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Twenty-three patients with major pulmonary embolism were examined clinically and investigated by cardiac catheterization with selective pulmonary angiography. Two and Wagner, I967). The availability of more accurate diagnostic methods and of more specific treatment has heightened the responsibility of the attending clinician to diagnose correctly or at least to suspect the diagnosis of major pulmonary embolism. Furthermore, the interpretation of these investigations and the selection of the most appropriate form of therapy require greater understanding of the pathological physiology of major pulmonary embolism. During a recent prospective study of the rate of natural resolution of major pulmonary embolism and of the effects of streptokinase therapy (Hirsh et al., I968; McDonald, Hirsh, and Hale, I97i), an opportunity was provided to correlate the clinical findings with haemodynamic and angiographic investigations and to analyse these data in the light of what is currently known about the physiology of major pulmonary embolism in man. This study also highlighted certain atypical features and diagnostic difficulties which will be discussed.

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