646 



ABNORMAL CONDITIONS OF THE HEART. 



Can this redness be distinguished from that 

 which is consequent upon inflammation ? It 

 seems to me that there is no anatomical charac- 

 ter by which the true nature of the discoloration 

 can be proved. The anatomist must be guided 

 in coming to a conclusion upon the question 

 by concomitant circumstances, of which the 

 time which has elapsed after death, the quan- 

 tity and quality of the blood in the heart, and 

 the state of the other organs or textures of the 

 body, are the most important. If the examina- 

 tion has been made soon after death, that is, 

 within twenty-four hours, if the blood in the 

 heart presents no undue predominance of co- 

 louring matter, nor has undergone any decom- 

 position, and if the other tissues retain their na- 

 tural state, and show no unusual tendency to 

 putrefaction, the redness may be inferred to be 

 morbid and inflammatory ; but this inference is 

 confirmed with the utmost degree of certainty, 

 if the redness is accompanied by an effusion of 

 coagulable lymph or of pus, and by an unequi- 

 vocal thickening or swelling of the endocardium 

 itself; sometimes, also, as Bouillaud remarks, 

 the adhesion of clots, resembling the buffy 

 coat of blood, are among the anatomical 

 .signs of inflamed endocardium. The in- 

 flamed endocardium is, according to Bouil- 

 laud, more easily detached from the internal 

 surface of the heart, owing in all probability to 

 the subjacent cellular tissue having lost its 

 force of cohesion, and become fragile. 



Lymph effused on the endocardium does not 

 generally take the laminated form as in pericar- 

 ditis, nor do we find it covering an extensive 

 surface, as in that disease. Small patches of 

 membranous lymph are sometimes met with 

 here and there, either on the surface of the 

 valves or over some part of one of the cavities; 

 at other times it assumes a granular or warty 

 form, or it projects in papilliform or conical or 

 globular masses from the surface of the valve. 

 Thus are formed the vegetations which are 

 among the most frequent valvular diseases, and 

 which offer the greatest impediments to the 

 adequate action of the valves. When examined 

 recently after their formation, they present all 

 the characters of the albumino-fibrinous exuda- 

 tions of serous membranes, their form being 

 determined by the frequent changes of relation 

 which the inflamed surface undergoes in the 

 heart's action, as well as by the current of 

 blood from the heart continually flowing over 

 it. 



The further progress of inflammation of the 

 endocardium induces thickening of the mem- 

 brane or of the valves, organization of the effu- 

 sed lymph, which thus becomes more firmly 

 adherent to the surface on which it had arisen, 

 and induration of the membrane from cartilagi- 

 nous or calcareous deposits, which however are 

 generally met with within the fold of membrane 

 constituting the valves, and more intimately 

 ronnected with the interposed fibrous than with 

 the serous membrane. 



When inflammation of the folds of endocar- 

 dium forming the valves runs its course with 

 great rapidity, it may induce destruction of 

 them -to a greater or less extent. Softening, 



ulceration, and rupture of the affected valve are 

 very speedily produced. " The ruptured and 

 ulcerated portions," to borrow Dr. C. J. Wil- 

 liams's description, " are found loaded with 

 ragged, soft, fragile vegetations, more or less 

 tinged with blood, and these are also some- 

 times seen adhering to adjacent parts where the 

 endocardium is entire. The remaining parts of 

 the valves are much thickened and opaque yel- 

 lowish white, with a pink hue; and pink patches 

 are often seen in the aorta with atheromatous 

 thickening." Sometimes a valve is perforated 

 in its centre by ulceration, and the circumfe- 

 rence of the perforation is surrounded by warty 

 vegetations. 



It is well known that the endocardium of 

 the left side is much more liable to disease than 

 that of the right, whether as regards the valvu- 

 lar portion of it or that which lines the interior 

 of the heart. But the views of Bichat and 

 others, who denied the occurrence of disease 

 on the right side, have been abundantly refuted 

 by modern observations. 



Chronic valvular diseases. Chronic endocar- 

 ditis affects the valves of the heart in such a 

 manner as in all cases to occasion more or less 

 obstacle to the flow of the blood from the ven- 

 tricle or auricle. Sometimes, however, the 

 disease is not of a kind to interfere with the 

 valvular action and to permit regurgitation ; but 

 at other times the disease has gone so far in 

 one or more of the valves as to prevent its con- 

 tributing to the perfect closure of the orifice, 

 and consequently to destroy the power of the 

 valves to oppose regurgitation. Hence the 

 subdivision proposed by Dr. Williams, for val- 

 vular diseases, into those which more or less 

 obstruct the current of the blood in its proper 

 channel, or the obstructive, and those which 

 permit it to pass in the reversed direction, or the 

 regurgitant. Thickening of a valve, so as to 

 prevent its complete apposition to the internal 

 surface of the artery or of the ventricle, will oc- 

 casion obstruction, the degree of which will 

 depend on the degree of perfection of apposi- 

 tion with which the valve may be applied to 

 the neighbouring surface; on the other hand, 

 the degree to which regurgitation is permitted 

 will depend upon the degree of induration of 

 the valve, and the want of extensibility which 

 it manifests. 



Thickening of the edges of the valves is 

 among their most common diseased states; the 

 attached margin or base of the valve is also very 

 frequently the seat of thickening, and in both 

 these situations the fibrous tissue seems to be 

 engaged principally in the disease. The inter- 

 vening portion is generally affected as a conse- 

 quence of the extension of the disease from 

 these margins. In such cases the thickening 

 arises from a deposit between the layers of the 

 fold forming the valve; in other cases the thick- 

 ening is produced by a deposit upon the surface 

 of the valve. On the aortic valves this deposit, 

 when on the ventricular surface, is apt to assume 

 the form of two crescents corresponding in po- 

 sition as well as form to the two crescentic por- 

 tions of fibrous tissue within the fold of mem- 

 brane by which the valve is formed. This fact 



