1846.] PERICARDITIS-ENDOCARDITIS. 185 diseases can be given, except by the admission that, the primary blastema may and does occasionally germinate within the vessels. This subject has been discussed by Dr. Walshe in his work on Cancer with great acumen, and he appears to have been compelled to come to the same conclusion. In the fifth chapter, which treats of Disease of the Heart, our author gives due prominence to the various modifications of pericardial inflammation as influencing most materially the ulterior course of the disease and the consequences to which it gives rise. Both in respect of prognosis and treatment it is of much practical importance to be aware of the great difference that exists in the character and amount of effusion which attends pericarditis. The most intractable forms of pericarditis are referable frequently not so much to the violence of the inflammation as to the unorganizable character of the effused matter. "The products of pericarditis are not always uniform, even in the same subject, but as before stated, the same exudation frequently contains varicus elements, which, by virtue of the ulterior changes wrought in them, modify the course of the disease in many different ways. This variable composition of the exudation may proceed from alternations in the intensity of the inflammation,—a rapid succession of inflammatory attacks giving rise in turn to serous and sanguineous -organizable and unorganizable effusion; or else it may proceed from some peculiar ingrained morbid predisposition to engender diseased products. Thus it not unfrequently happens that true tubercle, and even medullary fungus, is developed out of the exuded substances, as seen both by Kolletschka and by myself." P. 116. The Section treating of Endocarditis is admirably drawn up, and most valuable. We regret that our limits prevent our extracting largely from it. Having indicated the distinctions between the various forms of fibrinous coagula found in the heart's cavities, he thus points out the means of discriminating "between redness of the endocardium from inflammation, and redness from imbibition; as also between polypous formations engen. dered by exudation, and coagula resulting from the inflammatory irritation of other organs.' "The inflammatory redness is almost always spotted,-pale and dark alternately; in one place more of a violet, in another more of a scarlet colour. The redness of imbibition is, on the contrary, more equable throughout, and darker, perhaps, where the blood makes a prolonged sojourn. The redness of imbibition is therefore almost invariably observed in the following descending order: darkest in the right auricle, paler in the right ventricle, with the exception of the valves of the pulmonary artery, which are as deeply coloured as the auricle; still paler in the left auricle, whilst the left ventricle often retains quite its natural tint, except that the aortal valves are darker; in the great vessels the posterior surface is strikingly dark in comparison with the anterior. Moreover, the endocardium continues smooth and polished, and in all other respects natural, whilst inflamed portions of it assume a dull, velvety appearance, and are sometimes thickened and softened. If besides the polypous coagulum the endocardial surface is invested with a soft, firmly adherent false membrane, the inflammatory state is no longer doubtful. At the valves, particularly the tricuspid and mitral, this membranaceous covering takes the character of soft, hemispherical granulations, capable of increasing in bulk, and in some instances, as shown by Kreysig and Bouillaud, susceptible of organization. Secondly, these polypoid concretions can be regarded as products of endocarditis only when met with on the inner surface of the heart, in the manner before described, or when they cannot be traced to any other morbific condition. Here absence of inflammatory redness is not always a sufficient reason for denying their inflammatory origin,-seeing that the redness is very fugitive, more particularly in intense degrees of inflammation, when the colour of the membrane gradually from a dull and equable brown red becomes paler,-changing to a dirty grayish yellow. Carswell has figured a remarkable case of inflammatory polypus, in which the lining of the heart appears preternaturally pale. This polypus was partly of a grayish, partly of a lively red colour; it exhibited, both on its surface and in its substance, little drops and stripes of pus, had insinuated itself amongst the columna carneæ, and adhered as if glued to the equally pallid mitral valve. Legroux and others contend that the pus is the result of inflammation of the fibrinous layers, within which it is sometimes found to accumulate, an error probably refuted by Bouillaud. Admitting the above granulations resulting from exudation to be susceptible of organization, it may still be doubted whether the polypous coagula are so. Otto could never detect in them any vascular development. It is true that they exhibit points and streaks of blood, sometimes extending into their interior, and which might certainly pass for the rudiments of organization; but it is not conceivable that foreign bodies of such dimensions could occupy the central organ of circulation without speedily inducing death. The few authenticated instances of organized polypi leave it problematical whether they were anything more than mere vegetations upon the valves; and vegetations there, as elsewhere, can hardly be reckoned among the immediate products of inflammation." "The first and most constant change resulting from endocarditis relates to the endocardial membrane. This, after the aforesaid red spots and patches have disappeared, loses its smooth pellucid aspect, becomes relaxed, turgescent, and rough, puts on a grayish and dull appearance, and is capable of being stripped off with comparative ease. Rokitansky states that under these circumstances the endocardium frequently becomes the seat of irregularly-jagged fissures, which forthwith form a depot for a grayish yellow coagulum." "When the inflammation assails more particularly the apparatus of the auricular valves, a still more frequent occurrence is the rupture of one or more of the papillary tendons. This is particularly common at the mitral valves. The filaments or shreds of such lacerated tendons curl up and form little elevations, invested with fibrinous coagulum and hardened lymph, whilst the valve, previously angular, recedes and acquires a broad raised margin." P. 128-130. After observing that, according to Bouillaud's views, all defects of the valves, all ossifications,-in a word, all diseases of the heart's apertures, are directly referable to endocarditis, Hasse very justly says: "This view does not, however, fully correspond with facts; for, in the first place, experience shows that the several organic changes above alluded to, affect the left side of the heart far more frequently than the right; whilst, according to Bouillaud, endocarditis is observed with equal frequency on both sides, and with 1846.] DISEASED Heart. 187 most intensity on the right. In the second place, we meet with those indurations and ossifications, especially after the prime of life, too often to admit their having been universally preceded by endocarditis; in many subjects, indeed, the contrary could be proved. Thirdly, most of those changes present, in the mode of their development, so perfect a similarity to the progress of atheromatous disease of the arteries as to render it more appropriate to class them under this head. "It cannot be denied, however, that, under propitious circumstances, endocarditis may be productive of thickening of the internal lining of the heart and of the valves, as well as of granulations and ossifications of the latter, though much less frequently than Bouillaud pretends. In fact, ossification, even when met with in young individuals, cannot invariably be ascribed to endocarditis. After careful consideration of all the circumstances, it would appear that the following organic changes arise from either a partial or a general inflammation of the internal surface of the heart: the milk-white or mother-of-pearl coloured patches and thickenings,—perhaps themselves the relics of earlier relaxation, disorganization, and scar-like puckerings,—of the endocardium; secondly, membranaceous deposits on the inner surface of the heart, more especially in the left auricle, and also in the left ventricle, upon the septum and about the origin of the aorta. These have the appearance of elevated, rough, and puckered connecting membranes. They are of a dull yellow tint, and are easily separated. To the same class belong adhesions of the valves amongst each other, and with the heart's parietes, rupture of the tendinous filaments of the auricular valves; and, finally, a state of partial destruction of the valves, with irregular notchings, and fringed appendices of variable length. This has heretofore been observed only in the semilunar valves of the aorta, and twice by myself in the pulmonary artery. Sometimes it is complicated with partial adhesion of the valves together." P. 132. There are certain secondary phenomena produced by endocarditis, which are but little attended to, and of which Hasse thus speaks :— "They are referable to the effusion almost always consequent upon that affection, in the various forms and localities already specified. A considerable portion of the effused substances being carried away in the first instance by the circulation, and another portion during the subsequent period of softening, it is obvious that these inflammatory products must, just as in phlebitis, act a subordinate part within the capillary system. The spleen and kidneys appear particularly liable to such changes. In the spleen, coagulated fibrin is found of some breadth at the periphery, but gradually tapering towards the centre, having mostly a tolerably sharp outline and a brownish-yellow hue. Smaller deposits, of a similar kind, are met with in the cortical substance of the kidney; sometimes even intersecting the papillæ. According as the inflammatory product of the endocardium partakes more of the character of fibrin or of pus, the secondary deposit will be of a more or less consistent kind, and shrivel in the event of recovery,or else liquefy, and terminate in abscess. Though frequent in the localities above indicated, these secondary phenomena are proportionately rare in other organs, as in the liver for instance. Sometimes, however, they occur in the serous cavities." P. 134. In the sections on inadequate valves and hypertrophy and dilatation of the heart, will be found an excellent account of these important morbid states and their pathological relations, with full reference to the labours of Kingston, Bizot, and other recent investigators. A just tribute is paid to the value and general correctness of the statements and views of Bizot. On the relative width of the pulmonary artery and aorta, our author says: "I began, several years ago, to pay attention to the width of the pulmonary artery relatively to that of the aorta. In E. H. Weber's edition of Hildebrandt's Anatomy, and in J. Müller's Physiology, it is asserted that the former is narrower by one third than the latter, and from this statement many physiological inferences have been drawn. Great was my astonishment, however, to find that, on the contrary, the pulmonary artery is somewhat more capacious than the aorta; yet, on repeating the trial in a multiplicity of cases, I invariably arrived at the same results. Whilst I was thus engaged, Bizot's comprehensive Researches were published, and proved far in advance of my own. Nevertheless, whenever I found time I continued my ad measurements upon a somewhat more comprehensive principle and improved method. My results, based upon 122 admeasurements, almost entirely coincide with Bizot's, and are richly suggestive in a pathological point of view. It should be stated that the measurements from which the general results are taken were made on subjects who, during life, had betrayed no symptoms of diseased heart." P. 156, Note. There is, we think, frequently a very vague and incorrect notion entertained with regard to the relation between cardiac and hepatic disease. On this subject Hasse observes, "hepatic disorders effect inconsiderable passive dilatation in the instance of fatty heart only; they engender, besides, a thickening, only ascertained by measurement, in the walls, of the right auricle and ventricle. Thus, in my tables I find almost invariably in the cases presenting the largest dimensions, short of actual hypertrophy, hepatic disease noted; and it appears that enlargement resulting from chronic inflammation, with or without fatty or wax-like degeneration, bears a much closer relation to diseased heart than scirrhosis and simple fatty degeneration. Liver-disease may, however, be a consequence, as well as a cause of disease of the heart. We rarely meet with disease of the heart, coupled with stagnation of blood in the right chambers and in the veins generally, without hyperæmia, and a flabby condition of the liver. Nay, this stagnation may go so far as to occasion extravasation of blood within the parenchymatous texture (Bouillaud.) The so-called nutmegliver is a very common sequence of hypertrophy and dilatation of the heart." The phenomena connected with the respiratory organs, are among the most prominent and well-known symptoms of cardiac disease, but it is important to be aware that the pulmonary congestion is apt to merge in inflammation, and we have met with some cases that have strongly impressed us with the importance of being awake to this tendency, for the complication, it need hardly be said, is important and dangerous, and very apt to be overlooked amid the more common and habitual symptoms with which these deplorable cases are attended. On this point Hasse says— "In several instances of considerable hypertrophy, I have seen the resulting pulmonary affection merge in inflammation. The inferior lobe, sometimes of the left, sometimes of both lungs, was displaced, shrunken, not crepitant, softened within a greater or smaller range, of a clear reddish brown colour, and of augmented density. On being cut into, the section was tolerably even, presenting only here and there those soft elevations which, in pneumonia, produce the wellknown granular aspect; these, when aggregated in distinct groups (which was however seldom the case) were moister, more decidedly gray, (if not of a dirty yellow,) and much softer than the rest of the texture. While the whole remainder of the lungs was marked by an excess of blood, the portions alluded to contained more or less of a dingy reddish troubled fluid; circumstances all com 1846.] PLEURISY. 189 bining to establish a peculiar modification of the second stage of inflammation of the pulmonary substance." P. 167. There are two forms of fatty heart that are well known, the one in which there is an unusual deposition of fat in the cellular tissue betwixt the serous investment and the muscular substance of the heart, and the other where the fat globules collect not only within the compartments of the sub-serous cellular tissue, but are deposited within the muscular sub. stance, even between its primitive fibres. There is, however, a perfectly distinct species of fatty heart, occurring almost exclusively in hypertrophied hearts, which exhibit at the same time the remains of earlier endocarditis and carditis. In this form, which was first described by Rokitansky," the fat does not accumulate in masses, there being no fat-vesicles inclosed within fasciculi of cellular tissue, but is beaded, as it were, in minute microscopic granules, closely interlaced, and imbedded among the primitive fibres of the heart's muscles. Those primitive fibres have lost their transverse striæ; the fibrils are friable, and easily reduced to minute molecules. The whole heart may suffer this species of fatty infiltration, although commonly distinct portions alone are diseased. In the latter case the flesh is here and there found, within a certain sphere, pallid and dull, of a dingy yellow -soft and flaccid; at a more advanced stage these spheres become more numerous, and pass very gradually into the healthy mass; the endocardium has become thin and transparent, rendering the dull aspect of the heart's muscle here and there conspicuous; the trabeculæ, and the papillary muscles are either wholly or partially diseased. In its greatest extent this fatty condition may affect an entire ventricle, more commonly the left, although, when partaking of the hypertrophy, the right ventricle, and consequently, as above stated, the whole heart may become involved. Rokitansky is of opinion that spontaneous rupture of the hypertrophied left ventricle is, in the majority of cases, referable to this disease of the heart's muscle. In youth this form of fatty heart has been observed, even where there was no hypertrophy, the organ being dilated, probably in consequence of the degeneration. Rokitansky believes that, when in such instances the papillary muscles are diseased, the consequent imperfect tension might occasion insufficiency of the valves." Passing over the remaining section on cyanosis, we come to the second part of Hasse's work. The first Chapter of this division of the work treats of Pleurisy. After alluding to the frequency of this form of inflammation, and the influence exerted by the degree of the morbid action on the character of the products, and thus on the whole progress and issue of the disease, he describes the first appearance of inflammation of the pleura as consisting in a congested state of its blood vessels, which are seen congregated here and there, in dense though delicate nets beneath the still transparent membrane. The redness, at first punctated, gradually spreads till the whole becomes uniform, and the membrane loses its polish. At the same time, the sub-serous cellular tissue manifests increased vascularity and numerous ecchymosis, the meshes or intervals between the cells being here and there filled with a yellowish, half-fluid, half-gelatinous effusion. This implication of the external cellular tissue is, however, by no means |