Cases of Organic Diseases of the Heart

by John Collins Warren

CASE OF HYDROTHORAX.

The following case of hydrothorax will shew, that water may exist in the chest without the symptoms, which we have attributed to organic diseases of the heart.

Mrs. T——, aged 56 years, of an excessively corpulent habit, had been affected for a great number of years with a scirrhus of the right breast. Finding her health decline, she at last disclosed it, and in coincidence with the opinion of Dr. Warren, sen. I amputated it on the 30th of May, of the present year. We however informed her friends, that the probability of eradicating the disease was extremely small. The skin was in many places hardened and drawn in, and in others discoloured, and ulcerated at the nipple, so that it was found necessary to remove, not only what covered the breast, but some portion of that which surrounded it. A long chain of diseased glands, extending quite to the axillary vessels, was also extirpated. She bore the operation well, lost no great quantity of blood, and recovered her appetite and strength surprisingly in a few days, while the wound healed rapidly. At the end of twenty days a difficulty of breathing commenced, and soon became so oppressive, that she could no longer lie in bed; partly, no doubt, on account of her extraordinary obesity. The pulse was small, quick, and commonly feeble, but sometimes a little hard, when any degree of fever was present. The countenance became pale, the lips of a leaden hue, the eyes dim. We were surprised at the change, and conjectured that the cancerous action had suddenly extended to the lungs. Yet she had not the slightest cough; and it was remarked by Dr. Warren, sen. that he had never observed that diseased action to increase, while the wound remained open. At last the lower extremities swelled, which might be attributed to the upright posture, and the pressure on the absorbent vessels in that posture. The appetite failed; she complained of a constant sense of depression at the stomach, and, without any remission of the difficulty of breathing, died on the 1st of July.

On the next morning the body was examined. The pleura in both cavities of the thorax was studded with small, white, and apparently homogeneous tubercles; the lungs contained a great number of similar bodies. The right cavity of the pleura was entirely filled with water, of which we removed at least three quarts. The heart was of the usual size, very flaccid and tender; but not otherwise disordered. The liver was enlarged, of its usual colour, much hardened, and had on its surface, and in its substance, many tubercles like those in the thorax. It had also a great number of encysted cavities, each about the size of a hazle nut, which contained a thin yellow fluid. The gall bladder was wanting, and in its place there was a small, but very remarkable depression, without a vestige of any former gall bladder, for the coat of the liver was as smooth and perfect there as in any other part[15]. The pancreas was in a scirrhous state. The abdomen did not contain any water.

It seems, then, that water may exist in the cavity of the thorax, without any remarkable symptoms, except dyspnœa and difficulty in assuming the horizontal posture. But in organic diseases of the heart, there is a long train of frightful symptoms, distinguishable by the most superficial observers. We infer that these disorders have been unnecessarily confounded.

FOOTNOTES:

[1] A careful examination of the works of some of the most eminent English practical writers does not afford evidence of any clear distinction of these diseases of the heart. Dr. Cullen, whose authority is of the highest estimation, evidently enumerates symptoms of them in his definition and description of the hydrothorax. In § 1702 Th. and Pr. he places much confidence on a particular sign of water in the chest, and remarks, that the same sign is not produced by the presence of pus. Now, there is no sufficient reason, why this symptom should not arise from the presence of pus, as well as from that of water; but it probably can depend on neither of those alone. See Morgagni de causis et sedibus morborum, Epist. 16. art. 11. The experienced Heberden says in the chapter “De palpitatione cordis,” “Hic affectus manifesta cognitione conjunctus est cum istis morbis, qui existimantur nervorum proprii esse, quique sanguinis missione augentur; hoc igitur remedium plerumque omittendum est.”—“Ubi remediis locus est, ex sunt adhibenda, quæ conveniunt affectibus hypochondriacis.”

Dr. Baillie’s knowledge of morbid anatomy has enabled him to make nearer approaches to truth; yet it will probably be found, when this subject shall be fully understood, that his descriptions of the symptoms of diseases of the heart and of hydrothorax are not quite accurate, and, that with respect to the former, they are very imperfect.

Some of the French physicians have devoted much attention to this subject; especially M. Corvisart, professor in the hospital of La Charite, at Paris, from whose clinical lectures is derived the most important information.

[2] During this time it was thought adviseable to acquaint his friends, that an organic disease of the heart existed, which doubtless consisted in an ossification of the semilunar valves of the aorta, attended, perhaps, by enlargement of the heart; that the disease was beyond the reach of art, and would prove fatal within three months, possibly very soon; that if it lasted so long, it would be attended by frequent recurrences of those distressing symptoms, general dropsical affections, and an impaired state of the mental faculties.