Melanotic Schwannoma of Adrenal Gland - A Rare Entity/ Diagnostic Dilemma
NOTE ON A CASE OF MELANOTIC SARCOMA PRIMARILY AFFECTING THE ORBIT, WITH SECONDARY DEPOSITS IN LIVER,...
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937 round cells. Sections of the meninges on the surface of the brain show extensive round-cell infiltration, and some of the vessels are obviously diseased, and contain strands of material suggesting commencing organisation. The vessel walls, together with patches of the surrounding tissue, are the seat of caseous degeneration, most probably a gum- matous arteritis. Liver normal. Kidneys : commencing degeneration of secreting tubules. As far as can be ascer- tained, the hasmorrhagic encephalitis might be regarded as an infarction secondary to the occlusion of some of the larger cerebral vessels on the surface of the meninges by microscopic gummata." " The principal points in the case are : (1) The serious character of a specific lesion in middle life ; (2) the severity of the secondary eruptions ; and (3) the early onset of cerebral symptoms. Liverpool. NOTE ON A CASE OF MELANOTIC SARCOMA PRIMARILY AFFECTING THE ORBIT, WITH SECONDARY DEPOSITS IN LIVER, PLEURÆ, AND LUNGS. BY B. C. A. LEEPER, L.R.C.P. & S. IREL., L.M. (ROTUNDA), ASSISTANT MEDICAL OFFICER, EARLSWOOD ASYLUM. THE patient, a man aged 60 years, single, was admitted on Sept. 25th, 1906. The family history was unimportant and the previous history showed that the left eye was enucleated a year before admission on account, his friends said, of a " swell- ing." No history of syphilis, alcoholism, or insanity. On ad. mission the patient was well nourished and developed. The heart and lungs were normal, as were also the abdominal organs. The urine, of specific gravity 1020, acid, contained a slight trace of albumin. Mentally the patient was very lost and confused. He sat about by himself all day and talked to himself ; he was untidy in his habits. He remained in this condition till Dec. 21st, 1908, during which time a growth had again appeared in the left orbit. Up to this time he had never complained of any feeling of discomfort. In February, 1909, he complained of feeling unwell, and on examination was found to have the parotid and sublingual glands enlarged, also the growth in the eye commenced to trouble him, especially at night. The urine was very dark and gave the reaction for melanin. His appetite was very poor and he developed symptoms of secondary deposits in the lungs. Death took place on March 3rd, 1909. Neo’l’opsy.-A post-mortem examination was made two days later, the temperature being 540 F. Cadaver of elderly man. Very emaciated ; lividity and rigidity marked. Tumour the size of a Tangerine orange protruding from left t orbital cavity. Parotid gland of same side enlarged. Calvarium : orbital walls of left side eroded and brittle. Dura mater thickened and studded all over with punctiform hemorrhages. Pia and arachnoid thickened and congested. Brain substance healthy. Ribs : Very little cancellous tissue present. Pleurse covered all over with small black nodules. Lungs : whole substance of both covered with small black nodules identical with those on pleuise. I Heart degenerated and covered with fat ; valves com- petent. Liver enormously enlarged and projecting into thorax. Surface very hard and tough. Large nodular masses of a deep black colour on the surface and through substance. Liver weighed 8 lb. 12 oz. Supra- renals and kidneys were all studded over with fine black projections. Large quantity of brownish fluid in abdominal cavity. From orbit was removed a tumour weighing 8 oz., encapsuled in a sac which was filled with a gelatinous sub- stance of a deep black colour, which had a putrid smell. Microscopical examination showed the presence of a spindle- celled sarcoma. CENTRAL LONDON OPHTHALMIC HOSPITAL.-This institution has acquired a site in Judd-street, the lease of its present buildings in Gray’s Inn.road being on the eve of expiration, and building operations have been begun. In addition to the 12,000 in hand, a further sum of C5000 will be required to complete the building. Medical Societies. ROYAL SOCIETY OF MEDICINE. MEDICAL SECTION. The Electro-car(liographio Method. -Su.ffoaative Catarrh. A MEETING of this section was held on March 28th, with Sir WILLIAM ALLCHIN in the chair. Dr. THOMAS Lnwis (University College Hospital Medical School) read a paper on the E)ectro-cardiographic Method and its Relationship to Clinical Medicine. He said that the latest development of the galvanometer method was the new " string galvanometer" of Einthoven. It was an instru- ment which, on account of the quickness of its response, its- sensitivity, and the ease with which it was managed, was rapidly superseding all other instruments of its class. It consisted of a powerful electro-magnet, the separate poles of which were closely approximated, and left between them a narrow chink. In the chink an extremely fine fibre (of platinum or silvered quartz) was suspended. The principle of the instrument was simple. An electric current was passed through a conductor lying in a magnetic field ; con- ductor and magnet reacted upon each other ; and if one system was fixed and the other was moveable, the latter (the moveable system) was deviated in a definite direction. In the string galvanometer the magnet was fixed, the string was slack and flexible ; the string was the moveable system, and it deviated when a current was passed through it. The quickness and sensitiveness of the instru- ment depended upon the lightness of the fibre and upon the strength of the magnetic field. The strength of the magnetic field of the string galvanometer and the lightness of the fibres were such that accurate measurements might be made of very minute currents. When the instrument was properly adjusted the deviation of the string was directly proportionate to the strength of current passed into it. An estimate of the practical value of a si[Jgle method of physical examination was at no time easy, and it was espe- cially difficult when they dealt with a method which was still in its infancy. In offering his own impressions of the relationship of the electro-cardiographic methods to the practice of medicine it was to be understood that he gave them as they appealed to him at the present time and after three years’ study. He thought he should do wisely if he placed in the foreground, not the method itself, but the general conclusions which had been arrived at as a result of its employment, confining atten- tion to those facts which had an immediate influence upon their conceptions of pathological conditions. Regarded from that point of view, their attention concentrated at the present time upon two conditions, which were usually referred to as delirium cordis and paroxysmal tachycardia. As a result of investigations carried out with the galvano- meter, they were now in a position to assert in the most positive fashion that what had been termed in the past delirium of the heart was, in fact, a condition known to experimentalists by the name" fibrillation of the auricle." The clinical importance of recognising that disorder of the cardiac mechanism could scarcely be exaggerated ; it was directly accountable for 50 per cent. of all irregular pulses- as they were encountered in a general out-patient depart- ment, and for an even higher percentage in the wards of a general hospital. In patients who were the sub- jects of heart affections attributable to a rheumatic infec-- tion, and in elderly patients who succumbed as a result of progressive sclerotic myocarditis, the final break-down was often, if not generally, heralded by the onset of that curious, distinct, and easily recognisable mechanism. The importance of identifying it was obvious, not only on account of its universality, its profound influence upon the life- history of the heart affected by it, but equally because, being a mechanism sui generis, it reacted to cardiac drugs in a specific manner. It was not the place in which to refer to the disorder in greater detail, but only to emphasise the imperative need of an acquaintanceship with the condition, and to claim for the galvanometer its final isolation and analysis. He passed to the second con- dition-namely, paroxysmal tachycardia. Formerly it was
Transcript of NOTE ON A CASE OF MELANOTIC SARCOMA PRIMARILY AFFECTING THE ORBIT, WITH SECONDARY DEPOSITS IN LIVER,...
937
round cells. Sections of the meninges on the surface of thebrain show extensive round-cell infiltration, and some ofthe vessels are obviously diseased, and contain strands ofmaterial suggesting commencing organisation. The vesselwalls, together with patches of the surrounding tissue, arethe seat of caseous degeneration, most probably a gum-matous arteritis. Liver normal. Kidneys : commencingdegeneration of secreting tubules. As far as can be ascer-tained, the hasmorrhagic encephalitis might be regarded asan infarction secondary to the occlusion of some of the largercerebral vessels on the surface of the meninges by microscopicgummata."
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The principal points in the case are : (1) The seriouscharacter of a specific lesion in middle life ; (2) the severityof the secondary eruptions ; and (3) the early onset ofcerebral symptoms.Liverpool.
NOTE ON A CASE OF MELANOTIC SARCOMAPRIMARILY AFFECTING THE ORBIT, WITH
SECONDARY DEPOSITS IN LIVER,PLEURÆ, AND LUNGS.
BY B. C. A. LEEPER, L.R.C.P. & S. IREL.,L.M. (ROTUNDA),
ASSISTANT MEDICAL OFFICER, EARLSWOOD ASYLUM.
THE patient, a man aged 60 years, single, was admitted onSept. 25th, 1906. The family history was unimportant and theprevious history showed that the left eye was enucleated ayear before admission on account, his friends said, of a " swell-ing." No history of syphilis, alcoholism, or insanity. On ad.mission the patient was well nourished and developed. Theheart and lungs were normal, as were also the abdominalorgans. The urine, of specific gravity 1020, acid, contained aslight trace of albumin. Mentally the patient was very lost andconfused. He sat about by himself all day and talked tohimself ; he was untidy in his habits. He remained in thiscondition till Dec. 21st, 1908, during which time a growthhad again appeared in the left orbit. Up to this time hehad never complained of any feeling of discomfort. In
February, 1909, he complained of feeling unwell, and onexamination was found to have the parotid and sublingualglands enlarged, also the growth in the eye commenced totrouble him, especially at night. The urine was verydark and gave the reaction for melanin. His appetitewas very poor and he developed symptoms of secondarydeposits in the lungs. Death took place on March 3rd,1909.Neo’l’opsy.-A post-mortem examination was made two
days later, the temperature being 540 F. Cadaver of elderlyman. Very emaciated ; lividity and rigidity marked.Tumour the size of a Tangerine orange protruding from left torbital cavity. Parotid gland of same side enlarged.Calvarium : orbital walls of left side eroded and brittle.Dura mater thickened and studded all over with punctiformhemorrhages. Pia and arachnoid thickened and congested.Brain substance healthy. Ribs : Very little cancelloustissue present. Pleurse covered all over with smallblack nodules. Lungs : whole substance of both coveredwith small black nodules identical with those on pleuise. IHeart degenerated and covered with fat ; valves com-
petent. Liver enormously enlarged and projecting intothorax. Surface very hard and tough. Large nodularmasses of a deep black colour on the surface andthrough substance. Liver weighed 8 lb. 12 oz. Supra-renals and kidneys were all studded over with fine blackprojections. Large quantity of brownish fluid in abdominalcavity. From orbit was removed a tumour weighing 8 oz.,encapsuled in a sac which was filled with a gelatinous sub-stance of a deep black colour, which had a putrid smell.Microscopical examination showed the presence of a spindle-celled sarcoma.
CENTRAL LONDON OPHTHALMIC HOSPITAL.-Thisinstitution has acquired a site in Judd-street, the lease of itspresent buildings in Gray’s Inn.road being on the eve ofexpiration, and building operations have been begun. Inaddition to the 12,000 in hand, a further sum of C5000 willbe required to complete the building.
Medical Societies.ROYAL SOCIETY OF MEDICINE.
MEDICAL SECTION.
The Electro-car(liographio Method. -Su.ffoaative Catarrh.A MEETING of this section was held on March 28th, with
Sir WILLIAM ALLCHIN in the chair.Dr. THOMAS Lnwis (University College Hospital Medical
School) read a paper on the E)ectro-cardiographic Methodand its Relationship to Clinical Medicine. He said that thelatest development of the galvanometer method was thenew " string galvanometer" of Einthoven. It was an instru-ment which, on account of the quickness of its response, its-sensitivity, and the ease with which it was managed, wasrapidly superseding all other instruments of its class. Itconsisted of a powerful electro-magnet, the separate polesof which were closely approximated, and left between thema narrow chink. In the chink an extremely fine fibre (ofplatinum or silvered quartz) was suspended. The principleof the instrument was simple. An electric current was
passed through a conductor lying in a magnetic field ; con-ductor and magnet reacted upon each other ; and if one
system was fixed and the other was moveable, the latter (themoveable system) was deviated in a definite direction. Inthe string galvanometer the magnet was fixed, the stringwas slack and flexible ; the string was the moveable
system, and it deviated when a current was passedthrough it. The quickness and sensitiveness of the instru-ment depended upon the lightness of the fibre and upon thestrength of the magnetic field. The strength of the
magnetic field of the string galvanometer and the lightnessof the fibres were such that accurate measurements might bemade of very minute currents. When the instrument was
properly adjusted the deviation of the string was directlyproportionate to the strength of current passed into it.An estimate of the practical value of a si[Jgle method ofphysical examination was at no time easy, and it was espe-cially difficult when they dealt with a method which was stillin its infancy. In offering his own impressions of the
relationship of the electro-cardiographic methods to thepractice of medicine it was to be understood that he gavethem as they appealed to him at the present timeand after three years’ study. He thought he shoulddo wisely if he placed in the foreground, not themethod itself, but the general conclusions which had beenarrived at as a result of its employment, confining atten-tion to those facts which had an immediate influenceupon their conceptions of pathological conditions. Regardedfrom that point of view, their attention concentrated at thepresent time upon two conditions, which were usuallyreferred to as delirium cordis and paroxysmal tachycardia.As a result of investigations carried out with the galvano-meter, they were now in a position to assert in the mostpositive fashion that what had been termed in the pastdelirium of the heart was, in fact, a condition known toexperimentalists by the name" fibrillation of the auricle."The clinical importance of recognising that disorder of thecardiac mechanism could scarcely be exaggerated ; it was
directly accountable for 50 per cent. of all irregular pulses-as they were encountered in a general out-patient depart-ment, and for an even higher percentage in the wardsof a general hospital. In patients who were the sub-
jects of heart affections attributable to a rheumatic infec--tion, and in elderly patients who succumbed as a resultof progressive sclerotic myocarditis, the final break-downwas often, if not generally, heralded by the onset of thatcurious, distinct, and easily recognisable mechanism. The
importance of identifying it was obvious, not only on accountof its universality, its profound influence upon the life-history of the heart affected by it, but equally because,being a mechanism sui generis, it reacted to cardiac drugs ina specific manner. It was not the place in which to referto the disorder in greater detail, but only to emphasisethe imperative need of an acquaintanceship with thecondition, and to claim for the galvanometer its finalisolation and analysis. He passed to the second con-
dition-namely, paroxysmal tachycardia. Formerly it was
