Cases of Organic Diseases of the Heart Part 3

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 dyspna 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 acc.u.mulation of carbon in the system; for the countenance becomes livid, and the skin, especially that of the extremities, receives a permanent dark colour. This dyspna 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 dyspna 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 phnomena 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 dyspna, 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 appet.i.te 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 acc.u.mulation 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 acc.u.mulation 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 circ.u.mstance more remarkable in the course of this complaint, than the alternations of ease and distress. At one time the patient suffers the severest agonies, a.s.sumes the most ghastly appearance, and is apparently on the verge of death; in a day or a week after, his pain leaves him, his appet.i.te 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 dyspna 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 distinguis.h.i.+ng 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 dyspna 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 const.i.tutions; 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 princ.i.p.ally 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 quant.i.ty 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 diminis.h.i.+ng the impetus of the heart, but by lessening the quant.i.ty 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 dyspna. 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 quant.i.ties, stimulating liquors cautiously avoided, and the repose of body and mind preserved, as much as possible.

The causes of some of the phnomena 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 b.l.o.o.d.y; and that, for sometime before death she suffered inexpressible distress.

We found the body somewhat emaciated, and the lower extremities and left arm dematous. 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 b.l.o.o.d.y, 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 s.p.a.ce, 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 acc.u.mulated; but whether this acc.u.mulation 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 acc.u.mulation of blood in the lungs seems to me to be the probable cause of the dyspna, which so much distresses those affected with diseases of the heart; for if there be an inordinate quant.i.ty of blood, there must be a deficiency of air.

This acc.u.mulation 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 b.i.+.c.hat, 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 pa.s.sed 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 a.s.sembled, 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 b.l.o.o.d.y 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 circ.u.mstance, 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 princ.i.p.ally 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 circ.u.mstance 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 acc.u.mulation 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 quant.i.ty 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 circ.u.mstance, which will be presently noticed.