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of blood in the ventricles in the course of an attack there is allowed opportunity for coagulation of a portion of the fibrine: as the heart recovers, the filaments of fibrine thus separated interlace themselves with the chordæ tendineæ, the curtains of the valves are brought into approximation, and the results are, complete arrest of the current of blood through the heart, and death.

While yet this sheet has been in hand, I have had a singularly good illustration of the termination of life in the way here described.

A patient of my friend Dr. Marshall, of Norwood, 74 years of age, had suffered for a long time from cardiac apnoea. The paroxysms usually occurred in the night, often preventing sleep, and offering those characteristic symptoms which I have described in previous pages. On the evening of Friday, the 25th of October, this gentleman went to bed dreading somewhat the possibility of a disturbed night, and a return of thoracic spasm. On the following morning, he was found by his attendant sitting up in bed lifeless. He had put on his dressing-gown, and propped himself with pillows, having, as the evidence seemed to show, risen (as was his custom when a paroxysm was coming on), walked the room, and returned to his couch. On making a post mortem examination, we found the heart disorganised in the way named in the third division given above. The organ was loaded with fat; the walls were thin and flabby; the right cavities were full of blood, the left empty; there was atheroma of the mitral valve, and also atheroma

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FIG. 1.-C C C. Concretions; Centre Concretion looping up the Cords of Tricuspid Valve.

[graphic]

FIG. 2.-Concretion filling Right Auricle and Ventricle, and fixing Tricuspid Valve.

tous deposit along the coronary arteries, but not to such an extent as to reduce their calibre. The final cause of the stoppage of the heart was here found on the right side. The chorda tendineæ of the tricuspid valve were looped together by filaments of fibrine, so that the curtains of the tricuspid were brought into approximation, and their action suspended. I have described this form of concretion in my work on Fibrinous Deposition in the Heart, and have there given a drawing, showing the way in which fibrinous bands may loop up the curtains of the tricuspid, which corresponds so absolutely with the appearances observed in Dr. Marshall's patient, that I reproduce it in fig. 1 of pl. II.

It is necessary, therefore, in examining the heart and blood-vessels in cases of cardiac apnoea, to remember the existence of these filamentous cords, and to look for them with delicate manipulation, as the mechanical obstacles which may have led ultimately to the arrest of the circulation.

The next pathological condition, most frequent after those conditions which have been described, consists in the presence of fibrinous deposition in the cavities of a heart which in other respects is healthy. We find the concretion, giving rise to cardiac apnœa, in a large number of cases of an inflammatory kind; in croup, for example. Here the concretion is usually met with on the right side of the heart, where it may fill the auricle, or the auricle and ventricle, and send a prolongation into the pulmonary artery. Such an extension of concretion is well depicted in fig. 2, pl.

III. Or again, the concretion may take the tubular character, and may produce a cylinder within one of the great vessels, as the pulmonary artery; or it may line a cavity, as the auricle; or it may exist as a solid cylinder grooved on the outside in a spiral form. In the work on fibrinous deposition above cited, I have depicted every one of these varieties of obstruction from deposited fibrine.

In some rare cases, fibrine may be laid down without any inflammatory symptoms; and the indications of cardiac apnoea may occur at intervals, according as the concretion shall lie in regard to the course of the blood; that is to say, according to its position as an obstruction to the blood-current, or its removal from the course of the current. The case, the particulars of which are given at page 227 of this volume, and which occurred in the practice of Mr. McNab, is an apt illustration of the pathological state now being considered.

Again, a concretion may undergo organisation; the organised mass may have a point of attachment, like a pedicle, to some portion of the endocardial surface. It may thus be suspended in the current of the blood; may at times offer no difficulty; but may at other times, under a little extra exertion, float across the current, arrest the blood, and produce a distinct paroxysm of cardiac apnœa. Many years ago, I received the heart of a patient who had been under the care of my friend Mr. Beresford, of Narborough. In the left ventricle of this heart there was a globular concretion, perfectly organised, and at

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