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                                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  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
, 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 ; 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  mucus, sometimes
tinged with blood. The abdominal viscera lost their activity. The face
was sometimes turgid and high , 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 ,
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 .

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
, 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 <DW64>, 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
 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 . 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 , 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  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 .
      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 , 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 ,
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  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  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

*** 