ment of alarming syncope, in a person advanced in years, who had previously presented evidence of cardiac disease, and especially of fatty degeneration, warrants a strong suspicion of rupture.

Rupture of the valves of the heart, or of the tendinous cords and papillary muscles, falls more appropriately under the head of valvular lesions than in the present connection.

In addition to the lesions affecting the walls of the heart, which have been considered in this chapter, there are some others, extremely rare and unattended by any distinctive symptoms or signs, and, therefore, of little interest or importance in a practical point of view. Carcinomatous and tuberculous deposits have been known to extend from beneath the endocardial and pericardial membranes more or less into the muscular substance of the organ. Few organs of the body, however, are more exempt from these heteromorphous formations than the heart. So slight is the probability of their existence in a given individual case, that they are scarcely to be taken into account in the investigation of cardiac affections which are evidently anomalous. The presence of these deposits in other parts of the body may constitute a slight ground for suspicion that they have invaded the heart, if the signs and symptoms show that the organ is affected with some indeterminable form of disease. In this category are to be included extravasation of blood, or cardiac apoplexy, to which allusion has been already made, and cysts containing entozoa.

CHAPTER III.

LESIONS AFFECTING THE VALVES AND ORIFICES OF THE HEART.

Aortic lesions-Mitral lesions-Primary effects of valvular lesions on the circulationPoints to be observed in post-mortem examinations-Pathological processes involved in the production of valvular lesions-Symptoms and secondary pathological effects of lesions affecting the valves and orifices of the heart-Symptoms and pathological effects referable to the heart-Enlargement of the several portions of the heart in relation to mitral, aortic, tricuspid, and pulmonic lesions, respectively-Pain, palpitation, the pulse, venous turgescence, and pulsation-Symptoms and pathological effects referable to the circulation-Cardiac dropsy-Arterial obstruction by fibrinous deposits detached from the valves or orifices of the heart (embolia)—Symptoms and pathological effects referable to the respiratory system: Dyspnea, cardiac asthma, cough, muco-serous expectoration and hæmoptysis, pulmonary apoplexy and oedema, bronchitis, pneumonitis, pleurisy, and emphysema-Symptoms and pathological effects referable to the nervous system: Apoplexy, paralysis, arterial obstruction, defective supply of blood to brain, pseudoapoplexy, cephalalgia, vertigo, tinnitus aurium, etc., sleep, mental condition-Symptoms and pathological effects referable to the digestive system and nutrition: Hepatic congestion, nutmeg liver, portal congestion, enlargement of liver, cirrhosis, indigestion, hæmatemesis, enterorrhoea, melæna, hæmorrhoids, enlargement of spleen, nutritionSymptoms and pathological effects referable to the genito-urinary system: Congestion of kidneys, diminished secretion of urine, albuminuria, structural degenerations of kidney, or Bright's disease-Generative functions-Symptoms and pathological effects referable to the countenance and external appearance of the body: Lividity, expression, anæmia, capillary congestion, erythema, bloodless fingers.

LESIONS of the valves or orifices of the heart, or valvular lesions, as they are concisely called, are present in a very large proportion of the cases of organic disease of this organ which come under the cognizance of the physician. In addition to the intrinsic interest which they possess as subjects for clinical study, they are important as standing in a causative relation to other cardiac lesions, more especially enlargement of the heart, and also as giving rise to pathological effects manifested in other parts of the body. They are important as sustaining a relation of dependence to other diseases, particularly acute rheumatism, a relation which has been established by modern researches. In connection with physical signs, and as exemplifying the wonderful precision of diagnosis which has resulted from the application of auscultation within the

past few years, the clinical study of these lesions is highly interesting. Inquiries with respect to their origin and mode of production involve pathological points of much interest and importance. To the latter, brief reference will alone be made, a full discussion of them being inconsistent with the practical objects of this work. The various morbid appearances incidental to the lesions will be summarily considered, a lengthened description belonging more appropriately to works on pathological anatomy. In treating of valvular lesions, the main objects will be to show their immediate and remote effects, the symptomatic phenomena to which they give rise, their physical signs and diagnosis, and, finally, the indications for treatment. The physical signs of these lesions consist of abnormal modifications of the natural heart-sounds, and also of superadded adventitious sounds distinguished as murmurs. The importance of the latter, and the various considerations connected with their diagnostic application, require that they should be treated of at some length.

Lesions of the valves and orifices of the heart, exclusive of congenital malformations, are seated as a rule in the left half of the organ; that is to say, in the great majority of cases they are either mitral or aortic. The tricuspid and pulmonic valves and orifices rarely become affected after birth. Still more unfrequently do the latter present extensive structural alterations such as are often found in the corresponding situations in the left half. When they occur, they are generally, but not invariably, associated with mitral and aortic lesions. It is a curious fact that the lesions of foetal life, giving rise to the congenital malformations which will be noticed in a subsequent chapter, affect by preference the right half of the heart, reversing the rule which obtains after birth. The changes which the valves and orifices present in different cases, vary greatly in degree and kind. The morbid appearances are exceedingly diversified. As before remarked, a full description of these belongs more appropriately to the works on pathological anatomy, and to these the reader is referred.' I shall content myself with a simple enumeration of the more prominent forms or varieties, considering the aortic and the mitral lesions under distinct heads. Pulmonic and tricuspid lesions will be noticed in connection with the pathological effects of valvular lesions, referable to the heart, and also in treating of congenital malformations.

'Rokitansky's great work, or Jones and Sieveking, may be consulted for this

purpose.

Aortic Lesions.-Lesions may be confined to one or two of the semilunar segments; but in general all are more or less affected, although rarely in an equal degree. The segments may be simply thickened and somewhat contracted. If the contraction be not enough to render them insufficient, that is, permitting regurgitation, the thickening only renders their action less free than in health. One or both the surfaces may present vegetations or excrescences, varying in size from a pin's head to a pea or bean. These are frequently situated on or near the free extremity of the segments. I have seen in one case masses resembling fibrin attached to the lower surface, as large collectively as a walnut, hanging downward an inch within the ventricle. These vegetations are sometimes easily detached, so easily as to render it altogether probable that they are sometimes washed away by the current of blood during life. In other instances they are firmly attached. They must, in proportion to their number and size, embarrass the movements of the valve. Morbid growths of cartilaginous hardness, and calcareous deposits are often found situated at the attached margins of the semilunar segments, extending partially or entirely over them. These render the segments more or less rigid and permanently expanded. One or more of them may be thus affected. In proportion to the amount of morbid material, and the space which the expanded segment or segments occupy, will the size of the arterial orifice be diminished, and the current of blood broken and interrupted. Occasionally the segments become united at their sides, and, remaining expanded, the orifice is diminished to a small aperture. I have seen it as small as a crow's quill; it has been observed even considerably smaller than this, so as hardly to admit the passage of a fine probe. One or more of the segments may be expanded and crumpled, being bent either upward or downward. They are sometimes greatly shrivelled or corrugated, leaving a permanently open aperture of greater or less size. The partition between two of the segments is occasionally wanting, fusion into a single segment having taken place. It is sometimes difficult to say whether this is due to disease after birth, or a congenital malformation. Attenuation of the segments is another variety of lesion, a species of atrophy, and in this condition they are liable to become perforated or cribriform.

Finally, rupture may take place in different directions. A segment may be torn vertically from the free margin toward the base; it may be partially torn away from its attachment, or there may be

one or more fissures at the base, the lateral ends remaining attached. These different varieties of lesion are by no means observed separately in different cases, but they are usually to a greater or less extent combined in the same case.

Mitral Lesions.-These are essentially the same as the aortic lesions, the points of difference relating chiefly to the different form and arrangement of the mitral valve. They consist of thickening and contraction of the valvular curtains; rigidity from calcareous deposit; attenuation and perforation; adhesion of the sides of the two curtains, giving rise to a funnel-shaped canal from the auricle to the ventricle, opening into the latter by a slit or small aperture; adhesion of the curtains to the walls of the heart; shortening and, in some instances, cretaceous hardness and brittleness of the tendinous cords; accumulation of masses of calcareous matter at the base of the curtains, diminishing the size of the auriculo-ventricular orifice, and presenting an irregular surface to the current of blood; rupture of the curtains in various directions and of the tendinous cords; warty vegetations or excrescences and deposit of fibrin in masses of variable form and size, adhering loosely or firmly, etc. This valve is subject to circumscribed dilatations called aneurisms, which form pouches varying from the size of a pea to that of a walnut, protruding into the cavity of the auricle, and containing coagula or laminated fibrin. These aneurismal dilatations present, in some instances, all the membranous structures of the valve unbroken, and, in other instances, perforation of one of the endocardial laminæ, the distinction between false and true aneurisms being thus maintained here as in aneurismal dilatations of the cardiac walls. This variety of lesion is of rare occurrence.

The foregoing summary of the various lesions affecting the valves and orifices of the heart is intended merely to refresh the memory of the reader. In order to form a proper idea of the great diversity of morbid appearances, it is important to consult works on morbid anatomy in which they are fully described and illustrated, and, as far as practicable, also to examine morbid specimens. The immediate pathological importance of the lesions depends on the primary effects which they produce on the blood-currents. Arranged with reference to these effects, they may be distributed into three classes, to wit: First, as involving obstruction to the