474
WADSWORTH: A Case of Tuberc'ulosis REMARKS.
THE PRESIDENT remarked that within the last year a case had come under observation in New York which presented certain remarlZable difficulties in diagnosis. The patient was four years of age. The gross appearances were such as to make it impossible to distinguish between a gliomatous condition and a metastatic choroiditis. The case continued under observation several weeks without much progress. Finally the eye was enucleated, and on examination it was. found that tubercular disease was the true nature of the lesion. At that time it was felt by those who saw the case to be impossible to make a satisfactory differential diagnosis between tubercular disease and the gliomatous condition.
A CASE OF TUBERCULOSIS OF THE CILIARY BODY AND IRIS. BY 0. F. WADSWORTH, M.D.t BOSTON, MASS.
, aged three and a half, was sent to me by MARY MCG Dr. H. Derby for consultation, on October 24th, I882. Dr. Derby wrote: "I first saw this eye October 4th. The process had then lasted two weeks. It seemed to be a keratoiritis, as well as I could make out. The pupil was small, and remained so in spite of atropine. The cornea was hazy. Atropine, shade, fomentations, oleum morrhuxe, have been used. The eye has grown steadily worse and pain more frequent. October ioth the yellowish reflex from the pupil was' first visible. Since then it has become more pronounced, and the pupil has enlarged. I have seen no vessels, but perhaps have not looked as closely as I might." The questionwas as to glioma or irido-choroiditis. The father stated that both he and the mother were in good health; that there were two children older and two younger than this one, the oldest seven years, all well, " never a doctor in the house with any of them." These statements as to
of the Ciliary Body and Iris.
4475-
the Ihealth of the family were found later to be quite incorrect.
The child's mother had noticed redness of the left eye five or six weeks before- after a few-,days the child complainedw of light, and a handkerchief was tied over the eye. The mother said that, except when the eye was looked at or drops put in, there had been no complaint of pain till the last day or two, and then not much; that the child,slept well and played about all -day with a bandage over the affected eye. I found, as had, Dr. Derby, that it was very difficult to obtain a view of the eye. Even. when the patient was held and the lids forcibly opened, the- rolling up of the eye and the great flow of tears prevented a satisfactory inspection. The lids were natural; the cornea hazy; the conjunctiva of the bulb moderately congested, but no very marked ciliary congestion; the anterior chamber of good depth; pupil moderately dilated; the upper portion of the iris apparently thickly set with vessels; a yellowish reflex from the- pupil. My diagnosis wavered between glioma and irido-choroiditis, and I suggested to Dr. Derby the advisability of an examination under-ether before advising enucleation. Two days later, October 26th, Dr. Derby etherized the child, and found much vascularity of the upper part of the iris, but no trace of vessels in the yellow mass in the pupil. November 15th, Dr. Derby examined again under ether, found the disease much advanced, and advised enucleation. On the following day I also examined under ether. There was considerable circumcerneal congestion. Above-was. a staphyloma in the ciliary region, generally dark in, color, perhaps 5"' by 3"'. No trace of iris was visible, but a growth reached forward everywhere nearly to the cornea, its surface yellowish-white and showing numerous vessels and some hemorrhages. Some vessels also extended into the cornea from its periphery.. Both Dr., Derby and I believed the growth to be -a glioma., The eye was enucleated the same day by Dr. Derby, placed; in Muller's fluid, and given to me for examin4tiont
31.
476
WADSWORTH: A Case of Tuberculosis
Some weeks later the eye was divided through the centre of the staphyloma, nearly in the vertical meridian. The retina and choroid lay everywhere in contact with the sclera. The greater part of the vitreous chamber was occupied by a thin serous fluid. A solid grayish mass filled the anterior part of the globe. The posterior surface of this mass, irregularly concave, extended across the globe from a little behind the ciliary body-from a point 8 mm. from the cornea below to a point IO to I I mm. from the cornea above. It was about 6 mm. thick in the centre. From the most prominent part of the staphyloma, which projected about 3 mm., it measured 7 .to 8 mm; in thickniess. Something more than the anterior half of the thickness of the mass, starting from a point 2 to 3 mm. behind the cornea below and extending upward to a little behind the posterior border of the staphyloma above, was in appearance denser and of a duller, somewhat darker tint than the rest. It was partly and irregularly divided from the posterior portion of the mass by a broken dark line, apparently the remains of the iris. The posterior part of the mass was of a lighter tint of gray and less dense, seeming somewhat fibrous and like condensed and altered vitreous. Behind the edges of the mass the retina, and the choroid so far as it could be seen, appeared normal. There was no sign of the lens. Microscopic examination showed the greater part of the solid mass to be mainly made up of granulation tissue, varying in different parts, here containing closely packed small cells, there mostly consisting of fibres running approximately parallel. The latter were most numerous at and near the anterior border, and now and again broad bundles of the fibres curved forward to the posterior surface of the cornea. Through the mass ran large vessels, and there were remains of many hemorrhages. The pigment, irregularly scattered, was for the most part all that could be made out as remainder of the normal tissues of iris or ciliary body. Throughout this tissue, except in the-more fibrous portions, were scattered rounded agglomerations of cells, more deeply stained by haematoxylin, and showing the characteristic cell forms and
of the Ciliary Body and Iris.
477
arrangement of tubercle; giant cells, containing many nuclei, surrounded by epithelioid and small granulation cells. The posterior layer of the mass was much more free frorm cells, and appeared to consist of the infiltrated and thickened remains of the vitreous. In this was seen also, in the sections, the collapsed and folded lens capsule, lined here and there for a short distance by what seemed to be its degenerated epithelium, and containing- apparently some d6bris of lens fibres. One-half of the globe was given to Dr. H. C. Ernst, then engaged in the investigation of the bacillus of Koch, and, although the fact that the eye had been in Muller's fluid made the search more difficult, he was able to demonstrate satisfactorily the presence of the bacillus in the specimen. Until the result of the microscopic examination was reached there had been no suspicion of the tuberculous nature of the disease. This was the first case of the kind either Dr. Derby or I had seen, and the family history, as given by the parents, gave no indication that such disease was at all likely. Indeed, looking back now, with the knowledge of the true nature of the case before me, I um unable to recognize anything in the visible appearances of the growth when I saw it, or in the history of its course, by which it could be distinguished from a glioma, unless, perhaps, the great vascularity of the iris which preceded the development of the growth into the anterior chamber may be regarded as of some value for the differential diagnosis. The statement that the child herself and the whole family had been free from anything pointing to tubercle made the case one of much interest to follow. The child continued in apparently good health for more than five months after the enucleation; then for five or six weeks she complained of headache, not enough to lead the parents to call a physician; suddenly became worse, and Dr. Ferguson, who was called, found her in convulsions. She died three days later with the diagnosis by Dr. Ferguson of tubercular meningitis. There was no autopsy. It was only some time after her death that I learned from
478 WADSWORTH: Tuberculosis of Ciliary Body and Iris. Dr. Ferguson that he had attended the family for several years, that the child's father and a brother of the father had phthisis, and that the children had been subject to bronchial
attacks. REMARKS.
DR. PROUT asked if there was increase of tension. DR. WADSWORTH replied that it was impossible to test tension until the patient was under ether, and at that time the entire anterior chamber was filled with the growth. DR. PROUT said that he asked because he had had a case in which the tension was extreme, occurring in a boy six years of age, whose eye gave a whitish reflex through a small and unyielding pupiL The intra-ocular pressure was so great that the sclera was beginning to yield in the superior ciliary region. The media were not clear, and there was doubt as to whether the reflex was caused by a tumor-or by exudative cyclitis or choroiditis. As the local condition seemed to impair his general health, the eyeball was enucleated. and'is now in the hands of Dr. C. S. Bull for microscopical examination, who has not yet had time to make a report. DR. WEBSTER had a case under observation of supposed tubercular disease of both irides, occurring in the person of a farmer, thirty-five years of age, who when he first came under observation presented all the appearances of syphilitic iritis. There was three or four tolerably large nodules upon one iris and something of the same appearance on the other. He put him under treatment by mercurial inunction followed by the iodide of potassium, but without improvement, at the same time using atropine faithfully. The man grew worse and worse, and finally Dr. Agnew performed iridectomy upon both eyes and the operation was subsequently repeated, and still later Dr. Agnew removed the lens from one eye. The patient had recurring attacks of inflammation, but finally was discharged from the Manhattan Eye and Ear Hospital with a slight amount of vision. The trouble was diagnosed as tubercular iritis, more from the fact that the man had evidence of tubercular disease in the lungs with undoubted history of consumption in the family; and that the ordinary treatment in such cases failed to arrest the process. The portion of the iris removed was -examined by Dr. Prudden, who failed to find anything to make it certain that the disease was tubercular in character.
WADSWORTH: A Case of Tuberc'ulosis REMARKS.
THE PRESIDENT remarked that within the last year a case had come under observation in New York which presented certain remarlZable difficulties in diagnosis. The patient was four years of age. The gross appearances were such as to make it impossible to distinguish between a gliomatous condition and a metastatic choroiditis. The case continued under observation several weeks without much progress. Finally the eye was enucleated, and on examination it was. found that tubercular disease was the true nature of the lesion. At that time it was felt by those who saw the case to be impossible to make a satisfactory differential diagnosis between tubercular disease and the gliomatous condition.
A CASE OF TUBERCULOSIS OF THE CILIARY BODY AND IRIS. BY 0. F. WADSWORTH, M.D.t BOSTON, MASS.
, aged three and a half, was sent to me by MARY MCG Dr. H. Derby for consultation, on October 24th, I882. Dr. Derby wrote: "I first saw this eye October 4th. The process had then lasted two weeks. It seemed to be a keratoiritis, as well as I could make out. The pupil was small, and remained so in spite of atropine. The cornea was hazy. Atropine, shade, fomentations, oleum morrhuxe, have been used. The eye has grown steadily worse and pain more frequent. October ioth the yellowish reflex from the pupil was' first visible. Since then it has become more pronounced, and the pupil has enlarged. I have seen no vessels, but perhaps have not looked as closely as I might." The questionwas as to glioma or irido-choroiditis. The father stated that both he and the mother were in good health; that there were two children older and two younger than this one, the oldest seven years, all well, " never a doctor in the house with any of them." These statements as to
of the Ciliary Body and Iris.
4475-
the Ihealth of the family were found later to be quite incorrect.
The child's mother had noticed redness of the left eye five or six weeks before- after a few-,days the child complainedw of light, and a handkerchief was tied over the eye. The mother said that, except when the eye was looked at or drops put in, there had been no complaint of pain till the last day or two, and then not much; that the child,slept well and played about all -day with a bandage over the affected eye. I found, as had, Dr. Derby, that it was very difficult to obtain a view of the eye. Even. when the patient was held and the lids forcibly opened, the- rolling up of the eye and the great flow of tears prevented a satisfactory inspection. The lids were natural; the cornea hazy; the conjunctiva of the bulb moderately congested, but no very marked ciliary congestion; the anterior chamber of good depth; pupil moderately dilated; the upper portion of the iris apparently thickly set with vessels; a yellowish reflex from the- pupil. My diagnosis wavered between glioma and irido-choroiditis, and I suggested to Dr. Derby the advisability of an examination under-ether before advising enucleation. Two days later, October 26th, Dr. Derby etherized the child, and found much vascularity of the upper part of the iris, but no trace of vessels in the yellow mass in the pupil. November 15th, Dr. Derby examined again under ether, found the disease much advanced, and advised enucleation. On the following day I also examined under ether. There was considerable circumcerneal congestion. Above-was. a staphyloma in the ciliary region, generally dark in, color, perhaps 5"' by 3"'. No trace of iris was visible, but a growth reached forward everywhere nearly to the cornea, its surface yellowish-white and showing numerous vessels and some hemorrhages. Some vessels also extended into the cornea from its periphery.. Both Dr., Derby and I believed the growth to be -a glioma., The eye was enucleated the same day by Dr. Derby, placed; in Muller's fluid, and given to me for examin4tiont
31.
476
WADSWORTH: A Case of Tuberculosis
Some weeks later the eye was divided through the centre of the staphyloma, nearly in the vertical meridian. The retina and choroid lay everywhere in contact with the sclera. The greater part of the vitreous chamber was occupied by a thin serous fluid. A solid grayish mass filled the anterior part of the globe. The posterior surface of this mass, irregularly concave, extended across the globe from a little behind the ciliary body-from a point 8 mm. from the cornea below to a point IO to I I mm. from the cornea above. It was about 6 mm. thick in the centre. From the most prominent part of the staphyloma, which projected about 3 mm., it measured 7 .to 8 mm; in thickniess. Something more than the anterior half of the thickness of the mass, starting from a point 2 to 3 mm. behind the cornea below and extending upward to a little behind the posterior border of the staphyloma above, was in appearance denser and of a duller, somewhat darker tint than the rest. It was partly and irregularly divided from the posterior portion of the mass by a broken dark line, apparently the remains of the iris. The posterior part of the mass was of a lighter tint of gray and less dense, seeming somewhat fibrous and like condensed and altered vitreous. Behind the edges of the mass the retina, and the choroid so far as it could be seen, appeared normal. There was no sign of the lens. Microscopic examination showed the greater part of the solid mass to be mainly made up of granulation tissue, varying in different parts, here containing closely packed small cells, there mostly consisting of fibres running approximately parallel. The latter were most numerous at and near the anterior border, and now and again broad bundles of the fibres curved forward to the posterior surface of the cornea. Through the mass ran large vessels, and there were remains of many hemorrhages. The pigment, irregularly scattered, was for the most part all that could be made out as remainder of the normal tissues of iris or ciliary body. Throughout this tissue, except in the-more fibrous portions, were scattered rounded agglomerations of cells, more deeply stained by haematoxylin, and showing the characteristic cell forms and
of the Ciliary Body and Iris.
477
arrangement of tubercle; giant cells, containing many nuclei, surrounded by epithelioid and small granulation cells. The posterior layer of the mass was much more free frorm cells, and appeared to consist of the infiltrated and thickened remains of the vitreous. In this was seen also, in the sections, the collapsed and folded lens capsule, lined here and there for a short distance by what seemed to be its degenerated epithelium, and containing- apparently some d6bris of lens fibres. One-half of the globe was given to Dr. H. C. Ernst, then engaged in the investigation of the bacillus of Koch, and, although the fact that the eye had been in Muller's fluid made the search more difficult, he was able to demonstrate satisfactorily the presence of the bacillus in the specimen. Until the result of the microscopic examination was reached there had been no suspicion of the tuberculous nature of the disease. This was the first case of the kind either Dr. Derby or I had seen, and the family history, as given by the parents, gave no indication that such disease was at all likely. Indeed, looking back now, with the knowledge of the true nature of the case before me, I um unable to recognize anything in the visible appearances of the growth when I saw it, or in the history of its course, by which it could be distinguished from a glioma, unless, perhaps, the great vascularity of the iris which preceded the development of the growth into the anterior chamber may be regarded as of some value for the differential diagnosis. The statement that the child herself and the whole family had been free from anything pointing to tubercle made the case one of much interest to follow. The child continued in apparently good health for more than five months after the enucleation; then for five or six weeks she complained of headache, not enough to lead the parents to call a physician; suddenly became worse, and Dr. Ferguson, who was called, found her in convulsions. She died three days later with the diagnosis by Dr. Ferguson of tubercular meningitis. There was no autopsy. It was only some time after her death that I learned from
478 WADSWORTH: Tuberculosis of Ciliary Body and Iris. Dr. Ferguson that he had attended the family for several years, that the child's father and a brother of the father had phthisis, and that the children had been subject to bronchial
attacks. REMARKS.
DR. PROUT asked if there was increase of tension. DR. WADSWORTH replied that it was impossible to test tension until the patient was under ether, and at that time the entire anterior chamber was filled with the growth. DR. PROUT said that he asked because he had had a case in which the tension was extreme, occurring in a boy six years of age, whose eye gave a whitish reflex through a small and unyielding pupiL The intra-ocular pressure was so great that the sclera was beginning to yield in the superior ciliary region. The media were not clear, and there was doubt as to whether the reflex was caused by a tumor-or by exudative cyclitis or choroiditis. As the local condition seemed to impair his general health, the eyeball was enucleated. and'is now in the hands of Dr. C. S. Bull for microscopical examination, who has not yet had time to make a report. DR. WEBSTER had a case under observation of supposed tubercular disease of both irides, occurring in the person of a farmer, thirty-five years of age, who when he first came under observation presented all the appearances of syphilitic iritis. There was three or four tolerably large nodules upon one iris and something of the same appearance on the other. He put him under treatment by mercurial inunction followed by the iodide of potassium, but without improvement, at the same time using atropine faithfully. The man grew worse and worse, and finally Dr. Agnew performed iridectomy upon both eyes and the operation was subsequently repeated, and still later Dr. Agnew removed the lens from one eye. The patient had recurring attacks of inflammation, but finally was discharged from the Manhattan Eye and Ear Hospital with a slight amount of vision. The trouble was diagnosed as tubercular iritis, more from the fact that the man had evidence of tubercular disease in the lungs with undoubted history of consumption in the family; and that the ordinary treatment in such cases failed to arrest the process. The portion of the iris removed was -examined by Dr. Prudden, who failed to find anything to make it certain that the disease was tubercular in character.
