c EKERALIZED reactions following the ingestion of aspirin are by no means uncommon, manifesting themselves by more or less pen-

eralized urt,icaria, nausea and vomiting, asthma, or by some combina- tion of all of these. Death reslilting from aspirin sensitiveness is ap- parently relatively rare. c’asw rwdiu g in tlrath have been reported by Dpsart,’ and by Tiaw\rso~~ and Thomas.”

CASE REPORT

W. H., male, aged twenty-seven years, Italian. At th(a age of twenty- four years following a, severe cough for four months the patient grad- ually began l-0 have dyspnea of the asthma.tic type. Thereafter there was scarcely a day when he was free from tlyspnea. In the last year of his life he required from 2 to 8 ~10s~ of rpinrphrinr daily.

The patient appeared in the allergy clinic of tli(a Rochester General Hospital in 3iaS, 1931, and was seen there at int,ervals until a meek before his death in February, 1934. Skin tests with Ihc inhalants, foods, etc.. were negat,ivr. Several operations for the remora1 of nasal polyps mere lwrformrd. The maxillary antrums were washed out on one occasion. The washings containril a small aniollnt of pnrulent mate- rial. Further surgical procedures on the sinuses wrre advocated but tha patient refused. When the nasal polyps wcrf’ first removed. there was slight temporary relief from thr asthma.

Treatment with autog:cnons and stock vaccines, potassium iodide, and a variety of cough medicines lxotlncctl 110 benefit. A member of the patient’s family was instruct,ecl in the use of a. hypodermic syringe and administered cpinephrine whenever necessary.

In September, 1931, the patient, was KiTen 5 grains of aspirin for severe headache. One-half hour later he was brought to the emer- gency department of the hospital snEerin g from an extremely severe attack of asthma for x~hich he needed epinephrine in doses of 10 minims repeated four times in t\vo hours. He was hospitalized four days. At this time he uolunteetwl t,he information that he had had one similar but milder attack of asthma after t,alring aspirin one year previously. A skin t,est mit,h aspirin done al this time was negat,ive.

*F1Wnr the Allergy Clinic of the Rochester C:~:neral Hospital and the Medical Serv- ice of the Genesre Hospital.

504

FRANCIS ET AL. : DEATH FROM TEN GRAINS OF ASPIRIN 505

On February 4, 1934, the patient appeared in the emergency room of the Genesee Hospital where he had never been before, complaining of severe asthma. Physical examination showed a small emaciated man who was extremely dyspneic; blood pressure 124/‘70 mm. Hg ; pulse 120 per minute; temperature 99” rectally. There were no physi- cal findings of importance except those related to the respiratory ap- paratus. His nose was moderately obstructed by swollen mucous membrane. The chest was distended and moved but little on respira- tion. The percussion note was hyperresonant throughout. Expiration was prolonged, and there were many coarse riles and whistling rhon- chi. The heart was not enlarged, and the heart sounds were normal.

The patient was given 15 minims of epinephrine subcutaneously, 3/s grain of ephedrine sulphate, and 3/~ grain of amytal by mouth. His asthma was considerably relieved by medication, but he still appeared so sick that he was admitted to the ward. He complained of very severe headache and was given 10 grains of acetylsalicylic acid. One-half hour later he became very excited, his asthma became much worse, and he then stat,ed that he was sensitive to aspirin and had previously suffered severe reactions from it. Immediately after t,his he went into collapse. He became very cyanotic, the pulse was weak and thready, and respirations were gasping with periods of apnea lasting several seconds. He was given ‘71/z grains of caffeine sodium brnzoate, and 15 minims of epinephrine. Oxygen was given by nasal catheter. The blood pressure after his collapse was unreadable. After about one- half hour the respirations gradually became of the asthmatic type. His pulse was 112 per minute; his blood pressure rose to 160/120 mm. Hg, but, he never regained consciousness. Thirty hours later the pa- tient died.

Autopsy l%ading.“-The principal points of interest in t,he autopsy were findings in the lungs and in the brain. The pia arachnoid was edematous and the blood vessels were congested. All the ventricles of t,he brain seemed normal, but the capillaries of the roof of the fourth ventricle were congested causing general reddening of this tissue. Sec- tions through the cerebral hemispheres showed evidence of moderate congestion. The thorax was moderately rounded out laterally and an- teroposteriorly. When the thorax was opened, the lungs were found fully distended and did not collapse. Filliform adhesions bound the visceral and parietal pleura loosely together. There was no fluid in the pleural sacs. The left lung weighed 330 grams and the right 440 grams. Although the dependent parts were somewhat darker reti than the rest of the lung, they remained crepitant on palpation. Sec- tions through the freshly cut lungs were cream and pink in color. There were no masses, cavities, or pneumonic consolidations. The

*‘me autopsy was performed by Dr. Herbert Brown.

506 THE, .JOlJRNAI, OF ALLERGY

mucosa of the bronchi and bronchioles was moderately congested and coated with rather tenacious mucus.

The heart was small, weighed 250 grams, and was normal in outline. The myocardium was normal in thickness. The endocardium and valves were normal in appearance. The coronary vessels were patent and of normal size. The stomach and int,estines were normal. The liver was normal in appearance as were t,he pancreas and kidneys. The spleen was slightly enlarged, but otherwise appeared normal.

This patient had had two previous episodes of severe asthma and pros- trat,ion following the ingestion of small doses of aspirin. It seems probable that the summation of the efYects of the severe asthmatic at- tack for the treatment of which he applied at the Genesee Hospital, and the reaction to the ingested aspirin, were necessary to produce death.

REFERENC’ES

1. Dysart, B. R.: J. A. M. A. 101: 446, 1033. 2. Lawson, R. W., and Thomas, Roy: J. A. M. A. 99: 107, 19X.