REPORT OF A CASE OF 
Sudden Death from Coronary Obstruction 
WITH SPECIMEN. 
By Dr. Cassius D. Wescott, Chicago. 
The woman whose heart I show you I saw but twice during 
life, and her history as obtained from herself and mother is not 
very satisfactory. But the heart is so interesting and tells it own 
story so plainly that I am glad to be able to present it. The 
patient was only twenty-two years of age, of good physique, mar- 
ried, and the mother of one child two and a-half years old. 
Her family history was negative. She had been well and 
strong until her confinement but at that time suffered laceration 
of both cervix and perineum, and had never since been well. 
She said she had never had a serious illness of any kind. At the 
time of my first visit she was complaining of loss of appe- 
tite, with considerable distress in the stomach after taking food, 
constipation, occasional pain in the region of the heart, and palpi- 
tation. There was no oedema, no complaint of dyspnoea, and no 
history of rheumatism or other fever. She was not confined to 
her bed but said she was so weak that she could not do much, and 
was liable to “ weak spells ” if she tried to walk even about the 
room. 
Her tongue was broad and flabby and coated white, her tem- 
perature normal, the pulse small and rapid, about 100. Not hav- 
ing my stethoscope with me, I made no examination of the heart. 
My diagnosis, as expressed to the patient and her mother, was 
chronic catarrh of the stomach and a weak heart, but in my own 
mind I attributed her excessive lack of strength to nervous ex- 
haustion, resulting from her pelvic injuries and poor assimilation, 
At my second visit I was in a hurry, and expecting to see her again soon, did not take the time to explore the chest. I did, however, 
examine the abdomen, but found nothing except some tenderness 
in the region of the stomach. I had prescribed a laxative, powders 
of the subnitrate of bismuth and pure pepsin, and a tonic contain- 
ing strychnia, put her upon a liberal but simple diet, and did not 
change or add to the treatment. This call was at about 5 o’clock 
in the afternoon. During the night the patient had an attack of 
pain and vomiting, and Dr. D. A. Payne was hastily summoned. 
He prescribed powders of morphia and bismuth which gave her 
relief. Between 4 and 5 o’clock in the morning she again com- 
plained of feeling badly, and asked for a glass of cold milk, which 
was given her. She drank a portion of it and fell back, dead. Dr. 
Payne was again called, but the patient was beyond resuscitation, 
and he immediately reported to me what had occurred during the 
night. At the autopsy, eight hours after death, rigor mortis was 
well marked. 
On section it was found that the undertaker had perforated 
both abdomen and thorax and filled these cavities and their con- 
tained organs, as far as possible, with his preservative fluid. Even 
the heart had been entered by his instrument and his chemicals 
mixed with its blood. For this reason the examination was limited 
to the heart, kidneys and stomach. 
The latter was found dilated, and its mucous membrane showed 
the usual appearances of chronic catarrhal inflammation. The 
kidneys were apparently quite normal, and no portions were taken 
for microscopical examination. Dr. Hektoen, who assisted me, 
kindly demonstrated the heart. It was of normal size, with some- 
what flabby walls, containing a moderate amount of fat. The 
pericardium was apparently normal, and the semilunar valves 
competent to the water test. On section the myocardium of both 
ventricles was seen to be streaked with yellowish patches which 
the microscope showed to be areas of fibrous degeneration. The 
endocardium was apparently normal, save for several yellowish- 
white areas distributed over both ventricles. Upon opening the 
ascending aorta the orifice of but one coronary artery was seen, 
the right or anterior one, much reduced in size, and partly oc- 
cluded by one division of a leaf-shaped, thrombotic body which 
had formed about the opening, and a portion of which can still be 
seen in the specimen, attached to the roughened surface of the 
aorta. You will also notice that the intima of the aorta, just above 3 
the valves, is much thickened for a distance varying from one to 
two centimeters, and extending around nearly the entire circum- 
ference of the vessel, the upper margin of the thickened portion 
being well marked by an irregularly curved line. 
At the point where we normally find the orifice of the left 
coronary artery it is especially thickened, as shown by an incision 
made in search of the artery. On opening the left coronary ves- 
sel in its course and diverting backward, the doctor came to a 
blind extremity, which can be demonstrated in the specimen, at a 
point behind and 3 or 4 m.m. outside of where it should open into 
the aorta. The aortic semilunar valves were slightly thicker than 
usual; the other valves of the heart seemed quite normal. 
The anatomical diagnosis in this case, as I read it, was 
chronic gastric catarrh with dilatation ; nodular or circumscribed 
arterio-sclerosis of the aorta causing obliteration of the posterior 
coronary artery and narrowing of the orifice of the anterior, fol- 
lowed by chronic fibrous myocarditis, the immediate cause of 
death being acute anaemia of the heart, due to sudden occlusion of 
the narrowed orifice of the sole remaining coronary vessel by a 
parietal thrombus of the aorta. I regret that I did not make a 
more thorough examination of this patient during life, but as Dr. 
Osier says, “ the symptoms of myocardial disease are so notori- 
ously uncertain,” I might have said, even after the most careful 
examination, as I did at my first visit, that the patient had chronic 
gastric catarrh and a weak heart. 
By the courtesy of Dr. Hektoen I am able to show you a 
second heart so similar to the one from my own patient as to be of 
almost equal interest. You will readily see in the aorta the same 
thickening of the intima, due to a similar circumscribed arterio- 
sclerosis. 
The man was thirty-five years old, a book agent. He was 
walking along the street, sat down on a doorstep and died. 
Post-mortem examination showedagood physique and fair nour- 
ishment. The right side of the heart was full of blood, the left was 
empty; the myocardium was pale and of normal consistence ; no en- 
docardial changes. In the right aorta was found a band of thicken- 
ing in the intima about two centimeters wide, situated immediately 
above the aortic valves and involving the coronary orifices so as to 
reduce the lumen of the orifices to the size of a pin point. No 4 
thrombosis in the coronary arteries, or other changes. The thick- 
ening in the aorta presented a smooth surface and was raised to 
the extent of four millimeters above the surface of the vessel, 
which presented slight atheromatous changes down as far as the 
origin of the iliac vessels. The other organs were normal. 
Dr. Ludvig Hektoen: The most striking feature in connec- 
tion with these specimens is the peculiar distribution of the endo- 
carditis in the aorta, being, as you see, in both specimens a band 
extending completely around the vessel situated immediately 
above the aortic valve involving, in one specimen, both coronary 
openings, to such an extent as to practically close the anterior one 
and very largely limit the posterior, and in the second specimen, 
completely and permanently closing the posterior orifice and lim- 
iting the anterior until a thrombus excluded it. The complete 
closure of the posterior coronary orifice in Dr. Wescott’s specimen 
is, I think, very unique. Another fact about Dr. Wescott’s case 
that is interesting is the patient’s age being only twenty-two years, 
which is an unusually early time for any of these changes in the 
vessels to develop. The other heart was taken from a man thirty- 
five years of age, which is also rather young. Dr. Crook, of Lon- 
don, has lately reported one case similar to these with narrowing 
of both orifices and final closure of one, at least, by parietal throm- 
bosis. In his case the patient was suffering from secondary 
syphilitic symptoms at the time of death and there was found upon 
the aorta not a chronic endocarditis, as we see here, but an acute 
one, the process being demonstrated as acute by microscopic sec- 
tions as well as from the appearance of the gross specimen, the 
appearance in the aorta being very similar to that of acute vegeta- 
tive endocarditis. He closes his paper with the statement that 
when a bandlike formation like the ones we see in these specimens, 
are formed in young people, we have a right to infer that the origin 
of the disease is syphilitic. The most unique part of his specimen 
was the fact that the changes in the aorta were acute, not chronic 
as they are here. 
Dr. H. N. Moyer: What is the relation of this condition to 
sudden death? 
Dr. Ludvig Hektoen : In the vast majority of cases sudden 
death has been demonstrated by various observers to be due to 
disease of the coronary vessels. One investigator demonstrated 
that over 00 per cent, of all the cases he observed of ordinary 5 
sudden death, the only demonstrable cause of death was disease of 
the coronary vessels, most frequently in the course of the vessels 
rather than, as in these specimens, located at the orifice. 
Dr. H. N. Moyer: Would you in a given case of sudden 
death in which you found marked sclerosis of the coronary arteries, 
give an opinion that death was caused by that condition of the 
coronary arteries, in the absence of thrombosis? 
Dr. Ludvig Hektoen : Yes; in the absence of other demon- 
strable causes. 
Dr. H. N. Moyer : I once saw a remarkable instance of 
sclerosis of the coronary arteries, but was unable to obtain a his- 
tory of the case. They were found in a woman who had been 
murdered by stab wounds in the neck. When dissected out they 
could be bent slightly and would then break with a clean fracture, 
just as a pipe stem breaks. There was the most extreme degree 
of calcification of these arteries that I had ever seen. The heart 
muscles showed the chronic changes found in cases of endocarditis, 
the whitish appearance of the endocardium and the thickening 
of the intima of the aorta, but no obstruction at the mouth or in 
the course of the coronary arteries. 
Dr. Henry M. Lyman : Dr. Danforth showed me some time 
ago a heart illustrating beautifully the relation between the 
coronary artery and its branches and the portion of the heart 
muscle nourished by them. It was a case in which the coronary 
artery was diseased, but not throughout its whole extent; there was 
disease involving different branches, and those branches that were 
considerable sclerosed were surrounded by a portion of the muscle 
substance in an advanced state of degeneration; in other portions 
where the artery was in good condition there was comparatively 
healthy heart substance. 
The question that Dr. Moyer brings up in regard to the con- 
dition of the heart if there is any slight arterio-sclerosis, I think is 
a question of degree entirely. I believe it is impossible to have 
disease of the coronary arteries of a sclerotic character that has ad- 
vanced sufficiently to be recognized after death without a corre- 
sponding failure of the nutrition of the heart muscle. 
Dr. J. M. Patton : This is a very interesting specimen. The 
peculiar absence of an opening for the coronary vessel on one side, 
together with the formation of a thrombus over the opening of the 
vessel on the other side, is rather unique. 6 
The question brought up by Dr. Moyer as to sudden death is 
an interesting one, and I believe Dr. Hektoen is right when he 
says he would consider sclerosis of the coronary vessels a possible 
cause of death in the absence of thrombosis or embolism of those 
vessels ; it might occur from cardiac ischaemia. It is a well 
known clinical fact that in cases of arterial sclerosis, whether of 
the coronary arteries or of the general system, there may be attacks 
of dyspncEa which might cause sudden death, or comparatively 
sudden, in an hour or two, and they are due to spasm of the ar- 
teries, and in a degenerated heart from coronary sclerosis, where 
the heart muscle has suffered from chronic ischaemia, the inter- 
ference with its already scanty blood supply resulting from arterial 
spasm, might readily induce total functional inability of the organ. 
I think we give the credit to the heart in these cases a great many 
times when it is not due. It is very common to call all cases of 
sudden death heart disease, but sudden death rarely occurs in heart 
disease, except where the coronary vessels are involved. There is 
no reason why we should have sudden death in valvular disease of 
the heart, except in embolism of the coronary or cerebral arteries. 
Embolism of the cerebral arteries is a very rare condition: out of 
a hundred cases you will hardly run across one. In my practice 
I have only seen two cases of undoubted cerebral embolism occur- 
ring in valvular disease of the heart where I was absolutely certain 
as to the diagnosis. I think a great many deaths due to the heart 
occur in those cases of sclerosis of the coronary arteries, and may 
occur without thrombosis or embolism. Dr. Lyman is certainly 
right in saying that any degree of sclerosis of the coronary arteries 
means failure of nutrition of the heart muscle, and that opinion is 
borne out by the views of various eminent pathologists. 
In regard to the cause of the various cardiac neuroses which 
are largely considered to be due to nutritrive changes in the 
heart muscle which are the result of coronary sclerosis, it is diffi- 
cult to make a a diagnosis of such a condition in life, because you 
merely have evidence of a weak heart muscle, but it will be easy, 
associated with a diagnosis of chronic myocarditis to make a diag- 
nosis of coronary sclerosis, inasmuch as you have evidence of 
general sclersois, and can associate this condition in a general 
way with the other. 
Dr. A. H. Foster : I would ask what is the present relation 
between angina pectoris and coronary trouble ? 7 
Dr. J. M. Patton: Opinion is divided on that question, a 
number of writers on that subject still hold to the theory of coro- 
nary sclerosis in all cases of true angina pectoris, others claim that 
it may occur in any case of myocardiac degeneration, especially 
those cases that are fibroid in character, general fibroid degenera- 
tion of the heart muscle, and as that condition is so often associ- 
ated with coronary sclerosis, it is difficult to separate the two. 
Some again claim that it is associated with disease of the cardiac 
ganglia. 
Dr. Henry M. Lyman: I wish Dr. Wescott would tell us 
whether there was any connection between these cases and previous 
syphilitic disease. This subject of syphilis of the heart is becom- 
ing quite interesting; there have been quite a number of cases 
referred to syphilis of the connective tissue of the heart, syphi- 
litic carditis ancj the like, which have been greatly benefited by 
iodide of potassium and antisyphilitic treatment. 
Dr. C. D. Wescott: As I stated in my paper, the history of 
my patient was very unsatisfactory. She seemed to be rather feeble- 
minded and what I did get from her and her mother was by a proc- 
ess of pumping. Without asking any leading questions, I tried 
to investigate the matter of syphilis, but got no reply from her that 
would indicate that she had had such trouble, and my examina- 
tion of her during life revealed no evidence whatever, and we came 
across nothing in the post-mortem that would indicate any more 
positively than the condition of these vessels indicate that she had 
syphilis. The history of Dr. Hektoen’s case was practically un- 
known, the man was found dead on a doorstep where he sat down 
to rest a moment. My case is in a way disappointing. I am 
sorry I could not make it more complete as to history and physical 
examination. The fact that this woman had a living child that 
appeared perfectly well, would contraindicate syphilis, although 
not positively. 
I have nothing more to add to what has already been said, 
except to thank the members for their interest and discussion of 
the case. 
551 Jackson Boulevard.