more clearly marked. On pressing the ball of the thumb forcibly to the spine, at the situation of the impulse, a tremor is communicated to the hand; the pressure produces pain. On looking along the anterior surface of the chest horizontally, a distinct elevation perceptible at the top of the sternum, where percussion, also produces pain, and pulsation can be felt; no dullness in the situation of the impulse. All the general symptoms increased in severity. The dyspnoea causes her great alarm, and makes her frequently start up in bed and call for assistance.

She died suddenly on the night of the 5th February, as I understood from the nurse, in a fit of dyspnoea, before assistance could be procured. Post mortem examination.—On opening the chest, the heart and pericardium were found to be natural. An aneurismal tumour was discovered arising from the descending portion of the arch of the aorta, where it is in contact with the left bronchial tube, and stretching across the vertebræ to the right side. The œsophagus ran directly in front of of the tumour, separating it from the bifurcation of the trachea. At the junction of the transverse with the descending portion of the aorta, a smaller aneurism, large enough to contain a bean, extended behind, and pressed upon the left bronchial tube, between it and the œsophagus, and communicated with the aorta by a well defined opening. The larger tumour rested upon the bodies of the third and fourth dorsal vertebræ; the osseous portion of which was absorbed, leaving the intervertebral substance prominent. This portion of the spine formed the posterior wall of the sac, the pressure of which had somewhat flattened the right bronchial tube. The sac communicated with the aorta by a well defined opening, large enough to admit a man's thumb. Its interior was lined with a firm, fleshy-looking coagulum, and did not appear to contain much recently coagulated blood. Its size was about that of a small orange, and the walls were perfect. CASE III-Aneurism of the Thoracic Aorta.-Sudden Death from Rupture of the Sac into the left Bronchial Tube.

This case was first diagnosed by Dr. Wm. Stokes, at the Meath Hospital. The accuracy of his examination will be best perceived by reading the following note, which was taken when the aneurism must have been in a very incipient state, and is on that account very valuable. The case is also interesting, because the same physical signs were discovered at the Richmond Hospital, House of Industry, where, previous to the man's death, he was examined by myself and Mr. McDowell, whose patient he became, and both of us were satisfied as to the existence of the disease. I shall first, by Dr. Stokes' permission, insert his note of the symptoms, and afterwards that of Mr. M'Dowell, which was copied for me by Mr. Mayne, who, with Mr. Cumming, one of the pupils of the Richmond Hospital, diligently observed the progress of the case. The

following is Dr. Stokes' account of the examination of the case, with the diagnosis he made at the time.

Suspected Aneurism of the Arch of the Aorta.

Michael Hughes, a butler, ætat. 38, a stout, well-made man, was admitted into the Meath Hospital, complaining of great dyspnoea, cough and wandering pains about the back and chest. The whole of the chest sounds clear on percussion. Respiration in the right lung intensely puerile, altogether absent in the superior portion of the left, and only feebly audible in the interior portion. On applying the stethoscope to the left axillary region, and the patient being desired to draw in a deep breath, no sound is heard during the first half of inspiration, but during the latter half the air appears to overcome some obstruction to its entrance, and suddenly rushes in to expand the lungs. The left side of the chest is almost immovable during respiration, but the right acts freely. On applying the hand to the upper part of the left side, no vibration of the voice could be detected. The vibration is very feeble below on the the same side, but well marked on the right side; impulse and sounds of the heart natural; a strong, double pulsation is heard over the sub-clavicular region of the left side, also over the postero-superior portion of the same side, and on applying the hand over the former situation a distinct impulse is communicated to it; no bruit de soufflet could be detected. The cough is loud and ringing, and of a peculiar croupy character; expectoration scanty, consisting of frothy mucus; respiration hurried. Pulse 86, and moderately full; tongue clean, appetite good; never had any difficulty in swallowing, or pain in the throat. He attributes his complaint to cold caught five months ago from sleeping in a damp pantry, shortly after which he became affected with perspirations, wandering pains in the back and sides, increased upon exertion, and attended with some dyspnoea. The pain in the back he describes as being of a lancinating character, resembling that which would be inflicted by a knife. The distress of breathing increased, with inability to use any violent exertion, and after some time was attended by a loud dry cough. The treatment since he entered the hospital has consisted chiefly in local depletion, together with small doses of tinct. digitalis.

May 2nd.-A strong double pulsation is now heard across to the right clavicle; the pulsation has increased in the sub-clavicular region, and also over the scapula, with a strong impulse below the middle third of the clavicle; after the patient walking several times up and down the ward, a sharp, well-marked bruit de scie was detected in the latter situation. It disappears, however, after the patient has remained quiet for a short time, and again returns after exercise.

I shall now insert the report of the physical signs taken from the case book of Mr. M'Dowell, at the Richmond Hospital.

Anteriorly the right side of the thorax sounds well on percussion; a little dullness in the sub-clavicular and mammary region of the left side;

respiration in the right lung remarkably loud and clear, very obscure in the left lung, except on taking a deep inspiration, which produces a feeble vesicular murmur. A strong impulse communicated to the stethoscope, two inches below the clavicle, and about an inch and a half to the left of the median line of the sternum; impulse also perceptible across the sternum to the right clavicle; it is greater than that of the heart, and appears to be double; it is also perceptible to the hand. A slight impulse communicated to the stethoscope at the left side of the second and third dorsal vertebræ; no bruit de soufflet could be detected in this situation, nor anteriorly except after great exertion; pain on percussion of the upper third of the sternum, and in the situation of the vertebræ above mentioned. His general symptoms are severe cough of a shrill, croupy character, attended with copious frothy and purulent expectoration. Excruciating pains of a lancinating character, extending from the superior part of the chest, in various directions; urgent dyspnea, and copious perspirations, confined to the head and chest; does not complain of dif ficulty of swallowing; the jugular vein of left side distended; pulse in both wrists the same; does not complain of numbness in his arms, nor is there any œdema of the upper extremities; impulse and sounds of the heart natural. These symptoms increased progressively, for which he was occasionally bled, and put under the influence of digitalis, with counter-irritants. Nothing, however, appeared to give him decided relief, and he expired suddenly one night during a fit of coughing; at the same time spitting up a quantity of blood.

On dissection an aneurismal tumour was found arising from the deseending portion of the aorta, and pressing upon the left bronchial tube, which was considerably indented and narrowed. The posterior wall of the sac was made up by the bodies of the second and third dorsal vertebræ, the osseous portion of which was absorbed, and presented nearly the same appearances as in the case last detailed. The interior of the sac was lined with a fibrous coagulum, and it opened into the left bronchial tube; the œsophagus was slightly pushed to the left side; the interior of the aorta was crowded with antheromatous depositions between the internal and middle coat; the heart and pericardium were natural.

On examining these cases, it will be perceived that there were some symptoms common to them all. The first I shall consider is the remarkable difference in the respiration of the two lungs, and I am the more anxious to call attention to this fact, from its having been much insisted on as an additional means of assisting our diagnosis in this disease, in a valuable paper on the pathology and diagnosis of aneurism, by Dr. Wm. Stokes, in the fifth volume of the Dublin Medical Journal.

The value of the sign, according to Dr. Stokes, consists in this, that the absence of respiration cannot be accounted for by any lesion of the lung, discoverable by auscultation or percussion. The fact of there

being a clear sound on percussion, and at the same time a feebleness of the respiration, naturally leading to the conclusion that some impediment must exist to the entrance of the air into the lung on inspiration. He also suggests that perhaps it may be found, from further observations, that a solid tumour pressing on the bronchial tube will produce a permanent feebleness of respiration, but that an aneurismal tumour may allow of the occasional reappearance of it, according to the variable nature of the contents of the sac. I could not perceive, however, in any of the cases above mentioned, that this latter phenomenon took place, but I found the fact of a feeble respiratory murmur, combined with a forcible entrance of the air into the bronchial tube on deep inspiration, of great assistance in forming a diagnosis. The only case I have met with of a solid tumour compressing the trachea, or its divisions, was that of a woman named Mary White, who was admitted into one of the chronic wards of the Whitworth Hospital, for acute bronchitis. The general symptoms of this affection were strongly marked; and the clearest evidence of it obtained by percussion and auscultation. She was treated by bleeding, which it was necessary to resort to several times, and put under the influence of tartar emetic. This treatment gave her decided relief; but the symptoms uniformly returned with the same violence upon discontinuance of the treatment. This led me to examine the chest with great attention; I suspected an aneurismal tumour might be the cause of the great dyspnoea, and recurring cough, but after several examinations, I could not satisfy myself as to the existence of this affection; no appreciable difference in the respiration of the two lungs could be discovered, nor was there an anormal pulsation in any part of the chest. The bronchial râles were intensely loud; the dyspnea, notwithstanding every attempt to relieve her, increased in frequency and severity, and she expired one night in the act of rising from bed, apparently with a design of seeking relief from an upright posture.

On dissection I found an enlarged bronchial gland about the size of a large walnut, just in the bifurcation of the trachea, and adhering to it. It was filled with osseous and caseous deposites, similar to those mentioned by Mr. Carswell and other pathologists; scrofulous matter was found in the right bronchial tube, but there was reason to suppose it had escaped from the tumour, by an incision accidentally made in examining the parts. The dyspnoea in this case could not have arisen from the pressure of the tumour on the bronchial tubes, as their natural calibre was not in any way altered. It is more reasonable to ascribe it to the irritation of the nerves, particularly of the phrenic, which was in close contact with the sharp spicule of bone, with which the tumour was studded. These nerves are accurately shown in the preparation of the tumour, and were carefully dissected by Mr. Robert Smith, curator of the museum of the Richmond Hospital. It would have been interesting to have observed in this case whether the dyspnoea would have increased,

as it almost invariably does in the case of aneurism, on making the patient walk quickly, so as to increase the circulation, and thus produce a distension of the sac, but being persuaded of the non-existence of that disease, I did not resort to this expedient. The bronchial tubes presented through their entire extent marks of intense inflammation.

In the two last cases of aneurism, the effects of the pressure of the tumours on the left bronchial tube are shown in the plates accompanying this paper, and in the case of Hughes in particular, it will be seen by an inspection of the drawing, how, in the act of inspiration, the air rushed through the tube in the manner described by Dr. Stokes. When I examined this man, I did not detect the phenomenon of the inspired air appearing to overcome an obstacle, but considerable changes must have occurred in the sac since the time the disease was first discovered. Notwithstanding this circumstance, I have no doubt that had my attention been directed to the sign in question, I might have detected it, but as it was, great feebleness of respiration was what I observed.

In the case of Lee, the compression of the tube was not so obvious, as it was produced by the smaller tumour, which requires a manual examination of the preparation, to be seen properly, and could not be well delineated in the drawing. This smaller tumour pressed the œsophagus against the left bronchial tube, and hence produced the great dysphagia. From its position, also, it must have nearly prevented the ingress of air into the left lung. In the first case the left bronchial tube was also compressed, and the respiration of that lung consequently feeble; but as I did not suspect the existence of the second aneurism, I neglected to examine the postero-inferior portion of the lung, with the same accuracy I would otherwise have done, and consequently cannot state what modification of the respiration took place in consequence of its pressure on the lung.

In alluding to this sign, it is not meant to be inferred by Dr. Stokes; that it will be found to be pathognomonic of the disease in question, as it may be produced by other tumoars besides those of aneurism; but it becomes important when occurring with the other symptoms of the affection, both general and physical. It is clear, also, that an aneurism may be developed in the inferior descending portion of the aorta, where we would be altogether deprived of this sign. From studying the anatomy of this vessel, so accurately described by Professor Harrison,* it will be seen, that a long portion of it, from about the third dorsal vertebra to its entrance into the abdominal cavity, is unconnected with the primary divisions of the trachea, and hence, whatever modifications in the function of respiration may be produced from pressure of the tube, must be sought for in the portion of the lung inferior to these divisions. The next sign I shall consider as having occurred in these cases, is the

* Harrison on the Surgical Anatomy of the Arteries, third edition.