PART THIRD. Original Communications. ART. I. On Contraction and Obliteration of the Aorta near the Junction of the Ductus Arteriosus. By THOMAS B. PEACOCK, M.D., F.R.C.P., Assistant-Physician to St. Thomas's Hospital, and Physician to the Hospital for Diseases of the Chest, Victoria Park. THE occasional occurrence of great contraction or entire obliteration of the aorta at or near the point at which the ductus arteriosus is united with that vessel, has been known to pathologists since the end of the last and the earlier portion of the present century. In 1828,* M. Reynaud, in recording a case of the kind, offered some general remarks on the nature and cause of the defect. In 1841, it was made the subject of a memoir by Dr. Craigie,† in which, in addition to the description of a case which had occurred in his own practice, he gave full reports of nine cases, nearly the whole of those which had up to that time been placed on record, and very ably illustrated the general results. Tiedemann, in his work on the narrowing and closure of arteries, published in 1843, quoted, in addition to the cases collected by the former writer, two other instances of the same kind; and Rokitansky,§ in a note to his 'Pathological Anatomy,' which appeared in 1844, added the particulars of four others. Hamernjk,|| writing in 1844, and Dr. Chevers¶ in 1845, referred to 12 cases as then recorded; Van Leeuwen** in 1850, and Lebert++ in 1852, mentioned 18; Rokitansky, in his monograph on Diseases of the Arteries, published in the latter year, stated that the cases then known could not be less than 26 in number; and Leudet,§§ in a • Journal Hebdomadaire de Médecine, tome i. p. 161. 1828. † Edinburgh Medical and Surgical Journal, vol. lvi. p. 427. 1841. Von der Verengung und Schliessung der Pulsadern in Krankheiten. Heidelberg und Leipzig, 1843; critical analysis in Edinburgh Medical and Surgical Journal, vol. lxv. pp. 111, 413. 1846. § Handbuch der Pathologischen Anatomie, Band ii. p. 587. Wien, 1844. London Medical Gazette, vol. xxxvi. (new series, vol. i.) p. 187. 1845. ** Nederlandsch Lancet, second series, fifth year, No. 2. Sydenham + Archiv für pathologische Anatomie, von Virchow und Reinhardt, s. 827. Berlin, 1852. ‡‡ Ueber einige der wichtigsten Krankheiten der Arterien. Wien, 1852. Comptes Rendus et Mémoires, tome iv., deuxième série, p. 63. Paris, 1858. memoir read at the "Société de Biologie" in 1857, referred to 30 cases. At the present time, the published cases of obstruction of the aorta at the point named amount to about 40. In the following paper I propose briefly to abstract the particulars of the different published cases, and to offer some general remarks on the nature of the defect, and the symptoms by which it is characterized during life. 1. In 1791, M. Paris* found in the body of a female, about fifty years of age, injected for dissection, the portion of the aorta beyond the origin of the left subclavian artery or at the point of insertion of the arterial ligament, so much contracted that it had only the size of a writing quill, and from the thickening of the coats, the cavity of the vessel was extremely small. The portion of the aorta above the seat of constriction was scarcely dilated, and that below resumed its ordinary capacity, and there were no changes detected in the condition of the parts immediately adjacent to explain the peculiarity. The carotid arteries were of natural size, but the subclavian, internal mammary, intercostal and epigastric arteries, and their branches, were greatly dilated and tortuous. 2. In 1814, Dr. Grahamt related the particulars of the case of Henry Freer, aged fourteen, who died in the Royal Infirmary of Glasgow, after an illness of four months and a half, with symptoms of disease of the heart or large vessels. On examination after death it was found that the aorta, after giving off the vessels to the head and upper extremities, became contracted and diminished, till, after its union with the canalis arteriosus, it became completely impervious. The obliteration was about a line in length; a probe could be passed along the canalis arteriosus to the obstructed part of the aorta, but from its thickened condition it did not seem probable that much communication had been allowed through that vessel. The aorta was expanded at its origin but its coats were not diseased, except that about half an inch below the obliteration, there was an elevation about the size of a split-pea. The arteries given off at the arch and their branches were dilated, and the left ventricle of the heart was hypertrophied. Of this case an account was published by H. Rainey, a gentleman present at the examination, in the Journal of Corvisart, which corresponds with the report of Dr. Graham, except in stating that the ductus arteriosus was impervious. 3. Shortly after the publication of the last case, Sir Astley Cooper,‡ in the surgical essays published conjointly with Mr. Travers, referred to the case of a gentleman, a patient of Mr. Winstone's, fifty-seven years of age, who was healthy, except that he suffered from chronic asthma, when he was suddenly seized during the night with dyspnea, pain at the sternum, and faintness, and died in a few hours. On examination, blood was found in the pericardium, and was traced to a rupture of the right ventricle involving one of the coronary veins; and the aorta at the part where the arterial duct is inserted was found so • Journal de Chirurgerie, par M. Desault, tome ii. p. 107. Paris, 1791. Surgical Essays, by A. Cooper and B. Travers, part i. p. 103. 1818. contracted from the thickening and ossification of its coats, that it with difficulty admitted the little finger. 4. In 1820, Dr. A. W. Otto* reported the case of a girl, seventeen years of age, and regarded as healthy, except that she occasionally experienced uneasiness in the chest, who was seized during the night, after exposure to the cold, with violent pain in the region of the heart, followed by loss of intelligence and excitement of pulse, and died suddenly the following morning. On dissection, the pericardium was found to contain blood, and this proved to have proceeded from a dissecting aneurism which derived its origin from a rupture of the internal coats of the aorta near the origin of the left subclavian artery. It was further ascertained that the aorta gradually became narrowed till it reached the point of junction with the closed ductus arteriosus, where it was so small as barely to admit the passage of a quill. Beyond that point it expanded to its proper size. 5. In 1827, Albert Meckelt published an account of a miller's labourer, aged thirty-five, who, when conveying a heavy sack, suddenly felt pain, and became incapable of moving. He partially recovered in about an hour and had left his bed on the sixth day, when he suddenly fell lifeless. The post-mortem examination was performed by M. Herman, and the pericardium was found distended with blood, which proceeded from a rent in the right auricle. The body was injected, and it was found that while the lower vessels were filled, the aorta at the seat of the duct was reduced to the size of a straw. 6. In the following year (1828), M. Reynaud‡ described a similar condition which he had met with in the body of a shoemaker, ninetytwo years of age, who had been paralytic, and died with symptoms of fever, sloughing of the back, &c. In addition to old apoplectic extravasations, the aorta immediately beyond the origin of the left subclavian artery exhibited a very considerable contraction of a circular form, as if produced by a cord tied round it. The vessel shortly after became dilated, and then resumed its natural size. The coats of the aorta were healthy, though somewhat thickened, and the body having been injected, it was found that a free collateral circulation had been established. In M. Reynaud's paper, the cases of M. Paris, Sir Astley Cooper, and Dr. Graham, and the latter as reported by M. Rainey in 'Corvisart's Journal,' under the supposition of its being a distinct case, are referred to. 7. In the year in which the last case was published, a second was reported by M. Pellétier.§ The patient, a man forty years of age, under the care of M. Trouvé, of Caen, died after an illness of nineteen months, characterized by dyspnoea, palpitation, &c. The heart was greatly enlarged, and its cavities dilated. The commencement of the aorta was also dilated, and its coats contained osseous plates, and at * Neue seltene Beobachtungen, p. 66. Berlin, 1824. Meckel's Archiv für Anatomie und Physiologie, p. 345, 1827; Tiedemann von der Verengung, etc., der Pulsadern, p. 15. Journal Hebd. de Méd., tome i. § Archives Générales de Médecine, tome xviii. (sixième année) p. 205. 1828. the point of origin of the ductus arteriosus there was a contraction which would barely admit the forefinger. The abdominal aorta was natural. S. In 1831, Mr. Jordan, of Manchester,* related the case of a man, twenty-one years of age, who dropped down dead in the street, and no other information of his previous state of health was obtained than that he had been subject to fits. He was of intemperate habits. The pericardium was distended with blood, which had escaped from the sac of a dissecting aneurism of the aorta. The aorta three lines below the insertion of the ductus arteriosus was completely obliterated; its coats were healthy. The collateral vessels were greatly dilated, and the abdominal aorta retained its natural size. 9. In 1834, a full report of a very interesting case of contraction of the aorta was published in Dublin, by Mr. Nixon. The patient `was a medical man, twenty-seven years of age, who had from early life been subject to attacks of pain in the right side. Latterly he had a tumour in the left hypogastrium, with symptoms of cardiac disease, and a bruit de soufflet was audible in the course of the aorta. He died after an illness of nine months. The heart was found larger than natural, and there was great hypertrophy and dilatation of the left ventricle, with disease of the aortic valves and constriction of the orifice. The aorta, opposite the point where it united with the arterial duct, was contracted as if by a sharp instrument having been pressed upon its upper surface, so that its calibre was reduced to one half. The coats of the aorta were not diseased; the arterial duct was pervious. The liver was diseased, but the cause of the hypogastric tumour noticed during life was not ascertained. In the remarks appended to the report of this case, the cases of M. Paris, Mr. Winstone, M. Reynaud, Mr. Jordan, and Dr. Graham, and the latter from the Report in the French journal, are referred to. 10. During the same year in which the last case was reported, another was placed on record by M. Le Grand,‡ in a tract published in Paris. The patient, a man forty-eight years of age, was first seen by M. Le Grand and M. Kapeler two years before his death, and then presented symptoms of plethora, under which he had laboured for two years. He subsequently suffered from violent palpitation of the heart, and of the innominate, carotid, and subclavian arteries, and a bruit de soufflet was heard in the course of the aorta. These symptoms were followed by anasarca, and the usual evidences of cardiac asthma. His death was accelerated by an undue dose of morphia. The examination of the body was performed by M. Amussat. The heart was found very large, and the left ventricle especially greatly hypertrophied and dilated. Immediately beyond the origin of the left subclavian artery, where the aorta becomes descending, there was a slight contraction, followed * North of England Medical and Surgical Journal, from Aug. 1830, to May, 1831, vol. i. p. 101. ↑ Dublin Journal of Medical Science, vol. v. p. 386. 1834. Du Rétrécissements de l'Aorte, &c., Paris, 1834, noticed in the Gaz. Méd. de Paris, 1834; and Arch. Gén. de Méd., deuxième série, tome viii. p. 528. 1885. by a swelling, which was again succeeded by a still more marked contraction, as if the vessel had been included in a knot; beyond this point the vessel dilated, but did not attain its usual size. In the seat of the greatest contraction, the interior of the vessel displayed a circular partition with an aperture only one and a-half line in diameter. The memoir of M. Le Grand contains abstracts of five of the previously published cases, the error being again committed of relating the case of Dr. Graham from the report in Corvisart's Journal, as well as from the original source. The same mistake was also committed by M. Barth, who published a memoir on the different forms of aortic obstruction and obliteration in successive numbers of the Presse Médicale,' also in the year 1834. In 1839, two cases of this form of aortic defect were published, one by M. Mercier, the other by M. Roemer.+ 11. The subject of the first case, a patient at La Charité, was a man, thirty-eight years of age, who suffered from vertigo, with epistaxis, followed by pain in the region of the heart, inability to lie on the left side, undue pulsation of some of the intercostal arteries, and deficiency of pulsation in the vessels of the lower extremities, and a bruit was heard at the lower angle of the left scapula. He died in three months. The aorta proved to be dilated to beyond the origin of the left subclavian artery, it then became greatly contracted so that its cavity would only admit the passage of a blunt probe, and was filled with coagulated blood. The heart was enlarged, and the aortic valves diseased. 12. In the case related of M. Roemer the patient was an Austrian officer, who had seen much service in the wars of the French Revolution. He died suddenly, in his fiftieth year, and had previously been under the care of M. Eichler, suffering from dyspnoea, hoarseness, and a troublesome cough. The heart proved to be greatly enlarged and hypertrophied, and the coronary arteries were ossified, but the valves were free from disease. The ascending aorta was greatly dilated, and at its point of union with the ductus arteriosus its calibre was entirely obstructed for the space of half an inch. The lower portion of the vessel had only the size of the aorta in a boy of ten or twelve. The primary vesssels and their branches were greatly dilated. 13 and 14. In the plates of Pathological Anatomy,' which appeared between 1835 and 1842, Cruveilhier‡ has figured a specimen in which the aorta at the usual situation would only admit a fine stilet, the coats of the vessel being otherwise natural and the large branches dilated; and in the 'Catalogue of the Pathological Museum of the Royal College of Surgeons of Ireland,' published by Dr. Houston in 1840, a similar preparation,§ removed from the body of a soldier, a patient of Dr. Hargraves, is described. The arch of the aorta was dilated, and beyond the origin of the left subclavian artery it became * Bulletin de la Soc. Anat., quatorzième année, p. 158. 1839. Liv. xl. pl. 3, fig. 3. |