Cases of Organic Diseases of the Heart

by John Collins Warren

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 phœnomena, 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 phœnomenon 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.