loss of consciousness, and since then there has been paralysis of the left side of the body. Consciousness was regained after the convulsion, but she had periods of semiconsciousness since. Yesterday, the day before her admission to the hospital, the patient again became unconscious and has been so since. The paralysis of the left side of the face, arm and leg was still present. Her pulse was very slow and of a very low tension128 millimeters of mercury. Her breathing was stertorous at times. She was a very unfavorable subject for operation. During the process of lifting the flap over the right motor area and before I had completely cut through the skull, the patient stopped breathing. It was with difficulty, under artificial respiration, that her breathing was restored. The pulse became very weak at the wrist, the blood in the wound became very dark and bleeding stopped almost entirely. At this period of the operation there was a delay in trying to establish respiration, which appeared to be without avail. In spite of these conditions I decided to continue the operation and hurriedly tried to give her relief from the intracranial pressure. The osteoplastic flap was raised, the dura quickly incised and the brain bulged high up into the wound. Almost immediately upon relief of pressure, after the incision of the dura, the patient began to breathe regularly and well. It was a most noteworthy phenomenon. I found a subcortical hemorrhage of very large size. The patient continued to breathe well but her pulse was small, thready, and very rapid. She died twentyfour hours after the operation. I am sure in this case, if she could have been operated upon earlier, the result might have been different. The diagnosis of this case, made by Dr. Mailhouse before the operation, was of tumor with acute hemorrhage.

In this series of cases there are a number of most interesting histories and results which I would like to give you, but from which I must refrain because it would consume much time and the main object of the paper would suffer.

There are a few facts, however, which I would like to impress relative to the dangers and difficulties attending all operations upon the brain and spinal cord, which when

enumerated will prove that operations upon these structures are not any more dangerous than operations elsewhere.

The worst and most troublesome condition one encounters is that of hemorrhage. Both the organs and the structures covering them are abundantly supplied with blood vessels. Naturally one must be familiar with every possible method of control of hemorrhage that is known in surgery. There is no place in the human body where a surgeon is more likely to find himself at his wit's end, facing a rapidly bleeding wound and baffled by every method at his command for the control of hemorrhage. Rough, dashing operating should give way to gentle, deliberate manipulations. Hartley gives hemorrhage first place as a cause of mortality in head operations. Infection is the second chief factor in mortality in these operations. In my whole series I was in only one case obliged to stop on account of hemorrhage, and I am sure that I have encountered many difficult and troublesome cases which might have required two-stage operations had the technique been less careful. The only case of infection was that of a child who was operated upon for a tumor of the cerebellum, which at the operation proved to be a tuberculoma, and which was removed without difficulty, but the operation was performed in a private house and without trained nursing the case afterward became infected. This case, I am sure, under different surroundings would have added one more to the number of cured. There is not a single case in which death could be ascribed to fault in technique.

Another point I would like to emphasize is the matter of making exploratory incisions into the brain and cerebellum. There is not a single thing to be gained by the introduction of needles into the different places of the brain for the exploration of tumors. The vast majority of brain tumors have a consistency not much different than the brain itself. In fact, most brain tumors which grow from the neuroglia have a much softer consistency than the brain. In a number of these cases I have made incisions for exploration which have resulted in no harm. These incisions I have been able to close with very fine

PLATE I. OSTEOPLASTIC RESECTION OF SKULL.

Fig. 1. First step, small V-shaped incision for trephine opening. Fig. 2.-Incision through scalp completed and skull cut with the DeVilbis forceps. Fig. 3.-Osteoplastic flap reflected, dura not yet opened. Note the small ledge at the upper part of the margin of the opening made by chisel.

catgut sutures, which bring about perfect coaptation and control hemorrhage. The sutures when passed with the greatest gentleness have been very satisfactory. I have found the cerebellar tissue much firmer for the introduction of sutures than the cerebrum.

In three of the cases, all of which were cerebellar tumors, in no instance could I elicit the presence of a tumor by palpation which had a deep-seated origin, and if I had not practiced incision into the cerebellum they would not have been discovered.

I want to impress upon you again the fact that an operation for osteoplastic resection of the skull is as devoid from risk as an operation upon the abdomen, provided, however, the patient is in a fit condition. It is not wise to wait too long to localize a tumor. The great benefit which is derived from an operation for decompression is incalculable. The relief from symptoms and the preservation of vision secured in these decompressive measures are manifestly clear to all who have had occasion to observe them. The operation for decompression has a wide field of application. It is indicated in all cases of tumors which cannot be localized. It is also indicated in epilepsy and chronic meningitis with or without hydrocephalus. In cases of tumors one should not be content until a thorough search has been made for them.

Cushing calls attention to the fact, in his subtemporal operation for decompression, that inoperable and unlocalizable tumors do sometimes emerge from their silent situations and show focal symptoms. His bilateral subtemporal decompression operation should be confined to those cases in which a tumor is diagnosed in a nonaccessible situation. It is difficult to make any extensive exploration of the brain through this incision.

One can scarcely realize the amount of good obtained in these palliative operations. In a few of my cases, where the tumor could not be definitely localized, I have made the usual. osteoplastic flap and proceeded with a thorough exploration. If a tumor could not be found, or if the tumor was so infiltrat