CONGENITAL CHANGEA IN THE ATRIOVENTRICULAR OSTIA These anomalies form a very small portion of the congenital heart affections. The venous valvular apparatus, of the right side of the heart especially, is affected very frequently, whether in the form of arrestetl development up to the complete absence of ostiurn and -valves, or in the form of fcetal inflammatory processes and their results, stenosis and insufficiency. Indeed, congenital tricuspid and mitral insufficiency and stenosis are not rare, though they never occur as isolated affections, but always in association with other anomalies, the foremost of which is defective septum. The diagnosis of the isolated affection does not differ from that of the same cardiac anomaly when acquired. When in combination with other congenital cardiac changes, the diagnosis of the limits of the changes in the venous ostia of the heart is scarcely to be thought of.
Complete absence of the tricuspid valve, in association with pul monary steilosis, making the right venous ostium insufficient, has recently been described by Spolverini and Tiarbieri, in an apparently healthy boy eleven years old.
The same writers have observed atresia of the mitral valve in a cyanotic boy with a systolic murmur but without other anomalies, who died when forty days of age.
4. Congenital Changes in the Position of the Heart Dextrocardia, with or without transposition of the cardiac cavi ties (complete or incomplete) is either a partial symptom of complete situs inversus or it arises as an isolated displacement of the organ and is then almost always found to be associated with other errors of car diac development.
Mesoeardia (median position of the heart) is synonymous with a preservation of the position of the fcetal heart in the centre of the thorax.
This abnormal position is not so rare (Filatow) and the cliagnosis is to be made if the apex-beat is felt in the epigastrium, the heart sounds are heard clearly behind the sternum and no adhesive changes be tween the heart and neighboring organs can be found.
The congenital changes in the position of the heart, -whether accom panied by situs inversus or not, are almost always associated with intracarclial arrest of development.
Ectopia of the heart is of more anatomical than clinical impor tance. With ectopia the sternum is wholly or partially absent and the skin may be normal or may also be lacking. Ectopia may be an isolated arrest of development or may be but part of an eventration, in w-hich the greater portion of the anterior chest and abdominal wall is absent, so that the viscera of the thorax and abdomen come to lie outside of the body. Both ectopia, in which the heart may be covered by peri cardium or be absolutely uncovered, and eventration do not allow of living.
For all other teratologic anomalies of the heart reference should be made to the text books upon pathologic anatomy.
Finally, primary congenital ptosis of the heart, discovered by Rummo, which Ferrannini, who found it with ptosis of the viscera, considers as a partial symptom of a general ptosis, should not be passed without mention. Ptosis of the heart occurs together with low position of the diaphragm. Ferrannini found congenital (?) mitral stenosis at the same time in four cases.