lies in the triangular space bounded by the tendons of the extensor primi and extensor secundi internodii pollicis. The neuroma, as large as a ripe cherry, was then dissected from the nerve without any difficulty, the wound rapidly healed, and there was no impairment of the sensation of the hand. Judging from a study of the literature relating to the subject, it would appear that the wrist is a very unusual situation for neuromata.

In

They are by no means uncommon on the intercostal nerves. one of my cases, a woman thirty years of age complained of a lobulated tumor occupying the eighth intercostal space on the right side in the axillary line, which was a source of trouble and pain to her because preventing her from tightening her stays. The tumor was shaped like a dumb-bell; the extremities were as large as the top of the middle finger, freely movable, and non-adherent to the skin. Several who examined the patient regarded it as a fatty tumor, but its mobility, its situation (deeply in the intercostal space), and its painfulness induced me to regard it as a neuroma. On incising the skin, the tumor was found lying between the external and internal intercostal muscles, connected with the nerve by a stalk: it was easily removed.

Some of you will doubtless remember a woman of twenty-eight years, recently under my care, who complained of a painful swelling in the bend of the elbow, which on account of its situation, lateral mobility, the depth at which it was situated, and the pain it caused in the fingers when pressed or even lightly manipulated, led several of us to think the tumor was a neuroma of the median nerve. Under this supposition I cut down upon it, and found a tumor in the substance of the supinator brevis muscle the size of a marble; it was slightly adherent to the sheath of the brachial artery just at its bifurcation. On microscopical examination it turned out to be a gumma. After a most careful interrogation we failed to get a history of syphilis, but a year later the woman again came under observation with a similar tumor higher in the arm, which quickly yielded to iodide of potassium internally, and thus confirmed the opinion as to the syphilitic nature of · the swelling in the supinator brevis muscle.

It is somewhat curious that neuromata rarely produce pain unless touched; then the sensations are usually very acute. Probably of all nerves the trigeminal is the one most liable to be the seat of neuromata, and even on such a sensitive nerve as this they rarely produce much suffering; but there are conditions under which they render life unendurable. Smith in his admirable monograph on "Neuroma" describes the case of a woman who complained of severe pain in the

course of the right trigeminal nerve, which was so increased by mastication that she ate but little; speaking aggravated the pain to such a degree that she always remained silent unless interrogated, and frequently on these occasions she replied by signs. The patient died after enduring severe and uninterrupted pain during four and a half months. At the post-mortem examination a neuroma as large as a walnut occupied the situation of the right Gasserian ganglion. It is probable that the intense pain experienced by this unfortunate woman was due to the fact that the tumor grew in a confined situation. This view was impressed upon me by the following case:

A woman twenty-two years of age complained of very severe pain confined to the region of the right upper jaw. Notwithstanding the intense pain (which at night amounted to agony) this patient complained of, the region of the face supplied by the palpebral, nasal, and labial branches of the right infraorbital nerve was anesthetic; a slight thickening could be made out by the finger along the lower margin of the orbit, and there was a slight upward displacement of the eyeball. On examination, the skin supplied by the temporal twig of the orbital branch of the second division of the fifth nerve was found to be normally sensitive; this was also true of the mucous membrane supplied by the posterior dental branch of the same nerve. The symptoms were best explained by supposing the right infraorbital nerve to be entangled in a tumor connected with the roof of the antrum or floor of the orbit. Acting on this hypothesis, I reflected the skin of the cheek, and on cracking away the anterior wall of the antrum I found the cavity occupied by a gelatinous sarcomatous-looking tumor. The parts were freely removed, including the Gasserian ganglion. The pain was immediately and permanently relieved. On investigating the tumor it turned out to be a neuroma growing from the infraorbital nerve and invading the antrum; in the main it consisted of myxomatous tissue. A neuroma of this character on a limb-nerve would have been painless save when submitted to pressure, but imprisoned within the unyielding walls of the maxilla it was subjected to unremitting pressure, and was in consequence the source of continual pain.

It by no means follows because a neuroma is seated upon a sensory or a mixed nerve that it will be productive of pain. I have seen these tumors on the supraorbital and lingual nerves, but they gave rise to no painful sensations, and cases have been described in which neuromata grew on the cords of the brachial plexus, the median nerve, and the greater sciatic nerve unaccompanied by pain. When springing from the

trunk of a motor nerve they are painless; it is important to bear this in mind, as a neuroma has been observed on the trunk of the facial nerve in the parotid gland; the tumor was removed under the impression that it was an ordinary parotid adenoma, and permanent facial palsy was the unfortunate consequence. Cases have been reported in which surgeons have removed tumors from the forearm which had been absolutely painless, and subsequent examination showed that in the course of the operation a large and important nerve, such as the median, had been completely severed. This is very unsatisfactory, and could be avoided if surgeons realized that neuromata are encapsuled tumors, and when situated in the immediate neighborhood of large vessels, and upon important nerves, admit of easy enucleation, as the following case will show.

A single woman, thirty-five years of age, was placed under my care for a tumor of the mamma. On examining it there was little doubt that it was a carcinoma, and whilst examining the axilla for enlarged lymph-glands I perceived a tumor in the supra-clavicular region. Manipulation of this tumor provoked pain, not in the neck, but in the ball of the thumb and in the tips of the thumb and forefinger of the same side. The patient was an intelligent woman, and stated that the tumor in the breast had attracted her attention only a few months, whereas the cervical tumor had been present fourteen years. This definite statement was, of course, important, for nothing would have been easier than to regard the neck tumor as a collection of supra-clavicular lymph-glands infected by the mammary cancer. The long duration of the tumor, the pain referred to the digits when it was pressed, and its mobility and uniformity, induced me to regard it as a neuroma connected with the fifth and sixth cervical nerves, implicating more particularly those strands which help to form the median This diagnosis was verified at the operation, for after amputating the mamma I exposed the tumor in the posterior triangle by a vertical incision, and saw a large nerve-trunk embedded in it: the capsule of the neuroma was then opened with a knife, and a tumor the size of a bantam's egg was readily enucleated by means of a raspatory. There was no bleeding from the capsule. After the removal of the tumor the conjoined trunks of the fifth and sixth cervical nerves were made out. As soon as the patient recovered consciousness I tested the movements of the thumb and fingers, and had the satisfaction of assuring myself that there was no paralysis nor evidence of anaesthesia in any part of the limb. In this instance, had I attempted to remove the tumor with its capsule I should have been obliged to perform a

nerve.

very difficult dissection in an extremely dangerous region, and run the risk of irretrievably paralyzing important muscles of the forearm, of wounding some large venous or arterial trunks, or of opening the pleural cavity. By simply enucleating the tumor from its capsule, a proceeding which consumed only a very few minutes, I avoided all these risks, and the patient was convalescent in a few days.

A very important case was published in the Medico-Chirurgical Transactions, vol. lxix., in which Chavasse removed a neuroma as large as a duck's egg from the right posterior triangle of the neck. The dissection was difficult and deep. The patient, a woman thirty years of age, died six days after the operation, from spinal meningitis. At the post-mortem examination it was found that in removing the tumor the sixth cervical nerve had been torn off, the root giving way inside the dura mater. Pus from the wound had leaked into the canal, producing fatal meningitis.

My chief object in this lecture is to impress upon you the importance of remembering that all simple neuromata are encapsuled tumors, and that when the capsule is split they can be shelled out with the greatest ease and safety. When growing from the side of a nerve they may be removed with their capsules.

It is true that in some instances where surgeons have unconsciously divided large nerve-trunks they have sometimes been able to repair the breach in their continuity by nerve-suture or nerve-grafting. It is, however, always better to avoid the accident by careful surgery than to remedy it by secondary measures, however brilliant.

TUMOR OF THE CEREBELLUM, PROBABLY TU

BERCULAR.

CLINICAL LECTURE DELIVERED AT ST. ANTHONY'S HOSPITAL.

BY HOWELL T. PERSHING, M.Sc., M.D.,

Professor of Nervous and Mental Diseases in the University of Denver; Neurologist to St. Luke's Hospital and St. Joseph's Hospital; Alienist to the Arapahoe County Hospital.

GENTLEMEN,―The patient is a well-built though somewhat emaciated man, aged twenty-eight, with no apparent hereditary taint. Twelve years ago a chronic cough set in, and for about a year he occasionally spat blood, but these symptoms gradually disappeared. Six years ago he worked for a short time with lead ores, without any apparent bad effects. Although he confesses to frequent attacks of gonorrhoea, there is no history of syphilis. He says that for three years, ending in March, 1893, he was drunk half the time; since then he has had no alcohol.

A year ago he began to have severe headaches, and at the same time noticed that he sometimes staggered in walking. For six months past, the headaches growing more intense, there have been attacks of giddiness, dimness of vision, and vomiting. Once, during July, he fell and was unconscious for some minutes.

For a short time this summer he was in the County Hospital, where, on account of some mental symptoms, he was transferred from the general ward to the care of Dr. Eskridge, who found, among other symptoms, optic neuritis and exaggerated knee-jerks. A few days ago, while I was examining his ears, he suddenly fell back with all his muscles rigid. His head was drawn back, the eyes opened widely and the pupils dilated, while respiration was somewhat quickened. In three or four minutes the tonic spasm had passed off and consciousness gradually returned.

He now complains of intolerable headaches, pains over the body generally (more especially in the left thigh), giddiness, frequent vomiting, failing sight, and occasional visions, which he recognizes as hallu