SUDDEN DEATH FROM LATENT ANEURISM. By J. Lewtas, M.B A.
is.,
a
sailor,
was
(Lond) Officiating Surgeon, Regiment N. I. ,
admitted to the i.
41sf
residency U-eneral Hos-
pital, complaining of cough and debility. He said he had been drinking hard, and attributed his cold" to exposure. On making a physical examination of his chest a few mucous rales were heard, no dulness was perceptible anywhere over the lungs, and the sounds of the heart were natural. The case was looked upon as one of sub-acute bronchitis. Two days later as he continued to cough up a considerable amount of which were in some nummular muco-purulent expectoration, masses, suspicions of phthisis were aroused and his chest was as before, the detection, with the same result examined again namely, of scattered mucous r&les. He made no complaint of feeling pain anywhere in his chest or back ; nor had he spat up "
any blood. But in the evening of this, the third day after admission, the He was seized with a case assumed suddenly a serious aspect. severe pnin in the pit of his stomach, so severe was this that he sat bent forwards on the edge of the bed, groaning incessantly. This continued to be his condition until about four the next morning when he left the ward to go to the latrine. A few minutes later he came back to his bed and was seized with fit of coughing; he then for the first time, in the course a of his illness, expectorated some blood-stained sputa. Almost immediately after this he fell from the bed on to the floor in a fainting fit, a small quantity of blood (not more than an ounce) escaped from his nose and mouth, and he expired instantly. Post-mortem examination six houi's after death.?The surface of the body was pale, the beard and moustache were clotted with blood, and the nostrils were plugged witlicoagula. On removing the sternum the left lung appeared of a deep purple colour and much distended; there was about lialf-apint of blood in the left pleural cavity, and more than a pint in the right. The lining membrane of the trachea was bloodstained, and the cavity of both it and the larynx occupied by a blood-clot which extended also into both bronchi, forming a cast of their divisions to the third or fourth degree. The whole substance of the left lung was non-crepifant, dark, and carnifled as though its air-passages had been injected with blood ; the right lung was crepitant, soft, and natural, there being no blood in its smaller air-passages.
November 1,
1876.]
A MIRROR OF HOSPITAL PRACTICE.
The heart which was hypertrophied in its left ventricle, but otherwise normal, was now removed with the thoracic aorta and lungs, with a view of searching for the point of escape of nil this blood. The inner coat of the thoracic aorta, throughout its extent, was puckered and seamed with atheromatous deposits and cicatrices. A small hole in its coats, about the size of a two-anna piece, was found in its anterior wall directly behind and in apposition with the posterior, non-cartilaginous portion of the left bronchus. There was a perforation in the latter corresponding with the perforation in the wall of the aorta. Although there was no aneurismal sac in the proper sense of the word, there was a thin-walled sac of fibrous tissue, about the size of a cherry, attached to the outer coat of the vessel at the margin of the perforation. This barnacle-like diverticulum had apparently burst simultaneously into the bronchus and into the pleura, thus accounting for the accumulation of blood in the last named cavity. Possibly, pressure by this sac in the dilatation which may have preceded its rupture, irritating the branches of the pneumo-gastric and sympathetic nerves in its neighbourhood, caused that excruciating pain at the epigastrium which lasted for about twelve hours before death. This case is of interest as showing how slight and utterly indistinctive may be the symptoms attending the development of a fatal disease ; and how reserved should be our diasnosis of chest-diseases when we are unable to detect any condition sufficient to account for some persistent symptom, in this instance, expectoration. Had an insurance been effected on this man's life shortly before death, as might very well have been the case, many undeserved reflections would have been made upoji the efficiency of the medical examiners.
297
is.,
a
sailor,
was
(Lond) Officiating Surgeon, Regiment N. I. ,
admitted to the i.
41sf
residency U-eneral Hos-
pital, complaining of cough and debility. He said he had been drinking hard, and attributed his cold" to exposure. On making a physical examination of his chest a few mucous rales were heard, no dulness was perceptible anywhere over the lungs, and the sounds of the heart were natural. The case was looked upon as one of sub-acute bronchitis. Two days later as he continued to cough up a considerable amount of which were in some nummular muco-purulent expectoration, masses, suspicions of phthisis were aroused and his chest was as before, the detection, with the same result examined again namely, of scattered mucous r&les. He made no complaint of feeling pain anywhere in his chest or back ; nor had he spat up "
any blood. But in the evening of this, the third day after admission, the He was seized with a case assumed suddenly a serious aspect. severe pnin in the pit of his stomach, so severe was this that he sat bent forwards on the edge of the bed, groaning incessantly. This continued to be his condition until about four the next morning when he left the ward to go to the latrine. A few minutes later he came back to his bed and was seized with fit of coughing; he then for the first time, in the course a of his illness, expectorated some blood-stained sputa. Almost immediately after this he fell from the bed on to the floor in a fainting fit, a small quantity of blood (not more than an ounce) escaped from his nose and mouth, and he expired instantly. Post-mortem examination six houi's after death.?The surface of the body was pale, the beard and moustache were clotted with blood, and the nostrils were plugged witlicoagula. On removing the sternum the left lung appeared of a deep purple colour and much distended; there was about lialf-apint of blood in the left pleural cavity, and more than a pint in the right. The lining membrane of the trachea was bloodstained, and the cavity of both it and the larynx occupied by a blood-clot which extended also into both bronchi, forming a cast of their divisions to the third or fourth degree. The whole substance of the left lung was non-crepifant, dark, and carnifled as though its air-passages had been injected with blood ; the right lung was crepitant, soft, and natural, there being no blood in its smaller air-passages.
November 1,
1876.]
A MIRROR OF HOSPITAL PRACTICE.
The heart which was hypertrophied in its left ventricle, but otherwise normal, was now removed with the thoracic aorta and lungs, with a view of searching for the point of escape of nil this blood. The inner coat of the thoracic aorta, throughout its extent, was puckered and seamed with atheromatous deposits and cicatrices. A small hole in its coats, about the size of a two-anna piece, was found in its anterior wall directly behind and in apposition with the posterior, non-cartilaginous portion of the left bronchus. There was a perforation in the latter corresponding with the perforation in the wall of the aorta. Although there was no aneurismal sac in the proper sense of the word, there was a thin-walled sac of fibrous tissue, about the size of a cherry, attached to the outer coat of the vessel at the margin of the perforation. This barnacle-like diverticulum had apparently burst simultaneously into the bronchus and into the pleura, thus accounting for the accumulation of blood in the last named cavity. Possibly, pressure by this sac in the dilatation which may have preceded its rupture, irritating the branches of the pneumo-gastric and sympathetic nerves in its neighbourhood, caused that excruciating pain at the epigastrium which lasted for about twelve hours before death. This case is of interest as showing how slight and utterly indistinctive may be the symptoms attending the development of a fatal disease ; and how reserved should be our diasnosis of chest-diseases when we are unable to detect any condition sufficient to account for some persistent symptom, in this instance, expectoration. Had an insurance been effected on this man's life shortly before death, as might very well have been the case, many undeserved reflections would have been made upoji the efficiency of the medical examiners.
297
