[Reprinted from The Medical News, April 22, 1893.] 
PRENATAL CLOSURE OF THE PULMONARY 
ARTERY. \ 
BY A. J. BURGESS, M.D., 
OF MILWAUKEE WIS. 
After a normal labor at term, a male child was born. 
The child was of good size, and presented no external 
abnormality. The child's face made the contortions of 
one crying, but no sound was uttered. A full hour was 
spent in trying to restore the child. After the lungs had 
been inflated several times by artificial means, the heart 
beat vigorously, but upon ceasing the inflation the heart- 
beat gradually became slower and weaker. After each 
inflation during an hour, the heart-beat underwent the 
same modification, and efforts on the part of the child 
at crying and breathing were made with only one result, 
viz., the drawing inward of the lower border of the chest 
by the action of the diaphragm. Powerful inflations 
did not seem to expand the chest. The hand felt a 
churning sensation over the lower chest in front during 
systole. The child was considered non-viable, and soon 
died after inflation ceased. 
At the autopsy, the costal pleura was found to be ad- 
herent to an underlying membrane, about as firmly as 
two pieces of wet newspaper adhere. The underlying 
membrane proved to be the pericardium, of which the 
cavity was largely distended, filling the whole chest. The 
lungs were not visible from the front. The entire con- 
tents of the chest were removed en masse. The lungs 
Ihy collapsed behind a fluctuating mass that proved to 
be the heart, the right side of which was enormously 
distended with blood. The right auricle and ventricle 
held blood estimated to be at least three ounces. 2 
The right auricle and ventricle were both dilated, and 
the walls of both excentrically hypertrophied. The 
right auriculo-ventricular opening was dilated largely 
enough to admit the tips of the index and middle fingers. 
The tricuspid valve formed a fringe around this opening, 
and was covered with a papillary growth. The valve 
was entirely incompetent. There was absolutely no 
opening from the right ventricle into the pulmonary 
artery. The occlusion was musculo-membranous. The 
segments of the pulmonary valves had apparently 
become adherent to one another and overlaid, on the 
ventricular side, by a muscular band. From above, the 
pulmonary artery was open to the valvular surface, and 
was probably somewhat contracted in caliber. The papil- 
lary fringe on the right auriculo-ventricular valves may 
or may not have been the remains of a morbid process 
which closed the pulmonary orifice. 
The foramen ovale admitted a large forefinger easily. 
The left auricle was dilated, but not largely so, and its 
walls were hypertrophied. The left auriculo-ventricular 
opening was not far from normal in caliber, and the mitral 
valve was normal. The left ventricle was dilated and 
hypertrophied to a moderate extent. The ductus arte- 
riosus Botalli was in the usual situation, but had a caliber 
larger than usual. The aorta and its valves were normal. 
There was no defect of the interventricular septum. 
There was no congenital defect of the interauricular sep- 
tum, the large foramen ovale being due to the enormous 
dilatation of the right auricle, and to the fact that it 
served its own function, plus that of the pulmonary 
orifice, which had closed. It is probable that the course 
of events was as follows: At a time late in fetal life, sub- 
sequent to the completion of the ventricular and other 
septa, a morbid process closed the pulmonary orifice of 
the right ventricle; the right ventricle, its auricular open- 
ing, its auricle, the foramen ovale, the left auricle, its 
ventricular opening, and the left ventricle, became suc- 
cessively dilated ; the walls of the several cavities became 3 
hypertrophied ; and the caliber of the ductus arteriosus 
became widened. 
The reason why this child could not breathe, was that 
the enormously distended right auricle and ventricle so 
completely filled the chest-even distending it-that the 
lungs, collapsed behind the heart, were incapable of 
inflation by the force at the disposal of the child. The 
heart was practically a neoplasm distending the chest and 
compressing its contents. 
It seems possible that, had the pulmonary closure 
taken place earlier, the various compensatory arrange- 
ments might have become complete enough to have per- 
mitted a longer extra-uterine existence. 
In Pepper's System of Medicine, vol. iii, page 695, the 
following statement is made: " If the pulmonary artery 
is obliterated or exceedingly narrowed at a later period 
{i. e. subsequent to completion of the ventricular septum 
in the third fetal month), the ventricle shrivels, because 
no blood is able to pass, and gradually more and more 
of the fetal current passes through the foramen ovale to 
the left side." The present case is satisfactory proof 
that it is not true that the right ventricle always shrivels 
under the circumstances noted. In this case the pul- 
monary closure was complete; the ventricular septum 
was complete; the right ventricle was dilated and hyper- 
trophied. Aside from the condition of the ventricular 
septum, there is another factor not considered in the quo- 
tation made, and that is, the condition of the tricuspid 
valve and its orifice. In this specimen the tricuspid 
orifice was dilated, its valve diseased and incompetent, 
if not entirely functionless. The right auricle and ven- 
tricle thus formed practically one cavity, viz., an auricle. 
The right ventricle functionated in the direction of 
the right auricle, because no valves opposed it at the 
tricuspid orifice ; and because it could functionate it did 
not atrophy. 
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