She was detained on board ten days after the attack, by the tempestuous state of the weather. In the waiting-room, she attracted our attention chiefly by the hard, though. oedematous swelling of her legs; but, on examination, more serious complaints appeared. She had been attacked at first with symptoms of pectoral inflammation, succeeded next day by rheumatic affections of the joints. When admitted, nothing of the latter remained except the swelling of the lower extremities, but the pectoral symptoms were still alarming. I considered it as a case of pleuritis; and, from the seat of pain, both in the sternum and between the scapulæ, as a case of pleuritis mediastini. Besides, as she could not lie in the horizontal position, I conjectured that the inflammation was chiefly anterior. For these complaints, she was repeatedly bled, blistered, and purged; and, on the 17th of the month, the pain is reported to be entirely gone. But, on the evening of the 19th, she relapsed. The pain was again relieved by bleeding; but, from this date, until she was exhausted, and almost moribund, she never could lie down in bed. Indeed, nothing could be more distressing than to witness her fruitless endeavours to find out a position in which she might have some rest. My supposition at the time was, that the inflammation was over, and that effusion had taken place, not into the cavities of the thorax, but into the mediastinum, or at least that it was confined by adhesion, or otherwise, to the anterior part of the chest. I confess that pericarditis never occurred to me, as her pulse was generally full and soft, and throughout had never been unequal, except on the 29th and 31st, after the use of digitalis, nor had she ever had palpitation or syncope. Pericarditis is indeed said to be a very obscure disease. And yet, except for my having at first taken up the erroneous notion that it was pleuritis, it was sufficiently obvious in the present instance. We had fever characterizing active inflammation, and the seat of the pain sufficiently indicated the place. Now, the only organs which could be affected there, were the pleura, mediastinum, or pericardium. The cough and expectoration, and the absence of symptoms usually enumerated as characteristic of carditis, misled me in my judgment. Rickman had not the pulsus inequalis, palpitatio et syncope, of Cullen; nor the constant vomiting of Darwin; nor the palpitation, faintings, quick and unequal pulse of Sauvages; nor the very intense thirst of Burserius; nor the hydrophobia of Daniel; nor the delirium of Davis. * And yet the intensity of pain, or rather anguish, in the region *An Inquiry into the Symptoms and Treatment of Carditis. By John Ford Davis, M. D. pp. 190. 12mo. Bath, 1808. of the heart, combined with the comparatively natural state of respiration during the inflammatory stage, might have directed me to the heart. Add to this, the absolute inability to lie down, the extreme jactitation, and, when it was discovered, the total want of resonance from the percussion of the sternum. Even this symptom did not undeceive me, for I had previously supposed a purulent collection to have been formed under the sternum, which was the reason of my making the trial; and its value, as a diagnostic symptom, is, I think, very apparent from this case. Our error in regard to the nature of this disease was not, however, of very great importance in this instance, as the treatment would not have been very much altered; nor probably could any treatment have been of use after she came under our care. The symptoms in this case, which seemed to depend chiefly upon the inflammation of the pericardium, were, 1. The pain or anguish under the sternum. 2. The great jactitation and want of sleep from the commencement of the attack. 3. The total inability to lie down, and the comparative ease which the patient experienced by leaning forward. 4. The febrile state of the pulse, which could, however, be only characterized as full and soft. The cough and expectoration I would ascribe to the inflammation of the pleura, and the effusion of water into the chest. All these contributed to the great dyspnoea which came on after the disease had subsisted for some time. The dissection of this case presented a most striking instance of universally and violently inflamed pericardium; and I think I am warranted in considering the inflammation of the pleura in the vicinity, causing agglutination of the neighbouring lobes of the lungs, and effusion into the cavities of the chest, as an effect of the original pericarditis, in consequence of the inflammation spreading by contiguity. The pericardium, in this woman, adhered universally to the heart by a layer of coagulable lymph, without any effusion of serum. Cases of this kind are not always necessarily fatal; for, whenever we find the pericardium adhering to the heart after death, we may infer, that it is the consequence of pericarditis at some former period. This is not a very rare occurrence. I have myself seen it in a man who died apparently of asthma; and Corvisart has a chapter on the subject. * But the most remarkable circumstance in this woman's heart was its partial conversion into fatty matter. Of that I was assured, not only by its appearance, but by chemical experiments, which were perfectly conclusive as to the fact. Corvisart himself never saw an example of this conversion, but says, that it has been seen by some modern anatomists, although their observations have not been published. He also confesses his ignorance of the manner in which such a transformation takes place. In the present instance, we find it accompanying pericarditis, but it does not follow that it was an effect of the inflammation. It may have existed before the commencement of the fatal disease. I do not know that any connexion has ever been traced between the conversion into fat of other muscles, and preceding inflammation. The commencing ossification of the valves, in so young a woman, is, however, an argument in favour of some state of inflammation having existed in the heart on a former occasion; and the membranous bands, causing lateral adhesions of the lungs, were evidently the effect of pectoral inflammation some time before the fatal attack. CASE III. JOHN MACLEOD, æt. 17, sailor. January 25th.-Is affected with pain in the right side, on deep inspiration or on cough; which last is pretty severe, and attended by a bloody sputum. The chest feels hot, but not oppressed. Has headach, nausea, retching, and an occasional vomiting of a slimy black matter. Thirst; tongue whitish, and moist at the edges. No appetite; B. regular; no sleep; pulse 92, small and soft. Complaints of three days duration. Sputum became bloody yesterday morning. Was immediately bled to considerable extent; and a cathartic was administered. Appl. vesić. lateri dolenti. Hab. aq. menth. pip. i. pro re nata, nausea urgente; et haust. anód. h. s. B Mist. mucil. 3vss. Acet. scill. 3j. Tinct. opii amm. 3ij. M. Sumat. 3ss. tussi urgente. 26th.-Blister rose well; breast considerably relieved; hæ noptysis diminished; pulse about 100; two stools. Hab. haust. sal. efferv. 4ta qq. hor. Omitt. aq. menth. 27th.-Considerable pain on coughing. Pulse 120; slight headach; face flushed; expectoration copious, and at present easy; several stools; had some sleep. B. Aq. font. 3iij. Aq. cass. 3. Tinct. digit. gtt. xl. M. Sumat. 3i. sexta qq. hora. Cont. med. ut a. Hab. decoct. furfur. ad lib. *P. 166. 28th.-Frequent loose stools; cough has continued severe; very little blood in the sputum ; pain pretty nearly general over the left and lower parts of the breast, but not nearly so severe at present; retching at times; pulse 112, softer; face not flushed; no headach. Cont. med. ut antea. Appl. vesic. parti dolenti. 29th.-Side much easier; some sleep in the former part of the night; delirium towards morning; pulse about 120, rather feeble; intermitting; two stools. Omitt. mist. cum digit. et haust. salin. Cont. alia. Hab. emuls. camph. 3ss. 3tia qq. hor. 30th. A good night; cough has not been so frequent; less dyspnoea; feels no pain; thirst; pulse quick and intermittent; belly regular. Cont. omnia ut heri. 31st.-Cough at times has been distressing; considerable dyspnoea, but no pain; only one stool; pulse quick, feeble and irregular. Hab. ser. vinos. 3x. Cont. alia ut a. February 1st. Had a better night; still much dyspnoea, and pulse as yesterday; no stool. Cont. ser. vinos. ad 3xiv. et alia u. a. Hab. pil. rhæi comp. iij. 2d. Had a pretty good night; cough has not been very frequent. Pulse 120, feeble and irregular; continues very weak; one stool. Cont. ser. vin. ad 3xvi. Alia ut a. 3d.-Cough has been very frequent; dyspnoea continues ; expectoration difficult; pulse 106; one natural stool; has ta ken the whey, but little of any other thing. Cont, ser, vinos. Omitt. alia, B. Aq. cass. iv. Tinct. digit. gtt. xl. M. Sumat. i. bis indies. 4th.-Is very feeble; has taken very little food; cough very distressing, and respiration laborious; two stools. Omitt. mist. cum digital. Cont. alia. B Solut. ammoniac. vi. Syrupi 3ss. Aq. menth. 3ij. Acet. scill. 3ij. M. Sumat. 3j. 4ta qq. hor. Hab. aq. cardiac. 3vj. Hab. haust. cum tinct. hyoscyam. gtt. xl. 5th.-Has had a good deal of sleep; is asleep at present; breathing easier; two stools; pulse 106. Cont. med. 6th. Has been much disposed to sleep since yesterday; pulse about 116, firmer and more regular; one stool; thirst; and complains much of weakness. Cont. med. 7th.-Has been affected with pain of breast since last night; cough troublesome; sputum tinged with blood; pulse about 80, but with frequent intermissions; several stools. Rep. haust. Omitt. alia. Appl. vesic. quamprimum lateri. Hab. mist. acid. sulph. 3j. 3tia vel 4ta Utatur linctu comm. more solito. Sth. Hæmoptysis has been constant; cough troublesome; pulse very feeble; has had little or no sleep, Hab. ser. vinos. 3x. Cont. alia ut a. 9th.- Died. On opening the thorax next day, few or no adhesions were observable; nor was there any considerable effusion of serum into the sacs of the pleura. A little to the right of the sternum there extended from the lower part of the left side a dirty chocolate-coloured bag, which, on being opened, proved to be the pericardium adhering to the lungs, thickened and much distended; also containing two pounds six ounces of perfectly formed pus. The inner side of the pericardium, and that part which is reflected over the heart, were covered with a thick coating of a substance resembling condensed curds; and in some parts to a greater depth than others. The substance of the heart was very much paler than usual. It had no other peculiarity. * The dissection of this case showed that it was an example of pericarditis, nearly as free from complication as it can occur ; and, on this account, it becomes the more valuable, as Corvisart informs us that he is in possession of no proper case of acute pericarditis without complication. But here, while we have a very high degree of inflammation of the pericardium, both where it invests the heart itself, as its outer membrane, and where it is reflected as a loose bag around it, there was almost no affection of the neighbouring parts. The leading symptoms were at first pain in the right side; certainly a very anomalous symptom; but it must be observed, that the pericardium extended to the right of the sternum; cough, |
