5. Vegetations

Vegetations, as we have already seen, are deserving of attention, although they cannot be regarded as absolute characteristics of endocarditis.

In the course and as consequences of inflammation of the valves, we observe: a. Occasional Laceration of the Valves in one or other of the above-named forms, or laceration of one or more of the papillary tendons; the margins of the rent here generally exhibit an exuberant quantity of vegetations. Laceration is an invariable evidence of the existence of a high degree of the inflammatory process.

b. Inflammation, giving rise to a purulent product and to purulent fusion (suppuration) of the tissue of the valve, is also not very rare. It may under certain conditions give rise to aneurism of the valves; and is distinguished by an exuberant production of vegetations, which may be considerably diffused, and very frequently undergo purulent disintegration.

c. The most common termination of inflammation of the valves is:

1. Permanent Thickening Of The Valve

Permanent Thickening Of The Valve, arising from the product which is deposited in the tissue and on the free surface, and becomes converted into fibroid tissue. The degree of rigidity attained either by the valve and the papillary tendons, or by the former alone, depends upon the extent of the inflammatory process. Contraction of the ostium, and insufficiency of the valve, are frequent results of this condition.

2. This anomaly is rendered more striking when the thickened valve is finally shrivelled. This shrivelling may occur either in the direction of the perpendicular diameter of the valve, or concentrically with the axis of the ostium. The former produces shortening of the valve, and at the same time insufficiency, and the latter contraction of the contiguous ostium. Both acquire importance in proportion to the extent to which the valve is inflamed, and the contraction is most considerable in the auriculo-ventricular valves, when the inflammation has extended to their margin of insertion.

Hence arise numerous Malformations of the Valves and of the corresponding Ostia. Thus the auriculo-ventricular valves, when their free margin and the papillary tendons have been thickened and shortened, present the appearance of a rigid funnel penetrating into the cavity of the ventricle, and exhibiting an elliptic fissure-like opening at the mitral valve and a triangular opening at the tricuspid valve. When the whole or the greater portion of the valve has been thickened and shrivelled, the auriculo-ventricular opening of the left side degenerates into a fissure or button-hole-like aperture surrounded by a rigid string-like ring, while that on the right side appears like a somewhat rounded triangular opening. The arterial valves degenerate into an annular protuberance around the ostium, being of regular height and thickness when the disease is of uniform extent, or irregular in consequence of inequalities in the subjacent surface. In some extreme cases they form a diaphragm inclining with the concavity of its sinus towards the heart and perforated in the centre by a small opening. These are often associated with -

3. Adhesion, Coalescence Or Fusion

Adhesion, Coalescence Or Fusion of the different apices of the valve and of the tendons of the papillary muscles to a greater or less extent. These papillary tendons are often found to be fused together into one single or several thick, smoothly roundish rigid strings or bands; but it is only in rare cases that one or more of these apices adhere to the contiguous wall of the heart or of the vessel. It is obvious that such a condition must contribute to produce contraction of the valve on the one hand, and insufficiency of the ostium on the other.

The contractions of the ostia produced by these consecutive anomalies of the valves are, moreover, heightened by the vegetations which so commonly occur.

4. Osseous Concretions

Osseous Concretions are frequently and variously developed as a secondary disease in the newly-formed fibroid tissue of the valves. These are occasionally small, scattered, nodular and roundish, or larger nodular rough band-like formations, and at other times complete osseous rings surrounding the ostium. From these rings the formations diverge in various directions towards the inner part of the valve, passing outwards from the attached margin, where they come in contact with other concretions developed in a simultaneously occurring pericarditic fibroid exudation. They may also be occasionally connected with concretions in the contiguous wall of the heart, when, together with its endocardium, it had been the seat of inflammation.

These morbid metamorphoses of the valves are, as we have already observed, by far the most frequent originating causes of dilatations and hypertrophies of the heart. Inflammation of the valves and its results must not be confounded with hypertrophy of the valves, - with excessive endocarditic deposition on them and its metamorphoses.

By way of supplement to this subject we will now treat of the so-called Aneurism of the Valves.