Part 5

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 the preceding cases, are the following:

The first notice of disorder is commonly from an irregular and tumultuous movement of the heart, which occurs some time before any perceptible derangement of the other functions. This irregularity slowly increases, and arrives at its height before the strength of the patient is much impaired, at least in the cases which I have noticed; and as the vigour of the patient lessens, the force of the palpitations diminishes. These palpitations are often so strong, as to be perceptible to the eye at a considerable distance. They are seldom most distinct in the place where the pulsation of the heart is usually felt. Sometimes they are perceived a little below; often in the epigastric region; and not unfrequently beneath, and on the right side, of the sternum.

After the palpitations have lasted some time, a little difficulty of breathing, accompanied with sighing, is perceived, especially on any great exertion, ascending an eminence, or taking cold, of which there is an uncommon susceptibility. This dyspnoea becomes, as it increases, a most distressing symptom. It is induced by the slightest cause; as by an irregularity in diet, emotions of the mind, and especially movement of the body; so that on ascending stairs quickly, the patient is threatened with immediate suffocation. It occurs at no stated periods, but is never long absent, nor abates much in violence during the course of the disease. It is attended with a sensation of universal distress, which perhaps may arise from the circulation of unoxygenated blood, or the accumulation of carbon in the system; for the countenance becomes livid, and the skin, especially that of the extremities, receives a permanent dark colour. This dyspnoea soon causes distress in lying in an horizontal posture. The patient raises his head in bed, gradually adding one pillow after another, till he can rarely, in some cases never, lie down without danger of suffocation; he inclines his head and breast forward, and supports himself upon an attendant, or a bench placed before him. A few hours before death the muscular power is no longer capable of maintaining him in that posture, and he sinks backward. The dyspnoea is attended with cough, sometimes through the whole of the disease, sometimes only at intervals. The cough varies in frequency. It is always strong, and commonly attended with copious expectoration of thick mucus, which, as the disease advances, becomes brown coloured, and often tinged with blood; a short time before death it frequently consists entirely of black blood.

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

The functions of the brain suffer much disturbance. Melancholy, and a disposition for reverie, attend the early stages of the complaint; and there is sometimes an uncommon irritability of mind. The dreams become frightful, and are interrupted by sudden starting up in terror. Strange illusions present themselves. The mental faculties are impaired. The termination of the disease is attended with slight delirium; sometimes with phrenzy, and with hemiplegia.

The abdominal viscera are locally, as well as generally, affected. Although the digestive functions are occasionally deranged, the appetite is at some periods remarkably keen. The action of the intestines is sometimes regular, but a state of costiveness is common. The liver is often enlarged, probably from accumulation of blood. This distention is attended with pain, varies much, and, in all the cases I have seen, has subsided before death, leaving the coats of the liver wrinkled, flaccid, and marked with appearances of inflammation, caused by the distention and pressure against the surrounding parts. An effect of the accumulation of blood in the liver, and consequently in the mesenteric veins, is the frequent discharge of blood from the hæmorrhoidal vessels. This occurs both in the early and late stages of the disease, and may become a formidable symptom. Evacuations of blood from the nose are not uncommon.

Dropsical swellings in various parts of the body succeed the symptoms already enumerated. They commence in the cellular membrane of the feet, and gradually extend up the legs and thighs; thence to the abdominal cavity, to the thorax, sometimes to the pericardium, to the face and superior extremities; and, lastly, to the ventricles and meninges of the brain. These collections of water may be reabsorbed by the aid of medicine; but they always return and attend, in some degree, the patient's death.

There is no circumstance more remarkable in the course of this complaint, than the alternations of ease and distress. At one time the patient suffers the severest agonies, assumes the most ghastly appearance, and is apparently on the verge of death; in a day or a week after, his pain leaves him, his appetite and cheerfulness return, a degree of vigour is restored, and his friends forget that he has been ill. The paroxysms occasionally recur, and become more frequent, as the disease progresses. Afterwards the intermissions are shorter, and a close succession of paroxysms begins. If the progress of the complaint has been slow, and regular, the patient sinks into a state of torpor, and dies without suffering great distress. If, on the contrary, its progress has been rapid, the dyspnoea becomes excessive; the pain and stricture about the præcordia are insupportable; a furious delirium sometimes succeeds; and the patient expires in terrible agony.

Such are the symptoms, which a limited experience has enabled me to witness. Others, equally characteristic of the disease, may probably exist.

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

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

It is probable, that the two diseases commonly arise in patients of opposite physical constitutions; the hydrothorax in subjects of a weak relaxed fibre; the organic diseases of the heart in a rigid and robust habit. The subjects of the latter affection, in the cases which have fallen under my observation, were, with the exception of one or two instances, persons of ample frame, and vigorous muscularity, and who had previously enjoyed good health. In nearly all these cases the collection of water was principally on one side, yet the patients could lie as easily on the side where there was least fluid, as on the other; which, in the opinion of most authors, is not the case in primary hydrothorax. It should also be observed, that, in many of the cases, there was only a small quantity of water in the chest, and that in neither of them was there probably sufficient to produce death. May not primary hydrothorax be much less frequent, than has commonly been imagined?

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

The causes of this disease may, probably, be whatever violently increases the actions of the heart. Such causes are very numerous; and it is therefore not surprising, that organic diseases of the heart should be quite frequent. Violent and long continued exercise, great anxiety and agitation of mind, excessive debauch, and the habitual use of highly stimulating liquors, are among them.

The treatment of this complaint is a proper object for investigation. Some of its species, it is to be feared, must forever remain beyond the reach of art; for it is difficult to conceive of any natural agent sufficiently powerful to produce absorption of the thickened parietes of the heart, and at the same time diminish its cavities; but we may indulge better hopes of the possibility of absorbing the osseous matter and fleshy substance deposited in the valves of the heart and coats of the aorta. A careful attention to the symptoms will enable us to distinguish the disease, in its early stages, in which we may undoubtedly combat it with frequent success.

Although it may not admit of cure, the painful symptoms attending it may be very much palliated; and, as they are so severely distressing, we ought to resort to every probable means of alleviating them. Remedies, which lessen the action of the heart, seem to be most commonly indicated. Blood-letting affords more speedy and compleat relief, than any other remedy. Its effect is quite temporary, but there can be no objection to repeating it. The digitalis purpurea seems to be a medicine well adapted to the alleviation of the symptoms, not only by diminishing the impetus of the heart, but by lessening the quantity of circulating fluids. Its use is important in removing the dropsical collections; and for this purpose it may often be conjoined with quicksilver. Expectoration is probably promoted by the scilla maritima, which, in a few cases, seemed also to alleviate the cough and dyspnoea. Blisters often diminish the severe pain in the region of the heart, and the uneasiness about the liver. It has been seen, that the excessive action of the heart sometimes produces inflammation of the pleura and pericardium, and that the distention of the coat of the liver has the same effect upon that membrane in a slighter degree. Vesication may probably lessen those inflammations. When the stomach and bowels are overloaded, a singular alleviation of the symptoms may be produced by cathartics, and even when that is not the case, the frequent use of moderate purgative medicines is advantageous. Full doses of opium are, at times, necessary through the course of the complaint. The antiphlogistic regimen should be carefully observed. The food should be simple, and taken in small quantities, stimulating liquors cautiously avoided, and the repose of body and mind preserved, as much as possible.

The causes of some of the phoenomena of this disease are easily discovered; those of the others are involved in obscurity, and form a very curious subject for investigation. I shall not at present trouble you with the ideas relating to them, which have occurred to me, but hope to be able to present some additional remarks on the subject, at a future period. In the mean time, I beg leave to invite the attention of the society to the observation of the symptoms of this interesting disorder, and of the morbid appearances in the dead bodies of those, who have become its victims.