attenuation, and increased transparency of the valves; as this advances, one or more openings are effected, which may be sufficiently numerous to induce a cribriform appearance. It is only when the perforations are large or numerous that they interfere, to any serious extent, with the circulation. Thus, in the case of a man who died recently at St. Mary's Hospital, after an operation for popliteal aneurism, the cause of death being extensive pneumonia, there was much fibrinous deposit on the aortic valves, with two valve-like perforations, apparently the result of ulceration, which had given rise to murmurs of a peculiar character before death, but not, apparently, inducing any other symptoms of cardiac disease. Dr. Kingston,' who was the first to draw attention to this point, observes, that atrophy may be defined a simple shortening of the valve, and, in the first instance, a mere atrophy in the direction of the length. He speaks of the cribriform appearance in the flaps as also resulting from the same process, and has found the two conditions chiefly in the mitral and tricuspid valves. In this, he differs from other authors. Rokitansky, for instance, has only met with the lesion in the arterial valves. Dr. Kingston, out of about thirty cases of valvular disease, found the lesion to be atrophy in ten. The mitral valve was shortened in five, the tricuspid in five; both in two. In one the mitral valve was cribriform, in two the tricuspid, and in one both the aortic and pulmonary valves were so.

Fig. 143.

The lesions of the valves hitherto spoken of may be variously complicated with one another, or with heterologous growths. Pathological records contain instances of a great variety of changes of form, the result of morbid processes or accident. Thus, the individual flap of the semilunar valve may be reverted or inverted, the valves of the aorta may become detached at their bases, and thus lose the fulcrum by which they resist the impetus of the blood, or the tendinous cords of the mitral may induce a deficiency of the valve by a shortening and thickening, a lesion which Dr. Hope considers as constituting one of the worst varieties of disease of the valves.

Aortic valves of a child aged four years; they are opaque and thickened, and their free margin curled backward towards the artery. Two of the valves are closely united by their adjacent margins.-St. Bartholomew's Museum. 11th Series,

Among the anomalies of consistence, Rokitansky describes, besides the increased density of thickened and shrivelled valves, and the softening that results from inflammation, a gelatinous condition of the valve which he has found in the valves of the left side of the heart exclusively. There is a loss of fibrous tissue, for which a gelatinous, non-adhesive substance is substituted, causing the valve throughout, or only in parts, to become soft and pliable while its color is converted into a pale yellow or reddish hue. The author is of opinion that there is no effusion of new matter, but that the gelatinous substance is merely the disintegrated fibrous tissue

52.

'Medico-Chirurg. Trans., vol. xx. p. 90.

of the valve itself. It appears that while on the one hand this condition may lead to lacerations, especially of the valves of the aorta, pre

Atheromatous deposit in the valves of the aorta of a man aged 26, with rupture at the point marked by *; there was also congenital union at the point (marked by f) of two of the valves. The case is described in the Reports of the Pathological Society, vol. iv. p. 100.

senting the fissured appearance of true rents, to distinguish them from the perforations resulting from atrophy, it is also susceptible of cure by a reconversion into fibrous tissue.

Fibrous and ossific deposits, which we have seen to be not uncommon on the surface of the heart, are very rarely met with under the endocardium except in connection with the valves. To the former, which are often rather hypertrophied states of the normal fibrous tissue, we must attribute many of the lesions already adverted to, consisting of malposition, eversion, and inversion, of the valves; the fibro-cartilaginous and

cartilaginous induration spoken of by Bouillaud and others, may be referred to this head. The calcareous or ossific deposit is a distinct new formation. It presents the most varied forms, which may be compared to the fantastic shapes assumed by molten lead when poured into water; sometimes resembling stalactitic projections, at others forming irregular rounded eminences, stretching across the orifices of the heart like rigid

bars, maintaining the valves in a state of permanent erection or distension, and inducing symptoms both of obstruction and of regurgitation. A single flap or curtain may be rendered rigid while the others retain their natural pliability: the valves of one side of the heart may be more or less intimately united by the morbid growth; but whatever forms the lesion may assume, it is scarcely possible to occur without a permanent narrowing of the orifice. Kreissig and Bouillaud refer the disease uniformly to inflammatory action; and Dr. Watson is also of opinion that it is somehow certainly connected with inflammation of the internal lining of the heart. But we must not overlook the important fact of the natural tendency existing in the arterial system generally, as well as in other tissues of the body, to induration and ossification with advancing life; and though we are far from looking upon ossification of the valves as a physiological process, we are justified by analogy, as well as by the positive fact of the very chronic nature of these deposits, in looking upon them in many cases as of a non-inflammatory character allied to the general species of degenerative disease. Lobstein's view, that these concretions are intimately allied to the gouty diathesis, is one that must not be lost sight of; though he perhaps erred in restricting them too closely to this particular constitution. Although we have used the term ossification in accordance with common usage, to designate the change under consideration, it is important not to confound the process with the one in which genuine bone is formed: cretification or calcareous deposition would be a more appropriate term, for there is no resem

Ossification of the aortic valves; a thick calcareous deposit has taken place between the valvular membranes, interposing a rigid and almost imperforate diaphragm between the cavity of the heart and the vessel. A. Upper surface. B. Under surface. From St. George's Hospital Museum, E 18.

blance between the morbid product and true bone. It consists essentially of carbonate and phosphate of lime deposited in irregular, amorphous nodules, and resembling more a chemical precipitation than an organic formation. The material is more or less friable, and is connected by the remains of the fibroid, or atheromatous matter, in which it formed. It is soluble in the mineral acids. It is often difficult, when we meet with an advanced case, to determine in what part the deposit first takes place; whether beneath or on the surface of the lining membrane. The opinions of different writers differ with regard to this question. The most common form undoubtedly is the conversion of atheromatous or fibroid deposit underneath the lining membrane analogous to what we

see occurring in the arteries; and as this enlarges, the membrane becomes softened and destroyed, and the ossification then projects free into the sanguineous current. It is not the mere increase of the deposit which determines this solution, but an element in producing this result is undoubtedly a morbid affection of the lining membrane itself, in which, even in early stages of degeneration of the subjacent tissue, we have observed disintegrating processes, of which we shall speak further when discussing the diseased conditions of the arterial system. One of the most extreme cases of narrowing of the aortic orifice in an adult, that we have met with, is the one delineated (Fig. 146), in which the continuity of the lining membrane was preserved entire over the ossific deposit. The passage was contracted to the size of a pea.

Rokitansky is of opinion that we may establish three varieties of concretions: the first is similar to the form just described, but he terms it exclusively ossification of the fibroid tissue developed in the interior of the valve by inflammation; he calls the second form, ossification of endocardial deposit, on the surface of the valve; and he describes the third as an osseous concretion in a stalactitic form, or as a rough calcareous agglomeration, which constitutes a metamorphosis of the vegetations on the valve. These stalactitic osseous masses, he says, occasion and promote the continued formation of new vegetations; and are consequently very commonly surrounded by them. Calcareous concretions and morbid affections of the valves generally follow the law which determines the great prevalence of disease on the left side of the heart as compared with the right side: ossification, especially, is so rare on the right side that it has been denied altogether. Hasse, however, has seen partial ossification of the pulmonary artery; and Dr. Hodgkins' also reports a case of thickening and bony deposit in the pulmonary artery close to the valves.

A condition of the valves remains to be pointed out, which was first demonstrated by Dr. Thurnam; it consists in a saccular dilatation, which he attributes to a gradual distension, and hence terms aneurism of the valves. It is met with in the aortic and tricuspid, but most commonly in the mitral valves. Dr. Peacock3 has also recorded a similar affection of the valve of the foramen ovale. We find that the dilatation may exist without any lesion of continuity in the tissue; the endocardial lining being traceable throughout the pouch. This, in the case of the mitral valve, projects into the left auricle, and is often filled with a clot of blood. This form would correspond with what is termed true aneurism of the arteries. A second variety is that resulting from inflammation of the valves, by which a solution of continuity is effected in the lining membrane. Rokitansky states that he has found it occur either as a fissure brought on by softening of the membrane, or by disintegration of the subjacent tissue; or again, by ulceration of the endocardium resulting from an abscess proceeding from the lowest part of the valve. Thus, he continues, when the valve has been perforated to

1 Catalogue of Guy's Hospital Museum. No. 1403.

2 Medico-Chirurgical Transactions, vol. xix. p. 162, vol. xxi. p. 187, vol. xxiii. p. 323. 3 Pathological Reports, 1850–51, p. 80. Several instances of valvular aneurism are detailed in the same volume, pp. 72, 77, and 78.

a greater or less extent, the blood which impinges on it penetrates into its parenchyma and causes more or less extensive infiltration. We give this explanation in deference to the authority from whom it emanates;

Aneurism of the mitral valve; a pouch projecting into the cavity of the left auricle about three-quarters of an inch bigh, and half an inch wide. It has burst by an irregular rent on one side. St. Bartholomew's Museum, 12th Series, 62.

we cannot, however, deny that the evidence in favor of the prevailing cause of valvular aneurism being dilatation of the coats, rather than a rupture of the membrane, appears to us to be the stronger. The form

of the aneurism is almost invariably that of a circular cup, varying in size from a pea to a walnut; nor does it appear from the cases which we have analyzed, that the affection so uniformly terminates in laceration as Rokitansky affirms.

We have for the sake of convenience reviewed the diseases affecting the individual tissues of the heart separately; but before proceeding further, it may be well to dwell for a brief space upon their complications with one another, and with morbid phenomena in other vital organs. The fact of the intimate connection between a rheumatic diathesis and pericardial and endocardial inflammation, has already been alluded to. We cannot show the relation better than by extracting from Dr. Latham's Lectures on Clinical Medicine, the statistical facts. illustrative of the subject, to which that author's large experience had led: The number of cases of acute rheumatism which occurred to him were 136, out of which 90 presented symptoms of heart disease; of these 63 were diagnosed as affecting the endocardium alone, 7 the pericardium alone, and 11 both endo and pericardium. Out of the total number only three proved fatal; they were men, and in them both surfaces of the heart were inflamed. In all cases of heart disease other organs will be liable to be affected in proportion, as different parts of the circulation are more immediately involved. While disorders of the arterial system more directly induce deranged action in the brain, the spleen, and the kidneys; the lungs, the liver, and the chylopoietic viscera suffer chiefly in derangements acting immediately upon the venous system. As a matter of course this distinction is one that cannot be always demonstrated, as in an advanced stage of cardiac disease of either side of the heart, or of any one portion, the entire circulation must of necessity be impaired. On the arterial side we find that more particularly a complication between granular degeneration of the kid