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.
While concluding these observations, a case of this disease presented itself, which comprehends so many of the symptoms, that I cannot neglect an opportunity of recording it, especially as it exhibits the complaint in an earlier stage than the others, with appearances equally unequivocal. I may here be allowed to remark, that no cases have been introduced which occurred before my attention was directed to a close observation of this disorder, and that there are many others, under the care of practitioners of eminence belonging to this society, with symptoms perfectly well marked, which it has not been thought necessary to adduce. In proof of this, reference may be had to Dr. Warren, sen. who has a number of cases, and also to Dr. Dexter, Dr. Jackson, and Dr. J. C. Howard.
A lady from the country, of a robust habit, whose age is about thirty-four years, complains of uneasiness in the right side below the edge of the ribs, sometimes attended with swelling, external soreness, and a throbbing pain, which often reaches to the shoulder, and produces a numbness of the right arm. She is rather uncertain at what time her complaints commenced. About two years since she lost her husband, and was left with but small means to support a number of children. She became in consequence, much dejected. While nursing a child, about a year since, she first was sensible of palpitations of the heart, which, in about three months, were followed by dyspnœa very much augmented by ascending an eminence; and profuse discharges of blood from the mouth, first raised, she believes, by vomiting, and afterwards by coughing. Evacuations of blood from the hæmorrhoidal vessels appeared about the same time, and occasionally since, till within six weeks, during which time there have been no sanguineous discharges, and this suppression has aggravated her other complaints.
The pulsation of the heart is felt most distinctly quite on the left side of the thorax, where there is a painful spot; it is perceptible also in the epigastric region. It is irregular and variable, at one moment hard, strong, distinct, and vibrating; at another, feeble and confused. There is also sometimes perceived a pulsation above the left clavicle, within the insertion of the mastoid muscle, commonly attended with a visible fulness of the superior part of the breast. The thorax feels, to the patient, as if it were girt across, and there is a distinct pain in the heart. Both these sensations are aggravated by a very hard, frequent, and dry cough, which however begins to be less violent from the use of the scilla maritima. The countenance is animated, and rather flushed, but not so much overcharged with blood as happens in many instances; perhaps it little exceeds a blush, so moderate that it might be considered as an indication of perfect health; yet the head is greatly disturbed with dizziness, and frequent and intense pain, and is seen to be shaken by the palpitations.
The functions of the abdominal viscera are not much deranged. The appetite varies, though it is commonly good; the intestinal evacuations, and the menstrual discharges, are regular; the urine is turbid, and so small in quantity as sometimes to produce strangury. The abdomen and inferior extremities are swelled, and the distention produces an uneasiness in the former, and pain and a livid colour about the gastroenemii muscles in the latter. The pulse is hard, without strength or fulness, slightly intermittent, variable, and irregular; yet it has not so much irregularity as in most of the cases recorded above.
This patient is uneasy in bed, though she raises her head almost upright; her sleep is disturbed by unpleasant dreams, and by startings, sometimes quite to an upright posture, without any cause discoverable to herself. She can incline a little to the left side, but never to the right, because it brings on a singular oppression, and a sense of weight drawing on the left side. When most distressed by dyspnœa she bends her head and trunk forward, and remains thus seated a considerable portion of the night, often sighing quickly and convulsively. She is subject to profuse sweatings, and very liable to take cold, and is then more uneasy.
This lady is still corpulent. She has taken much medicine, under the direction of eminent physicians, sometimes with temporary relief, but most commonly without any. The exercise of walking slowly, in pleasant weather, although it increases the palpitations at the moment, is followed with relief from the distressing feelings, which are increased when she sits still for a long time. She has no suspicion of her hopeless situation, and confidently expects relief from medicine, yet labours under a melancholy which is unnatural to her.