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friends and advisers of my patient I intimated the hopelessness of his case. In the way of treatment, I ordered tonics, and forbade violent exercise and over-anxiety. It was the fortune of this patient to consult, on the same day, another member of our profession, but his misfortune that he intentionally held back the fact that any previous opinion of his case had been arrived at. The physician consulted was in the midst of morning engagements, and seeing a strong looking man before him, complaining of nothing but an occasional irregularity of pulse, did not examine the chest at all; but, thinking that the irregularity was purely functional, that the spasmodic attacks were due to flatulency, gave an opinion that there was no reason for any change in life, and that the symptoms would all pass away under digitalis and alteratives, which were forthwith prescribed.
The sufferer went home satisfied, and made no provision for danger. A few months later, he attended a near relative in labour, concluded the delivery, retired to another room, and, with a scream, fell in one of his old spasmodic attacks. There was relaxation of the spasm, and recurrence; but this time there was no escape: he died in the midst of one of the seizures.
I saw another illustration of this kind, also in a medical man, who had lived very freely, and had undergone much exposure to the night air. In this case, signs of hepatic enlargement, for a time, drew attention away from the heart, the true seat of the disease. Ultimately the exact nature of the malady became only too apparent. The cardiac dyspnoea in this case was, however, never so intense as in the case preceding; but the attacks were much more frequent, and sufficiently distressing. I went down to the country one evening to see this gentleman, and slept in his house. In the night I was awakened suddenly, to find him in his dressing-gown by my bedside, imploring me to do something that should enable him to sleep, or to lie for one hour at rest, or to make one deep inspiration.
In this patient, the lungs gave no indication of obstruction: in him, too, by careful auscultation of the left side, the systolic and diastolic sounds could be made out; but on the right aspect all was confusion—vermicular action. I made the same diagnosis here as in the preceding case; and that diagnosis was correct. The patient died in one of the attacks of cardiac apnea ; and the right side of the heart was found, after death, utterly disorganised; the structure in parts translucent, and tearing like wet paper. The walls on the left side were pale, but of ordinary thickness; the valvular machinery was normal; and the lungs were free from disease. The liver had undergone but little morbid change.
In these cases the cardiac apnoea depended on disorganisation of the right muscular wall of the heart.
I attended, in concert with Dr. Willis, in the year 1851, a man, 45 years of age, who in June of that year was suddenly seized with great languor, and inability to move. Twelve years before, he had suf
fered from rheumatic fever; but had recovered, as he thought, completely. In March, 1851, he had a second attack of rheumatism, for which he would allow no treatment to be adopted, and after which he was never well. On the 16th of June, when I first saw him, he was sitting in a chair, his face presenting extreme anxiety; his gait was feeble and trernulous; his limbs restless; and his mind irritable. On examining the chest, the lungs were found free from any disease. The heart was enormously enlarged, and, as it seemed, pushed downwards, so as to displace the liver ; the point of visible pulsation was an inch and a half above the umbilicus, but during a deep inspiration the pulsation was observable immediately over the umbilicus. The action of the heart was irregular, the sounds indistinct. On listening to this heart, it conveyed the idea of a large, soft, Indiarubber bag filled with fluid, on which the walls of the bag were irregularly contracting. The pulse was small and irregular ; the veins were turgid; and there was regurgative pulsation of the jugulars. The skin was of yellow paleness; but there was no indication of enlargement of the liver, nor of dropsy. The secretions were natural.
The marked subjective feature of this case, again, was cardiac apnea. But it occurred somewhat otherwise than in the other cases. The man himself was conscious of the want of air, and the anxiety for air during acute paroxysms was as great in his case as in the others; but throughout the respiration did not, to the observer, appear so laboured. Whenever the patient was asked to take a long inspiration, he could do it, and the transmission of the air into the lungs was, to the ear, freely accomplished. The pain which attended the paroxysms was referred rather to the back and abdomen than to the sternum.
The man continued under our observation without evincing much change of symptom until August, when he was almost altogether prevented from sleep by the recurrence of the attacks whenever he resigned himself to repose. On the 6th of August, during one of the paroxysms of breathlessness, he threw up some blood, bright, red, and frothy. This did not cause an increase of the paroxysms, but rather lightened them. By this time the breathing had become distinctly oppressed ; the chest was fixed; and the pain in the back and abdomen during a paroxysm was greatly increased. On the morning of the 10th, he felt slightly relieved ; his breathing was free, and he could hold his breath as long as I could hold mine. But the relief was only transient. At nine in the evening, his oppression from want of air, and his efforts to bring the contracted chest into play, were terrible: withal, he was collected. I detected now that there was some effusion taking place in the right pleural cavity. At eleven o'clock, he died while I was present. He rose up in bed, and, saying that another fit was coming on, fixed himself to meet it, with his clenched hands buried in a pillow on each side of him : he opened his mouth widely, as if to inspire, and there he sat fixed as a statue, as I had often seen him before. But this time was the last. I waited,
and found there was no pulsation going on at the wrist; yet the features, drawn firmly in expression of inscrutable agony, continued so fixed, that I did not know whether he was living or not. We put pillows behind him, and gradually he relaxed upon them, unmistakably a dead man.
The diagnosis I had formed in this case was, that there was a source of obstruction to the circulation through the right side of the heart; but I thought that obstruction was in the cavity of the ventricle, consisting, perhaps, of an organised fibrinous concretion. The latter part of the diagnosis was incorrect; for the post mortem examination revealed a heart enormously enlarged from dilatation; the pericardium adherent over the whole surface; a firm adhesion between a large surface of the pericardium and the diaphragm ; and a girdle of ossific matter, two lines thick and half an inch broad, surrounding the heart almost completely. The bony ring was imperfect only for a short distance over the left ventricle. The right ventricle was large enough to enclose a full sized orange, and its walls were hypertrophied. It had evidently been doing its work as a fixed ventricle.
There was some effusion into the right pleural cavity ; but the lungs were normal. The mouths of all the great vessels were much dilated. There were no separated fibrinous concretions; but the enlarged right auricle was filled with red coagulated blood. All the other viscera of the body were healthy.
In this illustrative case, the cardiac apnoea was due