ABNORMAL CONDITIONS OF THE HEART. 



633 



parently as a consequence of this contracted 

 state of the arterial outlet of the right ventricle 

 the ductus arteriosus often remains open, which, 

 by its communication with the aorta, conveys 

 some blood into the pulmonary arteries from 

 that vessel ; and, as a further complication, the 

 right ventricle is very small and appears merely 

 as an appendage to the left ; sometimes also 

 the left auricle is very small, while the right is 

 much dilated. 



Where so much complication exists, as that 

 just detailed, one is only surprised that vitality 

 can be at all supported after extra-uterine life 

 has commenced; yet we find that children with 

 hearts so malformed live three, four, or five 

 days, and even as many weeks or months; 

 but where the perforation of the septum is not 

 accompanied with the contracted state of the 

 pulmonary artery, life may be prolonged to a 

 considerable period. Thus, Louis quotes one 

 case of a general officer (age not stated), whose 

 death was occasioned by the active part he took 

 in the American war. Along with ossified 

 valves of the right auriculo-ventricular orifice, 

 there existed a perforation of the septum ven- 

 triculorum large enough to admit the extremity 

 of the little finger. In another case, quoted 

 from Richerand, the patient aged 40, the per- 

 foration of the septum was half an inch in 

 diameter. 



We say that the two sides of the heart com- 

 municate indirectly when the ductus arteriosus 

 continues, as in its foetal state, to convey the 

 blood of the right heart into the aorta descen- 

 dens, where it becomes intermixed with the 

 blood of the left heart. But it is very rare to 

 find this condition existing alone, and when it 

 does so exist, the canal of communication is 

 generally very narrow. More frequently it is 

 complicated with a contracted state of the pul- 

 monary artery, the place of which it seems to 

 supply. In a case related by Mr. Howship,* 

 this vessel constituted, in fact, the trunk of 

 the pulmonary artery. The pulmonary artery 

 proper arose in its usual situation, but was 

 quite impervious at its root, though far beyond, 

 and terminated in a cul-de-sac beside the heart. 

 Similar cases are recorded by Dr. Farre. At 

 other times the ductus arteriosus is employed 

 to supply the place of the aorta descendens; the 

 aorta is perfect only as far as the termination 

 of its arch, where it contracts, and its con- 

 tinuation is formed by the ductus arteriosus, 

 through which the descending aorta receives 

 its whole supply of blood.f 



A very perfect case of this kind is quoted 

 by Dr. PagetJ from Steidele. The aorta and 

 pulmonary artery arose as usual ; the aorta was 

 entirely distributed to the head and upper 

 extremities, while the pulmonary artery, after 

 giving off two branches to the lungs, con- 

 tinued as the aorta descendens without any 

 communication with the aorta ascendens. 



Malformations of the valves. A not un- 

 important class of defective malformations in 



* Edin. Med. and Surg. J<u-n. vo 1 . ix. 



t See Sir A. Cooper's CASCS in Farrc, loc. cit. 



$ Loc. cit. 



the heart consists of imperfections in the num- 

 ber or structure of the valves. The aorta may 

 have two valves only, one of which may retain 

 its natural form and size, while the other pre- 

 sents the appearance of having been formed 

 by the fusion of two valves ; it may therefore 

 present one or more openings in it, so as to 

 appear somewhat cribriform. A similar con- 

 dition is met with in the pulmonary artery, 

 when sometimes the three valves seem as it 

 were united to form one membrane, which like 

 a diaphragm stretches across the mouth of the 

 artery, and is perforated in the centre by an 

 opening through which the blood finds its way 

 into the artery. This narrowing of the orifice 

 of the pulmonary artery is the most frequent 

 of the congenital malformations of the valves : 

 we have already described it as a frequent con- 

 comitant of imperfect septum of the ventricles. 

 Congenital imperfections of the mitral and 

 tricuspid valves are of very rare occurrence. 

 The perforated or cribriform condition which 

 is frequently seen affecting these valves, the 

 Eustachian and Thebesian valves, and more 

 rarely the semilunar valves, is probably the 

 result of a morbid atrophy. 



Congenital absence of the pericardium. 

 Connected with the malformations by defect 

 of developement we may mention the con- 

 genital absence of the pericardium, which, 

 although very rare, rests on too strong evidence 

 to admit any further doubt of the possibility 

 of its occurrence. Most of the cases related 

 by the older authors weie in connexion with 

 displacement of the heart, and from the liabi- 

 lity of mistaking universal adhesion of the 

 pericardium for this congenital absence, many 

 anatomists, among whom was Haller, denied 

 that such a defect had ever existed. 



Dr. Baillie* was the first of modern anato- 

 mists who accurately described a case of this 

 kind. " Upon opening," he says, " into 

 the cavity of the chest, in a man about forty 

 years of age, in order to explain at lecture the 

 situation of the thoracic viscera, I was ex- 

 ceedingly surprised to see the naked heart 

 lying on the left side of the chest, and could 

 scarcely at first believe what I saw, but the 

 circumstances were too strong to keep me long 

 in doubt. The heart was as bare and distinct 

 as it commonly appears in opening into the 

 cavity of the pericardium, and every collateral 



circumstance confirmed the fact The 



heart lay loose in the left cavity of the chest, 

 unconnected in any way except by its vessels ; 

 was of a large size, elongated in its shape, 

 and had its apex opposite to the eighth rib. 

 The right auricle was obviously in view in the 

 same manner as when the pericardium has 

 been opened, and the vena cava superior and 

 inferior were clearly observed entering into it. 

 The appendage of the left auricle was as clearly 

 in view; and when the heart was inverted, so 

 as to have its apex turned upwards, the extent 

 of its cavity was seen with the two pulmonary 



* On the want of a pericardium in the human body, 

 in Transactions of a Society for the Improvement 

 of Med. and Chir. Knowledge, vol. i. p. 91, with 

 a plate of the appearances. 



