shown us, and there is no evidence of its connection with emotional excitement.

It seems most likely that the vessel must be diseased at one point before any cause such as violent emotion or bodily exertion can contribute to the formation of an aneurism, for the arteries within the cranium are more protected from accidental strain than any others. Dr. J. W. Ogle has lately offered a very ingenious and reasonable suggestion as to the formation of aneurisms in connection with embolism. He supposes that the fibrinous deposits met with in the valves of the heart may be carried into the circulation and obstruct an artery, and that, when thus fixed,

"The constant pressure of the blood a tergo cannot fail (whilst wedging the mass more firmly in the blood-vessel) to have a tendency to dilate the yielding walls of the vessel, as well at the part exactly corresponding to the plug as on the proximal side of the plug."

6

Such a dilatation of an artery in connection with embolism he has seen occasionally post-mortem, and similar cases are recorded in the Pathological Transactions.' This process, Dr. Ogle thinks, "has specially seemed to apply to the formation of aneurisms on the intra-cranial and the coronary or cardiac arteries," and he further remarks that where there is no disease of the coats of the vessel existing it is difficult to account for an ancurism on any plausible theory. He mentions several such cases, and when, moreover, heart disease is also present, the explanation he offers would seem to be the most likely one.

These aneurisms may be formed either by simple dilatation of the artery or by rupture of the inner coats, and adhesion of the lining membrane and outer coat. The first supposition is that held by Gull, Albers, and Cruveilhier, as the most probable in the brain.

There is one recorded instance of recovery by obliteration of the sac from coagulation in it of fibrine, but this is, of course, quite exceptional. The consequences of a cerebral aneurism vary according to its seat. The membranes suffer, as a rule, but little; the pia mater becomes more vascular, and thickened at the spot, but the dura mater escapes, though, in one instance, it was found thickened, and contained four ounces of blood between its layers, after rupture of the middle meningeal. The brain becomes softened at the spot by pressure, and the nerves may suffer in the same way, though generally they are compressed without loss of structure, and have been known to give evidence of a recovery of powers on the rupture of the sac which compressed them. The termination of these cases is, in the great majority, by rupture and effusion of blood either into the cellular tissue of the arachnoid or into its general cavity, but

softening of the cerebral substance may also occur and lead to death by itself. When the latter happens the softening is extensive, followed by apoplectic attacks with paralysis, and is due not to the constant pressure of the tumour, but to an arrest of circulation in a certain region by the blocking up of a large vessel. This is due, of course, to coagulation in the sac of an aneurism, and the effect is to deprive a certain portion of the brain of its blood, leaving it in a state of white softening with the capillaries filled with venous blood. The following interesting case illustrates this condition. It is related by M. Hayem, and we have condensed it from Dr. Gouguenheim's pages.

A man, æt. 71, of generally good health, suddenly lost consciousness, and vomited, and, after rallying in some degree, was found to have incomplete right hemiplegia, without any loss of sensation. He afterwards became comatose, and died in four days. Autopsy. The right lobe of the cerebellum was generally softened, and formed a pale, rose-coloured mass, which adhered slightly to the membranes. The finger easily sank into the nervous substance, which was soft and traversed by red lines, formed of large capillarics, in which the blood had coagulated. There was no extravasation of blood. The rose coloration was evidently due to the intimate mixture of the elements of the blood and of the nervous substance. The right anterior cerebellar artery was completely filled by a clot of blood, which reached from the commencement of the vessel to its smallest divisions. At the bifurcation of the basilar trunk a large clot was found, projecting into the basilar, and prolonged upwards into the right superior cerebellar and posterior cerebral arteries, quite obliterating them. The left posterior cerebral was slightly impeded by this clot; but all the other arteries were free, and all the other parts of the brain were healthy. In the right anterior cerebellar artery, besides atheroma of the internal membrane, there was a lateral dilatation, at which the inner coat was wanting, and where there was a small aneurism.

In this case the thrombosis of the artery had interrupted the entire circulation of one side of the cerebellum and upper part .of the pons, and had given rise to the softening, the coagulation being due to the atheroma of the wall, without doubt.

The diagnosis of cerebral aneurism must always be difficult, but there are signs which serve to indicate its presence. The symptoms may be classed in two categories:-1st. Those common to all cerebral aneurisms; and, 2nd, those which vary according to the seat of the disease.

Under the first head come headache and affections of sensation, motion, and of the intelligence.

The headache is in all cases constant, intense, and subject to

exacerbations, which may be explained by the shock communicated to the cerebral mass by the continual pulsations of the tumour, varying according to the conditions of circulation. If the headache be limited to one side, or any particular spot, it may assist in the formation of an opinion. Pain behind one eye has been noticed where the internal carotid has been affected.

Progressive paralysis would indicate softening of the nervous substance from pressure by the tumour, while sudden loss of power is due to rupture of the sac. Sensation is generally exalted during the slow progress of the disease, and that in a limited part, such as one limb, or the hand or foot merely, according as the softening extends, but is abolished when the fatal rupture occurs. The intellect usually remains clear; but in lingering cases the mind may become affected secondarily, and then it is probable that the anterior lobes are compressed or their vessels obstructed. It has happened that both anterior cerebrals have been affected, and that the patients have then fallen into complete dementia.

Under the second head we study the signs due to aneurism of particular arteries, and the following indications are given by Dr. Gouguenheim for our guidance. When the basilar and vertebral arteries are affected the pons and medulla oblongata are likely to suffer. When the pons is compressed in front we find progressive paralysis, loss of voice, impairment, and often total loss of power of deglutition. When the pons is compressed anteriorly there is no pain, but there is considerable pain when the pressure is on the posterior aspect.

When the medulla is pressed on by an aneurism there occurs headache, generally occipital, and also paraplegia, which may be distinguished from that of a spinal origin by the absence of pain along the back, and of paralysis of the sphincters.

In the case of the posterior communicating artery the symptoms are more definite. The third nerve always suffers, and ptosis occurs, often followed by an external squint and dilated pupil, and perhaps diplopia. If the aneurism attains any great size the ophthalmic nerve may get compressed, or the fifth may suffer, causing anæsthesia and hyperæsthesia of the side of the. face.

When the internal carotid is affected the signs are frontal headache, sometimes limited to the back of one eye, followed by ptosis, and sometimes by paralysis of the fourth nerve, and more rarely of the optic and the sixth nerves.

Aneurism of the anterior cerebral is to be known by these symptoms: frontal headache, amaurosis of one eye, sometimes loss of smell, loss of memory, and affections of the intellect, sometimes attacks of acute mania ending in dementia.

Affections of the middle cerebral are the most difficult to recognise, as its course does not lie near the nerves, and consequently the symptoms are less definite in character.

The character of the headache and the paralysis will serve, in a general way, to indicate to a careful observer the presence of a tumour; but its diagnosis as an aneurism is more difficult, and probably the most distinctive sign is the remission of the paralysis in some cases on the bursting of the sac, owing to the removal of the pressure. It must often happen that the previous symptoms are few and indefinite till the fatal hæmorrhage suggests the real nature of the disease, and we therefore think the minute differences specified by Dr. Gouguenheim are more ingenious than practical.

It happens, though rarely, that an aneurismal varix forms in the cavernous sinus, and such a case has been recorded by M. Nélaton. It is one remarkable, likewise, as being of traumatic origin-a cause not influencing the production of intra-cranial aneurism, except at this particular spot. The chief features of the case were as follows:-A student, æt. 21, in January, 1855, received a blow on the inner half of the left eyelid from an umbrella. This accident was followed by right ptosis and diplopia. M. Nélaton soon after diagnosed an aneurism of the ophthalmic or internal carotid. The following symptoms were observed:-Left eye healthy; right eye exophthalmos, ptosis, external squint, and pulsation, with a bruit synchronous with the heart, and ceasing on compression of the carotid in the neck. After repeated epistaxis the patient died suddenly whilst vomiting blood, four months after the injury.

Post-mortem.-At the back part of the inner side of the left orbit was the mark of an old fracture. The brain was softened, and the membranes were adherent over the outer part of the right cavernous sinus, and at this spot the sinus was open above, and the right wall of the sphenoidal sinus was quite gone, which allowed its communication with the right cavernous sinus. In the external wall of the cavernous sinus there was a splinter of bone about a centimètre in breadth, and apparently the wall of the sphenoidal sinus was pushed outwards. The third nerve was pressed on by the upper edge of the fragment of bone, and was at that spot red, softened, and less in size than the left one. The internal carotid was divided across within the sinus, and its two cicatrised extremities were several millimètres apart.

In taking leave of this subject we can but compliment Dr. Gouguenheim on the complete and exhaustive character of his essay, and the wide search he has made for materials, as evidenced. by his illustrative cases.

IX.-Asylums for Inebriates.'

Most of our readers are doubtless aware that Dr. Dalrymple last session introduced a bill into the House of Commons "To Amend the Law of Lunacy, and to Provide for the Management of Habitual Drunkards." When the time appointed for its second reading arrived, the session was so far advanced, and so little time could have been devoted to its discussion, that he very prudently withdrew it. Whether the bill in its present form will ever pass is, we think, very doubtful; but at all events its mover has done the State good service in thus directing the attention of the public to a matter of much importance, and we are glad to learn, from the paper which Dr. Dalrymple has just read on this subject at the Social Science Congress, that he intends to re-introduce it next year with various improvements. From this paper we learn that he was anxious to have avoided the first part of the title, and in no way to have associated drunkards and lunatics, but that the existing lunacy laws would have interfered with the essential object of his bill. As the law at present stands, a person who is insane by reason of drink may be sent to an asylum, but he cannot be kept there long enough to secure his permanent recovery; for as soon as he recovers from the delirium induced by drink he becomes sane, and if he is any longer detained against his will, the persons in charge of him may be exposed to an action for false imprisonment. While a very brief period of abstinence is required to restore a patient of this kind to perfect apparent sanity, it takes a far longer timea time varying according to the duration of the previous evil habits and the constitution of the individual-before he is restored to that power of self-control on which his future welfare depends. Hence in dealing with an habitual drunkard it is necessary that he should be legally retained in such confinement as shall totally exclude him from access to stimulants for a

11. The Annual Reports of the Washington Home, Boston, for the years 1866, 1867, 1868, and 1869. 2. The Superintendent's Reports of the New York State Inebriate Asylum, at Binghamton, for the years 1867 and 1868. 3. Ceremonies, etc., New York State Inebriate Asylum, Binghamton, 1859. 4. The Report of the Inebriate Asylum, Ward Island, City of New York, for 1868 (contained in the Report of the Commissioners of Public Charities, &c., New York '). 5. Inebriate Asylums, and a Visit to One. (The Atlantic Monthly,' for October, 1868.) 6. Our Inebriates Classified and Clarified. (The Atlantic Monthly,' for April, 1869.) 6. Our Inebriates Harbored and Helped. (The Atlantic Monthly,' for July, 1869.) 7. Anchored off Binghamton. (Putnam's Monthly Magazine,' July, 1869.