paralysis was sudden, the lesion was probably hæmorrhagic. Here we have then arteritis hæmorrhagica, paralytic dementia.

Here is another patient, a man, who unfortunately does not speak English. As he lies in bed he seems to be quiet and amiable; but he has given the nurses a great deal of trouble, so that it became necessary to strap him to the bed most of the time. He became wildly delirious at times, and even now does not like interference. His general condition is one of depression, and it is doubtless largely due to his senility. He belongs to the same class as the other patient, although in his case there is no paresis. His arteries are of the same general character, and while he is only fifty-six years of age, according to the case record, his arteries are those of a man of seventy-six.

This is a case of senile dementia.

For the organic dementias there is but little relief and that must come from the treatment of the conditions upon which they depend.

CLINICAL LECTURES UPON THE ÆTIOLOGY, PATHOLOGY, DIAGNOSIS AND TREATMENT OF TUMORS.-By A. H. LEVINGS, M. D., Milwaukee, Wis. Professor of the Principles and Practice of Surgery and Clinical Surgery in the Wisconsin College of Physicians and Surgeons; Surgeon to St. Joseph's Hospital and to Notre Dame Infirmary; Consulting Surgeon to the Milwaukee County Hospital for the Insane.

Hyaline Peritheliomata.—These growths are found especially upon the serous membranes and more especially upon those of the brain. They have often been called papillomata, on account of their appearance. Upon the peritoneum they are characterized by a diffuse plexiform arrangement. Borst had a case of hyaline perithelioma of the peritoneum which in one and one-half years' growth filled the abdomen, pressing the diaphragm upwards. The abdomen was found filled with gelatinous, transparent globules, the size varying from that of a cherry stone to that of an adult fist. Their color was varied. Their surface was smooth and glassy. All the organs in the abdomen were covered with tumors and were compressed. There were no metastases in the glands. Microscopically there was a plexiform arrangement of the blood vessels showing many in the process of sprouting.

Cylindromata, both endothelial and perithelial, are found with special frequency in the orbit, the parotid, submaxil-lary region, gums, membranes of the brain and cord, serous membranes and especially in the peritoneum. They are also found in the skin, the bones, the antrum of Highmore, mammary gland and the muscles and lungs. Their course of growth is usually slow. They seldom produce metastases,

but recurrence locally after removal is the rule. BirchHirschfeld saw a peritoneal cylindroma with numerous metastases in the serosa of the abdominal organs. Numerous mestatases have been observed also in other cases. In the orbit they have spread into the frontal and nasal sinuses and into the antrum of Highmore. The endothelial cylindromata are often mixed. This is especially true of those occurring in the parotid gland. The admixture may consist of cartilaginous, myxomatous, sarcomatous or carcinomatous tissue. Muscular tissue has also been found as a part of the endothelial cylindroma. The glycogen which is found in cylindroma is said to be identical with that which occurs in the liver. If the cells contain any considerable amount of glycogen they appear like epitheloid cells and have a sharp contour and a contents light, glassy and highly refractive. It is thought by some that the hyaline and colloid change may be mistaken for the degeneration due to glycogen.

Psammomata.-This is not a specific growth in that sand is found in a variety of tumors. In many kinds of growths calcareous degeneration of the elements of the tumor occurs. This is true of the myoma, fibroma, carcinoma, sarcoma and adenoma. In these, however, sand is a secondary condition. According to most writers there is but one species of tumor which should be called a psammoma, namely that coming from the meninges and consisting of a new growth of endothelial cells. Virchow described the psammomata as whitish, chalk-like bodies which take the form of globules or eggshaped concretions. These, according to Virchow, are not connective tissue tumors but epithelial. These sand bodies are globular and egg-shaped. They are in the form of elongated clubs, needles, thorns, spears and splinters. The globular sand bodies under pressure break into radiating pieces. The varied forms of these chalky bodies indicate various origins. All of those excepting the round and eggshaped find their origin in calcareous degeneration of the connective tissue bundles and of the walls or vessels, especially

when these have undergone hyaline degeneration. The round and egg-shaped are of cellular origin; that is, of endothelial origin and in them are found irregular and beautiful layers of endothelial cells. The layers are often arranged concentrically around the cell elements which have undergone hyaline degeneration. If one of these hyaline layers becomes calcified we have a typical psammoma tumor. Virchow says that these bodies have developed from connective tissue bundles. and from the intercellular substance of the connective tissue. Cornil and Ranvier think the psammomata are formed in the lumen of the vessels. J. Arnold thinks they come from petrification of the vessel contents or are due to local petrification of the vessel wall, or to both.

Engert found the development of a psammoma to be in close relation with a hyaline vessel and to be either with or without a perivascular concentrical cell mantle. In the center of the chalk bodies he saw traces of blood, pigment and traces of the lumen of the vessels. He believes they originated from vessels. Ernst demonstrated the relationship between hyaline and calcareous degeneration. J. Arnold believes that the colloid metamorphosis of the concentrically arranged endothelial cells, and especially of the vessels, precedes the process of petrification. Borst believes that in order to have petrification one must have a deficient blood supply and a deficient metabolism. In all of these degenerative products, impregnation of sand molecules were seen in large or small deposits. In this way sand bodies were produced of various forms. The greater the calcification the more these become foreign bodies. Borst saw psammomata in vessels and in endothelial cells and cell layers. He was able to trace all the stages between hyaline and calcareous degeneration of the vessels. He often saw a hyaline thrombus in a vessel undergo calcification. A hyaline mantle often surrounds a sand kernel and later both vessel wall and contents become calcified. Borst says he has determined beyond may be developed from hyaline en

a doubt that sand bodies

Out

dothelial cells and endothelial cell layers. Sand bodies may occur in consequence of the piling up of hyaline endothelial cells in layers, these subsequently becoming calcified. side of the characteristic sand bodies the psammomata often contain a varied system of endothelial cell-proliferations. The connective tissue may be so well developed in these tumors that the growth resembles a fibroma. Then the endothelial cell strands are forced into the background or form dense fasciculi. These fasciculi are closely woven and not easily distinguished from an intercellular substance. These tumors have been divided into three classes.

In the first the connective tissue may be so abundant that the tumor has the appearance of a fibroma. In the second the vessels may be so numerous and lie so close together that only a delicate strand of endothelial cells is to be seen between the vessels. In the third the cells are most numerous, the structure becoming alveolar with fine nests or strands of alveolar cells. Inside of the cell nests the layers undergo hyaline degeneration or secondary calcification.

Ernst had four cases of psammomata of the dura which he studied carefully. One was a plexiform endothelial growth having a large number of vessels. In the second there was a great number of cells. In the third the connective tissue was greatly increased. The fourth was a typical fascicular structure. Borst thinks that the endothelial structure in psammomata come from a proliferation of the endothelial cells in the lymphatic spaces and in part from the perithelial elements of the adventitia of the proliferated vessels. The real psammomata occur as solitary or multiple nodules. Most frequently they are found in the dura, then in the pia, and next in the pineal gland. They occur in the choroid plexus. One was seen in the vessels at the base of the brain, another as a small, egg-shaped growth in the peritoneum. On the dura they usually have a broad base and occur as a hard, superficially-situated mass which is covered by a vascular capsule. Virchow saw a chronic inflammation cause the formation