Injuries And Diseases Of The Orbit | Operating Microscopes

Injuries And Diseases Of The Orbit
By F. BULLER, M.D.,
OF MONTREAL, CANADA.

CONGENITAL ANOMALIES.
CONGENITAL faults in the development of the orbits have been described in all degrees, from trifling defects in limited portions of their bony walls to complete absence of these cavities, one or both; in the latter case the structures they are designed to enclose are also wanting. In the lesser defects the orbital contents may be modified in various ways. Such modifications as affect the eyeballs are of special interest. Of these there are four well known, conditions. They are anophthalmos, microphthalmos, megalophthalmos, and cyclopia. The first three of these are not, however, necessarily associated with anomalies in the construction of the orbits. Although congenital defects of this class are usually bilateral, one sided faults are by no means uncommon.

Anophthalmos. Congenital absence of both eyes is a rare condition (still more rarely is this condition unilateral monophthatmos). In most of these cases the palpebral fissure has been found closed or very narrow, the conjunctival sac small, of a pale red color, and the eyeball totally absent or only represented by a soft, irregular flesh like mass. Several or all of the extrinsic ocular muscles have been found in connection with this rudimentary mass. The orbital cavities are always smaller than normal, and the adnexa of the eye, when present, are small and ill developed. The faulty development in these cases is not confined to the orbits and their contents, but involves also the chiasma, optic tracts, corpora quadrigemina, and sometimes adjacent parts of the cerebrum.

A few instances of monolateral anophthalmos have been observed. In one of these the single eye was normally developed. This anomaly is explained by failure of the primary optic vesicle to bud from the anterior primary encephalic vesicle, or, having budded, it has failed to form a secondary optic vesicle. In every case the eve was properly situated, even when very imperfect a feature which justifies the use of the term monophthatmos in describing this deformity, and distinguishes it from the more common monstrosity known as cyclopia.

Cyclopia. This anomaly is a fusion of both orbits and their contents, with a single eyeball situated in the middle line just above the ordinary position of the root of the nose. This single eye may be larger or smaller than normal for the general development, but always shows unmistakable evidence of an imperfect fusion of the two eyes. The same is true of the adnexa of the eye. In all such cases the ethmoid is absent or only rudimentary. The olfactory nerves are wanting, and the cerebrum is so imperfectly formed that, although some cyclops have been living when born, all that the writer has been able to find records of have died within a very short time after birth.

Microphthalmos. Eyes which at birth are considerably smaller or larger than normal are seldom, if ever, sufficiently normal in other respects to admit of useful vision. These peculiarities are probably the result of some pathological process in utero, rather than a mere arrest or excess of development. Either condition may be found in one or both eyes.

microphthalmos the whole globe is uniformly spherical, sometimes flattened below; the cornea is usually very much smaller than normal, its margins ill defined, and curvature of the same radius as the adjacent sclerotic; the anterior chamber, iris, and pupil are correspondingly diminished. The palpebral fissure is narrow, and the lids, unsupported by the globe, are partly deprived of their ordinary functions. The changes in the interior of the globe have not been fully studied. According to Manz, they are often of a degenerative character, such as occur in phthisis bulbi from other causes. In the higher grades of microphthalmos vision is, of course, entirely wanting.

Megalophthalmos is a rare congenital anomaly in which the cornea and anterior chamber are larger than normal (hydrophthalmos anterior). The explanation of this is probably to be found in some intra uterine pathological condition in which the intra ocular tension has been increased at a time when the cornea possessed less resisting power than the sclerotic, and 'therefore became distended, whilst the posterior segment of the eyeball remained relatively unaffected in its development (see also pages 329 and 385).

DISEASES OF THE ORBIT.

A glance at Fig. 323 shows that the eyeball is rather loosely slung in the conical bony cavity of the orbit, well toward its anterior part. The bony walls of this hollow cone are so unyielding that any considerable augmentation of its contents or encroachment from without will have the effect of displacing the eyeball. The displacement will naturally be greatest in the direction of least resistance, which, in a general way, is obviously forward.

Symptoms of Orbital Disease. Most of the pathological conditions met with in the orbit either increase its contents or come from encroachment upon some part of its walls; hence a more or less forward displacement of the eyeball proptosis is the most usual sign of disease of the orbit.

In the normal state the eyeball is freely movable in every direction by means of the three pairs of ocular muscles, each one of which is situated entirely within the orbit, and therefore liable to loss of function from changes in the tissues surrounding them; hence another common sign of orbital disease is alteration in the mobility of the eye. Inflammatory processes or morbid growths, which cause infiltration of the tissues surrounding the muscles, are especially liable to result in fixation of the eyeball. Periostitis, even of a limited extent, at the apex of the orbit may have a similar effect by pressure upon the motor nerves as they pass through the Sylvian fissure, thus causing a paralytic immobility.

On the other hand, a high degree of proptosis, caused by non infiltrating growths arising within the orbit or projecting into it from adjacent parts, is compatible with free mobility of the eyeball, as in certain orbital cysts and other encapsuled new growths. Only i~ case of one sided exophthalmos can a fairly accurate estimate of the displacement be made by comparison with the position of the eyeball in the normal orbit. If the displacement is bilateral, its degree is a matter of conjecture, and allowance must be made for the fact that a wide palpebral fissure simulates exophthalmos, whilst a narrow fissure may simulate the opposite condition or enophthalmos.

The differential diagnosis of orbital disease will be greatly facilitated by a careful consideration of the following less constant signs:

(1) Redness, swelling, and edema of the lids, especially conspicuous in the inflammatory affections of the cellular tissue of the orbit.

(2) Chemosis of the conjunctiva, either general or localized, over a certain portion of the globe nearest the area of disease.

3) Fluctuation is likely to be present when an' abscess of the orbit has formed, but cannot always be made out with certainty.

4) Pain, intensified when the patient attempts to rotate the eyeball or when it is pressed backward, and the surroundings are palpated by the surgeon. Tenderness on pressure of the orbital margins is a common sign in periostitis of the orbit, and frontal headache is often intense during the acute stages of inflammation in the orbital tissues, or of the frontal sinus.

(5) Disturbance of vision is often absent, but becomes a valuable sign when associated with changes in the fundus oculi, such as papillitis, pallor of the optic nerve, or retinal hemorrhages. Diplopia is also common.

Periostitis. Periostitis of the orbit occurs in two forms, acute and chronic. The terms circumscribed and diffuse are applicable according to the supposed periosteal area involved in either variety.

Etiology. Certain diathetic states predispose to this disease. They are scrofula, syphilis, and rheumatism. Injuries and sudden changes of temperature are recognized exciting causes, but in many cases the exciting cause cannot be positively determined.

This disease attacks by preference the margin of the orbit (especially the outer margin), and extends more or less widely; suppuration (abscess) is prone to occur.

. The symptoms of an ordinary acute marginal periostitis are swelling, edema, and redness of the lids ; chemosis of the conjunctiva, commencing at the equator of' the globe; pain and tenderness on pressure at the part of the orbital margin affected. Sometimes a highly sensitive, tense spot may be discovered with the finger or fluctuation if pus has formed.

Acute parietal (deep seated) orbital periostitis is difficult to distinguish from cellulitis. The symptoms are violent and severe intense headache, pyrexia, sometimes nausea, vomiting, and great prostration. The local symptoms are swelling of the lids, chemosis, pain, increased when the eyeball is pressed backward, and more or less displacement and immobility of the eyeball.

orbital periostitis is far more frequent than the acute form, and is nearly always distinctly circumscribed. Its course is tedious, lasting for months or years. All the symptoms are less intense, though similar in other respects, except that the swelling of the lids is more a simple edema and the patient complains of a dull pain, usually worse at night. It commonly results in abscess of the orbit, occasionally in gradual resolution. Whenever pus has formed beneath the periosteum. caries or necroses of the bone are liable to occur, and there is always danger of extension to the cranial cavity or septic infection, particularly when the disease is parietal. If the consecutive bone disease involves the orbital margin, adhesion and retraction of the adjacent skin may cause eversion and distortion of tile eyelids. This result is very common in children,

. This must be based chiefly on a recognition of the foregoing facts, and, in acute cases, on the immediate effects of treatment.

Treatment. If the case is seen before pus has formed, leeches applied to the temple, cold compresses over the eyelids, and other antiphlogistic measures may arrest the inflammation. If pus is present or its formation seems to be inevitable, hot applications may be used, but incision should Dot be long delayed (see Operations on the Orbit); and in no case, acute or chronic, should an abscess formation in the orbit be allowed to undergo spontaneous rupture. After an opening has been established suitable drainage and careful daily cleansing will be required so long as the discharge continues from the opening.

Appropriate remedies for the underlying constitutional cause must be administered in all cases. If syphilitic, the judicious use of mercury and iodid of potassium may be expected to give excellent results. In rheumatic or strumous cases constitutional treatment, although undoubtedly beneficial, is not so distinctly curative.

and necrosis of the orbit are probably always preceded by periostitis, of which they are, therefore, common sequels.

affects by preference the lower outer orbital margin, but may attack any part of the orbital walls, when deep seated brain compli cations are not unlikely to occur. It is seldom seen in adult life ; often in children. A fistulous opening, surrounded by granulations, leads to an area of softened bone, which may be detected by careful use of a probe. Retraction of the skin and deformity of the lid, usually ectropion, ensues in most cases.

Necrosis is far less frequent than caries, and belongs to adult life. It is apt to follow denudation of' a large area of bone from periostitis, or a fragment of bone detached by traumatism from the orbital margin may become necrosed (Fig. 324).

. The fistulous opening and sinus should be gently cleansed two or three times daily with some antiseptic fluid. Mineral acids may be cautiously employed locally for the purpose of gradually dissolving the diseased bone. Meddlesome surgery and the injudicious use of probes are harmful, and may induce orbital cellulitis or an extension of the disease. Removal of diseased bone may only be undertaken when near the surface or obviously completely detached; when the roof of the orbit is the part affected, the surgeon should be extremely careful in the use of instruments.

disease is essentially chronic, and, besides the local treatment, appropriate constitutional remedies will be in order until a cure is effected.

case represented in Fig. 324 recovered without a trace of deformity, after a course of mercurial inunctions followed by potassium iodid in large doses.

Cellulitis (Phlegmon of the Orbit). This disease does not always present the same clinical picture. in all its forms the soft tissue surrounding the eyeball is inflamed, but the inflammation may be acute, subacute, or chronic, monolateral or bilateral. The inflammatory process may terminate in resolution, but commonly leads to suppuration and abscess.

In mild cases the symptoms are moderate swelling of the lids, some exophthalmos, diplopia, dull pain, and little or no constitutional disturbance.

phleginonous orbital cellulitis comes on with chills, pyrexia, and deep-seated pain, aggravated by movements of the eyes intense headache is a common symptom. Loss of mobility of the eyeball may be complete. The lids become greatly swollen, red, and edematous; the conjunctiva is chemosed and hyperemic, suggesting a violent purulent conjunctivitis or a panophthalmitis; but the absence of profuse suppuration of the conjunctiva and the preservation of a normal red reflex from the pupil will prevent such an error of diagnosis (Fig. 325). Vision may be unaffected for some time, but it is not unusual for neuro retinitis to appear, and this, in turn, may pass over into atrophy of the optic nerve and blindness. The pressure on the eyeball may cause dilatation of the pupil, anesthesia, or ulceration of the cornea, and, occasionally in bad cases, panophthalmitis.

certain cases of an erysipelatous type extensive intra ocular changes have been observed, due probably to arrest of the circulation in the retinal blood vessels, and consequent edematous exudation and hemorrhages in the retina. Finally, an abscess forms, with characteristic fluctuation, usually below the inner portion of the supra orbital ridge. Sometimes the inflammation leading to abscess formation is of a more chronic character, and may not involve the entire orbital cellular tissue, as where the disease originates in the bone or periosteum in scrofulous subjects, or in the vicinity of a foreign body imbedded in the orbit.

Etiology. When orbital cellulitis cannot be traced to any definite cause, it is said to be idiopathic. Among the many recognized causes are exposure to excessive changes of temperature, certain febrile conditions, such as searlatina, typhoid fever, meningitis, and facial erysipelas. The last disease is responsible for the most violent tvpes of orbital cellulitis, which is then apt to be bilateral. Diseased teeth and suppuration in adjacent cavities have been known to cause the affection. It occurs as a metastasis in pyemia and in puerperal septicemia, and in all eases of less diffuse inflammation of the tissues acute panophthalmitis there is more or surrounding the eyeball.

Prognosis. This is favorable in mild cases and those of a more chronic character, and recovery is likely to be perfect when the disease terminates in resolution.

Although purulent collections in the orbit usually tend toward the surface, there is always a liability to cerebral complications, which almost certainly terminate fatally. These are meningitis, cerebral abscess, and the extension of phlebitis of the orbital ' veins to the cerebral sinuses. In this way the other orbit may become involved through the intervention of the cavernous sinus. In double cases of this nature a fatal issue is to be expected. If orbital cellulitis originates from pyemia or septicemia, the chances of recovery are of course exceedingly limited.

danger to vision is to be estimated by the character and extent of the ocular complications already mentioned.

. Absolute rest in bed is essential. In the early stage of acute inflammation cold compresses, leeches to the temple, aconite, and derivatives may be employed. If these measures are not effective in a short time, a change must he made to hot fomentations and general supporting treatment, or this plan must be adopted at the outset if there is evident depression of the vital forces.

If there is reason to believe that suppuration has taken place, no time is to be lost in making one or more incisions deep enough to reach the suspected pus. Incisions are best made with a Graefe knife, through the conjunctiva, the flat of the blade facing the eyeball. If pus is discovered, drainage must be maintained by means of rubber tubing or strips of iodoform gauze, and cleansing of the cavity with antiseptic solutions will be necessary until all suppuration has ceased. Ocular complications which threaten loss of vision demand operative interference even when there is no positive evidence of suppuration.

of the Oculo orbital Fascia (Tenonitis). As a primary affection this disease is exceedingly rare, and is supposed to be an inflammatory, serous exudation into Tenon's capsule of rheumatic origin, but a few cases have been observed in connection with diphtheria and during attacks of influenza.

Its characteristic feature is a watery chemosis of the ocular conjunctiva, 1) rtial or complete, and out of proportion to other local manifestations of disease. There is, however, more or less edema of the eyelids, some loss of mobility of the eye, perhaps diplopia, exophthalmos, and a feeling of tension about the eye, and pain when its ordinary movements are attempted. The treatment consists in hot fomentations and the administration of potassium iodid, salicylates, or the subcutaneous injection of pilocarpin.

A secondary tenonitis, with more solid exudation, is associated with any violent inflammation of the eyeball, and occasionally follows certain traumatisms, such as squint operations performed without antiseptic precautions.

Thrombosis of the cavernous sinus, as already stated, may result from phlebitis of the orbital veins during phlegmonous inflammation of the orbit, or it may be of intercranial origin, as in caries of the petrous portion of the temporal bone resulting from middle ear disease, with infection of tile superior petrosal and cavernous sinus.

fetid discharge from the ear, with or without edema over the mastoid, and evidences of an orbital cellulitis and grave cerebral symptoms, are characteristic of this condition, which probably always terminates fatally.

Tumors of the Orbit. The scope of this article admits only of a brief outline of this extensive subject, which, for convenience, may be arranged according to the following headings:

Tumors of the tissues of the orbit
Tumors arising from the periosteum or bony walls of the orbit (exegesis, etc.) ;
Tumors arising in the cavities or tissues close. to the orbit

New growths originating within the eyeball are not classified as orbital tumors, except when met with as local recurrences after removal of the eye.

The terms primary, metastatic, congenital, malignant, and benign, as applied to tumors of the orbit, have the same significance as in other departments of surgery, and are intended to convey an idea as to the nature of the growth.

All orbital tumors that have attained appreciable dimensions are likely to cause displacement of the eyeball. When confined within the funnel of the straight muscles the proptosis is in a forward direction; displacement in any other direction will depend upon the size and position of the tumor according to the position or point of origin of the growth. Special symptoms in any case will depend upon the size, position, nature, and density of the growth. As the eyeball becomes pushed out of its natural position, the lids become distended and apparently enlarged; occasionally, in high degrees of proptosis, they fail to close over the eyeball, and sometimes even recede beyond its equator.

Prognosis. This depends on the nature, position and size, density, rate of growth, and possibility of successful surgical interference and its complete removal.

Treatment. In most cases treatment should consist in complete removal of the growth by operations conducted on general surgical principles. Certain growths originating in some vascular disease cannot be safely extirpated.

Benign tumors may often be removed without sacrificing the eyeball, but those of a distilled malignant type call for complete exenteration of the y orbit.

1. Tumors Originating in the Tissues of the Orbit. Of these the cystic formations supply a large contingent. They are sebaceous, serous, blood and dermoid cysts, echinococci and cysticerei. Besides these there are simple and cavernous angiomas, lympbangiomas ( Fig. 327), lipomas,(Fig. 328), enchondromas, lymphomas, and a variety of sarcomata which may take their origin from fibrous or connective tissue anywhere within the orbital cavity (Fig. 330).

Carcinoma as a primary tumor has been met with in connection with the lachrymal gland. Tumors originating in the lachrymal gland are, however, mostly of the adeno sarcomatous type and nonmalignant.

The differential diagnosis is not always an easy matter, but can generally be achieved by a careful study of all the signs and symptoms.

Treatment. Cysts with fluid contents may be cured by simple incision followed by astringent or irritant injections.

Dermoid cysts should be thoroughly evacuated and the lining of the cavity destroyed with strong pigment of iodin or with nitrate of silver: excision of deep seated cysts should never be attempted, since the cyst walls can readily be destroyed by either of the drugs just named without damaging other structures. Many of the solid growths can be shelled out without much disturbance of the surrounding tissues.

Electrolysis has been found efficient in treating orbital angiomas. Some of them are sufficiently circumscribed to admit of removal by careful dissection.

II. Tumors which Arise from the Periosteum. or Bony Walls of the Orbit. These comprise the following:

(1) Sarcomata or fibro sarcomata occasionally spring from the periosteum.

Figure 329 represents a case of the latter occurring in a boy of fourteen, in whom the entire periosteum of both orbits became involved' Some months after removal of these growths death resulted from metastatic formations elsewhere.

(2) Thickening of the periosteunt of an inflammatory nature sometimes simulates a neoplasm, especially if localized and associated with hyperostosis of the underlying bone.

(3) Exostoses are a somewhat rare form of orbital tumor, characterized by slowness of growth, extreme hardness, and evident continuity with the adjacent bone. They may attain so large a size as to occasion great deformity. Most of these growths spring from the periosteum at or near the orbital margin or from neighboring cavities. They consist of an outer layer of ivorylike hardness and an inner more spongy structure. Some are of congenital origin, others may be traced to injury, or there may be no discoverable cause.

Treatment. The only effective operation for exostoses is ablation by means of drill, Hammer, and chisel. This operation is likely to be difficult and dangerous if the growth involves the roof of' the orbit.

III. Tumors which Arise in the Cavities or Tissues close to the Orbit. These are

(1) Encephalocele or meningocele is an exceedingly rare form of tumor, containing cerebro spinal fluid, with or without a hernial protrusion of brainsubstance. It is of congenital origin, the result of defective ossification at some part of the orbital wall, by preference the anterior part of the frontoethmoidal suture and appearing as a smooth, fluctuant, sometimes pulsating swelling, not adherent to the skin ' and existing since birth at the upper inner angle of the orbit, is liable to be mistaken for a dermoid cyst.

Unlike the latter, it is not amenable to any form of operation or treatment. A correct diagnosis is therefore of paramount importance if an operation is contemplated.

(2) Nevi, lupus, and epithelioma, originating in the skin of the eyelids or face, may extend into the orbit.

(3) Polypoid growths, originating in the nasal cavities, sarcomatous, cancerous, or osteoid growths in the frontal, sphenoidal, or maxillary sinuses, ethmoid mucocele (Fig. 331), or, even distention of these cavities by fluid secretion, may, by invasion, simulate orbital tumors. An exact diagnosis may be difficult or impossible. The character of the proptosis, the condition of adjacent parts, and a careful consideration of all the signs and symptoms present will, however, usually reveal the true nature of the affection (see page 4541).

Pulsating exophthalmos is a form of orbital tumor which results from some vascular disease within the orbital cavity, the primary lesion being commonly situated within the cranial cavity immediately behind the orbit.

Symptoms. The ordinary signs of pulsatmg exophthalmos are protrusion of the eyeball (occasionally both), and pulsation, which may sometimes be both seen and felt. The stethoscope reveals a distinct bruit when placed upon the brow or closed evelid. There are swelling and a passive hyperemia of the latter and of the Subconjunctival sometimes presenting an appearance not unlike that of orbital cellulitis. The retinal veins are usually distended and tortuous, and there may be retinal hemorrhages, optic neuritis, and more or less impairment of vision. The protrusion, fulness of the vessels, and pulsation are increased by stooping the head.

The subjective symptoms are pulsating tinnitus or noises in the head, and pain, likewise increased by stooping, and diminished by compression of the carotid artery.

This assemblage of symptoms is nearly always due to the formation of aneurysival rarix in the cavernous sinus, the internal carotid thus directly pumping blood into the orbital veins. The initial lesion is in most cases caused by traumatism, such as falls or severe blows upon the head or face; not very rarely, however, especially in women, the arterio venous communication (rupture of the carotid in the SiDus) has occurred spontaneously.

Some other lesions, so rare as to constitute pathological curiosities, have been known to cause pulsating exophthalmos : they are aneurysm of the ophthalmic artery within or behind the orbit, or of the carotid in the sinus, pulsating angioma, and medullary osteo sarcoma of the orbital walls.

Treatment. Spontaneous cure is possible: SO long, therefore, as there are no urgent symptoms, such as severe pain, attacks of epistaxis, or impairment of vision, with extensive or increasing intra ocular changes, there is no necessity for active interference. Rest in bed, full doses of potassium iodid, and intermittent but frequent compression of the common carotid may arrest the disease ; but in the presence of urgent Symptoms ligation of tile common carotid should not be delayed. The results of this operation have been satisfactory in a large percentage of cases so treated.

Exophthalmic Goiter (Basedou's Disease, Graves's Disease, Cardiac Exophthalmos). This disease comes rather more appropriately within the domain of general medicine, since the ocular Symptoms are but a local manifestation of a more serious general disturbance or form of debility, which is associated not only with exophthalmos, but also with enlargement of the thyroid gland and increased action of the heart (tachycardia). Any one of this trio of symptoms may be in abeyance or may predominate over the other two. For this reason there is a lack of uniformity in the signs which indicate the presence of this disease.

Symptoms. With regard to the ocular symptoms, the exophthalmos, almost always bilateral, is much greater in some cases than in others, is subject to a certain amount of spontaneous variability, and may, in the early stages at least, be temporarily diminished by pressure. The eyeballs are pushed straight forward; their mobility is not impaired. In extreme cases the lids may not sufficiently cover them to secure adequate protection, and damage to the cornea may ensue.

Vision is unimpaired, and intraocular changes have not been observed, except occasionally visible pulsation of the central artery of the retina, and sometimes the retinal arteries appear relatively larger than they should be as compared with the veins.

The exophthalmos, even when slight, is characterized by a peculiar staring appearance of the eyes giving the patient an astonished or frightened look. This is due to a refraction of the organic levator of the lid. The resulting widening of the palpebral fissure is known as Dalrymple's sign.

On looking downward the upper lids do not perfectly follow the movements of the eyeballs, as in health; consequently the sclera above the corneal margin becomes visible (v. Graefe's sign). This symptom is not always present, and it may exist without exophthalmos in the early stage, or be persistent after the latter has disappeared if a cure has been effected. Diminished or imperfect winking movements of the lids are often noticeable (Stellwag's sign). These, together with the widened palpebral fissure, may induce a tendency to desiccation of the cornea, and probably account for the sense of heat and discomfort in the eyes of which these patients often complain.

The enlargement of the thyroid body primarily due to enlargement of its blood vessels may be slight or very considerable. As a rule, it is evenly distributed, but there are some marked exceptions to this rule; in these the right side is apt to be the larger. The enlarged thyroid feels soft and elastic in most, but not in all, cases. The chief point of distinction between exophthalmic and other forms of goiter is that in the former the hand detects a whirring sensation and strong pulsatory movement with each cardiac impulse. These circulatory phenomena are associated, as might be expected, with a loud rasping bruit.

The carotids are probably distended and pulsate strongly. This pulsation is visible, as well as audible, along the course of these arteries, and the patient often complains of a beating sensation communicated to the head. Signs of engorgement of the large cervical veins are also often present. Pulsatory phenomena sometimes also exist in the thorax and abdomen. The action of the heart is increased both in frequency and intensity; the pulse, never less than 100, becomes considerably accelerated by the slightest exertion or mental excitement.

Some enlargement of the heart, especially of the left ventricle, is not uncommon, and variable cardiac murmurs may be present; but if recovery takes place, these signs disappear: they are therefore assumed to be of a functional character.

suffering from Basedow's disease are often irritable and excitable; most of them are anemic, some chlorotic ; a tendency to emaciation even when the appetite and digestion are unimpaired has often been observed.

Etiology. This disease belongs almost exclusively to adult life, and in women rarely develops after the menopause. The male sex is comparatively exempt from it. As recognized exciting causes may be mentioned diseases of the genital organs, worry, mental excitement, anxiety, and fright.

exophthalmia goiter has been known to come on suddenly, this is the exception; as a rule, the onset is gradual first palpitation, later enlargement of the thyroid, still later exophthalmos; often months or years elapse before the disease is fully developed. Innumerable functional nervous disturbances, often of an hysterical type, come and go during the course of the disease. After a long period of sameness a gradual improvement may take place, ending in recovery, or there may be indefinitely repeated periods of improvement, and relapse or gradual exhaustion, with intercurrent complications, may end in death.

. The prognosis is said to be least favorable when the disease attacks elderly persons of the male sex. As far as vision is concerned, the source of danger has already been alluded to. An excessive exophthalmos,. with imperfect closure of the* lids, may lead to keratitis e lagophthalmo, and the resultant corneal opacity or ulceration may lead to partial or complete blindness of one or both eyes (see also page 317).

In the absence of definite and constant pathological lesions discoverable after death, we are, for the present, constrained to class exophthalmic goiter as a functional disease which seems to depend upon a disturbance of innervation, especially that of the sympathetic. The present tendency is to regard certain parts of the central nervous system (medulla and upper part of the spinal cord) as the primary seat of this strange disease.

Treatment. For the general treatment the reader will find this part of the subject elaborately discussed in most of the standard works on general medicine and neurology. The ophthalmic surgeon may, however, be called upon to deal with corneal complications. Undue exposure of the cornea may be obviated by an operation for narrowing the palpebral fissure (tarsorrhaphy, see page 547). Slight degrees of corneal irritation may be relieved by the use of a carefully adjusted compressive bandage and by soothing applications, such as vaselin, or mucilaginous collyria containing a small quantity of sodium biborate or boric acid. Refractive error should always be corrected.

INJURIES OF THE ORBIT.

Injuries may be limited to the soft parts or involve the bony walls as well. The danger of such injuries depends upon their nature and extent. It is often impossible to estimate either of these factors exactly, except in the light of subsequent events.

With injury of the soft parts there may be more or less damage to the lids and eyeball. The appearance of orbital fat in the wound is proof positive that the orbit has been penetrated. Extravasation of blood with ecchymoses of the conjunctiva and integument. and exophthalmos, are commonly present. Paralysis of ocular muscles and loss of vision from damage to the optic nerve are significant. Foreign bodies of considerable size remaining in the orbit may displace, or even completely luxate, the eyeball.

Foreign bodies thrust into the orbit may be difficult to discover, and when aseptic have been known to remain for an indefinite period without creating serious reaction. Small foreign bodies e. g. shot grains not readily discoverable by ordinary examination may be located by means of the X-rays (see Appendix, page 607). Pointed or blunt objects withdrawn after penetration Dot infrequently have. pierced the cranial cavity, the gravity of the lesion only being discoverable when cerebral complications occur.

Injuries to the bones of the orbital margins are a common result of crushing blows upon this part. The diagnosis is not difficult if the injured bone is sufficiently displaced to cause distinct unevenness or if a portion of the margin is detached. Mere sensitiveness to pressure is not diagnostic of fracture, though always coincident with it. The marginal fracture may extend as a fissure to any part of the orbit, even to the optic foramen; in the latter case blindness may result from laceration of the optic nerve or hemorrhage into its sheath, or fissure of the orbital walls may occur from fractures of the base of the skull.

Emphysema of the lids and orbital tissues is quite common even where the violence has not been great, and indicates fissure of the thin walls between the nasal or ethmoidal cavities and the orbit: suddenly developed elastic and crepitant swelling is quite characteristic of this. Exophthalmos due to this condition can be reduced by pressure with the finger. If due to extravasation of blood, as it often is in orbital fractures, the swelling cannot be reduced in this way.

Injuries of the orbit may recover perfectly after absorption of extravasated blood or air, but lesions of the eyeball, the optic or the third nerve, or the ocular muscles, often cause permanent impairment of function; or phlegmon of the orbit, with its attendant danger, may set in; or the contents of the cranial cavity may be involved directly or become so in consequence of the extension of septic inflammation following the injury. A fatal issue is then to be expected.

Treatment. In recent injuries of the orbit, if there be an open wound it must be carefully and thoroughly cleansed and disinfected. Exploration for suspected foreign bodies is a matter which can only be left to the judgment and skill of the surgeon. Exploration with the finger, when practicable, is always to be preferred. Small and probably aseptic foreign bodies should on no account be searched for. Suitable provision for drainage of the wound may be required, and an antiseptic dressing is to be applied. Should suppuration ensue, the treatment will be that of orbital cellulitis. Rest in bed is essential if the injury is still severe.

Hemorrhage into the orbit when at all abundant causes an immediate exophthalmos, later ecchymoses of lids and conjunctiva; this latter may be the only sign of atrophic hemorrhages. It is a common result of severe injuries of the orbit, often occurs with fracture of the skull implicating the orbital roof, occasionally without this lesion.

Spontaneous orbital hemorrhages have occasionally been seen in scorbutus, hemophilia, and during violent paroxysms of coughing. A copious bleeding into Tenon's capsule is an accident, fortunately rare, in operation for squint.

Injury of the Optic Nerve. Laceration of the optic nerve may occur, as has been stated, in connection with fracture of the bony walls of the orbit. But, independently of such an association, the optic nerve may be injured by a sharp stick, as in a case reported by Noyes, by a knife thrust, or by a bullet. Atrophy of the nerve and blindness are the results of such accidents, which are not frequent, twenty one cases having been collected by Aschman in 1884. Laceration of the nerve and the central retinal blood vessels may be followed by retinitis proliferans, as in the case recorded by C. Zimmermann.

Dislocation or luxation of the eyeball exists when the eyeball has been pushed so far forward that the lids remain contracted behind it.

Traumatisms, such as when a large foreign body has been driven into the orbit from the outside, the use of an assailant's thumbs in certain brutal assaults the so called gouging and a similar self mutilation by insane persons, have been known to cause this condition, which would probably be less rare if the eyeball did not usually rupture at the time of injury. Traumatic dislocation is apt to cause blindness from rupture or laceration of the optic nerve.

The luxation that readily occur during the continuance of any morbid condition attended with excessive exophthalmos are a mere complication of a more serious condition.

Treatment. The eyeball should be replaced as soon as possible. To effect this division of the outer canthus may be necessary. After reposition a compressive bandage may be required, and in the second class of cases tarsorrhaphy (page 547) may be done to prevent recurrence.

Enophthalmos (Idiopathic and Traumatic). A condition in which the appearance of file eye is the opposite of exophthalmos, the eyeball being retracted, is met with under various circumstances, as in wasting diseases %6th extreme emaciation and absorption of orbital fat; in Asiatic cholera because the enormous waste of fluids causes shrinkage of the orbital as well as other tissues; as one of the symptoms of paralysis of' the cervical sympathetic; in neurotic anesthesia of the face, as in lepra anesthetica ; and, finally, in a form distinctly traumatic in its origin.

In some cases immediately in others weeks or months after traumatism such as a blow upon the upper margin of the orbit without direct injury to the eye, enophthalmos appears, and may be due to paralysis of (Mullers) retractor of the lids i. e. a local lesion of the sympathetic or to trophic disturbance with atrophy of the orbital tissues. It has also been ascribed to fracture with depression of the orbital floor, and to cicatricial contraction of the orbital tissues following certain injuries (Fig. 332).

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