Clinical Paper: Two cases of sudden death from haemorrhage from ulceration of the aorta

British Medical Journal, 24 June 1853, pages 539-40

TWO CASES OF SUDDEN DEATH FROM HAEMORRHAGE FROM ULCERATION OF THE AORTA.*

By CHARLES COWDELL, MD. Lond., Physician to the Dorset County Hospital.

(Read before the Dorset Branch of the Provincial Medical and Surgical Association, on May 31, 1853.)

* Reported by W. G. Bacot, Esq., House Surgeon. The meeting at which this paper was read was held at Bridport, Dorset; S. S. Cory, Esq., President, in the chair. The paper was illustrated with pathological preparations of the diseased parts.

CASE I. George Cockerell, labourer, aged 37, admitted June 27th, 1852, stated that he had always enjoyed good health until June 1851, when, after a hard day’s mowing, he was suddenly seized with rheumatism, from which, however, he thoroughly recovered. He had since been in the hospital at Salisbury, where he was cupped and blistered on his loins, which were then the seat of much pain. On examination when admitted, he was found to be moderately fat, but flabby; and, indeed, in a state of general cachexia. The sound on percussion over the apices of the lungs was good; respiration was tolerably free, with somewhat prolonged expiration; sonorous and sibilant rhonchi were present in both bases posteriorly, and some finer subcrepitant rhonchus in the left base. He complained still of much pain in his loins. He had some cough, with slight expectoration of thick mucus. He had never spat blood. There was slight aortic regurgitation and constriction: no hypertrophy.

The treatment was directed to the bronchitic symptoms. He took with advantage a mixture containing chlorate of potass, compound tincture of camphor, and tincture of squills, with wine of ipecacuanha, and an expectorant pill at bed-time. Under this treatment, his cough and lumbar pains abated; but he was always listless and inactive. In this way he went on for about a month, when he began to expectorate a little blood mixed with the mucous sputa, and it was thought probable that there was latent phthisis, notwithstanding the slight indications of pulmonary disorder. He was accordingly directed to apply leeches to the chest, and to take oleum jecoris aselli. There was no indication of aneurism.

July 27th. When sitting on a bench in the garden this evening, he coughed slightly, was immediately deluged with blood, and died in a few minutes.

EXAMINATION OF THE BODY. The organs in the chest were found tolerably healthy, except the heart and aorta. Slight aortic disease, affecting the sigmoid valves, and diminishing the aortic orifice, was discovered. Patches of incipient atheroma were diffused over the inner surface of the aorta throughout. In the middle of one of these patches of atheroma was an ulcer, extending through the coats of the artery into the right bronchus. There was no dilatation of the artery; but between it and the bronchus there was a very small sac, formed by the outer coat of the vessel.

CASE II. George Whittle, aged 30, married, a labourer, was admitted at the end of August 1852. He had always enjoyed good health (except an attack of scarlet fever, four or five years previously) until eight weeks before admission, when, after getting wet through while ploughing, he was seized with pain in the left leg, which gradually increased. Of the progressive history of his illness he could give no account, having, as he said, been too ill to remember anything about it.

When he was admitted, the face was worn and pale; there was great emaciation of the upper extremities. The right shoulder could not be moved without great suffering; indeed, he could with difficulty be carried to his bed, or turned when in it. The legs were oedematous, especially the left; as were also the walls of the abdomen, which pitted under pressure. The heart’s apex beat between the fourth and fifth ribs, just under the nipple. The sounds at the apex were very indistinct, though a low soft murmur could be caught; at the base, a distinct rubbing to and fro sound was heard. The heart’s dulness [sic] appeared to extend towards the costo-clavicular articulation. The pulse was 104, and thready.

In the lungs, percussion was decidedly duller under the left clavicle than under the right. There were strong sibilant and sonorous rhonchi on both sides of the chest; mostly on the right side, where, in the clavicular region, the respiration was loud and blowing, and equal in length to the inspiration. On the left side, the expiration was prolonged, but not nearly as much so as on the right.

Over the front of the abdomen, there was a rash of a blueish shade, disappearing under pressure; the patches varying in size from that of a fourpenny piece to a pin’s head.

The bowels were open; the appetite was good.

The following treatment was followed. A blister was applied over the heart, and the following mixture prescribed:-  [formula and Latin names of drugs not reproduced in this transcription]

September 3rd. He was much improved, though the legs, especially the left, were much swollen. The urine was moderate in quantity, and deposited phosphates.

He gradually improved from this time, so as to be able in two or three weeks to leave his bed, and walk about on crutches, and even to go into the garden to smoke his pipe when the sun shone; but he continued weak and cachectic, with a dejected air and expression.

Oct. 4th. Mr. Bacot, the house-surgeon, was called in the evening to see him, and found him sitting on the bed-chair (having just passed a motion), complaining of pain in his bowels. By the administration of stimulants at short intervals, he rallied from a state nearly approaching collapse.

October, 5th. He was this morning quite free from pain, but his pulse was excessively small and weak.

At 2.30 when visited again, he was found in articulo mortis, and rapidly sank.

EXAMINATION OF THE BODY. Chest. The lungs were covered with recent false membrane, not uniting them to the costal pleura in front, although it did so behind. There was no tubercle. The lungs were crepitant, and buoyant in water. The pericardium contained a little fluid, and some fine adhesions united the roots of the vessels to the pericardium. The heart was of normal size. There was a large white patch on the anterior surface of the right ventricle, the walls of which were a quarter of an inch thick. The tricuspid valves were healthy; the pulmonary valve had fine reticulations on two of its segments. The wall of the left ventricle was half an inch thick. The aortic valve was thickened and opaque, and had some reticulations. The mitral valve also was thickened at the points of insection of the chordae tendineae; and the opposite portion was puckered and greatly diminished in breadth.

Abdomen. This cavity being opened, a dark plum-coloured fluid escaped, and the intestines on the right of the median line were found to be encased in a coagulum of blood an inch thick. On close examination, the liver was found united to the right pillar of the diaphragm. The aorta and vena cava were imbedded in a mass of fibrin, extending from the aortic opening in the diaphragm to just above the iliac arteries. This mass was removed entire, and exposed an aneurismal sac, bounded by the right pillar of the diaphragm, the anterior inferior surface of the liver – the lobulus Spigelii projecting into the sac, and in front by a layer of thick lymph, together with the vena portae and hepatic artery, which were moreover united by recent lymph to the lower edge of the liver. This cavity was divided into two of unequal size, that attached to the aorta being as large as a walnut and separated from the larger one by a thick layer of lymph, perforated with an opening of the size of a goose-quill, and having another opening, by which it communicated with the aorta, as large as a chicken’s quill. This last op9ning was found just above the giving off of the arteries, which usually unite to form the coeliac axis, but which in this case arose separately from the aorta. The aorta was roughened by a patch, apparently of atheroma, at this precise spot, without any dilatation, and was elsewhere smooth and healthy. The smaller cavity was rugose, like the lining membrane of the gall-bladder, and contained a tough, tawny coagulum. The larger one – twice the size of the smaller – appeared to be of more recent existence, and to be formed principally by adhesion of the parts and organs whereby it was naturally bounded.

REMARKS. In neither of these cases was the calibre of the aorta at all increased. In both, there was deposit in the inner coat, though very slight, and confined to the immediate neighbourhood of the perforation of the artery in the case of Whittle. In both, the cellular coat appeared to form the aneurismal sac, being dissected away by the infiltration of blood. Both patients were in the state of rheumatic cachexy, contracted under very similar circumstances. But in Whittle there was something more: the valvular heart-affection, and an abscess over the right shoulder-blade (not mentioned in the account of the autopsy).

It appears sufficiently clear that, in the case of Cockerell, the affection of the artery commenced with his rheumatic attack. The inflammation of the serous lining of the heart (endocarditis) was continued to that of the aorta, ending in atheroma of the vessel; the peculiar characteristics of which – fatty globules and crystalline matter – were distinctly visible under the microscope. Rokitansky affirms that this succeeds to hypertrophy of the lining membrane of the vessel in such cases. In the case of Whittle, the incrustation in the aorta was so small and thin, that it may be doubted if it was of the same nature as that of Cockerell ; and when it is remembered that there were two sacs – the inner one only containing a coagulum, and that, besides the coagulated blood, there was found in the abdomen a quantity of thick plum-juice-like fluid – we retain the impression then felt, that an abscess had given way. The outer and larger sac was probably that of an abscess, which had caused arteritis at the point of contact, with ulceration through its coats, and their dissection of its outer one by the effused blood, thus gradually causing the aneurismal sac. This conclusion is, however, somewhat at variance with the appearance which the larger sac presented, of being more recently formed than the smaller one.

The sudden pain in the belly, and the supervention of syncope in the recumbent posture, indicated internal haemorrhage from the yielding of arterial coats, either by ulceration or aneurismal rupture. Happily, the cause of death was clearly demonstrated by the post mortem examination, and as clearly exhibited in the well prepared pathological specimens with which the remarks on the case were illustrated.

Dorchester, June 1853.

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