TREATMENT.-The general plan of treatment is very similar to that recommended for cellulitis, as we should at first endeavor to prevent destruction of tissue, but, if that does occur, give the pus free vent. If the bone should be diseased the opening must be kept open and an injection of a solution of carbolic acid 1to 100, or of the sulphate of zinc gr. x to 3j may be used with advantage. If any of the loose pieces of the bone are discovered they should be removed. The remedies described under cellulitis are also applicable to this disease; in addition to which we note the following:
Kali iod.-This form of potash is one of the most important remedies we possess for periostitis. It is especially adapted to the syphilitic variety, though useful when dependent upon other causes. The pain is usually marked, though may be absent entirely. The lids will often be oedematous. The crude salt in large doses has seemed to act more rapidly than the attenuations.
Aurum.-For both periostitis and caries, when dependent upon or complicated with mercurio-syphilitic dyscrasia; also useful in strumous subjects. The pains are tense, and seem to be in the bones, are worse at night, bones sensitive to touch and the patient is excessively sensitive to pain.
Mercurius.-As described under cellulitis, will be found very useful in both periostitis and caries, particularly when dependent upon syphilis, as the nocturnal aggravation is very marked under both the drug and disease. The difficult forms are employed according to general indications.
Silicea.- Its action upon diseased bones renders it especially valuable in caries of the orbit. The roughened bone and moderately profuse yellow-white discharge are the principal indications, though the weakened general condition, relief from warmth and other concomitant symptom will be present.
Calcarea hypophos.- In appreciable doses, has been used as a “tissue remedy” in scrofulous subjects, apparently with good results.
The following remedies may be required; Asafoetida, Calcarea carb., Fluoric acid, Hecla lava, Lyco., Mezer., Nitr. ac., Petrol., phosphor. and Sulphur.
Empyema of the Frontal Sinus is extremely rare. The cause is uncertain. It may occur at any time of life, except in young children. The early swelling and distension are unnoticed, but it finally perforates the bony wall and a swelling appears at the upper and inner angle of the orbit, causing epiphora, displacement of the eye downwards, foreward and outward, with diplopia. The patient may have had headache for a long time, or it may have caused but little discomfort.
TREATMENT.-Similar to that given for cellulitis and periostitis.
Tumores Orbitae.-In the orbit may be found both benign and malignant tumors, which may have developed primarily in the orbit, in some of the neighboring sinuses such as the antrum or ethmoidal, or have spread from the eyeball or face. They usually cause more or less exophthalmos and restriction in the mobility of the eye; the displacement of the eye depends upon the location of the growth. The eye may suffer from inflammation, the optic nerve may become inflamed or atrophic, the retina detached, etc. The examination should be directed to the degree and direction of the exophthalmos; to the impairment in motion, whether in one direction or all; to the feel of the growth, its smoothness, mobility, solidity, pulsation, fluctuation. etc.
We note the effect of pressure upon the eyeball, if it causes pain on being pushed backward or if the position of the tumor is altered. We inspect the nostrils, the pharynx, the frontal and maxillary sinuses. The tumor may be explored with the hypodermic syringe. The history of the case should be elicited for hereditary tendency, the progress of the growth whether slow or rapid, whether associated with pain or not. All these points and many more should be considered, as an aid to diagnosis, prognosis and treatment. Nearly all varieties of tumors may be found in the orbit, viz. Osteoma, naevi, angioma, lipoma, fibroma, cysts (dermoid or hydatid), neuro- fibroma, lymphoma, sarcoma, scirrhus, encephalocele, epithelioma, etc.
TREATMENT.- The most approved method of treatment of all tumors of the orbit is to remove them as early as possible, endeavoring to save the eye whenever sight is present. Unless it be a malignant growth and there is danger of not removing the whole of the tumor without sacrificing the globe; in which case it is usually better to remove all the contents of the orbit. A careful diagnosis must be made before operating, in order to aid in the operation and prevent the opening of a vascular tumor.
Electricity is of great value in removing vascular tumors of the orbit. When the growth is small the negative pole may be applied by a sponge to the temple. but if large both poles should be attached to platinum needles, two or three inches in length, which are then to be inserted into the tumor. The positive needle should remain in one position while the negative may be inserted at different points for a few moments at a time. Care should be taken to make the first sitting brief, from fear of a too severe inflammatory reaction.
Our remedies are the same as for tumors in other portions of the body, though we would especially mention Thuja and Kali iodata, which have been of service in some cases.
Wounds and Injuries of the Orbit may prove serious from inflammation of the orbital tissue, or periostitis, which they may cause. Penetrating injuries from knives, shot, pitchforks, etc., cause laceration of the soft parts. Injury causing fracture of the orbital walls may prove more or less serious according to the location and extent of the fracture; a slight lesion of the orbital margin may heal without trouble; in fracture of the frontal or ethmoidal cells we will usually have emphysema of the orbit and lids, due to an entrance of air into the cellular tissue. If the injury has occurred in the vault of the orbit, we may have a serious inflammation of the brain or its membranes. Fracture of the roof of the orbit has frequently been found with a fracture of the base of the skull. Out of 86 cases of fracture of the base of the skull, fracture of the orbital roof was found in 79. Berlin: Graefe and Saemisch, Handbuch der Augenheikunde, 1880. Haemorrhage into the cellular tissue is very apt to occur in all injuries or wounds of the orbit, hence exophthalmos is usually present. Foreign bodies of large size have frequently remained imbedded in the orbital tissues for a long while without creating any material disturbance.
TREATMENT.-When a foreign body has penetrated the orbit it should be removed as soon as possible, after which cold compress of calendula in solution, or the ice bag should be applied.
Injuries with an effusion of blood into the orbit, causing the eye to protrude, will be benefited by a cold compress and a firm bandage. In emphysema of the orbit and lids a compress bandage will be required.
Morbus Basedowii (Exophthalmic Goitre, Graves’ Disease).
SYMPTOMS.-The main symptoms of this disease are : rapidity of the heart’s action, enlargement of the thyroid and protrusion of the eyes, although any one of these symptoms may be absent. The acceleration of the heart’s action is the earliest, most constant and essential symptom, and this may reach from 100 to 200 beats per minute and may be weak and irregular. Linnell plus Trans. Amer. Inst. Homoe., 1892. in an excellent paper on this disease calls attention to one case in which there was no change in the pulse beat, whether sitting or standing, the usual variation returning as the case improved. The heart symptoms are usually first developed, followed later by the enlargement of the thyroid and the exophthalmos either simultaneously or in succession. The goitre may develop suddenly, has a soft, elastic feel, a visible pulsation, and a systolic murmur on auscultation. The enlargements of the thyroid and the exophthalmos are originally due to vascular engorgement. The exophthalmos is almost universally bilateral, though it may be confined to one side. The degree of protrusion varies. It may be so excessive that the lids are unable to cover the eyes, and ulceration of the cornea may result from the exposure. The protrusion is straight forward, causes no interference with the movements of the eyes, and the eyes may be pressed back into their normal position, but will become prominent again on relief of the pressure. The exophthalmos gives the patient a frightened, staring appearance. On turning the eyes downward the upper lid does not follow it at all, or moves along for a certain distance and then remains stationary. This peculiarity, called Graefe’s sign, because first noticed by him, is of much diagnostic value, because highly characteristic of this disease, and is rarely found in exophthalmos from any other cause. Other symptoms of this disease are dyspnoea and excessive nervousness. There is usually excessive nervous excitability and tremulousness of the hands. The disposition is often changed. The patient is easily frightened and flushes readily. Epistaxis or haemorrhage from other parts may occur. Dilatation and pulsation of the retinal arteries has been observed. Anaemia is often present, and in women may be associated with menstrual disturbances; rapid emaciation may occur in some cases.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.