These are almost entirely limited to the occurrence of fibroid tissue and anomalous osseous substance (ossification), both of which are of very frequent occurrence.

1. The fibroid tissue presents various anomalies in reference to the elements of which it is composed. Thus, for instance, as will be seen under their respective heads: a. It is found to be abnormally developed in hypertrophy of the valves.

b. It occurs in excess in those products (exudations) of inflammation of the valve which are developed in the tissue as well as on its surface.

c. The endocardium, deposited in excess on the valve, usually undergoes some metamorphosis of this nature.

d. A similar metamorphic process is observed in reference to the vegetations of the valves.

2. Osseous formation occurs in various essentially different forms, to which little attention has hitherto been paid: a. The fibroid tissue produced by the process of inflammation, occurs in the above-mentioned form of protuberant, roundish, and band-like concretions. They are originally developed in the inner part of the thickened and shrivelled valve, from whence they increase in circumference, owing to the continued ossification of the fibroid tissue, and at length come to view uncovered in different portions of the cavity of the heart. They are closely analogous to the ossifications of fibroid exudations found in serous membranes.

b. The endocardium abnormally deposited upon the valve becomes ossified. These concretions are very frequent at the aortic valves, and of rarer occurrence at the mitral valve. In the former case, they frequently attain considerable bulk; but, in the latter, they are merely small plates. They correspond with the ossifications of the inner lining membrane which is deposited in excess in the arteries, and are originally developed, like these, in the lowest and earliest strata, being denuded and coming to view when all have been ossified. Such are the ossifications frequently observed in advanced life which have no connection with pre-existing endocarditis, however they may be associated with endo-carditic products.

c. In addition to these concretions there is a third variety,1 which is highly interesting from the many analogies with which it is associated. It presents itself most frequently (more especially at the aortic valves) as an osseous concretion in a stalactitic form, or as a rough granular agglomeration. These calcareous formations constitute a metamorphosis or conversion of the vegetations on the valve into bony and chalky matter.

1 Oesterr. Jahr. B. xxiv., St. 1.

As might be expected, and in accordance with experience, they are frequently found to be associated with one or more of the two above-named forms (more especially, however, with the ossifications considered under a), which are developed in the valve after it has been thickened by inflammation. These stalactitic osseous masses occasion and promote the continued formation of new vegetations, and are consequently very commonly surrounded by them.

Even the normal tissue of the valve becomes of a dirty yellow, faded color in advanced life, and exhibits a layer of fat and calcareous salts in a finely comminuted form.

Besides these secondary processes, we will consider:

3. The Atheromatous Disintegration

The Atheromatous Disintegration of newly-deposited endocardium as it commonly occurs in a low degree on the valves.

4. Finally, in rare cases, where the necessary constitutional conditions are present, the vegetations on the valves of the heart exhibit a carcinomatous character, the cancer being usually of the medullary kind.

Review of the Anomalies of the Valves, and more especially those producing Contraction of the Ostia and Insufficiency.

We have endeavored, in the foregoing observations, to indicate those cases in which an anomaly of the valve produces contraction of the corresponding ostium, or the causes by which the valve itself becomes insufficient.

The causes on which contraction of an ostium depends, the mode in which it is variously developed through thickening or rigidity of the valvular apparatus, vegetations, etc, and the manner in which it may finally give rise to consecutive heart-diseases, in the form of hypertrophy and dilatation, are alike self-evident. This contraction is frequently so considerable, that the diameter of the auriculo-ventricular opening, more especially on the left side, scarcely equals that of the nail of the little finger, or even of a goose-quill, while the arterial opening would not admit of the passage of anything larger than a crow-quill.

The condition of the valves known as insufficiency, has only been adequately considered by modern observers. By the term insufficiency, we understand that condition of the valves in which they are unable to close the ostium, and thus allow the blood to return or regurgitate into a cavity of the heart which would be isolated if the ostium were completely closed. In this way, the insufficiency of the auriculo-ventricular valves allows a portion of the blood to return from the ventricles into the auricles during the systole of the former, while the insufficiency of the arterial valves allows the blood to return into the ventricle during its diastole.

As might be expected, we frequently find that one and the same anomaly of the valves produces contraction of the ostium and insufficiency. The latter is especially owing to the following anomalies.

1. A Relative Diminution In The Size Of The Valves

A Relative Diminution In The Size Of The Valves with dilatation of the Ostia, the degree of the former depending on the intensity of the latter. As we have observed, the valves in these cases are commonly enlarged at the expense of their thickness and power of resistance, and they may continue to remain sufficient when the ostia are very considerably dilated.

2. Perforation Of The Valve

Perforation Of The Valve, in consequence of atrophy. It must be very well marked before it can give rise to any considerable degree of insufficiency.

3. Laceration Of The Valve

Laceration Of The Valve, under various forms, in consequence of the gelatinous condition of the valve, or perhaps, still more from its inflammatory state. The degree of insufficiency is increased in proportion to the extent of the laceration.

In like manner, laceration of one or more of the papillary tendons produces insufficiency of the valves.

4. Shrivelling And Shortening Of The Valve And Its Tendons

Shrivelling And Shortening Of The Valve And Its Tendons: - the valve does not close the ostium, in consequence of its rigidity or its insufficient length. This insufficiency in the case of the mitral valve is in general owing to well-marked endocarditis; in the aortic valves it is often very slowly developed, and in advanced life, it is generally owing to an excessive deposit on the endocardium. This is the most frequent form of insufficiency, and the one which attains the most considerable degree of intensity; it is usually attended with contraction of the ostium, owing to the rigid, thickened, and shrivelled state of the valve. It will be seen from what we have already stated, at p. 173, that it is only in very rare cases that insufficiency ensues in consequence of shortening of the valve depending on atrophy.

5. Fusion Of The Valves With One Another

Fusion Of The Valves With One Another, or their Coalescence with the wall of the Heart or Vessel, generally induces a high degree of insufficiency in combination with the above-named conditions.

It will be easily understood, that not only carditis and its metamorphoses, but also fatty degeneration of the muscular substance of the heart, especially when seated in the papillary muscles, may induce insufficiency of the valves.

Insufficiency of the valves gives rise to the same heart-diseases as contraction of the ostia; but, as has been already observed in p. 129, it has not been clearly demonstrated whether it specially induces dilatation, and on the other hand whether the stenosis specially gives rise to hypertrophy.