THE OBBIT 389 



and Kuwahara, 1 in Oeller's clinic, examined such a case, and found the 

 Streptococci extending in the lymph spaces and the optic sheath right 

 up to the meninges (the globe also contained bacilli and Diplococci), 

 although the orbital tissues showed no macroscopical change. 



The danger is greatest in those globes which have open septic 

 wounds or ulcers, where the orbital tissues can be directly infected at 

 the operation, while those cases with more encapsulated abscesses 

 appear less precarious. 



Meningitis is much rarer after exenteration of eyes with panoph- 

 thalmitis. In Pes's case (K. M.f. A., 1905, ii., p. 550) death from 

 meningitis occurred three days after the exenteration. In the globe 

 with the panophthalmitis Staphylococci were found, and in the 

 meninges Streptococci. In the single case of Bocci 2 recorded by 

 Enslin and Kuwahara Pneumococci were found. A further case of 

 Alfieri, 3 though caused by Pneumococcus, is put aside by them, there 

 being a general pneumococcal sepsis present. 



The panophthalmitis, for which the eye was exenterated, was itself 

 metastatic, and the meningitis could equally well be metastatic, and 

 not the result of the exenteration. 



In a case of meningitis following on a septic wound of the globe 

 De Lapersonne found Pneumococci in the orbital tissues. He also 

 succeeded in infecting the meninges from the optic sheath. Menin- 

 gitis caused in this way by a panophthalmitis is comparatively rare, 

 as the passages from the eye are rapidly closed by inflammatory 

 coagulation and thrombosis. 



In those well-known cases where erysipelas 4 of the face or the lids 

 passes into the orbit, and finally affects the meninges, the lymph 

 spaces around the nerves or vessels in the orbital fissures, the sheath 

 of the optic nerve, or the veins (thrombo-phlebitis), are to be con- 

 sidered as the means of passage for the Streptococci. 



The orbit must be considered as an emissary passage through the skull, convey- 

 ing erysipelas along its veins in the form of a septic thrombo-phlebitis to the 

 meninges. 5 The inflammatory and degenerative changes which occur in the orbit 

 are partly due to Streptococci and their poisons, partly to vascular changes, and 

 partly to compression. 



Addario 6 argues that blindness can be caused by a necrosis of the optic nerve, 

 due either to toxins or to thromboses blocking the nutrient vessels ; for comparison 

 he experimentally determined the influence of streptococcal poison, and also that of 



1 A f. A. 1904, 1., S. 285 (cf. here the full literature ; also found in Bruckner's work). 



2 Arch. diOttal., 1896, iv. 104. 3 Arch, di Ottal., 1897, iv. 328. 



4 Leber considered that certain of the etiologically indeterminate orbital inflammations 

 were due to transient erysipelas. The possibility that such can occur cannot be denied, 

 but a sinusitis is more commonly the cause. 



5 Cf. Leber, A. f. 0., 1880, p. 212 et seq. 6 Arch, di Ottal., 1904, xii., fasc. 1, 2. 



