RUPTURE OF THE AORTA, AND EMBOLISM OF ILIAC ARTERY. W. M. CHAMBERLAIN, M. D. RUPTURE OF AH' ATHEROMATOUS AORTA, AND EMBOLISM OF TEE LEFT ILIAC ARTERY. BY W. M. CHAMBERLAIN, M. D., PHYSICIAN TO CHARITY HOSPITAL AND DEMILT DISPENSARY. {REPRINTED FROM THE N. Y. MEDICAL JOURNAL, OCT, 1874.] NEW YORK: D. APPLETON AND COMPANY, 649 & 551 BROADWAY. 1874. EUPTUEE OF AN ATHEEOMATOIJS AOETA, AND EMBOLISM OF THE LEFT ILIAC AETEEY. The following history seems to present points worthy of record and remark: J. 0. 8., a manufacturer, fifty-one years of age, five feet six inches in height, weighing one hundred and eighty pounds, in every way well developed, of regular and temperate life, came under my notice on the 17 th of August, 1874. His family were not aware that he had consulted a physi- cian for eighteen years before that date, except on one occa- sion, when he was told that he was suffering from nervous prostration, advised to leave off smoking, obeyed and got bet- ter, finally quite well. He had taken two life-insurance poli- cies in the last two years, after examination. His wife had sometimes noticed a rapid action of his heart, but when she mentioned it he replied that he was not conscious of it. He was habitually quiet in all his movements, but no one knew that active exertion incommoded him in any way. On the 15th of August he went down to Long Branch for recrea- tion. After retiring for the night, he reports that he had a “nervous chill, followed by some fever,” but it passed away, and did not much impress his own mind. The following evening he returned to New York. At breakfast on the morn- ing of the 17th, his health and spirits excited the notice of friends, and he replied that he never felt better in his life. At or about 12 m. on that day, while standing and writing at his desk, he felt a sudden snarp pain in his “ chest.” From the fact that at the time he thought of it as perhaps “ wind,” I infer that the pain was felt about the epigastrium. 4 Directly it “ passed downward to the kidneys,” he felt a faintness, weakness, and oppression for breath, but shortly he was able, with the assistance of two men, to walk across the street, and up two flights of stairs to a bedroom. About fifteen minutes later I found him slightly livid in color, bathed in cool perspiration, complaining of great difficulty in breathing, pulse weak, about 150 per minute, a condition like collapse. He said that, directly after the pain attacked him, he felt a numbness and loss of power in the left leg. The respiratory sounds were hurried but normal, both sounds of the heart audible, no murmur or thrill. The percussion note was clear all over the thorax, front and rear; air trayersed all portions of the lungs. There was total loss of impulse in the left femoral artery, as high as the ring. A feeble, doubtful pulse in the posterior tibial. Treatment appropriate to collapse was directed, and, the gravity of the case being apparent, Dr. A. B. Mott was called in consultation, and continued in attendance as consult- ing-physician until death occurred. By degrees the symptoms of collapse passed off, but the dyspnoea and interruption of circulation in the limb continuing, it was enveloped in blank- ets and heat applied. At 9 p. m. the pulse was 150 ; respirations 50-60 ; dyspnoea continuing; limb warm. At 9 p, m. the next morning the pulse was 130, of fair volume; both limbs of the same tem- perature, but the left pulseless and a little livid. The dysp- noea was not relieved or materially increased. The chest wras generally and abnormally resonant under percussion, and the respiration “rude” throughout. Heart-sounds muffled. The patient had passed a night in tolerable comfort, sleeping at short intervals. The evening record was essentially the same. The following morning (third day) Dr. J. R. Learning was added to the consultation. A very careful examination of the chest shovred the same conditions above recorded, except that there was a crackling sound across the lower portion of the chest posteriorly, on both sides. Ho doubt was felt that all portions of the lung were pervious to air, but it was believed that the abnormal resonance was due to an interruption to the entrance of blood. Ho abnormal thrill or impulse could be heard. The left lower extremity was warm and free from pain, but heavy and pulseless. Cutaneous sensibility dimin- ished, but not abolished. The following morning (fourth day) the dyspnoea was ap- parently increasing, the moist rales continuing, hut air still passing all through the lungs. The general condition of the patient was not materially changed ; action of the bowels and kidneys maintained by drinking Congress-water. Dyspnoea palliated by inhalation of oxygen. Food was taken with rel- ish, and in sufficient quantities. The following morning (fifth day) the left chest was found dull on percussion throughout, except at the upper and lateral portion. Marked flatness from the apex of the heart upward to the middle third of the clavicle, and across to the right of the sternum. Egophony distinct as high as the middle of the scapula. Dyspnoea persistent and increasing. Complained of some pain about the heart, and shrank from percussion. 9 p. m.—Condition about the same. Objected to further ex- amination of the chest; limb warm and natural in appearance. Had more power in it. Thought he felt better, and talked with his family of a hope of recovery. After sitting awhile in his chair, he returned to his bed, a little before 11 p. m. ; was shortly observed to straighten himself backward and become incapable of articulation. Death occurred at 111 p. m. Autopsy, Sixteen Hours after, the hody haring been on ice.—Present, Drs. Mott, Austin Flint, Sr., Gfuleke, Rogers, Wagner, and Pooley. The sternum was removed with diffi- culty, on account of ossification of the cartilages. Beneath it, from the level of the heart to the root of the neck, lay a long compressed mass, inclosed in the anterior mediastinum, all the areolae of which were distended with firm coagula of blood.. The right pleura contained a little serum, the left was three- fourths tilled with serum and soft coagula; of the latter a mass, equal in size to the healthy adult liver was lifted out, and about a quart of serum. Since this serum was clear, free from, fibrinous flakes, and the serous membrane was everywhere smooth and shining, there was no evidence of inflammatory effusion or exosmose. That which we saw, therefore, was the- separation of the liquor sanguinis from the crassamentum, as appeared by the relative quantities of each. The pericardium was smooth, transparent, entire, and col- 6 lapsed. The Jungs were free from traces of old or recent dis- ease, pale, crepitant' everywhere except about the entrance of the vessels, particularly on the left side, where there was a considerable area solidified by the infiltration of blood. Pro- longed effort was made to find the point where the blood es- caped into the pleura, the viscera being in situ, but the search was not successful. Therefore, the trachea and vessels were cut at the root of the neck, the organs lifted, and the aorta cut in its descending portion. The pericardium was now opened, and showed a heart of normal size. The ventricles, opened longitudinally, were found to have firm walls of clear red color; the cavities were empty, and the internal surfaces everywhere free from signs of disease or degeneration, except that the corpora Arautii of the aortic valves were gritty and enlarged. About an inch without the valves, in the aorta, there were three patches of atheroma, about three lines in diameter, arranged in line parallel to the course of the vessel. They were in a softened and excavated condition. The ulceration extended through the intima and nearly through the muscular coat, but there bad been no sepa- ration of one coat from another. dSTo sinus or sacculated por- tion was found upon any portion of the thoracic or abdominal aorta, nor was the point where the blood escaped into the me- diastinum found; that portion of the aorta which was re- moved with the heart, extending an inch or more beyond the left subclavian, was opened and carefully examined, but showed nothing more than an occasional patch of atheroma. Time was not allowed us to dissect up the remainder of the aorta, but we saw no apparent dilatation or rupture anywhere in its course. The common iliac of the left side was plugged, just below the bifurcation of the aorta, by a gritty fragment of the vessel. At the point where this was arrested, the calibre of the iliac was narrowed by a calcareous patch, which extend- ed nearly around the artery,' Between the plug and the fe- moral ring, the vessel was filled with a soft coagulum like cur- rant-jelly. Wherever examined, the muscular coat of the artery could be easily split, and the adventitia very easily detached from it. I could not say whether the muscular coat would more readily divide into laminae, or separate as a whole from the adventitia. A little care would secure either result, and 7 this condition was observed both in the arch of the aorta and throughout the iliac. It is much to be regretted that we were unable to prolong the examination so as to find the sinus by which blood entered the mediastinum. It probably lurked somewhere on the pos- terior wall of the vessel below the arch and above the bron- chial arteries, perhaps coinciding with the point whence the aortic fragment was detached to constitute the embolus. The infiltration of the lungs about the root was in the areolar tis- sue, not in the air-cells. There was never, in the progress of the case, any cough or bloody sputa. In the review of this interesting case wre are at liberty to make the following conjectures: The chill which wras felt on the night of August 15th may have marked the penetration of blood between the coats of the aorta at the site of some athe- romatous patch. But the obstruction was not such as to occa- sion any continuous disturbance of comfort. On the morning of the 17th, at the moment when the patient felt a sudden pain in the epigastrium, sweeping downward to the kidneys, quick- ly followed by arrest of circulation in the left leg, and increas- ing dyspnoea, the lifted portion of the aortic wall was de- tached and carried downward into the iliac, and there stopped at a point made narrow by calcareous infiltration. About the same time the external coat ruptured into the mediastinum. A considerable volume of blood escaped, producing the symp- tom of temporary collapse. Perhaps it traveled along the sheath of the bronchial arteries into the pulmonary parenchy- ma, or it somewhat compressed the pulmonary artery, in some way shutting off the supply of blood to the lung, producing dyspnoea. It will be remembered that, until the last day, the chest found to be abnormally resonant, and that at the autopsy there was no clot in the right heart, and the lungs were pale. This could hardly have been the case if the pul- monary veins, pulmonary artery, or the thin walls of the left auricle, had been subjected to forcible compression. More- over, after the first collapse passed off, the circulation was good and even strong. It is probable, therefore, that effusion into the mediastinum was first limited to the posterior portion, and that coagulation took place, temporarily arresting further escape. The thoroughly consolidated character of the clot in 8 the mediastinum indicated that it was not formed at a late period in the case. Probably it continued to dilate slowly all the mediastinal spaces, and,'since we found fluid in the chest twelve hours before death, it had even then begun to flow into the pleura. At length, after a change of position, a wider rent was made, a fuller current flowed in, and. fatal syncope oc- curred. The observation that the artery admitted of ready separa- tion of laminae in the middle coat, corresponds with Dr. Pea- cock’s observations on that point. A case, which constitutes in its rational signs a close par- allel to the above, is cited in “ Holmes’s Surgery,” from the “ Transactions of the British Pathological Society,” as fol- lows : “A man, aged fifty-one years, who had suffered for some time under symptoms referred to a diseased heart, with aortic regurgitation (to which one of his medical attendants, Dr. Latham, had. added disease of the aorta), was seized suddenly one evening, as he was returning from a day of some exertion and excitement, with a very severe, tearing pain in the chest, instantly followed by a second agonizing pain, which seemed, to dart from mid-sternum down the left of the spinal column, and only to be arrested a few fingers’-breadth below and to the left of the umbilicus, at which point of arrest the patient thought he heard a distinct crack. He lost power in both lower extremities at once. A bellows murmur was heard be- low and to the left of the umbilicus. The tearing pain re- curred, and he then passed into a state of syncope, followed by great exhaustion and distress. Reaction set in next day with much congestion, greatly relieved by bleeding. He sur- vived about three months, dying of dropsy and hydrothorax. The pulse had recurred, feebly in the right femoral artery be- fore death. The diagnosis of dissecting aneurism originating near the root of the aorta, and passing downward, so as to compress the channel of the vessel near its bifurcation, was made at the time of the seizure, and confirmed by dissection. A transverse rent was found in the arch of the aorta just be- low its three large branches, a clot of blood was impacted near the bifurcation of the artery, obstructing the left common iliac completely and the right partially.”