Dr. Peacock has given an able and elaborate analysis of forty cases, recorded by various authors, from which it appears that when the obstruction is not referable to the presence of tumours, coagula, or inflammatory exudation, the contraction is always situated at or near the point of junction of the ductus arteriosus and the aorta, the constriction being referable to contraction and thickening of the internal tissues, or else to the formation of a more or less complete septum. The defect probably originates, as suggested by M. Raynard, in the faulty development of the portions of the bronchial arches, which form the continuation of the aorta from the origin of the left subclavian to beyond the insertion of the ductus arteriosus; and the contraction of some portion of that space is sometimes so great as to prevent the closure of the duct after birth, and to make that passage the channel by which the blood either wholly or in part reaches the descending aorta. Below the seat of contraction the vessel is generally dilated, the dilatation sometimes occurring quite abruptly. Above it is also usually dilated, and the coats thickened, atheromatous, or calcified, and not unfrequently these changes extend to the larger portion of the arch. In ten instances the canal of the vessel was entirely obliterated, the obstruction extending usually from half a line to a quarter, but in one instance to half an inch; in thirty the obstruction was incomplete. In 73.7 per cent. of the cases the patients were males; in 22:3 only females, their ages varying from that of twenty-two days to that of ninety-two years.*

* Dr. Peacock, loc. cit., p. 484, gives the following table indicative of the age and sex of the patients affected with aortic contraction or obliteration:

In the nine cases in which the aorta was completely obliterated, the ages were 22 days, 7 years, 14, 21, 42, 45, 50, and 57 years; and 1 middle-aged, the precise age not stated.

In twelve cases the patients died of diseases which had little connection with the aortic obstruction, in eight or nine death occurred suddenly, and was directly traceable to the condition of the aorta, and in six out of thirty-six cases, in which the cause of death is clearly stated, cardiac asthma and dropsy, with their usual complications, proved the immediate cause of the patient's death. The circulation was carried on by means of anastomosing branches of the subclavian arteries, and the aortic branches below the seat of constriction. Thus, in some instances, there were anastomoses of the posterior scapular branch of the transversalis colli, derived from the thyroid axis, with the posterior branches of the aortic intercostal arteries; or of the superior intercostal artery, derived from the subclavian, with the aortic intercostals; or of the branches of the internal mammary with the intercostals and the ascending epigastric. The valves and endocardium were diseased in more than one fourth of the cases, and the heart, in consequence of the obstruction to the circulation, was dilated and hypertrophied.

The symptoms which have been observed in these cases somewhat resemble those of aneurism, viz., pain, dyspnoea, palpitation and violent throbbing of the carotid and temporal arteries, accompanied by intense systolic murmur and well-marked thrill. It is obvious, therefore, that something more is needed than systolic murmur and arterial thrill to justify the diagnosis of aneurism; and the points on which reliance must be placed are, first, the absence of tumour and of dulness on percussion over the seat of pain and murmur; secondly, the absence of the signs of pressure which are usually produced by aneurismal and other tumours; thirdly, the dilated condition of the anastomosing vessels before referred to; fourthly, the violence of the pulsation observed in the carotids, temporal, subclavian, and the before-mentioned anastomosing arteries, as contrasted with the feeble pulsation of the vessels which supply the lower extremities. A permanent harsh systolic aortic murmur, following the impulse of the heart, and of greater intensity over the upper part of the sternum under the clavicles, and on each side of the neck in front, than over the central organ of circulation, and accompanied by a thrill in the second intercostal space on either side of the sternum, by violent throbbing of the carotid and temporary arteries, by dilatation and pulsation of the smaller anastomosing vessels, and by very feeble or imperceptible pulsation of the vessels supplying the lower extremities, affords just grounds for diagnosing the existence of a constricted or obliterated thoracic aorta;

and if these symptoms be unattended by bulging of the thoracic walls, by dulness on percussion, and by the phenomena indicative of morbid pressure within the chest, which would probably exist if aneurism were present, the diagnosis would be greatly confirmed. Anasarca is seldom observed in these cases, but when the obstruction is the result of disease in the coats of the vessels, and occurs in the abdominal aorta, gangrene of the extremities has been known to follow.

It is difficult to determine how long a person may live in the enjoyment of apparent health whilst suffering from this morbid condition of the arteries, inasmuch as the precise date of the commencement of the mischief cannot be positively ascertained; but it may be pointed out that in one of the cases collected by Dr. Peacock, the patient had attained the age of ninety-two, and that considerable contraction of the aorta has been discovered after death in many instances, in which the patients had reached the middle period of life without presenting any symptom calculated to direct attention to the the organs of circulation.*

Functional Pulsation of the Aorta.

Functional pulsation of the aorta is an affection of considerable practical importance, inasmuch as it is extremely distressing to the patient, and is apt to mislead the unwary practitioner into the belief that the vessel is organically diseased, and that aneurism is the form of mischief he has to encounter.

The occurrence of this affection has been referred to a variety of causes, amongst which may be mentioned hysteria, dyspepsia, and spinal irritation, acute gastritis, and the use of strong green tea and tobacco. But inasmuch as these agencies are frequently in full operation without producing aortic pulsation, and as aortic pulsation is often observed in cases in which there is no evidence of their action, the conclusion seems inevitable that however much any one of these agencies may seem to aggravate or even excite the pulsation, when a tendency to it already exists, some peculiar predisposition to aortic pulsation, connected probably with perverted innervation, must be a condition precedent to its occurrence.

Functional pulsation sometimes affects the thoracic aorta, but much more frequently the abdominal portion of the vessel. When the

* Dr Peacock's paper above referred to will well repay a careful perusal.

thoracic aorta is affected there may be oppression in the upper part of the chest, with dyspnoea, violent throbbing in the upper sternal region, and visibly increased action of the large arteries in the neck, and yet with all this evidence of morbid action there may be no organic disease of the vessel. The absence of organic mischief, however, can only be determined by a careful inquiry into the history of the case, and by the aid of physical diagnosis. The mode in which the pulsation arose and the special nature of the symptoms which accompany it, coupled with the age, sex, and appearance of the patient, and with the absence of any extension of the dulness on percussion, of arterial thrill and murmur, and of evidence of pressure on the thoracic organs will generally indicate the true nature of the malady, and prevent the experienced physician from falling into error.

When the abdominal aorta is the subject of pulsation there is usually considerable uneasiness and throbbing in the epigastrium, with a feeling of nausea or faintness. Pulsation may not only be perceptible to the patient, but visible to the bystander. The hand, placed along the course of the vessel, perceives a forcible yet abrupt impulse, synchronous, or nearly so, with the systole of the heart; but if the physician is cautious in his examination he will be struck with the extraordinary elongation of the pulsation, and with the absence of circumscribed tumour, of dulness on percussion, of diastolic impulse, of lateral expansion, and of aneurismal thrill and murmur. Tumour, indeed, there may be, and dulness on percussion, and systolic murmur also, if a malignant growth or other mass of diseased structure chances to lie over and compress the throbbing aorta ; and when this is the case, and pain, which is a constant attendant on these forms of disease, is present, a positive diagnosis is difficult, if not impossible. Under these circumstances even the lateral expansion of an aneurismal tumour may be simulated by the impulse communicated to the diseased mass; and there may be diastolic pulsation and diastolic murmur also. Even when no tumour is present, murmur may be excited in a very thin person by forcible pressure with the stethoscope. Nevertheless, when no tumour exists, and no disease of the vertebra, of a nature to push forward the artery and excite arterial murmur and thrill, the diagnosis in most cases is not likely to be mistaken by experienced practitioners. The history of the case, the age, sex, and appearance of the patient-for this form of complaint is most common in women-the mode in which the pulsation commenced, the peculiar character of the concomitant symptoms and the

absence of the physical signs already described as accompanying abdominal aneurism can leave little doubt as to the nature of the malady.

This functional pulsation of the aorta is often said to be difficult of removal, and Dr. Walshe even quotes a case to prove that it is susceptible of complete cure." Judging from my own experience in the matter, I cannot understand how any doubt has ever been entertained on the subject; for amongst the many examples of it which have fallen under my notice at St. George's Hospital and elsewhere, I have never met with one which did not yield readily to appropriate remedies. The treatment, however, to be efficacious, must be directed against the functional derangements which happen to be present in each particular instance; and no single remedy or set of remedies can avail for this purpose. As a general rule, the patients are weakly, nervous, and more or less dyspeptic, and therefore the administration of some of the preparations of iron, combined with quinine or strychnine, valerian, and camphor, diffusible stimulants, and antispasmodics, and aided in their action by the shower-bath or dripping-sheet, or a cold douche to the spine, constitute an essential element of success. But even these remedies will fail in producing the desired effect, if the stomach is deranged or the bowels costive; and in this case the frequent exhibition of the compound sagapenum or galbanum pill, in combination with aloes, podophyllin, belladonna, and nux vomica, is often of essential service. Sometimes, again, an emetic is serviceable under these circumstances, more especially when it is followed by brisk purgation and by the administration of bismuth, soda, magnesia, and hydrocyanic acid, in a light bitter infusion calculated to give tone to the digestive organs. Opiates internally are seldom of much service, and may even prove mischievous, by deranging secretion and producing constipation; but I have seen marked benefit result from the application of an opium or belladonna plaster down the spine and over the seat of pulsation in the abdomen. Digitalis, aconite, the veratrum viride, and other vascular sedatives and medicines, such as hyoscyamus and conium, which have the reputation of allaying nervous excitement, are far less efficacious than might be anticipated, and fall far short of the remedies first referred to in producing a satisfactory result; and bloodletting, whether by venesection or by leeches, should not be had recourse to, unless unquestionable symptoms of gastritis are present.

The diet should be light, yet nutritious; all articles such as tea and coffee, which are apt to occasion nervousness and palpitation, should be