A Successful Case of Removal of a Large 
Brain-tumor from the Left Frontal 
Region—Opening and Packing of 
the Lateral Ventricle with 
Iodoform-gauze. 
H. M. THOMAS, M.D., 
CLINICAL PROFESSOR OF NERVOUS DISEASES IN JOHNS HOPKINS UNIVERSITY, 
NEUROLOGIST TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE) 
BY 
AND 
W. W. KEEN, M.D., 
professor of the principles of surgery and of clinical surgery in the 
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
November, 1896. Extracted from The Amex-ican Joui-nal of the Medical Sciences, November, 1896. 
A SUCCESSFUL CASE OF REMOVAL OF A LARGE BRAIN- 
TUMOR FROM THE LEFT FRONTAL REGION—OPEN- 
ING AND PACKING OF THE LATERAL VEN- 
TRICLE WITH IODOFORM-GAUZE. 
By H. M. Thomas, M.D., 
CLINICAL PROFESSOR OF NERVOUS DISEASES IN JOHNS HOPKINS UNIVERSITY, NEUROLOGIST TO 
THE JOHNS HOPKINS HOSPITAL, BALTIMORE ; 
AND 
W. W. Keen, M.D., 
PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY IN THE 
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
History by Dr. Thomas. 
E. de B., aged seventeen years, was referred to me by Dr. George 
Reuling on March 27,1896, with the request that I should examine him 
as to his nervous symptoms, double optic neuritis being present. The 
young man at that time complained of having had headaches, sick 
stomach, and some difficulty in seeing. 
His family history is exceptionally good ; both his father and mother 
are alive and in good health ; neither of them knows of any hereditary 
disease in their families. The occurrence of syphilis, tuberculosis, and 
malignant growths was especially inquired for. One brother of the 
patient died from an infectious fever, when a child, in Cuba. The other 
brothers and sisters are unusually strong and vigorous. 
The patient himself is the youngest child of seven. He was a strong 
baby and child; had measles and mumps, but no other infectious diseases 
of childhood. Other than this, he has enjoyed exceptional health. 
He has been active and very fond of outdoor sports, at which he 
excelled. When about eight years old he received a cut on the head 
by running through a glass door. The wound was not serious, and 
healed quickly under a dressing applied by his father. The scar is still 
evident. Three years ago he was struck on the left side of his forehead 
by a baseball, thrown by one of his companions. He says the blow was 
a hard one, and that he felt badly in consequence of it for a day or two. 
These are the only injuries he has received that could bear any causative 
relation to the development of his trouble. 
He never complained of headache until the beginning of his present 
trouble. The patient spent last summer at the seashore, and was ap- 
parently in robust health. In September, on two occasions, while shoot- 
ing reed-birds, he was obliged to stop on account of severe pain in the 
head. He attributed the .pain to the sun and the constant discharge of 2 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
his gun. Such an occurrence had never happened in previous seasons. 
In the autumn it Avas noticed by his family that after an afternoon’s 
tennis he Avould seem tired, spending most of the evening on the lounge. 
He entered a neAV school and did his A\rork satisfactorily, although he 
has never been an enthusiastic student. He began to have difficulty 
Avith his eyes during the late autumn, finding that if he studied much 
at night they Avould pain him. This Avas not very pronounced, being 
only sufficient to cause him to do his work during the daylight. 
On December 20,1895, he had a very severe attack of pain in the head 
and eyes. He Avas dull and somnolent, could eat nothing, and A'omited 
a great deal. He remained in bed until Christmas-day, and even then 
felt badly. About this time Dr. Reuling made his first examination of 
his eyes, and he has kindly alloAved me to use his notes, Avhich are as 
folloAVS : 
December 24, 1895. Complained of visual fatigue after reading, and 
occasional frontal headaches. 
Examination. Hm. 0.67 each. No abnormal condition. Fundus 
normal. 
Treatment, -f- 0.67 R. L. 
After the holidays he returned to school, but on January 10th he had 
another attack of severe pain in the head accompanied by vomiting. 
He AATas confined to his bed for a week; during this time Dr. Reuling 
made his second examination and then found double optic neuritis. His 
notes at that time are : 
January 24, 1896. Complains of frequent headaches, slight dizziness ; 
had an attack of nausea. 
Ophthalmic Examination. Neuritis optica descendens partial in right, 
complete in left. In the right eye inner margin of disk yet normal, 
outer margin indistinct and considerably more peripheric; veins of 
this section large and tortuous. Left eye: the Avliole discus opticus 
enlarged, its periphery considerably extended ; infiltration causing con- 
siderable prominence. Several of the tortuous veins shoAV distinct 
thrombi; arteries slightly covered by the infiltration. Diagnosis : tumor 
cerebri. V. Avith -f- 0.67 D. 20/20. General vision remarkably good ; 
reads No. II. Avith j- 1.25 D. Avith each eye. Focal Arision not defective. 
After this attack he had no very severe headache, but AA'as never free 
from more or less pain, Avhich he localized as being above and back of 
his eyes. Indeed, all the pain that he has ever had has been entirely 
frontal, but not more on one side than the other. His mental condition 
Avas changed, and he Avas dull, often spending most of the day on the 
bed, and he Avas someAvhat self-AA’illed. It Avas noticed that at times he 
staggered and seemed to have difficulty in AATalking. 
About February 25th his sister noticed that in speaking he used the 
left side of his face more than the right, and it had been noticed for a 
day or two that the left eye Avas slightly more prominent than the right 
and Avas someAvhat bloodshot. In March he left the city for a AA7eek and 
Avas very uncomfortable ; he vomited every morning when his coffee ay as 
brought to him, and had difficulty in standing or walking. For a month 
before I saAV him he had complained of momentary loss of ATision, and 
he gave an indistinct history of having seen double. 
The examination made on March 27th shoAved the patient to be a tall, 
Avell-developed young man. His intelligence seemed fairly good, although 
he Avas unable to remember certain facts in the history of his disease, THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
3 
and often contradicted his mother and aunt, who were with him. His 
voice was normal, although a little loud, and there was no sign of aphasia. 
He was apparently able to distinguish odors. 
His left eyeball was somewhat more prominent than the right, and in 
the inner canthus there were some superficial bloodvessels, wdiich gave a 
dark appearance to this portion of the eye. The eyeballs were steady 
and freely movable in all directions. There was no ptosis. The pupils 
were moderately dilated, round, and equal; they reacted to light and 
during accommodation. The vision was practically normal in both eyes 
(20/30 in each), although he said he saw a little better with his left than 
with his right eye. The visual fields, tested quickly, showred no abnor- 
mality ; the colors were seen in the usual order. An ophthalmoscopic 
examination revealed the presence of well-marked neuritis in both eyes, 
more intense in the left eye. 
Sensation wTas unaffected over the face. Muscles of mastication acted 
well and equally on the two sides. 
When the patient’s face was at rest, the left naso-labial fold was more 
marked than the right, and in speaking the left side of the mouth was 
used more actively than the right. He elevated and contracted his eye- 
brows normally, closed his eyes well and forcibly. In elevating the 
upper lip the left side was drawn higher than the right, although when 
strong effort was made very little difference could be perceived. He 
puckered his lips well and was able to whistle. 
Hearing was acute in both ears. 
His sense of taste was unaffected. 
The movements of the soft palate, pharynx, larynx, and tongue were 
perfectly normal. The pulse was counted, and nothing abnormal was 
noted. 
There was no paralysis or incoordination in any of the muscles of 
the trunk or limbs, and sensation was unaffected. The deep reflexes 
Avere normal. The patient walked well, stood steadily \\rith feet together 
and eyes closed. 
Neither pressure nor percussion caused pain anywhere over the skull. 
The urine had been examined on several occasions, and nothing abnor- 
mal found. 
There could be hardly a doubt that the patient was suffering from a 
brain-tumor, AArhich fact I)r. Reuling had already told the boy’s family. 
As there was no history of tuberculosis or syphilis either in the family 
or in the patient himself, the patient stating that he had never been 
exposed to venereal contagion, it seemed more probable that the growth 
Avas either a sarcoma or a glioma; but, to give him the benefit of every 
doubt, he was put on increasing doses of iodide of potassium and Avas 
directed to be rubbed e\Tery night with mercurial ointment. 
The patient took the medicine very Avell, but there Avas no change in 
his symptoms. Dr. Osier saAV him on April 10th, and confirmed the 
diagnosis of brain-tumor. He dictated the folloAving note in regard to 
his heart and bloodvessels : “ Pulse is difficult to compress ; no definite 
sclerosis of the radial. Cardiac impulse is seen just beneath and Avithin 
the nipple, better felt just in the same situation. Heart-sounds are clear 
at apex ; first perhaps a little murmurish. Aortic second is decidedly 
accentuated.” 
Dr. Osier advised pushing the iodide and mercury. 
I made urinary analyses at four different times ; the first, Avhen the 4 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
patient had been taking the treatment about three weeks. At that time 
there was a considerable quantity of albumin. On the next occasion, 
about four days later, there was less albumin; the third time, only a 
trace; and at the fourth analysis, which was made for me at the Johns 
Hopkins Hospital, there was no albumin. Tube-casts were looked for 
at each examination, and were not found. There wTas never any sugar 
present. 
On April 17th, at which time the patient Avas taking 80 minims of 
iodide of potassium three times daily, he became sick at his stomach and 
vomited frequently. The sickness lasted most of that day and AAas 
unaccompanied by any severe pain in the head. 
This was on Friday ; he Avas better on Saturday, Sunday, and Monday ; 
on Tuesday he Avas very restless, alAvays moving about. He took a long 
Avalk on that day. On Wednesday morning he awoke AA'ith sick stomach 
and vomited a good deal. At this time he AAras in the country under 
the care of another physician. When I saw him on Sunday, the 26th, 
he had been in bed since Wednesday. The iodide and mercury had 
been stopped, but the sick stomach still continued. He AATas dull and 
often someAvhat delirious, haATing, on one occasion, endeavored to get out 
of the second-story window, in the middle of the night, under the idea 
that he wanted to go to the garden. He several times passed his urine 
in bed, apparently Avithout noticing it. The sick stomach AA’as almost 
constant, and he vomited nearly everything that he took. It AA’as noticed 
that Avhen he sat up in bed he would become dazed and seem to lose con- 
sciousness. At these times his pulse Avas said to be very AA'eak. Once 
or twice, Avhen endeavoring to drink from a cup, his right hand shook 
a good deal, and he AAfas unable to raise the cup to his mouth. This dis- 
ability lasted for a feAAT moments, and he A\Tas then able to move the right 
hand normally. Upon examination the only change in his symptoms 
that I noted Avere the increased mental dulness; a slight thickness in 
speech, wrong Avords having been used on one or tAATo occasions; decided 
loss of vision in his right eye, he being barely able to see at all with that 
eye ; and a peculiar uneasiness of the right hand. This AA’as constantly 
in motion, picking the bedclothes, drumming on the bed, etc. When 
asked to make any movement Avith that hand he performed it accurately 
and Avell. The muscular strength Avas unimpaired. He said that he 
suffered very little pain. His pulse Avas someAA’hat AA’eak and s1oaat, beat- 
ing betAveen 52 and 60 to the minute. Temperature was normal, and 
respiration 14. He Avas given strychnine and small doses of bromide. 
April 27th. Dr. Reuling reported : “ Vision in right eye reduced to 
quantitative perception of light. Left eye : fingers at tAventy feet by 
peripheric fixation. Ophthal. stat. idem.” 
The exophthalmos of the left eye, the mental dulness, the slight paral- 
ysis of the right side of the face, and the peculiar uneasiness of the 
right hand, taken together AA’ith the absence of other symptoms, led me 
to the belief that the tumor Avas in the left frontal lobe, and I told the 
boy’s parents of my belief and suggested an exploratory operation. 
Dr. Osier saw him again with me, and urged the operation. On May 4th 
Dr. M. Allen Starr, Dr. Reuling, and myself saw him together. Dr. Starr’s 
examination and opinion, AA’hich he kindly alloAA’s me to use, are as folloAvs : 
“ The general symptoms and course of the case make it eA’ident that 
Mr. de B. is suffering from a tumor of the brain. The existence of a 
right facial paralysis, a thickness of speech, of a protrusion of the left THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
5 
eyeball, Avith greater degree of optic neuritis in the left eye, and very 
marked change in mental characteristics and mental activity, the hebe- 
tude and indisposition to move about, with some decided instability in 
motion, point to the left frontal lobe as the seat of this tumor. The 
sIoavIv progressive character of the symptoms, with lack of great varia- 
bility in their character, and the absence of headache and tenderness on 
percussion, make it seem probable that the tumor is of a hard sarcomatous 
character rather than a vascular glioma, and make it open to operation. 
Such an operation is necessarily exploratory, and it seems likely that the 
best point for exploration will be over the second frontal convolution 
about its middle, the probable situation of the tumor being subcortical 
within the \AThite matter of the frontal lobe, pressing backAvard upon the 
motor tract and upward tOAvard the cortex of the posterior part of the 
second frontal convolution. 
“ It is the absence of epileptic attacks which leads specially to the 
idea of the tumor being subcortical. If exploratory operation is under- 
taken, I suggest that the method employed be that of a large bony flap, in 
order that the surface exposed may be as large as possible. If, after the 
opening of the dura, nothing is found at the spot indicated, and palpation 
at the bottom of the deepest fissure accessible fails to reveal any growth, 
I suggest that the base of the frontal lobe over the orbit be investigated, 
if possible, by lifting the entire lobe and exploring with the finger beneath. 
“ From the fact that destructive lesions of the forward tip of the 
frontal lobe appear to give rise to few symptoms, I think it would be 
justifiable to make an incision into the frontal lobe for the purpose of 
exploring the Avhite matter in case the tumor is not found at either of 
these tAvo positions.” 
After a good deal of discussion the boy’s family decided to have the 
operation clone. Dr. W. W. Keen Avas asked to perform it, which he 
did on May 10th. For a Aveek before the operation the patient’s con- 
dition remained about the same, except that vision in the right eye 
became entirely lost, and in the left eye began to fail, especially for near 
objects. In the distance he had approximately fifteen-thirtieths \rision. 
Both pupils were dilated, but reacted to light. There Avas no marked 
change in the condition of the optic nerves. His general condition im- 
proved somewhat; he vomited very seldom, and AAras able to take more 
nourishment. The pulse varied between 52 and 70, and the temperature 
Avas normal. The uneasiness of the right hand persisted and extended 
to the right foot; his nurse said that she had noticed it during sleep. 
The Operation by Dr. Keen. 
May 10,1896. I first saw the patient to-day, and found his condition as 
follows: A tall, muscular young man seventeen years of age ; vision was 
lost in the right eye, but he could read test-letters with the left. Both 
pupils were widely dilated, but reacted to light. The left eyeball was 
protuberant to a moderate extent, the upper lid having the appearance 
of being swollen. On the left forehead, an inch to the left of the median 
line and just at the border of the hair, was an irregular scar about an 
inch long, which was stated to have been caused by striking his head 
against a glass door with some force about ten years ago. No evil con- 
sequences followed at the time. It is doubtful whether this has any 
relation to the tumor, as the operation did not disclose any special injury 
to the bone either externally or internally, nor did the tumor found later 6 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
start apparently at the corresponding point in the brain. Possibly the 
blow with the baseball may have been the cause of the tumor. His right 
lower face was slightly changed in expression in repose by a moderate 
paresis ; when he smiled the paresis was very evident. I was not able to 
examine the skull by percussion, as he was already prepared for opera- 
tion. His mental condition was rather dull; but, at the same time, he 
appreciated who I was and that an operation was about to be done. His 
speech was not very thick. 
I was ably assisted surgically by Prof. L. McLane Tiffany and Drs. 
Martin, Lanier, and William J. Taylor. Drs. Thomas, Osier, and 
Reuling also were present, and advised us from time to time. 
Operation, May 10, 1896. An incision was begun 1.5 cm. below the 
temporal ridge. This was extended 6.5 cm. horizontally a little more than 
2.5 cm. above the upper border of the orbit to within 1.5 cm. of the median 
line. It was then continued posteriorly parallel with the median line for 
a distance of 12 cm., where it reached a point 2 cm. in front of the Ro- 
landic fissure. From this point it passed downward nearly parallel to the 
Rolandic fissure a distance of 12.5 cm., which brought the termination of 
the line again 1.5 cm. below the temporal ridge. (Figs. 1 and 6.) This large 
bony flap was chiselled loose and turned downward, breaking through the 
bone just below the temporal ridge. So great was the intracranial press- 
ure that when I had completed the chiselling of the bone, before fractur- 
ing its base, its internal edge was lifted above the level of the skull more 
than half a centimetre. The moment that the bone was reflected the 
dura bulged at least half a centimetre above the level of the opening. 
By touch it was excessively tense and elastic. Pulsation was evident. 
At no point over the dura was there any such special hardness as to 
indicate a tumor. Accordingly, in view of the early beginning-symp- 
toms in the left eye and the possibility, therefore, that the tumor might 
be on the orbital aspect of the frontal lobe, I decided to explore first the 
inferior surface of the frontal lobe. My incision in the bone above the 
orbit had been purposely placed at a point high enough not to invade the 
frontal sinus. I now gnawed my way cautiously downward toward the 
orbit by the rongeur-forceps, so as to enable me to explore the under 
surface of the frontal lobe. The frontal sinus was not opened ; but had 
a small opening been made in it, it was my intention to have puttied it 
up with Horsley’s wax, so as to prevent infection. I was soon able to 
lift the frontal lobe sufficiently to feel the crista galli, and also to see as 
well as feel the curved lesser wing of the sphenoid and the dura over 
the temporo-sphenoidal lobe beyond the lesser wing. Had there been 
any reason for it, I am sure I could have seen the anterior clinoid pro- 
cess without difficulty. Nothing abnormal was seen on the under sur- 
face of the frontal lobe, in or under the dura. I next passed my 
finger under the frontal lobe, but could feel no abnormal hardness or 
softness. Accordingly, I decided to open the dura on the superior 
aspect of the brain. I made my incision parallel with the borders of 
the bony opening. As soon as the dura was opened the brain bulged far 
above its level; inspection showed a dark area at a point just above and 
in front of the junction of the second frontal sulcus with the precentral. 
This dark-colored area was evidently the tumor protruding through 
the raptured cortex. (Fig. 1 ©.) As the tumor evidently extended pos- 
teriorly and interiorly beyond the limits of my bony opening, I now 
gnawed away some bone downward into the temporal fossa and back- THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
7 
ward till my opening reached the line of the Rolandic fissure, or possibly 
a little back of it. Extending the incision in the dura, I was now able 
to see normal brain-tissues posteriorly and interiorly, showing that the 
visible limits of the tumor had been reached. Four large vessels which 
ran toward the tumor were now tied in the peripheral normal brain- 
tissue. During these manipulations the rent in the cortex at the point 
already specified had extended anteriorly, and showed that the tumor was 
much larger in the subcortical tissue than on the surface. I, therefore, 
attempted to enucleate it, and was quite surprised to find the ease with 
which by three fingers I finally scooped it out of its bed, much as one 
would scoop an egg out of its shell with a spoon. No serious hemor- 
rhage followed the removal of the tumor. In order to check what hem- 
orrhage did occur I packed the cavity for a few minutes with iodoform- 
Diagram to show approximately the relations of the tumor, which is represented by the 
shaded area. The interrupted line represents the osteoplastic flap. I, II, and III are the three 
frontal convolutions. © represents the place where the tumor had broken through the cortex- 
R. Fissure of Rolando. V. Vertical or precentral sulcus. IP. Intraparietal sulcus. S. Fissure 
of Sylvius. T. Temporal ridge. 
gauze. Meanwhile, while waiting for the hemorrhage to be arrested, 
Drs. Thomas, Osier, and Reuling examined the tumor carefully, and in 
their opinion it was a well-delimited sarcoma of rather hard texture, and 
they believed that the entire tumor had been removed. I next removed 
the gauze-packing, and, to make sure that all the tumor was removed, 
I inspected very carefully the walls of the cavity in which it had lain. 
These, apparently, were entirely normal; no appearance of sarcoma- 
tous tissue existed at any point. At the bottom of the cavity lay a clot 
as large as the end of my thumb. This, I thought, should be removed, 
lest it should undergo decomposition after closing the wound, and, accord- 
ingly, with a curette and finger, I lifted it out. During the removal of 
the tumor, I should have stated that when my fingers reached its base 8 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
there was a considerable gush of fluid mingled with the blood, which 
I suggested came from the lateral ventricle. When I removed the clot, 
therefore, I was not altogether surprised at the fact that I looked directly 
into the lateral ventricle, which was widely open anteriorly at about the 
point where the anterior cornu joins the main cavity of the ventricle. I 
saw clearly an opening which I took to be the mouth of the middle or 
that of the posterior horn, though it may have been the general cavity 
of the ventricle. I packed a small strip of iodoform-gauze into the cavity 
occupied by the tumor, the end of the gauze filling the anterior portion 
of the lateral ventricle to prevent blood passing into that cavity. (See 
Remarks.) As there was now but little hemorrhage, I closed the wound, 
suturing the dura excepting where the gauze-drain came out, and then 
secured the flap in place by silkworm-sutures. 
When the operation was over, although it had lasted for two and a 
half hours, the condition of the patient was quite as good as when he 
was placed upon the operating-table. His pupils had contracted to 
their normal size and were responsive to light. He unconsciously moved 
both arms and both legs before he left the table, showing that there was 
no paralysis. So far as his face was concerned we were not able to tell, 
as up to the time I left him no conscious movement of the face had 
been made. This was especially gratifying to me, because the tumor 
had evidently displaced the pre-Rolandic convolution backward and the 
third frontal downward. I was not able to judge well of his speech, 
for he only muttered a half-intelligible reply to a question I asked him 
before I left. His pulse was good and respiration tranquil. A culture 
was made from the surface of the brain and sent to Dr. Kyle, with a 
negative result. 
12th. I saw him again this afternoon with Drs. Thomas and Martin. 
He passed quite a comfortable day yesterday, and had not had a particle 
of pain, so that no opium had been given him in any form. His tongue 
was a little dry and coated, and for this Dr. Tiffany had ordered one- 
tenth of a grain of calomel every hour until the bowels were moved ; an 
enema in the early evening gave a satisfactory movement. His temper- 
ature yesterday (the day after the operation) in the evening rose to 102.4°; 
this afternoon to 101.4°. He feels hungry, but has only been allowed 
from three to five ounces of milk every two hours. His pulse, which 
had been 150 after the operation, fell to 120 yesterday, and to 104 to-day. 
His skin is in good condition. The wound had been dressed on the even- 
ing of the day of operation, when the dressing was quite saturated, and 
again yesterday, when the discharge was much less. I dressed it myself 
when I saw him this evening, and found the dressings but slightly satu- 
rated. Both the gauze-drain, the inner end of which lay in the front 
part of the lateral ventricle, and a silkworm-gut drain in the forehead 
were removed. A very small amount of blood-stained serum escaped 
from both apertures. Small bits of gauze were introduced a slight dis- 
tance into the two openings merely to keep the skin from uniting. The 
wound in every respect looked normal. Instead of the depression of the 
flap which existed immediately after the operation, there was distinct 
rounding of the head, and pressure on the flap disclosed a moderate 
amount of resistance underneath. He had had some bromide for sleep 
last night, and fifteen grains of trional were ordered for to-night. Saving 
this moderate rise of temperature, his condition leaves nothing to be 
desired. THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
9 
14th. His temperature in the morning has been usually a little above 
99°, and to-night is 100.5°. He is hungry, has eaten an egg this morning, 
has had the bowels opened by an enema. His intelligence is quite 
marked, though he is not very talkative. He appreciates his surround- 
ings and the gravity of the operation, and is anxious to see his parents. 
The pupils are again dilated, but mobile to light. His right lower 
face is slightly paretic, the arm and leg not at all so. There is no 
aphasia. The wound looks perfectly well. Slight bulging of the flap 
still continues. The drains are out and the wound entirely united by 
first intention, excepting at the two points where the drains were. 
24th. He is out of bed to-day, the fourteenth day after operation, and 
able to walk about; his appetite is excellent, and he is on full diet. His 
temperature slowly but steadily decreased, reaching the normal at the 
end of a week. 
Fig. 2. 
The external appearance of the tumor. Natural size. (Drawn hy Dr. J. M. Taylor.) 
Fig. 3. 
Antero-posterior section of the tumor. Natural size. (Drawn hy Dr. J. M. Taylor.) 
The tumor was oval-shaped, 7.5 cm. long, 5.5 cm. broad, and 4 cm. 
deep (31 inches by inches by 1T inches), and weighed 21 ounces. 10 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
The surface of the tumor was somewhat lobulated and its color darkish- 
gray. On section it showed a point of yellowish discoloration toward 
the posterior portion about its middle, from which distinct rays of tissue 
proceeded as from a focus in all directions. 
Fig. 4. 
Diagram to show the depth and relation of thfe tumor to the convolutions and the ventricle. 
The shaded portion represents the tumor. (The section is from Dalton's Topographical Anatomy 
of the Brain.) 
Fig. 4 shows the relative position and depth of the tumor in a cross- 
section of the brain, and that it involved all three of the frontal convo- 
lutions and the ventricle. The corpus striatum may have escaped 
entirely; but, if it was involved, it was presumably displaced rather 
than destroyed. 
After-history and Remarks by Dr. Thomas. 
After the removal of the tumor, and the patient had recovered from 
ether, his mental condition was much improved. It was noticed imme- 
diately after the operation that his pupils, which were widely dilated 
before, were of normal size. At the first dressing it was noted that the 
pupils were again widely dilated, and they have remained so ever since. 
Since then there has been very little to note, as he had an uninter- 
rupted convalescence. His vision has become progressively worse. Dr. 
Reuling’s notes are: 
“May 28th (eighteen days after removal of tumor). Right: vision 
almost nil, slight perception in extreme outer corner. Ophth.: papilla THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
11 
optica flat, grayish, discolored, showing proliferation of connective tissue 
and atrophic nerve-fibres in radiating arrangement. Arteries very thin. 
Left: neuritis optica degenerativa, some swelling and redness. Pupils 
of both eyes dilated almost ad maximum. No central fixation, no accom- 
modation, and almost no reaction to light. Eserin brings on contraction 
and greatly increases reaction to light. Left: fingers at eighteen feet. 
Right: nil. As the patient’s eyes were going from bad to Avorse, at 
Dr. Reuling’s suggestion, Dr. de Schweinitz, of Philadelphia, Avas asked 
to see him. This he did on June 3d, and the result of his examination 
is abstracted from his letter as folloAvs: 
“ I regret to say that he is entirely blind in the right eye ; in the left 
eye his vision is eccentric, and amounts to reading very large letters 
at about 1 metre—actually, 1/60. The field of vision is markedly con- 
tracted, only a small patch being preserved on the temporal side. Both 
optic disks show subsiding neuritis, the swelling being 3 D. The 
vessels are shrinking, particularly the arteries, and there are here and 
there throughout the retinas splotches of fatty degeneration. The pupils 
in ordinary light are dilated ad maximum. They do not respond to 
the strongest artificial light-stimulus, but when exposed to bright sun- 
light, or the white light reflected from a cloud, they slowly contract to 
nearly their normal size, and in this same light still maintain, unstably, 
this contraction. This curious phenomenon, for which there is no ade- 
quate explanation, has been observed in cases of optic-nerve degenera- 
tion a number of times. There is no color-perception for even very large 
colored objects, red being called gray, green black ; there is no attempt 
to name the other colors. The prognosis is exceedingly bad. The exu- 
dation into the nerve has evidently been very extensive, and atrophy of 
he fibres is now rapidly taking place. 
“Very unusual features in this case, so far as my experience goes, are 
the rapidity with which the optic neuritis developed and the resulting 
early blindness. Clinically, it is well known that cerebellar growths are 
associated with papillitis, which quickly develops into that type which 
was at one time known as “ choked disk,” and in which blindness quickly 
takes place even before the stage of the subsidence of the inflammatory 
process. These same phenomena in growths situated in the frontal 
region, as in the present case, must be rare.” 
The diagnosis in this case, as has already been said, was based, first, 
on the general symptoms of brain-tumor combined with mental dulness, 
the protrusion of the left eyeball, the slight right-sided facial paralysis, 
and the peculiar uneasiness in the right hand and foot. The remark- 
able disturbances of locomotion which are often associated with tumors 
of the frontal lobe were present in only a very slight degree. The 
patient did at times complain of difficulty in walking, but this was 
not seen during any of the examinations, except, perhaps, when he was 
gotten out of bed during Dr. Starr’s examination ; he was then very 
weak, and walked in a tottering, unsteady fashion. This symptom— 
frontal ataxia—to which Bruns1 has called particular attention, is of very 
1 Bruns; Deutsche med. Wochenschr., 1892; and Real-Encyclopadie (Eulenberg), 1895, Bd. 
viii. p. 663. 12 
THOMAS, keen: removal of a brain-tumor. 
great interest, and at times complicates the diagnosis between tumors of 
the frontal lobe and those of the cerebellum. The mental disturbances 
consisted in a general dulling of his faculties and the occurrence of mild 
delirium on one or two occasions. He was never guilty of making 
puns, nor did he indulge in witticism (Bruns: Oppenheim, Arch. f. Psycli., 
xxi. and xxii.), and, so far as was evident, he had a proper appreciation 
of his personality. 
The unilateral exophthalmos which assisted in the diagnosis is not 
easy to explain, as it is generally believed that the intracranial pressure 
is the same throughout the skull-cavity; it may possibly have been due 
to some local disturbance of the circulation. The condition has persisted 
since the operation, but is less marked. 
October 1, 1896. Patient was seen to-day. He states that he has 
passed the summer without any symptoms referable to his head. He 
has been perfectly free from headache, and seems in excellent health 
and spirits. The scar is hardly noticeable on his forehead. There is no 
longer any exophthalmos of the left eye, and the muscles of the face act 
equally on the two sides. He thinks that the vision of the left eye has 
improved somewhat, but he is still unable to see sufficiently well to walk 
alone. 
It is interesting that after such an extensive destruction of the left 
frontal lobe that there should be so few symptoms; indeed, except for 
the slight remains of the paralysis on the right side of the face and the 
symptoms referable to his blindness, the boy seemed perfectly normal. 
The functions of the frontal lobes have always been a fruitful field for 
speculation, but they have become especially interesting at this time 
through the recent experimental work of Bianchi, of Naples, and par- 
ticularly so through the brilliant investigation and deductions of Flechsig. 
Bianchi (Winter, Brain, 1895, p. 497), experimenting on dogs and 
monkeys, believes that he lias arrived at definite conclusions. He 
determined the limits of the excitable areas by electrical stimulation, 
and extirpated all of the lobes in front. When one frontal lobe was 
removed, he very generally noticed some motor symptoms during the 
first week or two, but after this time the animals seemed to be perfectly 
normal. The motor symptoms consisted in rotary movements (the truncal 
concavity being toward the mutilated side) and a paresis of the opposite 
arm for delicate movements. In all the animals he was able to demon- 
strate visual disturbances, consisting in an inability to recognize objects 
in the temporal half of the visual field of the opposite eye. Thus, if 
the eye on the mutilated side was closed, the animal would walk and 
run about without ever coming in contact with objects placed in his way ; 
but if his attention was fixed, and some food of which he was very fond 
was brought into the field of vision from the temporal side, it was not 
noticed until it was in a line with the visual axis, when it was quickly 13 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
seized and eaten. When the eye on the operated side was tested, the 
animal grasped the object as soon as it came within his visual field. The 
visual disturbances lasted for two and sometimes three weeks. 
Bianchi found, when he extirpated but one frontal lobe, that there was 
no discoverable change in the animal’s behavior, or psychical manifesta- 
tions, but that when both lobes were removed the animals were very 
markedly changed. They became inert, dirty, forgot their playmates 
and friends, and were indifferent as to what they ate, etc. 
Bianchi believes that the whole nervous system takes part in the for- 
mation of the psychical personality, and that there is no such thing as a 
centre for intelligence. Still, he insists that these phenomena which he 
has observed after the destruction of the frontal lobe must be accounted 
for. His hypothesis is “ that the frontal lobes are the seat of coordina- 
tion and fusion of the incoming and outgoing products of the several 
sensory and motor areas of the cortex. . . . The frontal lobes would 
thus sum up into series the products of the sensori-motor regions, as well 
as the motive states which accompany all the perceptions, the fusion of 
which constitutes what has been called the psychical tone of the indi- 
vidual.” 
He attempts no explanation of the curious visual disturbances. 
Flechsig, in his recent address, “ Gehirn und Seele,” and particularly 
in the notes which he has just now published with the second edition, 
gives the result of many years of work upon the appearance of medul- 
lated fibres in the developing brain. The tracts which connect the 
cortex with gray masses below, the so-called projection-fibres, develop 
early, and first of all those which serve for the conduction of sensory 
impulses. By the study of many brains in different stages of develop- 
ment he has been enabled to mark out accurately the different sensitive 
areas, among which, it may be remarked, that he includes what we com- 
monly call the motor region. Between these sensitive areas are regions 
in which no projection-fibres either enter or leave the cortex, but in 
which he has been able to trace fibre-tracts from the different sensitive 
areas ; these regions he has designated association-centres, and he thinks 
that it is upon their development that the intellectual power of the indi- 
vidual depends. He prophesies that, by careful study of the intellectual 
activity of normal and diseased individuals and a thorough anatomical 
investigation of their association-centres, we will be able to arrive 
at a scientific basis for the localization of these mental characteristics. 
He thinks that he has already been able, in cases of general paresis, to 
explain the peculiar symptoms by the areas which are involved in the 
morbid process. Flechsig’s association-centres are what have been called 
the silent areas of the brain; but we are forced to believe that they 
are silent, not because they do not speak, but because we are too dull 
of understanding to hear what they say. The frontal lobe corresponds 14 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
to Flechsig’s anterior association-centre. In this region, although no 
projection-fibres reach the cortex, a band of such fibres does run in 
the white matter of the lobe, and, turning back, enters the cortex of the 
somatic sense-area (korperfuhlsphare), which includes what we commonly 
know as the motor area of the cortex. It may be that it is the involve- 
ment of this tract which is the cause of the motor symptoms, the 
and the ataxia. Flechsig has demonstrated that the cortex of the lobe 
itself is in connection with the olfactory centre and with the somatic 
sense-area, and probably with the other sense-centres, and he believes that 
we have stored here the memories upon which the idea of individuality 
of the person depends. It will be seen that the views of Bianchi and 
Flechsig in regard to the function of the frontal lobe agree fairly well. 
Kemarks by Dr. Keen. 
Size and Weight of the Tumor. The present tumor is the second 
largest I have ever removed. The largest and my very first modern 
brain-operation was done on December 15, 1887 ; therefore, nearly nine 
years ago (The American Journal of the Medical Sciences, Octo- 
ber, 1888). That patient I saw recently. His appearance two years ago is 
seen in Fig. 5. His eyesight is quite imperfect. His epileptic attacks 
occur at intervals of about a year. He is still, however, very nervous 
and unable to do any work. 
Fig. 5. 
Result seven years after the removal ol a large fibroma of the brain. 
Iii that case the tumor, a fibroma, measured two and seven-eighths by 
two and one-half inches and one and three-quarters inches in thickness, 
and weighed 3 ounces and 49 grains. The present tumor, therefore, is THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
15 
nearly as large, but is much less in weight, because of its different char- 
acter. Pasting on the skull a piece of paper which shows the size of 
the present tumor, it is seen to occupy the second frontal, encroach on 
the first, and practically to occupy nearly all of the third frontal con- 
volution and very largely the area of the pre-Rolandic convolution. In 
fact, I judge (though the surgical exigencies of the moment did not allow 
me to determine it absolutely) that the tumor extended all the way back 
to the fissure of Rolando. It is another illustration of even how direct 
as well as distant pressure is compatible with but very slight symptoms. 
That there was no more marked aphasia is surprising. 
It is also extremely gratifying to observe that the mechanical injury 
done to the rest of the brain in removing the tumor and the later neces- 
sary pressure from swelling and accumulation of wound-fluids, a swelling 
so marked as to lift the flap very distinctly above the level of the scalp 
and to make it quite tense to the touch, were not followed by either any 
increase in the aphasia or in the motor paralysis of the face, and did not 
produce any paralysis in the right arm or leg. 
At least seven tumors larger than the present one and one equally 
large have been removed from the brain. 
First, the largest tumor of all by Bramann, nine ounces, followed by 
recovery. (.Annals of Surgery, 1892, vol. vi. 378.) 
Second, Bramann, five and a half ounces; recovered. (.Annals of 
Surgery, 1892, vol. xvi. 378.) 
Third, Durante, the size of an apple; recovery. (.Lancet, October 1, 
1887.) 
Fourth, Weir, five and a half ounces; died. (Medical News, April 
16, 1887.) 
Fifth, Horsley, four ounces ; result not stated. (The American 
Journal of the Medical Sciences, April, 1887, 362.) 
Sixth, Czerny, nearly seven ounces; died. (Beitr. klin. Chir., 1894, 
xii. 107.) 
Seventh, Keen, three ounces and forty-nine grains ; recovery (foe. cit.). 
Eighth, Starr and McBurney also reported the removal of a tumor 
which was a little longer, but not quite so wide as the present one, 
measuring three and a half by two inches ; died in eight hours. (New 
York Medical Record, January 21, 1893, 87.) 
Ninth, the present case. 
It will be seen that of these nine large tumors weighing from two and 
a half to nine ounces, four recovered and four died, while in one the 
result is not stated. It would seem almost as if large removable tumors 
were scarcely more dangerous than small ones. 
Mode of Access. The osteoplastic flap which I raised (was the most 
extensive resection of the skull I have ever done. I have not quite 
reached the point in audacity of Doyen, of Reims (Rev. de Chirurgie, 16 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
1895, p. 900), who advocates and has practised the removal of one entire 
hemisphere of the skull. He even declares that cerebral localization in 
future is only of physiological interest and is not necessary to the sur- 
geon. I was, however, very much pleased with the extensive view of 
the brain which I got, a view which in this case was needful to the proper 
treatment. It was desirable that the orbital surface of the frontal lobe 
should be examined. This is the first case in which I ever had occasion 
to examine it, and I was very much struck with the ease of access and 
the extensive view that I had. Should it have been necessary to open 
the dura before lifting the frontal lobe, I think there would have been 
no difficulty in seeing the pituitary body and the vessels. At the best, 
manipulations here would have been, however, of course, much more 
dangerous than on the free surface, by reason of the relative inaccessi- 
bility. If in future I should have a case in which an extensive frontal 
operation is necessary, I should make, if needful, an osteoplastic resection 
of the whole forehead, either in one piece or bilaterally in two. There 
would be no difficulty, of course, in separating the superior longitudinal 
sinus from the skull after the first flap had been resected and drawn back. 
Removal of the Tumor. Fortunately, the tumor was not an infil- 
trating sarcoma, but well delimited. As in my case of the large fibroma 
above alluded to, I was able to scoop it out with perfect ease, because of 
its lying loose in its bed. The hemorrhage after the enucleation was 
very much lessened by the prior ligation of the vessels connecting the 
tumor with the cortex at the point where it had broken through the 
cortical layer. 
Prognosis. The apparently non-infiltrating character of the tumor, 
which was confirmed by Dr. Flexner’s examination, would also lead us 
to take a much more hopeful view of the future of the patient, as to 
non-recurrence of the growth. As it may take, however, some years 
to determine these facts, it seemed desirable to report the case at once 
and then supplement it at a later period. It is encouraging to re- 
member that in Durante’s well-known case a fibro-cellular sarcoma- 
tous tumor the size of an apple was removed from the left anterior lobe, 
and in spite of its character the patient was in good health four years 
later. 
Opening and Packing of the Lateral Ventricle. This is the 
first case in which I ever have actually looked into the lateral ventricle 
in the living, and, so far as I know, is the first in which the ventricle has 
ever been packed. The entire cavity was disclosed, so that I could see 
certainly into the cavity and possibly into the opening of the middle or 
posterior horn. In view of the free opening and, of course, of the grad- 
ual oozing of blood which would take place after the flap was replaced, 
I was fearful lest the blood might flow from the lateral into the third 
ventricle and then through the Sylvian aqueduct reach the fourth ven- THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
17 
tricle, where any pressure would be excessively dangerous and possibly 
fatal. This accident, I discovered later, actually occurred to Horsley, and 
the patient died from pressure on the respiratory centre from the blood 
which reached the fourth ventricle from the lateral (.British Medical 
Journal, 1893, ii. 1367). For a moment I hesitated, I confess, to place 
any packing in the ventricle ; but I thought that this would be less dan- 
gerous than allowing the blood to accumulate in that cavity, and so 
I packed rather lightly a strip of gauze a little over an inch wide and 
several inches long into the anterior part of the ventricle and the 
adjacent part of the bed in which the tumor had lain, thus shutting off 
the ventricle, and brought the other end of the gauze through the 
incision in the scalp. It drained very well, and after forty-eight hours 
was removed. The amount of cerebral spinal fluid to which it gave 
exit was not very large. The dressing had to be changed the same even- 
ing, and again on the next day. It was but slightly saturated on the 
third day, and by the fourth, two days after the drainage was removed, 
was scarcely soiled at all. 
Fig. 6. 
From a photograph four months after the operation. The figures are in centimetres. 
The facts proved by this case as to the bolder surgery of the lateral 
ventricle which may be indulged in with impunity, are very encourag- 
ing for the future. 
That the patient made so admirable a recovery is largely due to the 
extremely kind and careful attention of Dr. Tiffany and his assistant, 
Dr. Martin, as well as, I may add with propriety, to the discreet judg- 
ment of my colleague, Dr. Thomas. 
Fig. 6 shows the present appearance of the scar (Sept. 1, 1896), four 
months after the operation. 18 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
Microscopical Examination op the Tumor by Dr. Flexner. 
“ The specimen is in tAvo parts Avhich can be more or less closely 
approximated. Besides the sides, which had been united and present 
uneven surfaces, the external surface generally has a lobulated appear- 
ance. This does not, however, resemble to any great degree the con- 
volutions of the cerebral cortex. Adhering to a portion of the mass 
are shreds which are taken to be portions of the cerebral membranes. 
“ Muller’s fluid has been employed as the hardening-agent, and the 
specimen is well hardened and preserved. For the purpose of the his- 
tological examination portions were removed from several situations, 
including a portion of the tumor to which the membranes adhered. A 
separate piece of membrane AAras also studied. 
*£ On making the incisions for the purpose of removing pieces for micro- 
scopical examination it was noticed that not infrequently small, Avhitish 
or grayish-white, opaque foci occurred at variable distances, but usually 
not more than 5 to 6 mm. below the surface. As it was desired to pre- 
serve the specimen the incisions were not carried entirely through the 
tumor. The impression obtained, however, Avas that these patches be- 
came more numerous in the deeper parts. They Avere irregular in shape 
and averaged about 2 mm. in Avidth and several in length. 
“ The tissue Avas imbedded in celloidin, sectioned, and stained in 
Upson’s carmine and Mallory’s phospho-molybdic and hsematoxylin 
stains. The stained sections A\Tere examined in Canada-balsam and 
glycerin. 
“ The tumor is composed of cells, intercellular substance for the most 
part fibrillated, strands of fine fibrils and bands of coarser ones. The 
latter consist of homogeneous connective-tissue bundles carrying many 
bloodvessels. 
“ The greater part of the tumor is made up of cells, which, hoAvever, 
are not scattered uniformly over the field, but are collected into more or 
less definite groups, some round, others oval, and still others elongated 
in form. The cell-groups are separated chiefly by the strands of fine 
fibrils described. As regards the cells tliemseUes, they vary somewhat 
in form, the majority being round or oval, about the size or a little larger 
than the normal glia-cells ; but a few are distinctly elongated, and rarely 
a cell tAvo or three times the average one is met AATith. The larger cells 
are found at times to form small cell-groups or to lie two or three in one 
place. 
“ Noav and again an area of the section of the extent of a dozen or 
more cell-groups Avill refuse to stain, appear pale and granular, or per- 
haps a stained cell here and there Avill stand out in sharp contrast to the 
remainder. These places correspond with the opaque and degenerated 
spots already mentioned. They are composed of cells, fragments of cells, 
granules, and fibrils. The cells which do not stain are indistinct in out- 
line and irregular in size. The few staining-nuclei belong to leucocytes. 
Not infrequently red blood-corpuscles, outside of vessels, are present 
intermingled with the other elements. The intercellular material is 
also more or less indefinite, chiefly irregularly granular, but at times 
showing a feAAr fibrils. 
‘ \ The non-degenerated portions of the tumor are much more uniform 
in appearance and structure. They consist of groups of cells, as de- 
scribed, separated by bands of fibrils. The cells, it is true, are not THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
19 
sharply cut off from the fibres, for now and again the same cell-forms 
are found lying among the fibrils in the peripheries of the groups. The 
individual cells in the groups are separated from each other by single or 
small clusters of fine fibrils which often appear to be continuous with the 
thicker strands separating the large groups. In these portions very little 
only of the intercellular substance is of a granular nature. 
“ Not infrequently these fibres present an appearance suggesting a 
union with or origin from the cells. The elongated cells are seen to send 
off streaming fibrils from each extremity, and the round or oval ones 
appear as if surrounded by hair-like processes, or to give off a bunch 
from one or two sides. Moreover, a part at least of these fibrils appear 
to pass into the strands separating the cell-groups from one another. 
“ Cells having the size and form of ganglion-cells were not encoun- 
tered. 
“ The tumor is moderately vascular, and bloodvessels are met with 
within the substance of the tumor, running amid the fine fibrils or sur- 
rounded by round and oval cells. These vessels are distinguished by 
their very thin walls and from an outer investment of fibrils such as are 
present between the cells. The bloodvessels in the coarser bands have 
thick and well-formed walls. Punctiform hemorrhages occur in the 
tumor, but chiefly in the degenerated areas. 
“ At one point of the section the meninges are still attached to the 
surface of the tumor, and the cells from the latter can be traced directly 
into the membranes in this situation. The separated piece of dura 
mater shows adherent cerebral cortex. It is free from infiltrations with 
tumor-elements. 
“ A small amount of coarsely fibrillated fibrin also occurs in the 
degenerated portions. 
“ From this description it is considered that the tumor is a glio- 
sarcoma. 
“ It may be worth while to speak on one or two points regarding the 
foregoing description in the light of the more recent studies of neurog- 
lia, especially in view of the fact that a considerable part of the tumor 
is composed of the so-called glia or Dieters cell. The opinion ventured by 
Boll (1874), that the fibres of neuroglia pass by and actually do not 
•emanate from the cells, received later (1883,1892) the support of Ranvier, 
whose well-known studies led him to regard the fibres and cells of the 
neuroglia as independent structures. This view, which was opposed to 
many of the older conceptions, was not borne out by the application of 
the method of Golgi to the study of the question. On the other hand, 
the elaborate study of Weigert, (Beitrage zur Kenntniss der normalen 
menschlichen Neuroglia, Frankfort-on-the-Main, 1895), just published, 
has led to confirmation of the view advanced by Ranvier. Through 
the use of a new method of staining devised by him Weigert has suc- 
ceeded in demonstrating the fibres in neuroglia independently of the 
•cells over and next to which they may be observed to pass. He believed 
that he could exclude definite connection between these processes or 
fibrils and the cell-protoplasm. Mallory independently and at almost 
the same time (Centralblattfur Pathologie, 1895, Bd. vi. p. 753) arrived 
at a similar conclusion, having used a method in some respects similar 
to Weigert’s. Mallory further found that the glia in sclerotic conditions 
•of the cord and brain of human beings was of essentially the same coiisti- 
tution. Recently I have received from Dr. Mallory a specimen of glioma 20 
THOMAS, KEEN: REMOVAL OF A BRAIN-TUMOR. 
in which the independence of the fibres and the cells of the tumor is well 
shown. 
“ Unfortunately the method employed for hardening the tumor in this 
case did not suffice for the use of the staining-methods suggested, espe- 
cially for the demonstration of the glia. The phospho-molybdate stain, 
while staining glia-elements, stains other structures as well. In view of 
these facts it is clear that in the description of the tumor only such 
appearances as could be obtained by the methods at command are given ; 
and with respect to the ultimate question of actual union between the 
cell-protoplasm and fibrils no statement is ventured.”  Jotirijal 
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