitis there was a thin layer of exudate lying upon the mucosal surface. At times the trachea was filled with a frothy serous fluid, the greater part of which had its origin in the lung. Nevertheless, as we shall point out later, we did obtain microscopical evidence indicating that during the early acute stage of the tracheitis a considerable serous exudate escapes from its mucosa. This serous inflammatory reaction is an important one for all of the mucosal structures upon which the virus of influenza obtains a footing. This we have found true for the trachea, bronchi and alveoli of the lungs. In some cases the exudate was grey and lay in close contact with the injected tissues. At first sight this grey exudate suggested necrosis, but it was readily wiped from the underlying structure. Some leucocytes and cell debris with many bacteria made up the content of this grey exudate.
The macroscopic appearance of the trachea was that of an intensely injected structure which had largely lost its normal lustre. The naked eye could distinguish that anatomical change had occurred in the surface tissue of the trachea and that there was unusual evidence of intensely injected vessels lying in the submucosa. In only one instance was there an appearance of a true necrotic membrane lying upon the surface of this intensely inflamed layer. This apparent membrane was found to consist of a wide patch of desquamated epithelial cells which was lying as a delicate necrotic plate upon the surface. This thin layer was devoid of a meshwork of fibrin threads as usually accompanies a true false membrane of other sources.
The early intense inflammatory reaction of the surface membrane of the trachea was characteristic, and in our experience was never exceeded in intensity by other infections. A desquamation of the lining membrane was also a common finding. Naturally this intense reaction so commonly found in the trachea extended without interruption into the main bronchi and their divisions. The finding of this continuous surface inflammation is good evidence of the mode of spread of the infectious process along these membranes, beginning in the upper portions and by direct continuity involving more and more of the respiratory tubes toward the lung.
225The varying grades in the intensity of the inflammatory reaction upon the inner surface of the trachea was well illustrated in the microscopic sections. Even with the different degrees of the reaction there was a fairly constant character to the inflammation. In this way the response was found to differ from that commonly observed in ordinary infections of the respiratory tract. The first striking feature is the marked response of the vascular channels, both blood and lymphatic. The vessels lying in the submucosa were found intensely engorged so that their walls were stretched to the point of bursting. In fact, not a few vessels were seen whose walls, probably under the stress of intoxication and dilatation, had given way leading to a flooding of the neighboring tissue with their contents. Where such vessels lay close underneath the surface the hemorrhage escaped into the lumen of the trachea. Accompanying this early vascular response there was found a marked serous exudate leading to a stretching of the submucosal tissues by distention of the interstitial spaces. This reaction resembled an acute inflammatory œdema and occupied the area between the mucosa and the inner border of the cartilage rings. Beyond this region no response was found. Thus in the earliest stages, and where the mucosa was still intact, the main reaction was of the nature of an intense serous inflammation with congestion of the blood vessels and frequent interstitial hemorrhages.
Shortly following the development of the serous exudate in the submucosal tissues, the epithelial lining is found to suffer from the reaction. The serous exudate does not remain confined to the interstitial tissues, but is poured out through the mucosa into the trachea. It would appear that the amount of this clear exudate may become greater than can be dealt with by the mucosa, with the result that an accumulation of this serous fluid takes place between this epithelial layer and its basement membrane. We have repeatedly seen considerable stretches of the mucosa lifted from the basement membrane and shed in large plaques into the lumen. These mucosal cells at the time of their desquamation retain fairly well their morphological characters, and do not show evidence of necrosis prior to their removal. Disintegration of these cells naturally occurs while lying in the secretion of the trachea, and a variable cellular mass in stages of disintegration may often be found both in smears and sections. 226When the epithelial cells are lifted in wide plates, a type of bleb develops which is easily broken and then disintegrates.
The desquamation of the lining membrane is a fairly constant occurrence in the cases coming to autopsy. In the majority of those which we have examined the greater portion of the trachea was completely denuded, save for small islands lying in the recesses near the mouths of the mucous ducts. In one case this lesion was accompanied by a process of ulceration, due in all probability to the invasion by other micro-organisms. The denuded tracheal surface usually shows a further inflammatory reaction in which a cellular exudate then makes its appearance. This reaction is mainly one in which lymphocytes and plasma cells infiltrate the spaces previously occupied by the serous fluid. The reaction is limited to the submucosa and does not extend into the tissues beyond the cartilages. We have found only occasional polymorphonuclear leucocytes lying close below the surface. During this period, however, varying grades of degeneration may occupy the upper layers. The basement membrane particularly seems to suffer by losing its characteristic outline and staining qualities. This membrane becomes swollen, softened and indefinite. At times a homogeneous precipitate occurs along its free surface giving rise to an appearance resembling a false membrane. This deposit is, however, distinctively different from the diphtheritic membrane of other infections. It is interesting, however, that where such deposits and degeneration occur in the basement membrane more or less degeneration and necrosis also occur in the connective tissues immediately neighboring to it. These tissues show a peculiar granular destruction and alter their staining qualities. Moreover, and what is more important, under these conditions the dilated blood vessels are found to suffer from the injuries taking place in their neighborhood. We have repeatedly found partially or completely thrombosed capillaries, arterioles and venules in these surface layers. These thromboses took place while the vessel was in its distended state and thus produced a mold of the dilated vessel. This observation is of importance in indicating the severity of the effect of the virus and toxin upon the tissues of the trachea, and it is also of importance to appreciate that this damaging influence is very different from that which we encounter in pneumococcus infections, and we shall point out in our discussion on lung a reaction 227very similar to that which takes place very superficially in the trachea may also occur in the alveolar walls of the lung.
Having referred to the intensity of the responses of the blood vascular system, we must also indicate the part played by the lymphatics. Simultaneously with the reactions taking place about the blood vessels of the trachea we observed similar responses in the lymphatic channels. At first these dilated structures contained only fluid. Later the migration of the lymphocytes took place along these routes, and rarely micro-organisms could be demonstrated either free or within an occasional leucocyte. The sharp response of the lymphatics during the serous inflammation is noteworthy, inasmuch as we have found that the lymph glands lying about the respiratory tubes and lungs were early in their response to the irritating virus.
Bacteria were demonstrated in the secretions lying upon the surface of the trachea. In those specimens in which the mucous membrane was still intact we attempted to demonstrate the clustering of the micro-organisms about the ciliated cells as was described by Mallory in whooping cough. Although the organisms, and particularly small Gram negative bacilli, could be demonstrated lying about these cells no characteristic arrangement was found. Furthermore where the mucosa was still attached to its basement membrane we were never able to demonstrate organisms below the surface of the epithelial layer. In several cases where the mucosa was lifted in bleb-like structures a number of organisms were detected below the epithelial layer and in contact with the basement membrane of the submucosa. We have rarely demonstrated bacteria in the interstitial spaces of the submucosa, even where large numbers of organisms were lying upon the inner denuded surface.
The distinction which was made by the gross examination of the trachea between the acute tracheitis with serous exudate, subacute tracheitis and mucopurulent tracheitis was not so readily distinguished in the microscopic sections. In the gross the character of the exudate lying upon the surface was the main guide suggesting the nature and intensity of the inflammatory reaction. In the microscopic sections this exudate was largely wanting, or was not sufficiently characteristic to confirm the gross findings. On the other hand, differences in the nature of the injury were to be found mainly in the reaction of the submucosa. 228As we have indicated above, the early inflammatory reaction of the trachea is mainly evident in an intense congestion accompanied by an inflammatory œdema of the submucosal tissues, hemorrhage sometimes accompanying this response. In the later stages of the reaction a cellular deposit takes the place of the inflammatory œdema and usually consists of lymphocytes and plasma cells. It is only in those cases where the intensity of the irritant continues to act over a longer period of time that a superficial necrosis with leucocytic infiltration makes its appearance. The epithelial layer of the trachea is desquamated early in the acute reaction, and hence a denudation of the surface is to be found in all stages of the acute lesion. The mucous glands have not been found to show any particular involvement in the inflammatory process, and in the majority of instances they were found to have escaped entirely the damaging effect of the virus. Their response in an over-secretion of mucus may be the outcome of a stimulation by toxins or soluble irritants; but on the other hand, may also probably be a reflex response to the injury of the mucosal surface, which being bared of its covering is highly sensitive. The increased discharge of mucus from the deep glands may well be a protective response to such injury.
Bronchi
The lesions in the bronchi were in every way comparable to those in the trachea. The main bronchial tubes differ in no material way from the structure of the trachea, and the extension of the inflammatory process from above downwards leads to a reaction in their walls similar to what has been above described. As we follow the subdivisions of the bronchi we gradually lose some of the characteristics contained in the larger tubes. The mucous glands gradually become fewer and eventually disappear. The cartilage rings become smaller and no longer completely encircle the bronchus, and with the further diminution in the size of these structures disappear entirely. A relatively greater amount of muscle tissues takes the place of the cartilage rings. This change in the anatomy of these structures has a certain influence in modifying the character and distribution of the inflammation.
229TABLE V
BRONCHITIS AND TRACHEITIS
Acute bronchitis and tracheitis 26
Subacute bronchitis and tracheitis 1
Acute mucopurulent tracheitis 5
Acute purulent bronchitis 2
Acute mucopurulent bronchitis 7
Ulcers of trachea 1
Acute bronchiectasis 1
Thus whereas we have indicated that the inflammation of the trachea and of the large bronchi is of a peculiar kind and remains confined to the tissue lying inwardly from the cartilage rings, we found that where these structures give place to a loose muscle tissue with a more extensive lymphatic drainage the zone of inflammation is not so limited, but proceeds outwardly into the neighboring tissues. We often use the terms bronchus and bronchioles very freely without clearly distinguishing any real difference. In a study of the inflammatory reactions of the respiratory tubes in epidemic influenza (as well as in other infections) it is best to accept the anatomical definition that the bronchioles not only represent the minute tubules passing to the alveoli, but also those small air passages which devoid of cartilage, mucous glands and heavy connective tissue stroma are in close relation to the parenchymatous tissues of the lung. These soft muscular tubes possess blood and lymphatic vessels which freely communicate with the blood vessels of the lung alveoli. It is in association with these distant tubes that concomitant inflammatory reactions are found in the alveoli and in the bronchial tubes.
Desquamation of the epithelial lining is to be found in every size of bronchial tube where the infection has caused an acute inflammatory reaction. Throughout the pulmonary tissues where the lung is found in some stage of influenzal pneumonia the bronchial tubes, both large and small, are either entirely denuded of the mucosa or show only remnants attached to irregular areas. In the smaller passages dense clusters of desquamated cells are sometimes found within the lumen and indicate the accumulation of a desquamated epithelium obtained from portions 230of the tubular system in deeper portions of the lung. In the early stages, this desquamation is accompanied by a serous exudate and a certain amount of hemorrhage. Later we find masses of leucocytes which fill up the tube, and though appearing to arise from these structures have in fact largely come from the lung alveoli. Like the larger bronchial tubes the distant ramifications show relatively little cellular reaction in their walls in the early period. It is only when the neighboring lung tissues are extensively implicated in a purulent inflammation that we find a similar exudate occupying the tissues of the bronchioles. Polymorphonuclear leucocytes are equally distributed through the region of the basement membrane, submucosa, muscular coat and outer connective tissue layer. Some grades of degeneration may occupy the inner surface wherein the basement membrane first shows a homogeneous swelling and later a granular degeneration. In a few instances where the small bronchioles have communicated with regions with abscess formation an ulcerating surface occupied the inner boundary.
The evidence in the smaller bronchial tubes, both those with cartilage and those without, that an inflammatory reaction of some degree may occupy the muscular coat is of importance. We have found reactions of inflammation in the muscular coat varying from a mild œdema and cellular exudate to an intense polymorphonuclear leucocyte involvement. In the latter the muscle fibers showed evidence of degenerative change and suggested an acute weakening of this layer. We lay particular importance upon this finding as indicating a causative factor in the development of acute bronchiectasis as was met with in one of our cases. In this particular instance the bronchi passing to the lower lobes of each lung were unusually dilated and could be followed, in the gross, to their distant extremities. The dilatation was more or less uniform and no large pouches or cavities had developed. A mucopurulent exudate was found occupying these dilated tubes. Others have likewise observed the development of acute bronchiectasis under these conditions. Goodpasture and Burnett found that as early as the second to the fourth day one of the striking appearances was the gaping dilated condition of the infundibula, and the tendency to dilatation of the air passages was manifested in a bronchiectasis in 4 out of 30 cases. Boggs as well as Lord have reported upon chronic bronchiectasis 231associated with the B. influenzæ and there appeared to be evidence that a certain percentage of cases recovering from influenza permanently develop irregular dilatations of the bronchial tubes.
The recognition of inflamed bronchi or bronchioles was never difficult. In the gross the presence of the abnormal exudate and the intense injection of the mucosal surfaces always attracted attention to the inflammatory state. Furthermore where the mucosa had been desquamated the surface of these tubes was found to be quite granular if closely observed. With moderate magnification by means of a hand lens the granular appearance was shown to be due to the engorged vessels. Much easier, of course, was the recognition of the inflammatory reaction by the microscope. The importance, however, of the bronchitis and bronchiolitis lay in the amount of involvement which had occurred in the neighboring tissues. As we, however, indicated elsewhere, we do not doubt that many of the cases of three-day fever have a state of tracheitis and bronchitis equal to that which we have observed in many of our cases. Whether the inflammatory reaction progressed beyond the firmer bronchial tubes to the softer and more vascular structures would be difficult to say where our evidence rests upon the clinical findings alone. It is, however, probable that a certain number of the severe and sharp attacks of influenza not only cause a tracheitis and bronchitis of the larger tubes, but also extend more deeply into the smaller ramifications tending to simulate the reactions which we have above described. When we ask ourselves, however, how distantly must the infection invade the smaller bronchial tubes before involving the parenchymatous tissues of the lung we are at a loss to enunciate a general rule. It is more than probable that there are modifying influences which determine whether the bronchitis with a certain amount of its bronchiolitis will progress to a true pneumonia or will remain localized to these tubular systems. I can well appreciate that in the event that a bronchitis has an inflammatory reaction accompanied by much serous exudate there is great danger of flooding the neighboring alveoli with this inflammatory fluid and of carrying the large numbers of the micro-organisms within the tubes to the air sacs of the lung. Under these conditions the virus has an unusual ability to develop the disease from one localized in the air passages to that of a true pneumonia. It is probable that the peculiar early acute reaction which is present in the air passages in epidemic influenza is responsible for the extensive involvement of the lung in the severe and dangerous form of inflammation.
232TABLE VI.
EXTENT AND DISTRIBUTION OF PNEUMONIA.
Autopsy Number. Age. RIGHT LUNG. Type of Lesion. LEFT LUNG. Type of Lesion. Pleura. Abscess of Lung. Day of Disease.
Weight of Lung. Involvement of Lobes. Weight of Lung. Involvement of Lobes.
Upper. Middle. Lower. Upper. Lower. Right. Left.
741 18 720 G. + + ++ Lobar S. & H. 850 G. + ++ Lobar S. & H. S.F. S.F. 3d.
743 20 825 G. + + + Lobular S. & H. 1375 G. +++ +++ Lobar S. & H. Early P. F. S.F. 5th
744 30 900 G. + – ++ Lobar and Lobular S. & H. 900 G. ++ ++ Lobar S. & H. S.F. S.F. 7th
745 18 575 G. + – ++ Lobular S. & H. 480 G. – ++ B.P. with Necrosis. S.F. – + 10th
746 21 900 G. + ++ +++ Lobar S. & H. 650 G. + +++ Lobar S. & H. – – 5th
747 27 1510 G. +++ ++ +++ Lobar S. & H. 1000 G. +++ +++ Lobar S. & H. S.F. – 6th
748 22 900 G. + + +++ Lobar and Lobular S. & H. 1250 G. + +++ Lobar S. & H. and B.P. – – 4th
749 23 1480 G. ++ ++ +++ Lobar S. & H. Slight Purulent. 1250 G. ++ +++ Lobar S. & H. Slight P. F. – 4th
750 24 1200 G. +++ + +++ Lobar and Lobular. Early Purulent. 825 G. + +++ Lobar and Lobular. Early P. F. F. 9th
751 22 1250 G. – – +++ Lobar Purulent. 610 G. ± ± B.P. slight. S.F. – 7th
752 27 1125 G. +++ + +++ Lobar S. & H. 775 G. ± +++ B.P. and Lobar P. F. S.F. 13th
756 22 1000 G. ++ ++ ++ Lobar S. & H. Slight Purulent. 820 G. +++ ++ Lobar and Lobular S. & H. F. S.F. 8th
757 21 815 G. ++ – ++ Lobular S. & H. 1075 G. +++ +++ Lobar S. & H. and Purulent. F. F. 6th
758 22 1150 G. +++ + + Lobar Purulent 1400 G. +++ +++ Lobar Purulent. F. F. 14th
761 21 1250 G. +++ ++ +++ Lobar S. & H. and Lobular Purulent. 550 G. + + Lobular S. & H. – – 7th
762 21 680 G. + + + Lobular S. & H. 750 G. + +++ Lobar S. & H. and Lobular P. S.F. S.F. 10th
763 22 920 G. + – + B. P. and Lobar S. & H. 540 G. – + B.P. F.P. – 11th
764 23 725 G. – + + Lobular S. & H. 550 G. + + B.P. – – 9th
765 25 1100 G. ++ – ++ Lobar S. & H. 1400 G. – +++ Lobar S. & H. and Early P. – – 9th
767 25 1075 G. + +++ +++ Lobar and Lobular S. & H. and Lobular Purulent. 850 G. – ++ Lobar S. & H. Lobular P. – F. 10th
770 21 900 G. ++ ++ ++ Lobar S. & H. and Lobular Purulent. 750 G. ++ ++ Lobar S. & H. Lobular P. S.F. F. + 11th
773 22 2050 G. +++ ++ +++ Lobar S. & H. and Purulent. 780 G. – +++ Lobar S. & H. Lobular P. F. F. 20th recurrence
778 22 1100 G. ++ + ++ Interstitial Pneumonia. 975 G. ++ ++ Interstitial Pneumonia. S.F. S.F. 23d
781 21 1000 G. +++ ++ +++ Lobar S. & H. 540 G. + +++ Lobar S. & H. Purulent. S.F. S.F. + 5th
782 18 650 G. + – ++ Lobular S. & H. Slight Purulent. 875 G. ++ +++ Lobar S. & H. and Early P. F. F. 8th
783 21 1250 G. +++ +++ +++ Lobar S. & H. 580 G. + ++ Lobar S. & H. S.F. S.F. 8th
784 21 1590 G. +++ +++ +++ Lobar Purulent. 1400 G. +++ +++ Lobar S. & H. and Purulent. S.F. S.F. 8th
786 20 1100 G. ++ +++ +++ Lobar S. & H. Slight Lobular Purulent. 700 G. – ++ Lobar S. & H. and Early P. S.F. – 4th
787 21 750 G. ++ – ++ Lobular S. & H. 1125 G. +++ +++ Lobar S. & H. S.F. S.F. 8th
791 21 775 G. + ++ ++ Lobular S. & H. and Purulent. 1050 G. ++ +++ Lobar S. & H. and Slight P. F. S.F. 6th
792 21 1050 G. + + +++ Lobar and Lobular S. & H. 950 G. + ++ Lobar and Lobular S. & H. S.F. S.F. 6th
793 18 500 G. – – + Slight Lobular S. & H. 435 G. – + Slight Lobular Purulent. – F. Strep. Bacteriemia. 10th
S—Serous. H—Hemorrhagic. P—Purulent. B.P.—Broncho-pneumonia. S.F.—Serofibrinous. F.—Fibrinous. F.P.—Fibrinopurulent.
234It was very evident that the smaller bronchi and bronchioles were much more readily involved in a severe inflammatory reaction than the larger tubes. A purulent inflammation was not uncommonly found in the bronchioles of the lung when a pneumonic state with leucocytic infiltration was present. Even where such purulent infiltration of the walls of the bronchioles was readily demonstrable the trachea and main bronchi were devoid of this intense reaction. These purulent inflammations were not uniformly distributed in the bronchioles of the lung, but only occurred in those regions where the parenchymatous tissues were in themselves involved in a purulent reaction. It was difficult to find the evidence whether the purulent bronchitis preceded or followed the presence of a purulent pneumonia. The intimacy of the lung tissues with those of the small bronchioles makes it impossible for one or other of these structures to escape when one of them is implicated in a purulent reaction. It is equally important to appreciate that to a considerable extent the lung tissue surrounding the small bronchioles becomes involved by a direct radial extension through the walls of the thin respiratory tubes. Such extension laterally is assisted by the free lymphatic communication lying about the bronchioles and stretching into the lung parenchyma. Purulent processes of the small air tubes always showed a similar reaction in the interstitial tissues of the neighboring air sacs.
Our material did not permit of following the bronchial reactions to their conclusion. In some instances we have found that where abscesses developed within the lung the contiguous bronchi and bronchioles either became eroded or suffered intense suppurative inflammatory lesions on their inner surface. The manner in which repair of the more common inflammatory processes of the bronchi is accomplished could not be demonstrated in the cases dying during the acute stage. In one case an organizing bronchitis was associated with an organizing lobular pneumonia. In this instance the connective tissues were proliferating freely from the inner wall of the bronchi, there being no evidence of a basement membrane at the point where the connective tissue was growing. The development of the connective tissue appeared to 235be spontaneous and was not taking place within an unresolved fibrinous exudate. In as much as the fibrosing process was largely scattered through all of the lobes, the numerical involvement of the respiratory tubes was quite great. In this instance the amount of obstruction which was imposed upon the respiratory tissues by the fibrosing pneumonia and bronchitis was sufficient to cause considerable distress and dyspnœa during the last few days of the patient’s life. The amount of dyspnœa was out of proportion to the clinical manifestations of pulmonary involvement, and from a clinical point of view it was difficult to arrive at a conclusion of the nature of the lung lesion.
Undoubtedly during the subsidence of the inflammatory process within the bronchi the gradual restitution of the tissues with little or no fibrosis is accompanied by a reproduction of the lining membrane arising from the epithelial remnants in the small mucous crypts. In a few cases lately coming to autopsy where the patients had suffered an influenza five or six weeks previously, the mucosa of the trachea and bronchi had assumed its normal appearance and was fully clothed by a normal epithelial covering.
Lung—Early Stage
We have just discussed the importance of the inflammation of the trachea and bronchi in the cases of influenza. It is our belief that every case of influenza has some tracheitis, and a great many have both tracheitis and bronchitis. This is true in the absence of localizing signs and symptoms, as was evident even in these cases in which the simple influenza passed into its more severe type with its pulmonary lesions. In many of these instances clinical evidences of an inflammatory reaction in the respiratory tubes were wanting, while the reactions observed at autopsy were often astounding.
Just as we feel that simple influenza and inflammation of the respiratory tubes go hand in hand, or better that these respiratory localizations are the all-important ones in every case of simple influenza, so, too, we are of the belief that the pulmonary lesions bear the same relation to all cases of severe and fatal epidemic influenza. We hold that no case comes to his death through acute epidemic influenza without having a lesion in the lung. The pulmonary condition, therefore, is of first importance 236and its analysis is imperative for a proper understanding of this disease. There has been divided opinion as to the part played by the pulmonary lesion in epidemic influenza, some holding that it is to be looked upon as a part of the disease and others that it must be viewed as a complicating lesion. Complications of various kinds are very common, and there are a number of conditions arising in the lung (abscess, gangrene, necrosis) which must be viewed as complications. There is, however, a type of pneumonia, and here I use the term in its broad sense, which is not in truth a complication but merely a wider extent of involvement of the respiratory tract by the same virus which is always present to cause lesions in the respiratory tubes. The reaction within the lungs is distinctive and differs from the pneumonias which are met with under other conditions and with various bacterial agencies. Nor are our findings in this matter unique for this epidemic. They have been described and discussed in the past. True it is that, like in the epidemic which has just passed us, the incidence of clinical and pathological pneumonia varied quite widely in different communities, so, too, the reports of past epidemics do not give a uniform description of a pulmonary lesion. Where, however, the analysis has been made during the four weeks’ period of the acute epidemic and where the descriptions have been recorded by painstaking observers, the similarity with our present findings is very striking. I would refer in particular to one report made in 1893 in Petrograd by Kuskow. His report deals with 40 carefully studied cases in which records both macroscopic and microscopic were accurately made.
One of the great difficulties in placing an accurate interpretation upon the pulmonary findings lies in the fact that true pneumonia as seen in epidemic influenza in man has not been reproduced in animals. Furthermore, as the majority of the fatal human cases of epidemic influenza with their associated pneumonias present a mixed infection of the lung tissues, it is difficult, if not impossible, to indicate the lesions which have resulted through the activity of one of these as against those induced by the other bacteria present. In our own carefully studied cases wherein bacteriological cultures were taken from every lung there was not a single instance in which the influenza bacillus was present in pure culture. This is more fully commented upon 237in the studies by Dr. Holman, but the point we wish to make here is the difficulty in arriving at a conclusion in our material as to the actual effects induced by any one type of organism. As it is fully discussed by Dr. Holman we are convinced of the importance of the influenza bacillus in this epidemic. We also appreciate that pneumonia lesions in animals have been induced by a variety of materials gained from influenza patients, but yet in view of the abnormal manner of producing such lesions these are hardly comparable to those in man. We may well expect severe œdema, inflammation and hemorrhage, if in guinea pigs, rabbits and monkeys we introduce by intra-tracheal insufflation large quantities of fluid suspensions of bacteria. And thus we find positive results obtained by the use of a filtrable virus, streptococci, influenza bacilli and other organisms. The lung is a sensitive tissue which quite readily responds to a variety of irritants. In many respects some of these lesions simulate those in influenza, but still we are far from the conclusion that the disease, influenza, with all its manifestations has been actually reproduced.
The pathology of the pulmonary lesions in acute epidemic influenza is so distinctive that except for the late purulent stage which may resemble types of reinfected and unresolved pneumonia the condition cannot be confused with the stages of frank lobar pneumonia. We appreciate that this is a very positive statement, and that opposition will be taken by those who resting their opinion upon individual factors may claim that a clear distinction from other forms of pneumonia is not available. We, however, base our opinion not upon a single feature, but upon the combined pathological complex observed in many individual cases. These features are mainly those seen in the type of the lesion, the character of the distribution, extent of involvement and the multiple stages so commonly present at one time in different portions of the lung. The type lesion that has become so well known in pneumococcus lobar pneumonia has its distinctive stages which for teaching purposes are divided into the stage of (1) congestion, (2) red hepatization, (3) gray hepatization and (4) resolution. In dealing with lobar pneumonia from the standpoint of illustrating these stages the majority of teachers annually confess their inability to present for the student’s study the stage of congestion. The student is impressed that 238the congestive stage of lobar pneumonia is very transient and rapidly passes into the stage of red hepatization. Patients do not die with pneumococcus pneumonia in the stage of congestion. And this is also largely true of the stage of red hepatization, which is but rarely seen at the autopsy table. This community (Pittsburgh) gives its large quota to the mortality statistics of pneumococcus pneumonia, but it is most unusual to meet with a specimen of red hepatization except for the borders of the advancing gray area. And, furthermore, red hepatization even when found in the unusual cases shows remarkably little of this character when seen under the microscope. True it is that a certain number of red blood cells will be found in the alveoli and a certain degree of congestion will occupy the alveolar walls, but its extent is far less than what we may have hoped to demonstrate to others. So that broadly speaking the intensely congested lung with or without red hepatization is unusual in our frank lobar pneumonia. This was quite the reverse in our cases of acute epidemic influenza-pneumonia. Furthermore lobar pneumonia in the great majority of instances illustrates a distribution distinctive for the name. Massive lobar, or pneumococcus pneumonia is found to occupy one or more lobes or parts of lobes. The involved lobe is fairly uniform in the stage of the inflammatory process. If it is in the early gray stage, this will be seen with equal intensity in the different areas of the lobe. Patches of pneumonia in different stages within the same lobe are not to be found, while this finding is not uncommon in the pneumonias of acute epidemic influenza. And lastly, the frequency with which an inflammatory œdema occupied the lungs in the cases of influenza was in quite striking contrast with the dry fibrinous lesion of common pneumonia. This wet state of the lung was but a stage in the inflammatory process varying in its extent in the different periods, but nevertheless inducing a character in the early pulmonary lesions which was quite foreign to our usual finding. This wet state also assisted in modifying the subsequent picture so that when the lung assumed its gray appearance it was rather of a slimy character than of the firm dry nature. In this late gray stage the slimy lung somewhat resembled the appearance of unresolved pneumonia where this condition had been brought about by a new infection upon the original cause of the pneumonia.
239It is incorrect in influenza pneumonia to speak of the lesions as lobar pneumonia or broncho-pneumonia if by these terms we have in mind the pathological characters observed in the pneumococcic pneumonia with its lobar or bronchial distribution. Influenza-pneumonia appeared with both lobar and lobular characteristics. Nearly every case had both types of lesions present, but the nature of the inflammatory process is so decidedly different from that of the ordinary endemic pneumonia that a confusion in the interpretation is likely to arise and in fact has already raised a considerable polemic. Influenza-pneumonia is commonly lobar, lobular or bronchial in distribution. It is, however, not of the characters that are associated with the lesions designated under these terms. When, therefore, we here use the word “lobar” we mean lobar in distribution but not lobar in type. As will be seen from our table, it was usual to have multiple lobes involved. But the lesions, not only in the different lobes varied in their character and distribution, but even within the same lobe a variety of types was present.
TABLE VII
Day of Pneumonia on Which Death Occurred No. of Cases
Second 2
Third 4
Fourth 7
Fifth 6
Sixth 7
Seventh 3
Eighth 1
Tenth 1
Twentieth 1
To a certain degree we were able to analyze the types of the lesions as they occurred in the different stages and progress of the pulmonary inflammation. Briefly, these were as follows: the earliest stage of congestion following rapidly upon the infection from the bronchi was followed by (1) inflammatory œdema, (2) hemorrhage, (3) cellular exudate (a. mononuclear cells, b. leucocytes, c. interstitial infiltration) and (4) resolution or organization, abscess, infarct and gangrene. The majority of our cases 240died during the stages of congestion, hemorrhage or early purulent infiltration. In the early stages the amount of fibrin was small or entirely absent, later, with the appearance of leucocytes, some fibrin was present.
For the estimation of the time elapsing between the onset of the pneumonia and death we are dependent upon the clinician. This is often quite difficult to do, in as much as with a primary respiratory disease, such as epidemic influenza represents, it is very difficult to determine the time when there is a transition from the inflammatory process of the upper respiratory tubes to that of the pulmonary tissue. In many of the cases where from the onset there was intense prostration and every evidence of marked intoxication the clinical manifestations of localized processes taking place in the respiratory system were very much in the background and often of insidious progress. In four of our cases it appeared as if the pulmonary manifestations had made their appearance with the first sudden and severe onset of the influenza. On the other hand, also, the clinical signs and symptoms of lung involvement were different from those of frank lobar pneumonia. We would, from our experience at the autopsy table, say that where in the cases of epidemic pneumonia there are present the signs of pulmonary consolidation like those of true lobar pneumonia, that there has been an antecedent period of a pulmonary lesion which passed unrecognized by the clinician. To more clearly state the case, whereas in lobar pneumonia the stage of congestion preceding the stage of red hepatization gives rise to no signs whereby the clinician can indicate the time of its onset or determine the time when it has passed into the succeeding stage, and moreover, the stage of congestion is of short duration to be measured in a period of a few hours, this stage in epidemic influenza though equally indefinite in its clinical manifestations is much prolonged, lasting not only a period of hours but even a period of several days. It is this pulmonary state which is difficult or even impossible to recognize in the living. All gradations of it occur and the clinician can only broadly suggest from all the evidence at hand, the period when inflammation with definite exudate began in the lung. In as much as the total length of illness of a number of cases was only three, four and five days, whereas there was nothing at the onset to suggest pulmonary involvement, we can estimate approximately, 241at least, the duration of the lung condition. This makes it possible to give a relative estimate of the character of the lesions present at different periods of time. The outstanding finding, as we will discuss again, was that a distinct and peculiar pulmonary reaction was primarily imposed upon the lung, which made its appearance at periods different from those of frank lobar pneumonia.
We were repeatedly surprised at finding death to have occurred during the stage of acute congestion with some hemorrhage and inflammatory œdema of lung and in the absence of any sign of grey hepatization or purulent infiltration. In many of these cases the involved areas of lung though heavy and œdematous, were still partly air-containing and the amount of lung involvement was insufficient, on the basis of mechanical interference, in accounting for the severity of the clinical symptoms and the fatal outcome. This must have impressed everyone dealing with the autopsies during the acute epidemic. It immediately suggests that in some cases at least the pulmonary lesion, in as far as incapacitating the external respiratory system, was not the sole or even the important cause of death, but that a condition of intoxication, borne out by the evidence of damage in muscles, blood and kidney is a large factor of danger in this disease.
We shall briefly describe the important pulmonary findings as we have met with them in the successive stages of influenza-pneumonia. This, we hope, will make clear the interpretation of the pathology of the lung lesion of the epidemic as it came under our observation.
The earliest pulmonary lesion which we encountered was one of congestion, inflammatory œdema and hemorrhage. These three conditions were usually present at the same time and were found in the height of intensity in all of the cases dying within the first four days of illness. During this early period these manifestations of inflammation were not accompanied by definite red or grey hepatization as might ordinarily be expected. The lesions varied greatly in their intensity, the œdema always being very prominent, while the hemorrhage varied from a diffuse infiltration of the involved lobe or added to this, was localized in massive collections four or five cm. in diameter and commonly occupying the central portions of the lobes. We have seen several hemorrhages lying in close proximity to each other 242with their borders coalescing and leading to a larger central involvement. In the regions where the hemorrhage and inflammatory œdema were diffuse, air was still present within the lung tissue, sometimes to an extent permitting the lung tissue to float on water but more often in quantity sufficient only to suspend the tissue at various depths. On pressure the fine air bubbles were recognized amidst the blood-stained fluid. Acute compensatory emphysema often occupied the anterior borders of the lobes or formed interstitial blebs beneath the pleura. The quantity of fluid, inflammatory œdema and hemorrhage, contained within these bulky lobes was often very surprising. A lobe when compressed would leak fluid with the ease that it could be obtained from a sponge. Out of the lower lobe on one occasion we pressed 700 c.c. of limpid blood-stained exudate. The acute emphysema which may make its appearance suddenly, is
TABLE VIII
Distribution of Pneumonic Lesions and Grades of Severity
Degree of Involvement + ++ +++ Total
Left upper lobe 10 6 7 23
Left lower lobe 4 10 17 31
Right upper lobe 12 8 9 29
Right middle lobe 10 9 4 23
Right lower lobe 5 9 18 3
All lobes were simultaneously involved in some grade of pneumonia in 18 cases—56 per cent.
at times quite remarkable. It may appear very early in disease. We have not met with a single case where the emphysema of the lung led to a rupture of the air sacs and an interstitial infiltration of air through lung, mediastinum, neck and subcutaneous tissues. Some very remarkable cases are reported by different authors where this emphysema was of astounding grade leading to a crepitating infiltration throughout the mediastinum, neck and the subcutaneous tissues over the thorax and abdomen as low as the pubis. The milder grade of emphysema consisted mainly of an abnormal expansion of the air sacs which were not infiltrated by exudate and which probably had some effect in preventing the diffusion of the inflammatory fluid from entering 243certain regions. These emphysematous areas could be readily recognized by the naked eye along the anterior borders of the lung as well as between the involved pneumonic patches within the lung.
These lungs, involved in this early serous and hemorrhagic exudate varied considerably in their appearance according to the regional and quantitative involvement. As is seen from Table viii, the lower lobes were more commonly occupied by massive exudate than the upper, and the involvement of multiple lobes was the usual. Still more remarkable is the fact that all lobes were simultaneously involved in some grade of reaction (pneumonia) in 56 per cent. of cases. In complicated influenza-pneumonia Goodpasture and Burnett found the inflammatory reaction in both lungs and involving to a greater or less degree the lobes on each side. Most commonly this involvement consisted of a lobar distribution in one or two lobes with a lobular or patchy disposition of exudate in one or more of the remaining lobes. Where the distribution was lobar the involved lobe was distended to its fullest and the pleura tightly stretched over the lung tissue which, heavy with fluid, was not solid but flabby. The lung could be moulded under the finger and could be compressed into various shapes. At first sight this flabby, heavy lung tissue suggested the appearance of the waterlogged lung which one encounters in renal disease or failing circulation. A closer analysis, and particularly when the lung was sliced, showed an entirely different character.
Where the inflammatory œdema was accompanied by much focal hemorrhage the distribution was nodular and suggested the appearance of the hemorrhagic lung of plague pneumonia. It was this appearance which led to the suggestion that the pandemic was not one of influenza but possibly of an infection related to the eastern plague. The nodular masses of hemorrhage at times occupied areas varying from the size of a walnut to that of a golf ball and were localized amidst a relatively mildly involved lung tissue making a sharp contrast between the involved and relatively normal tissue. With the removal of the lung from the body and the partial collapse of the aerated tissues these nodules became still more prominent. The greater the amount of hemorrhage within these areas the more solid became the occupied tissue. Such sporadic distribution of hemorrhagic 244lesions occurred in the two most intense and rapidly fatal cases. Both of these individuals died within 48 hours of the time of onset of the lung conditions. In these two cases we do not believe that the pulmonary lesions had been prolonged over a time even as long as 36 hours but with the difficulty of estimating the onset of the lung involvement we are giving a liberal estimate of this time.
Besides meeting with the stages of congestion, œdema and hemorrhage during the earliest days of the pulmonary lesions we have found that they are to be encountered virtually through all the stages of the fatal cases either as remnants of the original reactions which had not been entirely obliterated by the succeeding purulent process or as was so commonly found, new reactions occurred in other regions of the lung so that, in the same individual, inflammatory reactions of different stages of development could be defined. I do not recollect a single autopsy of a case dying during the acute period which did not show evidence of some areas in the stages of this early acute reaction. Naturally where resolution is well advanced within the lung all trace of inflammatory exudate of various kinds is removed and where such individuals with their resolved pneumonia are brought to death through succeeding complications the above finding will not be borne out. We limit, however, our statement to the findings in the acute deaths.
We have previously intimated that the œdema present in the early stages of the reaction is to be looked upon as an inflammatory œdema or better as a true serous exudate, and must not be confused with the transudation of fluids in non-inflammatory conditions. We have on several occasions collected the fluid expressed from the soggy lungs and have made some determinations of their chemical qualities. The difficulty immediately arises in separating the materials arising from cellular degeneration from the natural constituents of the serous exudate. We were unable to obtain specimens in which laked blood was not present, so that even though the cellular constituents and fibrin were removed, decomposition products could not be separated. The analyses, however, gave a differentiation from the transudate seen in renal and cardiac conditions.
During the period of the accumulation of this inflammatory fluid the clinician could often recognize a profuse watery exudate 245within the lung or even observed an abundant serous discharge arising in bronchi and trachea. At times the quantity of expectoration was great. Frothy serous fluid accumulated in the air passages and would periodically be expectorated. At other times the hemorrhage was of quite serious extent and the patient would suddenly bring up several mouthfuls or more of bright blood. This pulmonary hemorrhage was without manifestations different from the acute illness with cyanosis of other individuals. The two most acute cases, which we have referred to above, were of this kind, both of them having marked hæmoptysis with the loss of upwards of a pint of blood at a time.
The early pulmonary lesion which we have described, we have called acute serous pneumonia and acute hemorrhagic pneumonia (or we might speak of it as an acute sero-hemorrhagic pneumonia) and is one which is distinctive for epidemic influenza. The cut surface of a lobe involved in this reaction is wet, glassy, meaty and oozes much blood-stained fluid. It contains no visible fibrin and presents no characters of a “cellular consolidation.” As a serous inflammation of the lung it is unique. The further remarkable character to the pulmonary lesion is that in advancing through the other stages, it never passes through a stage of “red hepatization.” Here again we have a distinctive difference from the pneumococcus-pneumonia. From what we have previously said about the nature of this early acute inflammation of the lung in this disease it is apparent that red hepatization has no place in its process. The stage of red hepatization is attained only when the inflammatory reaction is accompanied by certain constituents in the exudate, which upon coagulation (separation out of the fibrin) renders the lobe dry and solid, while there is a sufficient abundance of red blood cells and congestion to maintain a dark red color. The hepatized lung on section is dry, more or less granular, containing fibrin, red cells and leucocytes within the alveoli. Extensive œdema is unusual except in the cases of hypostatic pneumonia, which in well marked cases bears some resemblance to the gross appearance of the early influenza pneumonia. We have not encountered a single case of the red meaty lung of influenza which showed evidence of true red hepatization in the gross.
The microscopical examination of the lung tissue confirmed the observations which were made in the gross. In the early 246stages of congestion the reaction was much more extensive than what could be spoken of as a broncho-pneumonia. The capillary dilatation in the alveolar walls occupied diffuse areas varying from multiple lobules and areas several cm. in size to the common diffuse congestion of an entire lobe. Capillaries were distended to their full capacity and often this engorgement was associated with the leakage of blood or a serous fluid. Not uncommonly a clear serous fluid was exuded into the interstitial tissues of the alveolar wall and collected within the air sacs. The high albuminous content of this fluid was seen in the homogeneous coagulation which occurred when the tissues were placed in fixatives. The microscopical sections of such parts demonstrated the coagulum occupying the alveoli as a clear homogeneous substance containing relatively few cells and looking not unlike the colloid deposit of the thyroid. The alveolar walls, themselves, were infiltrated with fluid so that the distended tissues and vessels made these structures thick and bulky. In our own observations we were impressed by the differences of the early inflammatory reaction from those ordinarily seen in pneumonia. Amongst these differences was the quantity of fluid extruded into the lung with a relative absence of fibrin. In some instances fibrin was completely wanting, although small quantities could be demonstrated in isolated areas. This observation upon the quantity of fibrin can be made only during the early stage of the disease in as much as after secondary infection of various kinds has become implanted the presence of fibrin has become a variable quantity often exceeding that seen in the early stages. This is one of the points upon which the older authors have laid stress in differentiating influenza pneumonia from others. In this we fully concur. Whether this lack of fibrin in the inflammatory exudate is a characteristic to be associated with the infection by the B. influenzæ alone is hard to say, but in as much as it was such a prominent finding we are led to lay some stress upon it. It is, of course, to be realized, as with all other micro-organisms that under certain conditions fibrin will form an important part of the exudate even when the B. influenzæ is present. This is true in the inflammatory reactions of the meninges present in infections due to this bacillus. Under the conditions of epidemic influenza where the lung lesion is the prominent and unique 247reaction this micro-organism fails by itself to bring out this quality in the exudate.
Not uncommonly this stage of inflammatory œdema was accompanied by various grades of hemorrhage, varying from the presence of small aggregations of red cells to a complete flooding of the lung tissue making it look not unlike a red infarct of lung, save that the alveolar walls still showed an active circulation and living cells. It was remarkable that even though there was such an intense reaction taking place in the lung tissue there was little or no evidence of a cellular exudate during this stage of the process. Where much blood was extruded into the alveoli occasional fibrin threads were found in the coagulum. In these early cases the bronchicles and small bronchi were found to contain an exudate similar to that in the alveoli. Not uncommonly the vessels from which the red blood was escaping, could be demonstrated in sections. The appearance of the vascular wall suggested that a definite opening had occurred in the side of the capillary from which the blood escaped. We were not able to demonstrate a fatty or other type of degeneration in the cells of the capillary walls. It is probable that the process of injury was much too acute to permit of the demonstration of the products of degeneration within the surviving cells.
The hemorrhagic lesions which had existed for a longer period of time gradually showed a varying infiltration by wandering cells. The earliest cells not belonging to those of the hemorrhage or œdema appearing within the alveoli were mononuclear elements partly arising from the alveolar walls and partly coming from the circulation. Numerous mononuclear cells of epithelial type desquamating from the inner surface of the alveoli accumulated in the œdematous fluid and the hemorrhage within a short time after their occurrence. These cells either appeared in clusters or as single elements. Accompanying this were also large mononuclear cells loaded with different quantities of pigment which had apparently escaped from the lymphatic channels within the alveolar walls. These latter cells belong to the wandering endothelial type which are active in phagocytosis for foreign material and which assist so largely in inducing the deposit of carbon in the lungs and lymph glands. A third mononuclear cell appearing early in the reaction was the lymphocyte. The numbers and extent of distribution of this cell were not constant. We 248have seen it in some of the reactions where very few leucocytes were to be seen, and where it constituted the main infiltrating cell of the alveolar wall or the air sacs. We have previously mentioned its presence in the inflammatory reactions of the bronchi. Here we find it in the early response within the lung tissue and appearing amidst a reaction which is intensely acute. It is not long after the finding of these various cell elements that the polymorphonuclear leucocyte wanders in large droves to numerically overshadow the mononuclear cells. Nevertheless, the three types above mentioned can be recognized in the exudate through the succeeding stages of reactions in the lung. The large macrophage shows its phagocytic properties in taking up numerous red blood cells, lymphocytes and occasional leucocytes.
It is not difficult to demonstrate that the inflammatory reaction within the bronchi and bronchioles precedes the responses within the alveoli. Quite often one may find an acute bronchiolitis with desquamation of the lining epithelium and the early serous exudate lying amidst the lung parenchyma unaffected by any irritant and reaction. There is every evidence that the bacteria reach the lung tissue by extending along the walls of the respiratory tubes and eventually reaching the air sacs either in the distant extremities of the bronchioles or when they have arrived at the thin-walled structures extend through them into the neighboring air sacs.
It is during this early period that we are able to observe the characteristics of the initial inflammatory exudate as we have described it above. The serous exudate and the infiltration by mononuclear cells appear early while the absence of fibrin also attracts attention. In place of fibrin there appeared in a certain number of cases a peculiar material of a hyaline nature which becomes plastered against the borders of the air sacs forming a fairly thick laminated structure and within which thread-formation is not to be seen. Occasionally a few cells lie within this hyaline substance. Some have referred to this as a type of fibrin. We have found, however, that it does not give the staining reactions for fibrin and does not appear to be of the same composition. These masses are tightly welded to the alveolar walls and the borders are often indistinguishable. In part this material appeared to be made up of necrotic cells of the septum which previously had suffered œdema and circulatory 249interference. We have found in a number of cases hyaline thromboses of the fine capillaries with more or less necrosis of the alveolar septum. At times the septum was entirely destroyed so that a thick hyaline mass alone separated neighboring air sacs. This hyaline necrosis resembles in part the superficial necrosis which was observed along the borders of the denuded bronchi. There is, however, more than necrosis of cells constituting this deposit for the bulk of material eventually deposited is much greater than could arise from tissue cells alone. These hyaline masses have never been found to lie upon the alveolar wall with an intact lining, but it is always accompanied by a loss of the lining cells and more or less destruction of the wall itself. As to the nature of the hyaline deposit which is laid down in lamellae we do not know. Fibrin threads occasionally appear to arise from these hyaline deposits and extend amidst the exudate in the air sac. One cannot assume, however, that the fibrin and the hyaline material have any relation to each other as their chemical characteristics (and mode of deposition) appear to be quite different. It has been suggested by some that this hyaline material represents an imperfectly formed fibrin which has formed a jelly-like clot, not having the property of developing the usual threads.