Part 2
Di-chlor-ethyl-sulphide may cause some catarrhal desquamation of the pulmonary endothelial cells, but it rarely excites an outpouring of oedema fluid from the pulmonary vessels. The pathological changes in the bronchioles and in the alveoli are therefore in the sharpest contrast with those caused by phosgene (see Plate No. I). As infection spreads into the lung tissues, patches of septic broncho-pneumonia and small abscesses develop, and these often excite an inflammatory oedema around them.
If the patient lives, his bronchial mucous membrane is slowly regenerated; and during this time he is naturally subject to reflex spasms of coughing or even to a protracted bronchitis.
[Illustration: PLATE X.]
PLATE NO. XIA Severely burned eye in the acute stage.
Early in the second day after exposure to mustard gas vapour the eyelids and the external surface of the globe show an intense inflammatory reaction. Tears stream from between the closed oedematous eyelids, which may even be blistered, and there is often severe pain behind the eyes and in the forehead. The conjunctiva is swollen, oedematous, and bright red from injection of the blood vessels. The injury of the cornea, even when severe, is not so obvious, and careful examination is of great importance for its detection. Photophobia and blepharospasm render examination of the eye very difficult.
The majority of gassed eyes exhibit inflammation of a general character that is not illustrated in this Atlas. But examples are continually occurring in which the eye is more severely burned, and these may be recognized by certain characteristic features that are depicted in the drawing, Plate No. XIA. Whenever a dead white band crosses the exposed area of the conjunctiva, while the parts of this membrane covered by the upper and lower lids are red and oedematous, serious injury from the burning is likely to have occurred.
In the case illustrated, the caustic effect of the vapour is seen chiefly in the interpalpebral aperture. On each side of the cornea there is a dead white band due to coagulative oedema, which compresses the vessels, impairs the circulation, and thus acts as a menace to the nutrition of the cornea. The swelling in the region of this white band is slight, while the protected conjunctiva above and below it is greatly swollen and injected and may even bulge between the lids.
The exposed portion of the cornea is grey and hazy; it has lost its lustre, and when viewed with a bright light and a magnifying glass it shows a blurred ‘window reflex’ and a typical ‘orange-skinned’ surface. The haze gradually fades off above in the region of the protected part of the cornea where the surface is usually bright and smooth. The pupil is at first contracted as the result of irritation and congestion. In this drawing it is shown as artificially dilated by atropine ointment, which should always be used early in severe cases or where there is much pain and blepharospasm.
PLATE NO. XIB Slightly later stage of acute burning.
The swelling in the conjunctiva above and below has subsided, but the vascular injection remains, and the solid white oedema in the palpebral aperture is still well marked. The cornea is grey in the exposed area.
[_For_ History of the case _see page facing Plate XII_.
[Illustration: PLATE XI.]
_History of the case._ The casualty was caused by the bursting of a Yellow Cross shell close to the man when he was riding a restive mule, and his box respirator was momentarily displaced. A fine spray of the liquid must have splashed lightly over his right side, for cutaneous blisters developed on the neck, the cheek, and the forehead on this side only. The right eye showed serious burning with the central white band, while the left eye was only in the state of general red conjunctivitis.
With the lowering of the nutrition of the corneal epithelium, secondary infection is liable to take place. In this case an infiltrated corneal ulcer is seen associated with a hypopyon. It is therefore important when there is conjunctival discharge, which indicates secondary infection, that in addition to the use of atropine the conjunctival sac should be cleansed by frequent bland irrigations and by the instillation of antiseptic drops so as to check infection of any corneal ulceration which may develop. Otherwise the infective progress which has led to hypopyon may progress till panophthalmitis supervenes.
PLATE NO. XIIA Stage of resolution after severe burning.
The vascular injection is passing off, the solid oedema is becoming absorbed, and the corneal epithelium has regained its normal lustre. In this stage the use of atropine should be discontinued.
PLATE NO. XIIB Late stage of resolution.
The earlier vascular injection above and below the cornea has practically disappeared; the solid white oedema has been absorbed, and the conjunctiva in the palpebral aperture now shows definite injection, often of a bright violet tint. The entire picture has changed, so that the parts which were red in the acute stage are now white and the part which was formerly white is now red. This drawing would illustrate equally well the condition that may follow immediately on a very slight exposure to the irritant gas, when only a slight central band of red injection develops instead of the bloodless state of white oedema that is caused by the more severe burns.
At this stage atropine and shades should be abandoned. Astringent drops should be instilled and photophobia combated with cold douching, &c., while fresh air and occupation will help to restore the general health of the individual and mitigate any tendency to neurasthenia.
[Illustration: PLATE XII.]
PLATE NO. XIIIA Drawing of the cornea in the acute stage of severe burning.
This corresponds with Plate No. XIA. The exposed central area shows grey haze and loss of lustre on its stippled surface, which gradually fades off to the bright lustrous normal surface in the part above that has been protected by the eyelid. Injection of the conjunctival vessels is seen only in relation to this upper and less burned area.
PLATE NO. XIIIB Drawing of cornea in the stage of resolution after severe burning.
The cornea is now smooth and bright with a clear light reflex on its surface. But some grey superficial nebulae are seen in the centre, and these may persist for several weeks. The injection of the conjunctival vessels is now limited to the central band.
[Illustration: PLATE XIII.]
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TRANSCRIBER’S NOTES
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