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
82
BURNETT: Tumor of the
the back of the head, which, most probably, had no connection with the eyes, and his general condition seemed unaffected. He ate, slept, and played as usual. The accompanying photograph (Fig. L) was taken about a year before I saw him, that is, two years after the trouble was first observed. At the date of the examination the protrusion was considerably greater than this,- the posterior wall of the globe being
FIG. I.
about on a level with the bridge of the nose and the lids very frequently closed behind the ball. The protrusion was directly forward or slightly downward, and the movements of the globe, though much restricted, were about the same in all directions. The cornea was clear and the iris normal; pupil large and reacted slightly consensually, but not directly to light. The veins of the conjunctiva and of the lids were swollen and tortuou's (obstructed return circulation). The refracting media were
Intervaginal Space of the Optic-Nerve Sheath.
83
clear. The optic disk was bluish white with an irregular edge and the retinal veins were enlarged and tortuous. (Fig. 2.) Operative interference was advised, and he returned on the i8th of July and was sent to the Children's Hospital. The operation was performed under chloroform on the igth. Under anesthesia, a careful examination was made by palpation and auscultation to determine the nature and connections of the
FIG. 2.
growth. The heart sounds
were normal and there was no bruit
fremitus heard on or around the eyes, and only a slight retrocession of the ball was caused by compression. The finger passed behind the globe met with no irregularities on the orbital walls, and the optic-nerve close up to the globe and for some distance beyond, though enlarged, was smo'oth. It was traced to an elastic mass, with a smooth flat anterior surface, which apparently filled the apex of the orbit. It was considered inadvisable to attempt the removal of this large mass with preservation of the eyeball. The muscles were, therefore, detached from their insertion into the sclera nor
and the nerve cut close to its entrance in the large mass, and the ball and attached nerve removed in order to have a freer field for operation.
84
BURNETT: Tumor of the
The removal of the large tumor was effected through the opening in the conjunctiva. The mass was found to be tightly pressed against the orbital walls but not adherent to them except, possibly, near .he optic foramen, where the capsule of the tumor gave way under the scissors, and a quantity of gelatinous material escaped. The optic nerve itself could not be distinguished as a distinct cord at the posterior wall of the tumor nor at the foramen. There was a free but not excessive hemorrhage. The patient bore the anaesthetic well and rallied promptly. A sponge was applied over the closed lids and held rather tightly in place by a simple bandage and was to be kept moist with an antiseptic liquid. This dressing was removed by the resident physician that evening, and' when a fresh sponge was applied the bandage was not drawn sufficiently tight, and as a result, there was a hematoma of the orbit and considerable ecchymosis of that side of the face in the vicinity of the orbit. Temp. ioo.6°. The case progressed well, and the boy was up and playing around the ward on the 3d day, ate and slept well, and the hematoma was gradually subsiding. On the afternoon of the 28th, he complained of feeling badly, and an examination revealed a temperature of I03.4°. This was the beginning of an attack of pneumonia of the left side for which he was treated by Dr. Acker. The course of improvement in the condition of the orbit was not in any way checked by this intercurrent affection, a connection of which with the operation could not be established. When he was discharged from the hospital on the 22d of August, there remained very little swelling of the orbital tissues, and there was a fair amount of movement in the stump. The boy did well and had no untoward symptoms until Nov. 2d, when he was seized with what his father described as "inward spasms," which have continued ever since at intervals. These attacks come on at periods varying from 2 to 4 weeks, and usually last all day, during which time he has had as many as fifteen of them. They begin with nausea, seldom accompanied with vomiting, some twitching of the mouth, but no general convulsions, and end in unconsciousness, lasting for a few minutes. In the intervals he has as good or better health
Intervaginal Space of the Optic-Nerve Sheath. than he has ever had. It should be said that he is allowed unrestricted indulgence in an appetite for all kinds of indigestible things. I saw the boy on May 9, I894, and found the stump smooth, of good motility, and not any larger than it was on complete healing three months after the operation. The eye and the tumor were put first in 50 per cent. alcohol. Fig. 3 gives the actual size and form of the eye and the attached optic nerve after they had been hardened in
FIG. 3.
FIG. 4.
absolute alcohol. Fig. 4 shows the anterior and part of the lateral aspect of the tumor with the section of optic nerve where it enters it, of actual size, after it had been. hardened in absolute alcohol. It measured, at that time, 36 mm. vertically, 25 mm. transversely, and 15 mm. antero-posteriorly. At the time of its removal it was at least 20 per cent. larger. In -shape it represented almost exactly a cast of the walls of the apex of the orbit at that locality. The eye was cut by Dr. Wm. M. Gray, Director of the Lionel Laboratory at the Emergency Hospital. The sections show that the pathological process originated in and is limited almost entirely to the intervaginal space, and that in the main, both the pial and dural sheaths are intact. A section through the globe at the optic nerve entrance (Fig. 5 ) shows that the new growth comes close up to the nerve entrance, dilating the intervaginal space to its utmost, and occupying it, but not passing beyond it in any direction. Moreover, the optic nerve at this point does not appear to suffer from
86
BURNETT: Tumor of the
pressure, being- of approximately normal size and shape, and entirely free from invasion of any pathological process from the outside, though in a state of atrophy. The central retinal vessel which is cut at the papilla appears of normal size. The relations of the nerve trunk to the growth are shown probably still better in Fig. 6, which is a cross section of the nerve near the distal end of the portion attached to the globe. It occupies a very nearly central position of the almost perfect oval, and its inner sheath is intact though some fibres run towards and con-
FIG. 5.
FIG. 6.
nect it with the mass of morbid tissue at one end of the oval. It is not compressed, and the vessels (probably those of the central retinal group) here, as everywhere where the nerve was examined anterior to the large mass, are at least up to the normal in number. The same conditions and relations are present after the entrance of the nerve into the large mass (Fig. 7). Both sheaths are intact and the state of the nerve is approximately the same as at its anterior part, except that it is not vascular, being posterior to the entrance of the central retinal vessels. At the more posterior portionsj however, the nerve and the morbid tissue appear to mingle until the one is lost in the other, and the nerve is no longer to be clearly dis-
tinguished. It is apparent, then, that the growth has had its origin in and is entirely confined to the intervaginal space and that whatever invasion of the nerve we may have is only secondary, and occurs at the latest periods of the pathological development
Intervaginal Space of thie Optic-Nerve Sheath.
87
or degeneration. A most interesting fact in connection with the tumor's growth is that it should be divided into two parts so sharply defined from each other. It is quite common, it is true, to find in such tumors inequality of size at different parts, but in none described in the literature I have examined has the demarcation been so close. The inference is that the growth began about midway of the leng-th of the nerve -that is, about
FIG. 7.
the point of entrance of the central retinal vessels, as has been noted in a number of cases,- and traveled backward, and that the anterior part is of more recent origin, as, indeed, its structure would indicate. The structure of the tumor itself is far from uniform in all its parts. In the anterior portion, from the optic nerve entrance to the large tumor, it is composed of a net-work of fibres, most of which have nuclei at some part of their course. The fibres in some portions of the growth are very fine (a, Fig. 8); others are broader and almost hyaline (b), and some are very long (c). Scattered among these are hyaline plaques (d), and here and there are small nests of cells, mostly nucleated (e). In some portions of the growth one of the elements predominates; in others another. This anterior portion is much less vascular than the larger mass. Sections of the large tumor show it to be much firmer in texture and highly vascular, and the walls of the vessels in some portions are distinctly hyaline. It is composed of short fibres, which in some parts are reduced to typical spindle-shaped cells, which are nucleated (f, Fig. 8).
88
BURNETT: Tumor of the
In some parts hyaline plaques of various sizes and shapes (g) are very numerouis. The nests of nucleated cells (h) are also very numerous in places, and are much larger than in its anterior part. It is not necessary to discuss here in any detail the pathology of these tumors around the optic nerve, since it has been again fully gone over very recently by Braunschweig, and by
cii
FIG. 8.
Salzmann in Band 39 (1893), Heft 4, of Grwfe's Archives, and by Ugo Tailor in the Annali di Ottalmologia, Anno. xxvi, I,894, Fas. i and 2. The article by Braunschweig claims to be exhaustive as to its statistics of reported cases, which at that time were 94 in number; but they are rendered almost valueless by the unpardonable omission of the place of publication of the articles. Histologically, the tumor belongs to the group to which the vast majority of such tumors as have been reported upon belong, and it is a fair assumption that they are all essentially the same in structure and development, the differences in their microscopical appearances, as described, being due to the different periods at which they were examined, the various stages of their growth or degeneration, and the personal equation of
Intervaginal Space uJ the Optic-Nerve Sheath.
89
the observer. They have been variously described as myxoma, myxo-sarcoma, fibroma, myxo-fibroma, endothelioma, and sarcoma. An examination confined to certain isolated parts of the tumor here described would justify the diagnosis of any one of the above-mentioned forms of morbid growth, since they are all typically represented. There is one clinical fact, however, which stands out with marked prominence, and that is that they are not malignant, and seldom show a tendency to recur, which they would certainly do were they of a truly sarcomatous character. The burden of evidence, from their clinical history and the manner of their development, seems to be in favor of an embryonal origin, since they are developed, with rare exception, very early in life, grow slowly, and show none of the tendencies of acquired pathological processes to rapid development and a spread to other tissues, either by contiguity or metastasis. The changes in the nerve are due entirely to the mechanical pressure of the growth upon the nerve trunk, and the pathological state being, most probably, that of choked disk. As to operative procedures, the experience with removals with retention of the eyeball has not been such as to justify its attempt, except when the tumor is very small, and they are seldom seen or diagnosticated at that period. The suggestion of Braunschweig, that a portion of the temporal wall of the orbit be removed in order to facilitate the extraction of these tumors with preservation of the eyeball, I do not consider a justifiable one, since any growth connected with the globe that cannot be removed from an intact orbit had better carry with it the eyeball itself. In any such case the eye, even if preserved, is sure to atrophy, if not undergo suppuration; and an artificial eye is much to b, preferred, so far as appearance goes, and is, on the whole, much safer than a degenerated stump. DISCUSSION.
DR. H. KNAPP of New York. - I would like to touch upon the last part of Dr. Burnett's paper -that is, the removal of the outer wall of the orbit by osteo-plastic -method, according to Kr6nlein. I have seen such a case operated on by Dr. Frederic Lange of New York. An orbital tumor was removed
90
BURNETT: Tumor of thze Intervaginial Space, etc.
about two years ago. There has been no recurrence, and there is scarcely a scar. I am, therefore, rather inclined to believe that this modern procedure of thorough surgery should not be ignored by oculists. One word with reference to the preservation of the eye in the removal of tumors of the optic nerve. I think r was the first to attempt and perform, this operation. It was 20 years ago, in a case of endothelioma of the sheath of the optic nerve, published in Arclh. of Ophtzal., Vol: IV, p. 323, I874. I desire to say that I saw this patient again about a month ago, and that there has been no recurrence, and the patient has had no evidence of any metastatic tumor. The eyeball is there, well but shrunken - certainly not so nice as an artificial eye would be, but, nevertheless, the operation has not given the woman any discomfort. Shortly after that operation Dr. Gruening, in my clinic, removed another optic nerve tumor, with preservation of the eyeball - a myxosarcoma, much smaller than that of the case just mentioned. I saw the patient several years afterwards. Her eyeball was not disfigured in the least; there had been no reaction whatever. I tried it in another case, but the eye sloughed. It is certainly easier to remove optic-nerve tumors after the eye has been taken out. In small tumors, however, it is better, I think, to spare the globe, for the natural eye, even though blind, is much better than an artificial one. DR. J. A. LIPPINCOTT of Pittsburgh. -One point in regard to a statement made by the reader of the paper in regard to the simple nature of the tumors. If I mistake not, he thought they were never actually of malignant character. Can they not assume a malignant character? Of course, myxomatous growths of the optic nerve are generally removed without evil consequences. I removed one ten years ago. I saw the patient two or three years ago, and found that there had been no recurrence; but in a case which I operated upon about a year ago, the issue of which, I may say, was fatal from meningitis, the tumor, which seemed to be originally a fibrous tumor of the optic nerve, slow in development and comparatively benign in character, suddenly began to progress very rapidly, with marked increase in the exophthalmos and other symptoms, which indicated the necessity for an early operation. This was performed, and the microscopic examination showed the fibrous character of the tumor, but with what seemed to be a recent development of round-celled sarcoma. I think this would account, in some cases, for the sudden exophthalmos - a symptom which might probably be correctly attributed, in the majority of cases, to disease of the cavities adjacent to the orbit.
WILMER: Melanotic Giant-Celled Sarcoma of Lid.
9I
DR. SWAN M. BURNETT of Washington. - In looking over the statistics prepared by Braunschweig, so far as it can be relied upon,. I find that there are very few cases indeed in which there seems to be any tendency to malignancy. Of course, one could hardly say that all tumors of the optic nerve are benign, but the cases which are reported as typical cases of myxosarcoma and sarcoma, and which take their origin in the intravaginal space, from what I have been able to study of them, were not malignant. I think it is a question which it will be profitable to study, since we have a good deal to learn with regard to the pathology of these tumors around the optic nerve. It seems to me .they are embryonic in their character, and that they are not essentially malignant. The cases which have been reported as malignant probably did not originate in the intravaginal space, but in some other part of the orbit.
A CASE OF MELANOTIC, GIANT-CELLED, ALVEOLAR, MYXO-SARCOMA OF THE EYELID. By W. H. WILMER, M.D., WASHINGTON, D. C.
While the literature of ophthalmology is so rich in other respects, the reports of cases of primary sarcoma of the eyelids are comparatively limited in number. A case of this nature is therefore presented without further apology, as it seems to me to possess features that are not common. On April I5, I893, a woman about thirty years of age consulted me concerning a small tumor of the right lower eyelid. This tumor was first noticed about six or eight months previous. Its growth had been gradual but steady. The patient was confident that the lid had never been injured in any way. In fact, she had never had any trouble whatever with her eyes except a slight attack of conjunctivitis in I887. The tumor was situated a little to the outer side of the median line of the lid, with its long axis parallel to the margin. It was hard and unyielding to the touch. Although the tumor projected toward the skin, the latter was freely movable, and
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
82
BURNETT: Tumor of the
the back of the head, which, most probably, had no connection with the eyes, and his general condition seemed unaffected. He ate, slept, and played as usual. The accompanying photograph (Fig. L) was taken about a year before I saw him, that is, two years after the trouble was first observed. At the date of the examination the protrusion was considerably greater than this,- the posterior wall of the globe being
FIG. I.
about on a level with the bridge of the nose and the lids very frequently closed behind the ball. The protrusion was directly forward or slightly downward, and the movements of the globe, though much restricted, were about the same in all directions. The cornea was clear and the iris normal; pupil large and reacted slightly consensually, but not directly to light. The veins of the conjunctiva and of the lids were swollen and tortuou's (obstructed return circulation). The refracting media were
Intervaginal Space of the Optic-Nerve Sheath.
83
clear. The optic disk was bluish white with an irregular edge and the retinal veins were enlarged and tortuous. (Fig. 2.) Operative interference was advised, and he returned on the i8th of July and was sent to the Children's Hospital. The operation was performed under chloroform on the igth. Under anesthesia, a careful examination was made by palpation and auscultation to determine the nature and connections of the
FIG. 2.
growth. The heart sounds
were normal and there was no bruit
fremitus heard on or around the eyes, and only a slight retrocession of the ball was caused by compression. The finger passed behind the globe met with no irregularities on the orbital walls, and the optic-nerve close up to the globe and for some distance beyond, though enlarged, was smo'oth. It was traced to an elastic mass, with a smooth flat anterior surface, which apparently filled the apex of the orbit. It was considered inadvisable to attempt the removal of this large mass with preservation of the eyeball. The muscles were, therefore, detached from their insertion into the sclera nor
and the nerve cut close to its entrance in the large mass, and the ball and attached nerve removed in order to have a freer field for operation.
84
BURNETT: Tumor of the
The removal of the large tumor was effected through the opening in the conjunctiva. The mass was found to be tightly pressed against the orbital walls but not adherent to them except, possibly, near .he optic foramen, where the capsule of the tumor gave way under the scissors, and a quantity of gelatinous material escaped. The optic nerve itself could not be distinguished as a distinct cord at the posterior wall of the tumor nor at the foramen. There was a free but not excessive hemorrhage. The patient bore the anaesthetic well and rallied promptly. A sponge was applied over the closed lids and held rather tightly in place by a simple bandage and was to be kept moist with an antiseptic liquid. This dressing was removed by the resident physician that evening, and' when a fresh sponge was applied the bandage was not drawn sufficiently tight, and as a result, there was a hematoma of the orbit and considerable ecchymosis of that side of the face in the vicinity of the orbit. Temp. ioo.6°. The case progressed well, and the boy was up and playing around the ward on the 3d day, ate and slept well, and the hematoma was gradually subsiding. On the afternoon of the 28th, he complained of feeling badly, and an examination revealed a temperature of I03.4°. This was the beginning of an attack of pneumonia of the left side for which he was treated by Dr. Acker. The course of improvement in the condition of the orbit was not in any way checked by this intercurrent affection, a connection of which with the operation could not be established. When he was discharged from the hospital on the 22d of August, there remained very little swelling of the orbital tissues, and there was a fair amount of movement in the stump. The boy did well and had no untoward symptoms until Nov. 2d, when he was seized with what his father described as "inward spasms," which have continued ever since at intervals. These attacks come on at periods varying from 2 to 4 weeks, and usually last all day, during which time he has had as many as fifteen of them. They begin with nausea, seldom accompanied with vomiting, some twitching of the mouth, but no general convulsions, and end in unconsciousness, lasting for a few minutes. In the intervals he has as good or better health
Intervaginal Space of the Optic-Nerve Sheath. than he has ever had. It should be said that he is allowed unrestricted indulgence in an appetite for all kinds of indigestible things. I saw the boy on May 9, I894, and found the stump smooth, of good motility, and not any larger than it was on complete healing three months after the operation. The eye and the tumor were put first in 50 per cent. alcohol. Fig. 3 gives the actual size and form of the eye and the attached optic nerve after they had been hardened in
FIG. 3.
FIG. 4.
absolute alcohol. Fig. 4 shows the anterior and part of the lateral aspect of the tumor with the section of optic nerve where it enters it, of actual size, after it had been. hardened in absolute alcohol. It measured, at that time, 36 mm. vertically, 25 mm. transversely, and 15 mm. antero-posteriorly. At the time of its removal it was at least 20 per cent. larger. In -shape it represented almost exactly a cast of the walls of the apex of the orbit at that locality. The eye was cut by Dr. Wm. M. Gray, Director of the Lionel Laboratory at the Emergency Hospital. The sections show that the pathological process originated in and is limited almost entirely to the intervaginal space, and that in the main, both the pial and dural sheaths are intact. A section through the globe at the optic nerve entrance (Fig. 5 ) shows that the new growth comes close up to the nerve entrance, dilating the intervaginal space to its utmost, and occupying it, but not passing beyond it in any direction. Moreover, the optic nerve at this point does not appear to suffer from
86
BURNETT: Tumor of the
pressure, being- of approximately normal size and shape, and entirely free from invasion of any pathological process from the outside, though in a state of atrophy. The central retinal vessel which is cut at the papilla appears of normal size. The relations of the nerve trunk to the growth are shown probably still better in Fig. 6, which is a cross section of the nerve near the distal end of the portion attached to the globe. It occupies a very nearly central position of the almost perfect oval, and its inner sheath is intact though some fibres run towards and con-
FIG. 5.
FIG. 6.
nect it with the mass of morbid tissue at one end of the oval. It is not compressed, and the vessels (probably those of the central retinal group) here, as everywhere where the nerve was examined anterior to the large mass, are at least up to the normal in number. The same conditions and relations are present after the entrance of the nerve into the large mass (Fig. 7). Both sheaths are intact and the state of the nerve is approximately the same as at its anterior part, except that it is not vascular, being posterior to the entrance of the central retinal vessels. At the more posterior portionsj however, the nerve and the morbid tissue appear to mingle until the one is lost in the other, and the nerve is no longer to be clearly dis-
tinguished. It is apparent, then, that the growth has had its origin in and is entirely confined to the intervaginal space and that whatever invasion of the nerve we may have is only secondary, and occurs at the latest periods of the pathological development
Intervaginal Space of thie Optic-Nerve Sheath.
87
or degeneration. A most interesting fact in connection with the tumor's growth is that it should be divided into two parts so sharply defined from each other. It is quite common, it is true, to find in such tumors inequality of size at different parts, but in none described in the literature I have examined has the demarcation been so close. The inference is that the growth began about midway of the leng-th of the nerve -that is, about
FIG. 7.
the point of entrance of the central retinal vessels, as has been noted in a number of cases,- and traveled backward, and that the anterior part is of more recent origin, as, indeed, its structure would indicate. The structure of the tumor itself is far from uniform in all its parts. In the anterior portion, from the optic nerve entrance to the large tumor, it is composed of a net-work of fibres, most of which have nuclei at some part of their course. The fibres in some portions of the growth are very fine (a, Fig. 8); others are broader and almost hyaline (b), and some are very long (c). Scattered among these are hyaline plaques (d), and here and there are small nests of cells, mostly nucleated (e). In some portions of the growth one of the elements predominates; in others another. This anterior portion is much less vascular than the larger mass. Sections of the large tumor show it to be much firmer in texture and highly vascular, and the walls of the vessels in some portions are distinctly hyaline. It is composed of short fibres, which in some parts are reduced to typical spindle-shaped cells, which are nucleated (f, Fig. 8).
88
BURNETT: Tumor of the
In some parts hyaline plaques of various sizes and shapes (g) are very numerouis. The nests of nucleated cells (h) are also very numerous in places, and are much larger than in its anterior part. It is not necessary to discuss here in any detail the pathology of these tumors around the optic nerve, since it has been again fully gone over very recently by Braunschweig, and by
cii
FIG. 8.
Salzmann in Band 39 (1893), Heft 4, of Grwfe's Archives, and by Ugo Tailor in the Annali di Ottalmologia, Anno. xxvi, I,894, Fas. i and 2. The article by Braunschweig claims to be exhaustive as to its statistics of reported cases, which at that time were 94 in number; but they are rendered almost valueless by the unpardonable omission of the place of publication of the articles. Histologically, the tumor belongs to the group to which the vast majority of such tumors as have been reported upon belong, and it is a fair assumption that they are all essentially the same in structure and development, the differences in their microscopical appearances, as described, being due to the different periods at which they were examined, the various stages of their growth or degeneration, and the personal equation of
Intervaginal Space uJ the Optic-Nerve Sheath.
89
the observer. They have been variously described as myxoma, myxo-sarcoma, fibroma, myxo-fibroma, endothelioma, and sarcoma. An examination confined to certain isolated parts of the tumor here described would justify the diagnosis of any one of the above-mentioned forms of morbid growth, since they are all typically represented. There is one clinical fact, however, which stands out with marked prominence, and that is that they are not malignant, and seldom show a tendency to recur, which they would certainly do were they of a truly sarcomatous character. The burden of evidence, from their clinical history and the manner of their development, seems to be in favor of an embryonal origin, since they are developed, with rare exception, very early in life, grow slowly, and show none of the tendencies of acquired pathological processes to rapid development and a spread to other tissues, either by contiguity or metastasis. The changes in the nerve are due entirely to the mechanical pressure of the growth upon the nerve trunk, and the pathological state being, most probably, that of choked disk. As to operative procedures, the experience with removals with retention of the eyeball has not been such as to justify its attempt, except when the tumor is very small, and they are seldom seen or diagnosticated at that period. The suggestion of Braunschweig, that a portion of the temporal wall of the orbit be removed in order to facilitate the extraction of these tumors with preservation of the eyeball, I do not consider a justifiable one, since any growth connected with the globe that cannot be removed from an intact orbit had better carry with it the eyeball itself. In any such case the eye, even if preserved, is sure to atrophy, if not undergo suppuration; and an artificial eye is much to b, preferred, so far as appearance goes, and is, on the whole, much safer than a degenerated stump. DISCUSSION.
DR. H. KNAPP of New York. - I would like to touch upon the last part of Dr. Burnett's paper -that is, the removal of the outer wall of the orbit by osteo-plastic -method, according to Kr6nlein. I have seen such a case operated on by Dr. Frederic Lange of New York. An orbital tumor was removed
90
BURNETT: Tumor of thze Intervaginial Space, etc.
about two years ago. There has been no recurrence, and there is scarcely a scar. I am, therefore, rather inclined to believe that this modern procedure of thorough surgery should not be ignored by oculists. One word with reference to the preservation of the eye in the removal of tumors of the optic nerve. I think r was the first to attempt and perform, this operation. It was 20 years ago, in a case of endothelioma of the sheath of the optic nerve, published in Arclh. of Ophtzal., Vol: IV, p. 323, I874. I desire to say that I saw this patient again about a month ago, and that there has been no recurrence, and the patient has had no evidence of any metastatic tumor. The eyeball is there, well but shrunken - certainly not so nice as an artificial eye would be, but, nevertheless, the operation has not given the woman any discomfort. Shortly after that operation Dr. Gruening, in my clinic, removed another optic nerve tumor, with preservation of the eyeball - a myxosarcoma, much smaller than that of the case just mentioned. I saw the patient several years afterwards. Her eyeball was not disfigured in the least; there had been no reaction whatever. I tried it in another case, but the eye sloughed. It is certainly easier to remove optic-nerve tumors after the eye has been taken out. In small tumors, however, it is better, I think, to spare the globe, for the natural eye, even though blind, is much better than an artificial one. DR. J. A. LIPPINCOTT of Pittsburgh. -One point in regard to a statement made by the reader of the paper in regard to the simple nature of the tumors. If I mistake not, he thought they were never actually of malignant character. Can they not assume a malignant character? Of course, myxomatous growths of the optic nerve are generally removed without evil consequences. I removed one ten years ago. I saw the patient two or three years ago, and found that there had been no recurrence; but in a case which I operated upon about a year ago, the issue of which, I may say, was fatal from meningitis, the tumor, which seemed to be originally a fibrous tumor of the optic nerve, slow in development and comparatively benign in character, suddenly began to progress very rapidly, with marked increase in the exophthalmos and other symptoms, which indicated the necessity for an early operation. This was performed, and the microscopic examination showed the fibrous character of the tumor, but with what seemed to be a recent development of round-celled sarcoma. I think this would account, in some cases, for the sudden exophthalmos - a symptom which might probably be correctly attributed, in the majority of cases, to disease of the cavities adjacent to the orbit.
WILMER: Melanotic Giant-Celled Sarcoma of Lid.
9I
DR. SWAN M. BURNETT of Washington. - In looking over the statistics prepared by Braunschweig, so far as it can be relied upon,. I find that there are very few cases indeed in which there seems to be any tendency to malignancy. Of course, one could hardly say that all tumors of the optic nerve are benign, but the cases which are reported as typical cases of myxosarcoma and sarcoma, and which take their origin in the intravaginal space, from what I have been able to study of them, were not malignant. I think it is a question which it will be profitable to study, since we have a good deal to learn with regard to the pathology of these tumors around the optic nerve. It seems to me .they are embryonic in their character, and that they are not essentially malignant. The cases which have been reported as malignant probably did not originate in the intravaginal space, but in some other part of the orbit.
A CASE OF MELANOTIC, GIANT-CELLED, ALVEOLAR, MYXO-SARCOMA OF THE EYELID. By W. H. WILMER, M.D., WASHINGTON, D. C.
While the literature of ophthalmology is so rich in other respects, the reports of cases of primary sarcoma of the eyelids are comparatively limited in number. A case of this nature is therefore presented without further apology, as it seems to me to possess features that are not common. On April I5, I893, a woman about thirty years of age consulted me concerning a small tumor of the right lower eyelid. This tumor was first noticed about six or eight months previous. Its growth had been gradual but steady. The patient was confident that the lid had never been injured in any way. In fact, she had never had any trouble whatever with her eyes except a slight attack of conjunctivitis in I887. The tumor was situated a little to the outer side of the median line of the lid, with its long axis parallel to the margin. It was hard and unyielding to the touch. Although the tumor projected toward the skin, the latter was freely movable, and
