Reprinted from 
University Medical Magazine, 
July, 1891.* 
PRESBYTERIAN HOSPITAL. 
REPORT OF A CASE OF A DISSECTING ANEURISM OF THE AORTA—RUPTURE AND DEATH. 
[Service of De Forest Willard, M.D.] 
The patient, a colored man, aged 64, unmarried, and a laborer, occupied at Dobson s 
carpet mills, this city, was admitted to the wards of the Presbyterian Hospital with the 
following history : On the day previous to admission, April 8, 1884, a bale of carpet, weigh- 
ing about 300 pounds, fell from a height (distance not stated), striking him upon the 
shoulder; in the effort made to retain his balance he sustained a severe strain of the 
back and chest. On admission to hospital he complained of pain and soreness over thorax 
and small of back. Attempts at motion aggravated the pain, which was constant in char- 
acter, even when patient was lying quietly. The bowels were moved naturally several times. 
An examination of the urine showed a normal condition of the excretion. No paralysis or 
other evidence of spinal injury present. No cough was noted, fhe treatment was purel} 
symptomatic : morphine for the pain, a stimulating liniment for the sprained muscles and 
absolute rest. The evening temperature was (The character and rate of the pulse 
are not recorded in the notes.) 
April 10, 1884. Patient’s appetite is good, and he feels easier than yesterday. In the 
latter part of afternoon he complained of a severe paroxysmal pain about and below the re- 
gion of the umbilicus. The abdomen was somewhat distended and tympanitic ; a carminative 
was therefore administered. From this time on, until 10 o’clock in the evening, he was appar- 
ently resting quietly. At this latter hour he suddenly arose, jumped out of bed, placed his 
hand over the region of the heart, and with an exclamation of pain sank on the floor. Two 
minutes later he was dead. 
The autopsy, held eighteen hours after death, revealed the following facts : 
Rigor mortis marked ; muscular system well developed, and subject generally well 
nourished. 
Upon opening the thorax the right pleural cavity was found to be completely filled 
with a straw-colored pleuritic effusion of a rather thick consistency. Covering this lung and 
forming a perfect sac for the fluid was a thick layer of dense, fibrous, closely-adherent 2 
CLINICAL DEPARTMENT. 
lymph, from one to two lines thick, and so tough that it could not be readily torn by the 
fingers. The upper lobe of the lung was crepitant but pressed closely up under the clavicle, 
and, as a consequence, was much diminished in size. The middle and lower lobes were flat- 
tened against the spinal column and ribs and were bound down under the lymph-sac, much in 
the same way that the kidneys are fastened beneath the peritoneum, only more tightly. The 
lobes of this viscus were nowhere over half an inch in thickness, and were absolutely im- 
pervious to air. Upon section of this portion of the lung it was found to be tough and sank 
readily in water. There was nothing like a pneumonic condition present. 
An examination of the left pleura revealed its cavity filled with a currant-jelly clot and 
blood-serum, the lung being squeezed into the upper part of the thorax. The lung tissue 
was not adherent, save in one small spot, and its structures were otherwise entirely normal. 
The heart was slightly hypertrophied, but the valves were normal. 
The aorta wras normal in size and condition until below the arch. Just below the 
descending portion of the arch was an atheromatous spot, and immediately beneath this 
was found a transverse fissure on the outer side of the vessel, nearly half an inch long, ex- 
tending through the middle and inner coats of the artery. The outer coat or adventitia had 
been dissected from the muscular layer for about half its circumference, and for a distance 
of at least five inches below the diaphragm. At this latter point the artery was torn in the 
dissection. There was no evidence of another opening readmitting the blood to the aorta. 
About an inch below the opening through the two inner coats was a large rent in the adven- 
titia, through which the blood had entered the pleural cavity. At this point the adventitia 
seemed somewhat distended, but only slightly so below it. 
The other organs of the body were normal. 
The history of this case seems to indicate that the direct cause of the 
aneurism was the severe strain sustained at the time of injury, and indirectly 
the weakened condition of the aorta, as shown by the atheromatous changes 
noted in the coats of the vessel. 
The features of this case worthy of special note are: 
(1) The length of time lived after the injury. 
(2) The character of the aneurism, its diffuse nature, involving not only 
the thoracic, but also the abdominal aorta. 
(3) Its causation, indirectly an injury, producing sufficient strain upon a 
vessel already weakened by disease. 
(4) Its termination by rupture into the left pleura. 
(5) The fact that but one opening was found in the aorta communicating 
with the aneurismal sac. 
(6) The condition of the lung and pleura of the right side of chest. 
Lewis H. Adler, Jr., M.D., 
Late Resident Physician at the Episcopal Hospital. 
1610 Arch St., Philadelphia.