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diff --git a/26836-h/26836-h.htm b/26836-h/26836-h.htm new file mode 100644 index 0000000..279de4f --- /dev/null +++ b/26836-h/26836-h.htm @@ -0,0 +1,2730 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> + +<html xmlns="http://www.w3.org/1999/xhtml" lang="en" xml:lang="en"> + <head> + <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" /> + <title> + The Project Gutenberg eBook of Cases of Organic Diseases of the Heart, by John C. Warren + </title> + <style type="text/css"> +/*<![CDATA[ XML blockout */ +<!-- + p {margin-top: .75em; + text-align: justify; + margin-bottom: .75em; + text-indent: 1em; + } + + h1,h2,h3,h4,h5,h6 {text-align: center; /* all headings centered */ + clear: both; + } + + h1 {line-height: 120%;} + + h2 {line-height: 150%; + padding-top: 2em; + padding-bottom: 0.5em;} + + h3 {padding-top: 1em;} + + hr {width: 10%; + margin-top: 1.5em; + margin-bottom: 1.5em; + margin-left: auto; + margin-right: auto; + clear: both; + height: 1px; + border: 0; + background-color: black; + color: black; + } + + table {margin-left: auto; + margin-right: auto; + } + + body{margin-left: 10%; + margin-right: 10%; + } + + p.publisher {margin-top: 4em; + text-align: center; + font-size: smaller; + margin-bottom: 3em; + text-indent: 0em; + } + + p.subtitle {font-size: 80%; + text-align: center; + text-indent: 0em; + padding-top: 2em;} + + p.author {text-align: center; + text-indent: 0em; + font-size: 90%; + padding-top: 2em; + font-weight: bold;} + + div.plate {margin-left: 18%; + margin-right: 18%; + padding-top: 2em; + padding-bottom: 2em;} + + img {border-style: none; + margin-bottom: 1em; + } + + ul {list-style: none; + line-height: 130%; + } + + .pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + right: 1%; + font-size: x-small; + text-align: right; + font-weight: normal; + font-style: normal; + letter-spacing: 0ex; + text-indent: 0em; + } + + a:link {text-decoration: none; + color: #104E8B; + background-color: inherit; + } + + a:visited {text-decoration: none; + color: #8B0000; + background-color: inherit; + } + + a:hover {text-decoration: underline;} + + a:active {text-decoration: underline;} + + .blockquot{margin-left: 20%; + margin-right: 20%; + } + + div.blockquot p {padding-left: 2em; + text-indent: -2em;} + + div.footnotes p {text-indent: 0em;} + + .center {text-align: center; + text-indent: 0em;} + + .right {text-align: right; + margin-right: 10%; + } + + .smcap {font-variant: small-caps; + } + + .figcenter {margin: auto; + text-align: center; + text-indent: 0em; + } + + .footnotes {border: dotted 1px; + padding-bottom: 1em; + margin-top: 4em; + } + + .footnote {margin-left: 10%; + margin-right: 10%; + font-size: smaller; + } + + .footnote .label {position: absolute; + right: 84%; + text-align: right; + } + + .fnanchor { vertical-align: baseline; + font-size: 80%; + position: relative; + top: -.4em; + } + + // --> + /* XML end ]]>*/ + </style> + </head> +<body> + + +<pre> + +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. 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’ 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 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.</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 +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<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 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.</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 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<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 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<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, 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<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 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.</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 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.</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 œdematous.</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 +dyspnœa 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 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<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. 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<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‘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 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. +<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. 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. 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 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 +<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 œdematous.</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 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 +<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 +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<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, +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.<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 +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.</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> </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 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<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 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.</p> + +<p><span class="smcap">The</span> 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<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 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.</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’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 dyspnœa becomes excessive; +the pain and stricture about the præcordia 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 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<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 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<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 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.</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 œdematous. +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 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.</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 “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:<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 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.</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 +phœnomena, 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 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 <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 phœnomenon 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 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.</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, “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,<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. 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 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.</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 +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.</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——, 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 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.</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 § 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 <i>nervorum +proprii esse</i>, quique <i>sanguinis missione augentur</i>; hoc igitur remedium +plerumque omittendum est.”—“Ubi remediis locus est, ex sunt adhibenda, +quæ conveniunt <i>affectibus hypochondriacis</i>.” +</p><p> +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. +</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, 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.</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’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 + +*** END OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE *** + +***** This file should be named 26836-h.htm or 26836-h.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/2/6/8/3/26836/ + +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.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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