On malformations of the human heart, etc. : With original cases and illustrations

Front matter

U^ty a/ O^crv^^^i^^

BOSTON MEDICAL LIBRARY

IN THE

Preface

October, 1858.

Several examples of malformation of the heart having fallen under my notice, I have for some years paid special attention to this branch of pathology ; and in 1854, shortly after an interesting case of malformation had occurred at St. Thomases Hospital, I delivered a series of lectures on the subject to the students. These lectures were subsequently published in the " Medical Times and Gazette ;" and, together with several cases which have been at various times contributed to diflFerent medical societies and journals, are now reprinted, after the whole has been carefully revised and considerably extended.

There are few subjects which have attracted more attention in the profession than the irregularities in the development of the heart and large vessels. Longer or shorter notices of the chief varieties of malformation are contained in different works on Morbid Anatomy, and in systematic treatises on cardiac affections by Burns, Corvisart, Bertin, Laennec, Bouillaud, and Hope. They have been made the subject of a special essay by Dr. Farre,' and of

^ On Malformationa of the Human Heart. London, 1814.

b

VI PREFACE.

shorter memoirs by Dr. Paget/ Dr. Williams/ Dr. Todd/ Dr. Joy/ and Dr. Craigie -^ by Haase/ Meckel/ and Hein / and by Louis' and Gintrac.^" More recently tlie subject has been discussed in graduation theses by MM. Deguise" and Pize/^ and in a series of valuable and interesting papers by Dr. Chevers.'^

It might thus appear that there was scarcely scope for a new work on the subject. Several of the memoirs however which I have named, were published at a period when the defects in the conformation of the heart were less studied than they have recently been. Others are limited to one department of the subject ; and the treatise of Dr. Farre is

^ On the Congenital Malformations of the Human Heart. Edin. Med. and Surg. Joum., vol. xxxvi. 1831, p. 263.

2 Cyclopaedia of Practical Medicine, vol. iii. 1834, p. 65.

^ Cjclopsedia of Anatomy and Physiology, vol. ii. 1839, p. 630.

* Library of Medicine, vol. iii. 1840, p. 381.

^ Edin. Med. and Surg. Joum., vol. Ix. 1843. Case of Cyanosis, or Blue Disease, p. 265.

® Dissertatio Inauguralis Medica de Morbo Coeruleo. Lipsise, 1813.

' De cordis conditionibus abnormibus Dissertatio Inauguralis. Halse, 1802. Beitrag zur Geschichte der Bildungsfehler des Herzens welche die Bildung des rothen Blutes hindern. Deutsches Archiv f. d. Physiologie, Halle und Berlin, 1815, p. 221.

8 De istis cordis deformationibus quae sanguinem venosum cum arterioso misceri permittunt. Grcettingse, 1816.

8 Archives Generales de Medecine, 2™^ serie, t. iii. 1823 ; Memoires ou Eecherches Anatomico-Pathologiques. Paris, 1826, p. 300.

1" Observations et Recherches sur la Cyanose, ou Maladie Bleue. Paris, 1824.

11 De la Cyanose Cardiaque, etc. These de Paris, 1843.

12 Considerations sur les Anomalies Cardiaques et Vasculaires qui peuvent Caiuser la Cyanose. These de Paris, 1854.

13 Collection of Facts illustrative of Morbid Conditions of the Pulmonary Artery. London, 1851, originally published in London Medical Gazette, 1845 to 1851. The causation of Cyanosis is also discussed by Ferrus in the art. Cyanose, Diet, de Med., 2""® ed., t. ix. 1835, p. 527 ; by Stille on Cyanosis or Morbus Cseruleus, in Am. Jour, of Med. Sc, N.S., vol. viii., Phil. 1844, p. 25; and by Copland, in the Dictionary of Practical Medicine, art. Blue Disease, vol. i. p. 199.

PREFACE. VU

professedly incomplete. I have^ therefore^ thouglit that a work containing the more recent information would not be without interest and value to the profession. The subjects treated of in the Essay embrace : —

I. Congenital Misplacements of the Heart. II. Deficiency of the Pericardium.

III. Malformations of the Heart.

IV. Irregularities of the Primary Vessels.

V. Mode of formation ; Symptoms and Effects ; Diagnosis and Medical Management of cases of Malformation.

In the Essay it has been my aim to present the subject in a practical point of view, and I have not, therefore, alluded to those forms of defect in the development of the heart which are incompatible with the existence of extra-uterine life, or which have only been met with in the lower animals. The medical periodicals of Germany, France, England, and the United States, abound in cases of malformation. I have, however, not thought it desirable to quote many of these at length, but have preferred to allude concisely to those which formed the earliest published examples of each form of defect, or which presented some rare and remarkable deviation, and have generally contented myself with referring to the periodicals and other publications in which the more recent or ordinary cases are reported. A brief inspection of the numerous references cited, will show that to have quoted more extensively would have greatly swelled the bulk of the volume. Those who desire to investigate the subject further, I may refer to the original

Vlll PREFACE.

sources of information here indicated ; or to tlie essay of M. Gintrac, the theses of M. Deguise and M. Pize, and the papers of Dr. Che vers ; in one or other of which, but particularly the latter, a large proportion of the cases, only briefly noticed or alluded to in this work, will be found quoted at length.

October, 1866.

The former edition of this work was a small one, and was rapidly disposed of, so that it became out of print in a short time. The present edition has been carefully revised, several cases and illustrations have been added, and the references have been considerably increased. In its preparation I have availed myself of various treatises and memoirs which have been recently published or which I had not previously seen. I may particularly mention the works of Friedberg,^ Tiedemann," and Forster,^ and the papers of Professors Mayer^ and Kussmaul,^ and of Dr. Carl Heine.^ It should also be mentioned that, in addition to

' Die angebornen Krankheiten des Herzens und der grossen Qefasse des Menschen. Leipzig, 1844.

^ Von der Verengung und Schliessung der Pulsadern in Krankheiten. Heidelberg and Leipzig, 1843.

^ Die Missbildungen des Menschen. Jena, 1861.

* Virchow's Archiv fiir path. Anat. und Phys., etc., xii'®' Band, 1857, pp. 364, 495.

^ Henle and Pfeuffer's Zeitschrift fiir Rationelle Medicin, xxvi**"" Band, 1865, p. 99. Reprinted at Freiberg, I.E., 1865.

PREFACE. IX

the references before given, longer or shorter notices of the various malformations of the heart and vessels have also appeared in the treatises of Walshg, FuUerj and Markham.

Notwithstanding that some very remarkable deviations from the natural conformation of the heart were placed on record at an early period, it is only recently that attempts have been made to reduce the different forms of irregular development to any scientific arrangement, or to explain their nature and mode of production. The earlier writers on cardiac affections, Corvisart, Laennec, Burns, Bertin, &c., contented themselves with simply alluding to the different forms of defect with which they were acquainted ; and even so recent a writer as Dr. Hope regarded them as " so irregular in their combinations as scarcely to admit of being classified on general principles." Dr. Farre adopted an arrangement into, 1st, Malformations of the heart or arteries occasioning the mingling of black with red blood; and, 2ndly, those causing impediment to the circulation of the blood. The former class he further subdivided according to the degree of imperfection in the development of the heart. Dr. Paget and Andral described the various malformations as consisting in defective, excessive, or perverted development ; and most subsequent writers have followed a similar arrangement. M. Bouillaud has treated of the various congenital anomalies of position and development of the heart and its vessels under the heads of — 1st. Dexiocardia, or transposition. 3ndly. Communications between the right and left cavities of the heart from non- obliteration of the foramen ovale or ductus arteriosus, or the existence

X PREFACE.

of a perforation in the septum of the auricles or ventricles. Srdly. Anomalies of number, defective or excessive development of the heart or its several parts ; and, Mhly. Anomalies of reciprocal connexion and insertion of the heart and its vessels. M. Berard^ classifies the cardiac malformations into — 1st. Anomalies of number; 2nd. Of direction and relation; 3rd. Those which do not cause the admixture of arterial and venous blood ; and, 4th. Those which are attended by such intermixture.

Friedberg, whose treatise, though published in 1844, I had not seen when the first edition of this work appeared, arranged the different forms of congenital malformation into three classes, founded upon the periods at which the process of development of the ovum is arrested or perverted. 1st. Those in which the formation of the partition- wall in the heart and the common arterial trunk has not taken place ; or anomalies belonging to the first period of foetal development. 2nd. Those where the partition- wall is imperfectly formed or irregularly arranged, causing abnormal communications below the several cavities of the heart, or faulty origin of the vessels ; these cases originating in the second period of development ; and, Srdly. Those where the orifices and their valves are defectively constructed, or the connexion with the aorta continues; defects which have their explanation in derangements of the formative processes of the third period.

Dr. Carl Heine, a recent writer on the subject, proposes a classification, founded on the systems of Forster and

'■ Art. Anomalies du Coeur, Diet, de Mdd,, 1834.

PREFACE. XI

Bischofi], into — 1st. Malformations whicli deviate quantitatively from the type of their kind ; and, 3ndly. Those which differ qualitatively. The former he subdivides into anomalies consisting in defective and excessive development as to number and size ; the latter he further distributes into deviations of form and position, and irregularities of the large vessels. The defective developments he classes under the heads of — a. entire defects ; h. imperfect formations ; c. abnormal smallness ; d. obliteration of the passages or vessels, and e. fissure formations.

In the present edition of this work, I have adhered to the arrangement of the misplacements of the heart proposed by M. Breschet; treating, first, of the cases in which the organ does not occupy its proper position within the thorax ; and, secondly, of those in which, from defect in some portion of the parietes, the heart is situated wholly or in part external to the thoracic cavity. I have, however, followed Dr. Alvarenga' in the employment of terms, in some cases different from those of M. Breschet.

Of the malformations of the heart itself, I adopted, in the former edition, an arrangement founded partly on the period at which the development of the organs becomes arrested or perverted, and partly on the degree of impediment to the circulation which such deviation occasions, and the consequent interference with the functions of the heart after birth. To this arrangement, though with some modification as to details, I still adhere.

See paper read before the Academy of Sciences in Lisbon, 1866.

Xn PREFACE.

The cardiac anomalies are^ therefore^ classed into —

1*^. Those dependent on arrest of development at an early period of foetal life^ or probably from about the fourth to the sixth weekj so that the organ retains its most rudimentary forms ; — the auricular and ventricular cavities being still single or presenting very slight indications of division, and the primitive arterial trunk being retained, or the aorta and pulmonary artery very imperfectly evolved.

2ndly. Those in which the arrest of development occurs at a more advanced period of foetal existence, or probably from about the sixth to the twelfth week, when the auricular and ventricular partitions have already been partly formed, and the aorta and pulmonary artery more or less completely developed. Such are the cases in which, with imperfect separation of the ventricles, the arterial or auriculo-ventricular apertures are constricted or obliterated, and the origins of the primary vessels, and especially of the aorta, are misplaced.

Srdly. Cases in which the development of the heart has progressed regularly till the later periods of foetal life, so that the auricular and ventricular septa are completely formed, and the primary vessels possess their natural connexions ; but in which, from the occurrence of disease, the organ is either prevented undergoing the changes which should ensue after birth, or there are slighter morbid conditions which may become the source of serious obstruction at more advanced periods of life. Such are the premature closure of the foetal passages, and the occurrence of irregularities in the number and form of the valves.

PREFACE. Xlll

The irregularities of the primary vessels may be similarly classed into —

1st. Those taking place at the earlier periods of foetal life^ and consisting in the defective evolution of the aorta and pulmonary artery from the primitive vessel and branchial arches.

2ndly. Those in which the development of the aorta and pulmonary artery is less deranged, but in which there are defects which may give rise to serious results in after-life.

The former class includes the cases in which the origins of the pulmonary artery and aorta are transposed, or the descending aorta is wholly or in part derived from the pulmonary artery. Of the latter class the most striking examples are the cases in which the aorta beyond the origin of the left subclavian artery is more or less constricted, and so occasions disease which may ultimately lead to very marked contraction or even entire obliteration of the canal.

From the arrangement of the various congenital defects into misplacements, malformations, and irregularities of the vessels, it must not, however, be supposed that these anomalies are to be regarded as distinct and independent deviations from the natural process of development. On the contrary, as the position of the heart varies with the different stages in the evolution of the organ and its connexion with the primary vessels, arrest or perversion of the process of growth may occur coincidentally and produce similar irregularities in all these particulars. Such is not, however, by any means always the case ; in many

XIV PREFACE.

instances the heart being misplaced, the organ itself imperfectly formed, or the vessels arising from it irregular, without any deviation from the natural evolution of the other parts. It is thus convenient to treat of these several defects separately.

In applying any system of classification to individual cases, difficulties will, however, often occur. For to decide the position which any given case of anomaly should occupy, it is necessary to ascertain what has been the primary defect. This is often very difficult when the specimen can itself be examined, and becomes almost impossible in published cases, which are often imperfectly and sometimes incorrectly described. In the following pages I cannot venture to hope that these difficulties have always been satisfactorily solved. I have indeed been often compelled to refer to the same case as illustrating different forms of defect, or to speak of anomalies which may only have been secondary or necessary results of other changes which could not be ascertained. This objection applies, however, not only to the arrangement here adopted, but would equally occur in any other which has been proposed. I have also, in some cases, intentionally deviated from the method of arrangement laid down. Thus, under the heads of atresia of the pulmonic orifice and of constriction at the point of union of the sinus with the infandibular portion of the right ventricle, I have treated of all the forms of anomaly, without reference to the period of foetal life at which, as indicated by the state of the inter-ventricular septum, the deviation occurs. To have classed these cases under different heads might have been more scientifically

PREFACE. XV

accurate^ but would certainly have rendered tlie subject very complicated and much less easily intelligible. I have also, when treating of the defects of the pulmonary valves which prevent the closure of the foramen ovale, alluded to the cases in which the valves are found diseased without any other imperfection in the conformation of the heart. The latter cases should more properly have been placed under the head of congenital diseases of the valves, but I have preferred the arrangement adopted from the close analogy which exists between them and the other forms of anomaly. I have only to add, that it has not been thought necessary generally to quote more recently published cases, or to add to the number of those which had previously been subjected to statistical analysis. To have do:pie so would have occupied considerable additional space, and have entailed much labour without any proportionate advantage. Where, however, recently reported cases have either modified views previously expressed, confirmed inferences which were before doubtful, or thrown light upon forms of anomaly imperfectly understood, I have not failed to refer to them or quote them more in detail.

Table Of Contents

CHAP. PAGH

I. MISPLACEMENTS OE THE HEART 1

II. DEFICIENCY, ETC., OE THE PERICARDIUM .... 9 III. MALFORMATIONS OF THE HEART U

I. Misplacements Of The Heart

The heart may be congenitally misplaced in varioiis ways^ occupying either an unusual position within the thorax^ or being situated external to that cavity.

INTERNAL MISPLACEMENTS ECTOCARDIA INTRA-

THORACICA.

Transposition — Dexiocardia,

The most frequent of the internal misplacements is that in which the heart is placed in a position on the right side of the chest corresponding to that which it should occupy on the left. "When this occurs^ the viscera of the body generally are also most usually transposed; but such is not always the case, the heart being occasionally situated on the right side, while the other viscera retain their natural positions. The occurrence of misplacement of the heart to the right side in conjunction with transposition of the viscera generally, has been long known occasionally to occur, cases of the kind having been met with in Eome in 1643,' in Paris in 1650/ and in London in 1674;^ and numerous ex-

^ & ^ Thomas Bartholinus, Hist. Anat. Cent. ii. Hist. 29. Amstelodami, 1654, f. 199. In the man who was executed for the murder of the Duke of Beaufort, as related by Gruy Patin. The case seen at Rome by Servius, and one by Schenkius, are also referred to.

3 Phil. Trans. 1674, vol. x. No. 107, p. 146.— See also Riolanus, Op. Anat. 1649, — Sandifort, Obs. Anat. Path., lib. i. cap. ii. p. 39. — De Blegny, Zodiacus Medico-Gallicus. Genevae, 1680, p. 129.

B amples of the same condition have since been placed on record. The occurrence of transposition of the heart while the other organs retain their natural positions^ is of much more rare occurrence ; but M. Breschet in his memoir' states that he has seen four instances of this in newly-born children ; and Otto also refers to similar cases."

When the heart is transposed^ it may be well formed, as in the instances related by Dr. Sampson/ M. Mery and M. Morand/ Dr. Baillie/ M. J. F. Meckel/ M. Dubled/ M. Bosc/ and Dr. Allen Thompson.^ In cases of this kind the vessels may retain their natural relations, or the arteries may be misplaced relatively to the ventricles, as in a case reported by Mr. Gamage,'" in which the aorta arose from the right ventricle, and the pulmonary arteries from the left. In other cases the heart may be very imperfectly developed, and the vessels arising from its cavities or entering into them, may be irregular, as in the instances related by Breschet," Valleix,'^ Martin,'^ and Boyer.'^

In cases of transposition, the aorta generally follows an irregular course, crossing over the right bronchus, and pass-

^ Sur I'Ectopie de I'appareil de la Circulation et particulierement sur celle du Coeur; R^p. G^n. d'Anat. et de Phys. Pathol., t. ii. 1826, p. 1.

'■> Salt. Brob. pt. 1, p. 95, and pt. ii. p. 47.

3 Phil. Trans, for the year 1674, vol. ix. No. 107, p. 146.

* Hist, de I'Acad. Royale des Sc, t. ii. 1686 to 1699; Paris, 1733, p. 44; observation contributed in 1688.

5 Phil. Trans., 1788, pt. 1, p. 350; Works by Wardrop, vol. i. p. 148.

^ De Cordis conditionibus abnormibus, Dissertatio inauguralis, Halse, 1802, Tab. 1 and 4.

8 Bullet, de la Soc. Anat. de Paris, an. 4, 1829, p. 42.

^ Glasgow Medical Journal, vol. i. 1854, p. 216. In a man forty-eight years of age, who died of broncho-pneumonia. The viscera generally were displaced.

^^ New England Journal of Medicine and Surgery, vol. iv. 1815, p. 244.

See also a paper on transposition of the heart and viscera, by Yalleix. Bullet, de la Soc. Anat. de Paris, 9™« annee, 1823, p. 253.

" Breschet, Op. Cit., 2""' obs. p. 9 ; and Bullet, de la Soc. Anat. 1826, p. 39.

ing to the right side of the bodies of the vertebrse^ and the right carotid and subclavian arteries are given oflF as separate trunks^ while the brachio-cephalic trunk is placed on the left side. This occurred in a case described by Mr. Abernethy, in an infant of ten months, which has been frequently referred to as having presented an unusual arrangement of the vessels of the liver — the portal veins having terminated in the vena cava, and the liver being supplied with blood from an unusually large hepatic artery.^ Such an arrangement does not, however, always obtain. In some instances, as in the case related by Mr. Douglas Fox/ the aorta, after crossing the right bronchus, passes behind the lower end of the trachea over the bodies of the vertebrae, and pursues its usual course to the left of the spine. In some instances, also, though the aorta may occupy the right side of the spine, the vessels at the arch are not transposed, the brachio-cephalic trunk being situated on the right side, and the left subclavian and carotid arteries arising separately.

Though a considerable number of instances of transposition of the heart have been observed, I have not myself had the opportunity of examining any case of the kind after death. In 1849, however, a boy presented himself at the Victoria Park Hospital for Diseases of the Chest, in whom the heart was placed on the right side, its apex beating an inch and a half below the right nipple, while the liver was situated on the left side. He had been an invalid since he was three years old, and, although then eighteen years of age, he looked like a much younger person, and had a peculiar sickly, unhealthy appearance ; but there were no signs of any defect in the conformation of the heart.

More recently a patient was in St. Thomases Hospital, under the care of Dr. Bristowe, in whom the heart was obviously situated on the right side, and the liver on the

1 Phil. Trans. 1793, p. 59. ^ London Medical and Physical Journal, vol. li. Jan. to June, 1824, p. 474, In a fcetus of the fifth month.

B 2 left. The patient, a female^ twenty-two years of age, was labouring under phthisis.^

Mesocardia.

When the heart is seriously malformed, it is frequently also found to retain the situation in the median line of the chest, which it occupies at the earlier periods of foetal life. Of this form of misplacement M. Breschet gives an instance, which will again be referred to as an example of defective development of the organ. It is also mentioned as existing in a case recently related by M. Kussmaul ; and I have myself seen the same anomaly under similar circumstances. M. Breschet also admits the existence of displacements in ' the transverse and antero-posterior directions, but gives no examples of either of these forms.

EXTERNAL MISPLACEMENTS ECTOCARDIA EXTRA-

THORACICA.

The most remarkable deviations from the natural position of the heart are, however, those in which the organ is situated wholly or in part external to the thoracic cavity. Of this form three varieties have been described by Breschet.

Ectocardia Pectoralis.

{Ectopia Pectoralis Cordis, Weese and Breschet.) — This form of misplacement may occur without any defect or fissure of the thoracic parietes or with such imperfections. As examples, Breschet refers to cases by Shulz and Vaubonnais, in which the misplacement existed in foetuses ; to others, by Buttner and Weese, in a child which lived thirty-six to forty hours ; by Martinez, in which life was prolonged twelve hours ; and by Sandifort, in which the child survived

1 Similar cases are quoted in the Bull, de I'Acad. de M6d., t. xxvi. 1860-61, p. 1174, in a female of twenty-one, still alive ; and in the Lancet for 1863, by Dr. Maclean, vol. ii. p. 159, in a soldier of twenty-five years of age.

MISPLACEMENTS OE THE HEART. 5

for a day. Alone^ this form of malformation is rare; but when tlie viscera of the abdomen also are protruded, it is not of uncommon occurrence. Cases have more recently been related by Dr. O'Bryan/ MM, Cruveilhier and Monod/ Mr. Mitchell/ Mr. Sydney Jones/ and Mr. Daniel.^

Ectocardia Abdominalis.

{Ectopia Cordis Ventralis, Weese and Breschet.) — Of this form of misplacement there are also two varieties. In one, the heart is protruded through the diaphragm without forming a tumour externally ; in the other, there is an external tumour. As examples of the first kind, M. Breschet refers to the case of E-amel, in which a female, ten years of age, had the heart situated immediately below the diaphragm. A much more remarkable instance is that related by M. Deschamps of Laval, of a man who had served in the army, and retired in consequence of suffering from severe pains in the loins. He, however, married, and had three children ; . but the lumbar pains continued, he became emaciated, and died exhausted by continued suffering. On examination, the right kidney was found large, hard, and in a state of suppuration ; and a solid mass containing a cavity filled with sanies was situated in the pelvis. The heart occupied the place of the right kidney, and the vessels arising from it passed through an opening in the diaphragm into the thorax.

Of the second variety, the case of Mr. WUson to be hereafter mentioned, and others by Prochaska, Klein, Sandifort, Chaussier,^ &c., afford examples; and cases have recently been published by M. FoUin^ and Mr. Barrett.^

1 Prov. Med. and Surg. Traus., vol, vi, 1837, p, 374,

2 Gaz. Med, de Paris, 2"^ serie, Q"'^ an, 1841, p, 497.

3 Dublin Journal, vol. xxvi. 1844, p. 262.

6 Bull, de la Soc, de Med., t, iv. 1814, p. 93.

'' Arch. Gen. de Med,, 4'"« serie, t. xxiv. 1850, p. 101 ; and Gaz, Med. de Paris, 3™« serie, t, v. 1850, p. 629.

b MISPLACEMENTS OF THE HEART.

Ectocardia Cervicalis.

[Ectopia Cordis Cephalica, Breschet.) — In this form of displacement^ the heart lies in the front of the neck, in connexion with the ramus of the jaw. In the only cases on record, the malformation existed in foetuses or in infants which scarcely survived birth, and which presented other serious defects. It is therefore much less important than the other forms.

The most interesting cases of this description of misplacement which have been published since the appearance of M. Breschet^s memoir are those of M. Cruveilhier and M. Monod, Dr. O^Bryan and Mr. Sydney Jones, and Mr. Daniel.

In the case of M. Cruveilhier and M. Monod, the child lived only a few hours. The heart lay externally, having escaped through a round opening in the upper part of the sternum, and was exposed as if after the pericardium had been incised.

Mr. Sydney Joneses case occurred in the practice of Dr. Bain of Poplar, and the specimen was exhibited at the Pathological Society in 1855. The child was believed to have been born at the eighth month, and it survived thirteen hours. The heart, devoid of pericardium, was situated wholly external to the thoracic cavity. A fissure existed in the sternum of an oval shape, its longer diameter being nearly vertical and three-quarters of an inch in length, and its shorter diameter transverse and half an inch long. Through this opening the vessels passed from the heart into the thorax. The margin of the fissure was obscured anteriorly by a prolongation of skin on the great vessels, and from thence on the external surface of the heart. The cuticle could be traced as far as the base of the viscus and slightly over the amides; but beyond this point there was no epithelial covering, — the muscular substance being only protected by a structure shown on microscopical examination to be a white fibrous, mixed with yellow, elastic tissue. The closing up of the foramen was completed posteriorly by the reflexion of the pleura from the great vessels on to the parietes of the thorax. The heart appears to have been well formed, and the child presented no other defect.'

In the case of Mr. Daniel of Newport-Pagnell, the child did not breathe after birth, but the heart continued to beat for four hours. It was situated in the front of the chest, having protruded through an aperture formed by deficiency of the middle and lower part of the sternum. The septum of the ventricle was defective. The other organs of the body occupied their natural positions.

In these cases the heart lay in front of the chest, and they therefore constituted examples of the Ectopia Pectoralis of Breschet ; but in the cases of Dr. O'Bryan and Mr. Barrett the heart was situated partly in the abdomen, having passed through an aperture in the diaphragm. They were therefore examples of ectopia ventralis.

In Dr. O^Bryan^s case, the xyphoid cartilage was deficient, together with the fibres of the diaphragm inserted into that body ; a triangular aperture was thus left, through which a portion of the left ventricle, covered with pericardium, was protruded, so as to form a soft, oval, unequal and semitransparent tumour at the anterior and upper part of the abdomen. The part of the left ventricle protruded was one inch and three-quarters in length, and a further portion was prevented escaping by the apex of the right ventricle. The lower part of the tumour was occupied by a portion of colon. The child survived three months, and died of bronchitis brought on by exposure.