strictly forbidden, and so also should food, of whatever nature, which would be likely to create acidity or flatulence. Malt liquor should be avoided, and should be replaced by wine or brandy. Ice and cold drinks are often very serviceable; moderate exercise, change of air and scene, and constant occupation and amusement, without any strain on mind or body, are useful adjuncts to the treatment.

Diseases of the Pulmonary Artery.

Diseases of the pulmonary artery are rare, and their variety is equalled by the obscurity in which they are at present involved.

Inflammation of the vessel is said to have been observed in various distempered conditions of the blood; but, I am not aware of any recorded example of the disease in which conclusive evidence is adduced of the existence of local inflammation. Cases in which fibrinous coagula have formed in the pulmonary artery have been carefully observed by several excellent pathologists, but many of them have been shown to be unconnected with inflammation of the vessel; and the narratives of those which are said to have been dependent on acute inflammation leave considerable doubt in my mind as to whether the disease was not spontaneous coagulation of the blood, occurring independently of arterial inflammation. Personally, however, I have had no experience in the matter, and those who are interested in the subject will do well to refer to Mr. Paget's papers On the Obstructions of the Branches of the Pulmonary Artery',* and to Dr. Norman Chevers' admirable work,† in which all that is known respecting the morbid conditions of the pulmonary artery is carefully recorded.

Dilatation of the pulmonary artery, when of slight extent, is not of unfrequent occurrence in connection with diseases productive of long continued impediment to the circulation through the lungs. In no disease is it seen more strikingly than in emphysema, in which dilatation of the right cavities of the heart is of constant occurrence. The main trunk of the artery and its various branches are all apt to suffer to a greater or less extent; the latter especially being often

*Med.-Chir. Trans.,' vols. xxvii and xxviii.

+ Collection of Facts illustrative of the Morbid Conditions of the Pulmonary Artery,' by Dr. Norman Chevers (London, 1851), pp. 79-98.

almost varicose in appearance, and more or less thickened and opake. Dr. Hope* and Dr. Stokes,† both make mention of a case in which dilatation had proceeded to such an extent as to cause insufficiency of the pulmonary valves. In my own practice an instance has never occurred in which regurgitation has taken place through the pulmonary valves, as the result of simple dilatation; and, although theoretically there is no inherent impossibility in such an occurrence, yet its extreme rarity is unquestionably proved by the almost entire absence of recorded cases. In a case detailed by Dr. Alfred Taylor, in the 'Medical Gazette,' vol. xxxvi, p. 19, the pulmonary artery measured four metres and five lines immediately above the semilunar valves, and yet there was no reason to doubt the efficiency of the valves. Unless regurgitation takes place, there is no means of diagnosing the disease, as the enlargement does not proceed to an extent sufficient to cause dulness on percussion, and is not productive of any characteristic general symptoms.

Aneurism of the pulmonary artery is an exceedingly rare disease, but has been met with well developed. Drs. Fletcher§ and Blakeston|| have put one case on record; another has been detailed by Skoda, and a few other cases have been collected or referred to by Dr. Norman Chevers.¶ Lividity of the face, dyspnoea, cough, dysphagia headache, and pain in the chest and epigastrium, are the principal symptoms which have been observed in these cases, and pulsation between the second and third left ribs, accompanied by a superficial rough systolic murmur, a purring thrill, and dulness on percussion in the same situation, are the principal physical signs which have been recorded. But the physical signs and general symptoms above enumerated are not of constant occurrence, nor are they distinctive of pulmonary aneurism. Dysphagia, as far as I am aware, has only been observed in a single instance.** Dyspnoea has not always been a constant symptom, and

The only instance of persistent insufficiency of the pulmonary valves which has fallen under my observation resulted from fibrinous vegetation on the valves. It is possible, however, that, shortly before death, a double pulmonary murmur may sometimes arise from the presence of fibrinous clots, extending from the right ventricle into the artery.

§ Med.-Chir. Trans.,' vol. xxv.

|| On 'Certain Diseases of the Chest,' p. 98.

Loc. cit., pp. 118-121.

** A case recorded by Dr. Harlan in his Medical and Physical Researches,' and quoted by Dr. Norman Chevers.

lividity, as in Dr. Fletcher's case, has been wholly absent. So also in regard to the physical signs. Even if they were all present they might be produced by a tumour in the anterior mediastinum pressing upon and causing a murmur in the pulmonary artery, and at the same time receiving an impulse from it. Possibly, however, the murmur in this case might not convey the impression of being seated superficially to the same degree as that which accompanies pulmonary aneurism.

Contraction and obstruction of the pulmonary artery are far more frequent, and, therefore, more important lesions than pulmonary aneurisms. They may result from congenital malformation, from endocarditis, from the pressure of aneurismal and other tumours, and from the formation of clots of fibrin in the vessels. In all cases a systolic murmur, superficial in seat, is heard over the base of the right ventricle, and in the course of the pulmonary artery; the complexion is usually livid, or of a cyanotic tinge; the pulse is habitually small and quick, yet regular; there is shortness of breath, which is aggravated in paroxysms, and the patient assumes a horizontal posture either habitually or during the paroxysms, a fact, the true diagnostic importance of which was first pointed out by Dr. Norman Chevers. In all other forms of disease of the heart or great vessels the patient breathes easier when the shoulders are raised; but in this the dyspnoea results from insufficiency of the supply of blood to the lungs, and to the system generally, and, hence, a recumbent posture affords relief by removing the impediment which gravity would offer to the action of the heart and thus by promoting the supply of blood to the brain.

The treatment in these is precisely that already described as applicable to cases of cyanosis.

INDEX.