Tumors of the Orbit and Neigh- 
boring Cavities. 
by 
CHARLES STEDMAN BULL, A. M., M. D., 
Pro feasor of Ophthalmology in thfirVEiiversity of the City of 
New York; Surgeon to the New York Eye and Ear 
Infirmary. 
REPRINTED FROM 
CTtje Neto ¥orfc fHeUical 
for January Ilf. and SI, 1893. Reprinted from the New York Medical Journal 
for January Ilf and 21, 1893. 
TUMORS OF THE ORBIT AND 
NEIGHBORING CAVITIES.* 
By CHARLES STEDMAN BELL, A. M., M. D., 
PROFESSOR of OPHTHALMOLOGY IN THE UNIVERSITYOF THE CITY OF NEW YORK; 
SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY. 
Case I. Spindle-cell Sarcoma of Periosteum of Orbit.—T. D. 
8., a boy, aged four years and a half, was brought to me by his 
parents in the latter part of January, 1876, with the following 
history: He was a large child for his age, of the average men- 
tal development, and had always been robust in health. There 
was no unfavorable family history to be elicited aftercareful 
questioning, and no evidence of inherited syphilis in the child. 
For several months the parents had noticed a slight swelling at 
the outer angle of the left orbit, accompanied by slight redness 
of the eyeball and some swelling at the outer angle of the upper 
lid. These symptoms gradually increased, but there was no 
complaint of pain and no evidence of any disturbance of vision. 
When I saw the child there was a very perceptible orbital 
growth at the outer angle, which seemed to involve the upper 
and outer parts of the orbit. The left eye was pushed down- 
ward and inward, but not forward, and its motility was decid- 
edly limited upward and outward. The upper lid was slightly 
swollen and drooped a little, but could be freely opened and 
* Read before the New York State Medical Association, November 
16, 1892. 
Copyright, 189-3, by D. Appleton and Company. 2 
TUMORS OF THE ORBIT AND 
shut. The growth was entirely non-sensitive. The media were 
perfectly clear, the iris reacted promptly, and the ophthalmo- 
scopic examination was negative. Vision was apparently nor- 
mal. There was a slight mucous discharge from the conjunc- 
tiva. A careful rhinoscopic examination revealed nothing ab- 
normal. No history of any injury could be obtained. The boy 
was carefully hatched, and by the middle of February the 
symptoms had all increased. The eye was displaced downward 
more decidedly and motility upward was entirely lost. For 
two days the child had complained of some pain. The pre- 
auricular gland on the left side had become swollen and some- 
what painful. Ophthalmoscopic examination negative. 
By the 1st of March all the symptoms were much increased 
in severity. A slight ulceration of the cornea appeared just 
above the center. The motility of the eye was limited in all 
directions. The pre-auricular gland was very much enlarged, 
but there was no other glandular infiltration. The orbital 
margin was swollen, and the swelling extended up on the fore- 
head and backward into the temporal fossa. There was little 
or no protrusion of the eye forward and the lids could still be 
opened. A diagnosis was made of pure orbital tumor, probably 
starting in the periosteum, and owing to the somewhat rapid 
increase of the symptoms and the high fever of the last two 
days it was decided to operate and attempt to save the eye. 
On March 3d the left external canthus was split, the incision 
being carried outward upon the temple for somewhat more than 
an inch. The left temporal artery was divided and at once 
ligated. The upper lid was then carefully 'dissected upward 
and turned over upon the forehead. After the bleeding had 
been checked, the orbital periosteum was found very much 
thickened on the outer and upper walls of the orbit. The in- 
filtration also involved the orbital tissue as far back as the 
finger could extend, but did not seem to involve the capsule of 
the eyeball. The latter was pushed carefully toward the nasal 
side and held there. An incision was then made through the 
periosteum along the superior orbital margin, and the peri- 
osteum was then carefully stripped up from the bone on the 
upper and outer walls of the orbit as far back as the knife and NEIGHBORING CAVITIES. 
3 
forceps could reach. This was removed in strips, and with it 
also the orbital tissue and the lacrymal gland. The periosteum 
was also removed from the frontal bone and temporal fossa as 
far as it seemed to be infiltrated, and the pre-auricular gland was 
carefully dissected out and removed. The orbital cavity was 
then washed out with a mild solution of zinc chloride and the 
upper lid brought down in place, and the lines of incision ac- 
curately coapted and sutured. Atropine was instilled and the 
eye closed with the ordinary dressings then in use. For the 
first three days there was considerable reaction, the lids being 
much swollen and the wound discharging considerable pus, so 
that one or two stitches had to be removed. The cornea be- 
came generally hazy, but did not slough, and eventually cleared 
up remarkably. 
On March 15th a purulent discharge appeared from the left 
ear without any preceding pain, but followed by severe pain 
extending down on the left side of the neck and accompanied 
by high fever and a pulse of 140. An examination showed a 
perforation of the membrana tympani just back of the handle 
of the malleus. The discharge from the auditory canal ceased 
in four days, but the perforation did not close for nearly three 
weeks. From this time there were no adverse symptoms, and 
the patient was discharged at the end of the sixth week. A 
microscopical examination of the growth proved it to be a 
spindle-cell sarcoma, which had originated in the periosteum. 
The little boy was carefully watched, being seen regularly 
once a month, but there was no return of the growth until the 
spring of 1880. Its progress was then very rapid, for in less 
than two months it filled up the entire orbit, causing marked 
exophthalmus and destruction of the eyeball by sloughing of the 
cornea. The entire contents of the orbit were then removed 
including the eyeball and the entire periosteal lining as far back 
as the apex. The orbit was then carefully washed out with a 
solution of mercuric bichloride (1 to 1,000), and the lids closed 
and dressed in the usual manner. The patient did very well 
there being little or no reaction, and he was discharged at the 
end of a week. He was seen at rather irregular intervals, al- 
though his parents had been warned that the growth would 4 
TUMORS OF THE ORBIT AND 
probably return. In May, 1885, he presented himself with a 
swelling of the lower lid and cheek on the left side, which had 
appeared two weeks before. This proved to be a dense infiltra- 
tion of the tissues of the lid and cheek springing undoubtedly 
from the diseased periosteum at the edge of the orbit. There 
was no return of the growth in the orbit, and the appearance 
of the external infiltration did not suggest its having spread 
from any complication in the maxillary sinus. The parents de- 
clined to permit any further operative interference, but allowed 
me to keep the boy under observation. The orbit gradually 
filled up with the growth, while the external infiltration steadily 
advanced into the temporal fossa, over toward the nose and 
upward upon the forehead, and the patient finally died from 
exhaustion, without any head symptoms, a little more than ten 
years after the first appearance of the tumor. 
Case II. Small cell Sarcoma of Crbit, Maxillary Antrum, 
Nasal Meatus, and Ethmoid Cells.—Mrs. A. II., aged twenty- 
nine, came to me on June 12, 1876, with the following history : 
Twelve years before a small growth appeared at the external 
angle of the left orbit, just beneath the superior orbital mar- 
gin. It was the size of a large pea, and for a number of years 
occasioned no discomfort and showed no tendency to increase 
in size. After about six years of quiescence it began slowly to 
grow until it reached the size of a walnut and caused a protru- 
sion of the upper lid and external canthus, and a slight displace- 
ment of the eye inward. It then ceased growing until about 
four months before I saw her, when it suddenly began to in- 
crease in size and became very painful. On examination, I 
found the following condition of the parts: The upper lid was 
pushed forward and drooped considerably over the eye, but 
could be elevated, and the skin was of a marked dusky-red 
color. The eyeball was pushed downward and inward, and 
protruded nearly half an inch beyond the plane of the fellow- 
eye, and its motility was limited in all directions. The con- 
junctiva was injected, and the palpebral veins were engorged 
and prominent. The media were clear, and the retinal veins 
were extremely engorged and tortuous. The patient complained 
of a constant pain over the anterior surface of the superior NEIGHBORING CAVITIES. 
5 
maxilla and at the infra-orbital foramen, and said that during 
the last four months the vision of the left eye had materially 
failed. She could not read, but could count fingers at twenty 
feet. The other eye was normal. The tumor could be seen 
and felt through the lid, and by careful palpation the growth 
could be felt along the fioor and outer wall of the orbit. Rhino- 
scopic examination revealed a displacement of the saeptum nasi 
toward the right side, and a nearly complete obliteration of the 
left nasal meatus by what appeared to be a moderately hard 
mass coming from the middle meatus. Nothing could be felt 
with the finger posteriorly. The patient stated that for some 
months she had not been able to breathe through her nose. 
With this history and the digital examination, it seemed proba- 
ble that the tumor had begun in the maxillary antrum or nasal 
meatus, and had involved the orbit secondarily. Assuming this 
to be a correct diagnosis, the patient was told that the only 
means of relief was an operation, but that, owing to the deep- 
seated nature of the growth and its probable origin, its removal 
would probably not be complete, and that it would be likely to 
return. She was also told that in all probability the eye could 
not be saved, but that an attempt would be made to preserve 
it. The vision by this time had sunk to counting fingeis at two 
feet, and the optic disc was beginning to assume a dirty-white 
color. She consented to an operation, which was done on the 
following day. The external canthus was split, and the upper 
lid turned up over the forehead and held there. A further ex- 
amination with the finger and large probe showed that the en- 
tire orbit was filled with the growth, and that any attempt to 
save the eye would prove a failure. Enucleation was imme- 
diately done, and then the entire contents of the orbit were 
carefully removed. After this was done the tumor could be 
seen projecting through a large opening in the orbital plate of 
the ethmoid and also through the sphenoidal fissure. It evi- 
dently filled the ethmoidal cells, extending to them from the 
superior and middle nasal meatus, and was of much greater ex- 
tent than had been at first recognized. The orbital plate of the 
ethmoid was then removed, and all the growth that could be 
reached was dissected out. The floor of the orbit had not been 6 
TUMORS OF THE ORBIT AND 
perforated, and the possibility of the antrum not being in- 
volved was recognized. The lacrymal bone was next removed, 
and a free opening made into the nasal meatus. This was 
found filled with the growth, which was removed by forceps 
and fingers as far down as possible. It was necessary to break 
down and remove the entire inner wall of the orbit, and even 
then the growth could not be reached without great diffi- 
culty. The meatus was cleaned entirely of the growth by work- 
ing from below through the nostril as well as from above, and 
then the orbit, ethmoid cavity, and nasal meatus were thor- 
oughly washed out w’ith a solution of carbolic acid. A careful 
examination of the opening from the maxillary antrum into 
the nasal meatus was made, but no protrusion of the growth or 
enlargement of the opening was discovered. The orbit was 
then tamponed, the upper lid replaced and the canthus sutured, 
and the ordinary bandage applied. The patient did very well, 
having but little local reaction and but slight rise in tempera- 
ture. She was discharged on the eighth day, with directions to 
report once a week until further orders. There was no return 
of the growth for eight months, when a small nodule was no- 
ticed in the left temporal fossa. The left nostril remained still 
free, and the orbit was healthy and normal in appearance. The 
patient was urged to allow the removal of this nodule, but de- 
clined to have it done. It grew slowly to the size of a walnut, 
and then remained quiescent for several months. It then sud- 
denly began to increase, and at the same time a nodule was felt 
at the apex of the orbit, and another on the inner side in the 
cavity of the ethmoid bone. All these nodules grew rapidly, 
and the one in the temporal fossa soon extended from the lower 
margin of the zygoma upward and forward upon the forehead 
and backward to the auricle. The lower portion was moder- 
ately hard, but the portion which extended upon the forehead 
was soft, fluctuating, and very sensitive to the touch. I de- 
clined all further operative interference, as it would undoubted- 
ly have hastened the patient’s death, which occurred, after great 
suffering, four months later, and about thirteen years after the 
first appearance of the growth. Before the patient’s death the 
orbit and nasal meatus had become entirely filled by the growth, NEIGHBORING CAVITIES. 
7 
which had also extended back into the pharynx. The tumor 
removed from the orbit and neighboring cavities was sarcoma- 
tous in nature, of the small-cell variety, but in places was dis- 
tinctly myxo-sarcomatous. After the patient’s death I was per- 
mitted to examine the orbit, and found that the neighboring 
cavities, including the maxillary sinus, were entirely filled by 
the growth, though the floor of the orbit was still intact. 
Case III. Spindle-cell Sarcoma of Orbit and Adjacent Cavi- 
ties.—J. H., a young gentleman, aged twenty-two, consulted 
me in December, 1879. The left eye had been defective in vi- 
sion since childhood, and occasionally squinted. For the past 
two weeks there had been a constant dull pain in the orbit, 
with ptosis and some protrusion of the eye. Examination 
showed limitation of motility in all directions, chemosis of the 
ocular conjunctiva on the temporal side, some ptosis and slight 
exophthalmos, media clear, fundus normal, and V. = On 
the floor of the orbit, reaching from the infra-orbital notch to 
the external cantbus, was a hard, resisting growth, which 
pressed the lower lid forward, and which could be traced for 
some distance backward into the orbit. It was very sensitive 
to pressure. The patient refused all operative treatment. 
By February 16th the exophthalmia was very marked, and 
the patient complained of severe occipital headache, and at times 
staggered when he walked. The lower lid was everted and the 
•orbital growth was very prominent at the external angle. There 
was dense infiltration of the palpebral and ocular conjunctiva, 
the eye was immovable, the cornea was hazy, and vision was 
reduced to perception of light. The patient complained also of 
constant pain in the region of distribution of the infra-orbital 
nerve. He consented to an operation, and two days later the 
eye was enucleated and the tumor removed with comparative 
case. The latter was attached very firmly to the sheath of the 
optic nerve and only loosely to the orbital tissue ; but the latter 
was densely infiltrated, especially along the floor of the orbit, 
and on this account the entire contents of the orbit were re- 
moved down to the periosteum, which latter seemed perfectly 
healthy. The infiltration of the orbital tissue and the pain over 
the infra-orbital nerve led me to make another careful rhino- 8 
TUMORS OF THE ORBIT AND 
scopic examination, but nothing abnormal was found. The tu- 
mor, on being examined, proved to be a spindle-cell sarcoma, 
and the orbital tissue was infiltrated with small round cells. By 
the middle of April, or two months after the first operation, 
there were well-marked signs of a recurrence of the tumor in 
the periosteum on the floor of the orbit. A second operation 
was immediately done, the periosteum, which was very much 
thickened, being stripped upon all sides from the orbital margin 
to the apex. It was very vascular, and the haemorrhage was 
profuse. The orbit was then washed out with a strong solution 
of carbolic acid, and a careful examination with the finger was 
made of the floor, inner wall, sphenoidal fissure, and optic fora- 
men, but no trace of abnormal growth could be discovered. 
The haemorrhage still continued, and it became necessary to 
plug the orbital cavity. Violent reaction followed in the skin 
of the lids, cheek, and temple, and the plugging was removed 
the next morning. The skin of the left side of the face became 
decidedly erysipelatous. The reaction slowly subsided, but left 
both lids retracted and adherent to the external angle of the 
orbit, and the lower lid adherent to the inferior orbital margin 
for its outer third, and the cavity of the orbit was much con- 
tracted. The floor of the orbit was found intact. 
Two months later, on June 25, 1880, a firm nodule, as large 
as a filbert, appeared over the left malar prominence. It was 
firmly adherent to the periosteum, but the skin was freely mov- 
able over it. In a month this nodule had increased threefold in 
size; it was elastic and sensitive to the touch. Another nodule, 
much smaller, was discovered along the lower margin of the 
orbit. On July 30th these two external nodules were thoroughly 
removed, the bone was carefully scraped and then cauterized 
with the actual cautery. By the first week in September, an 
external tumor over the malar bone had returned and had 
reached the size of a small pear, but it was very irregular and 
nodulated. The skin was drawn tightly over it and was but 
slightly movable. This external growth was found to be con- 
tinuous with an orbital growth, which involved the floor, inner 
and outer walls of the orbit, while the external growth extended 
down upon the superior maxilla, and over into the temporal NEIGHBORING CAVITIES. 
9 
fossa. The patient urged a fourth operation, which was done 
in the following way : An incision was made along the lower- 
lid margin as in the Arlt-Jaescbe operation for entropion, and 
was extended an inch and a half from the external can thus to- 
ward the ear. Another incision was made from the inner end 
of the first incision down along the nasal furrow to the ala of 
the nose. This skin tiap was carefully dissected up and reflected 
from the growth. The htemorrhage was profuse and it was 
necessary to ligate several vessels. The extra-orbital portion of 
the growth was then thoroughly removed, and there was then 
revealed a ragged opening through the anterior wall of the su- 
perior maxilla into the antrum, through which the growth pro- 
truded. The growth was then removed from the orbit and here 
a large ragged hole was discovered through the floor of the orbit. 
The tumor filled the antrum, nasal meatus, ethmoid cavity, and 
sphenoidal fissure, and as much of it as could be reached was 
removed, the antrum and nasal meatus being thoroughly evacu- 
ated. The parts and cavities were then thoroughly washed out 
with a solution of mercuric bichloride (1 to 1,000) and the wound 
closed. No great reaction followed, though the temperature 
went up to 103°, and there was not much suppuration. The 
external wound healed, but in less than six weeks the growth 
again appeared in the orbit and externally over the malar bone. 
The case had long been regarded as hopeless, but the patient 
lingered in great suffering till the latter part of January, 1881, 
and died from exhaustion. 
Case IV. Epithelioma of the Lid and Sarcoma of the Orbit. 
—In the latter part of September, 1880, a,woman, aged forty- 
two, from whom I had previously removed a small growth, ap- 
parently epicheliomatous in character, from the inner angle of 
the left lower lid three years before, presented herself with the 
following history : There had been no trouble with the eye or 
lids for nearly two years. The eye then began to be limited in 
motion outward and to slightly protrude. These symptoms 
slowly increased, the upper lid became swollen, and a constant 
dull ache in the orbit began. Finally the sight of the left eye 
began to fail, and this frightened her and brought her to me. 
An examination showed the right eye to be normal in every re- 10 
TUMORS OF THE ORBIT AND 
spect. Tn the left eye the vision was f-g- + unimproved ; the 
media were clear ; there was a grayish discoloration of the tem- 
poral half of the disc and a narrowing of the arteries. The perim- 
eter showed a contraction of the nasal half of the field. The 
left upper lid was decidedly oedematous and somewhat reddened. 
The eyeball was pushed inward and protruded very perceptibly 
in advance of the plane of the other eye. There was a decided 
infiltration of the tissue on the temple and on the cheek just 
below the inferior orbital margin. The patient was told that 
she probably had a tumor of the orbit, and that it must be re- 
moved, but that I would attempt to save the eye, and she con- 
sented to the operation. As the exophthalmia was decidedly 
forward and the limitation of motility was outward, the con- 
junctiva was divided at the outer canthus and the wound then 
enlarged upward and downward with the scissors and handle of 
a scalpel. Almost immediately a growth was felt extending 
along the outer wall of the orbit and filling the entire apex. 
The external rectus muscle was then divided at its insertion and 
the eyeball turned far inward. The dissection of the tumor was 
then continued, but it was found so intimately connected with 
the sheaths of the muscles and of the optic nerve, as well as 
with the periosteum, that I cut through the nerve and the mus- 
cles near the apex of the orbit, as a necessary preliminary to 
the removal of the tumor from its orbital attachments. The 
growth extended on the inner side of the eye as well as on the 
outer side, and after considerable trouble was removed, leaving 
the eye in place. About three quarters of an inch of the optic 
nerve was removed with the tumor. The floor of the orbit ap- 
peared healthy and there was no demonstrable connection be- 
tween the growth in the orbit and the infiltration in the cheek 
and temple. There was no reaction, and the patient was dis- 
charged at the end of ten days. The eyeball became slowly 
atrophic and the cornea cloudy. This case was watched very 
carefully, being seen every week or two, as the history of the 
case pointed to a recurrence of the tumor. The infiltration of 
the cheek and temple slowly subsided, and at the end of three 
months there was nothing abnormal in the patient’s appearance 
except the phthisical eyeball. Nearly ten months after the op- NEIGHBORING CAVITIES. 
11 
eration, however, there appeared a well-marked nodule on the 
external surface of the superior maxilla on the left side, just be- 
low the orbital margin and external to the infra-orbital foramen, 
and the diffuse infiltration reappeared on the temple. The eye- 
ball, which had previously receded into the orbit, began again 
to protrude. Another careful examination was made of the 
naso pharynx, but nothing abnormal was discovered. As the 
microscopical examination of the first tumor had shown it to be 
a small-cell sarcoma, I advised an immediate operation including 
the removal of the atrophied eye, but the patient refused her 
consent till November, 1881, nearly four months after the reap- 
pearance of the growth. She was then suffering severe pain at 
times in the orbit and temple. The eye was again protruded 
beyond the orbital margin and the growth on the cheek had be- 
come as large as a horse-chestnut and was very sensitive. The 
skin was movable over this growth, which was firmly adherent 
to the bone. The eyeball and entire contents of the orbit were 
first removed. After the hemorrhage had been checked a care- 
ful examination showed a defect in the orbital plate of the eth- 
moid, rather far back, and another in the floor of the orbit. A 
probe passed through these openings into the ethmoid cells and 
maxillary antrum discovered a gelatinous mass of considerable 
consistence in both. This was sufficient evidence that both these 
cavities were filled with the growth. The large nodule was then 
removed from the superior maxilla and the external surface of 
the bone carefully examined, but no opening into the antrum 
was found. No further attempt was made to remove the growth 
from the cavity of the ethmoid or the antrum, both on account 
of the severity of the operation and the hopelessness of any suc- 
cessful removal of the diseased bones. The patient made a good 
recovery, and there was no return of the external tumor on the 
surface of the superior maxilla. The disease, however, soon ex- 
tended from the neighboring cavities to the orbit, and also in- 
vaded the nasal meatus and made rapid progress. The patient 
suffered considerable pain and the nasal cavity soon became so 
completely blocked that she breathed almost entirely through 
her mouth. In three months the growth filled the orbit and 
protruded between the lids and could be seen at the entrance of 12 
TUMORS OF THE ORBIT AND 
the left nostril. About four months after the last operation she 
began to complain of intense frontal headache, which at times 
rendered her delirious, and in one of these severe paroxysms she 
had a violent convulsion. This was general in character and 
ended in coma from which she never rallied. An autopsy could 
not be obtained. 
Case V. Myxo-sarcoma of Orbit and all Adjacent Cavities.— 
On January 12, 1881, a gentleman, R. M., aged thirty-eight, 
presented himself at my office with the following history: The 
first symptom which he had noticed had been a protrusion of 
the right eye, which began five years ago, and five months later 
the left eye also began to protrude. During these five years 
there had been a steady increase in the exophthalmia and in the 
limitation of motility in both eyes in all directions. There had 
been some pain of late, which was located at the root of the nose 
and just above both eyes. For a long time—but just how long 
he does not know—there had been difficulty in breathing 
through the left nostril, and for more than a year respiration 
was entirely abolished through both nostrils, and he had be- 
come an absolute mouth-breather. He had had several polypi 
removed from the right nostril at different times, with a tem- 
porary improvement in breathing. 
An examination showed a marked protrusion forward and 
outward of both eyes, so that the lids could with difficulty be 
closed over them, and the axes were widely divergent. At one 
period of the disease there had been crossed diplopia, which sub- 
sequently disappeared. The eyes were almost immovable, and 
the ocular conjunctiva was deeply injected. The irides re- 
sponded to light, the media were clear, and the ophthalmoscopic 
examination showed nothing but engorged and pulsating veins. 
R. E. V. = L. E. V. = perception of light. The sight 
had begun to fail one year ago in both eyes and had slowly 
grown worse. There was pain on pressure backward of the 
eyeballs. The posterior nares on both sides were blocked by a 
growth extending across the anterior pharyngeal space. The 
left nostril was impervious. The right nostril was blocked by 
a polypus, which apparently grew from the left wall of the 
meatus, entirely filled it, and pushed the inferior tur inated NEIGHBORING CAVITIES. 
13 
bone and saeptum nasi over to the left side. It was soft and 
bled easily. The growth behind, which filled the posterior 
nares and extended into the pharynx, was hard and resistant, 
and apparently was attached to the body of the sphenoid. 
Nothing was discernible on the floor or inner wall of the right 
orbit, but in the left orbit the floor was pushed upward and the 
orbital plate of the ethmoid pushed outward, and I thought 1 
could detect a tumor in the orbit. The external surface of 
both cheeks and temples was smooth and normal in appear- 
ance. The desperate character of the case was at once recog- 
nized, and the patient was told that a complete removal of the 
growth was hopeless, but that the growth could be removed 
from the nostrils and bis respiration made more comfortable. 
To this he consented, and this was done both anteriorly and 
posteriorly. A large, gelatinous, polypoid mass, attached to 
the outer wall high up, was removed from the right nostril. 
By means of a guarded bistoury, blunt scissors, and polypus for- 
ceps, the entire mass was removed from the posterior nares, in- 
cluding with it a large portion of the inferior turbinated bones. 
The haamorrhage at first was profuse, but was soon checked, 
and a careful examination of the parts made. The whole mid- 
dle and superior nasal meatus were filled with the tumor, which 
could also be felt protruding from the opening into the left 
maxillary antrum. After the first week I did not see this pa- 
tient again until five months had elapsed, when he came again 
for relief of his respiration. His condition was then deplor- 
able. The left eye was sightless, the cornea cloudy and ulcer- 
ated, and the lids could not be closed. The growth had ap- 
peared as a large protuberance at the left inner canthus, pro- 
jecting through the lids, and had also appeared at the inferior 
margin of the orbit and filled up the temporal fossa. He had 
perception of light still in the right eye, in which the optic disc 
was found in a condition of gray atrophy. Both nostrils had 
again filled up with a solid, somewhat resistant mass. I re- 
peated the same operation, removing as much of the growth as 
could be reached, and again rendering the nostrils free. The 
mass was not polypoid, but on both occasions proved, on micro- 
scopical examination, to be myxo-sarcomatous in character. In 14 
TUMORS OF THE ORBIT AND 
two months the nasal meatus had filled up again, while the 
growth in the right orbit had increased very rapidly. He suf- 
fered greatly from pain deep in the orbits and frontal headaches, 
but lived for nearly four months longer without any additional 
head symptoms, and finally died from exhaustion. In this case, 
although all the deep bones of the face and skull had become 
involved, the tendency of the growth had been outward. In 
spite of all urging an autopsy was positively refused. Before 
death the tumor had perforated the conjunctiva at the inner 
angle of the left eye, and extended over the side of the nose 
and down upon the cheek. 
Case VI. Melano-sarcoma of Conjunctiva and Orbit.—Early 
in August, 1881, a woman, F. A., aged forty-five, consulted 
me and gave the following history : About two months before 
a small, dark nodule had appeared at the supero-temporal mar- 
gin of the left cornea, seated mainly in the conjunctiva. It was 
slightly movable, and slowly increased to the size of a small 
Lima bean. When I saw her the growth had encroached some- 
what upon the cornea and was painless to the touch. On Au- 
gust 8th I removed the tumor, which was found to be adherent 
to the sclera, and extended somewhat along the infero-temporal 
margin of the cornea. It was friable and bled easily. It was 
thoroughly removed, and the surface of the sclera was then 
scraped and cauterized, and the edges of the conjunctiva brought 
together loosely over the wound. I did not see the patient 
again until November4th, when the growth had returned. The 
tumor occupied the upper, outer, and lower quadrants of the 
ocular conjunctiva and sclera, and covered the temporal third 
of the cornea. It was irregularly lobulated and somewhat 
flattened, dark in color, quite vascular, and non-sensitive. It 
extended above the eyeball into the orbit as far as the equa- 
torial region; the eye was displaced somewhat toward the nose, 
and its motility upward and inward was limited. The field of 
vision was limited on the temporal side, but central vision was 
still + , and the fundus was normal. The patient was told 
that the eye must be enucleated at once, and on November 21st 
the entire contents of the orbit, including tumor, eyeball, and 
ocular conjunctiva, were removed. The optic nerve was divided NEIGHBORING CAVITIES. 
15 
far back and looked perfectly healthy, and the periosteum of 
the orbit also appeared normal. The case did well, and there 
was nothing abnormal noticed until the following June, 1882, 
when a small, dark nodule was found on the outer wall of the 
orbit about halfway back. The patient declined another opera- 
tion, and I did not see her till the last of October, wThen the 
growth tilled the orbit and protruded between the lids. It 
seemed as yet to be confined to the orbit, for the naso-pharynx 
was clear and there was no evidence of any trouble in the maxil- 
lary antrum. The patient now consented to an operation, and 
on November 2, 1882, the entire contents of the orbit were re- 
moved with ease, though the haemorrhage was profuse. The 
periosteum was then cut through all round the orbital margin, 
and was stripped up on all sides as far as the apex of the orbit 
and removed. After the haemorrhage had ceased, the bone 
was thoroughly scraped, and then the orbit was washed out 
with a sublimate solution (1 to 1,000). There was little or no 
suppuration and the raw surface soon healed. I saw this pa- 
tient at intervals until the autumn of 1886, a period of four 
years, and there was no return of the tumor in that interval. 
She then disappeared from observation, and I have heard nothing 
of her since. All the specimens removed at different times and 
examined proved to be true melano-sarcoma. The eyeball on 
examination proved a very interesting specimen. The tumor 
was almost entirely superficial and extrinsic. None of the tis- 
sues of the eye were invaded by the growth except the sclera, 
and even here only the superficial layers were infiltrated by the 
sarcoma cells. The region of the lymphatic channels around 
the openings of the vasa vorticosa was entirely free from any 
infiltration, as were also the sheath of the optic nerve and the 
nerve itself. 
Case VII. Fibrosarcoma of the Orbit.—A gentleman, H. 
A., aged twenty-two, first seen on June 12, 1882, gave the fol- 
lowing history: Has always been perfectly well, and has never 
noticed anything abnormal about his eyes until five months ago, 
when the right eye began to protrude. Since then the exoph- 
thalmos has slowly but steadily increased, but there has never 
been any pain. The vision of the right eye remained good 16 
TUMORS OF THE ORBIT AND 
until ten days ago, when it suddenly and rapidly became im- 
paired, and now he says it is entirely blind. An examination 
showed that vision was reduced to perception of light. The 
protrusion of the eye was forward and slightly outward, and 
motility outward and inward was decidedly impaired. The iris 
reacted, the media were clear, and the fundus showed a well- 
marked condition of papillitis with haemorrhages. At the inner 
side of the orbit a tumor could be felt, apparently springing 
from the inner wall of the orbit, and sensitive on pressure. The 
left eye was normal in every respect. The patient was told the 
probable nature of the trouble and consented to an operation, 
which was done on June 14th. The external canthus was in- 
cised for the distance of an inch outward and the upper lid 
turned up on the eyebrow. The ocular conjunctiva was divided 
in the horizontal meridian from the internal canthus to the cor- 
neal margin. The tendon of the internal rectus muscle was 
divided and the eye turned strongly to the temple. The tumor 
could then be plainly seen on the inner wall of the orbit, its 
anterior aspect being flattened. By means of blunt hook and 
blunt-pointed scissors it was readily dissected from its periosteal 
adhesions and removed entire, with but trifling haemorrhage. 
It proved to be a long, flattened growth, the size of a large 
Lima bean, and was apparently entirely inclosed in a capsule. A 
careful examination of the orbit discovered no trace of any fur- 
ther growth, and the muscles and optic nerve seemed to be in- 
tact, though the latter was somewhat flattened. The cavity 
was then carefully washed out with a sublimate solution (1 to 
2,000), the tendon ot the internal rectus was stitched in place 
to the sclera, the conjunctiva brought together and closed over 
the opening with sutures, and the slight wound in the can- 
thus closed in the same way. The eye was then bandaged 
in the usual way. Not a drop of suppuration occurred, 
and the patient was discharged at the end of a week. The 
tumor was hardened and sections were carefully made in all 
directions. It proved to be entirely inclosed in a fibrous cap- 
sule, and was divided into several parts by fibrous trabeculae, 
which seemed to be prolongations inward of the fibrous 
capsule. The spaces between the trabeculae were filled with NEIGHBORING CAVITIES. 
17 
large and small round cells, with nucleus and granular contents. 
Regarded as a whole, the growth would be classed as a sar- 
coma, or possibly a fi bro-sarcoma, as there were a few fusiform 
cells between the fibers of the trabeculae. The superior oblique 
muscle wxis not injured. The patient’s vision slowly improved, 
so that at the end of a month he could count fingers at three 
feet from the eye, but beyond this it did not improve, and 
eventually the optic disc took on the appearance of gray atrophy. 
The patient was last seen in the autumn of 1884, a period 
of more than two years, during which there had been no 
return of the growth, and from the encapsulated condition 
of the tumor it is probably safe to conclude that it has not 
reappeared. 
Case VIII. Fibro-sarcoma of the Sheath of the Optic Nerve 
and Orbit.—Fanny S., aged seventeen, was first seen on Sep- 
tember 2±, 1884. Two years before she had suffered from an 
attack of meningitis, during which the vision of both eyes be- 
came affected, and has since grown slowly but steadily worse. 
She lias been deaf in both ears for eight years, the cause being 
catarrhal inflammation of the middle ear extending from the 
naso-pbarynx. The right eye began to protrude about a year 
ago, and the exophthalmos has slowly increased, but without any 
pain. When I saw her, the right eye protruded forward and 
outward and was limited in motion in all directions. The iris 
was moderately dilated and immovable. The fundus showed a 
gray, atrophic disc. Vision was There was marked en- 
gorgement of the subconjunctival and episcleral veins. The 
cornea was slightly cloudy from old keratitis. In the left eye 
the cornea was still more cloudy, and the iris was dilated above 
the normal and very sluggish. The optic disc was discolored on 
the temporal side and the retinal veins looked engorged. Vision 
was There was no exophthalmia and no limitation of mo- 
tility. An examination of the naso-pbarynx showed nothing 
abnormal beyond a general hypertrophy of the mucous mem- 
brane. There was no trace of any growth. When the right 
eye was pressed backward, a hard resisting mass was felt at the 
bottom of the orbit. A diagnosis of orbital tumor on the right 
side was somewhat hypothetical, and the patient was told that 18 
TUMORS OF THE ORBIT AND 
she must await developments. The exophthalmia slowly in- 
creased and vision slowly grew worse, but nothing absolutely 
certain was discovered until eight months had elapsed, when a 
growth was for the first time felt on the nasal side of the orbit. 
The patient was then told that an operation was necessary and 
that the eye must be enucleated, to which she consented. The 
eyeball was first removed in the ordinary way, great difficulty 
being met with in cutting the optic nerve; and, on examining 
the eye after removal, the whole nerve was found to be envel- 
oped in a dense fibrous mass, showing that the tumor had been 
cut through. The entire contents of the orbit, including the 
conjunctiva, were then removed, considerable dissection being 
necessary around the optic foramen. The periosteum was ap- 
parently healthy except at the apex of the orbit, where it was 
much roughened from the adhesions to the growth. The latter 
measured about three quarters of an inch in length and was 
roughly molded to the shape of the orbit. The optic nerve 
passed nearly through its center and was decidedly flattened. 
The orbit was then washed out antiseptically and bandaged in 
the usual way. There was no defect in the orbital walls, and 
no apparent prolongation of the tumor into any of the neigh- 
boring cavities. A careful examination of the growth, after 
hardening, showed that it mainly involved the sheath of the 
optic nerve, the nerve itself being but slightly encroached upon. 
It could not positively be decided whether the tumor had origi- 
nated in the sheath or in the periosteum of the orbit. It ex- 
tended forward upon the sclerotic for a short distance, this 
membrane being intimately involved in the pathological pro- 
cess. Sections through the tumor, both longitudinally and 
transversely, showed it to be composed almost entirely of con- 
nective tissue bundles, the fibers being densely pressed together. 
In some places between the fibers were a few fusiform cells. 
The nearer the optic nerve was approached the denser became 
the fibers. The cells in the perineural lymphatic space were in- 
creased in number and size. The optic nerve behind the eye 
and within the tumor was flattened and showed signs of inter- 
stitial neuritis. The optic disc and the immediately surround- 
ing zone of the retina showed the traces of neuro-retinitis, but NEIGHBORING CAVITIES. 
19 
the rest of the eyeball, with the exception of the cornea, was 
normal. 
The patient rapidly recovered and has been carefully watched 
since, but no return of the tumor has been observed. An in- 
teresting feature in the case is the possible, I might almost say 
the probable, connection between the preceding meningitis as a 
cause and the development of the orbital tumor as the effect. 
We know that complications on the side of the eye are by no 
means infrequent during or after the meningeal disease. The 
ocular complication is sometimes a purulent chorioiditis, but 
more often it is a neuro-retinitis,' with or without papillitis. It 
is by no means an improbable supposition that, in the case just 
described, the intracranial inflammation extended along the 
membranes of the brain, involved the dural sheath of the optic 
nerve, and set up a hypertrophic vaginitis, which subsequently 
took on the form of a tumor of the optic nerve, or more properly 
of the nerve sheath, compressing the optic nerve and producing 
the exophthalmus. 
Case IX. Cyst of the Orbit and Ethmoid Cells.—On Octo- 
ber 6,1884:, a young child, Jennie S., aged two years and a half, 
was brought to me by the mother, who gave the following his- 
tory : About a year before, after an attack of bronchitis, the 
mother noticed a small swelling at the inner angle of the left 
orbit beneath the upper lid which caused the lid to protrude. 
This was much less marked when the child was lying down than 
when she was in an erect position. It had grown somewhat in 
size during the year. There had been no other symptom. When 
I saw the child there was a small circumscribed orbital growth 
at the upper and inner angle of the left orbit, beneath the upper 
lid and outside the periosteum. When the child sat or stood 
the protrusion occupied the region of the inner canthus above 
the lacrymal sac, but when she lay down it receded almost en- 
tirely from view. It felt elastic and I concluded it was an ex- 
ample of a retention cyst of the orbit. The tumor was punctured 
through the cul-de-sac beneath the lid, and a quantity of clear, 
strqw-colored fluid escaped, and the cyst at once collapsed. I 
told the mother that the little tumor might return, but that the 
child was so young it might be better to wait and see whether 20 
TUMORS OF THE ORBIT AND 
any more serious operation would be necessary. For nearly 
three months there was no return of the cyst. Then it began 
to fill up again and soon regained its former dimensions. The 
mother also noticed that when the head was bent forward the 
swelling became much more prominent than ever before. I 
then determined to attempt the removal of the entire cyst, still 
regarding it as a retention cyst developed in the orbital tissue. 
The upper lid was strongly everted and the eyeball turned to 
the outer canthus and held there by a strong suture passed 
through the conjunctiva on the nasal side of the cornea, cross- 
ing the cornea and passing through the skin of the external 
canthus. The cul-de-sac was then opened at the inner canthus 
and the cyst at once presented. It extended well up under the 
arch of the orbit and far back into the orbit, but seemed to hug 
the inner wall. Its attachments to the orbital tissue were very 
slight and easily broken, but on the side of the bone they were 
more firm, and in endeavoring to separate the cyst wall from 
one of these adhesions the sac ruptured and a large quantity of 
cloudy yellowish fluid escaped. The cyst collapsed and my fin- 
ger passed into a large cavity. An examination showed that 
the orbital plate of the ethmoid bone and most of the lacrymal 
bone were absent and that the ethmoid cells formed one large 
cavity which communicated with the superior nasal meatus. 
This was proved by the fluid used in washing out the orbit and 
cavity in the bone passing down and out through the nostril. A 
drainage-tube was then inserted. The little patient did very 
well. There was hardly any suppuration, the drainage-tube 
was removed on the third day, and the child was discharged on 
the eighth day. There has been no return of the disease, but 
there was rather a marked sinking in of the tissues at the inner 
canthus and beneath the inner end of the orbit, so that there is 
a decided difference in the appearance of the two eyes. 
If there had been a carious process in the bone which led to 
the disappearance of the inner wall of the orbit, there would 
almost certainly have been some general as well as local symp- 
toms in the child during the process. For this reason I am more 
inclined to regard the case as one of congenital absence or arrest 
of development of the inner wall of the orbit, and the cystoid NEIGHBORING CAVITIES. 
21 
development in the cavity of the ethmoid and orbit as the result 
of a chronic catarrhal irritation of the nasal passages, perhaps 
connected with the bronchitis from which the child had suf- 
fered. 
Case X. Sarcoma of the Nose, Nasal Meatus, and Orbit.— 
Early in November, 1884, I was called in consultation to see a 
gentleman, aged fifty two, and learned the following history of 
his case: For many years he had been a sufferer from lupus of the 
face, which had first appeared as a small nodule on the left ala 
of the nose. It slowly extended in several different directions, 
healing as it extended, until the cicatrix and the sore covered a 
space as large as a silver half-dollar. It then remained quiescent 
for nearly two years, but subsequently extended upon the left 
side of the nose and orifice of the left nostril. During the past 
year its growth had been rather more rapid. When I saw him 
the growth had entirely occluded the left nostril, filled the pos- 
teriornares, and extended over the cheek and malar prominence 
and slightly into the orbit from the outside, pushing the eye up- 
ward, outward, and forward. It had also extended into the 
zygomatic fossa. The eyeball was still freely movable and the 
axes of the two eyes could be made parallel, when the diplopia 
which ordinarily existed disappeared. Vision was normal, the 
media were clear, and the fundus was healthy. 
Myopinion had been desired in regard to the advisability and 
feasibility of an operation, and 1 advised against any attempt to 
remove the external portion of the growth, on account of the 
great extent of d-seased tissue and the impossibility of procuring 
a flap of sound skin of sufficient size to close the wound. There 
also seemed a probability that the growth had extended from 
the nasal meatus to the maxillary antrum, and any attempt to 
remove this part of the growth would have necessitated the re- 
moval of the anterior bony wall of the antrum. The growth in 
the naso-pharynx might be removed, and this would render the 
patient much more comfortable and his respiration easy, and 
this I advised should be done. 
On November 13th the patient was etherized and with some 
difficulty the left nostril and naso-pharynx were cleared of the 
growth, part being removed through the nostril and part 22 
TUMORS OF THE ORBIT AND 
through the pharynx. The sseptum nasi was found driven over 
to the right side, and the growth had extended far up the nasal 
cavity on the left side beyond the reach of operative interfer- 
ence. The immediate result was a great improvement in the 
patient’s comfort, which remained for nearly six months before 
his respiration became again obstructed. I declined any fur- 
ther interference on account of the hopelessness of the case. 
The progress of the disease was slow but steady. The whole 
left side of the face became gradually involved, the disease ex- 
tending down to the angle of the jaw, over on the temple, and 
up on the forehead and bridge of the nose. The orbit filled up, 
apparently from the orbital margin, and the eye was pushed 
forward and inward toward the nose; the eyelids became in- 
volved, the cornea ulcerated and then perforated, and a large 
staphyloma developed and protruded between the swollen and 
half-closed lids. The patient lived for two years and a half after 
the operation, suffered greatly, and finally died from exhaustion. 
Throughout the entire course of the disease the progress had 
been from without inward, and the resulting disfigurement was 
unpleasant in the extreme. No autopsy was permitted, and 
thus no opportunity was offered of determining whether there 
had been any change in the microscopical character of the 
growth. Before 1 first saw the patient portions of tissue 
had been removed from the external growth on the nose 
and had proved to be lupus. The portion removed from the 
interior of the nose had the mixed appearance’of both lupus 
and sarcoma. 
Case XI. Caries and Abscess of the Orbital Walls.—A little 
boy, R. P., aged three, was brought to me in November, 1884, 
with the following history : About two weeks before, the mother 
had noticed a staring appearance of the right eye, which in- 
creased to a positive protrusion of the eye. When I saw the 
child the lids were somewhat reddened and the exophtlialmia 
was directly forward. Pressure of the eye backward gave an 
elastic sensation and caused some pain. Inquiry developed 
the fact that the child had had some symptoms of congenital 
syphilis at birth and that the father was undoubtedly syphilitic. 
The case was watched for several weeks, but nothing abnormal NEIGHBORING CAVITIES. 
23 
was observed except a slow increase in the exophthalmos. The 
eyeball was apparently normal in every respect. I suspected 
the presence of either a cyst or an abscess and advised an ex- 
ploratory puncture. This was done and a small trocar was 
passed into the orbital tissue on the nasal side of the eye, but 
with no result. No trace of any growth could be felt in the 
orbit, and nothing was found in the nasal meatus or naso- 
pharynx. The exploratory puncture, however, seemed to set up 
a more active process in the orbit, for the exophthalmos rapidly 
grew worse and the child began to complain of constant pain. 
A more extensive operation was then proposed and consented 
to by the parents. The conjunctiva was opened horizontally 
on the temporal side, the tendon of the external rectus was 
divided, and the eye turned strongly to the nose. The finger 
was then introduced and almost immediately felt a tumor, 
which seemed to occupy the apex of the orbit and to be firmly 
attached to the outer wall of the orbit far back. It had no at- 
tachments to the eyeball, and was easily detached from the 
orbital tissue and sheath of the optic nerve, but was with great 
difficulty separated from the periosteum on the outer wall of 
the orbit. In doing this the sac wall was ruptured far back and 
a quantity of ill-smelling pus came out, and the tumor collapsed. 
The sac wall was then carefully removed as far as possible, and 
the little finger being introduced discovered a small patch of 
denuded bone far back on the outer wall of the orbit. There 
had evidently been a focus of periostitis or perhaps of osteitis 
with caries, and an abscess had developed in the orbital tissue. 
The dead bone was scraped as well as possible, the cavity thor- 
oughly washed out with a solution of sublimate (1 to 2,000), 
and a loop of carbolized silk inserted for drainage. 
The case did remarkably well. Some suppuration occurred 
from the orbital tissue and from the suture points which united 
the tendon of the external rectus, but this ceased within the 
first week. The eyeball gradually receded within the orbit, and 
in two months scarcely a trace of the operation was left. There 
has been no return of the orbital trouble, but the child has had 
a rather severe osteitis in the right ankle joint, from which he 
eventually recovered. 24 
TUMORS OF THE ORBIT AND 
Case XII. Myxo sarcoma of the Orbit and Adjacent Cavi- 
ties.—A young woman, K. M., aged twenty-one, was brought 
to me on January 12, 1885. Three months before, she began to 
be troubled with epiphora in the left eye, and very shortly after 
she noticed a small tumor along the orbital margin just beneath 
the lower lid and at about its middle. It was painless and oc- 
casioned no annoyance. This has increased in size -and now 
begins to push the lower lid forward. Careful examination 
proved that the tumor could be plainly felt in the orbital cavity, 
lying along the floor of the orbit beneath the eye and extending 
up slightly upon the inner wall. On being questioned, the pa- 
tient stated that for more than a year she had suffered from a 
pain in the cheek just beneath the orbital margin, which was 
dull in character but never severe, and she had considered 
it neuralgia. The teeth were examined and several were 
found badly decayed, with large cavities. The nose and nasal 
meatus were examined, but nothing specially abnormal found. 
A diagnosis was made of thmor of the orbit, with the possibility 
of its origin in the maxillary antrum and subsequent perforation 
of the floor of the orbit. Both eyes were normal in every re- 
spect. The patient was advised to have the growth removed 
before the vision of the eye became affected, but declined all 
interference. In two weeks she came again and a great change 
in her appearance had occurred. The growth of the tumor 
had been very rapid. The eyeball was displaced upward and out- 
ward and vision was reduced to The lids were swollen and 
protruded perceptibly. The growth covered the entire floor of 
the orbit, extended over the inner wall and involved the orbital 
plate of the ethmoid, and had spread over the lower edge of the 
orbit and down upon the anterior surface of the superior maxilla. 
She was then eager for an operation, although she was told 
that in all probability the eye could not be saved. The nose 
and pharynx were again carefully examined, but nothing ab- 
normal was found. 
On January 30th I enucleated the eye and then found that 
nearly the whole orbit was filled with the growth. It varied 
in consistence, being in some places hard and in others soft. 
In examining the floor of the orbit, the probe passed into a NEIGHBORING CAVITIES. 
25 
cavity, showing that communication with the antrum existed. 
The orbit was thoroughly cleaned out in the usual way, and 
a large opening was then discovered in the floor of the orbit, 
which extended nearly to the orbital margin, and the growth 
could be seen and felt in the antrum. The extra-orbital por- 
tion of the growth was then removed from the surface of the 
upper jaw and was found closely united with the periosteum. 
The antrum was then emptied of its contents, and an examina- 
tion showed that the growth had not apparently extended into 
the nose. The cavity of the antrum and the orbit was care- 
fully washed out with bichloride solution fl to 2,000), and the 
surface of the periosteum thoroughly scraped and cauterized. 
The patient recovered rapidly and went home at the end of two 
weeks. She was told that, the tumor would almost certainly 
return, and that she must be seen at short intervals. I did not 
see or hear of her for nearly a year, and then she came with a 
return of the growth just beneath the lower margin of the 
orbit, on the superior maxilla. There was no sign of the recur- 
rence of the tumor in the orbit, and the antrum was empty ex- 
cept for a considerable amount of thick, glairy mucus. The 
pain in the upper jaw had appeared at intervals, but did not 
last long. The external growth was removed through the 
lower cul-de-sac, the latter being incised throughout nearly its 
entire length, and the lid depressed. After the nodule had 
been dissected out, the bone was thoroughly scraped and then 
cauterized with the actual cautery. Considerable suppuration 
followed this operation, and the lid remained averted for sev- 
eral weeks, but eventually this defect entirely disappeared. I 
saw this patient at intervals for several months, but she then 
disappeared and I have heard nothing of her since. The growth 
in the orbit, on microscopic examination, proved to be of a 
mixed nature. The denser portion of the tumor was pure sar- 
coma of the small-cell variety. The softer portion, together with 
the growth in the antrum, was myxo-sarcomatous in character. 
It was impossible to decide, from an examination of the tumor 
and of the orbit and antrum, where the disease originated, 
though the combined evidence was rather in favor of the 
antrum. 26 
TUMORS OF THE ORBIT AND 
Case XIII. Cyst of the Ethmoid Cells and Orhit.—Early in 
March, 1885, a man, C. K. aged twenty-eight, came to me with 
a very incomplete and fragmentary history of trouble in the 
orbit on the left side. There bad been a dull pain in the orbit 
and left side of the head for some months. It was constant but 
never severe. Lately there had been some failure of the vision 
and some prominence of the eyeball. He had had two decayed 
teeth removed, one from each jaw on the left side, but the pain 
continued. An examination showed a very slight prominence 
of the eyeball, with V. = clear media and a normal fundus. 
On the inner side of the left orbit, far back, a slight elastic 
prominence could be felt. The naso-pharynx was examined, 
but beyond a chronic catarrhal condition, with rather profuse 
secretion, nothing abnormal was discovered. The pain was now 
confined to the supra orbital region and the root of the nose. 
There seemed nothing to do but to watch the patient and await 
developments. One month later there seemed a slight increase 
in the elastic prominence on the nasal side of the orbit, and, a 
small trocar being introduced, a small quantity of yellowish, 
turbid fluid was evacuated. During the next day this continued 
to dribble through the wound and beneath the conjunctiva. 
That night the patient slept well, but toward morning he woke 
up with a feeling of a severe cold in his head. In endeavoring 
to clear his nose he made several violent expiratory efforts, and 
finally an immense mass of fluid and gelatinous discharge was 
passed through the nostrils, and he felt as if something had given 
way in his eye. He came to see me early in the morning. The 
discharge was still coming from the nose, and the ocular con- 
junctiva was swollen and distended all round the cornea, as in 
a case of extreme chemosis. The diagnosis was now somewhat 
easier. As a consequence of the chronic nasal catarrh, there 
had been an accumulation of fluid in the upper nasal meatus, 
ethmoid cells, and probably the frontal sinus. As a result of 
the pressure, either one of the fissures in the orbital plate of the 
ethmoid had been widened or the bone itself had been worn 
away, thus forming a communication with the orbit and the 
development of an apparent cyst in the orbit. This was punc- 
tured and the contents flowed out beneath the conjunctiva. NEIGHBORING CAVITIES. 
27 
The violent expiratory efforts had produced an enlargement of 
this opening in the ethmoid plate and an evacuation of a large 
quantity of fluid discharge into the orbital tissue, as well as 
through the nose. I punctured the conjunctiva in several 
places, and had the eye and conjunctival cul-de-sac irrigated 
every two hours with a sublimate solution (1 to 5,000), while 
the naso-pharynx was frequently washed out with a saturated 
solution of warm potassium chlorate. The patient recovered 
without an adverse symptom, and vision was gradually restored 
to the normal standard. 
Case XIV. l)isease of the Maxillary Antrum, involving the 
Orbit.—In the latter part of September, 1885, a gentleman, Mr. 
W., aged fifty-eight, came to me with the following complaint: 
In October, 1884, be began to have a dull pain in the right side 
of the face, near the external angle of the right eye and over 
the malar prominence, which lasted for some months. Think- 
ing it might come from the teeth, be consulted his dentist, who 
extracted the third and fourth molars from the upper jaw on 
the right side, which were badly decayed. The fangs of the 
fourth molar had penetrated the antrum. For more than a 
month after the removal of the teeth there had been a slight 
offensive discharge into the mouth from the alveolar opening 
into the antrum, but this ceased and was followed by a more or 
less profuse purulent discharge through the right nostril and 
into the pharynx. The dull ache over the malar prominence 
still continued and was supplemented by pain in the region of 
the right frontal sinus. In June, 1885, the right eye was noticed 
to be on a higher level than the left eye and to be somewhat 
more prominent. He consulted an oculist in a neighboring city, 
who told him that there was a tumor in the orbit and that the 
eye must be removed. There was at this time no impairment 
of vision, but during the summer he began to have vertical di- 
plopia. When I saw him there was a slight difference in eleva- 
tion of the two eyes but no exophthalmia, and the right eye 
could be moved freely in all directions. Shortly after his first 
visit the purulent discharge from the nostril, which had been 
very slight for some months, became again profuse, and the 
right eye was restored to its normal position and the diplopia 28 
TUMORS OF THE ORBIT AND 
almost entirely disappeared This induced me to believe that 
the trouble was entirely in the antrum and was of the nature of 
an abscess, and I urged an operation. To this the patient ob- 
jected, as his condition was very comfortable and the frontal 
pain had subsided, and I did not see him again until March, 
1886. At that time the discharge from the nose had nearly 
ceased, the right eye was displaced decidedly upward and some- 
what outward, and was distinctly protruding from the orbit. 
The diplopia was more marked than ever, and the pain over the 
malar bone and frontal sinus was at times severe. The naso- 
pharynx showed little abnormal. Vision in the right eye was 
still perfect and the opbtha’moscope gave a negative result. In- 
fluenced by my experience with a former very similar though 
less severe case, which I had transferred to the care of a gen- 
eral surgeon who operated on the patient with excellent results, 
I urged an operation on the antrum through the mouth, and -to 
this the patient consented. 
The alveolar opening at the root of the fourth molar still 
existed, though closed by mucous membrane. This I enlarged 
with small bone forceps, first dissecting away the mucous mem- 
brane and gum. There followed at once the discharge of an 
immense amount of apparently healthy pus. The antrum was 
then irrigated with a warm saturated solution of boric acid, 
the irrigation being continued until the fluid returned clear. 
The cavity was then filled with a solution of sublimate (1 to 
5,000) and the opening temporarily plugged. The nose and 
orbit were then carefully examined. Some of the fluid escaped 
through the nose. The floor of the orbit, which had been 
pushed upward, had receded, and proved to be excessively thin 
but apparently unperforated. The plug was then removed 
from the opening in the antrum, the sublimate solution allowed 
to run out, and the antrum again irrigated several times with 
the boric-acid solution. 
The result was extremely satisfactory. There was no re- 
action, and the patient rapidly recovered. A thin semi-puru- 
lent discharge continued for about two weeks, but the cavity 
was washed out twice daily, and at the end of the second 
month the patient was discharged cured. NEIGHBORING CAVITIES. 
29 
Case XV. Small-cell Sarcoma of the Orbit and Adjacent 
Cavities.—About the middle of May, 1886, a gentleman, C., 
aged thirty-two, consulted me in regard to one of his eyes. 
About six months before, he had noticed a small nodule at the 
inner canthus of the left eye, which at first looked like an en- 
largement of the caruncle. This slowly increased in size until 
it projected outside the canthus between the edges of the closed 
lids. While in Europe he consulted a surgeon, who removed 
the growth together with the caruncle. It returned within two 
months, and increased rapidly in size and occasioned great dis- 
comfort. When I saw him the growth involved the entire in- 
ner canthus, including the conjunctival folds, the ocular con- 
junctiva as far as the corneal margin throughout the nasal half, 
both cuts-de sac, and had extended deeply into the orbit along 
the inner wall, being apparently closely connected with the 
periosteum over the lacrymal and ethmoid bones. The inner 
ends of both lids were also infiltrated. The eye was limited in 
motility in all directions, except outward. The media were clear, 
the fundus was healthy, and vision was normal. I advised a 
very complete and radical operation—viz., the enucleation of 
the eye, the removal of the entire contents of the orbit, includ- 
ing the periosteum if necessary, and of the inner halves of both 
lids. To this the patient would not consent and went home, 
but subsequently submitted to an operation by a local surgeon, 
the exact nature of which I do not know, but it included the 
enucleation of the eye. The tumor again returned within two 
months and grew with great rapidity, so that less than four 
months after the second operation, when he again consulted me, 
the growth had filled the orbit, involving nearly the whole of 
both lids, the cheek, side of the nose, and temple. The left 
nostril was also occluded, though by what could not be ascer- 
tained definitely, but probably by a prolongation of the growth 
from above. Inasmuch as nearly all the deep bones of the face 
were involved, as well as the adjacent cavities, I declined to 
operate, but I removed a piece of the orbital growth for exami- 
nation. The patient returned home and a fourth operation was 
done, but he died within two weeks of exhaustion. The micro- 
scopical examination of the portion of orbital growth removed 30 
TUMORS OF THE ORBIT AND 
by me proved it to be a small-cell sarcoma. I subsequently 
learned that the family history of the patient showed a dis- 
tinctly cancerous tendency. His mother had been operated 
upon for cancer of the breast, and had subsequently died of the 
disease. A maternal aunt had died of cancer of the uterus, 
and so had his maternal grandmother. 
Case XVI. Small-cell Sarcoma of the Arm and Orbit.—In 
the latter part of December, 1887, a little boy, aged three, 
was brought to me, which proved to be a case of great inter- 
est. About fourteen months before, the child had received 
an injury to the left arm from a fall. The exact nature of this 
injury I could not ascertain, but it was not a From 
this injury there resulted a tumor, which involved the left up- 
per arm from the elbow to the head of the humerus, and the 
glands in the axilla were infiltrated. Some time during the 
summer of 1887 the left arm was amputated at the shoulder 
joint and the enlarged glands were removed from the axilla. 
The mother said the tumor proved to be a cancer on examina- 
tion with the microscope. Soon after the amputation of the arm 
the right eye was noticed to be more prominent than the left 
eye, and the upper lid drooped. When I first saw the child the 
exopbthalmus was forward, downward, and outward, and the 
infiltration of the lid was marked. The evidence of the pres- 
ence of an orbital tumor was unmistakable, and the parents were 
told of the probable malignancy of the growth and of its con- 
nection with the tumor in the arm. The presence of the same 
trouble in the lid was inferred from its swollen, infiltrated con- 
dition, and the hard sensation it gave when compressed between 
the fingers. I advised that the orbit be emptied of its contents, 
including the eyeball, that the upper lid be removed, and that 
the orbit be closed up by a plastic operation. This advice was 
declined, and I heard nothing of the child until four weeks later, 
when the father informed me that the child was ill with pneu- 
monia. Death followed on the third day, and I received per- 
mission to remove the contents of the orbit, including the eye- 
ball. The tumor had grown very rapidly, and was closely ad- 
herent to the periosteum and to the sheath of the optic nerve, 
so that the eye and the tumor were removed together. The NEIGHBORING CAVITIES. 
31 
growth had also extended into the sphenoidal fissure and over 
on the cheek. It proved to be a small-cell sarcoma, very vas- 
cular, arising from the periosteum, and involving in its growth 
the sheath of the optic nerve, the intravaginal lymphatic space 
being filled with small round cells, similar to those in the main 
growth. None of the tissues of the eyeball itself were invaded 
by the growth. I was not permitted to make any further ex- 
amination of the body. 
Case XVII. Fibrosarcoma of the Orbit.—I was consulted 
in March, 1889, by a gentleman, J. W., aged forty, who told me 
that the vision of the right eye had been defective from early 
childhood, although it could be somewhat improved by glasses, 
which be sometimes wore. Three months before, vertical diplo- 
pia suddenly appeared, preceded by a severe pain in the left eye, 
and the double vision had persisted ever since. He thought 
also that the left eye was somewhat more prominent than it had 
been. For the last six weeks the upper lid on the left side had 
been swollen. When I saw him the left upper lid was swollen 
and seemed to be pushed downward. The left eye protruded 
forward, downward, and outward, but the motility was not 
greatly impaired, except upward. Media clear and fundus nor- 
mal in both eyes. Diplopia upward and to the right for all 
large objects. R. E., ; with cyl.—D. 2'75, axis 90° = 
L. E., ; with cyl. —D. 0 50, axis 90° = . Just beneath 
the superior orbital margin on the left side, near the inner an- 
gle of the orbit, and reaching nearly to the outer angle of the 
orbit, was an elastic, nodular mass, extending backward for 
some distance and apparently closely connected with the roof 
of the orbit. The naso pharynx was normal, as was also the 
orbit on the opposite side. The patient was told that he had 
an orbital tumor, and that, if an operation were done for its 
removal at once, the eye might be saved. He consented, and 
the operation was appointed for the next day. 
The location of the tumor was such that it was necessary to 
displace the eyeball downward and outward as far as possible, 
and this was done without dividing any one of the ocular mus- 
cles. The conjunctiva was divided through the upper cul-de- 
sac, the incision extending the whole length of the superior or- 32 
TUMORS OF THE ORBIT AND 
bital margin. The adhesions between the orbital tissue and 
eyeball, and between the latter and the tumor, were then care- 
fully broken through with the finger and a strabismus hook, 
which was easily done, as none of the adhesions were firm. It 
was then found that the tumor involved nearly the entire roof 
of the orbit, and extended as far back as the finger could reach. 
It was flattened in the center by pressure on the eyeball, but was 
thicker on the temporal and nasal sides. It was very firmly 
attached to the periosteum of the roof, and its dissection was 
extremely tedious. Great care had to be exercised to avoid 
wounding the pulley of the superior oblique, and, at the apex of 
the orbit, to avoid injury to the optic nerve and superior oblique 
and superior rectus muscles. After its removal, as much of the 
periosteum of the roof as could be reached was stripped off and 
removed and the underlying bone scraped. The hole was then 
thoroughly irrigated with sublimate solution (1 to 2,000), the 
wound in the cul-de sac carefully closed by a number of sutures, 
and the eye bandaged. There was scarcely any reaction, but 
the infiltration in the upper lid subsided very slowly. At the 
end of a week the eyes were tested for diplopia, and it was 
found that the superior oblique had been injured during the 
operation, the relation of the double images to each other being 
quite characteristic. This persisted for more than four months, 
but eventually nearly entirely disappeared. The eyeball re- 
sumed its normal position, but slowly. This patient still is un- 
der observation at somewhat long intervals, but there has been 
as yet no trace of a recurrence of the disease, a period of three 
years and a half since the operation. The tumor was very care- 
fully examined, and proved to be a fibro-sarcoma, with a very 
large preponderance of dense fibrous tissue and but compara- 
tively few cells, which were of the fusiform variety. 
Case XVIII. Spindle cell Sarcoma of the Eyelid, Orbit, and 
Adjacent Cavities.—Early in April, 1889, a man was sent to my 
office with the following history: He was twenty-three years 
of age, apparently in perfect health, with unusually fine muscu- 
lar development. Five or six weeks before, he had first noticed 
a small lump in the lower lid of the left eye, near the inner 
canthus. It was at first movable and painless, but increased NEIGHBORING CAVITIES. 
33 
rapidly in size, became painful, and led him to seek advice. 
When I saw him the lower lid was swollen, reddened, and par- 
tially everted. The growth had extended downward and out- 
ward over the superior maxillary and malar bones, and back- 
ward into the orbit, along the floor and inner wall. It was ir- 
regularly nodulated, and the skin was freely movable over it. 
The left eye was limited in motility inward and downward. 
Both eyes were normal in every respect. The naso-pharynx 
was apparently healthy. It was impossible to determine by the 
examination whether the growth had begun in the orbit or in 
the eyelid. I gave an unfavorable prognosis, and told him that 
the only advice I could give him was to have an operation for 
the removal of the tumor done as speedily as possible, and that 
it would necessitate the loss of part of the eyelid and possibly of 
the eye itself. He agreed to do whatever I advised, and the 
operation was done on the second day following my examina- 
tion. 
The internal can thus was split by a horizontal incision extend- 
ing to the bridge of the nose. The lower lid was then split into 
an anterior lamina of skin and orbicularis muscle, which seemed 
to be healthy, and a posterior lamina containing the tarsus, 
conjunctiva, and connective tissue, as in the old Arlt-Jaesche 
operation for entropion. The incision was carried from the 
outer end of the first incision outward to the middle of the lid, 
and extended vertically downward to the level of the lower 
margin of the orbit. This was done because the skin of the lid 
seemed healthy. The ocular conjunctiva was then dissected 
free from the nasal half of the eyeball, being cut entirely across 
along the lower orbital margin and inner side of the orbit, and 
turned over on the cornea. It was then seen that to reach the 
extra-orbital portion of the growth the lower lid must be cut 
in half down to the orbital margin, which was done and the 
halves of the lid turned as far as possible out of the way. The 
growth was not very adherent to the underlying bone outside 
and was somewhat easily removed by the scissors and forceps. 
Inside the orbit it was more flattened out and adherent to the 
bone, especially along the floor of the orbit, and here the pro- 
cess of dissection was much more slow. It extended about 34 
TUMORS OF THE ORBIT AND 
two thirds of the way back into the orbit, was closely attached 
to the periosteum but not at all to the eyeball, which was read- 
ily pushed out of the way. After nearly an hour’s work the 
tumor was apparently entirely removed, and a careful exam- 
ination was then made of the floor and inner wall of the orbit, 
without discovering any remains of the growth. The bone was 
then scraped and the cavity in the orbit washed out with a sub- 
limate solution (1 to 5,000). The inner half of the lid, consist- 
ing of skin and muscular tissue, was then cut away and re- 
moved, and the vacancy filled by a flap of skin taken from the 
forehead and root of the nose, twisted on its base, and united 
with the inner end of the outer half of the lid by suture pins 
and the necessary sutures. There was considerable reaction on 
the next three days, but almost no suppuration, and the flap 
healed well, so that the patient was discharged from treatment 
in about five weeks with a very presentable lower lid. Nothing 
more was heard from the patient for a period of eight months, 
when he presented himself with an unmistakable return of the 
growth in the orbit and eyelid. A very radical operation, in- 
cluding the removal of the eyeball, was the only advice I could 
give him, and this he declined. Nearly a year later an opera- 
tion was done in a distant city for the removal of the growth, 
which had attained enormous proportions. The nature of the 
operation was unknown to me, but it involved the removal of 
several large pieces of bone, probably the superior maxilla and 
ethmoid. He recovered from this operation, but died soon 
after from some cerebral complication, and an autopsy was not 
allowed. 
The tumor removed by me at the first operation proved to 
be a sarcoma of the spindle-cell variety, with considerable fibrous 
tissue scattered throughout, and contained but very few blood- 
vessels. 
Case XIX. Small-cell Sarcoma of the Orbit, Eyeball, and 
Adjacent Cavities.—On October 4, 1889, a woman, aged thirty- 
five, was brought to me with the following history: For about a 
year she had suffered from severe neuralgia in the right side of 
the head and right orbit. She had had defective vision in both 
eyes for four or five years, but had never consulted any physi- NEIGHBORING CAVITIES. 
35 
cian. Four days before I saw her she suddenly discovered that 
she was blind in the right eye. 
An examination showed the following condition : The right 
eye protruded straight forward and its motility was limited in 
all directions. It resisted any attempt at replacing it in its nor- 
mal position, and the pain produced by any such attempt re- 
sembled that present in orbital cellulitis and periostitis. The 
iris was dilated and immovable. The right eye was situated at 
least a quarter of an inch in advance of the left eye, but in the 
same horizontal plane. There was an apparent infiltration of 
the orbital cellular tissue, which was most marked along the 
floor of the orbit, and upward and outward just inside the su- 
perior orbital margin. There was a chain of enlarged glands 
on the right side, beginning at the pre-auricular gland and ex- 
tending down along the border of the sterno cleido-mastoid 
muscle to the lei-el of the thyreo-cricoid region. The patient 
had had repeated epistaxis for some months, together with a 
profuse purulent discharge from the right nostril. An exam- 
ination of the nose revealed a hypertrophied and displaced in- 
ferior turbinated bone, but no visible growth in the naso- 
pharynx. The patient complained of a constant pain over the 
malar and superior maxillary bones. 
A diagnosis was made of a tumor in the nasal meatus, orbit, 
and maxillary antrum, with the strong probability of its origin 
in the antrum. Two weeks later the growth along the floor of 
the orbit appeared at the inner canthus, where it felt like a 
hard though slightly yielding mass, and I urged an immediate 
and radical operation. The right eye was entirely blind; the 
ophthalmoscope showed a neuro-retinitis or papillitis in the 
stage of atrophy. The family consented to an operation, which 
was done on October 19th. 
So far as could be discovered, there was no external growth 
on the cheek. The eyeball was enucleated in the usual man- 
ner, and the posterior part of the sclera and sheath of the optic 
nerve, was found to be surrounded and intimately connected 
with the growth in the orbit. On cutting through the optic 
nerve a mass of the tumor was cut through and came away with 
the eyeball. The floor of the orbit was found entirely absent, 36 
TUMORS OF THE ORBIT AND 
except a narrow rim of bone along the orbital margin, and the 
antrum was filled with the growth. The conjunctiva was then 
cut through at the culs-de-sac, and, with the entire contents of 
the orbit, was then removed. The inner wall, roof, and outer 
wall of the orbit seemed to be intact and the periosteum was 
smooth. There did not appear to be any extension of the 
growth into the optic foramen or sphenoidal fissure, and these 
facts seemed to emphasize the probability that the tumor origi- 
nated in the antrum. The communication between the antrum 
and nasal meatus was found much enlarged. The growth was 
removed from the antrum, and the cavity thoroughly washed 
out with bichloride solution (1 to 5,000). Part of the inner 
wall of the antrum and part of the nasal process of the superior 
maxilla were then removed, and the growth was then taken 
out from the nasal meatus. Small pieces of the tumor and bits 
of the turbinated bones were removed in this way, until it was 
possible to syringe freely from the antrum into the nose and 
pharynx. A large amount of detritus was washed out in this 
way, until the lower and middle meatus were entirely free. A 
drainage-tube was then introduced through the nose and the 
orbit dressed in the usual way. The bony walls of the antrum 
seemed to be intact, except that which separated it from the 
orbit, and this was entirely gone. In view of this fact, I did not 
deem it wise to attempt the removal of the maxillary bone, as 
the patient was greatly prostrated by the long operation. I 
told her family that the tumor would probably return and in a 
comparatively brief space of time, but in this I was mistaken. 
The patient recovered rapidly from the effects of the opera- 
tion. The orbit and antrum were irrigated twice daily for a 
period of three weeks, but there was not at any time much dis- 
charge, and it soon changed into a slight mucous secretion. At 
the end of two months the periosteum lining the antrum and 
orbit looked smooth and normal, and the patient could breathe 
through the right nostril. There was no positive evidence of a 
return of the growth till the November following, a period of 
thirteen months. It then appeared in the nose from above, 
extending downward into the nostril and also through the en- 
larged opening into the antrum. She began to complain of NEIGHBORING CAVITIES. 
37 
severe frontal headache, which probably pointed to an exten- 
sion of the growth into the frontal sinus or ethmoid or both. 
I advised another operation, beginning in the nose, but did not 
urge it very strongly, as 1 regarded the case as hopeless from 
the first, and the patient herself did not wish it. I attended 
the case to the end. The growth, gradually filled the antrum 
and orbit, extended into the ethmoid, broke through the orbital 
plate of the ethmoid into the orbit, and also filled the sphe- 
noidal fissure. The growth in the nose was so extensive as to 
obliterate both nasal cavities, and for the last months of her life 
she breathed entirely through the mouth. She finally died 
from pure exhaustion without any head symptoms nearly two 
years, lacking a few days, after the operation. Her family 
would not allow an autopsy. The tumor on examination proved 
to be a small-cell sarcoma, very vascular, which had intimately 
involved the sclera and sheath of the optic nerve as well as all 
the orbital tissues. 
Conclusions. 
Tumors of the Sphenoid.—So long as a pathological 
process, whether it be inflammatory or a new growth, is 
limited to the sphenoidal antrum, the subjective symp- 
toms are either entirely absent or there may be severe pain 
in the head. If the process extends to the neighboring- 
structures, symptoms arise which point to the probability 
that the sphenoid bone is the seat of the disease—such 
as blindness due to compression of one or both optic nerves, 
and the visible or tangible presence of the growth in the 
naso-pharynx, ethmoid, orbit, or skull. The entrance of the 
growth into the cranial cavity may occur without any sub- 
jective symptoms, or there may be severe headache. If 
the progress of the growth is very rapid, meningitis or 
cerebral abscess will result. The ophthalmoscopic symp- 
toms are either papillitis or atrophy of the optic nerves, due 
to perineuritis and pressure of the swollen nerve sheath on 
the optic nerve-fibers. In some cases the pressure is ex- 38 
TUMORS OF THE ORBIT AND 
erted on the optic nerve in the optic canal. Tumors of the 
sphenoid antrum may perforate the middle fossa of the 
skull without causing blindness, and when blindness does 
occur in these cases, it is not necessarily due to pressure on 
the optic chiasm, for it may be unilateral. If an orbital 
tumor rapidly causes blindness, and the latter starts from 
the temporal side of the field and leaves the region of the 
macula lutea unaffected to the last, and if at the same 
time a growth appears in the naso-pharynx, it is probable 
that the tumor began in the sphenoid antrum. 
Tumors of the Ethmoid.—A morbid growth confined 
within the ethmoid cells gives rise either to no symptoms 
at ah or merely to headache, paroxysmal in character. The 
orbital symptoms are the same as those of tumor of the 
orbit. The motility of the eyeball is limited. The vision 
may be slightly affected, or there may be complete blind- 
ness. The visual field may not be involved. If the tumor 
has entered the naso-pharynx, the mouth is more or less 
open and the speech is nasal. Later there is loss of the 
sense of smell. There may be more or less continuous 
dropping of clear fluid from the nose even in solid tumors, 
owing to a communication between the upper wall or roof 
of the ethmoid cells and fissures at the base of the skull. 
There may also be orbital or palpebral emphysema and 
haemorrhage from the nostrils. 
Tumors of the Superior Maxilla and Maxillary An- 
trum.—Tumors of the maxillary antrum may cause pain 
in the teeth of the upper jaw, a dull pain in the region of 
the antrum, or in the region of distribution of the infra- 
orbital nerve, but not until they have attained considerable 
size and have more or less completely filled the antrum, 
the distention of the walls of the cavity causing the pain 
by pressure on the nerve-twigs. As the tumor grows, the 
walls of the antrum are gradually absorbed, and a new NEIGHBORING CAVITIES. 
39 
thin scale of bone is developed from the periosteum. This 
may occur in the anterior wall, or in the orbital wall, or in 
the alveolar wall, and the tumor soon extends toward the 
nose, and causes great enlargement of the hole communi- 
cating with the nasal meatus. These nasal growths extend- 
ing from the antrum are often erroneously mistaken for 
nasal polypi. Subsequently the diagnosis is rendered easier, 
either by a projection forward of the anterior wall of the 
antrum, or by displacement of the eyeball upward and out- 
ward, or upward and inward, by the protrusion of the floor 
of the orbit. A large tumor of the antrum would probably 
increase the breadth of the cheek and would push the nose 
toward the opposite side. If the tumor grows from the 
bone itself, the inferior orbital margin is decidedly broad- 
ened. Tumors from the antrum itself rather tend to break 
through into the nose, mouth, or orbit. They early involve 
the nasal meatus, thence extend into the spheno-maxillary 
and palatine fossae and pharynx, and may finally perforate 
the base of the skull. They usually involve the orbit later, 
sometimes extending into it from the ethmoid cells, even 
before the floor of the orbit is perforated. In no case is it 
possible to diagnosticate a tumor of the maxillary antrum 
early in its development. 
Tumors of the Naso-pharynx.—Tumors of the nasal and 
pterygo-palatine fossae may enter the orbit through the in- 
fra-orbital fissure. They cause neuralgia of the infra-orbital 
or posterior alveolar nerves. The orbital portion of the 
tumor may divide into two branches, one involving the or- 
bit and the other extending into the cranial cavity through 
the supra-orbital fissure. They eventually extend into ah 
the neighboring cavities. 
Finally, in the treatment of these growths, it is abso- 
lutely necessary that they should be completely extirpated 
early in their development, together with all the surround- 40 
TUMORS OF THE ORBIT. 
ing tissues, including the bony walls of the cavities in- 
volved. If a malignant growth has already invaded the 
deep bones of the face and base of the skull, including the 
cavities contained within them, the case may be regarded as 
hopeless, and while an operation may relieve the patient 
temporarily, it undoubtedly hastens the fatal termination. REASONS WHY 
Physicians sliouifl Sul)scr0B 
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