PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 17 page

thrust into the orbital cavity may by this route reach the brain. There

is a record of death caused by a wound of a cavernous sinus through the

orbit by the stem of a tobacco-pipe. Bower saw a woman at the

Gloucester Infirmary who had been stabbed in the eye by the end of an

umbrella. There was profuse hemorrhage from the nostrils and left eye,

but no signs indicative of its origin. Death shortly ensued, and at the

necropsy a fracture through the roof of the orbit was revealed, the

umbrella point having completely severed the optic nerve and divided

the ophthalmic artery. The internal carotid artery was wounded in

one-half of its circumference at its bend, just before it passes up

between the anterior clinoid process and the optic nerve. The cavernous

sinus was also opened. In this rare injury, although there was a

considerable quantity of clotted blood at the base of the brain, there

was no wound to the eyeball nor to the brain itself.

Pepper records a case in which a knife was thrust through the

spheroidal fissure, wounding a large meningeal vein, causing death from

intracranial hemorrhage. Nelaton describes an instance in which the

point of an umbrella wounded the cavernous sinus and internal carotid

artery of the opposite side, causing the formation of an arteriovenous

aneurysm which ultimately burst, and death ensued. Polaillon saw a boy

of eighteen who was found in a state of coma. It was stated that an

umbrella stick had been thrust up through the roof of the orbit and had

been withdrawn with much difficulty. The anterior lobe of the brain was

evidently much wounded; an incision was made in the forehead and a

portion of the frontal bone chiseled away entrance being thus effected,

the aura was incised, and some blood and cerebrospinal fluid escaped.

Five splinters were removed and a portion of the damaged

brain-substance, and a small artery was tied with catgut. The debris

of the eyeball was enucleated and a drain was placed in the frontal

wound, coming out through the orbit. The patient soon regained

consciousness and experienced no bad symptoms afterward. The drains

were gradually withdrawn, the process of healing advanced rapidly, and

recovery soon ensued.

Annandale mentions an instance in which a knitting-needle penetrated

the brain through the orbit. Hewett speaks of perforation of the roof

of the orbit and injury to the brain by a lead-pencil.

Gunshot Injuries of the Orbit.--Barkan recites the case in which a

leaden ball 32/100 inch in diameter was thrown from a sling into the

left orbital cavity, penetrating between the eyeball and osseous wall

of the orbit without rupturing the tunics of the eye or breaking the

bony wall of the cavity. It remained lodged two weeks without causing

any pain or symptoms, and subsequently worked itself forward, contained

in a perfect conjunctival sac, in which it was freely movable.

Buchanan recites the case of a private in the army who was shot at a

distance of three feet away, the ball entering the inner canthus of the

right eye and lodging under the skin of the opposite side. The eye was

not lost, and opacity of the lower part of the cornea alone resulted.

Cold water and purging constituted the treatment.

It is said a that an old soldier of one of Napoleon's armies had a

musket-ball removed from his left orbit after twenty-four years'

lodgment. He was struck in the orbit by a musket-ball, but as at the

same time a companion fell dead at his side he inferred that the bullet

rebounded from his orbit and killed his comrade. For twenty-four years

he had suffered from cephalalgia and pains and partial exophthalmos of

the left eye. After removal of the ball the eye partially atrophied.

Warren reports a case of a man of thirty-five whose eyeball was

destroyed by the explosion of a gun, the breech-pin flying off and

penetrating the head. The orbit was crushed; fourteen months afterward

the man complained of soreness on the hard palate, and the whole

breech-pin, with screw attached, was extracted. The removal of the pin

was followed by fissure of the hard palate, which, however, was

relieved by operation. The following is an extract of a report by

Wenyon of Fatshan, South China:--

"Tang Shan, Chinese farmer, thirty-one years of age, was injured in the

face by the bursting of a shot-gun. After being for upward of two

months under the treatment of native practitioners, he came to me on

December 4, 1891. I observed a cicatrix on the right side of his nose,

and above this a sinus, still unhealed, the orifice of which involved

the inner canthus of the right eye, and extended downward and inward

for about a centimeter. The sight of the right eye was entirely lost,

and the anterior surface of the globe was so uniformly red that the

cornea could hardly be distinguished from the surrounding conjunctiva.

There was no perceptible enlargement or protrusion of the eyeball, and

it did not appear to have sustained any mechanical injury or loss of

tissue. The ophthalmia and keratitis were possibly caused by the

irritating substances applied to the wound by the Chinese doctors. The

sinus on the side of the nose gave exit to a continuous discharge of

slightly putrid pus, and the patient complained of continuous headache

and occasional dizziness, which interfered with his work. The pain was

referred to the right frontal and temporal regions, and the skin on

this part of the head had a slight blush, but there was no superficial

tenderness. The patient had been told by his native doctors, and he

believed it himself, that there was no foreign body in the wound; but

on probing it I easily recognized the lower edge of a hard metallic

substance at a depth of about one inch posteriorly from the orifice of

the sinus. Being unable to obtain any reliable information as to the

probable size or shape of the object, I cautiously made several

attempts to remove it through a slightly enlarged opening, but without

success. I therefore continued the incision along the side of the nose

to the nostril, thus laying open the right nasal cavity; then, seizing

the foreign body with a pair of strong forceps, I with difficulty

removed the complete breech-pin of a Chinese gun. Its size and shape

are accurately represented by the accompanying drawing. The breech-pin

measures a little over three inches in length, and weighs 21 ounces, or

75.6 grams. It had evidently lain at the back of the orbit, inclined

upward and slightly backward from its point of entrance, at an angle of

about 45 degrees. On its removal the headache was at once relieved and

did not return. In ten days the wound was perfectly healed and the

patient went back to his work. A somewhat similar case, but which

terminated fatally, is recorded in the American Journal of the Medical

Sciences of July, 1882."

The extent of permanent injury done by foreign bodies in the orbit is

variable. In some instances the most extensive wound is followed by the

happiest result, while in others vision is entirely destroyed by a

minor injury.

Carter reports a case in which a hat-peg 3 3/10 inches long and about

1/4 inch in diameter (upon one end of which was a knob nearly 1/2 inch

in diameter) was impacted in the orbit for from ten to twenty days, and

during this time the patient was not aware of the fact. Recovery

followed its extraction, the vision and movements of the eye being

unimpaired.

According to the Philosophical Transactions a laborer thrust a long

lath with great violence into the inner canthus of the left eye of his

fellow workman, Edward Roberts. The lath broke off short, leaving a

piece two inches long, 1/2 inch wide, and 1/4 inch thick, in situ.

Roberts rode about a mile to the surgery of Mr. Justinian Morse, who

extracted it with much difficulty; recovery followed, together with

restoration of the sight and muscular action. The lath was supposed to

have passed behind the eyeball. Collette speaks of an instance in which

186 pieces of glass were extracted from the left orbit, the whole mass

weighing 186 Belgian grains. They were blown in by a gust of wind that

broke a pane of glass; after extraction no affection of the brain or

eye occurred. Watson speaks of a case in which a chip of steel 3/8 inch

long was imbedded in cellular tissue of the orbit for four days, and

was removed without injury to the eye. Wordsworth reports a case in

which a foreign body was deeply imbedded in the orbit for six weeks,

and was removed with subsequent recovery. Chisholm has seen a case in

which for five weeks a fly was imbedded in the culdesac between the

lower lid and the eyeball.

Foreign bodies are sometimes contained in the eyeball for many years.

There is an instance on record in which a wooden splinter, five mm.

long and two mm. broad, remained in the eye forty-seven years. It was

extracted, with the lens in which it was lodged, to relieve pain and

other distressing symptoms. Snell reports a case in which a piece of

steel was imbedded and encapsulated in the ciliary process twenty-nine

years without producing sympathetic irritation of its fellow, but

causing such pain as to warrant enucleation of this eye. Gunning speaks

of a piece of thorn 5/8 inch long, imbedded in the left eyeball of an

old man for six years, causing total loss of vision; he adds that,

after its removal, some improvement was noticed.

Williams mentions a stone-cutter whose left eye was put out by a piece

of stone. Shortly after this his right eye was wounded by a knife,

causing traumatic cataract, which was extracted by Sir William Wilde,

giving the man good sight for twelve years, after which iritis attacked

the right eye and produced a false membrane over the pupil so that the

man could not work. It was in this condition that he consulted

Williams, fourteen years after the loss of the left eye. The eye was

atrophied, and on examination a piece of stone was seen projecting from

it directly between the lids. The visible portion was 1/4 inch long,

and the end in the shrunken eye was evidently longer than the end

protruding. The sclera was incised, and, after fourteen years' duration

in the eye, the stone was removed.

Taylor reports the removal of a piece of bone which had remained

quiescent in the eye for fourteen years; after the removal of the eye

the bone was found adherent to the inner tunics. It resembled the lens

in size and shape. Williams mentions continual tolerance of foreign

bodies in the eyeball for fifteen and twenty-two years; and Chisholm

reports the lodgment of a fragment of metal in the iris for

twenty-three years. Liebreich extracted a piece of steel from the

interior of the eye where it had been lodged twenty-two years. Barkar

speaks of a piece of steel which penetrated through the cornea and

lens, and which, five months later, was successfully removed by the

extraction of the cataractous lens. Critchett gives an instance of a

foreign body being loose in the anterior chamber for sixteen years.

Rider speaks of the lodgment of a fragment of a copper percussion cap

in the left eye, back of the inner ciliary margin of the iris, for

thirty-five years; and Bartholinus mentions a thorn in the canthus for

thirty years. Jacob reports a case in which a chip of iron remained in

the eyeball twenty-eight years without giving indications for removal.

It was clearly visible, protruding into the anterior surface of the

iris, and although it was rusted by its long lodgment, sight in the eye

was fairly good, and there was no sign of irritation.

Snell gives an instance in which a piece of steel was imbedded close to

the optic disc with retention of sight. It was plainly visible by the

opthalmoscope eighteen months after the accident, when as yet no

diminution of sight was apparent. Smyly speaks of a portion of a

tobacco pipe which was successfully removed from the anterior chamber

by an incision through the cornea. Clark mentions a case in which

molten lead in the eye caused no permanent injury; and there are

several cases mentioned in confirmation of the statement that the eye

seems to be remarkably free from disastrous effects after this injury.

Williamson mentions eyelashes in the anterior chamber of the eye, the

result of a stab wound of this organ.

Contusion of the eyeball may cause dislocation of the lens into the

anterior chamber, and several instances have been recorded. We regret

our inability to give the reference or authority for a report that we

have seen, stating that by one kick of a horse the lenses of both eyes

of a man were synchronously knocked through the eyeballs by the calkins

of the horseshoe. Oliver mentions extraction of a lens by a thrust of a

cow's horn.

Lowe speaks of rupture of the anterior capsule of the lens from violent

sneezing, with subsequent absorption of the lenticular substance and

restoration of vision. Trioen mentions a curious case of expulsion of

the crystalline lens from the eye in ophthalmia, through the formation

of a corneal fissure. The authors have personal knowledge of a case of

spontaneous extrusion of the lens through a corneal ulcer, in a case of

ophthalmia of the new-born.

Injury of the Eyeball by Birds.--There are several instances in which

birds have pierced the eyeball with their bills, completely destroying

vision. Not long since a prominent taxidermist winged a crane, picked

it up, and started to examine it, when it made one thrust with its bill

and totally destroyed his eyeball. In another instance a man was going

from the railroad station to his hotel in a gale of wind, when, as he

turned the corner of the street, an English sparrow was blown into his

face. Its bill penetrated his eyeball and completely ruined his sight.

There are several instances on record in which game fowls have

destroyed the eyes of their owners. In one case a game cock almost

completed the enucleation of the eye of his handler by striking him

with his gaff while preparing in a cock-pit.

Moorehead explains a rare accident to an eye as follows:--

"Mr. S. B. A., while attending to his bees, was stung by one upon the

right upper eyelid near its center. An employee, who was assisting in

the work, immediately discovered the sting driven in the lid and

cautiously extracted it, stating that he made sufficient traction to

lift the lid well away from the globe. In a few hours the lid became

much swollen, but the pain experienced at first had disappeared. Before

retiring for the night he began gentle massage of the lid, stroking it

horizontally with his finger. The edematous condition was by this means

much reduced in a short time. While thus engaged in stroking the lid he

suddenly experienced intense pain in the eye as if it had been pierced

by a sharp instrument. The suffering was very severe, and he passed a

wretched night, constantly feeling 'something in his eye.'

"The next morning, the trouble continuing, he came to me for relief.

Upon examination of the lid, no opening could be made out where the

sting had penetrated, and a minute inspection of the conjunctival

surface with a good glass failed to reveal any foreign substance.

Cleansing the lid thoroughly, and carefully inspecting with a lens

under strong light, a minute dark point was made out about the center

of the lid. Feeling that this might be the point of the sting, I had

recourse to several expedients for its removal, but without success.

Finally, with a fine knife, I succeeded in cutting down by the side of

the body and tilting it out. Examination with a 1/5 inch objective

confirmed my opinion that it was the point of the bee-sting.

"The barbed formation of the point explains how, under the stroking

with the finger, it was forced through the dense tarsal cartilage and

against the cornea of the eye."

There is a story told in La Medecine Moderne of a seamstress of Berlin

who was in the habit of allowing her dog to lick her face. She was

attacked with a severe inflammation of the right eye, which had to be

enucleated, and was found full of tenia echinococcus, evidently derived

from the dog's tongue.

Gabb mentions a case of epistaxis in which the blood welled up through

the lacrimal ducts and suffused into the eye so that it was constantly

necessary to wipe the lower eyelid, and the discharge ceased only when

the nose stopped bleeding. A brief editorial note on epistaxis through

the eyes, referring to a case in the Medical News of November 30, 1895,

provoked further reports from numerous correspondents. Among others,

the following:--

"Dr. T. L. Wilson of Bellwood, Pa., relates the case of an old lady of

seventy-eight whom he found with the blood gushing from the nostrils.

After plugging the nares thoroughly with absorbent cotton dusted with

tannic acid he was surprised to see the blood ooze out around the

eyelids and trickle down the cheeks. This oozing continued for the

greater part of an hour, being controlled by applications of ice to

both sides of the nose."

"Dr. F. L. Donlon of New York City reports the case of a married woman,

about fifty years old, in whom epistaxis set in suddenly at 11 P.M.,

and had continued for several hours, when the anterior nares were

plugged. In a short time the woman complained that she could scarcely

see, owing to the welling up of blood in the eyes and trickling down

her face. The bleeding only ceased when the posterior nares also were

plugged."

"Dr. T. G. Wright of Plainville, Conn., narrates the case of a young

man whom he found in the night, bleeding profusely, and having already

lost a large amount of blood. Shortly after plugging both anterior and

posterior nares the blood found its way through the lacrimal ducts to

the eyes and trickled down the cheeks."

"Dr. Charles W. Crumb cites the case of a man, sixty-five years old,

with chronic nephritis, in whom a slight bruise of the nose was

followed by epistaxis lasting twenty-four hours. When the nares were

plugged blood escaped freely from the eyes. A cone-shaped bit of

sponge, saturated with ferrous sulphate, was passed into each anterior

naris, and another piece of sponge, similarly medicated, into either

posterior naris. The patient had been taking various preparations of

potassium, and it was thought that his blood contained a deficiency of

fibrin. Upon removal of the nasal plugs a catarrhal inflammation

developed which lasted a long time and was attended with considerable

purulent discharge."

Late Restoration of Sight.--There are some marvelous cases on record in

which, after many years of blindness, the surgeon has been able, by

operation, to restore the sight. McKeown gives the history of a blind

fiddler of sixty-three, who, when one and a half years old, had lost

the sight of both eyes after an attack of small-pox. Iridectomy was

performed, and after over sixty years of total blindness his sight was

restored; color-perception was good. Berncastle mentions a case of

extraction of double cataract and double iridectomy for occluded

pupils, which, after thirty years of blindness, resulted in the

recovery of good sight. The patient was a blind beggar of Sydney.

To those interested in this subject, Jauffret has a most interesting

description of a man by the name of Garin, who was born blind, who

talked at eight or nine months, showed great intelligence, and who was

educated at a blind asylum. At the age of twenty-four he entered the

hospital of Forlenze, to be operated upon by that famous oculist. Garin

had never seen, but could distinguish night or darkness by one eye

only, and recognized orange and red when placed close to that eye. He

could tell at once the sex and age of a person approximately by the

voice and tread, and formed his conclusions more rapidly in regard to

females than males. Forlenze diagnosed cataract, and, in the presence

of a distinguished gathering, operated with the happiest result. The

description that follows, which is quoted by Fournier and is readily

accessible to any one, is well worth reading, as it contains an account

of the first sensations of light, objects, distance, etc., and minor

analogous thoughts, of an educated and matured mind experiencing its

first sensations of sight.

Hansell and Clark say that the perplexities of learning to see after

twenty-six years of blindness from congenital disease, as described by

a patient of Franke, remind one of the experience of Shelley's

Frankenstein. Franke's patient was successfully operated on for

congenital double cataract, at twenty-six years of age. The author

describes the difficulties the patient had of recognizing by means of

vision the objects he had hitherto known through his other senses, and

his slowness in learning to estimate distances and the comparative size

of objects.

Sight is popularly supposed to be occasionally restored without the aid

of art, after long years of blindness. Benjamin Rush saw a man of

forty-five who, twelve years before, became blind without ascertainable

cause, and recovered his sight equally without reason. St. Clair

mentions Marshal Vivian, who at the age of one hundred regained sight

that for nearly forty years had gradually been failing almost to

blindness, and preserved this new sight to the time of his death.

There are many superstitions prevalent among uneducated people as to

"second sight," recovery of vision, etc., which render their reports of

such things untrustworthy. The real explanations of such cases are too

varied for discussion here.

Nyctalopia etymologically means night blindness, but the general usage,

making the term mean night-vision, is so strongly intrenched that it is

useless and confusing to attempt any reinstatement of the old

significance. The condition in which one sees better by night,

relatively speaking, than by day is due to some lesion of the macular

region, rendering it blind. At night the pupil dilates more than in the

day-time, and hence vision with the extramacular or peripheral portions

of the retina is correspondingly better. It is, therefore, a symptom of

serious retinal disease. All night-prowling animals have widely

dilatable pupils, and in addition to this they have in the retina a

special organ called the tapetum lucidum, the function of which is to

reflect to a focus in front of them the relatively few rays of light

that enter the widely-dilated pupil and thus enable them the better to

see their way. Hence the luminous appearance of the eyes of such

animals in the dark.

Hemeralopia (etymologically day-blindness, but by common usage meaning

day-vision or night-blindness) is a symptom of a peculiar degenerative

disease of the retina, called retinitis pigmentosa. It also occurs in

some cases of extreme denutrition, numerous cases having been reported

among those who make the prolonged fasts customary in the Russian

church. In retinitis pigmentosa the peripheral or extramacular portions

of the retina are subject to a pigmentary degeneration that renders

them insensitive to light, and patients so afflicted are consequently

incapable of seeing at night as well as others. They stumble and run

against objects easily seen by the normal eye.

Snow-blindness occurs from prolonged exposure of the eyes to snow upon

which the sun is shining. Some years ago, some seventy laborers, who

were clearing away snow-drifts in the Caucasus, were seized, and thirty

of them could not find their way home, so great was the photophobia,

conjunctivitis, and lacrimation. Graddy reports six cases, and many

others are constantly occurring.

Other forms of retinal injury from too great or too prolonged exposure

to light are "moon-blindness," due to sleeping with the eyes exposed to

bright moonlight, and that due to lightning--a case, e.g., being

reported by Knies. Silex also reports such a case and reviews the

reported cases, 25 in number, in ten of which cataract ensued. In the

Annual of the Universal Medical Sciences, 1888, there is a report of

seven cases of retinal injury with central scotoma, amblyopia, etc., in

Japanese medical students, caused by observation of the sun in eclipse.

In discussing the question of electric-light injuries of the eyes Gould

reviews the literature of the subject and epitomizes the cases reported

up to that time. They numbered 23. No patient was seriously or

permanently injured, and none was in a person who used the electric

light in a proper manner as an illuminant. All were in scientific

investigators or workmen about the light, who approached it too closely

or gazed at it too long and without the colored protecting spectacles

now found necessary by such workers.

Injuries to the Ear.--The folly of the practice of boxing children's

ears, and the possible disastrous results subsequent to this

punishment, are well exemplified throughout medical literature. Stewart

quotes four cases of rupture of the tympanum from boxing the ears, and

there is an instance of a boy of eight, who was boxed on the ear at

school, in whom subsequent brain-disease developed early, and death

followed. Roosa of New York mentions the loss of hearing following a

kiss on the ear.

Dalby, in a paper citing many different causes of rupture of the

tympanic membrane, mentions the following: A blow in sparring; violent

sneezing; blowing the nose; forcible dilatation of the Eustachian

canal; a thorn or twig of a tree accidentally thrust into the head;

picking the ear with a toothpick. In time of battle soldiers sometimes

have their tympanums ruptured by the concussion caused by the firing of

cannon. Dalby mentions an instance of an officer who was discharged for

deafness acquired in this manner during the Crimean War. He was

standing beside a mortar which, unexpectedly to him, was fired, causing

rupture of the tympanic membrane, followed by hemorrhage from the ear.

Similar cases were reported in the recent naval engagements between the

Chinese and Japanese. Wilson reports two cases of rupture of the

membrane tympani caused by diving. Roosa divides the causes into

traumatic, hemorrhagic, and inflammatory, and primary lesions of the

labyrinth, exemplifying each by numerous instances. Under traumatic

causes he mentions severe falls, blows about the head or face, constant

listening to a telegraphic instrument, cannonading, and finally eight

cases of boiler-makers' deafness. Roosa cites a curious case of sudden

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