TUMOURS OF THE CHOROID. racteristics. SARCOMA OF THE CHOROID, like similar abnormal SARCOMA: growths in other parts of the body, is characterized by its chaa preponderance of cellular elements, of a stellate, spindle-shaped, or roundish form, resembling those of connective-tissue cells, and containing numerous nuclei. These cells differ, however, very materially from those of connective tissue, in that they are incapable of passing into the stage of perfect connective tissue. They are prone, however, to combine with intercellular substances, and thus form a relatively firm vascular and coherent structure. In these respects sarcoma presents a different growth from epithelial formations, and also from cancer. In sarcoma Cells often we often find the cellular elements not only preponde- contain pigment. rating, but containing a quantity of dark pigment assuming the medullary or melanotic form. This is especially the case when the disease springs from a structure already containing much pigment, as is the case with the choroid. The intercellular substance of sarcoma differs chemically from connective tissue, in Intercellular that it contains albumen, and on boiling does not yield gelatine. In structure it may be fibrillated (fibrosarcomatous), granular (gliosarcomata), homogeneous (myxosarcomata), or it may be dense and cartilaginous. substance. neighbour cause en Sarcomata, after a longer or shorter period, infect Infects the parts around them, and by metastasis (?) the ing parts. internal organs of the body. The disease is hereditary. Does not Its growth is often very slow, the lymphatic glands remaining unaffected, especially when the sarcoma is largement of glands. of intra-ocular growth; but if it has once invaded hard structures, such as the cornea or sclerotic, the system will scarcely escape infection. Symptoms.-Sarcoma of the choroid commences as a Symptoms. slight elevation or patch in the choroid, which may be seen with the ophthalmoscope; the base extends, and at the same time the tumour advances forwards upon the retina, inducing changes in its delicate structure, so as to render its nervous matter opaque, and thus prevent our noticing the further changes that take place in the choroid. At the same time it often happens that a collection of fluid takes place between the advancing sarcoma and the opaque retina, the latter therefore Advanced stage of disease. May atrophy. forming an undulating projection vibrating with every movement of the eye, and clearly recognisable in the vitreous chamber by aid of the ophthalmoscope. As a general rule, the disease does not take long to grow, but may be interrupted by periods of inactivity. As the sarcoma increases, involving more of the choroid, the lens and vitreous become opaque, preventing our watching its subsequent growth within the eye. During the early stages of the disease irido-choroiditis most frequently complicates the other symptoms, and at a later period the cornea becomes hazy and ultimately opaque. The intra-ocular tension is much increased, and the patient usually suffers intensely from pain in the eye and over the corresponding side of the head. As the disease advances, staphylomatous bulging may appear in the ciliary region, from degeneration of the sclerotic. The cornea or sclerotic is perforated, and the tumour protrudes through the opening, presenting the appearance of sarcoma as seen in other parts of the body. It sometimes happens, however, that while still intra-ocular, the sarcoma degenerates into a fatty mass and becomes atrophied, the eyeball at the same time shrinking up to a small button over the remains of the morbid growth, which we have too much reason to fear will, sooner or later, again put forth its latent energies and grow with May invade increased rapidity. In some few instances sarcoma of the choroid has been known to invade the sheath of the optic nerve, and growing backwards has filled the apex of the orbit so as to thrust the eye outwards, protruding it from between the eyelids before the nature of the tumour behind could be exactly ascertained. sheath of optic nerve. CARCINOMA: its characters. Malignant. CARCINOMA or cancer differs in its anatomical relations from sarcoma in that it consists of a meshwork or stroma, the interspaces being filled in by groups of cells, often of a spindle-shape, with fine processes as their poles. The alveolar spaces formed in the stroma of carcinoma are readily seen on a section of the tumour, and slight pressure applied to the specimen is sufficient to squeeze out the cellular elements from the meshwork in which they are contained. These cells often include a large quantity of pigment matter. Carcinoma is most malignant; it invades tissues with little difficulty, even those as hard as bone, and much more a fibrous structure such as the sclerotic. The lymphatic glands in the neighbourhood of a cancerous growth are soon involved, and cachexia is a Glands prominent symptom of the disease. The patient involved. usually suffers severely from pain in the part affected Cachexia, by cancer. Carcinoma of the choroid is, however, a rare form of disease, but is occasionally met with both in the medullary and melanotic forms. pain. move the Treatment.In the early stages of both sarcomatous In first and cancerous affections of the choroid, and before the stage remorbid growth has invaded the orbit, we should cer- eyeball. tainly attempt to remove the disease by excising the globe of the eye. Subsequently, when the tumour has burst through the sclerotic and involved the parts around, we are not justified in attempting to remove it with the knife.* We may diminish the patient's Later, resuffering by means of anodynes, and the vapour of lieve pain, chloroform applied to the surface of the growth; but beyond attempting to relieve pain, little can be done. "A Practical Work on the Diseases of the Eye," by F. Tyrrell, vol. ii. p. 165-187; Dalrymple, "Pathology of the Eye," PI. XXXIII. (letter press), HYPER EMIA OF RETINA: transient. Persistent, with œdema. CHAPTER XI. DISEASES OF THE RETINA, ELASTIC LAMINA, AND Hyperemia of the Retina-Retinitis-Haemorrhage- HYPERÆMIA AND INFLAMMATION. HYPERÆMIA OF THE RETINA may be a transient affection, depending simply on over-exertion of the eye, or upon a deranged state of the stomach. Under these circumstances it passes away so rapidly, that it is not likely to attract the attention of either the surgeon or patient. But whatever the exciting cause of the hyperæmia, should it remain in force, inducing chronic congestion of the retina, serious results may follow. We shall almost invariably find the retina more or less oedematous in cases of hyperemia (Plate V., Fig. 1), unless the congestion be of a very transitory nature; and if congestion of the vessels and oedema co-exist, we may be sure that the bounds of health have been passed, and that disease has commenced.* In such cases, although the congestion and its consequences may entirely disappear, leaving the parts in a normal state, still it is always necessary to be on our The form of disease under consideration is described by some authors as serous retinitis. guard, remembering that the effusion, though harmless in itself, has taken place in a most fragile and delicate tissue, which may readily be injured or detached from the choroid. native's eye. morbid; Ophthalmoscopic Appearances.-I have already explained why the healthy retina of the native of India appears of a uniformly bright slate colour when ex- Grey amined with artificial light (p. 40), except where the fundus of central artery and vein meander through it. These vessels may be traced up to their finest ramifications, but the capillaries cannot be seen with the ophthalmoscope on account of their minute size, nor does the blood they contain, under ordinary circumstances, redden the fundus of the eye. Consequently, if in the case of a native, the retina appear of a crimson hue, A crimson however slight the tinge may be, we may be certain tinge that there is something wrong, although the changes which have occurred in it may not amount to actual disease. For instance, if the pupil has been dilated with atropine, and the patient subsequently exposed to the glare of the sun, the excitation thus induced will Denotes cause temporary hyperæmia and redness of the retina. hyperæmia, I may take this occasion to observe, that it is advisable to delay putting atropine into a patient's eye, Caution as until just before making an ophthalmoscopic inspection; and we should never, after applying it, turn our patient out into the sun, telling him to call again for examination the next day; for it will then be impossible to judge if any alteration in the vascular condition of the retina is due to the effects of the disease, or to the excitation induced by over-exposure to light. But excluding exceptional cases, the above rule holds good, and a tinge of red observed in a native's retina indicates a departure from health. to atropine. in Euro What has just been said does not of course apply to Retinal the case of Europeans; nevertheless, among fair- hyperemia skinned races, the congested state of the vessels of the pean. retina, in cases of hyperæmia, is generally apparent,* and should one eye only be affected, a comparison of Compare its condition with that of the other will generally the two remove any doubts we may have had as to the nature eyes. of the disease. The retinal veins also, under these circumstances, may become tortuous and turgid; in * "Maladies des Yeux," par L. A. Desmarres, t. iii, p. 452. |
