with essentially the same symptoms produced by the passage of a cart wheel over the man's head. I never saw the man but once, and know not what became of him.

Case of Suspected Orbital Aneurism.-R. W., æt. 24, of stout figure, robust health, and sanguine temperament, was injured by the horn of a calf on January 18, 1876. The point of the horn struck the lower lid, glancing inwards and backwards and entering the orbit just above the tendo-oculi, causing an ugly contused wound and a severe concussion. The wound bled profusely, but healed in the course of a week, without surgical treatment. There was no bleeding from the nose, nor ocular hemorrhage, nor was the patient rendered unconscious by the shock. Sight was not affected, and there was no diplopia, headache, giddiness, nor other symptom of injury of the brain. There was no protrusion noticed. About five weeks after the accident, while stooping and driving a cross-cut saw, a sharp pain was felt above the right eye, running back over the ear to the temple. This sharp, peculiar pain came on at intervals, several times during the day, but was always provoked by stooping and straining, and soon passed off when the patient straightened himself up, and rested from sawing.

There was no giddiness, throbbing, or bruit. Late in April it was first noticed that the sight of the eye was misty at times, but without pain or other symptom of trouble. For this failure in sight a physician was consulted, who first detected an undue prominence of the eye. From that period, about May 1, till within the past four weeks, the exophthalmos increased slowly, but varied very perceptibly between morning and evening, being always greater in the morning. Since then it has remained stationary. When I first saw this patient, three weeks ago, there was a striking exophthalmos of over onefourth of an inch, with slight injection of the sclerotic conjunctiva, and some serous, chemotic swelling within the external commissure. Corresponding to this were seen some large, deep-seated, inosculating vessels on the sclerotic. The pupil was larger than the other, and somewhat sluggish. The movements of the globe were limited by the prominence and the stretching of the muscles, but there was no paralysis. There was a divergence of 14" when fixing with the other eye, and the motion upwards and inwards was less excursive, but there was no diplopia, which I explained by the imperfect sight. Strongly marked features of swollen disk, and some neuritis; boundaries of disk obscured, and veins very large and tortuous to their extreme branches; slight alteration of macula lutea, blurring its distinctive features. Vision very defective in consequence of a large central scotoma, which patient expresses as well defined but not complete.

Tension of the globe natural. No pulsation whatever of the globe nor bruit on auscultation. When the eyeball is pressed directly backwards, it is arrested by a solid resistance. Diagnosis: Tumor of some kind at apex of orbit, probably of an aneurismal nature. In the complete absence of the three most characteristic symptoms of aneurism, pulsation, bruit, and some degree of elasticity on pressure, I rely upon the evident traumatic origin of the difficulty; its peculiar history; the absence of inflammatory symptoms, and the exclusion of the symptoms of either benignant or malignant tumor at the apex of the orbit. The symptoms followed so soon after the injury, and in the beginning were so characteristic, as to make this opinion more probable than any other. The sudden, sharp, severe pain running backwards over the temple, and caused by stooping and straining, coming on about four weeks after the blow, might be explained by the sudden rupture of the ophthalmic artery, directly as it enters the orbit through the optic foramen. Its coats may have been weakened by the original concussion, or the very slight rupture occurring there might have been plugged by the formation of a coagulum. The history of several published cases of supposed orbital aneurism, makes this latter supposition at least tenable. If the vessel then split or the plug was then suddenly dislodged

by the increased congestion from stooping and straining, why did not immediate protrusion of the eye, pulsation, bruit, etc., occur? It may be that the opening was very small, and close in the narrow apex where rapid expansion and consequent protrusion were prevented. It will be remembered that not till this occurrence was the vision impaired; and that the troubled sight took the patient to a physician who first, detected the exophthalmos. The immediate effect of a slow oozing of blood from a small arterial rent in the supposed situation, would, of itself, be pressure upon the optic nerve and very slow protrusion of the ball without pulsation. As the sac, fed by so small a source, enlarging almost imperceptibly, may be filled as it forms with coagulated blood, and make a solid mass without pulsation either from its own expansion or from impulse conveyed to it by the throbbing, small artery, the complete absence, as yet, of pulsation and bruit may be accounted for. The same explanation would account for the absence of any serious symptoms of pressure on the ophthalmic vein or other structures. Of course this theory of the case must as yet be considered as open to question. The characteristic symptoms may yet be developed and make the case clear. My opinion, however, is so strongly in favor of an arterial lesion, that I believe that the symptoms can be relieved by systematic pressure on the carotid. As the patient is present, it gives me great pleasure to submit him to the Section for examination. I can only say that with one exception the symptoms are to-day what they were three weeks ago. The tension of the globe is now minus. It was not so then.'

[The patient was then presented.]

In conclusion, I will sum up the symptoms which seem to justify the diagnosis of true intra-orbital aneurism, as follows:-(1) If traumatic in origin, the nature of the injury. If it is by direct penetration of the orbit by a long, slender body, or a small shot or similar foreign substance, the ophthalmic artery may have been wounded, as was probable in one of my cases. (2) If the injury to the head or face, though severe, is not attended by symptoms of fracture of the base of the skull, or, in the absence of the positive symptoms of fracture, if the severity and character of the trauma are not such as to make such a lesion probable. (3) The strictly rhythmical character of the pulsations, if such exist. (4) The limitation of the region over which the bruit is heard, to the eye and orbit. (5) The strictly intermittent character of such bruit. (6) The fact that the patient himself does not hear the souffle, or, if so, very slightly. (7) The less frequent occurrence of paralysis of motion or sensation, or of any symptoms indicating a disturbing cause in the cavity of the cranium. (8) The less frequent and less serious impairment of vision. (9) The absence, except at an advanced period, and even then the less intensity, of the symptoms of obstruction in the ophthalmic vein, such as the existence of soft, thrilling, pulsating tumors around the eye, and of enlarged and pulsating frontal veins. (10) The complete curability of the disease by direct compression through the eye; or by compression of the common carotid; or by ligature of one (the corresponding) carotid.

The symptoms, till recently, accepted as characteristic of intra-orbital aneurism, are much graver and more extensive in their distribution. When we submit them to the test of pathological anatomy, as far as such cases have been examined, it is seen that they depend on lesions

This patient was seen again on April 15, 1877, when there was great protrusion of the eyeball with aggravation of all the other symptoms; a tumor could now be felt behind the globe. Enucleation of the eyeball was resorted to, when the tumor, which was firm and fibrous in character and the size of a small pullet's egg, was readily removed. It was situated between the optic nerve and the inner wall of the orbit, but was not firmly connected with either. (July 5, 1877.)

beyond the orbit. Of the 73 cases reported in Mr. Rivington's paper, in 12 only were autopsies made. Some of Mr. R.'s conclusions I will quote: "In no single instance has aneurism by anastomosis, or cirsoid aneurism within the orbit, been verified by post-mortem discovery." "In no single instance has an arterio-venous aneurism been found within the orbit at a post-mortem examination." "In no case have the symptoms of intra-orbital aneurism been proved to be due to a tearing across of the ophthalmic artery at or near the optic foramen." In the case of Guthrie, an aneurism was actually found in each orbit. In one case, no arterial lesion was found, but partial obliteration of the orbital veins, with evidences of previous inflammation in the orbital tissues. In the other ten, in which autopsies were made, the symptoms were caused by disease of the vessels just back of the orbit, in the cavity of the cranium. Of these, some were dependent upon obstruction to the return of the venous blood from the orbit to the brain. In one a small aneurism existed on the ophthalmic artery at its origin from the internal carotid. In three there was rupture of an aneurism of the internal carotid, within the cavernous sinus. In one," simple dilatation and atheromatous degeneration of the internal carotid artery in the cavernous sinus." "In three, traumatic cases, a direct communication between the carotid artery and the cavernous sinus was found."

Finally, a word as to treatment. Compression, either direct, or of the common carotid, or both, is advisable in all cases, and succeeds in some. Coagulating injections may sometimes be successfully practised, but require great caution. And finally, ligation of one or both carotids will be nearly always necessary for the extra-orbital cases.

SPONTANEOUS CURE OF CONGENITAL PULSATING
EXOPHTHALMOS.

BY

GEORGE C. HARLAN, M.D.,

SURGEON TO WILLS HOSPITAL, OPHTHALMIC AND AURAL SURGEON TO THE CHILDREN'S HOSPITAL,

PHILADELPHIA.

THIS case was reported at the last meeting of the American Ophthalmological Society, but since then the aneurismal tumor has spontaneously undergone complete consolidation. The following abstract of the history, to date of last report, is taken from the transactions of the society referred to:

L. L., æt. 25. General health good. Left eye always prominent, and left side of head larger than right. Has always had a "rushing sound in his head and eye." Left eye enormously protruded, forced downwards and outwards, and immovable. No useful vision. Whole left side of face hypertrophied. Mucous membrane of left side of mouth thickened, and left side of tongue twice as large as right. A localized tumor, probably a distended vein, above and to inner side of ball, and a doughy swelling of the soft parts extending about an inch above the orbit. There was strong pulsation, and an aneurismal bruit could be heard several feet from the patient's head. Five years after the first examination, the protrusion had slightly increased, but the bruit had decidedly diminished. The supra-orbital and frontal vessels were much distended, and pulsated strongly, and this aneurismal condition extended down the angular branch of the facial, on the right side.

On December 27, 1875, the patient came to me, complaining of pain in the eye, and over the bridge of the nose, and along the course of the angular artery on the right side. There was slight erysipelatous inflammation at the seat of pain, but not much change in the appearance of the parts. The bruit had entirely disappeared, and there was no thrill in any of the vessels, and no pulsation anywhere except in the localized tumor above the ball. The supra-orbital vessels were scarcely perceptible. He had not been under any treatment, as he was not able to keep up even occasional, intermittent compression of the carotid, on account of the giddiness and faintness which it produced. The continuous application of iced water was directed.

December 31. There was violent pain in the tumor and head. The tumor was increased to at least twice its former size. Pulsation was just perceptible. The exophthalmos was enormous, and the eye could no longer be covered by the distended lids. The patient was admitted to Wills Hospital, and anodynes were given in large doses, and dry cold substituted for the iced-water applications.

January 2, 1876. The pain was somewhat relieved, and all trace of pulsation in any part of the tumor had disappeared. The cornea was completely anæsthetic, and was beginning to slough. The pulse was feeble, and the pulsation of the left carotid was weaker than that of the right. From this time the pain and swelling gradually subsided, and

when the patient left the hospital, on February 2, the tumor was com pletely consolidated, and had considerably diminished in size.

No satisfactory way of accounting for this sudden and unlooked-for termination of the disease suggests itself to my mind. It is interesting as illustrating the possibility of spontaneous cure under circumstances that would seem to be about as discouraging as possible, and suggests the inquiry, what percentage of cases, if let alone, might end in the same way? This question cannot be answered, as nearly all reported cases have been subjected to some kind of surgical treatment.

I find records of five other cases of spontaneous cure, all but one having been of traumatic origin.

CASE I. Collard; quoted by Erichsen (Science and Art of Surgery, American Edition, 1869, p. 643). A man, 41 years of age. Injured by fall on back of head. Bruit, pulsation, exophthalmos. Symptoms entirely disappeared in three years and a half.

CASE II Erichsen (Ibid.). Man, 44 years of age. Fall on head. Attacked by symptoms of aneurism of left orbit in most marked manner. Bruit, pulsation, exophthalmos. Ligature of carotid urged by Mr. Erichsen but declined by patient. At the end of fourteen months the symptoms had, to a very great extent, disappeared.

CASE III. Holmes (American Journal of the Medical Sciences, July, 1864). Man, 23 years of age. Gunshot injury. Exophthalmos, chemosis conjunctivæ, bruit, pulsation. In about three months all the symptoms had entirely disappeared, except slight congestion of the conjunctiva.

CASE IV. France (Guy's Hospital Reports, 1853). Woman, 38 years of age. Point of umbrella thrust into orbit. Exophthalmos, pulsation of eyeball, and defined, pulsating tumor above and to inner side of globe; complete blindness. All the symptoms but blindness disappeared in eight months.

CASE V. Julliard, of Geneva ("Note sur un Anévrisme Intra-orbitaire, etc.," quoted by Rivington, Medico-Chirurgical Transactions, London, vol. lviii. p. 272). Woman, 69 years of age. Spontaneous. Enormous exophthalmos, pulsation, bruit, chemosed conjunctiva. In two months all the symptoms but exophthalmos and blindness had disappeared. A few months later, the exophthalmos was also gone.

In none of these cases was any local treatment resorted to, except that in two or three instances cold applications were employed in the early stages. In connection with the case reported to the Section by Dr. Wil liams, and that now submitted, they make a total of seven instances of spontaneous cure of this affection.

Though statistics prove beyond doubt that ligation of the carotid affords the largest percentage of cures, it is well, before deciding upon its performance, to remember not only the possibility of cure by milder means, or even without resort to any surgical procedure at all, but to bear in mind also that, though one of the most brilliant operations in surgery, it is not without its chances of failure and its dangers of a fatal result. All the operations that I have been able to collect, including two of Dr. T. G. Morton's, not yet reported, furnish sixteen per cent. of deaths and about the same proportion of failures, leaving only sixty-eight per cent. of cures and partial cures.