TWO CASES OF VASCULAR DISEASE OF THE ORBIT. DR. GEO. C. HARLAN, Phila. NEITHER of the cases that I am about to report to the Society are new, but they are not on that account entirely without interest, as marked changes have taken place in each since they appeared in public before. They were under my care at the same time about six years ago. One of them I reported in the Am. Jour. of Medical Sciences for July, 1870, and a brief account of the other was given by Dr. Newton, in a paper on orbital aneurism in the same journal.
Case i1-Aneurism by anastomosis in the orbit. L. L., set. 25. General health good. So long as he can remember the left eye bas been prominent, and the left side of the head larger than the right. He can remember noticing, in his early childhood, a rushing sound in his head and eye. The following was his condition when first seen, six years ago: The deformity is verv striking, as, besides the protrusion anid distortion of the eye, the whole of the left side of the face is enormously hypertrophied. There is no cedema of the thickene(d soft parts; they are dense and firm. The beard is coarse, and grows much more rapidly on this than on the other side. The hypertrophy subsides gradually towards the upper part of the forehead, and does not extend to the scalp. The external meatus of the left ear is nearly ciosed by the encroachment upon it of the anterior wall. The soft parts are so much thickened that it is almost impossible to determine if the bones are enlarged or not. The mucouis membrane of the left side of the mouth is thickened, and the left side of the tongue is twice as large as the right, presenting, with its coarse papillae, a marked contrast. His appearance is very suggestive of facial paralysis, and the tongue, when protruded, is directed towards the right side, but there is an entire absence of any kind of paralysis. The left eye is enormously protruded, and is fixed in its distorted position downwards and outwards, the upper border of the cornea being a quarter of an inch below the lower border of the other cornea. He can couint fingers with that eye, but has no useful vision. The lids are distended, and still cover the eye. Immediately above the
328 eyeball, and lying more towards the inner side, there is a distinct tumor of almost cartilaginous density; it is flattened from above downwards, and its narrow edge projects beyond the orbit. In this tumor, and the ball with it, there is a pulsation strong enough to communicate an evident motion to the head of the auscultator. There is a lou(d aneurismal bruit, which is not only a source of annoyance to the patient himself, but can be heard by others at some distance from his head. There is a doughy swelling of the soft parts, extending, abouit an inch above the orbit, in which strong puilsation can be felt. Pressure on the left carotid stops all pulsation, and the tumor becomes soft and compressible, and can be pushed back into the orbit. A vascular tumor, formed by engorgement and hypertrophy of the inferior palpebral fold of the conjunctiva, almost conceals the cornea, and not only greatly increases the deformity, buit occasions a good deal of pain, being constantly irritated and inflamed from exposure. It has also bled quite freely several times, and was the immediate cause that brought the patient to the hospital. This conjunctival tumor was removed in several operations by means of constriction with silk ligatures, and the patielnt, not caring to undergo further treatment, left the hospital. Dec., 1874. He called on me again, on account of trouble in the right eye. He states that about a year ago the sound in the left eye commeniced to diminish, and is now very rarely heard. Last spring the bulging of the left eye increased, and about the same time he noticed an enlargement of the vessels on the forehead. Two or three months ago his attention was called to the bulging forward of the right eye, and lately his vision has failed. There has been very little change in the appearance of the left eye; it is, perhaps, a little more protruded. The aneurismal bruit has decidedly diminished, and is now heard only directly over the tumor. The sound cannot be heard on auscultation of the temple, nor is it heard by the patient himself. The ophthalmoscope shows the media clear, the disc atrophied, the retinal arteries contracted, and the veins enormously contorted and engorged. It also shows an hypermetropic refraction of i, which, supposing the eye to have been originally emmetropic like the other, proves that its antero-posterior diameter has been shortened by the pressure to the extent of one millimetre and a quarter. The supra-orbital and frontal arteries are much enlarged, and can be plainly seen to pulsate. None of the other vessels on that side seem affected, but the varicose condition extends down the
atngular branch of the facial on the right side. Aneurismal fremitus
329 can be distinctly felt in this artery for an inch or more below the internal angle of the eye. The pulsation in all these vessels is immediately stopped by pressure on the left carotid. The vessels on the right side of the forehead are not affected. There is a very evident exophthalmus of the right eye, but no pulsation. It can easily be pressed back into its normal position, but instantly bulges forward again when the pressure is removed. The larger conjunctival veins are in a varicose condition, forming quite broad red lines radiating from the edge of the cornea. V.= it. Refraction = Em. Disk slightly hypetsemic, but not at all swollen. Retinal veins engorged. He was ordered a sedative and astringent wash for the right eye, and atropia was used to diminish the irritation of the left. Has general directions about his mode of life, etc., and to keep the left eye more completely protected. but complains of night May, 1875. Mich imnproved. V. 0. D. x2B xx(?) blindness. Cannot trust himself in the street aloine after dusk. Protrusion 0. D. rather less, varicose condition of vessels of forehead diminished, and thrill in angular artery of right side hardly perceptible. Ophtbalmoscope shows in 0. D. rather less engorgement of retinal veins, but margin of disk hazy and indistinct, and contour of vessels in its lneighborhood not clear-indicating cedema. I think that there can be little doubt of the character of the affection in this case. Its congenital origin, the hypertrophy of the whole side of the face, the involvement of some of the external vessels, and the evident extension of the disease beyond the orbit to the subcutaneous tissue of the brow, poilt definitely to aneurisin by anastomosis. The disease is nlot confined even to the internal carotid and its branches, as is shown by the excessive nutrition of parts that receive their blood from the external carotid. I have not been able to satisfy myself whether the protrusion of the other eye, recently noticed, is the result of verious obstruction from the extension of the disease behind the orbit, or whether the disease is creepinig over into the right orbit from in front, by means of the free anastomosis at the root of the nose. On either supposition it is difficult to account for the only serious symptom remaining, which is, unfortunately, very marked, of night blindiness. The question of treatment has given me a good deal of anxiety. Not much is to be expected from compression, though I have made a not very successfuil attempt to teach the patient to control the
330 artery himself. The disease seems to be too extensive, and not sufficiently defined to be treated by injection, which at best is an uncertain and dangerous remedy. There remains the question of ligature of the carotid, which some of my surgical friends have strongly urged, but I hesitate to insist upon it, because of the danger it involves, anid of the fact that the patienit is able to attend to work and support his family, and, above all, because the records of surgery show that the treatment of aneurism by anastomosis, and cirsoid aneuirism by distal ligature, has been extremely discouraging in other localities, and, at the same time, furnish good reason for suspecting that its reputed exceptional success in the same form of disease in the orbit has been fouinded in nistakes in diagnosis. Case II.-Pulsating exophthalmus following injury.
The following history of this case is taken from the Am. JoTurnal
qf Med. Sciences for July, 1870. S. G., set. 25-a robust manbrakesman on the Penn. IR. R., was admitted to Wills' Ophthalmic I-Hospital, August 14th, 1869. On the 20th of June, 1868, while standing on the platform of a car in motion, he received a violent blow upon the head from another car, moving in the opposite direction, on a side track, which fractured the lower maxilla on both sides, and inflicted several scalp wounds. He stated that he was partially insensible for three weeks, and that when he returned to consciousness his right eye was very prominent, and that he "heard a roaring sound, like falling water, in his eye," with every stroke of the pulse, which he had niever been free from since. A " red tumlor," which had appeared on the right eye, partly covering the pupil alnd interfering with vision, had been cut out by his medical attendant. A cicatrix in the conjunctiva, at the inferior palpebral fold, proved the tumor to have been a chemosis. The left eye commenced to protrude in about two months. At the time of his admission, four-teen months after the injury, there was great exophthalmus of both eyes, greater of the left, which seemed almost dislocated, the equator of the ball being in front of the edge of the orbit. The left ball couild be pressed back into its proper position and easily held there, without pain to the patient, but immediately bulged forward agaiii when the pressure was removed. The right eye resisted pressure, its position coul(l not be altered, and strong pressure gave pain. He had excelient binocular vision; accommodation = ; puipils freely movable, and ophthalmoscopic appearances normal. In addition to the " sound in the eye" referred to, he felt every
331
arterial pulsation "1 like a little jerk all over his head," and coincidentally there was a slight apparent motion of any object that he looked at steadily; on auscultation a loud aneurismal murmur could be heard over any part of the head or face, most distinctly over the right temple. This murmur, as well as the pulsation, was entirely stopped by pressure on the right carotid. There was never any pulsation of the left ball. Duiring the pressure on the artery the right ball could be replaced. No effect was produced upon either eye by pressure on the left carotid, or upon the left eye by pressure on either artery. Complete digital pressure of the right carotid was kept up continuously from three P.M. until eleven P.M.-a period of eight hours-the pulse ranging in the meantime, under the influence of veratrum, from 44 to 56. The murmur, though still quite distinct, was now much less loud, and altered in character. The patient stated that the "roaring was fainter and had a shriller sound" after this intermittent pressure was applied from four to six houirs daily, principally by the patieint himself, who learned to control the artery better than any one else; he accomplished it somietimes by the, thumb, sometimes by a tourniquet I had made for the purpose, and sometimes by means of a contrivance of his own, consisting of a stick about a foot long, with the end properly shaped and padded, which he pressed against the artery and held in his hands or rested on a table. The diminution of the sound continued, and the exophthalmus was decidedly lesselned, particularly of the left eve, making, an evident chatige for the better in the patient's appearance. This treatment was continued for five weeks, during the last two of which no progress was made. Continuous pressure was then again tried, being kept up by relavs of students for twenty-four hours, but with scarcely any effect. The patient then left the hospital, expressing himself satisfied that the improvement attained fully compensated him for all he had endured. Eight or nine months afterwards he wrote me that he had resumed his occupation of brakesman, and that the former condition of his eyes had returned; that he was no better than when be entered the hospital. November 17th, 1870. About six months later he wrote again that he had been keeping uip intermittent compression, at frequent intervals each day, and was improving. Two years after this time, November 9th, 1872, his brother called at mv office to say that the prominence of both eyes had entirely disappeared. There was still some sound, and he continued to practise occasional compression for
332
several months longer (more than three years after the commence. ment of treatment), when all symptoms had disappeared. Of course there is a possibility that this may have been a case of spontaneous cure. I find three cases reported, two by Erichsen (Science and Ar t of Surgery, Am. Ed., vol. ii. p. 108), and one by Dr. E. L. Holmes, of Chicago (Am. Jour. Afed. Sciences, July, 1864), in which all the symptoms of orbital aneurism disappeared under medical treatment, without either ligation or pressure. They were all of traumatic origin. The duration of the disease was, in one case, one year, in another eighteen months, and in the third, three years and a half. There is, however, aufficient ground for connecting the compression with the result, to justify us in giving this kind of treatment a more prolonged trial than has usually been done. The followino extract from the patient's letter will show the immediate effect of each compression: " I kept up the compression on the artery uuitil abouit two years ago, when a perfect cure was effected. I could have been relieved of the task of compressing the artery sooner, if I had confined myself more closely to it, but as long as it did not give pain I seldom compressed it; but as soon as it would pain I would put my thumb on the artery, often without noticing what I was doing, as I got so accustomed to it that it was no task. After reinoving my thumb from the artery, it would be but an hour or two until I would have a slight pain. So the compression was kept up several hours a day." Compression of the carotid has been tried in a number of cases, but only two instances of success are recorded, those of Gioppi and Scarramuzza (Hart, Lancet, March 15, 1862). In the case reported by Freeman, of Canada, the pressure was made not on the artery, but directly over the tumor (Am. Jour. Med. Sciences, No. 103, p. 277). Gioppi made intermittent digital compression, suspended every few minutes, for a few hours, during four days. In the other case the cure was effected by intermittent compression, occupying seven hours and twenty minutes, in the couirse of eighteen days. Galvano-puncture failed in the hands of Bourguet and P6tuqin, though ligature of the carotid proved equally unsuccessful in the latter case; six cases of cure by injections have been reported (Noyes, N. Y. Med. Jour., vol. viii. p. 666), and the brilliant success of ligation of the carotid is well known. When the case of S. G. was reported before, I had not the slightest hesitation in calling it an " orbital aneurism," but the more I have looked into the subject the less confident I have been of my opinion,
333 and in view of the admitted difficulties of diagnosis, and the many recorded mistakes of the high authorities, I have thought it safer to retire behind the comprehensive term of " pulsating exophthalmus." Following the view maintained by Travers in his report of the first case in 1809 (Med. Chirurg. Trans., vol. ii. p. 1), no onae, for thirty years, seems to have had a doubt that these cases of so-called aneurism of the orbit were all of the anastomotic variety. Then Busk's paper (Id., vol. xxii. p. 124) threw a doubt on this, and it was pretty generally held that they were of the ordinary spontaneous or traumatic kinds, until Nunnely, in 1864, maintained that " in the great majority of such cases of protrusion of the eyeball there is no disease whatever in the orbit, but that the symptoms depend oIn obstrulction to the return of blood through the ophthalmic vein." There is good ground for believinig that this view is correct, and that orbital aneurism is, to say the least, an extremely rare disease. In the decision of questions of pathology, the post-mortem room may be consi(lered the supreme court, and, with the exception of the complicated case briefly recorded by Guthrie (Operative Surgery of the Eye), who attributed the protrusion of the ball as much to an extensive hypertrophy of the recti muscles as to the aneurism, we are still, so far as I can learn, without positive proof that such a tlhing as an aneurism in the orbit has ever existed. The following post-mortem records, which are all that I have been able to find, speak for themselves, and it may be taken for granted that a post-mortem exai-ination that proves a mistake is, at least, not more likely to be published than one that confirms the previous diagnosis. I. Reported by Nunnely (Med. Chlirurg. Trans., 1864). Diagnosis, orbital aneurism. Origin, spontaneous. Ligature of carotid. Postmortem, ophthalmic artery "considerably enllarged," but principal disease in the carotid, which was decidedly dilated as it emerged from the bony canal. II. Nunnely (Ibid.). Diagnosis, orbital aneurism. Spontaneous. Ligature of carotid. P. M., eighteen months afterwards, pressure on cavernous sinus and ophthalmic vein by a malignant growth. III. Nunnely (Ibid.). Diagnosis, orbital aineurism. Spontaneous. Ligature of carotid. P. M., four and a half years after, circumscribed aneurism of ophthalmic artery, just at its origin on the right side of the sella turcica, as larg,e as a hazel nut; arteries of the orbit of very small size. IV. Bowman (1. L. 0. H. R., ii., p. 6). Diagnosis, orbital
334 aneurism. Traumatic. Ligature of carotid. Death from hemorrhage. P. M., cavernous sinus and ophthalmic vein, at its origin, obstructed by clot from phlebitis. Mr. Bowman states positively that " all the physical signs of orbital aneurism were present in a marked degree" in this case. V. Nelaton. Trauimatic. Diagnosis, according to Dr. E. L. Holmes (Am. four. Med. Sciences, July, 1864), who saw the case at N6laton's clinique, " aneurism of ophthalmic artery; " according to Dr. Delens, of Paris (quoted by T. Holmes, Lancet, Aug. 2d, 1873), wound of initernal carotid. No operation. P. M., aneurismal varix from direct wound of carotid and cavernous sinus. VI. Nelaton (Holmes, Lancet, Aug. 2d, 1873). Traumatic. Exophthalmus, pulsation, bruit. Small, rounded, movable pulsating tumor at upper and inner part of orbit. Intense chemosis. Diagnosis, aneurismal varix between carotid and cavernous sinus. Ligature of carotid. P. M., wound of carotid and cavernous sinus by spicula of bone from fracture of base of skull. VII. Baron (Ibid.). Exophthalmus and intense bellows murmur over the eyeball. Spontaneous. P. M., aneurism of carotid in cavernous sinus.
VIII. Gendrin (Wecker, Mal. des Yeux, vol. ii. p. 806). Diagnosis, orbital aneuirism. Spontaneous. No operation. P. M., obstructioII of cavernous sinus and ophthalmic vein by clots. Arteries also diseased, but nothing like an aneurism. IX. Aubrey (Ibid.). Diagnosis, aneurism of ophthalmic artery within the orbit. Spontaneous. No operation. P. M., great dilatation of cavernous sinus and ophthalmic vein. X. Lenoir (Ibid.). Diagnosis, aneurismal tumor within the orbit. Supposed to be traumatic. Ligature of carotid. Death nine months after. P. M., encephaloid tumor of the orbit. XI. Hainilton (Noyes, N. Y. Med. four., vol. viii. p. 666). Diagnosis, not given. Spontaneous. Ligature of carotid. P. M., malignant growth in orbit. XII. Richet (Oph. Congress, 1868). Diagnosis, pulsating tumor of the orbit. Exophthalmus, pulsation, loud bruit. Spontaneous. Ligature of carotid. P. M., dilatation of ophthalmic vein from phlebitis. No affection of any artery. XIII. Eltingen (Klin. Monatsbl., Feb., Miirz, 74, p. 58). Diagnosis, suspicion of aneurism, but probably venous thrombosis. Exophthalmus, pulsation, bruit. Spontaneous. No operation. P. M., two years afterwards, partial obliteration of orbital veins, but no change in the arteries.
335 XIV. Morton (unpublished). Diagnosis, post-orbital aneurism of' ophthalmic artery or carotid. Exophthalmus and bruit, but no pulsation. Spontaneous. Ligature of carotid. P. M., venous obstruction from clot, but nothing like an aneurism. An analysis of these fourteen cases gives: Venous clot from phlebitis, 4 cases. Venous dilatation from phlebitis, 2 cases. Malignant growths, 3 cases. Post-orbital aneurism, 3 cases. Post-orbital varix, 2 cases. Comnpetent observers had committed themselves to the diagnosis of orbital aneurism in nearly all these cases, and in the remainder the same conclusion could hardly have been resisted by any surgeon whose attention had not been particularly called to the subject. In only five cases was there anything like an aneurism, and in them the arterial lesion was so situated that it could be the cause of the orbital symptoms only in the same manner as any other obstruction to the venouls flow might be. Since the above was written, I find in The Lancet (April 3d, 1875) a condensed report of a paper on pulsating tumor of the orbit, read by Mr. Walter Rivington before the Royal Med. Chirurg. Society, whose Transactions contain so large a proportion of the literature of this subject. Twelve cases in which examination was made after death are referred to, but as the paper is not yet published, I have no means of knowing how many of his cases are not incluided in the list that I have given. A very interesting discussion followed the reading of the paper, during which Sir James Paget made the following remarks upon the cause of the pulsation in these tumors: "The conditions of pulsation of other tumors situated in bony cavities migiht throw some light on the mode of its occurrence. Any swelling lying in a bony cavity, even when there is no large cavity behind it, will pulsate. Thus, in a recent case of tumor of the antrum, in which there were no large vessels, there was distinct pulsation. Mr. Stanly has also collected and published cases of similar pulsating tumors of bone. A tumor of any sort in a cavity may receive a commnunicated pulsation from vessels of small size in the walls of the cavity. Another similar condition often seen is that of a cavity in a necrosed bone filled with pus, in which the fluid resting there shows a distinct pulsation visible to the eye. Sueb a hollow bone, with blood-vessels in its walls, is preciselv similar to a bony cavity, such as the orbit, which, to complete the analogy, is full
336 -of fat, which is really flutid at the ordinary temperature of the body." The same thing is well illustrated by the pulsation at the bottom of the external auditory meatus, which forms a familiar symptom of perforation of the membrana tympani. The pulsation and exophthalmus are natural enough results of venous obstruction, but the cause of the aneurismal bruit, which has been so often noticed without arterial disease, is not so plain. It is probably the result of constriction of the carotid artery by pressure. After all that has been said and written about orbital aneurism in the last seventy years, we cannot yet avoid the conclusion that we have no means of detecting it with any degree of certaintv. In the words of Mr. T. Holmes, " At present all we can say is, that the symptoms of orbital aneurism are, in some cases, exactly imitated by cases in which only the venous system is affected." One point that may be considered pretty well established is, that there is scope for much deliberation and some modesty in the matter of diagnosis.
The Society adjourned to meet Friday morning at 9.30.
July 23, 1875. The Society met at 9.30 A.M. The President, Dr. Agnew, in the Clhair. The minutes of the last meeting were read and accepted. DR. PROUT made the following motion, which was adopted: "It is recommended that the printed Reports of Special Puiblic Institutions for the Treatment of Diseases of the Eye anid Ear, with which members of this Society are connected, be sent by thein to all their fellow-Mnembers." In blehalf of the Committee appointed for the purpose of selecting a subject for disculssion for the next annual meeting, Dr. Kipp recommended the following: The Nature and Treatment of Tumors of the Optic Nerve.
Case i1-Aneurism by anastomosis in the orbit. L. L., set. 25. General health good. So long as he can remember the left eye bas been prominent, and the left side of the head larger than the right. He can remember noticing, in his early childhood, a rushing sound in his head and eye. The following was his condition when first seen, six years ago: The deformity is verv striking, as, besides the protrusion anid distortion of the eye, the whole of the left side of the face is enormously hypertrophied. There is no cedema of the thickene(d soft parts; they are dense and firm. The beard is coarse, and grows much more rapidly on this than on the other side. The hypertrophy subsides gradually towards the upper part of the forehead, and does not extend to the scalp. The external meatus of the left ear is nearly ciosed by the encroachment upon it of the anterior wall. The soft parts are so much thickened that it is almost impossible to determine if the bones are enlarged or not. The mucouis membrane of the left side of the mouth is thickened, and the left side of the tongue is twice as large as the right, presenting, with its coarse papillae, a marked contrast. His appearance is very suggestive of facial paralysis, and the tongue, when protruded, is directed towards the right side, but there is an entire absence of any kind of paralysis. The left eye is enormously protruded, and is fixed in its distorted position downwards and outwards, the upper border of the cornea being a quarter of an inch below the lower border of the other cornea. He can couint fingers with that eye, but has no useful vision. The lids are distended, and still cover the eye. Immediately above the
328 eyeball, and lying more towards the inner side, there is a distinct tumor of almost cartilaginous density; it is flattened from above downwards, and its narrow edge projects beyond the orbit. In this tumor, and the ball with it, there is a pulsation strong enough to communicate an evident motion to the head of the auscultator. There is a lou(d aneurismal bruit, which is not only a source of annoyance to the patient himself, but can be heard by others at some distance from his head. There is a doughy swelling of the soft parts, extending, abouit an inch above the orbit, in which strong puilsation can be felt. Pressure on the left carotid stops all pulsation, and the tumor becomes soft and compressible, and can be pushed back into the orbit. A vascular tumor, formed by engorgement and hypertrophy of the inferior palpebral fold of the conjunctiva, almost conceals the cornea, and not only greatly increases the deformity, buit occasions a good deal of pain, being constantly irritated and inflamed from exposure. It has also bled quite freely several times, and was the immediate cause that brought the patient to the hospital. This conjunctival tumor was removed in several operations by means of constriction with silk ligatures, and the patielnt, not caring to undergo further treatment, left the hospital. Dec., 1874. He called on me again, on account of trouble in the right eye. He states that about a year ago the sound in the left eye commeniced to diminish, and is now very rarely heard. Last spring the bulging of the left eye increased, and about the same time he noticed an enlargement of the vessels on the forehead. Two or three months ago his attention was called to the bulging forward of the right eye, and lately his vision has failed. There has been very little change in the appearance of the left eye; it is, perhaps, a little more protruded. The aneurismal bruit has decidedly diminished, and is now heard only directly over the tumor. The sound cannot be heard on auscultation of the temple, nor is it heard by the patient himself. The ophthalmoscope shows the media clear, the disc atrophied, the retinal arteries contracted, and the veins enormously contorted and engorged. It also shows an hypermetropic refraction of i, which, supposing the eye to have been originally emmetropic like the other, proves that its antero-posterior diameter has been shortened by the pressure to the extent of one millimetre and a quarter. The supra-orbital and frontal arteries are much enlarged, and can be plainly seen to pulsate. None of the other vessels on that side seem affected, but the varicose condition extends down the
atngular branch of the facial on the right side. Aneurismal fremitus
329 can be distinctly felt in this artery for an inch or more below the internal angle of the eye. The pulsation in all these vessels is immediately stopped by pressure on the left carotid. The vessels on the right side of the forehead are not affected. There is a very evident exophthalmus of the right eye, but no pulsation. It can easily be pressed back into its normal position, but instantly bulges forward again when the pressure is removed. The larger conjunctival veins are in a varicose condition, forming quite broad red lines radiating from the edge of the cornea. V.= it. Refraction = Em. Disk slightly hypetsemic, but not at all swollen. Retinal veins engorged. He was ordered a sedative and astringent wash for the right eye, and atropia was used to diminish the irritation of the left. Has general directions about his mode of life, etc., and to keep the left eye more completely protected. but complains of night May, 1875. Mich imnproved. V. 0. D. x2B xx(?) blindness. Cannot trust himself in the street aloine after dusk. Protrusion 0. D. rather less, varicose condition of vessels of forehead diminished, and thrill in angular artery of right side hardly perceptible. Ophtbalmoscope shows in 0. D. rather less engorgement of retinal veins, but margin of disk hazy and indistinct, and contour of vessels in its lneighborhood not clear-indicating cedema. I think that there can be little doubt of the character of the affection in this case. Its congenital origin, the hypertrophy of the whole side of the face, the involvement of some of the external vessels, and the evident extension of the disease beyond the orbit to the subcutaneous tissue of the brow, poilt definitely to aneurisin by anastomosis. The disease is nlot confined even to the internal carotid and its branches, as is shown by the excessive nutrition of parts that receive their blood from the external carotid. I have not been able to satisfy myself whether the protrusion of the other eye, recently noticed, is the result of verious obstruction from the extension of the disease behind the orbit, or whether the disease is creepinig over into the right orbit from in front, by means of the free anastomosis at the root of the nose. On either supposition it is difficult to account for the only serious symptom remaining, which is, unfortunately, very marked, of night blindiness. The question of treatment has given me a good deal of anxiety. Not much is to be expected from compression, though I have made a not very successfuil attempt to teach the patient to control the
330 artery himself. The disease seems to be too extensive, and not sufficiently defined to be treated by injection, which at best is an uncertain and dangerous remedy. There remains the question of ligature of the carotid, which some of my surgical friends have strongly urged, but I hesitate to insist upon it, because of the danger it involves, anid of the fact that the patienit is able to attend to work and support his family, and, above all, because the records of surgery show that the treatment of aneurism by anastomosis, and cirsoid aneuirism by distal ligature, has been extremely discouraging in other localities, and, at the same time, furnish good reason for suspecting that its reputed exceptional success in the same form of disease in the orbit has been fouinded in nistakes in diagnosis. Case II.-Pulsating exophthalmus following injury.
The following history of this case is taken from the Am. JoTurnal
qf Med. Sciences for July, 1870. S. G., set. 25-a robust manbrakesman on the Penn. IR. R., was admitted to Wills' Ophthalmic I-Hospital, August 14th, 1869. On the 20th of June, 1868, while standing on the platform of a car in motion, he received a violent blow upon the head from another car, moving in the opposite direction, on a side track, which fractured the lower maxilla on both sides, and inflicted several scalp wounds. He stated that he was partially insensible for three weeks, and that when he returned to consciousness his right eye was very prominent, and that he "heard a roaring sound, like falling water, in his eye," with every stroke of the pulse, which he had niever been free from since. A " red tumlor," which had appeared on the right eye, partly covering the pupil alnd interfering with vision, had been cut out by his medical attendant. A cicatrix in the conjunctiva, at the inferior palpebral fold, proved the tumor to have been a chemosis. The left eye commenced to protrude in about two months. At the time of his admission, four-teen months after the injury, there was great exophthalmus of both eyes, greater of the left, which seemed almost dislocated, the equator of the ball being in front of the edge of the orbit. The left ball couild be pressed back into its proper position and easily held there, without pain to the patient, but immediately bulged forward agaiii when the pressure was removed. The right eye resisted pressure, its position coul(l not be altered, and strong pressure gave pain. He had excelient binocular vision; accommodation = ; puipils freely movable, and ophthalmoscopic appearances normal. In addition to the " sound in the eye" referred to, he felt every
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arterial pulsation "1 like a little jerk all over his head," and coincidentally there was a slight apparent motion of any object that he looked at steadily; on auscultation a loud aneurismal murmur could be heard over any part of the head or face, most distinctly over the right temple. This murmur, as well as the pulsation, was entirely stopped by pressure on the right carotid. There was never any pulsation of the left ball. Duiring the pressure on the artery the right ball could be replaced. No effect was produced upon either eye by pressure on the left carotid, or upon the left eye by pressure on either artery. Complete digital pressure of the right carotid was kept up continuously from three P.M. until eleven P.M.-a period of eight hours-the pulse ranging in the meantime, under the influence of veratrum, from 44 to 56. The murmur, though still quite distinct, was now much less loud, and altered in character. The patient stated that the "roaring was fainter and had a shriller sound" after this intermittent pressure was applied from four to six houirs daily, principally by the patieint himself, who learned to control the artery better than any one else; he accomplished it somietimes by the, thumb, sometimes by a tourniquet I had made for the purpose, and sometimes by means of a contrivance of his own, consisting of a stick about a foot long, with the end properly shaped and padded, which he pressed against the artery and held in his hands or rested on a table. The diminution of the sound continued, and the exophthalmus was decidedly lesselned, particularly of the left eve, making, an evident chatige for the better in the patient's appearance. This treatment was continued for five weeks, during the last two of which no progress was made. Continuous pressure was then again tried, being kept up by relavs of students for twenty-four hours, but with scarcely any effect. The patient then left the hospital, expressing himself satisfied that the improvement attained fully compensated him for all he had endured. Eight or nine months afterwards he wrote me that he had resumed his occupation of brakesman, and that the former condition of his eyes had returned; that he was no better than when be entered the hospital. November 17th, 1870. About six months later he wrote again that he had been keeping uip intermittent compression, at frequent intervals each day, and was improving. Two years after this time, November 9th, 1872, his brother called at mv office to say that the prominence of both eyes had entirely disappeared. There was still some sound, and he continued to practise occasional compression for
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several months longer (more than three years after the commence. ment of treatment), when all symptoms had disappeared. Of course there is a possibility that this may have been a case of spontaneous cure. I find three cases reported, two by Erichsen (Science and Ar t of Surgery, Am. Ed., vol. ii. p. 108), and one by Dr. E. L. Holmes, of Chicago (Am. Jour. Afed. Sciences, July, 1864), in which all the symptoms of orbital aneurism disappeared under medical treatment, without either ligation or pressure. They were all of traumatic origin. The duration of the disease was, in one case, one year, in another eighteen months, and in the third, three years and a half. There is, however, aufficient ground for connecting the compression with the result, to justify us in giving this kind of treatment a more prolonged trial than has usually been done. The followino extract from the patient's letter will show the immediate effect of each compression: " I kept up the compression on the artery uuitil abouit two years ago, when a perfect cure was effected. I could have been relieved of the task of compressing the artery sooner, if I had confined myself more closely to it, but as long as it did not give pain I seldom compressed it; but as soon as it would pain I would put my thumb on the artery, often without noticing what I was doing, as I got so accustomed to it that it was no task. After reinoving my thumb from the artery, it would be but an hour or two until I would have a slight pain. So the compression was kept up several hours a day." Compression of the carotid has been tried in a number of cases, but only two instances of success are recorded, those of Gioppi and Scarramuzza (Hart, Lancet, March 15, 1862). In the case reported by Freeman, of Canada, the pressure was made not on the artery, but directly over the tumor (Am. Jour. Med. Sciences, No. 103, p. 277). Gioppi made intermittent digital compression, suspended every few minutes, for a few hours, during four days. In the other case the cure was effected by intermittent compression, occupying seven hours and twenty minutes, in the couirse of eighteen days. Galvano-puncture failed in the hands of Bourguet and P6tuqin, though ligature of the carotid proved equally unsuccessful in the latter case; six cases of cure by injections have been reported (Noyes, N. Y. Med. Jour., vol. viii. p. 666), and the brilliant success of ligation of the carotid is well known. When the case of S. G. was reported before, I had not the slightest hesitation in calling it an " orbital aneurism," but the more I have looked into the subject the less confident I have been of my opinion,
333 and in view of the admitted difficulties of diagnosis, and the many recorded mistakes of the high authorities, I have thought it safer to retire behind the comprehensive term of " pulsating exophthalmus." Following the view maintained by Travers in his report of the first case in 1809 (Med. Chirurg. Trans., vol. ii. p. 1), no onae, for thirty years, seems to have had a doubt that these cases of so-called aneurism of the orbit were all of the anastomotic variety. Then Busk's paper (Id., vol. xxii. p. 124) threw a doubt on this, and it was pretty generally held that they were of the ordinary spontaneous or traumatic kinds, until Nunnely, in 1864, maintained that " in the great majority of such cases of protrusion of the eyeball there is no disease whatever in the orbit, but that the symptoms depend oIn obstrulction to the return of blood through the ophthalmic vein." There is good ground for believinig that this view is correct, and that orbital aneurism is, to say the least, an extremely rare disease. In the decision of questions of pathology, the post-mortem room may be consi(lered the supreme court, and, with the exception of the complicated case briefly recorded by Guthrie (Operative Surgery of the Eye), who attributed the protrusion of the ball as much to an extensive hypertrophy of the recti muscles as to the aneurism, we are still, so far as I can learn, without positive proof that such a tlhing as an aneurism in the orbit has ever existed. The following post-mortem records, which are all that I have been able to find, speak for themselves, and it may be taken for granted that a post-mortem exai-ination that proves a mistake is, at least, not more likely to be published than one that confirms the previous diagnosis. I. Reported by Nunnely (Med. Chlirurg. Trans., 1864). Diagnosis, orbital aneurism. Origin, spontaneous. Ligature of carotid. Postmortem, ophthalmic artery "considerably enllarged," but principal disease in the carotid, which was decidedly dilated as it emerged from the bony canal. II. Nunnely (Ibid.). Diagnosis, orbital aneurism. Spontaneous. Ligature of carotid. P. M., eighteen months afterwards, pressure on cavernous sinus and ophthalmic vein by a malignant growth. III. Nunnely (Ibid.). Diagnosis, orbital aineurism. Spontaneous. Ligature of carotid. P. M., four and a half years after, circumscribed aneurism of ophthalmic artery, just at its origin on the right side of the sella turcica, as larg,e as a hazel nut; arteries of the orbit of very small size. IV. Bowman (1. L. 0. H. R., ii., p. 6). Diagnosis, orbital
334 aneurism. Traumatic. Ligature of carotid. Death from hemorrhage. P. M., cavernous sinus and ophthalmic vein, at its origin, obstructed by clot from phlebitis. Mr. Bowman states positively that " all the physical signs of orbital aneurism were present in a marked degree" in this case. V. Nelaton. Trauimatic. Diagnosis, according to Dr. E. L. Holmes (Am. four. Med. Sciences, July, 1864), who saw the case at N6laton's clinique, " aneurism of ophthalmic artery; " according to Dr. Delens, of Paris (quoted by T. Holmes, Lancet, Aug. 2d, 1873), wound of initernal carotid. No operation. P. M., aneurismal varix from direct wound of carotid and cavernous sinus. VI. Nelaton (Holmes, Lancet, Aug. 2d, 1873). Traumatic. Exophthalmus, pulsation, bruit. Small, rounded, movable pulsating tumor at upper and inner part of orbit. Intense chemosis. Diagnosis, aneurismal varix between carotid and cavernous sinus. Ligature of carotid. P. M., wound of carotid and cavernous sinus by spicula of bone from fracture of base of skull. VII. Baron (Ibid.). Exophthalmus and intense bellows murmur over the eyeball. Spontaneous. P. M., aneurism of carotid in cavernous sinus.
VIII. Gendrin (Wecker, Mal. des Yeux, vol. ii. p. 806). Diagnosis, orbital aneuirism. Spontaneous. No operation. P. M., obstructioII of cavernous sinus and ophthalmic vein by clots. Arteries also diseased, but nothing like an aneurism. IX. Aubrey (Ibid.). Diagnosis, aneurism of ophthalmic artery within the orbit. Spontaneous. No operation. P. M., great dilatation of cavernous sinus and ophthalmic vein. X. Lenoir (Ibid.). Diagnosis, aneurismal tumor within the orbit. Supposed to be traumatic. Ligature of carotid. Death nine months after. P. M., encephaloid tumor of the orbit. XI. Hainilton (Noyes, N. Y. Med. four., vol. viii. p. 666). Diagnosis, not given. Spontaneous. Ligature of carotid. P. M., malignant growth in orbit. XII. Richet (Oph. Congress, 1868). Diagnosis, pulsating tumor of the orbit. Exophthalmus, pulsation, loud bruit. Spontaneous. Ligature of carotid. P. M., dilatation of ophthalmic vein from phlebitis. No affection of any artery. XIII. Eltingen (Klin. Monatsbl., Feb., Miirz, 74, p. 58). Diagnosis, suspicion of aneurism, but probably venous thrombosis. Exophthalmus, pulsation, bruit. Spontaneous. No operation. P. M., two years afterwards, partial obliteration of orbital veins, but no change in the arteries.
335 XIV. Morton (unpublished). Diagnosis, post-orbital aneurism of' ophthalmic artery or carotid. Exophthalmus and bruit, but no pulsation. Spontaneous. Ligature of carotid. P. M., venous obstruction from clot, but nothing like an aneurism. An analysis of these fourteen cases gives: Venous clot from phlebitis, 4 cases. Venous dilatation from phlebitis, 2 cases. Malignant growths, 3 cases. Post-orbital aneurism, 3 cases. Post-orbital varix, 2 cases. Comnpetent observers had committed themselves to the diagnosis of orbital aneurism in nearly all these cases, and in the remainder the same conclusion could hardly have been resisted by any surgeon whose attention had not been particularly called to the subject. In only five cases was there anything like an aneurism, and in them the arterial lesion was so situated that it could be the cause of the orbital symptoms only in the same manner as any other obstruction to the venouls flow might be. Since the above was written, I find in The Lancet (April 3d, 1875) a condensed report of a paper on pulsating tumor of the orbit, read by Mr. Walter Rivington before the Royal Med. Chirurg. Society, whose Transactions contain so large a proportion of the literature of this subject. Twelve cases in which examination was made after death are referred to, but as the paper is not yet published, I have no means of knowing how many of his cases are not incluided in the list that I have given. A very interesting discussion followed the reading of the paper, during which Sir James Paget made the following remarks upon the cause of the pulsation in these tumors: "The conditions of pulsation of other tumors situated in bony cavities migiht throw some light on the mode of its occurrence. Any swelling lying in a bony cavity, even when there is no large cavity behind it, will pulsate. Thus, in a recent case of tumor of the antrum, in which there were no large vessels, there was distinct pulsation. Mr. Stanly has also collected and published cases of similar pulsating tumors of bone. A tumor of any sort in a cavity may receive a commnunicated pulsation from vessels of small size in the walls of the cavity. Another similar condition often seen is that of a cavity in a necrosed bone filled with pus, in which the fluid resting there shows a distinct pulsation visible to the eye. Sueb a hollow bone, with blood-vessels in its walls, is preciselv similar to a bony cavity, such as the orbit, which, to complete the analogy, is full
336 -of fat, which is really flutid at the ordinary temperature of the body." The same thing is well illustrated by the pulsation at the bottom of the external auditory meatus, which forms a familiar symptom of perforation of the membrana tympani. The pulsation and exophthalmus are natural enough results of venous obstruction, but the cause of the aneurismal bruit, which has been so often noticed without arterial disease, is not so plain. It is probably the result of constriction of the carotid artery by pressure. After all that has been said and written about orbital aneurism in the last seventy years, we cannot yet avoid the conclusion that we have no means of detecting it with any degree of certaintv. In the words of Mr. T. Holmes, " At present all we can say is, that the symptoms of orbital aneurism are, in some cases, exactly imitated by cases in which only the venous system is affected." One point that may be considered pretty well established is, that there is scope for much deliberation and some modesty in the matter of diagnosis.
The Society adjourned to meet Friday morning at 9.30.
July 23, 1875. The Society met at 9.30 A.M. The President, Dr. Agnew, in the Clhair. The minutes of the last meeting were read and accepted. DR. PROUT made the following motion, which was adopted: "It is recommended that the printed Reports of Special Puiblic Institutions for the Treatment of Diseases of the Eye anid Ear, with which members of this Society are connected, be sent by thein to all their fellow-Mnembers." In blehalf of the Committee appointed for the purpose of selecting a subject for disculssion for the next annual meeting, Dr. Kipp recommended the following: The Nature and Treatment of Tumors of the Optic Nerve.
