THE

Journal of Medical Research.

(NEW SERIES, VOL. III.)

VOL. VIJI.

JUNE, I90Z.

No. i.

THREE GLIOMATA OF EPENDYMAL ORIGIN: TWO IN THE FOURTH VENTRICLE, ONE SUBCUTANEOUS OVER THE

COCCYX.I
F. B. MIALLORY, M.D. (Fr-om tile Sears Patholqogical L-aboroator-y of tAie'Ifr-vazrd Unziversity Mledical School.)

In i890,2 in announcing his discovery of a specific stain for neuroglia fibers, Weigert called attention to certain dots or granules (Kornchen) in the protoplasm of ependymal cells, which stain by the same differential methods that are used for neuroglia fibers. In his monograph " Die Neuroglia" 3 he states that these granules are present not only in the ependymal cells lining the ventricles and the neural canal, but also, in adult cords, in certain cells and groups of cells which have been cut off from the neural canal by the neuroglia fibers and lie imbedded in them. So far as known these granules do not occur in any other kind of cell; they afford, therefore, a very characteristic marking by which to distinguish ependymal cells from all other cells. Their significance is entirely unknown. Weigert speaks of them as " K6rnchen " and " Punktierung," but does not describe them further. He has, however, proved definitely that they are not cilia. Careful examination of these characteristic markings of ependymal cells shows that they vary considerably in size, shape, and nuLmber in different cells. They may be round, oval, or rod slhaped; as the markings appear in the cells they stronigly suggest minute cocci or delicate bacilli. The
I Read March 29, I902, at the Second Annual Meeting of the American Association of Pathologists and Bacteriologists, at Cleveland, Olio. 2 Weigert. Centralbl. f. allg. Path. u. Path. Anat., I890, p. 736. 3Weigert. Die Neuroglia. I895.

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rod forms may be from two to four times as long as broad; as a rule the ends are square. They vary from two to about ten in a clump in a single cell, while of the round form twenty to thirty are sometimes present. The phosphotungstic acid hematein method, which colors the protoplasm slightly, often shows them lying in a lighter staining area. They do not always adjoin the inner edge of an ependymal cell, but may lie at any point between it and the nucleus. The rod forms do not run in any one direction, but are irregularly clumped together. As the following three gliomata present peculiarities which have not hitherto been described, it seems advisable to put them on record. The first occurred in an adult and was pendent from the roof of the fourth ventricle. It was irregularly spherical in shape, measuring four by five by three centimeters, reddish gray in color, soft in consistence, and very vascular. Microscopically the tumor consists of two very different structures, of cells which form a fairly coarse meshwork, and of large blood vessels, surrounded by connective tissue, which lie in the spaces in the meshwork. The relative proportions of cells and of blood vessels vary considerably in different parts, but on the whole the cells predominate. The cells are distinguished by two peculiarities: most of them contain in their protoplasm the markings characteristic of ependymal cells; and they have running between them and touching their protoplasm numerous delicate neuroglia fibers. The cells are epithelial in type. The nuclei are of fair size, round to oval in shape, although sometimes irregular, and occasionally quite large. They contain numerous fine chromatin granules, but as a rule no distinct nucleoli. The protoplasm of the cells is fairly abundant in amount, although some of the cells possess little or apparently none. As a rule it is not distributed equally around the nucleus which in consequence often lies eccentric. The limits of the protoplasm are not well defined: it fades otut at the periphery. The cells show a marked tendency to form small clumps with fusion of their protoplasm. When this occurs the

THREE GLIOMATA OF EPENDYMAL ORIGIN.

nuclei are usually arranged at the periphery, but in no very definite order: the long axes of the nuclei may run in any direction. Only occasionally does one of these cell masses suggest the appearance of a giant cell. In this mass of protoplasm there is often found a very small, round or irregular, sharply defined cavity like the lumen of a small gland. Occasionally as many as four of these cavities are present. Besides these apparent attempts at gland formation, many perfectly definite gland cavities are present in the tumor; the smaller ones are usually round, the larger, irregular. These cavities are lined by cells exactly like the ependymal cells. Like them they also contain the characteristic markings in the protoplasm on the side adjoining the lumen. Within some of the larger gland cavities a process similar to that seen in chronic ependymitis has occurred; that is, the ependymal cells are lacking in places and a mass of naked neuroglia fibers projects into the lumen. The characteristic markings of the ependymal cells are found not only in the cells lining the gland cavities, as already mentioned, but also in the protoplasm of the clumps of cells and in many but not all of the single cells. In sections stained by the phosphotungstic acid hematein method, the markings are found to be almost invariably in a lighter staining area in the protoplasm. They show a tendency to arrange themselves around the periphery of this lighter area. They vary in number from about ten to thirty. In shape the markings vary from round and oval bodies to definite rods with square ends, which are from two to four times as long as broad. In the cell clumps there may be one large group of these peculiar bodies or as many small clumps as there are nuclei. When a minute gland-like cavity is present the markings are grouped in the protoplasm adjoining it. The neuroglia fibers are not in any way remarkable; they are quite numerous, and fairly fine for the most part, although occasionally coarse; they run in all directions between the cells and cell clumps. The stroma of the tumor consists of very numerous, usually rather large blood vessels surrounded by a compara-

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tively small amount of connective tissue. The walls of many of the blood vessels are hyaline. The remains of old hemorrhages are shown by areas of connective tissue containing numerous large pigmented cells. In some parts of the tumor numerous corpora amylacea are present, always among the neuroglia cells from which in this case they seem to arisb. One was found within the nucleus of a large neuroglia cell. The floor of the fourth ventricle shows well-nmarked chronic ependymitis, and the cerebellar tissue adjoining the new growth considerable sclerosis. The remains of old hemorrhages and the absence of mitotic figures would seem to indicate that the tumor grew slowly. The second tumor 1 likewise occurred in the fourth ventricle, which it completely filled. It formed a semitranslucent, grayish, somewhat pear-shaped mass measuring five by six and five-tenths by three ceintimeters. It was attached to the floor of the ventricle and the smaller conical end projected beneath the pia over the posterior surface of the pons and the beginning of the medulla. On section it presented the same grayish translucent appearance as the outer surface. Microscopically the tumor is composed of areas consisting chiefly of neuroglia fibers and of other areas about equal in extent which are very cellular. The two forms of tissue are not very sharply marked off from each other, but tend to fuse together. The cellular areas closely resemble the appearance of the first tumor described. The cells tend to arrange themselves in clumps; occasionally there occur welldefined gland cavities lined with a definite epithelium. In this tumor as in the other small groups of the characteristic ependymal cell markings are present in the protoplasm of the cells. They are not so numerous as in the first case, but vary from two to about ten in ntumber in a cell. As a rule they are round or oval, but occasionally rod-shaped. They are present in most of the cells in the cellular areas, in1I am indebted for this case to Dr. E. M. Holmes. Patient, a boy aged seventeen years; symptoms for over two years. Brain: convolutions flattened; interpeduncular space bulging; lateral ventricles much dilated; weight of brain after escape of fluid one thousand five hundred and forty grammes.

THREE GLIOMATA OF EPENDYMAL ORIGIN.

cluding the cells lining the gland-like cavities, and in many of the cells in the denser areas, but where the neuroglia fibers are most abundant, the cells are few in number, have practically no protoplasm around them, and no markings can be found. Throughout the tumor the neuroglia fibers are all fine; no coarse ones occur. Even in the cellular parts of the growth they are fairly abundant and run in all directions between the single cells and cell-clumps. The finding of several mitotic figures is evidence that the tumor was growing rapidly. The blood vessels are not nearly so numerous as in the first case, are thin-walled, and are rather more numerous in the cellular parts. The third tumor is much the most interesting of the series. It has always been taught that gliomata -develop only in the central nervous system and in the eye. The following case, however, shows that they may occur elsewhere, and it is probable, Inow that attention is called to such a possibility, that other gliomata not directly connected with the central nervous system will be found. The tumor in question was sent to me for diagnosis by Dr. Joseph M. Sheahan, of Quincy, Mass., to whom I am indebted for the following clinical history. The patient was a woman forty-four years old who had always enjoyed good health. The tumor had been present for twenty-five years to the patient's knowledge and was probably congenital, because when first noticed it was a nodule the size of a hickory nut situated in the median line of the back over the coccyx. It kept that form and size until about one year before removal, when it rapidly increased in size. The enlargement was particularly marked during the three months preceding the operation. At that time it had reached the size of a base-ball. It lay almost exactly in the median line over the coccyx and lower part of the sacrum. It was not attached to the underlying bony structures, and the skin covering it was freely movable. The operation was simple, consisting of an incision half around the base of the growth, and of enucleation with the finger. The wound closed by first intention.

MALLORY.

A little over half the tumor was sent to me for examination. It consisted of a hemispherical mass partly covered with skin, and of several smaller pieces. The growth was dense, slightly lobulated, and definitely encapsulated. On section the surface was gray, translucent, and rather granular, with numerous irregular, opaque areas of necrosis scattered throughout it. In its gross appearance the tumor suggested a fibro-sarcoma. A small piece of the tissue was preserved in Zenker's fluid, and the rest was put on ice. The structure of the growth on microscopic examination suggested a glioma, and this diagnosis was confirmed later by differential stains. When the nature of the tumor was suspected the tissue preserved on ice was immediately brought out and sections of it put into formaldehyde. As this was ten days after the operation, not much in the way of the usual differential stains of neuroglia fibers could be hoped for, although a low temperature has the property of preserving the peculiar chemical properties of neuroglia fibers remarkably well. Only fair results were obtained from this material. Fortunately that part of the tumor which had not originally been sent to me, had been carried off by an assistant at the operation and been by him preserved in formaldehyde. This tissue was later kindly placed at my disposal and from it a perfectly satisfactory differential staining of the neuroglia fibers was obtained. Histologically the tumor closely resembles at first sight a carcinoma. It consists of a connective tissue stroma in the meshes of which lie masses of epithelial-like cells. In places the stroma is slight, the masses of cells large; in other places the stroma is very abundant and the tumor cells occur in small groups or in rows of single cells: in other words, the growth is partly medullary, partly scirrhous in type. On careful examination, however, the growth presents a very peculiar appearance due to the presence, between the cells in the alveoli, of comparatively coarse, homogeneous, refractive fibers which vary greatly in different parts of the growth, but in places are very abundant. For the most part the fibers in the alveoli tend to run in the same general direc-

THREE GLIOMATA OF EPENDYMAL ORIGIN.

tion. They are usually straight or a little curved, but occasionally are wavy or even corkscrew-like, as though confined within too narrow quarters. This latter appearance may, however, be an artifact. It is impossible to determine the length of the fibers, but many of them certainly are long. One end of them seems always to start from the wall of an alveolus; the other end probably terminates in the same way. Just how the fibers end is difficult to decide. So far as can be made out they swell slightly, forming a sort of foot which ends squarely and stains less intensely than the rest of the fiber. The swollen ends unite laterally and thus form, at least in places, a fairly definite surface which is closely applied to the connective tissue stroma. In places the limiting surface thus formed has been stripped away from the stroma by the shrinkage due to the fixing reagent, and here its structure can be more readily studied. The neuroglia fibers vary much in size. Some of them are very fine, but many of them are extremely coarse. A given fiber always preserves a uniform size; it does not branch, and does not begin or end in the protoplasm of a cell, although the fibers often touch the protoplasm in passing a cell. With the analin blue connective tissue stain the neuroglia fibers stain intensely red in marked contrast to the blue of the connective tissue fibrillk. The neuroglia cells in the alveoli are epithelial in type. The nuclei are vesicular, containing numerous fine chromatin granules, but no distinct nucleolus, and are usually oval in shape; occasionally quite large nuclei occur. The protoplasm around the nucleus is finely granular and usually fairly abundant; as a rule a process of protoplasm extends out on each side of the nucleus, running in the same direction as the neuroglia fibers; the limits of the cells are not sharply defined. The fact that the tumor is growing rapidly is shown by the presence of comparatively numerous mitotic figures which occur even in cells surrounded by numerous neuroglia fibers. The connective tissue of the stroma is not remarkable. It

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varies considerably in amount in different places, and occasionally sends small bundles of fibrille in between the neuroglia cells and fibers. The interest in this tumor lies, of course, in its situation and in its histogenesis. The latter, it seems to me, admits of a simple explanation. In a paper on Sacro-Coccygeal Dimples, Sinuses, and Cysts,' published in I892, I stated that examination of the tissues over the coccyx and sacrum of seven embryos showed in each of six of them one or more gland-like structures lined with epithelium. These I believed to be the remains of the lower end of the neural canal which closes very irregularly. It seems to me that the explanation of the tumor described in this paper is connected with these same embryonic remains. These cells unquestionably have, in consequence of their origin, the potential possibilities of differentiating either into cells like the epidermis (as seen in the dermoid sinuses and cysts found in this region), or into ependymal cells and their derivatives, in this case neuroglia tissue. This view is strengthened by the fact that in the more cellular parts of the tumor and to a less extent in the denser portions, from one to five minute rod-shaped bodies with square ends, and three to six times as long as broad, are present in the protoplasm of at least most of the cells. They stain by the differential methods for neuroglia fibers, but cannot be demonstrated in any other way. They may lie near the nucleus or at some distance from it in the cell process. They have no definite arrangement within the cell, although when the cell is elongated and the marking is single, its long axis usually coincides with that of the cell, but it may lie crosswise or oblique. By the phosphotungstic acid hematein method the markings are often seen to lie in a lighter staining area in the protoplasm. Twice they were found in cells in mitosis. It would be interesting to study the fetal remains of the neural canal in embryos by means of the new differential stains to see if neuroglia fibers or the protoplasmic markings characteristic of ependymal cells are ever present; this I
'Mallory. Amer. J. Med. Sciences, I892, Vol. I03, p. 263.

THREE GLIOMATA OF EPENDYMAL ORIGIN.

have not had an opportunity to do. I may add in this connection, however, that I have recently studied a case of spina bifida of the lower lutmbar vertebrx below the termination of the cord, in a two-weeks-old infant, in which the lesion was due to an adenocystoma, of which the cells were lined with ciliated epithelium as are the cells lining the neural canal in early embryonic life. Unfortunately the tissue had not been fixed in such a way that it could be stained for the markings characteristic of ependymal cells.

Summnary and Conclusionzs.

The first tumor is a very vascular slowly growing glioma of the fourth ventricle. The cells tend to fuse together into cell-clumps, some of which contain minute lumina. Definite gland cavities of various sizes are also present. The peculiar round, oval, and rod-shaped, differentially staining markings characteristic of ependymal cells are present not only in the cells lining the gland-like cavities, but also in the cell clumps and in many of the single cells. They vary from about ten to thirty in a group and are usually situated in the periphery of a lighter staining area in the protoplasm. Delicate neuroglia fibers are quite abundant throughout the tumor. The second tumor, likewise from the fourth ventricle, is much less vascular, and is composed of cellular and dense areas of neuroglia tissue. In the cellular areas the cells tend to fuse together, and definite gland-like cavities occur. The markings peculiar to ependymal cells are present in the cells of this tumor also, but in smaller numbers than in the first. They vary from two to about ten in a cell. The third tumor is interesting from its location, its structure, and its histogenesis. Situated subcutaneously over the coccyx, it resembles in its structure a carcinoma, consisting of masses of epithelioid cells embedded in the meshes of a connective tissue stroma; but between the epithelioid cells occurs a second intercellular substance, namely, fine and coarse fibers which stain by the differential methods for neuroglia fibers. Moreover many of the cells contain from

IO

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one to five minute rod-shaped markings which stain by the same methods. In consequence of the presence of characteristic, differentially-staining markings in the cells of these gliomata, it seems reasonable to infer that the tumors are of ependymal origin. Possibly all gliomata of ependymal origin are definitely characterized in the same manner.
DESCRIPTION OF PLATE.
PLATE I.

(Figs. I, 2, and 3 are from the first tumor described, and show the markings characteristic of ependymal cells.) FIG. I. - Cells in the wall of the bottomn of a gland cavity. FIG. 2. - A fused clump of cells. FIG. 3. -A single cell. (Figs. 4, 5, and 6 are from the glioma over the coccyx.) FIG. 4. - Shows the neuroglia fibers terminating in swollen ends which unite laterally to form a sort of membrane which is applied to the connective tissue stroma. FIG. 5. - Straight and corkscrew-like neuroglia fibers. FIG. 6. -Cells showing single rod-shaped markings in the protoplasm. One is on end, the other four are lying flat.

JOURNAL OF MEDICAL RESEARCH,

VO L. VI I1.PLATEI1.

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