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Pulmonary embolism by amniotic fluid
!52
AMERICAN
HEART
JOURNAL
live weeks, although cyanosis had been present since birth. Death was preceded by the rapid development of respiratory distress and congestive heart failure. Associated anomalies included a patent ductus arteriosus and a patent foramen ovale. .Z twin brother in whom a loud basal systolic murmur had been heard at the age of 4 weeks, died at the age of 2 months following a sudden attack of dyspnea and cyanosis. Although some form of congenital heart disease was suspected in this twin infant, autopsy was refused and, therefore, the exact diagnosis was never established. WENDKOS. Blakemore, Aorta:
A. H.: The 4 Rational
Clinical Surgical
Behavior Therapy.
of Arteriosclerotic Ann. Surg.
Aneurysm 126:195
(Aug.),
of
the
Abdominal
1947.
Blakemore outlines the characteristic features of abdominal aneurysms and differentiates between thearteriosoleroticandsyphiliticvarieties. The former was encountered twenty-six times, while the latter was observed six time at the Presbyterian Hospital, New York City, in recent years. Arteriosclerotic abdominal aneurysms are fusiform, rarely erode vertebrae (one out of twenty-six cases), originate 3.0 to 4.0 cm. above the orifice of the renal arteries, seldom cause significant symptoms until they leak retroperitoneally, and usually end fatally two to six days after the original rupture. Syphilitic aneurysms of the abdominal aorta, on the other hand, are saccular, usually have their point of origin above the renal arteries, erode vertebral bodies, and therefore, are associated with marked radicular pain. The author then discusses the hemodynamics of fusiform and wide- and narrow-mouthed saccular aneurysms, pointing out that nature’s cure consists in brimful clotting which occurs spontaneously only occasionally in narrow-mouthed saccular aneurysms. The rate of blood flow in the aneurysm is the second important factor in considering a therapeutic approach. By means of his electrothermic method of coagulating aneurysms, Blakemore can determine the rate of blood flow and hence the type of ancursym, and further how much wire is necessary to introduce and heat in order to obtain brimful clotting. In fusiform abdominal aneurysms it is necessary to completely occlude the aorta and the aneurysm in stages from within, thereby permitting the development of an adequate collateral circulation to the legs. The author has dealt successfully with three out of tvvcnty-six cases of fusiform arteriosclerotic aneurysms and two out of six cases of syphilitic fusiform aneurysmof the abdominal aorta. LORD. J. H., and Isoe, I. RI., Intravenous Oxygen and Pulmonary Embolism. Ann. Surg. 126:208 (Aug.), 1947. The authors studied the arterial oxygen saturations in a group of patients who were subjected to an intravenous injection of oxygen. In the first patient 9.3 cc. of oxygen per minute were administered for twenty minutes and the arterial oxygen saturation fell from 91 per cent to 55.5 per cent. Associated with this fall, the patient experienced a sensation of pressure in the lower chest, cough, restlessness, and profuse perspiration. These symptoms cleared in a few minutes after cessation of the oxygen injection. Three other experiments in patients not in shock and two in patients in shock further demonstrated that intravenous oxygen is not of value in elevating the arterial oxygen saturation and, on the contrary, aclually lowers it. The explanation of this phenomenon is that the oxygen gas bubbles occlude the small arteries and arterioles and are not absorbed by the blood stream. One in vitro experiment demonstrated that a small amount of oxygen bubbled through venous blood does not increase the oxygen saturation. The authors conclude that intravenous oxygen is of doubtful therapeutic value in the treatment of shock and may actually be harmful. Sanders,
LORD. Gross,
P.,
and
Benz,
E.
J.:
Pulmonary
Embolism
by
Amniotic
Fluid.
Surg.,
Gynec.
Obst. 85:315 (Sept.), 1947. In addition to the well-known causes of embolism to the lungs, such as thrombi from venous sources in the legs and fat emboli from fracture sites, Gross and Benz report three cases of pulmon-
&
SELECTED
ABSTRACTS
153
ary embolism by amniotic fluid. The three cases experienced their emboli near the end of labor or in the immediate puerperium. The event in each case was characterized by shock which rapidl! progressed to a fatal termination within one hour of onset. Antishcck therapy was without avail. There are no significant gross pathologic findings. However, the characteristic lesion is seen in the lungs on microscopic examination where there is found in the smailer arteries, arterioles, and alveolar capillaries a bloodless mixture “consisting of abundant polymcrphonuclear leuc-ocytes, mucin, bile-stained debris, (meconium), epithelial cells, lanugo hair, and granular debris with or without fatty elements.” The authors point out that examinations and analysis of the centrifuged blood from the right side of the heart reveals three strata in the sediment. “The presence of three instead of two strata should be considered pathognomonic of this condition. The particulate constituents of amniotic fluid including mucus, being of lcwer specilic gravity, settle out as a flocculent layer above the leucocytic cream.” The authors believe that pulmonary embolism by amniotic fluid is a common cause of shock and rapid fatality occurring during labor or in the immediate puerperium. LOKI). and Langley, F. .A.: Chronic Dissecting Aneurysm. Brit. Heart J. 8:191 A. M., (Oct.), 1946. The authors report two cases of dissecting aneurysm in which the diagnosis was made during life; one patient survived for three years and the other is alive and comparatively well eight years after radiographic recognition of the aortic lesion. The first patient had enjoyed good health until the age of 52 years, when she developed a severe stabbing pain in the left anterior chest which radiated to the left scapular region and the and she had no further severe difficulty until dorsolumbar area. After a time the pain abated, the age of 55 years when severe pain in the back of the chest and in the lumbar area forced her to seek hospital care. When admitted to the hospital her blood pressure was 210’135 in the right arm and 19.5/130 in the left. Fluoroscopyshowed gross dilatation cf the acrta. The ~Vassernrann reaction was negative. The history and findings led to a diagnosis of chronic dissecting aneurysm. She remained in bed for four months but was never free from pain. Eight weeks after a secontl admission she collapsed and remained semiconscious until she died four da!-s later. Necropsy revealed the aorta to be greatly dilated from just below the origin of the left subctavian artery to the level of the diaphragm. At about the middle of the lateral surface of the dilated portion there was a transverse tear 2 cm. long where the aneurysm had ruptured into the left pleural space. On opening the aneurysm two channels were seen. Where the two channel:, arose from the arch of the aorta the free edge of the septum separating them was rounded anti smooth and continuous, with a ridge around the mouth of the larger channel; the free margin had clearly been separated from this ridge when the dissection started and since both ridge and free edge were smooth and healed, thrs separation obvrousty was not recent. /in rtnusual feature \~a:. the presence of atheromatous plaques on the wall of the aneurysm. The second patient, a 36-year-old woman, had been well until the age oi 30 years, when she began to suffer from severe pain in the back which after treatment with radiant heat and massage had disappeared after several months. A return of these symptoms led to hospital admission. The pulse rate was 120, and the blood pressure, 200/140. The heart sounds were loud but no murmurs were present. Fluoroscopy showed some enlargement of the left ventricle, and considerable diffuse enlargement of the thoracic aorta with calcified plaques in its wall. Kymography revealed quite good pulsations of the descending aorta. An electrocardiogram showed striking left axis deviation associated with diphasic T waves in Leads I and II and depression of the corresponding KS-T segments. She was thought to have a chronic dissecting aneurysm. Whilein the hospital she suffered from severeaching pain in the left scapular region, headache, and palpitation. On several occasions she became confused and disoriented. Two years after hospitalization her right arm and leg became paralyzed while she was walking. Some months later she was readmitted to the hospital because of the severity of her epigastric and chest pain. Her blood pressure was then 165/l 10, and the dorsalis pedis pressure, 205/l 10. While in the hospital she had two sudden severe attacks of “grinding” pain in the left chest which could be relieved only Jones,
AMERICAN
HEART
JOURNAL
live weeks, although cyanosis had been present since birth. Death was preceded by the rapid development of respiratory distress and congestive heart failure. Associated anomalies included a patent ductus arteriosus and a patent foramen ovale. .Z twin brother in whom a loud basal systolic murmur had been heard at the age of 4 weeks, died at the age of 2 months following a sudden attack of dyspnea and cyanosis. Although some form of congenital heart disease was suspected in this twin infant, autopsy was refused and, therefore, the exact diagnosis was never established. WENDKOS. Blakemore, Aorta:
A. H.: The 4 Rational
Clinical Surgical
Behavior Therapy.
of Arteriosclerotic Ann. Surg.
Aneurysm 126:195
(Aug.),
of
the
Abdominal
1947.
Blakemore outlines the characteristic features of abdominal aneurysms and differentiates between thearteriosoleroticandsyphiliticvarieties. The former was encountered twenty-six times, while the latter was observed six time at the Presbyterian Hospital, New York City, in recent years. Arteriosclerotic abdominal aneurysms are fusiform, rarely erode vertebrae (one out of twenty-six cases), originate 3.0 to 4.0 cm. above the orifice of the renal arteries, seldom cause significant symptoms until they leak retroperitoneally, and usually end fatally two to six days after the original rupture. Syphilitic aneurysms of the abdominal aorta, on the other hand, are saccular, usually have their point of origin above the renal arteries, erode vertebral bodies, and therefore, are associated with marked radicular pain. The author then discusses the hemodynamics of fusiform and wide- and narrow-mouthed saccular aneurysms, pointing out that nature’s cure consists in brimful clotting which occurs spontaneously only occasionally in narrow-mouthed saccular aneurysms. The rate of blood flow in the aneurysm is the second important factor in considering a therapeutic approach. By means of his electrothermic method of coagulating aneurysms, Blakemore can determine the rate of blood flow and hence the type of ancursym, and further how much wire is necessary to introduce and heat in order to obtain brimful clotting. In fusiform abdominal aneurysms it is necessary to completely occlude the aorta and the aneurysm in stages from within, thereby permitting the development of an adequate collateral circulation to the legs. The author has dealt successfully with three out of tvvcnty-six cases of fusiform arteriosclerotic aneurysms and two out of six cases of syphilitic fusiform aneurysmof the abdominal aorta. LORD. J. H., and Isoe, I. RI., Intravenous Oxygen and Pulmonary Embolism. Ann. Surg. 126:208 (Aug.), 1947. The authors studied the arterial oxygen saturations in a group of patients who were subjected to an intravenous injection of oxygen. In the first patient 9.3 cc. of oxygen per minute were administered for twenty minutes and the arterial oxygen saturation fell from 91 per cent to 55.5 per cent. Associated with this fall, the patient experienced a sensation of pressure in the lower chest, cough, restlessness, and profuse perspiration. These symptoms cleared in a few minutes after cessation of the oxygen injection. Three other experiments in patients not in shock and two in patients in shock further demonstrated that intravenous oxygen is not of value in elevating the arterial oxygen saturation and, on the contrary, aclually lowers it. The explanation of this phenomenon is that the oxygen gas bubbles occlude the small arteries and arterioles and are not absorbed by the blood stream. One in vitro experiment demonstrated that a small amount of oxygen bubbled through venous blood does not increase the oxygen saturation. The authors conclude that intravenous oxygen is of doubtful therapeutic value in the treatment of shock and may actually be harmful. Sanders,
LORD. Gross,
P.,
and
Benz,
E.
J.:
Pulmonary
Embolism
by
Amniotic
Fluid.
Surg.,
Gynec.
Obst. 85:315 (Sept.), 1947. In addition to the well-known causes of embolism to the lungs, such as thrombi from venous sources in the legs and fat emboli from fracture sites, Gross and Benz report three cases of pulmon-
&
SELECTED
ABSTRACTS
153
ary embolism by amniotic fluid. The three cases experienced their emboli near the end of labor or in the immediate puerperium. The event in each case was characterized by shock which rapidl! progressed to a fatal termination within one hour of onset. Antishcck therapy was without avail. There are no significant gross pathologic findings. However, the characteristic lesion is seen in the lungs on microscopic examination where there is found in the smailer arteries, arterioles, and alveolar capillaries a bloodless mixture “consisting of abundant polymcrphonuclear leuc-ocytes, mucin, bile-stained debris, (meconium), epithelial cells, lanugo hair, and granular debris with or without fatty elements.” The authors point out that examinations and analysis of the centrifuged blood from the right side of the heart reveals three strata in the sediment. “The presence of three instead of two strata should be considered pathognomonic of this condition. The particulate constituents of amniotic fluid including mucus, being of lcwer specilic gravity, settle out as a flocculent layer above the leucocytic cream.” The authors believe that pulmonary embolism by amniotic fluid is a common cause of shock and rapid fatality occurring during labor or in the immediate puerperium. LOKI). and Langley, F. .A.: Chronic Dissecting Aneurysm. Brit. Heart J. 8:191 A. M., (Oct.), 1946. The authors report two cases of dissecting aneurysm in which the diagnosis was made during life; one patient survived for three years and the other is alive and comparatively well eight years after radiographic recognition of the aortic lesion. The first patient had enjoyed good health until the age of 52 years, when she developed a severe stabbing pain in the left anterior chest which radiated to the left scapular region and the and she had no further severe difficulty until dorsolumbar area. After a time the pain abated, the age of 55 years when severe pain in the back of the chest and in the lumbar area forced her to seek hospital care. When admitted to the hospital her blood pressure was 210’135 in the right arm and 19.5/130 in the left. Fluoroscopyshowed gross dilatation cf the acrta. The ~Vassernrann reaction was negative. The history and findings led to a diagnosis of chronic dissecting aneurysm. She remained in bed for four months but was never free from pain. Eight weeks after a secontl admission she collapsed and remained semiconscious until she died four da!-s later. Necropsy revealed the aorta to be greatly dilated from just below the origin of the left subctavian artery to the level of the diaphragm. At about the middle of the lateral surface of the dilated portion there was a transverse tear 2 cm. long where the aneurysm had ruptured into the left pleural space. On opening the aneurysm two channels were seen. Where the two channel:, arose from the arch of the aorta the free edge of the septum separating them was rounded anti smooth and continuous, with a ridge around the mouth of the larger channel; the free margin had clearly been separated from this ridge when the dissection started and since both ridge and free edge were smooth and healed, thrs separation obvrousty was not recent. /in rtnusual feature \~a:. the presence of atheromatous plaques on the wall of the aneurysm. The second patient, a 36-year-old woman, had been well until the age oi 30 years, when she began to suffer from severe pain in the back which after treatment with radiant heat and massage had disappeared after several months. A return of these symptoms led to hospital admission. The pulse rate was 120, and the blood pressure, 200/140. The heart sounds were loud but no murmurs were present. Fluoroscopy showed some enlargement of the left ventricle, and considerable diffuse enlargement of the thoracic aorta with calcified plaques in its wall. Kymography revealed quite good pulsations of the descending aorta. An electrocardiogram showed striking left axis deviation associated with diphasic T waves in Leads I and II and depression of the corresponding KS-T segments. She was thought to have a chronic dissecting aneurysm. Whilein the hospital she suffered from severeaching pain in the left scapular region, headache, and palpitation. On several occasions she became confused and disoriented. Two years after hospitalization her right arm and leg became paralyzed while she was walking. Some months later she was readmitted to the hospital because of the severity of her epigastric and chest pain. Her blood pressure was then 165/l 10, and the dorsalis pedis pressure, 205/l 10. While in the hospital she had two sudden severe attacks of “grinding” pain in the left chest which could be relieved only Jones,