were of not infrequent occurrence. Shortly after this she complained
of pain in the right leg and lower lumbar region. She visited the
Hospital for the Ruptured and Crippled, on Forty-second street in
this city, where she was examined and assured that both leg and spine
were normal. The surgeons, noticing that she was suffering from some
acute illness, referred her to this hospital.
Present Ilhi ess. â€” This dates back one month, and commenced with
pain in right side of abdomen, radiating down into right leg and also
into the right shoulder. The pain was accompanied and followed by
nausea, vomiting, and headache. During the past six days she has
become jaundiced and has had slight chills followed by fever. Vomit-
ing has continued. Bowels constipated ; color of feces unobserved.
Urine is dark in color. Menstruation had always been regular, both
as regards time and amount, until this month, when it became profuse.
Physical Examination on admittance. â€” General condition was good.
Body of medium frame and well nourished. General well-marked
icterus. Sensorium dulled. Very drowsy.
Heart: Borders normal. Sounds clear. No murmur. Action
regular and somewhat accelerated.
MOUNT SINAI HOSPITAL REPORTS.
Liver: Dulness commenced at fourth intercostal space; flatness at
the sixth rib and reaching to free border.
Spleen: Upper border at ninth rib; reached to mid-axillary line.
Free border not palpable.
Abdomen: Slightly distended. A tongue-shaped mass felt in the
right hypochondrium below free border of ribs for about 4 em., and
lying between the parasternal and mammary linesâ€” probably liver
tissue. Below and beneath this is felt a resistant mass. Percussion
note dull and elicits tenderness. There is general abdominal tender-
ness. No glandular enlargements. No edema of extremities. Ten-
derness over lower ends of femurs. Leucocytes, 10,000. Tempera-
ture 97.2Â°-98Â°, pulse 98-120, respiration 20-28. Urine: acid; 1024;
albumin present ; no sugar ; bile present ; trace of indican ; urea 1.5
per cent. ; microscopical examinationâ€” a few hyaline and granular
casts, few pus and epithelial cells.
November 29, 10 a.m. : Patient lies in stupor. Sensation present.
Icterus has increased. There are no petechiae. Lungs are negative.
KUDISCIl : ACUTE YELLOW ATROPHY OF THE LI\*ER. 17
Heart action rapid and forcible. Liver flatness begins in fifth space,
and the free border is palpable one finger's breadth below the ribs.
Spleen is not palpable, and splenic diilness is obscured by tympanitic
note. The abdomen has become more distended and tenderness has
disappeared. The mass cannot be felt below the liver. Knee jerks
active, and ankle clonus present in both extremities. Leucocvtes. 7,500.
Temperature 98Â°-97.8Â°. pulse 118-120, respiration 20-22. Urine : acid ;
1038: albumin present; no sugar; urea 1.8 per cent.; bile increased
in quantity: microscopical examinationâ€” hyaline and granular casts;
few piis and epithelial cells : no leucin or tyrosin.
1:30 P.M.: Becoming more restless; moaning: got out of bed; had
to be restrained.
4 :30 P.M. : Patient's body in position of moderate opisthotonos, with
right side of body arched more than the left. Arms continually moved
back and forth across body. Fingers of left hand clenched. Feet
held in extreme plantar flexion. Knee jerks present. Left pupil
dilated more than right: both react to light. Stupor and muttering
delirium. Kesponded slightly when straw was inserted in nostrils.
Dr. Janeway saw patient at this time and remarked upon the close
resemblance of the clinical picture to that presented sometimes in the
state known as hystero-epilepsy.
8 :30 P.M. : Patient quieter : deep stupor ; breathing and pulse irregu-
lar. Liver percusses slightly smaller. Temperature 101.2Â°. pulse 144,
November 30 : In coma. Exitus at 3 a.m. Urine : acid ; specific
gravity 1032 : trace of albumin : .sugar absent : urea 2 per cent. ; bile,
large quantity: hyaline and granular casts: epithelial cells, no leucin
or tyrosin : no phosphorescence obtained through distillation.
Clinical diagnosis: Acute yellow atrophy of the liver (Dr. Rudisch).
abstract of protocol of autopsy' made seven hol'rs post mortem
(dr. e. libmax. assistant pathologist).
IMarked rigor mortis : all organs bile-stained. Diaphragm : right
side, third space: left side, fourth space. Liver extends to seventh
interspace in mammillary line: in median line, 3 cm. below ensiform
cartilage. Small amount of bile-stained, clear fluid in abdominal
Splcm. â€” 14 by 7.5 cm.: fine deposits of fibrin on surface. On sec-
tion, pulp fairly ea.sily scraped oft:': connective tissue somewhat promi-
nent: weight, 185 grammes.
Kidneys. â€” Left: capsule not adherent; superficial veins congested;
section firm: medulla congested: cortex, marked fatty degeneration;
weight, 180 grammes. Right : same as left : weight, 180 grammes.
AfZrf /mis. â€”Negative.
Lungs. â€” Congested: edematous: full of large hemorrhagic areas;
bronchial nodes not enlarged.
18 MOUNT SINAI HOSPITAL REPORTS.
Heart: Edge of tricuspid and of mitral flaps slightly thickened;
muscle is fatty, cloudy in spots.
Liver.â€” 2^ by 19 by 8 cm. Weight, 1,300 grammes (43 ounces).
Liver very fatty ; consistence soft ; depressions between lobules. Large
number of areas absolutely yellow ; many elevated from surface on
cut section, varying in size and shape, the smallest pinpoint in size,
largest 3 cm. in diameter. Some of the areas collected near each
other so as to involve comparatively large areas of tissue. Areas lie
mainly about branches of portal veins, but veins themselves show no
macroscopic changes. After specimen was kept in formalin for a
few hours, the yellow areas were found to be markedly bile-stained
and to be surrounded by hemorrhagic zones varying in size from that
of a pinhead to one-third of an inch in diameter.
Gall Bladder, Vessels, and Z>i<cf5.â€” Negative.
Stomacli. â€” ^Moderately distended by fluid blood contents and coffee-
ground material. Mucous membrane swollen. Near pylorus are a
large number of hemorrhagic areas. ^Mucosa shows marked depres-
sions between groups of tubules.
Intestine. â€” From duodenum and for a stretch of small gut six feet
in length, contents markedly bloody; then for two feet contents fairly
normal and yellow ; then for four feet intestine contains fairly firm,
slimy, greenish-gray contents ; then contents are bloody down to cecum.
In the colon is fluid grayish stool having a metallic lustre. Intes-
tinal wall shows moderate congestion. In places throughout small in-
testine are numbers of small hemorrhages in mucous membrane.
Colon much dilated, not congested or inflamed. Slight enlargement of
lymphoid nodules in colon.
Mesentery. â€” Mesenteric nodes slightly enlarged; pink color; large
hemorrhagic extravasation in left part of mesentery, and another of
moderate extent in postperitoneal connective tissue.
Pa n creas. â€” Negative.
Adnexa. â€” Corpus luteum in left ovary.
Bacteriological Examination. â€” A blood culture made before death,
and in which 10 c.c. of blood were used, proved negative when grown
both aerobically and anaerobically. Postmortem cultures taken from
all the organs showed both streptococci and bacilli eoli communis.
MICROSCOPICAL EXAMINATION (dR. F. S. MANDLEBAUM, PATHOLOGIST).
Liver. â€” It is with difficulty that the lobules can be recognized, on
account of the marked changes that have occurred throughout the
sections. Here and there a few liver cells are seen which have escaped
the degenerative processes, and these seem to mark the periphery of
the lobules. The nuclei of these cells also appear quite normal. A
marked fatty degeneration is seen everywhere, and in some places even
the nuclei can no longer be distinguished. In other situations the
degeneration is so marked that a true necrosis of all the structures
is apparent, presenting a granular appearance with barely any stain-
â– RUDISCH : ACUTE YELLOW ATROPHY OF THE LIVER. 19
ing power. The nuclei are also missing in these situations. A mod-
erate amount of acnte inflammation about the branches of the hepatic
artery is noted, and the walls of this vessel appear slightly thickened.
The intralobular veins, as well as the portal vein, show a moderate
dilatation. The bile ducts show only a moderate tendency to prolifera-
tion. The capillaries are dilated, and in places slight hemorrhage
has occurred. A moderate amount of blood pigment is seen.
Diagnosis : Fatty degeneration ; acute degeneration with necrosis ;
congestion and hemorrhage (acute yellow atrophy).
Malie L., married, aged 21 years. Admitted September 25, 1902.
Family History. â€” Negative.
Previous History. â€” Ordinary diseases of childhood. Normal men-
struation. ^Married five months. Pregnant about four and a half
months. Four and a half years ago had acute otitis media in left
ear. In May, 1899, was treated in this hospital for typhoid fever
Present History. â€” l^wo weeks ago began to have severe continuous
headache (not localized) ; later epigastric pain followed by vomiting
of all ingesta (five or six times daily) for several days, but vomiting
gradually abated. To-day vomited blood (swallowed during an epis-
taxis). Has had chilly sensations since onset of illness. Bowels have
moved in response to cathartics and enemata ; urination apparently
normal. No vaginal hemorrhage. Profuse leucorrheal discharge.
No cough or expectoration. No jaundice, no edema. Has complained
constantly of headache. Cries out and acts hysterically.
Physical Examination. â€” General condition fair; well nourished;
appearance septic; exalted mental state, at times real delirium alter-
nating with sleepiness; no enlargement of glands; tongue dry and
coated ; throat dry ; no petechige : no .jaundice.
Lungs: At right base posteriorly, dulness from angle of scapula
and base -. breathing and voice normal ; line of dulness descends "\vith
Heart: Borders normal; action, over-active; rapid; at pulmonic
area, transmitted almost to the apex, is a loud systolic murmur; basic
sounds loud. Pulse full but soft.
Liver: Dulness from fourth intercostal space to just above free
border, fifth intercostal space in axilla. Free border not palpable.
Posteriorly dulness reaches iieai'ly to angle of scapula.
S}')lce'n: Percussion note obscure liy tymiiany : not palpable.
Al)(lomen. â€” Tymx)an\t\c: slightly distended: right side somewhat
rigid. From about one and one-half fingers l)elow umbilicus to pubes,
chiefly on right side, well to outer border of rectus, is a rounded, hard
mass (pregnant uterus), not sensitive.
Vaginal.â€” Cer\ix soft, almost as soft as vagina : by bimanual palpa-
tion the uterus is felt to be enlarged.
Extremities.â€” Negatixe. Had severe epistaxis; necessary to cathe-
MOUNT SINAI HOSPITAL REPORTS.
terize. Leucocytes, 11,000. Temperature 101.8Â° F., pulse 132, res-
September 22 : Mental condition somewhat improved. Tempera-
ture 102Â° in A.M., 103Â° at noon, and 100.2Â° at midnight; pulse 116 and
124, respiration 24 and 30. Urine : acid ; 1018 ; faint trace of albumin
and sugar ; urea 1.1 per cent. ; total quantity of urine in twenty-four
hours, 28 ounces; microscopical examination negative. Had another
epistaxis. Complained of severe headache; catheterized ; sedatives
September 24: Distinct ptosis of left eye; pupils large, equal, do
not react to light. Facial weakness on left side, increasing rapidly
during day. Increasing stupor. Hyperesthesia and subconjunctival
icterus. Dr. Brettauer says uterus is normal. Delirious most of the
night ; attempted to get out of bed. Catheterized. 9 :30 p.m. : Pupils
unequal, left larger. Breathing irregular, at times stertorous, and
later Cheyne-Stokes'. * Convulsive twitchings on both sides, more es-
pecially on left. Eyeâ€” Fundus of left eye shows papillitis; right eye
RrnisriT : acute yellow atrophy op the t>iver. 21
normal. Â£'r/>-sâ€” Left shows retracted drum Avith dinii)]e below malle-
olus. Knee JfrA,sâ€” Exaggerated on right side, on which side there
is a decreased reaction to stimuli ; on left side the opposite obtains.
Slight tacJte cerehrale present. Temperature 101.8Â° a.m., fell to 98.2Â°
at midnight; pulse 122 in morning and 90 at night; respiration 26 to
40. Urine: alkaline; 1018; no albumin; no sugar; urea 1.4 per cent,
in total quantity of 6 ounces; microscopically, phosphate crystals and
a few epithelial cells.
September 25 : Deep coma ; both pupils widely dilated. Breathing
slow and stertorous; slight twitchings and automatic movements of
both arms during the day. Temperature subnormal, 94.8Â°. Icterus
increased. Liverâ€” Y\i\\\ rib to above free border, posteriorly one
and one-half fingers' breadth below angle of scapula. Leucin and
tyrosin found in urine.
Dr. ]\ray finds a marked papillitis in left side, with hemorrhage near
disc; right eye practically normal. Patient continued stuporous. At
6 P.M. a general convulsion with foaming at mouth. Ceased to breathe
7 :35 P.M. Temperature post mortem 101.2Â°.
Clinical diagnosis: Acute yellow atrophy of the liver.
abstract of protocol of autopsy MADE THREE HOURS POST MORTEM
(dr. e. libman, assistant pathologist).
No rigor mortis ; no edema ; body poorly nourished ; slight icterus
of skin and conjunctiva?; no petechise, no ascites (organ bile-stained ").
llnjuius. â€” Not evident.
Lh Â«(/.Â§.â€” Moderately firm adhesions over right lung. Both lungs
show emphysema of upper lobes; both are congested and edematous;
numerous hemorrhagic areas; no consolidation. Left bronchial nodes
enlarged and pigmented. Right bronchial nodes calcareous.
//f7//-/.â€” Flabby and muscle cloudy; right auricle markedly, and
both ventricles moderately, dilated ; valves normal ; no atheroma of
aorta or of coronaries ; no congenital lesions.
LM>er.â€” Weight 1 kilogrannue 575 grammes (8 pounds 2'^A ounces) ;
lower border just within free border of ribs in mammillary line; in
median line, extends one-third of the distance from ensiform to um-
bilicus. Liver somewhat soft. As a whole it appears very fatty.
Scattered throughout it are a number of slightly elevated areas, ochre-
yellow in color, surrounded by a dark-red riuL The yellow areas
vary in size from pinhead to one-half centimetre in long dinmeter.
In places they seem to be mainly grouped about the central veins, in
others about the branches of the portal vein. On the whole the dis-
tribution is irregular, but the entire liver is involved. Portal vessels
distended by fluid blood.
Gall Bladder. â€” The gall bladder and ducts show no changes. The
gall bladder is moderately filled with dark-colored bile.
Portal Veins.â€” y^ot thrombosed.
22 MOUNT SINAI HOSPITAL REPORTS.
Large Abdominal yesseis.â€” Negative.
Spleen. â€” Slightly enlarged; weight, 200 grammes; surface very
dark; on section, marked congestion; bodies very large; pulp easily
scraped off ; splenic vessels normal.
*S'^09?)flc/i.â€” Moderately distended; contains brownish fluid; mucosa
swollen, studded with hemorrhages.
Intestines.â€” Mucosa, here and there shows some swelling with marked
injection of vessels; small intestine contains partly fluid material,
partly from fecal masses, the entire contents being olive-green in
color. The large intestine contains firm yellowish stool. Mesenteric
nodes slightly enlarged.
Pancreas.â€” Soft, yellowish. No gross pathological change.
' Kidneys.â€” Right weighs 250 grammes, left 190 grammes. Both
quite firm ; marked congestion on surface. On section, appear con-
gested, cloudy. Cortex yellowish in color; capsules not adherent.
Both pelves dilated. Ureters size of small finger, both being ob-
structed by pressure of the uterus; they contain clear fluid.
Uterus and Adn exa.-JJterus reaches to umbilicus. Contains a male
fetus 23 cm. in length, apparently normal, but yellowish in color.
Genital apparatus well formed; nails present; placenta on anterior
wall of uterus. Uterus, vessels, etc., show usual changes of pregnancy.
Brain. â€” lightly edematous; veins on surface implicated. Thin
exudate over base, involving cerebellum; exudate whitish, in some
places rather yellowish. Fluid between arachnoid and dura increased.
Fluid in ventricles increased, clear. Choroid plexuses congested:
show small cysts. No focal lesions in brain. Z>wraâ€” Negative.
Sinuses negative ; tegmen tympani on both sides negative.
Bacteriological Examination. â€” Spleen: In sugar bouillon, strepto-
cocci (Gram-positive) ; and a Gram-negative, short bacillus with
rounded ends. Spreads made from exudate at base of brain showed
MICROSCOPICAL EXAMINATION (dR. F. S. MANDLEBAUM, PATHOLOGIST).
Sections from the liver show the lobules to be fairly well marked.
The periphery of each lobule is well defined, and the liver cells at this
situation are the least changed of all, showing only a slight granular
degeneration of the protoplasm. The nuclei are somewhat sAvollen.
The cells take up the stain fairly well, and the nuclei appear practi-
cally normal with the exception of a slight variation in size. Toward
the centre of each lobule the cells become more and more changed.
The border of each individual cell is still well seen, but the proto-
plasm has been entirely changed by a marked degeneration, mostly
albuminous in character. Here and there some fatty degeneration is
also noted. The cells have lost their power of staining to a marked
extent. At the periphery of some of the lobules a collection of
lymphoid cells is seen, also a few leucocytes. The capillaries are much
dilated and filled with l)lood. In some places an actual hemorrhage
RUDISCH : ACL'TE YELLOW ATROPHY OF THE IJVER, 23
into the liver parenchyma has taken place, and a small amount of
blood pigment is also seen. The intralobular veins appear somewhat
dilated. The branches of the portal vein and hepatic artery show
no changes. The bile ducts are normal and show no tendency to
proliferation. No true necrosis of the liver can be demonstrated.
Diagnosis : Acute congestion ; acute albuminoid degeneration ; mod-
erate fatty degeneration.
The clinical interest in these two cases of acute yellow atrophy of
the liver centres in the nervous symptoms which they presented. In
fact, it was the resemblance between this symptom of the second case
and the nervous disturbances of the first, together with the presence
of jaundice, which led me to suspect that we had to deal with another
case of atrophy. The cerebral symptoms were such as we are accus-
tomed to regard as caused by severe toxemia. There was severe head-
ache ; moaning ; constant restlessness ; convulsive movements ; drowsi-
ness, deepening into stupor and finally coma. In the first case this
l)icture was complicated by the addition of elements which had much
of a hysterical nature about them. The patient held her body for
some time in a position closely resembling the arc de cercle of hysteria
major, and could most easily be roused from her stupor by tickling
the nasal mucous membrane with a straw. Leube calls attention to
the fact that cases of hysteria accompanied by jaundice, when they
occur in women, sometimes manifest such severe cerebral symptoms,
as delirium and convulsions, that they are apt to be mistaken for acute
yello^v atrophy. Besides the general symptoms in the second case,
there were evidences of focal cerebral disturbances in the form of
ptosis and facial paresis, as well as optic neuritis. These constituted
a very unusual feature of the case and were probably due to the .
exudate found at the base of the brain.
The liver was found to be enlarged intra vitam in both cases, but
there was subsequent diminution in size only in the first. This dim-
inution did not reach the extreme degree reported as especially char-
acteristic of most cases of acute yellow atrophy, and the weight of the
organ post mortem in either ease Avas not much below the normal.
Neither case could be said to have run a febrile course ; the first re-
mained afebrile until just before death, while the second was admitted
to the hospital with a temperature of 101.8Â°. which rose on the fol-
lowing day to 103Â°, and then fell steadily, until five hours ante mortem
it had fallen to 94.8Â°. The high postmoi-tem temperature observed in
cases of acute atrophy was not noted.
24 MOUNT SINAI HOSPITAL REPORTS.
In the urine also we find differences in the two eases. In the first,
at no time was leucin or ty rosin present, nor was any found in the liver
after death. Both were present in the urine of the second case. The
absence of these two substances in the urine in cases of acute yellow
atrophy is not unknown, and their presence is likewise not pathog-
nomonic. Both substances have been recently found in cases of sepsis
in the surgical division of the hospital. The quantity of urine passed
could not be accurately ascertained because of involuntary micturition.
but it appeared to be much below the normal.
The percentage of urea, however, remained 2 per cent, or under,
thus showing a diminution in the total quantity excreted. This is in
line with the facts generally observed. On the other hand, the quan-
tity of urine obtained from the second case varied anywhere from
28 to 60 ounces in tAventy-four hours, and the urea remained slightly
under 1.4 per cent. â€” not so marked a lessening in the quantity.
Hemorrhage occurred only in the first ease. It was from the
stomach and intestines.
The etiological factor in either case remains unknown. There was
no history of taking phosphorus or other poison, nor any attempt at
abortion, in the second case. In the first case there were no evidences
of pregnancy. However, her marked psychopathic family history and
the evidences she herself gave of psychical abnormality would not
make an assumption of suicide at all improbable. The urine and
livers of both cases were examined for traces of phosphorus, but with
â€¢Pathologically, we have two distinct pictures presented to us. In
the liver of the first case there is the typical microscopical picture of
fatty degeneration in the liver cells, more especially about the intra-
lobular veins. There is also commencing proliferation of the bile