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+The Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Cases of Organic Diseases of the Heart
+
+Author: John Collins Warren
+
+Release Date: October 7, 2008 [EBook #26836]
+
+Language: English
+
+Character set encoding: UTF-8
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE ***
+
+
+
+
+Produced by Bryan Ness, Irma Spehar and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+                                CASES
+                                  OF
+                           ORGANIC DISEASES
+                                OF THE
+                                HEART.
+
+      WITH DISSECTIONS AND SOME REMARKS INTENDED TO POINT OUT THE
+                DISTINCTIVE SYMPTOMS OF THESE DISEASES.
+
+
+                      READ BEFORE THE COUNSELLORS
+                 OF THE MASSACHUSETTS MEDICAL SOCIETY.
+
+
+                       BY JOHN C. WARREN, M. D.
+
+
+                                BOSTON:
+                PRINTED BY THOMAS R. WAIT AND COMPANY.
+                             COURT-STREET.
+                                 1809.
+
+
+
+
+                               PLATE I.
+
+Appearance of the valves of the aorta in Case 3d, Article 10.
+
+_a a_ The two valves thickened.
+
+_b b_ Bony projections, one of which extends across the cavity of the
+valve.
+
+_c_ The orifices of the coronary arteries.
+
+_d d_ Fleshlike thickening of the aorta.
+
+                               PLATE II.
+
+Is a representation of the fleshlike thickening of the aorta in case
+7th. The valves are smaller than usual, and their form is in some
+degree changed. A round spot, thickened, is seen at a little distance
+from the seat of the principal disease.
+
+[Illustration]
+
+[Illustration]
+
+
+
+
+                               CASES OF
+                    ORGANIC DISEASES OF THE HEART,
+                           WITH DISSECTIONS.
+
+
+Morbid changes in the organization of the heart are so frequent, as to
+have attracted the observation of those, who have devoted any
+attention to the study of morbid anatomy. Derangements of the primary
+organ of the circulation cannot exist without producing so great
+disorder of the functions of that and of other parts, as to be
+sufficiently conspicuous by external signs; but, as these somewhat
+resemble the symptoms of different complaints, especially of asthma,
+phthisis pulmonalis, and water in the thorax, it has happened, that
+each of these has been sometimes confounded with the former[1]. The
+object of the following statement of cases is to shew, that, whatever
+resemblance there may be in the symptoms of the first, when taken
+separately, to those of the latter diseases, the mode of connection
+and degree of those symptoms at least is quite dissimilar; and that
+there are also symptoms, peculiar to organic diseases of the heart,
+sufficiently characteristic to distinguish them from other complaints.
+
+    [Footnote 1: A careful examination of the works of some of
+    the most eminent English practical writers does not afford
+    evidence of any clear distinction of these diseases of the
+    heart. Dr. Cullen, whose authority is of the highest
+    estimation, evidently enumerates symptoms of them in his
+    definition and description of the hydrothorax. In § 1702 Th.
+    and Pr. he places much confidence on a particular sign of
+    water in the chest, and remarks, that the same sign is not
+    produced by the presence of pus. Now, there is no sufficient
+    reason, why this symptom should not arise from the presence
+    of pus, as well as from that of water; but it probably can
+    depend on neither of those alone. See Morgagni de causis et
+    sedibus morborum, Epist. 16. art. 11. The experienced
+    Heberden says in the chapter “De palpitatione cordis,” “Hic
+    affectus manifesta cognitione conjunctus est cum istis
+    morbis, qui existimantur _nervorum proprii esse_, quique
+    _sanguinis missione augentur_; hoc igitur remedium plerumque
+    omittendum est.”—“Ubi remediis locus est, ex sunt adhibenda,
+    quæ conveniunt _affectibus hypochondriacis_.”
+
+    Dr. Baillie’s knowledge of morbid anatomy has enabled him to
+    make nearer approaches to truth; yet it will probably be
+    found, when this subject shall be fully understood, that his
+    descriptions of the symptoms of diseases of the heart and of
+    hydrothorax are not quite accurate, and, that with respect to
+    the former, they are very imperfect.
+
+    Some of the French physicians have devoted much attention to
+    this subject; especially M. Corvisart, professor in the
+    hospital of La Charite, at Paris, from whose clinical
+    lectures is derived the most important information.]
+
+
+                                CASE I.
+
+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 dyspnœa 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 hæmorrhoidal 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 dyspnœa 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,
+    dyspnœa and palpitations. Thus in the case related above,
+    and in some others, the pulse became regular, the
+    palpitations subsided, and the dyspnœa 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.]
+
+
+                  DISSECTION, NINE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The whole body was much emaciated; the face pale and contracted. The
+hands were slightly œdematous. Discolourations, answering to the
+ribs, were observed on the thorax; many small purple spots, hard and
+prominent, on the back; excoriations on the nates; and purple spots,
+resembling incipient mortification, on the heel and toe.
+
+
+                                THORAX.
+
+The integuments of the thorax were free from fat: the cartilages of
+the ribs ossified in various degrees, some perfectly, others slightly.
+Upon laying open the cavity of the thorax, it was found to contain
+about three pints of water, the proportion being greatest on the left
+side.
+
+The lungs were contracted into a smaller compass than usual, and were
+very firm to the touch. Their colour anteriorly was whitish, with
+small distinct purple spots; posteriorly, of a deep red, with similar
+spots. The right lobe adhered closely to the pericardium; it also
+adhered to the pleura costalis, by a great number of strong cords,
+which seemed to be elongations of the original adhesions. Some of them
+were nearly as hard as ligament, and many an inch in length.
+Internally the lungs presented a very compact structure. Their cells
+were crowded with mucus, and their vessels filled with black blood,
+partly fluid, and partly coagulated. Some portions were firmer and
+more condensed than others, but no tubercles were discovered.
+
+The pericardium, viewed externally, appeared very large, and occupied
+almost the whole space behind the opening formed by removing the
+sternum and cartilages of the ribs. It was situated principally on the
+left side, and contained about double the usual quantity of water; but
+was principally filled by the enlarged heart, to which it adhered
+anteriorly about two inches, near its base. Its parietes were, in
+every part, very much thickened and hardened.
+
+The heart presented nearly its usual colour and form, excepting on its
+anterior surface, which was somewhat discoloured by coagulated lymph.
+It was enlarged in bulk to, at least, one half more than the healthy
+size. The auricles and ventricles contained coagulated blood. The
+tricuspid valves were in a sound state. The left auricle was double
+the usual size. The left ventricle was enlarged, about three times
+thicker and much firmer than usual. The mitral valves were very much
+thickened, and near the insertion of their columnæ, which were sound,
+cartilaginous, so that they were quite rigid, and the opening made by
+them, from the auricle to the ventricle, was scarcely large enough to
+admit the passage of a finger. The semilunar valves of the aorta were
+ossified at their bases and apices, and the portion intermediate,
+between the base and apex, partly ossified, and partly cartilaginous,
+so as to render the valves very rigid. The aorta was at least one half
+larger than usual, especially at its arch. The arteria innominata, the
+carotid, and subclavian arteries, were uncommonly large and thick. The
+coronary arteries were considerably ossified.
+
+
+                               ABDOMEN.
+
+The omentum was destitute of fat. The stomach distended with flatus on
+the pyloric side; its cardiac extremity, lying under the liver, was
+pressed down and contracted. The liver was shrunk; its tunic
+corrugated, as if it had been distended, and bearing marks of
+inflammation; its substance harder than usual; its vessels, when
+divided, pouring out liquid black blood. The gall bladder was filled
+with bile. The kidneys were thicker, and more irregular in form, than
+is common. The abdominal cavity contained some water.
+
+
+                                 HEAD.
+
+The bones of the cranium were unusually thick. The dura mater, which
+was thickened, and in many places bore marks of former inflammation,
+adhered to the bone at the vertex. On its internal surface, near the
+longitudinal sinus, there was a small ossified portion, half an inch
+long and the eighth of an inch thick. The convolutions of the brain
+were narrow, and very strongly marked. The pia mater bore marks of
+pretty extensive inflammation, and adhered to the dura mater at the
+vertex. The cortical substance ran deep into the medullary part of
+the brain. The ventricles contained about double the usual quantity of
+water; their parts were all remarkably well defined. The vessels of
+the pia mater, over the corpora striata, were unusually injected with
+blood. The velum interpositum was very firm; the plexus choroides
+uncommonly thick, but pale; the opening from the right to the left
+ventricle large. The vessels of the brain were generally not much
+filled with blood.
+
+The blood appeared every where fluid, except in some portions of the
+lungs, and in the cavities of the heart. It was very dark coloured,
+perhaps more than ordinarily thin, and oozed from every part, which
+was cut.
+
+The cellular membrane, in all dependent parts, effused, when cut, a
+serous fluid.
+
+
+                               CASE II.
+
+Mr. John Jackson, fifty-two years of age, had been affected for more
+than two years with palpitations of the heart, and paroxysms of
+dyspnœa. These symptoms increased in October, 1808, and were followed
+by strong cough, uneasiness in lying down, sudden startings in sleep,
+and an inclination to bend the body forward and to the left side. His
+cough, during the last part of his life, was attended with copious
+bloody expectoration. His countenance was florid; his pulse very
+irregular, though not quite intermittent. The occasional variations in
+the state of the disease were remarkable. Some periods were marked
+with uncommon mental irritability. Pain in the region of the liver,
+œdema of the inferior extremities, paucity and turbidness of the
+urine, yellowness of the skin, and great emaciation attended the
+latter stages of the disease. A degree of stupor occurred. The
+termination on the 30th of January, 1809, was tolerably quiet. Two
+days before death he sank into the recumbent posture, and his pulse
+became more regular[5].
+
+    [Footnote 5: The symptoms of this patient were related by Dr.
+    Rand, sen. to whose politeness and love of medical
+    improvement I am indebted for the opportunity of examining
+    this and the following case.]
+
+
+                              DISSECTION,
+                    TWENTY-FOUR HOURS AFTER DEATH.
+
+On opening the thorax, its right cavity was found to contain a large
+quantity of water; the left, a smaller quantity.
+
+The lungs were of a firm, condensed texture, especially at the lower
+part, where their solidity was nearly equal to that of a healthy
+liver. They contained black blood.
+
+The heart was much enlarged, and proportionally thickened. Its tunic
+was in some places covered with coagulated lymph, especially over the
+coronary arteries. Its cavities were filled with black coagulum, which
+in the right auricle and ventricle had a slight appearance of polypus.
+The semilunar valves of the pulmonary artery and aorta were unusually
+small, and their bases cartilaginous. Those of the aorta had lost
+their form, and were slightly ossified. The remaining valves were
+partially thickened. The arch of the aorta was very much dilated, its
+internal coat covered with a bony crust, which extended through the
+remaining thoracic portion, gradually diminishing. This portion was
+also considerably dilated.
+
+The liver was indurated; its peritonæal coat exhibited a flaccid or
+wrinkled appearance, and bore marks of slight inflammation. The gall
+bladder was filled with bile, and the pancreas indurated.
+
+
+                               CASE III.
+
+Captain Job Jackson, forty-five years of age, a man of vigorous
+constitution, after an indisposition of some years continuance, was
+seized with palpitations of the heart and dyspnœa, occurring by
+variable paroxysms, especially on ascending an eminence, and attended
+by hardness, irregularity, and intermission of the pulse. To these
+symptoms were superadded dizziness and severe head-ache, a disposition
+to bend the body forward, sudden starting from sleep, with dread of
+suffocation, violent cough with copious expectoration, which for
+fifteen days before death consisted of black blood, distressing pain
+across the chest, especially on the left side, great œdema of the
+lower extremities, and paucity of urine.
+
+He died painfully in January, 1809, after violent struggles for
+breath. The day before death the pulse became regular. He rested his
+head upon an attendant, and made no attempts to lie down for some
+days previous[6].
+
+    [Footnote 6: The symptoms of this case were related to me by
+    Dr. Rand, sen.]
+
+
+                              DISSECTION,
+                      SIXTEEN HOURS AFTER DEATH.
+
+The skin was of a yellow colour. The inferior extremities, quite to
+the groins, were œdematous.
+
+The left cavity of the thorax was filled with water; the right
+contained only a small quantity. The pleura costalis, on the left side
+opposite to the heart, was thickened and covered with a very thick
+flocculent coat of coagulated lymph, and the pericardium opposite to
+it had the same marks of inflammation. The lungs on that side were
+pushed up into a narrow space. They were dense and dark coloured.
+
+The pericardium contained little more than the usual quantity of
+water. The heart, which exhibited marks of some inflammation on its
+surface, was astonishingly large, and firm in proportion. Its cavities
+were principally filled with coagulum. The semilunar valves of the
+pulmonary artery had their bases slightly ossified, and the remaining
+part thickened. There were only two valves of the aorta, and these
+were disorganized by the deposition of ossific matter about their
+bases, and a fleshlike thickening of the other part[7]. The parietes
+of the heart, especially of the left ventricle, were greatly
+thickened, and somewhat ossified near the origin of the aorta.
+
+    [Footnote 7: See plate first.]
+
+The liver had the same appearance as in case second.
+
+
+                               CASE IV.
+
+Thomas Appleton, thirty-eight years of age, of a robust constitution,
+was affected with excessive difficulty of breathing, occurring at
+intervals of different duration. It commenced three years before his
+death, and gradually increased. He was subject to palpitations of the
+heart for at least two years before his death, and was distressed with
+violent cough, attended with copious expectoration, which finally
+became very bloody. The palpitation and dyspnœa were greatly
+augmented by ascending stairs. His countenance was very florid.
+
+Sometimes he was seized with violent head-ache and dizziness, which,
+as well as the other symptoms, were greatly relieved by venesection.
+About two months before death œdema of the legs appeared, which was
+soon followed by frequent and alarming syncope. His pulse was
+irregular, intermittent, hard, and vibrating. When lying down he
+frequently awoke, and started up in great terror. His usual posture
+was that of sitting, with his trunk and head bent forward, and
+inclining to the left side. For some time before death a recumbent
+posture threatened immediate suffocation; yet, three days previous to
+the occurrence of that event, he sank back upon the pillow. He was, at
+intervals, so much better as to think himself free from disease.
+Slight delirium preceded his death, which occurred in January,
+1809[8].
+
+    [Footnote 8: The symptoms in this case were related to me by
+    Dr. Warren, sen.]
+
+
+                              DISSECTION,
+                      EIGHTEEN HOURS AFTER DEATH.
+
+The countenance continued florid. The inferior extremities were much
+distended with water, and the cellular membrane abounded in fat.
+
+The right cavity of the pleura contained a moderate quantity of water;
+the left, scarcely any. The lungs were firm, condensed, and dark
+coloured, from venous blood. The pleura, on the left side opposite to
+the pericardium, appeared to have been inflamed, as there was an
+effusion of coagulated lymph on its surface.
+
+The pericardium was much distended with water. The heart, on the
+anterior surface of which were some appearances of inflammation, was
+very much enlarged. Its parietes were thickened; its cavities
+unnaturally large, and filled with black coagulum. Each of the valves
+had lost, in some degree, its usual smoothness, and those of the aorta
+were, in some points, thickened, and partly cartilaginous.
+
+The liver was small, and, when cut, poured out dark blood. Its tunic
+was whitish, opaque, and corrugated.
+
+
+                                CASE V.
+
+A. B. a negro, about thirty-five years of age, had paroxysms of
+dyspnœa and violent cough, attended with œdema of the extremities
+and ascites, violent head-ache, dizziness, brightness of the eyes,
+palpitations of the heart, irregular, intermittent, slow, and soft
+pulse. These symptoms slowly increased, during three or four years, in
+which time the dropsical collections were repeatedly dispersed. He
+gradually and quietly died in the alms-house, in January, 1809.
+
+
+                              DISSECTION.
+
+On dissection, the cavities of the pleura were found to contain a
+considerable quantity of water. The pericardium was filled with water;
+the heart considerably enlarged; its parietes very thin, and its
+cavities, especially the right auricle and ventricle, morbidly
+large[9].
+
+    [Footnote 9: This dissection was performed by Dr. Gorham.]
+
+
+                               CASE VI.
+
+Mrs. M‘Clench, a washer-woman, forty-eight years of age, of good
+constitution and regular habits, was attacked, in the summer of 1808,
+with palpitations of the heart and dyspnœa on going up stairs, severe
+head-ache, and discharges of blood from the anus. These symptoms did
+not excite much attention. In the winter of 1808-9, all of them
+increased, except the palpitations. The inferior extremities and
+abdomen became distended with water; the region of the liver painful;
+the skin quite yellow; the pulse was hard, regular, and vibrating; the
+countenance very florid. Violent cough followed, and blood was
+profusely discharged from the lungs. This discharge being suppressed,
+evacuations of blood from the anus ensued, under which she died, in
+March, 1809.
+
+
+                              DISSECTION.
+
+The right cavity of the thorax was filled with water; the left
+contained none. The lungs were sound, but very dense, full of dark
+coloured blood, and, on the right side, pressed into the upper part of
+the thorax. The heart was one half larger than natural; its substance
+firm, and its anterior part, especially near the apex, covered with
+coagulated lymph. The right auricle and ventricle were large, and
+their parietes thin. The parietes of the left auricle and ventricle,
+particularly of the latter, were much thickened, and their cavities
+were filled with black coagulum.
+
+The liver was contracted; its coat wrinkled, and marked with
+appearances of recent inflammation.
+
+
+                               CASE VII.
+
+                       To JOHN C. WARREN, M. D.
+
+MY DEAR SIR,
+
+Your important communication to our society, which is about to be
+published, will lay before the American public much more knowledge
+respecting the diseases of the heart, and large vessels, than has
+hitherto been presented to them. A case has lately fallen under my
+observation, having so much similarity to those of organic diseases of
+the heart, which have occurred to you, as to mark its affinity, yet
+with some differences, which characterize it as a variety. If the
+statement of it will add any value to your collection of cases, you
+are at liberty to publish it.
+
+A. S. twenty-eight years of age, and of middle stature, was attacked,
+after a debauch, with pain in the region of the heart, which subsided,
+but returned a year after on a similar occasion. He then became
+affected with palpitations of the heart for six months, great
+difficulty of breathing, which was augmented by ascending an eminence,
+severe cough, dizziness, and violent head-ache, attended by a
+disposition to bend the body forward, and sudden startings from sleep.
+His pulse was always regular, and never remarkably hard. His
+countenance, till within a few weeks of death, presented the
+appearance of blooming health. His feet and legs did not swell at any
+period of the disease. He suffered exceedingly from flatulence, to
+which he was disposed to attribute all his complaints. This symptom
+might have been aggravated by his habits of free living, and
+occasional intoxication, which he acknowledged, and to which he traced
+the origin of his disease.
+
+After death, water was discovered in the thorax; but the lungs had not
+that appearance of accumulation of blood, in particular spots, which
+is commonly observed in cases of organic disease of the heart. The
+only very remarkable morbid appearance about the heart was in the
+aorta, and its valves. The valves had lost their transparency, and
+were considerably thickened in various spots. The inner surface of
+the aorta, for about an inch from its commencement, was elevated and
+thickened, and the external surface singularly roughened and
+verrucated. This appearance was so peculiar, that no words will give a
+competent idea of it, and perhaps it would be sufficient for me to
+call it a chronic inflammation[10].
+
+                              I am, my dear sir,
+                                  Your friend and obedient servant,
+                                                         JAMES JACKSON.
+
+    [Footnote 10: See plate second.]
+
+
+                              CASE VIII.
+
+Col. William Scollay, aged fifty-two, of a plethoric habit of body,
+was attacked, in the year 1805, with dyspnœa and palpitation of the
+heart, attended with irregularity of the pulse, and œdema of the
+lower extremities. By the aid of medicine, the dropsical collections
+were absorbed, and he recovered his health, so far as to follow his
+usual occupations, nearly a year; but was then compelled to relinquish
+them. The symptoms afterwards underwent various aggravations and
+remissions, till the beginning of the winter of 1808-9, when the
+attacks became so violent, as to confine him to the house. His face
+was then high coloured. The faculties of his mind were much impaired.
+The dyspnœa became more constant, and was occasionally attended by
+cough; the palpitations rather lessened in violence; the pulse was
+more irregular, and exceedingly intermittent. The abdomen and inferior
+extremities were sometimes enormously distended with water, and
+afterwards subsided nearly to their usual size. One of the earliest,
+most frequent, and distressing symptoms, was an intense pain in the
+head. About two months before death, a hemiplegia took place, but
+after a few days disappeared. This so much impaired the operations of
+the mind, that the patient afterwards found great difficulty in
+recollecting words sufficient to form an intelligible sentence. During
+the existence of the last symptom the pulse was regular.
+
+He gradually expired, on the 15th of March, 1809.
+
+
+                  DISSECTION, FIVE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The countenance was somewhat livid and pale; the lips were very livid.
+The chest resounded, when struck, except over the heart. The abdomen
+was tumid, and marked by cicatrices like those of women, who have
+borne children. The superior extremities were emaciated, and marked
+like the abdomen. The lower extremities were œdematous.
+
+
+                                THORAX.
+
+The cartilages of the ribs were ossified. The left cavity of the
+pleura contained about twelve ounces of water; the right, about three
+ounces. The lungs, externally, were dark coloured, especially the
+posterior lobes; internally, they were very firm, and, in some places,
+as dense as the substance of the liver. A frothy mucus was effused
+from them in great quantities. They were coloured by very dark blood,
+especially in the middle portion of the left superior lobe. One or two
+calcareous concretions were observed in them. The pericardium was a
+little firmer than usual, and contained about five ounces of water.
+The heart was enlarged, and covered with tough fat. In the right
+auricle, and ventricle, was some coagulated blood. The tricuspid
+valves had lost their smoothness and transparency; the semilunar
+valves of the pulmonary artery were cartilaginous at their bases. The
+left auricle and ventricle, particularly the first, contained
+coagulum. The mitral valves were roughened by many bony spots.
+Considerable ossification had taken place in the semilunar valves of
+the aorta, so that one of them had quite lost its form; and the aorta
+was ossified for the space of a square inch, at a small distance from
+the valves. The coronary arteries were also ossified.
+
+
+                               ABDOMEN.
+
+The coat of the liver was somewhat wrinkled, as if shrunk. Its
+substance was hard, and discharged, when cut, great quantities of
+blood. The veins of the omentum, mesentery, and intestines, were full
+of blood. The abdomen contained a considerable quantity of water.
+
+
+                                 HEAD.
+
+Water was found between the dura and pia mater, and between the pia
+mater and arachnoides. The vertical portion of the pia mater bore
+marks of former inflammation. The convolutions of the brain were very
+distinct; their external surface was pale. The veins were empty[11].
+No bloody points were observed in the medullary portion of the brain,
+when cut. The ventricles contained between one and two ounces of
+water; the communication between them was very large. The plexus
+choroides was pale.
+
+    [Footnote 11: In this case, and in case first, the vena cava
+    ascendens had been divided, before the brain was examined.]
+
+
+                               CASE IX.
+
+A lady, about forty-five years of age, the mother of many children,
+has been troubled during the course of the past year with violent
+palpitations of the heart, and great difficulty of respiration,
+especially on going up stairs. These complaints have lately increased,
+so that she has kept in her chamber about two months. Her countenance
+is florid; her eyes are clear and bright. She has dizziness,
+especially on moving, without pain in her head. She had for some time,
+a severe cough, which is now relieved. The dyspnœa is not yet very
+distressing, except on using motion; it often occurs in the night, and
+obliges her to rise and sit up in bed. The palpitations are very hard,
+and so strong, that they may be perceived through her clothes; the
+tumult in the thorax is indescribable. The functions of the abdominal
+viscera are unimpaired. The pulse is hard, vibrating, irregular,
+intermittent, very variable, corresponding with the motions of the
+heart, and similar in each arm. There is not yet the slightest reason
+to suspect any dropsical collection. The alternations of ease and
+distress are very remarkable, but on the whole, the violence of the
+symptoms increases rapidly.
+
+There is no difficulty in discovering in this case an organic disease
+of the heart, which probably consists in an enlargement and thickening
+of the heart, and an ossification of the semilunar valves of the
+aorta.
+
+
+                                CASE X.
+
+Levi Brown, a cabinet-maker, forty-eight years of age, complained in
+February, 1809, of great difficulty of breathing, and an indescribable
+sensation in the chest, which he said was sometimes very distressing,
+and at other times quitted him entirely. Being a man of an active
+mind, he had read some medical books, whence he got an idea, that he
+was hypochondriac.
+
+On examining his pulse, it was found to be occasionally intermittent,
+contracted, and vibrating. He had some years previously been attacked
+with copious hæmorrhages from the stomach or lungs, which have
+occasionally recurred, though they have lately been less frequent.
+Eight years since he suffered from an inflammation of the lungs; and
+about two or three years ago he first experienced a beating in the
+chest, and pain in the region of the heart, which increased till
+within six or eight months, since which the beating has been
+stationary, and the pain has much increased. In the course of the last
+summer, dyspnœa, on using exercise, and especially ascending any
+eminence, commenced. This has greatly increased, so as to render it
+almost impossible for him to go up stairs. His countenance is turgid,
+and uniformly suffused with blood; his eyes are bright and animated;
+his lips livid. The pulsation of the heart cannot be felt on the left
+side, and is barely perceptible on the right side of the sternum, and
+in the epigastric region. When he is distressed with fits of dyspnœa,
+he feels something as if rising to the upper part of the thorax, and
+the heart then seems to him to be beating through the ribs. I have not
+witnessed any of these paroxysms. The inferior extremities and abdomen
+have been swelled about three weeks. When in bed, he has his head and
+shoulders elevated, and, upon the attack of his paroxysms, sits up and
+inclines his head forward; but he keeps from the bed as much as
+possible. In his sleep he is apt to start up, suddenly, in distress,
+especially when he first slumbers. His dreams are often frightful,
+and, when awake, he is affected with reveries, during which, though
+conscious of being awake, strange illusions present themselves. At
+intervals he seems slightly delirious. He has a violent cough, with
+very copious expectoration of thick mucus. He often suffers from
+severe head-ache, and the least exercise produces dizziness.
+
+This man has a very robust frame of body, and has been accustomed to a
+free use of ardent spirits, and of opium, of which he now takes about
+twelve grains in a day. His appearance is such, that, on a slight
+survey, one would not suppose him diseased, but, on observing him with
+a little attention, a shortness and labour of respiration are
+perceived, with some interruption in speaking, and a frequent catching
+of the breath, or sighing.
+
+April. Since writing the above account, the dropsical collections were
+absorbed, and the palpitations and other symptoms moderated, so that
+he considered himself nearly well, and attended to his usual business.
+Within a few days, however, the symptoms have returned with more
+violence. The dyspnœa is at times very distressing; the pulse more
+irregular and intermittent; the palpitations are more constant. His
+sufferings from lying in bed are so increased, that in the most
+comfortable nights he passes, he sits up once in an hour or two. The
+appetite is keen. The legs begin to swell again.
+
+Some organic disease of the heart exists in this case. The
+indistinctness of the palpitations, the want of hardness in the pulse,
+and the slow progress of the disease, indicate a loss of power in the
+heart, the effect of the distention and thinness of its parietes. The
+irregularity of the pulse affords some reason to suspect disorder of
+the aortal valves, which is not yet very considerable.
+
+
+ENUMERATION _of the principal morbid changes, observed in the organization
+of the heart, in the preceding cases_.
+
+Enlargement of the volume of the heart, or aneurism.[12]
+Increase of the capacity, or aneurism of the right auricle,  } with
+                                      of the right ventricle,} thickened,
+                                      of the left auricle    } or thin,
+                                      of the left ventricle, } parietes.
+                                      of the aorta, with thickening of
+                                         its coats.
+
+Fleshlike[13] thickening of the mitral valves.
+                         of the aortal valves.
+                         of the aorta.
+
+Cartilaginous thickening of the internal membrane of the heart, and
+generally of its valves.
+
+Ossification of the parietes of the heart.
+                    mitral valves.
+                    aortal valves.
+                    aorta.
+                    coronary arteries.
+
+    [Footnote 12: Morgagni uses this term, which he borrows from
+    Ambrose Pare, to express dilatation of the cavities of the
+    heart. It seems to be as applicable to the dilatation of the
+    heart, as to that of an artery. I have therefore adopted it
+    in this enumeration.]
+
+    [Footnote 13: The term fleshlike is employed to express that
+    roughness of the valves, which somewhat resembles flesh in
+    its appearance, but which is very different from the
+    thickening of the parietes of the heart.]
+
+
+ENUMERATION _of the principal morbid appearances, observed in these
+cases of disease of the heart, which may be considered secondary_.
+
+    IN THE CAVITY OF THE CRANIUM.
+
+Inflammation of the meninges.
+Water between the meninges.
+Water in the ventricles.
+
+    IN THE PLEURA AND ITS CAVITY.
+
+Inflammation and thickening of the pleura.
+Collection of water in its cavity.
+Lungs dark coloured.
+      generally very firm, and particularly in some parts.
+      loaded with black blood.
+      crowded into a narrow space.
+
+    IN THE PERICARDIUM AND ITS CAVITY.
+
+Inflammation and thickening of its substance.
+Adhesion to the heart and lungs.
+Collection of water in its cavity.
+
+    IN THE CAVITY OF THE ABDOMEN.
+
+Collection of water.
+Liver very full of fluid blood.
+      having its tunic flaccid and inflamed.
+Mesenteric veins full of blood.
+
+    CELLULAR MEMBRANE full of water.
+
+    THE BLOOD every where fluid, except in the cavities of the heart.
+
+
+                               REMARKS.
+
+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 dyspnœa 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 dyspnœa 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 dyspnœa 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 phœnomena 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 dyspnœa, 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 hæmorrhoidal 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 dyspnœa becomes excessive;
+the pain and stricture about the præcordia 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 dyspnœa 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 dyspnœa. 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 phœnomena 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 œdematous. 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 dyspnœa, 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 venæ cavæ 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 phœnomena, 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
+columnæ approximate, till their sides are in contact, to protect the
+parietes of the heart; but, if these be distended, the columnæ 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 phœnomenon 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 hæmorrhoidal 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 hæmorrhoidals must consequently be also affected,
+and they easily burst open from too great distention. The hæmoptoe,
+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 dyspnœa
+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 hæmorrhoidal
+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 dyspnœa 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.
+
+
+                         CASE OF HYDROTHORAX.
+
+     The following case of hydrothorax will shew, that water may
+     exist in the chest without the symptoms, which we have
+     attributed to organic diseases of the heart.
+
+Mrs. T----, aged 56 years, of an excessively corpulent habit, had been
+affected for a great number of years with a scirrhus of the right
+breast. Finding her health decline, she at last disclosed it, and in
+coincidence with the opinion of Dr. WARREN, sen. I amputated it on the
+30th of May, of the present year. We however informed her friends,
+that the probability of eradicating the disease was extremely small.
+The skin was in many places hardened and drawn in, and in others
+discoloured, and ulcerated at the nipple, so that it was found
+necessary to remove, not only what covered the breast, but some
+portion of that which surrounded it. A long chain of diseased glands,
+extending quite to the axillary vessels, was also extirpated. She bore
+the operation well, lost no great quantity of blood, and recovered her
+appetite and strength surprisingly in a few days, while the wound
+healed rapidly. At the end of twenty days a difficulty of breathing
+commenced, and soon became so oppressive, that she could no longer lie
+in bed; partly, no doubt, on account of her extraordinary obesity. The
+pulse was small, quick, and commonly feeble, but sometimes a little
+hard, when any degree of fever was present. The countenance became
+pale, the lips of a leaden hue, the eyes dim. We were surprised at the
+change, and conjectured that the cancerous action had suddenly
+extended to the lungs. Yet she had not the slightest cough; and it was
+remarked by Dr. WARREN, sen. that he had never observed that diseased
+action to increase, while the wound remained open. At last the lower
+extremities swelled, which might be attributed to the upright posture,
+and the pressure on the absorbent vessels in that posture. The
+appetite failed; she complained of a constant sense of depression at
+the stomach, and, without any remission of the difficulty of
+breathing, died on the 1st of July.
+
+On the next morning the body was examined. The pleura in both cavities
+of the thorax was studded with small, white, and apparently
+homogeneous tubercles; the lungs contained a great number of similar
+bodies. The right cavity of the pleura was entirely filled with water,
+of which we removed at least three quarts. The heart was of the usual
+size, very flaccid and tender; but not otherwise disordered. The liver
+was enlarged, of its usual colour, much hardened, and had on its
+surface, and in its substance, many tubercles like those in the
+thorax. It had also a great number of encysted cavities, each about
+the size of a hazle nut, which contained a thin yellow fluid. The gall
+bladder was wanting, and in its place there was a small, but very
+remarkable depression, without a vestige of any former gall bladder,
+for the coat of the liver was as smooth and perfect there as in any
+other part[15]. The pancreas was in a scirrhous state. The abdomen did
+not contain any water.
+
+    [Footnote 15: See Soemmerring de corporis humani fabrica,
+    vol. 6, pag. 188 and Baillie’s morbid anatomy, pag. 248.]
+
+It seems, then, that water may exist in the cavity of the thorax,
+without any remarkable symptoms, except dyspnœa and difficulty in
+assuming the horizontal posture. But in organic diseases of the heart,
+there is a long train of frightful symptoms, distinguishable by the
+most superficial observers. We infer that these disorders have been
+unnecessarily confounded.
+
+
+
+
+
+End of the Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
+
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+The Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Cases of Organic Diseases of the Heart
+
+Author: John Collins Warren
+
+Release Date: October 7, 2008 [EBook #26836]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE ***
+
+
+
+
+Produced by Bryan Ness, Irma Spehar and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+                                CASES
+                                  OF
+                           ORGANIC DISEASES
+                                OF THE
+                                HEART.
+
+      WITH DISSECTIONS AND SOME REMARKS INTENDED TO POINT OUT THE
+                DISTINCTIVE SYMPTOMS OF THESE DISEASES.
+
+
+                      READ BEFORE THE COUNSELLORS
+                 OF THE MASSACHUSETTS MEDICAL SOCIETY.
+
+
+                       BY JOHN C. WARREN, M. D.
+
+
+                                BOSTON:
+                PRINTED BY THOMAS R. WAIT AND COMPANY.
+                             COURT-STREET.
+                                 1809.
+
+
+
+
+                               PLATE I.
+
+Appearance of the valves of the aorta in Case 3d, Article 10.
+
+_a a_ The two valves thickened.
+
+_b b_ Bony projections, one of which extends across the cavity of the
+valve.
+
+_c_ The orifices of the coronary arteries.
+
+_d d_ Fleshlike thickening of the aorta.
+
+                               PLATE II.
+
+Is a representation of the fleshlike thickening of the aorta in case
+7th. The valves are smaller than usual, and their form is in some
+degree changed. A round spot, thickened, is seen at a little distance
+from the seat of the principal disease.
+
+[Illustration]
+
+[Illustration]
+
+
+
+
+                               CASES OF
+                    ORGANIC DISEASES OF THE HEART,
+                           WITH DISSECTIONS.
+
+
+Morbid changes in the organization of the heart are so frequent, as to
+have attracted the observation of those, who have devoted any
+attention to the study of morbid anatomy. Derangements of the primary
+organ of the circulation cannot exist without producing so great
+disorder of the functions of that and of other parts, as to be
+sufficiently conspicuous by external signs; but, as these somewhat
+resemble the symptoms of different complaints, especially of asthma,
+phthisis pulmonalis, and water in the thorax, it has happened, that
+each of these has been sometimes confounded with the former[1]. The
+object of the following statement of cases is to shew, that, whatever
+resemblance there may be in the symptoms of the first, when taken
+separately, to those of the latter diseases, the mode of connection
+and degree of those symptoms at least is quite dissimilar; and that
+there are also symptoms, peculiar to organic diseases of the heart,
+sufficiently characteristic to distinguish them from other complaints.
+
+    [Footnote 1: A careful examination of the works of some of
+    the most eminent English practical writers does not afford
+    evidence of any clear distinction of these diseases of the
+    heart. Dr. Cullen, whose authority is of the highest
+    estimation, evidently enumerates symptoms of them in his
+    definition and description of the hydrothorax. In � 1702 Th.
+    and Pr. he places much confidence on a particular sign of
+    water in the chest, and remarks, that the same sign is not
+    produced by the presence of pus. Now, there is no sufficient
+    reason, why this symptom should not arise from the presence
+    of pus, as well as from that of water; but it probably can
+    depend on neither of those alone. See Morgagni de causis et
+    sedibus morborum, Epist. 16. art. 11. The experienced
+    Heberden says in the chapter "De palpitatione cordis," "Hic
+    affectus manifesta cognitione conjunctus est cum istis
+    morbis, qui existimantur _nervorum proprii esse_, quique
+    _sanguinis missione augentur_; hoc igitur remedium plerumque
+    omittendum est."--"Ubi remediis locus est, ex sunt adhibenda,
+    qu� conveniunt _affectibus hypochondriacis_."
+
+    Dr. Baillie's knowledge of morbid anatomy has enabled him to
+    make nearer approaches to truth; yet it will probably be
+    found, when this subject shall be fully understood, that his
+    descriptions of the symptoms of diseases of the heart and of
+    hydrothorax are not quite accurate, and, that with respect to
+    the former, they are very imperfect.
+
+    Some of the French physicians have devoted much attention to
+    this subject; especially M. Corvisart, professor in the
+    hospital of La Charite, at Paris, from whose clinical
+    lectures is derived the most important information.]
+
+
+                                CASE I.
+
+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 h�morrhoidal 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.]
+
+
+                  DISSECTION, NINE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The whole body was much emaciated; the face pale and contracted. The
+hands were slightly oedematous. Discolourations, answering to the
+ribs, were observed on the thorax; many small purple spots, hard and
+prominent, on the back; excoriations on the nates; and purple spots,
+resembling incipient mortification, on the heel and toe.
+
+
+                                THORAX.
+
+The integuments of the thorax were free from fat: the cartilages of
+the ribs ossified in various degrees, some perfectly, others slightly.
+Upon laying open the cavity of the thorax, it was found to contain
+about three pints of water, the proportion being greatest on the left
+side.
+
+The lungs were contracted into a smaller compass than usual, and were
+very firm to the touch. Their colour anteriorly was whitish, with
+small distinct purple spots; posteriorly, of a deep red, with similar
+spots. The right lobe adhered closely to the pericardium; it also
+adhered to the pleura costalis, by a great number of strong cords,
+which seemed to be elongations of the original adhesions. Some of them
+were nearly as hard as ligament, and many an inch in length.
+Internally the lungs presented a very compact structure. Their cells
+were crowded with mucus, and their vessels filled with black blood,
+partly fluid, and partly coagulated. Some portions were firmer and
+more condensed than others, but no tubercles were discovered.
+
+The pericardium, viewed externally, appeared very large, and occupied
+almost the whole space behind the opening formed by removing the
+sternum and cartilages of the ribs. It was situated principally on the
+left side, and contained about double the usual quantity of water; but
+was principally filled by the enlarged heart, to which it adhered
+anteriorly about two inches, near its base. Its parietes were, in
+every part, very much thickened and hardened.
+
+The heart presented nearly its usual colour and form, excepting on its
+anterior surface, which was somewhat discoloured by coagulated lymph.
+It was enlarged in bulk to, at least, one half more than the healthy
+size. The auricles and ventricles contained coagulated blood. The
+tricuspid valves were in a sound state. The left auricle was double
+the usual size. The left ventricle was enlarged, about three times
+thicker and much firmer than usual. The mitral valves were very much
+thickened, and near the insertion of their column�, which were sound,
+cartilaginous, so that they were quite rigid, and the opening made by
+them, from the auricle to the ventricle, was scarcely large enough to
+admit the passage of a finger. The semilunar valves of the aorta were
+ossified at their bases and apices, and the portion intermediate,
+between the base and apex, partly ossified, and partly cartilaginous,
+so as to render the valves very rigid. The aorta was at least one half
+larger than usual, especially at its arch. The arteria innominata, the
+carotid, and subclavian arteries, were uncommonly large and thick. The
+coronary arteries were considerably ossified.
+
+
+                               ABDOMEN.
+
+The omentum was destitute of fat. The stomach distended with flatus on
+the pyloric side; its cardiac extremity, lying under the liver, was
+pressed down and contracted. The liver was shrunk; its tunic
+corrugated, as if it had been distended, and bearing marks of
+inflammation; its substance harder than usual; its vessels, when
+divided, pouring out liquid black blood. The gall bladder was filled
+with bile. The kidneys were thicker, and more irregular in form, than
+is common. The abdominal cavity contained some water.
+
+
+                                 HEAD.
+
+The bones of the cranium were unusually thick. The dura mater, which
+was thickened, and in many places bore marks of former inflammation,
+adhered to the bone at the vertex. On its internal surface, near the
+longitudinal sinus, there was a small ossified portion, half an inch
+long and the eighth of an inch thick. The convolutions of the brain
+were narrow, and very strongly marked. The pia mater bore marks of
+pretty extensive inflammation, and adhered to the dura mater at the
+vertex. The cortical substance ran deep into the medullary part of
+the brain. The ventricles contained about double the usual quantity of
+water; their parts were all remarkably well defined. The vessels of
+the pia mater, over the corpora striata, were unusually injected with
+blood. The velum interpositum was very firm; the plexus choroides
+uncommonly thick, but pale; the opening from the right to the left
+ventricle large. The vessels of the brain were generally not much
+filled with blood.
+
+The blood appeared every where fluid, except in some portions of the
+lungs, and in the cavities of the heart. It was very dark coloured,
+perhaps more than ordinarily thin, and oozed from every part, which
+was cut.
+
+The cellular membrane, in all dependent parts, effused, when cut, a
+serous fluid.
+
+
+                               CASE II.
+
+Mr. John Jackson, fifty-two years of age, had been affected for more
+than two years with palpitations of the heart, and paroxysms of
+dyspnoea. These symptoms increased in October, 1808, and were followed
+by strong cough, uneasiness in lying down, sudden startings in sleep,
+and an inclination to bend the body forward and to the left side. His
+cough, during the last part of his life, was attended with copious
+bloody expectoration. His countenance was florid; his pulse very
+irregular, though not quite intermittent. The occasional variations in
+the state of the disease were remarkable. Some periods were marked
+with uncommon mental irritability. Pain in the region of the liver,
+oedema of the inferior extremities, paucity and turbidness of the
+urine, yellowness of the skin, and great emaciation attended the
+latter stages of the disease. A degree of stupor occurred. The
+termination on the 30th of January, 1809, was tolerably quiet. Two
+days before death he sank into the recumbent posture, and his pulse
+became more regular[5].
+
+    [Footnote 5: The symptoms of this patient were related by Dr.
+    Rand, sen. to whose politeness and love of medical
+    improvement I am indebted for the opportunity of examining
+    this and the following case.]
+
+
+                              DISSECTION,
+                    TWENTY-FOUR HOURS AFTER DEATH.
+
+On opening the thorax, its right cavity was found to contain a large
+quantity of water; the left, a smaller quantity.
+
+The lungs were of a firm, condensed texture, especially at the lower
+part, where their solidity was nearly equal to that of a healthy
+liver. They contained black blood.
+
+The heart was much enlarged, and proportionally thickened. Its tunic
+was in some places covered with coagulated lymph, especially over the
+coronary arteries. Its cavities were filled with black coagulum, which
+in the right auricle and ventricle had a slight appearance of polypus.
+The semilunar valves of the pulmonary artery and aorta were unusually
+small, and their bases cartilaginous. Those of the aorta had lost
+their form, and were slightly ossified. The remaining valves were
+partially thickened. The arch of the aorta was very much dilated, its
+internal coat covered with a bony crust, which extended through the
+remaining thoracic portion, gradually diminishing. This portion was
+also considerably dilated.
+
+The liver was indurated; its periton�al coat exhibited a flaccid or
+wrinkled appearance, and bore marks of slight inflammation. The gall
+bladder was filled with bile, and the pancreas indurated.
+
+
+                               CASE III.
+
+Captain Job Jackson, forty-five years of age, a man of vigorous
+constitution, after an indisposition of some years continuance, was
+seized with palpitations of the heart and dyspnoea, occurring by
+variable paroxysms, especially on ascending an eminence, and attended
+by hardness, irregularity, and intermission of the pulse. To these
+symptoms were superadded dizziness and severe head-ache, a disposition
+to bend the body forward, sudden starting from sleep, with dread of
+suffocation, violent cough with copious expectoration, which for
+fifteen days before death consisted of black blood, distressing pain
+across the chest, especially on the left side, great oedema of the
+lower extremities, and paucity of urine.
+
+He died painfully in January, 1809, after violent struggles for
+breath. The day before death the pulse became regular. He rested his
+head upon an attendant, and made no attempts to lie down for some
+days previous[6].
+
+    [Footnote 6: The symptoms of this case were related to me by
+    Dr. Rand, sen.]
+
+
+                              DISSECTION,
+                      SIXTEEN HOURS AFTER DEATH.
+
+The skin was of a yellow colour. The inferior extremities, quite to
+the groins, were oedematous.
+
+The left cavity of the thorax was filled with water; the right
+contained only a small quantity. The pleura costalis, on the left side
+opposite to the heart, was thickened and covered with a very thick
+flocculent coat of coagulated lymph, and the pericardium opposite to
+it had the same marks of inflammation. The lungs on that side were
+pushed up into a narrow space. They were dense and dark coloured.
+
+The pericardium contained little more than the usual quantity of
+water. The heart, which exhibited marks of some inflammation on its
+surface, was astonishingly large, and firm in proportion. Its cavities
+were principally filled with coagulum. The semilunar valves of the
+pulmonary artery had their bases slightly ossified, and the remaining
+part thickened. There were only two valves of the aorta, and these
+were disorganized by the deposition of ossific matter about their
+bases, and a fleshlike thickening of the other part[7]. The parietes
+of the heart, especially of the left ventricle, were greatly
+thickened, and somewhat ossified near the origin of the aorta.
+
+    [Footnote 7: See plate first.]
+
+The liver had the same appearance as in case second.
+
+
+                               CASE IV.
+
+Thomas Appleton, thirty-eight years of age, of a robust constitution,
+was affected with excessive difficulty of breathing, occurring at
+intervals of different duration. It commenced three years before his
+death, and gradually increased. He was subject to palpitations of the
+heart for at least two years before his death, and was distressed with
+violent cough, attended with copious expectoration, which finally
+became very bloody. The palpitation and dyspnoea were greatly
+augmented by ascending stairs. His countenance was very florid.
+
+Sometimes he was seized with violent head-ache and dizziness, which,
+as well as the other symptoms, were greatly relieved by venesection.
+About two months before death oedema of the legs appeared, which was
+soon followed by frequent and alarming syncope. His pulse was
+irregular, intermittent, hard, and vibrating. When lying down he
+frequently awoke, and started up in great terror. His usual posture
+was that of sitting, with his trunk and head bent forward, and
+inclining to the left side. For some time before death a recumbent
+posture threatened immediate suffocation; yet, three days previous to
+the occurrence of that event, he sank back upon the pillow. He was, at
+intervals, so much better as to think himself free from disease.
+Slight delirium preceded his death, which occurred in January,
+1809[8].
+
+    [Footnote 8: The symptoms in this case were related to me by
+    Dr. Warren, sen.]
+
+
+                              DISSECTION,
+                      EIGHTEEN HOURS AFTER DEATH.
+
+The countenance continued florid. The inferior extremities were much
+distended with water, and the cellular membrane abounded in fat.
+
+The right cavity of the pleura contained a moderate quantity of water;
+the left, scarcely any. The lungs were firm, condensed, and dark
+coloured, from venous blood. The pleura, on the left side opposite to
+the pericardium, appeared to have been inflamed, as there was an
+effusion of coagulated lymph on its surface.
+
+The pericardium was much distended with water. The heart, on the
+anterior surface of which were some appearances of inflammation, was
+very much enlarged. Its parietes were thickened; its cavities
+unnaturally large, and filled with black coagulum. Each of the valves
+had lost, in some degree, its usual smoothness, and those of the aorta
+were, in some points, thickened, and partly cartilaginous.
+
+The liver was small, and, when cut, poured out dark blood. Its tunic
+was whitish, opaque, and corrugated.
+
+
+                                CASE V.
+
+A. B. a negro, about thirty-five years of age, had paroxysms of
+dyspnoea and violent cough, attended with oedema of the extremities
+and ascites, violent head-ache, dizziness, brightness of the eyes,
+palpitations of the heart, irregular, intermittent, slow, and soft
+pulse. These symptoms slowly increased, during three or four years, in
+which time the dropsical collections were repeatedly dispersed. He
+gradually and quietly died in the alms-house, in January, 1809.
+
+
+                              DISSECTION.
+
+On dissection, the cavities of the pleura were found to contain a
+considerable quantity of water. The pericardium was filled with water;
+the heart considerably enlarged; its parietes very thin, and its
+cavities, especially the right auricle and ventricle, morbidly
+large[9].
+
+    [Footnote 9: This dissection was performed by Dr. Gorham.]
+
+
+                               CASE VI.
+
+Mrs. M'Clench, a washer-woman, forty-eight years of age, of good
+constitution and regular habits, was attacked, in the summer of 1808,
+with palpitations of the heart and dyspnoea on going up stairs, severe
+head-ache, and discharges of blood from the anus. These symptoms did
+not excite much attention. In the winter of 1808-9, all of them
+increased, except the palpitations. The inferior extremities and
+abdomen became distended with water; the region of the liver painful;
+the skin quite yellow; the pulse was hard, regular, and vibrating; the
+countenance very florid. Violent cough followed, and blood was
+profusely discharged from the lungs. This discharge being suppressed,
+evacuations of blood from the anus ensued, under which she died, in
+March, 1809.
+
+
+                              DISSECTION.
+
+The right cavity of the thorax was filled with water; the left
+contained none. The lungs were sound, but very dense, full of dark
+coloured blood, and, on the right side, pressed into the upper part of
+the thorax. The heart was one half larger than natural; its substance
+firm, and its anterior part, especially near the apex, covered with
+coagulated lymph. The right auricle and ventricle were large, and
+their parietes thin. The parietes of the left auricle and ventricle,
+particularly of the latter, were much thickened, and their cavities
+were filled with black coagulum.
+
+The liver was contracted; its coat wrinkled, and marked with
+appearances of recent inflammation.
+
+
+                               CASE VII.
+
+                       To JOHN C. WARREN, M. D.
+
+MY DEAR SIR,
+
+Your important communication to our society, which is about to be
+published, will lay before the American public much more knowledge
+respecting the diseases of the heart, and large vessels, than has
+hitherto been presented to them. A case has lately fallen under my
+observation, having so much similarity to those of organic diseases of
+the heart, which have occurred to you, as to mark its affinity, yet
+with some differences, which characterize it as a variety. If the
+statement of it will add any value to your collection of cases, you
+are at liberty to publish it.
+
+A. S. twenty-eight years of age, and of middle stature, was attacked,
+after a debauch, with pain in the region of the heart, which subsided,
+but returned a year after on a similar occasion. He then became
+affected with palpitations of the heart for six months, great
+difficulty of breathing, which was augmented by ascending an eminence,
+severe cough, dizziness, and violent head-ache, attended by a
+disposition to bend the body forward, and sudden startings from sleep.
+His pulse was always regular, and never remarkably hard. His
+countenance, till within a few weeks of death, presented the
+appearance of blooming health. His feet and legs did not swell at any
+period of the disease. He suffered exceedingly from flatulence, to
+which he was disposed to attribute all his complaints. This symptom
+might have been aggravated by his habits of free living, and
+occasional intoxication, which he acknowledged, and to which he traced
+the origin of his disease.
+
+After death, water was discovered in the thorax; but the lungs had not
+that appearance of accumulation of blood, in particular spots, which
+is commonly observed in cases of organic disease of the heart. The
+only very remarkable morbid appearance about the heart was in the
+aorta, and its valves. The valves had lost their transparency, and
+were considerably thickened in various spots. The inner surface of
+the aorta, for about an inch from its commencement, was elevated and
+thickened, and the external surface singularly roughened and
+verrucated. This appearance was so peculiar, that no words will give a
+competent idea of it, and perhaps it would be sufficient for me to
+call it a chronic inflammation[10].
+
+                              I am, my dear sir,
+                                  Your friend and obedient servant,
+                                                         JAMES JACKSON.
+
+    [Footnote 10: See plate second.]
+
+
+                              CASE VIII.
+
+Col. William Scollay, aged fifty-two, of a plethoric habit of body,
+was attacked, in the year 1805, with dyspnoea and palpitation of the
+heart, attended with irregularity of the pulse, and oedema of the
+lower extremities. By the aid of medicine, the dropsical collections
+were absorbed, and he recovered his health, so far as to follow his
+usual occupations, nearly a year; but was then compelled to relinquish
+them. The symptoms afterwards underwent various aggravations and
+remissions, till the beginning of the winter of 1808-9, when the
+attacks became so violent, as to confine him to the house. His face
+was then high coloured. The faculties of his mind were much impaired.
+The dyspnoea became more constant, and was occasionally attended by
+cough; the palpitations rather lessened in violence; the pulse was
+more irregular, and exceedingly intermittent. The abdomen and inferior
+extremities were sometimes enormously distended with water, and
+afterwards subsided nearly to their usual size. One of the earliest,
+most frequent, and distressing symptoms, was an intense pain in the
+head. About two months before death, a hemiplegia took place, but
+after a few days disappeared. This so much impaired the operations of
+the mind, that the patient afterwards found great difficulty in
+recollecting words sufficient to form an intelligible sentence. During
+the existence of the last symptom the pulse was regular.
+
+He gradually expired, on the 15th of March, 1809.
+
+
+                  DISSECTION, FIVE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The countenance was somewhat livid and pale; the lips were very livid.
+The chest resounded, when struck, except over the heart. The abdomen
+was tumid, and marked by cicatrices like those of women, who have
+borne children. The superior extremities were emaciated, and marked
+like the abdomen. The lower extremities were oedematous.
+
+
+                                THORAX.
+
+The cartilages of the ribs were ossified. The left cavity of the
+pleura contained about twelve ounces of water; the right, about three
+ounces. The lungs, externally, were dark coloured, especially the
+posterior lobes; internally, they were very firm, and, in some places,
+as dense as the substance of the liver. A frothy mucus was effused
+from them in great quantities. They were coloured by very dark blood,
+especially in the middle portion of the left superior lobe. One or two
+calcareous concretions were observed in them. The pericardium was a
+little firmer than usual, and contained about five ounces of water.
+The heart was enlarged, and covered with tough fat. In the right
+auricle, and ventricle, was some coagulated blood. The tricuspid
+valves had lost their smoothness and transparency; the semilunar
+valves of the pulmonary artery were cartilaginous at their bases. The
+left auricle and ventricle, particularly the first, contained
+coagulum. The mitral valves were roughened by many bony spots.
+Considerable ossification had taken place in the semilunar valves of
+the aorta, so that one of them had quite lost its form; and the aorta
+was ossified for the space of a square inch, at a small distance from
+the valves. The coronary arteries were also ossified.
+
+
+                               ABDOMEN.
+
+The coat of the liver was somewhat wrinkled, as if shrunk. Its
+substance was hard, and discharged, when cut, great quantities of
+blood. The veins of the omentum, mesentery, and intestines, were full
+of blood. The abdomen contained a considerable quantity of water.
+
+
+                                 HEAD.
+
+Water was found between the dura and pia mater, and between the pia
+mater and arachnoides. The vertical portion of the pia mater bore
+marks of former inflammation. The convolutions of the brain were very
+distinct; their external surface was pale. The veins were empty[11].
+No bloody points were observed in the medullary portion of the brain,
+when cut. The ventricles contained between one and two ounces of
+water; the communication between them was very large. The plexus
+choroides was pale.
+
+    [Footnote 11: In this case, and in case first, the vena cava
+    ascendens had been divided, before the brain was examined.]
+
+
+                               CASE IX.
+
+A lady, about forty-five years of age, the mother of many children,
+has been troubled during the course of the past year with violent
+palpitations of the heart, and great difficulty of respiration,
+especially on going up stairs. These complaints have lately increased,
+so that she has kept in her chamber about two months. Her countenance
+is florid; her eyes are clear and bright. She has dizziness,
+especially on moving, without pain in her head. She had for some time,
+a severe cough, which is now relieved. The dyspnoea is not yet very
+distressing, except on using motion; it often occurs in the night, and
+obliges her to rise and sit up in bed. The palpitations are very hard,
+and so strong, that they may be perceived through her clothes; the
+tumult in the thorax is indescribable. The functions of the abdominal
+viscera are unimpaired. The pulse is hard, vibrating, irregular,
+intermittent, very variable, corresponding with the motions of the
+heart, and similar in each arm. There is not yet the slightest reason
+to suspect any dropsical collection. The alternations of ease and
+distress are very remarkable, but on the whole, the violence of the
+symptoms increases rapidly.
+
+There is no difficulty in discovering in this case an organic disease
+of the heart, which probably consists in an enlargement and thickening
+of the heart, and an ossification of the semilunar valves of the
+aorta.
+
+
+                                CASE X.
+
+Levi Brown, a cabinet-maker, forty-eight years of age, complained in
+February, 1809, of great difficulty of breathing, and an indescribable
+sensation in the chest, which he said was sometimes very distressing,
+and at other times quitted him entirely. Being a man of an active
+mind, he had read some medical books, whence he got an idea, that he
+was hypochondriac.
+
+On examining his pulse, it was found to be occasionally intermittent,
+contracted, and vibrating. He had some years previously been attacked
+with copious h�morrhages from the stomach or lungs, which have
+occasionally recurred, though they have lately been less frequent.
+Eight years since he suffered from an inflammation of the lungs; and
+about two or three years ago he first experienced a beating in the
+chest, and pain in the region of the heart, which increased till
+within six or eight months, since which the beating has been
+stationary, and the pain has much increased. In the course of the last
+summer, dyspnoea, on using exercise, and especially ascending any
+eminence, commenced. This has greatly increased, so as to render it
+almost impossible for him to go up stairs. His countenance is turgid,
+and uniformly suffused with blood; his eyes are bright and animated;
+his lips livid. The pulsation of the heart cannot be felt on the left
+side, and is barely perceptible on the right side of the sternum, and
+in the epigastric region. When he is distressed with fits of dyspnoea,
+he feels something as if rising to the upper part of the thorax, and
+the heart then seems to him to be beating through the ribs. I have not
+witnessed any of these paroxysms. The inferior extremities and abdomen
+have been swelled about three weeks. When in bed, he has his head and
+shoulders elevated, and, upon the attack of his paroxysms, sits up and
+inclines his head forward; but he keeps from the bed as much as
+possible. In his sleep he is apt to start up, suddenly, in distress,
+especially when he first slumbers. His dreams are often frightful,
+and, when awake, he is affected with reveries, during which, though
+conscious of being awake, strange illusions present themselves. At
+intervals he seems slightly delirious. He has a violent cough, with
+very copious expectoration of thick mucus. He often suffers from
+severe head-ache, and the least exercise produces dizziness.
+
+This man has a very robust frame of body, and has been accustomed to a
+free use of ardent spirits, and of opium, of which he now takes about
+twelve grains in a day. His appearance is such, that, on a slight
+survey, one would not suppose him diseased, but, on observing him with
+a little attention, a shortness and labour of respiration are
+perceived, with some interruption in speaking, and a frequent catching
+of the breath, or sighing.
+
+April. Since writing the above account, the dropsical collections were
+absorbed, and the palpitations and other symptoms moderated, so that
+he considered himself nearly well, and attended to his usual business.
+Within a few days, however, the symptoms have returned with more
+violence. The dyspnoea is at times very distressing; the pulse more
+irregular and intermittent; the palpitations are more constant. His
+sufferings from lying in bed are so increased, that in the most
+comfortable nights he passes, he sits up once in an hour or two. The
+appetite is keen. The legs begin to swell again.
+
+Some organic disease of the heart exists in this case. The
+indistinctness of the palpitations, the want of hardness in the pulse,
+and the slow progress of the disease, indicate a loss of power in the
+heart, the effect of the distention and thinness of its parietes. The
+irregularity of the pulse affords some reason to suspect disorder of
+the aortal valves, which is not yet very considerable.
+
+
+ENUMERATION _of the principal morbid changes, observed in the organization
+of the heart, in the preceding cases_.
+
+Enlargement of the volume of the heart, or aneurism.[12]
+Increase of the capacity, or aneurism of the right auricle,  } with
+                                      of the right ventricle,} thickened,
+                                      of the left auricle    } or thin,
+                                      of the left ventricle, } parietes.
+                                      of the aorta, with thickening of
+                                         its coats.
+
+Fleshlike[13] thickening of the mitral valves.
+                         of the aortal valves.
+                         of the aorta.
+
+Cartilaginous thickening of the internal membrane of the heart, and
+generally of its valves.
+
+Ossification of the parietes of the heart.
+                    mitral valves.
+                    aortal valves.
+                    aorta.
+                    coronary arteries.
+
+    [Footnote 12: Morgagni uses this term, which he borrows from
+    Ambrose Pare, to express dilatation of the cavities of the
+    heart. It seems to be as applicable to the dilatation of the
+    heart, as to that of an artery. I have therefore adopted it
+    in this enumeration.]
+
+    [Footnote 13: The term fleshlike is employed to express that
+    roughness of the valves, which somewhat resembles flesh in
+    its appearance, but which is very different from the
+    thickening of the parietes of the heart.]
+
+
+ENUMERATION _of the principal morbid appearances, observed in these
+cases of disease of the heart, which may be considered secondary_.
+
+    IN THE CAVITY OF THE CRANIUM.
+
+Inflammation of the meninges.
+Water between the meninges.
+Water in the ventricles.
+
+    IN THE PLEURA AND ITS CAVITY.
+
+Inflammation and thickening of the pleura.
+Collection of water in its cavity.
+Lungs dark coloured.
+      generally very firm, and particularly in some parts.
+      loaded with black blood.
+      crowded into a narrow space.
+
+    IN THE PERICARDIUM AND ITS CAVITY.
+
+Inflammation and thickening of its substance.
+Adhesion to the heart and lungs.
+Collection of water in its cavity.
+
+    IN THE CAVITY OF THE ABDOMEN.
+
+Collection of water.
+Liver very full of fluid blood.
+      having its tunic flaccid and inflamed.
+Mesenteric veins full of blood.
+
+    CELLULAR MEMBRANE full of water.
+
+    THE BLOOD every where fluid, except in the cavities of the heart.
+
+
+                               REMARKS.
+
+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 h�morrhoidal 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 pr�cordia 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 ven� cav� 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
+column� approximate, till their sides are in contact, to protect the
+parietes of the heart; but, if these be distended, the column� 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 h�morrhoidal 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 h�morrhoidals must consequently be also affected,
+and they easily burst open from too great distention. The h�moptoe,
+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 h�morrhoidal
+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.
+
+
+                         CASE OF HYDROTHORAX.
+
+     The following case of hydrothorax will shew, that water may
+     exist in the chest without the symptoms, which we have
+     attributed to organic diseases of the heart.
+
+Mrs. T----, aged 56 years, of an excessively corpulent habit, had been
+affected for a great number of years with a scirrhus of the right
+breast. Finding her health decline, she at last disclosed it, and in
+coincidence with the opinion of Dr. WARREN, sen. I amputated it on the
+30th of May, of the present year. We however informed her friends,
+that the probability of eradicating the disease was extremely small.
+The skin was in many places hardened and drawn in, and in others
+discoloured, and ulcerated at the nipple, so that it was found
+necessary to remove, not only what covered the breast, but some
+portion of that which surrounded it. A long chain of diseased glands,
+extending quite to the axillary vessels, was also extirpated. She bore
+the operation well, lost no great quantity of blood, and recovered her
+appetite and strength surprisingly in a few days, while the wound
+healed rapidly. At the end of twenty days a difficulty of breathing
+commenced, and soon became so oppressive, that she could no longer lie
+in bed; partly, no doubt, on account of her extraordinary obesity. The
+pulse was small, quick, and commonly feeble, but sometimes a little
+hard, when any degree of fever was present. The countenance became
+pale, the lips of a leaden hue, the eyes dim. We were surprised at the
+change, and conjectured that the cancerous action had suddenly
+extended to the lungs. Yet she had not the slightest cough; and it was
+remarked by Dr. WARREN, sen. that he had never observed that diseased
+action to increase, while the wound remained open. At last the lower
+extremities swelled, which might be attributed to the upright posture,
+and the pressure on the absorbent vessels in that posture. The
+appetite failed; she complained of a constant sense of depression at
+the stomach, and, without any remission of the difficulty of
+breathing, died on the 1st of July.
+
+On the next morning the body was examined. The pleura in both cavities
+of the thorax was studded with small, white, and apparently
+homogeneous tubercles; the lungs contained a great number of similar
+bodies. The right cavity of the pleura was entirely filled with water,
+of which we removed at least three quarts. The heart was of the usual
+size, very flaccid and tender; but not otherwise disordered. The liver
+was enlarged, of its usual colour, much hardened, and had on its
+surface, and in its substance, many tubercles like those in the
+thorax. It had also a great number of encysted cavities, each about
+the size of a hazle nut, which contained a thin yellow fluid. The gall
+bladder was wanting, and in its place there was a small, but very
+remarkable depression, without a vestige of any former gall bladder,
+for the coat of the liver was as smooth and perfect there as in any
+other part[15]. The pancreas was in a scirrhous state. The abdomen did
+not contain any water.
+
+    [Footnote 15: See Soemmerring de corporis humani fabrica,
+    vol. 6, pag. 188 and Baillie's morbid anatomy, pag. 248.]
+
+It seems, then, that water may exist in the cavity of the thorax,
+without any remarkable symptoms, except dyspnoea and difficulty in
+assuming the horizontal posture. But in organic diseases of the heart,
+there is a long train of frightful symptoms, distinguishable by the
+most superficial observers. We infer that these disorders have been
+unnecessarily confounded.
+
+
+
+
+
+End of the Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
+
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+      The Project Gutenberg eBook of Cases of Organic Diseases of the Heart, by John C. Warren
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+
+The Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Cases of Organic Diseases of the Heart
+
+Author: John Collins Warren
+
+Release Date: October 7, 2008 [EBook #26836]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE ***
+
+
+
+
+Produced by Bryan Ness, Irma Spehar and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+</pre>
+
+
+
+<h1><span style="font-size: 70%">CASES</span><br />
+<span style="font-size: 40%">OF</span><br />
+<span style="font-size: 90%">ORGANIC DISEASES</span><br />
+<span style="font-size: 40%">OF THE</span><br />
+HEART.</h1>
+
+<p class="subtitle">WITH DISSECTIONS AND SOME REMARKS INTENDED TO POINT OUT THE<br />
+DISTINCTIVE SYMPTOMS OF THESE DISEASES.</p>
+
+<p class="subtitle">READ BEFORE THE COUNSELLORS OF THE MASSACHUSETTS<br />
+MEDICAL SOCIETY.</p>
+
+<p class="author">BY JOHN C. WARREN, M.&nbsp;D.</p>
+
+<p class="publisher"><big>BOSTON:</big><br />
+PRINTED BY THOMAS R. WAIT AND COMPANY.<br />
+COURT-STREET.<br />
+1809.</p>
+
+
+
+<div class="plate">
+<p class="center"><b>PLATE I.</b></p>
+
+<p>Appearance of the valves of the aorta in <a href="#CASE_III">Case 3d</a>, Article 10.</p>
+
+<ul>
+<li><i>a a</i> The two valves thickened.</li>
+
+<li><i>b b</i> Bony projections, one of which extends across the cavity of the
+valve.</li>
+
+<li style="padding-left: 0.9em"><i>c</i> The orifices of the coronary arteries.</li>
+
+<li><i>d d</i> Fleshlike thickening of the aorta.</li>
+</ul>
+
+
+<p class="center" style="padding-top: 1em"><b>PLATE II.</b></p>
+
+<p>Is a representation of the fleshlike thickening of the aorta in
+<a href="#CASE_VII">case 7th</a>. The valves are smaller than usual, and their form is in
+some degree changed. A round spot, thickened, is seen at a little
+distance from the seat of the principal disease.</p>
+</div>
+
+
+
+<div class="figcenter" style="width: 500px;">
+<img src="images/illo1.jpg" width="500" height="451" alt="" title="" />
+</div>
+
+<div class="figcenter" style="width: 416px; padding-top: 2em">
+<img src="images/illo2.jpg" width="416" height="500" alt="" title="" />
+</div>
+
+
+
+<h2><span style="font-size: 60%"><a name="CASES_OF" id="CASES_OF"></a>CASES OF</span><br />
+ORGANIC DISEASES OF THE HEART,<br />
+<span style="font-size: 60%">WITH DISSECTIONS.</span><span class='pagenum'><a name="Page_1" id="Page_1">[1]</a></span></h2>
+
+
+<p><span class="smcap"><big>M</big>orbid</span> changes in the organization of the heart
+are so frequent, as to have attracted the observation
+of those, who have devoted any attention to the
+study of morbid anatomy. Derangements of the
+primary organ of the circulation cannot exist without
+producing so great disorder of the functions of
+that and of other parts, as to be sufficiently conspicuous
+by external signs; but, as these somewhat
+resemble the symptoms of different complaints, especially
+of asthma, phthisis pulmonalis, and water in
+the thorax, it has happened, that each of these has
+been sometimes confounded with the former<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a>. The
+<span class='pagenum'><a name="Page_2" id="Page_2">[2]</a></span>object of the following statement of cases is to shew,
+that, whatever resemblance there may be in the
+symptoms of the first, when taken separately, to
+those of the latter diseases, the mode of connection
+and degree of those symptoms at least is quite dissimilar;
+and that there are also symptoms, peculiar
+to organic diseases of the heart, sufficiently characteristic
+to distinguish them from other complaints.</p>
+
+
+<h3><a name="CASE_I" id="CASE_I"></a>CASE I.</h3>
+
+<p><span class="smcap">The</span> 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
+<span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span>knowledge of a complaint is obtained from a
+successive view of its stages.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">At</span> 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.</p>
+
+<p><span class="smcap">In</span> 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<span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>
+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&#8217; 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.</p>
+
+<p><span class="smcap">At</span> 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<span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>
+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.</p>
+
+<p><span class="smcap">These</span> 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<span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>
+of any material alteration in the condition of the
+patient.</p>
+
+<p><span class="smcap">On</span> the approach of warm weather, in June, the
+violence of the symptoms increased. Paroxysms
+of dyspn&#339;a 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 h&aelig;morrhoidal 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.</p>
+
+<p><span class="smcap">Such</span> 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
+dyspn&#339;a 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<span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span>
+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<span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>
+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<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a>.</p>
+
+<p><span class="smcap">This</span> 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
+<span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>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.</p>
+
+<p><span class="smcap">After</span> 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<span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>
+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.</p>
+
+<p><span class="smcap">From</span> 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<span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span>
+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<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a>.</p>
+
+<p><span class="smcap">Once</span> 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.</p>
+
+<p><span class="smcap">On</span> 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
+<span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span>at the end of twenty-four hours they very gradually
+ceased.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a></p>
+
+
+<h4>DISSECTION, NINE HOURS AFTER DEATH.</h4>
+
+
+<h5>EXTERNAL APPEARANCE.</h5>
+
+<p><span class="smcap">The</span> whole body was much emaciated; the face
+pale and contracted. The hands were slightly &#339;dematous.
+Discolourations, answering to the ribs, were
+observed on the thorax; many small purple spots,
+hard and prominent, on the back; excoriations on
+the nates; and purple spots, resembling incipient
+mortification, on the heel and toe.</p>
+
+
+<h5>THORAX.</h5>
+
+<p><span class="smcap">The</span> integuments of the thorax were free from
+fat: the cartilages of the ribs ossified in various
+degrees, some perfectly, others slightly. Upon laying
+open the cavity of the thorax, it was found to
+contain about three pints of water, the proportion
+being greatest on the left side.</p>
+
+<p><span class="smcap">The</span> lungs were contracted into a smaller compass
+than usual, and were very firm to the touch. Their
+colour anteriorly was whitish, with small distinct
+purple spots; posteriorly, of a deep red, with similar
+spots. The right lobe adhered closely to the pericardium;
+it also adhered to the pleura costalis, by a
+great number of strong cords, which seemed to be
+elongations of the original adhesions. Some of them
+were nearly as hard as ligament, and many an inch
+in length. Internally the lungs presented a very
+<span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span>compact structure. Their cells were crowded with
+mucus, and their vessels filled with black blood,
+partly fluid, and partly coagulated. Some portions
+were firmer and more condensed than others, but
+no tubercles were discovered.</p>
+
+<p><span class="smcap">The</span> pericardium, viewed externally, appeared
+very large, and occupied almost the whole space
+behind the opening formed by removing the sternum
+and cartilages of the ribs. It was situated
+principally on the left side, and contained about
+double the usual quantity of water; but was principally
+filled by the enlarged heart, to which it adhered
+anteriorly about two inches, near its base. Its parietes
+were, in every part, very much thickened and
+hardened.</p>
+
+<p><span class="smcap">The</span> heart presented nearly its usual colour and
+form, excepting on its anterior surface, which was
+somewhat discoloured by coagulated lymph. It was
+enlarged in bulk to, at least, one half more than the
+healthy size. The auricles and ventricles contained
+coagulated blood. The tricuspid valves were in a
+sound state. The left auricle was double the usual
+size. The left ventricle was enlarged, about three
+times thicker and much firmer than usual. The
+mitral valves were very much thickened, and near
+the insertion of their column&aelig;, which were sound,
+cartilaginous, so that they were quite rigid, and the
+opening made by them, from the auricle to the ventricle,
+was scarcely large enough to admit the passage
+of a finger. The semilunar valves of the aorta
+were ossified at their bases and apices, and the portion<span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span>
+intermediate, between the base and apex, partly
+ossified, and partly cartilaginous, so as to render the
+valves very rigid. The aorta was at least one half
+larger than usual, especially at its arch. The arteria
+innominata, the carotid, and subclavian arteries,
+were uncommonly large and thick. The coronary
+arteries were considerably ossified.</p>
+
+
+<h5>ABDOMEN.</h5>
+
+<p><span class="smcap">The</span> omentum was destitute of fat. The stomach
+distended with flatus on the pyloric side; its cardiac
+extremity, lying under the liver, was pressed down
+and contracted. The liver was shrunk; its tunic
+corrugated, as if it had been distended, and bearing
+marks of inflammation; its substance harder than
+usual; its vessels, when divided, pouring out liquid
+black blood. The gall bladder was filled with bile.
+The kidneys were thicker, and more irregular in
+form, than is common. The abdominal cavity contained
+some water.</p>
+
+
+<h5>HEAD.</h5>
+
+<p><span class="smcap">The</span> bones of the cranium were unusually thick.
+The dura mater, which was thickened, and in many
+places bore marks of former inflammation, adhered
+to the bone at the vertex. On its internal surface,
+near the longitudinal sinus, there was a small ossified
+portion, half an inch long and the eighth of an
+inch thick. The convolutions of the brain were narrow,
+and very strongly marked. The pia mater
+bore marks of pretty extensive inflammation, and
+adhered to the dura mater at the vertex. The cortical<span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>
+substance ran deep into the medullary part of
+the brain. The ventricles contained about double
+the usual quantity of water; their parts were all
+remarkably well defined. The vessels of the pia
+mater, over the corpora striata, were unusually injected
+with blood. The velum interpositum was
+very firm; the plexus choroides uncommonly thick,
+but pale; the opening from the right to the left
+ventricle large. The vessels of the brain were
+generally not much filled with blood.</p>
+
+<p><span class="smcap">The blood</span> appeared every where fluid, except
+in some portions of the lungs, and in the cavities of
+the heart. It was very dark coloured, perhaps more
+than ordinarily thin, and oozed from every part,
+which was cut.</p>
+
+<p><span class="smcap">The cellular membrane</span>, in all dependent
+parts, effused, when cut, a serous fluid.</p>
+
+
+<h3><a name="CASE_II" id="CASE_II"></a>CASE II.</h3>
+
+<p><span class="smcap">Mr. John Jackson</span>, fifty-two years of age, had
+been affected for more than two years with palpitations
+of the heart, and paroxysms of dyspn&#339;a. These
+symptoms increased in October, 1808, and were followed
+by strong cough, uneasiness in lying down,
+sudden startings in sleep, and an inclination to bend
+the body forward and to the left side. His cough,
+during the last part of his life, was attended with
+copious bloody expectoration. His countenance
+was florid; his pulse very irregular, though not
+quite intermittent. The occasional variations in the<span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>
+state of the disease were remarkable. Some periods
+were marked with uncommon mental irritability.
+Pain in the region of the liver, &#339;dema of the
+inferior extremities, paucity and turbidness of the
+urine, yellowness of the skin, and great emaciation
+attended the latter stages of the disease. A degree
+of stupor occurred. The termination on the 30th
+of January, 1809, was tolerably quiet. Two days
+before death he sank into the recumbent posture,
+and his pulse became more regular<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a>.</p>
+
+
+<h4>DISSECTION,<br />
+<small>TWENTY-FOUR HOURS AFTER DEATH.</small></h4>
+
+<p><span class="smcap">On</span> opening the thorax, its right cavity was found
+to contain a large quantity of water; the left, a smaller
+quantity.</p>
+
+<p><span class="smcap">The</span> lungs were of a firm, condensed texture,
+especially at the lower part, where their solidity was
+nearly equal to that of a healthy liver. They contained
+black blood.</p>
+
+<p><span class="smcap">The</span> heart was much enlarged, and proportionally
+thickened. Its tunic was in some places covered
+with coagulated lymph, especially over the coronary
+arteries. Its cavities were filled with black coagulum,
+which in the right auricle and ventricle had a
+slight appearance of polypus. The semilunar valves
+of the pulmonary artery and aorta were unusually
+small, and their bases cartilaginous. Those of the
+aorta had lost their form, and were slightly ossified.
+<span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span>The remaining valves were partially thickened. The
+arch of the aorta was very much dilated, its internal
+coat covered with a bony crust, which extended
+through the remaining thoracic portion, gradually
+diminishing. This portion was also considerably
+dilated.</p>
+
+<p><span class="smcap">The</span> liver was indurated; its periton&aelig;al coat exhibited
+a flaccid or wrinkled appearance, and bore
+marks of slight inflammation. The gall bladder was
+filled with bile, and the pancreas indurated.</p>
+
+
+<h3><a name="CASE_III" id="CASE_III"></a>CASE III.</h3>
+
+<p><span class="smcap">Captain Job Jackson</span>, forty-five years of age,
+a man of vigorous constitution, after an indisposition
+of some years continuance, was seized with
+palpitations of the heart and dyspn&#339;a, occurring by
+variable paroxysms, especially on ascending an eminence,
+and attended by hardness, irregularity, and
+intermission of the pulse. To these symptoms were
+superadded dizziness and severe head-ache, a disposition
+to bend the body forward, sudden starting
+from sleep, with dread of suffocation, violent cough
+with copious expectoration, which for fifteen days
+before death consisted of black blood, distressing
+pain across the chest, especially on the left side,
+great &#339;dema of the lower extremities, and paucity
+of urine.</p>
+
+<p><span class="smcap">He</span> died painfully in January, 1809, after violent
+struggles for breath. The day before death the
+pulse became regular. He rested his head upon an<span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>
+attendant, and made no attempts to lie down for
+some days previous<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a>.</p>
+
+
+<h4>DISSECTION,<br />
+<small>SIXTEEN HOURS AFTER DEATH</small>.</h4>
+
+<p><span class="smcap">The</span> skin was of a yellow colour. The inferior
+extremities, quite to the groins, were &#339;dematous.</p>
+
+<p><span class="smcap">The</span> left cavity of the thorax was filled with
+water; the right contained only a small quantity.
+The pleura costalis, on the left side opposite to the
+heart, was thickened and covered with a very thick
+flocculent coat of coagulated lymph, and the pericardium
+opposite to it had the same marks of inflammation.
+The lungs on that side were pushed up
+into a narrow space. They were dense and dark
+coloured.</p>
+
+<p><span class="smcap">The</span> pericardium contained little more than the
+usual quantity of water. The heart, which exhibited
+marks of some inflammation on its surface, was astonishingly
+large, and firm in proportion. Its cavities
+were principally filled with coagulum. The semilunar
+valves of the pulmonary artery had their bases
+slightly ossified, and the remaining part thickened.
+There were only two valves of the aorta, and these
+were disorganized by the deposition of ossific matter
+about their bases, and a fleshlike thickening of
+the other part<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a>. The parietes of the heart, especially
+of the left ventricle, were greatly thickened, and
+somewhat ossified near the origin of the aorta.</p>
+
+<p><span class="smcap">The</span> liver had the same appearance as in <a href="#CASE_II">case
+second</a>.</p>
+
+
+<h3><a name="CASE_IV" id="CASE_IV"></a>CASE IV.<span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span></h3>
+
+<p><span class="smcap">Thomas Appleton</span>, thirty-eight years of age,
+of a robust constitution, was affected with excessive
+difficulty of breathing, occurring at intervals of different
+duration. It commenced three years before
+his death, and gradually increased. He was subject
+to palpitations of the heart for at least two years
+before his death, and was distressed with violent
+cough, attended with copious expectoration, which
+finally became very bloody. The palpitation and
+dyspn&#339;a were greatly augmented by ascending
+stairs. His countenance was very florid.</p>
+
+<p><span class="smcap">Sometimes</span> he was seized with violent head-ache
+and dizziness, which, as well as the other symptoms,
+were greatly relieved by venesection. About
+two months before death &#339;dema of the legs appeared,
+which was soon followed by frequent and alarming
+syncope. His pulse was irregular, intermittent,
+hard, and vibrating. When lying down he frequently
+awoke, and started up in great terror. His usual
+posture was that of sitting, with his trunk and head
+bent forward, and inclining to the left side. For
+some time before death a recumbent posture threatened
+immediate suffocation; yet, three days previous
+to the occurrence of that event, he sank back upon
+the pillow. He was, at intervals, so much better as
+to think himself free from disease. Slight delirium
+preceded his death, which occurred in January,
+1809<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a>.</p>
+
+<h4>DISSECTION,<br />
+<small>EIGHTEEN HOURS AFTER DEATH.</small><span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span></h4>
+
+<p><span class="smcap">The</span> countenance continued florid. The inferior
+extremities were much distended with water, and
+the cellular membrane abounded in fat.</p>
+
+<p><span class="smcap">The</span> right cavity of the pleura contained a moderate
+quantity of water; the left, scarcely any. The
+lungs were firm, condensed, and dark coloured,
+from venous blood. The pleura, on the left side
+opposite to the pericardium, appeared to have been
+inflamed, as there was an effusion of coagulated
+lymph on its surface.</p>
+
+<p><span class="smcap">The</span> pericardium was much distended with water.
+The heart, on the anterior surface of which
+were some appearances of inflammation, was very
+much enlarged. Its parietes were thickened; its
+cavities unnaturally large, and filled with black coagulum.
+Each of the valves had lost, in some degree,
+its usual smoothness, and those of the aorta were, in
+some points, thickened, and partly cartilaginous.</p>
+
+<p><span class="smcap">The</span> liver was small, and, when cut, poured out
+dark blood. Its tunic was whitish, opaque, and
+corrugated.</p>
+
+
+<h3>CASE V.</h3>
+
+<p>A.&nbsp;B. a negro, about thirty-five years of age, had
+paroxysms of dyspn&#339;a and violent cough, attended
+with &#339;dema of the extremities and ascites, violent
+head-ache, dizziness, brightness of the eyes, palpitations<span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span>
+of the heart, irregular, intermittent, slow,
+and soft pulse. These symptoms slowly increased,
+during three or four years, in which time the dropsical
+collections were repeatedly dispersed. He
+gradually and quietly died in the alms-house, in
+January, 1809.</p>
+
+
+<h4>DISSECTION.</h4>
+
+<p><span class="smcap">On</span> dissection, the cavities of the pleura were
+found to contain a considerable quantity of water.
+The pericardium was filled with water; the heart
+considerably enlarged; its parietes very thin, and
+its cavities, especially the right auricle and ventricle,
+morbidly large<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a>.</p>
+
+
+<h3><a name="CASE_VI" id="CASE_VI"></a>CASE VI.</h3>
+
+<p><span class="smcap">Mrs. M&#8216;Clench</span>, a washer-woman, forty-eight
+years of age, of good constitution and regular habits,
+was attacked, in the summer of 1808, with palpitations
+of the heart and dyspn&#339;a on going up stairs,
+severe head-ache, and discharges of blood from the
+anus. These symptoms did not excite much attention.
+In the winter of 1808-9, all of them increased,
+except the palpitations. The inferior extremities
+and abdomen became distended with water; the region
+of the liver painful; the skin quite yellow; the
+pulse was hard, regular, and vibrating; the countenance
+very florid. Violent cough followed, and
+blood was profusely discharged from the lungs.
+<span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>This discharge being suppressed, evacuations of
+blood from the anus ensued, under which she died,
+in March, 1809.</p>
+
+
+<h4>DISSECTION.</h4>
+
+<p><span class="smcap">The</span> right cavity of the thorax was filled with
+water; the left contained none. The lungs were
+sound, but very dense, full of dark coloured blood,
+and, on the right side, pressed into the upper part
+of the thorax. The heart was one half larger than
+natural; its substance firm, and its anterior part,
+especially near the apex, covered with coagulated
+lymph. The right auricle and ventricle were large,
+and their parietes thin. The parietes of the left
+auricle and ventricle, particularly of the latter, were
+much thickened, and their cavities were filled with
+black coagulum.</p>
+
+<p><span class="smcap">The</span> liver was contracted; its coat wrinkled, and
+marked with appearances of recent inflammation.</p>
+
+
+<h3><a name="CASE_VII" id="CASE_VII"></a>CASE VII.</h3>
+
+<h4>To JOHN C. WARREN, M.&nbsp;D.</h4>
+
+<p><small>MY DEAR SIR,</small></p>
+
+<p><span class="smcap">Your</span> important communication to our society,
+which is about to be published, will lay before the
+American public much more knowledge respecting
+the diseases of the heart, and large vessels, than has
+hitherto been presented to them. A case has lately
+fallen under my observation, having so much similarity
+to those of organic diseases of the heart, which<span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span>
+have occurred to you, as to mark its affinity, yet
+with some differences, which characterize it as a
+variety. If the statement of it will add any value
+to your collection of cases, you are at liberty to publish
+it.</p>
+
+<p>A.&nbsp;S. twenty-eight years of age, and of middle
+stature, was attacked, after a debauch, with pain in
+the region of the heart, which subsided, but returned
+a year after on a similar occasion. He then became
+affected with palpitations of the heart for six months,
+great difficulty of breathing, which was augmented
+by ascending an eminence, severe cough, dizziness,
+and violent head-ache, attended by a disposition to
+bend the body forward, and sudden startings from
+sleep. His pulse was always regular, and never
+remarkably hard. His countenance, till within a
+few weeks of death, presented the appearance of
+blooming health. His feet and legs did not swell at
+any period of the disease. He suffered exceedingly
+from flatulence, to which he was disposed to attribute
+all his complaints. This symptom might have
+been aggravated by his habits of free living, and
+occasional intoxication, which he acknowledged, and
+to which he traced the origin of his disease.</p>
+
+<p><span class="smcap">After</span> death, water was discovered in the thorax;
+but the lungs had not that appearance of accumulation
+of blood, in particular spots, which is commonly
+observed in cases of organic disease of the heart.
+The only very remarkable morbid appearance about
+the heart was in the aorta, and its valves. The valves
+had lost their transparency, and were considerably<span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span>
+thickened in various spots. The inner surface of
+the aorta, for about an inch from its commencement,
+was elevated and thickened, and the external surface
+singularly roughened and verrucated. This
+appearance was so peculiar, that no words will give
+a competent idea of it, and perhaps it would be sufficient
+for me to call it a chronic inflammation<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a>.</p>
+
+<p class="right">
+<span style="padding-right: 12em">I am, my dear sir,</span><br />
+<span style="padding-right: 4em">Your friend and obedient servant,</span><br />
+JAMES JACKSON.</p>
+
+
+<h3>CASE VIII.</h3>
+
+<p><span class="smcap">Col. William Scollay</span>, aged fifty-two, of a
+plethoric habit of body, was attacked, in the year
+1805, with dyspn&#339;a and palpitation of the heart,
+attended with irregularity of the pulse, and &#339;dema
+of the lower extremities. By the aid of medicine,
+the dropsical collections were absorbed, and he recovered
+his health, so far as to follow his usual occupations,
+nearly a year; but was then compelled to
+relinquish them. The symptoms afterwards underwent
+various aggravations and remissions, till the
+beginning of the winter of 1808-9, when the attacks
+became so violent, as to confine him to the house.
+His face was then high coloured. The faculties of
+his mind were much impaired. The dyspn&#339;a became
+more constant, and was occasionally attended
+by cough; the palpitations rather lessened in violence;
+the pulse was more irregular, and exceedingly
+intermittent. The abdomen and inferior extremities
+<span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span>were sometimes enormously distended with
+water, and afterwards subsided nearly to their usual
+size. One of the earliest, most frequent, and distressing
+symptoms, was an intense pain in the head.
+About two months before death, a hemiplegia took
+place, but after a few days disappeared. This so
+much impaired the operations of the mind, that the
+patient afterwards found great difficulty in recollecting
+words sufficient to form an intelligible sentence.
+During the existence of the last symptom the pulse
+was regular.</p>
+
+<p><span class="smcap">He</span> gradually expired, on the 15th of March, 1809.</p>
+
+
+<h4>DISSECTION, FIVE HOURS AFTER DEATH.</h4>
+
+
+<h5>EXTERNAL APPEARANCE.</h5>
+
+<p><span class="smcap">The</span> countenance was somewhat livid and pale;
+the lips were very livid. The chest resounded, when
+struck, except over the heart. The abdomen was
+tumid, and marked by cicatrices like those of women,
+who have borne children. The superior extremities
+were emaciated, and marked like the abdomen.
+The lower extremities were &#339;dematous.</p>
+
+
+<h5>THORAX.</h5>
+
+<p><span class="smcap">The</span> cartilages of the ribs were ossified. The left
+cavity of the pleura contained about twelve ounces
+of water; the right, about three ounces. The lungs,
+externally, were dark coloured, especially the posterior
+lobes; internally, they were very firm, and, in
+some places, as dense as the substance of the liver.
+A frothy mucus was effused from them in great<span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span>
+quantities. They were coloured by very dark blood,
+especially in the middle portion of the left superior
+lobe. One or two calcareous concretions were observed
+in them. The pericardium was a little firmer
+than usual, and contained about five ounces of water.
+The heart was enlarged, and covered with tough
+fat. In the right auricle, and ventricle, was some
+coagulated blood. The tricuspid valves had lost
+their smoothness and transparency; the semilunar
+valves of the pulmonary artery were cartilaginous at
+their bases. The left auricle and ventricle, particularly
+the first, contained coagulum. The mitral
+valves were roughened by many bony spots. Considerable
+ossification had taken place in the semilunar
+valves of the aorta, so that one of them had quite
+lost its form; and the aorta was ossified for the
+space of a square inch, at a small distance from the
+valves. The coronary arteries were also ossified.</p>
+
+
+<h5>ABDOMEN.</h5>
+
+<p><span class="smcap">The</span> coat of the liver was somewhat wrinkled, as
+if shrunk. Its substance was hard, and discharged,
+when cut, great quantities of blood. The veins of
+the omentum, mesentery, and intestines, were full
+of blood. The abdomen contained a considerable
+quantity of water.</p>
+
+
+<h5>HEAD.</h5>
+
+<p><span class="smcap">Water</span> was found between the dura and pia
+mater, and between the pia mater and arachnoides.
+The vertical portion of the pia mater bore marks of<span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span>
+former inflammation. The convolutions of the brain
+were very distinct; their external surface was pale.
+The veins were empty<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a>. No bloody points were
+observed in the medullary portion of the brain,
+when cut. The ventricles contained between one
+and two ounces of water; the communication between
+them was very large. The plexus choroides
+was pale.</p>
+
+
+<h3><a name="CASE_IX" id="CASE_IX"></a>CASE IX.</h3>
+
+<p><span class="smcap">A lady</span>, about forty-five years of age, the mother
+of many children, has been troubled during the
+course of the past year with violent palpitations of
+the heart, and great difficulty of respiration, especially
+on going up stairs. These complaints have lately
+increased, so that she has kept in her chamber about
+two months. Her countenance is florid; her eyes
+are clear and bright. She has dizziness, especially
+on moving, without pain in her head. She had for
+some time, a severe cough, which is now relieved.
+The dyspn&#339;a is not yet very distressing, except on
+using motion; it often occurs in the night, and
+obliges her to rise and sit up in bed. The palpitations
+are very hard, and so strong, that they may be
+perceived through her clothes; the tumult in the
+thorax is indescribable. The functions of the abdominal
+viscera are unimpaired. The pulse is hard,
+vibrating, irregular, intermittent, very variable, corresponding
+<span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>with the motions of the heart, and similar
+in each arm. There is not yet the slightest
+reason to suspect any dropsical collection. The
+alternations of ease and distress are very remarkable,
+but on the whole, the violence of the symptoms
+increases rapidly.</p>
+
+<p><span class="smcap">There</span> is no difficulty in discovering in this case
+an organic disease of the heart, which probably consists
+in an enlargement and thickening of the heart,
+and an ossification of the semilunar valves of the
+aorta.</p>
+
+
+<h3><a name="CASE_X" id="CASE_X"></a>CASE X.</h3>
+
+<p><span class="smcap">Levi Brown</span>, a cabinet-maker, forty-eight years
+of age, complained in February, 1809, of great difficulty
+of breathing, and an indescribable sensation in
+the chest, which he said was sometimes very distressing,
+and at other times quitted him entirely.
+Being a man of an active mind, he had read some
+medical books, whence he got an idea, that he was
+hypochondriac.</p>
+
+<p><span class="smcap">On</span> examining his pulse, it was found to be occasionally
+intermittent, contracted, and vibrating. He
+had some years previously been attacked with copious
+h&aelig;morrhages from the stomach or lungs, which
+have occasionally recurred, though they have lately
+been less frequent. Eight years since he suffered
+from an inflammation of the lungs; and about two
+or three years ago he first experienced a beating in
+the chest, and pain in the region of the heart, which<span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span>
+increased till within six or eight months, since
+which the beating has been stationary, and the pain
+has much increased. In the course of the last summer,
+dyspn&#339;a, on using exercise, and especially
+ascending any eminence, commenced. This has
+greatly increased, so as to render it almost impossible
+for him to go up stairs. His countenance is
+turgid, and uniformly suffused with blood; his eyes
+are bright and animated; his lips livid. The pulsation
+of the heart cannot be felt on the left side, and
+is barely perceptible on the right side of the sternum,
+and in the epigastric region. When he is distressed
+with fits of dyspn&#339;a, he feels something as
+if rising to the upper part of the thorax, and the
+heart then seems to him to be beating through the
+ribs. I have not witnessed any of these paroxysms.
+The inferior extremities and abdomen have been
+swelled about three weeks. When in bed, he has
+his head and shoulders elevated, and, upon the attack
+of his paroxysms, sits up and inclines his head
+forward; but he keeps from the bed as much as
+possible. In his sleep he is apt to start up, suddenly,
+in distress, especially when he first slumbers.
+His dreams are often frightful, and, when awake,
+he is affected with reveries, during which, though
+conscious of being awake, strange illusions present
+themselves. At intervals he seems slightly delirious.
+He has a violent cough, with very copious expectoration
+of thick mucus. He often suffers from
+severe head-ache, and the least exercise produces
+dizziness.<span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span></p>
+
+<p><span class="smcap">This</span> man has a very robust frame of body, and
+has been accustomed to a free use of ardent spirits,
+and of opium, of which he now takes about twelve
+grains in a day. His appearance is such, that, on a
+slight survey, one would not suppose him diseased,
+but, on observing him with a little attention, a shortness
+and labour of respiration are perceived, with
+some interruption in speaking, and a frequent catching
+of the breath, or sighing.</p>
+
+<p><span class="smcap">April.</span> Since writing the above account, the
+dropsical collections were absorbed, and the palpitations
+and other symptoms moderated, so that he
+considered himself nearly well, and attended to his
+usual business. Within a few days, however, the
+symptoms have returned with more violence. The
+dyspn&#339;a is at times very distressing; the pulse
+more irregular and intermittent; the palpitations
+are more constant. His sufferings from lying in bed
+are so increased, that in the most comfortable nights
+he passes, he sits up once in an hour or two. The
+appetite is keen. The legs begin to swell again.</p>
+
+<p style="padding-bottom: 1em"><span class="smcap">Some</span> organic disease of the heart exists in this
+case. The indistinctness of the palpitations, the
+want of hardness in the pulse, and the slow progress
+of the disease, indicate a loss of power in the heart,
+the effect of the distention and thinness of its parietes.
+The irregularity of the pulse affords some
+reason to suspect disorder of the aortal valves, which
+is not yet very considerable.<span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span></p>
+
+
+<div class="blockquot">
+<p>ENUMERATION <i>of the principal morbid changes, observed in the organization
+of the heart, in the preceding cases</i>.</p>
+</div>
+
+<table summary="enumeration">
+
+<tr><td>Enlargement of the volume of the heart, or aneurism.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></td><td>&nbsp;</td></tr>
+<tr><td>Increase of the capacity, or aneurism of the right auricle,<br />
+<span style="padding-left: 14em">of the right ventricle,</span><br />
+<span style="padding-left: 14em">of the left auricle</span><br />
+<span style="padding-left: 14em">of the left ventricle,</span><br />
+<span style="padding-left: 14em">of the aorta, with thickening of its coats.</span></td>
+<td>with thickened, or thin, parietes.</td></tr>
+
+<tr><td>Fleshlike<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a> thickening of the mitral valves.<br />
+<span style="padding-left: 9.2em">of the aortal valves.</span><br />
+<span style="padding-left: 9.2em">of the aorta.</span></td></tr>
+
+<tr><td>Cartilaginous thickening of the internal membrane of the heart, and generally
+of its valves.</td></tr>
+
+<tr><td>Ossification of the parietes of the heart.<br />
+<span style="padding-left: 7em">mitral valves.</span><br />
+<span style="padding-left: 7em">aortal valves.</span><br />
+<span style="padding-left: 7em">aorta.</span><br />
+<span style="padding-left: 7em">coronary arteries.</span></td></tr>
+</table>
+
+<hr />
+
+<div class="blockquot">
+<p>ENUMERATION <i>of the principal morbid appearances, observed in these
+cases of disease of the heart, which may be considered secondary</i>.</p>
+</div>
+
+<ul style="line-height: 150%">
+<li style="padding-left: 4em; font-size: 90%">IN THE CAVITY OF THE CRANIUM.</li>
+
+<li>Inflammation of the meninges.</li>
+<li>Water between the meninges.</li>
+<li>Water in the ventricles.</li>
+
+<li style="padding-left: 4em; font-size: 90%; padding-top: 0.5em">IN THE PLEURA AND ITS CAVITY.</li>
+
+<li>Inflammation and thickening of the pleura.</li>
+<li>Collection of water in its cavity.</li>
+<li>Lungs dark coloured.</li>
+<li style="padding-left: 2.5em">generally very firm, and particularly in some parts.</li>
+<li style="padding-left: 2.5em">loaded with black blood.</li>
+<li style="padding-left: 2.5em">crowded into a narrow space.</li>
+
+<li style="padding-left: 4em; font-size: 90%; padding-top: 0.5em">IN THE PERICARDIUM AND ITS CAVITY.</li>
+
+<li>Inflammation and thickening of its substance.</li>
+<li>Adhesion to the heart and lungs.</li>
+<li>Collection of water in its cavity.</li>
+
+<li style="padding-left: 4em; font-size: 90%; padding-top: 0.5em">IN THE CAVITY OF THE ABDOMEN.</li>
+
+<li>Collection of water.</li>
+<li>Liver very full of fluid blood.</li>
+<li style="padding-left: 2.2em">having its tunic flaccid and inflamed.</li>
+<li>Mesenteric veins full of blood.</li>
+
+<li style="padding-top: 0.5em"><span style="font-size: 90%">CELLULAR MEMBRANE</span> full of water.</li>
+
+<li><span style="font-size: 90%">THE BLOOD</span> every where fluid, except in the cavities of the heart.</li>
+</ul>
+
+
+
+<h4>REMARKS.<span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span></h4>
+
+<p><span class="smcap">The</span> symptoms, which are most observable, in
+some or all of the preceding cases, are the following:</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">After</span> 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 dyspn&#339;a
+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<span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span>
+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 dyspn&#339;a 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 dyspn&#339;a 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.</p>
+
+<p><span class="smcap">The</span> changes in the ph&#339;nomena 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 dyspn&#339;a, when it becomes
+livid; and it is very frequently puffed, or turgid.
+The brightness of the eyes, dizziness, which is a<span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span>
+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.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span>
+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 h&aelig;morrhoidal
+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.</p>
+
+<p><span class="smcap">Dropsical</span> 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&#8217;s
+death.</p>
+
+<p><span class="smcap">There</span> 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<span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span>
+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 dyspn&#339;a becomes excessive;
+the pain and stricture about the pr&aelig;cordia are insupportable;
+a furious delirium sometimes succeeds;
+and the patient expires in terrible agony.</p>
+
+<p><span class="smcap">Such</span> are the symptoms, which a limited experience
+has enabled me to witness. Others, equally
+characteristic of the disease, may probably exist.</p>
+
+<p><span class="smcap">From</span> 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.</p>
+
+<p><span class="smcap">The</span> cough in hydrothorax, unlike that which
+attends organic diseases of the heart, is short and
+dry; the dyspn&#339;a 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<span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span>
+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.</p>
+
+<p><span class="smcap">It</span> 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?</p>
+
+<p><span class="smcap">Idiopathic dropsy</span> 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 <a href="#CASE_IV">fourth case</a>, a remarkable
+disposition to syncope, on movement, distinguished
+the latter periods of the disease, and might<span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>
+have arisen from the great collection of water in the
+pericardial sac.</p>
+
+<p><span class="smcap">The</span> 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<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a>,
+excessive debauch, and the habitual use of highly
+stimulating liquors, are among them.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">Although</span> 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
+<span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span>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 dyspn&#339;a.
+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<span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span>
+cautiously avoided, and the repose of body and mind
+preserved, as much as possible.</p>
+
+<p><span class="smcap">The</span> causes of some of the ph&#339;nomena 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.</p>
+
+<hr />
+
+<p><span class="smcap">At</span> the time the preceding pages were going to the
+press, the subjects of the <a href="#CASE_IX">ninth</a> and <a href="#CASE_X">tenth</a> cases died,
+on the same day, and an opportunity was given of
+ascertaining whether their complaints had been
+rightly distinguished.</p>
+
+<p><span class="smcap">It</span> 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.</p>
+
+
+<h4>DISSECTION OF CASE NINTH.<br />
+<small>THIRTY HOURS AFTER DEATH.</small></h4>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span>
+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.</p>
+
+<p><span class="smcap">We</span> found the body somewhat emaciated, and
+the lower extremities and left arm &#339;dematous.
+Might not this swelling of the left arm have depended
+on her constant posture of inclining to her left
+side?</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>
+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 dyspn&#339;a, 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.</p>
+
+<p><span class="smcap">This</span> 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<span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>
+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.</p>
+
+<p><span class="smcap">On</span> 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<span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>
+other parts, and rather small, compared to the size
+of the heart.</p>
+
+<p><span class="smcap">It</span> 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 <a href="#CASE_VI">sixth case</a> 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 <a href="#CASE_IV">fourth case</a> 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 <a href="#CASE_VII">seventh case</a>, where the pulse was
+not irregular, the valves of the aorta were &#8220;considerably
+thickened in various spots;&#8221; 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:<span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span>
+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.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+
+<h4>DISSECTION OF CASE TENTH.<br />
+<small>TWENTY-FOUR HOURS AFTER DEATH</small>.</h4>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span>
+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.</p>
+
+<p><span class="smcap">A number</span> 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<span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span>
+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.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>
+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 ven&aelig; cav&aelig; 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.</p>
+
+<p><span class="smcap">Why</span> 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<span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span>
+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.</p>
+
+<p><span class="smcap">An</span> 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
+ph&#339;nomena, as would satisfy the most scrupulous
+anatomist.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span>
+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.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span>
+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 column&aelig; approximate,
+till their sides are in contact, to protect the
+parietes of the heart; but, if these be distended, the
+column&aelig; 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 <i><a href="#CASE_I">case the first</a></i>, and others; and, if the mitral
+valves be thickened and rigid, the left auricle will<span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>
+be more dilated than in a case of simple aneurism of
+the left ventricle, as appeared also in the <i><a href="#CASE_I">first case</a></i>.</p>
+
+<p><span class="smcap">The</span> 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?</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">The</span> cause of this ph&#339;nomenon can easily be
+explained. If an obstruction exist in either side of
+the heart, or in the lungs, the blood to be poured<span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span>
+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 h&aelig;morrhoidal 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 h&aelig;morrhoidals must consequently
+be also affected, and they easily burst
+open from too great distention. The h&aelig;moptoe,
+which also is so frequent, is as easily explained on
+the same principle.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span>
+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.</p>
+
+<p><span class="smcap">That</span> 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.</p>
+
+<p><span class="smcap">The</span> examinations of the <i><a href="#CASE_IX">ninth</a></i> and <i><a href="#CASE_X">tenth</a> cases</i>
+are particularly valuable, because they confirm what
+had been observed in other subjects; they exhibit<span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span>
+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 <i><a href="#CASE_X">case tenth</a></i>.</p>
+
+<p><span class="smcap">Dr. William Hamilton</span>, 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, &#8220;the
+patient can lie down with ease, and seldom experiences
+much difficulty of breathing.&#8221; 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&#8217;s
+&#8220;observations,&#8221; and by that which may be drawn
+from these cases, and future investigations of the
+subject. It will perhaps hereafter appear surprising,<span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span>
+that derangements in the structure of so important
+an organ as the heart should have been lightly estimated
+by very respectable authors.</p>
+
+<hr />
+
+<p><span class="smcap">While</span> 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.&nbsp;C. Howard.</p>
+
+<p><span class="smcap">A lady</span> 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<span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span>
+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 dyspn&#339;a 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 h&aelig;morrhoidal 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.</p>
+
+<p><span class="smcap">The</span> 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<span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>
+with dizziness, and frequent and intense pain, and
+is seen to be shaken by the palpitations.</p>
+
+<p><span class="smcap">The</span> 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.</p>
+
+<p><span class="smcap">This</span> 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
+dyspn&#339;a 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.</p>
+
+<p><span class="smcap">This</span> lady is still corpulent. She has taken much
+medicine, under the direction of eminent physicians,
+sometimes with temporary relief, but most commonly<span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>
+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.</p>
+
+
+<h3>CASE OF HYDROTHORAX.</h3>
+
+<div class="blockquot"><p><span class="smcap">The</span> following case of hydrothorax will shew, that
+water may exist in the chest without the symptoms,
+which we have attributed to organic diseases
+of the heart.</p></div>
+
+<p><span class="smcap">Mrs.</span> T&mdash;&mdash;, aged 56 years, of an excessively
+corpulent habit, had been affected for a great number
+of years with a scirrhus of the right breast.
+Finding her health decline, she at last disclosed it,
+and in coincidence with the opinion of Dr. <span class="smcap">Warren</span>,
+sen. I amputated it on the 30th of May, of the
+present year. We however informed her friends,
+that the probability of eradicating the disease was
+extremely small. The skin was in many places
+hardened and drawn in, and in others discoloured,
+and ulcerated at the nipple, so that it was found necessary
+to remove, not only what covered the breast, but
+some portion of that which surrounded it. A long<span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>
+chain of diseased glands, extending quite to the axillary
+vessels, was also extirpated. She bore the
+operation well, lost no great quantity of blood, and
+recovered her appetite and strength surprisingly in
+a few days, while the wound healed rapidly. At
+the end of twenty days a difficulty of breathing
+commenced, and soon became so oppressive, that
+she could no longer lie in bed; partly, no doubt, on
+account of her extraordinary obesity. The pulse
+was small, quick, and commonly feeble, but sometimes
+a little hard, when any degree of fever was
+present. The countenance became pale, the lips of
+a leaden hue, the eyes dim. We were surprised at
+the change, and conjectured that the cancerous action
+had suddenly extended to the lungs. Yet she
+had not the slightest cough; and it was remarked by
+Dr. <span class="smcap">Warren</span>, sen. that he had never observed
+that diseased action to increase, while the wound
+remained open. At last the lower extremities
+swelled, which might be attributed to the upright
+posture, and the pressure on the absorbent vessels
+in that posture. The appetite failed; she complained
+of a constant sense of depression at the stomach, and,
+without any remission of the difficulty of breathing,
+died on the 1st of July.</p>
+
+<p><span class="smcap">On</span> the next morning the body was examined.
+The pleura in both cavities of the thorax was studded
+with small, white, and apparently homogeneous
+tubercles; the lungs contained a great number of
+similar bodies. The right cavity of the pleura was
+entirely filled with water, of which we removed at<span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>
+least three quarts. The heart was of the usual size,
+very flaccid and tender; but not otherwise disordered.
+The liver was enlarged, of its usual colour,
+much hardened, and had on its surface, and in its
+substance, many tubercles like those in the thorax.
+It had also a great number of encysted cavities,
+each about the size of a hazle nut, which contained
+a thin yellow fluid. The gall bladder was wanting,
+and in its place there was a small, but very
+remarkable depression, without a vestige of any former
+gall bladder, for the coat of the liver was as
+smooth and perfect there as in any other part<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a>.
+The pancreas was in a scirrhous state. The abdomen
+did not contain any water.</p>
+
+<p><span class="smcap">It</span> seems, then, that water may exist in the cavity
+of the thorax, without any remarkable symptoms,
+except dyspn&#339;a and difficulty in assuming the horizontal
+posture. But in organic diseases of the
+heart, there is a long train of frightful symptoms,
+distinguishable by the most superficial observers.
+We infer that these disorders have been unnecessarily
+confounded.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> A careful examination of the works of some of the most eminent
+English practical writers does not afford evidence of any clear distinction
+of these diseases of the heart. Dr. Cullen, whose authority is of
+the highest estimation, evidently enumerates symptoms of them in his
+definition and description of the hydrothorax. In &sect; 1702 Th. and Pr.
+he places much confidence on a particular sign of water in the chest,
+and remarks, that the same sign is not produced by the presence of
+pus. Now, there is no sufficient reason, why this symptom should not
+arise from the presence of pus, as well as from that of water; but it
+probably can depend on neither of those alone. See Morgagni de causis
+et sedibus morborum, Epist. 16. art. 11. The experienced Heberden
+says in the chapter &#8220;De palpitatione cordis,&#8221; &#8220;Hic affectus manifesta
+cognitione conjunctus est cum istis morbis, qui existimantur <i>nervorum
+proprii esse</i>, quique <i>sanguinis missione augentur</i>; hoc igitur remedium
+plerumque omittendum est.&#8221;&mdash;&#8220;Ubi remediis locus est, ex sunt adhibenda,
+qu&aelig; conveniunt <i>affectibus hypochondriacis</i>.&#8221;
+</p><p>
+Dr. Baillie&#8217;s knowledge of morbid anatomy has enabled him to make
+nearer approaches to truth; yet it will probably be found, when this
+subject shall be fully understood, that his descriptions of the symptoms
+of diseases of the heart and of hydrothorax are not quite accurate,
+and, that with respect to the former, they are very imperfect.
+</p><p>
+Some of the French physicians have devoted much attention to this
+subject; especially M. Corvisart, professor in the hospital of La Charite,
+at Paris, from whose clinical lectures is derived the most important
+information.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> 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.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> 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, dyspn&#339;a and palpitations.
+Thus in the case related above, and in some others, the pulse
+became regular, the palpitations subsided, and the dyspn&#339;a was less
+observable. The cases of that accurate anatomist, therefore, are not
+so contradictory of those related here, as might at first be imagined.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Governour Sullivan was born December 4th, 1744, and died December
+10th, 1809.</p></div>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> The symptoms of this patient were related by Dr. Rand, sen. to
+whose politeness and love of medical improvement I am indebted for
+the opportunity of examining this and the following case.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> The symptoms of this case were related to me by Dr. Rand, sen.</p></div>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> See plate first.</p></div>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> The symptoms in this case were related to me by Dr. Warren, sen.</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> This dissection was performed by Dr. Gorham.</p></div>
+
+<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> See plate second.</p></div>
+
+<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> In this case, and in <a href="#CASE_I">case first</a>, the vena cava ascendens had been
+divided, before the brain was examined.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> Morgagni uses this term, which he borrows from Ambrose Pare, to express dilatation of
+the cavities of the heart. It seems to be as applicable to the dilatation of the heart, as to
+that of an artery. I have therefore adopted it in this enumeration.</p></div>
+
+<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> The term fleshlike is employed to express that roughness of the valves, which somewhat
+resembles flesh in its appearance, but which is very different from the thickening of the
+parietes of the heart.</p></div>
+
+<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> 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.</p></div>
+
+<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> See Soemmerring de corporis humani fabrica, vol. 6, pag. 188 and
+Baillie&#8217;s morbid anatomy, pag. 248.</p></div>
+
+</div>
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by 
+John Collins Warren
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+The Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by
+John Collins Warren
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Cases of Organic Diseases of the Heart
+
+Author: John Collins Warren
+
+Release Date: October 7, 2008 [EBook #26836]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE ***
+
+
+
+
+Produced by Bryan Ness, Irma Spehar and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+                                CASES
+                                  OF
+                           ORGANIC DISEASES
+                                OF THE
+                                HEART.
+
+      WITH DISSECTIONS AND SOME REMARKS INTENDED TO POINT OUT THE
+                DISTINCTIVE SYMPTOMS OF THESE DISEASES.
+
+
+                      READ BEFORE THE COUNSELLORS
+                 OF THE MASSACHUSETTS MEDICAL SOCIETY.
+
+
+                       BY JOHN C. WARREN, M. D.
+
+
+                                BOSTON:
+                PRINTED BY THOMAS R. WAIT AND COMPANY.
+                             COURT-STREET.
+                                 1809.
+
+
+
+
+                               PLATE I.
+
+Appearance of the valves of the aorta in Case 3d, Article 10.
+
+_a a_ The two valves thickened.
+
+_b b_ Bony projections, one of which extends across the cavity of the
+valve.
+
+_c_ The orifices of the coronary arteries.
+
+_d d_ Fleshlike thickening of the aorta.
+
+                               PLATE II.
+
+Is a representation of the fleshlike thickening of the aorta in case
+7th. The valves are smaller than usual, and their form is in some
+degree changed. A round spot, thickened, is seen at a little distance
+from the seat of the principal disease.
+
+[Illustration]
+
+[Illustration]
+
+
+
+
+                               CASES OF
+                    ORGANIC DISEASES OF THE HEART,
+                           WITH DISSECTIONS.
+
+
+Morbid changes in the organization of the heart are so frequent, as to
+have attracted the observation of those, who have devoted any
+attention to the study of morbid anatomy. Derangements of the primary
+organ of the circulation cannot exist without producing so great
+disorder of the functions of that and of other parts, as to be
+sufficiently conspicuous by external signs; but, as these somewhat
+resemble the symptoms of different complaints, especially of asthma,
+phthisis pulmonalis, and water in the thorax, it has happened, that
+each of these has been sometimes confounded with the former[1]. The
+object of the following statement of cases is to shew, that, whatever
+resemblance there may be in the symptoms of the first, when taken
+separately, to those of the latter diseases, the mode of connection
+and degree of those symptoms at least is quite dissimilar; and that
+there are also symptoms, peculiar to organic diseases of the heart,
+sufficiently characteristic to distinguish them from other complaints.
+
+    [Footnote 1: A careful examination of the works of some of
+    the most eminent English practical writers does not afford
+    evidence of any clear distinction of these diseases of the
+    heart. Dr. Cullen, whose authority is of the highest
+    estimation, evidently enumerates symptoms of them in his
+    definition and description of the hydrothorax. In Sec. 1702 Th.
+    and Pr. he places much confidence on a particular sign of
+    water in the chest, and remarks, that the same sign is not
+    produced by the presence of pus. Now, there is no sufficient
+    reason, why this symptom should not arise from the presence
+    of pus, as well as from that of water; but it probably can
+    depend on neither of those alone. See Morgagni de causis et
+    sedibus morborum, Epist. 16. art. 11. The experienced
+    Heberden says in the chapter "De palpitatione cordis," "Hic
+    affectus manifesta cognitione conjunctus est cum istis
+    morbis, qui existimantur _nervorum proprii esse_, quique
+    _sanguinis missione augentur_; hoc igitur remedium plerumque
+    omittendum est."--"Ubi remediis locus est, ex sunt adhibenda,
+    quae conveniunt _affectibus hypochondriacis_."
+
+    Dr. Baillie's knowledge of morbid anatomy has enabled him to
+    make nearer approaches to truth; yet it will probably be
+    found, when this subject shall be fully understood, that his
+    descriptions of the symptoms of diseases of the heart and of
+    hydrothorax are not quite accurate, and, that with respect to
+    the former, they are very imperfect.
+
+    Some of the French physicians have devoted much attention to
+    this subject; especially M. Corvisart, professor in the
+    hospital of La Charite, at Paris, from whose clinical
+    lectures is derived the most important information.]
+
+
+                                CASE I.
+
+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.]
+
+
+                  DISSECTION, NINE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The whole body was much emaciated; the face pale and contracted. The
+hands were slightly oedematous. Discolourations, answering to the
+ribs, were observed on the thorax; many small purple spots, hard and
+prominent, on the back; excoriations on the nates; and purple spots,
+resembling incipient mortification, on the heel and toe.
+
+
+                                THORAX.
+
+The integuments of the thorax were free from fat: the cartilages of
+the ribs ossified in various degrees, some perfectly, others slightly.
+Upon laying open the cavity of the thorax, it was found to contain
+about three pints of water, the proportion being greatest on the left
+side.
+
+The lungs were contracted into a smaller compass than usual, and were
+very firm to the touch. Their colour anteriorly was whitish, with
+small distinct purple spots; posteriorly, of a deep red, with similar
+spots. The right lobe adhered closely to the pericardium; it also
+adhered to the pleura costalis, by a great number of strong cords,
+which seemed to be elongations of the original adhesions. Some of them
+were nearly as hard as ligament, and many an inch in length.
+Internally the lungs presented a very compact structure. Their cells
+were crowded with mucus, and their vessels filled with black blood,
+partly fluid, and partly coagulated. Some portions were firmer and
+more condensed than others, but no tubercles were discovered.
+
+The pericardium, viewed externally, appeared very large, and occupied
+almost the whole space behind the opening formed by removing the
+sternum and cartilages of the ribs. It was situated principally on the
+left side, and contained about double the usual quantity of water; but
+was principally filled by the enlarged heart, to which it adhered
+anteriorly about two inches, near its base. Its parietes were, in
+every part, very much thickened and hardened.
+
+The heart presented nearly its usual colour and form, excepting on its
+anterior surface, which was somewhat discoloured by coagulated lymph.
+It was enlarged in bulk to, at least, one half more than the healthy
+size. The auricles and ventricles contained coagulated blood. The
+tricuspid valves were in a sound state. The left auricle was double
+the usual size. The left ventricle was enlarged, about three times
+thicker and much firmer than usual. The mitral valves were very much
+thickened, and near the insertion of their columnae, which were sound,
+cartilaginous, so that they were quite rigid, and the opening made by
+them, from the auricle to the ventricle, was scarcely large enough to
+admit the passage of a finger. The semilunar valves of the aorta were
+ossified at their bases and apices, and the portion intermediate,
+between the base and apex, partly ossified, and partly cartilaginous,
+so as to render the valves very rigid. The aorta was at least one half
+larger than usual, especially at its arch. The arteria innominata, the
+carotid, and subclavian arteries, were uncommonly large and thick. The
+coronary arteries were considerably ossified.
+
+
+                               ABDOMEN.
+
+The omentum was destitute of fat. The stomach distended with flatus on
+the pyloric side; its cardiac extremity, lying under the liver, was
+pressed down and contracted. The liver was shrunk; its tunic
+corrugated, as if it had been distended, and bearing marks of
+inflammation; its substance harder than usual; its vessels, when
+divided, pouring out liquid black blood. The gall bladder was filled
+with bile. The kidneys were thicker, and more irregular in form, than
+is common. The abdominal cavity contained some water.
+
+
+                                 HEAD.
+
+The bones of the cranium were unusually thick. The dura mater, which
+was thickened, and in many places bore marks of former inflammation,
+adhered to the bone at the vertex. On its internal surface, near the
+longitudinal sinus, there was a small ossified portion, half an inch
+long and the eighth of an inch thick. The convolutions of the brain
+were narrow, and very strongly marked. The pia mater bore marks of
+pretty extensive inflammation, and adhered to the dura mater at the
+vertex. The cortical substance ran deep into the medullary part of
+the brain. The ventricles contained about double the usual quantity of
+water; their parts were all remarkably well defined. The vessels of
+the pia mater, over the corpora striata, were unusually injected with
+blood. The velum interpositum was very firm; the plexus choroides
+uncommonly thick, but pale; the opening from the right to the left
+ventricle large. The vessels of the brain were generally not much
+filled with blood.
+
+The blood appeared every where fluid, except in some portions of the
+lungs, and in the cavities of the heart. It was very dark coloured,
+perhaps more than ordinarily thin, and oozed from every part, which
+was cut.
+
+The cellular membrane, in all dependent parts, effused, when cut, a
+serous fluid.
+
+
+                               CASE II.
+
+Mr. John Jackson, fifty-two years of age, had been affected for more
+than two years with palpitations of the heart, and paroxysms of
+dyspnoea. These symptoms increased in October, 1808, and were followed
+by strong cough, uneasiness in lying down, sudden startings in sleep,
+and an inclination to bend the body forward and to the left side. His
+cough, during the last part of his life, was attended with copious
+bloody expectoration. His countenance was florid; his pulse very
+irregular, though not quite intermittent. The occasional variations in
+the state of the disease were remarkable. Some periods were marked
+with uncommon mental irritability. Pain in the region of the liver,
+oedema of the inferior extremities, paucity and turbidness of the
+urine, yellowness of the skin, and great emaciation attended the
+latter stages of the disease. A degree of stupor occurred. The
+termination on the 30th of January, 1809, was tolerably quiet. Two
+days before death he sank into the recumbent posture, and his pulse
+became more regular[5].
+
+    [Footnote 5: The symptoms of this patient were related by Dr.
+    Rand, sen. to whose politeness and love of medical
+    improvement I am indebted for the opportunity of examining
+    this and the following case.]
+
+
+                              DISSECTION,
+                    TWENTY-FOUR HOURS AFTER DEATH.
+
+On opening the thorax, its right cavity was found to contain a large
+quantity of water; the left, a smaller quantity.
+
+The lungs were of a firm, condensed texture, especially at the lower
+part, where their solidity was nearly equal to that of a healthy
+liver. They contained black blood.
+
+The heart was much enlarged, and proportionally thickened. Its tunic
+was in some places covered with coagulated lymph, especially over the
+coronary arteries. Its cavities were filled with black coagulum, which
+in the right auricle and ventricle had a slight appearance of polypus.
+The semilunar valves of the pulmonary artery and aorta were unusually
+small, and their bases cartilaginous. Those of the aorta had lost
+their form, and were slightly ossified. The remaining valves were
+partially thickened. The arch of the aorta was very much dilated, its
+internal coat covered with a bony crust, which extended through the
+remaining thoracic portion, gradually diminishing. This portion was
+also considerably dilated.
+
+The liver was indurated; its peritonaeal coat exhibited a flaccid or
+wrinkled appearance, and bore marks of slight inflammation. The gall
+bladder was filled with bile, and the pancreas indurated.
+
+
+                               CASE III.
+
+Captain Job Jackson, forty-five years of age, a man of vigorous
+constitution, after an indisposition of some years continuance, was
+seized with palpitations of the heart and dyspnoea, occurring by
+variable paroxysms, especially on ascending an eminence, and attended
+by hardness, irregularity, and intermission of the pulse. To these
+symptoms were superadded dizziness and severe head-ache, a disposition
+to bend the body forward, sudden starting from sleep, with dread of
+suffocation, violent cough with copious expectoration, which for
+fifteen days before death consisted of black blood, distressing pain
+across the chest, especially on the left side, great oedema of the
+lower extremities, and paucity of urine.
+
+He died painfully in January, 1809, after violent struggles for
+breath. The day before death the pulse became regular. He rested his
+head upon an attendant, and made no attempts to lie down for some
+days previous[6].
+
+    [Footnote 6: The symptoms of this case were related to me by
+    Dr. Rand, sen.]
+
+
+                              DISSECTION,
+                      SIXTEEN HOURS AFTER DEATH.
+
+The skin was of a yellow colour. The inferior extremities, quite to
+the groins, were oedematous.
+
+The left cavity of the thorax was filled with water; the right
+contained only a small quantity. The pleura costalis, on the left side
+opposite to the heart, was thickened and covered with a very thick
+flocculent coat of coagulated lymph, and the pericardium opposite to
+it had the same marks of inflammation. The lungs on that side were
+pushed up into a narrow space. They were dense and dark coloured.
+
+The pericardium contained little more than the usual quantity of
+water. The heart, which exhibited marks of some inflammation on its
+surface, was astonishingly large, and firm in proportion. Its cavities
+were principally filled with coagulum. The semilunar valves of the
+pulmonary artery had their bases slightly ossified, and the remaining
+part thickened. There were only two valves of the aorta, and these
+were disorganized by the deposition of ossific matter about their
+bases, and a fleshlike thickening of the other part[7]. The parietes
+of the heart, especially of the left ventricle, were greatly
+thickened, and somewhat ossified near the origin of the aorta.
+
+    [Footnote 7: See plate first.]
+
+The liver had the same appearance as in case second.
+
+
+                               CASE IV.
+
+Thomas Appleton, thirty-eight years of age, of a robust constitution,
+was affected with excessive difficulty of breathing, occurring at
+intervals of different duration. It commenced three years before his
+death, and gradually increased. He was subject to palpitations of the
+heart for at least two years before his death, and was distressed with
+violent cough, attended with copious expectoration, which finally
+became very bloody. The palpitation and dyspnoea were greatly
+augmented by ascending stairs. His countenance was very florid.
+
+Sometimes he was seized with violent head-ache and dizziness, which,
+as well as the other symptoms, were greatly relieved by venesection.
+About two months before death oedema of the legs appeared, which was
+soon followed by frequent and alarming syncope. His pulse was
+irregular, intermittent, hard, and vibrating. When lying down he
+frequently awoke, and started up in great terror. His usual posture
+was that of sitting, with his trunk and head bent forward, and
+inclining to the left side. For some time before death a recumbent
+posture threatened immediate suffocation; yet, three days previous to
+the occurrence of that event, he sank back upon the pillow. He was, at
+intervals, so much better as to think himself free from disease.
+Slight delirium preceded his death, which occurred in January,
+1809[8].
+
+    [Footnote 8: The symptoms in this case were related to me by
+    Dr. Warren, sen.]
+
+
+                              DISSECTION,
+                      EIGHTEEN HOURS AFTER DEATH.
+
+The countenance continued florid. The inferior extremities were much
+distended with water, and the cellular membrane abounded in fat.
+
+The right cavity of the pleura contained a moderate quantity of water;
+the left, scarcely any. The lungs were firm, condensed, and dark
+coloured, from venous blood. The pleura, on the left side opposite to
+the pericardium, appeared to have been inflamed, as there was an
+effusion of coagulated lymph on its surface.
+
+The pericardium was much distended with water. The heart, on the
+anterior surface of which were some appearances of inflammation, was
+very much enlarged. Its parietes were thickened; its cavities
+unnaturally large, and filled with black coagulum. Each of the valves
+had lost, in some degree, its usual smoothness, and those of the aorta
+were, in some points, thickened, and partly cartilaginous.
+
+The liver was small, and, when cut, poured out dark blood. Its tunic
+was whitish, opaque, and corrugated.
+
+
+                                CASE V.
+
+A. B. a negro, about thirty-five years of age, had paroxysms of
+dyspnoea and violent cough, attended with oedema of the extremities
+and ascites, violent head-ache, dizziness, brightness of the eyes,
+palpitations of the heart, irregular, intermittent, slow, and soft
+pulse. These symptoms slowly increased, during three or four years, in
+which time the dropsical collections were repeatedly dispersed. He
+gradually and quietly died in the alms-house, in January, 1809.
+
+
+                              DISSECTION.
+
+On dissection, the cavities of the pleura were found to contain a
+considerable quantity of water. The pericardium was filled with water;
+the heart considerably enlarged; its parietes very thin, and its
+cavities, especially the right auricle and ventricle, morbidly
+large[9].
+
+    [Footnote 9: This dissection was performed by Dr. Gorham.]
+
+
+                               CASE VI.
+
+Mrs. M'Clench, a washer-woman, forty-eight years of age, of good
+constitution and regular habits, was attacked, in the summer of 1808,
+with palpitations of the heart and dyspnoea on going up stairs, severe
+head-ache, and discharges of blood from the anus. These symptoms did
+not excite much attention. In the winter of 1808-9, all of them
+increased, except the palpitations. The inferior extremities and
+abdomen became distended with water; the region of the liver painful;
+the skin quite yellow; the pulse was hard, regular, and vibrating; the
+countenance very florid. Violent cough followed, and blood was
+profusely discharged from the lungs. This discharge being suppressed,
+evacuations of blood from the anus ensued, under which she died, in
+March, 1809.
+
+
+                              DISSECTION.
+
+The right cavity of the thorax was filled with water; the left
+contained none. The lungs were sound, but very dense, full of dark
+coloured blood, and, on the right side, pressed into the upper part of
+the thorax. The heart was one half larger than natural; its substance
+firm, and its anterior part, especially near the apex, covered with
+coagulated lymph. The right auricle and ventricle were large, and
+their parietes thin. The parietes of the left auricle and ventricle,
+particularly of the latter, were much thickened, and their cavities
+were filled with black coagulum.
+
+The liver was contracted; its coat wrinkled, and marked with
+appearances of recent inflammation.
+
+
+                               CASE VII.
+
+                       To JOHN C. WARREN, M. D.
+
+MY DEAR SIR,
+
+Your important communication to our society, which is about to be
+published, will lay before the American public much more knowledge
+respecting the diseases of the heart, and large vessels, than has
+hitherto been presented to them. A case has lately fallen under my
+observation, having so much similarity to those of organic diseases of
+the heart, which have occurred to you, as to mark its affinity, yet
+with some differences, which characterize it as a variety. If the
+statement of it will add any value to your collection of cases, you
+are at liberty to publish it.
+
+A. S. twenty-eight years of age, and of middle stature, was attacked,
+after a debauch, with pain in the region of the heart, which subsided,
+but returned a year after on a similar occasion. He then became
+affected with palpitations of the heart for six months, great
+difficulty of breathing, which was augmented by ascending an eminence,
+severe cough, dizziness, and violent head-ache, attended by a
+disposition to bend the body forward, and sudden startings from sleep.
+His pulse was always regular, and never remarkably hard. His
+countenance, till within a few weeks of death, presented the
+appearance of blooming health. His feet and legs did not swell at any
+period of the disease. He suffered exceedingly from flatulence, to
+which he was disposed to attribute all his complaints. This symptom
+might have been aggravated by his habits of free living, and
+occasional intoxication, which he acknowledged, and to which he traced
+the origin of his disease.
+
+After death, water was discovered in the thorax; but the lungs had not
+that appearance of accumulation of blood, in particular spots, which
+is commonly observed in cases of organic disease of the heart. The
+only very remarkable morbid appearance about the heart was in the
+aorta, and its valves. The valves had lost their transparency, and
+were considerably thickened in various spots. The inner surface of
+the aorta, for about an inch from its commencement, was elevated and
+thickened, and the external surface singularly roughened and
+verrucated. This appearance was so peculiar, that no words will give a
+competent idea of it, and perhaps it would be sufficient for me to
+call it a chronic inflammation[10].
+
+                              I am, my dear sir,
+                                  Your friend and obedient servant,
+                                                         JAMES JACKSON.
+
+    [Footnote 10: See plate second.]
+
+
+                              CASE VIII.
+
+Col. William Scollay, aged fifty-two, of a plethoric habit of body,
+was attacked, in the year 1805, with dyspnoea and palpitation of the
+heart, attended with irregularity of the pulse, and oedema of the
+lower extremities. By the aid of medicine, the dropsical collections
+were absorbed, and he recovered his health, so far as to follow his
+usual occupations, nearly a year; but was then compelled to relinquish
+them. The symptoms afterwards underwent various aggravations and
+remissions, till the beginning of the winter of 1808-9, when the
+attacks became so violent, as to confine him to the house. His face
+was then high coloured. The faculties of his mind were much impaired.
+The dyspnoea became more constant, and was occasionally attended by
+cough; the palpitations rather lessened in violence; the pulse was
+more irregular, and exceedingly intermittent. The abdomen and inferior
+extremities were sometimes enormously distended with water, and
+afterwards subsided nearly to their usual size. One of the earliest,
+most frequent, and distressing symptoms, was an intense pain in the
+head. About two months before death, a hemiplegia took place, but
+after a few days disappeared. This so much impaired the operations of
+the mind, that the patient afterwards found great difficulty in
+recollecting words sufficient to form an intelligible sentence. During
+the existence of the last symptom the pulse was regular.
+
+He gradually expired, on the 15th of March, 1809.
+
+
+                  DISSECTION, FIVE HOURS AFTER DEATH.
+
+
+                         EXTERNAL APPEARANCE.
+
+The countenance was somewhat livid and pale; the lips were very livid.
+The chest resounded, when struck, except over the heart. The abdomen
+was tumid, and marked by cicatrices like those of women, who have
+borne children. The superior extremities were emaciated, and marked
+like the abdomen. The lower extremities were oedematous.
+
+
+                                THORAX.
+
+The cartilages of the ribs were ossified. The left cavity of the
+pleura contained about twelve ounces of water; the right, about three
+ounces. The lungs, externally, were dark coloured, especially the
+posterior lobes; internally, they were very firm, and, in some places,
+as dense as the substance of the liver. A frothy mucus was effused
+from them in great quantities. They were coloured by very dark blood,
+especially in the middle portion of the left superior lobe. One or two
+calcareous concretions were observed in them. The pericardium was a
+little firmer than usual, and contained about five ounces of water.
+The heart was enlarged, and covered with tough fat. In the right
+auricle, and ventricle, was some coagulated blood. The tricuspid
+valves had lost their smoothness and transparency; the semilunar
+valves of the pulmonary artery were cartilaginous at their bases. The
+left auricle and ventricle, particularly the first, contained
+coagulum. The mitral valves were roughened by many bony spots.
+Considerable ossification had taken place in the semilunar valves of
+the aorta, so that one of them had quite lost its form; and the aorta
+was ossified for the space of a square inch, at a small distance from
+the valves. The coronary arteries were also ossified.
+
+
+                               ABDOMEN.
+
+The coat of the liver was somewhat wrinkled, as if shrunk. Its
+substance was hard, and discharged, when cut, great quantities of
+blood. The veins of the omentum, mesentery, and intestines, were full
+of blood. The abdomen contained a considerable quantity of water.
+
+
+                                 HEAD.
+
+Water was found between the dura and pia mater, and between the pia
+mater and arachnoides. The vertical portion of the pia mater bore
+marks of former inflammation. The convolutions of the brain were very
+distinct; their external surface was pale. The veins were empty[11].
+No bloody points were observed in the medullary portion of the brain,
+when cut. The ventricles contained between one and two ounces of
+water; the communication between them was very large. The plexus
+choroides was pale.
+
+    [Footnote 11: In this case, and in case first, the vena cava
+    ascendens had been divided, before the brain was examined.]
+
+
+                               CASE IX.
+
+A lady, about forty-five years of age, the mother of many children,
+has been troubled during the course of the past year with violent
+palpitations of the heart, and great difficulty of respiration,
+especially on going up stairs. These complaints have lately increased,
+so that she has kept in her chamber about two months. Her countenance
+is florid; her eyes are clear and bright. She has dizziness,
+especially on moving, without pain in her head. She had for some time,
+a severe cough, which is now relieved. The dyspnoea is not yet very
+distressing, except on using motion; it often occurs in the night, and
+obliges her to rise and sit up in bed. The palpitations are very hard,
+and so strong, that they may be perceived through her clothes; the
+tumult in the thorax is indescribable. The functions of the abdominal
+viscera are unimpaired. The pulse is hard, vibrating, irregular,
+intermittent, very variable, corresponding with the motions of the
+heart, and similar in each arm. There is not yet the slightest reason
+to suspect any dropsical collection. The alternations of ease and
+distress are very remarkable, but on the whole, the violence of the
+symptoms increases rapidly.
+
+There is no difficulty in discovering in this case an organic disease
+of the heart, which probably consists in an enlargement and thickening
+of the heart, and an ossification of the semilunar valves of the
+aorta.
+
+
+                                CASE X.
+
+Levi Brown, a cabinet-maker, forty-eight years of age, complained in
+February, 1809, of great difficulty of breathing, and an indescribable
+sensation in the chest, which he said was sometimes very distressing,
+and at other times quitted him entirely. Being a man of an active
+mind, he had read some medical books, whence he got an idea, that he
+was hypochondriac.
+
+On examining his pulse, it was found to be occasionally intermittent,
+contracted, and vibrating. He had some years previously been attacked
+with copious haemorrhages from the stomach or lungs, which have
+occasionally recurred, though they have lately been less frequent.
+Eight years since he suffered from an inflammation of the lungs; and
+about two or three years ago he first experienced a beating in the
+chest, and pain in the region of the heart, which increased till
+within six or eight months, since which the beating has been
+stationary, and the pain has much increased. In the course of the last
+summer, dyspnoea, on using exercise, and especially ascending any
+eminence, commenced. This has greatly increased, so as to render it
+almost impossible for him to go up stairs. His countenance is turgid,
+and uniformly suffused with blood; his eyes are bright and animated;
+his lips livid. The pulsation of the heart cannot be felt on the left
+side, and is barely perceptible on the right side of the sternum, and
+in the epigastric region. When he is distressed with fits of dyspnoea,
+he feels something as if rising to the upper part of the thorax, and
+the heart then seems to him to be beating through the ribs. I have not
+witnessed any of these paroxysms. The inferior extremities and abdomen
+have been swelled about three weeks. When in bed, he has his head and
+shoulders elevated, and, upon the attack of his paroxysms, sits up and
+inclines his head forward; but he keeps from the bed as much as
+possible. In his sleep he is apt to start up, suddenly, in distress,
+especially when he first slumbers. His dreams are often frightful,
+and, when awake, he is affected with reveries, during which, though
+conscious of being awake, strange illusions present themselves. At
+intervals he seems slightly delirious. He has a violent cough, with
+very copious expectoration of thick mucus. He often suffers from
+severe head-ache, and the least exercise produces dizziness.
+
+This man has a very robust frame of body, and has been accustomed to a
+free use of ardent spirits, and of opium, of which he now takes about
+twelve grains in a day. His appearance is such, that, on a slight
+survey, one would not suppose him diseased, but, on observing him with
+a little attention, a shortness and labour of respiration are
+perceived, with some interruption in speaking, and a frequent catching
+of the breath, or sighing.
+
+April. Since writing the above account, the dropsical collections were
+absorbed, and the palpitations and other symptoms moderated, so that
+he considered himself nearly well, and attended to his usual business.
+Within a few days, however, the symptoms have returned with more
+violence. The dyspnoea is at times very distressing; the pulse more
+irregular and intermittent; the palpitations are more constant. His
+sufferings from lying in bed are so increased, that in the most
+comfortable nights he passes, he sits up once in an hour or two. The
+appetite is keen. The legs begin to swell again.
+
+Some organic disease of the heart exists in this case. The
+indistinctness of the palpitations, the want of hardness in the pulse,
+and the slow progress of the disease, indicate a loss of power in the
+heart, the effect of the distention and thinness of its parietes. The
+irregularity of the pulse affords some reason to suspect disorder of
+the aortal valves, which is not yet very considerable.
+
+
+ENUMERATION _of the principal morbid changes, observed in the organization
+of the heart, in the preceding cases_.
+
+Enlargement of the volume of the heart, or aneurism.[12]
+Increase of the capacity, or aneurism of the right auricle,  } with
+                                      of the right ventricle,} thickened,
+                                      of the left auricle    } or thin,
+                                      of the left ventricle, } parietes.
+                                      of the aorta, with thickening of
+                                         its coats.
+
+Fleshlike[13] thickening of the mitral valves.
+                         of the aortal valves.
+                         of the aorta.
+
+Cartilaginous thickening of the internal membrane of the heart, and
+generally of its valves.
+
+Ossification of the parietes of the heart.
+                    mitral valves.
+                    aortal valves.
+                    aorta.
+                    coronary arteries.
+
+    [Footnote 12: Morgagni uses this term, which he borrows from
+    Ambrose Pare, to express dilatation of the cavities of the
+    heart. It seems to be as applicable to the dilatation of the
+    heart, as to that of an artery. I have therefore adopted it
+    in this enumeration.]
+
+    [Footnote 13: The term fleshlike is employed to express that
+    roughness of the valves, which somewhat resembles flesh in
+    its appearance, but which is very different from the
+    thickening of the parietes of the heart.]
+
+
+ENUMERATION _of the principal morbid appearances, observed in these
+cases of disease of the heart, which may be considered secondary_.
+
+    IN THE CAVITY OF THE CRANIUM.
+
+Inflammation of the meninges.
+Water between the meninges.
+Water in the ventricles.
+
+    IN THE PLEURA AND ITS CAVITY.
+
+Inflammation and thickening of the pleura.
+Collection of water in its cavity.
+Lungs dark coloured.
+      generally very firm, and particularly in some parts.
+      loaded with black blood.
+      crowded into a narrow space.
+
+    IN THE PERICARDIUM AND ITS CAVITY.
+
+Inflammation and thickening of its substance.
+Adhesion to the heart and lungs.
+Collection of water in its cavity.
+
+    IN THE CAVITY OF THE ABDOMEN.
+
+Collection of water.
+Liver very full of fluid blood.
+      having its tunic flaccid and inflamed.
+Mesenteric veins full of blood.
+
+    CELLULAR MEMBRANE full of water.
+
+    THE BLOOD every where fluid, except in the cavities of the heart.
+
+
+                               REMARKS.
+
+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.
+
+
+                         CASE OF HYDROTHORAX.
+
+     The following case of hydrothorax will shew, that water may
+     exist in the chest without the symptoms, which we have
+     attributed to organic diseases of the heart.
+
+Mrs. T----, aged 56 years, of an excessively corpulent habit, had been
+affected for a great number of years with a scirrhus of the right
+breast. Finding her health decline, she at last disclosed it, and in
+coincidence with the opinion of Dr. WARREN, sen. I amputated it on the
+30th of May, of the present year. We however informed her friends,
+that the probability of eradicating the disease was extremely small.
+The skin was in many places hardened and drawn in, and in others
+discoloured, and ulcerated at the nipple, so that it was found
+necessary to remove, not only what covered the breast, but some
+portion of that which surrounded it. A long chain of diseased glands,
+extending quite to the axillary vessels, was also extirpated. She bore
+the operation well, lost no great quantity of blood, and recovered her
+appetite and strength surprisingly in a few days, while the wound
+healed rapidly. At the end of twenty days a difficulty of breathing
+commenced, and soon became so oppressive, that she could no longer lie
+in bed; partly, no doubt, on account of her extraordinary obesity. The
+pulse was small, quick, and commonly feeble, but sometimes a little
+hard, when any degree of fever was present. The countenance became
+pale, the lips of a leaden hue, the eyes dim. We were surprised at the
+change, and conjectured that the cancerous action had suddenly
+extended to the lungs. Yet she had not the slightest cough; and it was
+remarked by Dr. WARREN, sen. that he had never observed that diseased
+action to increase, while the wound remained open. At last the lower
+extremities swelled, which might be attributed to the upright posture,
+and the pressure on the absorbent vessels in that posture. The
+appetite failed; she complained of a constant sense of depression at
+the stomach, and, without any remission of the difficulty of
+breathing, died on the 1st of July.
+
+On the next morning the body was examined. The pleura in both cavities
+of the thorax was studded with small, white, and apparently
+homogeneous tubercles; the lungs contained a great number of similar
+bodies. The right cavity of the pleura was entirely filled with water,
+of which we removed at least three quarts. The heart was of the usual
+size, very flaccid and tender; but not otherwise disordered. The liver
+was enlarged, of its usual colour, much hardened, and had on its
+surface, and in its substance, many tubercles like those in the
+thorax. It had also a great number of encysted cavities, each about
+the size of a hazle nut, which contained a thin yellow fluid. The gall
+bladder was wanting, and in its place there was a small, but very
+remarkable depression, without a vestige of any former gall bladder,
+for the coat of the liver was as smooth and perfect there as in any
+other part[15]. The pancreas was in a scirrhous state. The abdomen did
+not contain any water.
+
+    [Footnote 15: See Soemmerring de corporis humani fabrica,
+    vol. 6, pag. 188 and Baillie's morbid anatomy, pag. 248.]
+
+It seems, then, that water may exist in the cavity of the thorax,
+without any remarkable symptoms, except dyspnoea and difficulty in
+assuming the horizontal posture. But in organic diseases of the heart,
+there is a long train of frightful symptoms, distinguishable by the
+most superficial observers. We infer that these disorders have been
+unnecessarily confounded.
+
+
+
+
+
+End of the Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by
+John Collins Warren
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