hysterical. It must be eliminated. Hysterical fields are rarely if ever hemiopic, nor are there scotomata. They differ from those of neurasthenia only in that the colors replace each other more completely in hysteria, although some fields of people suffering from neurasthenia are remarkably similar to those of hysteria.

REPORT OF CASE OF ANEURYSM OF THE ABDOMINAL

AORTA.

PAUL S. MILLER, A. B., M. D.

[FROM THE CLINIC OF INTERNAL medicine, UNIVERSITY OF MICHIGAN.]

It is entirely probable that abdominal aneurysm was recognized by Vesalius himself, while in 1719 Valisneri made a diagnosis of aneurysm most important will be mentioned.

It is entirely probable that abdominal aneurysm was recognized by Vesalius himself, while in 1719 Valisneri made a diagnosis of aneurysm. of the abdominal aorta, and verified this subsequently by section (Morgagni). Despite this earlier recognition, our first accurate knowledge of this condition dates from the publication of Beatty's case in 1830 ("Dublin Hospital Reports," Volume V. A synopsis of the case may be found in Stokes' work, "Diseases of the Heart and Aorta," 1838.) The value of Beatty's work is due to the accuracy and realism with which the symptoms are described, and the careful observation of the order of their appearance. The case was under observation continuously during the years 1827, 1828, and 1829, during that time being seen and examined by many noted physicians. In 1836 we have the report of an interesting case by Sir David J. H. Dickson, physician to the Royal Naval Hospital at Plymouth ("Medico-Chirurgical Transactions of the Royal Medical and Chirurgical Society of London," Volume XXI.) This case was one of enormous ventral aneurysm of the abdominal aorta, with findings at necropsy. A great number of cases have been reported in the literature since, but Beatty's case still remains as a classic in the symptomatology of aneurysm of the abdominal aorta. Stokes has collected a number of cases in his work on the "Heart and Aorta," and his consideration of the entire subject is one of the most complete and accurate to be found in the literature today.

Aneurysm of the abdominal aorta itself is not of frequent occurrence. It is hardly possible to give a definite ratio between this condition and the concurrence of aneurysm elsewhere in the body, because the comparative figures differ so in various localities. In Vienna, according to Schrötter, in two hundred twenty-two cases of aneurysm, only three were of the abdominal aorta. At Saint Bartholomew's Hospital the figures are placed by Oswald Browne at one to twenty. About sixteen per cent of cases of aneurysm occurring at Guy's Hospital between the years 1854 and 1900 were of the abdominal aorta (J. H. Bryant in Clinical Journal, 1903). Osler, in his article in the Lancet of October 14, 1905, places the comparative occurrence at about one

in ten. These figures would seem to indicate that the condition, while comparatively rare, is not so infrequent in its occurrence as is commonly supposed. The disease, however, is not often recognized, and in a large number of cases the diagnoses is only made at autopsy.

The symptoms of aneurysm of this portion of the aorta are often very obscure, and the physical signs misleading. In the case reported by Beatty the patient was repeatedly seen and examined by Graves, Cheyne, Brodie, Colles, Townsend, Wilson Phillip, and Andral, during the years 1827, 1828, and 1829. Andral made a diagnosis of a "rare form of intestinal neurosis." The real condition was only discovered at autopsy. Bryant, in his article (Clinical Journal, 1903), says that in only eighteen out of the fifty-four cases, on which his lecture was based, was a correct conclusion arrived at during life. Analysis showed that an abdominal tumor was detected in thirty-one, pulsation in thirty-five, expansile pulsation in eight only, and a systolic murmur in twenty-six. Incorrect diagnoses of a variety of conditions were made. R. Travers Smith (Dublin Journal of Medical Sciences, 1905, Volume CXX) reports a case of proving at autopsy to be aneurysm of the abdominal aorta, in which diagnosis had been made of "renal calculus with hydronephrosis." Often in cases such as this operative procedures are undertaken, and the results, while unavoidable, are regrettable in the extreme.

The great majority of cases occur in the male. Aneurysm of the abdominal aorta in the female is rare. This is of importance because of the frequent occurrence of pulsating aorta in nervous or hysterical women, which has often led to a diagnosis of aneurysm.

Etiologically, Osler considers syphilis as the all important factor in cases occurring before the age of forty years. A general atheromatous condition is usually present in the arteries, while the heart is seldom affected. Alcoholism is the rule. Nephritis, gout, and rheumatism are factors to be considered, while manual labor has apparently but little relation with the condition. A great majority of cases occur before the fiftieth year.

The following case is of interest, because of the misleading symptoms which characterized the beginning of the trouble.

The patient was admitted to Doctor Dock's clinic in the University Hospital, at Ann Arbor, late in the afternoon of October 14, 1905. The following notes were made by myself a short time after his admission. Patient, male, age forty-five years, occupation, that of laborer. His chief complaint at the time of admission is of a feeling of pressure in the epigastrium, and about the heart, stomach trouble, and inability to sleep because of constant pain of a dull, boring character, also paroxysmal pains of a sharp, cutting nature in the left lumbar and iliac regions. Concerning the patient's family history nothing worthy of note can be obtained. During the past ten years the patient has had trouble with stomach and bowels. The stomach trouble is described as a feeling of fulness and distress after eating. This has gradually become

worse during the last few years, until at present, after the ordinary meal a feeling of weight and discomfort is noticed, or, in the words of the patient, he "feels as though there was a stone in his stomach." Constipation has always been the rule. Patient uses tobacco and alcohol immoderately. Specific infection was denied, but he admits having had gonorrhea. Some time previous to the commencement of the present trouble he says that he was kicked by a horse, the hoof striking his abdomen. About six weeks previous to the date of his admission here, there had been a marked increase in the severity of his gastric symptoms; loss of appetite, marked distress after eating, and a feeling of nausea, but no vomiting. At this same time he noticed the presence of a dull, intense pain in the epigastrium and left hypochondrium.

The patient first saw a physician on the 20th of August, and from the doctor's case history the following extract was taken: "When first seen the man presented all the symptoms of an acute gastritis, and was treated accordingly. For some days improvement followed. On the 25th I was called hurriedly to see the patient and found him suffering great pain and highly excited. On examination I found the temperature to be 102°, pulse 138; friction sounds were believed to be heard over the heart; stomach distended; nothing found on abdominal palpation. Suspicion of pericarditis was entertained. On the following morning the temperature was normal, pulse 99, friction sounds. absent. Patient was last seen on the 12th of September, and at that time he was apparently much better."

After this, according to the patient's story, he became worse; the dull pain became more intense, until now it is of a constant, boring character. Also daily paroxysms of sharp, cutting pains, of agonizing character, come on during the evening, or at night. During these attacks he is unable to lie down, but is compelled to walk about. Pressure over epigastrium at times gives some apparent relief. About three weeks ago the location of the pain changed, and now it is more apparent in the left iliac and lumbar regions. Nausea is present, but at no time has vomiting occurred. The patient complains of a continuous feeling of pressure about the heart, also a sensation of impending death.

Since the beginning of the trouble the patient has consulted several doctors, and diagnoses of "tobacco heart," "neuralgia of the heart," "pressure upon the nerves of the heart," et cetera, have been made. The patient has lost some weight.

Status Prasens.-Patient presents rather an emaciated appearance, and has an anxious, worried expression of countenance. Lungs: Negative. Heart: Apex in the fifth intercostal space, just inside the nipple line. Heart dulness not enlarged to the right of the sternum. Soft, blowing, systolic murmur heard over the apex, and along the left. border of the sternum. A soft, blowing, systolic murmur is heard at the base. Radial pulse is full and bounding. Abdomen: Abdomen is on a level with the ribs. In the epigastrium, just to the left of the median line, is a tense tumor mass, about the size of a small orange.

The mass is expansile, and the impulse is synchronous with the apex beat. It does not descend on inspiration. Over the mass is felt a faint, fine thrill, and on auscultation a harsh, prolonged, systolic murmur is heard. The femoral pulse is of slow rise and fall, and of lower tension than the radial.

Diagnosis. From the long continued presence of pain in the epigastrium, and in the iliac and lumbar regions, from the character of this pain, dull and boring, with paroxysms of a sharp, agonizing nature, and its association with the presence of an expansile tumor in the epigastrium, the impulse of which was synchronous with the diastole, diagnosis of aneurysm of the abdominal aorta was made.

The patient being considerably exhausted as a result of his long journey to the hospital, and subsequent examination, was sent to his bed in the ward with instructions to keep as quiet as possible.

I again saw the patient about 7 o'clock that evening, and at that time he was feeling very comfortable. It was noted by others in the ward that about 2 o'clock the following morning the patient became restless, walking up and down the ward with hands clasped over the abdomen, occasionally groaning. He finally returned to his bed where he remained for a time. After this he walked from the ward into the adjoining sun parlor, where he remained for a few moments with hands pressed against abdomen, and in a crouching position. Patient then started for his bed in the ward, stumbled and fell against the door, but managed to reach his bed, upon which he fell, uttering several loud cries, and struggling for breath. I had been called in the meantime, but when I reached the patient, which was at 2:45 A. M., he was dead, lying on his right side with hands firmly pressed against the epigastrium and left side.

Postmortem.-This occurred at 3 o'clock the following afternoon, and was performed by Doctor Butterfield. The following is an extract of the findings:

Body, one hundred fifty-seven cubic centimeters in length; frame, large; muscular development, good; visible mucous membranes, pale.

Abdomen: Slightly below the level of the ribs. Large, irregular abrasions on left lateral thoracic region. No scars on skin or penis. Rigor mortis marked throughout. Body heat absent. Slight greenish discoloration in the lumbar region. Abdominal muscles dark; panniculus bright yellow. About one hundred cubic centimeters of bloodstained fluid in the abdominal cavity. Parietal peritoneum smooth and glistening. Colon prolapsed in a V-shaped manner, reaching the umbilicus; intestines moderately distended. Diaphragm on the left at the lower border of the sixth rib; fluctuation obtained through it. On the right the diaphragm is at the lower border of the fourth rib. Pleural cavities: A large quantity of thin blood-stained fluid is found in the left cavity, with a huge clot weighing one thousand nine hundred. sixty-five grammes, which completely surrounds the upper lobe and

part of the lower lobe of the left lung. The right pleural cavity is almost obliterated by old adhesions.

Left lung: This is pushed forward into anterior mediastinum, overlapping the median line. Lung is small, crepitant throughout, and emphysematous at the apex. On section the cut surface is moist, greyish-white; clotted blood in interlobar pleural space. Weight, two hundred fifty-five grammes.

Right lung: Firm, crepitant in the upper lobes; in the base there is marked hypostatic congestion and diminished crepitation. Weight, three hundred twenty grammes.

Heart: Musculature is pale and firm. Heart is not enlarged. The mitral valve presents nodular masses on the free margin of the leaflets. The tips of the papillary muscles are fibrous. The tricuspid leaflets áre slightly thick. The pulmonary valves are normal. The aortic cusps are large and slightly nodular along the free border.

Pericardium: This contains a few cubic centimeters of straw-colored fluid. Both layers of the membrane are smooth and glistening.

Aorta: In the abdominal aorta, ten cubic centimeters above the bifurcation, there is a large sac, about ten by seven centimeters in diameter. The superior pole of this sac has burrowed through the left leaf of the diaphragm close to the vertebral column, the opening into the diaphragm being about one and one-half centimeters in diameter, ragged, thick and infiltrated with clotted blood. The sac is directed towards the left, posteriorly and externally, overlying the left adrenal. It lies behind the fundus of the stomach extending as high as the lesser curvature, but it does not reach the median line of the body. The celiac axis, the renal, and the superior mesenteric arteries spring from the sac. The sac contains a mixed clot and a small amount of fluid blood. The aneurysm springs from the lateral wall of the aorta, its orifice being two centimeters to the left of the mouths of the lumbar arteries, roughly oval in outline, and measuring four by two and one-half centimeters. The margins are extremely thickened and contain an abundant deposit of lime salts. The wall of the aorta at the mouth of the aneurysm shows advanced sclerosis and atheromatous nodules, and is twice as wide as the portion immediately above the origin of the sac. Below the orifice of the aneurysm the aorta shows slight pouch-like bulging, four centimeters long, and directed externally towards the left. From this bulging portion springs the inferior mesenteric artery. The retroperitoneal tissues in the left lumbar fossa are edematous and infiltrated with blood. The arch of the aorta is extremely capacious and shows advanced sclerosis; the ascending portion of the arch measuring eleven centimeters in circumference.

Spleen: This organ is bound down by old adhesions; capsule lax. On section the pulp is a dark purplish-red, moderately soft and clings to the knife. The trabeculæ are obscure, and but few Malpighian bodies. are seen. Size, 12.5 x 7.5 x 3.5. Weight, one hundred fifty grammes.