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diff --git a/26836.txt b/26836.txt new file mode 100644 index 0000000..2010cc9 --- /dev/null +++ b/26836.txt @@ -0,0 +1,2123 @@ +The Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by +John Collins Warren + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Cases of Organic Diseases of the Heart + +Author: John Collins Warren + +Release Date: October 7, 2008 [EBook #26836] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE *** + + + + +Produced by Bryan Ness, Irma Spehar and the Online +Distributed Proofreading Team at http://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + + + + + CASES + OF + ORGANIC DISEASES + OF THE + HEART. + + WITH DISSECTIONS AND SOME REMARKS INTENDED TO POINT OUT THE + DISTINCTIVE SYMPTOMS OF THESE DISEASES. + + + READ BEFORE THE COUNSELLORS + OF THE MASSACHUSETTS MEDICAL SOCIETY. + + + BY JOHN C. WARREN, M. D. + + + BOSTON: + PRINTED BY THOMAS R. WAIT AND COMPANY. + COURT-STREET. + 1809. + + + + + PLATE I. + +Appearance of the valves of the aorta in Case 3d, Article 10. + +_a a_ The two valves thickened. + +_b b_ Bony projections, one of which extends across the cavity of the +valve. + +_c_ The orifices of the coronary arteries. + +_d d_ Fleshlike thickening of the aorta. + + PLATE II. + +Is a representation of the fleshlike thickening of the aorta in case +7th. The valves are smaller than usual, and their form is in some +degree changed. A round spot, thickened, is seen at a little distance +from the seat of the principal disease. + +[Illustration] + +[Illustration] + + + + + CASES OF + ORGANIC DISEASES OF THE HEART, + WITH DISSECTIONS. + + +Morbid changes in the organization of the heart are so frequent, as to +have attracted the observation of those, who have devoted any +attention to the study of morbid anatomy. Derangements of the primary +organ of the circulation cannot exist without producing so great +disorder of the functions of that and of other parts, as to be +sufficiently conspicuous by external signs; but, as these somewhat +resemble the symptoms of different complaints, especially of asthma, +phthisis pulmonalis, and water in the thorax, it has happened, that +each of these has been sometimes confounded with the former[1]. The +object of the following statement of cases is to shew, that, whatever +resemblance there may be in the symptoms of the first, when taken +separately, to those of the latter diseases, the mode of connection +and degree of those symptoms at least is quite dissimilar; and that +there are also symptoms, peculiar to organic diseases of the heart, +sufficiently characteristic to distinguish them from other complaints. + + [Footnote 1: A careful examination of the works of some of + the most eminent English practical writers does not afford + evidence of any clear distinction of these diseases of the + heart. Dr. Cullen, whose authority is of the highest + estimation, evidently enumerates symptoms of them in his + definition and description of the hydrothorax. In Sec. 1702 Th. + and Pr. he places much confidence on a particular sign of + water in the chest, and remarks, that the same sign is not + produced by the presence of pus. Now, there is no sufficient + reason, why this symptom should not arise from the presence + of pus, as well as from that of water; but it probably can + depend on neither of those alone. See Morgagni de causis et + sedibus morborum, Epist. 16. art. 11. The experienced + Heberden says in the chapter "De palpitatione cordis," "Hic + affectus manifesta cognitione conjunctus est cum istis + morbis, qui existimantur _nervorum proprii esse_, quique + _sanguinis missione augentur_; hoc igitur remedium plerumque + omittendum est."--"Ubi remediis locus est, ex sunt adhibenda, + quae conveniunt _affectibus hypochondriacis_." + + Dr. Baillie's knowledge of morbid anatomy has enabled him to + make nearer approaches to truth; yet it will probably be + found, when this subject shall be fully understood, that his + descriptions of the symptoms of diseases of the heart and of + hydrothorax are not quite accurate, and, that with respect to + the former, they are very imperfect. + + Some of the French physicians have devoted much attention to + this subject; especially M. Corvisart, professor in the + hospital of La Charite, at Paris, from whose clinical + lectures is derived the most important information.] + + + CASE I. + +The symptoms of organic disease of the heart are marked with +extraordinary clearness in the following case. The opportunity for +observing them was very favourable; and there was every incitement to +close observation, which could arise from the important and +interesting character of the patient. These advantages will justify an +uncommon minuteness in the detail of the case; especially, as the most +accurate knowledge of a complaint is obtained from a successive view +of its stages. + +The late Governour of this commonwealth was endowed with most vigorous +powers of mind and body. At the age of sixteen he was attacked with +fits of epilepsy, which first arose from a sudden fright, received on +awaking from sleep in a field, and beholding a large snake erecting +its head over him. As he advanced in life they became more frequent, +and were excited by derangement of the functions of the stomach, often +by affections of the mind, by dreams, and even by the sight of the +reptile which first produced the convulsions. + +At the commencement of the American revolution he became deeply +engaged in public affairs; and from that time devoted himself to +intense application to business, with which the preservation of his +health was never allowed to interfere. In the expedition against Rhode +Island, an attack of inflammation of the lungs had nearly proved fatal +to him. + +In the beginning of the year 1807, he suffered severely from the +epidemic catarrh; and a remarkable irregularity of the pulse was then +perceived to be permanent, though there is some reason to believe, +that this irregularity had previously existed, during the fits of +epilepsy, and for a few days after them. In the summer, while he was +apparently in good health, the circulation in the right arm was +suddenly and totally suspended; yet, without loss of motion or +sensation. This affection lasted from noon till midnight, when it as +suddenly ceased, and the circulation was restored. In the autumn he +was again seized with the influenza, which continued about three +weeks, leaving a troublesome cough of two or three months' duration, +and a slight occasional difficulty of breathing, which at that time +was not thought worth attention. Soon after, in November, he had one +or two singular attacks of catarrhal affection of the mucous membrane +of the lungs, which commenced with a sense of suffocation, succeeded +by cough and an expectoration of cream coloured mucus, to the quantity +of a quart in an hour, with coldness of the extremities, lividity of +the countenance, and a deathlike moisture over the whole body. These +attacks lasted six or eight hours, were relieved by emetics, and +disappeared, without leaving a trace behind. + +At this time he began to complain of palpitations of the heart; yet, +it is probable, that he had been affected with these before, since he +was unaccustomed to mention any complaint, which was not sufficiently +distressing to require relief. He experienced a difficulty of +respiring, as he ascended the stairs, and became remarkably +susceptible of colds, from slight changes of clothing, moisture of the +feet, or a current of cold air. His sleep was unquiet in the night, +and attended with very profuse perspiration; and, in the latter part +of the day, a troublesome heaviness occurred. The sanguiferous vessels +underwent an extraordinary increase, or, at least, became remarkably +evident. The pulsation of the carotid arteries was uncommonly strong; +the radial arteries seemed ready to burst from their sheaths; the +veins, especially the jugulars, in which there was often a pulsatory +motion, were every where turgid with blood. The countenance was high +coloured, and commonly exhibited the appearance of great health; but, +when he was indisposed from catarrh, this florid red changed to a +livid colour; which also, after an attack of epilepsy, was observable +for two or three days on the face and hands. This livid hue was often +attended, under the latter circumstances, with something like +ecchymosis over the face, at first formidable in its aspect, and +gradually subsiding, till it had the general appearance of an +eruption, which also soon vanished. + +These symptoms increased, almost imperceptibly, during the five first +months of the year 1808. Much of this time was passed in close +application to official duties; and it seemed that a constant and +regular occupation of the mind had the effect of obviating the +occurrence of any paroxysm of disease, as well of epilepsy, as of +difficult respiration; and that a very sudden and disagreeable +impression generally produced either one or the other. There were, +indeed, independently of such circumstances, some occasional +aggravations of those symptoms. Some nights, for example, were passed +in sitting up in bed, under a fit of asthma, as it was called; +sometimes the mind became uncommonly impatient and irritable; the body +gradually emaciated; yet the appetite and digestive functions remained +principally unimpaired; and persons around were not sensible of any +material alteration in the condition of the patient. + +On the approach of warm weather, in June, the violence of the symptoms +increased. Paroxysms of dyspnoea occurred more frequently, and were +more distressing. They commenced with symptoms of slight febrile +affection, such as hot skin, hard, frequent, and more irregular pulse, +disordered tongue, loss of appetite, and derangement of the digestive +functions. This kind of paroxysm lasted two or three days. Evacuations +of blood from the nose and haemorrhoidal vessels, which before rarely +occurred, became frequent; a fulness at the upper and right side of +the abdomen was sometimes perceptible, formed apparently by temporary +enlargement of the liver; the difficulty in ascending an eminence +increased sensibly. In the intervals of these attacks, which were +variable, but generally continuing ten or twelve days, the strength +was frequently good, and accompanied by a great flow of spirits, and +an aptitude, or rather ardour, for business. + +Such was the course of this complaint until the latter part of August, +when a very severe paroxysm occurred. It commenced, like the former, +with febrile symptoms, but those more violent than before. The +countenance became high coloured; the dyspnoea excessive, and rendered +almost suffocating by a slight movement, or attempt to speak; the +pulse hard, very irregular, intermittent, and vibrating; and the +digestive functions were suspended. These symptoms soon increased to +the highest degree. The respiration was so distressing, as to produce +a wish for speedy death; the eyes became wild and staring. No sleep +could be obtained; for, after dosing a short time, he started up in +violent agitation, with the idea of having suffered a convulsion. +During the few moments of forgetfulness, the respiration was sometimes +quick and irregular, sometimes slow, and frequently suspended for the +space of twenty five, and even so long as fifty seconds. At the end of +three days the febrile heat was less permanent; the red colour of the +face changed to a death like purple; the hands and face were cold, and +covered with an adhesive moisture; the hardness of the pulse +diminished, and a degree of insensibility took place. I seized this +opportunity to examine the region of the heart, which had not been +done before, from fear of alarming the active and irritable mind of +the patient. The heart was perceived palpitating, obscurely, about the +7th and 8th ribs; its movements were very irregular, and consisted in +one full stroke, followed by two or three indistinct strokes, and +sometimes by an intermission, corresponding with the pulse at each +wrist. The pulsation was felt more distinctly in the epigastric +region. During this paroxysm a recumbent posture was very uneasy, and +the patient uniformly preferred sitting in a chair. When the recumbent +posture was assumed, the head was much raised, inclined to the right +side, and supported by the hand; the knees were drawn up as much as +possible. He could not bear an horizontal posture; nor did he ever +lie on the left side, except a short time after the application of a +blister. At the end of the fifth day his sufferings abated, but the +sudden affusion of a small portion of a cold liquid on the head +produced a severe fit of epilepsy. This was followed by a return of +the symptoms equally distressing, and more durable, than in the first +attack[2]. + + [Footnote 2: During this time it was thought adviseable to + acquaint his friends, that an organic disease of the heart + existed, which doubtless consisted in an ossification of the + semilunar valves of the aorta, attended, perhaps, by + enlargement of the heart; that the disease was beyond the + reach of art, and would prove fatal within three months, + possibly very soon; that if it lasted so long, it would be + attended by frequent recurrences of those distressing + symptoms, general dropsical affections, and an impaired state + of the mental faculties.] + +This violent agitation gradually subsided, and was followed by a +pleasant calm. The natural functions resumed their ordinary course; +his appetite returned; his enjoyment of social intercourse was +unusually great; and he amused and instructed his friends by the +immense treasures of information, which his talents and observations +had afforded him, and which, he seemed to feel, would soon be lost. At +the end of September the feet began to swell, and after some time the +enlargement extended up to the legs and thighs, and increased to an +extraordinary degree; the abdomen next swelled, and, after it, the +face. Toward the end of October there were some indications of water +in the chest; there was a constant shortness and difficulty of +breathing; the cough, till now rare, became more frequent and +troublesome; the contraction of the thoracic cavity rendered the +action of the heart more painful, to that beside an uniform stricture +across the breast, he sometimes described a dreadful sensation like +twisting of the organs in the thorax. He suspected the existence of +water there, and was inclined to consider it as his primary disease, +but was easily convinced of the contrary. At one time he had a +suspicion of a complaint of the heart, and, although he had never +heard of a disease of that organ, slightly intimated it to one of his +friends, and mentioned a sensation he had experienced in the chest, +which he compared to a fluid driven through an orifice too narrow for +it to pass freely. In this month, beside the dropsical affections and +increase of cough, he had occasional painful enlargements of the +liver, frequent starting up from sleep, a slight degree of dizziness, +a great disposition for reveries, and sometimes extraordinary +illusions, one of which was, that he was two individuals, each of whom +was dying of a different disease. This idea often occurred, and gave +him much uneasiness. He was also afflicted with long continued +frightful dreams, and sometimes a slight delirium. + +After the use of much medicine, on the 6th of November, the effused +fluids began to be absorbed, and passed out through the urinary organs +with such rapidity, that on the 12th the dropsical enlargements had +nearly disappeared. The pulse was much reduced, in hardness and +frequency, by the medicine, and, as it fell, he became more easy. On +the 10th the state legislature convened, and the call of business +roused, like magic, the vigor of his mind; and the symptoms of his +disease almost disappeared. During this session he made little +complaint, dictated many important communications, and attended to all +the duties of his office, without neglecting the most minute. As soon +as the legislature adjourned, he declared, that his work was finished, +and that he had no desire to remain longer in this world. He entreated +that no farther means should be used to prolong his existence, and +immediately yielded himself to the grasp of disease, which appeared +waiting with impatience to inflict its agonies. + +From this moment the distressing difficulty of breathing had very +slight remissions. The consequent disposition to incline the superior +part of the body forward, for the purpose of facilitating respiration, +increased so much, that he frequently slept with his head reposed on +his knees. The cough became occasionally very violent, and was always +attended with an expectoration of a brown coloured mucus, sometimes +tinged with blood. The abdominal viscera lost their activity. The face +was sometimes turgid and high coloured, at other times pallid and +contracted. A gradual abolition of the powers of the mind ensued, with +a low delirium, and two short fits of phrenzy. The state of the +circulation was very variable; the pulse at the wrists principally +hard and vibrating, rarely soft and compressible; the less pulsations +becoming more indistinct, and at length scarcely perceptible. No +perfectly distinct beat of the heart was felt, but a quick undulating +motion, not corresponding with the pulse at the wrist. Three days +before death the arteries assumed this undulatory motion, corresponded +with the motion of the heart, and, for forty-eight hours, lost the +irregularity of pulsation[3]. + + [Footnote 3: The celebrated Morgagni has recorded some cases + of organic disease of the heart discovered by dissection, the + symptoms of which do not exactly accord with those observed + in this and the succeeding cases. It should be remembered, + however, that many of the subjects of those cases were not + examined by him, while living, and others but a very short + time before death. But it appears, that, in the last stage of + this disorder, some of the most important symptoms may be + materially changed, especially the state of the pulse, + dyspnoea and palpitations. Thus in the case related above, + and in some others, the pulse became regular, the + palpitations subsided, and the dyspnoea was less observable. + The cases of that accurate anatomist, therefore, are not so + contradictory of those related here, as might at first be + imagined.] + +Once or twice the expiring faculties brightened. On the 30th of +November he awoke, as if from death, conversed very pleasantly for two +or three hours, and humorously described scenes, which he had +witnessed in his youth. + +On the 4th of December came on the second attack of furious delirium. +Insensibility, and great prostration of strength, ensued. The +respiration became very slow, and obstructed by the accumulation of +mucus in the lungs; the pulse very intermittent, then regular, and +finally fluctuating. A hiccough commenced; coldness of the extremities +and lividity of the face followed, and continued three days before +death. On the 9th the incurvated posture was relinquished, and the +head sunk back upon the pillow; the respirations then diminished in +frequency, till they became only two in a minute; and at the end of +twenty-four hours they very gradually ceased.[4] + + [Footnote 4: Governour Sullivan was born December 4th, 1744, + and died December 10th, 1809.] + + + DISSECTION, NINE HOURS AFTER DEATH. + + + EXTERNAL APPEARANCE. + +The whole body was much emaciated; the face pale and contracted. The +hands were slightly oedematous. Discolourations, answering to the +ribs, were observed on the thorax; many small purple spots, hard and +prominent, on the back; excoriations on the nates; and purple spots, +resembling incipient mortification, on the heel and toe. + + + THORAX. + +The integuments of the thorax were free from fat: the cartilages of +the ribs ossified in various degrees, some perfectly, others slightly. +Upon laying open the cavity of the thorax, it was found to contain +about three pints of water, the proportion being greatest on the left +side. + +The lungs were contracted into a smaller compass than usual, and were +very firm to the touch. Their colour anteriorly was whitish, with +small distinct purple spots; posteriorly, of a deep red, with similar +spots. The right lobe adhered closely to the pericardium; it also +adhered to the pleura costalis, by a great number of strong cords, +which seemed to be elongations of the original adhesions. Some of them +were nearly as hard as ligament, and many an inch in length. +Internally the lungs presented a very compact structure. Their cells +were crowded with mucus, and their vessels filled with black blood, +partly fluid, and partly coagulated. Some portions were firmer and +more condensed than others, but no tubercles were discovered. + +The pericardium, viewed externally, appeared very large, and occupied +almost the whole space behind the opening formed by removing the +sternum and cartilages of the ribs. It was situated principally on the +left side, and contained about double the usual quantity of water; but +was principally filled by the enlarged heart, to which it adhered +anteriorly about two inches, near its base. Its parietes were, in +every part, very much thickened and hardened. + +The heart presented nearly its usual colour and form, excepting on its +anterior surface, which was somewhat discoloured by coagulated lymph. +It was enlarged in bulk to, at least, one half more than the healthy +size. The auricles and ventricles contained coagulated blood. The +tricuspid valves were in a sound state. The left auricle was double +the usual size. The left ventricle was enlarged, about three times +thicker and much firmer than usual. The mitral valves were very much +thickened, and near the insertion of their columnae, which were sound, +cartilaginous, so that they were quite rigid, and the opening made by +them, from the auricle to the ventricle, was scarcely large enough to +admit the passage of a finger. The semilunar valves of the aorta were +ossified at their bases and apices, and the portion intermediate, +between the base and apex, partly ossified, and partly cartilaginous, +so as to render the valves very rigid. The aorta was at least one half +larger than usual, especially at its arch. The arteria innominata, the +carotid, and subclavian arteries, were uncommonly large and thick. The +coronary arteries were considerably ossified. + + + ABDOMEN. + +The omentum was destitute of fat. The stomach distended with flatus on +the pyloric side; its cardiac extremity, lying under the liver, was +pressed down and contracted. The liver was shrunk; its tunic +corrugated, as if it had been distended, and bearing marks of +inflammation; its substance harder than usual; its vessels, when +divided, pouring out liquid black blood. The gall bladder was filled +with bile. The kidneys were thicker, and more irregular in form, than +is common. The abdominal cavity contained some water. + + + HEAD. + +The bones of the cranium were unusually thick. The dura mater, which +was thickened, and in many places bore marks of former inflammation, +adhered to the bone at the vertex. On its internal surface, near the +longitudinal sinus, there was a small ossified portion, half an inch +long and the eighth of an inch thick. The convolutions of the brain +were narrow, and very strongly marked. The pia mater bore marks of +pretty extensive inflammation, and adhered to the dura mater at the +vertex. The cortical substance ran deep into the medullary part of +the brain. The ventricles contained about double the usual quantity of +water; their parts were all remarkably well defined. The vessels of +the pia mater, over the corpora striata, were unusually injected with +blood. The velum interpositum was very firm; the plexus choroides +uncommonly thick, but pale; the opening from the right to the left +ventricle large. The vessels of the brain were generally not much +filled with blood. + +The blood appeared every where fluid, except in some portions of the +lungs, and in the cavities of the heart. It was very dark coloured, +perhaps more than ordinarily thin, and oozed from every part, which +was cut. + +The cellular membrane, in all dependent parts, effused, when cut, a +serous fluid. + + + CASE II. + +Mr. John Jackson, fifty-two years of age, had been affected for more +than two years with palpitations of the heart, and paroxysms of +dyspnoea. These symptoms increased in October, 1808, and were followed +by strong cough, uneasiness in lying down, sudden startings in sleep, +and an inclination to bend the body forward and to the left side. His +cough, during the last part of his life, was attended with copious +bloody expectoration. His countenance was florid; his pulse very +irregular, though not quite intermittent. The occasional variations in +the state of the disease were remarkable. Some periods were marked +with uncommon mental irritability. Pain in the region of the liver, +oedema of the inferior extremities, paucity and turbidness of the +urine, yellowness of the skin, and great emaciation attended the +latter stages of the disease. A degree of stupor occurred. The +termination on the 30th of January, 1809, was tolerably quiet. Two +days before death he sank into the recumbent posture, and his pulse +became more regular[5]. + + [Footnote 5: The symptoms of this patient were related by Dr. + Rand, sen. to whose politeness and love of medical + improvement I am indebted for the opportunity of examining + this and the following case.] + + + DISSECTION, + TWENTY-FOUR HOURS AFTER DEATH. + +On opening the thorax, its right cavity was found to contain a large +quantity of water; the left, a smaller quantity. + +The lungs were of a firm, condensed texture, especially at the lower +part, where their solidity was nearly equal to that of a healthy +liver. They contained black blood. + +The heart was much enlarged, and proportionally thickened. Its tunic +was in some places covered with coagulated lymph, especially over the +coronary arteries. Its cavities were filled with black coagulum, which +in the right auricle and ventricle had a slight appearance of polypus. +The semilunar valves of the pulmonary artery and aorta were unusually +small, and their bases cartilaginous. Those of the aorta had lost +their form, and were slightly ossified. The remaining valves were +partially thickened. The arch of the aorta was very much dilated, its +internal coat covered with a bony crust, which extended through the +remaining thoracic portion, gradually diminishing. This portion was +also considerably dilated. + +The liver was indurated; its peritonaeal coat exhibited a flaccid or +wrinkled appearance, and bore marks of slight inflammation. The gall +bladder was filled with bile, and the pancreas indurated. + + + CASE III. + +Captain Job Jackson, forty-five years of age, a man of vigorous +constitution, after an indisposition of some years continuance, was +seized with palpitations of the heart and dyspnoea, occurring by +variable paroxysms, especially on ascending an eminence, and attended +by hardness, irregularity, and intermission of the pulse. To these +symptoms were superadded dizziness and severe head-ache, a disposition +to bend the body forward, sudden starting from sleep, with dread of +suffocation, violent cough with copious expectoration, which for +fifteen days before death consisted of black blood, distressing pain +across the chest, especially on the left side, great oedema of the +lower extremities, and paucity of urine. + +He died painfully in January, 1809, after violent struggles for +breath. The day before death the pulse became regular. He rested his +head upon an attendant, and made no attempts to lie down for some +days previous[6]. + + [Footnote 6: The symptoms of this case were related to me by + Dr. Rand, sen.] + + + DISSECTION, + SIXTEEN HOURS AFTER DEATH. + +The skin was of a yellow colour. The inferior extremities, quite to +the groins, were oedematous. + +The left cavity of the thorax was filled with water; the right +contained only a small quantity. The pleura costalis, on the left side +opposite to the heart, was thickened and covered with a very thick +flocculent coat of coagulated lymph, and the pericardium opposite to +it had the same marks of inflammation. The lungs on that side were +pushed up into a narrow space. They were dense and dark coloured. + +The pericardium contained little more than the usual quantity of +water. The heart, which exhibited marks of some inflammation on its +surface, was astonishingly large, and firm in proportion. Its cavities +were principally filled with coagulum. The semilunar valves of the +pulmonary artery had their bases slightly ossified, and the remaining +part thickened. There were only two valves of the aorta, and these +were disorganized by the deposition of ossific matter about their +bases, and a fleshlike thickening of the other part[7]. The parietes +of the heart, especially of the left ventricle, were greatly +thickened, and somewhat ossified near the origin of the aorta. + + [Footnote 7: See plate first.] + +The liver had the same appearance as in case second. + + + CASE IV. + +Thomas Appleton, thirty-eight years of age, of a robust constitution, +was affected with excessive difficulty of breathing, occurring at +intervals of different duration. It commenced three years before his +death, and gradually increased. He was subject to palpitations of the +heart for at least two years before his death, and was distressed with +violent cough, attended with copious expectoration, which finally +became very bloody. The palpitation and dyspnoea were greatly +augmented by ascending stairs. His countenance was very florid. + +Sometimes he was seized with violent head-ache and dizziness, which, +as well as the other symptoms, were greatly relieved by venesection. +About two months before death oedema of the legs appeared, which was +soon followed by frequent and alarming syncope. His pulse was +irregular, intermittent, hard, and vibrating. When lying down he +frequently awoke, and started up in great terror. His usual posture +was that of sitting, with his trunk and head bent forward, and +inclining to the left side. For some time before death a recumbent +posture threatened immediate suffocation; yet, three days previous to +the occurrence of that event, he sank back upon the pillow. He was, at +intervals, so much better as to think himself free from disease. +Slight delirium preceded his death, which occurred in January, +1809[8]. + + [Footnote 8: The symptoms in this case were related to me by + Dr. Warren, sen.] + + + DISSECTION, + EIGHTEEN HOURS AFTER DEATH. + +The countenance continued florid. The inferior extremities were much +distended with water, and the cellular membrane abounded in fat. + +The right cavity of the pleura contained a moderate quantity of water; +the left, scarcely any. The lungs were firm, condensed, and dark +coloured, from venous blood. The pleura, on the left side opposite to +the pericardium, appeared to have been inflamed, as there was an +effusion of coagulated lymph on its surface. + +The pericardium was much distended with water. The heart, on the +anterior surface of which were some appearances of inflammation, was +very much enlarged. Its parietes were thickened; its cavities +unnaturally large, and filled with black coagulum. Each of the valves +had lost, in some degree, its usual smoothness, and those of the aorta +were, in some points, thickened, and partly cartilaginous. + +The liver was small, and, when cut, poured out dark blood. Its tunic +was whitish, opaque, and corrugated. + + + CASE V. + +A. B. a negro, about thirty-five years of age, had paroxysms of +dyspnoea and violent cough, attended with oedema of the extremities +and ascites, violent head-ache, dizziness, brightness of the eyes, +palpitations of the heart, irregular, intermittent, slow, and soft +pulse. These symptoms slowly increased, during three or four years, in +which time the dropsical collections were repeatedly dispersed. He +gradually and quietly died in the alms-house, in January, 1809. + + + DISSECTION. + +On dissection, the cavities of the pleura were found to contain a +considerable quantity of water. The pericardium was filled with water; +the heart considerably enlarged; its parietes very thin, and its +cavities, especially the right auricle and ventricle, morbidly +large[9]. + + [Footnote 9: This dissection was performed by Dr. Gorham.] + + + CASE VI. + +Mrs. M'Clench, a washer-woman, forty-eight years of age, of good +constitution and regular habits, was attacked, in the summer of 1808, +with palpitations of the heart and dyspnoea on going up stairs, severe +head-ache, and discharges of blood from the anus. These symptoms did +not excite much attention. In the winter of 1808-9, all of them +increased, except the palpitations. The inferior extremities and +abdomen became distended with water; the region of the liver painful; +the skin quite yellow; the pulse was hard, regular, and vibrating; the +countenance very florid. Violent cough followed, and blood was +profusely discharged from the lungs. This discharge being suppressed, +evacuations of blood from the anus ensued, under which she died, in +March, 1809. + + + DISSECTION. + +The right cavity of the thorax was filled with water; the left +contained none. The lungs were sound, but very dense, full of dark +coloured blood, and, on the right side, pressed into the upper part of +the thorax. The heart was one half larger than natural; its substance +firm, and its anterior part, especially near the apex, covered with +coagulated lymph. The right auricle and ventricle were large, and +their parietes thin. The parietes of the left auricle and ventricle, +particularly of the latter, were much thickened, and their cavities +were filled with black coagulum. + +The liver was contracted; its coat wrinkled, and marked with +appearances of recent inflammation. + + + CASE VII. + + To JOHN C. WARREN, M. D. + +MY DEAR SIR, + +Your important communication to our society, which is about to be +published, will lay before the American public much more knowledge +respecting the diseases of the heart, and large vessels, than has +hitherto been presented to them. A case has lately fallen under my +observation, having so much similarity to those of organic diseases of +the heart, which have occurred to you, as to mark its affinity, yet +with some differences, which characterize it as a variety. If the +statement of it will add any value to your collection of cases, you +are at liberty to publish it. + +A. S. twenty-eight years of age, and of middle stature, was attacked, +after a debauch, with pain in the region of the heart, which subsided, +but returned a year after on a similar occasion. He then became +affected with palpitations of the heart for six months, great +difficulty of breathing, which was augmented by ascending an eminence, +severe cough, dizziness, and violent head-ache, attended by a +disposition to bend the body forward, and sudden startings from sleep. +His pulse was always regular, and never remarkably hard. His +countenance, till within a few weeks of death, presented the +appearance of blooming health. His feet and legs did not swell at any +period of the disease. He suffered exceedingly from flatulence, to +which he was disposed to attribute all his complaints. This symptom +might have been aggravated by his habits of free living, and +occasional intoxication, which he acknowledged, and to which he traced +the origin of his disease. + +After death, water was discovered in the thorax; but the lungs had not +that appearance of accumulation of blood, in particular spots, which +is commonly observed in cases of organic disease of the heart. The +only very remarkable morbid appearance about the heart was in the +aorta, and its valves. The valves had lost their transparency, and +were considerably thickened in various spots. The inner surface of +the aorta, for about an inch from its commencement, was elevated and +thickened, and the external surface singularly roughened and +verrucated. This appearance was so peculiar, that no words will give a +competent idea of it, and perhaps it would be sufficient for me to +call it a chronic inflammation[10]. + + I am, my dear sir, + Your friend and obedient servant, + JAMES JACKSON. + + [Footnote 10: See plate second.] + + + CASE VIII. + +Col. William Scollay, aged fifty-two, of a plethoric habit of body, +was attacked, in the year 1805, with dyspnoea and palpitation of the +heart, attended with irregularity of the pulse, and oedema of the +lower extremities. By the aid of medicine, the dropsical collections +were absorbed, and he recovered his health, so far as to follow his +usual occupations, nearly a year; but was then compelled to relinquish +them. The symptoms afterwards underwent various aggravations and +remissions, till the beginning of the winter of 1808-9, when the +attacks became so violent, as to confine him to the house. His face +was then high coloured. The faculties of his mind were much impaired. +The dyspnoea became more constant, and was occasionally attended by +cough; the palpitations rather lessened in violence; the pulse was +more irregular, and exceedingly intermittent. The abdomen and inferior +extremities were sometimes enormously distended with water, and +afterwards subsided nearly to their usual size. One of the earliest, +most frequent, and distressing symptoms, was an intense pain in the +head. About two months before death, a hemiplegia took place, but +after a few days disappeared. This so much impaired the operations of +the mind, that the patient afterwards found great difficulty in +recollecting words sufficient to form an intelligible sentence. During +the existence of the last symptom the pulse was regular. + +He gradually expired, on the 15th of March, 1809. + + + DISSECTION, FIVE HOURS AFTER DEATH. + + + EXTERNAL APPEARANCE. + +The countenance was somewhat livid and pale; the lips were very livid. +The chest resounded, when struck, except over the heart. The abdomen +was tumid, and marked by cicatrices like those of women, who have +borne children. The superior extremities were emaciated, and marked +like the abdomen. The lower extremities were oedematous. + + + THORAX. + +The cartilages of the ribs were ossified. The left cavity of the +pleura contained about twelve ounces of water; the right, about three +ounces. The lungs, externally, were dark coloured, especially the +posterior lobes; internally, they were very firm, and, in some places, +as dense as the substance of the liver. A frothy mucus was effused +from them in great quantities. They were coloured by very dark blood, +especially in the middle portion of the left superior lobe. One or two +calcareous concretions were observed in them. The pericardium was a +little firmer than usual, and contained about five ounces of water. +The heart was enlarged, and covered with tough fat. In the right +auricle, and ventricle, was some coagulated blood. The tricuspid +valves had lost their smoothness and transparency; the semilunar +valves of the pulmonary artery were cartilaginous at their bases. The +left auricle and ventricle, particularly the first, contained +coagulum. The mitral valves were roughened by many bony spots. +Considerable ossification had taken place in the semilunar valves of +the aorta, so that one of them had quite lost its form; and the aorta +was ossified for the space of a square inch, at a small distance from +the valves. The coronary arteries were also ossified. + + + ABDOMEN. + +The coat of the liver was somewhat wrinkled, as if shrunk. Its +substance was hard, and discharged, when cut, great quantities of +blood. The veins of the omentum, mesentery, and intestines, were full +of blood. The abdomen contained a considerable quantity of water. + + + HEAD. + +Water was found between the dura and pia mater, and between the pia +mater and arachnoides. The vertical portion of the pia mater bore +marks of former inflammation. The convolutions of the brain were very +distinct; their external surface was pale. The veins were empty[11]. +No bloody points were observed in the medullary portion of the brain, +when cut. The ventricles contained between one and two ounces of +water; the communication between them was very large. The plexus +choroides was pale. + + [Footnote 11: In this case, and in case first, the vena cava + ascendens had been divided, before the brain was examined.] + + + CASE IX. + +A lady, about forty-five years of age, the mother of many children, +has been troubled during the course of the past year with violent +palpitations of the heart, and great difficulty of respiration, +especially on going up stairs. These complaints have lately increased, +so that she has kept in her chamber about two months. Her countenance +is florid; her eyes are clear and bright. She has dizziness, +especially on moving, without pain in her head. She had for some time, +a severe cough, which is now relieved. The dyspnoea is not yet very +distressing, except on using motion; it often occurs in the night, and +obliges her to rise and sit up in bed. The palpitations are very hard, +and so strong, that they may be perceived through her clothes; the +tumult in the thorax is indescribable. The functions of the abdominal +viscera are unimpaired. The pulse is hard, vibrating, irregular, +intermittent, very variable, corresponding with the motions of the +heart, and similar in each arm. There is not yet the slightest reason +to suspect any dropsical collection. The alternations of ease and +distress are very remarkable, but on the whole, the violence of the +symptoms increases rapidly. + +There is no difficulty in discovering in this case an organic disease +of the heart, which probably consists in an enlargement and thickening +of the heart, and an ossification of the semilunar valves of the +aorta. + + + CASE X. + +Levi Brown, a cabinet-maker, forty-eight years of age, complained in +February, 1809, of great difficulty of breathing, and an indescribable +sensation in the chest, which he said was sometimes very distressing, +and at other times quitted him entirely. Being a man of an active +mind, he had read some medical books, whence he got an idea, that he +was hypochondriac. + +On examining his pulse, it was found to be occasionally intermittent, +contracted, and vibrating. He had some years previously been attacked +with copious haemorrhages from the stomach or lungs, which have +occasionally recurred, though they have lately been less frequent. +Eight years since he suffered from an inflammation of the lungs; and +about two or three years ago he first experienced a beating in the +chest, and pain in the region of the heart, which increased till +within six or eight months, since which the beating has been +stationary, and the pain has much increased. In the course of the last +summer, dyspnoea, on using exercise, and especially ascending any +eminence, commenced. This has greatly increased, so as to render it +almost impossible for him to go up stairs. His countenance is turgid, +and uniformly suffused with blood; his eyes are bright and animated; +his lips livid. The pulsation of the heart cannot be felt on the left +side, and is barely perceptible on the right side of the sternum, and +in the epigastric region. When he is distressed with fits of dyspnoea, +he feels something as if rising to the upper part of the thorax, and +the heart then seems to him to be beating through the ribs. I have not +witnessed any of these paroxysms. The inferior extremities and abdomen +have been swelled about three weeks. When in bed, he has his head and +shoulders elevated, and, upon the attack of his paroxysms, sits up and +inclines his head forward; but he keeps from the bed as much as +possible. In his sleep he is apt to start up, suddenly, in distress, +especially when he first slumbers. His dreams are often frightful, +and, when awake, he is affected with reveries, during which, though +conscious of being awake, strange illusions present themselves. At +intervals he seems slightly delirious. He has a violent cough, with +very copious expectoration of thick mucus. He often suffers from +severe head-ache, and the least exercise produces dizziness. + +This man has a very robust frame of body, and has been accustomed to a +free use of ardent spirits, and of opium, of which he now takes about +twelve grains in a day. His appearance is such, that, on a slight +survey, one would not suppose him diseased, but, on observing him with +a little attention, a shortness and labour of respiration are +perceived, with some interruption in speaking, and a frequent catching +of the breath, or sighing. + +April. Since writing the above account, the dropsical collections were +absorbed, and the palpitations and other symptoms moderated, so that +he considered himself nearly well, and attended to his usual business. +Within a few days, however, the symptoms have returned with more +violence. The dyspnoea is at times very distressing; the pulse more +irregular and intermittent; the palpitations are more constant. His +sufferings from lying in bed are so increased, that in the most +comfortable nights he passes, he sits up once in an hour or two. The +appetite is keen. The legs begin to swell again. + +Some organic disease of the heart exists in this case. The +indistinctness of the palpitations, the want of hardness in the pulse, +and the slow progress of the disease, indicate a loss of power in the +heart, the effect of the distention and thinness of its parietes. The +irregularity of the pulse affords some reason to suspect disorder of +the aortal valves, which is not yet very considerable. + + +ENUMERATION _of the principal morbid changes, observed in the organization +of the heart, in the preceding cases_. + +Enlargement of the volume of the heart, or aneurism.[12] +Increase of the capacity, or aneurism of the right auricle, } with + of the right ventricle,} thickened, + of the left auricle } or thin, + of the left ventricle, } parietes. + of the aorta, with thickening of + its coats. + +Fleshlike[13] thickening of the mitral valves. + of the aortal valves. + of the aorta. + +Cartilaginous thickening of the internal membrane of the heart, and +generally of its valves. + +Ossification of the parietes of the heart. + mitral valves. + aortal valves. + aorta. + coronary arteries. + + [Footnote 12: Morgagni uses this term, which he borrows from + Ambrose Pare, to express dilatation of the cavities of the + heart. It seems to be as applicable to the dilatation of the + heart, as to that of an artery. I have therefore adopted it + in this enumeration.] + + [Footnote 13: The term fleshlike is employed to express that + roughness of the valves, which somewhat resembles flesh in + its appearance, but which is very different from the + thickening of the parietes of the heart.] + + +ENUMERATION _of the principal morbid appearances, observed in these +cases of disease of the heart, which may be considered secondary_. + + IN THE CAVITY OF THE CRANIUM. + +Inflammation of the meninges. +Water between the meninges. +Water in the ventricles. + + IN THE PLEURA AND ITS CAVITY. + +Inflammation and thickening of the pleura. +Collection of water in its cavity. +Lungs dark coloured. + generally very firm, and particularly in some parts. + loaded with black blood. + crowded into a narrow space. + + IN THE PERICARDIUM AND ITS CAVITY. + +Inflammation and thickening of its substance. +Adhesion to the heart and lungs. +Collection of water in its cavity. + + IN THE CAVITY OF THE ABDOMEN. + +Collection of water. +Liver very full of fluid blood. + having its tunic flaccid and inflamed. +Mesenteric veins full of blood. + + CELLULAR MEMBRANE full of water. + + THE BLOOD every where fluid, except in the cavities of the heart. + + + REMARKS. + +The symptoms, which are most observable, in some or all of the +preceding cases, are the following: + +The first notice of disorder is commonly from an irregular and +tumultuous movement of the heart, which occurs some time before any +perceptible derangement of the other functions. This irregularity +slowly increases, and arrives at its height before the strength of the +patient is much impaired, at least in the cases which I have noticed; +and as the vigour of the patient lessens, the force of the +palpitations diminishes. These palpitations are often so strong, as to +be perceptible to the eye at a considerable distance. They are seldom +most distinct in the place where the pulsation of the heart is usually +felt. Sometimes they are perceived a little below; often in the +epigastric region; and not unfrequently beneath, and on the right +side, of the sternum. + +After the palpitations have lasted some time, a little difficulty of +breathing, accompanied with sighing, is perceived, especially on any +great exertion, ascending an eminence, or taking cold, of which there +is an uncommon susceptibility. This dyspnoea becomes, as it increases, +a most distressing symptom. It is induced by the slightest cause; as +by an irregularity in diet, emotions of the mind, and especially +movement of the body; so that on ascending stairs quickly, the patient +is threatened with immediate suffocation. It occurs at no stated +periods, but is never long absent, nor abates much in violence during +the course of the disease. It is attended with a sensation of +universal distress, which perhaps may arise from the circulation of +unoxygenated blood, or the accumulation of carbon in the system; for +the countenance becomes livid, and the skin, especially that of the +extremities, receives a permanent dark colour. This dyspnoea soon +causes distress in lying in an horizontal posture. The patient raises +his head in bed, gradually adding one pillow after another, till he +can rarely, in some cases never, lie down without danger of +suffocation; he inclines his head and breast forward, and supports +himself upon an attendant, or a bench placed before him. A few hours +before death the muscular power is no longer capable of maintaining +him in that posture, and he sinks backward. The dyspnoea is attended +with cough, sometimes through the whole of the disease, sometimes only +at intervals. The cough varies in frequency. It is always strong, and +commonly attended with copious expectoration of thick mucus, which, as +the disease advances, becomes brown coloured, and often tinged with +blood; a short time before death it frequently consists entirely of +black blood. + +The changes in the phoenomena of the circulation are very remarkable. +The sanguiferous system is increased in capacity; the veins, +especially, are swelled with blood; the countenance is high coloured, +except in fits of dyspnoea, when it becomes livid; and it is very +frequently puffed, or turgid. The brightness of the eyes, dizziness, +which is a common, and head-ache, which is a frequent symptom, and in +some cases very distressing, are probably connected with these +changes. The motions of the heart, as has already been stated, are +inordinate, irregular, and tumultuous. The pulse presents many +peculiarities. In some cases, probably where there is no obstruction +in the orifices of the heart, it remains tolerably regular, and is +either hard, full, quick, vibrating and variable, or soft, slow, +compressible and variable. Most commonly, perhaps always, when the +orifices of the heart are obstructed, it is vibrating, very irregular, +very intermittent, sometimes contracted and almost imperceptible, very +variable, often disagreeing with the pulsations of the heart, and +sometimes differing in one of the wrists from the other. + +The functions of the brain suffer much disturbance. Melancholy, and a +disposition for reverie, attend the early stages of the complaint; and +there is sometimes an uncommon irritability of mind. The dreams become +frightful, and are interrupted by sudden starting up in terror. +Strange illusions present themselves. The mental faculties are +impaired. The termination of the disease is attended with slight +delirium; sometimes with phrenzy, and with hemiplegia. + +The abdominal viscera are locally, as well as generally, affected. +Although the digestive functions are occasionally deranged, the +appetite is at some periods remarkably keen. The action of the +intestines is sometimes regular, but a state of costiveness is +common. The liver is often enlarged, probably from accumulation of +blood. This distention is attended with pain, varies much, and, in all +the cases I have seen, has subsided before death, leaving the coats of +the liver wrinkled, flaccid, and marked with appearances of +inflammation, caused by the distention and pressure against the +surrounding parts. An effect of the accumulation of blood in the +liver, and consequently in the mesenteric veins, is the frequent +discharge of blood from the haemorrhoidal vessels. This occurs both in +the early and late stages of the disease, and may become a formidable +symptom. Evacuations of blood from the nose are not uncommon. + +Dropsical swellings in various parts of the body succeed the symptoms +already enumerated. They commence in the cellular membrane of the +feet, and gradually extend up the legs and thighs; thence to the +abdominal cavity, to the thorax, sometimes to the pericardium, to the +face and superior extremities; and, lastly, to the ventricles and +meninges of the brain. These collections of water may be reabsorbed by +the aid of medicine; but they always return and attend, in some +degree, the patient's death. + +There is no circumstance more remarkable in the course of this +complaint, than the alternations of ease and distress. At one time the +patient suffers the severest agonies, assumes the most ghastly +appearance, and is apparently on the verge of death; in a day or a +week after, his pain leaves him, his appetite and cheerfulness +return, a degree of vigour is restored, and his friends forget that he +has been ill. The paroxysms occasionally recur, and become more +frequent, as the disease progresses. Afterwards the intermissions are +shorter, and a close succession of paroxysms begins. If the progress +of the complaint has been slow, and regular, the patient sinks into a +state of torpor, and dies without suffering great distress. If, on the +contrary, its progress has been rapid, the dyspnoea becomes excessive; +the pain and stricture about the praecordia are insupportable; a +furious delirium sometimes succeeds; and the patient expires in +terrible agony. + +Such are the symptoms, which a limited experience has enabled me to +witness. Others, equally characteristic of the disease, may probably +exist. + +From this description of the symptoms it would appear, that there +could be no great difficulty in distinguishing this from other +diseases; yet probably it has sometimes been confounded with asthma, +and very frequently with hydrothorax. Some may think, that there is no +essential difference in the symptoms of these diseases. The +resemblance between them, however, is merely nominal. + +The cough in hydrothorax, unlike that which attends organic diseases +of the heart, is short and dry; the dyspnoea constant, and not subject +to violent aggravations. An uneasiness in a horizontal posture attends +it, but no disposition to incurvate the body forward. These are some +of the points, in which these two diseases slightly resemble each +other. Those, in which they totally differ, are still more numerous; +but as most of them have been already mentioned, it is unnecessary to +indicate them here. + +It is probable, that the two diseases commonly arise in patients of +opposite physical constitutions; the hydrothorax in subjects of a weak +relaxed fibre; the organic diseases of the heart in a rigid and robust +habit. The subjects of the latter affection, in the cases which have +fallen under my observation, were, with the exception of one or two +instances, persons of ample frame, and vigorous muscularity, and who +had previously enjoyed good health. In nearly all these cases the +collection of water was principally on one side, yet the patients +could lie as easily on the side where there was least fluid, as on the +other; which, in the opinion of most authors, is not the case in +primary hydrothorax. It should also be observed, that, in many of the +cases, there was only a small quantity of water in the chest, and that +in neither of them was there probably sufficient to produce death. May +not primary hydrothorax be much less frequent, than has commonly been +imagined? + +Idiopathic dropsy of the pericardium may, perhaps, produce some +symptoms similar to those of organic disease of the heart; but it +appears to be an uncommon disorder, and I have had no opportunity of +observing it. In the fourth case, a remarkable disposition to syncope, +on movement, distinguished the latter periods of the disease, and +might have arisen from the great collection of water in the +pericardial sac. + +The causes of this disease may, probably, be whatever violently +increases the actions of the heart. Such causes are very numerous; and +it is therefore not surprising, that organic diseases of the heart +should be quite frequent. Violent and long continued exercise, great +anxiety and agitation of mind[14], excessive debauch, and the habitual +use of highly stimulating liquors, are among them. + + [Footnote 14: It has been remarked by the French physicians, + and particularly by M. Corvisart, physician to the emperor of + France, that these organic diseases were very prevalent after + the revolution, and that the origin of many cases was + distinctly traced to the distressing events of that period.] + +The treatment of this complaint is a proper object for investigation. +Some of its species, it is to be feared, must forever remain beyond +the reach of art; for it is difficult to conceive of any natural agent +sufficiently powerful to produce absorption of the thickened parietes +of the heart, and at the same time diminish its cavities; but we may +indulge better hopes of the possibility of absorbing the osseous +matter and fleshy substance deposited in the valves of the heart and +coats of the aorta. A careful attention to the symptoms will enable us +to distinguish the disease, in its early stages, in which we may +undoubtedly combat it with frequent success. + +Although it may not admit of cure, the painful symptoms attending it +may be very much palliated; and, as they are so severely distressing, +we ought to resort to every probable means of alleviating them. +Remedies, which lessen the action of the heart, seem to be most +commonly indicated. Blood-letting affords more speedy and compleat +relief, than any other remedy. Its effect is quite temporary, but +there can be no objection to repeating it. The digitalis purpurea +seems to be a medicine well adapted to the alleviation of the +symptoms, not only by diminishing the impetus of the heart, but by +lessening the quantity of circulating fluids. Its use is important in +removing the dropsical collections; and for this purpose it may often +be conjoined with quicksilver. Expectoration is probably promoted by +the scilla maritima, which, in a few cases, seemed also to alleviate +the cough and dyspnoea. Blisters often diminish the severe pain in the +region of the heart, and the uneasiness about the liver. It has been +seen, that the excessive action of the heart sometimes produces +inflammation of the pleura and pericardium, and that the distention of +the coat of the liver has the same effect upon that membrane in a +slighter degree. Vesication may probably lessen those inflammations. +When the stomach and bowels are overloaded, a singular alleviation of +the symptoms may be produced by cathartics, and even when that is not +the case, the frequent use of moderate purgative medicines is +advantageous. Full doses of opium are, at times, necessary through the +course of the complaint. The antiphlogistic regimen should be +carefully observed. The food should be simple, and taken in small +quantities, stimulating liquors cautiously avoided, and the repose of +body and mind preserved, as much as possible. + +The causes of some of the phoenomena of this disease are easily +discovered; those of the others are involved in obscurity, and form a +very curious subject for investigation. I shall not at present trouble +you with the ideas relating to them, which have occurred to me, but +hope to be able to present some additional remarks on the subject, at +a future period. In the mean time, I beg leave to invite the attention +of the society to the observation of the symptoms of this interesting +disorder, and of the morbid appearances in the dead bodies of those, +who have become its victims. + + * * * * * + +At the time the preceding pages were going to the press, the subjects +of the ninth and tenth cases died, on the same day, and an opportunity +was given of ascertaining whether their complaints had been rightly +distinguished. + +It is a proof of an enlightened age and country, that no objections +were made in any instance to the examinations, which have afforded us +so much useful information. + + + DISSECTION OF CASE NINTH. + THIRTY HOURS AFTER DEATH. + +The lady, who was the subject of this case, died on the 10th of May, +but she was not seen by me after the 29th of March; so that it is not +in my power to relate exactly the symptoms which attended the latter +stages of her complaint. I was informed, however, that they increased +in violence, especially the difficulty of breathing, and inability to +lie down; that her cough returned, and her expectoration was sometimes +bloody; and that, for sometime before death she suffered inexpressible +distress. + +We found the body somewhat emaciated, and the lower extremities and +left arm oedematous. Might not this swelling of the left arm have +depended on her constant posture of inclining to her left side? + +The face, especially at the lips, was livid, though not so much as in +many other cases of this disease. On the left shoulder were small, +hard, and prominent livid spots. + +The cellular membrane, both on the outside and inside of the thorax, +was quite bloody, which is not usually the case in dead bodies. The +cartilages of the ribs were slightly ossified, and, upon their +removal, it appeared that the pericardium and its contents occupied an +extraordinary space, for the lungs were quite concealed by them. These +organs being drawn forward, appeared sound and free from adhesions; +their colour, anteriorly, was rather dark; posteriorly, still darker; +their consistence firm. Their vessels were so crowded with blood, as +to cause an uniform dark colour in the substance of the lungs, +especially in some particular spots, where the blood appeared to be +accumulated; but whether this accumulation was confined to the blood +vessels, or extended to the bronchial vesicles, could not be +satisfactorily determined. No one can doubt that blood may be +frequently forced through the thin membrane of the air vesicles, who +considers, that in these cases the heart often acts with uncommon +violence, that, when it is enlarged, it attempts to send toward the +lungs more blood than their vessels can contain, and that there is +commonly some obstruction to the return of blood from the lungs into +the heart, from derangement either in the mitral or aortal valves, or +in the aorta. The consequent accumulation of blood in the lungs seems +to me to be the probable cause of the dyspnoea, which so much +distresses those affected with diseases of the heart; for if there be +an inordinate quantity of blood, there must be a deficiency of air. + +This accumulation of blood in the lungs has, by some writers, been +considered as an appearance belonging to idiopathic hydrothorax. +Whether it ever exists in that complaint seems to me uncertain. The +pressure of water upon the lungs, may possibly interrupt the free +circulation of blood through their vessels, yet probably the same +pressure would prevent the entrance of blood into the vessels, unless +there be some other cause to overcome it, such as increased action of +the heart, which attends only the first stage of hydrothorax. It has +beside been proved by the experiments of Bichat, that the collapsion +of the lungs does not obstruct the circulation of blood through the +pulmonary vessels. It seems probable, therefore, that those who have +thought this collection of blood an appearance belonging to idiopathic +hydrothorax, have mistaken for it the secondary hydrothorax produced +by diseases of the heart. + +On pursuing the examination, we found, behind the lungs, about five or +six ounces of yellowish serum in each cavity of the pleura, and about +one ounce in the cavity of the pericardium. The heart was then seen +enlarged to more than double its natural size. Its surface, especially +along the course of the branches of the coronary arteries, was +whitened by coagulated lymph. In the cavities of the heart, which were +all enlarged and thickened, particularly the left, were found portions +of coagulum mixed with fluid blood. Near its apex, over the left +ventricle, was a small soft spot which, to the finger, seemed like the +point of an abscess ready to burst. The tricuspid valves, and the +valves of the pulmonary artery, had lost somewhat of their +transparency, and were a little thickened, though not materially. It +is worthy of remark, that these valves have not exhibited any great +appearance of disease in any of these cases, while those of the left +side of the heart have scarcely ever been found healthy. So it +appeared in this case. The mitral valves were uniformly thickened, and +partly cartilaginous; the left portion adhered to the side of the +heart. The valves of the aorta had lost their usual form, were +entirely cartilaginous, and almost equal in firmness to the aorta, +which was cartilaginous under the valves, sound in other parts, and +rather small, compared to the size of the heart. + +It may be thought that the symptoms, on which reliance was placed to +distinguish disorder of the valves of the aorta, are fallacious, +because it was supposed that these valves would be found ossified, +when they were in reality only cartilaginous. The difference, however, +would be small in the effects produced on the circulation by such a +state of the valves as existed in this case, and a very considerable +ossification; for, if the valves were rigid and unyielding, it is of +little importance whether they were rendered so by bone, or cartilage. +Whether the irregularity of the pulse in these diseases generally +depends on the disorganized state of the aortal, or other valves, we +have not at present observations sufficient to decide. In the sixth +case no irregularity of the pulse could be observed, although the +other symptoms were unequivocal, and no disease was found in the +valves; while, on the other hand, we find that the valves in the +fourth case were not importantly deranged, and yet there was an +irregularity and intermission of the pulse, which however might be +attributed to the dropsy of the pericardium. In the seventh case, +where the pulse was not irregular, the valves of the aorta were +"considerably thickened in various spots;" in the fifth, the pulse was +irregular, and the valves were not materially altered, but there was +water in the pericardium. In all the other cases, the pulse was +irregular, and the valves were much disordered: On a review of these +cases, therefore, we find some reason to believe, that the +irregularity of the pulse depends much on disease of the valves, +especially those of the aorta. + +The cavity of the abdomen being opened, no water was discovered in it, +nor any other uncommon appearance, except about the liver, the coat of +which had been rendered opaque by coagulated lymph, and was studded +over with soft, dark coloured tubercles. The substance of the liver +was tender, and full of bile and venous blood. + + + DISSECTION OF CASE TENTH. + TWENTY-FOUR HOURS AFTER DEATH. + +The symptoms of disease in this patient did not alter much, except in +degree, from the middle of April to the 10th of May. He became weaker, +had more straitness and pain about the heart on moving, an increase of +swelling in the legs and abdomen, return of the cough, and a pain from +the left shoulder to the middle of the arm. After his relapse in +April, he had been directed to employ blisters, the submuriate of +quicksilver, and the tincture of the digitalis purpurea. The dose of +the tincture he gradually increased, till he took two hundred drops, +two or three times in a day. Notwithstanding a profuse flow of urine, +the legs became so hard and painful, that I made punctures to +discharge the water from them. He would have had the water in the +abdomen drawn off, but believing it would not afford him great relief, +I dissuaded him from it. On the 10th of May, after having passed an +unusually comfortable night, he rose and left his chamber for five or +six hours, then retiring to it again, said he would be tapped that +day, and, after lying down, was quitted by his attendant, who went in +an hour after and found him dead. This was rather unexpected, for he +had the appearance of sufficient vigour to struggle with disease three +or four weeks longer. + +A number of medical gentlemen being assembled, as has been usual on +these occasions, we first remarked, that the face was swollen, and +extraordinarily livid; for, although a considerable degree of +lividity, and sometimes of redness, after death, is peculiar to these +cases, we had seen none which resembled this. Hard and prominent +purple spots were observed upon the shoulders, side, and back. The +surface of the body was moderately covered with fat; the legs and +abdomen were much swollen with water, the arms more slightly. The +integuments of the thorax being cut through, the cellular membrane +discharged a serous fluid from every part; these being turned aside, +to lay bare the cartilages of the ribs, we found them completely +ossified; and having divided them, with a saw, the cavity of the +thorax was opened. The cellular membrane, inside the thorax, about the +mediastinum, had not so bloody an appearance as we witnessed in the +preceding cases, nor were the lungs, either externally or internally, +so dark coloured as usual, though they were much darker, firmer, and +more filled with blood, than is common in subjects of other diseases. +The lungs of the left side adhered closely to the pleura costalis, and +those of the right were tied by loose and membranous adhesions; beside +which there was no appearance of disease about them. The cavity of the +pleura did not contain any water; that of the pericardium held about +six ounces. + +The anterior surface of the heart exhibited a considerable whiteness +of its coat over the coronary arteries. This appearance differed from +that of other cases, in being contained in the substance of the +membrane, instead of lying on its surface; and, either from this +circumstance, or from the length of time since it had existed, its +aspect was so peculiar that it might be supposed to be the first stage +of an ossification. A deposition of lymph on the heart has been +observed in every one of these cases of organic disease, and it has +existed principally over the branches of the coronary arteries, or +else near the apex of the heart, which is to be attributed to the +irritation of the membrane by the combined impulse of the heart and +coronary arteries, and to the stroke of the apex upon the ribs. This +is an appearance that, as it belongs to this complaint, might be +useful in a case otherwise dubious, if any such should occur, to aid +in deciding whether the action of the heart had been inordinate. + +The heart was enlarged to double its usual size, as we judged with +confidence, for pains had been taken to examine hearts in a healthy +state, for the purpose of forming a comparison. Its firmness was not +proportioned to its bulk, but it was considerably flaccid. Near the +apex, over the left ventricle, was a soft spot, similar to that found +in the preceding case. The venae cavae were then divided, and a torrent +of black blood issued from each of the orifices, in spite of our +efforts to restrain it. All the cavities of the heart were filled, as +we afterwards saw, with similar blood; in which circumstance this +resembles the other cases; though in this case the blood was entirely +fluid, and thinner than in cases of different disease: whereas, in +every other instance, was partly or wholly coagulated. This therefore +must be considered as another appearance peculiar to this complaint, +because it is well known, that blood is not usually found in the left +cavities of the hearts of those who die of other disorders. The cause +of it is doubtless an obstruction, which opposes the free discharge of +blood from the heart, whether that obstruction be in the aortal +valves, in the aorta itself, or in the disproportion between the +heart, or more precisely the left ventricle, and the parts it supplies +with blood. + +Why was the blood entirely fluid in this case? If we compare the +appearance of the cellular membrane, and of the lungs, in both of +which there was a deficiency of blood, with the aspect of the face, +where there was an accumulation of blood, and consider at the same +time the mode of termination of this case, we shall find reason to +believe, that death was produced by a violent pressure of the brain +from a congestion of blood in its vessels, in consequence of the +obstruction to the return of that fluid to the heart. An additional +proof of this opinion is derived from the great quantity of blood, +which poured from the vena cava superior, during the whole time of the +examination, and afterward; so that it was found impossible to +preserve the subject from the blood flowing between the ligatures, +notwithstanding the thorax was entirely emptied, before it was closed. +In cases of sudden death from apoplexy, related by Morgagni, the blood +was frequently fluid, and this may be supposed to be the cause of that +appearance in the present case. The extraordinary thinness or watery +state of the blood is a distinct circumstance, which will be presently +noticed. + +An examination of the brain, to ascertain the truth of the supposition +above mentioned, was relinquished with regret, but this was +impracticable; for the want of time on these occasions frequently +obliged us to content ourselves with investigating the state of the +most important parts. This must serve as our apology for not oftener +relating the appearance of all the principal organs; yet it should be +observed, that such methods have been employed to ascertain with +accuracy the most interesting morbid phoenomena, as would satisfy the +most scrupulous anatomist. + +The tricuspid valves and the semilunar valves of the pulmonary artery +had lost their healthy transparency, but were not otherwise diseased. +In all the above cases these valves had been found without important +derangement of their structure; a circumstance not less remarkable, +than difficult to be satisfactorily explained. The basis of the mitral +valves was marked by a bony projection, which nearly surrounded the +orifice of the ventricle; the valves themselves were thickened, and +one of them was smaller than the other. The semilunar valves of the +aorta were lessened in size, and somewhat thickened. One of them was +ossified sufficiently to annihilate its valvular function; the others +were slightly. The aorta under the valves was semicartilaginous, +ossified in one small spot, roughened by fleshlike prominences in +others, entirely deprived of the smoothness of its internal coat, and +in size proportioned to the heart. + +The parietes of the heart were thicker than those of a healthy heart, +but thin when compared with its whole volume; whence it follows, that +the cavities were enlarged. That of the left ventricle was +disproportionately larger than the others, but no difference of size +could be ascertained between the auricles. When a cavity of the heart +is situated in the course of the circulation immediately behind a +contracted orifice, it seems probable that the contraction may have an +important influence in originating the enlargement or aneurism of that +cavity; but, where there is no contraction of an orifice, what is the +obstruction which impedes the free discharge of blood from the heart, +and causes the first yielding of its parietes? Perhaps a violent +simultaneous action of many muscles, from great exertion, may, during +the systole of the heart, impede the passage of the blood through the +arteries, drive it back upon the valves of the aorta, and resist the +heart at the moment of its contraction. If the parietes of the heart +yield, in one part, it is easy to conceive a consequent distension of +the remainder to any degree; for, during the systole of the heart, the +columnae approximate, till their sides are in contact, to protect the +parietes of the heart; but, if these be distended, the columnae can no +longer come in contact with each other, and the blood passing between +them will be propelled against the parieties, and increase their +distention. The left ventricle being thus dilated, the mitral valves +will not be able to completely cover its orifice, and part of the +blood will escape from the ventricle, when it contracts, into the +auricle when dilated with the blood from the lungs; and this undue +quantity of blood will gradually enlarge the auricle. A resistance +will arise, from the same cause, to the passage of the blood from the +lungs, thence to that from the right ventricle and auricle, and thus +these cavities may become enlarged in their turns. When an +ossification of the aorta, or of its valves, exists, there will be a +resistance to the passage of the blood from the left ventricle, either +by a loss of dilatability in the artery, or a contraction of the +orifice by the ossified parts. In either case, the blood will reflow +upon the heart, and dilate the left ventricle, as in _case the first_, +and others; and, if the mitral valves be thickened and rigid, the left +auricle will be more dilated than in a case of simple aneurism of the +left ventricle, as appeared also in the _first case_. + +The coronary arteries, at their origin from the aorta, and a +considerable distance beyond, were ossified. How far does the +existence of this ossification in this and other cases related by +different authors, without symptoms of angina pectoris, disprove the +opinion that it is the cause of that disease? + +The abdomen being opened, the organs generally appeared sound, except +the liver, which had its tunic inflamed, its substance indurated and +filled with blood. The vestiges of inflammation in the coat of the +liver were traced in every instance already related, while at the same +time the liver, in all, appeared shrunken. The diminution of size in +the liver, after death, cannot at present be well explained; for it is +very certain that such a diminution is not an attendant of this +disorder, during most of its stages, but that on the contrary a state +exists precisely opposed to it. The indications of distention of the +liver, clearly perceived in some cases, have been pain, tenderness, +and sense of distention, in the right hypochondrium, and, what is less +equivocal than these, very considerable swelling and prominence of the +liver. The inflammation of its tunic is an effect of this distention +and of the consequent pressure against the adjacent parts. + +The cause of this phoenomenon can easily be explained. If an +obstruction exist in either side of the heart, or in the lungs, the +blood to be poured into the right auricle, from the vena cava +inferior, must be obstructed, its flow into that vessel from the liver +will be equally checked, the thin coats of the hepatic veins and of +the branches of the vena porta will yield and distend the soft +substance of the liver. Hence are caused the discharges of blood from +the haemorrhoidal veins, which form one of the characteristic symptoms +of the disease; for as these vessels empty their blood into the +meseraic veins, which open into the vena porta, if the meseraic veins +be obstructed, the haemorrhoidals must consequently be also affected, +and they easily burst open from too great distention. The haemoptoe, +which also is so frequent, is as easily explained on the same +principle. + +The cause of the serous collections is not so readily discovered. In +this case, as in most of the others, we found a considerable quantity +of water in the abdominal cavity. Dropsy is commonly considered as a +disease of debility, but in these cases it often appeared, while the +strength was unimpaired, and the heart acted with very extraordinary +force. If the blood was driven with rapidity through the arteries, +while an obstruction existed at the termination of the venous system +in the heart, the consequences must have been accumulation in the +venous system, difficult transmission of the blood from the extreme +arteries to the veins, overcharge of the arterial capillary system, +consequent excitement of the exhalant system to carry off the serous +part of the blood, for which it is adapted, and thence a serous +discharge into the cavities, and also on the surface of the body; for +great disposition to sweating is a common symptom. In addition to +these, there is another cause of the universality of these effusions. +The blood, in all the cases which I have examined, is both before and +after death, more thin and watery than healthy blood. How this +happens, our knowledge of the theory of sanguification does not enable +us to determine. Perhaps, as the imperfect respiration must cause a +deficiency of air, and consequently of oxygen, in the lungs; and as +the absorption of oxygen is a cause of solidity in many bodies, this +tenuity of the blood may proceed from a deficient absorption of +oxygen. However this may be, it is certain that the blood is very much +attenuated, though with considerable variations in degree, as it is +sometimes found thin on opening a vein, and at a subsequent period is +thicker; varying perhaps according to the continuance of ease or +difficulty in respiration. It is certain, that this attenuation of the +blood must tend to an increase of the serous exhalations. + +That these secondary dropsies are not the effect of debility appears +pretty evident from considering, that they often exist while the +strength of the patient is yet undiminished, while all the other +secretions, except that of the urine, are carried on with vigour, and +while the appetite and digestive functions are not only unimpaired, +but improved. + +The examinations of the _ninth_ and _tenth cases_ are particularly +valuable, because they confirm what had been observed in other +subjects; they exhibit two well marked instances of aneurism of the +heart, and present us a view of organic disease unattended by dropsy +of the pleura. This must be sufficient to remove the suspicion, that +the symptoms we have attributed to the former disease might arise from +the existence of the latter. No one probably will be willing to impute +a chronic disease, terminated by a sudden death, to five or six ounces +of water in the pericardium; for such a quantity, though it might +produce inconvenience, could not prove fatal, unless it were suddenly +effused; and, if this were true, it of course could not have been the +cause of the long train of symptoms observed in _case tenth_. + +Dr. William Hamilton, the author of a valuable treatise on the +digitalis purpurea, thinks the hydrothorax a more frequent disease +than has commonly been imagined, because he conceives that it has +often been mistaken for organic disease of the heart. He names, with +some precision, many symptoms of the latter complaint; but how remote +he is from an accurate knowledge of it may be discovered by his +opinion, that, in diseases of the heart, "the patient can lie down +with ease, and seldom experiences much difficulty of breathing." The +limits of this paper do not admit a discussion of this and other +points, respecting which he seems to be mistaken. We must therefore +submit them to be decided by the evidence adduced in Dr. Hamilton's +"observations," and by that which may be drawn from these cases, and +future investigations of the subject. It will perhaps hereafter appear +surprising, that derangements in the structure of so important an +organ as the heart should have been lightly estimated by very +respectable authors. + + * * * * * + +While concluding these observations, a case of this disease presented +itself, which comprehends so many of the symptoms, that I cannot +neglect an opportunity of recording it, especially as it exhibits the +complaint in an earlier stage than the others, with appearances +equally unequivocal. I may here be allowed to remark, that no cases +have been introduced which occurred before my attention was directed +to a close observation of this disorder, and that there are many +others, under the care of practitioners of eminence belonging to this +society, with symptoms perfectly well marked, which it has not been +thought necessary to adduce. In proof of this, reference may be had to +Dr. Warren, sen. who has a number of cases, and also to Dr. Dexter, +Dr. Jackson, and Dr. J. C. Howard. + +A lady from the country, of a robust habit, whose age is about +thirty-four years, complains of uneasiness in the right side below the +edge of the ribs, sometimes attended with swelling, external soreness, +and a throbbing pain, which often reaches to the shoulder, and +produces a numbness of the right arm. She is rather uncertain at what +time her complaints commenced. About two years since she lost her +husband, and was left with but small means to support a number of +children. She became in consequence, much dejected. While nursing a +child, about a year since, she first was sensible of palpitations of +the heart, which, in about three months, were followed by dyspnoea +very much augmented by ascending an eminence; and profuse discharges +of blood from the mouth, first raised, she believes, by vomiting, and +afterwards by coughing. Evacuations of blood from the haemorrhoidal +vessels appeared about the same time, and occasionally since, till +within six weeks, during which time there have been no sanguineous +discharges, and this suppression has aggravated her other complaints. + +The pulsation of the heart is felt most distinctly quite on the left +side of the thorax, where there is a painful spot; it is perceptible +also in the epigastric region. It is irregular and variable, at one +moment hard, strong, distinct, and vibrating; at another, feeble and +confused. There is also sometimes perceived a pulsation above the left +clavicle, within the insertion of the mastoid muscle, commonly +attended with a visible fulness of the superior part of the breast. +The thorax feels, to the patient, as if it were girt across, and there +is a distinct pain in the heart. Both these sensations are aggravated +by a very hard, frequent, and dry cough, which however begins to be +less violent from the use of the scilla maritima. The countenance is +animated, and rather flushed, but not so much overcharged with blood +as happens in many instances; perhaps it little exceeds a blush, so +moderate that it might be considered as an indication of perfect +health; yet the head is greatly disturbed with dizziness, and +frequent and intense pain, and is seen to be shaken by the +palpitations. + +The functions of the abdominal viscera are not much deranged. The +appetite varies, though it is commonly good; the intestinal +evacuations, and the menstrual discharges, are regular; the urine is +turbid, and so small in quantity as sometimes to produce strangury. +The abdomen and inferior extremities are swelled, and the distention +produces an uneasiness in the former, and pain and a livid colour +about the gastroenemii muscles in the latter. The pulse is hard, +without strength or fulness, slightly intermittent, variable, and +irregular; yet it has not so much irregularity as in most of the cases +recorded above. + +This patient is uneasy in bed, though she raises her head almost +upright; her sleep is disturbed by unpleasant dreams, and by +startings, sometimes quite to an upright posture, without any cause +discoverable to herself. She can incline a little to the left side, +but never to the right, because it brings on a singular oppression, +and a sense of weight drawing on the left side. When most distressed +by dyspnoea she bends her head and trunk forward, and remains thus +seated a considerable portion of the night, often sighing quickly and +convulsively. She is subject to profuse sweatings, and very liable to +take cold, and is then more uneasy. + +This lady is still corpulent. She has taken much medicine, under the +direction of eminent physicians, sometimes with temporary relief, but +most commonly without any. The exercise of walking slowly, in +pleasant weather, although it increases the palpitations at the +moment, is followed with relief from the distressing feelings, which +are increased when she sits still for a long time. She has no +suspicion of her hopeless situation, and confidently expects relief +from medicine, yet labours under a melancholy which is unnatural to +her. + + + CASE OF HYDROTHORAX. + + The following case of hydrothorax will shew, that water may + exist in the chest without the symptoms, which we have + attributed to organic diseases of the heart. + +Mrs. T----, aged 56 years, of an excessively corpulent habit, had been +affected for a great number of years with a scirrhus of the right +breast. Finding her health decline, she at last disclosed it, and in +coincidence with the opinion of Dr. WARREN, sen. I amputated it on the +30th of May, of the present year. We however informed her friends, +that the probability of eradicating the disease was extremely small. +The skin was in many places hardened and drawn in, and in others +discoloured, and ulcerated at the nipple, so that it was found +necessary to remove, not only what covered the breast, but some +portion of that which surrounded it. A long chain of diseased glands, +extending quite to the axillary vessels, was also extirpated. She bore +the operation well, lost no great quantity of blood, and recovered her +appetite and strength surprisingly in a few days, while the wound +healed rapidly. At the end of twenty days a difficulty of breathing +commenced, and soon became so oppressive, that she could no longer lie +in bed; partly, no doubt, on account of her extraordinary obesity. The +pulse was small, quick, and commonly feeble, but sometimes a little +hard, when any degree of fever was present. The countenance became +pale, the lips of a leaden hue, the eyes dim. We were surprised at the +change, and conjectured that the cancerous action had suddenly +extended to the lungs. Yet she had not the slightest cough; and it was +remarked by Dr. WARREN, sen. that he had never observed that diseased +action to increase, while the wound remained open. At last the lower +extremities swelled, which might be attributed to the upright posture, +and the pressure on the absorbent vessels in that posture. The +appetite failed; she complained of a constant sense of depression at +the stomach, and, without any remission of the difficulty of +breathing, died on the 1st of July. + +On the next morning the body was examined. The pleura in both cavities +of the thorax was studded with small, white, and apparently +homogeneous tubercles; the lungs contained a great number of similar +bodies. The right cavity of the pleura was entirely filled with water, +of which we removed at least three quarts. The heart was of the usual +size, very flaccid and tender; but not otherwise disordered. The liver +was enlarged, of its usual colour, much hardened, and had on its +surface, and in its substance, many tubercles like those in the +thorax. It had also a great number of encysted cavities, each about +the size of a hazle nut, which contained a thin yellow fluid. The gall +bladder was wanting, and in its place there was a small, but very +remarkable depression, without a vestige of any former gall bladder, +for the coat of the liver was as smooth and perfect there as in any +other part[15]. The pancreas was in a scirrhous state. The abdomen did +not contain any water. + + [Footnote 15: See Soemmerring de corporis humani fabrica, + vol. 6, pag. 188 and Baillie's morbid anatomy, pag. 248.] + +It seems, then, that water may exist in the cavity of the thorax, +without any remarkable symptoms, except dyspnoea and difficulty in +assuming the horizontal posture. But in organic diseases of the heart, +there is a long train of frightful symptoms, distinguishable by the +most superficial observers. We infer that these disorders have been +unnecessarily confounded. + + + + + +End of the Project Gutenberg EBook of Cases of Organic Diseases of the Heart, by +John Collins Warren + +*** END OF THIS PROJECT GUTENBERG EBOOK HEART DISEASE *** + +***** This file should be named 26836.txt or 26836.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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