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a seriously crippled heart. There might be a chance of obviating this
by means of the canula left in place, and the use through it of some
form of alterative injection. Rendu 1 reports such a case of cured
tuberculous pericarditis. The modifying injecting fluid employed by
Rendu was a solution of pure camphorated naphtol.

What is true in cases where effusion has been withdrawn as regards
some of the results to heart fibre is true where we leave the fluid in the
pericardial sac and do not attempt to remove it. By and by underneath
the thickened layer there comes a large layer of fat. This fat finally
penetrates the heart wall between the muscular fibres, and, in connection
with a deposit also of cellular tissue, leads to fatty degeneration of the
heart structure, and later, perhaps, to combined fibroid changes.

As regards serous effusions, even though large in amount, such as we
meet with as a complication, especially of acute articular rheumatism
and occasionally in nephritis, these rarely require, puncture, in my
judgment. Whenever the indication arises, unless the condition be very

1 Journal of the American Medical Association, 1901, p. 1432. Also, Bull, de la Soc. de
H3pitaux de Paris, March 21, 1901.



144 TUBERCULOUS PERICARDITIS.

imminent, I am of the opinion that one or a succession of fly blisters over
or near the heart will accomplish all that is urgently required. It is
not essentia], moreover, that much fluid be removed from the pericar-
dium in these cases so as to promote absorption ; a small quantity is
sufficient. The proof of this is that often after aspiration of the peri-
cardium, where very little fluid has been actually removed, a notably
beneficial effect quickly follows. The same thing results from a severe
counterirritant or revulsive. How this acts (blister) 1 I am not quite
sure. Evidently there is no immediate vascular connection between the
skin in the precordial region and the heart itself, and for this reason it
would seem as though the blister would do as much good were it placed
over a region far removed. Certainly, if mere reflex action comes into
play it is possible. And yet, somehow or other, I am a believer in its
good effects applied over the precordium, and I do know that revulsion,
irritation, or heat locally over the heart is of great practical value in
adding to its power. I can readily conclude, therefore, that wherever
effusion in large amount is partly passive, increased heart action may
be remedial in a very distinct and rapid manner.

With respect to the operation of paracentesis versus the use of coun-
terirritation in those cases where the effusion is limited and probably
serous, we should always have in view the possibility of change to a
purulent effusion caused by the little operation itself, especially if per-
formed with the ordinary trocar and canula. With proper aseptic pre-
cautions and the use of the aspirator, this to-day may be regarded as a
negligible quantity. Moreover, it is known that but one case has
resulted fatally following the puncture. " With this exception all the
patients were greatly relieved by the removal even of a small amount of
fluid, and many recovered completely who probably would have died if
the operation had not been performed." 2

In purely purulent effusions it is now generally admitted that surgery
with open wound, with or without drainage, should alone be considered.
Porter's case 3 and others still prove this. Only lately, for example,
H. Lilienthal has had a successful radical operation in a case of purulent
pericarditis. Here aspiration had proved insufficient. In Lilienthal's
case a portion of the fifth left costal cartilage was resected close to the
sternum under local anesthesia. Forty ounces of fluid were removed
from the pericardial sac. 4

In another case, reported by Ogle and Allingham, the pericardium
was opened, a large quantity of pus removed, and the pericardium

1 Dr. Shattuck never uses blisters. Drs. Tyson and Rotch would not let them go.
s The American Journal of the Medical Sciences, 1897, p. 458.

3 The only case ever treated by incision in Massachusetts General Hospital (F. C. S.). Boston
Medical and Surgical Journal, May 6, 1897, p. 438.

4 New York Medical Record, November 25, 1900.



TUBERCULOUS PERICARDITIS. 145

cleansed, without interference of the action of the heart and with
decided benefit to the patient. It was shown in this instance that the
heart can be handled without harm. It is therefore advisable to treat
these cases precisely as we would an empyema. Indeed, the operation
is more indicated than that of empyema, because the walls of the cavity
are better able to contract and finally lead to complete obliteration. We
know the outcome in empyema, where, to reach the best obtainable
result, portions of several ribs must often be resected. Even then we
have to deplore many incomplete successes.

Finally, in the operation by opening and drainage we have really the
only legitimate hope of entire recovery. No one has insisted upon this
operation more strenuously than Dr. J. B. Roberts since 1876. In a
late paper he reiterates his findings. Very properly he says, " the
diagnosis of the purulent character of the effusion was only determined
by exploratory puncture." 1 And "this should be done at the upper
part of the left xiphoid fossa close to the top of the angle between the
seventh cartilage and the xiphoid cartilage." 2

" The prognosis is good," says Dr. Roberts, " in pericardotomy for
pyopericardium. In a table of 26 collected cases 10 recovered and 16
deaths were shown. This gave a percentage of recovery of 38.4. Of
the fatal cases at least 9 were septic, and all the others who died had
complicated lesions, such as pleuritis, or pulmonary, cardiac, or renal
lesions." 3

" The results obtained by incision and drainage in tubercular peri-
tonitis suggest that drainage in tuberculous pericarditis may lead to a
permanent cure. The ease with which the pericardium can be irrigated
with solutions of iodoform would seemingly add to this probability of
success." i

After analyzing different cases, Roberts writes: " These observations
and other reported cases not here mentioned have almost convinced me
that incision is better than aspiration, even in cases not supposed to be
purulent. It establishes diagnosis in dubious cases, avoids cardiac
injury, saves the pleura from puncture, affords complete evacuation
of effusion, permits extraction of thick pus and membranous lymph,
and gives opportunity for disinfection of the sac when that is neces-
sary." 5

Porter cites one successful case of incision in serous pericarditis where
puncture failed to relieve. 6

Personally, so far as tuberculous cases are concerned, I agree with
Dr. Roberts. Ordinarily, in cases of simple serous effusion of other
provenance I do not believe incision is called for, and if any operative

1 Boston Medical and Surgical Journal, May 27, 1897, p. 522. 2 Loc. cit.

8 Loc. cit. * Transactions of the American Surgical Association, 1897, p. 108.

6 Loc. cit. • Transactions of the Surgical Association, vol. xv.



146 TUBERCULOUS PERICARDITIS.

interference is required I still prefer paracentesis. If irrigation be
employed as an adjunct in incision the outflow of fluid must be unim-
peded, or death may rapidly result from it.

In regard to the technic, it is not necessary to say more than to point
out that the best operation is the one usually which permits best drainage
in a given case. In one instance it may indicate resection of the fourth
or fifth rib on the left side; in another the pericardium should be opened
from below and through the insertion of the diaphragm near the central
tendon.

It should be remembered, in my judgment, that the question of radical
operation for pericarditis with effusion is different in one very important
particular from that of pleurisy with effusion. There are two lungs ;
there is only one heart. A patient may do fairly well a long time with
pleuritic adhesions, a retracted chest wall, and an atelectatic and fibroid
lung. No patient will continue long to be in any degree comfortable or
active who has adhesive pericarditis as a sequela of large and long-con-
tinued effusion, with the pathologic changes of heart walls which inva-
riably follow sooner or later.

To those who have had small clinical experience with these cases, and
who may be led to believe that the liability of heart puncture is slight,
I would point out that the anatomical relations of the pericardial sac,
despite Dr. Damsch's researches with the chest walls and left pleura, in
many instances are very perplexing and variable. As to the differential
diagnosis of pericardial effusion with a heart merely enlarged, while this
is often very simple and requires no great medical acumen, there are
occasions when the most careful use of physical methods of exploration
will leave one in a state of great uncertainty. Again, I have had to do
with cases where I was confident there was a large effusion and no risk
in introducing a small trocar connected with the aspirator. Unfortu-
nately, my diagnosis was incorrect, manifestly on one occasion, and
instead of withdrawing fluid from the pericardium my aspirating needle
penetrated the heart wall. This was obvious by reason of the fixed
position and special movements transmitted to the canula when the
trocar was withdrawn. In this instance no great or immediate harm
resulted. Still, it is an accident to be avoided, as far as possible, by
great care and attention.

Orphuls reports a case where, at the autopsy, the end of a trocar
needle was found in the scar tissue at the upper portion of the interven-
tricular septum. This needle probably broke off in an exploration or
in a previous operation of paracentesis. 1 Loison 2 affirms, also, that in
wounds of the heart and pericardium the " prognosis is not always

1 British Medical Journal, January 27, 1900.

2 The American Journal of the Medical Sciences, 1900, p. 218.



TUBERCULOUS PERICARDITIS. 147

grave." The judgment is strengthened by the statistics collected both
by Fischer and himself. On the other hand, Rotch has "known of a
case where pricking the heart with an aspirator needle caused sudden
death," and Janeway one where the aspirating needle tore the heart,
causing death.

Formerly, so as to avoid just such mishaps, I had constructed for
myself a modified Roberts canula. 1 This is a very good instrument
when kept in proper order. It is a little complicated, however, and
requires to be looked after. All that precedes acquires additional inter-
est, if we recognize, as many do, that the ordinary medicinal remedies
as applied to the treatment of pericarditis with effusion (especially the
tuberculous form) have very little value.

I am not aware, once pericarditis has become developed, that any
remedy given internally abridges its duration or changes its course very
perceptibly. I acknowledge, of course, in a few instances, that the
heart needs special stimulation in view of the failure that may come on
suddenly or by degrees. The alkaline treatment may prove very useful
in giving strength to cardiac contraction — more, indeed, than the use of
digitalis. This would be in accord with the experiments of Gaskell. 2
I also know that in a few — a very few sthenic cases — aconite may be
indicated for a short time to lower blood tension and decrease the rapidity
of the pulse ; but that is about all there is to do in the acute stage by
way of the mouth. Locally, as I have already pointed out, the ice-bag
or poultices, blood-letting (leeches and cups), are useful where there is
pain or great increase of heart action. Beyond some degree of soothing
or quieting thus produced, we should not count upon a great return.
The prophylactic measures to be employed have to do solely, it seems to
me, with the efficient causes of tuberculous pericarditis which prevail,
be it possibly pleurisy, pneumonia, sepsis of some sort, or mere exposure,
fatigue, or debauch.

As we know already, tuberculous pericarditis may show itself when
we have had little or no suspicion of its presence. It may also be
ushered in with so few obvious symptoms or signs, local or general, that
except in an accidental way it is not discovered during life. There are
many examples, indeed, where the presence of the disease was ignored
during life, and only ultimately revealed by the findings at the autopsy.

Appended is an abstract of the history of my second case :

History of Case of Tuberculous Pericarditis (No. 2). B. F., married,
a hod- carrier, born in the United States, aged thirty-eight years, was
admitted to St. Luke's Hospital under my care, March 19, 1901.
Family and personal history negative, save that he was a somewhat



1 The Medical Record, March 29, 1884, p. 361.

2 The American Journal of the Medical Sciences, 1896, p. 696.



148 TUBERCULOUS PERICARDITIS.

excessive drinker of beer and whiskey. Present illness began four
months ago, after a debauch, with pain in his right side. No cough,
chills, or vomiting. The pain in the side lasted a month, when he began
to cough, expectorated blood-stained mucus, had some fever, with after-
noon exacerbations, and became weaker. Two weeks ago pain in the
precordial region, with palpitations, developed ; also at times dyspnoea.
No swelling of the feet.

Physical examination shows marked increase of cardiac dulness, rapid
heart action, and a high-pitched systolic murmur, heard between the
nipple (left) line and sternum. Thoracentesis gave serous fluid in right
pleural cavity. Temperature, 99.3° F. ; pulse, 100 ; respiration, 49.
Urine, acid, 1020, no sugar, no albumin, few leukocytes. No tubercle
in sputum.

X-ray examination shows shadow corresponding to line of cardiac-
percussion dulness.

Microscopic examination of blood negative ; also examination of eyes
negative.

April 25th. Guinea-pig inoculated with fluid from right pleura. On
May 19th tubercle found in cheesy pus from enlarged lumbar glands of
guinea-pig.

May 26th. Patient paralyzed on right side. Soon became comatose
and died the same day. During sojourn in the hospital the patient was
feverish, with pronounced irregular rise in the afternoon.

Autopsy, made by Dr. N. E. Ditman, resident pathologist, showed
much thickened pericardium ; sac contained eight ounces of yellow,,
turbid fluid. Heart enlarged, muscle pale, and covered by a layer of
subpericardial fat ; valves normal, save a slight atheroma of one flap of
mitral. Dungs, liver, spleen, meninges, and peritoneum showed dissemi-
nated miliary tubercles.

Microscopic examination showed cheesy degeneration and numerous
giant cells throughout the pericardium. In the layer of fat over the
heart and beneath the pericardium were numerous small masses of small
round cells, and in each mass giant cells were present. The heart
muscle, superficially, was infiltrated with fat. More deeply there was
a moderate small round-cell infiltration between the muscle bundles, and
in places the latter are separated by connective tissue ; connective tissue
of bloodvessel walls increased in amount.



A STUDY OF SOME C1RRHOSES OF THE LIVER.



No doabt the majority of practitioners believe they know pretty
well about cirrhosis of the liver. It is a common affection, particularly
in hospitals and dispensaries. In its advanced stages it is readily diag-
nosed, as a rule.

In regard to its prognosis and treatment : These appear relatively
simple in that formerly at least it was assumed by very many that we
had to do with a fatal complaint ; and as for remedial measures, they
resolved themselves into few, among which paracentesis at the last
stage only was imperative, mainly to relieve distress. How far such
notions to-day are removed from truth I shall endeavor to show later.

That the liver is a difficult organ to study and know accurately
few will deny whose opportunities and mental make-up prove them
competent observers. As compared with other abdominal or thoracic
organs, where does it stand ? The lungs can be inspected, palpated,
percussed, auscultated, and in a way measured. So, perhaps, can the
liver ; but in the former case we seem to be in more accurate touch
latterly by reason of sputa examinations under the microscope and
inoculation experiments. The heart and its disorders have been the
source of so many investigations in the physiological laboratory, so
many accurate clinical observations in the office and the class room,
hospitals, and dispensaries— everywhere and at all times — that little
new may be added. With the advent of physiological chemistry, the
use of the microscope, and the opportunity, daily or hourly almost, of
knowing precisely what the urine shows, the kidneys as organs are very
clear to us. With the liver, on the contrary, much seems still conjec-
ture and hypothesis. We speak of its torpidity, engorgement, anaemia,
its functional derangements, its organic lesions, with glibness at times ;
and yet there is much that is obscure about its functions, healthy and
morbid, that is by no means evident, and about which there are very
honest and almost irreconcilable differences.

In this connection, only very lately, Dr. Goodhart writes : " The
largest organ of the body, its imports and exports must be enormous,
and from the familiar way in which it is spoken of there cannot be
a man in the whole world who does not think he knows all about it.
But what are the facts ? We know something about the physiology
of the liver ; but this knowledge has been mostly obtained by experi-
mentation on the lower animals, by observations that occasional cases



150 CIRRHOSES OF THE LIVER.

of disease afford us, and by certain inferences that we draw — very-
much at second hand — from the changes produced by disease in the
organ. But all these things — valuable as they are, and without which
where we should be I do not know — yet are very far from giving us
that real and intimate knowledge of the living organ that we require
to enable us to treat its diseases." 1

Should this not be adequate reason why we approach the study of
the cirrhoses with much diffidence and full recognition of our deficien-
cies, even in the role of an upright reporter ? " Good men and true "
have essayed this work faithfully in the past, and told us many things
we should know. A great deal more is required, much research remains
to be done, and only by degrees may we legitimately hope to secure
truth — entire and with full details.

In what relates to the cirrhoses there are many undetermined ques-
tions. The views ordinarily held are not entirely correct. In the first
place, the clinical facts, the more we become conversant with them, do
not justify invariably the gloomy prognosis of these affections which
has been entertained. Instead of separating with discrimination, there
has been confusion, because all forms of the disease have been thrown
together and included as one. In fact, here as elsewhere, the work of
the dead-house has reigned supreme for a time, and the close watching
of patients during life has been deemed of lesser value, when it should
always, as I believe, be the first thought of every good physician. How,
indeed, can we treat a patient properly unless we know just what
symptoms he presents during life and in what manner and to what
degree function was disturbed ? Everyone who has grown gray in
harness and whose experience has widened and deepened knows that
the morgue and the laboratory by themselves ignore too much and too
often the intricate and obscure of our economy in a dynamic sense,
and hence must be always controlled, as it were, from the horse-sense
point of view of even the humbler humdrum daily worker at the bed-
side. 2

There are different forms and degrees of cirrhosis. Not all at once
and every time does the final atrophic stage, with its irremediable
anatomical conditions and its absolutely gloomy horoscope, show itself.
This form is slow and insidious of development. At first it is not
recognized ; there are few or no symptoms we can attach to it. At
best we can only be suspicious. 3 If we have to do with a chronically
hard drinker of beer or spirits, of course, we think of the liver and

1 British Medical Journal, August 3, 1901, p. 251.

2 Vide Andrew Clark, British Medical Journal, February 3, 1883, p. 191 : " Address on Clini-
cal Investigation before the Clinical Society of London."

3 In writing of early stages of hepatic cirrhosis, Billings claims there is a relatively large
number of patients whose symptoms are those of neurasthenia, myalgia, mononeuritis, or
gastro-intestinal disturbance.— Medical News, July 26, 1902, p. 167.



CIRRHOSES OF THE LIVER. 151

fibroid changes ; and then if there be palpitations of the heart, evidences
of dyspepsia, vascular stigmata on the face, corpulency, and a some-
what enlarged liver we cry a halt to bad habits, and the outlook may
be sombre. On the same lines, if we find loss of strength, inap-
petence, and a failure of nutrition, as shown by loss of weight, even
though the liver be of normal size apparently, we cannot avoid some-
what gloomy forebodings unless we are able soou to control habits and
regimen. But are we sure — may we be reasonably certain — with such
vague characters that we shall even later be able to fix an absolute
and correct diagnosis ? The answer — the only one — must be negative.
The sooner the better for every medical student to know that disease
does not run closely at any time along so-called prescribed lines. It
varies, it differs ; one day we see certain forms of disease, another day
it is just the contrary. All cases are in a certain sense individual,
personal. There is nothing wholly general and all-absorbing about
any one instance. Take, for example, the abdominal effusion in cir-
rhosis — the ascites which in the later stages is so striking, so character-
istic, so grave of import in the eyes of many that it seems like to a
funeral knell in its fatality. Is it so ? May it not appear soon, and
in its earlier stages may it not be treated wisely and advantageously ?
And may not a patient do well for a long while, thus treated ? And
why is this ? May not very many of the liver cells still be function-
ally healthy, quite capable of carrying on good nutrition ? Is not
fibrous growth in the liver usually slow ? Does it not leave many
lobules untouched for many a day by its contracting power, and other-
wise in what degree is it really pernicious? These and other queries
immediately arise to one's mind. It is, moreover, a fact of daily ex-
perience almost to have patients come to our office or to out-door clinics
in whom ascites is undetermined. We are unable to affirm positively
that it exists. And this is true not for one examination only, but for
many. Days, months, and even years elapse with some patients before
we can say convincedly this is or this is not a case of hepatic cirrhosis.
The three principal forms of cirrhosis which are recognized by
writers are (1) atrophic, (2) hypertrophic, (3) syphilitic. Besides these
there are so-called minor, even undetermined, forms. Usually the
latter are due to passive congestion, brought on by pressure from
neighboring tumors or indicative of some chronic disturbance of heart
power, structure, or action. In these instances, especially where the
heart is the primary cause, the abdominal ascites is merely a symptom
which is part of a general anasarca. It may be, however, that the
ascites has something special in it ; it may stand by itself, as it were,
so far as effusion is concerned in the serous cavities. Then we have
to do with an expression of cardiac inefficiency accompanied by one of
the known effects of portal obstruction due to fibrosis around the vessels



152 CIRRHOSES OF THE LIVER.

of the liver. In these cases we should look rather for hypertrophy than
atrophy. The liver is enlarged and engorged. It is filled with blood
from overcongestion. There may or may not be already marked fatty
change, and thus, instead of the dense, hard, tough liver with sharp
lower margin, which is said to characterize the cirrhotic liver, we may
have a greasy, rather soft structure, which leaves the impress of the
finger upon its surface when we press with even very moderate force.
While, then, it may be admitted, and is certainly true with limitations,
that all three forms of cirrhosis of the liver are characterized by in-
crease of fibrous tissue, which penetrates its structure and distributes
in somewhat different ways along the branches of the interstitial tree,


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