Reports of Societies
BMJ (Clinical Research Edition)
Mr. HENRY STOKES in the Chair. Thrombosis of the Lateral Sinus. XR. 0. GOGARTY described a case in which he had resected the jagular vein on account of thrombosis of the lateral sinus. He reported this case in order to show the importance of considering disease of the middle ear in the diagnosis of obscure cases. The patient had been %diagnosed as suffering from gastric disturbance when vomiting was marked, and later from stoDe in the kidney, when great haematuria occurred, and did not
... nd did not seekadmission to-hospital until the disease had been present for six days. The temperature on two occasions had been 1050, -and rigors had occurred before admission. The prominent feature of the case was the total absence of localizing signs. Oedema over the mastoid, Greisioger's sign, tenderness over the jugular cord, and stiffness of the neck were .missing; though the presence of pyaemia made the case All but hopeless, it was decided to give the very slender chance of recovery by operation. A clot nearly 2 in. in length was removed from the lateral sinus after a considerable portion of the internal jugular vein had been resected. The patient lived only two days, dying of pyaemia, with a rash and well-marked jaundice. Dr. DEMPSEY said theyshould be grateful to the exbibitor for showing a case which was not an operative -euccess. Lateral sinus thrombosis was much more commonly met with since the radical mastoid operation had -come into vogue. The great difficulty was the question of diagnosis in certain cases, and in dealing with such he thought they should be guided by what they met with when treating the case. He hadEeen a case, in which the 'diagnosis was typhoid fever, that developed some discharge from the ears. He cut down on the mastoid, and found -extensive bone disease. He did the ordinary operation, and the patient was much better for several days. Then -came a temperature of 1050 and sharp rigor, suggesting lateral sinus disease. He reopened, but found things as at ,first. The same symptoms recurred for three weeks about four times a week, but further operation was refused, and yet the patient got steadily well, and was now in perfect health. In another case, in which the radical mastoid -operation was performed, the patient also developed a high 'temperature and rigor. The lateral sinus was exposed, -and showed a surface greyish, and breaking down, with the -emission of pus. The jugular vein was tied in the neck, -nd the sinus freely opened with free haemorrhage. The -patient died, and the trouble was found to be a cerebellar ,abscess. If one met with a vein clotted down in the neck, -itshould be cut down on and the vein excised; but if one found the sinus filled with clot in the region of the mastoid, the question arose as to whether the internal -jugular should be tied at all or not. Opinions were about -equally divided. Cases in which it was not tied had done just as well as if the ligature had been effected. But the -test was hardly a fair one, as the cases of tying were practically desperate cases which were given a last -chance. Dr. HARVEY sympathized with Mr. Gogarty in his -endeavour to save the patient's life. The procedure adopted was very wise, and he would like to know what were the indications as to when the internal jugular should .be opened. Mr. W. S. HAUGHTON said it was from such cases very -often that they learnt most. He had operated on five cases of suspected thrombosis, in three of which the condition was found and death followed. In the other -cases there was no apparent thrombosis, and death followed. He did not ligature the internal jugular, but he was inclined to think it should be done oftener than it had been done. In a case which was not .4eptic he adopted a trephine opening, and cut into the lateral sinus. Severe haemorrhage followed, and he was obliged to plug. Six days later he reopened and cemovad the plug, and no haemorrhage followed. He had, however, given up the trephine, as he found the broad gouge did the work more safely. Mr. WM. TAYLOR said he had seen the swelling which was found along the jugular vein to be due, not to an infection of the vein, or thickening, or clot, but to be an infection of the glands. Where they could easily recognize on palpation the cord-like swelling described in the books, it was too late; but there was one chance in five hundred which should be given to the patient. Where there was the smallest suspicion of any intracranial complication, operative interference should be undertaken at an early stage. In the combination of two intracranial complications due to ear disease, the difficulty of diagnosis was greatest, and he believed that septic sinus infection predominated. He hadseen a case in which the phenomena of cerebellar trouble did not manifest themselves until some twenty-four or tbirtysix hours after the lateral sinus had been opened. Cases of sinus infection, where there was not a clot, were, he felt, far more dangerous than those in which there was, and he would be inclined to ligature the jugular, even though the infection might be carried by other channels. He would have no hesitation in doing so where there was clear evidence that the sinus was infected; where there was a doubt he would expose the mastoid and the lateral sinus, and deal with the condition as he found it. Dr. PBARSON asked what were the indication,s for operating on obvious ear cases, where pus was found under tension in the mastoid without anydefinite evidence of other complication at the time. He rec4lled a case in .which the radical mastoid operation was done. After the operation the patient appeared to be very well, but the temperature rose later to 1030, and a blood count showed a marked leucocytosis. The patient became very dull, and answered questions slowly, but there were no other symptoms. The wound was reopened, and a large temporo-sphenoidal abscess was found with pus under very high tension. He felt certain the abscess was present at the first operation, but that it had passed the stage at which it gave the symptoms they were on the look-out for.