Chapter II: Influence of the Respiratory Complication of Influenza Upon

TUBERCULOSIS OF THE LUNG

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

_Autopsy No. 194._

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

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

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

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

FIG. XXXIII. GANGRENE OF THE LUNG.
]

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

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

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

_Summary._

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