duced by any mechanical cause, as one of the vegetations separated from the cardiac valves, carried along, in the case of the arm, for example, to the bifurcation of the humeral artery, and impacted there?" 2. "Was it not rather the result of an original puerperal arteritis?" 3. "Or might it be the effect of an effusion of coagulable lymph from phlebitic inflammation in the coats of the artery, a secondary phlebitic deposit upon the lining arterial membrane.'

In the summer of 1853, I saw, in consultation with my friend Dr. Moir, a similar case, in which, from the symptoms present during life, I made the diagnosis of arterial obstruction from separated cardiac vegetations-an opinion that was confirmed by the results of the autopsy.

CASE II. The patient was prematurely delivered in the country, of her first child, and continued to recover favorably for three weeks, when remittent feverish symptoms and diarrhoea supervened, and the lochia became slightly hemorrhagic. Soon afterwards pains, like those of neuralgia, were experienced in the right leg, and then in the left, where they remained fixed and occasionally very violent. Seven weeks after delivery, sudden pain and tenderness came on in the left groin. At this time I heard a loud systolic bruit on listening to the heart. No rheumatism had preceded. Some days subsequently, the pulse in the right arm became arrested suddenly, as the evening before it had been felt by Dr. Moir. Next day a careful examination was made of the arteries of the two lower extremities. No pulsation could be traced in the left femoral artery or its branches. The pulse in the right femoral and iliac was very weak, and in a day or two entirely disappeared, so that now the arterial pulsation in the larger vessels of all the extremities had ceased, with the exception of the left arm. It returned slightly for a few days before death, in the right wrist. At last, in the left lower extremity, where latterly there had always been excessive pain, gangrene of the great and two next toes began, ten weeks after delivery; and the mortification had not extended beyond these toes when the patient gradually sank and died a few days afterwards.

On opening the body, and examining the heart, the aortic aperture was blocked up by a mass of valvular excrescence, which appeared nearly as large as the whole calibre of the artery. It is represented in the accompanying wood-cut, Fig. 1. This excrescence was composed of three portions, one attached to each of the three semilunar valves. The left valve presented only a comparatively small excrescence on the centre of its free border. The vegetation attached to the right valve formed by far the largest proportion of

the morbid mass; while that on the posterior valve was intermediate in size. The whole excrescence seemed of comparatively recent formation, being very friable and granular. In each valve, the corpus aurantii seemed the centre of the morbid growth, and

each vegetation appeared to have been originally developed between the two serous layers of the valves, and only secondarily to have protruded through these layers, and become projected as cauliflowerlike growths, into the free cavity of the vessel. The openings of the coronary arteries were unaffected. Around the margin of the left auriculo-ventricular orifice, were a number of small red excrescences or carunculæ, about the size of sago grains, but evidently of the same nature as the larger masses placed on the aortic valves. The pericardial surface of the heart was healthy. The aorta, at the fourth lumbar vertebra, and iliac vessels were firmly bound by exudation to the surrounding parts. The aorta was found occluded at its lower extremity, by a large irregular mass, composed of small portions similar in consistence and general appearance to the vegetations formed on the aortic valves. The mass thus situated in the aorta, extended more than two inches above its bifurcation, and was somewhat conical in form-the apex pointing upwards, while prolongations were sent from its base along the common iliac arteries on each side. It was loose, and unattached to the walls of the ves

sels, and was covered with a coating of dark-colored blood, through which, at scattered points, portions of the granular structure were seen projecting, not colored like the rest, but bearing to the naked eye a marked resemblance to the valvular excrescences in the heart. In the right common iliac artery, some of the detached concretions were found not covered with blood, but lying loose in the canal of

Fig. 2.

the vessels, and were there seen to be of a grayish color, and granular appearance. The external iliac arteries on both sides were occupied by sanguineo-purulent matter, and here and there mixed with this purulent matter were small granular concretions, similar to the granular mass above. On the right side, this inflammatory appearance of the artery extended down as far as Poupart's liga

ment, but on the left side it reached two inches below Poupart's ligament; and a small granular mass was found blocking up the origin of the profunda on the left side. Two inches down the left internal iliac artery, a pulpy mass was found blocking up the vessel, and from this a yellowish pus extended upwards to the origin of the artery. The mode and extent to which these concretions filled up the lower part of the aorta is represented in the wood-cut, Fig. 2. Let me add, that the whole coats of the obstructed vessels were thickened, and the lining membrane in contact with the occluding masses was of a deep scarlet color. Along the external iliacs the lining membrane assumed a dirty red color. The left femoral vein for two inches below Poupart's ligament was occupied by a fibrinous clot. The lower part of the right humeral artery presented an inflammatory condition, in some respects similar to that of the iliac arteries. No portions of excrescence were found in its cavity, but at the bifurcation into the radial and ulnar branches, a pulpy mass was seen adherent to the lining membrane of the vessel, and seemed like a small granular portion of the valvular excrescence broken down and mixed with pus, which occupied the vessels at this situation. The humeral artery as far upwards as the pectoralis minor, and the radial and ulnar branches for several inches downwards, were quite obliterated and seemed like small cords firmly bound by exudation to the adjoining textures. When a portion of the mass from the aortic valves was placed under the microscope, it was seen to be composed of separated fatty granules, with blood-corpuscles, and a few compound granular cells interspersed. The sanguineo-purulent matter in the neighborhood of the masses deposited in the aorta and other vessels, was seen to be crowded with pus-corpuscles; while the masses themselves were chiefly composed of fat-granules, blood-corpuscles, and compound granular cells, like the excrescences present on the cardiac valves. The uterus presented no appearance of disease either in its cavity or walls. The spleen was pulpy and diffluent, except at one point, where there was a small mass of a cheesy consistence, and grayishwhite color. The other viscera were healthy.'

For notes of the following two analogous cases, I am indebted to the kindness of my friends, Professor Macfarlane of Glasgow, and Dr. Lever of London.

CASE III.—In this instance, the obstruction of the artery occurred suddenly ten days after the lady was delivered naturally and easily of her fifth child. At that time she began to complain of acute pain and numbness in her right arm, which, with slight intermission

The morbid parts in this case were, when still recent, shown to the Medico-Chirurgical Society.

from opiates, &c., continued till her death, which took place at the end of three weeks. No pulsation could, from the first or subsequently, be felt below the middle of the brachial artery. A week after this arterial occlusion in the upper extremity, a similar change took place in the right thigh, accompanied with acute pain. This ceased in a great measure four or five days after, when unequivocal indications of gangrene showed themselves, commencing at the toes and extending to the knee. On dissection, the aortic valves were found by Dr. Macfarlane covered with numerous vegetations, none of which exceeded in size a grain of linseed. The aorta was dilated and studded over with atheromatous deposits. At the points of obstruction (viz., the middle of the brachial, and the commencement of the lower third of the femoral arteries) fibrous clots were found, which completely closed these vessels. The upper or cardiac end of the clots contained, and was firmly attached to, a small hard body, which, on more careful inspection, was found to be identical in size, appearance, and structure with the aortic excrescences.

CASE IV. This patient suffered under an attack of acute rheumatism during pregnancy, and died of a few days' illness after delivery. During the short illness following the confinement, it was discovered by Dr. Lever, who attended the lady, that there was no pulsation in the arteries of the left arm; and subsequently the same want of pulse was observed in the left inferior extremity. The pain in both extremities was distressing; the hand and foot were both livid in color, and local symptoms of gangrene were manifest in each. At the post-mortem examination, mushroom-like vegetations were discovered on the valves of the heart; and in the arteries of both the affected extremities, vegetations were found obstructing their canal, and in the veins of both were phlebolites.

The first case which I have mentioned above, occurred, as I have already stated, in 1842, and was published in 1847. During the same year, 1847, Professor Virchow, of Wurzburg, perhaps the most original and industrious of living pathologists, published an essay on inflammation of arteries,' in which he mentioned several cases of arterial obstruction apparently produced by cardiac vegetations detached and carried forward into the arterial circulation. In 1852, Dr. Kirkes read an excellent paper before the Medico-Chirurgical Society of London on the same subject;2 and Ruhle,3 Tuffnel,♦ 1 "Ueber die akute Entzundung der Arterien," in Archiv. für Pathologische Anatomie, vol. i. (1847), part ii, p. 272. See cases, pp. 338, 342, &c.

2 London Medico-Chirurgical Transactions, vol. xxv, p. 285.

3 "Three cases of Hemiplegia produced by the plugging of one of the cerebral arteries." -Medical Times and Gazette for March, 1853, p. 299.

♦ Dublin Quarterly Journal of Medical Science, vol. xv (1853), p. 371.