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Related post: when, instead of stenosis, there is a complete atresia of the artery. In that case the right heart is small or rudimentary. Absence of the ventricle I fiave never seen or diagnosticated unless complicated with stenosis of the. pulmonary artery. In these latter cases there is a loud murmur over the stprnam which Cartia Xt 300 Mg extends far down and upward into the vessels of Cartia Australia May 12, igool JACOBI: HEART MURMURS IN INFANCY. 73' ihe neck. The secondary pulmonary sound is ac- centuated only when there is a hypertrophy of the right ventricle; when both ventricles are hypertrophied the second aortic and pulmonary sounds are of equal strength. The frequent statements in the books that pulmonary stenosis with defect of the septum is characterized by hypertrophy of the heart, I cannot verify. On the contrary, the absence of much hypertrophy I find to be characteristic of that condition ; it has led me to a correct diagnosis which I could Cartia 120 Mg verify by the autopsy. The record of one such case may be found ill the Archkcs of Pediatrics of a num- ber of years ago. Another class of c}'anotic cases owes its origin to an arrest of development of the common arterial trunk which did not separate into the aorta and pulmonary artery. In these cases, con- trary to many statements, I found but little hyper- trophy or dilatation, sometimes none at all. The loud murmur is heard over the sternum a little Cartia 100mg to the right and to the left, about the insertion of the second and third ribs ; Cartia Xt Generic it is very audible pos- teriorly, but much less than anteriorly. Very loud murmurs, audible at Cartia Xt 240 a distance, with- out the ear touching the chest, I have heard more in adults than in children, Cartia Xt without having an opportunity to make an autopsy. They are always systolic and are mostly attributed to hy- pertrophy and believed to be muscular only. In a few cases, however, I am certain that no in- crease of percussion dulness or of cardiac impulse corresponded with the Cartia Xt 180 Mg loudness of the tone; so I was inclined to believe that the peculiar phe- nomenon was due to torn and swinging papillary muscles. Not infrequently the general condition of the patient is vastly better than the formidable noise would appear Cartia Xt 120 Mg to suggest. Organic murmurs, when present, are not al- H'ays audible. They may not be heard at all when the heart-beats increase in number. Then Ihe blood-wave is small and the excursion of the valve short. Diminution of temperature, or a few doses of digitalis, therefore, restore a mur- mur which was temporarily absent; but under ordinary circumstances also, as I said before, an organic murmur may disappear for two reasons, one of which is recovery, the other compensation. I think I proved that the disappearance of a mur- mur, as, Cartia 240 Mg for instance, in Case III, and Case IV,, liescribed by Starck in Arch. f. Kind., 1900, p. 200, does not prove it to be functicmal. Nor is there any reason why an endocarditic thickening should not be absorbed as well as those on other tissues. A few words only on myocardial changes. About middle-age myocardial changes are mainly caused by everything that gives rise to hyper- trophy and dilatation. We find mostly a diffuse increase of the intermuscular connective tissue with atrophy of the muscular tisue which first was hypertrophic. The senile heart is very apt to Cartia Xt Discontinued exhibit hypertrophy and dilatation of a peculiar type. There is atheromatous degeneration of the coronary and the minute nutrient arteries. There is consequently an annoyance or destruction of the lymph interstices and channels in and on the myocardium, and of the two large trunks that carrj- the myocardial lymph to the mediastinal lobes, and, finally, degeneration of the myocar- dium resulting in either macroscopic, more or less local, thickening or in atrophy. That is why the contraction of the organ is liable to be irregu- lar, and partial, in instalments, as it were, al- though there be no accompanying sclerotic alteration of the. pericardium, or thickening of the valves and of the endocardium. What we call debility of the heart is a symp- tom Cartia Xt 240 Mg of a great many diiTerent conditions. There is a congenital atrophy which is liable to lead to lipomatosis, there are intoxications by infectious diseases, alcohol, syphilis, malaria, and tubercu- losis; nutritive disorders, such as rachitis and scrofula, overexertion and premature schooling with constipation, and subacute and chronic nephritis, one of the most frequent and most fre- quently overlooked diseases of early infancy. I mention only those causes of myocardial acute, Cartia Xl subacute or chronic changes that are most com- mon in the young, but Cartia Xt 180 should emphasize that what is called debility or failure at any age is in all the cases so occasioned not functional, but the result of organic lesions. Two most interest- ing cases of heart debility I found connected with purpura. Only in one could I obtain an Cartia Tablets autopsy. There were numerous blood-points in the walls of both ventricles and a livid appearance of the muscle. In infants and children myocarditis is mostly pa ren chym ato u s . 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