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Show Sicc'riox 11.] DING .h‘xII. ()F Till} IIEART \\I) ["51'ME Mhli \\ I... TA 121.1; Y. plete aeration of the hlood in the lungs. Fin. 1 .-/)'I'IIII'II IIII'II/I/II/ II7" IIIII IIIIII'I. ( 'IIIIIpIIII \‘(lIOI'I/ III/- ('yanosis of the lace and upper extremities. )IIII'II'II/I/II/II7 I/III III/III lII'IIIIII'.III IVIIIIIIsIs II7 III'I7IIIII II7' I/III [III/IIIIH/III‘I/ IIIIIIII/. I'IIIII/l/IIfi IIII'IIp/Ig II7' I/III sI'IIIII-III'IIIII' I"II/III.s'. 1;.I'II'ss'II'II (lH/"fl'll'r/IHI II7' I/III I'II/III III/II'III/II- Flo. L.-LIIIII'/II‘III/IIIII/ sIII'IIIIII II7' I/II IIIIIII I/IIIIIII/II IIIII/I I'I"'IIIIIII/Is'. -( I. l'. .piihiionai'y 211th1). 0.1!. l'.. ostiiiiii of pulmonary 2ii"'tc1y'. l7. 1).. right ventricle: l'.1\ .lcft vcii- Z"IIIIII"'(IIII/) IIII".7IIII triclc: C. Ii. septum ventriculi; II II/I IIIsIIflIIIIIIIIII/ II7' I/III I'II'I/ls/HI/ I",II/III' 411']II/IIII/ II7' I/III II7'I lII'".IIIIII/I' II/I'Is'III II7' IIs' IIII'- It'll]. IIII'I'IIIII/IIIIIIII'I/ II7' I/III IIIII‘IIII 2'IIlI',II I.III.IIs's'II'II (ll'/‘(Illll'l/ II7' IIIII III7'I IIIIII"IIII. \ There is no clinical history ofthe '21se. only 21 t'cw re- marks in regard to it. Symptoms I'L‘PUl'l't‘tI as follows: Bellows 111111'111111'. in consequence of friction ot' the hlood in passine' tl'nougli 21 \cr\ nariow oritice. (ten- eral serous infiltration. Ironi ohst2icle tormed in the \1 av (If the venous current. \utloclt()1\ attacks lroni illUIlll\e llow atrophy dittiers ti1'oni the hiown v 211'i( tv in he'mg. as 21 j't‘ll- er:il thine. ot an 21(11teeli'u'acter and constituting a second2irv or latet' st2 igie of 21 nutnher ot'higlily acute dise2ises. It may totni: l, the sequel ot' acute, t'chrile diseases, sticli as high graded reniittents, actttc exanthemata, typhus and severcr forms of typhoid; the car- diac lesion will he in the foi'iii of a. degeneration of the whole myo- cai'dium; 2, 2i fatty degeneracy of the superficial siihpericardial layer ot' the heart cI'rnsequent upon nutritive derangement (211121-- mia) from intlamtnatit'ni ot' the pericardium (pericarditis. etc); 3. ditiiuse niili2irv roti ot tat iii the sill )t-"ll(lt)(2II'Ill£ il muscular layer of hearts attected with chronic excessive dilatation of'thevc'mti1c les. In sin11 cases the degentrated muse ulai' tissue will hecome pei'cep- tihle through the attenuated endocardium, especially at the trahecull2e and papillary muscles iieai' the apex of the heart. It will appear whitish, yellowish, speckled or striped: ,larger centra ot' Iipoinatosis of an inch ormore. in diameter, most frequently found iii the apex of the left ventricle, oi' in the midst of the iiiuscnlai' tis- sue near it. The great t'i'iahility ot' the tissue leads very often to rupture ot' the wall. hut ditfers fi'oiii ruptures occurring in degenerated 111yo:ardia, in this. that here the muscular tissue is separated in layers and the hlood infiltrated between them. ('I'IIII' Sect. ll, Tah. V. Fig. 5}.) The most. fi'eqiieiit cause of sticli lesions is found to he an atlici'omatous state or thromhotic occlusion of the larger hranches of the coronary arteries. Fatty degeneration is chronic in its nature. Its most. ohvious causes appear to he valvular diseases ot' the heart: pulinonic em- physema, general systemic a112emia, or only cardiac antenna. A destruction oi' transsection of the cardiac hranches of the pneumogastric may also,accordiiig to I'lichhorst, produce fatty changes of the heart. Infectious and l()Xi(?tl'lIlit‘ diseases may also stipei'induce fatty changes, and he followed l_' 2ilhuminous tiii'hidity wherchy the muscular tissue will assume a peculiar grayish discoloration. The cells will appear as if covered with dust. and the alhuiiiinous granules will Ilis2i})p\ar on addition of some acetic acid. Ileart rupture, frequently forms the termination ot' such a lesion. Fatty degeneration of the etidocardiuni must he distinguished from the ahovc disease of the muscles. The eiidocai'diac lesions are generally found as minute, circumserihcd foci. forming opaque 1.. .T.( .tricuspid valve; 1'. .II.. mitral valve; 11. 1).. right auriclc; -l. 11.. arch of aorta; .1. (r'., left auricle; l'. l'.. pulmonary vein.) Flu. 3.-I\"III'IIIIII of file IIIfI l'IIIIII'II'III III II case of AT]///)- IIIII/III'I'II. (.II.. Aorta; (1'. ' left 11 Iart; 1'. 5.. send-lu- nai' valves.) Flo. I. .II'II/IIIII'III/ j)()I‘II'()/7 II7'/IIIIII'I. (13.. rupture.) F to. .I. - IfI/IIIIII/IIIIIIII Hm] I II/IIIIIII of I/III /III'III ( l'.. peri- Iarditun' (INT. arch of aorta; -l. l.. piilmonaiv artcrv.) arteries ot' the organ. l'lmholi seldom pi'odueetthisform of lesion. I11 the earlier stages of the disease the softened portions are mostly yellowish white and t'i'iahlc. \Yhen the soft- ening has so far progressed as to allow cxtravasation to take place from the capillaries of the ohstructed arteries. the iiifarcts formed in the tissue pi'odiiee in their surroundings either a dai'k red or yellowish and hrowiiish spotted appearance. which will gradually turn grayish. grayish-yellmv 211' 21 rusty color (Sect. II. Tah. \'l. Fig. 2), and will hecome somewhat de- pressed. The apex ot' the left ventricle seems to he the most clcctive locality for this lesion, although found in othcrportioiis ot' the heart. The papillary muscles may also hecome the seat of such softeningand assume 2i grayish vellow oi ha moiih2 uric 2i} pear; inc e. \\ hen the intima of 21221 he'ait hee omes allccted with such a lesion the tl'nomhi will f'oiiii polypi upon its surtaee. \\ hen the w hole: thickness of the myoe'ardium hetomts sot'ttned tuptuies olfthe tis- sue with tiioi'e oi less sev c re h2cmoi 1' homes into the per 1e ar dial spa( cs 11 ill take place. '1he rent thus t"-oimIdis generally ot 2111 irregular, 7.ig-721g shape. (\‘ett II, Tali. V, l'ig. ."1 ) The histological c112inees taking place in tliis lesion aie partly of 21 progressive and p221 tlv tetiogressiy e nature. Ise h2emiais the first cause ot the musc2"uln atiop'liv and decav. 'Ilie muscular tihi'es inideigo partial dcsti'uItion and form :1 1112111111211 I'lcttitus. 'llii connective tissue ot the bundles undergoes the sinic granular ( hanges. \thn h:'1morrhages are connected with the dccav ef the tissue, hlood coipuscles 1112 1y he loiiiid iii the decayed struc'tuics, which will Iave att'ei their partialahsorption, pienu tit granules. \\ hen the decay re'ic lies this pr'2i'dcol disintettt21t1on otftheIIaidi2i'c tissues, death iiioi'e oi' less sudden takes place. Should it not end fatally, the process of iepair hegins hy ahsorptioii ot the detritus, and cic at1'i7.ation ensues. A1 reactiveinllaiiimation sets i11,thellood vessels adjacent to the wound dilate, 21nd emigration of eoi'piiscles. which use up the remnants of living suhstaiicestill left in the injured tis~ site, will take place, and ci 'atricial connective tissue will hecome organized. The muscular tissue is forever lost. and the replacing structure contains htit few cellular elements. \Vhat little muscular suhstancc is left alive remains iiiihedded in the cicatrix. This also inc-loses the ha'iiiori'liagic detritus, sncli as pigiiientary material, white spots. and consist in a fatty change ol some of the endocar- hlood crvstals, etc. diac connective tissue. transparent gray and afterwards a glittering white (Sect. ll. Tah. \VI, Fig. 2. Sect II, '1ah .I\ Fig. 23). "The reconstructed portion of the heart 11c \er reachts' the volume of the former normal tissue htit remains as a thin hut very uiielastic and firm portion ot' Fattv spots ai'every often formcd on the auriculo-venti'iciilai' valves (es} Iec iall the mitral). They are sometimes minimal in size, sometimes occupying the larger portion ot' a valve. It is essentially a senile derangement, hut. does not spat'e younger, hut weaker persons. Ainyloid degeneration may affect the connective tissue of the or- gan. )liliai'y spots, recognizahle only hy the microscope and rea- gents, ai'e most frequently met with. Larger spots are very rare. It often happens that the connective tissue of the endocai'dium, myocardium or pericardium hecomes sclerotic. This alteration may he found iii the shape ot' llat spots or in rugous elevations, giving the valves a granular appearance. "'herever this process extends the muscular tissue hecomes atrophicd. It ditl'ers from ordinary connective tissue by being moretransparent and more con- sistent. The endo 'ardium often undergoes mucic. or liyaline change. [11 old age this menihraiic. especially neai' the valves, hecomes scle- rotic. This is due. to 2111 increase of its connective tissue. The papillary muscles, as well as the valvular l‘laps, hecome covered with excrescences atid prominciices. The nodules ot' the semi-lunar valves of the aorta mav also he thus enlarged and thickened. \\ ith thenicr2eise of volume there will also take place a change of structure. The tihiinousari'angciiient will yield to 21 morchomogcneous texture, and may resemhle aiiiyloid change, or may really tind place by the side ofthis. These changes may eventually lead to necrohiotic destruction. The mass may hecome turhid 21nd form a granular emiglomcrate of structural detritus. Fatty cliaiigeot'tcn precedes the necrohiotic, and there are deposited upon them calcareous crystals. Such 21 state of the valve has hceii called atheromatous. The. tissues assume an opaque white color. and when there is deposit. ot' lime salts in the tissue it hecomes stiff and ot' a hrilliant white color. I11 exti'eiiie old age 21 pcctiliai' kind of heart softening is met. a jelly. The tissue hecomes transparent and soft, like It is mostly located in the mitral and aortic valves (he ct. Il, 'l2 l).l \'lll. Figs. 1,3, 4 and .'>. In iiiiicic change the tissue hecomes semi-liquid oi' soiiietiniis like thin mucus. Associated with tlitese clianecs intl2 iiniiiatoi"_\ processes \eiy lreqtuiitlv hap- pen to exist. 1They lead to infiltration ot the altci'ed tissue with small ce21hilir e lemciits. Ne2opl ism2 ita are also found in it. \Ivomi ilaeia is a name given to a condition of soltcnine' ot the 1n_vIoIardiuin consequent upon arterial aiia-mia. Mic-h aniniia'aie the most frequent iesultsot scleiosisand athcroma ot the nutiieiit the wall." The appearance of such tissue is at lii'st ot'a (12'. ZI'I'I/ZIII' I'IIIIIIII. rllHIItIIIL, [25'2S'.2‘_ "Myomalacia has hitherto hecii hut little studied, for 21 tiumher of its phenomena hciiig common to many other diseases ot' the. heart, it, was confounded with those. Yet it is essentially 2i lesion ot' a special kind, constituting 2i peculiar form of an2cmic nccrohiosis. Fattv degeneration and inflammatory phenomena, though occ"uiiing inthis disease, are not iiecess rily manifestations of its pi'oc ess, httt ai'e only seeiond ii'\' in the chaiii of phases of its de\ elopmcnt. lt. rcsc 111 l'Iles111 its mode ot' proc ee'duie that of sof-tt ning of tlic hrain, and is not at all a rare disease. ItccentlyTantaiii, in his '1'/II'sI' III: I'II'I'I's 137-1 and IIII'II'IIII ['IIIIIII IIIIIII'III 1378, Ne. 37, have clearly deserihed it." (I{III/III IIII/ado". lIIIII2. Vol. II, 11,510,) \"aiiiiielsoii (‘onheim and \'e hulthcss lia\c in their cxpt i'iiiiellts‘ }11(1\ c 11 that stoppageot cii'eulation of thee'oion211_\ arte 11c s piodiu Is, h'oitly tli""‘l(1\\2‘lltl 2Lf2 l ll'otaoi'tic pressure aiidcessation of the heait' s action in 21 state of diastole. lrut as the ana- mi2 i tound111 discascs oftlic heartis slowly and gradually produced. atid likely exists only in c'iicumscrihid portions ot' the oi'gaii the clinical II‘lltIlUlIlt‘llzl ot' the altectioii will onlv he: te mporar\ iiiIompetIncc ot the hearts action, stenocai'dia aiidl loodl-sta.is 111 the lungs. II1.\'1uI('_\l:[II'I‘I>‘. Acttte endoearditis is 2111 intlamiiiatoi'y process caused hy a certain phlogogeiiic siihstaiice orsuhstances circulating in the hlood. The valves are oftcnest all'ected, although any other portion of the inHer surface of the heart may hecoiiic involved. The most frequent form of this inflammation is the one called 't‘ll'l'llI'tIllN. and is manifested hv formation of miliary or even larger nodules projecting ahove tli'e indotai'diIIil surface These new have a transparent or opaqueei2i\1sh white oi yellowish white 21} pcaraiicc' Thcv are eeiierallvc"-'o\c1cd with wliitc or gra\ ish i'cd thiomhi. 21nd only hecome v isihle attIi rc'moval of the throiiihi. \\ hen situated oh the valves, these excresceiices often foi'm rows coricspoiidiiig to th margin of the valvular tlaps. At times they are disseminatedover the laie‘est poition of the\ a-le and often form quite extensive groups ot wai't- like pioniiiicInI e s. (Se ct. ll ' l'ah. \'lll I'1‘; . 1.2.51.) \1tilited elscwlie-ic. these arrangements are not quite so rIgiilai When the pi'oiiiineiice s are \c 1y small hut \1' iy 1111111c1'olts, aiidc lose to one another, they give the surface a velvety appearance. They |
