Coarctation of the aorta (adult type) with rupture distal to the coarctation.

Coarctation of the aorta is by no means an uncommon lesion. Two types are generally recognized (1) the infantile, in which there is a diffuse narrowing of the aorta between the origin of the left subclavian artery and the insertion of the ductus arteriosus, and (2) the adult type, in which the area of constriction is very narrow, and is situated at or close to the site of insertion of the ductus. One of the most frequent causes of death is rupture of the aorta. As this is usually proximal to the coarctation it seemed of interest to report the following case of rupture distal to the coarctation, and to review similar cases previously reported. Case Report The patient, a boy aged 4 years, the third of three children, was born of healthy parents. There was no history of rubella during the pregnancy and birth was normal and at term, the weight being 7 lb. 3 oz. Development was normal. The only previous illness was measles at 1 year and the child also had occasional ' blue turns ' associated with displays of temper. One month before admission to hospital the child had a mild attack of bilateral otitis media, and eight days before admission the present illness began with a gradual onset of lassitude and anorexia which persisted. On the third day a moderate degree of tonsillitis was found. Attacks of fever accompanied by profuse sweating and preceded by shivering, pallor, and increased lethargy then began. The attacks lasted about two hours and recurred several times a day until admission. The child was sometimes delirious in these attacks. The temperature fluctuated between normal and 1020 F. An unrecorded amount of sulphathiazole was given on the sixth, seventh, and eighth days. During this period there was no coryza or cough and no evidence that the child had been in pain. On admission on the eighth day of his illness the child was pale and listless (temperature, 100° F.). His weight was 42 lb. 6 oz. and development and nutrition were normal for his age. The tongue was coated but moist and mild tonsillitis without exudate was present. There were no petechiae and the spleen was not palpable. No abnormality was found in the abdomen, the respiratory, or central nervous systems. There was marked arterial pulsation in the suprastemal region and capillary pulsation was seen in the nail beds. The radial pulses were equal and of high tension. No pulsation could be elicited in the femoral, dorsalis pedis, or posterior tibial arteries. The blood pressure in both arms was 150/100 mm. Hg. The pressure in the lower limbs was not recorded. Vigorously pulsating vessels were easily palpable in the supraand infrascapular regions, along the vertebral border of the scapula, and running along the lateral thoracic walls; systolic bruits were audible over the courses of these arteries. The deep epigastric arteries were not palpable. The apex beat was maximal in the fourth intercostal space in the nipple line and was not markedly forcible; no thrills were palpable and percussion did not suggest any enlargement of the base of the heart. Well-marked, rough systolic murmurs of approximately equal intensity were heard at the apex and in the second and third spaces to the left of the sternum, the former being conducted slightly to the axilla; a short diastolic murmur was audible at the apex. The rhythm was normal.