thorax. (Cases 13, 14, and 20.)

In all three carotid cases the murmur was troublesome, being audible to
the patient at night when the head was rested on the side corresponding
to the aneurism.

_Expansile pulsation._--Pulsation in combination with the existence of a
tumour is the main feature in the diagnosis between the conditions of
pure varix and varicose aneurism. It was not always existent or
prominent in the earliest stages, probably from temporary blocking of
the artery, or from the diffuse and irregular nature of the cavity
offering conditions unsuitable to the satisfactory transmission of the
wave. When localisation had occurred it was always present.

EFFECTS OF ANEURISMAL VARIX OR VARICOSE ANEURISM ON THE CIRCULATION

(_a_) _General._--The most striking feature in these injuries is the
remarkable effect of the disturbance to the even flow of the circulation
on the heart. This first struck me in two of the cases of carotid
arterio-venous aneurism recorded below (Nos. 10 and 11). In these I was
inclined at first to attribute the rapid and irritable character of the
pulse solely to injury to the vagus, as in each laryngeal paralysis
pointed to concussion or contusion of the nerve. The pulse reached a
rate of 120-140 to the minute. This disturbance was not of a transitory
nature, for in the two cases referred to the rapid pulse persists, in
spite of entire recovery of the laryngeal muscles, and the fact that in
one case the aneurismal sac has been absolutely cured, and in the second
only a small sac remains, in each as a result of proximal ligature of
the carotid artery. In the former a varix still exists, and at the end
of seven months the pulse is still over 100. In the latter, in which a
sac is still present, the pulse rate varies from 110 to 130. In each
case the condition has now existed twelve months. My attention once
directed to this point, I noted a similar acceleration of the pulse in
the case of these aneurisms elsewhere; thus in a femoral aneurism the
rate was 120, and in an axillary varix of twenty years' standing which
came under my observation the pulse rate varied from 110 to 120,
according to the position of the patient. Unfortunately I had not
directed my attention to this point in the early series of cases which
came under observation.

It will be remarked in cases 13 and 14 that at the expiration of a year
the pulse rate was still high, but these again are cervical aneurisms
each in co