Case I.
The symptoms of organic disease of the heart are marked with extraordinary clearness in the following case. The opportunity for observing them was very favourable; and there was every incitement to close observation, which could arise from the important and interesting character of the patient. These advantages will justify an uncommon minuteness in the detail of the case; especially, as the most accurate knowledge of a complaint is obtained from a successive view of its stages.
The late Governour of this commonwealth was endowed with most vigorous powers of mind and body. At the age of sixteen he was attacked with fits of epilepsy, which first arose from a sudden fright, received on awaking from sleep in a field, and beholding a large snake erecting its head over him. As he advanced in life they became more frequent, and were excited by derangement of the functions of the stomach, often by affections of the mind, by dreams, and even by the sight of the reptile which first produced the convulsions.
At the commencement of the American revolution he became deeply engaged in public affairs; and from that time devoted himself to intense application to business, with which the preservation of his health was never allowed to interfere. In the expedition against Rhode Island, an attack of inflammation of the lungs had nearly proved fatal to him.
In the beginning of the year 1807, he suffered severely from the epidemic catarrh; and a remarkable irregularity of the pulse was then perceived to be permanent, though there is some reason to believe, that this irregularity had previously existed, during the fits of epilepsy, and for a few days after them. In the summer, while he was apparently in good health, the circulation in the right arm was suddenly and totally suspended; yet, without loss of motion or sensation. This affection lasted from noon till midnight, when it as suddenly ceased, and the circulation was restored. In the autumn he was again seized with the influenza, which continued about three weeks, leaving a troublesome cough of two or three months’ duration, and a slight occasional difficulty of breathing, which at that time was not thought worth attention. Soon after, in November, he had one or two singular attacks of catarrhal affection of the mucous membrane of the lungs, which commenced with a sense of suffocation, succeeded by cough and an expectoration of cream coloured mucus, to the quantity of a quart in an hour, with coldness of the extremities, lividity of the countenance, and a deathlike moisture over the whole body. These attacks lasted six or eight hours, were relieved by emetics, and disappeared, without leaving a trace behind.
At this time he began to complain of palpitations of the heart; yet, it is probable, that he had been affected with these before, since he was unaccustomed to mention any complaint, which was not sufficiently distressing to require relief. He experienced a difficulty of respiring, as he ascended the stairs, and became remarkably susceptible of colds, from slight changes of clothing, moisture of the feet, or a current of cold air. His sleep was unquiet in the night, and attended with very profuse perspiration; and, in the latter part of the day, a troublesome heaviness occurred. The sanguiferous vessels underwent an extraordinary increase, or, at least, became remarkably evident. The pulsation of the carotid arteries was uncommonly strong; the radial arteries seemed ready to burst from their sheaths; the veins, especially the jugulars, in which there was often a pulsatory motion, were every where turgid with blood. The countenance was high coloured, and commonly exhibited the appearance of great health; but, when he was indisposed from catarrh, this florid red changed to a livid colour; which also, after an attack of epilepsy, was observable for two or three days on the face and hands. This livid hue was often attended, under the latter circumstances, with something like ecchymosis over the face, at first formidable in its aspect, and gradually subsiding, till it had the general appearance of an eruption, which also soon vanished.
These symptoms increased, almost imperceptibly, during the five first months of the year 1808. Much of this time was passed in close application to official duties; and it seemed that a constant and regular occupation of the mind had the effect of obviating the occurrence of any paroxysm of disease, as well of epilepsy, as of difficult respiration; and that a very sudden and disagreeable impression generally produced either one or the other. There were, indeed, independently of such circumstances, some occasional aggravations of those symptoms. Some nights, for example, were passed in sitting up in bed, under a fit of asthma, as it was called; sometimes the mind became uncommonly impatient and irritable; the body gradually emaciated; yet the appetite and digestive functions remained principally unimpaired; and persons around were not sensible of any material alteration in the condition of the patient.
On the approach of warm weather, in June, the violence of the symptoms increased. Paroxysms of dyspnœa occurred more frequently, and were more distressing. They commenced with symptoms of slight febrile affection, such as hot skin, hard, frequent, and more irregular pulse, disordered tongue, loss of appetite, and derangement of the digestive functions. This kind of paroxysm lasted two or three days. Evacuations of blood from the nose and hæmorrhoidal vessels, which before rarely occurred, became frequent; a fulness at the upper and right side of the abdomen was sometimes perceptible, formed apparently by temporary enlargement of the liver; the difficulty in ascending an eminence increased sensibly. In the intervals of these attacks, which were variable, but generally continuing ten or twelve days, the strength was frequently good, and accompanied by a great flow of spirits, and an aptitude, or rather ardour, for business.
Such was the course of this complaint until the latter part of August, when a very severe paroxysm occurred. It commenced, like the former, with febrile symptoms, but those more violent than before. The countenance became high coloured; the dyspnœa excessive, and rendered almost suffocating by a slight movement, or attempt to speak; the pulse hard, very irregular, intermittent, and vibrating; and the digestive functions were suspended. These symptoms soon increased to the highest degree. The respiration was so distressing, as to produce a wish for speedy death; the eyes became wild and staring. No sleep could be obtained; for, after dosing a short time, he started up in violent agitation, with the idea of having suffered a convulsion. During the few moments of forgetfulness, the respiration was sometimes quick and irregular, sometimes slow, and frequently suspended for the space of twenty five, and even so long as fifty seconds. At the end of three days the febrile heat was less permanent; the red colour of the face changed to a death like purple; the hands and face were cold, and covered with an adhesive moisture; the hardness of the pulse diminished, and a degree of insensibility took place. I seized this opportunity to examine the region of the heart, which had not been done before, from fear of alarming the active and irritable mind of the patient. The heart was perceived palpitating, obscurely, about the 7th and 8th ribs; its movements were very irregular, and consisted in one full stroke, followed by two or three indistinct strokes, and sometimes by an intermission, corresponding with the pulse at each wrist. The pulsation was felt more distinctly in the epigastric region. During this paroxysm a recumbent posture was very uneasy, and the patient uniformly preferred sitting in a chair. When the recumbent posture was assumed, the head was much raised, inclined to the right side, and supported by the hand; the knees were drawn up as much as possible. He could not bear an horizontal posture; nor did he ever lie on the left side, except a short time after the application of a blister. At the end of the fifth day his sufferings abated, but the sudden affusion of a small portion of a cold liquid on the head produced a severe fit of epilepsy. This was followed by a return of the symptoms equally distressing, and more durable, than in the first attack2.
This violent agitation gradually subsided, and was followed by a pleasant calm. The natural functions resumed their ordinary course; his appetite returned; his enjoyment of social intercourse was unusually great; and he amused and instructed his friends by the immense treasures of information, which his talents and observations had afforded him, and which, he seemed to feel, would soon be lost. At the end of September the feet began to swell, and after some time the enlargement extended up to the legs and thighs, and increased to an extraordinary degree; the abdomen next swelled, and, after it, the face. Toward the end of October there were some indications of water in the chest; there was a constant shortness and difficulty of breathing; the cough, till now rare, became more frequent and troublesome; the contraction of the thoracic cavity rendered the action of the heart more painful, to that beside an uniform stricture across the breast, he sometimes described a dreadful sensation like twisting of the organs in the thorax. He suspected the existence of water there, and was inclined to consider it as his primary disease, but was easily convinced of the contrary. At one time he had a suspicion of a complaint of the heart, and, although he had never heard of a disease of that organ, slightly intimated it to one of his friends, and mentioned a sensation he had experienced in the chest, which he compared to a fluid driven through an orifice too narrow for it to pass freely. In this month, beside the dropsical affections and increase of cough, he had occasional painful enlargements of the liver, frequent starting up from sleep, a slight degree of dizziness, a great disposition for reveries, and sometimes extraordinary illusions, one of which was, that he was two individuals, each of whom was dying of a different disease. This idea often occurred, and gave him much uneasiness. He was also afflicted with long continued frightful dreams, and sometimes a slight delirium.
After the use of much medicine, on the 6th of November, the effused fluids began to be absorbed, and passed out through the urinary organs with such rapidity, that on the 12th the dropsical enlargements had nearly disappeared. The pulse was much reduced, in hardness and frequency, by the medicine, and, as it fell, he became more easy. On the 10th the state legislature convened, and the call of business roused, like magic, the vigor of his mind; and the symptoms of his disease almost disappeared. During this session he made little complaint, dictated many important communications, and attended to all the duties of his office, without neglecting the most minute. As soon as the legislature adjourned, he declared, that his work was finished, and that he had no desire to remain longer in this world. He entreated that no farther means should be used to prolong his existence, and immediately yielded himself to the grasp of disease, which appeared waiting with impatience to inflict its agonies.
From this moment the distressing difficulty of breathing had very slight remissions. The consequent disposition to incline the superior part of the body forward, for the purpose of facilitating respiration, increased so much, that he frequently slept with his head reposed on his knees. The cough became occasionally very violent, and was always attended with an expectoration of a brown coloured mucus, sometimes tinged with blood. The abdominal viscera lost their activity. The face was sometimes turgid and high coloured, at other times pallid and contracted. A gradual abolition of the powers of the mind ensued, with a low delirium, and two short fits of phrenzy. The state of the circulation was very variable; the pulse at the wrists principally hard and vibrating, rarely soft and compressible; the less pulsations becoming more indistinct, and at length scarcely perceptible. No perfectly distinct beat of the heart was felt, but a quick undulating motion, not corresponding with the pulse at the wrist. Three days before death the arteries assumed this undulatory motion, corresponded with the motion of the heart, and, for forty-eight hours, lost the irregularity of pulsation3.
Once or twice the expiring faculties brightened. On the 30th of November he awoke, as if from death, conversed very pleasantly for two or three hours, and humorously described scenes, which he had witnessed in his youth.
On the 4th of December came on the second attack of furious delirium. Insensibility, and great prostration of strength, ensued. The respiration became very slow, and obstructed by the accumulation of mucus in the lungs; the pulse very intermittent, then regular, and finally fluctuating. A hiccough commenced; coldness of the extremities and lividity of the face followed, and continued three days before death. On the 9th the incurvated posture was relinquished, and the head sunk back upon the pillow; the respirations then diminished in frequency, till they became only two in a minute; and at the end of twenty-four hours they very gradually ceased.4
Dissection, Nine Hours After Death
External Appearance
The whole body was much emaciated; the face pale and contracted. The hands were slightly œdematous. Discolourations, answering to the ribs, were observed on the thorax; many small purple spots, hard and prominent, on the back; excoriations on the nates; and purple spots, resembling incipient mortification, on the heel and toe.
Thorax
The integuments of the thorax were free from fat: the cartilages of the ribs ossified in various degrees, some perfectly, others slightly. Upon laying open the cavity of the thorax, it was found to contain about three pints of water, the proportion being greatest on the left side.
The lungs were contracted into a smaller compass than usual, and were very firm to the touch. Their colour anteriorly was whitish, with small distinct purple spots; posteriorly, of a deep red, with similar spots. The right lobe adhered closely to the pericardium; it also adhered to the pleura costalis, by a great number of strong cords, which seemed to be elongations of the original adhesions. Some of them were nearly as hard as ligament, and many an inch in length. Internally the lungs presented a very compact structure. Their cells were crowded with mucus, and their vessels filled with black blood, partly fluid, and partly coagulated. Some portions were firmer and more condensed than others, but no tubercles were discovered.
The pericardium, viewed externally, appeared very large, and occupied almost the whole space behind the opening formed by removing the sternum and cartilages of the ribs. It was situated principally on the left side, and contained about double the usual quantity of water; but was principally filled by the enlarged heart, to which it adhered anteriorly about two inches, near its base. Its parietes were, in every part, very much thickened and hardened.
The heart presented nearly its usual colour and form, excepting on its anterior surface, which was somewhat discoloured by coagulated lymph. It was enlarged in bulk to, at least, one half more than the healthy size. The auricles and ventricles contained coagulated blood. The tricuspid valves were in a sound state. The left auricle was double the usual size. The left ventricle was enlarged, about three times thicker and much firmer than usual. The mitral valves were very much thickened, and near the insertion of their columnæ, which were sound, cartilaginous, so that they were quite rigid, and the opening made by them, from the auricle to the ventricle, was scarcely large enough to admit the passage of a finger. The semilunar valves of the aorta were ossified at their bases and apices, and the portion intermediate, between the base and apex, partly ossified, and partly cartilaginous, so as to render the valves very rigid. The aorta was at least one half larger than usual, especially at its arch. The arteria innominata, the carotid, and subclavian arteries, were uncommonly large and thick. The coronary arteries were considerably ossified.
Abdomen
The omentum was destitute of fat. The stomach distended with flatus on the pyloric side; its cardiac extremity, lying under the liver, was pressed down and contracted. The liver was shrunk; its tunic corrugated, as if it had been distended, and bearing marks of inflammation; its substance harder than usual; its vessels, when divided, pouring out liquid black blood. The gall bladder was filled with bile. The kidneys were thicker, and more irregular in form, than is common. The abdominal cavity contained some water.
Head
The bones of the cranium were unusually thick. The dura mater, which was thickened, and in many places bore marks of former inflammation, adhered to the bone at the vertex. On its internal surface, near the longitudinal sinus, there was a small ossified portion, half an inch long and the eighth of an inch thick. The convolutions of the brain were narrow, and very strongly marked. The pia mater bore marks of pretty extensive inflammation, and adhered to the dura mater at the vertex. The cortical substance ran deep into the medullary part of the brain. The ventricles contained about double the usual quantity of water; their parts were all remarkably well defined. The vessels of the pia mater, over the corpora striata, were unusually injected with blood. The velum interpositum was very firm; the plexus choroides uncommonly thick, but pale; the opening from the right to the left ventricle large. The vessels of the brain were generally not much filled with blood.
The blood appeared every where fluid, except in some portions of the lungs, and in the cavities of the heart. It was very dark coloured, perhaps more than ordinarily thin, and oozed from every part, which was cut.
The cellular membrane, in all dependent parts, effused, when cut, a serous fluid.