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(From the Surgical Clinic of the Montreal General Hospital.) BY . Geo. E. Abmstrono, M.D. Assistant Professor of Clinical Surgery, McGill University ; Surgeon to the Montreal General Hospital ; Attending Surgeon to the Western Hospital. Wm. C, aged 30, was admitted to the Montreal General Hospital on February 17, 1896, for a tumour on the left side of the head. The trouble was first noticed about Christmas, 1895, i. e., nearly eight weeks previous to admission, when his attention was directed to the prominence of the left temporal artery. Previous to that time it had never been noticeable. About one week later he noticed a small tumour over the left temple and on the artery. It was a small soft lump, and during the week that followed its appearance it grew very slowly. He then worked very hard and got overheated, the head became hot and an intense headache came on. The head seemed as though about to burst and the pain was principally at the back. The severe pain lasted about one hour, but a dull headache continued for several days. Following this overheating the tumour increased during the next three days almost to the dimensions it had on his admission. By that time it had reached almost to the middle line. Since then it has increased very slowly and has gradually become more prominent. No history of injury was obtained. He stated that he was born and had always lived in Canada and followed farming ; that when a child he had had scarlet fever, measles and croup ; that he had had erysipelas ten years, and again five years previous to admission ; that he had had no other illness and had always enjoyed good health ; as regards his habits, that be had used tobacco freely, alcohol very moderately, and that he had had no venereal diseases. Ever since he could remember he had been troubled with headaches, which would last two or three days at a time and then would not be felt for a week. Another fact he mentioned was that up till the time of his operation he had always been troubled with epistaxis, some- times three or four times a day. No information or points of interest were obtained on inquiry into the family history. Read before the Montreal MedicOhGSiiuf^iICa^-Spciety, April 3rd, 1896. 2 On admission his condition was that of a stout, intelligent, well- nourished man of 30 years, of florid complexion, and with a tumour situated on the anterior left part of the head. The left temporal artery was prominent and tortuous, pulsated visibly and extended up through the tumour. The longest measurement was from a point a little above the outer angle of the orbit one and a half inches upwards and backwards obliquely. In the middle line of the head the posterior border was nine inches from the nasion. The anterior border of the tumour extended forward only to the top of the forehead. Laterally it extended one and a half inches to the right of the median line, posteriorly to the line joining the external auditory meatus. Its general appearance was that of a large prominent tumour with tor- tuous margins. One saw and could feel well-marked pulsation over its whole surface. It was soft and yielded readily to pressure, which when removed showed the tumour to again till out with each pulsa- tion. Beneath the temporal and superior portions there seemed to be a complete absence of both tables of the skull. At the posterior part there was a detached portion of bone unconnected with the surrounding bone. This portion felt thin and friable and had very irregular, uneven margins. It was 6^ cm. in its longest and 4 cm. in its shortest diameter. Where the temporal artery coursed along the anterior border of the tumour was heard a well-marked bruit, having its maximum intensity over the temporal artery and occurring synchronously with the pulse It could be best described as resembling the placental souflle. The following observations, carefully made before operation, were veritied by several present at the time : {a.) Digital compression of the left common carotid caused the bruit to entirely disappear. (6.) Digital compression of the left common carotid arrested pulsa- tion of the temporal portion of the tumour and of the temporal artery, but did not arrest pulsation on the upper part of the tumour. (c.) Digital compression of the right common carotid lessened but did not altogether arrest pulsation in the major part of the tumour. (d.) Simultaneous digital compression of tho right and left common carotids arrested completely pulsation all over the tumour. (e.) Immediately after pressure was applied to the carotids the tumour visiVtly sank, and when the pressure was removed the tumour expanded. Examination of the lymphatic system showed no enlargement of glands anywhere. The respiratory and digestive systems were normal. 8 The pulse at the radial was regular, easily compressible, of good volume ; the artery was slightly sclerosed. Other than a slight reduplication of the second sound heard over the pulmonary cartilage, the heart was normal. The urine was normal in quantity and colour, with an abundant flocculent precipitate at the bottom ; specific gravity 1024, clear, con- tained no sugar ; urea grs. x. to the ounce. On admission albumin was present in the proportion of three grammes to the litre. It gradually under a milk diet diminished to one gramme and remained at that amount. Microscopically the urinary sediment gave urates, pus cells, squamous epithelial cells and granular casts. Examination of the eyes by Dr. John J. Gardner gave evidence of inequality of the pupils, the left being | mm. larger than the right. Both pupils reacted to light and accommodation, but the left not so readily as the right. The discs were about normal, but the arteries somewhat small, There was no fundus trouble. On February 27th, i.e., twelve days after admission, he was given ether and both external carotids were tied. At the operation several glands were seen and were removed. On examination by Dr. Wyatt Johnston they were found to contain only lymphoid tissue. After the operation immediate and marked diminution in the bulk of the tumour occurred. Pulsation ceased and the bruit disappeared. The following are taken from the bed-side notes of April 3rd: " The tumour has diminished in size and bulk ; there is no pulsation or bruit ; no further extension of absorption of bone has occurred in any direction ; he does not suffer any longer from headaches or nose bleeding and says he feels a remarkable improvement in his general health.