Serious Sequelae of Orbital Injuries.—In some instances injuries primarily to the orbit either by extension or implication of the cerebral contents provoke the most serious issues. Pointed instruments 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 It was stated that an umbrella stick had been thrust up through the roof of the orbit and had been withdrawn with much difficulty.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 The drains were gradually withdrawn, the process of healing advanced rapidly, and recovery soon ensued.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.