ducts. The occurrence in places of hemorrhagic areas may be re-
garded possibly as precursory to the stage of red atrophy. In the
second case, Avhile there is some fatty degeneration in the liver cells,
the striking and most prominent lesion is that the cells occupying the
y.one midway between the centre and periphery of the lobule are in a
state of coagulation necrosis. This is the area of the liver lobule where
the anastomosis between the capillaries of the portal vein and those
from the central vein takes place, and it would appear, judging from
the nature of the necrosis, that the toxin or other injurious substance
coming from the portal system caused a sudden death of those cells
with which it first came in contact. This mav account for the lesser
RUDISCII : ACUTE YELLOW ATKOPJIY OF THE LIVER. ^O
amount of fatty degeneration in this liver as compared with that of the
iirst case; and this same rapidity of toxic activity may also explain the
absence of proliferation of the bile ducts. From the pathological con-
ditions in this second case some might be inclined to consider it a case
of acute degeneration of the liver as distinct from acute yellow
atrophy. We do not believe that our present knowledge justifies our
founding such a distinction on a pathological basis. In eases of severe
sepsis arising from various causes, such as appendicitis, os,teomyelitis.
and infectious diseases, the liver is often the seat of degenerative
changes which are general or circumscribed and range in degree from
cloudy swelling (acute parenchymatous degeneration) to fatty de-
generation and actual necrosis. The degree of pathological change
depends upon the virulence of the toxic agent. AA"e consider that the
same gradations in degeneration in the liver most probably occur like-
wise in acute yellow atrophy, and that the degree of severity reached
by the process depends upon the strength of the toxic agent. Acute
yellow atrophy is a complex of symptoms, a clinical entity, caused by
some unknown toxin, and accompanied by degenerative changes in the
liver. The second case corresponds clinically in all essentials to thic*
symptom complex, just as well as does the first case. There is in addi-
tion necrosis of the liver substance, which we think was caused by some
intoxication ; and hence the case must be included within the category
of cases of acute yellow atrophy of the liver, even though pathologi-
cally the predominant lesion is one of coagulation necrosis rather than
of fatty degeneration.
PRIMARY SARCOMA OF THE LUNG AND PLEURA.
By Julius Rudiscii, M.D.,
Herman Schwarz, M.D.,
FORMER HOUSE PHYSICIAN.
Primary carcinoma and sarcoma of the lung and pleura are rela-
tively so uncommon that the two cases to be described are well worthy
of report. Reinhard found 5 primary carcinomata in 545 cases of
tumor of the lung. Passeler found 16 in 870 and 4 sarcomata in 130
cases. It occurs most frequently between the ages of 40 and 60 (Rein-
hard, Passeler, and AVolf), 20 to 40 (Osier, Hassa). Yet primary
sarcoma has been described as occurring in very young children,
these originating in the thjanus (Virchow). It is more common
in men than in women (76 to 24), this probably being due to the great-
er liability to trauma, which plays an important role in its etiology.
Aufrecht cites four cases, in which two had a distinct history of in-
jury. In our cases no such etiological factor could be made out.
The primary sarcomata usually affect but one lung ; they may be of
the spindle cell, the large or small round celled variety, or of the type
known as the lymphosarcoma. The spindle or round celled sarcomata
usually present one mass, taking in the whole of one lobe or the entire
lung, and actually replacing it, for on section no remains of lung tissue
can be made out. They tend to degenerate and break down, forming
soft cystic or purulent masses, this being in part an explanation of the
recurrent fever so often present in tumor of the lung. The lympho-
sarcomata usually form several tumors, starting at the root of the
lung and travelling along the bronchi. They are of firm hard or
softer elastic consistence, and on section present portions of lung tis-
sue or bronchi surrounded by tumor mass. They rarely break down.
Mrs. L. M., aged 53, admitted October 12, 1901 ; occupation, house-
wife ; German birth.
Family i? isf or i/.â Negative.
RUDISCIl : rKIMARV SARCOMA OK TllK \A'NV. AND PLEURA. 2/
Previous History. â Rhe\uui\i\sm i-i^-lit hip 15 years ago. Pneumonia
i'oiir years ago (history of lung involved cannot be obtained). Pleu-
risy with pain in both chests two years. Still has irregular menstrual
Present //w^or//.â Began two months ago with dyspnea and slight
edema of the face and neck. No headache, no fever, no cough and
expectoration. Physician was called in and diagnosticated fatty
heart, for which she was given digitalis. This caused considerable
irritability of the stomach. For the past five days breasts have been
swollen. No swelling of the feet. No urinary symptoms.
Status Presens. â A short, stout, well-nourished woman; panniculus
fidiposus marked. Edematous infiltration of the forehead, cheeks, neck
(especially left side), and both breasts. Infiltration of tissues of the
thorax as low down as two fingers above the umbilicus. No edema of
uvula, tongue, tonsils, oi- of lower extremities. Glands of neck cannot
be made out on account of infiltration of tissues. No glands in axillae
or groins. Marked dilatation of veins about the shoulders and chest.
Lungs.â T)\\\\, almost flat note at right apex; poor note over left
apex ; dull over upper half of sternum ; good note in axillae. Breath-
ing tubular at right apex, less markedly so over anterior of right chest
and in right axilla ; high-pitched over left chest. Voice bronchial
over right chest. Fremitus cannot be made out over both chests.
Posteriorly, dull note at right apex, becoming flat at base ; flat at left
apex, resonance becoming pulmonary in the midscapular region.
Breathing markedly tubular over right apex to angle of scapula ; at
left apex it is high-pitched and almost bronchial. Few crepitations
scattered over both lungs. Voice at right apex bronchial; bronchial
at left apex, becoming normal at spine of scapula.
Heart. â Normal as far as can be determined; sounds faint; no
Abdomen. â Cannot be properly examined on account of amount of
fat and the dyspnoic attacks which occur when put in prone position.
Vrin e. â Negative.
Temperature 99Â°. Radial pulses equal.
October 30 : Patient has attacks of dyspnea which make her blue,
pupils dilated, pulse rapid and feeble. There is no cough or expec-
toration. No temperature. Speech is slightly hoarse. Laiynx ex-
amined by Dr. Gruening: a left recurrent laryngeal paralysis present.
Noveml)er 15: Dyspnoic attacks very freciuent. Pulse very feeble.
General condition rapidly becoming worse. Some difficulty in swal-
lowing. Edema of right arm. Right radial smaller than left. No
temperature or cough. Urine negative.
December 1 : Dyspnea marked. Pulse feeble. Edema of face, neck,
etc., nnich increased.
December 12 : Ceased breathing.
Clinical diagnosis: Tumor of mediastinum and lung.
28 MOUNT SINAI HOSPITAL REPORTS.
PROTOCOL OF POSTMORTEM MADE FOUR HOURS AFTER Di!:ATH BY DR. LIBMAN.
Head, not opened. No rigor. Piiffiness of face. Slight bilateral
exophthalmos. No edema of legs. Considerable edema of chest Avail.
21iyroid.âYery much enlarged, entirely replaced by fairly firm
growth, white in color. Trachea compressed.
Thorax. â Entire mediastinum occupied by enormous growth. This
is white in color, uniform in appearance, and very firm; it extends
into right and left sides of thorax, compressing both lungs. The
growth has eroded the posterior surface of the sternum and has grown
out through the second, third, and fourth right intercostal spaces into
the subcutaneous tissues. The tumor extends above the jugulum about
1 cm. and infiltrates the muscles of the neeh. Some of the mediastinal
nodes are still distinct, being very large and diffusely infiltrated.
Right Ivi/>((/. â ^Moderate amount of bloody fluid in pleural sac.
Lung is considerably compressed, and the upper lobe is infiltrated
by the growth. Lung is pale as a whole, but the base is congested.
Bronchial nodes moderately enlarged, congested, and anthracotic.
Left Lung. â Congested and edematous; emphysematous at apex.
Bronchial nodes as on right side.
Larynx and Trachea. â Compressed from ])efore backward. Esopha-
gus surrounded by large infiltrated nodes. Trachea and left bronchus
infiltrated by growth which extends to the nuicosa.
Heart. â Displaced downward and to the left. Right ventricle and
auricle moderately dilated. Mitral valve thickened. Aortic valves
and aorta negative.
Superior Vena CÂ«iv/. â Almost closed oft' by growth which extends
Spleen. â ]\roderately enlarged, very flabby; pulp soft, congested;
connective tissue increased.
L/i'er.â Moderately enlarged, congested, and fatty. In left lobe,
under surface, there is a metastasis, white in color, one-half cm. in
Kidneys. â Capsule adherent; surface irregular; cut section firm;
markings good ; one small metastasis on surface of left kidney.
Adrenals. â One nodule in each, rather soft, about 1 cm. in diameter.
Intestiyies. â Negative.
Microscopical Examination hy Dr. Mandlehauni. â Thyroid: Angio-
sarcoma. Tumor: Angiosarcoma. Adrenal: Angiosarcoma (metasta-
tic). Kidney: Chronic nephritis, acute congestive. Liver: ^Meta-
stasis. Spleen: Chronic interstitial splenitis, acute congestion.
I. ]\L, aged 33 years, admitted to hospital January 4, 1901.
Family History. â Negative.
Previous fl'/sfor;?/. â Syphilis thirteen years ago; a short inunction
cure. Nine years ago specific skin eruption occurred. Eight years
ago, swelling of left testicle, which disappeared under specific treat-
RUDISCU : PKIMAKY SAKCUiMA OF THE LUNG AND PLEURA. 29
ment. Five years ago, testicle again swollen, but treatment of no
avail: was removed at the Cierman Hospital, January. 1897. Patho-
logical diagnosis was syphilis. Soon after this began to have feeling
of weight and oppression in epigastrium, most marked after eating.
This is still present. Did not vomit until two months ago, and since
then has vomited once or twice every day. No alcohol or tobacco
F re sent History. â Eight months ago began to have severe pain in
left chest, which prevented him from taking a deep breath. This
pain became less severe after a few days. About three months ago
pain again present, and took iodides, which seemed to relieve it some-
what. No cough except when eating. For the past four weeks noticed
that voice was hoarse when he got up in the morning. For the past
two weeks he has been hoarse all the time. Has lost considerable
weight. Bowels regular. No urinary symptoms.
Status Pre se)is. â Complexion sallow. General condition fair; fairly
well nourished. Throat negative. All the lymphatic glands slightly
enlarged. Bulging of left chest. Considerable tenderness over left
side of thorax. Veins of upper extremity and chest prominent.
Lungs. â Anteriorly: Right side hyperresonant, left flat. No res-
piratory murmur over left chest. Voice and fremitus absent. On
right side signs of compensatory emphysema. Posteriorly : Note over
right chest good, flat over entire left chest. Voice and fremitus absent
on left side. Few friction rales over both lungs posteriorly.
^fr/yf.â Borders cannot be made out. Sounds faint. No murmurs.
Left radial artery barely perceptible, right distinctly felt.
Liver. â Palpable two fingers below free border.
Spleen.â 'Sot palpable.
Abdomen. â In right lumbar region pear-shaped mass felt, moving
Scrotum. â Small; only one testicle.
Lower Extremities.â No edema. No bony tenderness.
Blood spread negative. White blood cells, 22,400; red blood cells,
January 10: Left chest aspiratedâ negative.
January 13 : Emaciation more marked. Blowing systolic heard in
third and fourth left interspaces.
January 15 : Faint respiratory murmur heard at spine of left
January 26: Small ])ortion of subcutaneous tissue removed from
left infrascapular region. Section showed nothing i)athological (Dr.
]\Iandlebaum). No tubercle bacilli in sputum.
February 7: Diastolic murunir heard over second right interspace.
Tubular breathing at left apex; absent breathing below this. Glands
in the neck are larger. Spleen palpable two fingers below free border.
Patient looks anemic. Left upper extremity and face slightly edem-
atous. Left chest measures 46 cm., right chest 41 cm.
February 12 : Complains of severe pain in left chest, slight pain in
30 MOUNT SINAI HOSPITAL REPORTS.
right chest. Considerable dyspnea. Edema of face and left ex-
tremit}^ increasing. Some edema of left chest wall present ; abdomen
and lower extremity not involved.
February 15 : Emaciation increasing. Edema of left forearm and
hand marked. Veins of trunk markedly distended.
Februarj^ 17 : Frequent attacks of dyspnea. Edema of lung pres-
ent. Ceased breathing.
Throughout his entire stay in the hospital patient ran a tempera-
ture varying from 99Â°-100Â° in the morning to 102Â°-103Â° in the eve-
ning, often going up to 104Â°.
Urine normal until a few days before death, when a slight amount
of albumin and a few casts were present.
Clinical diagnosis: Tumor of lung.
PROTOCOL OF AUTOPSY MADE NINE HOURS POST MORTEM BY DR. MANDLE-
Isaac Mendel, 33 years old, admitted January 4, died February 17.
Head not opened. jModerate rigor. Body slightly emaciated. Left
half of thorax distinctly larger than right. Edema of left side of
thorax, left arm and hand. On removing stenuim it is noted that
growth protrudes between the second and third costal cartilages on the
left side. Sternum is adherent to mass and fills the entire mediastinal
space. Heart occupies a position in the right thoracic cavity corre-
sponding to its usual position in the left side.
Lungs. â Eight: Rather voluminous. In upper lobe at apex an old
whitish cicatrix, slightly depressed. Beneath this are a few calcareous
nodules, healed tuberculosis. Moderate amount of edema, no consoli-
dation. Bronchial lymph nodes pigmented, but not especially en-
larged. Larger bronchi show moderate amount of congestion. Left:
The entire left side of the thorax and mediastinum is entirely filled
by a tumor mass. It is firmly adherent to the inner wall of the thorax
and vertebral column, so that a dissection is necessary to remove same.
The tumor is also firmly adherent to the pericardium. In removing
tumor, lungs, and heart in toto, a large abscess cavity is ruptured and
about a quart of foul-smelling pus is evacuated. Section through
mass shows remains of lung tissue remaining in the upper lobe, but
this is so infiltrated that lung tissue is barely perceptible. That por-
tion of the mass represented by the lower lobe is entirely composed
of new growth. The tumor is grayish white in color, very soft in
consistence. Scattered throughout are areas of necrosis. In these
situations the tumor is of a fluid, milky consistence.
Axillary lYoc/e.s. â In left axilla are some enlarged nodes consisting
of tumor mass with fluid contents of a pure white color resembling
Heart.â \]\)on opening the pericardium it is seen that this is firmly
adherent to the heart. The tumor mass is also found to have extended
completely throush the pericardium on the left side, forming small,
RUDISCH : PRIMARY SARCOMA OF THE LUNG AND PLEURA. 31
rough nodules upon the inner surface. Heart appears somewhat small,
and is not opened for examination. All the large vessels are entirely
surrounded by tumor and are almost hidden.
Spleen. â Somewhat enlarged; pulp soft, easily scraped from sur-
face ; color dark chocolate.
Kidneys. â Size normal. Capsules slightly adherent in places. Sur-
face slightly rough. On section, markings are plain. Some conges-
tion and a slight granular appearance of cortex are noted.
Liver. â Size normal. Slight congestion. Veins negative.
Stomach. â Vessels in mucosa somewhat engorged and prominent.
Pancreas. â Negative. Just below and behind pancreas is a mass,
about the size of a lemon, lying directly upon the vertebra. This is
similar to the growth in the thorax and appears to be a direct exten-
sion downward through the diaphragm and encircling the aorta. The
consistence is almost fluid. No other growths are found.
Intestines and 5/acMer.â Negative.
Microscopical Examination. â Lung: Endothelioma, purulent in-
flammation. Axillary Node: Endothelioma, purulent inflammation.
Liver: Congestion, pigmentation, acute inflammation. Spleen: Pig-
mentation, chronic inflammation. Kidney: Congestion, chronic ne-
phritis, acute degeneration.
In considering the symptoms and diagnosis of tumors of the lung
and pleura, it is almost impossible to distinguish between the car-
cinomata and sarcomata; yet, as we shall see later, one may venture
at a probable diagnosis of the variety of tumor.
Before going into a discussion of the symptoms, subjective and ob-
jective, which may be present, it is important to know that there are
cases in which there are absolutely no symptoms referable to the lungs
or pleura as the seat of the disease (Ebstein, Osier, AA^alshe). The
subjective symptoms which may be present are dyspnea, stridor, cough
and expectoration, and pain in the chest.
Dyspnea is very often the earliest and probably the most constant
symptom, as shown in Case I. It is a gradually progressive dyspnea,
greatly increased on lying down, more so than on exertion. Yet. in
contradistinction to this, Ewald cites a case where the tumor was
situated between the trachea and esophagus, in which the dyspnea
was greatly relieved when the patient was put in the prone position.
The dyspnea may, however, be almost absent, as in our second case,
appearing only a short time before death. It often occurs in par-
oxysms, during which the patient becomes deeply cyanotic, almost
unconscious, pupils dilated, pulse rapid and feeble. The stridor and
dyspnea are much more marked in the sarcomata as compared with
32 MOUNT SINAI HOSPITAL REPORTS.
the .carcinomata, and Schwalbe makes this a dififerential diagnostic
point between the two growths.
Cougli and expectoration are very often absent, as seen in both of
our cases. The cough depends to a certain extent upon the location
of the tumor; those involving the pleura present this symptom more
constantly. Yet it is absent so frequently that it has absolutely no
The sputum was at one time considered of great importance. The
so-called cranberry or prune-juice sputum was considered typical and
Stokes laid great stress upon it. It was present in 10 out of 18 of his
cases. Ebstein places no value upon it Avhatsoever, for it was absent
in all of his reported cases. Blood is often present in the sputum,
Stokes finding it in one-half of 49 cases. Blood-tinged mucus was
thought characteristic by Woillez. Grass-green sputum has also been
seen, but this has been found in pneumoniae going on to abscess forma-
tion, the sputum remaining in the bronchi, becoming mixed with blood
and changing to this color. Particles of the tumor found in the
sputum are diagnostic, but, as Ebstein pointed out, these are but rarely
found and it requires an expert to make the pathological diagnosis.
Hampeln considered groups of cylindrical cells of importance ; but
Traube showed that it was very uncertain to make a diagnosis from
these cells, for at times similar cells appeared in sputum from tuber-
This brings us to mention the pathological observation that tuber-
culosis of the lungs and malignant growth are not infrequently found
in the same subject ; thus the presence of tubercle bacilli in the sputum
does not exclude malignant growth.
Carcinomatous nodules have been found extending into tubercular
cavities. Wolf reports 31 cases of carcinoma, 13 of which showed the
combined lesions. Schwalbe reports 3 cases. Hildebrand and Fried-
lander report others.
Fain is a very variable symptom and is naturally more constant
where the pleura is involved. Fever is a symptom more often present
in sarcomata than in carcinomata. It is often of a remittent or inter-
inittent type (chronischer Rilckfallfieher of Ebstein), as seen in our
second case. Yet it may be entirely absent, as in our first case. It is
usually due to ulceration or purulent infiltration of the tumor, but
may be present without any demonstrable cause. Cachexia and rapid
loss of w^eight occur late in the disease.
The physical signs which are found in tumors of the lung and pleura
RUDISCH : PRIMARY SARCOMA OF THE LUNG AND PLEURA. 33
are very variable and not at all diagnostic. Local edema is of con-
siderable importance. It usually extends over the neck, thorax, and
arm of the same side on which the lung is affected. Senator says
that this is a good differential point from pleurisy with effusion, for
there is rarely edema of the chest wall and arm in this affection.
Dilatation of the superficial veins of the thorax and arm, especially
on the side affected, is also valuable.
Involvement of the glands of the neck and axilla may help by
enabling one to excise a gland, cutting same, and thus obtain an ac-
curate diagnosis. Yet the infiltration and edema may be so marked
as to prevent us from feeling the glands, as in Case I.
One radial pulse may be smaller than the other, thus aiding in the
diagnosis of intrathoracic growth.
In every case a laryngoscopic examination should be made, even
when there is no change in voice or aphonia. A paralysis of the right
cord speaks more for tumor and against aneurism, involvement of both
cords for tumor. In such a case one cord is in the median, the other
in the cadaveric position; thus fatal dyspnea is not likely to occur.
By tracheoscopy one sees the trachea pushed to one side in aneurism,
whereas in tumor it is compressed from before backward.
As far as the physical signs which are produced by the lesion in the
lung and pleura are concerned, there is absolutely nothing path-
ognomonic. AVhen one considers that the entire aft'air may be masked
by an immense pleural effusion, that areas of pneumonia may sur-
round the growth, or atelectases caused by the growth (v. Korner),
one can easily see what difl'ereut groups of auscultatory and percus-
sory signs may be made out.
Pleurisy with effusion is more common in the sarcomata than in the
carcinomata. These pleurisies are not usually hemorrhagic, as is
commonly believed, for in 200 cases described by INIoulard and Mar-
tin only 12 per cent, showed bloody fluid. Aufrecht says that hemor-
rhagic fluid is more common in non-malignant than in malignant
pleurisies. A. Frankel has drawn attention to cells which, when re-
peatedly found in pleural fluid, point to malignant growth. These
cells are ten to twenty times as large as the leucocytes and contain
many vacuoles ( Riesenvacuolenzellen) .
Dulness or flatness over the upper portion of the sternum is often
present. A flat note at one of the apices, with either absence of breath-
ing and fremitus or tubular breathing and absent fremitus, naturally
makes one suspect tumor; but, as we have said above, we may have
34 MOUNT SINAI HOSPITAL REPORTS.
practically any and almost every physical sign which pathological
conditions in the lungs may bring about, yet none are pathognomonic.
The X-ray was used in both of our cases and only showed darker
shadows where the new growths were situated.
The duration of the disease is, on the average, from six to eight
1. MOULARD AND MaRTIN.
3. Bollinger's Klinik der Sarkom. Miinchen. Eulenberg's Vierteljahres-
bericht fiir gewichtlichen Medicin, Bd. xxx.
4. ScHWALBE. J.: Deut. med. Woch., 1891.
5. Verhandlung der Berliner medicinischer Gesellschaft, Vortragender A.
Frankel. Ueber die Diag. der Brustholen geschwiilste. Nov. 4, 1891.
6. Ebstein: Zur Lehre der Krebs der Broncbien und Lungen. Deut. med.
Woch., 1890, No. 42.
7. Ebstein rxD Sciialbe: Lnngen-Sarkom. Pract. der Med.
8. Oslek: Practice of Medicine, 1902.
9. Reference Handbook of the Medical Sciences.
10. Darroles: Du Cancer pleuro-pulmonaire. These de Paris, 1887.
11. Possler: Malignant Growths. Virchow's Archiv., Bd. xlv., 1896.
12. Wolf: Carcinoma und Tuberculosis. Fortschritte der Medicin, Bd.