Journal : Photographic review of medicine & surgery ; vol. 2., no. 1.
Philadelphia : J. B. Lippincott & Co., 1871-72.
Description : p. 7-10,  pl. ; ill.: 1 photo. ; 24 cm.
Photograph : mounted albumen.
Subject : Abdominal aorta — Aneurisms.
JOSEPH J. SCHLANKA, aged thirty-two, five feet eleven inches in height, weight when in health, one hundred and sixty pounds, and a confectioner by occupation. He is intemperate in habit, and has been frequently exposed to wet and cold, which culminated in violent attacks of rheumatism. He states that he has had venereal disease. When he was eighteen years of age he was thrown from a colt and kicked in the lumbar region, though this accident was attended with but little suffering. A year after this injury he was struck on the left hip with a large paving-stone, which incapacitated him for work for some weeks. Nothing, however, of any moment occurred until about eighteen months ago, when he complained of a pain in the back and left leg. This pain came on suddenly, and remained seated in the lumbar region for three weeks, when it entirely left the back and located itself in the left thigh, from the effects of which he was crippled for five months. At this time he also complained of neuralgic pains through the thigh, particularly about the lower third. In August, 1870, a year ago, while in the erect position, he noticed for the first time the presence of a tumor, with pulsation, in the left lumbar region. Upon examination, he found that it varied in size, being larger at night than in the daytime. While in the recumbent position it would be as large as a man's head, and upon rising it would decrease in size, even as small as a goose-egg. His business, at this time, required the carrying of heavy weights, which he thought increased the size of the tumor. He noticed that excitement and drinking also caused it to become larger. When the patient first came under my observation, in June, 1871, it was confined to the left side, but during the last two months it grew rapidly, and spread in all directions, as represented in the photograph. It extended from the lumbar vertebras to the crest of the ilium, its transverse diameter being seventeen inches, while the perpendicular diameter measured fourteen inches. The circumference of the abdomen over the tumor was forty inches.
The skin over the tumor was tense and glistening, with a general redness upon the more prominent points. There was no enlargement of the superficial veins.
The tumor was irregular in outline, and, when pressed, gave a sensation of elasticity. Upon examination there was a distinct pulsation throughout the mass, perceptible with every beat of the heart. His complexion was pale, though his appetite was good and his bowels acted with regularity. His pulse gave one hundred and twenty beats per minute, was weak, and with a thrill much stronger in the right than in the left wrist. Pulsation was imperceptible in the lower extremities. Such is a brief account of the patient's early history, and his condition when he came under my care. The tumor grew rapidly in size, and he began to fail and lose strength. He fell into a comatose state one evening, and remained in this condition for several days, when he died.
The autopsy was made thirty-two hours after his decease, and presented the following appearances:
Everything was pushed into the right side. The connective tissue of the anterior mediastinum was infiltrated with blood, and the parts were matted together. The anterior margin of the left lung reached the median line, the right lung lacking an inch and a half of the median line. The apex of the heart extended an inch and a half to the right of the median line, and was behind the seventh intercostal cartilage of the right side. The left lobe of the liver extended but two inches to the left of the median line, while the lower point of the right lobe reached down to the crest of the ilium. The spleen was in the median line, and measured six inches in diameter. The right kidney extended two inches below the umbilicus, and the left one was situated upon the anterior and upper aspect of the tumor, in contact with the anterior wall of the abdomen. The eleventh and twelfth ribs were entirely denuded of their periosteum, and detached from their articulations. The tissue of the diaphragm was eroded and completely destroyed. The aneurism came from the aorta in the lumbar region, and extended two inches to the right of the median line, occupying the entire left side of the abdomen. The transverse colon in contact with the tumor, was very much contracted. The pancreas, stomach, and small intestines were pushed forward, and inclined to the right side. The old laminated clot was everywhere surrounded by a fresh clot, of about an inch in thickness. The aneurismal cavity was in direct contact with the skin, extending downwards and outside of the abdomen and pelvis, along the entire length of the osseous ilio-sacral articulation. The psoas muscle in its entire abdominal portion was incorporated with the anterior wall of the aneurismal sac.
When the case first presented itself to me, I was undecided whether it was an aneurism of the abdominal aorta or an immense abscess originating from caries of the lumbar vertebras, for it manifested signs common to both. On palpation it seemed to be entirely fluid in character, and the thrill felt appeared to be imparted by the pressure of the sac in contact with the aorta. No solidity could be detected upon close examination, and his general condition was such as to throw the question of aneurism in doubt. The diagnosis not having been positively made out, I called to my aid Dr. Agnew, Professor of Surgery in the University of Pennsylvania, Dr. F. F. Maury, Surgeon to the Philadelphia Hospital, Drs. S. S. Stryker, Sargent, Skillern, Neff, and others, whose opinions varied as to the character of the mass, though the majority were in favor of aneurism.
I cannot close this interesting case without expressing my sincere thanks to Dr. Harrison Allen, who furnished the notes of the autopsy, kindly recorded by my friend Dr. John S. Newton, and also to Drs. C. T. Hunter, Stryker, and others, who rendered me valuable assistance.