Chapter 2

The blood appeared every where fluid, except in some portions of the lungs, and in the cavities of the heart. It was very dark coloured, perhaps more than ordinarily thin, and oozed from every part, which was cut.

The cellular membrane, in all dependent parts, effused, when cut, a serous fluid.

CASE II.

Mr. John Jackson, fifty-two years of age, had been affected for more than two years with palpitations of the heart, and paroxysms of dyspnoea. These symptoms increased in October, 1808, and were followed by strong cough, uneasiness in lying down, sudden startings in sleep, and an inclination to bend the body forward and to the left side. His cough, during the last part of his life, was attended with copious bloody expectoration. His countenance was florid; his pulse very irregular, though not quite intermittent. The occasional variations in the state of the disease were remarkable. Some periods were marked with uncommon mental irritability. Pain in the region of the liver, oedema of the inferior extremities, paucity and turbidness of the urine, yellowness of the skin, and great emaciation attended the latter stages of the disease. A degree of stupor occurred. The termination on the 30th of January, 1809, was tolerably quiet. Two days before death he sank into the recumbent posture, and his pulse became more regular[5].

[Footnote 5: The symptoms of this patient were related by Dr. Rand, sen. to whose politeness and love of medical improvement I am indebted for the opportunity of examining this and the following case.]

DISSECTION, TWENTY-FOUR HOURS AFTER DEATH.

On opening the thorax, its right cavity was found to contain a large quantity of water; the left, a smaller quantity.

The lungs were of a firm, condensed texture, especially at the lower part, where their solidity was nearly equal to that of a healthy liver. They contained black blood.

The heart was much enlarged, and proportionally thickened. Its tunic was in some places covered with coagulated lymph, especially over the coronary arteries. Its cavities were filled with black coagulum, which in the right auricle and ventricle had a slight appearance of polypus. The semilunar valves of the pulmonary artery and aorta were unusually small, and their bases cartilaginous. Those of the aorta had lost their form, and were slightly ossified. The remaining valves were partially thickened. The arch of the aorta was very much dilated, its internal coat covered with a bony crust, which extended through the remaining thoracic portion, gradually diminishing. This portion was also considerably dilated.

The liver was indurated; its peritonaeal coat exhibited a flaccid or wrinkled appearance, and bore marks of slight inflammation. The gall bladder was filled with bile, and the pancreas indurated.

CASE III.

Captain Job Jackson, forty-five years of age, a man of vigorous constitution, after an indisposition of some years continuance, was seized with palpitations of the heart and dyspnoea, occurring by variable paroxysms, especially on ascending an eminence, and attended by hardness, irregularity, and intermission of the pulse. To these symptoms were superadded dizziness and severe head-ache, a disposition to bend the body forward, sudden starting from sleep, with dread of suffocation, violent cough with copious expectoration, which for fifteen days before death consisted of black blood, distressing pain across the chest, especially on the left side, great oedema of the lower extremities, and paucity of urine.

He died painfully in January, 1809, after violent struggles for breath. The day before death the pulse became regular. He rested his head upon an attendant, and made no attempts to lie down for some days previous[6].

[Footnote 6: The symptoms of this case were related to me by Dr. Rand, sen.]

DISSECTION, SIXTEEN HOURS AFTER DEATH.

The skin was of a yellow colour. The inferior extremities, quite to the groins, were oedematous.

The left cavity of the thorax was filled with water; the right contained only a small quantity. The pleura costalis, on the left side opposite to the heart, was thickened and covered with a very thick flocculent coat of coagulated lymph, and the pericardium opposite to it had the same marks of inflammation. The lungs on that side were pushed up into a narrow space. They were dense and dark coloured.

The pericardium contained little more than the usual quantity of water. The heart, which exhibited marks of some inflammation on its surface, was astonishingly large, and firm in proportion. Its cavities were principally filled with coagulum. The semilunar valves of the pulmonary artery had their bases slightly ossified, and the remaining part thickened. There were only two valves of the aorta, and these were disorganized by the deposition of ossific matter about their bases, and a fleshlike thickening of the other part[7]. The parietes of the heart, especially of the left ventricle, were greatly thickened, and somewhat ossified near the origin of the aorta.

[Footnote 7: See plate first.]

The liver had the same appearance as in case second.

CASE IV.

Thomas Appleton, thirty-eight years of age, of a robust constitution, was affected with excessive difficulty of breathing, occurring at intervals of different duration. It commenced three years before his death, and gradually increased. He was subject to palpitations of the heart for at least two years before his death, and was distressed with violent cough, attended with copious expectoration, which finally became very bloody. The palpitation and dyspnoea were greatly augmented by ascending stairs. His countenance was very florid.

Sometimes he was seized with violent head-ache and dizziness, which, as well as the other symptoms, were greatly relieved by venesection. About two months before death oedema of the legs appeared, which was soon followed by frequent and alarming syncope. His pulse was irregular, intermittent, hard, and vibrating. When lying down he frequently awoke, and started up in great terror. His usual posture was that of sitting, with his trunk and head bent forward, and inclining to the left side. For some time before death a recumbent posture threatened immediate suffocation; yet, three days previous to the occurrence of that event, he sank back upon the pillow. He was, at intervals, so much better as to think himself free from disease. Slight delirium preceded his death, which occurred in January, 1809[8].

[Footnote 8: The symptoms in this case were related to me by Dr. Warren, sen.]

DISSECTION, EIGHTEEN HOURS AFTER DEATH.

The countenance continued florid. The inferior extremities were much distended with water, and the cellular membrane abounded in fat.

The right cavity of the pleura contained a moderate quantity of water; the left, scarcely any. The lungs were firm, condensed, and dark coloured, from venous blood. The pleura, on the left side opposite to the pericardium, appeared to have been inflamed, as there was an effusion of coagulated lymph on its surface.

The pericardium was much distended with water. The heart, on the anterior surface of which were some appearances of inflammation, was very much enlarged. Its parietes were thickened; its cavities unnaturally large, and filled with black coagulum. Each of the valves had lost, in some degree, its usual smoothness, and those of the aorta were, in some points, thickened, and partly cartilaginous.

The liver was small, and, when cut, poured out dark blood. Its tunic was whitish, opaque, and corrugated.

CASE V.

A. B. a negro, about thirty-five years of age, had paroxysms of dyspnoea and violent cough, attended with oedema of the extremities and ascites, violent head-ache, dizziness, brightness of the eyes, palpitations of the heart, irregular, intermittent, slow, and soft pulse. These symptoms slowly increased, during three or four years, in which time the dropsical collections were repeatedly dispersed. He gradually and quietly died in the alms-house, in January, 1809.

DISSECTION.

On dissection, the cavities of the pleura were found to contain a considerable quantity of water. The pericardium was filled with water; the heart considerably enlarged; its parietes very thin, and its cavities, especially the right auricle and ventricle, morbidly large[9].

[Footnote 9: This dissection was performed by Dr. Gorham.]

CASE VI.

Mrs. M'Clench, a washer-woman, forty-eight years of age, of good constitution and regular habits, was attacked, in the summer of 1808, with palpitations of the heart and dyspnoea on going up stairs, severe head-ache, and discharges of blood from the anus. These symptoms did not excite much attention. In the winter of 1808-9, all of them increased, except the palpitations. The inferior extremities and abdomen became distended with water; the region of the liver painful; the skin quite yellow; the pulse was hard, regular, and vibrating; the countenance very florid. Violent cough followed, and blood was profusely discharged from the lungs. This discharge being suppressed, evacuations of blood from the anus ensued, under which she died, in March, 1809.

DISSECTION.

The right cavity of the thorax was filled with water; the left contained none. The lungs were sound, but very dense, full of dark coloured blood, and, on the right side, pressed into the upper part of the thorax. The heart was one half larger than natural; its substance firm, and its anterior part, especially near the apex, covered with coagulated lymph. The right auricle and ventricle were large, and their parietes thin. The parietes of the left auricle and ventricle, particularly of the latter, were much thickened, and their cavities were filled with black coagulum.

The liver was contracted; its coat wrinkled, and marked with appearances of recent inflammation.

CASE VII.

To JOHN C. WARREN, M. D.

MY DEAR SIR,

Your important communication to our society, which is about to be published, will lay before the American public much more knowledge respecting the diseases of the heart, and large vessels, than has hitherto been presented to them. A case has lately fallen under my observation, having so much similarity to those of organic diseases of the heart, which have occurred to you, as to mark its affinity, yet with some differences, which characterize it as a variety. If the statement of it will add any value to your collection of cases, you are at liberty to publish it.

A. S. twenty-eight years of age, and of middle stature, was attacked, after a debauch, with pain in the region of the heart, which subsided, but returned a year after on a similar occasion. He then became affected with palpitations of the heart for six months, great difficulty of breathing, which was augmented by ascending an eminence, severe cough, dizziness, and violent head-ache, attended by a disposition to bend the body forward, and sudden startings from sleep. His pulse was always regular, and never remarkably hard. His countenance, till within a few weeks of death, presented the appearance of blooming health. His feet and legs did not swell at any period of the disease. He suffered exceedingly from flatulence, to which he was disposed to attribute all his complaints. This symptom might have been aggravated by his habits of free living, and occasional intoxication, which he acknowledged, and to which he traced the origin of his disease.

After death, water was discovered in the thorax; but the lungs had not that appearance of accumulation of blood, in particular spots, which is commonly observed in cases of organic disease of the heart. The only very remarkable morbid appearance about the heart was in the aorta, and its valves. The valves had lost their transparency, and were considerably thickened in various spots. The inner surface of the aorta, for about an inch from its commencement, was elevated and thickened, and the external surface singularly roughened and verrucated. This appearance was so peculiar, that no words will give a competent idea of it, and perhaps it would be sufficient for me to call it a chronic inflammation[10].

I am, my dear sir, Your friend and obedient servant, JAMES JACKSON.

[Footnote 10: See plate second.]

CASE VIII.

Col. William Scollay, aged fifty-two, of a plethoric habit of body, was attacked, in the year 1805, with dyspnoea and palpitation of the heart, attended with irregularity of the pulse, and oedema of the lower extremities. By the aid of medicine, the dropsical collections were absorbed, and he recovered his health, so far as to follow his usual occupations, nearly a year; but was then compelled to relinquish them. The symptoms afterwards underwent various aggravations and remissions, till the beginning of the winter of 1808-9, when the attacks became so violent, as to confine him to the house. His face was then high coloured. The faculties of his mind were much impaired. The dyspnoea became more constant, and was occasionally attended by cough; the palpitations rather lessened in violence; the pulse was more irregular, and exceedingly intermittent. The abdomen and inferior extremities were sometimes enormously distended with water, and afterwards subsided nearly to their usual size. One of the earliest, most frequent, and distressing symptoms, was an intense pain in the head. About two months before death, a hemiplegia took place, but after a few days disappeared. This so much impaired the operations of the mind, that the patient afterwards found great difficulty in recollecting words sufficient to form an intelligible sentence. During the existence of the last symptom the pulse was regular.

He gradually expired, on the 15th of March, 1809.

DISSECTION, FIVE HOURS AFTER DEATH.

EXTERNAL APPEARANCE.

The countenance was somewhat livid and pale; the lips were very livid. The chest resounded, when struck, except over the heart. The abdomen was tumid, and marked by cicatrices like those of women, who have borne children. The superior extremities were emaciated, and marked like the abdomen. The lower extremities were oedematous.

THORAX.

The cartilages of the ribs were ossified. The left cavity of the pleura contained about twelve ounces of water; the right, about three ounces. The lungs, externally, were dark coloured, especially the posterior lobes; internally, they were very firm, and, in some places, as dense as the substance of the liver. A frothy mucus was effused from them in great quantities. They were coloured by very dark blood, especially in the middle portion of the left superior lobe. One or two calcareous concretions were observed in them. The pericardium was a little firmer than usual, and contained about five ounces of water. The heart was enlarged, and covered with tough fat. In the right auricle, and ventricle, was some coagulated blood. The tricuspid valves had lost their smoothness and transparency; the semilunar valves of the pulmonary artery were cartilaginous at their bases. The left auricle and ventricle, particularly the first, contained coagulum. The mitral valves were roughened by many bony spots. Considerable ossification had taken place in the semilunar valves of the aorta, so that one of them had quite lost its form; and the aorta was ossified for the space of a square inch, at a small distance from the valves. The coronary arteries were also ossified.

ABDOMEN.

The coat of the liver was somewhat wrinkled, as if shrunk. Its substance was hard, and discharged, when cut, great quantities of blood. The veins of the omentum, mesentery, and intestines, were full of blood. The abdomen contained a considerable quantity of water.

HEAD.

Water was found between the dura and pia mater, and between the pia mater and arachnoides. The vertical portion of the pia mater bore marks of former inflammation. The convolutions of the brain were very distinct; their external surface was pale. The veins were empty[11]. No bloody points were observed in the medullary portion of the brain, when cut. The ventricles contained between one and two ounces of water; the communication between them was very large. The plexus choroides was pale.

[Footnote 11: In this case, and in case first, the vena cava ascendens had been divided, before the brain was examined.]

CASE IX.

A lady, about forty-five years of age, the mother of many children, has been troubled during the course of the past year with violent palpitations of the heart, and great difficulty of respiration, especially on going up stairs. These complaints have lately increased, so that she has kept in her chamber about two months. Her countenance is florid; her eyes are clear and bright. She has dizziness, especially on moving, without pain in her head. She had for some time, a severe cough, which is now relieved. The dyspnoea is not yet very distressing, except on using motion; it often occurs in the night, and obliges her to rise and sit up in bed. The palpitations are very hard, and so strong, that they may be perceived through her clothes; the tumult in the thorax is indescribable. The functions of the abdominal viscera are unimpaired. The pulse is hard, vibrating, irregular, intermittent, very variable, corresponding with the motions of the heart, and similar in each arm. There is not yet the slightest reason to suspect any dropsical collection. The alternations of ease and distress are very remarkable, but on the whole, the violence of the symptoms increases rapidly.

There is no difficulty in discovering in this case an organic disease of the heart, which probably consists in an enlargement and thickening of the heart, and an ossification of the semilunar valves of the aorta.

CASE X.

Levi Brown, a cabinet-maker, forty-eight years of age, complained in February, 1809, of great difficulty of breathing, and an indescribable sensation in the chest, which he said was sometimes very distressing, and at other times quitted him entirely. Being a man of an active mind, he had read some medical books, whence he got an idea, that he was hypochondriac.

On examining his pulse, it was found to be occasionally intermittent, contracted, and vibrating. He had some years previously been attacked with copious haemorrhages from the stomach or lungs, which have occasionally recurred, though they have lately been less frequent. Eight years since he suffered from an inflammation of the lungs; and about two or three years ago he first experienced a beating in the chest, and pain in the region of the heart, which increased till within six or eight months, since which the beating has been stationary, and the pain has much increased. In the course of the last summer, dyspnoea, on using exercise, and especially ascending any eminence, commenced. This has greatly increased, so as to render it almost impossible for him to go up stairs. His countenance is turgid, and uniformly suffused with blood; his eyes are bright and animated; his lips livid. The pulsation of the heart cannot be felt on the left side, and is barely perceptible on the right side of the sternum, and in the epigastric region. When he is distressed with fits of dyspnoea, he feels something as if rising to the upper part of the thorax, and the heart then seems to him to be beating through the ribs. I have not witnessed any of these paroxysms. The inferior extremities and abdomen have been swelled about three weeks. When in bed, he has his head and shoulders elevated, and, upon the attack of his paroxysms, sits up and inclines his head forward; but he keeps from the bed as much as possible. In his sleep he is apt to start up, suddenly, in distress, especially when he first slumbers. His dreams are often frightful, and, when awake, he is affected with reveries, during which, though conscious of being awake, strange illusions present themselves. At intervals he seems slightly delirious. He has a violent cough, with very copious expectoration of thick mucus. He often suffers from severe head-ache, and the least exercise produces dizziness.

This man has a very robust frame of body, and has been accustomed to a free use of ardent spirits, and of opium, of which he now takes about twelve grains in a day. His appearance is such, that, on a slight survey, one would not suppose him diseased, but, on observing him with a little attention, a shortness and labour of respiration are perceived, with some interruption in speaking, and a frequent catching of the breath, or sighing.

April. Since writing the above account, the dropsical collections were absorbed, and the palpitations and other symptoms moderated, so that he considered himself nearly well, and attended to his usual business. Within a few days, however, the symptoms have returned with more violence. The dyspnoea is at times very distressing; the pulse more irregular and intermittent; the palpitations are more constant. His sufferings from lying in bed are so increased, that in the most comfortable nights he passes, he sits up once in an hour or two. The appetite is keen. The legs begin to swell again.

Some organic disease of the heart exists in this case. The indistinctness of the palpitations, the want of hardness in the pulse, and the slow progress of the disease, indicate a loss of power in the heart, the effect of the distention and thinness of its parietes. The irregularity of the pulse affords some reason to suspect disorder of the aortal valves, which is not yet very considerable.

ENUMERATION _of the principal morbid changes, observed in the organization of the heart, in the preceding cases_.

Enlargement of the volume of the heart, or aneurism.[12] Increase of the capacity, or aneurism of the right auricle, } with of the right ventricle,} thickened, of the left auricle } or thin, of the left ventricle, } parietes. of the aorta, with thickening of its coats.

Fleshlike[13] thickening of the mitral valves. of the aortal valves. of the aorta.

Cartilaginous thickening of the internal membrane of the heart, and generally of its valves.

Ossification of the parietes of the heart. mitral valves. aortal valves. aorta. coronary arteries.

[Footnote 12: Morgagni uses this term, which he borrows from Ambrose Pare, to express dilatation of the cavities of the heart. It seems to be as applicable to the dilatation of the heart, as to that of an artery. I have therefore adopted it in this enumeration.]

[Footnote 13: The term fleshlike is employed to express that roughness of the valves, which somewhat resembles flesh in its appearance, but which is very different from the thickening of the parietes of the heart.]

ENUMERATION _of the principal morbid appearances, observed in these cases of disease of the heart, which may be considered secondary_.

IN THE CAVITY OF THE CRANIUM.

Inflammation of the meninges. Water between the meninges. Water in the ventricles.

IN THE PLEURA AND ITS CAVITY.

Inflammation and thickening of the pleura. Collection of water in its cavity. Lungs dark coloured. generally very firm, and particularly in some parts. loaded with black blood. crowded into a narrow space.

IN THE PERICARDIUM AND ITS CAVITY.

Inflammation and thickening of its substance. Adhesion to the heart and lungs. Collection of water in its cavity.

IN THE CAVITY OF THE ABDOMEN.

Collection of water. Liver very full of fluid blood. having its tunic flaccid and inflamed. Mesenteric veins full of blood.

CELLULAR MEMBRANE full of water.