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Sectio Cadaveris. The body was opened by my skilful pupil Mr Wharrie. My colleague Dr Young was present, feeling much interest on account of a similar case under his care, published in the fifth volume of the Transactions of the College of Physicians.
Thorax.— The lungs did not collapse ; they appeared almost uniformly of a dark reddish colour, not unlike liver. Watery fluid between the lungs and costal pleura, perhaps half-a-pint in each cavity. In the pericardium about four ounces of a similar liquid. The heart was in its wonted position, but considerably larger and paler than usual, with much fat upon it. The right auricie was more distended than I ever saw on any former occasion, and the left was also distended. No thickening of the pleura menubrane, nor adhesions were seen denoting inflammation; no disease of structure or texture could be perceived er. ternally in any of the large blood-vessels of and near the beart.
The lungs being detached, appeared smaller, and felt comparatively dense, instead of their usual spongy feel, but they were not at all hard. They barely floated in water; for portions being immersed ascended very slowly. The condensation, or, more properly speaking, the liver-like consistence, was not partial, but uniform, anu there was only rather greater firmness of the left than the right lung. Being cut into the whole substance appeared greatly distended with dark-coloured blood, and perhaps there was effused blood into the cellular interstitial parts, or cellular membrane, between the air tubes and air cells. In the trachea no morbid appearances, but a little mucus tinged with blood in the bronchial iubes,
Heart.-— The auricles and ventricles were all full of black partially coagulated blood; not less than twelve or fourteen ounces. The texture of the heart was not hirm; it was soft and flaccid ; the hardness was felt on havdling it in any part, but the cavities being laid open, much diseased structure was found. The cavity of the right auricle was very much enlarged, as well as that of the right ventricle. Some of the carneæ columnæ attached to the tricuspidal valves were much thickened and shortened, by which the passage of blood into the pulmonary artery must have been considerably obstructed in the right heart. In the left heart an equal or still greater impediment was found from the mitral valves being partially cartilaginous, or at least thickened; and still more obstruction was produced from the same indurated state of the semilunar valves of the aorta ; thus considerably straitening the passage from the left ventricle into lhe aorta, and occasioning accumulation in the left heart.
The interior of the external jugular veins, and vena cava sile perior, were examined, as well as the interior of the pulmonary artery and aorta, but no morbid appearance was seen.
Abdomen.- The liver was large and pale, but I did not consider any part of it be in a morbid condition. The rest of the abdominal viscera were sound. In the cavity of the abdomen there were about three pints of watery liquid.
Wishing to afford further satisfaction before I read the clinical lecture on this disease, I desired Mr Wilson to examine the state of the above described heart. From this excelling anatomist I was most obligingly favoured with the following report, which, I apprehend, will remove every suspicion of inaccuracy.
“ My Dear Sir, I have examined the heart which you sent by my son. The passage into the pulmonary artery from the ventricle is much smaller than it ought to have been, and is rendered so by the unusual shortness and situation of some of the carneæ columnæ attached to the edge of the tricuspidal valves. « The passage
into the aorta from the left ventricle is not more than half of its natural size. This is partly owing to the carneæ columnæ attached to part of the mitral valves, but more parti. cularly to a considerable thickening in the valves of the aorta, and in the part of the heart nearly surrounding their attachments. By reason of the narrowness of the passages into the two great arteries, the whole of the blood passing into the ventricles could not, in their systole, be pushed into the arteries. This would occasion a great accumulation in the auricles, and, I think, accounts sufficiently for the semblance of pulsation in the jugular veins.—1 am,” &c.
" JAMES WILSON.” George Street, Hanover Square,
February 16, 1816.
Remarks. In the present state of physic, although there are no means hitherto discovered of curing the disease above described, the history may be of practical utility in several ways. 1st, It serves for improvement in the physiology of that admirably constructed organ, the heart ; 2d, It furnishes, perhaps, diagnostic characters to distinguish it from other different affections ; 3d, It may serve, not only to avoid useless, or even hurtful treatment, but to indicate palliative remedies.
I conceive that a reasonable explanation may be given of the phenomena from our presumed knowledge of the functions of the different parts of the grand instrument of the circulation of the blood. The obvious effect of the morbid state of the valves of the right or superior heart must have been to obstruct the discharge of blood into the lungs; but this impediment alone might not probably have done more than occasion some uneasi-, ness of the chest, and specially inability of muscular exertion in labour, or in walking rapidly, from dyspnea, and perhaps syncope; and, after considerable time, there would be anasarca and dropsy of the cavities of the thorax and abdomen. But, in the instance under contemplation, considerably greater derangement must be produced by the diseased state of the mitral valves of the left ventricle, and the semilunar valves of the aorta. Hence the blood transmitted with such exertion (owing to the diseased state just mentioned of the right heart) through the lungs into the left, would be accummulated in the left heart. Of course, the disease of the valves, with its consequences, accumulation of blood in the auricles and ventricles, and distention and weakness of the muscular power of the heart increasing, congestion was produced in the lungs, to cause effusion of blood into the connecting cellular membrane between the bronchi and air cells, as well as into those air tubes, manifested by the hæmoptysis above twelve hours antecedent to death, and by the firm consistence and liver-like colour of the lungs observed on dissection. In such a condition of both the right and left heart, it was not to have been expected that the pulsations of this organ would correspond to those of the arteries at the wrists and other distant parts. That so great a quantity of black or venous blood should be found, not only in the pulmonary or right heart, but in the corporeal or left, instead of red or arterial blood, is, I apprehend, satisfactorily explicable, from the incapability, at least, of transmission of oxygen gas by the air cells.
The extraordinary phenomenon remains, however, still to be interpreted, namely, the palpable pulsation of the jugular veins and of the venæ cavæ. Except a somewhat similar case under Dr Young's care, I did not find that such an occurrence had been observed in the hospital for the last 30 years; and it was quite novel to such practitioners as I happened to have intercourse with at the time. Although there seems no difficulty to explain this pulsation from the repulsion of venous blood by the diseased state of the right and left heart into the vena cava, superior and inferior, we must infer from its rarity, that no common obstruction does occasion such a phenomenon; and, accordingly, indeed I believe it is not very common for so considerable und extensive an obstruction to exist at the same time.
I apprehend it is quite unnecessary to offer a more particular and further explanation. That watery liquid should be found in the cavities of the chest and abdomen, as well as in the cellular membrane of its extremities, is according to the usual course of analogous cases. But I own I do not conceive there is any probability that the comparatively inconsiderable hydrothorax in this instance could have any influence in producing the pulsation in the jugular veins, so ingeniously proposed by Dr Young in the Medical Transactions.
While I was engaged in writing the substance of this clinical lecture, I accidentally met with a reference to Morgagni's well known work, for some histories of the kind above written. Lib. ii. De Morbis Thoracis, art. 12. He asserts, that the pulsatory motion of the jugulars may be occasioned either by disease of the right auricle or right ventricle, which may be distinguished in the following manner : “ Si forte quæris, qua liceat ratione internoscere, ab utro sit eorum cavorum ; licere tunc, dicam, ubi paulo minus frequentibus ictibus jam micent tum arteriæ, tum jugulares venæ. Si enim obtuitu simul in his fixo, simul digitis arteriæ aut temporum aut carpi admotis, evidenter cernes, eodem temporis puncto venas illas sè attollere quo pulsare senties arteriam ; a contractione illas micare, intelliges, ventriculi dexteri: sin contra, non ab hujus, sed a contractione auricula
Nosti enim, arterias tunc pulsare, non cum auriculæ contrahuntur, sed cum ventriculi, et vicissim tunc subsidere non cum ventriculi sed cum auriculæ contrahuntur. Itaque subsidentibus arteriis si venæ attolluntur jugulares ; harum pulsatio a dextero, qui tunc otiatur, ventriculo esse non potest: contra autem si arteriæ, et venæ illæ simul pulsant: necesse est, venarum pulsatio non ab otiante auricula, sed a ventriculo sit tunc agente, et sursum impulsis vehementer valvulis, si hæ quidem, orificium claudant, venarum sanguinem succutiente aut sui portionem sanguinis in venas repellente, si valvulis orificium non cxacte, ut natura instituit, occludatur.” Juster observers may determine whether or not these distinctions really ascertain the seat of the disease. While I am writing upon this subject, it may be useful to mention, that Morgagni considers the foundation of the dogma of Lancisi, that pulsation of the jugular veins is a pathognomonic symptom of dilatation of the right ventricle ; but from autopsia concludes: “ Signum ab Lancisio propositum sæpius quidem indicare ventriculi dextri dilatationem; interdum vero non hanc indicare, sed vîtium tamen semper aliquod, cujus aut sedes in cavis dexteris cordis sit, aut effectus ad hæc attineat sic ut circumitio sanguinis per dexteram cordis partem secundum naturam non perficiatur..”—Morgagni de Sedibus et Causis Morborum, Epistol. xviji. lib. 11. art. 10.
History of a Disease from Thickened and Cartilaginous Valves
of the left Ventricle, and of the semilunar Valves of the Aorta. By George PEARSON, M. D. F. R. S. senior Physician to St George's Hospital, &c. In a Letter to Andrew Duncan, M. D. Professor of the Institutes of Medicine, &c.
and the reasoning on the disease of Anne Allingham, described in my former letter.
John HERBOTT, 19 years of age, a cabinet-maker ; received into the hospital January 23d last. Had not enjoyed good health for two preceding years, being troubled at certain times with dyspnea, in different degrees, yet slightly, while pertorming his work, or when walking at a quick pace; also having had lately, pretty constantly, an uneasy sensation extending from the region of the heart across the chest to the right side. Since May last these complaints have been so distressing, that he has been unable to execute the work of his occupation. There is now general debility, with a cachectic countenance; no asparent difficulty of breathing in any position while the body is at rest, but upon walking across the room, there came on dyspnea, and strong accelerated pulsations of the heart. On walking up stairs especially affected, so as to be obliged to stop for breath, as he felt as if he should, on proceeding, fall. The easiest recumbent position was on the back; scarcely uneasy sensations wlien lying on the left side, but very uneasy on the right; not any more ease from the head and trunk raised in bed than in an even posture. On
repose, the pulse at the wrist and the heart were about 60 to 65, and synchronous ; thirsty ; tongue rather foul and brown. On the supposition that there was an inflanimatory state, or at least congestion of blood in the heart or lungs, the prescription was as follows:
Detrahantur sanguinis unciæ decem.
capiat magnesiæ sulphatis drachmas quatuor.
posit. grana decem. 25th. - Second visit. The former uneasiness of the chest was