Anatomical Revelations in 1921 Kindled Operative Repair of the Orbit, Eyelids, and Periorbit over the Ensuing 100 Years: The Diuturnity of Ernest Whitnall (1876–1950) of Oxford, Montreal, and Bristol

Abstract

Revelations of orbital, intraorbital, and periorbital anatomy by a single author in 1921 kindled attempts at operative repair of the orbit, eyelids, and periorbit over the ensuing 100 years. They are the lasting contributions—the diuturnity—of Samuel Ernest Whitnall (1876–1950) of Oxford, Montreal, and Bristol.

Anatomy of the cranium and facial skeleton was given short shrift for centuries, largely because Ancients gave preference to the human hand as God’s greatest creation.[1] Then dramatically and seemingly in intuitive concert, Rene Le Fort (1901), Jean-Leo Testut (1911), and Matthew H. Cryer (1916) (Figure 1a–c) published descriptions of human craniomaxillofacial form, to include buttresses,[2,3,4,5,6] all 7 of which spanned the distance between the palatal platform and the cranial vault.

Their collective understanding of craniomaxillofacial form foretold, in a sense, Ernest Whitnall’s published details of the anatomy of the orbit, eyelids, and periorbital soft tissue in 1921. In The Anatomy of the Human Orbit and Accessory Organs of Vision,[7] Whitnall (Figure 2) describes features of the orbital rims, the bilges of the floor and roof of the orbit, plate-like alignment of the orbital walls, triangulation of the orbital apex, ligaments restraining intraorbital soft tissue, and the layered (lamellar) architecture of the eyelids and adjacent periorbital soft tissue.

Samuel Ernest Whitnall (1876–1950)

Ernest Whitnall, son of Arthur W. Whitnall, was born on 30 March 1876, in Eccles, a conurbation of Greater Manchester (Figure 3), in North West England.

His early education was earned at Radley College (Figure 4), an independent boarding school, near Abington, Oxfordshire. The school, housed on an 800-acre campus in South East England, offered then, as it now does, a masterful curriculum.

After Radley College, Ernest became a student at Manchester University (Figure 5), closer to home, but then soon returned to the South East, to attend Magdalen College (Figure 6a,b), a constituent college of Oxford University. At Magdalen, the youngster was a recipient of a Welsh Memorial Award.

After receiving MD and BCh degrees from the Oxford University, Ernest Whitnall launched his clinical years by joining the staff at St. Thomas’ Hospital, on the southern bank of the river Thames, near London Bridge (Figure 7a,b).

Doctor Whitnall was Demonstrator of Anatomy at Oxford under Arthur Thomson, from the time of his qualifications in 1910 until the outbreak of war in 1914. Early in this period of dissection and teaching, he generated two papers of considerable note; each was published in the 1911 volume of the journal of the Anatomic Society, the Journal of Anatomy:

• “On a tubercle on the malar bone … [for] lateral attachment of the tarsal plate” [8].
• “On a ligament acting as a check to the action of the levator palpebral superioris muscle” [9].

Upon the outbreak of war, Ernest Whitnall accepted a commission in the Royal Army Medical Corp (RAMC) and was first assigned to the 3rd Southern General Hospital, located in the Somerville Section of Oxford, on Cowley Road (Figure 8a). The well-acred complex would eventually expand to 10 additional sites in Oxford, creating wards in several university and city buildings, before war-end (Figure 8b).

After his 3rd Southern General Hospital assignment, Whitnall served 3 years in France as a member of the Queen’s Own Oxfordshire Hussars (QOOH) affiliated with the second Cavalry Field Ambulance Service[10] (Figure 9a,b).

Doctor Whitnall briefly returned to Oxford after World War I, but, in 1919, was appointed Robert Reford Professor of Anatomy at McGill University, Montreal, Quebec, Canada. Arrival at McGill in 1919 could not have been more propitious: the University had been on a two-decade splurge, expanding the footprint of the University (Figure 10) by building the East Wing of McGill College (now called the Arts Building) in 1888; the Redpath Library, Physics, and Chemistry buildings in 1893–1896; and the Strathcona Medical Building in 1907. All were constructed with quebecois, gray limestone. Important to Doctor Whitnall’s arrival, the medical building was renamed the Strathcona Anatomy-Dentistry Building [11] (Figure 11a,b).

In 1921, Henry Frowde and Hodder and Stoughton of London published Whitnall’s The Anatomy of the Human Orbit and Accessory Organs of Vision (Figure 12). Whitnall (Figure 13a) had begun the manuscript of the book in 1913, basing it on a series of his lectures to the students of the Oxford Diploma of Ophthalmology.

Whitnall’s laboratory sketches were converted to line drawings by J. C. Simpson, an associate professor of histology and embryology. All but seven photographs in the book were taken at Oxford.[7,10] The completed 428 pages were dedicated to Arthur Thomson (Figure 13b), the chief of anatomy at Oxford. Publication was facilitated by a grant from the McGill University Cooper Fund for Medical Research.

Doctor Whitnall (1876–1950) remained in Canada for 16 years, until, in 1935, he returned home to accept the Chair of Anatomy at Bristol University, Bristol (Figure 14a,b). He held the post in South West England until retirement, in 1941.

His travels from North West England to South East England; to Montreal, Canada; and (to cap his career) to South West England (Figure 15a,b) were not as peripatetic as cursory review might suggest.

Discussion

Ernest Whitnall began writing the manuscript of Anatomy of the Human Orbit, we would again note, in 1913, in the midst of revelations of craniomaxillofacial form by Rene Le Fort (1901), Jean-LeoTestut (1911), and Matthew Cryer (1916).[2,3,4,5,6] Lectures to Oxford University ophthalmology candidates, interrupted by war, formed the basis for publication of his book in 1921. The first surgeon to utilize Whitnall’s anatomical insights appears to have been Julien Bourguet (Figure 16), in 1924. The Parisian retracted (and thus bypassed) the anterior lamella of the lower eyelid and made an incision deep in the lower fornix to remove herniated fat of the orbit.[12,13].

Surgeons over the ensuing century, to include Converse, McCoy, Dingman, Tenzel, Tessier, Rowe, Merville, Manson, Gruss, Jackson, McCord, Gossman, and Pollock, assuredly in the operating theater and in their publications, also applied the orbital, intraorbital, and periorbital anatomy unearthed by Whitnall.[14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41] In the case of trauma, thanks to Whitnall, exemplary orbital repair became possible in the presence of untoward polycomminution, dislocation, and fragment instability, even when underlying structure had been “rent asunder, splayed, and distorted.”[42] Exemplary outcomes follow the combined (canthofornix) approach, attributable to bypassing (and protecting) the anterior lamella [39,43].

The diuturnityof Ernest Whitnall is rivetingly dramatized by (1) citing a few of his key 20th century descriptions of the anatomyofthe orbit (inbold) [7] thenby (2) matching theselected passages with current 21st century admonishment, photography, and/or illustration germane to successful orbital repair:

1. “In each lid and canthus, four layers or planes of tissue are identified: cutaneous, muscular, fibrous (the tarsal plate and septum orbitale), and conjunctival.”

“The conjunctival fornix … is the circular cul-de-sac formed by the … reflection of the surface membrane from the eyelids to the globe …. In the diagonal regions of the fornix, that is in the intervals between the muscle sheath expansion, the connective tissue behind the membrane abuts the orbital fat ….” Whitnall (1921).

Access to the inferior orbital rim, its periosteum, and the lower orbit is efficiently gained by way of an incision in the lower fornix, as the eyelid is draped over the inferior orbital rim. In cases that are certain to require greater exposure, a lateral canthotomy is first achieved (Figure 17a–d).

2. “The brain is slightly hollowed by the domed roof of the orbit and presents … a composite fissure termed the sulcus orbitalis. The olfactory tract crosses obliquely the extreme posterior end of the roof on its medial side …. The orbital floor surface is slightly concave anteriorly and convex posteriorly, owing to the upward expansion of the maxillary sinus, … and each orbit has the shape of a pear.” Whitnall (1921).

The bilges of the floor and roof cause the orbits to appear pear-shaped, as dramatized by removal of cribriform plate and much of the ethmoid with cutting burrs (Figure 18a) and by medical art (Figure 18b).

Small-to-moderate defects of the bony orbital floor after trauma (in which the floor is displaced inferiorly and present as orbital “blow-out” injuries) are repaired using commercially available polyethylene implants imbedded with malleable titanium. The polyethylene–titanium implant is manipulated by thumb-and-digit, to mimic the bilge of the orbital floor, and secured to the inferior orbital rim with screw(s). Large defects glean better postoperative results after use of split-cranial bone, from the temporoparietal outer table above the temporal line. The inherently contoured bone grafts mimic the bilge (concavity) of the anterior orbital floor and the convexity of the apex posteriorly (Figure 18c,d). Bone grafting remains the “gold standard” in the repair of complex injuries [27,28,29,30,31,32,37,38,40].

3. “The orbital floor … is formed in greater part by the orbital plate of the maxilla, … and completed anterolaterally by part of the orbital surface of the zygoma and posteriorly by a small triangular area (the processus orbitalis) of the palatine bone.” Whitnall (1921).

The three bones in the floor of the apex are often preserved after high-velocity impact, even when the orbital frame and bilge of the floor of the orbit are disrupted. Preserved apical floor provides structure upon which a split cranial bone graft may rest and is referred to as the “posterior ledge”[34] and the “pre-annular shelf”[33,40] (Figure 19a). Most basilar and frontobasilar fracture lines traverse the roof of the ethmoid, then deviate laterally upon reaching the roof of the sphenoid sinus, to end at the carotid canal or the foramen ovale, lacerum, or spinosum [44] (Figure 19b). Even with such extreme skullbase injury,[43,45,46,47,48] the pre-annular shelf (in the floor of the apex) skirts injury and is consistently available (in a survivor cohort) [48] as a stable platform to facilitate pan-orbital repair.

Rudderman et al. have demonstrated distribution of facial force equilibrium circuits (FFEC) to and from the cranium[49] and, we have speculated the presence of circuits to and from “the microbuttresses of the apex of the orbit, posterior skull base (occiput), and the vertebrae of the upper cervical spine” following impact (Figure 19c),[50] even though the shelf in the surviving cohort is most often spared fracture, upon frontal impact.

4. “The lateral wall is … [linear], save for a slight concavity just behind the margin and is triangular in shape….”

“The lateral wall is formed chiefly by two bones, the greater wing of the sphenoid in its posterior thirds and the upper surface of the zygomatic in its anterior third ….” Whitnall (1921).

To restore the lateral orbital wall and maintain orbital volume, the orbital plate of the zygoma must realign with the orbital plate of the sphenoid (Figure 20a). The realignment would further be in line with the optic strut of the apex (Figure 20a,b), although intraoperatively visualization of the strut in the live patient is precluded by the mass of the globe.

Proper realignmentof lateralwallcomponents avoids inadequate rim-and-malar projection and disallows postoperative orbital expansion (manifest as enophthalmos) [32,33,34,36,38,40].

5. “The roof is formed in greater part by the frontal bone and, at the apex, by the lesser wing of the sphenoidal bone …; the roof presents in outline the shape of an isosceles triangle.”

“The roof … is separated from the medial wall in great part by the fronto-ethmoidal suture; a backward prolongation of this line passes just below the optic foramen.”

“The roof presents more variation in its thickness than any other wall … [but is most often delicate and thin] in the posterior two-thirds …; dehiscences due to atrophy … may be present, [and then] the periorbita is in contact with the dura mater.” Whitnall (1921).

Fracture of the orbital roof tends to be displaced inferiorly as a “blow-in” fracture. The displaced roof reduces orbital volume and may cause exophthalmos [25,26,28,30,33,34,37,44,45,50].

Anterior roof fractures are repaired with a commercial implant or a bone graft secured at the superior orbital rim. Posterior roof fractures, the most common because of relative thinness of the bone posteriorly, are usually medial and are best repaired with the so-called top-hat split-cranial bone graft placed by way of a combined neurosurgical approach (Figure 21a,b). The size and shape of the graft varies according to the defect to be filled.

6. “The …medial wall alone is quadrilateral in shape; the others are triangular …. [It] is formed by 4 bones (the lacrimal, the body of the sphenoid, the ethmoid, and the frontal) ….”

“The medial wall is the thinnest of the four orbital boundaries …. The orbital plate of the ethmoidal bone has paper-like delicacy … [and, it is thus appropriately] termed the lamina papyracea.”

“The surface of the medial wall is … convex about the centre and concave in front in harmony with the contour of the eyeball, though these curves are but slightly marked ….” Whitnall (1921).

The middle and posterior ethmoid cells project into the orbit, reducing subtly the posterior and middle orbital volume. The inward projection is apparent in oblique views (Figure 22a) but most obvious from above, after the orbital roof has been drilled away with cutting burs (Figure 22b). Labeled the “ethmoid jut,”[33,40] the degree of inward curvature varies among individuals.

Upon impact, the inward jut of the medial wall tends to be displaced medially into the ethmoid sinus, as its cross-struts (septae) collapse. The orbital expansion is challenging to reconstruct, but the inherent convexity of temporoparietal, split-cranial bone offers an excellent anatomical solution.[40] When the edges are tapered with a cutting burr (Figure 22c), the medial wall graft clicks into position and does not require rigid fixation.

An Afterword

Ernest Whitnall enjoyed satire and the humor of parody, as evident in his biweekly contributions to the London-based magazine Punch (The London Charivari) during the years before the Great War. He authored the numerous columns under the pseudonym “Tingle” [10] (Figure 23).

Astonishing Anatomy, an 80-page spoof, was published by Isaac Pittman & Sons of London in 1913 [51] (Figure 24). The witty tome, also written before the War under Whitnall’s pseudonym, was the subject of much fun, distortion of anatomical fact, and rather tangential, descriptive inaccuracy. One underlying premise of Astonishing Anatomy was the then-perceived need for 2-year, hands-on anatomical dissection and prosection in the education of medical students. Such posturing was a forerunner of similar arguments by John Skandalakis against ongoing erosion of student-laboratory experience by computerized learning in a 1980 issue of American Surgeon.[52] Astonishing Anatomy was most briefly reviewed in the inaugural issue of the British Medical Journal, on 29 March 1913 [51,53].