gested and oedematous. The heart was tilted up, and the great vessels were displaced. The ascending aorta passed outwards to the right more than usual, and the transverse portion passed off from it at a somewhat acute angle. The innominate was two inches long and twice its usual diameter. It came off from the aorta further to the left than usual, coming to the surface at the left sterno-clavicular articulation, and passing across the trachea in the lower part of the neck to the edge of the right sterno-cleido-mastoid muscle, beneath which it dipped and divided. The aorta was slightly atheromatous and dilated at its commencement, but perfectly free in every part from any saccular enlargement; its valves were much thickened and slightly incompetent. The heart itself was hypertrophied and dilated, particularly on its right side, but to no great extent. The mitral valve was competent, but had a few vegetations on its upper surface. The tricuspid valve was healthy; its opening admitted five fingers. The pulmonary valves were healthy and competent. The abdomen was filled with fluid, the liver was slightly enlarged, and the kidneys in a state of chronic congestion. No other organ was examined.

Here, then, you see we had another well-marked example of the influence of rickety distortion of the skeleton in giving rise to abnormal conditions of the blood vessels of such a character as very closely to simulate aneurism. Of this peculiar simulation, I think that this latter case may very well be considered rather an extreme example; and between it and the case with which I commenced this lecture, there are infinite gradations, examples of which are of occasional, though not very common, occurrence. It is well to be aware of, and prepared for, the occurrence of such cases, and thus avoid falling into mistakes, which, in any case similar to that I have just referred to, might be fraught with very serious results to one or other, possibly to both, of the parties concerned.

You will, therefore, remember that even a fluid pulsation in any // of the intercostal spaces is not necessarily an aneurism. That the

absence of any history of empyema, or even the distinct connexion of the pulsation with the aorta by continuity of dulness, is no proof of its being aneurismal in character, either in the sense of a sacculated aneurism, or of its being a simple dilatation. Because, even in the normal condition of the skeleton, the aorta may exceptionally be so deflected as to cause its pulsations to become perceptible in one or other of the intercostal spaces; while this occurrence of abnormal intercostal pulsation of simple arterial origin is a matter of no unfrequent occurrence whenever the thoracic skeleton is deformed by rickets; while we must also never forget that, even in chests deformed by rickets, sacculated aortic aneurisms may occur.

Where there is no twisting or bending of the artery, and no aortic regurgitation, the first case narrated would seem to show that-as we would naturally expect-there is no murmur to be heard over the abnormal pulsation, and that the only sounds audible are those

ordinarily heard at the base of the heart, the second, in particular, not being in any degree accentuated. Whenever, however, we have a murmur of regurgitation developed at the base of the heart, that of course is always more or less audible over the course of the ascending and transverse portions of the aorta; and, apart from any constriction at the mouth of the aorta, we are sure to have a systolic murmur developed over any part of that artery wherever any sharp twist or bend occurs. Moreover, as any abnormal intercostal pulsation of the aorta must be nearer the surface than any normally situated part of that artery, all sounds in its course are liable to be heard louder over that pulsation than elsewhere, yet without accentuation. But whenever over any abnormal pulsation we have marked accentuation of any abnormal, but especially of the normal, particularly the second cardiac sound, we must be suspicious of the occurrence of a sacculated aneurism, and that even though rickety malformation of the chest be present. To make our diagnosis certain, however, we must be able, not only to connect the pulsation directly with the aorta, but to show also that the dulness subtended by that pulsating body occupies a space greater, than would be the case were the pulsation due to a simple cylindrical vessel such as the aorta. Extension of dulness, therefore, beyond the pulsating tumour, associated with the signs and symptoms of pressure upon one or other, or upon several of the neighbouring organs, are among the most certain indications of the existence of a sacculated, or even of a cirsoid, aneurism. And from these signs and symptoms of pressure, associated with certain other phenomena which indicate the dependence of that pressure upon an elastic and distensile body of varying dimensions, we are often able to prognosticate the existence of an aneurism, even when no pulsating tumour has been detected; and, of course, we are in a still more favourable position for determining the existence of an aneurism when a pulsating tumour is perceptible. But I must reserve the full consideration of these phenomena till I come to speak of the diagnosis of thoracic aneurism.

ARTICLE II.-Royal Edinburgh Asylum Papers. Two Cases of Tumour of the Brain Contrasted. By T. S. CLOUSTON, M.D., F.R.C.P.E., Physician-Superintendent, Royal Edinburgh Asylum.

(Read before the Medico-Chirurgical Society of Edinburgh, 5th May.) A. E., æt. 62 on first admission in March 1872. First attack of insanity, which had been of short duration previous to admission. Her hereditary history unknown, and the exact course of her attack also unrecorded. On admission, she laboured under an attack of subacute maniacal excitement, with loss of memory, incessant incoherent talking, and changing delusions as to being turned inside out. She was looked on as a case of senile mania.

There

were no paralytic symptoms noticed. This excitement soon passed off, and she was discharged recovered in six weeks after admission. She kept pretty well for a year, when she was admitted again (March 1873), labouring under the same kind of excitement as before, but in a rather more acute form. She was more restless, quite delirious, and incoherent, and fancied that every one was begging from her. She was dirty in her habits for a time, but there was no evidence of motor paralysis or evident organic disease of the brain on admission.

She soon settled down into a quiet, slightly demented old woman, who could or would not employ herself in any way. She had no delusions of any kind. For the next six months she was subject to slight transient attacks of excitement of a few days' duration, appearing to get weaker in mind after each attack. She was not specially irritable during or between the attacks. About that time-that is, about eighteen months after the first attack of mental excitement-it was noticed that she was slightly hemiplegic on the right side after one of her attacks of excitement. This rapidly passed off, but recurred over and over again, always after mental excitement, the curious thing being that sometimes one side of the body was affected, and sometimes the other. She got steadily weaker in muscular power, fell off in flesh, and became more forgetful and demented, though when roused by questions she would answer coherently, until, in three months from the time she had the first attack of hemiplegia, she was almost constantly confined to bed. She lingered on, however, for another year, being up to within three months of her death subject to the attacks of excitement, which latterly consisted simply in her being restless and apt to come out of bed for about a day at a time. When the hemiplegic attacks came on she could not speak, her tongue and labial, as well as her facial, muscles being paralyzed on one side. Towards her death both sides of the body were permanently paralyzed, but the left more so than the right. There was never any tendency to permanent contraction of the muscles in any part of the body. She was wet and dirty in her habits, but never had any tendency to bed-sores. She never lost her sight, and she spoke slowly, like an old person. She lingered at the end for months after she was expected to die, not being able to articulate at all for the last six weeks of her life. She always ate well, digested well, and was regular in her bowels, up to near her end. She died of sheer exhaustion, without any convulsion, on the 5th April 1875, three years after her first mental attack, and eighteen months after the first attack of hemiplegia.

indeed.

Post-mortem Examination.-The body was very much attenuated Head.-Skull-cap slightly unsymmetrical, right side bulging. The dura mater had an opening in it about threequarters of an inch in diameter, in the middle of the frontal region, through which part of a tumour projected. On removing

this membrane, this tumour was found slightly attached to it, and embedded in the brain between the two hemispheres, but projecting much more into the left than the right anterior lobe. This tumour was scarcely adherent to the brain at all, but had pushed the cerebral structure out of its way; and the convolutions in contact with it were not apparently softened, and not much atrophied. It was almost globular in shape, about an inch and a half in diameter, and in consistence fleshy rather than fibrous. On section it was found to be of a grayish-white colour, easily lacerable, and showed a slight tendency to break down in the centre.

Near the tumour the dura mater, pia mater, and arachnoid were slightly matted together, but they did not adhere to the brain. The tumour seemed to have originated in the pia mater; the dura mater was very much thickened, and had three thin bony plates on its inner surface, along the junction of the falx, but to the left side just behind the vertex. The largest was three-quarters of an inch in circumference.

The arteries everywhere were excessively atheromatous, their calibre enlarged and patent, those at the base very tortuous.

On section, there was great irregularity in the vascularity of different parts of the brain-substance, some parts being excessively pale, and others very vascular. There were a great many small irregular patches of a gray absorptive degeneration throughout the corpus callosum, optic thalamus, and corpus striatum. There was considerable general atrophy of the convolutions at the vertex; the anterior pyramids of the medulla oblongata appeared somewhat flattened.

Microscopic Examination.-The tumour was found to consist of fibres and cells in about equal proportions, the cells being small, nucleated, and uniform in size. Both fibres and cells were disposed circularly round centres, the latter generally with extreme regularity in concentric rows, looking, in a large microscopic section, like an aggregation of small tumours. The centres of these concentric circles of fibres and cells seemed in some cases to be masses of nuclei, and in others very curious flattened circular bodies, with a concentric marking, very broad and coherent, and, but for their large size, very like large regularly-formed amyloid bodies. These took the staining in sections coloured by carmine, and were only seen after the section had been well cleared; but there were other curious irregular masses of granular material in the tumour which did not stain. The sections in this and the following case were made for me by Dr J. J. Brown.

The spots of "gray absorptive degeneration,"-as I have called them, because I think this term more clearly expresses their true pathological nature than any other, on section, were found to consist chiefly of neuroglia (fibres and nuclei), compound granular bodies, and masses of hæmatoidin crystals.

J. W., æt. 25, prostitute, admitted 28th January 1874. No

history, except that she was a prostitute, who was said to have wandered from Glasgow, and was apprehended by the police; but she had been earning her own livelihood up till a month of her admission; and an aunt of the patient informed me that three weeks before she was simply stupid, irritable, and melancholic. On admission she was confused and depressed-looking, but could not speak. Scarcely appeared to understand the questions put to her. Memory almost gone. She was a thin miserable-looking creature, frightfully dirty, with a vacant, confused, stupid look, who could give no account of herself. Had a black eye. Pupils unequal, right being larger than left, but both were slightly sensitive to light. Motions slow, and gait not very steady; and the left side was weaker than the right. Her tongue was foul, bowels constipated, appetite poor, pulse 70, and weak; temperature 97.8°.

It was found that she could not dress herself or comb her hair, but could feed herself. Complained at first of no pain in head, but the left side of her chest was painful and tender, so that she complained much of it when she was being dressed. When asked to do anything, such as to dress herself, said she could not do it. The day after admission, her temperature was 100-3°; she had no appetite. She had a dazed, pained look in her face. Could answer a question or two in a hesitating way, some time after asking, as if it was long before the impression had reached her sensorium.

Two days after admission, during the night she had six very severe epileptic fits, during each of which she ground her teeth very much indeed, and kept grinding her teeth between the fits; she did not bite her tongue. On the following morning she was very stupid indeed; the pain in the left side was intense, so that she could not bear to be touched there. She could not answer or understand questions, or put out her tongue. When she got up for a few minutes out of bed to have it made, she turned round and round from right to left during the whole time till she went to bed again, though she was so weak on her legs that there seemed a danger of her falling every minute.

After this she got slowly a little better, until she got much better than on admission. She often complained of frightful headaches. She had several epileptic fits of the same character as those described, but not so severe.

When in her better way, the account she gave of her fits was that they had come on after a man had struck her on the head, shortly before coming here. She said she suffered agony in her head, that it was like to fall in two; the headache was chiefly across the brow, and was worse in the mornings.

On the night of the 23d February, she died suddenly, whether in a fit or just after one was not quite certain; but the nightattendant, who came in when she was in articulo mortis, did not bserve any convulsion or sign of it.

Post-mortem Examination, 72 hours after death.-Head.—Skull