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following on a detached retina suggested an intra-ocular tumor, and enucleation was advised but refused. A solution of the sulphate of eserine, one grain to the ounce, was used locally, and the salicylate of sodium given internally. After a few days the acute attack subsided.
In May, 1896, that is about six months after this attack, and rather more than a year after the detachment of the retina, she again suffered with a violent glaucoma. In the interval there had been frequent but less severe pain. Operation was still refused, and the same measures were used as before. The following September, that is eighteen months after the beginning of the disease, I was again summoned to see her. The eyeball was now shrunken and tender, and subject to almost constant pain. There was a chronic irido-cyclitis. Finally, on November 12, 1896, she consented to its removal, and I enucleated the eye. A dark mass attached near the posterior fold occupied much of the interior, and a glistening black protrusion, the size of a sinall pea, grew backward from the sclera to the outside of the entrance of the optic nerve. To the naked eye no involvement of the orbital contents was perceptible. The recovery was uninterrupted, and three weeks later a glass eye was adjusted, which has been worn with very good cosmetic effect ever since. The microscope showed the growth to be a sarcoma and to proceed from the choroid.
This disease is rare. Hill Griffith, whose contribution to Norris and Oliver's System of Diseases of the Eye is perhaps the most recent article on the subject, found it once in 2,900 cases in a total of 119,500 diseased eyes in England. In Germany, among ten ophthalmological clinics Fuchs found it to occur once in 1,500 cases. Berry, DeSchweinitz, and other writers state that its most common origin is near the posterior pole of the eye, to the outside of the optic disc. It is rarely seen in early life; only eleven out of 259 cases collected by Fuchs occurred before the age of ten. Following the description by Knapp, the course of sarcoma of the choroid is generally divided into four stages: first, the quiescent or non-irritative; second, the irritative or inflammatory; third, the extra-ocular, and fourth, the metastatic stage. In the first stage the prominent symptom is detachment of the retina. As a rule this is attended by a serous sub-retinal discharge which renders the detachment less sharply defined and conceals the character of the growth beneath it. Occasionally the well-defined outline of the tumor and even the vessels contained in it may be seen. Griffith states that this latter condition prevails especially in growths near the pos
terior pole and the ciliary region, while in the equatorial zone the more loosely attached retina and the obstruction to the venæ vorticosæ favor the outflow of serum. Diagnosis at this stage is apt to be difficult, and is often impossible. Many writers, among them Berry and Graefe, as quoted by Fuchs, declare that the tension in idiopathic detachment is usually diminished, while in that due to tumor it is usually normal or increased. Hill Griffith, on the other hand, states that in the beginning the tension is either normal or sub-normal. In the case above reported it was at first reduced. This point does not seem to be of great diagnostic value. The quiescent period is shown by statistics of several hundred cases to be usually from eighteen to twenty-one months in duration. In the case herewith reported this stage was not quite six months. The second stage is characterized by pain and the symptoms of glaucoma. This, following on a detached retina for which no obvious cause can be found, such as traumatism or a high degree of myopia, is so suggestive of intra-ocular tumor as to make enucleation advisable. If seen for the first time in this condition, the disease might be confounded with acute idiopathic glaucoma, but the history of the preceding blindness will prevent this mistake. Berry says “in cases where the choroidal tumor gives rise to irido-cyclitis the diagnosis may certainly be rendered difficult, and still more so when shrinking of the globe takes place as the result of this inflammation, as sometimes happens.” Such cases are exceptional, but in the one above related exactly this course was followed. I had little doubt of the diagnosis, however, because I had observed the case in the stage of retinal detachment and then in the acute glaucoma, before the inflammation of the iris and ciliary body began. The average duration of the second stage is about one year, though often less. Thus from the beginning of the disease to the perforation of the sclera by the new growth, a period of about two and a half years. usually elapses. Griffith states that "the great power which the sclerotic possesses of resisting for years the action of sarcoma has an interesting parallel in the case of another fibrous structure, the large blood-vessels of the limbs, which may often be seen on the operating-table running uninjured through a huge sarcomatous growth which may have extensively involved the other tissues." In the third stage, that of orbitalinvasion, the growth of the tumor is usually rapid. As to the fourth stage, all that can be determined is the time when the symptoms of metastasis, which is most commonly to the liver, reveal themselves. The tumor growth may have begun long before.
As regards prognosis, there is a surprising difference of opinion. This may be accounted for partly by the rarity of the disease and partly by the failure to keep the patient under observation for a sufficiently long time. Of course without operation the prognosis is absolutely bad. Berry states that the average duration of life under these conditions from the onset of the disease is about five years. Fuchs in a collection of 243 cases found only six per cent alive four years after operation, but no other writer estimates the cures at so low a rate. Griffith thinks fifty per cent may be permanently cured. The greatest danger after operation, or before it, is metastasis, which is usually to the liver. Statistical reports seem to prove that the stage of the tumor when removed by operation has no effect upon the frequency with which this complication occurs. It is almost, if not quite, as likely to take place when enucleation is performed very early as when the orbit is already extensively involved. Griffith states that metastasis occurs almost invariably within two years of the date of operation. Cases are reported, however, in which its symptoms have appeared at a far later date. Thus Murchison, in his work on Diseases of the Liver, reports the case of a man who had suffered from pain in the right side for eighteen months, and one year later he died of sarcoma of the liver. Nine years previously the left eye had been excised for malignant tumor. Several similar instances have been reported. Far less frequent is local recurrence of the growth in the orbit. This is usually observed within a few months. In rare cases it is delayed for a much longer time.
As to treatment, there is little difference of opinion. Of course as soon as the diagnosis is established, or in a blind eye strongly suspected, enucleation should be performed. So long as the sclera has not been perforated, most authorities advise simple enucleation with cutting of the optic nerve as far back as possible. When the orbital contents are involved they should be absolutely removed, and Berry thinks this the safest course even in the second stage, that of glaucomatous irritation.
In the discussion of the specimen presented two years ago one of my colleagues and a well-known surgeon then in the Society both considered the wearing of a glass eye an ill-advised procedure. I have found no reference to such an opinion in the literature of the subject, and the eye has been worn without inconvenience. After this interval the patient may be considered free from danger of local recurrence, but the cases above related show that metastasis, though now very unlikely, is still a sad possibility.
END-TO-END ANASTOMOSIS OF THE INTESTINE.*
BY J. L. JOHNSON, M. D.
Having perhaps observed in the June number, 1896, of the New York Polyclinic and in other medical journals of that date a brief description of my operation for end-to-end anastomosis of the intestine, you will, I am sure, not be averse to a more complete explanation of its technique.
In other words, I wish to present to you my recently devised method of end-to-end anastomosis of the intestine. I say recently devised, yet as previously intimated, more than two years have elapsed since in the operating-room of the New York Polyclinic I originated what has been pronounced by the surgeons of that famous institution an ideal technique.
During the interval which has elapsed since the period referred to I have been engaged in an extensive post-graduate course in the famous hospitals of the Old World, and during that time I demonstrated this operation before the Surgical Society of London, and to many surgeons whose names are famous throughout the civilized world, among whom I will mention : Mr. Treves, of the London Hospital; Mr. Allingham, of St. George's, and that noble Scot, Macewen, of Glasgow, and last, but not least, that intellectual giant, the late Pean, of Paris, all of whom united in its praise.
Since returning to my native land I have been constantly urged by various professional friends to place this technique more effectively before you, consequently I avail myself of this opportunity to do so.
As an introduction to this paper I deem it expedient to refer to a few other methods to which in the past we have resorted in intestinal anastomosis.
Dennis, in his admirable work, refers to this subject as follows: Suturing of the intestines may be regarded as both ancient and modern. Intestinal suturing is mentioned by Celsus in the first century of the Christian era, also by Abul Kasum, one thousand years later. The earliest definite writings on the subject, however, were by Italian surgeons during the middle ages. Guilielmus de Salicelo about the year 1500 is said to have used a segment of dried gut over which he sutured the bowel. He afterwards used the trachea of a goose, in a similar manner, to keep the lumen of the bowel open. This work was
"Read before the Southern Kentucky Medical Association, 1898.
very soon forgotten, and at the beginning of the nineteenth century Dr. Virgir used practically the same methods, and regarded them as original.
“The old technique practiced by the majority of surgeons was to bring the divided ends of the intestines into the abdominal wound, and retain them by sutures to prevent extravasation of feces into the peritoneal cavity.
“Schacher, of Leipsic, in 1720 is said to have been the first to do this successfully in man. Later the surgeons attempted to hold the wounded bowel against the abdominal wound by passing a suture around the bowel and through the mesentery, thus anchoring it to the abdominal incision.
“The first successful case of end-to-end anastomosis of the intestine was that of Ramdohr, in 1780, who invaginated the upper end of the
FIG. 1.-Cylinder ready for use.
divided bowel into the lower, and secured it with a single suture, joining the bowel to the abdominal wall.
"Bell invaginated the bowel over a cylinder of tallow.
“Ammussat used a hollow cylinder of elder containing a transverse groove.
“Neuber used a cylinder of decalcified bone, with a deep groove in its center, over which the ends of the bowel were sutured.
Chopart and Desault used a cylinder of cardboard, over which the bowel was fastened with a single suture.
"All these methods are erroneous, because they approximated mucous to serous membrane.
“During the second and third decades of this century the proper mode of intestinal anastomosis was begun. Travers first experimented on animals, and met with such success that he published his work in 1812, entitled 'An Inquiry into the Process of Nature in Repairing Injuries