INFECTIVE SIGMOID SINUS THROMBOSIS -REPORT OF A CASE.*

L. HERBERT LANIER, M. D., Texarkana, Ark.-Tex.

The cranial sinuses are venous bloodvessels running in the layers of the dura mater for the purpose of collecting and conveying the return flow of the blood from the brain. The cranial sinuses and the cerebral veins are without valves and are not accompanied by corresponding arteries.

Among the largest of these sinuses is the sinus transversus or sinus lateralis, which on account of its course along the inner table of the temporal bone is the venous structure which most concerns the otologist.

The sinus is divided into a vertical and a horizontal portion, the vertical section being termed the sigmoid portion of the lateral sinus, or more commonly, the sigmoid sinus.

Etiology.-Thrombosis of the lateral sinus is induced either by means of (a) extension of the infective process within the temporal bone through the smaller veins, whereby the latter become involved with septic thrombi, which gradually extend to and infect the sinus, or (b) because the infection in the bone extends by contiguity, directly through its internal table to the walls of the blood vessel, where its farther advance is characterized by infection of the sinus walls, and thence into the blood-stream with resultant thrombosis.

Furthermore, according to Boenninghaus, thrombosis may occur from infection located within the labyrinth. In these cases the sinus is usually affected below the knee, or through involvement of the superior or the inferior petrosal sinuses. In another group of cases the infection proceeds from a labyrinthine infection directly toward the bulb, through involvement of the lymph spaces of the middle ear, or through the extension of a thrombus from the internal auditory vein.

*Read before the Medical Association of the Southwest at Galveston, Tex., November 11, 1914.

From the tympanic cavity proper a thrombosis of the jugular bulb may take place from direct infection through dehiscences in the floor of the tympanum. McKernon and others have reported cases of primary jugular-bulb thrombosis. Boenninghaus, Korner and others report cases wherein the infection entered the jugular bulb from the tympanic cavity proper through involvement of the carotid plexus, along the anterior wall of the tympanic cavity. We conclude, therefore, that phlebitis and thrombosis of any part of the lateral sinus and internal jugular vein take place as follows:

1. Through anatomical dehiscences in the bone tissue which covers its parietal surface, thus affording easy access to the pathologic process.

2. Through the direct extension into its walls of the active purulent lesion in the bone.

3. Through involvement of the smaller veins in the diseased bone, or through the involvement of intermediate anastomotic veins in the thrombotic area.

Thrombi, both of the wall type and the obstructive type, may either be of infectious or non-infectious character, the latter occurrence being more rare.

If the thrombus is not infected it becomes organized through the advent of connective tissue. On the other hand, if it becomes infected, it eventually breaks down, spreading the infection along the sius walls, and finally destroys these walls to a variable extent.

I will not have time to deal with the symptoms and diagnosis but will proceed to consider the treatment.

Surgical Treatment of Infective Sigmoid Sinus Thrombosis.-Before entering upon a description of operative methods, it may be well to refer briefly to certain questions which bear directly upon the treatment of sinus disease, and which are yet open to discussion.

Until quite recently it was almost an axiom among the leading aurists of America that, when a suppurative lesion within the sigmoid sinus demands that this vessel be isolated from the general blood stream, the jugular vein should be exposed and resected from a point a little above the clavicle to a point above the entrance of the facial vein. As opposing this view must be considered the interesting and remarkably successful series of cases reported a few years since by Dr. Crockett, and to which reference has already been made. In these cases, sixty in number, and operated upon by the various surgeons of the Boston Eye and Ear Infirmary, the vein was simply divided between two ligatures, no part of it being removed. Including within this series certain cases in which evidences of meningeal or brain lesion were present before the operation, the mortality was 16 per cent. By excluding the case of pre-existing brain or meningeal involvement, the mortality is reduced to 9 per cent. These results are at least as good as any following jugular resection of which I have seen reports.

While in Vienna, five years ago, I saw two cases which had been operated on by simple ligation I was told by an aurist in London that ligation was the method there. Employed in cases not giving physical signs of extensive jugular thrombosis.

The advantages claimed for simple ligation of the jugular vein as compared with resection are (1) its comparative simplicity; (2) the usual absence of shock; (3) absence of disfiguring post-operative deformity or scar; and, finally, its advocates claim that, through the smaller drain upon the patient's vitality and nervous force, the results are better.

As to which operation should precede the other, i.e., the exploration of the sinus or the ligation or resection of the vein, two views are held.

Ordinarily, I do not believe that it greatly matters which operation is performed first. When, however, the patient's condition is so profoundly septic and his vitality so greatly reduced that the condition of any fresh septic material to that already circulating in the blood might turn the scale unfavorably, I should say that ligation of the vein should precede the opening of the sinus.

In any case, and whichever order of precedence is observed, the sinus should always be freely exposed and ready for exploration before the vein is operated upon.

Obviously complete removal of the jugular is the only operation open to us when this vessel is occupied through a

considerable portion of its length by an organized and presumably infected clot.

Operation for resection of the jugular vein, is briefly as follows: The incision is carried from mastoid tip, along anterior border of sterno-mastoid to clavicular attachment. Having divided the deep fascial layer exposed beneath the sterno-mastoid muscle, we come quickly upon the "common sheath" enclosing the jugular vein, carotid artery, and pneumogastric nerve, the sheath is opened.

Having separated the vein from its companion structure, two catgut ligatures are passed around its lower part and tied, and the vein divided between them. As the vein is isolation from below upward, any branches met with are tied between two ligatures and divided.

It is important that the upper ligature upon the internal jugular should be at a point above the facial branch.

Ligation of the Jugular Vein.-But little need be said as to the technic of this comparatively simple operation. As the purpose is to ligate the vein above the facial, it is obviously unnecessary to make the long incision employed when the vein is to be exsected.

When the jugular has been exposed and isolated at the point at which the facial vein is given off, one or both vessels may be tied. When it is necessary to ligate the jugular, the additional tying of the facial vein seems so devoid of untoward results, that most surgeons will be better satisfied-probably with good reason.

The importance of surgical treatment is clearly shown in the history of the following case:

Girl 12 years of age referred by physician in near-by town, presented following history two weeks previous to consulting me. While seemingly in perfect health, suddenly felt severe pain, over the mastoid region of right side; after a few hours patient had a distinct chill followed by temperature 103 to 105, after a short time it receded to normal, only to rise again upon the advent of a subsequent chill.

There was vomiting accompanying each chill; there was headache constantly over mastoid parietal and occipital regions of the affected side.

The patient had no appetite, a coated tongue, had lost weight; skin and conjunctiva had a yellowish tinge; the mentality of the patient was abnormal; the clinical picture was similar to typhoid fever, but perhaps more like meningitis or brain abscess when she came to me prostration had

ensued and all the symptoms of sepsis became apparent. There was present swelling behind mastoid process which was painful to the touch, there was edema and swelling in the skin of the scalp. This patient had suffered an attack of acute otitis media, about one month previous to the time she became ill, but had recovered from it, there was no perforation of the drum.

No blood examination was made. Immedate operation was advised and parents of patient consented.

The neck of the patient as well as the mastoid region was prepared for operation, the simple mastoid operation was done, and the sinus exposed by sharp curet and slender bladed rongeur forceps. An assistant made pressure over the jugular vein in order to arrest any detached blood clots, which might flow from above, with two plugs of iodoform gauze one over the torcu

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lar end and the other over the cardiac end to control hemorrhage.

The sinus was freely exposed and incised to the extent of about one inch, free hemorrage resulted, the plug was inserted into the torcular end, and again removed and hemorrhage followed showing no obstruction there, then the plug was removed from the cardiac end, but no hemorrhage resulted.

Proving thrombosis here, I packed the wound and made an incision of two inches over the jugular, from mastoid tip, down along anterior border, sternomastoid; I exposed the jugular and ligated in two places above facial and below, divided the vessel between the two, closed the wound and then introduced ring curet into cardiac end of sinus located the thrombus, scraped it out, left cigarette gauze drains, put on regular mastoid dressing and patient made an uneventful recovery.

I.

II.

V.

Song Sermons

G. HENRI BOGART, M. D., Paris, Ill.
NO MATTER.

No matter what you may think you are,
No matter what others may hold,
No matter the rank you may make or mar,
No matter your upheaped gold,

'Tis your inmost self most counts.

The widow's mite outweighed serried wealth,
The deed done for love, aye lives,
The kindness, though mayhap done by stealth,
These gain you the best life gives,

To some joy. eternal mounts.

Some years ago a young man with an appearance of the most successful gain in business invited me into his office one evening, and asked me to write him a verse on the thought, "Doctor it isn't what a man seems but what he is that counts." I complied with his request and wrote the ten lines above, after which he thanked me, and folded the copy into his pocket-book.

More than any one else, was I mystified, when the next morning it was made public that he had disappeared, and that he was an embezzler in a large amount, something inexplicable, when it was recalled that in addition to his good business, he had many friends, good social position, a devoted sweetheart, and no known bad habits. Recently he was apprehended and returned to his former home for trial, and in his pocket-book was found the verses, frayed and worn.

I have often wondered what impulse moved him, when the end of his tether was reached to set forth the ideal, whose violation had proved his undoing. How little do we know of the egos of those round about A bay may lie a pellucid pool, a sheet to mirror the golden glow of noonday, the

us.

silver radiance of the moonbeams, or glow with the mingled purple and gold of the sunset, and yet convey no hint of the bottom over which it ebbs and flows. Its floor may be of pure white sand, studded with nuggets of gold, or it may be the home of the pearl fish; it may be filled with the cruel jagged teeth of reefs, fatal to any craft, amid which lurk the demon sharks and the horror of the devil-fish; or it may lie a bed of hungry treacherous quicksand, the smiling surface tells no tales of what is beneath.

Beauty is but skin deep, and smiles may hide aching hearts. Nor can we call it hypocrisy and dissimulation that shows a glowing exterior when within is seething and cankered pain.

The impulse of the wild sends the stricken one into the darkest thicket to die alone, and the compensating balance of all things, makes for a demand for confession, for a mate to share the burden, an irresistible soul faculty which spells the success of those unconscious psychologists, the successful detectives.

It is in times of stress and throes that the desire to open the hidden chambers of the soul is most powerful, just as the storm drives back the placid surface of the bay and shows glimpses of the bottom.

The sympathetic physician, he whose human and humane instincts are intuitively and unconsciously recognized will be made the father confessor of many a strange tale of passion, wreckage, wrong and of high aspiration unrealized; he should prepare to meet the occasions heartfully, soulfully, tenderly, with brotherly sympathy and should guide the wistful soul into a harbor of peace.

ASSOCIATE EDITORS

P. I. LEONARD, St. Joseph
J. M. BELL, St. Joseph
JNO. E. SUMMERS, Omaha

CONTRIBUTING EDITORS
JOE BECTON, Greenville, Texas
HERMAN J. BOLDT, New York
A. L. BLESH, Oklahoma City
G. HENRI BOGART, Paris, Ill.

ST. CLOUD COOPER, Fort Smith, Ark.
T. D. CROTHERS, Hartford, Conn.
W. T. ELAM, St. Joseph
JACOB GEIGER, St. Joseph

S. S. GLASSCOCK, Kansas City, Kan.
J. D. GRIFFITH, Kansas City
JAS. W. HEDDENS, St. Joseph
DONALD MACRAE, Council Bluffs
L. HARRISON METTLER, Chicago.
DANIEL MORTON, St. Joseph
D. A. MYERS, Lawton, Okla.
JOHN PUNTON, Kansas City

W. T. WOOTTON, Hot Springs, Ark.
HUGH H. YOUNG, Baltimore

DEPARTMENT EDITORS

KANSAS CITY

H. C. CROWELL, Gynecology

JOS. LICHTENBERG, Ophthalmology EDW. H. THRAILKILL, Rectal Diseases

ST. JOSEPH

J. M. BELL, Stomach

C. A. GOOD, Medicine

A. L. GRAY, Obstetrics

J. W. MCGILL, Rectal Diseases

L. A. TODD, Surgery

F. H. SPENCER, Surgery

OMAHA

H. M. McCLANAHAN, Pediatrics

H. S. MUNRO, Psychotherapy

DES MOINES

WALTER L. BIERRING, Medicine

Vol. XXXIV

HOPE FOR VENTILATION.

The most hopeful move for good, or at least better, ventilation of public schools has just begun and in an unexpected way. The start was made in Idaho. The process of improvement consists in nothing more nor less than the reduction of the number of pupils crowded into a school-room. The board of health of Idaho has proclaimed that, hereafter, there shall not be more than thirty-eight pupils to a room.

The subject of school ventilation has been receiving more and more attention recently, and partly because there has been increasing lack of ventilation, due, in large part, to the placing of more and more pupils in a room. The air, never too good, has become so bad as to cause this recent revolt against the condition. As a supposed matter of economy, as many as sixty pupils have been placed in a school room of ordinary size, which, twenty-five years ago, held not more than thirty. We are reminded in this

No. 2

method of economizing of a certain hospital ward which, only five years ago, was ideally fitted with twelve beds. Today that ward contains twenty beds and the atmosphere is noticeably changed. The comparison between this ward and a school room is, however, not appropriate, because the ward is larger than the school room and contains as yet only twenty persons. Hospitals and jails always have furnished their inmates far more air per person than have the public schools. The child takes what comes to him in the way of air and seldom objects. The sick are usually adults who may complain. There are also boards of visitors and daily rounds of doctors who possess een noses. There are no such visitors for the public schools. We once, in an official capacity, objected to the hanging of the children's wraps, wet or dry according to the weather, inside the school rooms of a certain building. The clothing is still hung there. It was suggested that the