He gradually expired, on the 15th of March, 1809.

DISSECTION, FIVE HOURS AFTER DEATH.

EXTERNAL APPEARANCE.

The countenance was somewhat livid and pale; the lips were very livid.

The chest resounded, when struck, except over the heart. The abdomen was tumid, and marked by cicatrices like those of women, who have borne children. The superior extremities were emaciated, and marked like the abdomen. The lower extremities were dematous.

THORAX.

The cartilages of the ribs were ossified. The left cavity of the pleura contained about twelve ounces of water; the right, about three ounces. The lungs, externally, were dark coloured, especially the posterior lobes; internally, they were very firm, and, in some places, as dense as the substance of the liver. A frothy mucus was effused from them in great quant.i.ties. They were coloured by very dark blood, especially in the middle portion of the left superior lobe. One or two calcareous concretions were observed in them. The pericardium was a little firmer than usual, and contained about five ounces of water.

The heart was enlarged, and covered with tough fat. In the right auricle, and ventricle, was some coagulated blood. The tricuspid valves had lost their smoothness and transparency; the semilunar valves of the pulmonary artery were cartilaginous at their bases. The left auricle and ventricle, particularly the first, contained coagulum. The mitral valves were roughened by many bony spots.

Considerable ossification had taken place in the semilunar valves of the aorta, so that one of them had quite lost its form; and the aorta was ossified for the s.p.a.ce of a square inch, at a small distance from the valves. The coronary arteries were also ossified.

ABDOMEN.

The coat of the liver was somewhat wrinkled, as if shrunk. Its substance was hard, and discharged, when cut, great quant.i.ties of blood. The veins of the omentum, mesentery, and intestines, were full of blood. The abdomen contained a considerable quant.i.ty of water.

HEAD.

Water was found between the dura and pia mater, and between the pia mater and arachnoides. The vertical portion of the pia mater bore marks of former inflammation. The convolutions of the brain were very distinct; their external surface was pale. The veins were empty[11].

No b.l.o.o.d.y points were observed in the medullary portion of the brain, when cut. The ventricles contained between one and two ounces of water; the communication between them was very large. The plexus choroides was pale.

[Footnote 11: In this case, and in case first, the vena cava ascendens had been divided, before the brain was examined.]

CASE IX.

A lady, about forty-five years of age, the mother of many children, has been troubled during the course of the past year with violent palpitations of the heart, and great difficulty of respiration, especially on going up stairs. These complaints have lately increased, so that she has kept in her chamber about two months. Her countenance is florid; her eyes are clear and bright. She has dizziness, especially on moving, without pain in her head. She had for some time, a severe cough, which is now relieved. The dyspna is not yet very distressing, except on using motion; it often occurs in the night, and obliges her to rise and sit up in bed. The palpitations are very hard, and so strong, that they may be perceived through her clothes; the tumult in the thorax is indescribable. The functions of the abdominal viscera are unimpaired. The pulse is hard, vibrating, irregular, intermittent, very variable, corresponding with the motions of the heart, and similar in each arm. There is not yet the slightest reason to suspect any dropsical collection. The alternations of ease and distress are very remarkable, but on the whole, the violence of the symptoms increases rapidly.

There is no difficulty in discovering in this case an organic disease of the heart, which probably consists in an enlargement and thickening of the heart, and an ossification of the semilunar valves of the aorta.

CASE X.

Levi Brown, a cabinet-maker, forty-eight years of age, complained in February, 1809, of great difficulty of breathing, and an indescribable sensation in the chest, which he said was sometimes very distressing, and at other times quitted him entirely. Being a man of an active mind, he had read some medical books, whence he got an idea, that he was hypochondriac.

On examining his pulse, it was found to be occasionally intermittent, contracted, and vibrating. He had some years previously been attacked with copious haemorrhages from the stomach or lungs, which have occasionally recurred, though they have lately been less frequent.

Eight years since he suffered from an inflammation of the lungs; and about two or three years ago he first experienced a beating in the chest, and pain in the region of the heart, which increased till within six or eight months, since which the beating has been stationary, and the pain has much increased. In the course of the last summer, dyspna, on using exercise, and especially ascending any eminence, commenced. This has greatly increased, so as to render it almost impossible for him to go up stairs. His countenance is turgid, and uniformly suffused with blood; his eyes are bright and animated; his lips livid. The pulsation of the heart cannot be felt on the left side, and is barely perceptible on the right side of the sternum, and in the epigastric region. When he is distressed with fits of dyspna, he feels something as if rising to the upper part of the thorax, and the heart then seems to him to be beating through the ribs. I have not witnessed any of these paroxysms. The inferior extremities and abdomen have been swelled about three weeks. When in bed, he has his head and shoulders elevated, and, upon the attack of his paroxysms, sits up and inclines his head forward; but he keeps from the bed as much as possible. In his sleep he is apt to start up, suddenly, in distress, especially when he first slumbers. His dreams are often frightful, and, when awake, he is affected with reveries, during which, though conscious of being awake, strange illusions present themselves. At intervals he seems slightly delirious. He has a violent cough, with very copious expectoration of thick mucus. He often suffers from severe head-ache, and the least exercise produces dizziness.

This man has a very robust frame of body, and has been accustomed to a free use of ardent spirits, and of opium, of which he now takes about twelve grains in a day. His appearance is such, that, on a slight survey, one would not suppose him diseased, but, on observing him with a little attention, a shortness and labour of respiration are perceived, with some interruption in speaking, and a frequent catching of the breath, or sighing.

April. Since writing the above account, the dropsical collections were absorbed, and the palpitations and other symptoms moderated, so that he considered himself nearly well, and attended to his usual business.

Within a few days, however, the symptoms have returned with more violence. The dyspna is at times very distressing; the pulse more irregular and intermittent; the palpitations are more constant. His sufferings from lying in bed are so increased, that in the most comfortable nights he pa.s.ses, he sits up once in an hour or two. The appet.i.te is keen. The legs begin to swell again.

Some organic disease of the heart exists in this case. The indistinctness of the palpitations, the want of hardness in the pulse, and the slow progress of the disease, indicate a loss of power in the heart, the effect of the distention and thinness of its parietes. The irregularity of the pulse affords some reason to suspect disorder of the aortal valves, which is not yet very considerable.

ENUMERATION _of the princ.i.p.al morbid changes, observed in the organization of the heart, in the preceding cases_.

Enlargement of the volume of the heart, or aneurism.[12]

Increase of the capacity, or aneurism of the right auricle, } with of the right ventricle,} thickened, of the left auricle } or thin, of the left ventricle, } parietes.

of the aorta, with thickening of its coats.

Fleshlike[13] thickening of the mitral valves.

of the aortal valves.

of the aorta.

Cartilaginous thickening of the internal membrane of the heart, and generally of its valves.

Ossification of the parietes of the heart.

mitral valves.

aortal valves.

aorta.

coronary arteries.

[Footnote 12: Morgagni uses this term, which he borrows from Ambrose Pare, to express dilatation of the cavities of the heart. It seems to be as applicable to the dilatation of the heart, as to that of an artery. I have therefore adopted it in this enumeration.]

[Footnote 13: The term fleshlike is employed to express that roughness of the valves, which somewhat resembles flesh in its appearance, but which is very different from the thickening of the parietes of the heart.]

ENUMERATION _of the princ.i.p.al morbid appearances, observed in these cases of disease of the heart, which may be considered secondary_.

IN THE CAVITY OF THE CRANIUM.

Inflammation of the meninges.

Water between the meninges.

Water in the ventricles.

IN THE PLEURA AND ITS CAVITY.

Inflammation and thickening of the pleura.

Collection of water in its cavity.

Lungs dark coloured.

generally very firm, and particularly in some parts.

loaded with black blood.

crowded into a narrow s.p.a.ce.

IN THE PERICARDIUM AND ITS CAVITY.

Inflammation and thickening of its substance.

Adhesion to the heart and lungs.

Collection of water in its cavity.