gans, other than the brain, normal. Prof. Harper carefully examined the hearing for me and reports deafness of the right ear to be catarrhal; patient can hear the trumpet, and the tuning fork is better heard on the right side than on the left; the condition of the membrana tympani and the nasal membrane is confirmatory; the duration of deafness conclusive.

Diagnosis:-From all the foregoing facts, I arrive at a diagnosis of brain tumor. The symptoms proper date back three and one half years. The absence of headache in this case is not so very uncommon. The absence of vomiting is, also, not uncommon. Optic neuritis is very common, but in the presence of certain other symptoms is not essential to a diagnosis of brain tumor. In this case the character of the convulsive seizures, their beginning and termination, together with the hallucinations are the chief localizing symptoms. Tenderness over left parietal region tends toward confirmation of the location-diagnosis. I locate the tumor at the Rolandic fissure of the left cerebral hemisphere, in or near the cortex.

Prognosis: The growth is apparently accessible. The nature of the tumor cannot be, surely, foretold. It is not syphilitic. The history of the symptoms shows it to be of slow growth and. therefore, apparently benign and probably encapsulated. Hope for relief by surgical interference, therefore, seems to be more than usually favorable. The chances for success appear to equal those of failure. I have therefore recommended an operation.

(The following from note-book of Feb. -

1897.)

I desire to report to you the result of operation in the case of Mr. A. H. D., presented to you recently as a case of brain tumor.

The operation was performed at the Lake Geneva Sanatorium, by my colleague, Prof. Thos. A. Davis. There were present, beside, Doctors Gordon, Reynolds, Metcalf and Stockley. A button of bone one inch in diameter, with its center over the Rolandic fissure and one and three-fourths inches below the vertex, was removed, and this opening enlarged by the forceps to an opening two inches in diameter. The cranial contents bulged strongly into the opening The

CASE II., Fig. 2. Microscopical section of tumor shown in Fig. 3. a, a, a, a a, blood vessels. b, b, delicate fibrils interspersed with round cells. x 150.

CASE II.. Fig. 3 tumor on the left, marked by pin.

dura mater was incised with a circular flap and found to be adherent to the tissues beneath. The brain, bulging into the opening, was much lacerated by the taut edges of the dura mater. Exploration revealed no removable tumor, but the vascularity was such that, after trephining, Dr. Davis regarded the growth as angiomatous. The subcortical substance was, later, found to be softer and of darker color than normal, and the evidence tended to show it to be an infiltrating glioma, lying just beneath the cortex, and, as is commonly the case in such growths, not destroying the function of the nervous tissues enclosed within its meshes. The arm and shoulder muscles of the right side responded to the stimuli of the brain electrode.

It was found impossible to unite the edges of the divided dura mater on account of the great bulging into the wound, so that the wound was necessarily closed only by the reflected periosteum and the scalp, a small opening with a strip of gauze being left at the most dependent point for drainage. After operation the pulse was 120, temperature normal, no movements in right arm and shoulder, but for a short time movements in right hand were made and for ten hours in right leg. No facial or tongue paralysis has resulted, but motor aphasia has existed from the return of consciousness, the patient being able at first to say, only, "oh, yes" and "oh no," the prefixing of "oh" not being usual with him previous to the operation. Since then he has been able to say "yes" and "no" without "oh" prefixed, "I want" "water" and "it pains here." Since the first ten hours there has been no voluntary movement of the right leg, and its muscles are in a spastic state.

Autopsy:-Before proceeding to the results of the autopsy today, I may state that the patient continued with normal temperature, and after a short time, with normal pulse, for a period of twelve days. The head was, of course, kept closely and aseptically bandaged. Primary union of the incised edges of the scalp took place except at the space left for drainage. At no time was there any formation of pus, or any apparent infection. The cranial contents, however, continued to bulge more and more through the cranial opening, until a prominent tumor presented beneath the scalp.

Right facial paralysis slowly developed after nine days, together with deviation of the tongue to the left on protrusion, as I believe, due to bulging. On the eleventh day, if asked to protrude his tongue, he would open his mouth very widely and carry his tongue backward and up to the roof of his mouth, evidently not lacking power of protrusion, but lacking knowledge of how to do it. On the twelfth day he suffered a chill, followed by greatly increased flow of cerebro-spinal fluid, gradual rise of temperature to 103 finally in the last hour of life, rise of temperature to 1080, dying at the end of the fourteenth day after the operation.

The autopsy was made by Dr. Metcalf and myself eighteen hours after death. The head and brain, only, were examined. On reflecting the scalp, part of the cranial con

A..

B.

C.F.W. Ready.

a. Rolandic fissure.
b. Infiltrating glioma.

CASE II., Fig. 4.

tents formed a mass outside of the skull at the point of the wound, the size of half a large orange. The surface of this mass was of normal brain firmness and overlaped the edges of the skull half an inch all around the opening in the cranium. The margins of this mass were lifted and compressed, allowing it to be drawn through the cranial opening as the