MORBID ALTERATIONS OF TILE MUSCULAR SUBSTANCE OF TILE UEART.
1. Inflammation of the muscular structure of the heart, or carditis (the carditis proper of some pathologists).—The same anatomical characters which would lead us to pronounce any muscu lar tissue in a state of acute inflammation, would justify a similar conclusion respecting the heart. But from the sparing deposition of cel lular tissue around this organ and between its fibres, the anatomical phenomena which denote the previous existence of inflammation are not so marked in it as in the muscles of animal life ; and judging from the rarity of these organic signs, as well as from the unfrequent occurrence of those symptoms which so great a morbid process could scarcely fail to produce, we may reasonably conclude that active inflammation deeply im plicating the carneous fibres of the heart, and originating in them, is very seldom met with.
The anatomical characters indicative of car ditis are a dark, almost black, colour of the muscular substance, the fibres of which have lost in a great measure their cohesive power; they are very compressible and readily torn, and consequently cannot be easily isolated to any great extent, although easily separable en masse. When the muscular wall of either ven tricle is pressed, the blood oozes out from the divided vessels on the cut surface in much greater quantity than usual. In Mr. Stanley's case, as in all cases, the dark colour of the fibres " evidently depended on the nutrient vessels being loaded with venous blood." When in addition to these signs we find purulent de posits in various parts of the muscular struc ture, and moreover, when it is manifest that the internal and external membranes are implica ted, from the effusion of coagulable lymph on them to a greater or less extent, no doubt can be entertained respecting the exact nature of the lesion. In Mr. Stanley's case, " upon looking to the cut surface exposed in the section of either ventricle, numerous small collections of dark-coloured pus were visible in distinct situations among the muscular fasciculi."-t. A similar case has been recorded by Dr. P. M. Latham, the anatomical characters of which ac corded with those above mentioned. " The whole heart was found deeply tinged with dark coloured blood, and its substance softened ; and here and there, upon the section of both ven tricles, innumerable small points of pus oozed from among the muscular fibres."t Every anatomist must have noticed how variable is the colour and the consistence of the muscular structure of the heart, even indepen dent of disease of the lining tissues. The pale, soft, compressible, flexible, and, to use a com mon word, flabby heart, strongly contrasts with the firm, plump, fresh-looking elastic one ; in the former, the flaccid parietes fall together im mediately the cavities are emptied ; in the lat ter, the surfaces retain their'convexity, although the contents of the cavities have been com pletely removed. Between these two extremes there are various grades of colour and consis tence, of which Bouillaud particularises three as being the result of inflammation, the red softening, the white or grey, and the yellow.
The first is probably that which may be said unequivocally to follow primary inflammation of the muscular texture; the other two, how ever, as Bouillaud admits, occur most fre quently in connection with pericarditis : they occur, too, as Dr. Copland observes, where no sign of inflammation is manifest, and where during life there had been no evidence of car diac disease ; in cases of general cachexia and of constitutional disease, attended by discolora tion of the surface of the body, arising, in fact, as Dr. Williams explains, from an altered state of the nutrition of the organ, owing perhaps to partial obstructions in the coronary vessels ra ther than to the immediate influence of inflam mation. This last excellent observer makes the following judicious remarks in reference to this matter.* " To judge that the tissue of the heart is especially diseased, we must see that it differs much in appearance from the other muscles of the same subject. You will find, on comparing the same muscles in different subjects, a remarkable variety of colour; and in some there is no freshness in any of the muscles, but all are pale, and verging on a pinkish drab or dingy brick colour." Perhaps the most correct arrangement of the various cir cumstances under which softening of the heart may take place is that given by Andral. 1st, Softening connected with active Hyperaemia of the heart ; 2d, softening connected with anaemia of the heart ; 3d, softening connected with atrophy of the heart; 4th, softening connected with an acute alteration in the general nutritive process (as in typhus); 5th, softening connected with a chronic alteration in the general nutritive process (as in a variety of chronic diseases); 6th, softening which we are not yet enabled to refer to any morbid condition of the heart itself or of the rest of the system.t Suppuration.—The occurrence of an abscess uncomplicated with any other lesion in the walls of the heart, does not unequivocally de note the previous existence of carditis, although it may afford strong presumptive evidence of the filet : when, however, we find abscess, with lymph or adhesions of recent date, we may rea sonably infer its inflammatory nature. Dr. Copland has introduced in a note to his inva luable and profoundly learned article on Dis cases of the Heart,* an abstract of several cases in which ims was found in the substance of the heart. Those quoted from Corvisart, Itaikem, and Simonet, and probably that from Dr. Oraves,t may be regarded as examples of puru lent formation following carditis, general or partial. So likewise is Laennec's case, in which, however, the carditis was consequent upon pericarditis. There is no anatomical cha racter which will enable us to distinguish whe ther a simple purulent deposit, surrounded by natural muscular texture, be inflammatory or not, for there is no reason why the heart should be exempt from that which we know often occurs in other muscles, namely, non-inflam matoty deposits.