Slow euthanasia-or "she will be better off in hospital".

PROFESSOR MITCHELL: Dr Emerson clearly identified the site of the process correctly, but this is a different sort of process from the ordinary dissection that he was talking about. Did he have aortic medionecrosis ? DR SMITH: He did not have dissection, with blood tracking through the media. PROFESSOR MITCHELL: Would Dr Emerson like to put it all together with investigations and management ? DR EMERSON: I have never seen a case like this before. I find it remarkable that blood at aortic pressure can go into the oesophageal wall and stay there as long as it did. The patient had a similar pain in his shoulder blades 12 years previously-was that relevant ? About the management. As I said, I think I would have done an aortogram and sampled the pleural effusion at the time when he was put on anticoagulants. But the diagnosis might not have been made. Even if it had been made, it would, I think, have been a hopeless situation. DR W WHITAKER (9): I would like to ask Professor Mitchell if he can explain how the lesions which have been demonstrated caused the symptoms which brought the man into hospital? Three days before admission the pain shifted to the right lower back and radiated to the right buttock and groin. PROFESSOR MITCHELL: It is very easy to say what people die with, but difficult to say at necropsy what caused their problems or what caused their death. I think the aneurysmal masses could have been a source of pain as they got bigger. I would like to suggest a reverse CPC, in which a pathologist is invited to reconstruct the clinical history from what he finds at necropsy. DR P P TURNER (10): How certain are we that the pathology is atherosclerotic? Multiple aneurysms are not common in atherosclerosis. How certain can we be that there was no arteritis ? DR SMITH: Multiple aneurysms, certainly below the diaphragm, are not infrequently found in atherosclerotic aortas. Numerous sections were examined and there was no evidence of aortitis or arteritis. PROFESSOR MITCHELL: I should like to thank Dr Emerson for his excellent analysis of this difficult case history.