438

OBSERVATIONS ON THE STRUCTURE AND CONNEXIONS OF THE VALVES OF THE HUMAN HEART.

By W. S. SAVORY,

TUTOR AT ST. BARTHOLOMEW'S HOSPITAL, ETC.
(Concluded from p. 422.)

In the larger ruminants two considerable portions of bone are found partly surrounding the orifice of the aorta, and smaller irregular fragments are occasionally observed between the principal pieces. The larger portions also vary much in size and shape in different hearts, even of the same species. They are usually elongated and curved, and the larger bone thickest from above downwards, bearing some resemblance to one of the upper ribs. The chief bone (Fig. 6), of the ox,

FIG. 6.

(from which the description is more immediately taken,) which exceeds the other considerably in size, embraces the whole of the right side, and the right half of the back part of the orifice of the aorta, while the little bone (Fig. 7), not generally found in

FIG. 7.

the smaller ruminants, as the sheep, its place being occupied by a portion of dense fibrous tissue, extends from the middle of the left side, round to the posterior part, where it more or less nearly joins the extremity of the larger bone. Thus the lateral and posterior portions of the aortic orifice are surrounded by firm bony arches, meeting posteriorly in the centre. From the large bone a small process usually passes backwards for some distance 'into the muscular substance of the septum between the ventricles, and is gradually lost in the dense fibrous tissue found in this part surrounding the right border of the left auriculo-ventricular aperture; and from the convex surface of the smaller portion a thin process of dense fibrous tissue is continued round the left margin of the auriculo ventricular orifice. These heart-bones are intimately connected above with the middle coat of the aorta; on the inner surface with the base of the adjacent arterial valves; and posteriorly with the anterior mitral valve; while at the sides, to their external and inferior surfaces the muscular fibres of the ventricle are attached. They may be seen and felt in the base of the pouches formed by the two posterior aortic valves, and no doubt greatly assist in sustaining the "force of the reflux." The larger bone towards its posterior extremity is usually pierced by one or two foramina. They possess the structure of ordinary bone; and they occupy the position of the two posterior festoons of the aortic valves. These curious bones seem to have attracted comparatively little attention. Generally, indeed, only one is mentioned under the name of "heart-bone." "Haller, in a small section headed "Os Cordis," refers as usual to numerous authors who have mentioned it in their writings. Blumenbacht cursorily alludes to two as existing in the stag, and the larger adult bisulca. In the human heart, in the situation corresponding to the position of these heart-bones, the tissue composing the festooned rings is thicker and denser than elsewhere, offering to the knife, in some cases, almost the resistance of bone. The processes of dense fibrous tissues found in the anterior portion of the border of the septum, &c., and extending round the right and left margins of the auriculo-ventricular orifice, have been already described. They are intimately connected with the thickened portion of the adjacent festoons.

The arterial valves have generally been described as consisting of a "duplicature of the lining membrane, with enclosed tendinous structure;" or as "formed of tough, close-textured, fibrous *Elementa Physiologiæ, (liber iv., sect. xviii.)

† Comparative Anatomy, translated by W. Lawrence, p. 238.

tissue, with strong interwoven cords, and covered with ep and the formation of the corpus Arantii, lunulæ, &c., have thelium." The arrangement of the principal tendinous bands, been accurately described. The bands of tendinous fibre are plainly seen spreading out into the substance of the valves. Their general direction is very obvious even to the naked eye Besides the principal bands which have especially received atter tion, more delicate ones may be observed, arranged throughout for the most part in the direction of either their free or attached the whole substance of the thicker portions of the valves, curving margins, according as they are nearer the one or the other. At the junction of two arterial valves, where they are continued up on the inner side of the vessel, many of these bands converge, into the formation of the festooned tendinous rings. In and becoming intimately blended with the arterial coat, enter the tendinous bands contained in the valves all the characters of the white fibrous tissue are very beautifully shown. The delicate undulating bands, composed of the finest filaments, cannot, with ordinary care, be mistaken for any other structure. The fibres of elastic tissue have been detected in the corpus Arantii, (Purkinge, Raenschel,) but there appears to be no record of their existence throughout the substance of the valves. In repeated examinations of different portions of the arterial valves, elastic fibres have been constantly found. They exist most abundantly in the thicker portions of the valves, but even in the thinner portions (lunula) a few delicate but well-marked elastic fibres may be generally seen, especially after the addition of acetic acid, which of course assists greatly in bringing them into view. The existence of muscular fibres in the arterial valves has been often affirmed. They are described by many of the older anatomists, Lancisi, Senac,+ &c. Morgagni says that fleshy fibres are very visible in the valves of the pulmonary artery, but it is not so easy, he adds, to demonstrate them in the valves of the aorta. He represents them, however, in the valves of this vessel." Cowpers speaks of " carneous fibres variously interwoven." Winslow declares that, "In examining these valves by the microscope, we find some fleshy fibres in the duplicature of the membranes of which they are composed." Haller alludes to some eminent men who describe them as forming two muscles which contract and dilate the valves. He himself speaks very cautiously, and strongly doubts their existence. More recently, Dr. Monneret** has given an elaborate description of several bundles of organic muscular fibres, which he declares exist in the valves. He divides them into two sets, according to their direction and supposed action, elevators and depressors, and he continues-"These fibres under a power of 700 diameters, had all the characters of the drical."(?) Mr. Moore,++ after quoting some authorities in support muscular fibres of organic life, being, namely, smooth and cylinof the opinion that muscular fibres exist in the valves, also figures two sets, which he describes as dilators and retractors. I have repeatedly sought for muscular fibres in the arterial valves, but have never yet succeeded in detecting any such structure; and from the descriptions given by the above-mentioned observers of their arrangement and direction, it seems highly probable that the tendinous bands before described have been mistaken for mus

cular fibres.

If now we examine a similar section of an auriculo-ventricular valve, we shall obtain an important view of its construction. Figures 8 and 9 represent vertical sections through the centre of the large tricuspid and posterior mitral valves. The convexity of the upper border of the ventricle is now well seen (and this is much more marked on the left side, where the ventricular wall is so much thicker) and sections of the coronary vessels are shown occupying the groove in this manner formed. In commencing to trace the lining membrane of the auricle downwards, we find that at a point either opposite, or, as in the case of the posterior tricuspid valve, just above the border of the ventricle, it is continued on to the upper surface of the valve, which is usually described as "formed by a doubling of the lining membrane of the auricle and ventricle, containing within it numerous membrane may be traced on to the inner surface of the ventricle. tendinous fibres." From the under surface of the valve the The section plainly shows that while the lining membrane of the auricle is continued on to the valve by a gentle curve, an acute angle is formed beneath, between the under surface of the valve and the inner wall of the ventricle. In tracing downwards the

3, Section of valve. 4, Section of coronary vesse'.

1, Section of auricle. 2, Section of ventricle. muscular wall of the auricle, we now at once observe what was before noticed, that it is continued down on to the inner surface of the ventricular border, and if minutely examined is seen to terminate by two attachments. The external portion, which is considerably the larger, is closely attached to the fibrous structure forming the auriculo-ventricular ring, while the thinner internal portion is continued forwards for a very short distance between the surfaces of the valves, and terminates more or less abruptly by an attachment to its tendinous tissue. This is generally best seen in one of the tricuspid valves, where, in a vertical section, the muscular fibres may be often observed terminating beneath its upper surface, immediately beyond its attachment to the ring. In the posterior mitral valve the muscular fibres seldom penetrate so far forwards; and this appears to result, when a section of the parts is examined, from the much greater thickness and density of the lining membrane of the left auricle. The observance of this arrangement is of importance in enabling us to explain some contradictory statements which will be presently noticed. The above description will hold good for all the valves, with the exception of the anterior mitral, the construction of which may now be examined. If we dissect down between the anterior wall of the left auricle and the posterior surface of the aorta, we shall find that the central fibres of the auricular wall are closely attached to the adjacent wall of the vessel. A little further dissection on either side will between these parts. At the sides, indeed, it is found, but is gradually lost at some distance from the mesial line. Hence it has been already noticed that these two orifices (the aortic and left auriculo-ventricular) are not separated, as the others are, by the intervention of mucular fibres, their boundaries being formed by other tissues. Fig. 10 represents a vertical section through the anterior mitral valve, near the centre, including the posterior wall of the aorta, and the anterior wall of the left auricle. If we trace downwards the lining membrane of the auricle, we find it The difference between the lining membranes of the two auricles is very marked, so obvious indeed that it is generally easy to tell at a glance to which auricle a portion of the lining membrane given for inspection belongs. On the left side it is much thicker, tougher, and more opaque, Dot allowing the colour of the muscle beneath to be seen through it as on the right side.

show that the muscular substance of the left ventricle is deficient

1, Section of aorta.

2, Section of anterior wall of left auricle.

3, Section of semilunar valve.

4, Section of anterior mitral valve.

directly continued on to the posterior surface of the valve; and in tracing upwards the membrane on the anterior surface of the valve, we find it continued over the tendinous festooned ring of the aorta on to the under surface of its valves, and into the space between them. The anterior mitral, it may be observed, lies beneath a portion of the two posterior arterial valves, their junction being somewhat to the right of the centre of the mitral valve; and in order to show the relations of the different parts more clearly, the sketch represents a section through that part of the mitral valve corresponding to the centre of one of the aortic valves. If now we trace the muscular wall of the auricle downwards, it is observed terminating by two distinct insertions. The anterior (the larger) division of fibres is attached to the posterior surface of the aorta, opposite to and below the festooned ring; while the posterior portion is continued directly downwards for a definitely by an attachment to its fibrous tissue. In tracing short distance into the valve, and terminates more or less downwards the wall of the aorta, we observe that, descending nearly vertically, and becoming suddenly much thinner opposite the upper border of the semilunar valve, it is continued down to the festooned ring, (shown in section;) or, in other words, that it here becomes blended with the base of the semilunar valve. Below this, we trace a dense layer of fibrous tissue, before described as existing below, and filling up the spaces between the attached bases of the semilunar valves, descending for some distance into the mitral valve, immediately behind its anterior surface. It is by a close attachment to the posterior surface of this layer that the muscular fibres of the auricular wall, which descend into the valve, terminate. This layer of fibrous tissue may, however, be generally traced downwards into the valve the aortic and auricular apertures is formed above the mitral farther than the muscular fibres. The boundary, then, between valve by the posterior wall of the aorta, terminating at its junction with the bases of the semilunar valves, and immediately below the posterior surface of which is attached the greater portion of the muscular fibres forming the anterior wall of the ruminants replace a portion of the lateral and posterior divisions left auricle. The extremities of the two bones which in of the festooned ring, nearly meeting in the centre behind, give additional support to the structures entering into the formation

of the mitral valve.

frequently been examined, and very contradictory statements have The tissues composing the auriculo-ventricular valves have been advanced as the result of observation. That the greater portion of the valves is composed of white fibrous (tendinous) tissue, is generally admitted, and this appears derived in great part from the chorda tendineæ, which spread out at their insertion scription of the arrangement of the three orders of tendinous into the substance of the valve. Kürschner's now well-known decords in the valves must be allowed to be very artificial. It is best seen in the anterior mitral, and in the largest tricuspid valve. An observation long since made by Cruveilhier has generally been overlooked. He says, "the chorda tendineæ of the heart terminate in the auriculo-ventricular zones, either directly, or in

6th.-Considerably better; has had no return of the rigor. Passed a good night; less headache; pulse 80; skin moist and cool; tongue cleaning; less thirst; complains of complete loss of strength; is greatly emaciated. Continue medicine.

12th.-Has had but one return of the symptoms since last report; may now be pronounced convalescent; is still, however, so much debilitated that he can hardly walk without assistance. To take good nourishing diet, with porter or wine.

20th. Much better; allowed to do duty during the day. Attacks similar to the above went through the whole of the midshipmens' berth to which Mr. S belonged. Out of eight inmates, one only escaped.

CASE 2.-May 1st. Mrs. C., upon going to bed last night felt perfectly well, but was seized about one A.M. with a most excruciating pain in the head, followed by a distinct attack of shivering, which, having continued for a period of fifteen minutes, was in its turn succeeded by a feverish or hot stage. In the morning, when I saw her, she complained of headache and vertigo; eyes suffused, and painful upon exposure to light; tongue dry and coated; complete loss of appetite; no sickness; bowels tolerably regular; no tenderness of the abdomen on pressure; great pain in the legs, joints, and back; skin very hot and dry; pulse 94, tolerably full. Heart-sounds normal; lungs healthy; urine of natural specific gravity, but scanty in amount. Has had no perspiration.

This case was therefore precisely analogous to the first, with this exception-it wanted the third, or sweating stage. Acting upon the belief that it was closely allied in its nature to the first, I commenced at once with the quinine mixture.

2nd.-During the past night has had a rigor, followed by fever, as yesterday. The febrile attack, from its commencement, kept steadily increasing, till it arrived at a certain height, and then as gradually subsided, never, however, entirely disappearing. Great lassitude; considerable thirst; desire, but inability to sleep; bowels freely open. Continue the medicine.

A Mirror

OF THE PRACTICE OF

MEDICINE AND SURGERY

IN THE

HOSPITALS OF LONDON.

441

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, et dissectionum historias, tum aliorum proprias, collectas habere et inter se comparare.-MORGAGNI. De Sed. et Caus. Morb., lib.14. Prooemium.

KING'S COLLEGE HOSPITAL.

Large Calculus in the Female, of which the Nucleus was a piece of Cork; Previous Paraplegia; Extraction; Recovery. (Under the care of Mr. PARTRIDGE and Mr. HENRY LEE.)

FROM the great number of cases of stone in the bladder which are met with, both in private and hospital practice, it may be inferred that our mode of life, and the nature of the ingesta in all ranks of society, are pretty favourable to vesical concretions. The actual circumstances which give rise to the formation of calculi, either in the kidney or bladder, have been extensively studied and elucidated; it may, indeed, be said, that a great deal is known on the subject; and we gladly refer to a course of lectures, by Mr. Coulson, publishing in ticular direction. But there is a point of some importance, this journal, which show that much is being done in this parwhich seems to be still rather ill-understood; and that is, the

very strong tendency to alkaline urine, and the subsequent formation of phosphatic stone in the bladder of patients follows in his Lectures on the Practice of Physic:affected with paraplegia. Dr. Watson expresses himself as

As to treatment, I tried every method at my disposal. Venesection, with calomel and opium; arsenic; quinine; diaphoretics, &c.; and at last came to the conclusion that it mattered little which was tried, the disease apparently running its own course, and terminating in the majority of cases by the fifth or sixth day. In one or two cases where no treatment was employed the attack terminated at the same time, the patients making as speedy a recovery as in the other instances.

Remarks.-I think the above cases interesting, inasmuch as they were well-marked cases of intermittent and remittent fever, occurring without any previous or present (so far as could be ascertained) exposure to malaria of any kind; commencing after we had been at sea for three or four weeks. The suddenness of the attack; the intense, the awful pain in the head; the great wakefulness; and the total prostration of strength, with the comparatively speedy return to health, also seem to me interesting points, as connected with the disease. The little control which medicine had over it, is also worthy of remark; and last, though not least, they are interesting, as showing that the same poison acting under similar circumstances, but upon different individuals, will in one produce intermittent, and in the other,

remittent fever.

The ship was free from any offensive smell from bilge water, or other source; till one day, at the end of May, the steward in clearing away for provisions, broached a cask of eggs, the smell from which was most intolerable; they were all rotten, and of course immediately thrown overboard. Strange to say, with them the disease disappeared. I may also remark that the place where the epidemic first showed itself-namely, in the midshipmens' berth-was the cabin nearest to the store-room, and that here the attacks were more violent than in any other portion of the vessel. It is right, however, to state that many of those who suffered were never near this part of the ship. Whether this was the exciting cause of the disease or no, I am of course unable to determine; but I must say I am strongly of opinion that it was. If not, I am quite at a loss to account for the appearance and disappearance of the attack. To say the least of it, the latter was an extraordinary coincidence. Downham Market, Norfolk, 1852.

Dr. Watson goes on to say, that the urine has been found acid after the bladder had been washed out, and also acid in the pelvis of the kidney, though it has been known to be secreted alkaline. But as to an explanation of these pathological phenomena, the following passage of the same author comes very near the truth:-The disorganization of the bladder, and the alkaline quality of the urine, may both have been common results of the interruption of the nervous influence." This explanation is the more likely to be correct, as, without nervous influence, nutrition is imperfect, and the secerning process of an altered and defective kind. calculi should form in the bladder, is a fact easily understood; That with a highly alkaline state of the urine phosphatic and hence the numerous cases of stone connected with paraplegia. We have heard Dr. Budd relate, in his clinical lectures, an extremely interesting case of paraplegia which occurred in his private practice, in which calculi formed again and again after operation,-this circumstance clearly showing that the effects remain ever the same, as long as the nervous influence is absent, or much altered. The present case offers this peculiarity, that the formation of stone during paraplegia was considerably favoured by the presence of a nucleus of a rather unusual description, being a piece of cork. The loss of power in the lower extremity was recovered from, but the calculus (it would seem) continued to increase, and after a lapse of years attained a size seldom to be seen with female patients. The case, as noted by Mr. Ray, one of Mr. Partridge's dressers, runs as follows:

Jane P, aged forty-two, married, was admitted Oct. 20, 1852, under the care of Mr. Partridge, suffering from stone in the bladder. Until four years ago, she seems to have enjoyed excellent health; about that time she was admitted into University College Hospital, probably for an attack of pleurisy. Two years before her present admission, she was in this hospital, under the care of Dr. Todd, for paraplegia, but was able

442

to walk after six weeks, at which time she was discharged. At that period she felt a slight inconvenience in passing her water, but not to a sufficient extent to excite attention. She has, however, grown worse up to the present time.

The symptoms on admission were, very severe pain in passing urine, the stream frequently stopping suddenly; the fluid very thick, mixed with blood, and depositing a ropy, unhealthylooking mucus on standing. The general health much broken down, great pain across the back, very little liking for food, frequent sickness, and constant nausea after meals.

Mr. Partridge, on examination, detected a calculus, which was supposed to be of the phosphatic kind. The patient had been a fortnight under the care of Dr. Budd, who had had her transferred to the surgical ward, when the nature of the disease was ascertained. Two days after she had been placed under Mr. Partridge's care, she was attacked with a severe paroxysm of pain. Towards night, Mr. Lawson, the house-surgeon, tried to introduce a catheter, and draw off the urine, but could not get the instrument into the bladder, as the stone was firmly impacted in the neck. Mr. Lee, in the absence of Mr. Partridge, was now called to the case, and found the urethra so wide, that the patient had herself tried to remove the stone with the aid of the index-finger. Mr. Lee was able to introduce the lithotomy forceps into the bladder, but the stone was so large that it could not be withdrawn without an incision upwards, and a very slight one downwards. No unfavourable symptom occurred, hardly any incontinence was noticed, and a week after the operation the patient passed her urine normally, and without pain. The stone weighed two ounces, and was of an oval, flattened shape. On a section, it was found to have formed around a nucleus, which looked very much like wood; but on a closer examination the foreign body was found to be a piece of cork. The section was about two inches in diameter, and the concentric layers of phosphate of lime were extremely regular and numerous.

It is hardly worth while inquiring how the piece of cork reached the urethra. Numerous cases have been put upon record of patients, both male and female, young and old, who, either from a depraved taste, or to remove obstruction, have passed various objects down the urethra. A case in point, treated at Guy's Hospital, will be found below.

As to Mr. Lee's case, we would just note how important it is for the subsequent well-being of the patient to make the

this circumstance is a very satisfactory proof that apprehe:sions as to the dilatation of the female urethra should not be carried too far.

The patient is about thirty-five years of age, and was operated upon by Mr. Simon on October 19, 1852. The poor woman had been suffering severely from the usual symptoms of stone for several years, and no course was left but to make an attempt at removing it. The calculus was not supposed to be of large size, and the patient being conveniently placed on a table, Mr. Simon, after ascertaining the position of the stone with the sound, attempted its removal by the aid of small forceps. This was, however, found extremely difficult, owing principally, as was afterwards found, to the elongated form of the stone.

The dilator was now used, and so completely did the urethra give way under its use, that after careful stretching, the canal first admitted the little, and finally the index finger. It had now become plain, from small fragments which came away with the instrument, that the calculus was of the phosphatic kind, and its position could be ascertained by the finger passed into the rectum. Larger forceps were now used; but the withdrawal of the calculus being still difficult, Mr. Simon passed one index-finger into the rectum, the other into the bladder, and by hooking the latter finger, succeeded in extracting a stone of an elongated form, about the size of a common gherkin. The operation had been somewhat protracted, the hæmorrhage rather abundant, and the patient, not having taken any chloroform, had experienced great suffering. But these circumstances had no prejudicial influence on her recovery; she progressed very favourably, and at the present time she is perfectly well, having left the hospital but a few days after the operation, no sign of pain or incontinence being noticed.

We saw some time ago Mr. Bransby Cooper operate for stone at Guy's Hospital, on a little girl about six years of age. Here incisions had to be made, and a very large globular calculus of the phosphatic kind was extracted. It was almost as large as a walnut, so that the child has had some incontinence. We shall very soon revert to this interesting case.

GUY'S HOSPITAL.

We witnessed, a short time ago, an operation of the same kind, performed by Mr. Simon, at St. Thomas's Hospital. The case offers several points of interest, as will be seen by the following details:

(Under the care of Mr. SIMON.)

It will be perceived that in the preceding case the size of the stone necessitated an incision of the urethra. The patient was in such distress, and the symptoms were so urgent, that Mr. Lee was right not to attempt breaking up the stone with the hope either of removing the fragments, or of the latter being passed with the urine. The irritation attendant upon this course might have been extremely prejudicial, and the incision was altogether the better plan.

In Mr. Simon's case, however, the operation was concluded without any incision, and the stone removed uncrushed. This case offers another illustration of the great dilatability of the female urethra; for that canal, after the use of Weiss's dilator, readily admitted the index-finger towards the end of the operation, though at the beginning very small forceps could hardly be made to pass. It is, perhaps, not of trifling importance to inquire which of the two modes, incision or stretching, is the most likely to be followed by incontinence of urine.

Perhaps it may be said with some truth, that an incision upwards heals very rapidly, as the margins of the wound are not constantly irritated by the urine; whilst the chances of cicatrization are much less when the urethra has been cut towards the rectum. The forcible dilatation of the urethra may, on the other hand, have very unpleasant consequences, as the parts may not recover their former elasticity, and a very uncomfortable incontinence be the result. Matters have, however, turned out very favourably in the present case, and I

Parsley Plant; Extraction; Recovery.

(Under the care of Mr. Cock.)

THE case of stone in the female bladder, under the care of Mr. Lee, at King's College Hospital, which we recorded above, shows that a piece of cork may form a convenient nucleus for calculous concretions. Mr. Cock has lately treated a case in which the nucleus of the stone was the stem of a plant.

The patient, a man about forty seven years of age, was in the habit of passing a parsley-stem down his urethra; this practice having arisen by the man's desire of thrusting back into the bladder fragments of stone which became impacted in the urethra, or else facilitating their exit by introducing the stem moistened with saliva. Whether, besides the mechanical effect, the patient expected any benefit from the supposed virtues of the parsley plant, we cannot say; but it is at least probable that he shared in the popular prejudice on the subject.

It should be noticed that Mr. Cock cut this man for stone in October, 1851; the operation was very successful, and the recovery rapid. It would appear that phosphate of lime formed the greater portion of the calculus.

After the usual incisions, on October 2, 1852, Mr. Cock felt the stone give way under the forceps, and by the appearance of the detritus, it was evident that the calculus was of the phosphatic description. Finally, however, a somewhat large mass of crumbling stone was extracted, and to it was found attached a stem of some plant about four inches long. The bladder was now carefully washed out, the remaining detritus removed, and the patient transferred to bed.

On examining the stone and debris found in the bladder, it was perceived that the ligneous stem which had been extracted belonged to the parsley plant, and that incrustations had principally formed on either extremity. There was every reason to believe that a stone already lay in the bladder when the stem slipped into it, for the calculus removed at the operation was quite independent of the organic foreign body which was extracted at the same time. The middle portion of the latter was free from concretions; and it may be supposed that the extremities, being in permanent contact with the mucous membrane of the bladder, received for a long period the de