In some cases valvular lesions are probably congenital in their origin, arising from endocarditis occurring during infra-uterine life. In most of these cases the valves on the right side of the heart only are attacked. Chronic valvular disease, according to some authors, is more common in boys than in girls ; but my own experience would point to a directly op posite conclusion.
Morbid most cases of chronic valvular disease in the young subject the lesion consists in a beading or puckering of valves or other cause of insufficiency, or in a narrowing of the valvular opening. The valVe most commonly affected is the mitral ; the next, that closing the aorta. Beading of the tricuspid valve is rarely seen. This lesion, how ever, occurred in a case under my care in the East London Children's Hospital. A girl aged thirteen was admitted, suffering from general venous congestion, cyanosis, and anasarca. The child's fingers were clubbed, and her breathing was hurried with some degree of orthopncea. The patient, was said never to have had rheumatism, but had suffered from measles and scarlatina, and seven years previously had had an attack of chorea, from which all her trouble was dated. On examination there was evidence of great hypertrophy of the left ventricle, and a strong pre-systolic thrill and loud pre-systolic murmur were discovered at the apex. There was also a short diastolic thrill at the base to the left of the sternum, and a diastolic murmur was heard at this spot. There were, in addition, signs of double hydrothorax. On examination of the body after death, the heart was found to be very large, especially transversely, and to weigh twelve and a half ounces. The right auricle and ventricle were much distended with dark post-mortem clot ; and were both dilated, the•ventricle being much hypertrophied. The tricuspid valve seemed to be competent, and measured three and a half inches in circumference. Its edges on the auricular sur face were fringed with papilke which measured about one-eighth of o a inch in length. The left auricle was dilated and hypertrophied to a less legree than the left ventricle. The mitral orifice was contracted to a mere slit, with a circumference of one inch. The pulmonary artery was very large, but the valves were competent. The aortic orifice leaked very slowly by the water test, but had probably been competent during life. The lungs and other organs showed the usual signs of prolonged venous congestion.
The heart was shown at a meeting of the Pathological Society by my colleague, Dr. Radcliffe Crocker. In his comments upon the case, Dr.
Crocker suggested that the basic systolic murmur had been probably due to a temporary incompetence of the pulmonary valves, owing to dilatation of the artery from extreme congestion of the lungs. Such a cause for pulmonary regurgitation is supported by the authority of Hope and Hayden. The tricuspid valve is seldom diseased primarily. When the seat of thick ening or other lesion, it almost always seems to be affected secondarily, being usually found, as in the above case, in connection with a serious stricture of the mitral orifice.
Adhesion of the layers of the pericardium is found in not a few cases. The adhesions are often very thick and strong ; and the lymph appears to have penetrated between the muscular fibres of the heart ; for these are often torn in the attempt to separate the firmly attached serous membrane. Great hypertrophy and dilatation of the organ usually accompanies this condition.
It is important not to mistake for pathological beading of valves a condition to which Parrot has drawn attention. According to this ob server, in a large proportion of infants who die during the first month after birth, hmmatomata and fibrous nodules are found on the auriculo ventricular valves. The luvmatomata are little spherical or conical tumours of a dark purple or nearly black colour. In size they may be so small as scarcely to be visible to the unaided sight, or may reach the size of a millet-seed. They are placed singly or are arranged in groups. These little projections are seated exclusively on the mitral and tricuspid valves at the part where the tendinous cords are inserted. They lie close to the free edge of the valve, and are covered by the most superficial layer of the endocardium. In a short time they lose their colour, and sink clown into little flattened prominences before they finally disappear. They cease to be visible shortly after the end of the first month of life. Parrot attributes their origin to rupture of intravalvular vessels. The fibrous nodules oc cupy the same situation as the preceding, and are seen as little flattened projections widened towards the base. They are composed of a dense fibro-elastic tissue. These nodules, especially the former, occur too fre quently, and are too harmless in their character, to be ranked as patholo gical lesions, for no ill results appear to follow their presence on the valves. Strictly speaking, no doubt, they are not healthy productions, but they scarcely merit the name of disease.