John Collins Warren

“ 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. ”

“ No one can doubt that blood may be frequently forced through the thin membrane of the air vesicles, who considers, that in these cases the heart often acts with uncommon violence, that, when it is enlarged, it attempts to send toward the lungs more blood than their vessels can contain, and that there is commonly some obstruction to the return of blood from the lungs into the heart, from derangement either in the mitral or aortal valves, or in the aorta. ”

“ 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 [35] 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. ”

“ 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 [36] 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. ”

“ It has been seen, that the excessive action of the heart sometimes produces inflammation of the pleura and pericardium, and that the distention of the coat of the liver has the same effect upon that membrane in a slighter degree. Vesication may probably lessen those inflammations. When the stomach and bowels are overloaded, a singular alleviation of the symptoms may be produced by cathartics, and even when that is not the case, the frequent use of moderate purgative medicines is advantageous. Full doses of opium are, at times, necessary through the course of the complaint. ”

“ If an obstruction exist in either side of the heart, or in the lungs, the blood to be poured [53] 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 ”

“ The pulsation of the heart cannot be felt on the left side, and is barely perceptible on the right side of the sternum, and in the epigastric region. When he is distressed with fits of dyspnœa, he feels something as if rising to the upper part of the thorax, and the heart then seems to him to be beating through the ribs. I have not witnessed any of these paroxysms. The inferior extremities and abdomen have been swelled about three weeks. When in bed, he has his head and shoulders elevated, and, upon the attack of his paroxysms, sits up and inclines his head forward ”

“ The cellular membrane, inside the thorax, about the mediastinum, had not so bloody an appearance as we witnessed in the preceding cases, nor were the lungs, either externally or internally, so dark coloured as usual, though they were much darker, firmer, and more filled with [47] blood, than is common in subjects of other diseases. The lungs of the left side adhered closely to the pleura costalis, and those of the right were tied by loose and membranous adhesions; beside which there was no appearance of disease about them. The cavity of the pleura did not contain any water ”

“ 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 ”

“ The cortical [15] 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. ”

“ 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 cellular membrane, both on the outside and inside of the thorax, was quite bloody, which is not usually the case in dead bodies. The cartilages of the ribs were slightly ossified, and, upon their removal, it appeared that the pericardium and its contents occupied an extraordinary space, for the lungs were quite concealed by them. ”

“ The consequent accumulation of blood in the lungs seems to me to be the probable cause of the dyspnœa, which so much distresses those affected with diseases of the heart; for if there be an inordinate quantity of blood, there must be a deficiency of air. ”

“ She has dizziness, especially on moving, without pain in her head. She had for some time, a severe cough, which is now relieved. The dyspnœa is not yet very distressing, except on using motion; it often occurs in the night, and obliges her to rise and sit up in bed. The palpitations are very hard, and so strong, that they may be perceived through her clothes; the tumult in the thorax is indescribable. The functions of the abdominal viscera are unimpaired. ”

“ This man has a very robust frame of body, and has been accustomed to a free use of ardent spirits, and of opium, of which he now takes about twelve grains in a day. His appearance is such, that, on a slight survey, one would not suppose him diseased, but, on observing him with a little attention, a shortness and labour of respiration are perceived, with some interruption in speaking, and a frequent catching of the breath, or sighing. ”

“ 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. ”

“ 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. ”

“ Although it may not admit of cure, the painful symptoms attending it may be very much palliated; and, as they are so severely distressing, we ought to resort to every probable means of [39] alleviating them. Remedies, which lessen the action of the heart, seem to be most commonly indicated. Blood-letting affords more speedy and compleat relief, than any other remedy. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ Since writing the above account, the dropsical collections were absorbed, and the palpitations and other symptoms moderated, so that he considered himself nearly well, and attended to his usual business. Within a few days, however, the symptoms have returned with more violence. The dyspnœa is at times very distressing; the pulse more irregular and intermittent; the palpitations are more constant. His sufferings from lying in bed are so increased, that in the most comfortable nights he passes, he sits up once in an hour or two. The appetite is keen. The legs begin to swell again. ”

“ To these symptoms were superadded dizziness and severe head-ache, a disposition to bend the body forward, sudden starting from sleep, with dread of suffocation, violent cough with copious expectoration, which for fifteen days before death consisted of black blood, distressing pain across the chest, especially on the left side, great œdema of the lower extremities, and paucity of urine. ”