and epithelial cells. No casts were present. The patient was placed upon full doses of quinine and iron, and locally frequently changed compresses soaked in a warm solution of bichloride of mercury-grain 1 to the pint-were ordered. On the 27th, the temperature, which on admission had been 101, rose to 104. The following is the Record of Pulse, Respiration and Temperature from January 24 to February 12: The patient was etherized and deep incisions made along the margin of the orbit of the left eye, above and below, and a similar incision in the lower lid of the right eye. The escape of pus was very free, not less than eight ounces being evacuated. This seemingly came from the infiltrated tissues all around, and in order to secure drainage, counter incisions were made in the dependent portions of the left side of the face. A director was pushed into each orbit, and from the orbit of the right side a small quantity of pus escaped. Great relief followed the incisions, which were daily syringed with the bichloride solution. Three days later the morning temperature was normal, and it never rose again above 100 until the 9th of February, when a large abscess, which formed over the left ear and was confined by the temporal fascia, was opened by my colleague, Dr. George M. Gould, who was at this time in charge of the wards. Subsequently a smaller abscess in the neighborhood of the original incision at the left eye appeared and was evacuated. The treatment during the entire period was quinine, tincture of the chloride of iron and whiskey. At the height of the attack the bogginess of the tissues, as well as the brawny flush, extended very high up in the scalp, completely over the face, and as far down the left side of the neck as the sterno-clavicular articulation. The amount of pus evacuted in the second incision fully equaled, if it did not exceed, that which was obtained at the original operation. 20 XX' As soon as the swelling had sufficiently subsided to render ophthalmoscopic examination possible, this was made by Dr. Gould, who reported practically negative findings. The vision was normal. Two months later the vision of each eye was There was no paralysis of any external eye muscle. The pupil reactions were normal. In the right eye there was an oval disc, the nasal edges veiled and the central lymph sheaths full; the veins full, dark in color, and slightly tortuous; no macular cha' ges. In the left eye there was an oval disc, a small physiological cup, and a similar condition of the retinal veins. Lying upon and overlapping the outer margin of the optic disc on this side there was a small linear hemorrhage, apparently such as might be produced by the rupture of a capillary. This had a fresh appearance and was not present at the time that Dr. Gould examined the patient shortly after the subsidence of the erysipelatous swelling. REMARKS. The character of the patient's occupation, a car driver, readily supplies exposure to inclement weather as the exciting cause of the erysipelas. The presence of intense headache six weeks before the appearance of any flush upon the face or eyelids, and diplopia, with pain on moving the head and eyes, five weeks before the onset of visible external inflammation, seem to point to the existence of orbital cellulitis in the earliest stage of this process. It should be remembered, however, in this connection, that the patient had in times past suffered from rheumatism, and these symptoms may be explained on the supposition that the "headache" was really the pain of a rheumatic affection of the fibrous tissue of the scalp, and 'the diplopia the result of a rheumatic palsy of the external rectus. When the erysipelas did appear this was manifest first in the tissue of the lids, and from this point spread to t face, scalp and neck. The incisions revealed the pus chiefly in the connective tissue of these regions, but apparently also in the right orbit; at least pus escaped after the introduction of a grooved director. Facial erysipelas associated with orbital cellulitis renders the prognosis to life and sight quite uncertain, as is evidenced by the following summary of thirty-five cases collected by Knapp (loc. cit.): Death, when one eye only was affected, in... Recovery in............ 4 cases. 6 Both eyes affected; sight restored in one, in the other lost in...... Both eyes temporarily blind; restoration of sight incomplete in both, in ..... Of these one eye only affected and permanently blind in............ 12 cases. Both eyes affected and permanently blind in....... 4 One eye affected, amblyopic but not blind; restoration of sight complete in........ Both eyes affected, amblyopic; restoration of sight complete in... 2 1 66 66 From this table it is manifest that the mortality is twenty-nine per cent. in cases of orbital cellulitis from erysipelas. The condition of the eye-sight in the surviving cases, according to the same author, was as follows: Blindness in both eyes occurred in........... 16 per cent. 60 66 12 66 12 If it is assumed that orbital cellulitis was present in this case, it is not a little remarkable there was no impairment of vision and no change in the eye-grounds. It is probable that this escape was due to the fact that at no time was there sufficient compression of the central vessels of the retina in the orbit, which Knapp has shown to be the cause of the intra-ocular changes, to produce stoppage of the circulation and oedema and exudation into the retina. It is interesting to note the presence of a small linear hemorrhage several months after the affection had entirely subsided, a hemorrhage, moreover, which was apparently not present during the stage of convalescence in this patient. Although impairment of vision and changes in the eye-ground from orbital cellulitis appear usually during the inflammatory stage of the erysipelas, they have been seen also in the period of convalescence. This small hemorrhage and the somewhat enlarged and tortuous retinal veins, are too far removed in point of time from either the onset, height or stage of convalescence of the erysipelas attack to be explained upon these grounds. There is absolutely nothing now in this patient, except a slight scar at the point of incision upon the cheek and lower lid of the left eye, to indicate that he had ever been through an attack of erysipelas that for some days threatened his life. The points of interest in the case seem briefly to be these: A period of several weeks with symptoms pointing to cellulitis of the orbit, or else to rheumatism of the scalp and rheumatic palsy of the external rectus; erysipelas at the end of this time having its point of origin in the tissue of the eyelids rapidly spreading, and associated, as far as this was ascertainable, with a low grade of cellulitis of the orbit; entire recovery of the patient without at any time disturbance of vision, and with no changes in the interior of his eye, except a smail linear hemorrhage, discovered so long after the attack that its origin can not be traced. |