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1847)

Rupture of the Heart from intense Emotion.

459

from the writings of two distinguished writers of our own day, may be appropriately quoted upon this point.

“ 'It is generally in the left ventricle,” remarks Dr. Hope," that the rupture [of the heart] takes place; a circumstance which at first appears remarkable, since this ventricle is the stronger, but for the same reason it contracts more energetically, and . . it is only strong muscles which undergo rupture from the energy of their own contraction. Hence rupture of the auricles is much more rare than that of the ventricles. The exciting causes of rupture are generally considerable efforts, paroxysms of passion, external violence, as falls, &c.

Rupture of the heart or great vessels into the pericardium is not always immediately fatal, as a solid coagulum or a fibrinous concretion has in several instances been known to arrest the hemorrhage for a few hours. Of ten cases mentioned by Bayle, eight died instantaneously, one in about two hours, and another in fourteen.'-Amongst the causes of rupture of the heart Dr. Copland enumerates,—'violent mental emotions, especially anger, fright, terror, unexpected disappointment, distressing intelligence abruptly communicated, anxiety, &c., sudden and violent muscular efforts, and laborious or prolonged physical exertions of any kind, particularly in constrained positions.

In some cases,'—he observes,—' inexpressible anxiety and pain have been felt in the præcordia and epigastrium, with cold extremities, and cramps, shortly before dissolution. In the majority rupture has produced instant death, but in some this has not been the case.

In most of the cases in which the rupture is preceded by violent pain, M. Ollivier thinks that it is produced gradually from the successive laceration of several layers or fasciculi of muscular fibres, and that the pericardium becomes only gradually distended by the effused blood. Where the laceration and aperture are at once large, a copious effusion instantly occurs, fills the pericardium, and abolishes the contractions of the organ.'

P. 90. It must be confessed, indeed, that there are not many instances on record in which sudden death from mental emotion has been provedby dissection, we mean-to have been owing to Rupture of the Heart. In many such cases, no post-mortem examination has been made. Nevertheless, it may be reasonably conjectured that this mortal lesion is not so extremely rare as has been generally supposed. Dr. Stroud thinks it highly probable that the death of Palmer, about the close of the last century, while enacting the part of the Stranger in the play of that name on the boards of the Liverpool theatre, was from this cause. The circumstances were these. For some time previously, he had been labouring under the most profound grief, in consequence of the death of his wife and a favourite son, and he had struggled to bear up against it, although he felt that his mental sufferings would very shortly bring him to the grave. “On the morning of the day, he was much dejected; but exerted himself with great effect in the first and second acts of the play. In the third act, he shewed evident marks of depression ; and in the fourth, when about to reply to the question of Baron Steinfort relative to his children, he appeared unusually agitated. He endeavoured to proceed, but his feelings overcame him. The hand of death arrested his progress, and he fell on his back, heaved a convulsive sigh, and instantly expired without a groan.

Dr. Mitchell and Dr. Corry gave it as their opinion,

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* “ Dr. Hope, On the Diseases of the Heart and great Vessels, pp. 198, 199 ; -Dr. Copland, Dict. of Practical Medicine, Part v., p. 224."

that he certainly died of a broken heart, in consequence of the family afflictions which he had recently experienced.”

The expression here used, it is very reasonably imagined, may have been literally, as well as metaphorically, true. We shall presently adduce several examples in corroboration of this idea. Meanwhile, it may not be upinteresting to remark, en passant, that the language of every nation has recognized, so to speak, its strict physiological truth. Hence, as well observed by our author, “although the term-broken heart—is not always used literally, but often in a figurative sense to denote intense or perhaps mortal sorrow, it was no doubt originally derived from the actual fact, either accidentally observed, or sagaciously conjectured by poets and moralists, habitually engaged in the study of the huntan passions and of their influence on the bodily frame." Shakespeare, with that intuitive penetration of genius which was so pre-eminent in him beyond all other writers, has repeatedly alluded to this cause of sudden death from agony of mind. An instance or two must suffice :

“ Give sorrow words: the grief that does not speak

Whispers the o’erfraught heart, and bids it break; and by a bold poetical license, Marc Antony is made to represent the death of Julius Cæsar as occasioned, not by the daggers of his conspirators, but by his anguish of soul on seeing his friend Brutus in their number:

Ingratitude, more strong than traitor's arms,
Quite vanquished him : then burst his mighty heart,
And, in his mantle mufling up his face,
Even at the base of Pompey's statue

Which all the while ran blood, great Cæsar fell.”
For other passages of a similar bearing, the curious reader must consult
Dr. Stroud's work: proceed we to more matter-of-fact details.

Although actual Rupture of the Heart is unquestionably a rare occurrence from mental emotion or from any cause whatsoever,* it is not a difficult thing to prove, from the concurrent testimony of numerous writers, the direct influence of strong passion in inducing less serious lesions of this vital organ. Harvey relates the case of a man who, under the longcontinued working of smothered indignation and revenge, fell into a scorbutic and hæmorrhagic state, attended with extreme oppression and pain of the chest, owing to an immense enlargement of the heart and principal arteries, which was entirely the result (it was believed) of mental emotion. "Had this emotion,” Dr. Stroud remarks, "been more intense, it is easy to conceive that, instead of a slight oozing of blood from the cutaneous vessels, and a mere enlargement of the central organs of circulation, the result would have been bloody sweat, and rupture of the heart.”

Dionis has related an interesting case of an officer affected with serious disease of the heart, attributed by the patient himself to the strong efforts

It has been asserted by some writers that Rupture of the Heart never takes place in a normal state of the organ; but this statement has been denied by Portal and Rostan, in whose writings are recorded numerous observations which . prove the contrary, and which serve to shew that rupture of the left ventricle may take place without any coexisting alteration of its muscular tissue.

1847]

Separation of effused Blood into Clot & Serum. 461 which, several years before, he had used to suppress a violent fit of anger. On dissection, the right auricle was found as big as the head of a new-born child, and contained nearly a pint and a half of blood, the greater part of which was coagulated. In like manner, Tissot quotes from Viridet the case of a merchant, who, in consequence of violent grief, was seized with constriction and severe pain of heart, terminating in death. On inspection of the body,—the heart was found twice as large as it should have been, and the whole of its left cavity filled with blood strongly coagulated.' -In another merchant, aged sixty-two years, who suddenly died of grief, Bonet states that the heart and lungs were found greatly distended with blood which, in the right ventricle, was almost entirely coagulated. Of the separation of the blood in some of these cases into its constituents, the same author gives two examples.—' A paralytic orphan girl, seventeen years of age, suddenly died of suffocation without any obvious cause. On dissecting the body, I found the heart of twice the usual size, its auricles very large, and like the veins and arteries, much distended with water and black clotted blood....... In a soldier who suddenly died after long-continued grief, whilst all the other viscera were healthy, the pericardium was found to contain not only water, but also much coagulated blood.'"*

In reference to this last case, Morgagni has remarked :-" Although you will see it repeated in a note that the heart was loaded both with blood and water, it is by no means necessary that you should believe this water to have been any other than the serum of the blood separated from the coagulated part, as not unfrequently happens to a considerable amount."

This remark of Morgagni leads us, by a natural transition, to the consideration of a topic connected with rupture of the heart, which will be found to have a most important bearing on the general argument of our present enquiry. It deserves, therefore, to be examined at some length.

The separation of the blood into its solid and fluid constituent parts seldom or never takes place completely while it remains within the heart and the vessels, unless, indeed, their structure or conformation be seriously altered, as in cases of aneurismatic enlargement, &c. It is commonly either wholly liquid or wholly solid, or a portion of liquid blood is intermixed with pale or dark-coloured coagula ; but its distinct or complete separation into serum and crassamentum-or, to use popular language, into blood and water-is scarcely ever met with. The attention of anatomists has hitherto been little directed to this subject. Two gentlemen, however, distinguished alike for the extent of their enquiries and the accuracy of theit observations, have very fortunately, within the last few years, published some remarks upon it; we allude to Dr. John Davy and Mr. Paget. The results of their labours may be briefly stated to be as follow. Of 164 cases in which the state of the blood was noted by the former of these gentlemen, it was found "coagulated and containing fibrinous concretions, in 105 ;-coagulated and broken up, as if by the contractions of the heart,

lies, pp.

Harvæus, Opera, pp. 127, 128 ;–Dionis, Anatomy of Human , 270, 445—451;--Tissot, Traité des Nerfs, &c. p. 361;—Bonetus, Sepulchretum, vol. i. pp. 585, 887, 899.

NEW SERIES, NO. XII. -VI,

II

feebly continued for some time after apparent death, in 17 ;-liquid, in 14; -in the state of soft coagulum, or merely grumous and without fibrinous concretions, in 12 ;-partly liquid and partly coagulated, in 9 ;-and wholly or nearly deficient in the heart, in 6. In one instance only there were fibrinous concretions without cruor, that is, without liquid blood or bloody serum. Dr. D. next gives a tabular account of 35 cases of postmortem examinations, made in the General Hospital at Fort Pitt, Chatham, from January to Sept. 1838. The various conditions in which the blood was found are still more minutely described in these cases, than in the preceding ones; but in none of either set does clear serum appear to have been discovered, except in one solitary instance, and under very peculiar circumstances ; namely, in No. 16, a case of phthisis, wherein, says the author,—' a mass of fibrin in the right ventricle contained a collection of transparent serum. The mass was firmest externally. There was some crassamentum, fibrinous concretions, and a good deal of cruor in the right cavities of the heart. Two hours after examination, the cruor was found jellied. After twenty four hours the coagulum had contracted, and serum had separated. When broken up and agitated, some air was given off.'

The testimony of Mr. Paget is still more precise :

“ In all cases it must be remembered that the coagulation which takes place in the body is much slower than that which ensues in blood drawn from it, either during life or after death ; so that a quantity of uncoloured fibrine is found in the heart and uppermost vessels of the dead body in many cases, in which it is most probable that, had the blood been drawn during life, it would not have presented a buffy coat. In the majority of cases, the blood does not coagulate in the body for the first four hours after its rest has commenced. In many it remains fluid for six, eight, or more hours, and yet coagulates within a few minutes of its being let out of the vessels. But, as this greater slowness of coagulation is common to all, it is not material in a comparison of the blood of the dead with that of the living.”+ P. 404.

Mr. Paget, in a letter addressed to our author subsequently to the publication of these remarks, observes :—“I have never found clear serum, such as I could suppose to be separated from the blood in its coagulation, collecting in any part of the body after death,” i. e. as long as the blood remained within its natural receptacles. The following passage from Dr. Carpenter's excellent work on Human Physiology contains an apposite illustration of this point.

“ Instances occasionally present themselves in which the blood does not coagulate after death, and in most of these there has been some sudden and violent shock to the nervous system, which has destroyed the vitality of solids and Auids alike. This is generally the case in men and animals killed by lightning, or by strong electric shocks, and in those poisoned by prussic acid, or whose life has been destroyed by a blow on the epigastrium. It has also been observed in some instances of rupture of the heart, or of a large aneurism near it, and a very in. teresting phenomenon then not unfrequently presents itself; the coagulation of the blood which has been effused into the pericardium, (the effusion having taken

* Researches Physiological and Anatomical. Vol. ii., pp. 190-213.

+ London Medical Gazette, for 1840. Vol. i, p. 618.

1847)

Effusion of Blood into the Pericardium.

463

place during the last moments of life,) whilst that in the vessels has remained fluid."* P. 150.

The various statements now made amply warrant the conclusion that the separation of the blood into serum and crassamentum seldom if ever takes place completely, as long as it remains in its natural receptacles, these being at the time in a normal state.

Dr. Stroud suspects, and with reason, that, in several cases of Rupture of the Heart on record, this separation had really taken place, although it is not specified in the account given of the appearances found on dissection. After alluding to three cases, related by Dr. Abercrombie in the first volume of the Transactions of the Medico-Chirurgical Society of Edinburgh, he quotes one that is recorded by Dr. Thurnam in the Medical Gazette for 1838. This was “a case of rupture of the heart from external violence, but without any penetrating wound. The pericardium contained several ounces of serum and coagulated blood. There was a considerable rupture of the right auricle, and a smaller one at the apex of the heart.' The same gentleman mentions an instance of spontaneous rupture of the right auricle and ventricle, attended with great and general softening. The pericardium was filled with liquid blood,'—coagulation having apparently been prevented by the feebleness of the heart's action, which is usually attended with a corresponding condition of the blood.”

Dr. Elliotsont has related the case of a female, who died suddenly with severe pain in the region of the heart. The pericardium was found distended with clear serum, and a very large coagulum : there was a rupture of the aorta near its commencement. In the case related by Dr. Fischer, and which was occasioned, it is said, by the slow operation of continued grief, it is stated in the account of the dissection :—" On puncturing the pericardium, which had the appearance of being distended by a substance of a dark blue colour, a quantity of reddish fluid escaped, and afterwards florid blood to the amount of two or three pounds. The membrane was then slit up, and the heart seen surrounded by a coagulum more than three pounds in weight. This having been cleared away, a rupture was discovered in the aortic [left] ventricle, which extended upwards from the apex, about an inch and a half on the external surface. The internal wound was found but about half-an-inch in length, and its lips (were] at least as wide again asunder as those of the external breach."!

Dr. Townsend | of New York mentions the case of a young female, who died suddenly in consequence, it was believed, of anguish of mind. “ On dissection, the sac of the pericardium was found filled with about ten

* The contrast between the state of the blood within the cavities of the heart, and of that which was extravasated into the pleura ?), is well marked in one of Morgagni's cases. The quantity of limpid serum was so great that, on first opening the chest, it was believed to be a case of dropsy.. But, on further examination, a large quantity of coagulated blood was found infra aquam, and the real disease was discovered to be an aneurism of the aorta, which had given way.

† Lumleyan Lectures on Diseases of the Heart, p. 30. London Medical Repository, vol. xi. pp. 422-427; and vol. xii. pp. 164-168. || On the Influence of the Passions in the production and Modification of Disease, pp. 51-56.

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