Then the intestines are empty, and no fermentation takes place afterward. If there should be a little mucus which the patient swallows and it causes gas, insert the stomach-tube and wash it out with hot water, and that will do away with gaseous distension, and there will be no intestinal obstruction after the operation. When we were using calomel or salts we had more or less trouble of that kind. After the operation, if the patient needs any support, he gets the Murphy drip.

What was said about the race-horse is perfectly correct, only they never give the race-horse castor oil. If they did he would win out every time if it was given before 4 P. M. the day before the race.

DR. JAMES F. PERCY (Base Hospital, Camp Kearny, Calif.): There is one thing not mentioned in this paper, and that is the pernicious practice of giving an enema to these patients about four o'clock in the morning. It is not only unnecessary in the average abdominal case, but it robs the patient of several hours of sleep which is too valuable to be wasted in this way.

DR. BYFORD (closing): I want merely to call attention to the fact that I spoke of routine cathartics. I do not believe extreme views are the right ones on any subject. The man who never gives a cathartic and the man who always does are equally wrong. If you want to open the abdomen of a patient with toxemia and distended intestines, I think it is the proper thing to give a large cathartic. I do not know whether any of you have ever taken a large cathartic for such a condition, but if you have you have probably been surprised by the amount of relief afforded in so short a time. But no one ought to make a routine practice of giving or not giving it. The point is, that every case should be individualized, and the question of purgation or no purgation, and the amount of purgation, should depend upon the condition of the alimentary canal and the requirements of the operation.

A FIBROSARCOMA OF THE SKULL

EARLE R. HARE, M.D., F.A.C.S.

MINNEAPOLIS, MINNESOTA

The origin, the etiology, and the classification of tumors, long have been, and are now, subjects of careful investigation and thoughtful discussion.

Many theories as to their etiology have been advanced, but as yet none has been proved.

Much talked of and familiar to all are the following: Parasitic stimuli.

Long-continued irritation by bacteria or protozoa. Injury.

Regression of tissues.

Disturbance of tissue-balance.

Displacement of embryonic cells.

Changes in cells by anaplasia.

Acquired tumors by metaplasia.

Each one of these has had enthusiastic supporters, but the problem remains unsolved.

Quoting F. B. Mallory: "We know a great deal about the gross and microscopic appearance of tumors and in regard to their classification, but nothing in regard to their cause, and little in regard to their origin."

The tumor under consideration is a very interesting one, and has been diagnosed as fibrosarcoma, endothelioma, and psammoma.

The patient, Mr. C. E., aged 46, Swedish, farmer.
Family history, entirely negative.

Past history; negative except for an injury to the skull twenty-three years ago, the patient being struck by an iron

bar, near the bregma. No medical attention was had.

Four years ago, noticed a small, hard, bone-like tumor at this area, which grew very slowly to a diameter of 2.5 cm. Four months ago the tumor began to grow rather rapidly, until now it measures 10x10x3 cm., and is hard and firmly attached to the cranium.

One month ago a surgeon attempted to remove the tumor, but desisted, owing to difficulties encountered. At that time the patient suffered an intense headache, lasting two days.

There has been no loss of weight or strength, and the general health has been good. The patient has had no pain except the headache referred to above.

Mindful that metastases are found in the skull, a careful search for a possible primary tumor was made, but without result. The x-ray plates show the tumor external to the skull.

The diagnosis is fibrosarcoma or endothelioma.

This patient had been advised against operation, and an x-ray therapy suggested. After careful consideration of all data obtained, operation seemed best, and was advised. The tumor was, in consequence, removed, under novocain anesthesia very skillfully administered by Dr. R. E. Farr, who also assisted at the operation.

The tumor was largely limited below by the bones of the skull, but it had eroded through at two areas, and passed downward between the cerebral hemispheres. It was found necessary to resect an area of the dura, including a portion of the longitudinal sinus, 7.5 cm. in length, in order to remove the entire tumor

mass.

The patient made an excellent recovery, and was able to leave the hospital in six weeks, walking with the assistance of a cane, having recovered from the paralysis which followed the operation.

During the five months since that time he has worked hard on the farm, and suffers no discomfort at all, except an occasional pain in his lower extremities.

There is no evidence of recurrence.

From the history, the tumor appears to have originated from the injured pericranium, and to have infiltrated the bone.

From the history and the examination of the gross specimen, in its relation to the dura, endothelioma seems less likely than fibrosarcoma.

It has been said that every unusual tumor which lacks characteristics which will permit its ready recognition, stands an excellent chance of being labeled endothelioma, and relegated to oblivion.

It is very difficult to prove that any tumor originates from endothelium. The cerebrospinal spaces are lined with endothelium, and tumors here are not infrequent, but they usually press inward and displace the brain tissue.

This tumor seems to have originated from the pericranium, and to have grown outward, and only at a late period to have passed through bone and involved the tissues of the longitudinal sinus by expansion.

From the microscopic examination, the tumor is a fibrosarcoma with some epithelial pearls and much hyaline degeneration present.