REPORT OF A CASE OF CHOROIDAL SARCOMA.*--By J. ELLIOTT COLBURN, M. D., Professor of Ophthalmology, Chicago Policlinic.

20.

On the 18th of November, 1902, a gentleman. forty-nine years of age was referred to me by one of my colleagues who noticed something in the patient's left eye but was unable to make a diagnosis. The family and general history was good and nothing of an hereditary nature seemed to favor the present trouble. The patient was robust and apparently in excellent health. Lately the sight in his left eye lowered and he started to consult me in June last, but by the advice of a layman called upon an optician and was given glasses. His vision became lower and the superior field cut off. Vision in the right eye equalled ; in the left, with scotoma of the upper three-fourths of the projected field. Correction secured vision in the right eye; left unchanged. Under mydriasis a growth of some sort could be plainly seen, without the aid of lens or mirror, occupying the lower and anterior part of the cavity of the vitreous. Oblique illumination demonstrated a swelling that was pushing forward the retina and ciliary body, as the retinal vessels and ciliary markings could be plainly seen in the abnormal position. Its color was brownish-gray with a velvety appearance. (Fig. 1.) With the ophthalmoscope the tumor presented a well-marked, rounded and regular border against the normal retina of the upper portion of the globe, and filled the greater portion of the lower half of the vitreous chamber. The conjunctival blood vessels were distended and varicosed over the region corresponding to the site of the tumor.

*Given in abstract before the Chicago Ophthalmological Society, March 10, 1903.

The rapidity of the growth and the age of the patient, combined with the visible appearances and the absence of pain and inflammation and the normal condition of the iris and lens, led to the diagnosis of malignant tumor, a sarcoma at the end of the first stage.

An enucleation was advised and performed. (Fig. 2)

It might be well to note that three fatty tumors were removed at the time of enucleation; one from the extensor surface of the right arm, about the size of a hen's egg, and two smaller ones from the anterior surface of the right thigh.

I am indebted to Dr. Herzog for the careful pathological examination reported as follows:

"After the eye was removed it was hardened and sectioned. The tumor presented itself as a more or less spherical mass of the size of a large pea. It is a grayish-pink on the whole, with some dark brown spots and areas. Microscopic examination shows that the tumor takes its origin from the choroidea, probably somewhere near the central axis of the eye. The neoplasm did not break through the uveal tract. but grew backwards, and in so doing displaced the retina and. choroidea forward. The retina, in consequence of the stretching, became completely atrophic over the anterior surface of the tumor. It is, however, preserved though ablated above

The cells

and below the central anterior areas of the tumor. composing the tumor are more or less round or oval, with vesicular nuclei. The tumor is moderately vascular."

At the present time, four months after the operation, the conjunctiva presents a glazed and sodden appearance, but no return of the growth is to be demonstrated. The patient constantly wears an artificial eye.

Knapp recognizes four stages:

Ist. The early period, when no irritative symptoms are present.

2nd. The period of inflammation with increase of tension and involvement of the ciliary body, iris and the anterior structures of the eye.

3rd.

transmitted light.

Perforation of the globe with extension of the disease to the orbital tissues.

4th. Metastasis to some remote part.

As an aid in recognition of sarcoma, I have tabulated a differential diagnosis of a few conditions with which it might be confounded.

As the usual history of this class of cases is a return of the trouble, especially when so far advanced, it would not be surprising to learn of a recurrence either in situ or in some remote organ of the body.

The earlier in its history the disease is recognized, and the eye removed, the more favorable the prognosis for the patient, but unfortunately they do not come under our care, unless by accident, in the beginning of the trouble as no untoward symptoms are at first noticed. Should the tumor occupy the macular region the lowered vision would in all probability cause early medical advice.

It is of prime importance to make an early diagnosis, as the eye is usually the primary seat of the disease and procrastination under these conditions will prove fatal to the patient.

What has been said of sarcoma may apply with equal effect to glioma of the retina. The two diseases are identical as regards prognosis and treatment, and the differential diagnosis is at times impossible without the aid of a microscope. 34 Washington St., Chicago.