ployed, but with unfavorable results. In severe cases thyroidectomy may be resorted to with a fair percentage of cures and improvements; but the operation is in itself a considerable source of danger. Ligation of the thyroid arteries has been recommended.

5. CONGENITAL MALFORMATIONS.

Congenital malformations may be due to arrested or abnormal development or to endocarditis during fetal life. The following classification is the one generally adopted:

Patency of the Foramen Ovale.-If the patency exists in but small degree, it is not of serious importance unless accompanied by other anomalies. The greater degrees of patency are not incompatible with fairly prolonged life. In these cases the diagnosis can be suspected by marked cyanosis, either without heart-murmurs (fairly diagnostic) or by systolic and presystolic murmurs heard over the mid-sternum at the level of the third and fourth ribs.

Defects of the Septa.-Minor defects of the ventricular systole are not rare and are not of much importance. Major defects rarely occur alone, but usually are associated with stenosis of the pulmonary valve, forming a most serious lesion. The defect results in the propulsion of blood from the stronger left ventricle into the right heart during systole, leading to embarrassed respirations and venous congestions. The physical sign is a loud systolic murmur heard over the whole precordium and between the shoulders, and not transmitted. Both auricular and ventricular septa may be defective, producing the cor biloculare, or the reptilian heart.

Stenosis or Incompetence of the Tricuspid and Mitral

Valves.-These defects are rare. For physical signs see Chronic Endocarditis, pp. 223-249.

Stenosis and Atresia of the Pulmonary Orifice or of the Conus Arteriosus.-These affections comprise the most important group of cases, being, moreover, relatively common. Pulmonary stenosis alone is not inconsistent with life for some years. For the physical signs see Pulmonary Stenosis, p. 243. The lesion, however, is usually associated with defects of the ventricular septum, and the prognosis is thereby rendered far more serious.

Persistence of the Ductus Arteriosus.-This channel should normally be closed on the fourteenth day. If patent, there result rapid hypertrophy and dilatation of the right ventricle, dilatation of the pulmonary artery, dyspnoea, cyanosis, and congestion of the lungs, with general venous congestions. The physical signs are a long-continued systolic murmur over the pulmonary area, a systolic thrill, and a protrusion of the upper part of the sternum.

Stenosis of the Aortic Orifice.-Stenosis of the aorta is rare. It is a serious lesion, incompatible with life for more. than a few weeks. Stenosis of the conus arteriosus is not inconsistent with a fairly prolonged life. The circulation is carried on by anastomoses between branches of the subclavian with those of the epigastric and intercostal arteries. The arteries of the upper extremities are regularly larger and fuller than those of the lower.

Transposition of Arterial Trunks.-This condition is necessarily fatal in utero, unless compensated by other anomalies, such as open foramen ovale or communication between the pulmonary vein and the right side of the heart.

Numerical Anomalies of the Valve-segments.-Supernumerary valves are of no significance. Deficiency of valve-segments is usually associated with other and more serious anomalies.

Ectopia cardis may occur with congenital fissure of the sternum and abdomen. Displacement of the heart into the neck or the abdomen may occur. There may be acardia, double heart, bifid apex, or absence of the pericardium.

Symptoms. Radical defects are inconsistent with life, so that the child dies in utero or shortly after birth. In those who live cyanosis is so marked a feature that the name "morbus cæruleus" has been given to the disease, and the term "blue babies" has been applied to these children. The cyanosis, which may be constant or may be induced only by exertion or by crying, varies from a lead color to a purplish hue. The child shows retarded mental and physical development. The nails are clubbed. The external temperature is low, and there is a great susceptibility to cold. Pulmonary affections are common, dyspnoea and cough are frequently observed, and the child is apt to succumb to an attack of bronchitis or of pulmonary congestion, or to any of the ordinary diseases of childhood.

Treatment consists in guarding the child from cold and in checking promptly intercurrent diseases. The treatment for the heart itself is the same as that for valvular disease of adults.

6. DISEASES OF THE ARTERIES.

ARTERIO-SCLEROSIS.

Etiology and Synonyms.-Arterio-sclerosis occurs as a disease of advanced age, usually in those over forty. It is one of the conditions of senility. Predisposition to arterial degeneration runs in some families and may be inherited. Among the exciting causes are chronic alcoholism, leadpoisoning, gout, syphilis, diabetes, and over-eating, especially with sedentary habits of life. There may be an antecedent history of uric-acid diathesis. The disease is common

with chronic articular rheumatism, and may precede, follow, or develop simultaneously with Bright's disease, especially with the granular kidney. It may follow severe over-work of the muscles. Synonyms: Chronic endarteritis; Atheroma.

Pathology. The aorta is almost always affected; next in frequency come the larger arteries. The disease may be uniformly distributed, or it may involve some arteries and not others; it may be either circumscribed or diffuse. The intima is much thickened by an increase of connective tissue and by the deposit of round cells. These cells may undergo fatty degeneration, imparting a yellow color in patches to the interior of the artery. In the deeper tissues the cells may break down to form a mixture of fat, detritus, and cholesterin-crystals from which the name "atheroma," or "pulp," is derived; or, if near the surface, an atheromatous ulcer is formed. Atheromatous patches and ulcers and the narrowed lumen allow of the formation of thrombi. other cases the intima becomes markedly sclerotic and of bony hardness from the deposit in it of salts of lime. The media and the adventitia may show similar changes, even to fatty degeneration and calcification, or the media may become atrophied.

In

Secondary lesions are found chiefly in the heart. The arterial lesion produces loss of elasticity, and consequently increases peripheral resistance to the work of the heart. The thickening of the intima may, moreover, cause such a narrowing of the lumen of the vessels that an added resistance results; in consequence, the left ventricle becomes hypertrophied in all cases in which the nutrition of the patient is good, and compensation is effected. Should general nutrition fail, dilatation will ensue.

The hypertrophied heart, pumping blood into the vessels whose outflow is impeded, raises arterial tension generally and causes an accentuation of the second aortic sound.

The changes in the aorta may so weaken its wall as to allow the formation of an aneurysm. For the same reason miliary aneurysms may be formed in the cerebral arteries and may result in rupture and cerebral hemorrhage.

Dry gangrene of the extremities may result from diminished supply of blood from the narrowing of the arterial lumen by connective tissue or thrombi.

Associated Lesions.-Contracted kidney occurs in the great majority of cases. It is often difficult to decide in a given case whether the arterial or the renal disease has

been primary.

Emphysema with chronic bronchitis is present in a large number of cases, and the patient is liable to have cirrhosis of the liver, as alcoholism is a common factor in cirrhosis and in arterial sclerosis. Atheroma of the aortic valves is a frequent complication.

The symptoms are exceedingly diverse, depending upon which arteries are most affected and upon the secondary and associated lesions. Arterial sclerosis with compensatory hypertrophy is not inconsistent with general good health. When compensation fails the general symptoms of dilatation and heart-inefficiency occur.

Sclerosis of the coronary arteries may produce thrombosis with sudden death, fibroid degeneration, aneurysm or rupture of the heart, and angina pectoris.

Cerebral symptoms are those of cerebral endarteritis. (which see), comprising acute and chronic degeneration, spasm of cerebral vessels with transient or permanent. paralyses, and cerebral hemorrhages.

Renal symptoms may be absent, or the urine may be increased in quantity and of low specific gravity, with but occasionally hyaline casts and a trace of albumin. In other cases the renal symptoms are distinctly uræmic and may terminate the life of the patient.