1847]

Adhesion of the Pericardial Surfaces, &c.

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But a much more serious organic change is sometimes found to have taken place, without its having been evidenced by any symptoms during life; viz, the Adhesion of the opposite Pericardial surfaces over the entire extent of the heart. True; the previous history of the person may not be accurately known; but of this we may be so far certain, that there was nothing in his case to make even the most enquiring physician suspect the existence of any cardiac lezion, while treating him perhaps for disease of another organ. "It is a question with me then after all, what are the consequences which naturally result to the functions and structure of the heart from simple adhesion of the pericardium. For I have not facts enough to appeal to of the sort which are required to settle it. Pericarditis indeed is common enough; but not simple pericarditis. The original disease is oftener a complex of pericarditis and endocarditis than pericarditis alone; and the original unsoundness a complex of the partially repaired effects of both. Hence whatever detriment the heart is afterwards found to suffer in its functions and organisation, it is difficult to make sure either how much is due to each, or whether the whole may not be imputed to one; how much the thickened valve produced, and how much the adhesion of the pericardium; or whether the thickened valve may not have been exclusively the source of all the mischief, and the adhesion of the pericardium altogether blameless from first to last." P. 112.

When the adhesion of the pericardial surfaces exists not universally, but only at different points, leaving intervening spaces of unattachment, these spaces (or loculaments as a Botanist might call them) may become, from a subsequent attack of pericarditis, the seat of a purulent effusion; and thus the heart may be found, upon dissection, to be apparently surrounded with a number of separate little abscesses.

The adventitious tissue, that unites the opposite pericardial surfaces, is found to vary exceedingly in point of density and thickness. Sometimes it is so attenuated that the two laminæ seem to be merely incorporated with each other, without any intermediate substance; while, in other cases, the uniting medium has been found to be half an inch, nay more than an inch, in thickness. The nature and appearance too of this substance may vary a great deal.

"Its texture sometimes laminated like the coagulum of an aneurismal sac, red or tawny near the heart, and pale or white more remote from it, sometimes of a mixed consistence, in part almost liquid and purulent and in part solid or tuberculous. Or the adventitious substance has been of one uniform texture, either so like muscle as to be at first mistaken for the fleshy substance of the heart itself, or so far firmer than muscle as to resemble flesh hardened in brine, either much paler than the heart, or much redder from being deeply injected with blood. This tough flesh-like substance may occupy a portion only of the surface of the heart or the whole of it. I have seen it opposite the right auricle, while every where else the pericardium has closely adhered with little intervening medium, and I have seen it enveloping the entire organ and forming round it (as it were) another case of muscle. And then, if (what often happens) the muscular substance of the heart itself be augmented, a strange spectacle is disclosed on dissection. There is an enormous mass displacing the lungs and leaving nothing visible in the entire front of the chest but itself." P. 116.

Now all this amount of most disorganizing change may unquestionably be traced back to an attack of simple Pericarditis, which may have occurred some years before. Successive accessions of inflammatory disease (masked and unrecognized although these have been) have only served to cause suc

cessive depositions of fresh layers of lymph; these layers indeed varying in point of colour and consistence, from causes which we do not understand. When the connecting substance exhibits a uniform colour and consistence throughout, it seems not improbable that a process of progressive interstitial deposition of new matter had been going on for a length of time, without the supervention of any fresh or distinct attacks of pericardial inflammation. But, in whatever way we choose to explain the formation of the morbid change, this one thing is certain, that a most serious amount of mischief may take place on the pericardial surface of the heart without producing any marked aggravation of the cardiac distress, which was unquestionably attributable to the first attack of pericarditis.

From the consideration of the diseases of the lining membranes, the Endocardium and the Pericardium, of the heart, we now pass on to that of the chief morbid changes to which the Muscular Substance of this vital organ is liable; as Suppurative Inflammation,-of which two cases are recorded; one of these we have related in a preceding page, the other is that detailed by Mr. Salter in the 22nd Vol. of the Medico-Chirurgical Transactions-Attenuation and Softening with or without aneurismatic Dilatation of one or more of the cardiac cavities, Hypertrophe, Fatty Degeneration, &c.

Whether it is correct to speak of the flabby, attenuated, and lacerable state of the heart as a result of chronic inflammation may be fairly questioned. Certainly, in the cases related by Dr. Latham, there is not a shadow of evidence to make one believe so. In both instances, the fatal attack began with vomiting and diarrhoea; the patients recovered for the time, and there was nothing to excite the suspicion of approaching death. But the weakness produced by the intestinal disorder seems to have so aggravated the long existing, although not suspected, disease of the heart, as very seriously to have interfered with the due performance of its functions. Perhaps it will be interesting to give the description of the condition of the left Ventricle, the chief seat of the lesion, in both cases.

In the first," that portion of the left ventricle already mentioned, which in its external aspect gave suspicion of an abscess, presented the following conditions of disease. There the heart was so attenuated as not to exceed the breadth of a half-crown piece, and rupture or ulceration preparatory to rupture was in progress. The internal lining was destroyed, and to the rough surface that it left a large irregular-shaped clot of blood was adherent. What remained exterior to the clot had lost all cognizable organisation; it hardly cohered together and was torn like wet paper.

The aorta throughout its course within the chest (for so far only it was examined) was dotted with little earthy and atheromatous deposits." In the second, "the left ventricle was very capacious and its walls thicker than natural, except at one circumscribed space. This was between the two large carneæ columnæ. Here, at the expense of the muscular substance which had entirely disappeared, a cavity was formed large enough to contain half a walnut. The thickened lining membrane was here united by lymph to the serous covering of the heart, and both together formed its external boundary. It was diaphanous, and served for the only barrier which prevented the blood flowing from the ventricle into the cavity of the pericardium. There was no laminated coagulum in the aneurismal pouch."

1847] Certain Peculiarities in grave Organic Lesions.

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In both instances, rupture was, as our author remarks, only just anticipated by death; the immediate cause of which was probably a paralytic incompetency of the heart to continue its contractions. In some cases, as is well known, actual laceration of the organ takes place; and then, we need scarcely add, the dissolution is almost immediate.

And here we may allude to a very important fact in the history of very serious organic lesions of the muscular substance of the heart; we mean, the circumstance of the arterial pulse being often but little affected. Cases of very great dilatation, accompanied with softening and attenuation of the ventricular parietes, not unfrequently occur, in which the pulse retains a regularity in point of frequency and force perfectly remarkable. We need not say how apt this circumstance must be to mislead the unsuspecting physician, more especially if he is not in the habit of exploring the state of the chest. In Mr. Salter's very remarkable case, already alluded to, one of its most striking features was the regularity of the arterial pulse and of the heart's action, until within the last 48 hours of life; and yet there cannot be a reasonable doubt but that the substance of the left ventricle had been the seat of Suppurative Inflammation for two or three weeks at least before death! Equally striking was this circumstance in the very interesting case of Rupture of the septum cordis narrated by Dr. Latham. Within 17 hours of death, at the time, too, when the patient was deadly pale and every part of the surface was as cold as marble, it is expressly stated that "the pulse was of a good strength, and the heart was contracting regularly and forcibly." Ten hours subsequently, no pulsation could be felt in the arteries, while the heart was perceived by the ear to move, but not by the hand: in this state the patient survived for seven hours.

The prolongation of life for several days, and even for a week or two, when dissolution has seemed to be almost impending, is another circumstance in the history of cardiac disease, that cannot have failed to have struck the attention of the practical physician. We have, more than once, left a patient over night in such an alarming condition of imminent asphyxia that we did not expect to find him alive next morning; yet he has lived for a good many days afterwards.

We have now to direct our reader's attention to a chapter in the history of cardiac diseases, which has hitherto been scarcely so much as mentioned, and therefore calls for a somewhat lengthened notice; we allude to what our author terms "Shocks of the Heart," in other words, traumatic injuries of one or more of the valves of the heart, induced by any violent bodily exertion, and laying the foundation for future hypertrophy, or dilatation, or both these morbid states of its muscular substance. Dr. Latham quotes the following case, communicated by Dr. Bence Jones, as a type or exemplar of such cases.

"A stableman, twenty-eight years of age, was admitted into St. George's Hospital. He was suffering, and had suffered for twelve months, severe palpitation of the heart, and was able to mark distinctly the moment of its commencement. It was one day just after running a horse down the yard to show off his paces to a purchaser. He had never had acute rheumatism. His lips were blue, his breath short, and his left side painful. He had a dry cough. His bowels were confined and his urine free. It was ten weeks before his ad

mission that his cough and dypsnoea had begun to be particularly distressing. Auscultation found dulness in the præcordial region over an extent of four inches square, the heart's impulse increased and its first sound prolonged with a low blowing (endocardial) murmur over the aortic valves, and its second sound indistinct. He was bled three times under the urgency of his cough and dyspnoa. These however continued to increase. Five weeks after his admission his legs became œdematous, and in two weeks more he died.

"On examination after death, three pints of fluid were found in the right pleura, and the heart enormously large. In length it reached from the second to the eighth rib, and across the base of the ventricles it measured six inches. The left ventricle was moderately hypertrophied and very largely dilated. The mitral valve was healthy, and the aortic was slightly thickened, and moreover had suffered rupture of a peculiar kind. One of its septa was torn away from its attachments, and thus two of its pouches were reduced to a single irregular one. The right ventricle was dilated, but both the auricles preserved their natural state. In the ascending aorta and in its arch there were atheromatous deposits. The liver was very large, and the spleen and the kidneys were healthy.” P. 194.

Now any violent effort or fatiguing exercise of the body may give rise to the mischief that was found in the preceding case. Many a youth lays the foundation of cardiac disease in feats of rowing, leaping, boxing and such like sports. The same thing is not unfrequently the case with horses that have been galloped severely indeed, immediate rupture of the heart, in a horse previously quite sound and healthy, has been known to be caused in this way.

Whether in "shocks of the heart," followed by tendency to palpitations and other symptoms of disordered heart, there is always a rupture or other lesion of one of the valves, it is not possible to say. It is sufficient to know that, unless great precautions-in the way of quietude, low diet, and (it may be necessary) sanguineous depletion-be used for a very considerable time after the injury, there is good reason to apprehend the supervention of hypertrophic enlargement or of dilatation of the heart. Dr. Latham narrates at length the case of one of his friends, in whom the symptoms of a "shock of the heart"-viz: excessive impulse, and pain in the cardiac region-followed upon a violent collision against another person in the street, while running at full speed. He was treated by the late Dr. Baillie, who bled him largely. It was only after the lapse of some months that he was allowed to return to his avocations. By this time, he had lost his constant palpitation. But for a few years, it was wont to return painfully upon occasions of excitement. At length he lost it altogether; and lived 25 years after the shock and perilous illness that was the consequence, actively engaged in a laborious profession. Now, is it at all improbable that, had not the judicious and long-continued precautionary treatment been followed in this case, hypertrophy and dilatation would have ensued? At all events, there is surely sufficient reason to believe that such consequences have followed upon severe bodily injuries, in persons who had never been suspected of having any tendency to, or degree of, cardiac enlargement.

In the last number of the Edinburgh Monthly Journal of Medical Science, Dr. Quain has published a very interesting paper, entitled "Cases illustrating the injuries to which the Aortic Valves are liable during muscular efforts." The first case recorded is the following:

1847 Injury of the Valves from violent Muscular Efforts. 43

A man, 26 years of age, who was in good health at the time, and had never suffered from rheumatism, palpitation of the heart, or shortness of breath, was suddenly seized (August 1843), while using a sledge-hammer, with a most distressing sensation in the region of the heart, which compelled him to give over. He complained of "an uneasy shaking of the heart," dyspnoea, and what he called "a noise up his ehest and neck, and in his ears," which prevented him from sleeping. For a week subsequently, he continued at light work; but, becoming worse, he came under Dr. Quain's care at the University College Hospital. "There were then very distinct evidences of imperfection of the aortic valves; in the situation of these valves, and replacing their sound, was heard a loud ringing musical murmur-the first sound was also accompanied by a murmur in the same situation, but much less loud: there was present the peculiar diastolic or regurgitant pulse."

Five weeks from the date of the accident, it is recorded that "there are now very evident signs of Enlargement of the heart. The dulness on percussion over its site and its impulse are extended, and the force of the latter is increased. The murmur is so loud that it can be heard at several inches distance from the aural end of the stethoscope, and the diastolic pulse is so marked as to give a very peculiar appearance to the course of the superficial arteries."

Three months later, when trying to do some heavy work, the patient again became conscious of a change in the heart's action; and it was now discovered that "the loud ringing murmur with the second sound, and the slight murmur with the first, were both replaced by the ordinary double bellows-murmur."

The poor fellow lived for two years after the accident, occasionally able to do some light work, but every now and then having attacks of bronchitis, dyspnoea, palpitation of the heart, and angina pectoris. The signs of Hypertrophy of the Heart increased; the loudness of the murmur diminished, but its character remained the same. In July 1845, he became anasarcous; the physical symptoms were nearly as before, regurgitation through the jugular veins being now very evident. On the 10th of August he died suddenly, in one of his attacks of dyspnoea.

Dissection." On the chest being opened, the heart, enveloped in the pericardium, was found to have encroached much on the situation of the inferior lobe of the left lung. There were traces of old disease of the apices of the lungs ; the bronchi were thickened, and the mucous membrane congested. All the cavities of the heart were enlarged and filled with blood. The arch of the aorta was somewhat dilated. The heart weighed 224 oz. The chief disease was found at the entrance of the aorta; here it was noticed that the conjoined attachments of two of the valves to the aorta had been separated from the wall of that vessel, and thus those valves were allowed to drop below the level of the third, which retained its connexions. In the drawing, a indicates the junction between the valves, b is the point at which the separation has taken place; here the wall of the vessel was raised into a superficial elevation about one-third of an inch in length and one-fourth of an inch across. The margin of one of the valves was everted slightly, and studded with small granulations, represented at c. It seemed as if a small strip of the living membrane had been torn off at this point. On trying the valves with water before the vessel was cut open, they were found to be quite inefficient, not so the pulmonary."