289

action and proportionate suffering, but, on the contrary, witha diminution of the most adverse symptoms. In two caseswhich have lately been treated in the out-patient department ofthe hospital the value of this plan of treatment has been mostmarked.

In one, a child of five years old, the right hip-articulationhad been extremely painful for two years, and the deformityassumed by the lower limb considerable, the thigh being flexedat a rio-ht angle to the pelvis, and turned across its fellow. Thelimb was, by the exercise of some little force, while the patientwas under the influence of chloroform, brought into a straightposition, and maintained so by means of the long side-splint,bandages, and perineal band. After the muscles had becomeaccustomed to their new position, relief from the old pain wascomplete. The limb was kept to the splint for two months,when it was removed, and a support of gutta-percha substi-tuted. Without any other treatment,-save medicines for theimprovement of the general health,-the child regained a use-ful, though shortened, limb.

In the other instance, a little girl had suffered for nearlyfour months with a painful affection of the right hip. The painat night was incessant, while the least motion increased itsseverity. The limb was flexed at an obtuse angle to the pelvis,and carried across the left thigh. By means of gradual ex-tending force the thigh was brought into a straight position,or one nearly so, and retained by means of the long side-splintof wood and suitable bandages. A space corresponding to theposterior part of the hip-joint was left uncovered, so as to admitof the application of plasters, iodine, &c., which were em-

ployed during the subsequent management of the case. Therelief to the painful symptoms during the first and subsequentmights was complete; but pain returned on removing the appa-ratus after the lapse of a few weeks, and was again mitigatedon its re-adaptation.

C)

The same plan of treatment has also been adopted by Mr.Price and Mr. Gay for subacute and chronic disease of the elbowand knee joints.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

TUESDAY, MARCH 12TH, 1861.DR. BABINGTON, PRESIDENT, IN THE CHAIR.

REMARKS ON THE CAUSE OF THE CLOSURE OF THE VALVESOF THE HEART.

BY W. O. MARKHAM, M.D.,PHYSICIAN TO ST. MARY’S HOSPITAL, AND LECTURER ON PATHOLOGY

AND PHYSIOLOGY AT THE SCHOOL.

DR. MARKHAM stated that the usually received accounts oithe mode of closure of the heart’s valves were unsatisfactory,and incapable of fully explaining the phenomena attending it.The closure is effected during different periods of the heart’saction, and may be divided into two stages. During the firststage (i.e., during the ventricular diastole) the valves graduallyrise upwards towards each other, pa1’i pass-a with the disten-sion of the ventricles, so that their free borders come into loose>contact. The second stage corresponds with the ventricularsystole, whereby the valves are suddenly and forcibly broughtinto firm and perfect contact by the pressure of the blood.The author considers that a satisfactory explanation of the

cause of the first stage of this closure has not yet been given.The usually received explanation is that the blood during theventricular diastole raises the valves up towards each other.But this is manifestly incorrect, because the pressure of theblood passing from the auricle to the ventricle must be as greatupon the auricular as upon the ventricular surface of thevalves; it is, in fact, greater.On investigation, Dr. Markham satisfied himself that the

valves are raised towards each other during this first stage oftheir closure by the agency of elastic tissue, this elastic tissuebeing so disposed in the valves as to act in a manner at oncemost simple and effective. The auriculo-ventricular and thesemilunar valves have all essentially the same structure. Theyare formed of elastic membrane, and inelastic white fibrouscords. In the case of the auriculo-ventricular valves, as ob-served in a bullock’s heart, a thickish layer of elastic membrane may be readily dissected from the auricular surface ofthe valve, being loosely attached, except at the free edge of

the valve, where it becomes blended with the under layer.This elastic membrane is retractile in all directions, but itsfibres seem to run chiefly in a direction from the attached tothe loose border of the valves. The lower (ventricular) surfaceof the valves may be said to consist of white fibrous cordsthe prolongations into them of the ohordse tendinese, unitedtogether by elastic tissue; the lower borders of these cordsprojecting from the under surface of the valves, giving them afurrowed appearance.

In consequence of the disposition of the elastic fibres, thefree borders of the valves have a tendency (when their elastictissue is brought into play) to approach their attached borders,and in the direction of the auricular surface of the valves. Atthe end of the ventricular systole the valves are pressed downinto the ventricles and lie flat against the inner walls, and theelastic tissue is put on the stretch. Then, during diastole, asthe blood flows into the ventricles, the weight of the valves isdiminished, and so the elasticity of the stretched elastic mem-brane is permitted to come into play. This contraction of theelastic tissue causes the closure of the valves during the firststage referred to.

! Anyone may readily satisfy himself that no other explana-, tion of the phenomenon is possible. When the auricles are- removed from the ventricles, the coagulated blood ca1’ifully re-

moved, and water poured into the ventricles, it will be seen; that the valves (if healthy) not only rise up towards each other, as the water flows in, but that they remain in contact when; the current is arrested, and will, if depressed in the water,

again rise towards each other when the pressure is removed.! As the specific gravity of the valves is considerably greater, than that of blood, it is evident that no other moving force

than that of elastic tissue can be in action here.Exactly the same disposition of parts occurs in the semilunar

valves, with this necessary difference-that the elastic layer isspread over their ventricular surface. The object is here mani-festly the same as in the former case,-namely, to assist indrawing the valves away from the arterial walls, so as to putthem in a position of being readily brought together at theinstant the ventt icular systole ceases.

These facts ma;., perhaps, explain some points in diagnosiswhich have hitherto puzzled the auscultator; for instance, thecause of a cardiac murmur heard during life in cases where thevalves have been found, after death, to all appearance compe-tent. In such cases we may fairly suppose that the elastictissue is impaired, and thus regurgitation permitted at thecommencement of the ventricular systole. We may also assumethat to prove the capacity of the auriculo-ventricular valvesfor effective closure, we must try them, as above described, byremoving the auricles and filling the ventricles with water.

Dr. BABINGTON inquired if Dr. Markham had found elastictissue in the valves of the human heart as well as in those ofthe hearts of animals.

Dr. MARKHAM said that on the table was a human heart, inwhich the mitral valves were perfectly closed, but in which onesegment of the tricuspid valve had fallen away. This segmentit was found was thickened, hence its elasticity was lost, andit had not risen like the rest.

Mr. PARTRIDGE inquired if precautions had been taken toprevent the insinuation of air under the lining membrane ofthe valves. If not, the valve, being thus rendered lighter,would rise from that cause only.

Dr. MARKHAM, in reply, said if Mr. Partridge would ex-amine the hearts on the table he would find that such asource of error did not exist. The heart might be turned over,and yet the valves would not rise into the ventricle, (in thisposition the highest point,) as they would have done if theywere influenced by the physical law, the result of the differingspecific gravity of the valves and the fluid.

Dr. SrBSOrT could confirm, from personal observation, theexperiments of Dr. Markham.

Dr. C. J. B. WILLIAMS thought the experiments and deduc-tions of Dr. Markham seemed to throw light on one part ofthe action of the mitral valves; but he (Dr. Williams) did notthink that the existence of elastic tissue would constitute morethan a subordinate agency in their functions. He thought thatthe mechanism of the valves, as commonly explained, was suffi-cient to effect closure during systole, but that through theaction of this elastic tissue they might be approximated at the eend of diastole. He believed that the action of the valves indiastole alluded to by Dr. Markham, although not enough initself to effect closure, yet by raising them from the sides) fthe ventricle would enable them to be influenced by the pres-sure of blood, and thus close in systole. He did not thinkthat elastic tissue could exert any very great power in closing

290

the mitral valves, as any such power would be utterly insig-nificant when opposed to the whole weight of the systemic cir-culation, which at each systole the mitral valves had to bear.Dr. Williams also alluded to experiments which, more thantwenty years ago, he had performed on the hearts of severalanimals-ox, ass, calf, &c. He then, on plunging the heartsin water, and on creating a current from the ventricle to theauricle, found that the margins of the valves did not readilyapproximate and close. He believed that the valvular adap-tation, independent of the action of the eolumnse oarnese, wasmore complete than was generally supposed, although thisaction was essential to prevent regurgitation during full ven-tricular systole. In reference to the pathological relations ofthis subject, Dr. Williams said that cases had been reported inwhich there existed mitral regurgitant murmurs, and yet therewas no lesion discovered after death. He could not say thatthis was impossible as an accidental occurrence, the murmurbeing caused by imperfect closure of the valves, the result ofdisplacement of the heart. He had been able to produce thisartificially in animals by pressure even through the parietesof the thorax. The point, however, to which he wished par-ticularly to refer was that in the very earliest stage of endo-carditis, before there was time for effusion of lymph, he hadfound a regurgitant mitral murmur; and many years ago hehad arrived at the conclusion that such murmurs were due toimperfect closure of the valves from irregular action of the co-lumnsa carnese. As we find that often in endocarditis onlylimited parts of the lining membrane are affected, he believedthat one set only of the fleshy columns might be rendered un-duly irritable and contract in excess during the first stage ofinflammation, that of exaltation of function; and that it mightbe partially paralysed, and fail in its contraction, in the secondstage,, even when there was no effusion of lymph. In either

case there would be regurgitation and a murmur. Whetherin neurosis of the heart a similar irregular action of one set ofthe fleshy columns might occur, is much more doubtful. Hedid not believe it was probable, and would conclude by offer-ing his conviction that in all cases of permanent mitral mur-murs the cause is organic.

Dr. HALFORD said that the author, he 1 elieved, had over.looked one point in his experiments-viz., the difference in thesize of the ventricle before and after distension. Neither couldhe understand why the author should object to the applicationof the hydrostatic law of the equal pressure of fluids in alldirections in the case of the heart. The author believed thatblood forced from the auricle would produce greater pressureon the auricular than on the ventricular surface of the valves.He (Dr. Halford) believed that if there were any difference,the contrary would be the fact; that the pressure was greateron the under surface, and also that the closure of the valveswas due to pressure of the blood on that surface. Dr. Halfordstated that in birds there was a mere trace of elastic tissue inthe valves, and yet the mechanism appeared perfect. He couldnot understand how closure of the valves could occur duringdiastole. During systole, however, he believed it would takeplace. _ _ _ _ _

Dr. MARKHAM stated, in reply, that several points in thepaper appeared to have been misunderstood, and perhaps thiswas owing to its brevity, as he had put as few words into it aspossible. If Dr. Halford would look at the specimens on thetable, he would find that the valves are floated up in the water,although of greater specific gravity than water. What sustainsand raises them up? evidently the elastic tissue within them.The author had turned his attention to the subject because, onconsideration, it seemed clear that the valves, to act efficiently, Ishould be in loose apposition when the ventricular diastole iscomplete, so that the instant the systole occurs they may bepressed firmly together, and firmly close the auriculo-ventri-cular orifice. If the valves were closed solely by the ventricularsystole, it is manifest that regurgitation must occur during thetime that the valves were in the act of closing. Anyone mayreadily satisfy himself by the simplest experiment that thevalves do float upwards towards each other during diastole,and that they are sustained in their up-raised position simplyby their elastic tissue. It is necessary in performing the expe-riment to keep the heart as far as may be in its natural posi-tion, suspended by its great vessels, or otherwise the walls ofthe ventricles, by falling apart, will draw the valves awayfrom each other. The most perfect demonstration of the factis obtained by separating a valve—sa,y the anterior mitral valve-with the ventricular wall to which it is attached, and placingit in water. Whichever way the valve is placed, it will beseen that it tends to approach the auricular border of the ven-tricular wall,

PATHOLOGICAL SOCIETY OF LONDON.

TUESDAY, MARCH 5TH, 1861.DR. COPLAND, PRESIDENT.

DR. GIBB exhibited specimens ofCALCIFICATION OF THE CARTILAGES OF THE LARYNX,

INCLUDING THE ARYTENOID,

taken from a man aged forty-one years, who died of pneu-monia and disease of the kidneys. He had the atheromatousexpression during life, and after death the vessels at the base-of the brain were found diseased, a small clot existing in theright hemisphere, which had become partially absorbed. Thecartilages of the larynx were beautiful examples of completocalcification, extending as well to both arytenoids. Calcifica.tion in the last is considered to be extremely rare by manypathologists, but Dr. Gibb showed that they were more com-monly affected in this way, conjointly with the other carti.lages, than is supposed. He referred to isolated examples re-corded by different writers, as well as to single specimens insome of the London museums.

Mr. CANTON had observed all the laryngeal cartilages calci-fied at various ages, and not necessarily in advanced years;, 9.the product being true bone. It was most important to ob.serve that calcification of the arteries coexisted. He had seenit in early life, and also at the advanced age of 103 years; inthe latter case no ossification had taken place, nor was thereany fatty degeneration of the muscular tissues.

Mr. DURHAM believed that calcification of arytenoid carti-lages was by no means rare. He had examined numerous-

dissecting-room subjects, and had come to that conclusion.Dr. GIBB also presented an illustration of

LARYNGITIS IN A WHITE-LIPPED PECCARY,which died in the Zoological Gardens in the latter part ofFebruary. The animal was observed to have great difficultyin swallowing its food, which it subsequently refused and thendied. The entire fauces were found red and inflamed, withextension of the inflammation to the whole of the larynx, whichwas of a dark purplish-red colour, interspersed with ashy-greypatches. In spots the mucous membrane was in a sloughycondition, and readily peeled off. The posterior surface of theepiglottis was bright-red, and the lips of the glottis were in astate of caclema. The animal evidently died of acute laryngitis.

CARTILAGES OF WRISBERG IN THE LARYNX OF A MONA

MONKEY.

The larynx of a Mona monkey was also shown by Dr. GIBB,as exhibiting a considerable development of the cuneiform orWrisbergian cartilages in the fold of mucous membrane be-tween the arytenoid cartilages and epiglottis. These smallbodies are known to be either very minute or wholly wantingin man.

TENDONS RECENTLY DIVIDED.

Mr. ADAMS exhibited two specimens of human tendon ro-cently divided. In one instance, nine days had elapsed afterthe operation; and, in the other, a few weeks. The appear-ances were described, and the results were well seen in thepreparations, which were fresh.

OBSTETRICAL SOCIETY OF LONDON.

WEDNESDAY, MARCH 6TH, 1861.DR. TYLER SMITH, PRESIDENT, IN THE CHAIR.

ON UTERINE HÆMATOCELE.

BY HENRY MADGE, M.D.

MRS. L--, aged thirty-four years, had been married thir-teen years, and had three children, the eldest being now eleven*and the youngest six years of age. Iiad inflammation of thebowels six years ago, and has not been pregnant since. Ap-pearance healthy and vigorous; catamenia regular. On Oct.27th, 1860, the menstrual discharge having existed two days,she was attacked with violent pains in the hypogastric region,and was treated for local peritonitis. In a week she was get-ting on well, but imprudently went out of doors. Whilst walk-ing the catamenia appeared in increased quantity; a feeling offaintness came on, and she was brought home in a state ofcollapse: this lasted until the following day. When reaction,took place, peritoneal symptoms were very evident in the