Cases of Organic Diseases of the Heart

by John Collins Warren

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 dyspnœa 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 dyspnœa 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 dyspnœa 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 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 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 dyspnœa 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 dyspnœa 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?