Report of a Case of Melano-Sarcoma of the Orbit

GUTHRIE MCCONNELL, RUDOLPH BURMAN
1908 Boston Medical and Surgical Journal  
surgery treated in this paper. Only two cases have been found on record. Dr. Win. J. Mayo reports a successful case of implantation of the hepatic duct.1 He had operated ten months previously for gallstones and had removed the gall bladder and drained the common duct. Recurrence of profound icterus necessitated the second operation which showed cicatrioial stenosis of the common duct. He was able to dissect out a sufficiency of the hepatic duct to effect an anastomosis with an adjacent portion
more » ... n adjacent portion of the duodenum. Ten months after the patient was well and had gaineel thirty-one pounds. He remarks upon the original removal of the gall bladder as unfortunate since, had it been left, cholecysterostomy might have been performed far easier and would probably have afforded sufficient drainage. franklin B. White and F. B. Lund-report excision of the pylorus and the first portion of the duodenum in the course of which the common duet was cut and successful reimplantation made in the second portion of the duodenum. Both Dr. Mayo's casi; and my own suggest the ejuestion of the propriety of the removal of the gall bladder as a primary operation in any case. If wdll be noted in my quotation that Dr. Mayo expresses regret that he made choleoysteetomy in the first operation. He further adds, " Since that time we have been more conservative about removal of the gall bladder in connection with common duct surgery." . In my case, as the weeks went by after the first operation with no sign of re-establishment of bile into the duodenum, I felt keen regret that I had not been more conservative and tried at least to save the gall bladeler even though it did not look promising. When I finally determined to proceed to a sccontl operation, it was with no definite plan of procedure, except that it seemed to me desirable to open the duodenum for exploration of the ampulla of Vater. The final reimplantation of the common duct and the posterior gastroenterostomy were wholly unanticipated, and determined upon only after the discovery of the true pathological condition. This case has been of extreme interest to the writer because of the rare and, as far as can be learned, almost unprecedented complications. The question naturally arises, Why did not the pancreatic duct also become occluded? Its point of discharge in the ampulla would suggest that it is equally likuly to become entangled in the cicatricial tissue and inflammatory infiltration of a duodenal ulcer located at that place. Its own solvent action upon dead or degenerate tissue may have enabled it to keep a channel clear. I do not know that it was not occluded but the patient gave no evidence of pancreatic complica! ion such as we should naturally expect would folhiw complete obstruction of the pancreatic duct. Some interesting facts were developed or confirmed as a result of the operative interference. All the while the whole volume of bile was discharging from the abdominal wound, the general condition of the patient-appetite, digestion, flesh, strength, anel color --was improving. As the icterus subsided and digestion improved, the change from intensely black to white clayey stools was an exceedingly interesting phenomenon. It appears a fair conclusion that all the while that the stools were black, an oozing of blood was going on from the duotlenal ulcer. What stopped it? Was the cessation due to the clearing up of the jaundice or the drainage of the stomach through the new outlet, or both? There is' one point of difference between my operation and the two others quoted which may or may not be an important one: in implanting the duct it was buried an appreciable distance, an inch or so (sei-illustration). It seems to the writer that such a method of implantation when possible is a better mechanical arrangement. Tut-: following case of melanotic sarcoma of the orbit seemed of sufficient interest, both clinically and pathologically, to warrant its being reported. The quite long interval between the primary operation and the recurrence with subsequent death is unusual. The lesions in the liver also attracted attention on account of the association of the sarcomatous métastases with a great hyperplasia of the epithelium of the bile ducts-a combination of both connective tissue and epithelial overgrowth. The history of the case and the autopsy findings are as follows : II. F., age sixty-four, white, male, laborer. Family history. -No malignant or tubercular disease in the family. Parents both dead, cause not known-Two brothers and one sister living and in good health. Personal history. -Always enjoyed good health until the present trouble, which appeared about seven years ago, when by accident he found that he could scarcely see with the left eye, which gradually became worse until there was complete loss of vision in that eye At this time he consulted an oculist who informed him that the pupil was destroyed. He then consulted several other oculists who told him that unless the diseased eye was removed that the vision of the right eye would probably be impaired or destroyed. He, acting on this advice, had the eye removed, after which time he wore an artificial eye. This he continued to wem for about four years. At the end of this time he noticed that the tissues of the orbit became painful and considerably inflamed. He again consulted an oculist who tolel him the trouble would probably result in cancer. The patient here stated that the eyelid and tissues of the orbit in general presented a marked congestion which gradually became worse; there was, however, not much pain at this time. An operation was again advised, to which he consented, when more of the tissues of the orbit were removed. He was told that all of the diseased tisst"3
doi:10.1056/nejm190807231590403 fatcat:dyuhj6caj5c4bkzfjufrtr2pau