WILMER: Melanotic Giant-Celled Sarcoma of Lid.
9I
DR. SWAN M. BURNETT of Washington. - In looking over the statistics prepared by Braunschweig, so far as it can be relied upon,. I find that there are very few cases indeed in which there seems to be any tendency to malignancy. Of course, one could hardly say that all tumors of the optic nerve are benign, but the cases which are reported as typical cases of myxosarcoma and sarcoma, and which take their origin in the intravaginal space, from what I have been able to study of them, were not malignant. I think it is a question which it will be profitable to study, since we have a good deal to learn with regard to the pathology of these tumors around the optic nerve. It seems to me .they are embryonic in their character, and that they are not essentially malignant. The cases which have been reported as malignant probably did not originate in the intravaginal space, but in some other part of the orbit.
A CASE OF MELANOTIC, GIANT-CELLED, ALVEOLAR, MYXO-SARCOMA OF THE EYELID. By W. H. WILMER, M.D., WASHINGTON, D. C.
While the literature of ophthalmology is so rich in other respects, the reports of cases of primary sarcoma of the eyelids are comparatively limited in number. A case of this nature is therefore presented without further apology, as it seems to me to possess features that are not common. On April I5, I893, a woman about thirty years of age consulted me concerning a small tumor of the right lower eyelid. This tumor was first noticed about six or eight months previous. Its growth had been gradual but steady. The patient was confident that the lid had never been injured in any way. In fact, she had never had any trouble whatever with her eyes except a slight attack of conjunctivitis in I887. The tumor was situated a little to the outer side of the median line of the lid, with its long axis parallel to the margin. It was hard and unyielding to the touch. Although the tumor projected toward the skin, the latter was freely movable, and
92
WILMER: Melanzotic Giant-Ce//ed Sarcoma of Lid.
normal in all respects; there was not even the slightest discoloration. The conjunctiva, likewise, was normal in appearance. There was every indication of its being a primary growth, for there was no evidence of disease in any other organ. On April 24, I893, the growth was removed through an incision in the skin, parallel to the margin of the lid. The tumor was easily dissected out, owing to its extremely tough fibrous capsule. At its center, the tumor was loosely attached to the conjunctiva by a few adhesions. Apparently, the bulk of the tumor was in front of the tarsal cartilage, but, at the site of the adhesions, it seemed to have perforated the tarsus. The location of the tumor and its microscopical elements warrant our supposing that the growth originated in the tarsal cartilage. The bleeding was not more profuse than usual. The wound was sutured with fine silk. On the fourth day after the operation, the sutures were removed and the union was firm. In a letter received a few weeks ago, the patient writes that there has been no symptom of a return of the growth. At my advice, she had consulted an oculist in her city, who found only a mild granular conjunctivitis in either eye. The tumor, after being thoroughly hardened in .Muller's fluid, measured I2 mm. in length, 7 mm. in breadth, and 41 mm. in thickness. Sections of the tumor were examined by Dr. C. L. Minor of this city, and by Dr. W. M. Gray of the Army Medical Museum. Dr. Gray has kindly prepared the following report of the microscopical examination of the tumor: The tumor is composed of a framework of wavy bands of dense fibrous connective tissue, which run in all directions; these bands are composed of long and short elements, and form an alveolated structure through the growth. The pigmentation occurs in small patches irregularly distributed, and is composed of small masses of dense black pigment; the majority of the pigment masses are round or irregular in shape, with a few branching pigment cells. The giant cells are confined to one side of the growth, and are comparatively few in number; they are imbedded in islands of myxomatous tissue surrounded by alveoli of the dense fibrous connective tissue. Throughout the growth are numerous isolated patches of myxomatous tissue;
WILMER: Me/anotic Giant-Celled Sarcoma of Lid.
93
these patches are surrounded by the fibrous connective tissue stroma, and form a typical alveolar structure' somewhat resembling cancer formation. The myxomatous tissue is composed of large round cells- epithelioid in character -medium-sized, and small round cells, and a few spindle and stellate cells. These cells are held in a fine meshwork composed of delicate connective tissue threads. The growth has a rich vascular supply; some of the vessels have fully formed walls, but the majority are without walls, typical of sarcoma. In looking over the literature of the subject, I have found the histories of thirty-five cases of primary sarcoma of the eyelid. I had the opportunity to examine fully only twenty-five of these cases. In this number, I found the age of the patients varying from ten months to seventy-six years; the duration of the tumor, before operation, from several weeks to thirteen years; the size ranging from that of a pea to a large apple. In I2 per cent., all four lids were involved. In i6 per cent., it was necessary to remove the eye with the tumor. In i6 per cent., all children, death is mentioned as having resulted from the disease. In 40 per cent., the return of the growth is mentioned; but in many other cases, the patients were last seen a short while after the operation. And some of the tumors were themselves recurrent, while others returned several times. I was able to examine the microscopical reports of all thirtyfive cases; and I found that 40 per cent. of these sarcomata were spindle-celled, 43 per cent. round-celled, I7 per cent. mixed, iI per cent. presented myxomatous elements. In one case, which I have classed among the mixed sarcomata, the author mentions the existence of large cells " not unlike the giantcell." The presence of pigment, in spots, was noted in 20 per cent., but a capsule in only I4 per cent., some of which were neither marked nor complete. Among these thirty-five cases of primary sarcoma already mentioned, I found the histories of four very interesting cases due to traumatism. Two of these Dr. Knapp mentioned at the meeting of the American Ophthalmological Society in 1893. Both of the patients were children, and the tumors resulted from falls. Death ensued in each case. Dr. Lagrange has also
94
WILMER: MAdanotic Giant-Celled Sarcoma of Lid.
reported a case due to a blow, the patient being seventy years old. Dr. Samelson has given the history of a sarcoma that was due to a bit of coal which had lodged in the conjunctival cul de sac a year previous. The coal was found in the base of the removed tumor. Although very interesting, certain cases of adenoma and congenital angio-sarcoma of the eyelids, have not been included among the above cases owing to the fact that the sarcomatous elements were meagre and therefore of secondary importance. LITERATURE. AGUILAR, B., " Melano-Sarcome de la paupiere," etc., 1882. Rec. d'Ophth., p. 620. GALLENGA, Ann. d'Oculist., Par., 1885. 13 S., Vol. 4, p. I85. From Gazz. del Cliniche, I884, NO. 35. EPERON, " Sarcome de la region interne de la paupicre gauche," 1883. Arch. d'Ophth., page I93. SCHIRMER, R., Klin. Monatsbl. f. Augenheilk, Erlangen, I867, V. 124. LILIENFELD, W., " Sarkom des rechten oberen Augenlids," 1875. Klin. Monatsbl. f. Augenheilk, XII., p. 55. OTTAVA, J., " Zwei Falle von Sarcom d. Augenlider," i88I. Szemeszel, Budapest, p. 65 and 8i. ROBERTSON, " An eye removed for a melanotic sarcoma affecting the conjunctiva of the lid and globe," I885. Transact. Med. Chir. Soc., IV, p. 3. HIRSCHBERG, J., " Sarcom des unteren Lides," I87I. Arch. F. Augen-u. Ohrenheilk, II, I-229. STORY, " Palpebral Sarcoma," i88i. Brit. Med. Journal, April 23, p. 647. VAN DUYSE AND CRUYL, Sarcome de la paupiere," I887. Ann. Soc. de Med. de Gond., LXVI, p. I93. SAMELSON, " Sarcoma of the eyelid," 1870. Brit. Med. Journal, II, p. 706. COOMES, M. F., " Round-celled sarcoma involving the eyelids and adjacent portions of the face," I882. Louisville Med. News, XIII, p. 38. RANDALL, " Sarcoma of lid simulating Meibomian cyst," I887. Transact. Am. Ophth. Soc., p. 5I7. PROUT, J. S., AND BULL, C. S., " Sarcoma of the Tarsus and Conjunctiva," I879. Arch. Ophth., VIII, p. 73. RICHET, " Sarcome fascicule melanique de la paupiere," 1879. Mouvem. Med..
P. 7I. FLACK, J.,
" Sarkome der Augenlider," I892. Inaug. Thesis 8. Konigsberg. MAHER, " A case of sarcoma of the eyelids," I889. Intercolonial Med. Congress of Australia. Transact. Melbourne II, 75I. CIIISHOLM, Ann. d'Oculist, Par., i88i, LXXXV, 270. CEPPI, Progres Med., Par., 28 Mai, i88i. FAGE, " Sarcome paupiere superieure," I893. Recueil d'Ophth., Par., 3, XV, 397. FEILCHENFELD, W., " Pigmentoses Sarcom der Conjunctiva Palpebrarum," I888. Centralbl. f. prakt. Augenheilk., Leipzig, XII, 97.
RICHEY: The Halo Symptoms in Glaucoma.
95
TEILLAIS, " Sarcome de la paupiere superieure," i886. J. de Med. de l'ouest, Nantes, XIX, 86. DIANOUX, " Sarcome de la paupiere superieure," i886. J. de Med. de l'ouest, Nantes, XX, 369. VON GRAEFE, "Sarkom des innern Augenwinkels," I864. Graefe's Arch. f. Ophth., Berlin, X, 184. HORNER, " Vielzelliges Melanosarkom der Conjunctiva Tarsi," I87I. Klin. Monatsbl. f. Augenheilk., IX, 4. FALKO, " Sarcoma conjunctiva palpebrae superiores," 1873. Klin. Monatsbl. f. Augenheilk, Erlangen, XI., 326. Fucuis, " Sarkom des Lides," I878. Graefe's Arch. f. Ophth., Berlin, XXIV, 163. BLANCH, "Melanosarcome de la paupiere," I882. Recueil d'Ophth., Par., 3 S., IV. RUMSCHEWITZ, K., " Sarcom des Lides," I890. Klin. Monatsbl., Erlangen, XXVII, 395. GRUENING, E., "A case of spindle-celled sarcoma of the eyelid," I893. Transact. Am. Ophth. Soc., VI, p. 505. KNAPP, H., "Two cases of traumatic sarcoma of the eyelid," I893. Transact. Am. Ophth. Soc., VI, p. 508. Discussion. LAGRANGE, "Du sarcome melanique des paupieres," I891. Recueil d'Ophth., P. 328. SAMELSON, "Recurrent Sclero-palpebral Sarcoma," i88o. Brit. Med. Journal, I, P. 325.
THE HALO SYMPTOMS IN GLAUCOMA. BY S. 0. RICHEY, M.D., WASHINGTON, D. C.
Halo is classed among the prodomata of glaucoma; it may occur later in the progress of primary simple glaucoma. Some subjects of glaucoma, more observant than others, mention it without suggestion from the physician. In many cases it is not noted, or little importance attached to it. A few attempts have been made to explain it. DeWecker thinks it "due to very slight alterations in the epithelial layer of the cornea, produced by temporary increase of pressure." Wolfe suggests that it " may. be owing to dilatation of the pupil, to change in the lens, or to disturbance in the circulation." Neither disturbance of the circulation nor dilatation of the pupil, when they exist under other circumstances, seem to cause the phenomenon. Alterations in the epithelial layer of the cornea, and
9I
DR. SWAN M. BURNETT of Washington. - In looking over the statistics prepared by Braunschweig, so far as it can be relied upon,. I find that there are very few cases indeed in which there seems to be any tendency to malignancy. Of course, one could hardly say that all tumors of the optic nerve are benign, but the cases which are reported as typical cases of myxosarcoma and sarcoma, and which take their origin in the intravaginal space, from what I have been able to study of them, were not malignant. I think it is a question which it will be profitable to study, since we have a good deal to learn with regard to the pathology of these tumors around the optic nerve. It seems to me .they are embryonic in their character, and that they are not essentially malignant. The cases which have been reported as malignant probably did not originate in the intravaginal space, but in some other part of the orbit.
A CASE OF MELANOTIC, GIANT-CELLED, ALVEOLAR, MYXO-SARCOMA OF THE EYELID. By W. H. WILMER, M.D., WASHINGTON, D. C.
While the literature of ophthalmology is so rich in other respects, the reports of cases of primary sarcoma of the eyelids are comparatively limited in number. A case of this nature is therefore presented without further apology, as it seems to me to possess features that are not common. On April I5, I893, a woman about thirty years of age consulted me concerning a small tumor of the right lower eyelid. This tumor was first noticed about six or eight months previous. Its growth had been gradual but steady. The patient was confident that the lid had never been injured in any way. In fact, she had never had any trouble whatever with her eyes except a slight attack of conjunctivitis in I887. The tumor was situated a little to the outer side of the median line of the lid, with its long axis parallel to the margin. It was hard and unyielding to the touch. Although the tumor projected toward the skin, the latter was freely movable, and
92
WILMER: Melanzotic Giant-Ce//ed Sarcoma of Lid.
normal in all respects; there was not even the slightest discoloration. The conjunctiva, likewise, was normal in appearance. There was every indication of its being a primary growth, for there was no evidence of disease in any other organ. On April 24, I893, the growth was removed through an incision in the skin, parallel to the margin of the lid. The tumor was easily dissected out, owing to its extremely tough fibrous capsule. At its center, the tumor was loosely attached to the conjunctiva by a few adhesions. Apparently, the bulk of the tumor was in front of the tarsal cartilage, but, at the site of the adhesions, it seemed to have perforated the tarsus. The location of the tumor and its microscopical elements warrant our supposing that the growth originated in the tarsal cartilage. The bleeding was not more profuse than usual. The wound was sutured with fine silk. On the fourth day after the operation, the sutures were removed and the union was firm. In a letter received a few weeks ago, the patient writes that there has been no symptom of a return of the growth. At my advice, she had consulted an oculist in her city, who found only a mild granular conjunctivitis in either eye. The tumor, after being thoroughly hardened in .Muller's fluid, measured I2 mm. in length, 7 mm. in breadth, and 41 mm. in thickness. Sections of the tumor were examined by Dr. C. L. Minor of this city, and by Dr. W. M. Gray of the Army Medical Museum. Dr. Gray has kindly prepared the following report of the microscopical examination of the tumor: The tumor is composed of a framework of wavy bands of dense fibrous connective tissue, which run in all directions; these bands are composed of long and short elements, and form an alveolated structure through the growth. The pigmentation occurs in small patches irregularly distributed, and is composed of small masses of dense black pigment; the majority of the pigment masses are round or irregular in shape, with a few branching pigment cells. The giant cells are confined to one side of the growth, and are comparatively few in number; they are imbedded in islands of myxomatous tissue surrounded by alveoli of the dense fibrous connective tissue. Throughout the growth are numerous isolated patches of myxomatous tissue;
WILMER: Me/anotic Giant-Celled Sarcoma of Lid.
93
these patches are surrounded by the fibrous connective tissue stroma, and form a typical alveolar structure' somewhat resembling cancer formation. The myxomatous tissue is composed of large round cells- epithelioid in character -medium-sized, and small round cells, and a few spindle and stellate cells. These cells are held in a fine meshwork composed of delicate connective tissue threads. The growth has a rich vascular supply; some of the vessels have fully formed walls, but the majority are without walls, typical of sarcoma. In looking over the literature of the subject, I have found the histories of thirty-five cases of primary sarcoma of the eyelid. I had the opportunity to examine fully only twenty-five of these cases. In this number, I found the age of the patients varying from ten months to seventy-six years; the duration of the tumor, before operation, from several weeks to thirteen years; the size ranging from that of a pea to a large apple. In I2 per cent., all four lids were involved. In i6 per cent., it was necessary to remove the eye with the tumor. In i6 per cent., all children, death is mentioned as having resulted from the disease. In 40 per cent., the return of the growth is mentioned; but in many other cases, the patients were last seen a short while after the operation. And some of the tumors were themselves recurrent, while others returned several times. I was able to examine the microscopical reports of all thirtyfive cases; and I found that 40 per cent. of these sarcomata were spindle-celled, 43 per cent. round-celled, I7 per cent. mixed, iI per cent. presented myxomatous elements. In one case, which I have classed among the mixed sarcomata, the author mentions the existence of large cells " not unlike the giantcell." The presence of pigment, in spots, was noted in 20 per cent., but a capsule in only I4 per cent., some of which were neither marked nor complete. Among these thirty-five cases of primary sarcoma already mentioned, I found the histories of four very interesting cases due to traumatism. Two of these Dr. Knapp mentioned at the meeting of the American Ophthalmological Society in 1893. Both of the patients were children, and the tumors resulted from falls. Death ensued in each case. Dr. Lagrange has also
94
WILMER: MAdanotic Giant-Celled Sarcoma of Lid.
reported a case due to a blow, the patient being seventy years old. Dr. Samelson has given the history of a sarcoma that was due to a bit of coal which had lodged in the conjunctival cul de sac a year previous. The coal was found in the base of the removed tumor. Although very interesting, certain cases of adenoma and congenital angio-sarcoma of the eyelids, have not been included among the above cases owing to the fact that the sarcomatous elements were meagre and therefore of secondary importance. LITERATURE. AGUILAR, B., " Melano-Sarcome de la paupiere," etc., 1882. Rec. d'Ophth., p. 620. GALLENGA, Ann. d'Oculist., Par., 1885. 13 S., Vol. 4, p. I85. From Gazz. del Cliniche, I884, NO. 35. EPERON, " Sarcome de la region interne de la paupicre gauche," 1883. Arch. d'Ophth., page I93. SCHIRMER, R., Klin. Monatsbl. f. Augenheilk, Erlangen, I867, V. 124. LILIENFELD, W., " Sarkom des rechten oberen Augenlids," 1875. Klin. Monatsbl. f. Augenheilk, XII., p. 55. OTTAVA, J., " Zwei Falle von Sarcom d. Augenlider," i88I. Szemeszel, Budapest, p. 65 and 8i. ROBERTSON, " An eye removed for a melanotic sarcoma affecting the conjunctiva of the lid and globe," I885. Transact. Med. Chir. Soc., IV, p. 3. HIRSCHBERG, J., " Sarcom des unteren Lides," I87I. Arch. F. Augen-u. Ohrenheilk, II, I-229. STORY, " Palpebral Sarcoma," i88i. Brit. Med. Journal, April 23, p. 647. VAN DUYSE AND CRUYL, Sarcome de la paupiere," I887. Ann. Soc. de Med. de Gond., LXVI, p. I93. SAMELSON, " Sarcoma of the eyelid," 1870. Brit. Med. Journal, II, p. 706. COOMES, M. F., " Round-celled sarcoma involving the eyelids and adjacent portions of the face," I882. Louisville Med. News, XIII, p. 38. RANDALL, " Sarcoma of lid simulating Meibomian cyst," I887. Transact. Am. Ophth. Soc., p. 5I7. PROUT, J. S., AND BULL, C. S., " Sarcoma of the Tarsus and Conjunctiva," I879. Arch. Ophth., VIII, p. 73. RICHET, " Sarcome fascicule melanique de la paupiere," 1879. Mouvem. Med..
P. 7I. FLACK, J.,
" Sarkome der Augenlider," I892. Inaug. Thesis 8. Konigsberg. MAHER, " A case of sarcoma of the eyelids," I889. Intercolonial Med. Congress of Australia. Transact. Melbourne II, 75I. CIIISHOLM, Ann. d'Oculist, Par., i88i, LXXXV, 270. CEPPI, Progres Med., Par., 28 Mai, i88i. FAGE, " Sarcome paupiere superieure," I893. Recueil d'Ophth., Par., 3, XV, 397. FEILCHENFELD, W., " Pigmentoses Sarcom der Conjunctiva Palpebrarum," I888. Centralbl. f. prakt. Augenheilk., Leipzig, XII, 97.
RICHEY: The Halo Symptoms in Glaucoma.
95
TEILLAIS, " Sarcome de la paupiere superieure," i886. J. de Med. de l'ouest, Nantes, XIX, 86. DIANOUX, " Sarcome de la paupiere superieure," i886. J. de Med. de l'ouest, Nantes, XX, 369. VON GRAEFE, "Sarkom des innern Augenwinkels," I864. Graefe's Arch. f. Ophth., Berlin, X, 184. HORNER, " Vielzelliges Melanosarkom der Conjunctiva Tarsi," I87I. Klin. Monatsbl. f. Augenheilk., IX, 4. FALKO, " Sarcoma conjunctiva palpebrae superiores," 1873. Klin. Monatsbl. f. Augenheilk, Erlangen, XI., 326. Fucuis, " Sarkom des Lides," I878. Graefe's Arch. f. Ophth., Berlin, XXIV, 163. BLANCH, "Melanosarcome de la paupiere," I882. Recueil d'Ophth., Par., 3 S., IV. RUMSCHEWITZ, K., " Sarcom des Lides," I890. Klin. Monatsbl., Erlangen, XXVII, 395. GRUENING, E., "A case of spindle-celled sarcoma of the eyelid," I893. Transact. Am. Ophth. Soc., VI, p. 505. KNAPP, H., "Two cases of traumatic sarcoma of the eyelid," I893. Transact. Am. Ophth. Soc., VI, p. 508. Discussion. LAGRANGE, "Du sarcome melanique des paupieres," I891. Recueil d'Ophth., P. 328. SAMELSON, "Recurrent Sclero-palpebral Sarcoma," i88o. Brit. Med. Journal, I, P. 325.
THE HALO SYMPTOMS IN GLAUCOMA. BY S. 0. RICHEY, M.D., WASHINGTON, D. C.
Halo is classed among the prodomata of glaucoma; it may occur later in the progress of primary simple glaucoma. Some subjects of glaucoma, more observant than others, mention it without suggestion from the physician. In many cases it is not noted, or little importance attached to it. A few attempts have been made to explain it. DeWecker thinks it "due to very slight alterations in the epithelial layer of the cornea, produced by temporary increase of pressure." Wolfe suggests that it " may. be owing to dilatation of the pupil, to change in the lens, or to disturbance in the circulation." Neither disturbance of the circulation nor dilatation of the pupil, when they exist under other circumstances, seem to cause the phenomenon. Alterations in the epithelial layer of the cornea, and
