108

TUBERCULOUS PERICARDITIS, WITH EF-
FUSION; REPEATED TAPPINGS; BACILLI
IN THE EXUDATE; RECOVERY.

By FLorence R. Sagtn, M.D., Fellow-in Anatomy, Johns
Hopkins Medical School; Late Interne Johns
Hopkins Hospital.

[From Professor Osler’s Clinic. ]

( Selected.)

The case was that of a colored boy, W. H., aged
20, who entered the Johns Hopkins Hospital under
Dr. Osler, March 31, 1901, complaining of pain over
the heart. He left the hospital six months later
improved, and at the present date, January, 1902,
is still improving.

His family and personal history were negative.

The present illness began two months before
admission, with pain in the right chest, sharp and
stabbing in character, worse on taking a deep
breath. He had cough and shortness of breath;
had never spat blood, but had had frequent night-
sweats. Three weeks before admission he began
to have pain over the heart, so severe that he gave
up work. ©

On admission he appeared well nourished, and
the mucous membranes were of good color. The
signs in the lungs were practically normal, except
over the lower right side, where the percussion
note was impaired and the breath sounds enfeebled.

Over the heart was heard a loud to and fro peri-
cardial rub. It was superficial, rough and altered
by pressure. The heart sounds were heard with
difficulty, but a point of maximum impulse was
clearly seen. The cardiac dullness was normal in
extent. The pulse was regular, of good volume;
the arteries were somewhat sclerosed. The ab-
dominal examination was negative. ‘The blood
showed hemoglobin of 85 per cent., and red blood-
corpuscles of 4,600,000 percm. The sputum was
scanty, muco-purulent, and not blood tinged. No

tubercle bacilli were ever found in it, though they.

were repeatedly sought. The urine showed albumen
and. casts.

Gradually the signs of pericardial effusion de-
veloped. The first change to be noted was in the
pulse. To April 8 the average rate was 114 beats
per minute. Between April 8 and 25, it was 120.
The temperature changed at the same time. Before
April 8, it ranged between 100 and 102 degrees;
after, it became irregular, occasionally intermittent,
ranging between 97 degrees and 104.7 degrees. The
area of cardiac dullness began to increase. By
April 15, there was movable dullness in Rotch’s
space. On April 19, the pulse became paradoxical.
On auscultation, both the friction rub and the heart
sounds became more and more feeble, especially at

The Woman's Medical Journal.

‘diaphragmatic pleurisy.

May, 1902

the apex. The most noticeable change in symptoms
was in the cough, which came in severe paroxysms,
ringing and high pitched in character. There was
some increase in the shortness of breath. By April
24, the cardiac dullness extended 14 cm., instead of
7cm., tothe left of the middle line in the fourth
interspace, and 3 cm., instead of 1.5 cm., to the
right.

On April 25 Dr. Osler noted three signs indicating
that the effusion was considerable in amount.
First, the apex impulse was no longer visible;
second, there was distinct bulging of the precard-
ium; and third, there were signs of compression of
the left lung, namely flat tympany in the left
axilla though not at the back. A needle was in-
troduced in the fifth interspace 1.5 cm. outside the
mammillary line. About 10 cc., of slightly yellow
fluid were removed. No organisms were found in
it. On April 27 the pericardium was again aspir-
ated and 25 cc. removed. The needle was inserted
at nearly the same place. The fluid contained a
few red and white blood-corpuscles, but no organ-
isms were found. After the aspirating the patient
was better. The cardiac dullness now extended
13.5 cm. to the left and 1.5 cm. to the tight. There
was no dullness in Rotch’s space. By May 1 the
apex beat was again visible, and by May 4 the heart
sounds were heard, but there was embryocardia.
The patient now began to complain of abdominal
pain, referred to the epigastrium. The cough
continued severe and the temperature was more
elevated. On May 11 Dr. Osler ordered a third
pericardial tapping. The needle was inserted twice,
once in the fifth interspace and once in the sixth.
Both times the heart was touched. Fifty cc. of
fluid was removed. It was centrifugalized and in
the pus a.clump of eight or ten tubercle bacilli were
found. For a few days the boy was more comfort-
able, but on May 14 he complained of pain in the
tight side, submammary region, where a loud
pleural friction was to be heard. It is probable
that the previous abdominal pain was due to
By June 7 the signs of
pericardial effusion had considerably diminished.

The apex beat was well seen 10cm. from the
middle line, the heart sounds were loud, and there
was gallop rhythm instead of the embryocardia.
No pericardial friction rule was heard. However,
signs of pleural effusion on the tight side began to
appear.

Increasing dullness, definitely movable, absent
vocal fremitus and suppressed breath sounds. On
June 8 the right pleural cavity was tapped, and
more than a litre of fluid was removed. The chest
filled up repeatedly, and was tapped in all14 times.
About 20 litres of fluid were removed. The fluid
Vol. XII, No. 5. The Woman’s Medical Journal. 109

was always blood-stained and sterile in cultures.
No tubercle bacilli were ever found—this was prob-
ably due to the fact that centrifugalization caused
the fluid to clot, thus making the difficulty of the
search great. No inoculation experiments were
made. At the fifth tapping a differential count of
the leucocytes of the exudate was made. Of 1,000
counted, 98.5 per cent. were small and 1.3 per cent.
large monoculear forms, while only 2 per cent. were
polynuclear forms. This ratio was constant.

The intervals between the tappings became pro-
gressively longer and the patient had shortness of
breath only when the fluid was high. He was
tapped last on September 7, and the fluid did not
collect again. On January 19, 1902, he was seen
by Dr. C. H. Bunting at the Hospital, to whom I,
am indebted for the following examination: There
were no signs of pleural nor pericardial effusion.
Heart: the point of maximum impulse was within
the nipple line, the sounds were well heard and
clear and there was no friction rub. Lungs: the
right shoulder droops; the left side of the chest is
fuller and expands more. Over the right lung the
note was resonant above, impaired below. The
vocal fremitus was diminished and the breath sounds
feeble over this impaired area. The general condi-
tion was good. ‘There was still marked cough with
scanty expectoration. Thus after extensive serous
membrane tuberculosis, the patient is left with a
quiescent process, the only physical signs being of
a thickened pleura and a partially collapsed lung.
The points of interest in the case are (1) the great
value of repeated tappings in serous effusions; (2)
the finding of tubercle bacilli in the pericardial
exudate; and (3) the high percent of mononuclear
forms in a tuberculous exudate. I wish to thank
Dr. Osler for the privilege of reporting the case.
—American Medicine, March 8, 1902.