guy's hospital. two cases of disease of the eye, simulating glioma

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meantime he used to get up and come downstairs, though com-plaining of his head and suffering from distressing vomiting.The day before his death, and nine days after the fall, I

was called to see him hurriedly for the first time, no otherprofessional assistance having been sought previously. Onthe occasion of my visit I found him in bed, drowsy andstupid, but capable of answering questions. He had beenwandering the previous night. There was paralysis of theleft side of the face, and also of the left arm; the corre-sponding leg was unaffected (he walked downstairs withassistance shortly after my visit); pulse 120, irregular. Hedied the next day before my visit, during "a fist. I certifiedthe death as having occurred from cerebral hemorrhage andconvulsions. Owing to an idea on the part of the widowthat death from an accident would interfere with thepayment of a sum of money for which his life was insured,she concealed the fact of his having had a fall from meuntil after I had given the certificate. I therefore felt it myduty to communicate with the coroner, who ordered aninquest and post-mortem.There was no external mark of injury. On removing the

calvaria and dura mater, a spot of extravasation wasvisible through the arachnoid-which was milky-lookingfor some distance around-about three-quarters of an inchto the right side of the median fissure, and situated at thejunction of the anterior and middle third of the hemisphere.This proved to be the upper part of a clot about the size ofa small walnut, embedded in the white substance, but ex-tending upwards to the surface of the grey substance. Theouter portion of the clot, for about one-eighth of an inch,was partly decolourised, and the brain substance in imme-diate contact with it was decidedly softened. I was muchinterested in observing the proximity of the clot to thatportion of the hemisphere which is marked in ProfessorFerrier’s work1 as being the centre for extension movementsof the arm and hand, there being a clear history of paralysisof these parts from the first. From the appearance of theclot I stated my belief at the inquest that the hmmorrhagetook place at the time of, and probably caused, the man’sfall. Dr. Monckton asks concerning his patient, in thepaper to which I have referred, " Could the man walk aboutfor two days, and do his work for one, with this clot in hisbrain?" The answer to this it appears must be conditional,depending upon the seat of the lesion. Had the clot in thebrain of Dr. Monckton’s patient involved the motor centreof the leg, for instance, as completely as the one in mypatient’s brain did the motor centre for the arm, it isevident he could not have worked; but being near thesurface of the brain, in a place where it did not necessitateparalysis of either upper or lower limb, there seems to beno difficulty in believing in the existence of such a clot fora limited period without definite symptoms.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

GUY’S HOSPITAL.TWO CASES OF DISEASE OF THE EYE, SIMULATING GLIOMA.

(Under the care of Mr. HIGGENS.)

Nulla autem est alia pro certo noscendivia, nisi quamplurimas et morborumet dissectionum historias, tum aliorum tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus.Morb., lib. iv. Proœmium.

THE following cases illustrate the difficulty that maysometimes attend the diagnosis of intraocular tumours, atthe same time that they tend to throw doubt on some of thealleged instances of non-recurrence of glioma after excisionof the globe. Every case, in order to be complete, needs thecorroboration of the microscope.CASE 1.—Walter R-, aged one year. A glistening

reflection had been noticed in the pupil of the left eye for amonth previous to Dec. 14th, 1877. The ophthalmoscopeshowed a whitish growth, springing from the inner side ofthe eyeball in two nodules, upon the surface of which blood-

1 The Functions of the Brain, p. 306.

vessels were visible. There was a normal red reflection fromthe outer half of the fundus oculi. The case was looked uponas a probable glioma. The eye was excised and subsequentlyexamined by Dr. Brailey, who reported as follows :-" Thereis a mass of connective tissue on the internal face of theretina on the inner side. It extends from the optic disc,which it covers as far forwards as the ciliary body. Itsfibres are closely connected with the hypertrophied con-nective tissue framework of the retina, from which, however,its origin appears to be independent. It contains a fewbloodvessels.’ The patient was seen on Jan. 31st, 1882, and there was nosign of return of the growth.CASE 2.-John H-, aged three and a quarter. A

yellow reflection from the pupil ef the right eye had beennoticed a week previous to Dec. lOth, 1881. Several nodulesof growth could be seen projecting into the vitreous chamberand coming quite up to the back of the lens, which was quitetransparent. The ophthalmoscope showed the eyeball to benearly filled with a yellowish growth projecting in severalnodules; some bloodvessels could be seen on its surface.On Jan. 2nd, 1882, the eyeball was excised; subsequent

examination by Dr. Brailey showed the retina detached inloose folds, but not contracted. On its under surface weremasses (very friable) of darkish colour, which were composedprincipally of large rounded cells, brownish in colour fromcontaining pigment granules. These resulted from a pro.liferation of the pigment-bearing epithelial cells betweenthe retina and choroid. A little of the same change wasvisible on the internal aspect of the ciliary body. Theretina was thickened and contained some inflammatorycorpuscles, and more were aggregated in loose masses on itsinternal surface. The ciliary body and iris exhibited glau.comatous changes. There was no conspicuous evidence ofany inflammation of the optic nerve or its sheath. Thispatient had been under treatment at the Royal LondonOphthalmic Hospital before coming to Guy’s. Severalgentlemen who saw him looked upon the case as one ofglioma, Mr. Lawson, however, under whose care he was,did not share that opinion.

QUEEN’S HOSPITAL BIRMINGHAM.A CASE OF SARCOMA.

(Under the care of Mr. JOHN CLAY.)THE patient to whom the following notes refer was ad.

mitted into the Queen’s Hospital under Dr. Carter, to whosecourtesy I am greatly indebted for the privilege of super.intending the treatment, my directions being carefullycarried out by Mr. Johnson, late resident obstetric surgeon.Thomas B-, aged seventy-nine, pattern maker for

coach harness, was admitted into the hospital on May 2nd,1881, for growths on the anterior part of the chest, and onthe upper and posterior part of the head. He was pale,with an anxious expression of countenance, but was fairlywell nourished. He stated that about six months previouslysome pimples appeared on the chest and head. They itcheda good deal and discharged a thin matter, and then seemedto run together, although some of them died away; andeventually they formed the growths which he presented atthe date of admission. After trying various simple reme-dies he placed himself under the care of a surgeon and hada variety of treatment, but as the growths had rapidly in-creased of late he applied for admission into the Queen’sHospital. His father died at seventy years of age, but hismother died during childbed. He had lived nearly all hislife at Walsall, but had worked occasionally in London andin Paris for a few weeks at a time. He had never sufferedfrom any particular illness, and strongly denied ever havinghad syphilis, but admitted that he had an attack of gonorrhoeaat nineteen years of age. He had been twice married. Hehad no children by his first wife, but his second wife gavebirth to a stillborn child. He had been a hard drinker, buthad not drunk so much of late years. The patient acknow.ledged that he had led a hard life and had been much exposedto all kinds of weather, having been a great poacher. Hisbowels were much constipated; appetite capricious, urinenormal and of average quantity. On examination four largegrowths were seen on the supra- and infra-mammary regionsof each side of the chest. They were of a flattened hemi-spherical shape, with irregular lobulated surfaces and irregular