been remarked in the thickness of the left ventricle of a boy aged six years by Luschka,* and Wagstaffe,† in a girl of three months, noted a fibroma situated within the septum and filling the greater part of the cavities of the heart.

Myomata, or muscular tumors of the heart, may not infrequently be noted. They are almost always congenital. Virchow and Recklinghausen§ have recorded several instances of this new growth. The following true tumors may also invade the heart primarily, but they are rare: sarcoma, lipoma, and myxoma.

Tubercles in acute miliary tuberculosis may be deposited in the heart. On very rare occasions we may find cheesy masses, the result of chronic tuberculosis of surrounding organs; almost invariably are they secondary to caseous nodules in the pericardium.

Secondary carcinomata is probably the most frequent new growth of the heart; syphiloma is more rare; gummata are extremely rare; when they occur they will be found in the myocardium, imbedded in dense hyperplastic fibrous tissue; if they are recent, will appear as soft grayish-red patches; if older, as a dry, yellowish, cheesy node.

B. Teisser || records an interesting case of cardiac syphilis in a young prostitute, who was in the third year of syphilis, which, however, had only manifested itself in the form of buccal mucous patches. She was suddenly seized with dyspnoea, followed by asphyxia and death within twenty-four hours. The autopsy showed extensive involvement of the anterior walls of the right ventricle in its upper half, the muscular tissue of which seemed to have become entirely transformed. The thickness of the cardiac wall appeared about normal, but it seemed of a peculiar light-gray color, and its corsistence much firmer. Section showed numerous milk-white lentilsized nodules, both in the cardiac walls and elsewhere. These presented a caseous appearance, but were in reality of quite

* Virch. Arch., Bd. viii.

Virch. Arch., Bd. xv., xxx.

†Trans. Path. Soc., xii., p. 121, 1871.

Myoma cordis.—Monatschr. f. Geburtsk., Bd. xx., 1862.

|| Annals de Derm. et de Syph., 2me sér., t. iii., No. 6; Gaillard's M. J., March 17, 1883.

firm consistence, showing no trace of softening even in the centre.

In addition to the interstitial myocarditis and the gummatous deposits, there were considerable vascular alterations in the form of peri-arteritis and endo-arteritis.

Ziegler remarks that simple inflammatory indurations of the heart-muscle occur as a consequence of congenital syphilis, and that this condition is much more common than are gummata.

Calcification of certain parts of the heart near the valves is not infrequently noted. At times concretions may be found in an abscess of the myocardium which has been absorbed.

Parasites.-Cysticercus, echinococcus, and trichinæ are found in the heart. According to Cobbold, 3.5 per cent. of all cases of hydatids in man occur in the heart.

Heart-clot will be considered in a special chapter.

CHAPTER VI.

VALVULAR DISEASE.

HAVING Considered the anatomy of the heart, the rationale of its sounds, the foetal circulation, and the congenital anomalies of the heart and circulatory vessels,* we are fully prepared to correctly interpret the murmurs which occur in the heart and great vessels. Heart-murmurs are modifications in, or replacement of, the normal heart-sounds by certain new and adventitious sounds which we designate murmurs. These new sounds are either produced within the heart (valvular murmurs), on its surface (friction-murmurs), or in the bloodcurrent within the heart or great vessels at its base (hæmic or functional murmurs).

We also find murmurs in the heart unconnected with any structural lesion, to which we will refer later on in our study.

It will be serviceable for a moment to consider the distribution of the blood-supply in the valves, as it has an important bearing upon valvular disease.

E. Coent has experimented on the human heart, and the heart of the various domestic animals, in order to study the blood-supply of the cardiac valves. In order to obtain complete injections he studied the hearts of the foetus and newborn children. His injections were made with gelatin and Berlin blue. He found (1) in the pulmonary and aortic semilunar valves no vessels in the substance of the valves.

* See Chapter I.

+ Blood-Supply of the Cardiac Valves; Bullet. delle Scienze Med., Sept. 1886; London Med. Rec., March 15, 1887, p. 116.

The vessels that come from the cardiac parietes with the muscular fibres stop at the margin of implantation of the valve itself, and then form a very distinct and fine net-work, sharply limited. (2) In the auriculo-ventricular valves bloodvessels are always present, which starting from the margin of implantation of the valves extend to them in a fine net-work. Three or four principal branches extend into the valve, and subdivide into an irregular net-work. This net-work is prolonged to the point of implantation of the chorda tendineæ, either in closed loops or with very fine terminal branches. The thickness and compactness of the net is greater towards the point of implantation of the valve than towards its free margin. Numerous vessels start from the papillary muscles, and extend for a certain distance along the chorda tendineæ; but Coen has never seen these little vessels pass through the whole length of the chorda tendineæ, nor their anastomosis with the capillary net-work of the valves, as Luschka, Henle, and Krause assert.

The vascularity of the auriculo-ventricular valves must, therefore, be admitted, but not that of the semilunar valves.

Let us first, then, consider endocardial murmurs, valvular disease, as at this situation we are able to detect the disease by the physical signs.

These murmurs have a common quality, they are all blowing; yet the sound itself may present all variations in the musical scale. Much time has been spent by writers in endeavoring to classify them by their relation to some familiar sound, as rasping, filing, sawing, blowing, cooing, and sighing, all of which are, however, irrelevant, as they teach us but little as to the real source of a murmur.

Most endocardial or valvular murmurs are due to a change at the valvular orifices, either a narrowing or stenosis or an insufficiency, with inability to close the aperture, permitting regurgitation. The possible valvular murmurs in the heart (exclusive of certain congenital defects, as slits and perforations) may be represented as follows: