ABNORMAL CONDITIONS OF THE HEART. 



635 



normal formations by excess. Thus, four or 

 even five valves are occasionally found in the 

 pulmonary artery more frequently than in the 

 aorta. The supernumerary valves are always 

 small, and sometimes appear to have been 

 formed at the expense of the next normal one. 

 Anomalous connexion of the vessels oj' the 

 heart. Our space will only permit us to 

 enumerate the principal observed varieties. 

 1. The aorta or pulmonary artery, or both, 

 appear to arise equally from both ventricles, 

 the septum of the ventricles being more or less 

 deficient. 2. The aorta may arise from the 

 right ventricle, and the pulmonary artery from 

 the left, the veins preserving their natural posi- 

 tion. 3. The vena azygos opens into the 

 right auricle. 4. The hepatic veins open into 

 the right auricle. 5. The ductus arteriosus 

 opens into the right ventricle. 6. Two superior 

 venae cavse open into the right auricle. 7. 

 Very rarely the right auricle gives insertion 

 to one or more pulmonary veins, and on the 

 other hand the left auricle receives sometimes 

 the superior vena cava, and at other times the 

 inferior. 8. Meckel states that he has seen the 

 great coronary vein of the heart to open into 

 the left ventricle.* Professor Jeffray, of Glas- 

 gow, relates a case in which the inferior cava 

 opened into the upper part of the right auricle, 

 taking the course as well as the place of the 

 vena azygos. 



On displacement or ectopia of the heart as a 

 consequence of* disease. The most common 

 cause of morbid displacement of the heart is 

 an effusion of air or liquid into one of the 

 pleural cavities. The displacement is most 

 manifest when it follows effusion into the left 

 side, by which the heart is pushed over to the 

 right, the degree of displacement depending 

 on the amount of effusion, and thus alteration 

 of the heart's position becomes one of the 

 diagnostics of empyema, hydrothorax, pneumo- 

 thorax. In general, the more rapid the effusion 

 the more certainly will the displacement be 

 effected, and the greater will be its extent. In 

 nine cases out of ten, as my friend Dr. Towns- 

 end remarks,f when the heart is removed out of 

 its natural situation, the displacement will be 

 found to have arisen from empyema or pneumo- 

 thorax ; and of twenty-seven cases observed by 

 him, the heart was perceptibly displaced in 

 every instance. On the other hand, when the 

 effusion is slow and gradual, the extensibility 

 of the neighbouring textures is more completely 

 brought into play, and the displacement of the 

 heart is thus counteracted, whence it happens 

 that in cases of chronic dropsical effusions into 

 the chest, displacement of the heart is not of 

 frequent occurrence, nor is it extensive when it 

 does take place. When the effusion occurs on 

 the right side, the heart may be pushed more to 

 the left, and upwards, than is natural, but to 

 effect this a considerable effusion is necessary. 

 The first notice of this fact is due to my able 

 friend, Dr. Townsend, to whose article I have 

 already referred. In a case of pneumothorax 



* This enumeration is taken from Bouillaud, 

 Traite des Maladies du Coeur, t. ii. p. 588. 

 t Cyclop. Pract. Med. vol. ii. p. 390. 



to which he refers, and which I also witnessed, 

 the effusion was on the right side, and the 

 heart was distinctly seen and felt pulsating 

 between the fourth and fifth ribs, near the left 

 axilla. After paracentesis, which was performed 

 by the late Dr. M'Dowel, the heart gradually 

 returned to its normal position, as the displacing 

 force was removed by drawing off the air and 

 fluid contained in the opposite pleura. More- 

 over, as has recently been ascertained by Dr. 

 Stokes, the absorption of an effusion of the right 

 side will cause the heart to be displaced to that 

 side, the pleural cavity being obliterated by 

 lymph, while the lung of the left side is en- 

 larged so as to aid in occupying the vacant 

 space and pushing the heart over. 



It is scarcely necessary to observe that tu- 

 mours forming in the right or left sac of the 

 pleura may occasion displacement ; thus aneu- 

 rismal tumours may push the heart to the right, 

 to the left and upwards, or even forwards and 

 outwards against the wall of the thorax, or 

 downwards, so that its apex will pulsate in the 

 epigastrium. Of this last displacement, Dr. 

 Townsend* relates an example. I have my- 

 self observed, some years ago, a case where the 

 heart was pushed forwards and outwards, and 

 as it were compressed against the ribs by an 

 enormous aneurism of the thoracic aorta; the 

 sounds of the heart were so modified by this 

 compression as to lead to the erroneous diagnosis 

 of concentric hypertrophy. In the case recorded 

 by Drs. Graves and Stokes,f the heart was 

 pushed upwards and to the right side by an 

 abdominal aneurism, so as to pulsate in the in- 

 tercostal space of the third and fourth ribs. Dr. 

 Hope mentions the displacement to the left by 

 an aneurism of the ascending aorta. Any 

 cause which pushes the diaphragm upwards 

 and prevents its descent, such as distension of 

 the abdomen by an enlarged viscus, a tumour, 

 or an effusion, will change the position of the 

 heart, so that its axis will be directed horizon- 

 tally ; and Dr. Hope has remarked that the 

 same position may be produced by an adhesion 

 of the pericardium to the heart, by which its 

 enlargement downwards is prevented. A 

 diaphragmatic hernia will displace the heart to 

 an extent proportionate to that of the visceral 

 protrusion. In a case recorded by Drs. Graves 

 and Stokes, the stomach and a large portion of 

 the transverse arch of the colon were lodged in 

 the left cavity of the thorax, and pushed 

 the heart and mediastinum towards the right 

 side. When the lung is enlarged from dilated 

 air-cells, the heart may be displaced : it may 

 be drawn considerably downwards by the dia- 

 phragm, which yields before the enlarged lung, 

 thus increasing the vertical diameter of the 

 chest ; or it may suffer a slight degree of lateral 

 displacement, the mediastinum being pushed to 

 the right side by the lung.J 



Dr. Stokes has related the remarkable, and 

 so far as I know unique case of displacement, 

 or as he terms it " dislocation," of the heart 



* Loc. cit. 



t Dub. Hosp. Rep. vol. v. p. 10. 

 j See Dr. Stokes's valuable work on Diseases of 

 the Chest, pp. 187-191. 



