A CASE OF GREAT SWELLING OF THE EYELIDS 
AND FACE FOLLOWING AN /UNSUCCESSFUL 
ATTEMPT TO EXTRACT THE/UPPER CANINE 
TOOTH ON THE LEFT SIDE/ABSCESS OF THE 
ORBIT; TOTAL BLINDNESS/ATROPHY OF THE 
DISC ; OBLITERATION OF /’HE RETINAL VES- 
SELS. 
By Dr. SWAN M. BURNETT, Washington. 
(With one wood-cut.') 
John H. Davis, a colored man, aged thirty-five, was operated 
on for cataract of the right eye by extraction, in 1874, with partial 
success only. The left eye continued to have perfect vision until 
the 28th of January, 1884. At that time the upper canine tooth 
on the left side began to ache, and he went to a dentist for the 
purpose of having it extracted. This the dentist attempted to do, 
but failed after many persistent efforts. He told Davis that the 
jaw-bone was broken from the violence of the pulling. That 
same evening the left side of the face began to swell and be pain- 
ful, and soon the left eye was closed. As it could not be opened 
for nearly two months, he was not able to tell whether there was 
any protrusion of the ball or what its condition otherwise was. At 
the end of twenty-one days, during which time there was fever, but 
no chill nor mental disturbance, a discharge set in from the region 
of the inner canthus, and afterward from the forehead and the 
cheek near the lower orbital ridge. When the swelling subsided 
so as to enable him to open his eye, he found that vision was 
abolished, not even perception of light remaining. 
On the 20th of May, 1884, when I examined him for the first 
time, I found the eye in proper position and its movements per- 
fect. There was a depression at the outer portion of the lower 
orbital ridge extending two cm. downward into the cheek, caused 
Reprinted from the Archives of Ophthalmology, Vol. xiv., Nos. 2 and 
3, 1885. 178 
Swan M. Burnett. 
by exfoliation of bone. There was no scar either in the skin or 
conjunctiva near the inner canthus. Exophthalmus was not 
present. There was no perception of light. 
An ophthalmoscopic examination revealed a condition of the 
fundus shown in the accompanying sketch (fig. 1). The disc- 
surface is sharply outlined, dead white, and not excavated. From 
its lower edge there ran three white lines downward, one almost 
directly, one deviating inward, and one running downward and 
Fig. i. 
outward. This latter divided and sent a branch which ran the 
unusual course shown in the figure, passing upward to the level of 
the centre of the o. d., becoming nearly horizontal, and sending at 
the same time two short branches downward. The other branch 
passed diagonally downward and outward, and became forked, as 
did the other two white bands running downward. 
From the upper edge of the disc one white band ran inward 
and upward for about the same distance as its companion on the 
same side below, but was not forked at the end. Proceeding from ♦ 
Orbital Asccss. Blindness. 
179 
a point somewhat above the centre of the disc and towards its 
inner edge there ran upward two vessels filled with blood, one 
smaller and lighter in color than the other. The lighter one curved 
slightly outward, sending one branch directly upward, and another, 
very fine, almost horizontal. The larger, darker vessel ran a 
course almost parallel to this one, but gradually diverged slightly 
to the outer side. It sent off no horizontal branch, but just where 
this branch should be given off there was a white band which ran 
outward and curved slightly downward. A very delicate light 
vessel ran upward and inward between the upper white band and 
the larger light vessel. On the surface of the disc several dark 
and very tortuous vessels were seen, all of them, except one, very 
delicate and fine ; three of them ran outward and two downward 
to the edge of the disc, but none of them could be followed over 
the border. None of the lines, either red or white, were broken— 
they were either red or white throughout,—but to the outer side of 
the smaller red vessel there was a distinct white line about f- of an 
o. d. in length, and the same thing was observed on the outer side 
of the larger dark vessel, just where it was joined by the large 
white line running horizontally. The fundus was even in tint, 
with the exception of two places : one above the bifurcation of 
the middle lower white band, and the other a little beyond the 
macula-lutea region and under the curve of the white line taking 
the unusual course. These alterations consisted in dark or black 
dots and larger masses, together with perfectly white and glistening 
dots and lines, which ran for the most part horizontally. These 
last alterations were found almost exclusively in the yellow-spot 
region as shown in the figure. 
The interest of this case lies in the striking resemblance 
—the exact identity, in fact—of the ophthalmoscopic ap- 
pearances to those found in blindness after facial erysipelas. 
If one will take the trouble to compare the drawing of our 
case with the fine chromo-lithographic plates of Knapp’s 
case of blindness from erysipelas of the face in vol. xii. of 
These ARCHIVES, and Carl’s case in Zehenders Monatsbl. f. 
Augenheilk. for April, 1884, it will be seen at once how all 
three agree in essential particulars. The question of the 
connection between erysipelas affecting the face and the 
orbital and ocular changes associated with it has been too 
recently discussed to render any further comment on the 180 
Swan M. Burnett. 
subject necessary. Knapp has, from his careful observation 
of a case from the beginning, clearly shown, I believe, that 
all the intra-ocular changes are due to mechanical pressure 
within the orbit, and that none are due to the specific poison 
of the disease. Our case lends support to that view, for the 
clinical history does not warrant a diagnosis of erysipelas. On 
the contrary, it is almost certain that there was an abscess of 
the antrum of Highmore caused by a fracture of its walls 
from the forcible but unsuccessful attempt to extract a 
tooth, which led to the inflammation in the orbit. Further 
evidence of this is the destruction of a part of the maxillary 
bone at the lower edge of the orbit. 
It has been known for a long time that abscesses in the 
antrum were attended by inflammations of the orbital tis- 
sues, followed by blindness. In 1862, Mr. James A. Satler, 
surgeon-dentist to Guy’s Hospital, reported such a case in 
the Medico-Chirurgical Transactions, vol. xlv.; and he al- 
ludes in his paper to an article by A. Th. Briick on 
“ Repeated Inflammations in the Antrum of Highmore and 
Amaurosis,” published in Caspar s Wochenschrift f.d.gesam. 
Heilk., March, 1851. 
Reference to some of the more recent literature of orbital 
and ocular disease associated with dental caries can be 
found in an article by Vossius in Graefes Archiv xxx., p. 
157. Vossius’ case, however, differs in many essential 
particulars from mine. 
It can be readily understood how such abscesses of the 
antrum lead to inflammations and abscesses within the 
orbit. The wall of bone separating the two cavities is ex- 
tremely thin, and will give way easily to the increased 
pressure within the antrum ; or the inflammation might be 
propagated along vessels which may happen to pass from 
the one to the other.