valve was ulcerated, soft, friable, of a dirty gray, and eroded; one presented a perforation. The two flaps, says M. Bouillaud,' closely resembled the appearance of gangrene of the cutaneous surface, with a red line of demarcation. Dr. Copland, as we have already seen, is of opinion that gangrene will only supervene when internal carditis attacks a cachectic habit of body, or when there is a septic tendency induced in the system, by a depraved state of the circulating fluids, or by impaired vital power.

A frequent concomitant of endocarditis, appears to be, according to the statistics of Bouillaud, who has met with a larger number of fatal cases of endocarditis than any English physician, the coagulation, during life, of the blood, and the organization, in the clot, of new bloodvessels; the coagulum is found adherent to the parietes of the cavity, and requires some force for its removal. It is colorless, elastic, and glutinous, and closely resembles the buffy coat of inflammation, or false membranes themselves. The symptom by which Bouillaud recognizes this occurence before death, is, a want of accordance between the pulse and the heart in point of force; the heart presenting evidence of violent excitement and action, while the pulse is small and evanescent. Gluge describes organized fibrinous coagula under the name of hæmatoma, and gives an interesting instance, with the minute anatomy of the clot, which occurred in a female, aged fifty-two. The left auricle was filled with a red tumor, surrounded by a delicate membrane, in the interior of which he distinctly traced capillary vessels, forming a retiform plexus. Similar instances may be also found in the records of the Pathological Society, and in Dr. Hodgkin's Catalogue of Guy's Hospital Museum. The cases in which organized clots or fibrinous coagula have been found by English observers, were generally connected with a cachectic condition, analo. gous to what Rokitansky terms the fibrinous crasis. The surface is found more or less intimately connected with the endocardium, while the interior of the clot may, in its turn, be undergoing further changes of an inflammatory or degenerative character. The fibrin is seen to be breaking up into a granular condition; exudation or inflammation corpuscles and fibro-plastic cells may be exhibited by the microscope. This does not necessarily apply to the pus that is occasionally found within the coagulum, which is to be regarded rather as the cause than the consequence of the coagulation. The pus may be derived from various sources; Cruveilhier3 observes that it may be generated at a distance, and be carried to the heart by the blood-current; that it may be the result of inflammation occurring in the coagulum, or that it may be the product of endocarditis; in which case it is absorbed into the coagulum, by capillary attraction. Tuberculous concretions have also been found in the clot; however they gain the position, it must be before death; changes affording sufficient proof of the independent vitality of the concretion. The older pathologists attributed a much greater importance to fibrinous coagula, or, as they termed them, polypi, in the

Traité Clinique des Maladies du Cœur, vol. ii. p. 87, Observ. 87e. 2 Atlas der Pathologischen Anatomie, Lieferung 11.

Anat. Pathol. livr. 25,

heart, than they now obtain, owing to their being regarded as the immediate cause of death. It is only in rare cases that we shall be justified in looking upon them as products formed during life; in the majority of instances they are merely the first evidence of the arrest of vitality, and the incipient influences of the metamorphoses of decay. When formed during the agony, or after death, there is no adhesion to the parietes; the polypus is moulded to the cavity which contains it, and a straw-colored fibrinous layer invests a blood-clot, similiar to the buffy coat covering the coagulum of blood obtained by venesection. The view we have taken of the organized polypi is supported by Hasse,' who observes that the seat of morbid action giving rise to them is, in the majority of instances, remote from the heart. Under certain circumstances the blood retained after the systole in the ventricles, and impelled into the network of the columnæ carneæ, acquires the opportunity to coagulate; and one fixed point being given, it is easy to understand how constantly fresh deposits are made on the surface, causing a laminated appearance, and aiding in the process of organization.

A second form of fibrinous concretion is described by Rokitansky, under the name of globular vegetations, as round masses, varying from the size of a pin's head to that of a nut, attached by means of ramifying cylindrical or flat appendages or bands, which entwine themselves among the trabecula of the heart, and are of a more or less uniformly dirty grayish-red or white color. He states them to be hollow in the interior, and to contain, within a wall of irregular thickness, a dirty grayish-red or even chocolate-colored fluid, resembling cream or pus. One or more of these concretions very frequently burst, when the fluid may be seen effused into the cavity of the heart, and distributed over the recent coagula, which have been formed either in the death-struggle or shortly after death.

Rokitansky establishes a third concretion, under which he comprises all vegetations of the valves of the heart, presenting a shaggy appearance, resembling villi, forming shaggy pedicled excrescences, or offering a cock's-comb or mulberry-like appearance. They affect the free margins of the valves, the tendons of the papillary muscles, and also attach themselves to the endocardium. They float in the blood, and necessarily lie in the direction of the current.

It appears that we have sufficient evidence to believe that they may occasionally become detached and be carried by the force of the circulation as far as the first angle of a vessel offering an impediment, or until they reach a channel which is too small to permit of their transmission. Dr. Kirkes, in an interesting paper presented to the MedicoChirurgical Society, has carefully investigated the circumstance, and recorded several instances in illustration. The part more immediately affected depends, according to this author, in the first instance, upon the circumstance of the fibrin being detached from the right or the left side

1 An Anatomical Description of the Diseases of the Organs of Circulation and Respiration, Syd. Soc. Ed. p. 127.

2 Medico-Chirurgical Transactions, vol. xxxv. p. 281.

of the heart. In the former case, the pulmonary, in the latter, the systemic circulation will become affected. When the mass of fibrin is detached from the left side, the lodgement is most commonly effected in one of the middle cerebral arteries, a circumstance explicable by the anatomical relation of these vessels. The arteries of the spleen and kidneys appear to be liable, next in order, to similar deposits, on account of their receiving their arterial supply by large vessels directly from the heart. That the plugging up of an artery must induce a change of nutrition in the part to which it leads, scarcely requires to be dwelt upon; while it causes coagulation of the blood behind, it acts as a foreign body, exciting inflammation and exudation, or degenerative processes, as softening and gangrene. In how far such an occurrence is remediable is very doubtful, though Dr. Kirkes suggests that a breaking up and absorption may take place, or that, by a dilatation of the bloodvessel, the current may be enabled to pass it; in the latter case, we should imagine it more probable that the plug would be propelled, especially as one characteristic of this variety of deposit is that it enters into no close adhesions to the inner coat of the vessels. Twenty-one cases have been analyzed by Dr. Kirkes, in which these deposits were found, and in every one but two he found disease of the valves and of the interior of the heart. One of these was a case of cholera, in which a doubtful mass of capillary phlebitis existed in the liver; the other was a case of aneurism of the aorta, which the author looks upon rather as favoring his views. In fourteen out of the remaining nineteen, fibrinous growths were noted on the surface of the left valves, or the interior of the left cavity.

NOTE. Since the above has been in type, we have seen that Dr. Todd is not inclined to adopt Dr. Kirkes's view, but would refer the coagulum found in the distant artery to an altered nutrition of its wall-to arteritis-and connected with a rheumatic or other morbid state of the blood. (Clinical Lectures on Paralysis, &c., 1854, p. 176.)

CHAPTER XXI.

DISEASES OF THE VALVES OF THE HEART.

THE estimates of different authors, with regard to the influence exerted by inflammation in producing valvular disease, have varied considerably. Bouillaud attributes nearly all changes occurring in the valves, such as altered consistency and form, fibrinous concretions, calcareous and ossific deposits, to inflammatory action, terming them the third stage of the inflammatory process; while Rokitansky, and many with him, are of opinion that they are only in part the product of endocarditis, but that the majority are the result of slow changes of nutrition, not connected with inflammatory action.

The most manifest direct results of endocarditis are white opacity and thickening of the endocardium and the lining membrane of the valves, and adhesion between the latter. Adhesions are most commonly found in the aortic valves, and this lesion must necessarily constitute a permanent and very serious obstacle to the circulation, in its turn giving rise to further disorganization and derangement, such as hypertrophy and dilatation, asthma and anasarca. In dealing with this species of malformation, it is often very difficult to determine whether it is congenital or the result of disease, especially when, subsequent to adhesion, an absorption of the partition separating the two pouches is effected, and the double valve thus converted into one. Dr. Peacock' has analyzed fifty cases of malformations of the pulmonary and aortic semilunar valves, among which he found forty-one of defective, and nine of excessive development. Of the former, nine were found at the pulmonic, and thirty-two in the aortic orifice. The varieties which the fusion of the valves with one another, or their adhesion to the walls of the heart, may present, are very numerous. In all cases an insufficiency of the valves must result, which both offers an obstacle to the free discharge of the blood from the heart, and fails adequately to close the orifice during the diastole, so as to prevent regurgitation. The left side of the heart generally, and especially in regard to inflammation, offers by far the greatest proclivity to disease. Very few cases are recorded in which a phlogistic process could be demonstrated on the right side. Gluge gives two observations in which the tricuspid valve was thickened and rendered insufficient by this cause. We also find two instances reported in Dr. Hodgkin's Catalogue of the Museum of Guy's Hospital (Nos. 1401 and 1402), in which the curtains of the tricuspid were thickened.

1 Reports of the Pathological Society, 1851-52, p. 292.

Atlas der Pathologischen Anatomie, 1850, Lieferung i. Beobachtung, 12 and 12a.

In one of these there was also shortening of the tendinous cords. While the arterial valves are more subject to this species of lesion, we find the mitral valve more prone to an hypertrophy of its fibrous tissue, which is especially liable to present itself in the shape of nodulated masses,

fringing the curtain, and in some instances closely resembling accumulations of fat. The microscope at once determines their real nature, as it exhibits, instead of fat-cells, a fibroid structure, containing nuclei and elongated nucleated cells. In connection with hypertrophy of the endocardium, we find the lining membrane of the valves also thickened; by which means it appears that, independently of inflammatory action, a secondary adhesion may be effected between the flaps. Here the aortic valves are more liable, though it is not at all unusual to find the curtains of the left auriculo-ventricular orifice opaque throughout, from the same

cause.

We have already alluded to perforation of the valves, as a result of

Fibroid thickening of a pulmonary valve, extending symmetrically on both sides of the curtain, and con sisting of a soft fibrillating deposit. It was found in a man who had a broken spine.

endocarditis. Another form in which the same lesion occurs is in connection with atrophy. This is manifested, in the first instance, by