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Cerebellar Hemangioblastoma
1038
NOTES, CASES, INSTRUMENTS
3
Posey, W. C. Myasthenia gravis. Trans. Sect. Ophth. Amer. Med. Assoc, 1921, p. 129. Walker, M. B. Treatment of myasthenia gravis with physostigmine. Lancet, 19.34, v. 1, June, p. 1200. 5 Pritchard, E. A. B. Prostigmin in treatment of myasthenia gravis. 1935, v. 1, Feb., p. 432. "Myerson, A. Human autonomic pharmacology. Jour. Amer. Med. Assoc. 1938, v. 110, Jan. 8, p. 101. 7 Aeschlimann, J. A., and Reinert, M. The pharmacological action of some analogues of physostigmine. Jour. Pharmac. and Exper. Therap., 1931, v. 43, p. 413. s Dale, H. H., and Feldberg, W. The chemical transmission of impulses in the cat. Jour. Physiol., 1934, v. 82, p. 121. ° Viets, H. R. and Schwab, R. S. Prostigmin in diagnosis of myasthenia gravis. New England Jour. Med., 1935, v. 213, Dec, p. 1280. 10 Gammon, G. D., and Scheie, H. Prostigmin as a diagnostic test of myasthenia gravis. Jour. Amer. Med. Assoc, 1937, v. 109, Aug., p. 413. II Viets, H. R., Schwab, R. S., and Mitchell, R. S. Prostigmin in diagnosis of myasthenia gravis. Arch. Neurol. and Psychiat, 1937, v. 38, p. 1349. 12 Thorner, M., and Yaskin, J. C. Treatment of mvasthenia gravis. Arch. Neurol. and Psychiat., 1937, v. 38, p. 423. 13 Paleari, A. The ocular syndrome in myasthenia. Riv. Oto-Neuro-Of t., 1937, v. 14, p. 356; Abst. Amer. Jour. Ophth., 1938, v. 21, p. 943. I
CERERELLAR HEMANGIOBLASTOMA L A T E RESULTS OF OPERATIONS EDWARD J A C K S O N , M.D.,
D.Sc.
Denver, Colorado T h e late results should be reported for any capital operation performed to pre vent blindness. J. L. S., aged 13 years, was seen in 1927 by Drs. R. P . Forbes and F . G. Ebaugh. In general, his health had been good, but he began to show great unsteadiness in gait, and extreme suboccipital pain on bending forward. H e frequently vomited on first awakening in the morning. H e was referred to Dr. Harvey Cushing with a tentative diagno sis of brain tumor. There was marked re striction of both fields of vision, and great swelling, 5 D., of each optic disc. May 16, 1927, under novocaine anes thesia, tapping of the lateral ventricles through the occipital bone showed on the right side that the fluid was under high tension, and gave great relief to his symp toms. T h e occipital bone was very thin. Its removal, with turning back of the dura, revealed "a tangle of veins" cours ing over the right cerebellar hemisphere. On account of bleeding, the operation was suspended, remaining merely a decom
pression operation. Recovery was prompt and the results excellent. T h e papilledema decreased to 1 D. in each eye. But the vision continued to decline. T o avoid the danger of total blindness, a second opera tion was performed on October 24, 1927, under novocaine and rectal ether. Reopen ing of the flaps of the dura showed a highly vascular tumor completely filling the right posterior fossa. This was re moved u p to the t e n t o r i u m ; and on No vember 17th the patient was; discharged in excellent condition. February 23, 1928, he was referred to the writer for observation of his eye conditions and vision. T h e ophthalmo scope showed the media clear; retinal reflexes n o r m a l ; optic discs grayish-white, with hazy m a r g i n s ; and the temporal quadrants white, the retinal vessels small, especially in the left eye. Otherwise the eyes were normal. H i s vision w a s : right 0.2; left 0.02. His general health had improved, and his father thought him well in all respects. On August 24th, vision of the right eye had slowly improved to 0.4, the left unchanged. T h e discs were a little less pale, the retinal vessels nearer normal. T h e periphery of the retina in each eye was free from lesions of any kind. It
NOTES, CASES, INSTRUMENTS was especially examined for evidences of retinal angiomatosis. T h e general con traction of the fields of vision had grown less. T h e greatest extent of the temporal fields on the horizontal meridian was for right eye, 50 degrees; left eye 80 degrees, and the lower nasal field of the left eye had reached about normal limits. Central vision slowly improved. On September 8, 1931, it was right 0.4, left 0.06. Since that time the fields have re mained unchanged. Meanwhile the pa tient has gone steadily ahead with his studies, in school and college, standing well in his classes, and graduating from the latter in 1939. His health seems sound in every way and, but for his narrowed fields of vision, he could qualify in ath letics. T h e impairment of vision seems to have been wholly due to the changes in the optic nerve. It has long been noticed that tumors of the cerebellum are partic ularly prone to cause choked disc. In re ported cases the removal of the tumor has checked the process, and some recovery has followed. All our experience points to the importance of early diagnosis. T h e fear that, in this case, retinal angiomatosis might also develop, proved to be ground less. Republic Building.
A SELF-SETTING CROSS CYLINDER* JOSEPH I. PASCAL, M.A.,
M.D.
New York The purpose of this device, conveni ently called a self-setting cross cylinder, is to make cross-cylinder tests a little more workable and more accurate. The instrument consists essentially of a cross cylinder set in a mount having its own axis scale and provided with an auto* Presented before the Section on Ophthal mology, New York Academy of Medicine, Feb ruary 19, 1940.
1039
matic stop so that twirling the cross cylin der rotates it through an angle of exactly 180 degrees. It also permits rapidly changing the cross-cylinder power to suit the case at hand. The mount can be held in front of the trial frame, or preferably set in the front cell of the trial frame. Of the six or seven applications of the cross cylinder I will refer to only two.
Fig. 1 ( P a s c a l ) . A self-setting cross cylinder.
To find the presence of astigmatism, the cross cylinder has to be tried with its axes in at least two different positions, preferably in three different positions at intervals of 30 degrees. In each position it has to be twirled through an angle of exactly 180 degrees. It is rather difficult to carry out this three-position test with an unsupported cross cylinder held in the hand. With the self-setting cross cylinder the three posi tions can be rapidly and accurately located and a rotation of exactly 180 degrees made in each setting. Astigmatism is generally detected most easily with the cross cylinder when the eye is not fogged by lenses. With this de vice in the front cell, if the patient's answer is negative or uncertain, the spherical lens can be changed without dis turbing the cross cylinder and the threeposition test rapidly repeated, until astig matism is either found or ruled out. Especially in cases where regular astig matism is obscured by a considerable amount of irregular astigmatism will this application prove useful. When locating the astigmatic axis, the loosely held cross cylinder is especially
NOTES, CASES, INSTRUMENTS
3
Posey, W. C. Myasthenia gravis. Trans. Sect. Ophth. Amer. Med. Assoc, 1921, p. 129. Walker, M. B. Treatment of myasthenia gravis with physostigmine. Lancet, 19.34, v. 1, June, p. 1200. 5 Pritchard, E. A. B. Prostigmin in treatment of myasthenia gravis. 1935, v. 1, Feb., p. 432. "Myerson, A. Human autonomic pharmacology. Jour. Amer. Med. Assoc. 1938, v. 110, Jan. 8, p. 101. 7 Aeschlimann, J. A., and Reinert, M. The pharmacological action of some analogues of physostigmine. Jour. Pharmac. and Exper. Therap., 1931, v. 43, p. 413. s Dale, H. H., and Feldberg, W. The chemical transmission of impulses in the cat. Jour. Physiol., 1934, v. 82, p. 121. ° Viets, H. R. and Schwab, R. S. Prostigmin in diagnosis of myasthenia gravis. New England Jour. Med., 1935, v. 213, Dec, p. 1280. 10 Gammon, G. D., and Scheie, H. Prostigmin as a diagnostic test of myasthenia gravis. Jour. Amer. Med. Assoc, 1937, v. 109, Aug., p. 413. II Viets, H. R., Schwab, R. S., and Mitchell, R. S. Prostigmin in diagnosis of myasthenia gravis. Arch. Neurol. and Psychiat, 1937, v. 38, p. 1349. 12 Thorner, M., and Yaskin, J. C. Treatment of mvasthenia gravis. Arch. Neurol. and Psychiat., 1937, v. 38, p. 423. 13 Paleari, A. The ocular syndrome in myasthenia. Riv. Oto-Neuro-Of t., 1937, v. 14, p. 356; Abst. Amer. Jour. Ophth., 1938, v. 21, p. 943. I
CERERELLAR HEMANGIOBLASTOMA L A T E RESULTS OF OPERATIONS EDWARD J A C K S O N , M.D.,
D.Sc.
Denver, Colorado T h e late results should be reported for any capital operation performed to pre vent blindness. J. L. S., aged 13 years, was seen in 1927 by Drs. R. P . Forbes and F . G. Ebaugh. In general, his health had been good, but he began to show great unsteadiness in gait, and extreme suboccipital pain on bending forward. H e frequently vomited on first awakening in the morning. H e was referred to Dr. Harvey Cushing with a tentative diagno sis of brain tumor. There was marked re striction of both fields of vision, and great swelling, 5 D., of each optic disc. May 16, 1927, under novocaine anes thesia, tapping of the lateral ventricles through the occipital bone showed on the right side that the fluid was under high tension, and gave great relief to his symp toms. T h e occipital bone was very thin. Its removal, with turning back of the dura, revealed "a tangle of veins" cours ing over the right cerebellar hemisphere. On account of bleeding, the operation was suspended, remaining merely a decom
pression operation. Recovery was prompt and the results excellent. T h e papilledema decreased to 1 D. in each eye. But the vision continued to decline. T o avoid the danger of total blindness, a second opera tion was performed on October 24, 1927, under novocaine and rectal ether. Reopen ing of the flaps of the dura showed a highly vascular tumor completely filling the right posterior fossa. This was re moved u p to the t e n t o r i u m ; and on No vember 17th the patient was; discharged in excellent condition. February 23, 1928, he was referred to the writer for observation of his eye conditions and vision. T h e ophthalmo scope showed the media clear; retinal reflexes n o r m a l ; optic discs grayish-white, with hazy m a r g i n s ; and the temporal quadrants white, the retinal vessels small, especially in the left eye. Otherwise the eyes were normal. H i s vision w a s : right 0.2; left 0.02. His general health had improved, and his father thought him well in all respects. On August 24th, vision of the right eye had slowly improved to 0.4, the left unchanged. T h e discs were a little less pale, the retinal vessels nearer normal. T h e periphery of the retina in each eye was free from lesions of any kind. It
NOTES, CASES, INSTRUMENTS was especially examined for evidences of retinal angiomatosis. T h e general con traction of the fields of vision had grown less. T h e greatest extent of the temporal fields on the horizontal meridian was for right eye, 50 degrees; left eye 80 degrees, and the lower nasal field of the left eye had reached about normal limits. Central vision slowly improved. On September 8, 1931, it was right 0.4, left 0.06. Since that time the fields have re mained unchanged. Meanwhile the pa tient has gone steadily ahead with his studies, in school and college, standing well in his classes, and graduating from the latter in 1939. His health seems sound in every way and, but for his narrowed fields of vision, he could qualify in ath letics. T h e impairment of vision seems to have been wholly due to the changes in the optic nerve. It has long been noticed that tumors of the cerebellum are partic ularly prone to cause choked disc. In re ported cases the removal of the tumor has checked the process, and some recovery has followed. All our experience points to the importance of early diagnosis. T h e fear that, in this case, retinal angiomatosis might also develop, proved to be ground less. Republic Building.
A SELF-SETTING CROSS CYLINDER* JOSEPH I. PASCAL, M.A.,
M.D.
New York The purpose of this device, conveni ently called a self-setting cross cylinder, is to make cross-cylinder tests a little more workable and more accurate. The instrument consists essentially of a cross cylinder set in a mount having its own axis scale and provided with an auto* Presented before the Section on Ophthal mology, New York Academy of Medicine, Feb ruary 19, 1940.
1039
matic stop so that twirling the cross cylin der rotates it through an angle of exactly 180 degrees. It also permits rapidly changing the cross-cylinder power to suit the case at hand. The mount can be held in front of the trial frame, or preferably set in the front cell of the trial frame. Of the six or seven applications of the cross cylinder I will refer to only two.
Fig. 1 ( P a s c a l ) . A self-setting cross cylinder.
To find the presence of astigmatism, the cross cylinder has to be tried with its axes in at least two different positions, preferably in three different positions at intervals of 30 degrees. In each position it has to be twirled through an angle of exactly 180 degrees. It is rather difficult to carry out this three-position test with an unsupported cross cylinder held in the hand. With the self-setting cross cylinder the three posi tions can be rapidly and accurately located and a rotation of exactly 180 degrees made in each setting. Astigmatism is generally detected most easily with the cross cylinder when the eye is not fogged by lenses. With this de vice in the front cell, if the patient's answer is negative or uncertain, the spherical lens can be changed without dis turbing the cross cylinder and the threeposition test rapidly repeated, until astig matism is either found or ruled out. Especially in cases where regular astig matism is obscured by a considerable amount of irregular astigmatism will this application prove useful. When locating the astigmatic axis, the loosely held cross cylinder is especially