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 are 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.

Adrenals: These show slight postmortem change.

Left kidney: The perirenal fat is abundant. Numerous cysts are found beneath the capsule, the largest being about the size of a marble. On section the cortex is pale, labyrinth indistinct and cloudy, pyramids pale, glomeruli invisible. Cortex measures four centimeters. The capsule strips easily, leaving a slightly granular surface. The cysts contain a clear, light-yellow fluid. Size, 9.5 x 5 x 3 centimeters. Weight, eighty-five grammes.

Right kidney: This is much smaller than the left. In the upper and anterior quadrant there is an enormous cyst. Cortex, six to nine centimeters. Otherwise the organ is similar to the left kidney. Size, 12 x 6.5 x 4 centimeters. Weight, two hundred fifty grammes.

Liver: Surface smooth; consistence medium; borders sharp. On section the parenchyma bulges above the surface, and the markedly accentuated central veins stand out sharply against the yellowishopaque parenchyma. Size, 25 x 20 x 6.5 centimeters. Weight, one thousand three hundred thirty grammes.

Gall-bladder: Moderately distended with yellowish, tenacious bile. Stomach: Very slight atrophy is shown. Intestines negative. The mesenteric and retroperitoneal lymph glands are moderately enlarged, hemolymph glands enlarged and pale pink on section.

Bladder: This contains a small quantity of turbid, yellow urine. The walls are thin and the mucosa pale. The prostate is enlarged and moderately firm. Testes apparently normal.

All the superficial lymph glands, inguinal, femoral, axillary and supraclavicular, are moderately enlarged; the inguinal glands being about the size of a hazelnut, greyish-white, homogenous, glistening and rather firm on section.

Microscopical findings: In the nodular thickenings in the aorta, the intima is from four to five times its usual thickness. The increase is due to numerous elastic fibers, and a collagenous substance. Nuclei are very scarce. Beneath the intima there is a structureless material containing numerous cholesterin clefts. The aneurysmal sac shows on the inner surface a layer of fibrin, then a layer of necrotic and infiltrated tissue, external to which the tissues show marked inflammatory reaction, fibroblastic proliferation, and hemorrhagic areas. In the neighboring muscle there are atrophy, inflammation and areas of regeneration. The arteries and arterioles around the sac show marked sclerosis, many being calcified.

In reviewing this case it is interesting to consider the way in which, during the early stages, the symptoms of the aneurysm were obscured by those arising from the stomach itself. From the long continued anorexia and distress following eating, one would suppose some functional disturbance of the stomach, but the microscopical findings in that organ following autopsy were negative. In fact the association of these symptoms with pain of a dull, persistent nature led to a diagnosis of gastritis, and treatment of a dietetic nature afforded relief for a time.

As to the cause of these symptoms and relief afforded by such treatment, one cannot definitely say. It is possible that the causative factor may have been the location of the tumor itself, its proximity to the fundus and lesser curvature of the stomach; in such a case it is entirely probable that the ingestion of solid food, or food digested with difficulty, by distending the organ and producing active peristalsis would increase the pressure symptoms and produce distress and increase of pain. In this case some relief would be obtained by the use of liquid and easily digested food.

In reviewing the literature a number of cases are found presenting gastric disturbances during the earlier stages, and in a few the entire course of the disease is marked by such symptoms.

In Osler's series of sixteen cases of aneurysm of the abdominal aorta occurring at the Johns Hopkins Hospital during the last sixteen years (Lancet, October 14, 1905, page 1089), nausea and vomiting were associated with the pain in two of the cases recorded. Cordier reports a case (Lancet, 1905, Number I, page 1718) in which the symptoms throughout the course of the disease, simulated those of dyspepsia. The patient, a male, thirty-five years of age, complained of indigestion for a period of two years. He suffered from pain coming on five or ten minutes after eating, lasting for an hour or more. Discomfort was lessened by dieting, but never left altogether. Before admission he used liquid diet almost exclusively.

Status Prasens.-Patient thin, moist, face drawn and anxious. Skin inelastic, bowels constipated, heart and lungs sound, no history of syphilis. Some pulsation in the epigastric notch extending to the left of the median line. On deep pressure there was a feeling of resistance, but no definite tumor. On auscultation, a faint, blowing murmur was heard, localized in a space about the size of a five-shilling piece. No diminution of pulse wave. The pain increased in the epigastrium and back, and was more marked at night; used morphine continuously. Sudden death.

Autopsy. An aneurysm about the size of a small pear, involving the whole of the celiac axis, and the anterior wall of the aorta was found. The wall of sac was ruptured, and peritoneal cavity filled with blood.

In this case Cordier explains the pain after eating by the relation of the aneurysmal sac to the stomach, and also thus explains the consequent benefit on dieting.

In Beatty's noted case, published in 1830 ("Dublin Hospital Reports," Volume V. A brief synopsis of the case may be found in Stokes' work), pain followed the ingestion of food and eructation of gas was common, often affording relief from the distress. In this case also there were marked spasmodic attacks of pain in the intestinal tract, resembling painter's colic, leading Andral to make a diagnosis of rare form of intestinal neurosis.