Treatise on the diseases of the heart, and great vessels

Front matter

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Glass RC &?/ Book_^ 7 3 $~6

TREATISE

Introduction

BY THE TRANSLATOR.

The physician, like the divine, should he endowed with all knowledge, not all the knowledge of every science, but so much of it as to be able to understand the moral and physical phenomena which occur in man, in a state of disease ; hence we obtain a mirror, which reflects the diseased condition of the system or constitution exposed to our observation.

Our actual knowledge of disease, then, consists of an interpretation of all the phenomena, moral, physical, and psychological, as they actually exist in the morbid state of the body.

Such knowledge is acquired by directing our attention to those general principles of induction, analogy, association, and experience, which are found to be consistent with that great moral principle of truth which pervades the whole human family.

Such knowledge includes especially the study of

Vi INTRODUCTION.

anatomy, physics, pathology, metaphysics, and the general or moral history of man, and may be greatly improved by experience and observation, and even perfected by attending to the topographical phenomena and organization of disease.

The physician's general knowledge, then, cannot be too extensive; but his knowledge of disease must depend, for the most, part upon the accuracy with which he notes morbid phenomena, and traces their analogy with his previous observations and the eifects produced after death. The pathological anatomy, then, of all the regions of the body should be the ultimate object of inquiry. With this view I have undertaken to supply, as far as I am able, the deficiencies in this particular department of American Medical Literature, by such translations from foreign works as portray the actual state of disease in the various regions of the body ; so that when the diseases of every part of the system have been studied, we shall be familiar with the morbid phenomena of every part, and the combinations of morbid phenomena which compose a complete body of medical anatomy.

As the heart is the most central organ of the body, we think it would be most proper to begin with the study of the peculiar diseases of that organ ; for this purpose we have selected Bertin, as containing a more complete exposition of those diseases than any other work with which we are acquainted- unless

INTRODUCTION. Vll

it be Laennec, who is too critical and positive for reference respecting the actual progress of any particular disease of that organ. In fact, it can scarcely be said that we are in possession of any complete and perfect history of the diseases of the heart. The French pathologists have prepared the way for a more thorough and satisfactory investigation of this class of diseases; and the plan devised by Bertin is, perhaps, better calculated to attain the object which has been proposed than any other. Corvisart was the first who understood the proper method of studying these diseases: the present author, however, was a pupil of Corvisart, and not only had the advantage of his discoveries, but of the generally improved state of medical science among his cotemporaries. Armstrong, Farr and Abercrombie, have done much in this department of medical inquiry; but Cruveilhier, Lerminier, Andral, Louis and Bouillaud, have effected much more. Bertin deserves to be ranked in this class of authors. His classification is anatomically correct, and he has investigated the diseases of the appropriate textures of that organ so accurately, that it is hardly possible to conceive of a case for which we may not find a parallel in the present w r ork.

It is somewhat singular that among the numerous translations and original works which have issued of late years from the American press, no work has as yet appeared which can justly be entitled to be con-

Viil INTRODUCTION.

sidered a monograph on these diseases, unless it be that portion of Laennec's work which treats of these diseases. A translation of Corvisart was published in Boston, in 1819; but that work, though valuable for occasional reference, has been nearly superseded by the sagacious remarks and criticisms of Laennec. Among the authors of the present day, who have given us information on the subject, Burns has been the principal author referred to for many years. His work, though highly meritorious for the physiological views it contains, has fallen considerably behind the improved state of medical pathology. Dr. Latham, of St. Bartholomew's Hospital, has published, in the London Medical Gazette, the substance of some highly interesting lectures which he delivered before the College of Physicians, and Mr. Hope has lately published some exceedingly valuable essays on the subject; but there is no work, on the whole, more justly entitled to rank as classic, than Bertin's. It is only necessary to dip into that part of Laennec's work which treats of the diseases of the heart, to estimate satisfactorily the repute and favour which that great physician uniformly entertained for the writings of Bertin. These two philosophers have differed on some of the nicer points of pathological inquiry, which gives more interest to their speculations, and renders them mutually interesting and necessary for the investigation of truth.

INTRODUCTION. \X

The author of the original work; a translation of which is herewith presented to the medical public, was for more than twenty years principal physician of one of the most popular hospitals of Paris, during which period he was more or less engaged in collecting the materials of the present work, in which he was assisted in his medico-pathological researches by M. Dejaer, chief physician of the Hospital of Liege, and M. Bouillaud, author of an accurate and beautiful work on encephalitis, and Editor of the present work, to whom the author was indebted for a considerable number of cases, and a great many valuable remarks and observations added to the manuscript confided to his special care and direction.

M. Bouillaud, while house physician to the Hospital Cochin, conceived a peculiar taste for the study of the diseases of the heart, and has analyzed, with greater precision than has hitherto been done, the phenomena peculiar to each disease, and thus placed the theoretical and physiological part of the work on a level with the anatomical.

In order that we may have a more definite view of the improvements and discoveries made by M. Bertin in this branch of knowledge, we shall insert the principal part of the report of Dumeril and Pelletan, to the Royal Academy of France.

In regard to the translation of the work, I have endeavoured to give a literal and exact interpretation

B x INTRODUCTION.

of the facts described by the author, without having sought to attain that smoothness and polish of style more commonly found in works of imagination. The principal merit of the original work depends upon the great number of cases described, and the anatomical classification of their arrangement.

Charles W. Chauncy.

New York, May 21st, 1833.

INSTITUTE OF FRANCE,

ROYAL ACADEMY OF SCIENCES.

Paris, January 15th, 182L

The Perpetual Secretary of the Academy of Natural Sciences, certifies that the following is extracted from the proceedings of the sitting on Monday, January 15th, 1821. —

" From the time of Morgagni to the present day, the best medical writers, and all those who have contributed to the progress of science, have taken pathological anatomy for the basis of their researches. To speak only of the diseases of the heart, we might mention the labours of Lancisi, Senac, MM. Portal, Corvisart, Kreysig, Burns, Testa, Meckel, Hodgson and Laennec.

The memoirs of M. Bertin, committed, by the Academy to MM. Pelletan, Dumeril and myself, is not inferior, in any respect, to the writings of any of the authors spoken of, and we might claim for M. Bertin, in many particulars, a priority of observation and inquiry respecting many of the organic lesions of the heart, which he communicated to the

Xii INTRODUCTION.

Academy at a period when some of the most esteemed works on the subject had not been published.

In fact, when the author presented his first memoir, on the organic diseases of the heart, on the 10th of August, 1811, thickening of that organ had only been partially distinguished from the dilatation of the parietes, and from enlargement of the cavities denoted by the term aneurism; it appears that the reverse, and entirely opposite state, as regards anatomy and physiology, had been confounded with the term thickening. Simply augmented nutrition of the muscular parietes of the heart does not appear to have been distinguished from those defections, or more profound alterations, induced by the nutrition of that organ. About this time M. Corvisart described these several alterations by the term active aneurism, without determining the circumstances, or the anatomical characters, which have a tendency to diminish and even destroy that active state, whether by the softening or hardening of the parietes, or of the muscular columnar of the heart, and of a multitude of other alterations resulting from an augmented nutrition, which frequently also thickens the parietes without rendering them hypertrophous. It was also at the same period that M. Portal considered this thickening of the heart only as a transformation into a substance unnatural to the muscular texture of that organ; and had thus been led to regard that anatomical condition as invariably of a passive nature.

It was at this period that M. Bertin, after having been ten years employed in the hospital confided to his care, in collecting, comparing, and collating numerous cases, confirmed by inspections of the body,

INTRODUCTION. Xlll

attempted to demonstrate, in his first memoir, that the aneurism did not give an exact idea of the dilatation of the heart; that the activity too generally attributed to a species of dilatation of the parietes, accompanied with thickening, should not be admitted, excepting in cases of increased nutrition of the muscular tissue; that this increased nutrition does not always coexist with dilatation; that simultaneous dilatation and thickening do not constitute augmented activity of the muscular parietes, since the author had in vain sought to find these anatomical dispositions in a great number of observations; that frequently, on the contrary, the cavities of the heart were very much diminished (a disposition the first discovery of which appears to have appertained to M. Bertin;) and that at last the morbid activity of the heart became weakened in consequence of its complication^ especially when the thickening, at first partaking of the characters of the muscular texture, but losing afterwards its density, consistence and colour, becomes hard, of a deep brown colour, softened and relaxed; or when it presents an inverse disposition, that is to say, hardening of its texture, met with most frequently in the pillars and columns of the cavity of the ventricles.

Such are the most remarkable results of the first memoir, confided to M. Corvisart by the Academy, in 1811, to make a report, but which his numerous occupations did not allow him time to present to you. We shall go on with the analysis of the other memoirs of M. Bertin, which should only be considered as the development of the ideas and observations contained in the first part of his work.

Xiv INTRODUCTION.

Each of the forms of hypertrophy, considered more particularly in reference to -the left ventricle, appears especially to have been thoroughly investigated in the three memoirs successively presented, about a year since, to the Academy. Thus M. Bertin, following in his second memoir the same analytical methods, begins with an exposition of the facts and observations proper to establish the first kind of hypertrophy, as follows: thickening, without dilatation of the left ventricle. This alteration is first considered in its primitive state, then with the different complications which frequently accompany it. Each of these observations, presented with the preparations, to several societies of medicine, is followed by reflections from which we may expect new and important discoveries.

The object of the third memoir is to discover and establish the symptoms and organic alterations which characterize hypertrophy of the left and right ventricles, with diminution of their cavities.

Senac has already consecrated one of the articles of his beautiful work to the diminished volume, narrowness of the cavities, or shrinking of the heart.

Malpighi and Fabricius Hildanus speak of small, wrinkled and shrunken hearts; Corvisart notices the constriction of the left or right ventricle, with diminution of the cavities, produced by a shortening of the parietes; occurring in consequence of indurations or cartilaginous and osseous alterations of the tricuspid or mitral valves.

In the observations which M. Bertin has collected, he has observed that the volume of the heart was not sensibly altered; that the ventricles were, however,

INTRODUCTION. XV

more fleshy than in the natural state, and that the muscular thickening was evidently formed at the expense of the cavity, without, however, appearing to present a trace of any alteration whatever.

His third memoir contains six cases, remarkable as well in relation to the description of the symptoms as to the details of pathological anatomy.

The fourth is consecrated to the investigation of hypertrophy of the parietes of the heart, accompanied by dilatation. The author has recognised this morbid disposition in ten of the c^ses detailed. He there explains the different degrees of hypertrophy of the left ventricle, the right ventricle and the auricles; he remarks that it is far from being uniform in the parietes of the heart, in the septum of the ventricles and auricles; that it varies in the columns carneae, and at different points of the parietes of the cavities; and that it offers different degrees, accordingly as the dilatation is greater or less than the proportional dimensions of the corresponding cavities.

The various degrees of alteration are described with much care by M. Bertin.

From the labours and researches which this author has presented to the Academy, he has been enabled to ascertain, 1st. That in the different species of organic lesions, the muscular texture may be more or less altered. 2nd. That the heart becomes thicker by dilatation, or without dilatation. 3rd. That thickening of the parietes offers two different anatomical characters, increase or alteration of nutrition, sometimes existing simultaneously, at other times individually. M. Bertin proves that this thickening by hypertrophy, the principal object of the memoirs which

XVI INTRODUCTION.

we have been analyzing, offers three different forms, two of which had not been, before the year 1811, attached to the doctrine of the diseases of the heart, and which we have already noticed; that is to say, increased volume of the cavities of the heart, and diminution of the cavities caused by hypertrophy. 5th. He thinks that the denomination aneurism is not applicable in any respect to these two kinds of alterations. 6th. He affirms that it is necessary to be very careful not to call hypertrophies active dilatations, because the energy of the parietes is singularly modified, sometimes even much weakened, either by the hardening or softening of the thickened parietes, and by all the other complications. 7th. He thinks, finally, that thickening, with or without dilatation of the parietes, should be distinguished according to its anatomical characters, and not according to the physiological phenomena which are so numerous and variable.

These various pathological views, since confirmed by recent and commendable labours, but which we must pass over, are especially adapted to impart a knowledge of the organic diseases of the heart, respecting which M. Bertin has been one of the first to fix the attention of observers. They are not, undoubtedly, new in the present day; but if we refer to the period when the author presented his first memoir, of which the others are only a development, we shall see that his labours are far from having been without their utility for science.

The distinctions admitted by the author have been deduced from a great number of well-observed facts, and which have required a great deal of sagacity and

INTRODUCTION. XV11

patience of anatomical research. The author has always been careful to confine himself to an exact description of facts, and to compare the symptoms with the various results furnished by pathological anatomy.

We think, also, that the labours of M. Bertin will powerfully concur to promote the knowledge of these diseases; we think, indeed, they have already served that purpose, and that his co-labourers will do no more than justice towards M. Bertin, by receiving his contributions favourably, and recognising the anteriority of his researches in numerous organic alterations of the heart.

It will, at all times, give us the greatest pleasure to be permitted to communicate the results of the labours of a man whose father was counted among the most distinguished members of the Academy, and who has left so many tokens of remembrance of anatomical science.

(Signed) Dumeril, Pelletan, Pinel,

Reporters.-

The Academy approves of the report and adopts

its conclusions.

Certified in conformity to the original.

Perpetual Secretary, Counsellor of State, Of*

ficer of the Royal Order of the Legion of

Honour.

B. Cuvier.

Table Of Contents

Page.

Introduction by the Translator v

Report of the Royal Institute of France xi

Chapter I

Inflammation of the Aorta; Internal Membrane of the Heart and Pulmonary Artery, and its Consequences, such as Ulcers, Perforations, Cartilaginous and Calcari-

ous Degenerations, &c. 27

Art. I. — Observations on Inflammation of the Aorta, Internal Membrane of the Heart, and Pulmonary Artery -27

Art, II. General History of Inflammation of the Aorta

and Internal Membrane of the Heart - §5

§ 1st. Anatomical Signs 66

§ 2nd. Physiological Signs 76

XX CONTENTS.

CHAPTER II. Dilatation and Aneurism of the Aorta

Art. I. — Observations relative to Dilatation and Aneurism of the Aorta, whether true or false 89 Art. II. — General History of Dilatation and Aneurism

of the Aorta 127

§ 1st. Formation and Anatomy of the various kinds of

Aneurism 127

§ 2nd. Influence of the Aneurisms of the Aorta on the

Parts with which they are found in Contact - 138 § 3rd. Signs and Diagnosis of Aneurism of the Aorta - 143 § 4th. Treatment of Aneurism of the Aorta, and the Mode

of Cure 154

Chapter IV

Induration and Vegetations of the Valves of the Heart,

and Constriction of its different Orifices - 170

Art. I. — Observations on Induration and Valvular Vegetations - 172

§ 1st. Indurations of the Valves 172

Art. II.- — General History of Induration and Vegetations of the Valves of the Heart, and Constriction of their several Orifices - 212 § 1st. Anatomical Description of the Induration of the

Valves of the Heart, in general - - - 212 § 2nd. Anatomical Description of the Vegetations of the

Valves of the Heart, in general - 221

§ 3rd. Of the Signs and Diagnosis of the Induration and

Vegetations of the Valves of the Heart - - 221 § 4th. Of the Causes of the Vegetations and Indurations

of the Valves of the Heart - - - - 231 § 5th. Of the Treatment of the Vegetations and Indurations of the Valves ----- 032

CONTENTS. XXI

Book II. Of The Diseases Of The Heart

§ 1st. Diseases of the Pericardium - 237

Chapter I

Of Pericarditis and its Consequences; such as Albuminous Effusions, False Membranes, Cellular Adhesions, Fibro-cartilaginous or Cartilaginous Membranes, Ossifications of the Pericardium, &c. ----- £38 Art. I. — Particular Observations respecting Pericarditis,

Acute or Chronic - 238

Art. II. — General History of Pericarditis - 263

§ 1st Signs of Acute Pericarditis - - . 266

§ 2nd. Signs and Diagnosis of Chronic Pericarditis - 268

Chapter II

Of Hydro and Pneumo-pericarditis - - - - 273 7. Particular Observations - 273 II. General History of Hydro-pericarditis and Pneu mo- Pericarditis ------- org

SECTION II. Diseases of the Muscular Substance of the Heart - - 281

CHAPTER I.

Hypertrophy or Nutritive Irritation of the Heart.

Art. I. — Cases of Hypertrophy of the Heart - - 287

§ 1st. Cases of Hypertrophy of the Left Ventricle - 287

§ 2nd. Cases of Hypertrophy of the Right Ventricle - 314

§ 3rd. Hypertrophy of the Auricles - - - - 331 § 4th. Simultaneous Hypertrophy of several or of all the

Cavities of the Heart 332

XXli CONTENTS.

Art. II. — General History of Hypertrophy or Nutritive

Irritation of the Heart 337

§ 1st. Anatomy of the Hypertrophy of the Heart - - 337 § 2nd. Formation of Hypertrophy of the Heart - - 341 § 3rd. Of the Causes of Hypertrophy of the Heart - 344

§ 4th. Of the Influence of Hypertrophy of the Ventricles

on the other Organs, and especially on the Brain

and Lungs - 346

§ 5th. Of the Symptoms and Diagnosis of Hypertrophy

of the Heart 349

§ 6th. Progress and Termination of Hypertrophy of the

§ 7th. Treatment of Hypertrophy of the Heart - - 362

CHAPTER II.

Of Dilatation or Aneurism of the Heart

Art. I. — Cases of Dilatation or Aneurism of the Heart - 367 Art. II. — General History of Dilatation or Aneurism of

the Heart 371

§ 1st. Anatomical Characters and various Forms of Dilatation of the Heart 371

§ 2nd. Formation and Causes of the Dilatation of the

§ 3rd. Of the Symptoms and Diagnostics of the Dilatation

or Aneurism of the Heart - 377

§ 4th. Of the Effects of Dilatation or Aneurism of the

§ 5th. Treatment of the Dilatation or Aneurism of the i CHAPTER III.

Of Atrophy of the Heart 383

Chapter IV

Of the Inflammatory Irritation of the Muscular Substance of the Heart, or of Carditis and its Consequences; such as Abscesses, Ulcers, Perforations, Gangrene, &c.

CONTENTS. XX111

Art. I.— Of Softening of the Heart, (Carditis) - - 391 Art. II. — Of Induration of the Muscular Substance of the

Art. III. — Of Gangrene or Sphacelus of the Heart - 402

Chapter V

Of Cancer and the other Accidental Productions of the Heart, which have nothing Analogous in other Parts of

the Animal Economy 405

§ 3rd. Of the Diseases of the Vessels of the Heart - 409

§ 4th. Of the Diseases of the Cellular Texture of the

§ 5th. Of the Defective Conformations and Positions of

the Heart 426

Art. I. — Of the Defective Conformation of the Heart, in

general, and of the Communication of the

Right and Left Cavities, in particular - - 426

Art. II. — Of the Displacements of the Heart - - 435

§ 6th. Of the Concretions of the Blood, most commonly

distinguished by the term Polypi, of the Heart

and Large Vessels 439

/. Anatomical Characters of Polypous Concretions - 441 II. Formation of Polypous Concretions ... 443 III Of the Effects and Symptoms of Polypous Concretions, in general -^ 444

§ 7th. Of the Reciprocal Complication of the Various

INTRODUCTION.

Anatomy, physiology, and pathology, have each of them such intimate relations and close connexions with each other, and mutually derive from each other such useful light, that they constitute, perhaps, less three absolutely distinct sciences, than three branches of one and the same science. Reasons, the truth of which no one can for a moment doubt, have induced us to prefix to the history of the diseases of the heart an abridged description of the structure and functions of that organ. We shall devote the first part of our introduction to this description, and in the second, present some historical researches on the diseases which form the subject of the work.

Part I. Anatomical And Physiological Considerations Respecting The Heart

§ I. ANATOMICAL CONSIDERATIONS.

The heart is a hollow organ, principally of a muscular nature, having the form of a cone reversed: it

D

XXVlii INTRODUCTION .

ing is known by the name of foramen Botalli.* The cavity of the ventricles, separated from each other by a common division, presents the orifices of the pulmonary arteries and aorta. These orifices, as well as those by means of which the auricles and ventricles communicate with each other, are furnished with membranous folds, which have been distinguished by the name of valves. The valves adapted to the auriculo- ventricular orifices have their free edges cut into a great number of dentations, and, farthermore, deeply divided into three principal lingual flaps in the right ventricle, and into two only in the left ventricle. It is in consequence of this arrangement that the name of tricuspid or triglochyne valve has been given to that valve which occupies the edge of the right auric ulo- ventricular orifice, and the name of bicuspid or mitral to the left auriculo-ventricular valve. When these valves are raised, they close the auriculo-ventricular orifices almost hermetically, like valves. These orifices, the circumference of which is elliptical, are bordered by a line or whitish zone, more apparent on the side of the auricles; and which appears owing, in part, to the presence of a small quantity of fat situated under the internal membrane, and in part to that of a tendinous ring, imbedded in the substance of the heart. The valves annexed to the arterial orifices of the heart, are known by the name of semilunar or sigmoid valves: the aortic valves, to the number of three, like the pulmonary valves, are larger and thicker than the latter. They are all arranged in such a manner as to oppose a sufficient ob-

f Hole of Botallus, or foramen ovale,

INTRODUCTION. XXIX

stacle to the retrograde course of the blood in the ventricles. Their free edge presents at the middle part a small tubercle which is called the tubercle of Arantius.

The muscular substance of which the heart is essentially composed, is denser, firmer, and of a deeper red than that of the voluntary muscles, and is composed of numerous fibres, the arrangement of which has been for a long time an impenetrable enigma for the anatomists. Steno was the first who exerted himself to unravel that inexplicable muscular network; his efforts were unsuccessful. The attempt of many anatomists succeeding Steno, were scarcely more fortunate. Finally, in these latter times the ingenious researches of MM. Wolff, Duncan and Gerdy, have succeeded in unravelling the tortuous and circumvolute fibres of the heart. It results from the researches of these anatomists, that the ventricles are formed of many muscular layers placed one over the other, the number of which differs in each of them :* besides, the direction and extent of the fibres which constitute these muscular planes, are not the same. The fibres of the external layers are, in general, oblique, from above downward, from before backward, and from right to left: the middle are arranged in the contrary direction, and the more profound, which are united together to form species of projecting columns on the interior of the ventricles, are, for the most part, longitudinal.! According to a law disco-

* These muscular layers are six in number for the left ventricle, and three only for the right ventricle, which explains why the first is much thicker than the second.

f The superficial layers occupy the whole circumference of the ventricles in passing round the apex of the heart, whilst the others diminish in length

XXX INTRODUCTION.

vered by M. Gerdy, all the fibres, whatever may be their length, situation, or direction, are disposed in the forms of loups, the convexity of which looks towards the apex of the heart, and which are more or less superficial at one extremity, and deep-seated at the other; so that the external and internal fibres are, in fact, the same, being reversed after having passed through the substance of the ventricle. The extremities of these muscular loops are uniformly inserted into the base of the heart, in the circumference of the various auricular and arterial orifices of the ventricles, either immediately or by the tendons attached to the auriculo- ventricular valves.

The auricles have a structure equally complicated : they are composed of two fleshy layers, the one external and the other internal. In the right auricle the muscular tissue is less abundant than in the left, and leaves intervals between the fibres, where the internal and external membrane of the heart are in immediate contact. This disposition is very remarkable in certain individuals affected with a considerable dilatation of the right auricle, with thickening of its fleshy fibres.

The muscular fibres of the heart, uniting in fasciculi, form on the interior of that organ what the anatomists call the fleshy columns of the heart. These columns differ in the ventricles and in the auricles, and even in each of its several cavities. They are much more developed in the ventricles than in the auricles; those of the right ventricle are more numerous and stronger than those of the left; the left au-

and breadth in proportion as they become deeper; hence the reason why the ventricles are thicker at the base than the apex.

INTRODUCTION. XXXI

ricle offers them only on its appendix, whilst the right is provided with them also on the right and anterior side. The fleshy columnar are interwoven with each other in a variety of ways, and give to the internal surface of the ventricles an appearance similar to a sort of network the meshes of which are of unequal size, and the filaments of various lengths. Some of these muscular pillars, detached from the heart in the whole of their middle part, are only held by their extremities. Many of the fleshy columnse give origin to a multitude of small tendons, which are fixed on the free edge of the auricular valves : this arrangement permits us to regard these fleshy fasciculi as the tensor muscles of the several valves to which they are attached.

The tendons of which we have spoken, are not the only part of an albugineous nature which the heart possesses. In fact, we find the tendinous, ligamentous, or fibrous tissue, at the point of union of the ventricles with the auricles, and with the aorta, and pulmonary arteries, and in the duplicature of the valves themselves. This tissue forms, at least in great part, the valvular circles which we observe round the auricular orifices, in the form of whitish zones. It is this tissue, which, by becoming converted into a cartilaginous or osseous texture, determines the diseases which we shall hereafter describe.* The natural consistence of the tendinous circles, situated at the orifices of the heart, very much resembles that of the cartilages or fibro-cartilages.