I have often found (I presume, therefore, that it is not an uncommon occurrence) coagula of an irregularly laminated texture having their colouring matter not entirely discharged, but unequally distributed through them, which have been most intimately adherent to some part of the lining of the heart. Of these some have admitted of separation, while the surface of the membrane and the surface of the clot were left rough at the place of contact, and others were incapable of being detached without the membrane being detached along with them. The appendix of the left auricle is a situation in which they are apt to occur, and they are generally accompanied by an extensively diseased condition of the lining membrane. These coagula, from their laminated texture, and from the intimacy of their union with the internal lining, seem to be essentially different from polypi of the heart. They appear to be connected with a process of disease in the membrane, and to have obtained their union with it long before the death of the patient.
I once saw two separate tumors, entirely resembling what are called polypi, between the carneæ columnæ of the left ventricle, and firmly adherent to the heart; and in the centre of each a distinct formation of pus. The heart was otherwise healthy[9].
There are three preparations in the museum of the College of Surgeons, put up by Mr. Hunter himself, and noted by him as exhibiting "Tumors on the inner surface of the right ventricle, seemingly composed of layers of coagulable lymph one upon another, the central part having the appearance of glary mucus." This last appearance (the mucus) no longer remains in any of the three, but in its stead there is a cavity. The tumors which I have mentioned as originally containing in their centre a distinct formation of pus, also now present in its stead a cavity. The preparation preserved at St. Bartholomew's, and those at the College of Surgeons, are probably specimens of the same disease.
Here what in the recent parts seemed to be pus or glary mucus, and the cavities still remaining in the preparations, must suggest the suspicion, that these tumors, whether they grew from the surface or were deposited from the blood, had become organized, and afterwards inflamed; and that the inflammation had terminated in the formation of an abscess.
ESSAY III.
Morbid Anatomy of the Muscular Substance of the Heart.
Dr. Baillie, speaking of inflammation of the substance of the heart, says, "When the pericardium covering its surface is inflamed, the inflammation sometimes passes a little way into the substance of the heart:" and then he gives these as the characteristic marks of such inflammation—that "it (the substance of the heart) becomes much more crowded with small vessels than in its natural state, and there are sometimes to be seen a few spots of extravasated blood." Now, this undue vascularity, and these few extravasated spots, where inflammation unquestionably belongs to a contiguous structure, may be deemed sufficient evidence of the muscular substance of the heart participating, or beginning to participate, in the same disease; but, absolutely and exclusively, it may be doubted whether more is not required to give a certain assurance of its inflammation. Here, as elsewhere, we must look for some of the proper products of inflammation; or for some of the permanent changes of texture which naturally result from it, according to its several modes of disorganizing.
It is a very rare event to find pus among the products of inflammation of the substance of the heart: yet this event has occurred twice to my observation. In one instance the whole heart was deeply tinged with dark-coloured blood, and its substance softened; and here and there, upon the section of both ventricles, innumerable small points of pus oozed from among the muscular fibres. This was the result of a most rapid and acute inflammation, in which death took place after an illness of only two days. In another instance, after death, which terminated an illness of long duration and characterized by symptoms referable to the heart, a distinct abscess was found in the substance of the left ventricle, closed externally by a portion of adherent pericardium, and connected internally with an ossified portion of the lining membrane.
This diffusion of pus, or rather its formation in innumerable separate points, throughout the muscular structure of the heart, by a rapid and acute inflammation, is a singular occurrence. No such case has ever fallen within the knowledge of the most experienced in morbid anatomy, of whom I have made inquiry; neither has any such (as far as I can learn) been recorded in books[10].
A single collection of pus[11], constituting an ulcer or abscess of the heart, and resulting from chronic inflammation, is also a rare occurrence, yet not so rare but that a specimen of it may be found in most collections of morbid anatomy[12].