CHAPTER XVIII.

THE MORBID ANATOMY OF THE HEART.

THE close relation existing in disease between certain affections of the pericardium and endocardium would be a sufficient excuse for taking the affections of the latter into consideration at once. But it appears more convenient to follow the anatomical sequence, both because there is an undoubted relation between many morbid states of the serous envelop and the muscular substance, and because the pathology of the endocardium is a natural transition to the morbid anatomy of the cardiac valves and the blood vessels. Much has been done of late to promote our knowledge of cardiac disease, and the main result has been to withdraw many so-called functional diseases of the organ from this category, and to classify them with the known lesions met with in other tissues of the body which are more accessible to examination in life. It is more particularly in the sphere of degenerative changes, and their effects, that the advance has taken place; much yet remains to be done in the demonstration of the simple and primary forms of disease.

Congestion of the heart may be assumed to exist in the early stages of several affections with which we become acquainted, when they interfere with the vital functions. We frequently find the heart of a dark color, and the veins overcharged with blood, as secondary effects of disturbance in the circulation; in the same way, we see an anæmic condition of the organ manifested by pallor, and a flabby condition of the muscular tissue, in the train of long standing and debilitating disease.

CARDITIS.

Genuine carditis, ulceration, and abscess of the heart, are conditions of which but few cases are recorded. Of the former, Dr. Latham' details a remarkable instance. It occurred in a boy, aged twelve years, who presented all the symptoms of acute cerebral disease, without any indications of the disorganization found after death. No vestige of morbid action was discovered in the brain, but the heart was the seat of the most intense inflammation, pervading both the heart and muscular structure. There was the ordinary evidence of recent pericarditis, and when the heart was itself divided, the muscular fibres were dark-colored, almost to blackness, loaded with blood, soft, and loose of texture, easily

separated, and easily torn by the fingers, and at the cut edges of both ventricles small quantities of dark-colored pus were seen among the muscular fibres. The internal lining was of a deep red color, without any effusion of lymph. A case which resembles the one just detailed, and which occurred in the practice of Mr. Salter, of Poole, is detailed in the twenty-second volume of the Medico-Chirurgical Transactions. It affected a man aged fifty, who died after a short illness, in which the main symptoms were oppression and distress at breathing, inability to lie down, and a dull, heavy pain at the sternum. The pulse at the same time was eighty, and regular, and the action of the heart seemed. natural. There was no serous or other effusion into the pericardium, nor any signs of disease in the valves or endocardium. The heart itself was somewhat larger than natural, and its substance of moderate firmness. The great deviation from the normal condition of the heart was to be found in the muscular condition of the left ventricle. Excepting a few lines in thickness on either surface, the left ventricle had entirely lost its muscular color; it was of lightish yellow hue, but still preserving the fibrous character of muscle. From all the cut surfaces purulent matter could be scraped; in some parts absorption had taken place, leaving small cavities in the muscular substance, varying from the size of a pin's head to that of a small pea; these were all filled with pus. A third case of the same kind is related by Mr. Stanley in the seventh volume of the Medico-Chirurgical Transactions, p. 323, which occurred in a boy aged twelve. In purulent infection, when deposits of pus are found in the parenchyma of every organ of the body, the heart rarely presents similar appearances. It is a common thing to find the muscular tissue in severe pericarditis of an abnormally dark color, and it seems probable that, in the cases alluded to, the primary disease lay in this membrane. In those rare cases in which an ulcer is found in the substance of the heart, and an abscess occurs in the muscular tissue, we may fairly assume local inflammation to have preceded, and in the cases which are presented by the records of pathological anatomy the appearances are generally mentioned as indicating such a process. In a case of general hypertrophy of the heart, accompanied by enormous dilatation of the mitral orifice, and diseased aortic valves, which was exhibited at the Pathological Society in 1847, by Dr. J. R. Bennett, an opening of the size of a quill was found in the ventricular septum; this was surrounded by ulceration, warty roughness, and thickening, and there were distinct traces of inflammation round the opening. Hemorrhage into the substance of the heart is occasionally met with in small spots, in connection with pericarditis; but in cases of genuine cardiac apoplexy, as Cruveilhier terms effusion of blood into the substance of the heart, which must be considered in the same category as spontaneous rupture of the organ, we almost invariably find fatty degeneration at and near the point, which has destroyed the uniform consistency of the organ.

Before entering into the examination of this morbid condition, we must mention one undoubted residue of inflammation, which presents the appearance of fibrinous deposit, or an interstitial deposit of lymph. We meet with this in rheumatic subjects. The heart presents a feeble, flabby

appearance, and spots of an irregular shape and a pale yellowish hue are found scattered through the tissue. The circumference of these spots is tolerably defined, or the deposit appears to follow the direction of the fibres. It may itself be associated with fatty degeneration, but the microscope sufficiently serves to distinguish it from this condition. It is found to consist of granular matter, within which nuclei and fibroid cells are imbedded, and oil-globules. This is entirely external to the muscular fibre, which commonly exhibit an atrophic condition in the immediate vicinity of the deposit. Dr. Hope' recognizes three varieties of softening occurring in the heart as a result of inflammatory action : a red, whitish, and yellow form. The red, he says, corresponds to the first stage of carditis, and is analogous to the inflammatory engorgement constituting the first degree of peripneumony; the whitish corresponds with a more advanced stage, analogous to the second and third degrees of peripneumony, when a pale tint is produced by the absorption of the red particles of the blood, and by the presence of lymph and pus in variable proportions. The yellow variety he considers rather the result of chronic inflammation. These views are supported by Laennec, Bouillaud, Corvisart, and other continental authors, who at the same time admit the distinct character of a fatty degeneration. The microscope has of late contributed much to unsettling these doctrines, inasmuch as the naked-eye view has been almost superseded, and, in some instances, we fear, to the detriment of true science. For, valuable as it is in analysis, if used exclusively it prevents that general coup d'œil which embraces more than one morbid phenomenon, and which is necessary to the due appreciation of disease in its totality. We are induced to make this warning remark, because, in analyzing the records of the post-mortem appearances of heart-disease during the last six years, we find that almost invariably a fatty degeneration of the organ, or of individual parts, has been discovered; and this condition is one which is by no means limited to a certain well-defined disease, but is found to prevail so extensively that we cannot but look upon the molecular disintegration implied by it as a mere symptom of various elementary morbid states. It is undeniable that the appearance of minute vessels, e. g. of the brain in a state of fatty degeneration, as found in the vicinity of apoplectic clots, or in connection with atheroma of the larger arteries, closely resembles the appearance presented by vessels of the pia mater surrounded by or containing so-called exudation-matter in meningitis. In both instances, microscopic globules, of a highly refracting character, are the characteristic symbol. The fibre of the heart, when affected in this manner, presents a similar appearance.

FATTY DEGENERATION.

The degeneration may be traced through various stages. It commences as an atrophic condition, in which the fibre loses its sharp edges, and the striæ, so well seen in the healthy heart, disappear. One or

1 A Treatise on Diseases of the Heart, &c., 3d edit. p. 333.

more oil-globules successively appear, until the whole fibre is occupied by them; its outline is broken, and in the highest development the fibres appear almost fused together into a confused, more or less opaque, mass, in which nothing of the original tissue can be traced. This molecular deposit of oil in the fibre is often accompanied by a generally adipose condition of the organ, and a layer of fat on the surface; but not necessarily so, and we must be careful not to infer that the heart is in a state of fatty degeneration because it is surrounded by adipose tissue. The fat may insinuate itself between the muscular fasciculi and fibres, and yet no change in the latter take place. The large circular fat-cell, with its sharp boundary of th of an inch in diameter, when seen under the microscope, occupies the former position, and cannot be mistaken for the minute oil-globule, which varies from a microscopic point to 30th of an inch, and is confined to the interior of the sarcolemma.

The heart affected with fatty degeneration has lost the firm muscular appearance which characterizes it in health, and presents a pale, yellowish, buff color, either throughout or limited to individual parts. When cut into, a greasy stain is often left on the knife, though the absence of this circumstance must not be looked upon as an indication that the heart is not degenerated. The left ventricle and the columnæ carneæ are most liable to be thus diseased; next in order the right ventricle and right auricle, while the left auricle is least frequently involved. Dr. Quain,' to whom we are indebted for a clear résumé of the whole subject of fatty degeneration of the heart, has found that in Fig. 139.

A. Heart-fibres taken from the columnæ carnea of the mitral valves of a young woman, æt. 30; the fatty degeneration was scarcely observable in the ventricle, where the fibres still retained their strice.

B. An extreme case of fatty degeneration, showing an entire conversion of the muscular fibre into oilmolecules, still retaining a linear arrangement. It is taken from the right ventricle of an old gentleman, who had Bright's disease of the kidney and pulmonary phthisis, and was affected with fits during the last two years of his life.

twenty-two cases, in which the seat of the disease was expressed, the two ventricles were affected in ten, the left alone in eight, and the right alone in four. Rokitansky describes three forms of fatty degeneration of the heart; the first two are varieties of fat-deposit upon and within

1 Medico-Chir. Trans. vol. xxxiii. p. 121.

the heart, external to the muscular fibre to which we have alluded above, and to which, with Dr. Quain, we would apply the term fatty growth, while the term fatty degeneration should be confined to that change in the muscular fibre which we have just described, and which constitutes Rokitansky's third form. The deposit and the degeneration may coincide, but there is no definite relation between the occurrence of the

two.

The frequency with which fatty degeneration of the heart occurs among the patients that present themselves in a London hospital, may be inferred from the circumstance that Dr. Ogle has met with it in 100 out of 143 post mortems, in which he noted the microscopic appearances of the organ; a circumstance sufficient to rivet the attention of nosologists upon the heart, in order to determine with more accuracy than we at present can bring to bear, the incipient morbid conditions to which this state is due. It is essentially a disease of middle and advanced life; and is, we may say, invariably associated with a fatty condition of other organs, more especially of the liver, the spleen, and the arterial system; in this is borne out the observation of Dr. Latham, that excepting those cases in which the damage done to the heart could be clearly traced to some distinct attack of accidental disease, his records of dissections do not supply him with a single instance of a person reputed to die of disorganized heart and its consequences, in whom, after death, other parts were not also found disorganized. And, he continues, the kind of disease in other parts has been such as could in nowise have been derived from the heart, but must have grown out of special morbid processes within themselves, whether prior or subsequent to, or simultaneous with, the disease of the heart.

Dr. Quain concludes, from the circumstances, that when muscular tissue is exposed to certain influences, such as a stream of running water or the action of dilute nitric acid, it assumes appearances identical with those of fatty degeneration, that the processes occurring in the dead meat and the living heart are identical. We are willing to admit the analogy, but we are of opinion that the uniform evidence of a degenerative tendency throughout the system, accompanying the fatty heart, is a strong proof of the ultimate cause residing in the organs and function of nutrition. The circumstance of the coronary arteries being almost invariably atheromatous, or in a state of ossification, is rather corroborative of the view, for we are not justified in assuming a primary and idiopathic affection of these vessels. Whatever may be the theory of the disorganization, its existence and frequency is sufficiently established, as well as the fact of its being the cause of further changes in the muscular tissue of the heart, which are a common source of suffering and death. Syncope and angina pectoris during life, are among the effects of fatty degeneration of the heart and diseased coronary arteries; apoplectic effusion into the substance of the organ, rupture, dilatation, and aneurism of the heart, are found in constant connection with this affection.