The operative treatment of these cases will be discussed by itself.
B. Sinus Thrombosis.
—The sinuses are predisposed to thrombosis by virtue of their size, inflexibility, shape, and the fact that they are not emptied during respiration, all of which tend to retard blood flow. If to these be added defect in the blood supply, then everything predisposes toward marasmic thrombosis. This occurs much less frequently than the infective form, is mostly confined to the longitudinal sinus, is noted mainly at the two extremes of life, and is often seen in cases of death following exhausting diarrhea in children. In the marasmic form the clots are dense, firm, stratified, and non-adherent; they rarely occupy the whole caliber. In old cases the clots may be tunnelled sufficiently to permit reëstablishment of circulation. Their principal evil consequences are edema of the frontal lobes and serosanguineous effusion into the ventricles or orbits—in the latter case producing exophthalmos. Sometimes epistaxis is produced. Strabismus, tremor, muscle rigidity, or contractures are more often seen conjoined, especially in children, with convulsions, sometimes unilateral, and choked disk.
Diagnosis.
—The diagnosis in adults is difficult, but in children, when convulsions occur after exhausting illness, with the signs just noted, marasmic thrombosis may ordinarily be diagnosticated.
Infective thrombosis, the other variety, is due exclusively to the invasion of pyogenic organisms. It is observed mostly in the basal sinuses; its origin is local, and it is always secondary to some external infection. Its most frequent cause is middle-ear disease; consequently the sigmoid sinus is the one most often involved. It may follow carbuncle, erysipelas, or cellulitis of the external parts, or nasal ulceration, as well as dental caries, suppuration of the tonsils, etc. Infection may be propagated by tissue continuity, or through the circulation.
Symptoms.
—Infective thrombosis presents few distinctive symptoms. Local ischemia, perversion of function, extracranial edema are too vague. Headache is nearly always constant and vomiting is frequent; temperature runs high, with marked remissions; the pulse is small and rapid, and remains so even under an anesthetic. Chills are frequent, of the pyemic type, and are followed by copious sweats. Should pulmonary infarct occur there will be typical thoracic signs, although at first physical examination may give negative results. Later, however, we get prune-juice expectoration, putrid sputum, etc. Cerebral function is disturbed late rather than early. The duration of the disease ordinarily is from two to four weeks. Should meningitis complicate the case there is more violent headache, persistent high temperature, great excitement, muscle spasm, strabismus, delirium, and coma; if the sigmoid sinus be involved there is usually retraction of the head. Should leptomeningitis extend down the spine, complaint of girdle pains will be made.
Differential Diagnosis.
—The two conditions which are most likely to be confused with sinus thrombosis are meningitis and brain abscess. In thrombosis there are pain and tenderness over the mastoid, extending down the neck. Fever is high, pulse rapid, respiration not affected, rigidity not usually present. Chills are frequently followed by profuse perspiration. The general picture is one of sepsis and the typhoid state. There are no special eye symptoms. Death is finally due to pyemic processes. In meningitis pain is an early, constant, and severe symptom. Headache is frontal or general, fever is not characteristic, pulse is rapid until the accumulation of pus causes slowness by pressure, breathing is short and rapid, and finally of the Cheyne-Stokes variety. Rigidity of the neck and back, with retraction of the head, is nearly always present, with spasmodic contractions or convulsions about the neck. Chills are not so pronounced, vomiting is almost invariably of the projectile type, optic neuritis is frequent, and the intellect is early impaired. In brain abscess pain is at first localized and severe, extending and becoming excruciating. This increases on pressure, and does not disappear until relief is obtained or the patient becomes unconscious. Temperature is normal or subnormal until the abscess ruptures. The pulse is slow, as in compression from other causes; breathing is slow and stertorous. Rigidity and vomiting are like those of meningitis. Eye symptoms are almost always present, photophobia at first, later inequality of pupils, with dilatation on the affected side, optic neuritis and irregular movements of the eye and lids. Drowsiness, dizziness, and impaired intellect are features when the abscess is in the cerebellum. Death occurs in coma unless the case be complicated by meningitis.