Globular Vegetations (Vegetations Globuleuses Of Laennec) in the cavities of the heart constitute a second form. The formations distinguished by this designation are generally round concretions, varying from the size of a pin's head to that of a nut, attached by means of ramifying, cylindrical, or flat appendages or bands which entwine themselves among the trabecule of the heart; and are of a more or less uniformly dirty, grayish-red, or white color. They are hollow in the interior, but contain, within a wall of irregular thickness, a dirty grayish-red, or even chocolate colored thickish fluid, resembling cream or pus, and which is occasionally of a dirty whitish or yellow color. One or more of these concretions very frequently burst, when the fluid may be seen effused into the cavity of the heart, and distributed over the recent coagula which have been formed either in the death-struggle or shortly after death; or it is found mixed with the fluid blood contained in the cavity. The band-like appendages which they throw out, are either solid, or softened and liquefied in their interior.

Besides the structures of this form, there are others belonging to the same class which exhibit different relations, being of an oval shape, somewhat like a wedge, and presenting a shaggy or villous appearance. They differ from those already named, by adhering directly and firmly to the endocardium.

Although we very commonly meet with these structures in the condition above described, this state is not the primary one in which they occur, but merely the result of a metamorphosis to which the fibrinous coagulum has been subjected, not only in its elementary character, but also in its external form. Cases may be occasionally met with in the course of a long-protracted series of observations, in which this metamorphosis may be followed through all its gradations.

The globular vegetation is originally a solid fibrinous coagulum of irregular form, which varies in color according to the number of blood-corpuscles it contains, from different shades of red to a reddish-white color. This coagulum gradually assumes a roundish form, probably in consequence of the outer portion being taken up in the blood in a finely comminuted state. The metamorphosis which it undergoes is very important, and begins as a softening disintegration or solution in the interior of the nucleus, from whence it extends towards the surface. This process is so far developed in the globular vegetations above described, that there only remains a peripheral layer, which encloses the dissolved part as in a capsule. The soft and diffluent mass consists, as has been already remarked, of a pulpy, cream-like fluid, very often resembling pus, and of a chocolate, or dirty brownish-red, reddish-gray, pale yellow, or whitish color. A similar metamorphosis affects the ramifying bandlike coagula, proceeding from the vegetations when they become hollow. The same process is occasionally discernible in the central layers of those coagula of the first form which have arisen during life; we sometimes observe in these coagula a tendency to decomposition, both by their turbidity and opacity, their dirty yellow color, their extreme lacerability, and by the appearance of a turbid cream-like moisture when they are compressed and torn.

This metamorphosis of the fibrinous coagulum is, moreover, highly interesting, from the numerous and important analogies it presents. It is here undoubtedly dependent on disease of the fibrin, from which the coagulum itself is formed, as we have invariably observed in these globular vegetations only in cases in which the blood is in a state of dys-crasia, as in croupous processes, after typhus, in the pyaemia of phlebitis, in a similar condition of the blood in the course of tuberculous or cancerous disorganization, etc.

It is a remarkable circumstance that globular vegetations are almost always limited to the left ventricle, where they are attached in the manner already described to the apex and the contiguous parts. We have, however, observed a few exceptional cases in which globular vegetations were situated in the left auricle as well as in the right ventricle and auricle.

A proof of the part contributed to their formation and attachment by mechanical conditions is afforded by the fact of their being deposited in the apex of the left ventricle, and in the appendages of the auricles - in short in those parts of the cavities of the heart which are most favorable to stagnation of the blood. We have seen these formations in the cavity of an aneurism seated at the apex of the left ventricle, and also, together with the ordinary valvular vegetations, on the mitral and the aortic valves in endocarditis.

While, on the one hand, every fibrinous coagulum, when considered in reference to its most essential feature - its metamorphosis - may be transformed into a globular vegetation, and coagula of the first form may thus be converted into these globular structures, there can, on the other hand, scarcely be said to be any true limits between the globular vegetations and those on the valves of the heart. The latter not only very frequently assume the globular form, as will be seen from the following remarks, but valvular excrescences pass through the metamorphosis of globular vegetations without assuming this form.

c. The third form comprises all those coagula that have in recent times been distinguished under the collective designation of vegetations of the valves of the heart. These were formerly known as sarcomatous, fungous, condylomatous excrescences of the valves of the heart, and have derived especial importance in our own day in consequence of being commonly regarded as an infallible criterion of endocarditis. This form, which is more frequent than either of the others, also presents the greatest variety in reference to number, bulk, shape, mode of attachment, color, consistence, and internal composition.