ORBITAL CELLULITIS 
E. E. HOLT, M.D., 
PORTLAND, ME. 
| Reprinted from American Ophthalmological Society Transactions, 1892.] [.Reprinted from American Ophthalmological Society Transactions, 1892.] 
ORBITAL CELLULITIS, THE INFLAMMATION 
SPREADING TO THE TEMPORAL REGION, 
THENCE TO TFIE NECK, OBSTRUCTING DE- 
GLUTITION, EXTENDING TO THE BRAIN, AND 
PRODUCING DEATH. WITH REMARKS UPON 
THE SAME AND BRIEF REPORTS OF FIVE 
OTHER CASES. 
By E. E. HOLT, M.D., 
PORTLAND, ME. 
On February 2d I was called to see Carroll Jennings, aged 
18 years. He was a deaf-mute, did chores for Mrs. Glover, and 
attended the school for the deaf. I found the upper eyelid 
swollen and oedematous, with the ocular and palpebral con- 
junctivae injected. He told the folks he thought he had got 
something into the eye. Careful inspection of the cornea and 
parts exposed by separating the lids as much as possible failed 
to reveal any foreign body. To make sure there was no foreign 
body under the lid, I pressed out the oedema a little, so the lid 2 
Holt : Orbital Cellulitis. 
could be raised better — it was so thick from swelling that it 
could not be everted — and passed a shell cataract-spoon along 
the whole length of the retro-tarsal fold. The spoon brought 
out some particles of a foreign body. This was repeated until 
nothing came out. A drop of a two-per cent, solution of hydro- 
bromate of homatropine was instilled, and also a drop of castor 
oil. I ordered an antiseptic collyrium to be applied freely 
over the eye on absorbent cotton. Dr. Pendleton had been 
called in, and ordered a saline cathartic and a fever mixture of 
nitre, acetate of ammonium, camphor water, and syrup of tolu. 
I was out of town twenty hours, and during my absence Dr. 
Pendleton said that the patient was completely unconscious at 
an early hour in the evening, and those in attendance said he 
remained so till early the following morning — a period of about 
ten hours. The pulse was high, 120 per minute, and the tem- 
perature 105°. 
At the consultation on the afternoon of the 3d the tempera- 
ture was 104°, and the pulse was full and hard at 100 per min- 
ute. One minim tinct. aconite, to be taken every hour, was 
prescribed. Ten grains of calomel were ordered, and two 
leeches were applied to the temple. At this time the inflam- 
mation of the oculo-orbital tissues had continued, and the swell- 
ing of the lid increased, and began to invade the tissues out- 
side the orbit on the temporal side. The pupil of the eye re- 
sponded to light and accommodation, and there did not appear 
to be any paralysis about the eye or body. On the 3d day of 
the attack his temperature was 104°, and his pulse was softer, 
at 110 per minute. The calomel had acted freely at 4 o’clock 
in the morning. He was removed, without accident or apparent 
fatigue, to the Maine Eye and Ear Infirmary, and appeared 
fairly comfortable in the evening. The temperature and pulse, 
however, remained about the same, and the inflammation and 
swelling about the eye had not abated, but had rather increased. 
On the 4th day of the attack the temperature in the morning 
was ; pulse about 100 per minute. At noon the swell- 
ing about the orbit and forehead was such that it was decided 
to make an exploration to see if pus was not present deep in 
the orbit. The oculo-orbital tissue had become intensely Holt : Orbital Cellulitis.' 
3 
swollen, the eye was pushed forward and outward, and the 
chemotic conjunctiva projected from the palpebral 
Accordingly, a needle was passed into the orbit above the eye, 
at the upper and outer quadrant, down to near its apex. No 
pus was found. A Graefe cataract knife was then passed in, 
and a free incision was made, but no pus was reached. It was 
thought that the origin of the inflammation might have been in 
the frontal sinus. Accordingly an incision was made above the 
brow, and the frontal sinus was entered at the upper and inner 
angle of the orbit. No pus was found there. This wound was 
united with interrupted sutures, and a flaxseed poultice applied 
over both wounds. In the evening the temperature was 
and pulse 100, softer, so that aconite was discontin- 
ued, and he was given a sponge 'bath. He appeared better, 
and expressed himself so, notwithstanding the high tempera- 
ture. On the 5 th day of the attack the temperature was 
1031° in the morning and at night. The pulse was 
about 100. The inflammation had extended further over the 
temporal region, and there was considerable swelling of the 
parts. He was ordered one grain of quinine every four hours, 
and one drachm of whisky every two hours ; liquid diet, 
mostly milk. On the 6th day of his sickness the tempera- 
ture was 103I0 in the morning and io^0 in the evening. 
The pulse was from 100 to 110. The inflammation had ex- 
tended down the left side of the head, and involved the neck, 
which had become swollen and hard, so that it was with great 
difficulty that he could swallow. 
For the past twenty-four hours he had complained a good 
deal of his throat, had coughed, raised some stringy mucus, 
and said his throat was sore. Dr. Gordon was added to the 
consultation, and agreed with Dr. Pendleton and myself as to all 
the essential features of the case and the treatment. Twenty 
drops of the tinct. chloride iron were ordered to be given every 
four hours, in addition to the quinine and whisky, while the 
fever mixture was to be omitted. On the 7th day the tempera- 
ture was in the morning, and the same in the even- 
ing. The pulse was recorded 100 per minute in the morning 4 
Holt: Orbital Cellulitis. 
and 90 in the evening. The swelling in the left orbit had sub- 
sided, the conjunctiva had retracted, the lids had relaxed, and 
there was some movement of the eye, and the pupil responded 
to light, as it had all along. There had, however, been but 
little or no discharge from the opening made into the apex of 
the orbit for drainage. The inflammation had extended, and 
there was swelling of the right cheek. The patient had a 
fairly comfortable day. On the 8th day the temperature was 
103° in the morning, ioo° at noon, and 103° in the evening. 
The tissues of the neck had become tense, and he was unable 
to swallow. Enemas were used, and most of them were re- 
tained. The tissues about the eye had assumed quite a normal 
appearance. There were two soft places above the temporal 
region on the forehead, indicative of the formation of pus. 
On the 10th day the temperature was 98°, and the pulse 80 
per minute, dicrotic, and not regular. His general appearance 
was not as good as on the preceding day. On the nth day 
the temperature was in the morning and at 
noon. The pulse was irregular, about 100 per minute. An 
incision was made into the two places on the forehead above 
the temporal region, and pus and broken-down tissue were 
pressed out. Dr. Pendleton ordered a poultice to be applied 
over the points of incision. Stimulants were ordered to be 
given more freely. Early in the afternoon the wounds began 
to bleed freely; and, upon being informed of the fact, Dr. 
Pendleton ordered the poultice to be discontinued, and had a 
compress applied ; but, upon being informed later that the 
wounds were still bleeding, he immediately saw the case, and 
united the wounds with deep sutures and applied a compress. 
He also gave a hypodermic injection of morphia. The pulse 
at this time was estimated at about 200 per minute, and the 
respiration from 48 to 60. In the evening Dr. Sullivan and 
Mr. Clough could find no radial pulse, but estimated that the 
heart-beats were about 200 per minute and the respiration 48. 
Stimulants were given per rectum, as much as he could retain. 
He gradually sank, and died on the morning of the 13th at 
2.30 o’clock, nearly twelve days from the beginning of the 
attack. Holt : Orbital Cellulitis. 
5 
In reviewing this case there are several interesting points 
to be considered. Although the patient was deaf and dumb, 
and therefore could not express his feelings very well, yet there 
was no doubt about the diagnosis of inflammation of the cellu- 
lar tissue of the orbit. He was of a kind, willing disposition, 
inclined to extenuate his sufferings, so that the amount of 
pain he suffered was difficult to ascertain, and on this account 
the diagnosis of the involvement of the periosteum was not so 
clear. Having made a positive diagnosis of inflammation of 
the tissues of the orbit, the next point to be considered was 
what was the cause. General inflammation of the tissues of 
the orbit in a previously healthy boy of eighteen years of age 
is not of common occurrence. It rarely exists as an independ- 
ent affection, but generally can be traced to inflammation of 
tissues adjacent to this cavity. 
The numerous openings, through which pass important ves- 
sels and nerves, place the orbit in direct communication with 
other parts, and readily show how inflammation may extend 
from them to it, and vice versa. Its close proximity to these 
cavities, which are not infrequently the seat of inflammation 
that may extend and break away the delicate natural boundaries 
between them and it, explain why orbital cellulitis is frequently 
dependent upon inflammation in these cavities. In the diag- 
nosis of this affection these anatomical relations and the in- 
flammation that may arise in them must be borne in mind if 
we are to make a correct diagnosis and adopt proper treatment. 
Careful examination convinced me that there was no inflamma- 
tion in the antrum or the nose, and the opening made into the 
frontal sinus demonstrated that the inflammation did not have 
its origin there. We are left, then, to determine whether it 
had its origin in one of the fossae connected with the orbit or 
the cranial cavity. 
I think the history and preponderance of symptoms point 
to its origin either in the orbit or cranium, and our diagnosis 
narrows down to these two places. He had got his feet damp 
or wet, and had taken cold ; had lost a schoolmate, and had 
wept a good deal; and also had got some foreign substance 
into his eye. He also had a quilt tied up with rope suspended 6 
Holt : Orbital Cellulitis. 
over his head, attached to one end of a lever, which was con- 
nected at the other end with an alarm clock. When the alarm 
went off in the morning it disengaged one end of the lever, 
and allowed the quilt tied up in the rope to fall and strike him 
on the face. As it fell four or five feet, it would produce quite 
an injury to a delicate organ like the eye if the rope should 
strike across it. As bearing upon the origin of the inflamma- 
tion in the cranial cavity, he fell downstairs about two weeks 
previous to this time, striking upon the right side of his head. 
The fall produced so little temporary or permanent effect that 
it was not mentioned to me until the affection had assumed a 
more serious aspect, and I was searching for a cause. 
There might have been a latent affection of the ears con- 
nected with the temporal bone, which was set into activity by 
the fall; but in the absence of any condition externally point- 
ing to it, or of any symptom that would indicate that it existed, 
it must be excluded. The fall, too, was two weeks previous 
to his sickness, during which time he had enjoyed his usual 
good health. I think we must exclude this as a cause 
producing the inflammation. We are left, therefore, to decide 
whether the inflammation originated de novo in the cranial 
cavity and extended to the orbit, or whether it was primary in 
the orbit. We had a clear history of two of the most common 
causes of this affection, namely, idiopathic and traumatic. The 
cold he took, the weeping, and the foreign body under the lid, 
with the probable injury from his arrangement to wake him, 
were sufficient to localize the inflammation in the region of the 
orbit. There was first redness of the oculo-palpebral con- 
junctiva common to a cold and excessive weeping — just the 
condition to give rise to inflammation from the addition of a 
foreign body or an injury. This inflammation, once started, 
extended rapidly to the subconjunctival tissue, thence to the 
connective tissue of the orbit and lids, producing great swell- 
ing of them, with but little secretion. There was pain, which 
was increased by pressure upon the eyeball backward, immo- 
bility of the eyeball, and high fever — a group of symptoms 
and conditions that form a true picture of the first stage of 
orbital cellulitis. The only diseases with which orbital cellu- Holt: Orbital Cellulitis. 
7 
litis is likely to be confounded are periostitis of the orbit and 
new growths. 
Periostitis of the orbit does not develop as rapidly as 
orbital cellulitis. Pain here, as elsewhere, is a prominent 
symptom of inflammation of the periosteum. There is usually 
much less swelling, and the finger can be passed around the 
margin of the orbit, thereby increasing the pain. This is an 
important diagnostic symptom of periostitis. In new growths 
the development is still less rapid, and there is usually func- 
tional disturbance previous to the occurrence of inflammation. 
The eye is rarely pushed directly forward in new growths. 
There are cases, however, as in the diagnosis of other diseases, 
where it is extremely difficult to make out the exact condition. 
This is well illustrated in a case cited by Dr. Harlan. The 
emperor sent Jaeger to Milan to see Marshall Redetzy, who 
had been suffering three months with exophthalmus and its 
accompanying symptoms. He reported that the patient, who 
declined any operative interference, was affected with scirrhus 
of the soft parts of the orbit, which would soon end his life. 
Not long afterward, under homoeopathic treatment, there was a 
copious discharge of pus, and the eye returned to its normal 
position. 
Having determined that the affection was cellulitis and 
primarily in the orbit, it behooves us to account for other condi- 
tions that existed. The loss of consciousness on the night of 
the second day of the attack may be accounted for in the rapid 
development of the inflammation in the orbit producing enor- 
mous swelling of the parts, and consequently great pain. We 
see loss of consciousness produced by severe pains in other 
parts of the body, like that from the passage of gall-stones. 
But here in the orbit we have not only all the conditions for 
the development of great pain when general inflammation 
exists, but we have the structures involved in close contiguity 
and continuity with the brain—the seat of all consciousness 
— and hence in violent inflammation of them we should ex- 
pect to have disturbances of the function of this organ. 
If we examine the relationships, we find that the optic 
nerve and retina are early outgrowths of the brain, which is de- 8 
Holt : Orbital Cellulitis. 
veloped from the epiblast. They are, therefore, genetically 
closely related, and this intimate relationship is continued 
through the lymph space which Schwalbe has shown to exist 
between the arachnoidal space and the lymph spaces which sur- 
round the sheath of the optic nerve and pass over into Tenon’s 
capsule. We have in the eye and its surroundings all the dif- 
ferent tissues of the body represented. Its fibro-vascular tis- 
sue is developed in common with those of the brain from the 
mesoblast, and, therefore, they are genetically closely related. 
The blood supply is through the ophthalmic artery, which is a 
branch of the internal carotid. This in its course lies along 
the inner wall of the cavernous sinus, into which the ophthal- 
mic vein that returns the blood from the eye and orbit empties. 
This sinus is of large size, extending from the anterior lacer- 
ated foramen to the apex of the petrous portion of the temporal 
bone. It communicates freely with its fellow, and with all the 
other sinuses of the dura mater. This brief review of the em- 
bryological, anatomical, and physiological relationship of the 
tissues of the orbit and those of the brain serve to recall how 
profoundly the latter may be affected by rapid and extensive 
inflammation of the former, without that inflammation extend- 
ing and involving those tissues. It also serves to recall how 
readily inflammation of the orbit may extend and directly in- 
volve the tissues of the brain, and, for this reason, why orbital 
cellulitis is considered a serious affection. 
From the condition of the patient as described by Dr. Pen- 
dleton and the attendants, I have no doubt that his unconscious- 
ness during the night of the second day of the attack was due 
not only to the great pain incident to the inflammation of the 
orbit, but that this latter had extended, and directly involved 
the tissues of the brain. Had psychical disturbances followed 
this attack of unconsciousness, it would have been conclusive 
evidence that the primary inflammation was intra-cranial. Al- 
though deaf and dumb, he had been taught to express his 
thoughts orally, and had quite a command of language, so that 
when the person addressing him was in the right position he 
always answered intelligently. His uninflamed eye, too, re- 
vealed a clear mental condition. In looking over published Holt: Orbital Cellulitis. 
9 
cases, I fail to find anywhere the temperature was recorded as 
high as it was in this case. Indeed, it is not mentioned in a 
large majority of the published cases. The constant high 
temperature and condition of the orbit led us to anticipate the 
formation of pus, and justified us in performing the operation 
on the fourth day. The extension of the inflammation over 
the forehead and temporal region (at two points of which pus 
was finally formed) down the neck, involving the other side up 
nearly to the other eye, and interfering with deglutition to such 
an extent that the patient was unable to swallow, is certainly a 
very rare complication, as I find no similar case recorded. It 
may account for the constant high temperature. 
The subnormal temperature on the tenth indicated a sub- 
sidence of the inflammation, which, however, recurred on the 
eleventh day. It clearly pointed to intra-cranial inflammation, 
and he undoubtedly died from the effects of meningitis, al- 
though no post-mortem was obtained. 
In looking over my case-books, I find that nearly three 
thousand cases were recorded before this affection occurred, 
and I find only six among over twelve thousand recorded cases. 
The first case occurred in April, 1884, in Mr. H. H. B., aged 
46, upon whom I had performed tenotomy of the left internal 
rectus, with advancement of the left external rectus. The 
patient was an overworked lawyer, who had an attack of 
diarrhoea, which he had contracted in the army. He made a 
good recovery, although the treatment was somewhat pro- 
longed. 
The second case was in November, 1885. This was a 
young man, T. J. P., aged 19, who went a-fishing with slippers 
on, got wet, and took a severe cold. He had pain over the 
right eye. He saw a physician, who advised him to apply a 
poultice, and to return the next morning. The pain continued 
and the lid swelled, and he continued the use of the poultice 
several days without seeing the physician. When I saw him 
suppuration had been established under the use of the poultice, 
but the eye broke down, and its contents ran out. 
The third case was a lady, Mrs. D , aged 71, who con- 
sulted me with Dr. Sullivan in October, 1888. She had had a 10 
Holt : Orbital Cellulitis. 
decayed tooth, with considerable suppuration, which she had re- 
moved. Very soon after, accompanied with severe pain, the 
tissues of the orbit began to swell. The pain and swelling con- 
tinued with great severity. The eye was pushed forward, and 
when I saw the case several incisions had been made, with a view 
to let out pus, but none escaped. As symptoms pointed unmis- 
takably to suppurative inflammation of the antrum of Highmore, 
I removed a decayed bicuspid tooth and opened the antrum at 
this point, letting out considerable pus. 
As the eye had been blind thirty years and was very hard, 
I removed it, and found the orbit had become involved through 
the infra-orbital canal, the bone around which was in a carious 
condition. Her recovery was tedious and unsatisfactory. 
The fourth case was seen in consultation with Dr. Wallace 
of Rochester, N. IT, in January, 1889. It was a child, aged 
two and a half years, who, without apparent cause other than 
a cold, had marked swelling of the lids of the left eye, with 
proptosis. As far as could be ascertained, the inflammation 
seemed to be primary in the orbit. It was not in a proper state 
for making an incision, and I advised waiting. In two days 
Dr. Wallace made an incision, evacuating pus, and the case 
made a good recovery. 
The fifth case is the one here related in full. 
The sixth case was seen in April, 1892. This occurred in 
a girl, aged 10 years, who had had purulent inflammation in 
this eye about a year before this time, and sustained a loss of 
the cornea to Decemet’s membrane at the scleral-corneal mar- 
gin, leaving the eye irritable and with poor vision. She had 
recently had the measles, and the eye became irritable and 
painful, for which leeches had been applied by her family 
physician, Dr. Morgan of Dover, N. H. The eye grew worse, 
and when seen the lids were intensely swollen, with the eye 
bulging outward. The temperature was 102°, and she was in 
a decidedly critical condition. As but little hope was given 
that the child would live, Dr. Ring was called in consultation, 
and on the following day Dr. Gordon was called. The tem- 
perature kept high for several days. The swelling remained 
about the same as when first seen, and at no time was it Holt : Orbital Cellulitis. 
11 
thought advisable to make an incision, and the inflammation 
subsided without suppuration. The eye became totally blind, 
shrunken, and irritable, and was removed in June last. 
In the preparation of this paper reference has been made 
to the following articles : 
1. “On the Pathology of Inflammation of the Orbital Cellular Tissue.” 
Am. Journal, No. 141, page 112, by Dr. Chas. S. Bull. 
2. “ Inflammation of the Cellular and B’atty Tissues of the Orbit, Terminat- 
ing in Absorption.” Presse Med., Vol. 30, page 78, by De Smet. 
3. “ Exophthalmus from Retro bulbar Suppuration, Spontaneous Cure.” A. 
O., Vol. 8, page 371, by Hirschberg. 
4. “A Case of Inflammation of the Retro-bulbar Cellular Tissue in Primary, 
Acute, Purulent Inflammation of the Middle Ear and Diphtheritis.” A. O., Vol. 
8, page 10, by Knapp. 
5. “Contributions to the Etiology and Treatment of Orbital Cellulitis.” A. 
O , Vol. 13, page 17, by Dr. Herman Pagenstacher. 
6. “ Observations of Orbital Abscess, and its Connection with Erysipelas 
and Thrombo-phlebitis, and its Complications, Especially Thrombosis of the Sinus, 
Cerebral Absct ss, and Abscesses in the Temporal Region.” A. F. O., Vol. 26, 
page 212, by Leber. 
7. “ Case of Orbital Cellulitis.” St. Thomas’s Hospital Reports, Vol. 2, 
1882, by Nettleship. 
8. “Abscess of the Orbit.” New York Med. Record, 1882, page 550, by Lip- 
pincott. 
9. “Cellulitis of the Orbit.” New York Med. Journal, March, 1884, by 
Pooley. 
10. “Case of Primary Orbital Cellulitis; Death on the Seventh Day; Post- 
mortem Examination.” Ophth. Rev., Vol. 3, page 147, by Griffith Hill. 
11. “Case of Orbital Phlegmone in Thrombophlebitis of the Orbital Vein, 
after Extraction of a Carious Molar Tooth, ending in Recovery, with Preservation 
of Sight, as well as of the Globe.” A. F. O., Vol. 30, page 157, by A. Vossius. 
12. “Cellulitis and Periostitis of the Orbit as Sequels of other Morbid Con- 
ditions, with Cases.” Trans. Oregon State Med. Society, 1884, by F. B. Eaton. 
13. “Two Cases of Orbital Abscess.” Trans. Am. Ophth. Society, 1884, by 
J. A. Lippincott. Dr. Theobald, in discussing this paper, reports a case of orbital 
cellulitis resulting in abscess, which was evidently primary. 
14. “Orbital Cellulitis.” Lancet, Vol. 2, No. 17, 1885, by A. Critchett. 
15. “Abscess de l’orbite consecutif a un coryzu aigu.” Ann. des mal de 
l’oreille et du larynx, 1885, PaSe &5> by Hartmann. 
16. “Acute Idiopathic Abscess of the Left Orbit.” British Med. Journal, 
1888, page 124, by J. Culling. 
17. “ Two Cases of Orbital Cellulitis, with Necrosis of the Horizontal Plate 
of the Frontal Bone, Accompanied with Cerebral Abscess.” London Oph. Hosp. 
Rep., Vol. 12, page 281, by E. T. Collins and C, H. Walker. 
18. “ Acute Cellulitis of Orbit; Fatal Result.” Trans. Oph. Society of 
United Kingdom, Vol. 10, page 51, by Simeon Snell. 12 
Holt : Orbital Cellulitis. 
19- “ Etude sur les absces des sinus frontaux consideres principalement dans 
leur complications orbitairs, leur diagnostic et leur traite.” Arch. d’Oph., Vol. 11, by 
A. Guillemain. 
20. “A Case of JOrbital Cellulitis.” Trans, of the Oph. Society of the 
United Kingdom, Vol. 6, page 155, by A. Critchett. 
The articles upon “ Orbital Cellulitis ” in the following text- 
books on ophthalmology : Stellwag, Wells, Noyes, DeWecker, 
Schweigger, Meyer, Swanzy, Berry, Green, Juler, Schmidt- 
Rimpler, Nettleship, and Harlan’s article in “ Reference 
Handbook.”