after

inflating the lungs and applying friction to the skin, but it was all in vain. After

four hours, when preparations were made for burying the child, it was observed hours.

with astonishment that the skin had a blush upon it; fresh endeavours at resuscitation were had recourse to, and the child soon began to breathe. Death took place in forty-two hours. Dr. Marchant is therefore of opinion that the present state of science does not warrant us in placing any definite limit to the prolongation of viability under the condition of asphyxia, and that we cannot be too cautious in coming to a conclusion as to whether a child be really dead or not. The grand resources of our art in such a case are insufflation of the lungs and the maintenance of the warmth of the body.-P.H.B.]

4

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BOOK VII.

DISEASES OF THE HEART.

Putting aside the vices of conformation, the organic diseases of the heart consecutive to birth are very rare in the infant and children at the breast. Billard simply devotes a few pages to their history, which, in the present state of science, it is still impossible to detail in a satisfactory manner.

The principal vices of the conformation of the heart are

1. Acardia, or absence of the heart, a deformity which is incompatible with extra-uterine life, and which very frequently coincides with acephalia and anencephalia.

2. Bicardia, or double heart, which is never met with except in cases of diplogenesis.

3. Ectopia of the heart, or displacement of this organ, which includes transposition of the heart, which always accompanies the transposition of the other viscera. The heart is observed on the right side, and the direction of the aorta is changed; its thoracic portion descends on the right side of the vertebral column. The heart is sometimes also observed displaced upwards, near the neck and head; this is what Breschet described under the name of ectopia cephalica; or, on the other hand, it occupies the abdomen by a congenital aperture in the diaphragm, or in consequence of the absence of this muscle; this is ectopia abdominalis, and it has been remarked that some individuals have lived a considerable time with this singular conformation.

[There may be deficiency of the pericardium, occurring generally when the heart lies outside the thorax, although it is also met with when this anomaly is not present. This deficiency is, in almost every instance, merely partial, con

sisting in the congenital anomalous position of the heart outside the thorax in a fissure of the pericardium. The heart and the left lung lie, as a general rule, in one common, large serous sac, which gives rise, at the place from whence the arterial trunks emanate, to traces of the membrane, in the form of fatty, mesentery-like folds. An excess of formation occurs in double monsters, where the pericardium is found to contain a double heart.

Anomalies of position. The congenital anomalies of position are very numerous, and admit, in part, of being referred to an arrest of development. Many depend on different adhesions of the heart resulting from inflammation in the foetus; and some, again, on different anomalies of neighbouring organs; as, for instance, on the deficient development of a lung, the partial deficiency of the diaphragm, and the position of the abdominal viscera in the thorax. These anomalies are very various in their character. The following are the most important:

Position of the heart exterior to the body. This anomaly occurs associated with a partial absence of the diaphragm and the abdominal and thoracic walls. When the former of these is absent, the heart is generally situated with all or several of the viscera externally to the body, in a closed or open sac occasionally contained in the sheath of the umbilical vessels.-P.H.B.]

4. Vices of conformation which lead to the mixture of the venous and arterial blood, these are—

1st. The heart is simple, composed of one auricle and on ventricle. 2nd. One auricle and two ventricles.

3rd. One auricle and two ventricles, one of which is rudimentary. 4th. One ventricle only, and two auricles.

5th. One ventricle only, two auricles, and the patency of the foramen ovale.

6th. The aorta and pulmonary artery originating in the right ventricle.

7th. The aorta originating from the right ventricle and the pulmonary artery from the left ventricle.

8th. Idem, the aorta from the right ventricle, the pulmonary artery from the left ventricle, and in addition the patency of the foramen ovale.

9th. Idem, the aorta from the right ventricle, the pulmonary artery from the left ventricle, the patency of the foramen ovale, and in addition the patency of the ductus arteriosus.

10th. Idem, the aorta proceeds from the right ventricle, the pulmonary artery from the left ventricle, and the patency of the two orifices of the foramen ovale and ductus arteriosus.

11th. The heart presents an opening in the ventricular septum. 12th. Idem, in addition the patency of the foramen ovale. 13th. Idem, in addition the patency of the ductus arteriosus.

14th. Idem, in addition the patency of the foramen ovale and the ductus arteriosus.

15th. Patency of both the foramen ovale and ductus arteriosus. 16th. Patency of the foramen ovale.

Such are the principal vices of the conformation of the heart which

I have merely enumerated. But in this organ, at the moment of birth, in a well formed child, there is a very important change of function, which is due to the establishment of the respiration and of a circulation independent of the mother. The foetal circulation disappears, and it is replaced by a new and particular circulation, favoured by the successive obliteration of the foramen ovale and ductus arteriosus. The ulterior regularity of the functions of the heart, and the production of some of its diseases, depend on the manner in which this obliteration has been accomplished. It is, then, important to know how the independent circulation of the child is established, and especially how the foetal openings, of which we have just spoken, close. Billard has studied this subject with the greatest care, and the following is borrowed from him.

ON THE ESTABLISHMENT OF THE INDEPENDENT CIRCULATION.

"I have most carefully observed the changes which take place in the heart, in the ductus arteriosus, in the ductus venosus, and in the umbilical arteries, during the first days of extra-uterine life. I am now about to point out the result of these researches. I shall successively pass in review, 1st, the epoch at which the foetal openings are obliterated; 2nd, the manner in which they are obliterated; 3rd, I shall point out the physiological and pathological consequences which naturally result from these researches."

1ST. EPOCH OF THE OBLITERATION OF THE FOETAL OPENINGS.

"Children one day old. In nineteen children of one day old, there were fourteen in whom the foramen ovale was entirely open, in two its obliteration had commenced, and lastly, in two others, it was entirely closed, and no more blood passed through.

Amongst these same children, the arterial canal (ductus arteriosus) was open and full of blood in thirteen, its obliteration had commenced in four, and in the remainder it was entirely obliterated. I may observe that one of these last was one of those children in whom there was complete closure of the foramen ovale. The other child observed in the same state had the ductus arteriosus yet open.

"With regard to the umbilical arteries, they were still quite pervious, close to their origin from the iliac arteries; their calibre was diminished in consequence of the remarkable thickening of their walls. Amongst all these children the umbilical vein and the venous canal (ductus venosus) were pervious, and the latter was usually observed gorged with blood.

"It results from this first examination that the foramen ovale and the ductus arteriosus are still pervious the first day of birth in most of the cases, although these openings may be obliterated at this epoch.

"Children of two days old. In twenty-two children of two days old there were fifteen in whom the foramen ovale was very pervious, in three it was nearly obliterated, and four presented this opening entirely closed. Amongst the same children I found the ductus arteriosus still pervious thirteen times, a commencement of its obliteration six times, and entirely obliterated three times. In all, the umbilical arteries were obliterated to a greater or less extent, but the umbilical vein and the ductus venosus, although empty and flattened, still allowed the entrance of a rather large probe. These facts clearly demonstrate that most frequently the foramen ovale and the ductus arteriosus are not yet obliterated two days after birth, although the child is obliged to live an independent life. As the umbilical arteries from henceforth become useless, they have already from this epoch undergone the modification which should result from their loss of action. "Children three days old. I have submitted to the same examination the bodies of twenty-two children of three days old; in fourteen of these the foramen ovale was still open, in five its obliteration had commenced, and was complete in the last three.

"The ductus arteriosus was also pervious in fifteen children; its obliteration had commenced in five, and the obliteration was complete in two only. These two subjects at the same time presented an obliteration of the foramen ovale. The umbilical vessels and the ductus venosus were empty and even obliterated in all these subjects. But it is evident that these vessels are obliterated before the foramen ovale and the ductus arteriosus have experienced a complete occlusion; and wẹ may further state that at three days old, the ductus arteriosus and the foramen ovale are not generally obliterated.

"Children four days old. I have observed, in twenty-seven children four days old, that in seventeen the foramen ovale was still open. Of these seventeen cases, there were six in which this opening was very large, and was distended by a large quantity of blood. In the other eleven individuals, the foramen ovale was simply pervious. Of the twenty-seven cases to which we are referring, the obliteration of this opening had commenced in eight, and it was completed in the remaining

two.

:

"The ductus arteriosus was still open in the seventeen children; its obliteration had begun, and even only presented a very narrow channel in seven of them; and its obliteration was complete in three subjects in nearly all, the umbilical arteries were obliterated near the umbilicus, but were still capable of being dilated near their origin from the iliacs. The umbilical vein and the ductus venosus, which were completely empty, were observed very much shrunken. Twenty-nine children, five days old,

"Children of five days old.

were submitted to the same

on as the preceding; in thirteen

the foramen ovale was still open; but this opening did not exist to the same extent amongst all these infants. It was largely dilated in four cases, and in the other ten it was of a medium diameter.

"This foetal opening was nearly completely obliterated in ten cases, and the other six it was sufficiently so as not to establish any communication between the two auricles.

"In these twenty-nine children, the ductus arteriosus was observed open fifteen times. Of these fifteen cases, in ten the canal was freely open. The obliteration was very much advanced in the other five subjects; this obliteration was nearly complete, or at least the calibre of this canal only consisted of a very narrow channel in seven children; lastly, in the other seven, the obliteration was complete. As to the umbilical vessels, their obliteration was complete in all the subjects. Up to the present time, we have observed that the fœtal openings were still pervious in a considerable number of children, even five days after their birth. None of these children presented particular symptoms which could be referred to the apparatus of circulation. We shall observe this number diminish amongst the subjects of more advanced age than those which have at present occupied our attention. "Children of eight days old. Very decided differences have not Neosh been observed between the children of six and seven days old and his Kent, those whose fœtal openings we have just examined, but it is not the same with children of eight days old. In fact, in twenty subjects Closed of which died at this age, in five only has the foramen ovale been found still open. It was incompletely closed in four individuals, and its occlusion was complete in eleven.

s

"Of these twenty children, there were only three in which the ductus arteriosus was not obliterated; one of them presented an Of The aneurism of this canal, which, in consequence of this aneurismal dilatation, acquired a size equal to that of a hazel nut. Its internal fuels lining presented a rather thick layer, having a fibrinous consistence and a yellowish colour; it was perfectly analogous to those fibrinous layers which line the interior of aneurismal sacs.

"Of these twenty cases, in six the ductus arteriosus was nearly entirely d obliterated; and in eleven others its obliteration was complete. In nearly all, the umbilical vessels were completely obliterated; I say, in nearly all, because in five cases neither the umbilical veins nor arteries were examined.

«From this last examination it may be remarked, that at eight days fel the foetal openings are very frequently obliterated, but that they may still be found open even at this age; I may add that at twelve, at fifteen days, and even at three weeks, the foramen ovale or the ductus arteriosus may still be found open, without the child thence exhibiting, during life, any peculiar symptoms; for it may be repeated, that I