The symptoms of organic disease of the heart are marked with
extraordinary clearness in the following case. The opportunity for
observing them was very favourable; and there was every incitement to
close observation, which could arise from the important and
interesting character of the patient. These advantages will justify an
uncommon minuteness in the detail of the case; especially, as the most
accurate knowledge of a complaint is obtained from a successive view
of its stages.
The late Governour of this commonwealth was endowed with most vigorous
powers of mind and body. At the age of sixteen he was attacked with
fits of epilepsy, which first arose from a sudden fright, received on
awaking from sleep in a field, and beholding a large snake erecting
its head over him. As he advanced in life they became more frequent,
and were excited by derangement of the functions of the stomach, often
by affections of the mind, by dreams, and even by the sight of the
reptile which first produced the convulsions.
At the commencement of the American revolution he became deeply
engaged in public affairs; and from that time devoted himself to
intense application to business, with which the preservation of his
health was never allowed to interfere. In the expedition against Rhode
Island, an attack of inflammation of the lungs had nearly proved fatal
to him.
In the beginning of the year 1807, he suffered severely from the
epidemic catarrh; and a remarkable irregularity of the pulse was then
perceived to be permanent, though there is some reason to believe,
that this irregularity had previously existed, during the fits of
epilepsy, and for a few days after them. In the summer, while he was
apparently in good health, the circulation in the right arm was
suddenly and totally suspended; yet, without loss of motion or
sensation. This affection lasted from noon till midnight, when it as
suddenly ceased, and the circulation was restored. In the autumn he
was again seized with the influenza, which continued about three
weeks, leaving a troublesome cough of two or three months' duration,
and a slight occasional difficulty of breathing, which at that time
was not thought worth attention. Soon after, in November, he had one
or two singular attacks of catarrhal affection of the mucous membrane
of the lungs, which commenced with a sense of suffocation, succeeded
by cough and an expectoration of cream coloured mucus, to the quantity
of a quart in an hour, with coldness of the extremities, lividity of
the countenance, and a deathlike moisture over the whole body. These
attacks lasted six or eight hours, were relieved by emetics, and
disappeared, without leaving a trace behind.
At this time he began to complain of palpitations of the heart; yet,
it is probable, that he had been affected with these before, since he
was unaccustomed to mention any complaint, which was not sufficiently
distressing to require relief. He experienced a difficulty of
respiring, as he ascended the stairs, and became remarkably
susceptible of colds, from slight changes of clothing, moisture of the
feet, or a current of cold air. His sleep was unquiet in the night,
and attended with very profuse perspiration; and, in the latter part
of the day, a troublesome heaviness occurred. The sanguiferous vessels
underwent an extraordinary increase, or, at least, became remarkably
evident. The pulsation of the carotid arteries was uncommonly strong;
the radial arteries seemed ready to burst from their sheaths; the
veins, especially the jugulars, in which there was often a pulsatory
motion, were every where turgid with blood. The countenance was high
coloured, and commonly exhibited the appearance of great health; but,
when he was indisposed from catarrh, this florid red changed to a
livid colour; which also, after an attack of epilepsy, was observable
for two or three days on the face and hands. This livid hue was often
attended, under the latter circumstances, with something like
ecchymosis over the face, at first formidable in its aspect, and
gradually subsiding, till it had the general appearance of an
eruption, which also soon vanished.
These symptoms increased, almost imperceptibly, during the five first
months of the year 1808. Much of this time was passed in close
application to official duties; and it seemed that a constant and
regular occupation of the mind had the effect of obviating the
occurrence of any paroxysm of disease, as well of epilepsy, as of
difficult respiration; and that a very sudden and disagreeable
impression generally produced either one or the other. There were,
indeed, independently of such circumstances, some occasional
aggravations of those symptoms. Some nights, for example, were passed
in sitting up in bed, under a fit of asthma, as it was called;
sometimes the mind became uncommonly impatient and irritable; the body
gradually emaciated; yet the appetite and digestive functions remained
principally unimpaired; and persons around were not sensible of any
material alteration in the condition of the patient.
On the approach of warm weather, in June, the violence of the symptoms
increased. Paroxysms of dyspnoea occurred more frequently, and were
more distressing. They commenced with symptoms of slight febrile
affection, such as hot skin, hard, frequent, and more irregular pulse,
disordered tongue, loss of appetite, and derangement of the digestive
functions. This kind of paroxysm lasted two or three days. Evacuations
of blood from the nose and haemorrhoidal vessels, which before rarely
occurred, became frequent; a fulness at the upper and right side of
the abdomen was sometimes perceptible, formed apparently by temporary
enlargement of the liver; the difficulty in ascending an eminence
increased sensibly. In the intervals of these attacks, which were
variable, but generally continuing ten or twelve days, the strength
was frequently good, and accompanied by a great flow of spirits, and
an aptitude, or rather ardour, for business.
Such was the course of this complaint until the latter part of August,
when a very severe paroxysm occurred. It commenced, like the former,
with febrile symptoms, but those more violent than before. The
countenance became high coloured; the dyspnoea excessive, and rendered
almost suffocating by a slight movement, or attempt to speak; the
pulse hard, very irregular, intermittent, and vibrating; and the
digestive functions were suspended. These symptoms soon increased to
the highest degree. The respiration was so distressing, as to produce
a wish for speedy death; the eyes became wild and staring. No sleep
could be obtained; for, after dosing a short time, he started up in
violent agitation, with the idea of having suffered a convulsion.
During the few moments of forgetfulness, the respiration was sometimes
quick and irregular, sometimes slow, and frequently suspended for the
space of twenty five, and even so long as fifty seconds. At the end of
three days the febrile heat was less permanent; the red colour of the
face changed to a death like purple; the hands and face were cold, and
covered with an adhesive moisture; the hardness of the pulse
diminished, and a degree of insensibility took place. I seized this
opportunity to examine the region of the heart, which had not been
done before, from fear of alarming the active and irritable mind of
the patient. The heart was perceived palpitating, obscurely, about the
7th and 8th ribs; its movements were very irregular, and consisted in
one full stroke, followed by two or three indistinct strokes, and
sometimes by an intermission, corresponding with the pulse at each
wrist. The pulsation was felt more distinctly in the epigastric
region. During this paroxysm a recumbent posture was very uneasy, and
the patient uniformly preferred sitting in a chair. When the recumbent
posture was assumed, the head was much raised, inclined to the right
side, and supported by the hand; the knees were drawn up as much as
possible. He could not bear an horizontal posture; nor did he ever
lie on the left side, except a short time after the application of a
blister. At the end of the fifth day his sufferings abated, but the
sudden affusion of a small portion of a cold liquid on the head
produced a severe fit of epilepsy. This was followed by a return of
the symptoms equally distressing, and more durable, than in the first
attack[2].
[Footnote 2: During this time it was thought adviseable to
acquaint his friends, that an organic disease of the heart
existed, which doubtless consisted in an ossification of the
semilunar valves of the aorta, attended, perhaps, by
enlargement of the heart; that the disease was beyond the
reach of art, and would prove fatal within three months,
possibly very soon; that if it lasted so long, it would be
attended by frequent recurrences of those distressing
symptoms, general dropsical affections, and an impaired state
of the mental faculties.]
This violent agitation gradually subsided, and was followed by a
pleasant calm. The natural functions resumed their ordinary course;
his appetite returned; his enjoyment of social intercourse was
unusually great; and he amused and instructed his friends by the
immense treasures of information, which his talents and observations
had afforded him, and which, he seemed to feel, would soon be lost. At
the end of September the feet began to swell, and after some time the
enlargement extended up to the legs and thighs, and increased to an
extraordinary degree; the abdomen next swelled, and, after it, the
face. Toward the end of October there were some indications of water
in the chest; there was a constant shortness and difficulty of
breathing; the cough, till now rare, became more frequent and
troublesome; the contraction of the thoracic cavity rendered the
action of the heart more painful, to that beside an uniform stricture
across the breast, he sometimes described a dreadful sensation like
twisting of the organs in the thorax. He suspected the existence of
water there, and was inclined to consider it as his primary disease,
but was easily convinced of the contrary. At one time he had a
suspicion of a complaint of the heart, and, although he had never
heard of a disease of that organ, slightly intimated it to one of his
friends, and mentioned a sensation he had experienced in the chest,
which he compared to a fluid driven through an orifice too narrow for
it to pass freely. In this month, beside the dropsical affections and
increase of cough, he had occasional painful enlargements of the
liver, frequent starting up from sleep, a slight degree of dizziness,
a great disposition for reveries, and sometimes extraordinary
illusions, one of which was, that he was two individuals, each of whom
was dying of a different disease. This idea often occurred, and gave
him much uneasiness. He was also afflicted with long continued
frightful dreams, and sometimes a slight delirium.
After the use of much medicine, on the 6th of November, the effused
fluids began to be absorbed, and passed out through the urinary organs
with such rapidity, that on the 12th the dropsical enlargements had
nearly disappeared. The pulse was much reduced, in hardness and
frequency, by the medicine, and, as it fell, he became more easy. On
the 10th the state legislature convened, and the call of business
roused, like magic, the vigor of his mind; and the symptoms of his
disease almost disappeared. During this session he made little
complaint, dictated many important communications, and attended to all
the duties of his office, without neglecting the most minute. As soon
as the legislature adjourned, he declared, that his work was finished,
and that he had no desire to remain longer in this world. He entreated
that no farther means should be used to prolong his existence, and
immediately yielded himself to the grasp of disease, which appeared
waiting with impatience to inflict its agonies.
From this moment the distressing difficulty of breathing had very
slight remissions. The consequent disposition to incline the superior
part of the body forward, for the purpose of facilitating respiration,
increased so much, that he frequently slept with his head reposed on
his knees. The cough became occasionally very violent, and was always
attended with an expectoration of a brown coloured mucus, sometimes
tinged with blood. The abdominal viscera lost their activity. The face
was sometimes turgid and high coloured, at other times pallid and
contracted. A gradual abolition of the powers of the mind ensued, with
a low delirium, and two short fits of phrenzy. The state of the
circulation was very variable; the pulse at the wrists principally
hard and vibrating, rarely soft and compressible; the less pulsations
becoming more indistinct, and at length scarcely perceptible. No
perfectly distinct beat of the heart was felt, but a quick undulating
motion, not corresponding with the pulse at the wrist. Three days
before death the arteries assumed this undulatory motion, corresponded
with the motion of the heart, and, for forty-eight hours, lost the
irregularity of pulsation[3].
[Footnote 3: The celebrated Morgagni has recorded some cases
of organic disease of the heart discovered by dissection, the
symptoms of which do not exactly accord with those observed
in this and the succeeding cases. It should be remembered,
however, that many of the subjects of those cases were not
examined by him, while living, and others but a very short
time before death. But it appears, that, in the last stage of
this disorder, some of the most important symptoms may be
materially changed, especially the state of the pulse,
dyspnoea and palpitations. Thus in the case related above,
and in some others, the pulse became regular, the
palpitations subsided, and the dyspnoea was less observable.
The cases of that accurate anatomist, therefore, are not so
contradictory of those related here, as might at first be
imagined.]
Once or twice the expiring faculties brightened. On the 30th of
November he awoke, as if from death, conversed very pleasantly for two
or three hours, and humorously described scenes, which he had
witnessed in his youth.
On the 4th of December came on the second attack of furious delirium.
Insensibility, and great prostration of strength, ensued. The
respiration became very slow, and obstructed by the accumulation of
mucus in the lungs; the pulse very intermittent, then regular, and
finally fluctuating. A hiccough commenced; coldness of the extremities
and lividity of the face followed, and continued three days before
death. On the 9th the incurvated posture was relinquished, and the
head sunk back upon the pillow; the respirations then diminished in
frequency, till they became only two in a minute; and at the end of
twenty-four hours they very gradually ceased.[4]
[Footnote 4: Governour Sullivan was born December 4th, 1744,
and died December 10th, 1809.]