Cases of Organic Diseases of the Heart Part 4

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 princ.i.p.al organs; yet it should be observed, that such methods have been employed to ascertain with accuracy the most interesting morbid phnomena, 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 circ.u.mstance 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 pa.s.sage 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 pa.s.sing 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 quant.i.ty of blood will gradually enlarge the auricle. A resistance will arise, from the same cause, to the pa.s.sage 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 pa.s.sage 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 phnomenon 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 quant.i.ty 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 acc.u.mulation 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 appet.i.te 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 quant.i.ty, 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 pract.i.tioners 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 dyspna 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 appet.i.te varies, though it is commonly good; the intestinal evacuations, and the menstrual discharges, are regular; the urine is turbid, and so small in quant.i.ty 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 dyspna 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 quant.i.ty of blood, and recovered her appet.i.te 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 appet.i.te 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 h.o.m.ogeneous 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 dyspna and difficulty in a.s.suming 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.