644 



ABNORMAL CONDITIONS OF THE HEART. 



stomach of the calf, or, as Laennec suggested, 

 to tlie appearance produced by quickly se- 

 parating two slabs of marble which have been 

 applied together, with a small quantity of 

 butter or some similar substance between them. 

 The depth of the depressions in this false 

 membrane varies with the thickness of the 

 membrane itself. Shortly after its deposition 

 the lymph is very tender and easily torn, but 

 when it has been some time deposited, it ac- 

 quires a considerable power of resistance. The 

 effused fluid in pericarditis varies likewise in 

 quality and quantity. In some cases it is 

 whey-coloured, with flocculi of lymph floating 

 in it ; in others it is of a yellowish colour, ap- 

 proaching that of pus, and in some degree of 

 the same consistence : sometimes it is of a 

 brownish colour. When it is in very small 

 quantity it is less turbid ; when in large quan- 

 tity it resembles whev. In some cases the 

 quantity is very considerable. It may be said 

 to vary from a few ounces to more than a pint ; 

 but in some extreme cases it goes even far be- 

 yond this; thus Corvisart mentions a case in 

 which the effused fluid amounted to eight 

 pounds, and in one described by Berlin the 

 distended pericardium formed a bag seven or 

 eight inches broad, five deep, and ten or eleven 

 in height. Sometimes the effusion cannot be 

 distinguished from pus. 



The coagulable lymph is effused not only on 

 the free surface of the visceral layer of the pe- 

 ricardium, but likewise on that of the parietal 

 layer. That which is effused upon this latter 

 layer is, however, often much thinner and 

 more delicate. These two deposits of lymph 

 are continuous with each other at the reflection 

 of the serous pericardium from the great vessels 

 on to the muscular fibres. When the effused fluid 

 has been removed by absorption, the two pseudo- 

 membranes being brought into apposition with 

 each other, areas it were glued together; they 

 become organised by new vessels shooting into 

 them from the cardiac vessels, and at length 

 they assume the form of cellular tissue. The 

 cavity of the pericardium thus becomes oblite- 

 rated by the development of this new cellular 

 tissue. The adhesions thus formed are more 

 or less extensive according to the extent of the 

 primitive inflammation, so that in some cases 

 the pericardium is universally adherent to the 

 heart ; in others the adhesion is circumscribed 

 within very narrow limits ; in this latter case 

 the new cellular membrane is often of conside- 

 rable length, inasmuch as the spots to which it 

 adheres on the opposed layers of serous mem- 

 brane do not at all correspond ; but when the 

 adt es on is extensive, the connecting cellular 

 membrane is generally short and close, so much 

 so in some cases that the pericardium and heart 

 appear to be completely identified. The mus- 

 cular substance subjacent to the inflamed peri- 

 cardium sometimes appeais to participate in 

 the inflammatory process, acquires a greater 

 hue of redness than is natural, and becomes 

 softer, and loses to a greater or less degree its 

 cohesive power. 



Such is the ordinary course and termination 

 of pericarditis. Every museum contains many 



specimens illustrative of the different stages of 

 this disease. Tlie cellular adhesion which fills 

 up the pericardial cavity occasionally exhibits 

 further alterations. Sometimes we find it infil- 

 trated with serum, and quite anasarcous; at other 

 times asero-purulent or purulent fluid is effused 

 into it. It becomes condensed, fibrous in its 

 character; or cartilaginous or fibro-cartilaginous 

 or even osseous plates are formed in it, which 

 sometimes are of so large a size that the heart 

 appears as if enveloped in an osseous case. 

 This cartilaginous or osseous deposit, however, 

 sometimes takes place in the fibrous pericardium. 

 Dr. Hodgkin mentions a case of osseous trans- 

 formation so extensive that the osseous plate 

 occupied a large portion of the base of the 

 heart, where it formed a complete bony ring, 

 the apex of the heart, however, beinj left at 

 liberty. A somewhat similar case is recorded 

 by my friend Mr. Smith. " The pericardium was 

 united to the surface of the heart by close and 

 old adhesions, and around the base of the 

 organ bony matter was deposited in considera- 

 ble quantity, apparently between the two serous 

 layers of the pericardium ; it formed an osseous 

 belt surrounding nearly theentireofthebaseofthe 

 heart ; its surface flat and rough, its margin 

 irregular and waving, and its average breadth 

 about one inch. This bony girdle penetrated 

 into the substance of the ventricles, and reached 

 in some parts almost to the lining membraneof the 

 latter."* In Mr. Burns' case the whole extent 

 of the pericardium covering the ventricles, and 

 the ventricles themselves, except about a cubic 

 inch at the apex of the heart, were ossified and 

 firm as the skull. 



White spot on the heart, There is no ap- 

 pearance with which anatomists are more 

 familiar than the white spots on the heart. A 

 single portion of white opaque, or nearly 

 opaque membrane, situated on the anterior part 

 of the right ventricle nearer its apex than its 

 base, and varying in circumference from that of 

 a shilling to that of a half-crown, as thick as 

 the pericardium itself and sometimes conside- 

 rably thicker, constitutes what I have most fre- 

 quently seen. They may be found, however, oc- 

 casionally on the posterior surface as well as the 

 anterior, on the left side as well as the right, 

 on the auricles as well as the ventricles. On 

 careful examination, it is evident that the opa- 

 city is occasioned by an adventitious deposit. 

 This deposit, in a great number of the cases 

 in which 1 have examined it, consisted of a 

 thin lamina of condensed cellular membrane 

 adherent to the free surface of the visceral 

 layer of the pericardium, which could easily be 

 dissected oft', and which 1 have often peeled off 

 with my fingers, leaving the pericardium appa- 

 rently as if no deposit had been found there. 

 Dr. Baillie, and more recently Laennec and 

 Louis, testify to the facility with which it 

 may be dissected off. Others, however, affirm 

 that the deposit is most frequently under the 

 serous covering of the heart, and consequently 

 in the subserous cellular tissue by which that 

 layer is connected to the heart. Corvisart 



* Dub. Journ, vol. ix. p. 419. 



