**v 
CASES
IlIOT^  0t]2BtAV(DIDIB0
THE  EYE.
  WITH AN ATTEMPT TO CHARACTERIZE TWO SPECIES

    OF THAT DISLASE AND OF CANCER

». ft S^    BY ALEX. H. STEVENS, M D.

 \ WRGEON TO THE NEW-YORK HOSPITAL, CONSULTING PHYSICIAN TO THE NEW
        YORK DISPENSARY, AND LECTURER ON CLINICAL SURGERY.
;ER OF^prffEYE.
                  CASE I.
                             March 3,1818.
  Isabella Johnson, a coloured woman, aged 37
years,  was brought to the New-York  Hospital
on account of a  fungous tumour proceeding
from the orbit of the  left eye.  It projects over
the greater part of the cheek, and extends late-
rally from  the left alas of the nose  to the left
temple;  its most prominent point  is about  three
and a half inches from the edge of the orbit.  Its
circumference, measured as  near the face as
possible, is nine inches.  The tumour  is  mode-
rately hard, and not painful to the touch;  on the
outer side  it is  covered  with skin greatly dis-
tended, but  not  diseased: the  inner side  is
smooth, shining, transparent,  and studded with
                     1 
2              rrvcr^ hf.matom ^
small prominences a! out the size of a shot, np-
p.-irrinly covered by the (O junctiva: numerous
blood voxels are som ratifying beneath it: the
nose is excoriated  by  its pressure.  The anterior
and  most prominent  part of the fungus  is in a
state of ulceration; a eoat  of a light  straw co-
lour, resembling dried pus, covers it partially,
and  where  this is abraded,  dark purple spots
are seen beneath.   The tumour  is irregularly
tnbcrculated, its edges are reverted ; it does not
easily bleed : the eye-ball, partly covered by the
upper eye-lid, and protruded without the orbit,
is very much flattened before  and behind, but
not enlarged : it occupies the upper and outer
part of the  tumour, into which it is partially im-
bo Ided ; notwithstanding which,  it is suscepti-
ble of slight voluntary movements.  The upper
half of the cornea,  which  alone is visible,  is flat-
tened, but almost transparent.  The retina and
iris discover no organic alteration; the former,
however, is  insensible of light, the latter motion-
less. The diameter of the pupil is equal to about
halt that of the cornea. The secretion of tears is
uninterrupted.  The submaxillary  glands on the
left side are much swollen.  There is also  a glan-
dular tumour  over the left  articulation  of the
lower jaw ;  these knots are quite moveable, and
like  the principal tumour, not painful  to the
touch.   The patient  is slightly comatose.  She
suffers  at night  especially  from a  pain shooting 
OF THE EYK.
3
backwards through the left temple, for which
she has taken Tinct. Opii.  She has become ema-
ciated of late. The menstrual discharge has been
regular.  The right eye is entirely free from dis-
ease.   She states that her left eye became weak
about six years ago,  after an attack of measles;
that it began to  swell  about a year since ;  that
six months ago, (the tumour then being as large
as  a  pullet's egg,) her  eye  still  retained the
power of vision.   Being informed that an opera-
tion for  the removal of the  tumour would be
hazardous, and  that its ultimate  success would
be very uncertain, she says she prefers it to the
prospect of certain death.
   March 1th.—The tumour has sensibly increas-
ed since  the last report: the cornea is more
opaque,  and  the ulcerated  portion greater  in
extent than on the 3d inst.: a few drops of blood
oozed from the part to which the dressings had
adhered.
   An operation  having been agreed on  in  con-
sultation of the surgeons, I commenced  it by a
free incision backwards from the external edge
of the orbit; from the termination of this incision
the scalpel was  carried around the lower part
of the base of the fungus to the internal canthus,
thence under the roof of the orbit to the exter-
nal canthus, dividing the palpebral conjunctiva
of the upper lid, and leaving the latter untouch-
ed.   In separating the tumour  from the  cheek, 
 4             FUNGUS HEMATODF3
 several arteries sprung, which bled so freely ns
 to render it necessary  to accelerate the opt ra-
 tion ; at the same time, the prodigious extent of
 the  disease showed  the impossibility of a nice
 removal of the morbid parts.   The tumour was
 therefore quickly detached from its further con-
 nexions within the orbit, by carrying the scalpel
 around its posterior part. A ball of lint was  plac-
 ed upon the bleeding vessels, and  the cavity of
 the orbit was filled with it.  The patient being
 now in a state of syncope, was laid upon the
 floor, and took wine; as she recovered, the up-
 per eye-lid was brought down, and the dressings
 kept perfectly tight to the  divided  surface by a
 monoculus bandage.
  Dissection  of the tumour.—Several portions of
 bone were removed with the tumour.  The hu-
 mours of the eye, all its tunics, and the optic-
 nerve, were  apparently natural.  The  mass of
 the tumour, since its removal, consists of a  light
yellow soft compact  substance, partaking of the
qualities of the medullary portion of  the brain,
 and  the  intervertebral  substance.   There are
several cavities filled  with a soft straw-coloured
unorganized substance not unlike custard, which
has  been baked  too much.  A lateral section
through the dark  coloured spots on  the anterior
part  of the  tumour  discovered a congeries of
blood vessels,  livid on the outer edge, and gra-
dually  becoming  more florid  to  the depth  of 
 
■**■<%*
7W„,   ^
f~iVt'»rtAiti+ir\

 
OF THE EYE.
5
three quarters of an inch, where they terminate
in the yellow portion of the tumour.
  2d day.—A slight bleeding occurred since the
operation ;  it was readily stopped by pressure.
  3d day.—The patient  is somewhat feverish;
otherwise comfortable.
  30th day.—She has been comfortable since the
last report:  the discharge  has been good: the
wound is diminishing in size: the submaxillary
glands are smaller.
  Afterwards the woman's health became great-
ly improved, and she passed six months in to-
lerable comfort.  At the  expiration  of this
time, however,  it was evident  that the  dis-
ease was returning, though she was still  able
to pursue her ordinary business:  the submaxil-
lary and. parotid glands had  considerably en-
larged, and she complained of pain in the tu-
mour, which was increasing in size.  At the pre-
sent time (Oct. 1818) the condition of this poor
creature  is truly frightful; the tumour is quite as
large as before the operation, and  enormous tu-
mours  have  formed on the  left side of the  face
and neck.
                  CASE II.

  A son of Mr. G. aged three years, complain-
ed of pains over the orbit of the left eye, which
                      o 
 6            Fl NOUS HF.M\TOnr.s
 were accompanied with moderate constitutional
 irritation.  A seton was introduced into the neck,
 and mercurial and antimonial prep irations were
 exhibited, under the idea that  his disease was
 hydrocephalus ;  and this opinion was strength-
 ened soon afterwards by the falling of the eye-
 lid of the left eye, the dilatation of its pupil, and
 gradual loss of sensibility in the retina.
   On the 10th of April,  when  I  first saw  him,
 the  uiobe  of the  e>e  was entirely  hid  from
 view bv the  upper eye-lid,  which  was  dis-
 tended, inflamed, and slightly  ^edematous.   On
 raising  the  e\e-lid  the globe  appeared some-
 what enlarged;  in  other respects,  except  the
 dilatation of the pupil,  the eye was  perfect-
 ly natural, but it was evidently protruded;  the
 angle formed by the nose  and  cheek, from the
 inner canthus half  the  distance  to  1 lie;  infe-
 rior part of the septum, was  partly  obliterat-
ed ;  an acrid fluid  oozed from the  left nostril,
which was  impervious to  air.    All medicines
were now  suspended,  and  the seton was with-
drawn.   The left eye-lid was kept moist by an
emollient application.
  On the 17th of April, all  the morbid  appear-
ances having increased, and  the coats of the
eye being distended, it was deemed adviseable to
evacuate the aqueous humour.  A small punc-
ture was accordingly made  through the  cornea, 
OF THE EYE.
7
about a line from the ciliary ligament; the side
of the instrument rested in contact with the ii'G.
During the discharge of the aqueous fluid, that
membrane contracted, and after the operation
the pupil was contracted to half its former dia-
meter.
  On the following day the wound in the cornea
was not visible, and the globe of the eye and the
pupil had acquired their former magnitude.
  On the  22d,  the  protrusion  of the eye had
become so great, that the upper eye-lid, though
it had yielded much,  no longer covered the globe,
which had protruded to  a distance equal to its
natural diameter.  A grayish silvery substance,
seen through the cornea, seemed to  occupy the
anterior part of the posterior chamber of the eye,
and to incline forward, pushing the iris before it,
so as to threaten to rupture the upper part of the
cornea.  I believed  it to be the chrystalliue lens,
rendered slightly opaque by inflammation, conse-
quent to the pressure of  a  tumour, and by the
same cause displaced anteriorly.  With a cor-
nea* knife, introduced behind  the ciliary liga-
ment, brought  out  at the opposite  point, and
made to divide  half the circumference of the
cornea, the lens and all the  humours of the eye
were  evacuated; the lens was  perfectly trans-
parent.  A tumour  protruded through the left
nostril,  beyond   the septum,  inclined to the 
0             Fl vols HEMATODFS
right  side; the upper  lip was  excoriated; the
velum pendulum palati seemed to be  pushed
forward : the parotid and submaxillary glands
were  swollen.
  The accompanying plate, No. 1, exhibits a ve-
ry accurate view of the parts on the  23d of April.
The retina of the right eye is dilated, but other-
wise natural.   The  diameter of the tumour was
judged  to be equal  to two inches.   It is  mode-
rately soft, and not very sensible to the touch.
  5th Maij.—The right eve has  lost its power of
virion;  the pupil has become dilated, as was the
case with the other ey<\ and a grayish silvery
body  is seen. Some difficulty of respiration is ex-
perienced, especially in a  recumbent posture.
The tumour in the nose and that from the orbit
have bled several times, to the amount of half
an ounce.
  On the 9th the child became unable to breathe
while lying down;  and  on the  13th it expired.
without exhibiting evidences of great pain,though
greatly emaciated and exhausted.
  Immediately  after death, the tumour shrunk
considerably, and lost its florid colour.  It was
removed in the same  manner as  in the pre-
ceding  case,  the  friends  not being  Milling
to permit an examination of its connexion with
the  ; lieiaal parts of the head.   The consistence
of thi- tumour was by no means so great as that 
                 OF THE EYE.               9
of the black woman, and it communicated to the
hand the same soapy feel as the medulla of the
brain,—more especially that part of it which lay
within the orbit.  The texture of the  eye was
totally disorganized.  Small portions of the bones
of the orbit  face adhered to it.   An  opening
through the lower and inner part of the orbit had
afforded a passage  for the adjacent portion of
tumour into the left septum nasi.   Except in the
circumstances above stated, the organization of
the tumour was similar to that of the  black wo-
man.
                 CASE III.

  I was requested by the physician of the Aims-
House, to~visit a middle aged woman, who  had
suffered several years from a tumour proceeding
from the left orbit. It had destroyed vision in the
corresponding eye.   The size of the tumour was
less than that of a pullet's egg.   A portion of it
had been separated by the sloughing process.   It
was not particularly painful.  The external ap-
pearances were very similar to those in the case
of Isabella Jackson. An operation was proposed,
but deferred on  account of the patient's preg-
nancy.  This was happily terminated about four 

10            Fivers HF.'w.vTonF.s
months  afterwards.  She  nursed  her child  six
months, then weaned it, and underwent  an ope-
ration for the removal of the tumour, which had
in the mean time increased in magnitude about
one half:  the operation was  performed by Dr.
B. H. Akerly.
  Dissection of the tumour.—Beneath the external
portion of the tumour, it did not present the pur-
ple spots formed by a congeries of vessels, and
resembling a part of an animal severely bruized
immediately before its death, as did that of Jack-
son.  But the mass of it consisted of the same cus-
tard-like substance.  In the posterior part were
two coagula  of blood, about the size of a ha/le-
nut:  the membranes of the eye were distinct.
Of the pigmentum nigrum, or some similar black
substance, the product  of disease, an unusual
quantity existed, not only on the retina and con-
tiguous parts, but within the optic nerve to an
extent of % of an inch from its termination.  In
other respects this nerve appeared natural.
  No untoward circumstance occurred, and the
woman enjoyed tolerable health for six months.
During the latter part of this period, however, a
small moveable tumour, free from discolouration
and pain, formed ju>t below the inner edge olthe
orbit of the left eye.  The  poor creature's health
became gradually  worse:  she became emaciat-
ed, and her countenance assumed a leaden co- 
                   OF THE EYE.               11
 lour.  She was not hectic, but suffered from the
 usual symptoms  of cancerous cachexia.   Tu-
 mours agreeing in external character with that
 on her  face,  formed in the  axilla  and groin.
 They acquired a prodigious size previous to her
 death,  which  occurred eight months after the
 operation.

   From these  gloomy details not one ray of con-
 solation can  be  derived.  The occurrence  of
 disease in parts distant from the primary affec-
 tion, in the two last cases, is  too remarkable to
 pass without notice.  It naturally  tends to the
 conclusion that the  disease is  not local, and of-
 fers a strong inducement to the surgeon to limit
 his views to the smoothing of the avenues to the
 grave, from which he can neither free nor respite
 his unhappy patient*.

   It will appear evident from the foregoing cases.
 that Fungus Hematodes affects  the eye under
 different forms.  The same is true  of cancer.
 Not having met with any attempt to classify these
 affections, I would offer the following:—
   Fungus Hematodes.  1st species.—The eye-ball
is  smooth, covered by  its  conjunctiva: the tu-

 * In each of these cases the disease was in tae left side.  Was
this accidental i 
 Ill           FLNf.CS lfE.MATODF.9, &C
 mour is smooth, and not ulcerated—exemplified
 in Case II.  2d species.—The surface of the  tu-
 mour is tuberculated;  its  edges  reverted;  its
 most prominent part is covered with dark livid
 spots, partially concealed by the dried secretion
 of the surface—exemplified  in Case I.
  Cancer.  1 st species.—Cauliflower excrescence
 with reverted edges, arising from  the conjuncti-
va; if carefully examined, its base will be found
small.   This tumour may be successfully ampu-
tated  in most instances.  2d species.—Cancer-
ous affection originating near the eye, and ex-
tending to it.