Rheumatism of the Diaphragm

1850 BMJ (Clinical Research Edition)  
The only solution of the difficulty we can suggest, which does not infringe upon ordinary probability, is, that in the peculiar condition of the cardiac circulation, the digestive disturbance which ushered in the attac4 caused a small amount of coagulation in the left auricle,-which by accidentally obstructing the mitral orifice, was the immediate cause of the sudden distress experienced in the cardiac region. By the consequent effort of the system it was displaced, but not ejected, while it
more » ... jected, while it rapidly increased in bulk, retarding; of course, the blood through the lungs and heart,. and fuily accouting for the feebleness and irregularity of the pulse. Small detached portions of coagulum, we believe, subsequently to have escaped from the cardiac cavities, and to have been accidentally entangled in the obstructed vessels. The local circulation being thus suddenly arrested, coagulation rapidly followed, and the solidified blood, acting like a foreign body, became quickly adherent to the inner membrane.. The great firmness and adhesion of the clot is explicable by the unimpaired power of the patient; and to the interruption of supply to the affected limbs, beyond what was furnished by a very feeble collateral circulation, combined with the freedom of the nervous system, and the unexhausted vitality, we may ascribe the absence of oedema, and the little tendency to decomposition. In this way, we think, all the symptoms may receive a rational elucidation, though such a combination of circumstances must ever be exceedingly rare, and we have not succeeded in finding a single instance stritly similar to the one we have now very imperfectly, detailed. Whatever the previous history, it would be consistent under approximative circumstances, to diagnose the presence of pre-existent cardiac disease, and that chiefly localised in the left auricle and mitral orifice. With regard to the treatment, it might, perhaps, be prudent to try the effect of small and repeated venesections, with the object of diminishing the volume and crasis of the blood, and lessening the amount of visceral congestion. The use of salines, as liquefiers of the blood, is also a rational though very unpromising therapeutical indication, as such conditions, when once established, are almost, if not absolutely, hopeless. We need scarcely remark, in conclusion, that the above case is not to be confounded with those examples of cardiac and vascular coagulation to which attention has been recently directed, chiefly limited to the right cavities and veins, occurring at the close of chronic diseases, attended with cachexy, emaciation, extreme debility, or accompanied with any considerable obstacle to the general circulation. In our own experience, what we have now recorded stands alone, but we cannot doubt that others may have encountered more or less analogous instances.
doi:10.1136/bmj.s1-14.23.626 fatcat:5cdi7rhq4nctlbben7kkhoq43q