the base of the heart. By these points its source may be determined with considerable confidence, but not with positiveness, for, exclusive of malformations, intra-ventricular murmurs are occasionally incident to disease which cannot be traced either to the arterial or auriculo-ventricular orifices by the ordinary rules of localization. The passage of blood through an open foramen ovale probably rarely, if ever, gives rise to a murmur.' The clinical study of cases of malformation, with respect to the physical signs, is highly interesting, and claims more attention than it has as yet received.

Of the causes of death in the various forms of malformation, the most frequent are, 1st. Cerebral disturbance resulting from the defective aeration of the blood and congestion of the brain; and, 2d. Imperfect expansion, collapse and engorgement of the lungs. It is worthy of note that dropsical effusions, so common in lesions. of the heart originating after birth, occur less frequently than would be expected from the obstruction to the circulation incident to many of the malformations. Death occurs not very infrequently from tuberculosis in the cases in which life is prolonged for several years. Of 56 cases, analyzed by Dr. Peacock, in which patients affected with different forms of malformation survived the age of eight years, in 9 tuberculosis became developed, being a ratio of 16.07 per cent. In six of the nine tuberculosis cases cyanosis existed in a marked degree. This appears to militate against the incompatibility of tuberculous disease and venosity of the blood, as asserted by Rokitansky. It is, however, certain that diseases of the heart developed after birth, and phthisis are rarely associated; and the inquiry arises, whether there is a law here applicable to morbid conditions and not to malformations. This is a question to be settled by further statistical data.

The general principles of treatment in cases of malformation, may be embraced in a very few words. They relate to measures to protect against cold; avoidance of over-exertion and great mental excitement; together with such palliative measures as the particular circumstances in individual cases may indicate.2

In six cases of open foramen ovale, reported by John W. Ogle, M. D., assistant physician at St. George's Hospital, London, no murmur was discovered during life.-British Med. Journ., p. 500, 1857, from Journal de la Physiologie, etc., publié sous la direction du Docteur E. Brown-Séquard, Janvier, 1850.

2 It is proper to state that the foregoing account of congenital affections has been mostly borrowed from an analytical review of Dr. Peacock's work, written by the author, and contained in the American Journal of Medical Sciences, No. for July, 1858.

CYANOSIS.

Blueness, or a purple color of the surface of the body and the mucous surfaces open to observation, occurring in connection with malformations of the heart, has been considered as constituting an affection called cyanosis,' morbus cæruleus, or blue disease. For the sake of precision, these names should be restricted, as they usually are, to the peculiar coloration due to abnormal conditions which are congenital, although this effect may not be manifested for some time after birth. But an analogous, if not identical appearance of the integument is observed in some cases of organic disease of the heart developed at different periods of life, and also independently of any cardiac lesions. It is well marked, for example, in the algid, or, as it is often termed, the cyanotic stage of epidemic cholera. This fact is to be borne in mind with reference to the rationale of the blueness which characterizes certain cases of cardiac malformation. The nature of the connection existing between cyanosis and malformations of the heart, has been much discussed, and is still open for discussion. To consider the subject at much length, would be inconsistent with the practical character of this work. I shall therefore present, very briefly, the views which seem to comport best with our present knowledge.

Cyanosis was attributed by Morgagni to congestion of the venous system caused by obstruction at the origin of the pulmonic artery. John Hunter attributed it to the admixture of venous and arterial blood in consequence of abnormal communication between the auricles or ventricles, or an abnormal arrangement of the primary vessels. The latter was the current doctrine until within the past few years the explanation of Morgagni has been revived and maintained by several distinguished pathologists-Louis and Valleix in France, Hasse and Rokitansky in Germany, Jay and Peacock in England, and the late Moreton Stillé, of this country. Many distinguished pathologists, however, still adhere to the Hunterian theory, while some adopt both explanations, referring the affection in certain cases to venous congestion solely; in other cases, to the

xúavoc, blue, and vós, disease.

2 On Cyanosis, or Morbus Cæruleus, by Moreton Stillé, M. D., American Journal of Medical Sciences, new series, vol. viii., 1844, p. 25.

admixture of the two kinds of blood, or to the combination of these two abnormal conditions.

In the endeavor to settle upon the true explanation of cyanosis, the first and most important point of inquiry is, whether it be uniformly associated with any particular class of malformations. This point is not readily ascertained, because, in the great majority of cases, malformation does not consist of a single abnormity, but several abnormal conditions are combined. Thus, obliteration or obstruction of the pulmonic orifice generally involves an open foramen ovale or deficiency of the ventricular septum. The former induces congestion of the venous system; the latter occasions admixture of the venous and arterial blood. Analyses of large collections of cases, in fact, show that, in by far the greater number, there exist pulmonic contraction, and, at the same time, communication between either the ventricles or auricles, or both. Of 62 of the cases collated by Stillé, in which the condition of the pulmonary artery was reported, in 53 it was obstructed or impervious. In the remaining 9 cases, the author concludes that the abnormal conditions present were of a nature to give rise to congestion of the venous system. On the other hand, in 5 only out of 71 cases collected by the same author was communication between the two sides of the heart wanting. Cyanosis has been observed when the foramen ovale was not open, and there was no deficiency of the ventricular septum, nor transposition of the primary vessels; and contraction of the pulmonic orifice is not always present. Again, cases have been reported in which the two kinds of blood must have been very freely mixed, as in some instances in which there existed a single ventricle, without cyanosis; and cases of great congenital pulmonic obstruction have been observed without cyanosis.

In short, constancy of connection with any particular class of malformations is not, as yet, established. Cyanosis cannot be considered as having any fixed special anatomical character. It may be associated with numerous and different abnormal conditions.

Continuing to regard the different forms of malformation as giving rise either to venous congestion or admixture of the two kinds of blood (although, as has been seen, both effects are usually combined), the facts adduced by Stillé, Peacock, and others, appear to show conclusively that the former effect is concerned in the production of cyanosis much oftener and to a much greater extent than the latter. The exceptions to the rule that obstruction either at the pulmonic orifice or elsewhere, inducing congestion of the

veins and venous radicles, exists in cases of cyanosis, must be exceedingly infrequent, if, indeed, there are any exceptions to the rule, and the instances in which great congenital obstruction at the pulmonic orifice are not attended by cyanosis, may, perhaps, be explained, as suggested by Dr. Peacock, by supposing that the right ventricle becomes, under these circumstances, sufficiently hypertrophied to compensate for the obstruction by the increased power of its contractions. The researches of Stillé have sufficiently established the fact, already stated, that the most complete commingling of arterial and venous blood, either by direct communication between the two sides of the heart or by mal-arrangement of the vessels, is not always adequate to give rise to cyanosis; and that, as regards intensity, cyanosis bears no constant relation to the freedom of communication between the two sides of the heart or the different systems of vessels. But the establishment of these facts does not prove that the commingling of the two kinds of blood is never involved in the production of cyanosis. That in certain cases this is an important element is probable. It is evident that the coexistence of pulmonic obstruction with either an open foramen ovale or deficiency in the ventricular septum must contribute in no small measure to the admixture of the blood through these communications; and hence it is intelligible that when these malformations are combined (as they usually are), cyanosis is much more likely to be the result than when either exists independently of the other.

The general conclusions, then, most consistent with our present knowledge of the subject are that cyanosis involves, in the vast majority of cases, if not invariably, venous congestion due to contraction or obliteration of the pulmonic artery, or to some other malformation which occasions obstruction to the flow of blood from the systemic veins; that it may be produced by obstruction alone without any admixture of the arterial and the venous blood, but that the latter may contribute, more or less, to its production. The presence of venous blood in the arterial system, it is to be remarked, contributes, not alone by the purple color which it acquires from the admixture to the cyanosis, but by increasing the venous congestion. The capillary circulation is impeded, and the flow of blood through the veins retarded in proportion to the venosity of the arterial blood.

The blueness of the skin in cyanosis is due, of course, to the blood contained in the minute or capillary vessels. Now, inasmuch

as obstruction of the venous system occurs, frequently in a great degree, in cases of organic lesions of the heart arising from disease developed after birth, the question arises, why is it that cyanosis is peculiar to, or at least occurs so much oftener and to a greater extent in connection with congenital affections? It is highly probable that the answer to this inquiry is contained in a suggestion by Dr. Chevers,' viz., that the capillary vessels become much more largely expanded when obstruction to the circulation exists before birth, or prior to the full development of the body, the vascular system being more readily dilatable, than in the adult. Cyanotic phenomena, however, are not exclusively observed in connection with malformations. They may be developed at any age as a result of obstruction at the right side of the heart in conjunction with deficient aeration of the blood. They are seen in cases of pulmonary obstruction due to atelectasis, collapse of lung, capil lary bronchitis, etc. They are well marked, as already stated, in the blue stage of epidemic cholera, being dependent, in the latter affection, in a great measure, on capillary congestion proceeding from the abnormal condition of the blood itself. The appearance of the tegumentary surfaces in these various affections does not differ essentially from that in cyanosis, the main difference being that the blueness or lividity is very rarely, if ever, so extreme as in the cases in which it is dependent on congenital affections.

The discoloration in different cases of cyanosis differs greatly in degree. Between slight blueness and darkness approaching nearly to blackness, in a sufficient variety of cases, every degree of gradation will be manifested. All portions of the body are not alike affected. Certain parts, viz., the lips, around the eyes, the cheeks, the ears, the extremity of the nose, the roots of the finger nails, and the genital organs, present a change in color more marked than over the surface generally. The blueness may be limited to parts in which the skin is delicate and the capillary vessels abundant. The degree of discoloration varies also greatly at different periods in the same case. Its intensity is increased by fits of coughing, muscular exercise, mental emotions, and any cause which excites the action of the heart. The cyanosis may exist only under these circumstances, being absent when the heart is tranquil. It is always increased by any intercurrent pulmonary or cardiac disease.

Dr. Peacock, op. cit., p. 128.