Death, primarily due to respiratory failure, is often preceded by general twitchings or convulsions.
The whole course of the illness seldom lasts more than a week, the more acute cases terminating within two or three days.
Treatment.
Whether threatening, developing, or obviously present, the patient should be treated with urotropin (see [p. 116]). In its early stages of development immediate operation affords some hope of cure, such treatment having as its basis the supply of adequate drainage. The source of the infection must be removed—so far as circumstances permit—the dura mater freely incised, and the pia-arachnoid region so opened up as to allow of the escape of some of the purulent or semi-purulent fluid. The wound is largely allowed to remain open, packed with gauze. The predominant organism may be isolated and, if time allows, suitable vaccine treatment instituted. In the meantime, 20 to 40 cc. of pyogenes serum should be administered.
From the point of view of diagnosis, lumbar puncture should never be omitted. The fluid escapes at high tension, is turbid and contains many polymorphonuclear leucocytes and organisms, the latter verified with the greatest advantage after centrifugalization. Repeated lumbar punctures are also said to be of some benefit with respect to treatment.
SINUS THROMBOSIS
Lateral sinus thrombosis.
Soon after entering on its course across the mastoid process the lateral sinus presents a well-marked S-shaped curve. This sigmoid sinus bulges markedly forwards—especially on the right side—towards the region of the mastoid cells and antrum, so much so that a mere shell of bone intervenes between the sinus on the one hand and the antral region on the other. Indeed, the relations are so intimate that one would expect a more frequent occurrence of lateral sinus thrombosis. Furthermore, the sinus receives numerous venous communications from the mastoid cells, antrum, and other parts of the temporal bone, conspicuous amongst the last-named group of vessels being the mastoid emissary vein which, passing inwards at the upper and posterior border of the mastoid process, connects the posterior auricular and occipital veins with the lateral sinus.
From these considerations it is obvious that any acute or chronic infective process originating either in the aural region or in the neighbourhood can readily infect the sinus by direct propagation of organisms along one or more of these inter-communicating vessels (thrombo-phlebitis).
The sinus may also become infected in middle-ear disease by the more gradual process of mining and sapping, the osseous barrier between the antrum and sinus being progressively destroyed by the backward progress of the aural disease. The sinus may erect an additional barrier by throwing out granulations (external pachymeningitis) against the invading host, but, in the event of the attack overcoming the defence, sinus thrombosis may result, at first perhaps of a non-infective type but soon becoming definitely septic, the clot softening and disintegrating (osteo-phlebitis).