The symptoms, which are most observable, in some or all of the
preceding cases, are the following:
The first notice of disorder is commonly from an irregular and
tumultuous movement of the heart, which occurs some time before any
perceptible derangement of the other functions. This irregularity
slowly increases, and arrives at its height before the strength of the
patient is much impaired, at least in the cases which I have noticed;
and as the vigour of the patient lessens, the force of the
palpitations diminishes. These palpitations are often so strong, as to
be perceptible to the eye at a considerable distance. They are seldom
most distinct in the place where the pulsation of the heart is usually
felt. Sometimes they are perceived a little below; often in the
epigastric region; and not unfrequently beneath, and on the right
side, of the sternum.
After the palpitations have lasted some time, a little difficulty of
breathing, accompanied with sighing, is perceived, especially on any
great exertion, ascending an eminence, or taking cold, of which there
is an uncommon susceptibility. This dyspnoea becomes, as it increases,
a most distressing symptom. It is induced by the slightest cause; as
by an irregularity in diet, emotions of the mind, and especially
movement of the body; so that on ascending stairs quickly, the patient
is threatened with immediate suffocation. It occurs at no stated
periods, but is never long absent, nor abates much in violence during
the course of the disease. It is attended with a sensation of
universal distress, which perhaps may arise from the circulation of
unoxygenated blood, or the accumulation of carbon in the system; for
the countenance becomes livid, and the skin, especially that of the
extremities, receives a permanent dark colour. This dyspnoea soon
causes distress in lying in an horizontal posture. The patient raises
his head in bed, gradually adding one pillow after another, till he
can rarely, in some cases never, lie down without danger of
suffocation; he inclines his head and breast forward, and supports
himself upon an attendant, or a bench placed before him. A few hours
before death the muscular power is no longer capable of maintaining
him in that posture, and he sinks backward. The dyspnoea is attended
with cough, sometimes through the whole of the disease, sometimes only
at intervals. The cough varies in frequency. It is always strong, and
commonly attended with copious expectoration of thick mucus, which, as
the disease advances, becomes brown coloured, and often tinged with
blood; a short time before death it frequently consists entirely of
black blood.
The changes in the phoenomena of the circulation are very remarkable.
The sanguiferous system is increased in capacity; the veins,
especially, are swelled with blood; the countenance is high coloured,
except in fits of dyspnoea, when it becomes livid; and it is very
frequently puffed, or turgid. The brightness of the eyes, dizziness,
which is a common, and head-ache, which is a frequent symptom, and in
some cases very distressing, are probably connected with these
changes. The motions of the heart, as has already been stated, are
inordinate, irregular, and tumultuous. The pulse presents many
peculiarities. In some cases, probably where there is no obstruction
in the orifices of the heart, it remains tolerably regular, and is
either hard, full, quick, vibrating and variable, or soft, slow,
compressible and variable. Most commonly, perhaps always, when the
orifices of the heart are obstructed, it is vibrating, very irregular,
very intermittent, sometimes contracted and almost imperceptible, very
variable, often disagreeing with the pulsations of the heart, and
sometimes differing in one of the wrists from the other.
The functions of the brain suffer much disturbance. Melancholy, and a
disposition for reverie, attend the early stages of the complaint; and
there is sometimes an uncommon irritability of mind. The dreams become
frightful, and are interrupted by sudden starting up in terror.
Strange illusions present themselves. The mental faculties are
impaired. The termination of the disease is attended with slight
delirium; sometimes with phrenzy, and with hemiplegia.
The abdominal viscera are locally, as well as generally, affected.
Although the digestive functions are occasionally deranged, the
appetite is at some periods remarkably keen. The action of the
intestines is sometimes regular, but a state of costiveness is
common. The liver is often enlarged, probably from accumulation of
blood. This distention is attended with pain, varies much, and, in all
the cases I have seen, has subsided before death, leaving the coats of
the liver wrinkled, flaccid, and marked with appearances of
inflammation, caused by the distention and pressure against the
surrounding parts. An effect of the accumulation of blood in the
liver, and consequently in the mesenteric veins, is the frequent
discharge of blood from the haemorrhoidal vessels. This occurs both in
the early and late stages of the disease, and may become a formidable
symptom. Evacuations of blood from the nose are not uncommon.
Dropsical swellings in various parts of the body succeed the symptoms
already enumerated. They commence in the cellular membrane of the
feet, and gradually extend up the legs and thighs; thence to the
abdominal cavity, to the thorax, sometimes to the pericardium, to the
face and superior extremities; and, lastly, to the ventricles and
meninges of the brain. These collections of water may be reabsorbed by
the aid of medicine; but they always return and attend, in some
degree, the patient's death.
There is no circumstance more remarkable in the course of this
complaint, than the alternations of ease and distress. At one time the
patient suffers the severest agonies, assumes the most ghastly
appearance, and is apparently on the verge of death; in a day or a
week after, his pain leaves him, his appetite and cheerfulness
return, a degree of vigour is restored, and his friends forget that he
has been ill. The paroxysms occasionally recur, and become more
frequent, as the disease progresses. Afterwards the intermissions are
shorter, and a close succession of paroxysms begins. If the progress
of the complaint has been slow, and regular, the patient sinks into a
state of torpor, and dies without suffering great distress. If, on the
contrary, its progress has been rapid, the dyspnoea becomes excessive;
the pain and stricture about the praecordia are insupportable; a
furious delirium sometimes succeeds; and the patient expires in
terrible agony.
Such are the symptoms, which a limited experience has enabled me to
witness. Others, equally characteristic of the disease, may probably
exist.
From this description of the symptoms it would appear, that there
could be no great difficulty in distinguishing this from other
diseases; yet probably it has sometimes been confounded with asthma,
and very frequently with hydrothorax. Some may think, that there is no
essential difference in the symptoms of these diseases. The
resemblance between them, however, is merely nominal.
The cough in hydrothorax, unlike that which attends organic diseases
of the heart, is short and dry; the dyspnoea constant, and not subject
to violent aggravations. An uneasiness in a horizontal posture attends
it, but no disposition to incurvate the body forward. These are some
of the points, in which these two diseases slightly resemble each
other. Those, in which they totally differ, are still more numerous;
but as most of them have been already mentioned, it is unnecessary to
indicate them here.
It is probable, that the two diseases commonly arise in patients of
opposite physical constitutions; the hydrothorax in subjects of a weak
relaxed fibre; the organic diseases of the heart in a rigid and robust
habit. The subjects of the latter affection, in the cases which have
fallen under my observation, were, with the exception of one or two
instances, persons of ample frame, and vigorous muscularity, and who
had previously enjoyed good health. In nearly all these cases the
collection of water was principally on one side, yet the patients
could lie as easily on the side where there was least fluid, as on the
other; which, in the opinion of most authors, is not the case in
primary hydrothorax. It should also be observed, that, in many of the
cases, there was only a small quantity of water in the chest, and that
in neither of them was there probably sufficient to produce death. May
not primary hydrothorax be much less frequent, than has commonly been
imagined?
Idiopathic dropsy of the pericardium may, perhaps, produce some
symptoms similar to those of organic disease of the heart; but it
appears to be an uncommon disorder, and I have had no opportunity of
observing it. In the fourth case, a remarkable disposition to syncope,
on movement, distinguished the latter periods of the disease, and
might have arisen from the great collection of water in the
pericardial sac.
The causes of this disease may, probably, be whatever violently
increases the actions of the heart. Such causes are very numerous; and
it is therefore not surprising, that organic diseases of the heart
should be quite frequent. Violent and long continued exercise, great
anxiety and agitation of mind[14], excessive debauch, and the habitual
use of highly stimulating liquors, are among them.
[Footnote 14: It has been remarked by the French physicians,
and particularly by M. Corvisart, physician to the emperor of
France, that these organic diseases were very prevalent after
the revolution, and that the origin of many cases was
distinctly traced to the distressing events of that period.]
The treatment of this complaint is a proper object for investigation.
Some of its species, it is to be feared, must forever remain beyond
the reach of art; for it is difficult to conceive of any natural agent
sufficiently powerful to produce absorption of the thickened parietes
of the heart, and at the same time diminish its cavities; but we may
indulge better hopes of the possibility of absorbing the osseous
matter and fleshy substance deposited in the valves of the heart and
coats of the aorta. A careful attention to the symptoms will enable us
to distinguish the disease, in its early stages, in which we may
undoubtedly combat it with frequent success.
Although it may not admit of cure, the painful symptoms attending it
may be very much palliated; and, as they are so severely distressing,
we ought to resort to every probable means of alleviating them.
Remedies, which lessen the action of the heart, seem to be most
commonly indicated. Blood-letting affords more speedy and compleat
relief, than any other remedy. Its effect is quite temporary, but
there can be no objection to repeating it. The digitalis purpurea
seems to be a medicine well adapted to the alleviation of the
symptoms, not only by diminishing the impetus of the heart, but by
lessening the quantity of circulating fluids. Its use is important in
removing the dropsical collections; and for this purpose it may often
be conjoined with quicksilver. Expectoration is probably promoted by
the scilla maritima, which, in a few cases, seemed also to alleviate
the cough and dyspnoea. Blisters often diminish the severe pain in the
region of the heart, and the uneasiness about the liver. It has been
seen, that the excessive action of the heart sometimes produces
inflammation of the pleura and pericardium, and that the distention of
the coat of the liver has the same effect upon that membrane in a
slighter degree. Vesication may probably lessen those inflammations.
When the stomach and bowels are overloaded, a singular alleviation of
the symptoms may be produced by cathartics, and even when that is not
the case, the frequent use of moderate purgative medicines is
advantageous. Full doses of opium are, at times, necessary through the
course of the complaint. The antiphlogistic regimen should be
carefully observed. The food should be simple, and taken in small
quantities, stimulating liquors cautiously avoided, and the repose of
body and mind preserved, as much as possible.
The causes of some of the phoenomena of this disease are easily
discovered; those of the others are involved in obscurity, and form a
very curious subject for investigation. I shall not at present trouble
you with the ideas relating to them, which have occurred to me, but
hope to be able to present some additional remarks on the subject, at
a future period. In the mean time, I beg leave to invite the attention
of the society to the observation of the symptoms of this interesting
disorder, and of the morbid appearances in the dead bodies of those,
who have become its victims.
* * * * *
At the time the preceding pages were going to the press, the subjects
of the ninth and tenth cases died, on the same day, and an opportunity
was given of ascertaining whether their complaints had been rightly
distinguished.
It is a proof of an enlightened age and country, that no objections
were made in any instance to the examinations, which have afforded us
so much useful information.
DISSECTION OF CASE NINTH.
THIRTY HOURS AFTER DEATH.
The lady, who was the subject of this case, died on the 10th of May,
but she was not seen by me after the 29th of March; so that it is not
in my power to relate exactly the symptoms which attended the latter
stages of her complaint. I was informed, however, that they increased
in violence, especially the difficulty of breathing, and inability to
lie down; that her cough returned, and her expectoration was sometimes
bloody; and that, for sometime before death she suffered inexpressible
distress.
We found the body somewhat emaciated, and the lower extremities and
left arm oedematous. Might not this swelling of the left arm have
depended on her constant posture of inclining to her left side?
The face, especially at the lips, was livid, though not so much as in
many other cases of this disease. On the left shoulder were small,
hard, and prominent livid spots.
The cellular membrane, both on the outside and inside of the thorax,
was quite bloody, which is not usually the case in dead bodies. The
cartilages of the ribs were slightly ossified, and, upon their
removal, it appeared that the pericardium and its contents occupied an
extraordinary space, for the lungs were quite concealed by them. These
organs being drawn forward, appeared sound and free from adhesions;
their colour, anteriorly, was rather dark; posteriorly, still darker;
their consistence firm. Their vessels were so crowded with blood, as
to cause an uniform dark colour in the substance of the lungs,
especially in some particular spots, where the blood appeared to be
accumulated; but whether this accumulation was confined to the blood
vessels, or extended to the bronchial vesicles, could not be
satisfactorily determined. No one can doubt that blood may be
frequently forced through the thin membrane of the air vesicles, who
considers, that in these cases the heart often acts with uncommon
violence, that, when it is enlarged, it attempts to send toward the
lungs more blood than their vessels can contain, and that there is
commonly some obstruction to the return of blood from the lungs into
the heart, from derangement either in the mitral or aortal valves, or
in the aorta. The consequent accumulation of blood in the lungs seems
to me to be the probable cause of the dyspnoea, which so much
distresses those affected with diseases of the heart; for if there be
an inordinate quantity of blood, there must be a deficiency of air.
This accumulation of blood in the lungs has, by some writers, been
considered as an appearance belonging to idiopathic hydrothorax.
Whether it ever exists in that complaint seems to me uncertain. The
pressure of water upon the lungs, may possibly interrupt the free
circulation of blood through their vessels, yet probably the same
pressure would prevent the entrance of blood into the vessels, unless
there be some other cause to overcome it, such as increased action of
the heart, which attends only the first stage of hydrothorax. It has
beside been proved by the experiments of Bichat, that the collapsion
of the lungs does not obstruct the circulation of blood through the
pulmonary vessels. It seems probable, therefore, that those who have
thought this collection of blood an appearance belonging to idiopathic
hydrothorax, have mistaken for it the secondary hydrothorax produced
by diseases of the heart.
On pursuing the examination, we found, behind the lungs, about five or
six ounces of yellowish serum in each cavity of the pleura, and about
one ounce in the cavity of the pericardium. The heart was then seen
enlarged to more than double its natural size. Its surface, especially
along the course of the branches of the coronary arteries, was
whitened by coagulated lymph. In the cavities of the heart, which were
all enlarged and thickened, particularly the left, were found portions
of coagulum mixed with fluid blood. Near its apex, over the left
ventricle, was a small soft spot which, to the finger, seemed like the
point of an abscess ready to burst. The tricuspid valves, and the
valves of the pulmonary artery, had lost somewhat of their
transparency, and were a little thickened, though not materially. It
is worthy of remark, that these valves have not exhibited any great
appearance of disease in any of these cases, while those of the left
side of the heart have scarcely ever been found healthy. So it
appeared in this case. The mitral valves were uniformly thickened, and
partly cartilaginous; the left portion adhered to the side of the
heart. The valves of the aorta had lost their usual form, were
entirely cartilaginous, and almost equal in firmness to the aorta,
which was cartilaginous under the valves, sound in other parts, and
rather small, compared to the size of the heart.
It may be thought that the symptoms, on which reliance was placed to
distinguish disorder of the valves of the aorta, are fallacious,
because it was supposed that these valves would be found ossified,
when they were in reality only cartilaginous. The difference, however,
would be small in the effects produced on the circulation by such a
state of the valves as existed in this case, and a very considerable
ossification; for, if the valves were rigid and unyielding, it is of
little importance whether they were rendered so by bone, or cartilage.
Whether the irregularity of the pulse in these diseases generally
depends on the disorganized state of the aortal, or other valves, we
have not at present observations sufficient to decide. In the sixth
case no irregularity of the pulse could be observed, although the
other symptoms were unequivocal, and no disease was found in the
valves; while, on the other hand, we find that the valves in the
fourth case were not importantly deranged, and yet there was an
irregularity and intermission of the pulse, which however might be
attributed to the dropsy of the pericardium. In the seventh case,
where the pulse was not irregular, the valves of the aorta were
"considerably thickened in various spots;" in the fifth, the pulse was
irregular, and the valves were not materially altered, but there was
water in the pericardium. In all the other cases, the pulse was
irregular, and the valves were much disordered: On a review of these
cases, therefore, we find some reason to believe, that the
irregularity of the pulse depends much on disease of the valves,
especially those of the aorta.
The cavity of the abdomen being opened, no water was discovered in it,
nor any other uncommon appearance, except about the liver, the coat of
which had been rendered opaque by coagulated lymph, and was studded
over with soft, dark coloured tubercles. The substance of the liver
was tender, and full of bile and venous blood.
DISSECTION OF CASE TENTH.
TWENTY-FOUR HOURS AFTER DEATH.
The symptoms of disease in this patient did not alter much, except in
degree, from the middle of April to the 10th of May. He became weaker,
had more straitness and pain about the heart on moving, an increase of
swelling in the legs and abdomen, return of the cough, and a pain from
the left shoulder to the middle of the arm. After his relapse in
April, he had been directed to employ blisters, the submuriate of
quicksilver, and the tincture of the digitalis purpurea. The dose of
the tincture he gradually increased, till he took two hundred drops,
two or three times in a day. Notwithstanding a profuse flow of urine,
the legs became so hard and painful, that I made punctures to
discharge the water from them. He would have had the water in the
abdomen drawn off, but believing it would not afford him great relief,
I dissuaded him from it. On the 10th of May, after having passed an
unusually comfortable night, he rose and left his chamber for five or
six hours, then retiring to it again, said he would be tapped that
day, and, after lying down, was quitted by his attendant, who went in
an hour after and found him dead. This was rather unexpected, for he
had the appearance of sufficient vigour to struggle with disease three
or four weeks longer.
A number of medical gentlemen being assembled, as has been usual on
these occasions, we first remarked, that the face was swollen, and
extraordinarily livid; for, although a considerable degree of
lividity, and sometimes of redness, after death, is peculiar to these
cases, we had seen none which resembled this. Hard and prominent
purple spots were observed upon the shoulders, side, and back. The
surface of the body was moderately covered with fat; the legs and
abdomen were much swollen with water, the arms more slightly. The
integuments of the thorax being cut through, the cellular membrane
discharged a serous fluid from every part; these being turned aside,
to lay bare the cartilages of the ribs, we found them completely
ossified; and having divided them, with a saw, the cavity of the
thorax was opened. The cellular membrane, inside the thorax, about the
mediastinum, had not so bloody an appearance as we witnessed in the
preceding cases, nor were the lungs, either externally or internally,
so dark coloured as usual, though they were much darker, firmer, and
more filled with blood, than is common in subjects of other diseases.
The lungs of the left side adhered closely to the pleura costalis, and
those of the right were tied by loose and membranous adhesions; beside
which there was no appearance of disease about them. The cavity of the
pleura did not contain any water; that of the pericardium held about
six ounces.
The anterior surface of the heart exhibited a considerable whiteness
of its coat over the coronary arteries. This appearance differed from
that of other cases, in being contained in the substance of the
membrane, instead of lying on its surface; and, either from this
circumstance, or from the length of time since it had existed, its
aspect was so peculiar that it might be supposed to be the first stage
of an ossification. A deposition of lymph on the heart has been
observed in every one of these cases of organic disease, and it has
existed principally over the branches of the coronary arteries, or
else near the apex of the heart, which is to be attributed to the
irritation of the membrane by the combined impulse of the heart and
coronary arteries, and to the stroke of the apex upon the ribs. This
is an appearance that, as it belongs to this complaint, might be
useful in a case otherwise dubious, if any such should occur, to aid
in deciding whether the action of the heart had been inordinate.
The heart was enlarged to double its usual size, as we judged with
confidence, for pains had been taken to examine hearts in a healthy
state, for the purpose of forming a comparison. Its firmness was not
proportioned to its bulk, but it was considerably flaccid. Near the
apex, over the left ventricle, was a soft spot, similar to that found
in the preceding case. The venae cavae were then divided, and a torrent
of black blood issued from each of the orifices, in spite of our
efforts to restrain it. All the cavities of the heart were filled, as
we afterwards saw, with similar blood; in which circumstance this
resembles the other cases; though in this case the blood was entirely
fluid, and thinner than in cases of different disease: whereas, in
every other instance, was partly or wholly coagulated. This therefore
must be considered as another appearance peculiar to this complaint,
because it is well known, that blood is not usually found in the left
cavities of the hearts of those who die of other disorders. The cause
of it is doubtless an obstruction, which opposes the free discharge of
blood from the heart, whether that obstruction be in the aortal
valves, in the aorta itself, or in the disproportion between the
heart, or more precisely the left ventricle, and the parts it supplies
with blood.
Why was the blood entirely fluid in this case? If we compare the
appearance of the cellular membrane, and of the lungs, in both of
which there was a deficiency of blood, with the aspect of the face,
where there was an accumulation of blood, and consider at the same
time the mode of termination of this case, we shall find reason to
believe, that death was produced by a violent pressure of the brain
from a congestion of blood in its vessels, in consequence of the
obstruction to the return of that fluid to the heart. An additional
proof of this opinion is derived from the great quantity of blood,
which poured from the vena cava superior, during the whole time of the
examination, and afterward; so that it was found impossible to
preserve the subject from the blood flowing between the ligatures,
notwithstanding the thorax was entirely emptied, before it was closed.
In cases of sudden death from apoplexy, related by Morgagni, the blood
was frequently fluid, and this may be supposed to be the cause of that
appearance in the present case. The extraordinary thinness or watery
state of the blood is a distinct circumstance, which will be presently
noticed.
An examination of the brain, to ascertain the truth of the supposition
above mentioned, was relinquished with regret, but this was
impracticable; for the want of time on these occasions frequently
obliged us to content ourselves with investigating the state of the
most important parts. This must serve as our apology for not oftener
relating the appearance of all the principal organs; yet it should be
observed, that such methods have been employed to ascertain with
accuracy the most interesting morbid phoenomena, as would satisfy the
most scrupulous anatomist.
The tricuspid valves and the semilunar valves of the pulmonary artery
had lost their healthy transparency, but were not otherwise diseased.
In all the above cases these valves had been found without important
derangement of their structure; a circumstance not less remarkable,
than difficult to be satisfactorily explained. The basis of the mitral
valves was marked by a bony projection, which nearly surrounded the
orifice of the ventricle; the valves themselves were thickened, and
one of them was smaller than the other. The semilunar valves of the
aorta were lessened in size, and somewhat thickened. One of them was
ossified sufficiently to annihilate its valvular function; the others
were slightly. The aorta under the valves was semicartilaginous,
ossified in one small spot, roughened by fleshlike prominences in
others, entirely deprived of the smoothness of its internal coat, and
in size proportioned to the heart.
The parietes of the heart were thicker than those of a healthy heart,
but thin when compared with its whole volume; whence it follows, that
the cavities were enlarged. That of the left ventricle was
disproportionately larger than the others, but no difference of size
could be ascertained between the auricles. When a cavity of the heart
is situated in the course of the circulation immediately behind a
contracted orifice, it seems probable that the contraction may have an
important influence in originating the enlargement or aneurism of that
cavity; but, where there is no contraction of an orifice, what is the
obstruction which impedes the free discharge of blood from the heart,
and causes the first yielding of its parietes? Perhaps a violent
simultaneous action of many muscles, from great exertion, may, during
the systole of the heart, impede the passage of the blood through the
arteries, drive it back upon the valves of the aorta, and resist the
heart at the moment of its contraction. If the parietes of the heart
yield, in one part, it is easy to conceive a consequent distension of
the remainder to any degree; for, during the systole of the heart, the
columnae approximate, till their sides are in contact, to protect the
parietes of the heart; but, if these be distended, the columnae can no
longer come in contact with each other, and the blood passing between
them will be propelled against the parieties, and increase their
distention. The left ventricle being thus dilated, the mitral valves
will not be able to completely cover its orifice, and part of the
blood will escape from the ventricle, when it contracts, into the
auricle when dilated with the blood from the lungs; and this undue
quantity of blood will gradually enlarge the auricle. A resistance
will arise, from the same cause, to the passage of the blood from the
lungs, thence to that from the right ventricle and auricle, and thus
these cavities may become enlarged in their turns. When an
ossification of the aorta, or of its valves, exists, there will be a
resistance to the passage of the blood from the left ventricle, either
by a loss of dilatability in the artery, or a contraction of the
orifice by the ossified parts. In either case, the blood will reflow
upon the heart, and dilate the left ventricle, as in _case the first_,
and others; and, if the mitral valves be thickened and rigid, the left
auricle will be more dilated than in a case of simple aneurism of the
left ventricle, as appeared also in the _first case_.
The coronary arteries, at their origin from the aorta, and a
considerable distance beyond, were ossified. How far does the
existence of this ossification in this and other cases related by
different authors, without symptoms of angina pectoris, disprove the
opinion that it is the cause of that disease?
The abdomen being opened, the organs generally appeared sound, except
the liver, which had its tunic inflamed, its substance indurated and
filled with blood. The vestiges of inflammation in the coat of the
liver were traced in every instance already related, while at the same
time the liver, in all, appeared shrunken. The diminution of size in
the liver, after death, cannot at present be well explained; for it is
very certain that such a diminution is not an attendant of this
disorder, during most of its stages, but that on the contrary a state
exists precisely opposed to it. The indications of distention of the
liver, clearly perceived in some cases, have been pain, tenderness,
and sense of distention, in the right hypochondrium, and, what is less
equivocal than these, very considerable swelling and prominence of the
liver. The inflammation of its tunic is an effect of this distention
and of the consequent pressure against the adjacent parts.
The cause of this phoenomenon can easily be explained. If an
obstruction exist in either side of the heart, or in the lungs, the
blood to be poured into the right auricle, from the vena cava
inferior, must be obstructed, its flow into that vessel from the liver
will be equally checked, the thin coats of the hepatic veins and of
the branches of the vena porta will yield and distend the soft
substance of the liver. Hence are caused the discharges of blood from
the haemorrhoidal veins, which form one of the characteristic symptoms
of the disease; for as these vessels empty their blood into the
meseraic veins, which open into the vena porta, if the meseraic veins
be obstructed, the haemorrhoidals must consequently be also affected,
and they easily burst open from too great distention. The haemoptoe,
which also is so frequent, is as easily explained on the same
principle.
The cause of the serous collections is not so readily discovered. In
this case, as in most of the others, we found a considerable quantity
of water in the abdominal cavity. Dropsy is commonly considered as a
disease of debility, but in these cases it often appeared, while the
strength was unimpaired, and the heart acted with very extraordinary
force. If the blood was driven with rapidity through the arteries,
while an obstruction existed at the termination of the venous system
in the heart, the consequences must have been accumulation in the
venous system, difficult transmission of the blood from the extreme
arteries to the veins, overcharge of the arterial capillary system,
consequent excitement of the exhalant system to carry off the serous
part of the blood, for which it is adapted, and thence a serous
discharge into the cavities, and also on the surface of the body; for
great disposition to sweating is a common symptom. In addition to
these, there is another cause of the universality of these effusions.
The blood, in all the cases which I have examined, is both before and
after death, more thin and watery than healthy blood. How this
happens, our knowledge of the theory of sanguification does not enable
us to determine. Perhaps, as the imperfect respiration must cause a
deficiency of air, and consequently of oxygen, in the lungs; and as
the absorption of oxygen is a cause of solidity in many bodies, this
tenuity of the blood may proceed from a deficient absorption of
oxygen. However this may be, it is certain that the blood is very much
attenuated, though with considerable variations in degree, as it is
sometimes found thin on opening a vein, and at a subsequent period is
thicker; varying perhaps according to the continuance of ease or
difficulty in respiration. It is certain, that this attenuation of the
blood must tend to an increase of the serous exhalations.
That these secondary dropsies are not the effect of debility appears
pretty evident from considering, that they often exist while the
strength of the patient is yet undiminished, while all the other
secretions, except that of the urine, are carried on with vigour, and
while the appetite and digestive functions are not only unimpaired,
but improved.
The examinations of the _ninth_ and _tenth cases_ are particularly
valuable, because they confirm what had been observed in other
subjects; they exhibit two well marked instances of aneurism of the
heart, and present us a view of organic disease unattended by dropsy
of the pleura. This must be sufficient to remove the suspicion, that
the symptoms we have attributed to the former disease might arise from
the existence of the latter. No one probably will be willing to impute
a chronic disease, terminated by a sudden death, to five or six ounces
of water in the pericardium; for such a quantity, though it might
produce inconvenience, could not prove fatal, unless it were suddenly
effused; and, if this were true, it of course could not have been the
cause of the long train of symptoms observed in _case tenth_.
Dr. William Hamilton, the author of a valuable treatise on the
digitalis purpurea, thinks the hydrothorax a more frequent disease
than has commonly been imagined, because he conceives that it has
often been mistaken for organic disease of the heart. He names, with
some precision, many symptoms of the latter complaint; but how remote
he is from an accurate knowledge of it may be discovered by his
opinion, that, in diseases of the heart, "the patient can lie down
with ease, and seldom experiences much difficulty of breathing." The
limits of this paper do not admit a discussion of this and other
points, respecting which he seems to be mistaken. We must therefore
submit them to be decided by the evidence adduced in Dr. Hamilton's
"observations," and by that which may be drawn from these cases, and
future investigations of the subject. It will perhaps hereafter appear
surprising, that derangements in the structure of so important an
organ as the heart should have been lightly estimated by very
respectable authors.
* * * * *
While concluding these observations, a case of this disease presented
itself, which comprehends so many of the symptoms, that I cannot
neglect an opportunity of recording it, especially as it exhibits the
complaint in an earlier stage than the others, with appearances
equally unequivocal. I may here be allowed to remark, that no cases
have been introduced which occurred before my attention was directed
to a close observation of this disorder, and that there are many
others, under the care of practitioners of eminence belonging to this
society, with symptoms perfectly well marked, which it has not been
thought necessary to adduce. In proof of this, reference may be had to
Dr. Warren, sen. who has a number of cases, and also to Dr. Dexter,
Dr. Jackson, and Dr. J. C. Howard.
A lady from the country, of a robust habit, whose age is about
thirty-four years, complains of uneasiness in the right side below the
edge of the ribs, sometimes attended with swelling, external soreness,
and a throbbing pain, which often reaches to the shoulder, and
produces a numbness of the right arm. She is rather uncertain at what
time her complaints commenced. About two years since she lost her
husband, and was left with but small means to support a number of
children. She became in consequence, much dejected. While nursing a
child, about a year since, she first was sensible of palpitations of
the heart, which, in about three months, were followed by dyspnoea
very much augmented by ascending an eminence; and profuse discharges
of blood from the mouth, first raised, she believes, by vomiting, and
afterwards by coughing. Evacuations of blood from the haemorrhoidal
vessels appeared about the same time, and occasionally since, till
within six weeks, during which time there have been no sanguineous
discharges, and this suppression has aggravated her other complaints.
The pulsation of the heart is felt most distinctly quite on the left
side of the thorax, where there is a painful spot; it is perceptible
also in the epigastric region. It is irregular and variable, at one
moment hard, strong, distinct, and vibrating; at another, feeble and
confused. There is also sometimes perceived a pulsation above the left
clavicle, within the insertion of the mastoid muscle, commonly
attended with a visible fulness of the superior part of the breast.
The thorax feels, to the patient, as if it were girt across, and there
is a distinct pain in the heart. Both these sensations are aggravated
by a very hard, frequent, and dry cough, which however begins to be
less violent from the use of the scilla maritima. The countenance is
animated, and rather flushed, but not so much overcharged with blood
as happens in many instances; perhaps it little exceeds a blush, so
moderate that it might be considered as an indication of perfect
health; yet the head is greatly disturbed with dizziness, and
frequent and intense pain, and is seen to be shaken by the
palpitations.
The functions of the abdominal viscera are not much deranged. The
appetite varies, though it is commonly good; the intestinal
evacuations, and the menstrual discharges, are regular; the urine is
turbid, and so small in quantity as sometimes to produce strangury.
The abdomen and inferior extremities are swelled, and the distention
produces an uneasiness in the former, and pain and a livid colour
about the gastroenemii muscles in the latter. The pulse is hard,
without strength or fulness, slightly intermittent, variable, and
irregular; yet it has not so much irregularity as in most of the cases
recorded above.
This patient is uneasy in bed, though she raises her head almost
upright; her sleep is disturbed by unpleasant dreams, and by
startings, sometimes quite to an upright posture, without any cause
discoverable to herself. She can incline a little to the left side,
but never to the right, because it brings on a singular oppression,
and a sense of weight drawing on the left side. When most distressed
by dyspnoea she bends her head and trunk forward, and remains thus
seated a considerable portion of the night, often sighing quickly and
convulsively. She is subject to profuse sweatings, and very liable to
take cold, and is then more uneasy.
This lady is still corpulent. She has taken much medicine, under the
direction of eminent physicians, sometimes with temporary relief, but
most commonly without any. The exercise of walking slowly, in
pleasant weather, although it increases the palpitations at the
moment, is followed with relief from the distressing feelings, which
are increased when she sits still for a long time. She has no
suspicion of her hopeless situation, and confidently expects relief
from medicine, yet labours under a melancholy which is unnatural to
her.