Symptoms.

Suffered from the effects of the explosion at Erith,
and received a penetrating wound of the skull by a
piece of wood. A splinter had been driven in. It
was removed, and, becoming worse, he was removed
to Guy's Hospital. Mr. Cock made an incision.
Some pus escaped, and after the pus some clear
fluid followed. The child appeared relieved, and
went to sleep; soon got worse, and died three days
afterwards.

Two weeks before admission into Guy's Hospital she
came one day as an out-patient, with a
wet rag
on the top of her head. She complained bitterly of
the pain in her head. Her tongue was furred, and
she had some pyrexia. Thinking it might be fever,
she was ordered salines and advised to come into
the hospital. About eleven days afterwards she
came again, and "still had the rag on her head,"
and complained very much of pain in the head.
This was her principal symptom.

Seat of abscess.

Autopsy showed an oval opening in the skull at the back
part of the head on the right side. Acute arachnitis
on both sides, more on the right. An abscess, the size
of a walnut, in the back part of the right hemisphere,
just below the descending cornua; purulent matter also
in the lateral ventricle. The clear fluid that escaped
was probably ventricular.

Post-mortem examination showed no disease of the bones.
A small tumour attached to the surface of the dura
mater, embedded into the edge of the hemisphere near
the longitudinal sinus. Vascular arachnoid. On sur-
face of brain a thick cyst the size of a grape, and filled
with liquid pus. In the brain substance there were
three abscesses exactly like it. Each had a thick cyst,
which was vascular, and could be easily turned out.
All close to the surface. All the size of small chestnuts.
Lungs filled with tubercular matter. Fallopian tube
near its end filled with a soft tubercular and purulent
matter; also the uterus, near the opening of the tube.
Post-mortem examination.-Calvarium was irregularly
thickened in parts, as if there might have been an
osteitis at some previous time, but no caries was dis-
covered. Arachnoid slightly greasy and opaque.
large abscess in the left hemisphere, with a distinct
wall, evidently some weeks old. It contained offensive,
viscid, yellow pus. Had opened into the left lateral
ventricle. Lungs congested. Heart, liver, kidneys,
bladder, spleen, peritoneum, all healthy.

A

Led an irregular life. Employed at a music hall, and
some years ago got his chest crushed in an accident,
and said after the injury that he spat blood. Not
known that he had injured his head. All that could
be learnt of any previous illness was that he had
been subject to "fainting-fits." Said to have been
well until three days before admission, when he was
seized with tingling and numbness in the left hand.
This increased; the arm got weak. On admission
much loss of power on the left side; this increased.
A week before he died, complete hemiplegia. The last three cases are recorded in 'Guy's Hospital
Twitching on the right side. Became insensible Post-mortem Records.' Dr. Wilks has kindly allowed us
and died.
to make use of them.

MEDICAL CENTER
STANFORD, CALIF. 94305

STANFORD UNIVERSITY

LANE MEDICAL LIBRARY

CASES

OF

ANEURISM OF THE CEREBRAL VESSELS.'

This

ANEURISM of the cerebral vessels has been regarded as a disease of extreme rarity, and judging by the scanty records of it, we should conclude that the opinion was true. apparent rarity, however, like all negative conclusions, is doubtful, and I think there is the more reason to suspect it as only apparent, and due to careless inquiry, since the discovery of these cases has been much more frequent during the last ten years. There are several reasons why intracranial aneurism is likely to be overlooked. First of all, as here hinted at, it has not been looked for, and it is notorious that the eye can see only that it brings with it the aptitude to see. Again, when death occurs from rupture of the sac, recent coagula may so imbed and conceal it that unless strictly looked for it will not be found, for the sac is often small and thin and transparent, except

at the point of rupture. Further, also, when death has taken place from changes around the aneurism, as by pressure or softening, the sac itself may present such appearances that unless a minute dissection be made of it, its true nature may not be discovered. Whenever young persons die with symptoms of ingravescent apoplexy, and after death large effusion of blood is found, especially if the effusion be over the surface of the brain in the meshes of the pia mater, the presence of an aneurism is probable.

Reprinted from the 'Guy's Hospital Reports,' vol. v, 1859, p. 281.

Though intracranial aneurism generally occurs on the larger trunks of the vessels as they lie at the base of the brain, or in the fissures between its lobes, the smaller branches, after entering the cerebral substance, are not exempt. Dr. Crisp records the case of a boy, aged fourteen, who died from rupture of one of two small aneurisms on the anterior cerebral artery in the substance of the anterior lobe. In the seventh volume of the 'Pathological Transactions' is a case by Dr. Van der Byl, where an aneurism on the posterior cerebral artery lay in the substance of the brain, as a tumour of the size of a hen's egg, composed of concentric layers of fibrin. In one of the cases given below (see Plate), it will be seen that death was occasioned by the rupture of a very small aneurism in the substance of the pons Varolii. This was found by hardening the brain-substance in spirit before removing the coagulum.

We are indebted to Dr. Brinton for a table of fifty-one cases of intracranial aneurism, from which it appears that the most frequent seat of the disease is the basilar artery, and next the middle cerebral of either side. If to the cases in Dr. Brinton's table be added eleven others, four from the seventh volume of the Pathological Transactions,' and seven referred to in this paper, the results are as follows:

Seat of sixty-two cases of intracranial aneurism.

1 'Transactions of Pathological Society,' vol. iii, p. 49. Note that in the table there are fifty-two cases, but No. 34 is omitted as not belonging to the category.

Of 58 of these cases, where the sex is given, 35 were males, and 23 females.

Men, it is well known, are more liable to all forms of aneurism than women, but there is great difference in the liability of the two sexes in respect to aneurism in different parts. Thus, in 137 cases of popliteal aneurism,1 133 were males, and only 4 females, or 33 to 1. Of 66 cases of aneurism of the femoral artery, 61 were males, 5 females, or 12 to I. The difference lessens as we come to the aorta, where, of 167 cases of aneurism of the thoracic aorta, 132 were males, 35 females, or nearly 4 to 1. In carotid aneurism the liability of the two sexes appears to be nearly equal, for, of 25 cases, 13 were males, 12 females.

Fifty-eight cases, where the age is given, are distributed as follows:

The relative importance of the disease at different ages is not, however, correctly expressed by these numbers, since in the later periods of life aneurism is not unfrequently found associated with more or less extensive disease of the cerebral vessels to which the symptoms and fatal results may be owing, the aneurism being an accidental and not important concomitant. In a case recorded by Dr. Bright (No. 5 in Dr. Brinton's table), in No. 25 of the same table, in Mr. Squire's case, and also in one given below, the aneurismal dilatation of the middle cerebral, as it lay in the fissure of Sylvius, was unimportant, and in no way concerned in the fatal result, which was due in all these cases to atheromatous disease of the vessels generally, producing softening and effusion of blood. It is not so, however, in younger subjects. In them aneurism commonly occurs without disease of the vessels generally, and is fatal either from rupture of the sac or from pressure or softening around it. Of 20

1 Crisp on Diseases of the Blood-vessels,' pp. 134, 224, 225.
2 See Table, Case 56.