Ulceration —As true carditis seems to be generally admitted to be rare, so we may con clude that ulceration is equally so. It is by the ulcerative process that some of the perfora tions or ruptures of the parietes of the heart take place ; it is probable, however, that the great majority of the ulcerations we meet with commence from the surface, and result from membranous inflammation rather than from that of the muscular substance; the ulcer commences on the surfaces, either in or imme diately subjacent to the internal or external membrane ; and as it burrows deeply, it may perforate the muscular wall, and so destroy the membrane on the side opposite to that on which the ulceration had commenced. Sometimes an ulceration of this kind gives rise to aneurismal tumours or sacs, very variable in size, projecting from that part of the cavity which corresponds to the artery. It seems evident that these tumours are produced by the pressure of the contained blood distending the thinned and yielding wall of the heart. We shall return to this subject further on in treating of aneurisms of the heart.
Induration.—This condition of the muscular structure of the heart seems most probably to be a result of inflammation, especially of the chronic kind. It is generally found in small circumscribed portions ; it may occur in any part of the heart, and may even co-exist with softening : the hardened portion has become particularly firm, is cut with d iffieulty, and when struck with the scalpel sounds, as Laennee says, like a leather dice-box. It is harder, denser, less elastic, and as regards colour is paler than the hypertrophied muscular tissue.
Cartilaginous and osseous tran!formations.— Induration of the subserous cellular tissue of the heart is in general the precursor of many of these transformations. This indurated portion increasing in thickness gradually assumes the appearance of cartilage—in this cartilage the calcareous particles are deposited. I have not been able to ascertain whether this so-called ossification exhibits, on examination by the mi croscope, the lamellar arrangement of true bone, as osseous transformations of certain permanent cartilages do, those of tire thyroid cartilage for example. These calcareous or osseous patches or tumours compress the subjacent muscular tissue, and produce atrophy of them, and ac cording to Andral, sometimes are connected by prolongations of tire same material with other calcareous deposits formed round the orifices. Many pathologists believe that these transfor mations are the result of inflammation. I sup pose there can be no doubt that they follow an increased afflux of blood, and so they may be considered, although not an immediate, at least a remote effect of inflammation, or rather of the altered nutrition and secretion to which inflam mation gave rise.
In a case recorded by my friend Mr. Robert Smith, of Dublin, the apex of the left ventricle was converted into a dense, white, firm, car tilaginous structure, the division of which with a scissors required the employment of con siderable force ; the alteration of structure had extended to some of the carneze columnar.* 2'ubcrcles.—These productions are very rarely if ever met with in the heart. No re liance can be placed on most of the instances recorded, in consequence of the imperfect and unsatisfactory descriptions accompanying them; what appears to one person to be tubercular may present a totally different aspect to another. Laennec says vaguely, " only three or four times have I met with tubercles in the muscular substance of the heart." And Andral states, that they are never met with in the heart, except when they likewise occur in other muscles. Otto says, "although I have dis sected a great number of scrofulous men and animals, I have never found a tubercle on the heart, and therefore consider them very rare." Dr. Elliotsont mentions a case in which there were scrofulous deposits in the walls of the left ventricle, surrounded by white and almost cartilaginous induration. In a case which came under my own observation, in a woman be tween 50 and 60 years of age, there were several white tumours in the parietes of the right ventricle, each about a quarter of an inch in diameter, of uniform consistence throughout, nor showing any disposition to softening in the centre.
Scirrhus.—Equally unsatisfactory are the reports of anatomists respecting this alteration. Ruliier and Billard relate cases in which seirrhus had developed itself on the heart. Rullier's: case was an instance of degeneration of the whole substance of the heart into a scirrhous mass, which formed irregular knobs on the ex ternal and internal surfaces of the heart. Bil lard found three scirrhous tumours embedded in the heart of an infant only three days oltl.§ Medullaryfiingus, or encepha laid tumours.— Of these, several instances are quoted by Andral from others, and he describes two which he saw himselfil In the first of Andral's cases the whole of the walls of the right auricle and ventricle were converted into a hard, dirty white substance, traversed by a number of reddish lines, and possessing all the characters of encephaloid. In the second case, the external wall of the right ventricle was occu pied by a tumour extending from its apex to its base, which projected so far externally as to lead him to mistake it for a supernumerary heart, and likewise protruded internally into the cavity of the ventricle. In a case which I saw myself, the tumour resembled the well-known encephaloid or cancerous tumour of the liver, being, like it, raised above the surrounding muscular structure, and irregular on its surface.