GRUENING: Tumor of the Left Occipital Lobe.
349
of cases and was much pleased with it, until finally it was followed in one case by pan-ophthalmitis. At that time antiseptic precautions were of course not employed. DR. KNAPP.-I did not consider it a safe operation one year ago, but since that time my views have considerably changed, as the result of experiments and of increased knowledge concerning the antiseptic treatment of wounds. More traumatic injury to the eyes is borne with impunity, than I would before have ventured to inflict. I think that it will not be possible to exclude suppuration in all operations, but where it occurs we must regard it as the result of infection and not due to the traumatism alone.
A CASE OF TUMOR OF THE LEFT OCCIPITAL LOBE WITH RIGHT HOMONYMOUS HEMIANOPSIA (WITH AUTOPSY). BY EMIL GRUENING, M.D., NEW YORK.
IN I855 Von Graefe pointed out the importance of the examination of the visual field in amblyopic affections, and foretold that the hemiopic visual defects would become important in the study of the intra-cerebral optic paths and centres. Since that time clinical ophthalmology has been cultivating the methods of examining the field of vision. As one of the many beautiful results yielded by this mode of functional examination, we may mention the clinical demonstration of the semi-decussation of the optic nerves in the chiasma. At the present day the physiologist Munk teaches that the primary visual centres occupy circumscribed regions in the occipital cortex, and that the visual area of each occipital lobe connects with the retina of both eyes in such a maniner that the right half of each retina belongs to the right occiput, and the left half of each retina to the left occiput. But modern physiology, as taught by Goltz, maintains that Munk's views have been derived from insufficient and erroneous observations, and 45
350
CRUENING: A Case of Tumor of the
that all attempts to map out in the cortex of the brain a mosaic of functional districts have hitherto proved futile. Thus, in regard to the localization of functional centres in the cortex of the brain, we have a positive and a negative modern school of physiology. The tenets of these schools are now being tested by clinical observations and pathological facts. Clinical medicine and special neurology vie with each other in the study of the visual field, as predicted by Von Graefe. Already certain lateral defects of the fields of vision, when combined with special groups of symptoms, allow the diagnosis of localized lesions of the brain. Aside from the well known tractus hemianopsia, we diagnosticate at present a thalamus hemianopsia, a fasciculus hemianopsia, and a cortex hemianopsia. Thus far clinical observation and pathological examination corroborate the physiological views held by Munk. In America two cases of hemianopsia with autopsy have recently been published, the first by Dr. E. C. Seguin in the January number (i886) of the Journal of Nervous and Mental Diseases, edited by Dr. B. Sachs, the second by Dr. E. G. Janeway, in the May-June double number of the same Journal. The following case of right homonymous hemianopsia, caused by a tumor of the left occipital lobe, came under my observation: History.-Frederick Henkler, a tailor, fifty-five years old, consulted me in October, 1883. He gave a good family history, and said that he himself had always been healthy. He had not acquired syphilis. In October, I882, he had been attacked by severe pain in the left temporal region. The pain radiated from the temple to the occiput, lessened toward evening, and vanished during the night. Sleep and digestion were not distqrbed. In April, I883, he observed that his vision had diminished, and an examination made by an oculist revealed that he could see nothing on his right side. Iodide of potassium was then prescribed. This, however, did not improve his condition, but rather, as he thought, caused indigestion. Frequent vomiting soon followed. The
Left Occipital Lobe.
351I
summer of I 883, he spent in the country. In spite of the use of the iodide of potassium, the headache increased, and the vomiting continued. The headache became very violent in the night. In this condition the patient returned to the city, in September, I883, and found his visual power greatly diminished. Soon afterwards he consulted me. The examination showed that the right halves of the fields of vision were lacking. It was a case of complete and absolute right-sided hemianopsia. The line of separation was vertical and fell about two degrees beyond the point of fixation. The left halves of the fields of vision were peripherally contracted. In the horizontal meridian the field of vision of the right eye measured only forty, that of the left eye fifty-five degrees, instead of sixty and ninety. Central acuity of vision was reduced to U& in each eye. The color perception was still good and the pupillary reaction prompt. The ocular muscles were not disturbed. By the ophthalmoscope both papillae were seen to be prominent, their outlines indistinct, the retinal veins broad and tortuous, the arteries threadlike. He presented the typical picture -of choked disk. Several weeks later the patient was examined by Dr. Landon Carter Gray, who had the kindness to write to me about him as follows: "The patient has an unsteady gait. This symptom may depend upon the visual disturbance. No staggering with closed eyes. The lower portion of the left half of the face is slightly paretic. There is a slight right-sided hemiparesis and hemianresthesia." I did not see the patient again. In February, I884, Dr. Pinner, the family physician, wrote me that the patient was dead, and that his friends allowed an examination of the head. Dr. Schapringer kindly assisted me in the autopsy. A ltopsy'.-On opening the cranium I found the dura mater very tense, the convolutions flattened. The left hemisphere was larger than the right. The pons was displaced to the right. Apart from this displacement, the base of the brain showed no anomaly. In viewing the surface of the brain a lhar(d mass was detected, occuLpying the posterior part of the left occipital lob.. The enitire tip of the occipital lobe was re-
352
GRUENING: A Case of Tumor of the
placed by this tumor. After removing the pia mater from the occipital lobe, the greater part of its second convolution and its entire first and third convolutions were found to he chahged into a soft, almost liquid substance, covering the hard mass of the tumor. At several points the latter rose beyond the surface of the convexity of the brain. When the brain had become stfficiently hardened in Mueller's fluid, an incision was made through the left hemisphere, at the distance of 2.5 centimetres from the median line. The incision passed through the mass of the hard tumor, which was enclosed in a capsule and measured about ten centimetres in diameter. The white substance of the occipital lobe was almost entirely destroyed by the growth. The white substance underlying the gyrus angularis had also disappeared. The optic nerves, the chiasma, the optic tracts, seemed normal to macroscopic inspection. The pulvinar and the corpus geniculatum laterale were slightly flattened, probably from the pressure of the tumor.
The tumor was examined by the microscope and found to be a spindle-cell sarcoma. Remarks.-The first alarming symptom in our case was the persistent headache, the second the diminution of vision. The ophthalmoscopic examination revealed the choked disc, the functional examination the right lateral hemianopsia. The continuous headache, the repeated attacks of vomiting, and the existence of choked disc, indicated the presence of a tumor in the brain, while the right homonymous hemianopsia indicated that this tumor was situated in the left hemisphere. We know that such lateral hemianopsia may be caused by disease (i) of the tractus, (2) of the thalamus, or the second optic centres, (3) of the fasciculus of Gratiolet, and (4) of the occipital cortex, or the first optic centres. In conjunction with the hemianopsia, we noted in our case right hemianaesthesia and hemiparesis. This combination of symptoms allowed the exclusion of both the pure tractus hemianopsia and the pure cortex hemianopsia. The association of hemianopsia with hemianaesthesia and hemiparesis argutied for either an affection of the thalamrus
Left Occipital Lobe.
353
(pulvinar, second centres) or the fasciculus of Gratiolet (white substance of the occipital lobe). The absence of convulsive movements, the tardy appearance of the hemianaesthesia and hemiparesis were valid arguments against the existence of a lesion of the thalamus. The clinical course of the case justified rather the assumption of the presence of disease in that portion of the white substance of the occipital lobe where the optic paths traverse the posterior division of the internal capsule. DISCUSSION.
DR. NOYES.-I should like to hear Dr. Gruening's opinion in regard to the statement made two years ago that lesion of the cortex is capable of producing total blindness of the eye of the opposite side. DR. GRUENING.-There is no such case on record. In the forty-five cases collected by Dr. Seg-uin, no such case is included. DR. LORING.-I think that Charcot's scheme was gotten up for that purpose. Ferrier also claimed that there was total blindness when the angular gyrus was destroyed. DR. GRUENING.-I speak only of clinical observations verified by pathological examinations. Those were physiolog,ical experiments on lower animals. The facts which I present are derived only from clinical observation with pathological confirmation. DR. LORING.-Do you mean to say that Hughling Jackson's case is not on record ? DR. GRUENING.-It is not on the list of Dr. Seg,uin. These are only cases in which post-mortem examinations have been made. DR. WVADSWORTH.-In regard to Charcot's scheme, it has been stated by one of the New York neurologists that he had recently been present at a lecture by Charcot, in which he used the ordinary scheme and had apparently abandoned his old one. It has also been stated that Fere, who was Charcot's pupil and formerly used his scheme, had given it up. I think that the evidence is all against Charcot's scheme. Of the cases which have been reported, I do not remember any clean case of blindness of one eye from injury of one side of the brain. Such cases as the result of experiment have been reported, but they may be explained in other ways than as the direct result of lesion of only otie side of the brain. When total
354
GRUENING: Tumor of the Left Occipital Lobe.
blindness of one eye has been accompanied by neuritis, the neuritis may be the cause of the blindness. DR. JACKSON.-I think that Charcot's scheme, which was proposed several years ago, was proposed to explain the cases then on record, and the results of experiments on the lower animals. The cases on record at that time had not been observed as carefully as those reported within the last few years. In a large number of those cases the only testimony as regards the field of vision was the statement of the patient. A patient might state that he was blind in one eye, when perhaps he was only blind for objects toward one side. He would notice blindness which affected the nasal side of the retina, while he might not notice that which involved the temporal side of the retina, and in these cases central vision is nearly always preserved, unless there be some complicating lesion. In reference to the lower animals, I think that there is none in which anatomical investigation shows the same arrangement of the afferent fibres of the optic nerve as in man. In most the decussation is complete, which makes the arrangement analogous to that of other afferent nerves. The same analogy is preserved in the case of human beings. There are few animals in which there is any approach to binocular vision. Their right eyes see objects on the right side, and their left eyes see objects on the left side; so that in the lower animals complete blindness in the opposite eye is analogous to blindness of the right or left halves of both retinae in the human eye. I am sure that Charcot has abandoned that explanation. DR. MITTENDORF.-I would ask whether or not the original idea of Munk, which I do not see indicated on the chart, of partial overlapping of the central occipital fibres in the median line, is still adhered to ? Was that omitted on purpose ? DR. GRUENING.-I think that Munk does not adhere to that view. The explanations intended to throw light into other cases of hemianopsia have not been successful. This seems to me very clear and is based upon pathological observation. It is furthermore confirmed by anatomical investigations, especially by the degeneration methods of Gudden and also by the latest physiological facts found by Munk. DR. MITTENDORF.-I think that Dr. Gruening did not understand my question. I think that Munk maintained that some fibres from one side would run to the other, and thus cause a partial decussation of the central fibres in the median line at the seat of origin, the gray matter of the occipital lobe. DR. GRUENING-.In my studies I have not met with the stateme2nt that there is a commissure between these fibres.
PROUT: Anomalous Formation in the Vitreous.
355
DR. NoYEs.-I might add a word in regard to the situation of the visual centre in the cortex. In the first experiments of Ferrier, it was located in the angular gyrus; later this was extended. I had an opportunity a year ago to go into the laboratory of Prof. Gudden, of Munich. He stated that his experiments had shown him that in cats the visual area in the cortex extended over a large surface and was not limited to such narrow bounds as some had been disposed to believe.
AN ANOMALOUS FORMATION IN THE VITREOUS HUMOR OF EACH EYE. By J. S. PROUT, M.D., BROOKLYN, N. Y.
MR. F. H. C., aged twenty-six, a medical student, who consulted me recently, described his condition as follows: "About two years ago I noticed a peculiar line-like object in each eye, resembling a flexible cord attached above and below, which played across the eye with a snake-like motion with the movements of the ball, and wvhich appeared most plainly when looking steadily at a bright object. It has continued unchanged since first seen. It seems to be semi-transparent, with a fringe-like border, does not cause any inconvenience and is only seen when my attention is called to it. The flame of a lamp or of an ordinary gas-jet when seen at the distance of about one hundred feet with the right eye appears as a bright circle with a central round dark spot, while with the left eye the same object appears as a bright circle with a small dark ring at the centre. In each case the circle is to the left side of and touches the flame. It causes no inconvenience." He further says that his eyes have never been inflamed, painful or injured in any way. They are entirely normal in external appearance. He has no asthenopic symptoms. 0. D. cyl. axis 20°, V. = 0. S. -^-4'w cyl. axis go', V. 45W.
349
of cases and was much pleased with it, until finally it was followed in one case by pan-ophthalmitis. At that time antiseptic precautions were of course not employed. DR. KNAPP.-I did not consider it a safe operation one year ago, but since that time my views have considerably changed, as the result of experiments and of increased knowledge concerning the antiseptic treatment of wounds. More traumatic injury to the eyes is borne with impunity, than I would before have ventured to inflict. I think that it will not be possible to exclude suppuration in all operations, but where it occurs we must regard it as the result of infection and not due to the traumatism alone.
A CASE OF TUMOR OF THE LEFT OCCIPITAL LOBE WITH RIGHT HOMONYMOUS HEMIANOPSIA (WITH AUTOPSY). BY EMIL GRUENING, M.D., NEW YORK.
IN I855 Von Graefe pointed out the importance of the examination of the visual field in amblyopic affections, and foretold that the hemiopic visual defects would become important in the study of the intra-cerebral optic paths and centres. Since that time clinical ophthalmology has been cultivating the methods of examining the field of vision. As one of the many beautiful results yielded by this mode of functional examination, we may mention the clinical demonstration of the semi-decussation of the optic nerves in the chiasma. At the present day the physiologist Munk teaches that the primary visual centres occupy circumscribed regions in the occipital cortex, and that the visual area of each occipital lobe connects with the retina of both eyes in such a maniner that the right half of each retina belongs to the right occiput, and the left half of each retina to the left occiput. But modern physiology, as taught by Goltz, maintains that Munk's views have been derived from insufficient and erroneous observations, and 45
350
CRUENING: A Case of Tumor of the
that all attempts to map out in the cortex of the brain a mosaic of functional districts have hitherto proved futile. Thus, in regard to the localization of functional centres in the cortex of the brain, we have a positive and a negative modern school of physiology. The tenets of these schools are now being tested by clinical observations and pathological facts. Clinical medicine and special neurology vie with each other in the study of the visual field, as predicted by Von Graefe. Already certain lateral defects of the fields of vision, when combined with special groups of symptoms, allow the diagnosis of localized lesions of the brain. Aside from the well known tractus hemianopsia, we diagnosticate at present a thalamus hemianopsia, a fasciculus hemianopsia, and a cortex hemianopsia. Thus far clinical observation and pathological examination corroborate the physiological views held by Munk. In America two cases of hemianopsia with autopsy have recently been published, the first by Dr. E. C. Seguin in the January number (i886) of the Journal of Nervous and Mental Diseases, edited by Dr. B. Sachs, the second by Dr. E. G. Janeway, in the May-June double number of the same Journal. The following case of right homonymous hemianopsia, caused by a tumor of the left occipital lobe, came under my observation: History.-Frederick Henkler, a tailor, fifty-five years old, consulted me in October, 1883. He gave a good family history, and said that he himself had always been healthy. He had not acquired syphilis. In October, I882, he had been attacked by severe pain in the left temporal region. The pain radiated from the temple to the occiput, lessened toward evening, and vanished during the night. Sleep and digestion were not distqrbed. In April, I883, he observed that his vision had diminished, and an examination made by an oculist revealed that he could see nothing on his right side. Iodide of potassium was then prescribed. This, however, did not improve his condition, but rather, as he thought, caused indigestion. Frequent vomiting soon followed. The
Left Occipital Lobe.
351I
summer of I 883, he spent in the country. In spite of the use of the iodide of potassium, the headache increased, and the vomiting continued. The headache became very violent in the night. In this condition the patient returned to the city, in September, I883, and found his visual power greatly diminished. Soon afterwards he consulted me. The examination showed that the right halves of the fields of vision were lacking. It was a case of complete and absolute right-sided hemianopsia. The line of separation was vertical and fell about two degrees beyond the point of fixation. The left halves of the fields of vision were peripherally contracted. In the horizontal meridian the field of vision of the right eye measured only forty, that of the left eye fifty-five degrees, instead of sixty and ninety. Central acuity of vision was reduced to U& in each eye. The color perception was still good and the pupillary reaction prompt. The ocular muscles were not disturbed. By the ophthalmoscope both papillae were seen to be prominent, their outlines indistinct, the retinal veins broad and tortuous, the arteries threadlike. He presented the typical picture -of choked disk. Several weeks later the patient was examined by Dr. Landon Carter Gray, who had the kindness to write to me about him as follows: "The patient has an unsteady gait. This symptom may depend upon the visual disturbance. No staggering with closed eyes. The lower portion of the left half of the face is slightly paretic. There is a slight right-sided hemiparesis and hemianresthesia." I did not see the patient again. In February, I884, Dr. Pinner, the family physician, wrote me that the patient was dead, and that his friends allowed an examination of the head. Dr. Schapringer kindly assisted me in the autopsy. A ltopsy'.-On opening the cranium I found the dura mater very tense, the convolutions flattened. The left hemisphere was larger than the right. The pons was displaced to the right. Apart from this displacement, the base of the brain showed no anomaly. In viewing the surface of the brain a lhar(d mass was detected, occuLpying the posterior part of the left occipital lob.. The enitire tip of the occipital lobe was re-
352
GRUENING: A Case of Tumor of the
placed by this tumor. After removing the pia mater from the occipital lobe, the greater part of its second convolution and its entire first and third convolutions were found to he chahged into a soft, almost liquid substance, covering the hard mass of the tumor. At several points the latter rose beyond the surface of the convexity of the brain. When the brain had become stfficiently hardened in Mueller's fluid, an incision was made through the left hemisphere, at the distance of 2.5 centimetres from the median line. The incision passed through the mass of the hard tumor, which was enclosed in a capsule and measured about ten centimetres in diameter. The white substance of the occipital lobe was almost entirely destroyed by the growth. The white substance underlying the gyrus angularis had also disappeared. The optic nerves, the chiasma, the optic tracts, seemed normal to macroscopic inspection. The pulvinar and the corpus geniculatum laterale were slightly flattened, probably from the pressure of the tumor.
The tumor was examined by the microscope and found to be a spindle-cell sarcoma. Remarks.-The first alarming symptom in our case was the persistent headache, the second the diminution of vision. The ophthalmoscopic examination revealed the choked disc, the functional examination the right lateral hemianopsia. The continuous headache, the repeated attacks of vomiting, and the existence of choked disc, indicated the presence of a tumor in the brain, while the right homonymous hemianopsia indicated that this tumor was situated in the left hemisphere. We know that such lateral hemianopsia may be caused by disease (i) of the tractus, (2) of the thalamus, or the second optic centres, (3) of the fasciculus of Gratiolet, and (4) of the occipital cortex, or the first optic centres. In conjunction with the hemianopsia, we noted in our case right hemianaesthesia and hemiparesis. This combination of symptoms allowed the exclusion of both the pure tractus hemianopsia and the pure cortex hemianopsia. The association of hemianopsia with hemianaesthesia and hemiparesis argutied for either an affection of the thalamrus
Left Occipital Lobe.
353
(pulvinar, second centres) or the fasciculus of Gratiolet (white substance of the occipital lobe). The absence of convulsive movements, the tardy appearance of the hemianaesthesia and hemiparesis were valid arguments against the existence of a lesion of the thalamus. The clinical course of the case justified rather the assumption of the presence of disease in that portion of the white substance of the occipital lobe where the optic paths traverse the posterior division of the internal capsule. DISCUSSION.
DR. NOYES.-I should like to hear Dr. Gruening's opinion in regard to the statement made two years ago that lesion of the cortex is capable of producing total blindness of the eye of the opposite side. DR. GRUENING.-There is no such case on record. In the forty-five cases collected by Dr. Seg-uin, no such case is included. DR. LORING.-I think that Charcot's scheme was gotten up for that purpose. Ferrier also claimed that there was total blindness when the angular gyrus was destroyed. DR. GRUENING.-I speak only of clinical observations verified by pathological examinations. Those were physiolog,ical experiments on lower animals. The facts which I present are derived only from clinical observation with pathological confirmation. DR. LORING.-Do you mean to say that Hughling Jackson's case is not on record ? DR. GRUENING.-It is not on the list of Dr. Seg,uin. These are only cases in which post-mortem examinations have been made. DR. WVADSWORTH.-In regard to Charcot's scheme, it has been stated by one of the New York neurologists that he had recently been present at a lecture by Charcot, in which he used the ordinary scheme and had apparently abandoned his old one. It has also been stated that Fere, who was Charcot's pupil and formerly used his scheme, had given it up. I think that the evidence is all against Charcot's scheme. Of the cases which have been reported, I do not remember any clean case of blindness of one eye from injury of one side of the brain. Such cases as the result of experiment have been reported, but they may be explained in other ways than as the direct result of lesion of only otie side of the brain. When total
354
GRUENING: Tumor of the Left Occipital Lobe.
blindness of one eye has been accompanied by neuritis, the neuritis may be the cause of the blindness. DR. JACKSON.-I think that Charcot's scheme, which was proposed several years ago, was proposed to explain the cases then on record, and the results of experiments on the lower animals. The cases on record at that time had not been observed as carefully as those reported within the last few years. In a large number of those cases the only testimony as regards the field of vision was the statement of the patient. A patient might state that he was blind in one eye, when perhaps he was only blind for objects toward one side. He would notice blindness which affected the nasal side of the retina, while he might not notice that which involved the temporal side of the retina, and in these cases central vision is nearly always preserved, unless there be some complicating lesion. In reference to the lower animals, I think that there is none in which anatomical investigation shows the same arrangement of the afferent fibres of the optic nerve as in man. In most the decussation is complete, which makes the arrangement analogous to that of other afferent nerves. The same analogy is preserved in the case of human beings. There are few animals in which there is any approach to binocular vision. Their right eyes see objects on the right side, and their left eyes see objects on the left side; so that in the lower animals complete blindness in the opposite eye is analogous to blindness of the right or left halves of both retinae in the human eye. I am sure that Charcot has abandoned that explanation. DR. MITTENDORF.-I would ask whether or not the original idea of Munk, which I do not see indicated on the chart, of partial overlapping of the central occipital fibres in the median line, is still adhered to ? Was that omitted on purpose ? DR. GRUENING.-I think that Munk does not adhere to that view. The explanations intended to throw light into other cases of hemianopsia have not been successful. This seems to me very clear and is based upon pathological observation. It is furthermore confirmed by anatomical investigations, especially by the degeneration methods of Gudden and also by the latest physiological facts found by Munk. DR. MITTENDORF.-I think that Dr. Gruening did not understand my question. I think that Munk maintained that some fibres from one side would run to the other, and thus cause a partial decussation of the central fibres in the median line at the seat of origin, the gray matter of the occipital lobe. DR. GRUENING-.In my studies I have not met with the stateme2nt that there is a commissure between these fibres.
PROUT: Anomalous Formation in the Vitreous.
355
DR. NoYEs.-I might add a word in regard to the situation of the visual centre in the cortex. In the first experiments of Ferrier, it was located in the angular gyrus; later this was extended. I had an opportunity a year ago to go into the laboratory of Prof. Gudden, of Munich. He stated that his experiments had shown him that in cats the visual area in the cortex extended over a large surface and was not limited to such narrow bounds as some had been disposed to believe.
AN ANOMALOUS FORMATION IN THE VITREOUS HUMOR OF EACH EYE. By J. S. PROUT, M.D., BROOKLYN, N. Y.
MR. F. H. C., aged twenty-six, a medical student, who consulted me recently, described his condition as follows: "About two years ago I noticed a peculiar line-like object in each eye, resembling a flexible cord attached above and below, which played across the eye with a snake-like motion with the movements of the ball, and wvhich appeared most plainly when looking steadily at a bright object. It has continued unchanged since first seen. It seems to be semi-transparent, with a fringe-like border, does not cause any inconvenience and is only seen when my attention is called to it. The flame of a lamp or of an ordinary gas-jet when seen at the distance of about one hundred feet with the right eye appears as a bright circle with a central round dark spot, while with the left eye the same object appears as a bright circle with a small dark ring at the centre. In each case the circle is to the left side of and touches the flame. It causes no inconvenience." He further says that his eyes have never been inflamed, painful or injured in any way. They are entirely normal in external appearance. He has no asthenopic symptoms. 0. D. cyl. axis 20°, V. = 0. S. -^-4'w cyl. axis go', V. 45W.
![[Homonymous hemianopsia].](/assets/img/hold.png)
