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FRIEDENWALD: Sarcoma of the Eyelid.

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a number of cases of dendritic keratitis and he has permitted me to say that his experience has borne out my statements. I do, not desire to make it appear that I am introducing iodine in the treatment of diseases of the eye, for many of our works refer to its having been used. It is my purpose to define those cases in which it may be used with advantage, and in which its usefulness cannot be overstated.

SARCOMA OF THE EYELID, WITH REPORT OF A CASE. By HARRY FRIEDENWALD, M.D.,

BALTIMORE, MD.

The great rarity of sarcoma of the eyelids and certain special features of the case to be narrated warrant its description. Miss C., aged I5, an otherwise healthy and well-developed girl, was brought to me July 3, I899, on account of a large swelling of the right upper eyelid. The onset of the growth could not be definitely determined; it was stated by her physician that this girl and another member of her family had had severely inflamed eyes three months previously, and that while the other recovered, the inflammation continued in our patient and the swelling of the lid rapidly increased. There had never been any pain. There was no history of injury. On admission to the Baltimore Eye, Ear, and Throat Charity Hospital the right upper lid was found to be enormously enlarged, thickened, and prominent. The tumefaction was so great that the lid hung below the lower lid, overlapping a part of the cheek. (See Phot. No. I.) The conjunctival surface protruded below. The skin was movable over the underlying tumor, its veins were much enlarged, and it had a bluish discoloration. The conjunctiva was very congested, velvety, and secreted much mucus which partly dried upon the exposed portion and formed a crust. Upon palpation the tumor

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FRIEDENWALD: Sarcoma of the Eyelid.

was felt to be soft and somewhat yielding, but here and there were firmer portions. Its surface presented a number of prominences, but was not lobulated. There was no sensitiveness to pressure. The lid could not be raised by the patient. With the assistance of an elevateur the eyeball was exposed, and appeared to be unaffected by the swelling, and was not displaced. The vision of this eye, difficult to examine under these conditions, appeared to be good. There was no glandular enlargement. No bruit could be heard. The left-eye was normal in every respect. The diagnosis of sarcoma was made. In order to render this more certain a piece was excised from the conjunctival surface (July iith). The wound bled freely and a few sutures were inserted to bring the lips together and stop the bleeding. The excised portion was frozen and cut into sections. These proved the tumor to be a sarcoma. It is interesting to note thzat the wound in the sarcomatous tissue closed byfirst intention. There was a perceptible increase in the size of the growth during the sixteen days while the patient was under observation. The question as to the advisability of sacrificing the apparently healthy eyeball was a difficult one. The absence of exophthalmos indicated that the growth did not extend deeply into the orbit. But, after consultation with colleagues, it was concluded to make the excision as radical as possible and sacrifice the eyeball.

Operation. On July.i9, I899, the tumor was excised, together with the eyeball and the other contents of the orbit. An incision was made along the line of the eyebrows from end to end and carried down to the periosteum. This was next separated with a periosteal rasp from the orbit as far as possible. After sweeping around on the nasal and temporal sides of the orbit the entire mass, comprising the contents of the orbit, the eyeball, and upper eyelid, were removed en masse. The small portions remaining in the orbit were then excised. After checking the hemorrhage the cavity was packed with iodoformn gauze and the lower lid was used to close the

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FRIEDENWALD: Sarcoma of the Eyelid.

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wound. For this purpose it was denuded of its conjunctival lining and of the skin at the margin and brought without difficulty into apposition with the upper lip of the wound in the line of the eyebrows and attached by a number of interrupted sutures. The inner part of the wound was kept open for drainage. The wound was dressed on July 24th and a drainage tube inserted. The lower lid had united with the skin of the forehead, though a few of the sutures were cutting through. The wound was then dressed frequently, the cavity gradually filling up. There was little discharge. The patient was allowed to leave the hospital August i8th, I899, and placed under the care of her physician at her home in Virginia. She returned to Baltimore October 3d and I found that the wound had healed perfectly. The lid had become somewhat retracted, but the deformity was much less than would be expected. (See photograph No. 2.) The orbit was covered by a small pad held in place by her spectacles, and this effectually hid the defect. I have not as yet been informed of a return of the growth.*

Examination of the Tumor. The tumor, after hardening in formol and alcohol, measures 4.5 cm. in width and 4 cm. vertically and 4.5 cm. from before backwards. A vertical incision has been made, passing from before backwards and almost bisecting the eyeball. (See Fig. 3.)t This shows that the greatest thickness of the lid is between 3.5 and 4 cm. On examining the cut surface we find that the tumor is apparently encapsulated, that it extends to the periosteum of the frontal bone above, and that it is so closely applied to the eyeball from near the upper margin of the cornea to the equator that separation would have been impossible. The cut surface of the tumor is not homogeneous. It contains numerous large and small blood vessels, and there are a few areas and streaks which appear gelatinous and are probably made'up of myxomatous tissue. *The last report from her physician was sent May x6,

xgoo.

He stated that "the

patient is in the best of health in every particular." t Reproduced from a life-size drawing by Mr. T. C. Worthington.

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FRIEnENWALD: Sarcoma of the Eyelid.

Microscopic Examinatian. A piece was excised from the temporal portion of the tumor embracing the margin of the lid and cut into sections, stained, and mounted. In these we find the tumor sharply separated from the tissues lying beneath the skin and the mucous membrane by a connective tissue capsule. The tumor is very vascular, some vessels showing distinct vascular walls; in other parts, large vessels without any definite wall structure, forming large lacunae, are found. The tumor is made up of large round cells, in a few places spindle shaped. It is not pigmented. The skin shows nothing abnormal. The mucous membrane is much thickened and is infiltrated with leucocytes, the infiltration extending to the submucous tissues. In these, as well as in the subcutaneous tissues, there are foci of small cell infiltration around blood vessels. A portion of the lachrymal gland is likewise densely infiltrated. The subject of sarcoma of the eyelid has been brought before this society by Dr. Randall in I887, by Dr. Gruening in I893, and by Dr. Wilmer in I894, and by Dr. Veasey in I899. In Dr. Wilmer's paper, thirty-five cases were collected. In four of these it was necessary to remove the eyeball, as was done in our case. " Forty per cent. of these sarcomata were spindle celled, fortythree per cent. were round celled, seventeen per cent. mixed, eleven per cent. presented myxomatous elements " (Wilmer). I wish to add the following reference in order to complete Dr. Wilmer's and Dr. Veasey's lists: i. Hohenberger, Arch. f. Ophth., I892, Vol. 38, 2, p. I40. (H. describes a pigmented navus with beginning sarcomatous degeneration. He mentions the following older references not found in Wilmer's list: Gibson, Phila. Lancet, i85I. Dauscher, Allg. Wien. Med. Zeitung, i859. Ruete, Bildl. Darstellung d. Krankh. d. menschl, Auges. Leipzig, i86o. Tafel XXXV. Hirschberg, Markschwamm d. Netzhaut, 1869, p. 115.

AYRES: Observations on Some Blind Eyes.

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2. Zimmerman, Ophth. Review, I894, Vol. LXIII, p. I84. (Small melanotic spindle celled sarcoma in the upper lid. Patient aged 50. Excision. No recurrence in eighteen months. He also describes an unreported case of Jackson, a small round celled melano-sarcoma. Excision. No recurrence within a few months. 3. Guibert, Rec. d'Opht., I896, P. 527. (Mixed celled melano-sarcoma in a man aged 48, developing in the cicatrix of a burn in infancy.- Removal together with the blind eyeball.) 4. Fage, Arch. d'Opht., I898, P. 298. (Non-pigmented sarcoma of the size of a large bean, composed of mixed cells. Patient aged 37. Excision. No recurrence within two years.) 5. Wood, Ophth. Record, I898, Vol. 7, p. 128. (Infant, aged 7 months; non-pigmented sarcoma composed of round and spindle cells. Excision. No return within three months.)

OBSERVATIONS ON SOME BLIND BUT QUIET AND APPARENTLY INOFFENSIVE EYES. DO THEY PRODUCE A PSEUDO-SYMPATHETIC INFLAMMATION? By S. C. AYRES, M.D.,

CINCINNATI, OHIO.

We are all disposed to treat blind but quiet and apparently inoffensive eyes kindly. We naturally consider a blind eye, which is free from inflammation and tenderness, not the probable source of trouble to the good eye, and it is better for the majority of our clients than an artificial eye. But are these blind eyes as inoffensive and free from danger as we are disposed to think? May they not exert some subtle influence which we in our clemency have overlooked? That in many cases blind eyes remain in the orbits for an indefinite number of years and are not a source of irritation to the fellow eye is a well-known fact.

Sarcoma of the eyelid, with report of a case.

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