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Malignant Tumor of the Orbit.
there was a subsequent return of normal vision in that eye, although the shot passed just without the limbus in the ciliary region, and the point of location at which the shot passed out of the eye could also be demonstrated on the fundus by ophthalmoscopic examination. It became a foreign body in the orbit, and became encysted there, I suppose. There was no further trouble, and the vision became normal. I think these cases of foreign bodies in the orbital cavity are very interesting. Fortunately we do not see very many of them, and I think it is a very good thing that we do not, although the orbital contents; certainly in a great many instances, are able to withstand a great deal of injury and come out of it in very good condition. Case No. 2, however, in which the foreign body penetrated the cerebral cavity, was very serious. In the reported cases of foreign body in the orbit which came to autopsy, the cerebral cavity had generally been penetrated and cerebral disease had resulted. Whether many of the other cases which recovered, although the foreign bodies were so large as to have almost certainly penetrated the cerebral cavity, really did recover after such penetration, can only be conjectured, although the indications all seem to point to the probability of such injury occurring without fatal termination.
THREE CASES OF MALIGNANT TUMOR OF THE ORBIT. BY GEORGE C. HARLAN, M.D., PHILADELPHIA, PA.
The great variety and grave significance of orbital diseases make this always an important subject in clinical ophthalmology, and may justify the report of three cases that have recently occurred in my practice, and which seem to present some points of sufficient interest to claim a few minutes of your time. CASE I. Epithelial Orbital Tumor Orzginatinzg in the Laclrymal Sac; Rapid Recurrence. J. McC., a farmer 40 years old, in good general health, was admitted to the Pennsylvania Hospital, November 25, I893. He stated that his attention had been first called to the right eye about eight months be-
HARLAN: Malignant Tumor of the Orbit.
71
fore by an overflow of tears. Afterwards there was a good deal of pain in eye and temple, and the lower lid commenced to swell. The lower lid was protruded and the eye was pushed upward and outward by a tumor which reached from the inner canthus to the junction of the middle and outer thirds of the lid, overlapped the orbital margin and extended back into the orbit on the lower and inner side of the ball. It was entirely beneath the conjunctiva, which was not involved, and was solid and very hard to the touch. The nasal sinuses were free from disease. Vision, W5/cc. With the ophthalmoscope, the fundus was indistinct from haziness of the cornea, but a swelling of the disc could be determined. There were no glandular enlargements. The tumor was removed on December 2, I893, through a free incision in the lid, without disturbing the eyeball. It was as large as a small hen's egg and of irregular conical form, was firmly adherent at the lachrymal groove and extended along the floor and inner wall of the orbit, where the bone was denuded of periosteum, nearly to the optic foramen. Recovery was delayed by the formation of an orbital abscess, which was lanced above the ball, but the patient was discharged in good condition in three weeks (January 23, I894). The eye had no power of adduction. The growth was examined by Dr. McFarland, Demonstrator in Pathology in the University of Pennsylvania, who pronounced it a " squamous epithelioma, greatly resembling scirrhous cancer, but an undoubted epithelioma." On March I3th, a little more than three months after the operation, the patient presented himself again. There was no exophthalmos, and vision had increased from 15/cc to 15/40; but a hard mass of considerable size could be felt at the inner canthus and extending back into the orbit in the position of the former tumor. It was decided to remove the whole contents of the orbit, including the periosteum, which was done on March I7, I894. There was extensive destruction of the walls of the lachrymal groove, making an opening large enough
72
HARLAN: Malignant Tumor of the Orbit.
to admit the end of the little finger. The edges of this opening were cut away with the gouge and the Paquelin cautery was freely applied. The points of interest in this case are the character df the growth, its place of origin, and its rapid recurrence. Tumors of an epithelial type are rare in the orbit, and have been described as originating in the lids, the conjunctiva, the lachrymal gland, or the mucous membrane of neighboring sinuses. A degenerated dermoid cyst may be the point of origin (Berlin). I have not met in literature with any report of a growth of this kind originating in the lachrymal sac. The history given by the patient, and the conditions revealed by the operation leave no doubt of such an origin in the present case. The earliest symptom was epiphora. The skin and conjunctiva were not involved, and the closest adhesion was at the lachrymal groove, the walls of which were subsequently extensively eroded. CASE II. Sarcomatous Growth Completely Filling the Orbit; Apparently Originating in Tenon's Capsule. S. F., a laborer, aged 52, was admitted to the Pennsylvania Hospital, February i, 1894. The history of the case was indefinite and obscure. We could only make out that the sight of the right eye had commenced to fail two or three months before, and that the patient had suffered a good deal from pain in the eye and head since that time. The lids were enormously distended, and the eye, which was sightless, was displaced outward and upward by a hard tumor that filled the orbit. The conjunctiva was chemosed, and the ball was perfectly immovable. The upper third of the cornea was covered by a mass of tissue presenting the appearance of a very dense pannus. There were no glandular enlargements. The contents of the orbit were removed, and were found to consist entirely of a solid mass in which the eyeball was imbedded, no anatomical structures being microscopically recognizable. The ball was compressed to a pear shape and firmly incorporated in the tumor, but the sclerotic was sound. A greater part of the floor of the orbit was destroyed, and there were two holes, about five millimetres in diameter, in the roof. What remained of the periosteum was carefully removed. The patient made a prompt and good recovery.
HARLAN: Maligniant Tumor of the Orbit.
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The tumor was examined microscopically by Dr. H. M. Fisher, Pathologist of the Hospital, who pronounced it a large, round-celled sarcoma. The chief point of interest in this case is the very rapid development of the tumor. The patient belonged to a class not likely to detect the earliest symptoms of disease, but he stated very positively that he had suffered no inconvenience until less than three months before his admission to the hospital. The solid incorporation of the eyeball in the tumor, and the encroachment of the growth upon -the -anterior part of the sclerotic and the cornea point to the capsule of Tenon as the place of origin. CASE III. Sarcoma of the Orbit, Rapidly Recurring and Attaining an Enormous Size, in a Child Nine Years of Age. W. H., a well-developed boy nine years old, rather large and mature for his age, was brought to the Wills' Eye Hospital on the igth of January, I894. His parents, who came with him, were both healthy; no constitutional taint could be elicited in the history of the family on either side; one other child was strong and well, and the patient had been hearty until the commencement of the present disease. The parents stated that about the first of August last a redness of the left eye was noticed, and in a few weeks the upper lid commenced to swell. Vision was not at first affected, and was not entirely lost until October, when the swelling was very great and the eyeball protruded. A little later there was slight bleeding from the eye. The child complained of temporal headache. On November 3d the contents of the orbit were removed by Dr. Chisholm of Baltimore, who, kindly replying to my inquiries, writes me that the growth originated in the orbital tissue, and that the protruded eye was destroyed by pressure. There was a fungus mass half as large as a man's fist, which bled occasionally. The patient was so exhausted that it was feared he might die upon the table, but recuperated rapidly after the operation, and in two weeks was apparently in good health and strong enough to ride upon his bicycle. About a month after the operation the parents first noticed -
74
HARLAN: Malzignant Tumor of the Orbit.
a swelling of the lids again, which rapidly increased. On admission to the hospital the patient was in fair general condition, and was free from pain. There was enormous distension of the lids, the skin of which, however, was nowhere broken. The ciliary margin of the upper lid measured more than nine centimetres. The swelling was limited above by the eyebrow, which was only slightly raised, and though tense gave such a decided sense of fluctuation on pressure that it was difficult to resist the impression that it contained fluid. The lower lid was distended to a globular form and was forced downward and outward. Between the lid margins projected a red mass, presenting the appearance of an excessively chemosed conjunctiva. There were no preauricular or other glandular enlargenments. The right eye was normal, with full vision. A few days after admission there was profuse hemorrhage, which was nearly fatal, but which was finally checked by dusting freely with finely powdered monsel salt. The blood came chiefly from along the lid margins, apparently welling up beneath them. The bleeding recurred several times, to a much less extent, but was easily checked by the same application, and after ten days ceased entirely with the exception of a slight oozing. The growth increased rapidly, assumed more and more a fungous character, was bathed with a fetid sanious discharge, threw off shreds of slough, and became very offensive. It extended through the lachrymal duct, filled the nasal cavity and appeared externally as a plug in the nostril. The skin showed a remarkable resistance to its encroachment, and even to the last that of the upper lid maintained its integrity except a superficial slough from pressure at the summit of the swelling; that of the lower lid lost its epithelium and was crowded back beneath the fungous mass. The tumor continued to increase until a few days before death, when its growth no longer kept pace with the loss by sloughing and there was some diminution in its size. These photographs show it at its maximum when it was fully half as, large as the patient's head, and extended nearly to the scalp above, to the ear at the side, and three inches beneath the chin below. The, margin of the
HARLAN: Malignant Tumor of the Orbit.
75
skin is seen in the side view; in the other it is lost by blurring of the outlines with the discharge which covered the surface. It was evident that operative interference would be worse than useless, and treatment was Confined to attempts to make the diseased mass as little offensive as possible. It was washed frequently with peroxide of hydrogen and various antiseptics were applied. The child never complained of pain, there were no cerebral symptoms, and death occurred at last, on March 24th, from exhaustion. A post-mortem examination was made by Dr. Guilford, the senior house surgeon, twelve hours after death. The portion of the tumor extending over the brow and face was necrosed, and was little more than an indistinguishable mass of sloughing tissue. The part chiefly contained within the orbit, about the size of a hen's egg, was vascular and firm. It completely filled the cavity and sent projections beyond it through the eroded walls. The lachrymal bone and about a third of the ethmoid were destroyed, leaving a large opening through which the growth extended into the left side of .the nose. There was also a circular opening, half an inch in diameter, in the orbital plate of the frontal bone through which a process of the tumor passed, pressing up the dura mater. The sphenoidal fissure was greatly enlarged by the destruction of the smaller wing of the sphenoid, and of a considerable portion of the larger wing, and the' growth passed into the cranial cavity, pushing a mass of orbital fat before it. The optic nerve showed no macroscopic changes, but the third nerve, at its point of exit, was involved in a nodule of the growth about half an inch in diameter. The dura mater was somewhat thickened where it came in contact with the tumor, but there was no general meningitis, and the brain was healthly. The orbital portion of the tumor was submitted for microscopical examination to Dr. D. B. Kyle, who pronounced it a "mixed-celled sarcoma, made up mostly of small round cells." The optic nerve was healthy. The rapid growth of the tumor, and the enormous size that it attained are remarkable, as is also the entire freedom from I
HARLAN: Malzignat Tumor of tke Orbit.
76
pain and from cerebral symptoms, even headache, though the intracranial cavity was invaded. The absence of glandular enlargements in this, as well as in the previous case, was a subject of remark, but it is known that the lymphatic glands usually remain unaffected in orbital sarcoma; a fact which tends to confirm the view that the germs of this disease are disseminated through the blood vessels rather than through the lymphatics. I had an impression, which was shared by some of my colleagues who were interested in this case, that extensive orbital tumors in children usually originate as retinal glioma, and that extraocular orbital. sarcoma is comparatively rare in very young subjects. I find, however, a number of cases reported. Among them, four by Lawford* in children from two to ten years of age, in none of which was the ball primarily involved; one of sarcoma in each orbit in a child four years of age by Snell ;t and one by Dr. Weisner of the Demilt Dispensary, in a child six years of age, which rapidly recurred and attained a very large
size.t DISCUSSION.
DR. A. G. HEYL of Philadelphia.- I would like to say a word or two with reference to aniline dyes in the treatment of epithelioma. In Germany the aniline dyes have been used in subcutaneous injections, and I have under my care at present a case which I will here mention. It came to me with the following history: Seven years ago a small scab appeared near the external canthus. It was removed by a surgeon, but the wound never perfectly healed. Two months ago there was a large ulcer with profuse granulations near the outer canthus. The cornea was destroyed and a subcutaneous brawny swelling clear out to the temple, existed. To have attempted to remove or dislodge the tissue would have required an area as large as the palm of my hand, with every chance of making matters much worse. I gave the patient a simple wash of yellow pyoktanin, and was surprised at the end of three weeks to find that the brawny swelling about the ulcer was disappearing. The case has continued to grow better until, at the present time, the ulcer is *Royal London Ophthalmic Hospital Reports, Vol. XII, Part I. t Trans. OpAth. Society, of the United Kingdom, October i9, I893. IInternat. 7ournal of Surgery, Vol. II, I889.
HARLAN: Malignant Tumor of the Orbit.
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closing, and it may be possible to do something in the way of an operative procedure. I have treated another case of epithelioma with this same lotion with little benefit, or with nothing like the benefit in this present case. The case I have in mind is one where the lid has been partially destroyed and the tissues below the lower lid are encroached upon by the ulcer. The two cases were microscopically dissimilar. The case benefited by the pyoktanin was characterized by exuberant granulations in the ulcer and brawny subcutaneous swelling. In the case not benefited the surface of the- ulcer was smooth and depressed below the skin surface, with little brawny infiltration about the edges of the ulcer. Possibly the great uncleanliness of this patient, along with alcoholism, may have interfered with the action of the drug. I speak of these cases to call attention to the use of aniline dyes as a palliative of some value in this disease. DR. C. S. BULL of New York.- Dr. Harlan's first case is very interesting. He describes the case as originating in the lachrymal sac. Was there in addition to that any growth in the nasal cavities ? DR. HARLAN.- The nasal cavities were carefully examined and found free from disease. DR. B. ALEXANDER RANDALL of Philadelphia.- I was of opinion that the aniline dyes might possibly be of some value in combatting neoplasms, so I used them in some epitheliomatous conditions. But any predilection I might have had in tlheir" favor was dashed the other day by the reappearance at my clinic of a patient with epithelioma of the auricle. I thought I had completely curetted away the growth when it was recent and small, as well as dressed freely with pyoktanin, but the man reappeared some six months later, perhaps a year later, with a much more extensive recurrence. This was again removed, and the surgical intervention may result in permanent success. DR. R. A. REEVE of Toronto, Ont.- I would like to mention a case of orbital sarcoma unconnected with the eyeball primarily, which was under my care some years ago, and in which case I photographed the tumor. This was twenty-one inches in circumference, weighed twenty-three ounces, and was removed simply to relieve the child from the effects of the weight and distress. DR. W. B. JOHNSON of Paterson, N. J.- In connection with the suggestion of medicinal injections in sarcomatous disease, I have had some little experience with the injection of the toxic products of erysipelas, and while I cannot say anything in their favor as being effective in these sarcomata of the orbit, I have
78
HARLAN: Malignant Tumor of the Orbit.
had one case of' sarcoma of the pharynx where cicatricial bands formed. and choked or destroyed by absorption the sarcomatous tissue to a very great extent, the accompanying glandular swelling disappeared, and the sarcoma has not returned, although no treatment has been given for four months. I had some experience with the toxic products of erysipelas also in connection with Dr. W. B. Coley, who has kindly furnished the products for use in the case mentioned, and treated a case of sarcoma of the squamous portion of the temporal bone, which, however, resulted unfavorably. It was a case involving the temporal bone, and extending to the dura. I would like to say here that I think that in view of the fact that there certainly have been cases of sarcomatous disease which have been alleviated, if not entirely cured, by the use of the injections of the toxic products of erysipelas, it is a desirable thing that it should be further tried; especially should further trial be made upon those cases of inoperable sarcoma where anything would be better than a nothing. DR. H. KNAPP of New York.- I would like to make a few remarks with regard to the three cases mentioned by Dr. Harlan. With regard to sarcoma of the orbit, these tumors may originate in the adjacent cavities, especially when they produce exophthalmos. I was very much puzzled by a case similar to one of Dr. Harlan's the winter before last, where a child of ,heRlthy parents developed an exophthalmos within two or three days. The upper lid was somewhat swollen and the eye pushed almost straight forward, but on the firmest pressure I could not detect any tumor. In a week the exophthalmos was very much greater, and a distinct tumor was felt on the inner upper side of the orbit. This tumor could not be anything but a sarcoma, and I -advised removal, which was done immediately afterward by a very large incision? going all around, and I removed the sarcoma, as it seemed to me, cleanly; but there was a defect in the upper inner part of the orbital walls, and the tumor rapidly returned. It came under the treatment of Dr. Coley, who has just been mentioned as being connected with another case, who applied the toxine of erysipelas. Then, during my absence, Dr. Born removed the eyeball and the relapse, and he went into it as thoroughly as he could. The eye treated was irritated with the toxine without the least effect. The doctor thought he could arrest the tumor, of which not much was left, but its return was just as rapid ; it filled the orbit very quickly, so that theiparents asked me to make another operation and remove whatever I could. I told them I considered the case hopeless, and advised them not to have it interfered with. They asked
HARLAN: Malignant Tumor of the Orbit.
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me what would become of the tumor if left alone, to which I replied that it would doubtless grow further and disfigure the child very much, and that during its growth, until it had terminated the child's life' by exhaustion, it would be very intractable. Thereupon they asked me to relieve the child as well as I could by removing whatever was left of the tumor - to go as far as- I thought proper. I did so. I found that the tumor had occupied and destroyed the upper inner portion of the wall of the orbit. In the removal of the tumor I took away a considerable portion of the base of the skull. In the progress of the operation a soft blue membrane, distinctly pulsating, was seen and felt behind the apex of the orbit. It was on the anterior wall of the cavernous sinus. The child bore the operation very well. It died, however, a month later. There was no particular suppuration. The interest in the case centered in the observation that the region of the tumor was either in the ethmoidal or sphenoidal cells. I have seen a number of such cases. They produce exophthalmos, which is rapidly progressive as soon as they pierce the orbital wall. The accessory cavities of the orbit and the nose are more 'frequently the origin of orbital disease than we suppose. The greater my experience has become, the more I am convinced of this fact. DR. C. S. BULL of New York.- My opinion, which has been gradually developed from, my experience in cases of orbital tumor in which there is a very rapid increase of the exophthalmos, is that the origin of the trouble is either in the ethmoid or sphenoidal sinuses. That is -the result of my experience in post mortem examinations and clinical observations. While, as surgeons, we are justified, I think, in doing everything we can to relieve the unpleasant symptoms, particularly that of pain, yet I think it is our duty to tell our patients, where we have formed an opinion as to 'the origin of these tumors, even in cases where an operation has not yet been done -not in the case of relapsing tumors, but in original tumors-that the seat of the disease is so deep that no favorable result can be expected; that even if we remove the portions in the'orbit, the growth will return because of the location of the original tumor, and that the life of that patient is inevitably shortened by operative procedure directed toward the removal of the tumnor. Furthermore, that in a relapsing tumor the removal of the growth materially and rapidly shortens the life of the patient. If these facts are stated to the patient and his family, and they are willing to accept the issue, it is probably our duty to' operate, but, in my opinion, not otherwise. P
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HARLAN: Malignant Tumor of the Orbit.
On motion of Dr. Knapp of New York, Dr. Robert R. Tilley of Chicago was invited to sit with the Society and participate in the discussions. DR. ROBERT TILLEY of Chicago.- I have had a case under my observation very similar I suppose, from the remarks of Dr. Knapp,-I did not hear the original paper,- to the one that is now under discussion. About three years ago an old lady from Wisconsin came to Chicago to consult me. Upon examination I found the left eye protruded excessively; it was directed certainly at an angle of 45 degrees from its ordinary course. The nose was so completely filled that her statement that she had not been able to lie down to sleep for six months was very easy to believe. I examined the nose carefully, and was unable to determine the nature of the tissues, because of the passages being so much occluded. It was absolutely useless to endeavor to get at it from the nares. I undertook the operation in St. Luke's Hospital in the presence of Dr. J. E. Owens and a number of railway surgeons. I opened the nose from the frontal sinus to within about half an inch of the tip of the nose, and extracted a quantity of tissue which turned out to be sarcomatous, and in size nearly as large as my two fingers. After exploring the cavity the two frontal lobes of the brain were clearlv exposed, and the pulsations could be distinctly seen. The operation was performed with very little difficulty, but the tumor began to appear after about one month. Immediately after the operation the old lady laid-down and slept through the entire night, something that had been entirely impossible for her to do in the preceding six months, according to her son's statement. Soon afterward she expressed herself as being perfectly well, and the eye returned to its normal position, which was a source of very great comfort to the old lady. Only two weeks ago I saw a case very similar, though perhaps not so far advanced. It was, however, associated with the right orbit, and there was a distinct enlargement of the middle turbinated bone. The eye was only slightly protruded, and relatively only slightly directed from its normal course, too much, however, for him to have any difficulty about double images. I told him and his son, an engineer, who was with him, what in all probability was the best course to adopt, but he did not choose to follow my advice, and probably I shall not see
him again. DR. GEORGE C. HARLAN of Philadelphia.- There is not the slightest doubt that in the case of my patient the disease originated in the orbit. At the time of the operation, Dr. Chisholm
BURNETT: Tumor of the Intervaginal Space, etc.
8I
removed the contents of the orbit and found none of the neighboring cavities open. Later, as I have stated, the disease did invade the nasal and intercranial cavities, but not until some time after the patient came under my care. The appearance of the tumor in the nasal cavity was not observed until a few days before death. At the post mortem, processes of the tumor were found in the intercranial cavity, and also a mass of orbital fat, not involved in the disease, which had been mechanically pushed before the rapidly increasing growth.
TUMOR OF THE INTERVAGINAL SPACE OF THE OPTIC-NERVE SHEATH. BY SWAN M. BURNETT, M.D., PH.D., WASHINGTON, D. C.
Joseph Messmann, 7 years of age, was brought to me on June 28, I893, on account of an extreme exophthalmus of the left eye. The following history I obtained from his father, who accompanied him, and from Drs. McSherry and Meyers of Martinsburg, W. Va., who had attended the boy since infancy. Though not at all strong-looking, nor large for his age, his general health, except for the ordinary diseases of childhood, is reported as having been fairly good. In the latter part of I889 he had an attack of la grippe, followed by a hacking cough and a remitting fever which latter lasted for some weeks. Accompanying and succeeding this there was a very quick and irregular action of the heart. It was during this period of irregular heart action that a slight protrusion of the eye was first noticed. The cardiac trouble subsided in about a year. In the spring of I890 it was discovered that he could not see very well with that eye. It is supposed that it was about this time that the exophthalmos was first noticed. Even at the time when the blindness was first detected he could count fingers only at 2 or 3 feet. By the autumn the blindness was complete, though the protrusion had increased but slightly and was noticeable only on careful inspection. The progress of the exophthalmos has been very gradual, and without any pain except an occasional slight one at OPH.-6
HARLAN:
Malignant Tumor of the Orbit.
there was a subsequent return of normal vision in that eye, although the shot passed just without the limbus in the ciliary region, and the point of location at which the shot passed out of the eye could also be demonstrated on the fundus by ophthalmoscopic examination. It became a foreign body in the orbit, and became encysted there, I suppose. There was no further trouble, and the vision became normal. I think these cases of foreign bodies in the orbital cavity are very interesting. Fortunately we do not see very many of them, and I think it is a very good thing that we do not, although the orbital contents; certainly in a great many instances, are able to withstand a great deal of injury and come out of it in very good condition. Case No. 2, however, in which the foreign body penetrated the cerebral cavity, was very serious. In the reported cases of foreign body in the orbit which came to autopsy, the cerebral cavity had generally been penetrated and cerebral disease had resulted. Whether many of the other cases which recovered, although the foreign bodies were so large as to have almost certainly penetrated the cerebral cavity, really did recover after such penetration, can only be conjectured, although the indications all seem to point to the probability of such injury occurring without fatal termination.
THREE CASES OF MALIGNANT TUMOR OF THE ORBIT. BY GEORGE C. HARLAN, M.D., PHILADELPHIA, PA.
The great variety and grave significance of orbital diseases make this always an important subject in clinical ophthalmology, and may justify the report of three cases that have recently occurred in my practice, and which seem to present some points of sufficient interest to claim a few minutes of your time. CASE I. Epithelial Orbital Tumor Orzginatinzg in the Laclrymal Sac; Rapid Recurrence. J. McC., a farmer 40 years old, in good general health, was admitted to the Pennsylvania Hospital, November 25, I893. He stated that his attention had been first called to the right eye about eight months be-
HARLAN: Malignant Tumor of the Orbit.
71
fore by an overflow of tears. Afterwards there was a good deal of pain in eye and temple, and the lower lid commenced to swell. The lower lid was protruded and the eye was pushed upward and outward by a tumor which reached from the inner canthus to the junction of the middle and outer thirds of the lid, overlapped the orbital margin and extended back into the orbit on the lower and inner side of the ball. It was entirely beneath the conjunctiva, which was not involved, and was solid and very hard to the touch. The nasal sinuses were free from disease. Vision, W5/cc. With the ophthalmoscope, the fundus was indistinct from haziness of the cornea, but a swelling of the disc could be determined. There were no glandular enlargements. The tumor was removed on December 2, I893, through a free incision in the lid, without disturbing the eyeball. It was as large as a small hen's egg and of irregular conical form, was firmly adherent at the lachrymal groove and extended along the floor and inner wall of the orbit, where the bone was denuded of periosteum, nearly to the optic foramen. Recovery was delayed by the formation of an orbital abscess, which was lanced above the ball, but the patient was discharged in good condition in three weeks (January 23, I894). The eye had no power of adduction. The growth was examined by Dr. McFarland, Demonstrator in Pathology in the University of Pennsylvania, who pronounced it a " squamous epithelioma, greatly resembling scirrhous cancer, but an undoubted epithelioma." On March I3th, a little more than three months after the operation, the patient presented himself again. There was no exophthalmos, and vision had increased from 15/cc to 15/40; but a hard mass of considerable size could be felt at the inner canthus and extending back into the orbit in the position of the former tumor. It was decided to remove the whole contents of the orbit, including the periosteum, which was done on March I7, I894. There was extensive destruction of the walls of the lachrymal groove, making an opening large enough
72
HARLAN: Malignant Tumor of the Orbit.
to admit the end of the little finger. The edges of this opening were cut away with the gouge and the Paquelin cautery was freely applied. The points of interest in this case are the character df the growth, its place of origin, and its rapid recurrence. Tumors of an epithelial type are rare in the orbit, and have been described as originating in the lids, the conjunctiva, the lachrymal gland, or the mucous membrane of neighboring sinuses. A degenerated dermoid cyst may be the point of origin (Berlin). I have not met in literature with any report of a growth of this kind originating in the lachrymal sac. The history given by the patient, and the conditions revealed by the operation leave no doubt of such an origin in the present case. The earliest symptom was epiphora. The skin and conjunctiva were not involved, and the closest adhesion was at the lachrymal groove, the walls of which were subsequently extensively eroded. CASE II. Sarcomatous Growth Completely Filling the Orbit; Apparently Originating in Tenon's Capsule. S. F., a laborer, aged 52, was admitted to the Pennsylvania Hospital, February i, 1894. The history of the case was indefinite and obscure. We could only make out that the sight of the right eye had commenced to fail two or three months before, and that the patient had suffered a good deal from pain in the eye and head since that time. The lids were enormously distended, and the eye, which was sightless, was displaced outward and upward by a hard tumor that filled the orbit. The conjunctiva was chemosed, and the ball was perfectly immovable. The upper third of the cornea was covered by a mass of tissue presenting the appearance of a very dense pannus. There were no glandular enlargements. The contents of the orbit were removed, and were found to consist entirely of a solid mass in which the eyeball was imbedded, no anatomical structures being microscopically recognizable. The ball was compressed to a pear shape and firmly incorporated in the tumor, but the sclerotic was sound. A greater part of the floor of the orbit was destroyed, and there were two holes, about five millimetres in diameter, in the roof. What remained of the periosteum was carefully removed. The patient made a prompt and good recovery.
HARLAN: Maligniant Tumor of the Orbit.
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The tumor was examined microscopically by Dr. H. M. Fisher, Pathologist of the Hospital, who pronounced it a large, round-celled sarcoma. The chief point of interest in this case is the very rapid development of the tumor. The patient belonged to a class not likely to detect the earliest symptoms of disease, but he stated very positively that he had suffered no inconvenience until less than three months before his admission to the hospital. The solid incorporation of the eyeball in the tumor, and the encroachment of the growth upon -the -anterior part of the sclerotic and the cornea point to the capsule of Tenon as the place of origin. CASE III. Sarcoma of the Orbit, Rapidly Recurring and Attaining an Enormous Size, in a Child Nine Years of Age. W. H., a well-developed boy nine years old, rather large and mature for his age, was brought to the Wills' Eye Hospital on the igth of January, I894. His parents, who came with him, were both healthy; no constitutional taint could be elicited in the history of the family on either side; one other child was strong and well, and the patient had been hearty until the commencement of the present disease. The parents stated that about the first of August last a redness of the left eye was noticed, and in a few weeks the upper lid commenced to swell. Vision was not at first affected, and was not entirely lost until October, when the swelling was very great and the eyeball protruded. A little later there was slight bleeding from the eye. The child complained of temporal headache. On November 3d the contents of the orbit were removed by Dr. Chisholm of Baltimore, who, kindly replying to my inquiries, writes me that the growth originated in the orbital tissue, and that the protruded eye was destroyed by pressure. There was a fungus mass half as large as a man's fist, which bled occasionally. The patient was so exhausted that it was feared he might die upon the table, but recuperated rapidly after the operation, and in two weeks was apparently in good health and strong enough to ride upon his bicycle. About a month after the operation the parents first noticed -
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HARLAN: Malzignant Tumor of the Orbit.
a swelling of the lids again, which rapidly increased. On admission to the hospital the patient was in fair general condition, and was free from pain. There was enormous distension of the lids, the skin of which, however, was nowhere broken. The ciliary margin of the upper lid measured more than nine centimetres. The swelling was limited above by the eyebrow, which was only slightly raised, and though tense gave such a decided sense of fluctuation on pressure that it was difficult to resist the impression that it contained fluid. The lower lid was distended to a globular form and was forced downward and outward. Between the lid margins projected a red mass, presenting the appearance of an excessively chemosed conjunctiva. There were no preauricular or other glandular enlargenments. The right eye was normal, with full vision. A few days after admission there was profuse hemorrhage, which was nearly fatal, but which was finally checked by dusting freely with finely powdered monsel salt. The blood came chiefly from along the lid margins, apparently welling up beneath them. The bleeding recurred several times, to a much less extent, but was easily checked by the same application, and after ten days ceased entirely with the exception of a slight oozing. The growth increased rapidly, assumed more and more a fungous character, was bathed with a fetid sanious discharge, threw off shreds of slough, and became very offensive. It extended through the lachrymal duct, filled the nasal cavity and appeared externally as a plug in the nostril. The skin showed a remarkable resistance to its encroachment, and even to the last that of the upper lid maintained its integrity except a superficial slough from pressure at the summit of the swelling; that of the lower lid lost its epithelium and was crowded back beneath the fungous mass. The tumor continued to increase until a few days before death, when its growth no longer kept pace with the loss by sloughing and there was some diminution in its size. These photographs show it at its maximum when it was fully half as, large as the patient's head, and extended nearly to the scalp above, to the ear at the side, and three inches beneath the chin below. The, margin of the
HARLAN: Malignant Tumor of the Orbit.
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skin is seen in the side view; in the other it is lost by blurring of the outlines with the discharge which covered the surface. It was evident that operative interference would be worse than useless, and treatment was Confined to attempts to make the diseased mass as little offensive as possible. It was washed frequently with peroxide of hydrogen and various antiseptics were applied. The child never complained of pain, there were no cerebral symptoms, and death occurred at last, on March 24th, from exhaustion. A post-mortem examination was made by Dr. Guilford, the senior house surgeon, twelve hours after death. The portion of the tumor extending over the brow and face was necrosed, and was little more than an indistinguishable mass of sloughing tissue. The part chiefly contained within the orbit, about the size of a hen's egg, was vascular and firm. It completely filled the cavity and sent projections beyond it through the eroded walls. The lachrymal bone and about a third of the ethmoid were destroyed, leaving a large opening through which the growth extended into the left side of .the nose. There was also a circular opening, half an inch in diameter, in the orbital plate of the frontal bone through which a process of the tumor passed, pressing up the dura mater. The sphenoidal fissure was greatly enlarged by the destruction of the smaller wing of the sphenoid, and of a considerable portion of the larger wing, and the' growth passed into the cranial cavity, pushing a mass of orbital fat before it. The optic nerve showed no macroscopic changes, but the third nerve, at its point of exit, was involved in a nodule of the growth about half an inch in diameter. The dura mater was somewhat thickened where it came in contact with the tumor, but there was no general meningitis, and the brain was healthly. The orbital portion of the tumor was submitted for microscopical examination to Dr. D. B. Kyle, who pronounced it a "mixed-celled sarcoma, made up mostly of small round cells." The optic nerve was healthy. The rapid growth of the tumor, and the enormous size that it attained are remarkable, as is also the entire freedom from I
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pain and from cerebral symptoms, even headache, though the intracranial cavity was invaded. The absence of glandular enlargements in this, as well as in the previous case, was a subject of remark, but it is known that the lymphatic glands usually remain unaffected in orbital sarcoma; a fact which tends to confirm the view that the germs of this disease are disseminated through the blood vessels rather than through the lymphatics. I had an impression, which was shared by some of my colleagues who were interested in this case, that extensive orbital tumors in children usually originate as retinal glioma, and that extraocular orbital. sarcoma is comparatively rare in very young subjects. I find, however, a number of cases reported. Among them, four by Lawford* in children from two to ten years of age, in none of which was the ball primarily involved; one of sarcoma in each orbit in a child four years of age by Snell ;t and one by Dr. Weisner of the Demilt Dispensary, in a child six years of age, which rapidly recurred and attained a very large
size.t DISCUSSION.
DR. A. G. HEYL of Philadelphia.- I would like to say a word or two with reference to aniline dyes in the treatment of epithelioma. In Germany the aniline dyes have been used in subcutaneous injections, and I have under my care at present a case which I will here mention. It came to me with the following history: Seven years ago a small scab appeared near the external canthus. It was removed by a surgeon, but the wound never perfectly healed. Two months ago there was a large ulcer with profuse granulations near the outer canthus. The cornea was destroyed and a subcutaneous brawny swelling clear out to the temple, existed. To have attempted to remove or dislodge the tissue would have required an area as large as the palm of my hand, with every chance of making matters much worse. I gave the patient a simple wash of yellow pyoktanin, and was surprised at the end of three weeks to find that the brawny swelling about the ulcer was disappearing. The case has continued to grow better until, at the present time, the ulcer is *Royal London Ophthalmic Hospital Reports, Vol. XII, Part I. t Trans. OpAth. Society, of the United Kingdom, October i9, I893. IInternat. 7ournal of Surgery, Vol. II, I889.
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closing, and it may be possible to do something in the way of an operative procedure. I have treated another case of epithelioma with this same lotion with little benefit, or with nothing like the benefit in this present case. The case I have in mind is one where the lid has been partially destroyed and the tissues below the lower lid are encroached upon by the ulcer. The two cases were microscopically dissimilar. The case benefited by the pyoktanin was characterized by exuberant granulations in the ulcer and brawny subcutaneous swelling. In the case not benefited the surface of the- ulcer was smooth and depressed below the skin surface, with little brawny infiltration about the edges of the ulcer. Possibly the great uncleanliness of this patient, along with alcoholism, may have interfered with the action of the drug. I speak of these cases to call attention to the use of aniline dyes as a palliative of some value in this disease. DR. C. S. BULL of New York.- Dr. Harlan's first case is very interesting. He describes the case as originating in the lachrymal sac. Was there in addition to that any growth in the nasal cavities ? DR. HARLAN.- The nasal cavities were carefully examined and found free from disease. DR. B. ALEXANDER RANDALL of Philadelphia.- I was of opinion that the aniline dyes might possibly be of some value in combatting neoplasms, so I used them in some epitheliomatous conditions. But any predilection I might have had in tlheir" favor was dashed the other day by the reappearance at my clinic of a patient with epithelioma of the auricle. I thought I had completely curetted away the growth when it was recent and small, as well as dressed freely with pyoktanin, but the man reappeared some six months later, perhaps a year later, with a much more extensive recurrence. This was again removed, and the surgical intervention may result in permanent success. DR. R. A. REEVE of Toronto, Ont.- I would like to mention a case of orbital sarcoma unconnected with the eyeball primarily, which was under my care some years ago, and in which case I photographed the tumor. This was twenty-one inches in circumference, weighed twenty-three ounces, and was removed simply to relieve the child from the effects of the weight and distress. DR. W. B. JOHNSON of Paterson, N. J.- In connection with the suggestion of medicinal injections in sarcomatous disease, I have had some little experience with the injection of the toxic products of erysipelas, and while I cannot say anything in their favor as being effective in these sarcomata of the orbit, I have
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HARLAN: Malignant Tumor of the Orbit.
had one case of' sarcoma of the pharynx where cicatricial bands formed. and choked or destroyed by absorption the sarcomatous tissue to a very great extent, the accompanying glandular swelling disappeared, and the sarcoma has not returned, although no treatment has been given for four months. I had some experience with the toxic products of erysipelas also in connection with Dr. W. B. Coley, who has kindly furnished the products for use in the case mentioned, and treated a case of sarcoma of the squamous portion of the temporal bone, which, however, resulted unfavorably. It was a case involving the temporal bone, and extending to the dura. I would like to say here that I think that in view of the fact that there certainly have been cases of sarcomatous disease which have been alleviated, if not entirely cured, by the use of the injections of the toxic products of erysipelas, it is a desirable thing that it should be further tried; especially should further trial be made upon those cases of inoperable sarcoma where anything would be better than a nothing. DR. H. KNAPP of New York.- I would like to make a few remarks with regard to the three cases mentioned by Dr. Harlan. With regard to sarcoma of the orbit, these tumors may originate in the adjacent cavities, especially when they produce exophthalmos. I was very much puzzled by a case similar to one of Dr. Harlan's the winter before last, where a child of ,heRlthy parents developed an exophthalmos within two or three days. The upper lid was somewhat swollen and the eye pushed almost straight forward, but on the firmest pressure I could not detect any tumor. In a week the exophthalmos was very much greater, and a distinct tumor was felt on the inner upper side of the orbit. This tumor could not be anything but a sarcoma, and I -advised removal, which was done immediately afterward by a very large incision? going all around, and I removed the sarcoma, as it seemed to me, cleanly; but there was a defect in the upper inner part of the orbital walls, and the tumor rapidly returned. It came under the treatment of Dr. Coley, who has just been mentioned as being connected with another case, who applied the toxine of erysipelas. Then, during my absence, Dr. Born removed the eyeball and the relapse, and he went into it as thoroughly as he could. The eye treated was irritated with the toxine without the least effect. The doctor thought he could arrest the tumor, of which not much was left, but its return was just as rapid ; it filled the orbit very quickly, so that theiparents asked me to make another operation and remove whatever I could. I told them I considered the case hopeless, and advised them not to have it interfered with. They asked
HARLAN: Malignant Tumor of the Orbit.
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me what would become of the tumor if left alone, to which I replied that it would doubtless grow further and disfigure the child very much, and that during its growth, until it had terminated the child's life' by exhaustion, it would be very intractable. Thereupon they asked me to relieve the child as well as I could by removing whatever was left of the tumor - to go as far as- I thought proper. I did so. I found that the tumor had occupied and destroyed the upper inner portion of the wall of the orbit. In the removal of the tumor I took away a considerable portion of the base of the skull. In the progress of the operation a soft blue membrane, distinctly pulsating, was seen and felt behind the apex of the orbit. It was on the anterior wall of the cavernous sinus. The child bore the operation very well. It died, however, a month later. There was no particular suppuration. The interest in the case centered in the observation that the region of the tumor was either in the ethmoidal or sphenoidal cells. I have seen a number of such cases. They produce exophthalmos, which is rapidly progressive as soon as they pierce the orbital wall. The accessory cavities of the orbit and the nose are more 'frequently the origin of orbital disease than we suppose. The greater my experience has become, the more I am convinced of this fact. DR. C. S. BULL of New York.- My opinion, which has been gradually developed from, my experience in cases of orbital tumor in which there is a very rapid increase of the exophthalmos, is that the origin of the trouble is either in the ethmoid or sphenoidal sinuses. That is -the result of my experience in post mortem examinations and clinical observations. While, as surgeons, we are justified, I think, in doing everything we can to relieve the unpleasant symptoms, particularly that of pain, yet I think it is our duty to tell our patients, where we have formed an opinion as to 'the origin of these tumors, even in cases where an operation has not yet been done -not in the case of relapsing tumors, but in original tumors-that the seat of the disease is so deep that no favorable result can be expected; that even if we remove the portions in the'orbit, the growth will return because of the location of the original tumor, and that the life of that patient is inevitably shortened by operative procedure directed toward the removal of the tumnor. Furthermore, that in a relapsing tumor the removal of the growth materially and rapidly shortens the life of the patient. If these facts are stated to the patient and his family, and they are willing to accept the issue, it is probably our duty to' operate, but, in my opinion, not otherwise. P
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HARLAN: Malignant Tumor of the Orbit.
On motion of Dr. Knapp of New York, Dr. Robert R. Tilley of Chicago was invited to sit with the Society and participate in the discussions. DR. ROBERT TILLEY of Chicago.- I have had a case under my observation very similar I suppose, from the remarks of Dr. Knapp,-I did not hear the original paper,- to the one that is now under discussion. About three years ago an old lady from Wisconsin came to Chicago to consult me. Upon examination I found the left eye protruded excessively; it was directed certainly at an angle of 45 degrees from its ordinary course. The nose was so completely filled that her statement that she had not been able to lie down to sleep for six months was very easy to believe. I examined the nose carefully, and was unable to determine the nature of the tissues, because of the passages being so much occluded. It was absolutely useless to endeavor to get at it from the nares. I undertook the operation in St. Luke's Hospital in the presence of Dr. J. E. Owens and a number of railway surgeons. I opened the nose from the frontal sinus to within about half an inch of the tip of the nose, and extracted a quantity of tissue which turned out to be sarcomatous, and in size nearly as large as my two fingers. After exploring the cavity the two frontal lobes of the brain were clearlv exposed, and the pulsations could be distinctly seen. The operation was performed with very little difficulty, but the tumor began to appear after about one month. Immediately after the operation the old lady laid-down and slept through the entire night, something that had been entirely impossible for her to do in the preceding six months, according to her son's statement. Soon afterward she expressed herself as being perfectly well, and the eye returned to its normal position, which was a source of very great comfort to the old lady. Only two weeks ago I saw a case very similar, though perhaps not so far advanced. It was, however, associated with the right orbit, and there was a distinct enlargement of the middle turbinated bone. The eye was only slightly protruded, and relatively only slightly directed from its normal course, too much, however, for him to have any difficulty about double images. I told him and his son, an engineer, who was with him, what in all probability was the best course to adopt, but he did not choose to follow my advice, and probably I shall not see
him again. DR. GEORGE C. HARLAN of Philadelphia.- There is not the slightest doubt that in the case of my patient the disease originated in the orbit. At the time of the operation, Dr. Chisholm
BURNETT: Tumor of the Intervaginal Space, etc.
8I
removed the contents of the orbit and found none of the neighboring cavities open. Later, as I have stated, the disease did invade the nasal and intercranial cavities, but not until some time after the patient came under my care. The appearance of the tumor in the nasal cavity was not observed until a few days before death. At the post mortem, processes of the tumor were found in the intercranial cavity, and also a mass of orbital fat, not involved in the disease, which had been mechanically pushed before the rapidly increasing growth.
TUMOR OF THE INTERVAGINAL SPACE OF THE OPTIC-NERVE SHEATH. BY SWAN M. BURNETT, M.D., PH.D., WASHINGTON, D. C.
Joseph Messmann, 7 years of age, was brought to me on June 28, I893, on account of an extreme exophthalmus of the left eye. The following history I obtained from his father, who accompanied him, and from Drs. McSherry and Meyers of Martinsburg, W. Va., who had attended the boy since infancy. Though not at all strong-looking, nor large for his age, his general health, except for the ordinary diseases of childhood, is reported as having been fairly good. In the latter part of I889 he had an attack of la grippe, followed by a hacking cough and a remitting fever which latter lasted for some weeks. Accompanying and succeeding this there was a very quick and irregular action of the heart. It was during this period of irregular heart action that a slight protrusion of the eye was first noticed. The cardiac trouble subsided in about a year. In the spring of I890 it was discovered that he could not see very well with that eye. It is supposed that it was about this time that the exophthalmos was first noticed. Even at the time when the blindness was first detected he could count fingers only at 2 or 3 feet. By the autumn the blindness was complete, though the protrusion had increased but slightly and was noticeable only on careful inspection. The progress of the exophthalmos has been very gradual, and without any pain except an occasional slight one at OPH.-6
