A CASE 
OF 
ANEURISM OF THE ABDOMINAL AORTA 
WITH THROMBOSIS OF THE 
RIGHT RENAL ARTERY. 
BY 
JOHN H. MUSSER, M.D., 
AND 
J. DUTTON STEELE, M.D., 
P III LAD ELP HIA • 
Reprinted from the International Medical Magazine for September, 1896. A CASE 
OF 
ANEURISM OF THE ABDOMINAL AORTA 
WITH 
THROMBOSIS OF THE RIGHT RENAL ARTERY. 
The patient was a negro, aged forty-seven years, a native of New Jersey, and a 
laborer by occupation. He was admitted to the medical wards of the Philadelphia 
Hospital, May 1, 1896. His mental condition was such that the following data were 
obtained with difficulty: 
His mother, father, and five brothers are dead of unknown causes. Four 
brothers and one sister are alive and healthy. There is a history of alcoholism in 
the family, but no tuberculosis or rheumatism. He had had typhoid fever and pneu- 
monia in boyhood, but never scarlet fever. No history of syphilis or alcoholism 
could be obtained. For two weeks previous to admission he had had much pain in 
the left iliac region, running across to the right hypochondriac. He was consti- 
pated, and had had several obstinate attacks of hiccough. There is no history of 
ascites or oedema at any time. The patient is delirious at intervals, and his state- 
ments are indefinite and unreliable. 
Examination, upon admission, by Dr. Musser: There is considerable emaciation 
and muscular wasting. The pupils are contracted and are equal. The patient is in 
a condition of muttering delirium and can be aroused with difficulty. The abdomen 
is contracted to a marked degree, and the muscles of the abdominal wall are so rigid 
and there is such exquisite tenderness over this entire region that no data can be 
obtained by the usual methods. 
Superficial cardiac dulness extends three and a half inches to the left of the 
midsternal line, and by auscultatory percussion three-fourths inch farther to the left. 
The right border corresponds with the midsternum. The upper limit is the upper 
border of the third rib. The apex-beat is in the fifth interspace in the midclavicular 
line. The heart-sounds at the apex are muffled and indistinct. The second sound 
in the aortic area is accentuated and bell-like in character. The pulse is of high 
tension, and the radial and temporal arteries are thickened and rigid. 
There is an area between the right nipple and the right edge of the sternum 
where the resonance on percussion is high-pitched, the tactile fremitus is lessened, 
and the breath-sounds are suppressed. The heart-sounds are transmitted to and 
clearly heard in this region. Vocal resonance is increased over the apex of the right 
lung anteriorly, but the breath-sounds are suppressed over both apices. Posteriorly 2 
JOHN H. MUSSER, M.D., AND J. DUTTON STEELE, M.D. 
there is suppression of the respiratory murmur over the upper third of both lungs. 
It is fairly distinct at the bases. There are no rales. 
The upper border of the liver dulness corresponds with the upper border of the 
seventh rib. 
Urine.-The amount secreted in the twenty-four hours following admission was 
twenty-four ounces. Its specific gravity was 1020. It was acid in reaction, and 
contained one-fourth, by bulk, of albumin, many pale granular casts, and much uric 
acid. 
The temperature upon admission was 99° F., but it soon became subnormal, and 
ranged between 96° and 97° F. until death. 
The amount of urine increased slowly to fifty-two ounces in the twenty-four 
hours upon May 12, and then gradually diminished in amount until death. Its 
chemical analysis remained practically the same. 
The patient had several severe and obstinate attacks of hiccough while under 
observation. He was constipated and vomited frequently. The mental symptoms 
grew progressively worse, and five days before death he passed into a condition of 
stupor. Death occurred May 17. 
Autopsy (at the Philadelphia Hospital, May 18, thirty hours after death).-The 
body of an emaciated negro. The abdomen is markedly retracted over its whole ex- 
tent. The muscles of the abdominal wall are firmly contracted, and on section are of 
a dark slaty-red color (post-mortem change?). There is very little subcutaneous fat. 
Rigor mortis is well marked. 
Abdominal Cavity.-'There is a small amount of clear fluid. No evidence of 
tuberculosis upon any of the peritoneal surfaces. The liver reaches to the fifth in- 
terspace above, and extends barely to the costal margin in the midclavicular line. 
Behind the pancreas, and lying upon the body of the first lumbar vertebra, is a 
rounded tumor. This is retroperitoneal, and is opposite the origin of the seventh 
costal cartilage. The inferior vena cava and the nerves of the solar plexus lie upon 
its anterior surface. This tumor measures six centimetres in its antero-posterior 
diameter and eight centimetres in its vertical diameter. On dissection, it is found to 
be a saccular aneurism of the abdominal aorta. The cceliac axis is given off imme- 
diately above the sac, and is adherent to it. The superior mesenteric artery comes from 
the aorta immediately below it. The left renal artery arises from the aorta directly 
behind the opening of the sac, and the right renal artery is given off from the sac 
itself. Upon opening the aorta the mouth of the dilatation is found to be clearly 
defined, and measures three by two centimetres. The long diameter of the opening 
is in the same direction as that of the artery. The sac is entirely filled with a red 
and firm coagulum. This has a definite, laminated structure, which is especially 
marked in the portion in relation with the aneurismal wall. 
When the right renal artery is opened, it is seen to contain a hard, white throm- 
bus that appears to totally occlude the artery for a distance of eighteen millimetres 
from its point of exit from the aneurism. This thrombus mass is closely adherent 
to the arterial wall, from which it can be stripped with difficulty. It is firm and 
resisting and has evidently undergone fibrous change. The artery and its branches 
to the distal side of the thrombus are filled with softer red coagula, until the kidney 
substance is reached, when the coagula cease, and the vessels are free from obstruc- 
tion. The left renal artery is normal. The intima of the abdominal and thoracic 
aorta shows many areas of fibrous change. 
The connective-tissue envelope of the aorta was stripped off down to the aneu- 
rism, and at one portion of the sac was found to constitute its only covering. At 
other points the coats of the artery appear to be intact. The inferior vena cava lies 
directly to the right of the tumor and receives the left renal vein, that crosses the 
tumor to join it and is much dilated, measuring two centimetres in diameter at its 
widest point. The vein of the right kidney is normal. A CASE OF ANEURISM OF THE ABDOMINAL AORTA. 
3 
Pleural Sacs.-The right is almost entirely obliterated by firm adhesions. The 
left has a few adhesions posteriorly at the apex. 
Lungs.-Hypostatic congestion and oedema of the lower lobes on both sides. 
Otherwise nothing of interest. 
Pericardium.-N or m al. 
Heart.-Full of liquid blood. The left ventricle is firmly contracted. Its myo- 
cardium is of fairly good texture and is much hypertrophied. The wall of the left 
ventricle measures twenty-four millimetres in thickness. There is considerable 
atheroma of the aorta directly above the semilunar valves, but the leaflets them- 
selves are not affected. There is slight fibrous thickening of the free edges of the 
mitral leaflets, but the valve appears competent. The right ventricle is dilated and 
its myocardium is somewhat hypertrophied. It measures six millimetres in thick- 
ness. Valves of the right heart are normal. The weight of the heart is four hun- 
dred and forty grammes. 
Spleen.-Small and is much congested. There is evidence of considerable in- 
crease in connective tissue. Its weight is sixty grammes. Dimensions: 9X7 X 1 
centimetres. 
Suprarenal Capsules.-Normal. 
Left Kidney.-Somewhat enlarged and measures 12.5 X 9 X 3 centimetres. The 
capsule strips readily. The organ is somewhat flabby. The stellate veins are plainly 
seen. The cortex is swollen and is generally of a pale yellow color. The pyramids 
and medullary rays are congested. 
Right Kidney.-Is smaller than usual, and measures 11 X 6.5 X 3 centimetres. 
It is intensely congested and drips blood from the section. The capsule is some- 
what adherent, and there are several small cysts upon the surface under it. The 
cortex is contracted and its consistency is increased. The cortex and pyramids are 
uniformly congested and dark-red in color. 
Ureters and Bladder.-Normal. 
Pancreas.-N or m al. 
Small Intestine.-Normal. No evidence of tuberculosis. 
Stomach and Duodenum.-Nothing of interest is noted. 
Colon and Rectum.-There is a large amount of fseces in scybalous masses. 
Both show irregular areas of intense congestion. The mucous membrane is covered 
by tenacious mucus. In the rectum are numerous hemorrhages into the mucous 
membrane, which average two centimetres in diameter. The impression is given 
that such areas are the result of pressure caused by the fecal masses. 
Liver.-Somewhat pale and irregularly mottled by yellowish areas. On section 
there is seen to be considerable perilobular congestion, and the parenchyma is pale 
with scattered yellow spots that appear fatty. 
Gall-ducts are patulous and are not dilated. 
Gall-Bladder.-Normal. 
Brain, Spinal Cord, and their Membranes.-Normal. 
Microscopical Examination : Left Kidney.-There is some increase of the connec- 
tive-tissue elements, as well as evidences of an acute inflammatory process. The 
glomeruli, as a rule, are swollen, the capillaries are dilated, and the connective tissue 
of the tufts shows a considerable amount of round-cell infiltration. In places the 
tufts have undergone a hyaline degeneration that appears to commence in the capil- 
lary walls. The Malpighian bodies become swollen and homogeneous with fragmenta- 
tion and, occasionally, complete loss of the nuclei. The hyaline material stains poorly 
with carmine, and when the process is not too advanced the faint outlines of the 
individual capillaries can still be seen. The cells of the tubules are much swollen 
throughout the cortex. In places there is much desquamation and an advanced fatty 
degeneration. The arterioles throughout the section show much increase of the con- 
nective tissue of the intima and adventitia. In many instances the endarteritic pro- 4 
A CASE OF ANEURISM OF THE ABDOMINAL AORTA. 
cess has caused complete obliteration of the lumen of the vessel. Occasionally com- 
mencing hyaline degeneration is seen in such an obliterated arteriole. There are 
numerous small hemorrhages scattered through the cortex. 
Right Kidney.-There is some increase in the connective tissue. This condition 
is rather more marked than in the left kidney. The Malpighian bodies are swollen 
and infiltrated, and in several places there is commencing hyaline degeneration, 
similar to that described above. The cells of the convoluted tubules have very gener- 
ally undergone fatty degeneration, and in many instances have lost their nuclei, and 
have entirely broken down, the tubules being filled by granular detritus. The arteri- 
oles show an endarteritis with occasional obliteration of the smaller vessels, and com- 
mencing hyaline change. There are no hemorrhages in this kidney. 
This case has seemed to us to be of interest, both on account of the 
rarity of thrombosis of the renal artery and the peculiarity of the clinical 
symptoms. 
There was no attempt, macroscopically at least, at collateral circulation 
between the branches of the occluded renal artery and the small branches 
of the lumbar vessels supplying the perirenal connective tissue. Indeed, in 
the authorities that we have consulted, there is no mention of such an 
anastomosis, but from the close proximity of the terminal branches of the 
two sets of vessels, such a communication is conceivable. The only apparent 
results of the stoppage of the arterial supply were the intense congestion of 
the organ and the advanced degeneration of the cells of the convoluted 
tubules. It is remarkable that the left kidney maintained the urinary 
secretion as long as it did, in view of its diseased condition, and the evident 
inability of its fellow to assist it. 
The previous history, that of the present disease, and the subjective 
symptoms did not aid us in the diagnosis. That of nephritis and uraemia 
was established by the results of the urinary examination, in connection 
with the cerebral and gastric symptoms, which were looked upon as uraemic. 
Of great interest and difficult to explain were the markedly hard and 
retracted abdominal walls. The emaciation of the subject led to the sus- 
picion of possible tubercular peritonitis or gastric carcinoma. Such remark- 
able retraction is seldom seen except as the result of peritoneal irritation in 
an aged subject. It is known to occur, of course, in meningitis of childhood. 
The great amount of sclerosis throughout the whole arterial system may 
perhaps be explained by alcoholism, though the extensive endarteritis of the 
smaller vessels of the kidney suggests a possible syphilitic origin. International 
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