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Show Sicc'riox II.] DISEASES OF THIS IIICA I't'l‘ AND ITS MEMBRANES. Some liquid blood was also found in this cavitv. 0n of an artery. (‘ases of this kind may be classed as chronic dilfuse myocarditis. The symptoms accompany- ing such lesions are various. ()n account ofthe inability the left ventricle some blackish ecchymotic spots‘pl'ovetl to be apoplectic focuses (\I". S. J". b'.-l"ig. 22). situated immediately below the visceral plate of the pericardium. which they had raised f. 1",): it showed an opening or rent (1". N. 0.). which seemed to be the source of the pericardiac htemorrhage. and must hay/e come from the left ventricle. The left ventricle was both hypertrophied and dilated. The left auriculo-ventricular oritice was narrowed. The aortic orifice exceedingly narrow. and obstructed with very large irregular phosphatic concre- tions. In this case. the muscular tissue of the heart had undergone. in certain localities. a gradual softening and disintegration. and at last broke down. in the same way as cerebral apoplexy is brought about. by gradual dis- integration of some of its tissue. with infarctus and focal haunorrhage. 'l‘his breaking down. which does often take place through the whole thickness of the walls of the ventricular walls to fully perform their function. there will generally be found an insuflicieut blood pressure in the aorta. with cousetlueut \enous eugorgcuieut; oedema. as well as passive hzemorrhage. will appear and disappear alternately in ditfereut organs. as constant and early symptoms of the disturbance of the circulation of the heart and lungs; there will always exist shortness of breath. moderate dyspntea. a sense of suffocation after a strong effort. and palpitatiou. with some pain in the region of the heart. In nearly all such cases there is a. disturbance of digestion. 7 The arterial pulse is nearly always irregular. The same irregularity is found in the. otherwise. clear heart sounds. In some rare cases there is a slight systolic Bruit: heard at the apex. In the early stages a fairly distinct heart-pulse may he discovered by palpation. but of rather irregular strength. In the latter stages. no pulse whatever. even at the apex. can be discovered. I'ercussion will indicate an enlarged space of dull sound. especially to the left. \Vhether an arterial and cardiac irregular pulse may not also indicate an endocarditis. or fatty degeneration of the muscular walls of the h ‘art. or valvular troubles. is not yet decided; for in many cases of valvular diseases and sir/Hosts of the left ostium venosum. great irregularity of both the cardia- and arterial pulse is often enough observed. But under such circumstances. the irregularity of both pulses may still be due more to myocarditis complicated with those diseases. than otherwise. A systolic Bruit. when only oc ‘asioually heard. or when a tone is heard simul- taneously with it. does not indicate an insufficiency of the mitral valve in myocarditis. The :etiology of diffuse myocarditis seems chiefly rheumatic affections. especially of the muscles. with over-fatigue of the heart. I'uerperal and miasmatic myocarditis do not differ in their symptoms from other forms of this lesion. of the heart. and which ‘auses sudden death. happened here only to a portion of its thickness; more at the out- side than the inside of" its walls; the haanorrhage took place outside and the blood discharged into the pericardial cavity. Had an extensive focus formed on the inner part of the wall. and broken internally. the blood of the ventricular 'avity would have penetrated into the little cavity of the infarct. and the heart would have sooner broken through. It might possibly sometimes happen. that the walls of the h tart resist the influx of blood from the ventricle. and a diverticular cavity. similiar to a false aneurism. would be the result. The constant, forward movement of the blood, coming from the ventricular cavity would so irritate that portion of the heart, that it might cause a repair either by inflammation or by cicatrization; or it might undergo a fibrous. cartilagenous or osseous transformation. Such transformation of the walls or parts of a diverticuhun. or pocket. in the heart- walls are not so very rare; but they differ totally from the mechanism of an aneurism, either of the 11 -art or T .X I), T. E 1\r. Spontaneous It'll/Marv of HIV [[eu/‘t. The, heart: represented in this plate (Fig. l. 2) was that of :1 11 old woman, eighty-six years old. She died suddenly. ,I'ost-mm‘t‘cm Autopsy.-.\fter the sternum was re- moved. the pericardium was found considerably distended. and of a purplish-blue color. It contained some liquid blood. which ran out. on opening the )avit‘y. and some eoagulated blood. which enclosed the heart. and extended to the pulmonary artery. Fig. 1 presents two perforations (I). 1'.) on a plane with the ventricular septum beneath the pericardium. Seve‘al hzemorrhagic spots and ecchymoses are to be seen in the space between the perforations. Fig. 2 presents the left ventricle opened by a verti 'al incision made along the track of the perforations. 'l‘he inferior is the largest. and is situated near the ventricular septum. and consists of a rent in the tissue of the heart; I l to date from a time before it was born. Newly-born children are often affected with all sorts of inllammations of the scrolls membranes. I'tlU/o/og/M- ('m/r/I'I‘fo/I of" f/II/ lua'fctlt'd/Hm I'll rupture of f/II‘ /m/r/. - In most of the ‘tlscs of rupture. especially when the rent is very large. the pericardial -a\'ity is distended. and filled with the extravasated blood. \thu the orifice is small. especially if the tissue which broke. down and sutfered the rupture has not been extensively degenerated by fatty or other trausformations. such as :unyloid. etc.. of the muscular fibres. cicatricial tissue is often speedily formed and repair allowed, provided the clot between the heart and the pericardium remain for a time stationary. Such ruptures. if closed up, cause attachment of the visceral plate (and nearly always the outer plate also) to the heart by fibriuous strings or hands. During life, such slight ruptures are barely discove ~able. \Vhen the internal surface of the infarctus heals. there is produced either a slight contraction of the cicatrized the infiltration took place from below upward. between portion. or some callus projecting into th‘ cavity of the the S(‘l'()llS membrane. which is (‘UVUI'Utl with fat and the columme curacm. and extended - much farther heart. which. if not of any considerable size. is also not noticeable during life. As a rule, an extensive rupture causes sudden death; than the superior perforation (\1'.-I"ig. 1) indicates- behind the pulmonary artery. between this and the aorta, where a hzemorrhagie focus had formed. 'l‘here was no general disease of the parenchyma of the h ~art visible to the naked eye. Neither was there any stenosis of the orifices. nor hypertrophy or alteration of the tissues generally. except a spot 11‘311‘ the perforated portion. which was very friable. and which was provcu by the microscope to be a portion of muscular tissue. softened by amyloid and partly fatty degeneracy. Flo. 3. l'scu(Io-Inc/nbl'unoas ,I'crfcm'I/ilis [n a {/I I'cr(lays-0M Int/Ir. The heart is enveloped by a neoplastic layer (F. .11.). The pericardium is covered with a similar layer. but thinner than that of the heart. This pericarditis seems for. not. only will the extravasated blood within the pericardium prevent diastole of the heart. but the vessels enclosed within the membrane will be completely com- pressed, and sudden cessation of the circulation will ensue. Besides. in spontaneous rupture. the muscular tissue of the heart must have undergone such a change. and have become so weakened as to be unable to resist the force of the passage of the blood through the ‘avi- ties. Outside of traumatic causes. eudocardial ulceration. most frequently existing in infectious diseases. and puerperal metritis. septic;emia. and the graver forms of ])leuro-pueumonia. most commonly give rise to ruptllrc. (I'I'III‘I'II/ l'rlf/m/otHL- liindtleisch in his I'athology very correctlv remarks. that myocarditis. or inflammation of |