CLINICAL HISTORY 
OF 
A Case of Spindle-celled 
Sarcoma of the Choroid, 
WITH A STUDY OF THE MICROSCOPIC CON- 
DITION OF THE GROWTH. 
By CHARLES A. OLIVER, M.D., of Philadelphia, Pa. 
\Reprinted from Proceedings American Ophthalmological Society, 1893.] CLINICAL HISTORY 
OF 
A Case of Spindle-celled 
Sarcoma of the Choroid, 
WITH A STUDY OF THE MICROSCOPIC CON- 
DITION OF THE GROWTH. 
By CHARLES A. OLIVER, M.D., of Philadelphia, Pa. 
\Reprinted from Proceedings American Ophthalmological Society, 1893.] CLINICAL HISTORY OF A CASE OF SPINDLE- 
CELLED SARCOMA OF THE CHOROID, WITH 
A STUDY OF THE MICROSCOPIC CONDITION 
OF THE GROWTH. 
By CHARLES A. OLIVER, M.D., 
OF PHILADELPHIA, PA. 
X. Y. Z. of Indian Territory, an active, energetic, and well- 
known business man of thirty-four years of age, consulted the 
writer for advice in reference to his left eye. He stated that 
five years previously he suddenly noticed that objects situated 
to the right side became dimmed when he attempted to look at 
them with his left eye. This dimness gradually and painlessly 
crept over the whole field of vision until in little more than 
three years' time the eye became blind. 
In October of 1889, he consulted Dr. J. II. Thompson of 
Kansas City, who, finding that he complained of dimness of 
vision in the left eye, - 20/xl brougfat|to 20/xxx by minus cy- 
linder O 50 D, axis 6o° ; the vitreOws about the disk being 
clouded. 
As he gave Dr. Thompson the history of primary syphilis 
six years previously, he was placed on tri-daily doses of thirty 
grains of iodide of potassium. Under this treatment the patient 
did reasonably well. At this time, however, as Dr. Thompson 
informs the writer, the patient had some trouble with his liver. 
He was seen again in June of 1890, when a tumor of the cho- 
roid beneath a detachment of the retina was noticed, which Dr. 
Thompson -although afraid of sarcoma - upon account of the 
diminished tension and irregularity of the blood-vessels,-was 
inclined to believe was a detachment of the choroid. Thinking Oliver : Spindle-Celled Sarcoma of the Choroid. 
4 
that it might be syphilitic, he renewed the treatment, and in 
another month's time was enabled to make the diagnosis of sar- 
coma, begging the patient to have the growth removed. 
Since that time he has had a number of varying diagnoses, 
such as retinal detachment, possible tumor, syphilitic gumma, 
etc , given to him. In spite of the fact that he was placed almost 
constantly under some form of alterative treatment, the tumor- 
growth gradually increased in size. 
In the early spring of 1892, exacerbations of intense tem- 
poral neuralgia more marked on the left side, supervened, last- 
ing several hours at a time and rendering the patient irritable, 
morose, and unmanageable at times. At the same time, the 
left eye began to recurrently diverge until in a period of a few 
weeks it became fixed outwardly. It was then noticed that he 
several times lost the power of counting money, making change, 
and performing any arithmetical problem. 
When first seen by the writer, on the seventh of June, 1892, 
a large yellowish-red and quite vascular growth was apparent 
in the upper outer part of the globe, just posterior to the crys- 
talline lens. The broad, mushroom-like head of the tumor, 
which was separated from the body of the mass by a ring-like 
constriction, curved sufficiently forwards, inwards, and down- 
wards, to hide the upper outer portion of the optic disk. The 
entire bulk of the tumor seemed to be enveloped in a membran- 
ous bag, which sharply curved around it in a fluid vitreous. 
Although studied by strong illumination and highly-magni- 
fying convex lenses, the mass did not appear to move with any 
motion given to the eyeball. The pupil, which was irregularly 
round, dilated to about four millimeters upon monocular ex- 
posure, and failed to present any apparent synechia. Tension 
was normal, and no ciliary tenderness could be elicited upon 
the most pronounced palpation. Vision was absolutely lost, 
and the iris failed to respond to the strongest light-stimulus 
from every meridian. Although there was a marked divergence 
of the left eye, and an inability for the internal rectus muscle 
of the same eye to act during attempts at convergence of the 
right eye upon a fine fixation object situated a short distance 
along the median line, yet the same muscle acted promptly in Oliver : Spindle-Celled Sarcoma of the Choroid. 
5 
association with the right external rectus muscle in right lat- 
eral deviation. 
Ophthalmoscopic examination without the use of a mydriatic, 
showed the optic nerve-head dimly through numerous vitreous 
opacities. The upper nerve distribution of the central retinal 
veins, which were all that could be plainly recognized, seemed 
somewhat enlarged and tortuous. Dilatation of the pupil to six 
millimeters in all meridians by cocaine, allowed the fundus to 
be fairly well seen. The optic disk was seven by eight in ap- 
parent size with its long axis at 1200. The scleral ring was vis- 
ible all around. The central retinal vessels were everywhere 
tortuous, the inferior nasal branches being quite large. The 
growth, which was now certain, sprang from the upper outer 
portion of the choroid and extended forwards, downwards, and 
inwards to a point immediately behind the lens. Its periphery, 
which projected directly out into the vitreous chamber, could 
be recognized throughout its entire extent. The deeper-lying 
vessels of the growth itself could be seen underlying in many 
places those of the superimposed retina. 
The right eye, which was functioning properly in every par- 
ticular, was entirely free from any evidences of the disease. 
The diagnosis being certain, an immediate enucleation was 
advised and accepted. 
Careful physical examination failed to reveal any evidences 
of organic disease. The lungs were capacious, gave good reso- 
nance throughout, and were free from rales. The heart was 
large for a man of his size, but not pathologically so. There 
were no murmurs and no evidence of any cardiac disease. Both 
the spleen and the liver were slightly, though insignificantly, 
enlarged. No enlargement of the superficial lymphatics could 
be recognized, and no lesions indicative of syphilis could be 
found. 'I'he urine, which was normal in appearance, had a spe- 
cific gravity of 1015, and was free from albumin and sugar. 
With the assistance of Dr. Daniel Longaker, enucleation 
was done on the following day under ether, there being but 
little hemorrhage. The external surface of the globe was care- 
fully examined and found to be entirely free from any nodules 
and maculae. The proximal end of the optic nerve was re-ex- 6 
Oliver : Spindle-Celled Sarcoma of the Choroid. 
cised far back, and the orbital tissues were painstakingly, 
though (happily) unsuccessfully searched for any indications of 
extension. The socket healed firmly with but little apparent 
conjunctival scar. In a month's time, after having him placed 
under carefully gauged anti-syphilitic treatment, an artificial 
eye was ordered and the patient allowed to return to his home. 
Immediately after the enucleation, in presence of the pa- 
tient's wife, who would be thus made witness of the correctness 
of the diagnosis, the eyeball was opened by a series of circum- 
linear incisions extending half way around the lower border of 
the optic-nerve entrance, and continued forward by two long 
longitudinal cuts in such a direction as to avoid touching the 
tumor-mass. 
It is interesting to note that on the sixteenth of August, 1893, 
the writer received the following note: "The operation has 
astonished the natives here. Most of them doubt my having a 
glass eye, and my only way of convincing them is to put my fingers 
against it." In November of the same year he wrote : " I am 
pleased to be able to report to you a decided improvement in 
my health, and I have gained seventeen pounds since coming 
home. My appetite is excellent, and I do not suffer from my 
old ailments. My headaches have left me entirely, and I trust 
that they and 1 have parted friendship forever." 
The patient has been seen by the writer within a few days. 
He has gained in weight, is sanguine, happy, and full of life 
and energy. The socket is clean, well-shaped, and free from 
any irritation, nodules, or macula- 
tions. No metatases in any avail- 
able situation could be determined 
after the most careful physical ex- 
amination. 
The accompanying reproduction 
of a photograph, which was kindly 
taken for the writer by Dr. Henry 
W. Cattell, Demonstrator of Mor- 
bid Anatomy in the University of Pennsylvania, shows the 
exact size and position of the tumor-mass. The inferior 
wall of the globe (seen at the top) is turned back upon itself Oliver : Spindle-Celled Sarcoma of the Choroid. 
7 
so as to expose the interior of the eye. The eye is resting partly 
upon its corneal surface, and the superior wall is everted by 
a couple of pins so as to bring the growth and its attachment 
more prominently into view. The eversion of the wall of the 
globe by the pins in the photograph, causes the summit of the 
tumor to appear to point more posteriorly than it did when 
the globe was in its proper shape and form. 
After the growth had been properly hardened in Muller's 
fluid, and had been placed in equal parts of this fluid and alco- 
hol, the following measurements were made by Dr. Cattell ; 
From the inside center of the tumor to inside center of the 
crystalline lens, the distance was eight millimeters. From the 
base of the tumor to the top of the growth, the distance was 
nine and a half millimeters. The greatest length of the mass 
was in the longitudinal direction of the eye : this situation - 
slightly beneath the top, measured one centimeter from side to 
side. The vertical diameter at this point measured one-fourth 
of a millimeter less. The pedicle varied from nine to nine and 
a half millimeters across, at different points. The mass again 
slightly broadened as it reached its base. The tumor pointed 
from the concavity of the eye towards the crystalline lens in 
such a way as to make its convex top visible during life to the 
ophthalmoscope. 
The specimen was submitted to Dr. Joseph McFarland, 
Demonstrator of Pathological Histology in the University of 
Pennsylvania, to whom the writer is indebted for a careful mi- 
croscopic examination and the accompanying drawings. 
As can be seen in Figures 3 and 4, the neoplastic formation 
proved to be a spindle-celled sarcoma. Figure 1 shows how it 
sprang from the external layers of the choroid, projected into the 
sclerotic tissue, and extended extensively into the vitreous cham- 
ber. The overlying retina was elevated by the mass, dissected 
loose in places, and so torn at many points as to frequently render 
the tumor devoid of any internal covering. The spindle cells, 
which are small, quite uniform in size, and contain oval vesicu- 
lar nuclei, run in irregular bundles. Throughout the growth 
numerous cavernous vascular spaces or sinuses could be recog- 
nized. In F'igure 2 three of them are visible, each containing 8 
Oliver : Spindle-Celled Sarcoma of the Choroid. 
red blood-corpuscles, and, in Figure 3, one can be noticed that 
is partly surrounded by an imperfect fibrous wall. As pointed 
out by Dr. McFarland, a second variety of sinuses could be 
found. These are shown in Figure 3. To use the language of 
his report, he says : " A second variety of sinuses exists sim- 
ilar to, but different from the blood channels, and seemingly 
having no connection with them. In these, too, a second cellu- 
lar element is present, viz.: large, round, pigmented cells. 
These are almost constantly found in these open spaces, while 
but rarely seen in the blood channels. They are very probably 
leucocytes loaded with pigment granules which have been picked 
up in the interstices of the tissue. Just what these second 
series of channels represent is questionable. At first one would 
suspect them of being patches of degenerated tissue, but after 
careful study we have been led to conclude that they are cav- 
ernous lymph spaces. If this be correct, we can account for 
the many pigmented cells which they contain, by supposing 
that leucocytes (which we find sparingly in the tissue), having 
picked up loads of pigment granules from the interstices of the 
tissue, are now returning through the lymph channels. Except 
for these pigmented cells, a little fibrin, and occasionally a little 
molecular matter, the channels were continually empty." 
The case is of the utmost interest, not only upon account of 
the recognition of the growth very early in the non-irritative 
stage of the disease, the comparative youth of the patient, the 
relative infrequency of the variety of the neoplasm, as well as 
the promptness in removing the tumor and its limiting nidus at 
the commencement of the second stage, and the rapid disap- 
pearance of the curious, though interesting cerebral symptoms 
after the enucleation and during the employment of the medi- 
cinal agents, but is of value where, by careful and painstaking 
analysis of the post mortem findings, it was distinctly proved 
that the neoplastic cells had extended at their utmost point to 
about four-fifths the lateral extent of the most resistant (and 
yet the most important for the life of the patient) of the ocular 
tissues. Fortunately, the position of the growth allowed its 
early recognition, and the late and sudden development of the 
incipient secondary stage, gave sufficient time and enough pain Oliver : Spindle-Celled Sarcoma of the Choroid. 
9 
for prompt radical action to be taken both upon the part of the 
patient and his medical advisor. The rather large, diffusely- 
placed and slowly-growing cells, the abundance of intercellular 
material, and the point of origin of the growth in the outer layer 
of the choroid (thus confirming Knapp's statement to this 
effect), are all of interest ; while the scarcity of pigmentation 
in the youngest cells, the characteristic parallel tracks of the 
cellular elements, their uniformity in size, their typical oval 
vesicular nuclei, and the imperfectly walled vascular sinuses, 
crowded in places with red-blood corpuscles, teach much as to 
the etiology of the mechanism of the formation of the neo- 
plasm ; and lastly, the peculiar, though probable cavernous 
lymph spaces containing the pigment-laden leucocytes, gives a 
new point for reflection and study to the scientific student and 
educated physician. Fig. i 
Fig. 2 
Fig. 3. 
Fig. 4.