Oplitlialmologlcal Contributions. 
(1.)—A CASE OF EPITHELIAL CANCER OF THE CON- 
JUNCTIVA (with Figs. 1-6, Tab. viii.) 
(2.)—TWO CASES OF RETINAL GLIOMA (with Figs. 7 
and 8, Tab. viii.) 
(3.)—A CASE OF NEURO-RETINITIS RESULTING 
FROM A GUMMI TUMOR OF THE DURA 
MATER. 
DR. H. KNAPP, OF NEW YORK. 
BY 
{Reprinted from the Archives of Opht'talmology and Otology. Vol IV., No. 2.) 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1 875. A CASE OF EPITHELIAL CANCER OF THE CON- 
JUNCTIVA. 
By Dr. JAS. CHAPMAN, of Medina, N. Y., and Dr. H. KNAPP.* 
(With Figs. 1-6, Tab. VIII.) 
Nathan Bancroft, aged 70 years, in March, 1873, while chopping 
wood, received a blow from a chip or splinter of wood on the sclerotic, 
a line or two from the outer and upper margin of the cornea. This in- 
jury was followed by some inflammation, which subsided without treat- 
ment. 
In November, 1873, I first examined the diseased eye. There ap- 
peared to be a thickening of the conjunctiva and subconjunctival tissue, 
these textures having a plicated appearance, the folds extending around 
the corneal margin, and encroaching a little upon its substance. Mr. 
Bancroft stated that he first discovered the growth in the month of Sep- 
tember preceding, and that it was then situated on the sclerotic, about 
a line outside the outer and upper part of the circumference of the 
cornea. He wanted my opinion as to the nature of the disease, and as 
I told him I was in doubt in regard to its pathology, and my prescription 
was to let it alone for a time, he consulted another surgeon. In Janu- 
ary, 1873,1 saw him at a meeting of the Orleans County Medical Society, 
to which he was presented by his medical attendant. The disease had 
extended somewhat, and now half, or nearly half, of the cornea had be- 
come opaque. The medical gentlemen present, while suspecting can- 
cer, agreed that they had never seen a case resembling it, and gave a 
very undecided opinion. During the months of February and March 
his eye became very painful. His sufferings were apparently increased 
by applications of sulphate of copper in substance to the growth, and he 
changed his medical attendant and treatment. Dr. T., who now took 
charge of him, confined himself to the administration of opiates and the 
instillation of sedative drops. The pain however increased, and became 
almost intolerable; and on the 24th of May, 1873, I was invited by Dr. 
T. to visit him in consultation. The cornea had become completely 
opaque to external appearance. He could, however, discern the light 
* The history is by Dr. Ch., the description of the specimen by Dr. K. 2 
fas. Chapman and H. Knapp : 
from a window with the diseased eye. A tumor about eight or nine lines 
in length, and three or four in breadth, extended around the outer and 
upper quarter of the corneal circumference. This tumor was elevated at 
its centre, above the surface of the globe, about a line, or a line and a 
half, and its color was a rusty, yellowish white. The conjunctiva was 
deep red and thickened, especially at the outer canthus. The pain was 
most severe in the temporal region, but was also acute in the globe, 
head, face, and neck of the affected side. The patient complained of a 
feeling that there was a stick in the eye, and could scarcely be convinced 
that a splinter of wood had not lodged in the globe at the time of the in- 
jury. His strength and flesh were greatly reduced. 
It was decided to remove the globe and the diseased conjunctiva re- 
flexa, which, on the 26th day of May, 1873, I proceeded to do, in the 
presence of Drs. Thayer and Clark, of this place. Chloroform was ad- 
ministered, but with complete anaesthesia syncope came on, and the 
symptoms were so threatening that the anaesthetic was abandoned, 
restoratives applied, and he rallied so that the operation could be com- 
menced. An incision was made through the outer canthus, then the 
conjunctiva was incised all round the globe, leaving only the conjunc- 
tival covering of the palpebral cartilages and the caruncle intact. The 
muscles were then drawn out with a strabismus hook, and divided; and, 
lastly, the optic-nerve was severed. The lachrymal gland was drawn out 
and removed, and any diseased tissue in the orbital cavity excised. 
The whole operation being done with the scissors, except the first in- 
cision through the outer canthus. The relief from pain was immediate ; 
and he declared he had the best night’s sleep, the night after the opera- 
tion, that he ever had in his life. The wound healed well. His appetite 
returned; and when I saw him this morning, May 13th, 1874, he told me 
that his health had steadily improved ever since his eye was removed, his 
weight being now one hundred and eighty pounds, while one year ago it 
was only one hundred and forty pounds. I also examined the cavity 
from which the eye was removed, and could see no signs of any return 
of the disease. He declares that he has no pain in the orbit whatever. 
The wound is cicatrized, the upper lid falling a little over the lower one. 
Anatomical Examination of the Specimen.—A small part of the 
cornea only, about one-sixth of its area, was unaffected ; the re- 
mainder was whitish-yellow (yellow, from the staining with Muller’s 
fluid), and greatly swollen. The surrounding conjunctiva, to the 
width of five to eight millimeters, was converted into a moderately 
dense substance of an uneven, granular surface. A meridional A Case of Epithelial Cancer of the Conjunctiva 
section showed the inner parts of the eye healthy, and the inner 
face of the cornea and sclerotic smooth and unchanged. The 
transverse section of the sclerotic (Tab. VIII., Fig. i, s) and of 
the small unaffected part of the cornea (Fig. I, c) mentioned 
above were likewise unaltered ; but the remainder of the cornea 
(Fig. I, d) was thickened inconsequence of the infiltration of the 
pseudoplasm into its substance, its outer surface (Fig. I, o) being 
smooth and moderately bright. That part of the growth (Fig. i, b) 
which surrounded the cornea was in some places loosely (Fig. i, 
/), in others firmly (Fig. I, i) connected with the sclerotic, and 
here the extension of the growth into the corneal substance could 
be directly traced. Where the tumor was largest it had seven 
millimeters in thickness, as is seen in Fig. 2, which represents the 
tumor (t) in a somewhat oblique section through the sclero- 
corneal junction and its vicinity. 
The pseiidoplasm consisted in all its parts of well-marked epi- 
thelial cells, which lay closely together without any intervening 
substance. The cells were mostly large, with large nuclei and 
distinct nucleoli. The cell-body frequently presented a finely 
striped appearance, the stripes running in a radiating direction 
(Fig. 3, a). The contour of these cells appeared serrated (Fig. 3, 
b), thus the cell-wall had a furrowed surface like a ribbed-shell 
(Fig. 3, c). In many places the epithelial cells were arranged in 
cone-like figures, in others they were seen in a state of prolifera- 
tion ; a number of nuclei were embedded in dotted protoplasma, 
which had no definite boundary lines ; or two and more cells, 
with single and double nuclei, lay in oblong or roundish spaces, 
with distinct, mostly serrated boundary lines. These figures 
bore some resemblance to capsulated cartilage cells. In its struc- 
ture, therefore, the growth had no distinguishing feature from the 
usual epithelial cancer. The serrated condition of the epithelial 
cells, which was so plain in the majority of preparations when 
examined with higher magnifying powers (Hartnack, No. 9 dry, 
or 12 immersion), may, perhaps, not prove a rare condition if 
closer attention be paid to the outline of the cells. See : Wald- 
eyer, Virch. Arch., vol. 41 p. 470, etc. 
The origin of the growth was, as far as we could judge, in the 
epithelial layer of the conjunctiva. Here a dense accumulation 
of cells indicated the hyperplasia of the 01 Iginal elementary parts. Jas. Chapman and II. Knapp 
The propagation of the pseudoplasm was by uninterrupted exten- 
sion of epithelioid cells into the neighboring tissue. The subcon- 
junctival cellular tissue had in many places preserved its fibrous 
character, but rows of epithelioid cells stretched from the growth 
between the fibre-bundles, evidence of the propagation of the 
pseudoplasm into the vicinity by unbroken strings of cells. The 
same mode of propagation could with the greatest distinction be 
demonstrated in the cornea. At the corneo-scleral juncture the 
cells, penetrating into the corneal substance, followed the tracks 
of the corneal canals, which they expanded and filled in a way 
similar to what we see in suppurative keratitis (Fig. 4, a.) The 
infiltration of the foreign elements could be readily recognized by 
their color, which was yellow, whereas the normal elementary parts 
of the cornea were white. The anterior epithelium (Fig. 4, e), 
Bowman’s lamella (<b), and the regular arrangement of the corneal 
corpuscles were preserved. A greater magnifying power showed 
that the cells (Fig. 5), which infiltrated the cornea, were epithe- 
lial cells. They were seen in small (Fig. 5, b) and large (Fig. 
5, e,) clusters, and in long rows (Fig. 5, a). In many places 
(Fig. 5, d) the corneal corpuscles were dilated and contained two 
or more epithelioid cells, recognizable by their size and color. A 
greater magnifying power (Hartnack, immersion No. 12) showed 
even in these small clusters (Fig. 6) the enclosed cells with all the 
characteristic qualities of epithelial formations. Some of these 
cells (Fig. 6, a) exhibited the stripes in the cell-body as plainly 
as was noticed in the episcleral tumor. The corneal tissue, apart 
from this infiltration, was healthy. The inner structures of the 
eye had been removed from the specimen, but Dr. Chapman 
stated that they presented nothing unusual. 
The case under consideration presents some features worthy of 
note : 
1. Its origin from an injury.—Though a number of instances 
are on record in which tumors of different description, cancers 
included, have been the result of injuries, yet the authenticity of 
the casual connection between the injury and the growth has 
been doubted. Those who believe that cancer is a primarily 
constitutional disease, cannot admit that a trauma may be the 
cause of a cancerous growth, and they assume in such cases that 
the patient, when receiving the injury, suffered already from can- A Case of Epithelial Cancer of the Conjunctiva. 
cerous diathesis. The successful operation of malignant intra- 
ocular growths (sarcomatous and encephaloid) by early enucleation 
of the eyeball, of which a limited number of zvcll-authenticated 
cases is now on the records of science, is, I should think, convinc- 
ing proof that in the initial stage a malignant growth may be a 
local affection. If irritations of different kinds may produce in a 
certain locality cells with infectious properties that will sooner 
or later manifest themselves at some distance from the original 
focus and poison the whole organism, why should not an injury as 
well as cold or other causes occasion such an irritation as is neces- 
sary to produce cellular elements with infectious properties ? I 
am under the impression that these views are supported by the 
authority of Virchow. In the case under consideration the injury 
had struck the conjunctiva scleroticae, a place which is only rarely 
the seat of primary cancer. It was followed by inflammatory 
reaction, which soon subsided. Six months later the patient had 
first noticed that a growth had developed at the place of the 
former injury, and frorn that time the increase of the tumor had 
been steady. 
2. It was an instance of primary epithelial cancer of the con- 
junctiva, which is a rare disease. The history states that the 
growth, when first noticed, was situated on the sclerotic, about a 
line from the corneal margin. This is its ordinary seat. The 
disease has in its first stage the appearance of a broad, flat phlyc- 
tenula, for which, in some instances, it has been mistaken. The 
literature on this subject, with abstracts of the cases, is to be 
found in A. CLASSEN’S paper : Ueber ein Cancroid der Cornea 
u. Sclera. Virch. Arch. L., p. 56; and in F. HORNER’S paper: 
Tumoren in der Umgebung des Auges. Klin. Monatsbl. f. 
Augenh., 1871, p. 1, etc. 
3. The extension of the neoplasm by uninterrupted rows of 
epithelial cells could, in the case under observation, unusually 
well be demonstrated in the cornea. In a case by H. ALTHOF 
(Graefe’s Archiv, X.), and another by B. SOCIN (Sarcoma con- 
junctivae. Virch. Arch. LII. p. 55°)) a similar condition is de- 
scribed, namely, club-like, polypoid excrescences, extended, like 
the roots of a tree, between the lamellae of the corneal tissue. 
No structure in the human body is so well adapted as the cornea 
to study the intrusion of foreign elements, since the elementary fas. Chapman and IP. Knapp. 
parts of the normal condition display a well-known picture of an 
exquisitely regular arrangement. The foreign elements in the 
case before us were found in long, unbroken strings of cells, 
emanating from the episcleral growth, and in smaller or larger 
clusters, which, on their part, followed likewise the course of 
the corneal (lymphatic) canals. It seems most plausible that 
young cells travelled through these channels, and, multiplying, 
first filled and expanded the lacunae (corpuscles) of the cornea, 
and after that their intermediate offsets. The hypothesis appears 
forced, that disseminate, isolated clusters, primarily formed in the 
neighborhood of the original growth, and by subsequent coales- 
cence, produced the long and uninterrupted rows of cells. 
No blood-vessels were recognizable in the infiltrated portion of 
the cornea. I mention this particularly, since Classen (1. c.) 
found blood-vessels in the tissue of the cornea and lymphoid 
cells in their vicinity. He .thinks that these lymphoid cells are 
white blood-corpuscles, transuded through the walls of the 
vessels, and are converted into epithelioid cells, the elementary 
parts of cancer. 
4. The young elementary parts in the corneal portion of the 
tumor had the characteristic of the original pseudoplasm. They 
were not indifferent lymphoid cells which we frequently find in 
growing sarcomata and alveolar cancers, but true epithelial cells. 
In the cornea of this specimen, therefore, we found no conversion 
of connective-tissue elements into cancer, but the immediate con- 
tinuation of the proliferating epithelial cells of the conjunctiva. 
In some places of the conjunctival tumor, small, round, lymphoid 
cells were distinct and abundant enough. TWO CASES OF RETINAL GLIOMA. 
By H. KNAPP, M.D. 
(With Figs. 7 and 8, Tab. VIII.) 
Dr. E. Williams, of Cincinnati, to whom I am indebted for 
many a valuable pathological specimen, recently sent me again 
the histories of two cases of glioma retinae, together with the 
enucleated eyeballs, the description of which shows some feat- 
ures worthy of being placed on record. 
Case I. Bischof, ret. 12 years, slender in form and sallow of com- 
plexion, but in good health, was brought to me Feb. 21, 1874. One week 
before a playmate at school noticed a peculiar reflection from her left eye, 
and on trial it was found blind. She had had no inconvenience from it, nor 
knowledge of its condition till then. Nothing in the history of the patient 
throws any light upon the occurrence, or fixes its date. The associated 
movements of the irides were intact, but exclusion of the good eye 
showed a large and fixed pupil. The fundus presented the characteristic 
metallic lustre, rather red, like the color of copper. Numerous vessels 
could he seen traversing the surface of the fundus, but not having the 
regular distribution of the retinal vessels. The eye was absolutely free 
from all pain, redness, or other external alteration, and the tension nor- 
mal. 
The eye was enucleated by my partner. Dr. Ayres, in the usual way, 
great pains being taken to divide the optic nerve far back. Recovery 
was prompt, and there has never been the slightest trouble or suspicion 
of reproduction up to the present time (Aug. 10, 1874). We advised 
against the use of an artificial eye, not wishing to increase the risk of re- 
production by any local irritation. I shall keep the patient under obser- 
vation, and report any thing that may take place hereafter. 
E. Williams. 
Anatomical Examination of the Eyeball.—The globe, hardened 
in Muller’s fluid, had its natural size, and presented no external 
anomaly. A meridional section (see Fig. 7, Tab. viii.) showed 
the retina totally detached and corrugated, passing like a cord H. Knapp: 
from the optic nerve to the posterior surface of the lens capsule, 
where it expanded laterally, and was attached to the posterior 
edge of the ciliary body. The parietal (external) surface of the 
corrugated retina, especially on its anterior part, was beset with 
a number of roundish elevations. The section-surface of the 
retinal cord was partially granular, partially striated, white, with 
some black patches. The front part, which extended transversely 
through the globe, could be readily detached from the ciliary pro- 
cesses and crystalline body. The tissue of the retina was re- 
placed by a dense accumulation of small round cells, embedded 
in a granular matrix. The black patches consisted of the same 
cells, the majority of which, however, were pigmented. In ad- 
dition to them, irregular pigment cells and pigment granules 
were seen in these patches. The nodular elevations on the exter- 
nal surface showed the ordinary glioma structure. A great part 
of their cellular elements originated in the pars ciliaris retinae, and 
may be considered as hyperplastic formations of the granules 
normally interspersed between the radiating fibres of that mem- 
brane. 
Two conditions were unusual in this case: 1st, the age of the 
patient (12 years) is more advanced than we commonly find in 
glioma of the retina ; 2d, the greatest development of the pseu- 
doplasm in the anterior and ciliary parts of the retina is also 
against the rule. The pigment patches, too, are not frequently 
seen in so great an extent as in this specimen. The pigment, in 
all probability, was the result of hemorrhage. 
The prognosis in this case appears favorable, as the pseudo- 
plasm did not seem to possess a great tendency to proliferate, 
and was limited to the retina. The comparatively advanced age 
of the patient may also be considered a favorable condition con- 
cerning a permanent recovery. 
Case II.—B. S., a boy, vet. years, of reddish complexion, well de- 
veloped and bright in intellect, came under Dr. E. Williams’ care on 
March 6th, 1874. About two years previously the parents noticed a 
“white spot in the pupil ” of one eye. which gradually enlarged, but en- 
tirely without pain. The physician called it cataract, and sight had been 
abolished for a year. About five weeks previously exophthalmus was first 
noticed, which increased rapidly to such a degree that the globe was Retinal Glioma. 
completely luxated, and the lids contracted behind it. The eye was ten- 
der, and the boy felt a good deal of pain in his bowels. The cornea, as 
far as it could be distinguished from the swollen and very vascular globe, 
was of a dark reddish-brown color, looking like a dry coagulum of blood. 
The diagnosis was glioma, extending along the optic nerve. As an only 
hope, Dr. W. advised and performed an immediate enucleation. The 
conjunctiva, very much thickened, was cut a little in front of the equator, 
easily detached by the scissors, and the eye enucleated in the usual way. 
The optic nerve was felt very much enlarged, and the pressure of the 
finger backward caused the rupture of the cornea and the escape of some 
brain-like substance. To avoid the further collapse of the eye, the nerve 
was divided a short distance behind the globe. The stump of the nerve 
was then isolated and cut off close to the optic foramen, where it was 
still large and lardaceous. The recovery from the operation was rapid ; 
and three days afterwards the boy was taken to his home in the country, 
greatly relieved. The prognosis, of course, was hopeless : rapid and fatal 
reproduction being anticipated in a few weeks or months at most. I 
could find no evidence of tumors elsewhere, although the abdominal pain 
was suspicious. 
From letters afterwards received from Drs. Weaver and Kin- 
dell, the following is a condensed report of the progress of the 
case. The boy was lively and doing well till April I, when 
he grew peevish and fretful, complaining of a pain in the head, 
and vomited frequently. He had dysuria and persistent con- 
stipation. After these symptoms had lasted for two weeks, 
they noticed a growth in the orbit, which increased rapidly, 
and soon projected between the lids. By the first of June 
the tumor was as large as a hen’s egg, of a dark-red color, 
with blood constantly oozing out, when not controlled by astrin- 
gents. He died June 15. No post mortem was allowed. The 
body was very much emaciated. On palpation a tumor could be 
felt in the abdominal cavity, the size of a man’s wrist, deep-seated 
and extending from the transverse colon to the iliac fossa. 
Three weeks before death he became blind in the right eye, the 
disease having then, no doubt, invaded the optic chiasm. The 
orbital tumor, removed after death, is round, lobulated, and 
about two inches in diameter in all directions. Microscopically 
examined by Dr. A. D. Bender, of this city, it was pronounced 
“ glioma-sarcoma.” H. Knapp. 
Anatomical Examination.—The eyeball, of which the figure 
8, Tab. viii., gives an illustration in natural size, had the shape of 
a goblet, and presented a number of roundish protrusions in the 
ciliary region, where the slcerotic was thinned, but not perforated. 
The cornea had sloughed away, and through the aperture pro- 
truded the soft, brain-like substance with which the whole globe 
was filled. On the posterior part of the sclerotic some soft tu- 
mors were seen, which partially surrounded the thickened optic 
nerve, but were in no connection with it. On careful dissection 
a place was found in which, by way of a short pedicle, the epis- 
cleral tumor communicated with the intra-ocular growth. On 
this place the sclerotic was thinned and macerated, yielding 
readily to a probe, but offering resistance enough to show that 
many fibres were preserved. The growth here made its exit from 
the globe by forcing its way through the interlamellar spaces of 
the sclerotic. The pseudoplasm had the structure of glioma in 
all its parts. The thickened optic nerve was densely filled with 
small cells, the nervous fibres being mostly replaced by the 
pseudoplasm.' 
This eyeball presented a marked specimen of the third stage of 
glioma in which the growth, enlarging and perforating the globe, 
extends into the orbit and the cranial cavity. Besides the usual 
place of perforation, there was one in the posterior part o_f the 
sclerotic, showing, even microscopically, the direct connection 
between the intra-ocular and orbital portions of the pseudoplasm. 
The ciliary staphylomata also were not without interest, demon- 
strating that not only an excess of fluid contents, as in hydroph- 
thalmus, but a neoplasm when filling the globe, overcomes the re- 
sistance of the sclero-corneal capsule by preference in the ciliary 
region. A CASE OF NEURO-RETINITIS RESULTING FROM A 
GUMMY TUMOR OF THE DURA MATER. 
By H. KNAPP, M.D. 
RETINITIS in syphilitic persons has mostly no peculiar features 
distinguishing it from retinitis produced by other causes than 
lues. Two conditions, however, may be mentioned as being, in 
the great majority of cases, of syphilitic origin : 1st, irregular 
white stripes radiating from the papilla optica in the course of the 
blood-vessels being sometimes flat, sometimes considerably raised 
over the level of the retina; 2d, small, roundish, white patches, 
of fatty appearance, dispersed in some cases over the whole retina, 
in others limited to certain places in which they are so densely 
crowded as to resemble a piece of mosaic work. In the region 
of the yellow spot and its surroundings I have seen striking 
pictures of this second condition, which is totally different from 
the well-known radiating figures so frequently witnessed in this 
region in cases of Bright’s disease and neuro-retinitis, the conse- 
quence of morbid processes in the orbital or cranial cavities. 
In the following case, which came under my care in Charity 
Hospital two weeks before the fatal issue, the retina showed the 
ordinary picture of neuro-retinitis passing into atrophy of the 
optic nerves. The arteries were small and straight, the veins 
thickened and somewhat tortuous, the optic discs whiter than 
usual, their choroidal borders irregular. No other abnormity 
was found in the fundus oculi, though the examination was made 
in remembrance of the distinct history of syphilis obtained from 
the patient. Her death occurred unexpectedly, and I am sorry 
that I was not informed of it in time to witness the autopsy and 
prevent the eyes from being buried. The brain, however, which 
was preserved for me intact, showed so conspicuous a lesion that 
its examination rendered the case both interesting and instructive. 
For the clinical history of the disease I am indebted to Dr A. M. H. Knapp : 
Pierce, at the time resident physician to Charity Hospital, 
N. Y. 
Eliza Ring, aged 32 years, native of Ireland, married, occupation 
domestic, has been in the hospital several times for treatment. Eleven 
years ago she had a sore on her vulva, which was followed in due course 
of time by the secondary and tertiary lesions of syphilis. Two and a half 
years ago a small tumor appeared on the centre of the frontal bone. It 
had reached the size of a hen’s egg, and was hard and immovable when 
she came into the hospital, May 30th, 1873. It disappeared under the 
influence of iodide of potassium. 
Nov. 5th.—Patient again admitted to the hospital. During the last 
four or five months she has had a constant headache. While in the hos- 
pital she had several epileptiform convulsions and notable exophthalmus 
with impairment of sight in both eyes. Under treatment she got better 
and was discharged. 
Jan. 28th, 1874.—Patient again enters the hospital. The exophthal- 
mus has neaily disappeared, but she still complains of dimness of vision 
and pain in her head, which is generally constant and worse at night. 
The examination with the ophthalmoscope revealed the ordinary fea- 
tures of neuro-retinitis, with comrnencing atrophy of the optic nerve in 
both eyes. Two hours before her death, which occurred February 18th, 
she had an epileptiform convulsion, which was followed by coma, and in 
this condition she remained until death. 
Sixteen hours after death the autopsy was made by Dr. Drake, who in 
substance entered the following notes into the post-mortem book : 
Body medium size, well developed, and well nourished. CEdema of 
the legs. 
Head. At the anterior portion of the anterior lobe of the left hemi- 
sphere was a large gummy tumor (see subsequent figure) of the dura 
mater extending into the brain substance. The brain substance {in) 
surrounding the tumor was softened, as far backward as the posterior 
lobe. At the most anterior portion it was almost fluid. The left ven- 
tricle was dilated, filled with fluid, and its floor softened. The veins on 
the left side were greatly distended. 
Thorax. Heart hypertrophied and dilated. The aorta was athero- 
matous. 
Lungs. Both lungs greatly congested and oedematous. 
Abdomen. Liver enlarged, congested and slightly waxy, exhibiting the 
characteristic coloration with the iodine test. 
Spleen soft. 
Kidneys in the first stage of acute parenchymatous inflammation. Nenro-Retinitis. 
Minute examination of the Brain.—The right hemisphere, the 
posterior lobe of the left, the cerebellum and the medulla oblon- 
gata showed no abnormity, the middle lobe of the left hemisphere 
was softened and white, showing no other alteration than the 
simple decay of the brain-substance by maceration, most advanced 
in the vicinity of the pseudoplasm. The meninges were normal, 
except on the front part of the left anterior lobe where the par- 
ietal surface of the dura mater was rough and reddish in a space 
two inches in the antero-posterior diameter, and one inch and a 
half in the transverse. In the same place the dura was insepar- 
ably united to a tumor (see accompanying figure) which was 
nodular and penetrated into the 
brain-substance. On careful dis- 
section the pia mater (p in the 
figure) was found unchanged ; 
it lined the surface of the tumor, 
and could be detached from it. 
At the periphery it was united 
to the dura, but lay loose over 
the nodules of the pseudoplasm, 
and dipped into the depressions 
between its larger nodes. On 
incision the tumor was found in 
intimate connection with the dura 
id). Its larger portion (Ji), which 
sprang from the dura, was yellow- 
ish-white, opaque and hardish like 
fibro-cartilage, whereas the pe- 
ripheric portion (s) was trans- 
parent, hyaline, and softer than 
the central portion which it lined 
in a nearly uniform thickness of 
three millimeters. 
The microscope revealed in the 
outer, gum-like layer, an accumulation of small cells embedded 
in a moderate quantity of homogeneous basis-substance. The 
majority of the cells were round, and had large nuclei sur- 
rounded by a thin, but conspicuous layer of protoplasm. 14 
//. Knapp: 
Some of the cells had one or two short offsets, others were 
elongated. There was in this layer a moderate amount of fat 
granules between the cells and within them, as well as a good 
supply of blood-vessels. The yellowish-white, hard portion 
consisted of the same kind of cells that were found in the 
softer layer, but, in addition, of a considerable quantity of 
spindle-shaped cells, which in some places lay densely together, 
in others were sparsely scattered through the round cells. Here 
and there was a net work of anastomosing stellate cells. The 
matrix of this harder portion of the tumor was likewise homo- 
geneous or finely granular, but less abundant than in the soft 
layer. The cells and matrix of the hard portion were distinguished 
by a large quantity of granular fat. In some places the cells 
had disappeared to such a degree under the fatty degeneration as 
to make the structure of the tumor appear to be a granular, fatty, 
amorphous substance. There were many blood-vessels in this 
portion also. 
The outer layers of the dura mater were unchanged, the inner 
were separated by rows of small cells which passed over into the 
pseudoplasm without the interposition of any other tissue-ele- 
ments. 
This examination showed clearly that the neoplasm was a 
gummy tumor originating in the visceral surface, of the dura 
mater. It answers in every respect to the classical description 
R. Virchow gives of it in his work on morbid growths, vol. II., p. 
449, etc. It is an uncommonly large specimen of its kind. The 
softening of the adjacent parts of the brain {in in the figure) is a 
usual concomitant symptom of gummy tumors of the meninges. 
Ophthalmologically this case is of importance, adding another 
example to those in which a tumor, remote from the cavernous 
sinuses, produced the well-known picture of neuro-retinitis in both 
eyes. The substance, meninges, and nerves of the base of the 
brain, showed no abnormity. Though the left ventricle was dis- 
tended and the veins of the left side were greatly dilated, the 
neuro-retinitis was of the same kind and degree on both sides. 
This is not always the case, as we frequently find that eye most 
affected which corresponds to the diseased hemisphere. The 
eyes having not been preserved, the case throws no light on the 
question as to whether neuro-retinitis owes its origin to increased Neuro-Re tin it is. 
intracranial pressure, or to the propagation of fluid exudation 
through the subvaginal space of the optic nerve. The prominent 
clinical symptom was the constant headache. Upon it, the 
neuro-retinitis, the epileptiform seizures, and the pronounced his- 
tory of tertiary syphilis, the diagnosis of gummy tumor in the 
cranium was based, a diagnosis which had been made prior to the 
patient’s death. Tab. VIII 
Fig.T- 
Fiq.3 
600 
t” 
Fiq.U, 
Fi3-2 Vi. 
Fig.6. 
%omo 
Fig. 4 
19 
1 
Fig.5. 
3&0 
1. 
H.Knapp linat. 
Arch. Ophthalm. & Otol. IV. 
■ LHh. Anst v.F.Wirtz.Larmstait