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VII.

Case of Conversion of the Substance of the Heart, accompanied by the production of a Sac at the Mouth of the Aorta. By THOMAS SPENS, M. D. Fellow of the Royal College of Physicians, Edinburgh, and one of the Physicians to the Royal Infirmary.

A LADY, æt. 41, returning from church on Sunday the 5th November 1815, fainted on the street. She could not be said to be in very good health, having lately had a severe illness, the principal symptoms of which were frequent and long continued attacks of acute pain in the lower part of the belly and back, extending down the thighs, with a bloody discharge both from the rectum and vagina, and incontinence of urine. The seat and nature of this disease were obscure, but she recovered, and was so well for months, as to be able to walk about and take an active share in the management of her children and family. The only symptom previous to this syncope was a degree of dyspnoea, lately felt on motion or exertion. She fainted two other times on Sunday evening, and had frequent vomiting.

November 6th.-She had almost constant nausea and frequent vomiting, and a feeling of faintness, and oppression, or anxiety about the breast, which was most distressing. Notwithstanding those feelings, however, the motions of expiration and inspiration were apparently going on quite regularly. Pulse 75.

7th. Continued in the same state, but the pulse now varied from 24 to 30, regular but not feeble; respiration apparently regular.

Sth.-Was quite easy from 7 A. M. till 9 P. M. but her pulse continued the same.

9th.-Pulse as before; great and constant uneasiness, but sometimes aggravated for a short time, with intermission of pulse. She complained of constant palpitation; but this could hardly, if at all, be felt by the hand. No nausea or vomiting; and she frequently took a little beef-tea or brandy and water, loathing every other kind of food or medicine.

10th.-Nearly in the same state as yesterday. Her bowels were kept open by laxative pills or injections.

11th. These fits of aggravation of distress were attended with turning up of the eyes, clenching of the hands, cessation

of pulse, and insensibility, continuing ten or twelve seconds. They were almost incessant from midnight to 4 A. M. She described her feelings, at the time of their accession, as those of going into a faint, and said she suffered very great uneasiness on the return of sensibility. Her pulse was felt repeatedly as low as ten in the course of last night; but early this forenoon the palpitation became excessive and constant; the beating of the heart and carotids so rapid, as hardly to be counted (I think about 200), and strong, while the pulse was scarcely to be felt at the wrist.

12th.-10 A. M. Palpitation has been constant, and of the same rapidity, attended with very great distress, and almost constant screaming, but no more convulsive fits; no pulse at the wrist; hands somewhat swelled, and at times of a darkish colour; also cold, as well as the feet, but all at present warm; voice strong; mind entire and firm, though quite aware of her danger. Forty drops of laudanum were given, and within an hour she became quiet, and remained so the whole day, though the palpitation continued undiminished. Thirty drops of laudanum were given at 10 P. M.

13th.-Lay quiet all night. About 8 A. M. being more uneasy, 30 drops of laudanum were given. 10 A. M.-Palpita tion continues nearly as rapid; hands cold; feet warm; breathing quick; speaks seldom, and with difficulty; takes some drink frequently, and the glass in her own hand. Between 7 and 8 P. M., when a drink was offered her, she said, "Stop a little;" had a smart convulsion, and expired.

The body was inspected by Dr Gordon, and the following is his accurate statement of the appearances.

"The cavities of the chest and abdomen were examined. "The lungs were healthy, both in their substance and on their surface. There was a slight effusion of a yellowish serum into each cavity of the pleura.

"The heart appeared a little larger than is usual, in proportion to the stature of the individual. A large portion of the middle of its anterior surface was covered with a loose flocculent matter, which adhered at one or two points to the pericardium. A large portion of the muscular coat of the right ventricle was converted into a firm whitish matter, like that which is found in scrofulous mesenteric glands. This conversion was confined to. of the anterior side of the ventricle, and to about an inch square the septum, close to the orifice of the pulmonary artery. In the anterior side of the ventricle it did not extend quite to the apex, but occupied chiefly the parts next the tricuspid valve, and there the sides of the heart were thickened in consequence,

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VOL. XII. NO. 46.

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ly a quarter of an inch. The tricuspid valve, however, as well as all the fleshy columns connected with it, were in a healthy state. In the septum of the ventricles the conversion did not penetrate to the left ventricle, but seemed to occupy only the half next the right. In consequence of the disease towards the orifice of the pulmonary artery, this opening was considerably diminished.

"The right auricle was a little larger than usual, and its fleshy columns were considerably thicker.

"The left ventricle presented a perfectly natural appearance, except in one circumstance: Close to the orifice of the aorta a little sac sprung from the surface of the ventricle, and projected into its arterial orifice, lying on the inferior semilunar valve. The sac looked as if composed of fibrin, and, when perforated, a greyish cream-looking matter issued out of it. Its connection to the surface of the ventricle was very firm.

"The left auricle was quite healthy, as well as the mitral valves. The semilunar valves, both of pulmonary artery and aorta, were in a natural state. There was about a table-spoonful of yellowish serum in the pericardium.

"The sides of the uterus were a little thicker than usual; but every thing else in the abdomen was healthy."

VIII.

The Substance of a Clinical Lecture on a Disease of the Valves of the Heart, producing Pulsation of the Jugular Veins. By GEORGE PEARSON, M. D. F. R. S. in a Letter to Dr DUNCAN, Professor of the Institutes of Medicine, &c.

"Hæc de pulsatione jugularium venarum, in præsentia habui quæ dicerem. Cujus signi, meique hujus examinis si quam vides utilitatem esse posse ad cordis morbos abditissimos internoscendos; vides simul, jure, an injuria adversus recentiores medicos scriptum sit; exacta cognitio usûs valvularum cordis quid prodest medico curanti in morbis cordis pro cognitione morbi ?"-MORgagni, Epist. Anat. xviii. l. 11. Art. 12, p. 143.

A NNE ALLINGHAM, admitted into St George's Hospital, January 23, 1816, fifty-three years of age, but with a countenance of disease denoting much greater age. Had been married, and born six children. For many years of her life had been in laborious servitude. Fell ill suddenly four months previous

to her admission, but could give no distinct or full account of her case; could only describe that she became “low, weak, sick;" in particular, never felt any topical pain, nor had any cough. The lower extremities were now oedematous; hence, she said, was not able to walk. The pulse at the wrist was 80 in a minute. It was suspected the patient might have brought on the debilitated and dropsical state by drinking spirits. Till further information could be obtained, by subsequent inquiries and observations, a mixture was prescribed of Infus. sennæ ziv. Tinct. aloes 3ij. Tinct. zingiberis 3vi. Syrupi bals. Tolut. 3ij. To take cochl. ij. majora cum cochl. ij. maj. aquæ fontis ter quotidie.

Also to have the limbs well rubbed with the linim. ammonia mitius, nocte maneque.

On the second examination, the neck being then without covering, an evident considerable pulsation, or more properly undulation in the course of the external jugular veins in the neck, attracted attention. At the same time, this undulatory motion, did not correspond either to the pulse at the wrist, or of the temporal artery, or of the heart. In a recumbent posture for some hours, the pulse of the jugulars was 120 to 130 in each minute; at the wrist 60, and about the same of the heart, but fluttering and rather irregular. The respiration seemed to influence the pulsation in the jugulars. In a state of quiescence, whether in an erect posture, or recumbent on the back or sides, the breathing was not affected. No startings or sudden waking occurred in the night-time. The lips appeared rather livid. The appetite for meat increased, and full diet was desired;-wine was also allowed. No complaint but of being so weak as commonly to lie in bed.

On a third visit of observation, in six days from the admission, the phenomena, to my apprehension, indicated diseased structure of the cavities of the heart, to obstruct the passage of blood, so as to occasion it to be repelled from the right or su perior heart into the vena cava and jugulars. I ventured to declare this opinion to the gentlemen attending the physicians' practice. The general debility had now greatly increased. A much greater obstruction was felt to the passage of the blood through the heart; the pulsations of which were so indistinct that I could not number them;-the mode of action being every way irregular, intermitting, and fluttered. I was surprised to perceive no dyspnoea, nor hear any coughing so long as the patient was at rest, whether in a recumbent or erect posture. At the same time, the pulse at the wrists was become weaker and rather irregular, but not synchronous with either that of the

heart or of the jugulars; the latter being double in frequency to that of the wrists. The patient was quite tranquil while reposing in a bed, but walking could not any longer be performed without the risk of fainting, attended by excessively accelerated pulsations at the wrists and jugulars, with very frequent, very irregular, and very feeble pulsations of the heart.

At this time the case became more clear, from the motion of the jugulars being found to extend down the right side of the thorax, to the right hypochondrium, at the margin of the liver, indistinctly; and then more distinctly in the abdomen, in the course of the vena cava inferior.

10th day after admission.—In addition to the former symptoms, the stomach was greatly affected by sickness pretty constantly; and sometimes with vomiting of apparently bile in the fluids rejected.

14th day after admission.-To all the former symptoms aggravated, a troublesome cough had supervened. In particular, few things were now retained in the stomach; the eyes too grew yellowish; the countenance sunk, elongated, and pasty.

In a few days further, there was expectoration of florid blood mixed with mucous matter; the difficulty of breathing was great; the cough frequent; the lips quite blue; the pulse at the wrist was no longer perceptible; the bowels became lax. On the 19th day of her residence in the hospital, the patient died in the morning without any struggle. The night before death, about eight ounces of florid frothy blood were brought up by coughing; the nose too became purple; the beating of the jugulars, I was informed by the nurse, never ceased, or even abated, to the time of dissolution; the breathing was at last not much affected, and there had been at no time orthopnoea, unless upon moving the body; no local pain, but much general uneasiness was manifested. She lay for some days on the left side, with the head raised up a little, but during the last day of life, the posture was changed to the right side.

I have given no detail of the prescriptions, as they were merely for urgent symptoms of the usual kind, and what are called cordial and gently stimulating remedies; but I was anxious to observe the symptoms in the progress of the disease. Dr, now Professor, Hewitt of Downing College, Dr Chambers, and Dr Sigmond, who attended the physicians' practice, constantly visited the patient, and taking notes daily, I have greatly profited by them, not only in confirmation of my own observations, but by the addition of symptoms which occurred in my absence, or escaped unnoticed.

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