Part 6

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At the time the preceding pages were going to the press, the subjects of the ninth and tenth cases died, on the same day, and an opportunity was given of ascertaining whether their complaints had been rightly distinguished.

It is a proof of an enlightened age and country, that no objections were made in any instance to the examinations, which have afforded us so much useful information.

DISSECTION OF CASE NINTH. THIRTY HOURS AFTER DEATH.

The lady, who was the subject of this case, died on the 10th of May, but she was not seen by me after the 29th of March; so that it is not in my power to relate exactly the symptoms which attended the latter stages of her complaint. I was informed, however, that they increased in violence, especially the difficulty of breathing, and inability to lie down; that her cough returned, and her expectoration was sometimes bloody; and that, for sometime before death she suffered inexpressible distress.

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

The face, especially at the lips, was livid, though not so much as in many other cases of this disease. On the left shoulder were small, hard, and prominent livid spots.

The cellular membrane, both on the outside and inside of the thorax, was quite bloody, which is not usually the case in dead bodies. The cartilages of the ribs were slightly ossified, and, upon their removal, it appeared that the pericardium and its contents occupied an extraordinary space, for the lungs were quite concealed by them. These organs being drawn forward, appeared sound and free from adhesions; their colour, anteriorly, was rather dark; posteriorly, still darker; their consistence firm. Their vessels were so crowded with blood, as to cause an uniform dark colour in the substance of the lungs, especially in some particular spots, where the blood appeared to be accumulated; but whether this accumulation was confined to the blood vessels, or extended to the bronchial vesicles, could not be satisfactorily determined. No one can doubt that blood may be frequently forced through the thin membrane of the air vesicles, who considers, that in these cases the heart often acts with uncommon violence, that, when it is enlarged, it attempts to send toward the lungs more blood than their vessels can contain, and that there is commonly some obstruction to the return of blood from the lungs into the heart, from derangement either in the mitral or aortal valves, or in the aorta. The consequent accumulation of blood in the lungs seems to me to be the probable cause of the dyspnoea, which so much distresses those affected with diseases of the heart; for if there be an inordinate quantity of blood, there must be a deficiency of air.

This accumulation of blood in the lungs has, by some writers, been considered as an appearance belonging to idiopathic hydrothorax. Whether it ever exists in that complaint seems to me uncertain. The pressure of water upon the lungs, may possibly interrupt the free circulation of blood through their vessels, yet probably the same pressure would prevent the entrance of blood into the vessels, unless there be some other cause to overcome it, such as increased action of the heart, which attends only the first stage of hydrothorax. It has beside been proved by the experiments of Bichat, that the collapsion of the lungs does not obstruct the circulation of blood through the pulmonary vessels. It seems probable, therefore, that those who have thought this collection of blood an appearance belonging to idiopathic hydrothorax, have mistaken for it the secondary hydrothorax produced by diseases of the heart.

On pursuing the examination, we found, behind the lungs, about five or six ounces of yellowish serum in each cavity of the pleura, and about one ounce in the cavity of the pericardium. The heart was then seen enlarged to more than double its natural size. Its surface, especially along the course of the branches of the coronary arteries, was whitened by coagulated lymph. In the cavities of the heart, which were all enlarged and thickened, particularly the left, were found portions of coagulum mixed with fluid blood. Near its apex, over the left ventricle, was a small soft spot which, to the finger, seemed like the point of an abscess ready to burst. The tricuspid valves, and the valves of the pulmonary artery, had lost somewhat of their transparency, and were a little thickened, though not materially. It is worthy of remark, that these valves have not exhibited any great appearance of disease in any of these cases, while those of the left side of the heart have scarcely ever been found healthy. So it appeared in this case. The mitral valves were uniformly thickened, and partly cartilaginous; the left portion adhered to the side of the heart. The valves of the aorta had lost their usual form, were entirely cartilaginous, and almost equal in firmness to the aorta, which was cartilaginous under the valves, sound in other parts, and rather small, compared to the size of the heart.

It may be thought that the symptoms, on which reliance was placed to distinguish disorder of the valves of the aorta, are fallacious, because it was supposed that these valves would be found ossified, when they were in reality only cartilaginous. The difference, however, would be small in the effects produced on the circulation by such a state of the valves as existed in this case, and a very considerable ossification; for, if the valves were rigid and unyielding, it is of little importance whether they were rendered so by bone, or cartilage. Whether the irregularity of the pulse in these diseases generally depends on the disorganized state of the aortal, or other valves, we have not at present observations sufficient to decide. In the sixth case no irregularity of the pulse could be observed, although the other symptoms were unequivocal, and no disease was found in the valves; while, on the other hand, we find that the valves in the fourth case were not importantly deranged, and yet there was an irregularity and intermission of the pulse, which however might be attributed to the dropsy of the pericardium. In the seventh case, where the pulse was not irregular, the valves of the aorta were "considerably thickened in various spots;" in the fifth, the pulse was irregular, and the valves were not materially altered, but there was water in the pericardium. In all the other cases, the pulse was irregular, and the valves were much disordered: On a review of these cases, therefore, we find some reason to believe, that the irregularity of the pulse depends much on disease of the valves, especially those of the aorta.

The cavity of the abdomen being opened, no water was discovered in it, nor any other uncommon appearance, except about the liver, the coat of which had been rendered opaque by coagulated lymph, and was studded over with soft, dark coloured tubercles. The substance of the liver was tender, and full of bile and venous blood.

DISSECTION OF CASE TENTH. TWENTY-FOUR HOURS AFTER DEATH.

The symptoms of disease in this patient did not alter much, except in degree, from the middle of April to the 10th of May. He became weaker, had more straitness and pain about the heart on moving, an increase of swelling in the legs and abdomen, return of the cough, and a pain from the left shoulder to the middle of the arm. After his relapse in April, he had been directed to employ blisters, the submuriate of quicksilver, and the tincture of the digitalis purpurea. The dose of the tincture he gradually increased, till he took two hundred drops, two or three times in a day. Notwithstanding a profuse flow of urine, the legs became so hard and painful, that I made punctures to discharge the water from them. He would have had the water in the abdomen drawn off, but believing it would not afford him great relief, I dissuaded him from it. On the 10th of May, after having passed an unusually comfortable night, he rose and left his chamber for five or six hours, then retiring to it again, said he would be tapped that day, and, after lying down, was quitted by his attendant, who went in an hour after and found him dead. This was rather unexpected, for he had the appearance of sufficient vigour to struggle with disease three or four weeks longer.

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

The anterior surface of the heart exhibited a considerable whiteness of its coat over the coronary arteries. This appearance differed from that of other cases, in being contained in the substance of the membrane, instead of lying on its surface; and, either from this circumstance, or from the length of time since it had existed, its aspect was so peculiar that it might be supposed to be the first stage of an ossification. A deposition of lymph on the heart has been observed in every one of these cases of organic disease, and it has existed principally over the branches of the coronary arteries, or else near the apex of the heart, which is to be attributed to the irritation of the membrane by the combined impulse of the heart and coronary arteries, and to the stroke of the apex upon the ribs. This is an appearance that, as it belongs to this complaint, might be useful in a case otherwise dubious, if any such should occur, to aid in deciding whether the action of the heart had been inordinate.

The heart was enlarged to double its usual size, as we judged with confidence, for pains had been taken to examine hearts in a healthy state, for the purpose of forming a comparison. Its firmness was not proportioned to its bulk, but it was considerably flaccid. Near the apex, over the left ventricle, was a soft spot, similar to that found in the preceding case. The venæ cavæ were then divided, and a torrent of black blood issued from each of the orifices, in spite of our efforts to restrain it. All the cavities of the heart were filled, as we afterwards saw, with similar blood; in which circumstance this resembles the other cases; though in this case the blood was entirely fluid, and thinner than in cases of different disease: whereas, in every other instance, was partly or wholly coagulated. This therefore must be considered as another appearance peculiar to this complaint, because it is well known, that blood is not usually found in the left cavities of the hearts of those who die of other disorders. The cause of it is doubtless an obstruction, which opposes the free discharge of blood from the heart, whether that obstruction be in the aortal valves, in the aorta itself, or in the disproportion between the heart, or more precisely the left ventricle, and the parts it supplies with blood.

Why was the blood entirely fluid in this case? If we compare the appearance of the cellular membrane, and of the lungs, in both of which there was a deficiency of blood, with the aspect of the face, where there was an accumulation of blood, and consider at the same time the mode of termination of this case, we shall find reason to believe, that death was produced by a violent pressure of the brain from a congestion of blood in its vessels, in consequence of the obstruction to the return of that fluid to the heart. An additional proof of this opinion is derived from the great quantity of blood, which poured from the vena cava superior, during the whole time of the examination, and afterward; so that it was found impossible to preserve the subject from the blood flowing between the ligatures, notwithstanding the thorax was entirely emptied, before it was closed. In cases of sudden death from apoplexy, related by Morgagni, the blood was frequently fluid, and this may be supposed to be the cause of that appearance in the present case. The extraordinary thinness or watery state of the blood is a distinct circumstance, which will be presently noticed.

An examination of the brain, to ascertain the truth of the supposition above mentioned, was relinquished with regret, but this was impracticable; for the want of time on these occasions frequently obliged us to content ourselves with investigating the state of the most important parts. This must serve as our apology for not oftener relating the appearance of all the principal organs; yet it should be observed, that such methods have been employed to ascertain with accuracy the most interesting morbid phoenomena, as would satisfy the most scrupulous anatomist.

The tricuspid valves and the semilunar valves of the pulmonary artery had lost their healthy transparency, but were not otherwise diseased. In all the above cases these valves had been found without important derangement of their structure; a circumstance not less remarkable, than difficult to be satisfactorily explained. The basis of the mitral valves was marked by a bony projection, which nearly surrounded the orifice of the ventricle; the valves themselves were thickened, and one of them was smaller than the other. The semilunar valves of the aorta were lessened in size, and somewhat thickened. One of them was ossified sufficiently to annihilate its valvular function; the others were slightly. The aorta under the valves was semicartilaginous, ossified in one small spot, roughened by fleshlike prominences in others, entirely deprived of the smoothness of its internal coat, and in size proportioned to the heart.

The parietes of the heart were thicker than those of a healthy heart, but thin when compared with its whole volume; whence it follows, that the cavities were enlarged. That of the left ventricle was disproportionately larger than the others, but no difference of size could be ascertained between the auricles. When a cavity of the heart is situated in the course of the circulation immediately behind a contracted orifice, it seems probable that the contraction may have an important influence in originating the enlargement or aneurism of that cavity; but, where there is no contraction of an orifice, what is the obstruction which impedes the free discharge of blood from the heart, and causes the first yielding of its parietes? Perhaps a violent simultaneous action of many muscles, from great exertion, may, during the systole of the heart, impede the passage of the blood through the arteries, drive it back upon the valves of the aorta, and resist the heart at the moment of its contraction. If the parietes of the heart yield, in one part, it is easy to conceive a consequent distension of the remainder to any degree; for, during the systole of the heart, the columnæ approximate, till their sides are in contact, to protect the parietes of the heart; but, if these be distended, the columnæ can no longer come in contact with each other, and the blood passing between them will be propelled against the parieties, and increase their distention. The left ventricle being thus dilated, the mitral valves will not be able to completely cover its orifice, and part of the blood will escape from the ventricle, when it contracts, into the auricle when dilated with the blood from the lungs; and this undue quantity of blood will gradually enlarge the auricle. A resistance will arise, from the same cause, to the passage of the blood from the lungs, thence to that from the right ventricle and auricle, and thus these cavities may become enlarged in their turns. When an ossification of the aorta, or of its valves, exists, there will be a resistance to the passage of the blood from the left ventricle, either by a loss of dilatability in the artery, or a contraction of the orifice by the ossified parts. In either case, the blood will reflow upon the heart, and dilate the left ventricle, as in case the first, and others; and, if the mitral valves be thickened and rigid, the left auricle will be more dilated than in a case of simple aneurism of the left ventricle, as appeared also in the first case.

The coronary arteries, at their origin from the aorta, and a considerable distance beyond, were ossified. How far does the existence of this ossification in this and other cases related by different authors, without symptoms of angina pectoris, disprove the opinion that it is the cause of that disease?

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

The cause of this phoenomenon can easily be explained. If an obstruction exist in either side of the heart, or in the lungs, the blood to be poured into the right auricle, from the vena cava inferior, must be obstructed, its flow into that vessel from the liver will be equally checked, the thin coats of the hepatic veins and of the branches of the vena porta will yield and distend the soft substance of the liver. Hence are caused the discharges of blood from the hæmorrhoidal veins, which form one of the characteristic symptoms of the disease; for as these vessels empty their blood into the meseraic veins, which open into the vena porta, if the meseraic veins be obstructed, the 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 same principle.

The cause of the serous collections is not so readily discovered. In this case, as in most of the others, we found a considerable quantity of water in the abdominal cavity. Dropsy is commonly considered as a disease of debility, but in these cases it often appeared, while the strength was unimpaired, and the heart acted with very extraordinary force. If the blood was driven with rapidity through the arteries, while an obstruction existed at the termination of the venous system in the heart, the consequences must have been accumulation in the venous system, difficult transmission of the blood from the extreme arteries to the veins, overcharge of the arterial capillary system, consequent excitement of the exhalant system to carry off the serous part of the blood, for which it is adapted, and thence a serous discharge into the cavities, and also on the surface of the body; for great disposition to sweating is a common symptom. In addition to these, there is another cause of the universality of these effusions. The blood, in all the cases which I have examined, is both before and after death, more thin and watery than healthy blood. How this happens, our knowledge of the theory of sanguification does not enable us to determine. Perhaps, as the imperfect respiration must cause a deficiency of air, and consequently of oxygen, in the lungs; and as the absorption of oxygen is a cause of solidity in many bodies, this tenuity of the blood may proceed from a deficient absorption of oxygen. However this may be, it is certain that the blood is very much attenuated, though with considerable variations in degree, as it is sometimes found thin on opening a vein, and at a subsequent period is thicker; varying perhaps according to the continuance of ease or difficulty in respiration. It is certain, that this attenuation of the blood must tend to an increase of the serous exhalations.

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

The examinations of the ninth and tenth cases are particularly valuable, because they confirm what had been observed in other subjects; they exhibit two well marked instances of aneurism of the heart, and present us a view of organic disease unattended by dropsy of the pleura. This must be sufficient to remove the suspicion, that the symptoms we have attributed to the former disease might arise from the existence of the latter. No one probably will be willing to impute a chronic disease, terminated by a sudden death, to five or six ounces of water in the pericardium; for such a quantity, though it might produce inconvenience, could not prove fatal, unless it were suddenly effused; and, if this were true, it of course could not have been the cause of the long train of symptoms observed in case tenth.

Dr. William Hamilton, the author of a valuable treatise on the digitalis purpurea, thinks the hydrothorax a more frequent disease than has commonly been imagined, because he conceives that it has often been mistaken for organic disease of the heart. He names, with some precision, many symptoms of the latter complaint; but how remote he is from an accurate knowledge of it may be discovered by his opinion, that, in diseases of the heart, "the patient can lie down with ease, and seldom experiences much difficulty of breathing." The limits of this paper do not admit a discussion of this and other points, respecting which he seems to be mistaken. We must therefore submit them to be decided by the evidence adduced in Dr. Hamilton's "observations," and by that which may be drawn from these cases, and future investigations of the subject. It will perhaps hereafter appear surprising, that derangements in the structure of so important an organ as the heart should have been lightly estimated by very respectable authors.