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 thevalve. 

_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 case7th. The valves are smaller than usual, and their form is in somedegree changed. A round spot, thickened, is seen at a little distancefrom 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 tohave attracted the observation of those, who have devoted anyattention to the study of morbid anatomy. Derangements of the primaryorgan of the circulation cannot exist without producing so greatdisorder of the functions of that and of other parts, as to besufficiently conspicuous by external signs; but, as these somewhatresemble the symptoms of different complaints, especially of asthma, phthisis pulmonalis, and water in the thorax, it has happened, thateach of these has been sometimes confounded with the former[1]. Theobject of the following statement of cases is to shew, that, whateverresemblance there may be in the symptoms of the first, when takenseparately, to those of the latter diseases, the mode of connectionand degree of those symptoms at least is quite dissimilar; and thatthere 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 § 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, quæ 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 withextraordinary clearness in the following case. The opportunity forobserving them was very favourable; and there was every incitement toclose observation, which could arise from the important andinteresting character of the patient. These advantages will justify anuncommon minuteness in the detail of the case; especially, as the mostaccurate knowledge of a complaint is obtained from a successive viewof its stages. 

The late Governour of this commonwealth was endowed with most vigorouspowers of mind and body. At the age of sixteen he was attacked withfits of epilepsy, which first arose from a sudden fright, received onawaking from sleep in a field, and beholding a large snake erectingits head over him. As he advanced in life they became more frequent, and were excited by derangement of the functions of the stomach, oftenby affections of the mind, by dreams, and even by the sight of thereptile which first produced the convulsions. 

At the commencement of the American revolution he became deeplyengaged in public affairs; and from that time devoted himself tointense application to business, with which the preservation of hishealth was never allowed to interfere. In the expedition against RhodeIsland, an attack of inflammation of the lungs had nearly proved fatalto him. 

In the beginning of the year 1807, he suffered severely from theepidemic catarrh; and a remarkable irregularity of the pulse was thenperceived to be permanent, though there is some reason to believe, that this irregularity had previously existed, during the fits ofepilepsy, and for a few days after them. In the summer, while he wasapparently in good health, the circulation in the right arm wassuddenly and totally suspended; yet, without loss of motion orsensation. This affection lasted from noon till midnight, when it assuddenly ceased, and the circulation was restored. In the autumn hewas again seized with the influenza, which continued about threeweeks, leaving a troublesome cough of two or three months’ duration, and a slight occasional difficulty of breathing, which at that timewas not thought worth attention. Soon after, in November, he had oneor two singular attacks of catarrhal affection of the mucous membraneof the lungs, which commenced with a sense of suffocation, succeededby cough and an expectoration of cream coloured mucus, to the quantityof a quart in an hour, with coldness of the extremities, lividity ofthe countenance, and a deathlike moisture over the whole body. Theseattacks lasted six or eight hours, were relieved by emetics, anddisappeared, 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 hewas unaccustomed to mention any complaint, which was not sufficientlydistressing to require relief. He experienced a difficulty ofrespiring, as he ascended the stairs, and became remarkablysusceptible of colds, from slight changes of clothing, moisture of thefeet, or a current of cold air. His sleep was unquiet in the night, and attended with very profuse perspiration; and, in the latter partof the day, a troublesome heaviness occurred. The sanguiferous vesselsunderwent an extraordinary increase, or, at least, became remarkablyevident. The pulsation of the carotid arteries was uncommonly strong;the radial arteries seemed ready to burst from their sheaths; theveins, especially the jugulars, in which there was often a pulsatorymotion, were every where turgid with blood. The countenance was highcoloured, and commonly exhibited the appearance of great health; but, when he was indisposed from catarrh, this florid red changed to alivid colour; which also, after an attack of epilepsy, was observablefor two or three days on the face and hands. This livid hue was oftenattended, under the latter circumstances, with something likeecchymosis over the face, at first formidable in its aspect, andgradually subsiding, till it had the general appearance of aneruption, which also soon vanished. 

These symptoms increased, almost imperceptibly, during the five firstmonths of the year 1808. Much of this time was passed in closeapplication to official duties; and it seemed that a constant andregular occupation of the mind had the effect of obviating theoccurrence of any paroxysm of disease, as well of epilepsy, as ofdifficult respiration; and that a very sudden and disagreeableimpression generally produced either one or the other. There were, indeed, independently of such circumstances, some occasionalaggravations of those symptoms. Some nights, for example, were passedin sitting up in bed, under a fit of asthma, as it was called;sometimes the mind became uncommonly impatient and irritable; the bodygradually emaciated; yet the appetite and digestive functions remainedprincipally unimpaired; and persons around were not sensible of anymaterial alteration in the condition of the patient. 

On the approach of warm weather, in June, the violence of the symptomsincreased. Paroxysms of dyspnœa occurred more frequently, and weremore distressing. They commenced with symptoms of slight febrileaffection, such as hot skin, hard, frequent, and more irregular pulse, disordered tongue, loss of appetite, and derangement of the digestivefunctions. This kind of paroxysm lasted two or three days. Evacuationsof blood from the nose and hæmorrhoidal vessels, which before rarelyoccurred, became frequent; a fulness at the upper and right side ofthe abdomen was sometimes perceptible, formed apparently by temporaryenlargement of the liver; the difficulty in ascending an eminenceincreased sensibly. In the intervals of these attacks, which werevariable, but generally continuing ten or twelve days, the strengthwas frequently good, and accompanied by a great flow of spirits, andan 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. Thecountenance became high coloured; the dyspnœa excessive, and renderedalmost suffocating by a slight movement, or attempt to speak; thepulse hard, very irregular, intermittent, and vibrating; and thedigestive functions were suspended. These symptoms soon increased tothe highest degree. The respiration was so distressing, as to producea wish for speedy death; the eyes became wild and staring. No sleepcould be obtained; for, after dosing a short time, he started up inviolent agitation, with the idea of having suffered a convulsion. During the few moments of forgetfulness, the respiration was sometimesquick and irregular, sometimes slow, and frequently suspended for thespace of twenty five, and even so long as fifty seconds. At the end ofthree days the febrile heat was less permanent; the red colour of theface changed to a death like purple; the hands and face were cold, andcovered with an adhesive moisture; the hardness of the pulsediminished, and a degree of insensibility took place. I seized thisopportunity to examine the region of the heart, which had not beendone before, from fear of alarming the active and irritable mind ofthe patient. The heart was perceived palpitating, obscurely, about the7th and 8th ribs; its movements were very irregular, and consisted inone full stroke, followed by two or three indistinct strokes, andsometimes by an intermission, corresponding with the pulse at eachwrist. The pulsation was felt more distinctly in the epigastricregion. During this paroxysm a recumbent posture was very uneasy, andthe patient uniformly preferred sitting in a chair. When the recumbentposture was assumed, the head was much raised, inclined to the rightside, and supported by the hand; the knees were drawn up as much aspossible. He could not bear an horizontal posture; nor did he everlie on the left side, except a short time after the application of ablister. At the end of the fifth day his sufferings abated, but thesudden affusion of a small portion of a cold liquid on the headproduced a severe fit of epilepsy. This was followed by a return ofthe symptoms equally distressing, and more durable, than in the firstattack[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 apleasant calm. The natural functions resumed their ordinary course;his appetite returned; his enjoyment of social intercourse wasunusually great; and he amused and instructed his friends by theimmense treasures of information, which his talents and observationshad afforded him, and which, he seemed to feel, would soon be lost. Atthe end of September the feet began to swell, and after some time theenlargement extended up to the legs and thighs, and increased to anextraordinary degree; the abdomen next swelled, and, after it, theface. Toward the end of October there were some indications of waterin the chest; there was a constant shortness and difficulty ofbreathing; the cough, till now rare, became more frequent andtroublesome; the contraction of the thoracic cavity rendered theaction of the heart more painful, to that beside an uniform strictureacross the breast, he sometimes described a dreadful sensation liketwisting of the organs in the thorax. He suspected the existence ofwater there, and was inclined to consider it as his primary disease, but was easily convinced of the contrary. At one time he had asuspicion of a complaint of the heart, and, although he had neverheard of a disease of that organ, slightly intimated it to one of hisfriends, and mentioned a sensation he had experienced in the chest, which he compared to a fluid driven through an orifice too narrow forit to pass freely. In this month, beside the dropsical affections andincrease of cough, he had occasional painful enlargements of theliver, frequent starting up from sleep, a slight degree of dizziness, a great disposition for reveries, and sometimes extraordinaryillusions, one of which was, that he was two individuals, each of whomwas dying of a different disease. This idea often occurred, and gavehim much uneasiness. He was also afflicted with long continuedfrightful dreams, and sometimes a slight delirium. 

After the use of much medicine, on the 6th of November, the effusedfluids began to be absorbed, and passed out through the urinary organswith such rapidity, that on the 12th the dropsical enlargements hadnearly disappeared. The pulse was much reduced, in hardness andfrequency, by the medicine, and, as it fell, he became more easy. Onthe 10th the state legislature convened, and the call of businessroused, like magic, the vigor of his mind; and the symptoms of hisdisease almost disappeared. During this session he made littlecomplaint, dictated many important communications, and attended to allthe duties of his office, without neglecting the most minute. As soonas the legislature adjourned, he declared, that his work was finished, and that he had no desire to remain longer in this world. He entreatedthat no farther means should be used to prolong his existence, andimmediately yielded himself to the grasp of disease, which appearedwaiting with impatience to inflict its agonies. 

From this moment the distressing difficulty of breathing had veryslight remissions. The consequent disposition to incline the superiorpart of the body forward, for the purpose of facilitating respiration, increased so much, that he frequently slept with his head reposed onhis knees. The cough became occasionally very violent, and was alwaysattended with an expectoration of a brown coloured mucus, sometimestinged with blood. The abdominal viscera lost their activity. The facewas sometimes turgid and high coloured, at other times pallid andcontracted. A gradual abolition of the powers of the mind ensued, witha low delirium, and two short fits of phrenzy. The state of thecirculation was very variable; the pulse at the wrists principallyhard and vibrating, rarely soft and compressible; the less pulsationsbecoming more indistinct, and at length scarcely perceptible. Noperfectly distinct beat of the heart was felt, but a quick undulatingmotion, not corresponding with the pulse at the wrist. Three daysbefore death the arteries assumed this undulatory motion, correspondedwith the motion of the heart, and, for forty-eight hours, lost theirregularity 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, dyspnœa and palpitations. Thus in the case related above, and in some others, the pulse became regular, the palpitations subsided, and the dyspnœa 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 ofNovember he awoke, as if from death, conversed very pleasantly for twoor three hours, and humorously described scenes, which he hadwitnessed in his youth. 

On the 4th of December came on the second attack of furious delirium. Insensibility, and great prostration of strength, ensued. Therespiration became very slow, and obstructed by the accumulation ofmucus in the lungs; the pulse very intermittent, then regular, andfinally fluctuating. A hiccough commenced; coldness of the extremitiesand lividity of the face followed, and continued three days beforedeath. On the 9th the incurvated posture was relinquished, and thehead sunk back upon the pillow; the respirations then diminished infrequency, till they became only two in a minute; and at the end oftwenty-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. Thehands were slightly œdematous. Discolourations, answering to theribs, were observed on the thorax; many small purple spots, hard andprominent, 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 ofthe ribs ossified in various degrees, some perfectly, others slightly. Upon laying open the cavity of the thorax, it was found to containabout three pints of water, the proportion being greatest on the leftside. 

The lungs were contracted into a smaller compass than usual, and werevery firm to the touch. Their colour anteriorly was whitish, withsmall distinct purple spots; posteriorly, of a deep red, with similarspots. The right lobe adhered closely to the pericardium; it alsoadhered to the pleura costalis, by a great number of strong cords, which seemed to be elongations of the original adhesions. Some of themwere nearly as hard as ligament, and many an inch in length. Internally the lungs presented a very compact structure. Their cellswere crowded with mucus, and their vessels filled with black blood, partly fluid, and partly coagulated. Some portions were firmer andmore condensed than others, but no tubercles were discovered. 

The pericardium, viewed externally, appeared very large, and occupiedalmost the whole space behind the opening formed by removing thesternum and cartilages of the ribs. It was situated principally on theleft side, and contained about double the usual quantity of water; butwas principally filled by the enlarged heart, to which it adheredanteriorly about two inches, near its base. Its parietes were, inevery part, very much thickened and hardened. 

The heart presented nearly its usual colour and form, excepting on itsanterior surface, which was somewhat discoloured by coagulated lymph. It was enlarged in bulk to, at least, one half more than the healthysize. The auricles and ventricles contained coagulated blood. Thetricuspid valves were in a sound state. The left auricle was doublethe usual size. The left ventricle was enlarged, about three timesthicker and much firmer than usual. The mitral valves were very muchthickened, and near the insertion of their columnæ, which were sound, cartilaginous, so that they were quite rigid, and the opening made bythem, from the auricle to the ventricle, was scarcely large enough toadmit the passage of a finger. The semilunar valves of the aorta wereossified 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 halflarger than usual, especially at its arch. The arteria innominata, thecarotid, and subclavian arteries, were uncommonly large and thick. Thecoronary arteries were considerably ossified. 

 ABDOMEN. 

The omentum was destitute of fat. The stomach distended with flatus onthe pyloric side; its cardiac extremity, lying under the liver, waspressed down and contracted. The liver was shrunk; its tuniccorrugated, as if it had been distended, and bearing marks ofinflammation; its substance harder than usual; its vessels, whendivided, pouring out liquid black blood. The gall bladder was filledwith bile. The kidneys were thicker, and more irregular in form, thanis common. The abdominal cavity contained some water. 

 HEAD. 

The bones of the cranium were unusually thick. The dura mater, whichwas thickened, and in many places bore marks of former inflammation, adhered to the bone at the vertex. On its internal surface, near thelongitudinal sinus, there was a small ossified portion, half an inchlong and the eighth of an inch thick. The convolutions of the brainwere narrow, and very strongly marked. The pia mater bore marks ofpretty extensive inflammation, and adhered to the dura mater at thevertex. The cortical substance ran deep into the medullary part ofthe brain. The ventricles contained about double the usual quantity ofwater; their parts were all remarkably well defined. The vessels ofthe pia mater, over the corpora striata, were unusually injected withblood. The velum interpositum was very firm; the plexus choroidesuncommonly thick, but pale; the opening from the right to the leftventricle large. The vessels of the brain were generally not muchfilled with blood. 

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

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

 CASE II. 

Mr. John Jackson, fifty-two years of age, had been affected for morethan two years with palpitations of the heart, and paroxysms ofdyspnœa. These symptoms increased in October, 1808, and were followedby strong cough, uneasiness in lying down, sudden startings in sleep, and an inclination to bend the body forward and to the left side. Hiscough, during the last part of his life, was attended with copiousbloody expectoration. His countenance was florid; his pulse veryirregular, though not quite intermittent. The occasional variations inthe state of the disease were remarkable. Some periods were markedwith uncommon mental irritability. Pain in the region of the liver, œdema of the inferior extremities, paucity and turbidness of theurine, yellowness of the skin, and great emaciation attended thelatter stages of the disease. A degree of stupor occurred. Thetermination on the 30th of January, 1809, was tolerably quiet. Twodays before death he sank into the recumbent posture, and his pulsebecame 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 largequantity of water; the left, a smaller quantity. 

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

The heart was much enlarged, and proportionally thickened. Its tunicwas in some places covered with coagulated lymph, especially over thecoronary arteries. Its cavities were filled with black coagulum, whichin the right auricle and ventricle had a slight appearance of polypus. The semilunar valves of the pulmonary artery and aorta were unusuallysmall, and their bases cartilaginous. Those of the aorta had losttheir form, and were slightly ossified. The remaining valves werepartially thickened. The arch of the aorta was very much dilated, itsinternal coat covered with a bony crust, which extended through theremaining thoracic portion, gradually diminishing. This portion wasalso considerably dilated. 

The liver was indurated; its peritonæal coat exhibited a flaccid orwrinkled appearance, and bore marks of slight inflammation. The gallbladder was filled with bile, and the pancreas indurated. 

 CASE III. 

Captain Job Jackson, forty-five years of age, a man of vigorousconstitution, after an indisposition of some years continuance, wasseized with palpitations of the heart and dyspnœa, occurring byvariable paroxysms, especially on ascending an eminence, and attendedby hardness, irregularity, and intermission of the pulse. To thesesymptoms were superadded dizziness and severe head-ache, a dispositionto bend the body forward, sudden starting from sleep, with dread ofsuffocation, violent cough with copious expectoration, which forfifteen days before death consisted of black blood, distressing painacross the chest, especially on the left side, great œdema of thelower extremities, and paucity of urine. 

He died painfully in January, 1809, after violent struggles forbreath. The day before death the pulse became regular. He rested hishead upon an attendant, and made no attempts to lie down for somedays 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 tothe groins, were œdematous. 

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

The pericardium contained little more than the usual quantity ofwater. The heart, which exhibited marks of some inflammation on itssurface, was astonishingly large, and firm in proportion. Its cavitieswere principally filled with coagulum. The semilunar valves of thepulmonary artery had their bases slightly ossified, and the remainingpart thickened. There were only two valves of the aorta, and thesewere disorganized by the deposition of ossific matter about theirbases, and a fleshlike thickening of the other part[7]. The parietesof the heart, especially of the left ventricle, were greatlythickened, 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 atintervals of different duration. It commenced three years before hisdeath, and gradually increased. He was subject to palpitations of theheart for at least two years before his death, and was distressed withviolent cough, attended with copious expectoration, which finallybecame very bloody. The palpitation and dyspnœa were greatlyaugmented 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 œdema of the legs appeared, which wassoon followed by frequent and alarming syncope. His pulse wasirregular, intermittent, hard, and vibrating. When lying down hefrequently awoke, and started up in great terror. His usual posturewas that of sitting, with his trunk and head bent forward, andinclining to the left side. For some time before death a recumbentposture threatened immediate suffocation; yet, three days previous tothe occurrence of that event, he sank back upon the pillow. He was, atintervals, 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 muchdistended 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 darkcoloured, from venous blood. The pleura, on the left side opposite tothe pericardium, appeared to have been inflamed, as there was aneffusion of coagulated lymph on its surface. 

The pericardium was much distended with water. The heart, on theanterior surface of which were some appearances of inflammation, wasvery much enlarged. Its parietes were thickened; its cavitiesunnaturally large, and filled with black coagulum. Each of the valveshad lost, in some degree, its usual smoothness, and those of the aortawere, in some points, thickened, and partly cartilaginous. 

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

 CASE V. 

A. B. A negro, about thirty-five years of age, had paroxysms ofdyspnœa and violent cough, attended with œdema of the extremitiesand ascites, violent head-ache, dizziness, brightness of the eyes, palpitations of the heart, irregular, intermittent, slow, and softpulse. These symptoms slowly increased, during three or four years, inwhich time the dropsical collections were repeatedly dispersed. Hegradually and quietly died in the alms-house, in January, 1809. 

 DISSECTION. 

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

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

 CASE VI. 

Mrs. M‘Clench, a washer-woman, forty-eight years of age, of goodconstitution and regular habits, was attacked, in the summer of 1808, with palpitations of the heart and dyspnœa on going up stairs, severehead-ache, and discharges of blood from the anus. These symptoms didnot excite much attention. In the winter of 1808-9, all of themincreased, except the palpitations. The inferior extremities andabdomen became distended with water; the region of the liver painful;the skin quite yellow; the pulse was hard, regular, and vibrating; thecountenance very florid. Violent cough followed, and blood wasprofusely discharged from the lungs. This discharge being suppressed, evacuations of blood from the anus ensued, under which she died, inMarch, 1809. 

 DISSECTION. 

The right cavity of the thorax was filled with water; the leftcontained none. The lungs were sound, but very dense, full of darkcoloured blood, and, on the right side, pressed into the upper part ofthe thorax. The heart was one half larger than natural; its substancefirm, and its anterior part, especially near the apex, covered withcoagulated lymph. The right auricle and ventricle were large, andtheir parietes thin. The parietes of the left auricle and ventricle, particularly of the latter, were much thickened, and their cavitieswere filled with black coagulum. 

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

 CASE VII. 

 To JOHN C. WARREN, M. D. 

MY DEAR SIR, Your important communication to our society, which is about to bepublished, will lay before the American public much more knowledgerespecting the diseases of the heart, and large vessels, than hashitherto been presented to them. A case has lately fallen under myobservation, having so much similarity to those of organic diseases ofthe heart, which have occurred to you, as to mark its affinity, yetwith some differences, which characterize it as a variety. If thestatement of it will add any value to your collection of cases, youare 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 becameaffected with palpitations of the heart for six months, greatdifficulty of breathing, which was augmented by ascending an eminence, severe cough, dizziness, and violent head-ache, attended by adisposition to bend the body forward, and sudden startings from sleep. His pulse was always regular, and never remarkably hard. Hiscountenance, till within a few weeks of death, presented theappearance of blooming health. His feet and legs did not swell at anyperiod of the disease. He suffered exceedingly from flatulence, towhich he was disposed to attribute all his complaints. This symptommight have been aggravated by his habits of free living, andoccasional intoxication, which he acknowledged, and to which he tracedthe origin of his disease. 

After death, water was discovered in the thorax; but the lungs had notthat appearance of accumulation of blood, in particular spots, whichis commonly observed in cases of organic disease of the heart. Theonly very remarkable morbid appearance about the heart was in theaorta, and its valves. The valves had lost their transparency, andwere considerably thickened in various spots. The inner surface ofthe aorta, for about an inch from its commencement, was elevated andthickened, and the external surface singularly roughened andverrucated. This appearance was so peculiar, that no words will give acompetent idea of it, and perhaps it would be sufficient for me tocall 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 dyspnœa and palpitation of theheart, attended with irregularity of the pulse, and œdema of thelower extremities. By the aid of medicine, the dropsical collectionswere absorbed, and he recovered his health, so far as to follow hisusual occupations, nearly a year; but was then compelled to relinquishthem. The symptoms afterwards underwent various aggravations andremissions, till the beginning of the winter of 1808-9, when theattacks became so violent, as to confine him to the house. His facewas then high coloured. The faculties of his mind were much impaired. The dyspnœa became more constant, and was occasionally attended bycough; the palpitations rather lessened in violence; the pulse wasmore irregular, and exceedingly intermittent. The abdomen and inferiorextremities were sometimes enormously distended with water, andafterwards subsided nearly to their usual size. One of the earliest, most frequent, and distressing symptoms, was an intense pain in thehead. About two months before death, a hemiplegia took place, butafter a few days disappeared. This so much impaired the operations ofthe mind, that the patient afterwards found great difficulty inrecollecting words sufficient to form an intelligible sentence. Duringthe 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 abdomenwas tumid, and marked by cicatrices like those of women, who haveborne children. The superior extremities were emaciated, and markedlike the abdomen. The lower extremities were œdematous. 

 THORAX. 

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

 ABDOMEN. 

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

 HEAD. 

Water was found between the dura and pia mater, and between the piamater and arachnoides. The vertical portion of the pia mater boremarks of former inflammation. The convolutions of the brain were verydistinct; 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 ofwater; the communication between them was very large. The plexuschoroides 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 violentpalpitations 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 countenanceis 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 dyspnœa is not yet verydistressing, except on using motion; it often occurs in the night, andobliges her to rise and sit up in bed. The palpitations are very hard, and so strong, that they may be perceived through her clothes; thetumult in the thorax is indescribable. The functions of the abdominalviscera are unimpaired. The pulse is hard, vibrating, irregular, intermittent, very variable, corresponding with the motions of theheart, and similar in each arm. There is not yet the slightest reasonto suspect any dropsical collection. The alternations of ease anddistress are very remarkable, but on the whole, the violence of thesymptoms increases rapidly. 

There is no difficulty in discovering in this case an organic diseaseof the heart, which probably consists in an enlargement and thickeningof the heart, and an ossification of the semilunar valves of theaorta. 

 CASE X. 

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

On examining his pulse, it was found to be occasionally intermittent, contracted, and vibrating. He had some years previously been attackedwith copious hæmorrhages from the stomach or lungs, which haveoccasionally recurred, though they have lately been less frequent. Eight years since he suffered from an inflammation of the lungs; andabout two or three years ago he first experienced a beating in thechest, and pain in the region of the heart, which increased tillwithin six or eight months, since which the beating has beenstationary, and the pain has much increased. In the course of the lastsummer, dyspnœa, on using exercise, and especially ascending anyeminence, commenced. This has greatly increased, so as to render italmost 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 leftside, and is barely perceptible on the right side of the sternum, andin the epigastric region. When he is distressed with fits of dyspnœa, he feels something as if rising to the upper part of the thorax, andthe heart then seems to him to be beating through the ribs. I have notwitnessed any of these paroxysms. The inferior extremities and abdomenhave been swelled about three weeks. When in bed, he has his head andshoulders elevated, and, upon the attack of his paroxysms, sits up andinclines his head forward; but he keeps from the bed as much aspossible. 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, thoughconscious of being awake, strange illusions present themselves. Atintervals he seems slightly delirious. He has a violent cough, withvery copious expectoration of thick mucus. He often suffers fromsevere head-ache, and the least exercise produces dizziness. 

This man has a very robust frame of body, and has been accustomed to afree use of ardent spirits, and of opium, of which he now takes abouttwelve grains in a day. His appearance is such, that, on a slightsurvey, one would not suppose him diseased, but, on observing him witha little attention, a shortness and labour of respiration areperceived, with some interruption in speaking, and a frequent catchingof the breath, or sighing. 

April. Since writing the above account, the dropsical collections wereabsorbed, and the palpitations and other symptoms moderated, so thathe considered himself nearly well, and attended to his usual business. Within a few days, however, the symptoms have returned with moreviolence. The dyspnœa is at times very distressing; the pulse moreirregular and intermittent; the palpitations are more constant. Hissufferings from lying in bed are so increased, that in the mostcomfortable nights he passes, he sits up once in an hour or two. Theappetite is keen. The legs begin to swell again. 

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

ENUMERATION _of the principal morbid changes, observed in the organizationof 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, andgenerally 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 thesecases of disease of the heart, which may be considered secondary_. 

 IN THE CAVITY OF THE CRANIUM. 

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

 IN THE PLEURA AND ITS CAVITY. 

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

 IN THE PERICARDIUM AND ITS CAVITY. 

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

 IN THE CAVITY OF THE ABDOMEN. 

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

 CELLULAR MEMBRANE full of water. 

 THE BLOOD every where fluid, except in the cavities of the heart. 

 REMARKS. 

The symptoms, which are most observable, in some or all of thepreceding cases, are the following:

The first notice of disorder is commonly from an irregular andtumultuous movement of the heart, which occurs some time before anyperceptible derangement of the other functions. This irregularityslowly increases, and arrives at its height before the strength of thepatient is much impaired, at least in the cases which I have noticed;and as the vigour of the patient lessens, the force of thepalpitations diminishes. These palpitations are often so strong, as tobe perceptible to the eye at a considerable distance. They are seldommost distinct in the place where the pulsation of the heart is usuallyfelt. Sometimes they are perceived a little below; often in theepigastric region; and not unfrequently beneath, and on the rightside, of the sternum. 

After the palpitations have lasted some time, a little difficulty ofbreathing, accompanied with sighing, is perceived, especially on anygreat exertion, ascending an eminence, or taking cold, of which thereis an uncommon susceptibility. This dyspnœa becomes, as it increases, a most distressing symptom. It is induced by the slightest cause; asby an irregularity in diet, emotions of the mind, and especiallymovement of the body; so that on ascending stairs quickly, the patientis threatened with immediate suffocation. It occurs at no statedperiods, but is never long absent, nor abates much in violence duringthe course of the disease. It is attended with a sensation ofuniversal distress, which perhaps may arise from the circulation ofunoxygenated blood, or the accumulation of carbon in the system; forthe countenance becomes livid, and the skin, especially that of theextremities, receives a permanent dark colour. This dyspnœa sooncauses distress in lying in an horizontal posture. The patient raiseshis head in bed, gradually adding one pillow after another, till hecan rarely, in some cases never, lie down without danger ofsuffocation; he inclines his head and breast forward, and supportshimself upon an attendant, or a bench placed before him. A few hoursbefore death the muscular power is no longer capable of maintaininghim in that posture, and he sinks backward. The dyspnœa is attendedwith cough, sometimes through the whole of the disease, sometimes onlyat intervals. The cough varies in frequency. It is always strong, andcommonly attended with copious expectoration of thick mucus, which, asthe disease advances, becomes brown coloured, and often tinged withblood; a short time before death it frequently consists entirely ofblack blood. 

The changes in the phœnomena of the circulation are very remarkable. The sanguiferous system is increased in capacity; the veins, especially, are swelled with blood; the countenance is high coloured, except in fits of dyspnœa, when it becomes livid; and it is veryfrequently puffed, or turgid. The brightness of the eyes, dizziness, which is a common, and head-ache, which is a frequent symptom, and insome cases very distressing, are probably connected with thesechanges. The motions of the heart, as has already been stated, areinordinate, irregular, and tumultuous. The pulse presents manypeculiarities. In some cases, probably where there is no obstructionin the orifices of the heart, it remains tolerably regular, and iseither hard, full, quick, vibrating and variable, or soft, slow, compressible and variable. Most commonly, perhaps always, when theorifices of the heart are obstructed, it is vibrating, very irregular, very intermittent, sometimes contracted and almost imperceptible, veryvariable, often disagreeing with the pulsations of the heart, andsometimes differing in one of the wrists from the other. 

The functions of the brain suffer much disturbance. Melancholy, and adisposition for reverie, attend the early stages of the complaint; andthere is sometimes an uncommon irritability of mind. The dreams becomefrightful, and are interrupted by sudden starting up in terror. Strange illusions present themselves. The mental faculties areimpaired. The termination of the disease is attended with slightdelirium; sometimes with phrenzy, and with hemiplegia. 

The abdominal viscera are locally, as well as generally, affected. Although the digestive functions are occasionally deranged, theappetite is at some periods remarkably keen. The action of theintestines is sometimes regular, but a state of costiveness iscommon. The liver is often enlarged, probably from accumulation ofblood. This distention is attended with pain, varies much, and, in allthe cases I have seen, has subsided before death, leaving the coats ofthe liver wrinkled, flaccid, and marked with appearances ofinflammation, caused by the distention and pressure against thesurrounding parts. An effect of the accumulation of blood in theliver, and consequently in the mesenteric veins, is the frequentdischarge of blood from the hæmorrhoidal vessels. This occurs both inthe early and late stages of the disease, and may become a formidablesymptom. Evacuations of blood from the nose are not uncommon. 

Dropsical swellings in various parts of the body succeed the symptomsalready enumerated. They commence in the cellular membrane of thefeet, and gradually extend up the legs and thighs; thence to theabdominal cavity, to the thorax, sometimes to the pericardium, to theface and superior extremities; and, lastly, to the ventricles andmeninges of the brain. These collections of water may be reabsorbed bythe aid of medicine; but they always return and attend, in somedegree, the patient’s death. 

There is no circumstance more remarkable in the course of thiscomplaint, than the alternations of ease and distress. At one time thepatient suffers the severest agonies, assumes the most ghastlyappearance, and is apparently on the verge of death; in a day or aweek after, his pain leaves him, his appetite and cheerfulnessreturn, a degree of vigour is restored, and his friends forget that hehas been ill. The paroxysms occasionally recur, and become morefrequent, as the disease progresses. Afterwards the intermissions areshorter, and a close succession of paroxysms begins. If the progressof the complaint has been slow, and regular, the patient sinks into astate of torpor, and dies without suffering great distress. If, on thecontrary, its progress has been rapid, the dyspnœa becomes excessive;the pain and stricture about the præcordia are insupportable; afurious delirium sometimes succeeds; and the patient expires interrible agony. 

Such are the symptoms, which a limited experience has enabled me towitness. Others, equally characteristic of the disease, may probablyexist. 

From this description of the symptoms it would appear, that therecould be no great difficulty in distinguishing this from otherdiseases; yet probably it has sometimes been confounded with asthma, and very frequently with hydrothorax. Some may think, that there is noessential difference in the symptoms of these diseases. Theresemblance between them, however, is merely nominal. 

The cough in hydrothorax, unlike that which attends organic diseasesof the heart, is short and dry; the dyspnœa constant, and not subjectto violent aggravations. An uneasiness in a horizontal posture attendsit, but no disposition to incurvate the body forward. These are someof the points, in which these two diseases slightly resemble eachother. Those, in which they totally differ, are still more numerous;but as most of them have been already mentioned, it is unnecessary toindicate them here. 

It is probable, that the two diseases commonly arise in patients ofopposite physical constitutions; the hydrothorax in subjects of a weakrelaxed fibre; the organic diseases of the heart in a rigid and robusthabit. The subjects of the latter affection, in the cases which havefallen under my observation, were, with the exception of one or twoinstances, persons of ample frame, and vigorous muscularity, and whohad previously enjoyed good health. In nearly all these cases thecollection of water was principally on one side, yet the patientscould lie as easily on the side where there was least fluid, as on theother; which, in the opinion of most authors, is not the case inprimary hydrothorax. It should also be observed, that, in many of thecases, there was only a small quantity of water in the chest, and thatin neither of them was there probably sufficient to produce death. Maynot primary hydrothorax be much less frequent, than has commonly beenimagined?

Idiopathic dropsy of the pericardium may, perhaps, produce somesymptoms similar to those of organic disease of the heart; but itappears to be an uncommon disorder, and I have had no opportunity ofobserving it. In the fourth case, a remarkable disposition to syncope, on movement, distinguished the latter periods of the disease, andmight have arisen from the great collection of water in thepericardial sac. 

The causes of this disease may, probably, be whatever violentlyincreases the actions of the heart. Such causes are very numerous; andit is therefore not surprising, that organic diseases of the heartshould be quite frequent. Violent and long continued exercise, greatanxiety and agitation of mind[14], excessive debauch, and the habitualuse 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 beyondthe reach of art; for it is difficult to conceive of any natural agentsufficiently powerful to produce absorption of the thickened parietesof the heart, and at the same time diminish its cavities; but we mayindulge better hopes of the possibility of absorbing the osseousmatter and fleshy substance deposited in the valves of the heart andcoats of the aorta. A careful attention to the symptoms will enable usto distinguish the disease, in its early stages, in which we mayundoubtedly combat it with frequent success. 

Although it may not admit of cure, the painful symptoms attending itmay 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 mostcommonly indicated. Blood-letting affords more speedy and compleatrelief, than any other remedy. Its effect is quite temporary, butthere can be no objection to repeating it. The digitalis purpureaseems to be a medicine well adapted to the alleviation of thesymptoms, not only by diminishing the impetus of the heart, but bylessening the quantity of circulating fluids. Its use is important inremoving the dropsical collections; and for this purpose it may oftenbe conjoined with quicksilver. Expectoration is probably promoted bythe scilla maritima, which, in a few cases, seemed also to alleviatethe cough and dyspnœa. Blisters often diminish the severe pain in theregion of the heart, and the uneasiness about the liver. It has beenseen, that the excessive action of the heart sometimes producesinflammation of the pleura and pericardium, and that the distention ofthe coat of the liver has the same effect upon that membrane in aslighter degree. Vesication may probably lessen those inflammations. When the stomach and bowels are overloaded, a singular alleviation ofthe symptoms may be produced by cathartics, and even when that is notthe case, the frequent use of moderate purgative medicines isadvantageous. Full doses of opium are, at times, necessary through thecourse of the complaint. The antiphlogistic regimen should becarefully observed. The food should be simple, and taken in smallquantities, stimulating liquors cautiously avoided, and the repose ofbody and mind preserved, as much as possible. 

The causes of some of the phœnomena of this disease are easilydiscovered; those of the others are involved in obscurity, and form avery curious subject for investigation. I shall not at present troubleyou with the ideas relating to them, which have occurred to me, buthope to be able to present some additional remarks on the subject, ata future period. In the mean time, I beg leave to invite the attentionof the society to the observation of the symptoms of this interestingdisorder, 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 subjectsof the ninth and tenth cases died, on the same day, and an opportunitywas given of ascertaining whether their complaints had been rightlydistinguished. 

It is a proof of an enlightened age and country, that no objectionswere made in any instance to the examinations, which have afforded usso 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 notin my power to relate exactly the symptoms which attended the latterstages of her complaint. I was informed, however, that they increasedin violence, especially the difficulty of breathing, and inability tolie down; that her cough returned, and her expectoration was sometimesbloody; and that, for sometime before death she suffered inexpressibledistress. 

We found the body somewhat emaciated, and the lower extremities andleft arm œdematous. Might not this swelling of the left arm havedepended on her constant posture of inclining to her left side?

The face, especially at the lips, was livid, though not so much as inmany 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. Thecartilages of the ribs were slightly ossified, and, upon theirremoval, it appeared that the pericardium and its contents occupied anextraordinary space, for the lungs were quite concealed by them. Theseorgans 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, asto cause an uniform dark colour in the substance of the lungs, especially in some particular spots, where the blood appeared to beaccumulated; but whether this accumulation was confined to the bloodvessels, or extended to the bronchial vesicles, could not besatisfactorily determined. No one can doubt that blood may befrequently forced through the thin membrane of the air vesicles, whoconsiders, that in these cases the heart often acts with uncommonviolence, that, when it is enlarged, it attempts to send toward thelungs more blood than their vessels can contain, and that there iscommonly some obstruction to the return of blood from the lungs intothe heart, from derangement either in the mitral or aortal valves, orin the aorta. The consequent accumulation of blood in the lungs seemsto me to be the probable cause of the dyspnœa, which so muchdistresses those affected with diseases of the heart; for if there bean inordinate quantity of blood, there must be a deficiency of air. 

This accumulation of blood in the lungs has, by some writers, beenconsidered as an appearance belonging to idiopathic hydrothorax. Whether it ever exists in that complaint seems to me uncertain. Thepressure of water upon the lungs, may possibly interrupt the freecirculation of blood through their vessels, yet probably the samepressure would prevent the entrance of blood into the vessels, unlessthere be some other cause to overcome it, such as increased action ofthe heart, which attends only the first stage of hydrothorax. It hasbeside been proved by the experiments of Bichat, that the collapsionof the lungs does not obstruct the circulation of blood through thepulmonary vessels. It seems probable, therefore, that those who havethought this collection of blood an appearance belonging to idiopathichydrothorax, have mistaken for it the secondary hydrothorax producedby diseases of the heart. 

On pursuing the examination, we found, behind the lungs, about five orsix ounces of yellowish serum in each cavity of the pleura, and aboutone ounce in the cavity of the pericardium. The heart was then seenenlarged to more than double its natural size. Its surface, especiallyalong the course of the branches of the coronary arteries, waswhitened by coagulated lymph. In the cavities of the heart, which wereall enlarged and thickened, particularly the left, were found portionsof coagulum mixed with fluid blood. Near its apex, over the leftventricle, was a small soft spot which, to the finger, seemed like thepoint of an abscess ready to burst. The tricuspid valves, and thevalves of the pulmonary artery, had lost somewhat of theirtransparency, and were a little thickened, though not materially. Itis worthy of remark, that these valves have not exhibited any greatappearance of disease in any of these cases, while those of the leftside of the heart have scarcely ever been found healthy. So itappeared in this case. The mitral valves were uniformly thickened, andpartly cartilaginous; the left portion adhered to the side of theheart. The valves of the aorta had lost their usual form, wereentirely cartilaginous, and almost equal in firmness to the aorta, which was cartilaginous under the valves, sound in other parts, andrather small, compared to the size of the heart. 

It may be thought that the symptoms, on which reliance was placed todistinguish 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 astate of the valves as existed in this case, and a very considerableossification; for, if the valves were rigid and unyielding, it is oflittle importance whether they were rendered so by bone, or cartilage. Whether the irregularity of the pulse in these diseases generallydepends on the disorganized state of the aortal, or other valves, wehave not at present observations sufficient to decide. In the sixthcase no irregularity of the pulse could be observed, although theother symptoms were unequivocal, and no disease was found in thevalves; while, on the other hand, we find that the valves in thefourth case were not importantly deranged, and yet there was anirregularity and intermission of the pulse, which however might beattributed 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 wasirregular, and the valves were not materially altered, but there waswater in the pericardium. In all the other cases, the pulse wasirregular, and the valves were much disordered: On a review of thesecases, therefore, we find some reason to believe, that theirregularity 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 ofwhich had been rendered opaque by coagulated lymph, and was studdedover with soft, dark coloured tubercles. The substance of the liverwas 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 indegree, 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 ofswelling in the legs and abdomen, return of the cough, and a pain fromthe left shoulder to the middle of the arm. After his relapse inApril, he had been directed to employ blisters, the submuriate ofquicksilver, and the tincture of the digitalis purpurea. The dose ofthe 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 todischarge the water from them. He would have had the water in theabdomen drawn off, but believing it would not afford him great relief, I dissuaded him from it. On the 10th of May, after having passed anunusually comfortable night, he rose and left his chamber for five orsix hours, then retiring to it again, said he would be tapped thatday, and, after lying down, was quitted by his attendant, who went inan hour after and found him dead. This was rather unexpected, for hehad the appearance of sufficient vigour to struggle with disease threeor four weeks longer. 

A number of medical gentlemen being assembled, as has been usual onthese occasions, we first remarked, that the face was swollen, andextraordinarily livid; for, although a considerable degree oflividity, and sometimes of redness, after death, is peculiar to thesecases, we had seen none which resembled this. Hard and prominentpurple spots were observed upon the shoulders, side, and back. Thesurface of the body was moderately covered with fat; the legs andabdomen were much swollen with water, the arms more slightly. Theinteguments of the thorax being cut through, the cellular membranedischarged a serous fluid from every part; these being turned aside, to lay bare the cartilages of the ribs, we found them completelyossified; and having divided them, with a saw, the cavity of thethorax was opened. The cellular membrane, inside the thorax, about themediastinum, had not so bloody an appearance as we witnessed in thepreceding cases, nor were the lungs, either externally or internally, so dark coloured as usual, though they were much darker, firmer, andmore filled with blood, than is common in subjects of other diseases. The lungs of the left side adhered closely to the pleura costalis, andthose of the right were tied by loose and membranous adhesions; besidewhich there was no appearance of disease about them. The cavity of thepleura did not contain any water; that of the pericardium held aboutsix ounces. 

The anterior surface of the heart exhibited a considerable whitenessof its coat over the coronary arteries. This appearance differed fromthat of other cases, in being contained in the substance of themembrane, instead of lying on its surface; and, either from thiscircumstance, or from the length of time since it had existed, itsaspect was so peculiar that it might be supposed to be the first stageof an ossification. A deposition of lymph on the heart has beenobserved in every one of these cases of organic disease, and it hasexisted principally over the branches of the coronary arteries, orelse near the apex of the heart, which is to be attributed to theirritation of the membrane by the combined impulse of the heart andcoronary arteries, and to the stroke of the apex upon the ribs. Thisis an appearance that, as it belongs to this complaint, might beuseful in a case otherwise dubious, if any such should occur, to aidin deciding whether the action of the heart had been inordinate. 

The heart was enlarged to double its usual size, as we judged withconfidence, for pains had been taken to examine hearts in a healthystate, for the purpose of forming a comparison. Its firmness was notproportioned to its bulk, but it was considerably flaccid. Near theapex, over the left ventricle, was a soft spot, similar to that foundin the preceding case. The venæ cavæ were then divided, and a torrentof black blood issued from each of the orifices, in spite of ourefforts to restrain it. All the cavities of the heart were filled, aswe afterwards saw, with similar blood; in which circumstance thisresembles the other cases; though in this case the blood was entirelyfluid, and thinner than in cases of different disease: whereas, inevery other instance, was partly or wholly coagulated. This thereforemust be considered as another appearance peculiar to this complaint, because it is well known, that blood is not usually found in the leftcavities of the hearts of those who die of other disorders. The causeof it is doubtless an obstruction, which opposes the free discharge ofblood from the heart, whether that obstruction be in the aortalvalves, in the aorta itself, or in the disproportion between theheart, or more precisely the left ventricle, and the parts it supplieswith blood. 

Why was the blood entirely fluid in this case? If we compare theappearance of the cellular membrane, and of the lungs, in both ofwhich there was a deficiency of blood, with the aspect of the face, where there was an accumulation of blood, and consider at the sametime the mode of termination of this case, we shall find reason tobelieve, that death was produced by a violent pressure of the brainfrom a congestion of blood in its vessels, in consequence of theobstruction to the return of that fluid to the heart. An additionalproof of this opinion is derived from the great quantity of blood, which poured from the vena cava superior, during the whole time of theexamination, and afterward; so that it was found impossible topreserve 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 bloodwas frequently fluid, and this may be supposed to be the cause of thatappearance in the present case. The extraordinary thinness or waterystate of the blood is a distinct circumstance, which will be presentlynoticed. 

An examination of the brain, to ascertain the truth of the suppositionabove mentioned, was relinquished with regret, but this wasimpracticable; for the want of time on these occasions frequentlyobliged us to content ourselves with investigating the state of themost important parts. This must serve as our apology for not oftenerrelating the appearance of all the principal organs; yet it should beobserved, that such methods have been employed to ascertain withaccuracy the most interesting morbid phœnomena, as would satisfy themost scrupulous anatomist. 

The tricuspid valves and the semilunar valves of the pulmonary arteryhad lost their healthy transparency, but were not otherwise diseased. In all the above cases these valves had been found without importantderangement of their structure; a circumstance not less remarkable, than difficult to be satisfactorily explained. The basis of the mitralvalves was marked by a bony projection, which nearly surrounded theorifice of the ventricle; the valves themselves were thickened, andone of them was smaller than the other. The semilunar valves of theaorta were lessened in size, and somewhat thickened. One of them wasossified sufficiently to annihilate its valvular function; the otherswere slightly. The aorta under the valves was semicartilaginous, ossified in one small spot, roughened by fleshlike prominences inothers, entirely deprived of the smoothness of its internal coat, andin 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, thatthe cavities were enlarged. That of the left ventricle wasdisproportionately larger than the others, but no difference of sizecould be ascertained between the auricles. When a cavity of the heartis situated in the course of the circulation immediately behind acontracted orifice, it seems probable that the contraction may have animportant influence in originating the enlargement or aneurism of thatcavity; but, where there is no contraction of an orifice, what is theobstruction which impedes the free discharge of blood from the heart, and causes the first yielding of its parietes? Perhaps a violentsimultaneous action of many muscles, from great exertion, may, duringthe systole of the heart, impede the passage of the blood through thearteries, drive it back upon the valves of the aorta, and resist theheart at the moment of its contraction. If the parietes of the heartyield, in one part, it is easy to conceive a consequent distension ofthe remainder to any degree; for, during the systole of the heart, thecolumnæ approximate, till their sides are in contact, to protect theparietes of the heart; but, if these be distended, the columnæ can nolonger come in contact with each other, and the blood passing betweenthem will be propelled against the parieties, and increase theirdistention. The left ventricle being thus dilated, the mitral valveswill not be able to completely cover its orifice, and part of theblood will escape from the ventricle, when it contracts, into theauricle when dilated with the blood from the lungs; and this unduequantity of blood will gradually enlarge the auricle. A resistancewill arise, from the same cause, to the passage of the blood from thelungs, thence to that from the right ventricle and auricle, and thusthese cavities may become enlarged in their turns. When anossification of the aorta, or of its valves, exists, there will be aresistance to the passage of the blood from the left ventricle, eitherby a loss of dilatability in the artery, or a contraction of theorifice by the ossified parts. In either case, the blood will reflowupon the heart, and dilate the left ventricle, as in _case the first_, and others; and, if the mitral valves be thickened and rigid, the leftauricle will be more dilated than in a case of simple aneurism of theleft ventricle, as appeared also in the _first case_. 

The coronary arteries, at their origin from the aorta, and aconsiderable distance beyond, were ossified. How far does theexistence of this ossification in this and other cases related bydifferent authors, without symptoms of angina pectoris, disprove theopinion that it is the cause of that disease?

The abdomen being opened, the organs generally appeared sound, exceptthe liver, which had its tunic inflamed, its substance indurated andfilled with blood. The vestiges of inflammation in the coat of theliver were traced in every instance already related, while at the sametime the liver, in all, appeared shrunken. The diminution of size inthe liver, after death, cannot at present be well explained; for it isvery certain that such a diminution is not an attendant of thisdisorder, during most of its stages, but that on the contrary a stateexists precisely opposed to it. The indications of distention of theliver, clearly perceived in some cases, have been pain, tenderness, and sense of distention, in the right hypochondrium, and, what is lessequivocal than these, very considerable swelling and prominence of theliver. The inflammation of its tunic is an effect of this distentionand of the consequent pressure against the adjacent parts. 

The cause of this phœnomenon can easily be explained. If anobstruction exist in either side of the heart, or in the lungs, theblood to be poured into the right auricle, from the vena cavainferior, must be obstructed, its flow into that vessel from the liverwill be equally checked, the thin coats of the hepatic veins and ofthe branches of the vena porta will yield and distend the softsubstance of the liver. Hence are caused the discharges of blood fromthe hæmorrhoidal veins, which form one of the characteristic symptomsof the disease; for as these vessels empty their blood into themeseraic veins, which open into the vena porta, if the meseraic veinsbe obstructed, the hæmorrhoidals must consequently be also affected, and they easily burst open from too great distention. The hæmoptoe, which also is so frequent, is as easily explained on the sameprinciple. 

The cause of the serous collections is not so readily discovered. Inthis case, as in most of the others, we found a considerable quantityof water in the abdominal cavity. Dropsy is commonly considered as adisease of debility, but in these cases it often appeared, while thestrength was unimpaired, and the heart acted with very extraordinaryforce. If the blood was driven with rapidity through the arteries, while an obstruction existed at the termination of the venous systemin the heart, the consequences must have been accumulation in thevenous system, difficult transmission of the blood from the extremearteries to the veins, overcharge of the arterial capillary system, consequent excitement of the exhalant system to carry off the serouspart of the blood, for which it is adapted, and thence a serousdischarge into the cavities, and also on the surface of the body; forgreat disposition to sweating is a common symptom. In addition tothese, there is another cause of the universality of these effusions. The blood, in all the cases which I have examined, is both before andafter death, more thin and watery than healthy blood. How thishappens, our knowledge of the theory of sanguification does not enableus to determine. Perhaps, as the imperfect respiration must cause adeficiency of air, and consequently of oxygen, in the lungs; and asthe absorption of oxygen is a cause of solidity in many bodies, thistenuity of the blood may proceed from a deficient absorption ofoxygen. However this may be, it is certain that the blood is very muchattenuated, though with considerable variations in degree, as it issometimes found thin on opening a vein, and at a subsequent period isthicker; varying perhaps according to the continuance of ease ordifficulty in respiration. It is certain, that this attenuation of theblood must tend to an increase of the serous exhalations. 

That these secondary dropsies are not the effect of debility appearspretty evident from considering, that they often exist while thestrength of the patient is yet undiminished, while all the othersecretions, except that of the urine, are carried on with vigour, andwhile the appetite and digestive functions are not only unimpaired, but improved. 

The examinations of the _ninth_ and _tenth cases_ are particularlyvaluable, because they confirm what had been observed in othersubjects; they exhibit two well marked instances of aneurism of theheart, and present us a view of organic disease unattended by dropsyof the pleura. This must be sufficient to remove the suspicion, thatthe symptoms we have attributed to the former disease might arise fromthe existence of the latter. No one probably will be willing to imputea chronic disease, terminated by a sudden death, to five or six ouncesof water in the pericardium; for such a quantity, though it mightproduce inconvenience, could not prove fatal, unless it were suddenlyeffused; and, if this were true, it of course could not have been thecause of the long train of symptoms observed in _case tenth_. 

Dr. William Hamilton, the author of a valuable treatise on thedigitalis purpurea, thinks the hydrothorax a more frequent diseasethan has commonly been imagined, because he conceives that it hasoften been mistaken for organic disease of the heart. He names, withsome precision, many symptoms of the latter complaint; but how remotehe is from an accurate knowledge of it may be discovered by hisopinion, that, in diseases of the heart, “the patient can lie downwith ease, and seldom experiences much difficulty of breathing. ” Thelimits of this paper do not admit a discussion of this and otherpoints, respecting which he seems to be mistaken. We must thereforesubmit them to be decided by the evidence adduced in Dr. Hamilton’s“observations, ” and by that which may be drawn from these cases, andfuture investigations of the subject. It will perhaps hereafter appearsurprising, that derangements in the structure of so important anorgan as the heart should have been lightly estimated by veryrespectable authors. 

 * * * * *

While concluding these observations, a case of this disease presenteditself, which comprehends so many of the symptoms, that I cannotneglect an opportunity of recording it, especially as it exhibits thecomplaint in an earlier stage than the others, with appearancesequally unequivocal. I may here be allowed to remark, that no caseshave been introduced which occurred before my attention was directedto a close observation of this disorder, and that there are manyothers, under the care of practitioners of eminence belonging to thissociety, with symptoms perfectly well marked, which it has not beenthought necessary to adduce. In proof of this, reference may be had toDr. 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 aboutthirty-four years, complains of uneasiness in the right side below theedge of the ribs, sometimes attended with swelling, external soreness, and a throbbing pain, which often reaches to the shoulder, andproduces a numbness of the right arm. She is rather uncertain at whattime her complaints commenced. About two years since she lost herhusband, and was left with but small means to support a number ofchildren. She became in consequence, much dejected. While nursing achild, about a year since, she first was sensible of palpitations ofthe heart, which, in about three months, were followed by dyspnœavery much augmented by ascending an eminence; and profuse dischargesof blood from the mouth, first raised, she believes, by vomiting, andafterwards by coughing. Evacuations of blood from the hæmorrhoidalvessels appeared about the same time, and occasionally since, tillwithin six weeks, during which time there have been no sanguineousdischarges, and this suppression has aggravated her other complaints. 

The pulsation of the heart is felt most distinctly quite on the leftside of the thorax, where there is a painful spot; it is perceptiblealso in the epigastric region. It is irregular and variable, at onemoment hard, strong, distinct, and vibrating; at another, feeble andconfused. There is also sometimes perceived a pulsation above the leftclavicle, within the insertion of the mastoid muscle, commonlyattended with a visible fulness of the superior part of the breast. The thorax feels, to the patient, as if it were girt across, and thereis a distinct pain in the heart. Both these sensations are aggravatedby a very hard, frequent, and dry cough, which however begins to beless violent from the use of the scilla maritima. The countenance isanimated, and rather flushed, but not so much overcharged with bloodas happens in many instances; perhaps it little exceeds a blush, somoderate that it might be considered as an indication of perfecthealth; yet the head is greatly disturbed with dizziness, andfrequent and intense pain, and is seen to be shaken by thepalpitations. 

The functions of the abdominal viscera are not much deranged. Theappetite varies, though it is commonly good; the intestinalevacuations, and the menstrual discharges, are regular; the urine isturbid, and so small in quantity as sometimes to produce strangury. The abdomen and inferior extremities are swelled, and the distentionproduces an uneasiness in the former, and pain and a livid colourabout the gastroenemii muscles in the latter. The pulse is hard, without strength or fulness, slightly intermittent, variable, andirregular; yet it has not so much irregularity as in most of the casesrecorded above. 

This patient is uneasy in bed, though she raises her head almostupright; her sleep is disturbed by unpleasant dreams, and bystartings, sometimes quite to an upright posture, without any causediscoverable 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 distressedby dyspnœa she bends her head and trunk forward, and remains thusseated a considerable portion of the night, often sighing quickly andconvulsively. She is subject to profuse sweatings, and very liable totake cold, and is then more uneasy. 

This lady is still corpulent. She has taken much medicine, under thedirection of eminent physicians, sometimes with temporary relief, butmost commonly without any. The exercise of walking slowly, inpleasant weather, although it increases the palpitations at themoment, is followed with relief from the distressing feelings, whichare increased when she sits still for a long time. She has nosuspicion of her hopeless situation, and confidently expects relieffrom medicine, yet labours under a melancholy which is unnatural toher. 

 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 beenaffected for a great number of years with a scirrhus of the rightbreast. Finding her health decline, she at last disclosed it, and incoincidence with the opinion of Dr. WARREN, sen. I amputated it on the30th 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 othersdiscoloured, and ulcerated at the nipple, so that it was foundnecessary to remove, not only what covered the breast, but someportion of that which surrounded it. A long chain of diseased glands, extending quite to the axillary vessels, was also extirpated. She borethe operation well, lost no great quantity of blood, and recovered herappetite and strength surprisingly in a few days, while the woundhealed rapidly. At the end of twenty days a difficulty of breathingcommenced, and soon became so oppressive, that she could no longer liein bed; partly, no doubt, on account of her extraordinary obesity. Thepulse was small, quick, and commonly feeble, but sometimes a littlehard, when any degree of fever was present. The countenance becamepale, the lips of a leaden hue, the eyes dim. We were surprised at thechange, and conjectured that the cancerous action had suddenlyextended to the lungs. Yet she had not the slightest cough; and it wasremarked by Dr. WARREN, sen. That he had never observed that diseasedaction to increase, while the wound remained open. At last the lowerextremities swelled, which might be attributed to the upright posture, and the pressure on the absorbent vessels in that posture. Theappetite failed; she complained of a constant sense of depression atthe stomach, and, without any remission of the difficulty ofbreathing, died on the 1st of July. 

On the next morning the body was examined. The pleura in both cavitiesof the thorax was studded with small, white, and apparentlyhomogeneous tubercles; the lungs contained a great number of similarbodies. The right cavity of the pleura was entirely filled with water, of which we removed at least three quarts. The heart was of the usualsize, very flaccid and tender; but not otherwise disordered. The liverwas enlarged, of its usual colour, much hardened, and had on itssurface, and in its substance, many tubercles like those in thethorax. It had also a great number of encysted cavities, each aboutthe size of a hazle nut, which contained a thin yellow fluid. The gallbladder was wanting, and in its place there was a small, but veryremarkable depression, without a vestige of any former gall bladder, for the coat of the liver was as smooth and perfect there as in anyother part[15]. The pancreas was in a scirrhous state. The abdomen didnot 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 dyspnœa and difficulty inassuming the horizontal posture. But in organic diseases of the heart, there is a long train of frightful symptoms, distinguishable by themost superficial observers. We infer that these disorders have beenunnecessarily confounded.