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Mr. President and Gentlemen:
I thank you for your flattering invitation to say something of the use of the ophthalmoscope in nervous diseases. In return, I shall endeavor to avoid dry technicalities and to mention only such points as may be of use to every physician. No neurologist worthy of the name can practice without the routine use of the ophthalmoscope, and as every general practitioner must be a neurologist as well as gynææcologist, obstetrician, dermantologist and what not, he, too, if he would do good work, must be familiar with the instrument and know something of the things he sees with it.
In neurology the interest of ophthalmoscopy centers about the choked disc. As specific examples are generally more instructive and stick better in the memory than broad generalities, I beg your kind indulgence while I mention with the greatest possible brevity a few cases seen within the last year. They will serve at once as a practical introduction and as fair illustrations of the value, as well as the limitations, of the ophthalmoscope in neurology, for the instrument has its limitations as well as its uses. It is an efficient ally and may enable us to make a diagnosis when other means fail, but alone it is not enough and we are to count it only one of the many diagnostic aids, mental or mechanical, in our professional armanentarium.
Last spring I was asked to see a girl of 17 who had severe headaches, and had had several peculiar convulsions, the character of which led her physician to suspect hysteria. A careful review of the history and a careful examination pointed rather to tumor of the brain, and an examination of the eyes showed choked disc, which certainly excluded hysteria and made the diagnosis of tumor almost certain.*
The young man whom you have just had the opportunity of examining came to us for failure of vision only. Examination, as you have seen, revealed choked disc, which led to examination for other symptoms of tumor which were then found.
Shortly before I saw the young girl whom
Since the above discussion the case has come to autopsy, which confirmed the diagnosis.
I have just mentioned, I had referred to me a man, aged 34, who had been seen by two most excellent physicians. He complained simply of headache, occasional vomiting and some silght tingling now and then on the right side. One doctor gave him something for his stomach, the other something for headache. He had a sudden slight apoplectic attack with right hemiplegia and aphasia, at which time I first saw him and found double choked disc. Careful inquiry then elicited a history that comported well with the diagnosis of tumor and an approximate localization was not difficult. He was put on active specific treatment to exclude gumma before operation, when three days later he had a second apoplectic stroke, evidently from thrombosis due to the tumor, with complete hemiplegia, total aphasia and hemianopia, a condition for which an operation could do but little. Had an ophthalmoscopic examination been made earlier in this case it is possible that the tumor might have been located and removed, saving the man from subsequent total disability.
I saw a few weeks ago, with Dr. Colburn, a boy who had rapidly lost sight in the left eye and was rapidly losing it in the right. Examination of the nervous system was absolutely negative. Now, this sort of thing occurs, especially in young people, as one of the symptoms of hysteria, but Dr. Colburn could make out a blurring of the discs, and a few days later Dr. Mahoney found unmistakable choked discs which at once definitely excluded functional disease, or at least was positive evidence of organic trouble, a decision which the subsequent course of the case confirmed.
A few days ago I saw, with Dr. Manierre Jr., a young lady who had complained for several days of severe headaches, with vomiting. Headache and vomiting are symptoms that occur in a multitude of affections. Examination showed choked discs, which at once excluded a number of these affections. The choked discs did not serve to make the diagnosis, but they brought us near to it.
Last summer I saw, through the kindness of Dr. Henrotin, a young married man who was said by one of the very best and most careful diagnosticians in this city to have artero-sclerosis. True, he did have some artero sclerosis, but a glance at the optic discs would have shown at once that that was not his principal trouble. He had pronounced choked discs and the case ran the typical course of a rapidly growing brain tumor, probably carcinoma.
On two different occasions, in probably the largest nervous clinic in Germany, I was enabled to correct a false diagnosis by an ophthalmoscopic examination. Both were cases of brain tumor.
Now, for the reverse side of the shield. Some months ago Dr. John Bartlett sent a young
man to me who was having severe epileptic fits. I saw him in a number of these and they were distinctly of the Jacksonian type, i. e., they pointed to a gross lesion of the cerebral cortex. I at once suspected a gumma and he had a clear syphilitic history, but the optic discs were normal, and principally on this account I made a diagnosis of local meningitis and not of tumor. He improved (but was not cured) under treatment and went to a neighboring city, where he died suddenly. A post-mortem revealed a tumor, said to be as large as a hen's egg, exactly in the location I had indicated. In this case the negative result of the ophthalmoscopic examination led to a wrong diagnosis.
Nearly a year ago Dr. Wm. H. Wilder, than whom there is certainly no more careful and competent ophthalmologist, sent me a young lady supposed to be suffering from brain tumor. She had obstinate headaches, vomiting, dizziness, impaired vision and double choked disc. After a careful examination I was inclined to think the whole might be due to anæmia. I examined the blood and found the girl had only one-half the hæmoglobin she was entitled to. Her symptoms, including the choked discs, cleared up under iron, fresh air and improved nutrition. In this instance, then, the ophthalmoscopic findings led the diagnostician
Before mentioning in detail some of the more important relations of choked disc to nervous diseases, I would like to venture a few practical hints, gleaned from my own experience, as to the use of the ophthalmoscope.
1. Never be satisfied with an imperfect view of the fundus; and to get this, unless you are an expert, you must dilate the pupils. Then do not be in a hurry, and do not desist until you have seen all the details.
2. Whether or not you use the indirect method, always examine by the direct, as a very slight choked disc may escape recognition by the former. Personally, I very seldom use it.
3. Unless you have become very skillful and have had a most extensive experience, such as our friend Dr. Wescott, do not make a diagnosis of hyperæmic, congested or pale discs; in other words, never draw conclusions from the color of the discs alone. It normally varies. enormously, as much as do the cheeks of your friends as you meet them on the street.
4. For us who are not among the most distinguished of ophthalmologists, optic neuritis and choked disc are interchangeable terms as far as the appearances of the fundus are concerned. There is said to be some difference between an optic neuritis, due to the propagation of inflammation from a lesion affecting directly the optic fibers and a choked disc due to a distant lesion, but we would do well not to
attempt to make the differential diagnosis with the ophthalmoscope.
I have been greatly interested in Dr. Wescott's demonstration of artificial eyes and his method of using them for instruction. They are doubtless a valuable aid to the student. But, ingenious and convenient and useful as they are, I wish to say, with some emphasis, that they are not necessary. Any practitioner who has an ophthalmoscope may learn to use it well at the cost of a little time and patience. It is not difficult. When I left medical college I had never tried to see the fundus. I believe I had never seen anyone else try, but as a hospital interne I soon learned that the use of the ophthalmoscope was a good thing to know and began to practice on the patients. Practice on yours. Practice on your office girl, on your servant girl, on your driver, on your friends. Your patients will not resent it; will rather esteem you for making so thorough an examination. The dilitation of the pupil, caused by cocaine, is ample for the purpose and disappears in a few hours.
To return to choked disc. The presence of choked disc nearly always indicates one of three diseases; tumor, abscess or meningitis. Tumor, of course, including gumma and the meningitis may also be due to syphilis. The majority (4-5) of cerebral tumors develop choked disc at some period of their course, and the majority of choked discs are caused by tumors. But the choked disc may occur late in the course of neoplasm, even as late as nine years after its inception. It is always a more or less transient condition, terminating either in optic atrophy or recovery. An optic neuritis may develop very rapidly after the tumor has existed for a long time.
In a general way, rapid development of choked disc means a rapid development of the tumor and visa versa. So, in a case in which the symptoms of tumors have existed for a long time and choked disc suddenly makes its appearance and develops rapidly, the prognosis would be bad. Tumors which invade by pressure and displacement only, not by infiltration, are not so apt to produce neuritis; possibly they are ordinarily of slow growth. Tumors springing from the dura-mater and those of the vertex are not so apt to produce optic neuritis as are those in the substance of the brain and at the base. Hence, in an old case of tumor in which there is no optic neuritis, the growth is probably of the vertex and superficial; that is, operable. Choked disc, perhaps, in the majority of instances develops first, and is more intense on the same side as the tumor, but the reverse is occasionally found. Aside from the secondary optic atrophy subsequent on choked disc, the tumor may cause primary or simple atrophy, but only when it involves directly the optic nerve itself.
It may be well to note that we may have a combination of these two conditions.
In hydatid cyst of the brain, optic neuritis is frequent. In aneurism it is rare and occurs only when the aneurism is contiguous to the optic nerve or the optic tract. In hydrocephalus it is very rare. When I was an interne we had a case which was apparently a typica! one of hydrocephalus and the child had choked discs, but the autopsy showed that it was a case of extensive meningitis with large effusiona so-called external hydrocephalus which should not be classed as hydrocephalus at all. In epidemic cerebro-spinal meningitis meningitis choked disc is rare. In tubercular meningitis of the base, optic neuritis may appear and may even precede the other symptoms of the disease, but it is rarely very pronounced. There may also be tubercles in the choroid, but they are exceedingly rare in this disease, being more often found in general tuberculosis without meningitis. In syphilitic meningitis the choked disc is slower in development, but reaches a more intense degree. In pachymeningitis the examination of the fundus is generally negative.
What has been said regarding choked disc in tumors of the brain applies equally to abscess, except that it is not so frequent in the latter lesion and is more apt to be limited to, or decidedly more intense, upon the same side as the lesion. It is worhty of note that choked disc may appear in caries of the temporal bone when there is neither abscess nor meningitis.
There is a certain chronic cerebritis which may sometimes simulate brain tumor and in which we frequently have choked disc.
In cerebral hemorrhage, embolism and thrombosis there is choked disc only when the lesion is indirectly connected with the optic fibers, except that it sometimes occurs as a concomitant condition and is then due to coexisting Bright's disease or artero-sclerosis. But we must remember that an apoplectic attack may be the first symptom of a tumor of the brain, due to a hemorrhage or acute softening within or around the tumor. In such a case of apoplexy we would probably find choked disc due, not to the apoplexy, but to the tumor.
You have probably seen it stated that in persons who have milliary aneurisms of the cerebral vessels, similar small aneurisms may be discovered on the retinal arteries, but this is not true, or at least if they are ever present, they belong to the rarest of clinical curiosities. What we do see occasionally are small extravasations of blood, but these are often present in patients who never have cerebral hemorrhage.
It is a curious fact that optic neuritis may appear in acute or sub-acute myelitis when
there is no discoverable anatomical connection between the cord and optic lesions.
Moderate choked disc occurs in a certain percentage (said to be as high as 8 to 10 per cent) of ordinary chorea. As we have seen, it may be a symptom of simple anæmia.
One word regarding optic atrophy. At least 50 per cent of all cases of simple optic atrophy show symptoms of spinal cord disease. Charcot was of the opinion that it is always due to locomotor ataxia. It is a singular fact that this optic atrophy occurs as an early symptom of locomotor ataxia and that when it does occur, the other symptoms of the disease remain stationary or never appear. Dejerine calls these "cases of tabes arrested by blindness." Of 400 cases of locomotor ataxia from Erb's private practice 6.75 per cent showed optic atrophy. Of 178 cases collected by Growers 14 per cent presented this lesion. The latter author mentions cases in which other symptoms of locomotor ataxia did not appear until 16 and 20 years, respectively, after the supervention of blindness, but it is not specifically stated that the knee-jerks were present, and our present knowledge would lead us to infer that they were absent. Venetian Building, Chicago.
TUMORS OF THE LACHRYMAL GLAND.*
BY ADOLF ALT, M. D., St. Louis, Mo.
Tumors originating in the lachrymal gland are of comparatively rare occurrence, so that the experience in this direction which may fall to the lot of any one man is not likely to be very great. In consequence the text-books, even those considered to be of the very best, give but little space to this subject. E. Treacher Collins, in his extensive report as curator of the Royal London Ophthalmic Hospital Museum, reports only one case of primary sarcoma of the lachrymal gland and adds, that adenomatous and carcinomatous tumors may also arise in this gland.
Schirmer, in Graefe and Saemisch (Vol. VII, I, page 7, etc.), gives a more detailed description of a resume of the literature on the subject up to his time of writing, and he agrees in the main with O. Becker, who maintained. that the tumors of the lachrymal gland, which before him had been described under various names, as simple hypertrophy, adenoma, adenoid, colloid tumor, sarcoma, myoma, and encephaloid cancer, really constituted only one form of tumor which he termed adenoid.
However, since his publication a considera
*Read at the ninth annual meeting of the National Association of Railway Surgeons, held at St. Louis, April 29, 30 and May 1, 1896.
ble number of tumors of the lachrymal gland have been reported and their histology has been thoroughly studied and O. Becker's sweeping criticism is evidently not substantiated by facts. Almost every year has brought forth the report of one or more such cases in literature, and while it is true that the majority of the tumors had a partially epithelial character, as is natural from their origin, there are quite a large number of tumors on record in which the epithelial character was altogether wanting or played a very inferior role. However, we shall return to this point later on.
The symptoms of the affection usually begin with a slight swelling in the outer upper part of the orbit by which the eye is pressed out of its normal position. As the swelling increases, which is usually a very slow process, the exophthalmus increases also and the eye is pressed down, in and forward, while up and outward movements become restricted. This is usually accompanied by diplopia. Gradually the outer part of the upper eyelid is pressed more forward, its folds disappear and it appears elongated. At this time, if not before, it is possible to feel the tumor at the location mentioned, and, perhaps, to see parts of it protruding under the conjunctiva when turning the upper eyelid. It may appear solid or lobulated to the palpating finger and it may feel hard or semi soft and elastic, according to its consistency; yet it is probably impossible to make a diagnosis as to its nature from these symptoms.
As the growth goes on the lid can neither be lifted nor does it fully cover the protruding eyeball. The veins of the lid and of the temple appear engorged. If the tumor grows more rapidly backward into the orbit, it may form a shell, so to speak, behind the eyeball, and thus produce an exophthalmus in an almost straightforward direction as we are accustomed to see due to tumors of the optic
fore, be removed as early as their presence is recognized.
In the earlier stages of their growth this may be done with the preservation of the eyeball and of vision, although ptosis may result and has in a number of instances resulted from this operation.
The removal is easiest accomplished by an incision through the upper eyelid along the orbital margin. As these tumors are usually very friable and soft, some even almost gelatinous, the removal must be done very carefully and with the avoidance of sharp-cutting instruments. It is often impossible, with the greatest care, even, to remove the tumor as a whole. Another method consists in removing the tumor from the conjunctiva after splitting the outer canthus.
Later on, when the tumor has filled the posterior parts of the orbit and the eye is lost, or when it has spread so far as to make a clean removal by the methods just mentioned impossible, it may become necessary to eviscerate the whole orbit. In such cases, however, the tumor has usually enterd the cranial cavity through the orbital fissures, and the effect of the operation can, at best, be only a palliative one.
The healing is usually very smooth and uneventful. When the eyeball has been saved, it returns to its normal position and the patient may even regain binocular vision.
As stated before, the histological character of these tumors varies greatly. It has been my good fortune to personally examine seven. tumors of the lachrymal gland, three of which I have myself removed and reported in Knapp's Archives and the American Journal of Ophthalmology. I have of late again studied my specimens very carefully and with the following results: Five of the tumors may be considered as being to some extent of an epithelial character, two show no epithelial structure whatever.
Of the five tumors showing epithelial structures there is only one in which this character is throughout the tumor the prevailing one. In fact, so closely does this tumor follow the normal appearance of the lachrymal gland, that I described and published it as an adenoma. The connective tissue between the glandular structures is also increased, but not to any very large extent.
The four other tumors, which also show an epithelial character, and which in their structure seem to be very much like those described by O. Decker as adenoids, are but little different from each other. The more I have studied them the more have I become convinced that the epithelial tissue found in them must be looked upon as the remnants of the original glandular tissue, which are in places somewhat hypertrophied, but that there is hardly
any new formation of glandular tissue, and that in consequence the real character of these tumors is not that of an epithelioma or a glandular carcinoma. The bulk of the tumors is made up of myoxomatous and cartilaginous tissue, by which the glandular structures are widely pressed apart and probably have atrophied and totally disappeared in places. The epithelial tissue still found shows, as a rule, a glandular, tubular arrangement of the cells around an open lumen. There are here and there cystic enlargements, which show that some secretion has been going on while the growth progressed. In some places small colloid bodies are found, probably metamorphosed cells.
The sixth tumor of the lachrymal gland which I examined was a spindle cell sarcoma of the purest type. It consists simply of smaller and larger spindle cells closely packed with no visible intercellular substance and some round cells in the younger portions. I may state that this tumor has grown back into the orbit and produced a straight forward exophthalmus with absolute abolishment of the motility of the eyeball. The patient died later on of multiple spindle-cell sarcomata in all important organs.
The last tumor of the lachrymal gland I removed was so soft that when on incision the thin capsule was opened the contents oozed out as a granular sticky mass. As the forceps could nowhere get a hold of it, I had to squeeze it out before I could thoroughly remove the capsule. It proved to be a chondrosarcoma. There is not a trace of glandular tissue to be found in this tumor. The only other tissue it contains is here and there a microscopical spicula of bone. There are also some colloid bodies in this tumor.
The number of tumors of the lachrymal gland here considered is, of course, not a large one in itself, although not so small when compared with the whole number of cases reported in literature. Yet, with the exception of the case, which I consider to be an adenoma, the remaining ones are chiefly characterized by connective tissue formations, not by an epithelial structure. I do not think, therefore, that I am wrong when concluding that the tumors of the lachrymal gland very frequently take their origin in the interstitial connective tissue and only in the rarer instances are truly epithelial in character.
Lymphoma, lymphadenoma, tubercular tumors and chloroma of the lachrymal gland, as have been described in a number of instances, I have not had an opportunity to see.
Dr. Nicholas Senn was unanimously elected president of the American Medical Association as the recent meeting at Atlanta.
The Location of Foreign Bodies in the Limbs by Means of the Roentgen Rays.
An instrument has been devised for this purpose by E. P. Hershey, C. E., M. D., of Denver, Colo., made from an from an ordinary T-square, the center being sawed through from above downward, and grooves made in the wood from the center to one side vertical to the center line. Within the portion sawed out was placed a piece of copper wire accurately fitting the space, and fastened within the grooves, made vertical to this wire, were placed fine pieces of German silver wire, at a distance of one inch apart.
The skiagraph taken by Lacombe and Johnston, and developed by Williamson & Haffner, shows the result obtained. The dark object being a crushed bullet, and below is to be found a pin, both pressed into the flesh and placed under the arm farthest away from the source of light. The most striking point of interest is the fact that the bullet is clearly shown through the bone, as the radius lay between the bullet and the source of the rays. It would be useless to locate a bullet by means of the X-rays unless there was a positive means of locating the foreign object. With this device any object may be located with unerring accuracy.
From experiments tried upon the chest and abdomen, there is no doubt but that within a short time foreign bodies may be located within them, and with the same instrument located to a nicety.
Massage in the Treatment of Sprains and Bruises.
The Revue Internationale de Médecine et de Chirurgie for January 25 contains an abstract of a paper which was read by Dr. Krafft of Lausanne, before the Société Médicale de la Suisse Romande. Dr. Krafft, says the writer, reported a hundred and three cases in which he had employed this treatment with excellent results. He stated that a careful toilet should be made of the region to be treated, and that the hands should be rubbed with a one per cent solution of corrosive sublimate in glycerin, so that they may slip easily over the skin and thus prevent irritation. Before beginning massage a cold douche should be applied locally; afterward prolonged effleurage is begun and continued by simple friction, which is made more energetic when following the course of the blood. Other manipulations, he said, such as kneading, were completely useless in cases of recent accidents. After massage, active and passive movements may be made. By this simple procedure, said Dr. Krafft, very satisfactory results might be obtained. New York Medical Journal.