Silent Dissection of the Aorta.

Dissecting aneurysm of the aorta has been known as a pathological entity for over a century (Maunoir, 1802); it was first diagnosed during life by Swaine (1856), and a full account of its clinical and pathological features was given by Peacock in 1863. Even so, until recently only thirteen accurate ante-mortem diagnoses had been reported (Glendy et al., 1937). Failure to diagnose the condition has been mainly due to its relative infrequency and to consequent lack of clinical suspicion. In a large series, Shennan (1934) reported one dissecting aneurysm in every 175 autopsies; Reich (1944) reported the average incidence as one in 380 autopsies, while in our own hospital it has been found only twice in the 900 autopsies performed during the last six years. In the last decade, however, clinicians have become increasingly aware of the condition and a further 84 cases, accurately diagnosed during life, have been reported. Although about 80 per cent of patients die within the first few days of dissection, accurate diagnosis is important because, in a small number, life and moderate health may be sustained for some years with appropriate supervision. The classical picture of dissecting aneurysm has been repeatedly described (Peacock, 1863; Gager, 1926; and White et al., 1935). The sudden onset of severe and prostrating pain, widely distributed throughout the body, together with evidence of interference with the blood flow in vessels arising from the diseased aorta, the appearance of an aortic diastolic murmur and a history of long-standing hypertension, form a syndrome which is not difficult to recognize once its significance is appreciated. Rare cases had, however, been reported where pain was absent and yet a recent or healed dissection was found at autopsy. These silent dissections are generally limited in extent, and it is not surprising that, in the absence of the characteristic pain, they are rarely suspected during life. We report the following case because we have evidence of a silent dissection of the aorta. It was possible to make the diagnosis during life because the patient suffered a second attack characterized by the classical features of dissecting aneurysm. We believe this case to be of interest because the patient survived a second dissection of his aorta for over eighteen months, and because his illness was complicated by paroxysmal auricular flutter.