INCOMPETENCE AND EXTENSIVE DISEASEOF AORTIC VALVES.

B SURGEON-MAJOR HAMILTON, M.D.

[Read in the Pathological Section, December 5, 1884.]

G. B., aged thirty, of fine physique, was admitted to Portobello

Station Hospital on the 1st of October, 1884. The man belonged

to a battery of the R.H.A., but for some time was employed on

the provost police, on which duty he had only to walk about, and

thus escaped the heavier work of an R.H.A. man. I am informed

that he would never run, as he knew for some time that his heart

was affected.

There was a distinct history of constitutional syphilis. He came

to hospital complaining of palpitation, and on examination organic

disease of an advanced character was recognised. There was

extensive precordial dulness, a well-marked systolic bruit at apex,

and over base a loud systolic and also a regurgitant bruit. The

man was proposed and passed for invaliding, and for nearly a

month remained in much the same condition.

On the 25th October, nearly four weeks after admission, his legs

began to swell. His urine was tested, and found free from albumen.

On the 26th be was worse, the dropsy was rapidly advancing, andfluid was diagnosticated in the abdominal cavity. On the morning of

the 27th he was much worse; face livid, breathing laboured, pulse

small and weak; dulness over precordial region increased; dropsy

had extended considerably ; heart's action tumultuous, and sound

over base one loud murmur, it being impossible to differentiate

between the systolic and diastolic bruits. That night the man sat

up contrary to orders, and died almost immediately.

Post )norte?n examination thirty hours after death. Body well

nourished; rigor mortis well established. Head not examined.

282 Incompetence and Extensive Disease of Aortic Valves.

Chest–fluid in cellular tissue; both pleuras contained fluid; peri-cardium distended with fluid. Lungs healthy. Heart enormously

enlarged; weighed one pound twelve ounces; removed for subse-

quent examination. Abdomen—much fluid in cavity; all viscera

normal.

c` Description of Heart with Incompetent Aortic Valves. By P. S.ABRAHAM, F.R.C.S.

"The cavities of the heart on both sides are dilated, and the walls

are everywhere hypertrophied, but otherwise apparently healthy.

On the right side the auriculo-ventricular valves are normal, andthe only lesions observable in the semilunars of the pulmonary

artery are a slight thinning in one of the cusps, and a reddish

thickening in the corner of another--viz., the left anterior cusp.

The inner surface of the pulmonary artery is of a remarkably deeppurple colour. On the left side one of the mitral cusps presents

some thickening at its edge, but, like the valves on the right side,

there is no evidence of incompetency or of stenosis. In the left

ventricle, near the aortic opening, there are some spots of com-

mencing atheroma. As on the other side, both the cavities contained

post mortem clots,

" On pouring water into the aorta its ventricular orifice was foundto be -widely patent, and, before splitting up the vessel, the fingercould distinguish a very abnormal condition of affairs. The valveseemed thick, rough, and frayed; a hole of considerable size could

be determined in one place, and just above and behind this a hard

nodule, and a cavity below it, could be distinctly felt."The vessel was then laid open from the ventricle, and the appear-

ances within it are as follows :—Bulging patches of atheroma---

not advanced to calcification—are extensively deposited in the

ascending arch, and a few smaller patches lower down opposite

valve, and on the bottom of the sinuses of Valsalva."Between the openings of the coronary arteries, and at their

level---i.e., nearly at the point where the anterior segment and the

left posterior segment of the valve should meet, is situated an

ovoid mass of bony consistence, measuring 9 mm. in its longest,

By SURGEON--MAJOR HAMILTON. 283

and 7 mm. in its shortest, diameter. The projecting surface of

this mass is rough, and one or two sharp spicules can be felt,

but a great part of its surface is covered by I vegetations.'

"Just beneath this nodule a cavity, nearly 2 cm. in length and1 cm. in depth, opens below the level of the bottom of the sinus,

behind the endocardium, and into the muscular substance of the

heart—i.e., a dissecting aneurysm has been formed."The anterior and left posterior cusps of the valve have become

confluent, and at the region of the junction—i.e., opposite to the

bony nodule, a wide opening, 1.5 cm. in diameter, exists, with a

fringed border. The remaining parts of the valve are thickened,

and an ulcerated spot is to be seen at one point of the ventricular

surface."