the affected surface." A few lines further on, we read that "the redness of the internal membrane of the sanguiferous system is sometimes of inflammatory origin, and at other times is the result of mere cadaveric imbibition. We must remain in doubt as to the real nature of this endocardial and vascular redness in some cases; where, the patients having exhibited during life the symptoms of an imperfectly-developed inflammation of the heart and blood-vessels, the post-mortem examination has been made at a time when incipient decomposition of the body has taken place. The uncertainty will be still greater, if putrefaction has fairly commenced, more especially when the patient has died from some typhoid affection, in which the dissolved state of the blood is more than usually apt to induce a sanguineous discolouration of most of the tissues. For my own part, I have been long in the habit of attributing it to the effects of inflammatory action, whenever it could not be reasonably ascribed to cadaveric imbibition."

In addition to increased redness, the Endocardium is frequently found to be swollen, thickened, and not so smooth as in health. These appearances are most conspicuous on the valves. Occasionally, this membrane is unusually friable, and is found to be much more easily detached than in the sound state. Now and then, its surface exhibits several erosions or points of ulcerative absorption.

In some cases, pseudo-membranous concretions, and, in others, genuine pus-either loose, or imbedded within a coagulum of blood-are met with in the cavities of the heart. The former, being possessed of great tenacity, become glued to the valves, and are interlaced with the chorda tendinea, causing a more or less complete adhesion of their opposite surfaces, and eventually a contraction of the valvular opening. In other cases, the lymph is deposited in the form of granules or rounded vegetations on the loose edges of the valves, &c. In course of time, these granules become so dry and friable as to be readily crushed between the fingers. Of all the cardiac valves, the bicuspid is most frequently the seat of these deposits; those of the aorta are next in point of frequency. In a few instances, M. Bouillaud has met with a putrilaginous softening of the endocardium, accompanied with a gaseous infiltration of the muscular substance of the heart; phenomena which he has regarded as (probably) the results of a gangrenous endocarditis.

As in the case of inflammation of the internal membrane of the arteries and veins, so in Endocarditis, there is a marked tendency to the formation of sanguineous concretions or coagula within the cavities of the heart. These are thus described by our author.

The following allusion by our author to the contraction of these chorda is so truly French, that we cannot withhold it from the reader.

"For some years past, the profession has been much occupied with the subject of Deformities, for the relief of which the operation of Tenotomy has been employed with a varying degree of success. Among the lesions of the cardiac valves, and of their tendons, there are some which enter into the category of those to which we allude. But, alas! the affected parts are in some sort (!) sacred against the surgeon, and inaccessible to his instruments."

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"These concretions, different from those which occur in the last moments of life, or immediately after death, are white, elastic, glutinous, adhering to the walls of the heart, just as pseudo-membranous concretions themselves, and, like these last, twisted around the tendons and the valvular laminæ. Analogous to the inflammatory crust of the blood, and imperfectly organized, they sometimes present to the eye, here and there, red points and lines which are in reality rudiments of vessels. They extend more or less deeply into the large vessels which proceed from the heart. Some of these concretions, deposited in the form of granules round the edge of the valves, become, as well as the pseudo-membranous granulations themselves, the origin of those vegetations of which we shall hereafter speak more fully."

After minutely describing the successive changes that take place in the cardiac cavities, and more especially in their orifices, from the time when the semifluid lymph is secreted during an attack of Endocarditis until the deposits acquire a horny or bony consistence, our author concludes with the following reflection:

"The organic contraction of the orifices of the heart, so commonly the result of a lengthened endocarditis, is a new feature of resemblance between the phlegmasia and those inflammations which affect other hollow viscera. Who knows not, in fact, that the urethra, the neck of the bladder, the various excretory ducts of the tears, of the saliva, of the bile, and of the urine, and that different portions of the digestive tube, &c., may experience an organic contraction more or less considerable, in consequence of a chronic inflammation of their internal membrane, and that, as in the case of the heart, it is the narrowest points, viz. the orifices of the organs now mentioned, which are more especially the seat of the

contraction ?"

M. Bouillaud in general descants at much greater length upon the necroscopic effects of diseases than upon the phenomena or symptoms which they exhibit during life. Here is a specimen of his semeiological descriptions:

"The want of harmony or correspondence between the force of the cardiac and of the arterial pulse, in the advanced stage of endocarditis, is always a very unfavourable symptom. The heart may be labouring and thumping with violence against the ribs, while the pulse at the wrist is feeble and compressible. When such is the case, we may generally suspect the presence of fibrinous concretions in the cardiac cavities-and especially around the valvular orifices—which necessarily obstruct the free issue of the blood into the arterial trunks. The pallor or livid hue of the countenance, the jactication of the limbs, the oppressive anxiety, the stiflings, and tendency to fainting, sufficiently attest the nature of the existing lesion. When the patient survives for some time, dropsy of the limbs and internal cavities is an almost invariable sequence."*

The following, not very satisfactory, tabular view of the discriminating symptoms between Endocarditis and Pericarditis is given :

* Perhaps our readers may be interested to learn that Mirabeau died of carditis: his sufferings were so severe that he besought Cabanis, his physician, to put an end to them by large doses of opium. "Had Cabanis," remarks our author, "known and practised the method we adopt (bloodletting upon bloodletting until the inflammation was arrested), he might have saved the life of his illustrious friend!"

The attempts to distinguish the exact seat of organic cardiac disease have not, it is well known, been attended with very satisfactory success. Seldom have two authors agreed in their observations upon this point, which is fortunately more curious than of practical moment. M. Bouillaud, indeed, lays claim to extraordinary skill in the diagnosis of this class of maladies; but we are by no means inclined to pin our faith to all his assertions.

"The isochronism of the blowing, sawing, or rasping sound with the systole or with the diastole of the ventricles is not, by itself, of so much value as has been alleged by some superficial observers who have, under the vague term 'insufficiency of the valves,' confounded several valvular lesions, that are obviously distinct from each other. Let it not, however, be forgotten, that, in the majority of cases of constriction of one orifice, the abnormal sound is audible, both during the heart's systole and its diastole; but it is important to know that the regular click-clack of the valves, corresponding with the contracted orifice, is extinct or nearly so, while the click-clack of the sound valves continues to be heard. It is quite true that, when the abnormal murmur exists both during the systole and during the diastole, it masks, nay, sometimes entirely conceals, the sound of the valves which are healthy. By removing, however, the ear from the point where the abnormal murmur is most intense, we may by degrees distinguish the sound of the healthy valves. If, for example, there be contraction of the left auriculoventricular valve with loud abnormal murmur, audible alike during the systole and the diastole, the ear, applied immediately over or very near to the seat of the sound, will probably not succeed in distinguishing the clacking through the morbid murmur with which it coincides. But, if the ear be applied to the middle or upper part of the sternum, or in the subclavicular region, the auscultator will

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Various Organic Lesions.

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generally hear, more or less distinctly, the sound in question-which, as is well known, is produced by the redressement of the aortic valves during the ventricular diastole. We cannot too urgently recommend physicians, in their use of auscultation in cardiac diseases, to attend to the sounds as heard at different points of the chest. Without this precaution, it would have been a matter of great difficulty for us to have carried our diagnosis of various valvular lesions to that degree of precision and exactitude which may be now attained."

When the first of the two cardiac sounds is chiefly affected in the way of irregularity or other abnormal modification, we may suspect the lesion to be seated in the aortic valves; whereas, when it is the second which is so affected, it is probably in the auriculo-ventricular orifice. In general, too, the pulse is more irregular and unequal, smaller and more intermittent, in the former than in the latter case. Moreover, it is specially and exclusively in the former that the peculiar vibratory fremitus, which Corvisart designated by the word bruissement, is perceptible along the course of the large arterial trunks, particularly of such as are near tothe heart. In the following passage, the reader is informed how he may diagnosticate simple and uncomplicated Hypertrophy of the Cardiac Valves-a rather uncommon state of things, we ween.

"When the valves are the seat of a well-marked hypertrophic thickening, while at the same time they are exempt from malformation and can play freely, the valvular sounds are stronger, more sonorous than in a normal state, and resemble the clacking of a strong piston, or, better still, that produced by two sheets of parchment being applied smartly one against the other; hence the name parchment sound, parchment clacking, which I have given to the valvular sounds thus modified. In some persons, the attentive application of the fingers over the region corresponding to the hypertrophied, parcheminés, aortic valves, has made the action of these valves to be distinctly felt, and I regret not having sooner employed this mode of examination. In a good many cases already, trusting to the presence of the double phenomenon now stated, particularly of a well-marked parchment clacking, I have diagnosticated the existence of Hypertrophy of the Valves specified, and on several occasions dissection has confirmed the correctness of the diagnosis. This will surprise only those physicians who are little conversant with the subject on which we are engaged; the number of these is unhappily still too large."

We proceed to another form of cardiac lesion.

The ramollissement or softening of the muscular tissue of the Heart from inflammatory action (for M. Bouillaud expressly admits that this structural lesion may arise from a very different cause), and the suppuration that occasionally takes place in consequence of it, are thus described in the "Nosographie."

"In the second period of Carditis, softening of the heart is apt to supervene. Of this morbid change there are three principal species: the red, the white, and the yellow. Whatever be the species present, the softening of the heart is recognised by the following characters. The tissue of this organ has lost its natural firmness, so that it readily gives way to the pressure of the finger; it has become friable, and even fragile. In the red softening, the muscular substance often exhibits a violet or a brownish colour; it is sometimes accompanied with the infiltration of a certain quantity of altered blood, like the lees of wine, into the muscular interstices and underneath the investing membranes of the heart. At a more advanced period of the disease, the red softening becomes transformed into No. 108

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the white or greyish kind. It is then that complete suppuration is sometimes to be seen. In the same way as this kind of softening follows upon the red kind, so the yellow softening is a sort of transformation of the white. This third species appears to me to belong to chronic pericarditis. Laennec compared the yellowish tint of the morbid change in question to that of some dead leaves, as they fall from the tree.

"Suppuration of the heart is coincident with one or other of the species of softening which we have now mentioned. The purulent matter is either simply infiltrated, or it is collected into a focus, and then there will either be a solitary or multiple abscesses. These abscesses may find their way either to the inner or to the outer surface of the heart."--Vol. I. p. 424.

Ulceration of the parietes of the Heart, the result of inflammatory action, commences almost invariably in the endocardial membrane, and thus proceeds from within outwards. It is much more frequent in the left ventricle than in any other of the cavities. The ulcerations vary a good deal in different cases, in point of number, extent, and depth. Occasionally the ventricular walls are completely corroded at one part; and then perforation must inevitably ensue. In a few cases, the effect of cardiac ulceration has been to give rise to a tumour or bulging of the ventricular parietes, altogether similar to an aneurism of an artery;-in short, to a genuine consecutive false aneurism of the heart. Formed by the external layers of the muscular walls (sometimes by the pericardial covering alone, which then plays the part of the external coat of an artery), the aneurismal cyst will contain a more or less considerable quantity of laminated coagula. The size of such a cyst has been known to vary from that of a filbert to that of a common egg, and even to be very much larger, as in a case detailed by Professor Breschet.

Of 13 cases of Aneurism of the Heart, which have been analysed by M. Reynaud, 6 were seated at the apex of this organ, and the remaining 7 in other points of its periphery. The rupture of a cardiac aneurism is a rare event. When this frightful accident occurs, it usually happens previous to the formation of an aneurismal pouch, and when the ulceration has destroyed the deepest-seated layers of the cardiac parietes.

Ulceration and Rupture may be limited exclusively to certain columnæ carnea, and more especially to some one or more of those belonging to the mitral valve.

The Diagnosis of Aneurism of the Heart must, in all cases, be merely conjectural. In none of the cases recorded, had its presence been so much as suspected.

With a few remarks on the subject of Arteritis, we shall close the present article.

As with the Heart, so it is with the larger arteries; inflammation of their lining membrane, or in other words Endo-arteritis, is, according to M. Bouillaud, of much more frequent occurrence than is generally imagined. "The cases," says he, "in which, upon dissection, various arteries-more especially the aorta, and the carotid, cerebral, subclavian, axillary, iliac and crural vessels-have exhibited morbid alterations of a distinctly inflammatory origin, are, I may say without exaggeration, almost innumerable. For some years, too, I have been able to announce, during the life of my patients, these alterations with a degree of precision which has not a little surprised those who have not paid due attention to the subject. They