DISEASES OF THE HEART. — FIBROID PATCH. 293 



nective-tissue layer in this region, never gives rise to any appre- 

 ciable elevation of the surface ; on the contrary, the affected 

 spot is from the first depressed below the level of the surrounding 

 parts; this depression passes by slow degrees into an actual 

 bulging, and finally into an aneurism. 



The anterior wall of the left ventricle Is the usual seat of such 

 alterations. Here, in the neighbourhood of the heart's apex, 

 the endocardium assumes a milky, tough, fibroid appearance 

 over a spot as large as a dollar, or even larger. Its surface is 

 smooth ; smoother Indeed than it ought to be ; we miss the Irre- 

 gular conformation which this region In particular owes to the 

 columnae carnej^. On cutting Into It we find that underneath 

 the thickened endocardium not only the columna? carnea3, but 

 the entire muscular coat has disappeared. We find a " tendi- 

 nous spot " extending through the entire thickness of the heart's 

 wall, from one to two lines thick, made up of white, dense, 

 inelastic connective tissue ; in It we are no lono-er able to dis- 

 tinguish endocardium from muscle, muscle from pericardium. 

 Under these circumstances it becomes a question, whether the 

 entire process Is not to be regarded as essentially a circum- 

 scribed indurative Inflammation of the muscular tissue (§ 242). 

 There can be no doubt that the muscular coat of the orofan is 

 really destroyed by an overgrowth and shrinking of the inter- 

 stitial connective tissue. At the edges of the affected part, 

 where the myocardium, growing gradually thinner, passes into 

 the tendinous patch, I have never failed to find atrophied 

 muscular fibres, lost in a connective tissue rich in corpuscular 

 elements, though not in a state of luxuriant proliferation. But I 

 insist that this process must be regarded as a direct extension of 

 the chronic inflammation of the endocardium to the subendo- 

 cardial and intermuscular connective tissue. For the myocar- 

 dium is not always utterly annihilated; and it is usually its 

 outer, not its Inner layers which still remain intact. 



§ 257. The fibroid patch, as I have already said, forms a 

 necessary preliminary to a circumscribed dilatation, a partial 

 aneurism of the heart. Notwithstanding its innate tendency to 

 contract, the newly-formed connective tissue which has taken 

 the place of a portion of the heart's muscular wall Is unable to 

 resist the pressure of the blood. The affected patch Is accord- 

 ingly stretched, and assumes the shape cither of a uniform, 



