56
BULL: Tumor of the Brain with Autopsy.
CASE II. Boy, aged i8; plexiform tumor of the upper eyelid and the neighboring temporal region. When freed from fat it was seen to be composed of grayish-white, smooth cords of plexiform arrangement sometimes ending in fine nerves. The center of the cords was composed of atrophic and fatty degenerated nerves. (Billroth, Archiv. f. klin. Chirurg., Bd. XI., I69, S. 232.) CASE III. Man, aged 28; part of the tumor, which occurred in the temporal region, reaching to and affecting the outer palpebral commissure. (Bruns, loc. cit.) CASE IV. Man, aged 33; tumor of the left upper eyelid and temporal reg.ion, and at the same time general neuromatosis and multiple neuromas of both vagi. (Bruns, loc. cit.) CASE V. A brother of the preceding case; neuroma of the left upper eyelid and corresponding temporal region. (Bruns, loc. cit. CASE VI. Boy, aged I 3; tumor of the left upper eyelid and corresponding temporal region. (Marchand, loc. cit.)
REPORT OF A CASE OF TUMOR OF THE BRAIN WITH AUTOPSY. BY CHARLES STEDMAN BULL, M.D., OF NEW YORK.
In April, I890, I was consulted by a gentleman aged 45, on account of the difference in the size of the two pupils, which had then existed for nearly a year without any change, and which interfered somewhat with his comfort in reading. I had known the gentleman for many years, but had never examined him professionally. He was a man of very active mind, by profession a civil engineer, and of somewhat irregular habits. He had always been myopic and astigmatic, and had worn glasses for twenty-five years. He had contracted a chancre fourteen years before, and had had numerous lesions of constitutional syphilis since then, but none of them severe. For five
BULL: Tumor of thle Brain witk Autopsy.
57 years he had had no demonstrable constitutional lesion until about two years before I saw him. He then began to have some curious, ill-defined brain or nerve symptoms, of which he' could give no very clear description, but he stated that he was sure they arose in his brain. From the general ill-defined description furnished, I concluded that they were probably attacks of "petit-mal," which were at times accompanied by transient loss of consciousness, which was never of long duration, but the attacks increased in frequency. There was no regularity in these attacks. There were at times lapses of memory of very varying duration. At no time was there any headache until a few hours before his death. When I saw him in April, there was a marked though not complete ptosis of the right upper lid and paresis of both internal recti. In the left eye the iris was moderately dilated and immovable, the pupil on this side being more than twice the diameter of the right pupil. With the right upper lid raised and the refractive error corrected, there was crossed diplopia, the right image being lower, and the two images were brought to a level by a prism of 20. The internal recti were not completely paralyzed, but paretic. There was no paresis of any of the other ocular muscles.. The difference in the size of the pupils had existed unchanged for nearly a year: R. E. 3/200; with sph.-D 8 cyl + D 2.50 axis go' = 20/30 L. E. 5/200; with sph.-D 42 cyl + D 0.50 axis go' = 20/20 There were small irreguiar central opacities in both lenses. In the right eye there was a moderate case of neuro-retinitis with not much swelling of the disc, but with two or three small hemorrhages in the retina near the margins of the disc. The fundus of the left eye showed merely the ordinary changes of a myopic eye. The field of vision was apparently normal in each eye, and there was no interference with the color sense. He was then under treatment by mercury and potassium iodide, and the dose of the latter was increased to thirty grains four times a day. Under this treatment, the neuro-retinitis and the muscular pareses slowly subsided, and finally entirely disappeared. During the summer he began to have attacks of ver-
58
BULL: Tumor of the Brain with Autopsy.
tigo, and in the early autumn these vertiginous attacks increased in intensity, and there appeared a hemianesthesia of the left side which gradually became well marked. During the autumn there were a number of regular well-marked epileptiform convulsions, and the lapses of memory became more marked. On November I4, I890, I made another careful examination, and found that not a trace remained of the neuro-retinitis, or of the ptosis, or of the paresis of the internal recti muscles. The vision remained the same. A test of the dynamics of the muscles showed for i8 inches a convergence of I20 and a divergence of 50. For twenty feet there was no convergence at all, and a divergence of 50. There was no diplopia at any distance. His intelligence was apparently unaffected, except for the lapses of memory. The condition of the left pupil had remained unchanged. There was .no loss of power in any of the extremities, but the hemianaesthesia was very marked. I had previously made a diagnosis of pachymeningitis, and a prominent and very careful neurologist had made a diagnosis of multiple sclerosis of the brain. The patient remained in about the same condition until the night of January 28, I89I. He had gone to bed feeling as well as usual, and woke suddenly about two o'clock in the morning, shrieking with severe pain in the occipital region. Be it marked that this was the first attack of pain in the head which had occurred. He became rapidly delirious, then sank into coma, and died comatose about I I A. M., Jan. 29, I89I. The autopsy was made at 4.30 P. M. the same day. The frame was large, the muscular condition good, and the adipose layer considerable. The dura mater was rather thicker than the average, and more adherent to the skull, but there was no trace of pachymeningitis anywhere within the skull. The sinuses were normal. The convolutions were flattened, especially over the anterior lobes. The anterior half of the left hemisphere was larger than that of the right hemisphere. A section made through the middle of the left frontal lobe, passed through a tumor two inches in longitudinal diameter, and one and three-quarter inches in a transverse diameter, with a broken-down center. The anterior portion of this growth was firmer than the brain substance, and was grayish pink in color,
SCHWEINITZ: Coloboma of the Iris, etc.'
59
with a few small hemorrhagic spots. This mass reached to within two inches of the anterior extremity of the hemisphere. A vertical incision made from the lower extremity of the fissure of Rolando and cutting the longitudinal fissure two and a half inches in front of the fissure of Rolando, passed behind the tumor. The tumor involved the corpus callosum and protruded downward from the roof of the left lateral ventricle. The heart was normal. The right lung was normal. The left lung- contained a few fibrous nodules in the lower lobe. In the right iliac, region there were several old peritoneal adhesions between the omentum, caecum, vermiform appendix, and the abdominal wall. The spleen was normal. The liver was normal. The capsule of the left kidney was adherent, and its surface a little roughened by fine irregular scars. A careful microscopic examination of the tumor proved it to be a glio-sarcoma. Careful microscopic examination of many sections taken from different parts of the brain, showed no trace of sclerosis of nerve tissue.
COLOBOMA OF THE IRIS, POLYCORIA, AND PRIMARY GLAUCOMA. BY G. E. DE SCHWEINITZ, M.D., OF PHILADELPHIA.
The occasional association of primary glaucoma with complete or partial congenital absence of the iris, has been noted in several instances. The most recent paper on the subject is one by E. Treacher Collins (O.phthalmic Review, April, I89I), in which he reports a case of primary glaucomna with apparently complete aniridia, and refers to the case of congenital coloboma of the iris and primary glaucoma recorded by Mr. Lang (Trans. Ophth. Soc., U. K., Vol. X, page io6), the instance of double microphthalmos and glaucoma, with partial absence of the iris, reported by Brailey (Ibid., page 139), and an example of glau-
BULL: Tumor of the Brain with Autopsy.
CASE II. Boy, aged i8; plexiform tumor of the upper eyelid and the neighboring temporal region. When freed from fat it was seen to be composed of grayish-white, smooth cords of plexiform arrangement sometimes ending in fine nerves. The center of the cords was composed of atrophic and fatty degenerated nerves. (Billroth, Archiv. f. klin. Chirurg., Bd. XI., I69, S. 232.) CASE III. Man, aged 28; part of the tumor, which occurred in the temporal region, reaching to and affecting the outer palpebral commissure. (Bruns, loc. cit.) CASE IV. Man, aged 33; tumor of the left upper eyelid and temporal reg.ion, and at the same time general neuromatosis and multiple neuromas of both vagi. (Bruns, loc. cit.) CASE V. A brother of the preceding case; neuroma of the left upper eyelid and corresponding temporal region. (Bruns, loc. cit. CASE VI. Boy, aged I 3; tumor of the left upper eyelid and corresponding temporal region. (Marchand, loc. cit.)
REPORT OF A CASE OF TUMOR OF THE BRAIN WITH AUTOPSY. BY CHARLES STEDMAN BULL, M.D., OF NEW YORK.
In April, I890, I was consulted by a gentleman aged 45, on account of the difference in the size of the two pupils, which had then existed for nearly a year without any change, and which interfered somewhat with his comfort in reading. I had known the gentleman for many years, but had never examined him professionally. He was a man of very active mind, by profession a civil engineer, and of somewhat irregular habits. He had always been myopic and astigmatic, and had worn glasses for twenty-five years. He had contracted a chancre fourteen years before, and had had numerous lesions of constitutional syphilis since then, but none of them severe. For five
BULL: Tumor of thle Brain witk Autopsy.
57 years he had had no demonstrable constitutional lesion until about two years before I saw him. He then began to have some curious, ill-defined brain or nerve symptoms, of which he' could give no very clear description, but he stated that he was sure they arose in his brain. From the general ill-defined description furnished, I concluded that they were probably attacks of "petit-mal," which were at times accompanied by transient loss of consciousness, which was never of long duration, but the attacks increased in frequency. There was no regularity in these attacks. There were at times lapses of memory of very varying duration. At no time was there any headache until a few hours before his death. When I saw him in April, there was a marked though not complete ptosis of the right upper lid and paresis of both internal recti. In the left eye the iris was moderately dilated and immovable, the pupil on this side being more than twice the diameter of the right pupil. With the right upper lid raised and the refractive error corrected, there was crossed diplopia, the right image being lower, and the two images were brought to a level by a prism of 20. The internal recti were not completely paralyzed, but paretic. There was no paresis of any of the other ocular muscles.. The difference in the size of the pupils had existed unchanged for nearly a year: R. E. 3/200; with sph.-D 8 cyl + D 2.50 axis go' = 20/30 L. E. 5/200; with sph.-D 42 cyl + D 0.50 axis go' = 20/20 There were small irreguiar central opacities in both lenses. In the right eye there was a moderate case of neuro-retinitis with not much swelling of the disc, but with two or three small hemorrhages in the retina near the margins of the disc. The fundus of the left eye showed merely the ordinary changes of a myopic eye. The field of vision was apparently normal in each eye, and there was no interference with the color sense. He was then under treatment by mercury and potassium iodide, and the dose of the latter was increased to thirty grains four times a day. Under this treatment, the neuro-retinitis and the muscular pareses slowly subsided, and finally entirely disappeared. During the summer he began to have attacks of ver-
58
BULL: Tumor of the Brain with Autopsy.
tigo, and in the early autumn these vertiginous attacks increased in intensity, and there appeared a hemianesthesia of the left side which gradually became well marked. During the autumn there were a number of regular well-marked epileptiform convulsions, and the lapses of memory became more marked. On November I4, I890, I made another careful examination, and found that not a trace remained of the neuro-retinitis, or of the ptosis, or of the paresis of the internal recti muscles. The vision remained the same. A test of the dynamics of the muscles showed for i8 inches a convergence of I20 and a divergence of 50. For twenty feet there was no convergence at all, and a divergence of 50. There was no diplopia at any distance. His intelligence was apparently unaffected, except for the lapses of memory. The condition of the left pupil had remained unchanged. There was .no loss of power in any of the extremities, but the hemianaesthesia was very marked. I had previously made a diagnosis of pachymeningitis, and a prominent and very careful neurologist had made a diagnosis of multiple sclerosis of the brain. The patient remained in about the same condition until the night of January 28, I89I. He had gone to bed feeling as well as usual, and woke suddenly about two o'clock in the morning, shrieking with severe pain in the occipital region. Be it marked that this was the first attack of pain in the head which had occurred. He became rapidly delirious, then sank into coma, and died comatose about I I A. M., Jan. 29, I89I. The autopsy was made at 4.30 P. M. the same day. The frame was large, the muscular condition good, and the adipose layer considerable. The dura mater was rather thicker than the average, and more adherent to the skull, but there was no trace of pachymeningitis anywhere within the skull. The sinuses were normal. The convolutions were flattened, especially over the anterior lobes. The anterior half of the left hemisphere was larger than that of the right hemisphere. A section made through the middle of the left frontal lobe, passed through a tumor two inches in longitudinal diameter, and one and three-quarter inches in a transverse diameter, with a broken-down center. The anterior portion of this growth was firmer than the brain substance, and was grayish pink in color,
SCHWEINITZ: Coloboma of the Iris, etc.'
59
with a few small hemorrhagic spots. This mass reached to within two inches of the anterior extremity of the hemisphere. A vertical incision made from the lower extremity of the fissure of Rolando and cutting the longitudinal fissure two and a half inches in front of the fissure of Rolando, passed behind the tumor. The tumor involved the corpus callosum and protruded downward from the roof of the left lateral ventricle. The heart was normal. The right lung was normal. The left lung- contained a few fibrous nodules in the lower lobe. In the right iliac, region there were several old peritoneal adhesions between the omentum, caecum, vermiform appendix, and the abdominal wall. The spleen was normal. The liver was normal. The capsule of the left kidney was adherent, and its surface a little roughened by fine irregular scars. A careful microscopic examination of the tumor proved it to be a glio-sarcoma. Careful microscopic examination of many sections taken from different parts of the brain, showed no trace of sclerosis of nerve tissue.
COLOBOMA OF THE IRIS, POLYCORIA, AND PRIMARY GLAUCOMA. BY G. E. DE SCHWEINITZ, M.D., OF PHILADELPHIA.
The occasional association of primary glaucoma with complete or partial congenital absence of the iris, has been noted in several instances. The most recent paper on the subject is one by E. Treacher Collins (O.phthalmic Review, April, I89I), in which he reports a case of primary glaucomna with apparently complete aniridia, and refers to the case of congenital coloboma of the iris and primary glaucoma recorded by Mr. Lang (Trans. Ophth. Soc., U. K., Vol. X, page io6), the instance of double microphthalmos and glaucoma, with partial absence of the iris, reported by Brailey (Ibid., page 139), and an example of glau-
