Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 118

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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DISTORTIONS OF THE VISUAL FIELDS IN CASES OF BRAIN TUMOR. STATISTICAL STUDIES. (FIRST PAPER.)

By HARVEY CUSHING, M. D., and GEORGE J. HEUER, M. D., The Johns Hopkins Hospital, Baltimore, Md.

INTRODUCTORY.

Of the manifold symptoms which may be produced by an intracranial growth none are of greater interest and none of greater importance than the various disturbances on the part of the visual apparatus. On the one hand, largely irrespective of the seat of the lesion the direct ophthalmoscopic examina- tion of the eye-grounds may reveal the characteristic neuro- retinal stasis and œdema (choked disc), which unfortunately is still regarded by many as essential to the diagnosis of tumor, despite the fact that it is a comparatively late pressure phe- nomenon. On the other hand, deviations from the normal outlines of the visual fields not only may serve as the only possible means of determining the siuation of the growth, but may at times even foretell the onset of a choked disc, for cer- tain distortions of the color field boundaries appear to be brought about by general pressure disturbances.

Hence the ophthalmoscope, though chiefly useful in dis- closing the most reliable of the objective signs of increased intracranial tension, nevertheless is of some value for localiza- tion, as it may show upon which side the tension is greater. The perimeter, contrariwise, is chiefly useful as an aid to local- ization, though it furnishes at the same time important in- formation in regard to the existence of an increase of tension. These two instruments, therefore, are the most useful and should be the most used of all the paraphernalia accessory to the making of a neurological investigation ; and, needless to say, every physician and every surgeon who desires to make an intelligent study particularly of intracranial tumors must familiarize himself with these important diagnostic aids, with-

out which he would be as helpless as the clinician unfamiliar with the stethoscope in the presence of a cardiac lesion.

As the outcome of some investigations relating to the subject of choked disc, started by one of us in 1905 in conjunction with Dr. James Bordley, it has become our clinical routine not only to make frequent, often daily, observations on the condition of the eye-grounds, but also to make serial tests of visual acuity and repeated perimetric charts of form and colo: before and after our operative procedures. Dr. Bordley drew attention early in the course of these studies to the frequent association of color interlacing with low grades of increasel intracranial tension. In a communication dealing primarily with this subject " comment was also made upon certain mat- ters which bear relation to the subject of hemianopsia. The more important of them in the present connection, was the fact that in cases of homonymous hemianopsia the color ir- version or interlacing is demonstrable for the seeing half of the retina just as it is for the entire field when there is no regional implication of the visual pathway.

Since presenting this earlier paper in May, 1909, corre- spondingly detailed studies have been made of 104 additional cases of tumor, and we desire in the present communication to record the results of perimetry in the entire series of 200 surgically treated cases which have been observed during the past five years.3

One must be familiar from personal experience with the

' This communication is the first of a series of five papers, the four to follow dealing respectively with dyschromatopsia and with the binasal, bitemporal and homonymous hemianopsias which have been observed in a series of 200 cases of brain tumor.

2 Bordley and Cushing: Alterations in the color fields in cases of brain tumor. Arch. Ophth., 1909, XXXVIII, p. 451.

" The fields in these cases have been plotted by Drs. Bordles, Heuer, Crowe, Goetsch and Sharpe, and when there has been any question of inaccuracy on the part of patient or observer, or any unusual peculiarity of the fields, they have been replotted by 3 second observer who has not seen the original charts, in order :D eliminate the possible errors of personal equation.

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BO TWTy realize the amount of patience and time often required if a reliable record is to be secured. The individual perform- ance is fatiguing enough, alike to observed and observer, but when alterations are taking place from day to day, so that serial performances are called for, one could hardly subject himself and his patient to the ordeal were not the results often of vital importance, either in presaging the necessity of prompt relief from pressure or in estimating the quality of elief which the operation has afforded. Naturally, in many of our surgically fatal cases but a single perimetric examina- ;ion has been made before the operation, but in far the larger number a series of charts has been plotted-as many as ten or twenty in some instances where patients have been kept ong under observation after simple palliative measures. While awaiting the time for a " silent " lesion to finally give evidence of its location, the condition of the visual fields-the color relationship in particular-taken in conjunction with the degree of œdema of the nerve-head, is the most accurate neans of estimating the need of further intervention.

The color inversion and choked disc of the average tumor in ts early stage disappear as a rule after the usual subtemporal lecompression. One must, however, in these cases have the expectation that the relief will be only temporary and that further intervention will be necessitated after a number of nonths, even though no localizing signs have as yet appeared. Ience, an examination of these patients every few weeks or nonths is advisable in order that a return of the pressure ymptoms may be promptly recognized. Thus it is that in nany of our cases the fields have been plotted a great number f times ; and in the series of authenticated tumor cases there re, all told, some four hundred perimetric charts appended o the histories, and if the charts of the patients under the uspicion of carrying a tumor were added to these the number could doubtless be doubled.

How helpless one may actually be in attempting to make a gional diagnosis without the aid of perimetry is realized lost effectually in the case of young children or of blind atients whose fields have not been previously taken. When a noked disc has advanced to the stage of complete atrophy Le occipital lobes and optic radiations become " silent," so r as any objective signs useful for a regional diagnosis are ncerned, and in several of our patients the localization of sions which proved post mortem to have been accessible and movable has been completely frustrated in this way.

A number of the patients who were blind upon admission .ve brought fields which had been plotted elsewhere before e total loss of vision occurred. Though these records have casionally been useful, they have, as a rule, been so casually sen-in one case, indeed, the blind areas were actually re- rsed on the cards that most of them (even those plotted by lled ophthalmologists, have been too unreliable for diag- stic purposes. Too few circumferential points are usually ten and the cards, as a rule, are so small that the color in- lacing, on which we have come to lay so much stress, is not parent. Furthermore, a number of our best illustrations

va diliiactivitatopold were cutifty overlooked off tests made shortly before the patients' admission to the hospital, the fields for form alone having been recorded.

How accurate one needs to be in plotting the charts is well illustrated by a recent experience in which an erroneous ob- servation of our own was fortunately corrected for us by Dr. Adolph Meyer, whose description of the course taken by the geniculo-calcarine fibers is of primary importance." The story is as follows :

SURGICAL No. 26762 .- The patient had been shot in the left eye five years before admission. The missile had destroyed the eye- ball, necessitating enucleation, and had produced an immediate, total and permanent left facial paralysis with complete deafness in the left ear. He recovered from the effects of the injury, but after some months began having peculiar seizures with inaugural subjective disturbances of taste and smell. These attacks gradu- ally became more severe and in the course of time led to typical convulsive fits with a gustatory aura, smacking of the lips and a final loss of consciousness-typical uncinate gyrus fits.

On examination there was a total peripheral palsy of the left seventh and eighth nerves, and with the X-ray a bullet was shown lodged in the petrous portion of the left temporal bone. There was a scar nicking the lower left eyelid, and it was apparant that the missile in its course must have transversed the lower part of the temporal lobe.

In view of Dr. Meyer's description of the temporal loop of the optic radiation it seemed probable that the perimeter would show a partial right hemianopsia, or at least some defect in the field of the remaining (right) eye. The fields were consequently taken (Fig. 1), and were interpreted as being normal. Fortunately Dr. Meyer saw the patient at this time and suggested that the fields be replotted, with a closer angulation, namely, for every fifteen degrees at least. When this was done the defective sector which he had foretold was disclosed in the upper outer quadrant (Fig. 2), corresponding with the damaged fibers of the lower part of the pathway in the injured temporal lobe. The defect, of course, would have been a bilaterally homonymous one had the left eye not been destroyed.

This experience serves as a good illustration of the care essential to the making of these records. A further need for precaution which is not fully appreciated lies in the possi- bility of misjudging the existence of a tendency to vertical hemianopsia. For in these cases it is necessary, in order to accurately determine the superior and inferior points on the vertical meridian, that the disc be advanced toward the fixa- tion point only a few degrees from the median line, first on one side and then on the other. If the median line alone is relied upon and the disc happens to be advanced toward the center merely a degree or two from the exact mid-line and on the side of the blind field, the highest (or lowest, as the case may be) median point will be missed and the field bound- ary will appear to slant across instead of dropping away rather abruptly from the poles of the vertical meridian. Unless regard is paid to this, an existing tendency toward hemia- nopsia may be entirely overlooked. This applies to the color fields as well as to that for form, and in estimating the field for form (or for white) in suspicious cases gray discs are

Adolph Meyer: The connections of the occipital lobes and the present status of the cerebral visual affections. Trans. Ass. Am. Physicians, 1907.

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JOHNS HOPKINS HOSPITAL BULLETIN.

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often useful, for the form outline may seem intact with the usual white disc and yet vision in one or the other half fields be definitely obscured.

There are other precautions which are more familiar and to which attention is more often called-the avoidance of dis- tortions from fatigue and inattention, the distinction of the white from the form fields, the employment of pure and uni- form colors, and the like."

STATISTICAL REVIEW.

All told, in the period of twenty-one years, from January 1, 1890, to January 1, 1911, 242 patients with cerebral neo- plasm have been operated upon in Professor Halsted's clinic at the Johns Hopkins Hospital. In the first fifteen years of this period, from January 1, 1890, to June 18, 1904, only

Adapted to the Meyrowitz Perimeter 105 7.5º 90

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FIG. 1 .- Chart October 18, 1910. Showing what was regarded as an indication of practically normal field relations. Note that eight points were relied upon for the form field and only four for both blue and red.

42 cases were admitted with the diagnosis of tumor, and of these in only 3 were fairly careful perimetric charts plotted, the tests for visual defects in the other cases amounting to nothing more than rough finger observations. The results in these cases are therefore negligible.

Since June 18, 1905, to the present writing, January 1, 1911-approximately a period of five years-the 200 cases

" Unless otherwise stated on the legends or case reports through- out this series of papers, discs of 0.5 mm. have been used in the making of the charts, and the outer boundary records the form field rather than that for white. We have usually confined our color observations to blue and red. The green field, though oc- casionally charted, we have found to be less useful for our pur- poses, and it has not been included in the charts reproduced in this series of papers.

which form the basis of the present report have come under observation, and with only one or two exceptions they have been surgically treated. The rapid increase in the number of these patients may be judged from the fact that 82 out of the 200 have been admitted for treatment during the past twelve months.

It has been possible to plot reliable perimetric charts in 123 out of the 200 patients, 61.5 per cent, repeated observations having been made in the majority of the 123 cases. In the remaining 77 cases of the series no examinations were pas- sible, or records were made which were too cursory to be of value from the standpoint or our present studies. These cases deserve a word in passing.

Cases in Which Perimetry was Omitted or Precluded .- The examination was precluded owing to blindness in 19

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FIG. 2 .- Chart October 19, 1910. Corrected chart disclosing upper right temporal defect indicating destruction of some lower fibers of Meyer's loop of the visual pathway in left temporal lobe. Points taken at every 15 degrees for form and nearly as fre quently for blue and red. Note the striking difference of color field configuration in the two charts.

cases." The patients were too young to permit of anything more than rough tests in 13 instances. In 28 they were un- conscious, aphasic or too ill and having too much vertigo for reliable perimetry, though in a number of these cases subse quent post-operative tests were possible. Nine patients were operated upon out of town, and the fields, if any, which at-

" That 11.6 per cent of all of our cases coming for operation are blind from atrophy secondary to a choked disc is a commentary on the present indecision of physicians in regard to the surgical nature of brain tumors. It is encouraging to note, however, that in the last 100 cases there were only 7 patients who were blind at the time of admission-contrasting favorably with the 12 blind patients in the preceding 100 cases.

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ame holds true for the records of 9 cases for which we are personally responsible, the fields having been plotted by un- eliable observers and not authenticated, or, owing to the ex- gencies of the case, either neglected entirely or the examina- ion restricted practically to finger tests for form alone.

Cases in Which Perimetry was Possible .- As we have stated, eliable charts were secured from 123 patients. Of this num- er 27 showed fields which were practically normal in all espects. There remain 95 cases-nearly one-half of the en- ire number, and 77 per cent of the cases in which the fields ould be taken-which displayed abnormalities of diagnostic alue. In 42 cases characteristic defects occurred which were efinitely of aid in localization. The charts of the other 53 ases showed fairly symmetrical interlacing with more or less endency toward inversion of the color fields, accompanied y some constriction of the fields for form-an indication of n increase of pressure. These three subdivisions deserve ›me further analysis.

1. Normal Fields .- As stated, these were observed in 27 of le 200 cases (13.5 per cent), and it is interesting to note hat practically all of them occurred in the second one hundred ises of the series-an evidence of the growing tendency ›ward more precocious diagnoses before symptoms have ad- anced to a high degree. Naturally, normal fields will more 'ten be observed when the tumor primarily involves an area hich promptly gives localizing symptoms. This is particu- rly true of early pontine tumors (2 cases) ; of many tumors hose first symptom is Jacksonian epilepsy (7 cases) ; of early tracerebellar or lateral recess lesions (6 cases), and par- cularly of early hypophyseal growths or hyperplasias which ive not reached the point of giving either general pressure or rious neighborhood symptoms (7 cases).

A few of these 27 cases with normal fields showed an early age of hyperæmia of the nerve-head. This, however, was the ception. In most of them there was neither interlacing nor suspicion of œdema of the papilla.

The diagnoses of tumors which, on the other hand, originate relatively silent areas of the brain will naturally depend re often on the existence of general pressure symptoms, im- tant among which are more or less outspoken perimetric riations. As a matter of fact, the mere enumeration of the 'centage of choked discs which have been observed in a en series of tumor cases is apt to mislead; for the figures ich are often given, varying from 70 to 80 per cent, depend rely upon the stage of the disease at which on an average patients have come under observation. And this hereto- ¿ has usually been an advanced stage. With the few ex- tions of cases in which the growth primarily originates in near some vital center in the brain stem causing sudden th before general pressure symptoms occur, all brain ors may ultimately be expected to show a choked disc. he pontine tumors furnish a good example of this. In various statistical studies on the occurrence of choked as a manifestation of brain tumors attention has been id to the surprisingly low figures in the case of pontine

growths. This is naturally accounted for by the fact that from the very situation of the lesion in what may be called the encephalic cross-roads, an early diagnosis is almost cer- tain to be made before pressure symptoms advance to any considerable degree. A tumor of corresponding size in a mute area of the brain would be practically symptomless. Hence it is natural that the existence of a pontine tumor is recognized early, but this does not mean that such a lesion is ultimately any less liable than others to produce a choked disc, except in the case of an early fatality. Indeed, a choked disc would be inevitable in the course of time from compression of the iter and the secondary increase of cerebral pressure due to a ventricular hydrops. The same thing naturally holds true for color interlacing in these cases, and in all of our eight pontine tumors not only choked disc, but color inter- lacing also-judging from the cases in which it was possible to use the perimeter-has been an inconspicuous or absent feature until late in the disease.

2. Fields Showing Color Interlacing (Dyschromatopsia) .- Interlacing with more or less inversion and constriction of the color fields was the only perimetric abnormality observed in 53 cases (26.5 per cent of the entire series, 43 per cent of the 123 cases possible to examine). If we add to these 53 cases the 16 in which color interlacing accompanied various types of homonymous hemianopsia there are 69 cases of in- terlacing in the series. Furthermore, if we deduct from the 123 cases the 27 showing normal fields, and about 20 others with complete loss of color vision (achromatopsia), a constricted form field alone being preserved, it will be seen that the 69 cases which showed interlacing before operation represent about 90 per cent of all those in which this type of perimetric deviation could have been expected. For the cases showing normal fields had not arrived at a stage where pressure was sufficient to produce interlacing; while those with achroma- topsia had gone beyond it."

" These figures may be compared with the statistics recorded by Bordley and Cushing (loc. cit.) two years ago, 50 out of the series of 56 cases then examined having shown color changes. The present figures (69 out of a series of 123 cases) represent a much lower percentage, due partly to the fact that we are seeing tumor cases much earlier in their course than formerly and also to the fact that the proportion of hypophyseal tumors in the series has increased greatly during the past year and has somewhat modi- filed the percentages.

We are aware that many have experienced difficulty in record- ing color interlacing, and the only corroboration, so far as we know, of our results has been given in a note by B. Sachs (Jour. Am. Med. Asso., 1909, p. 316) and in a report by Byrom Bramwell (Lancet, March 5, 1910, p. 631). There are of course other con- ditions which may produce interlacing, many of them associated with pressure or stasis, as enumerated by de Schweinitz in his chapter on the Psychoses and Neuroses in "The Eye and Nervous System " (Posey and Spiller). We have observed an occasional instance of typical interlacing in exophthalmic goitre.

It possibly should be stated that in plotting the charts the boundary points on each radius are determined for both colors at the same moment. If the fields for blue and red should be plotted separately the relationship of their periphery would be less dependable.

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In the 200 cases of our complete series there have been 134 supratentorial (cerebral) and 66 subtentorial lesions, a pro- portion of two to one. In the group of cerebellar cases more or less symmetrical and bilateral constriction with color in- terlacing is the only perimetric change we can expect; and of the 53 cases which have shown this change alone without a suggestion of an hemianopic defect, naturally a considerable number proved to be cerebellar (certified or suspected) cases -a proportion of three cerebral to two cerebellar.

Without further analysis of these figures it is apparent that interlacing proves to be one of the most constant of the signs of an increase in pressure, and, what is more important, that it is occasionally the earliest of these signs. In a number of - instances, as we have indicated, the condition has preceded a demonstrable choked disc, and, furthermore, when accom- panied by a choked disc it has been very commonly observed that the inversion and interlacing disappear after decompres- sion before there is any considerable subsidence of the neuro- retinal swelling. Thus, if this type of dyschromatopsia is to be attributed to pressure it appears to be a more sensitive reaction in many respects than the neuro-retinal œdema itself.

The cases in this group of 53 which showed dyschroma- topsia, either in the total absence of a choked disc or in com- pany with a very incipient process, will be recorded in some detail in our second paper. At the same time the perimetric changes observed in the outspoken stages of choked disc will be correlated with Marcus Gunn's five subdivisions of this process based on ophthalmoscopic appearances alone.

3. Hemianopic Fields .- Definite field defects other than the mere symmetrical constriction or color interlacing-defects, in other words, which are presumed to indicate direct im- plication of the visual pathway-have been observed in 42 of the 123 cases in which the examination was possible (33.3 per cent) ; and it may be said in passing that in a considerable number of the 77 patients in whom the taking of the fields was precluded, the pre-existence of gross hemianopsia of one form or another was indicated by the histories, or the patients may actually have brought suggestive fields taken elsewhere before blindness came on.

In this group of 42 hemianopsias we have included 12 cases of fairly typical binasal hemianopsia. Though the analysis of the cases exhibiting this type of defect will be reserved for the third paper in this series, it may be stated here that in all the condition accompanied an advanced choked disc, often with complete achromatopsia-cases in which merely a con- stricted temporal field was preserved in each eye. It will be observed that these binasal hemianopsias most often occur in cases of subtentorial growths which have led to a symmetrical change in the two nerves due to secondary atrophy without any direct implication of the visual pathway itself. Thus in con- sidering the prevalence of the true hemianopsias in a given series of intracranial tumors, one should exclude from the list the subtentorial lesions, which are barred from the pos- sibility of direct implication of optic tract and radiation.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 118

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189