A. Hyperoeemia, Anoemia

We are not acquainted with any special condition characteristic of hyperoemia of the heart. Occasionally however, hyperaemia, as it manifests itself in the hypertrophies and dilatations which arise especially from stenosis, and in asphyxia in new-born infants and adults, is marked by the dark color of the muscular substance of the heart, and by a fulness of the vessels, more particularly of the veins, and in its more highly developed stages, by slight extravasation in the form of ecchymoses, about the size of millet-seeds or lentils, especially in the external strata and near the base of the heart, at the auricles, and in the vicinity of the origin of the arterial trunks.

Apoplexy of the Heart, manifested by an extravasation of blood into the muscular substance, - a suffusion of the muscular tissue, - is a symptom of no importance in the various degrees of laceration of the heart.

Anosmia of the Heart is probably often overlooked on account of the indistinct signs by which it is characterized. Such a state constitutes, however, a very important (but as it would appear, a hitherto disregarded) morbid condition, as we may learn from the contractions and final obliterations of the openings of the coronary arteries occurring in diseases of the aorta.

B. Inflammations

After having spoken of inflammation of the external investment of the heart - pericarditis, - it still remains for us to notice inflammation of the lining membrane, and of the muscular substance of the heart.

1. Inflammation Of The Lining Membrane Of The Heart, Endocarditis

It is only in modern times, and from the observations of Bouil-laud, that this species of inflammation, under the name of endocarditis, has been shown to be the special basis of numerous consecutive heart-diseases. The importance of the subject, both intrinsically and with reference to the different opinions advanced regarding the frequency of the disease, the absence of any well-founded data for its correct diagnosis after death (notwithstanding the many attempts made for their establishment), and, lastly, our still inaccurate knowledge of its course, its termination, and sequelae, etc, have determined us to precede our general notice by a few explanatory observations; and at the same time we would simply remark, as will be seen in this section, that we have arrived, with reference to some points, at a totally different conclusion from the opinions usually expressed regarding endocarditis.

The endocardium corresponds with the inner coat of the vessels, and consists essentially, besides the epithelium, of a longitudinal fibrous coat (Henle), under which there is a very considerable layer of elastic and cellular tissue, which is most distinct in the auricles, and especially in their atria, and on which rests the muscular substance of the heart. In the left side of the heart, more especially in the left auricle, a layer similar to that of the circular fibres of the arteries is occasionally found under the longitudinal fibrous coat. This compound investment covers the trabeculae carneae, the papillary muscles, and their tendons, while the true endocardium invests the valves also, which, however, can only be regarded as duplications of that membrane, if we consider them as essentially composed of a fibrous tissue supplied with vessels. Besides this fibrous tissue, which is composed of a cellular-fibre-like substance, and delicate nucleated fibres, we also find unstriped muscular fibres in the auriculo-ventricular valves in individuals having a robust and muscular frame. The internal layers of this integument (the epithelium and longitudinal fibrous coat, which constitute the true endocardium) are devoid of vessels; but such is by no means the case with respect to the subjacent cellular tissue, which is permeated with numerous elastic fibres, or with the muscular substance of the heart. The endocardium, as we find in dilatations of the cavities of the heart, and in enlargements of the valves, arising from dilatations of the ostia, is capable of undergoing considerable expansion and attenuation. It is much thicker in the left side, and especially in the left auricle, than in the right side of the heart.

The relation of the true endocardium (the epithelium and the longitudinal fibrous coat) to the subjacent layer furnished with vessels, corresponds with that existing between the inner coat of the veins and their external coats. This condition affords a priori evidence of the possibility of inflammation of both coats, considering it, in its usual sense, with exudation of the free surface, whilst there is no inflammation, properly so called, in the inner coat of the arteries, at least not in the larger vessels, having a thick, yellow, muscular coat of circular fibres. The actual seat of these inflammations is the cellular substance lying under the endocardium and the inner coat of the vessel; we must, therefore, suppose, that in cases where products of inflammation are deposited on the inner surface of the heart or of the vein, the exudation must have penetrated through the permeable texture of the endocardium or through the inner coat of the vessel, or that the latter has been removed, either by solution or fusion, by means of the process of exudation. The latter condition will naturally be found to be of most common occurrence in inflammations having a purulent ichorous exudation. Such alterations manifest themselves by opacity, lacerability, and a felt-like porosity of the endocardium, excoriation of the subjacent layers, etc.

We learn from the foregoing observations how far the designation endocarditis is applicable to inflammation of the lining membrane of the heart. Thus, for instance, it is evident that since the endocardium, like the inner coat of the vessels, is non-vascular, it cannot be the seat of inflammation, which affects merely the tissue lying immediately below it, which is furnished with vessels. We purpose retaining the term endocarditis in this sense, discarding its use in reference to the valves, for which we shall simply retain the designation of inflammation of the valves.

Although endocarditis is a disease of very frequent occurrence, it must not be supposed that the term is applicable to all the diseases ascribed to it, its products, and sequelae, for, as we shall soon learn, many morbid conditions of the valves of the left side of the heart, especially of those of the aorta, are the products of the same process which manifests itself in the arteries as a morbid deposit on the inner coat.

Endocarditis attacks different portions of the lining membrane of the heart, affecting in some cases the endocardium covering the inner surface of a cavity, the papillary muscles, and the trabeculae, in others that of the valves, while in others again it affects both. Endocarditis of the valves is the most frequent and the most important, from the consecutive heart-diseases to which it gives rise. We will consider the signs of both under one head, referring specially to the peculiar characters of endocarditis of the valves.