The Cause of a Positive Agglutination Reaction in Icterus

HENRY A. CHRISTIAN
1907 Boston Medical and Surgical Journal  
pass a ligature around the vessel, but allowing it to remain untied. This provisional tourniquet could then be tightened at any time during the course of the operation if necessary. The following experiment of opening the cavernous sinus is quite easy on the cadaver and can be done without injuring the structures within the sinus. Introducing the instrument (Fig. 5 ) into the nose as far posterior as the pharyngeal wall one finds the inferior surface of the sphenoid above the naso-pharynx. This
more » ... naso-pharynx. This can be done by the sense of touch alone. Withdrawing the instrument until the curette passes just above the junction of the anterior and inferior wall of the sphenoidal cavity, it is forced backward and of necessity upwards through the roof directly into the cavernous sinus at its junction with the an-Fio. 8. Superior surface of base of skull. Hoof of both sphenoidal sinuses removed. 1. Cavities of sphenoidal sinus seen from above. 2. Median bony partition. 3. Anterior wall of right sphenoidal sinus. 4. Opening of sphenoidal sinus into tho nose. 5. Crista galli. tt. Groove for lateral sinus. (a) Anterior fossa. (6) Middle fossa, (c) Posterior fossa. terior circular. (Fig. 6 .) The curette enters the sinus as the thin endothelial lining of the sinus in contact with the bone is held down in place by the other structures within the sinus. The outer and superior wall of the cavernous sinus is the one which is thick and elastic, preventing the instrument from passing further on into the brain. The end of the curette can push this yielding wall of the sinus one-half inch without damage. With a finger at the mark on the shaft, the overhanging edge of the curette grasps the bone when the instrument is rotated. With this single instrument a hole of any size can be made. I was able to do this simple experiment on a patient dying^o f thrombosis of the cavernous sinus within an hour after death, Withdrawing my spoon, after opening the sinus. I found that it contained some pus. Removing the skull cap and brain and incising the cavernous from above the curette was found to have perforated the sinus exactly as outlined. With a portion of the floor wanting the pus within the thrombosed vessel was still slowly draining out of sight into the cavity below. (Fig. 7 and Fig. 8 .) It actually seems possible to remove the middle turbinate and anterior wall of the sphenoidal cavity and, with a good head light, under cocaine, open the cavernous sinus under primary anesthesia. If it is thrombosed it would hardly be likely to bleed. Luc's method of approaching the cavernous through the maxillary antrum on the opposite side is an excellent one. The pus would drain either into the nasopharynx or antrum. The latter could be kept open as long as desired. The advantages of an intranasal route over a craniectomy would be minimum of shock, comparative freedom from hemorrhage and accessibility of a possible aftertreatment. I do not believe that merely opening the ophthalmic vein will be sufficient in all cases to drain the cavernous. To expect results one would be inclined to think that the sinus must be opened as freely as a lateral sinus and with a chance for permanent drainage. It perhaps makes but little difference what method is selected as long as some attempt is made to drain the sinus directly. We can no longer, however, look for aid in speculation, but must patiently wait for the severer test of actual trial. Luc: " La voie la plus directe et la meilleure pour la réalisation de ce but nous parait être celle imaginée par Krönlein ot que Voss, conseille d'adjoindre a son procédé opératoire dans les cas ou l'infection caverneuse, au lieu de partir de l'oreille, tire son origine de l'orbite. " D'après cette méthode, un incision courbe, a concavité postérieure, passant entro le bord externe do l'orbite ot la commissure palpibrale externe, permet do rugincs les doux faces (temporale et orbitairo) de la paroi externe do l'orbite, a sa partie la plus antérieure, puis de libères celle-ci inférieurement. au moyen d'une scie a chaîne passée à la partie antérieure de la feUto pterygo-maxiïlairo ot ressortant, en arrière, audessus de l'arcade zygomalique, toudis que la libération est réalisée supérieurement avec la gouge. Apres quoi, le fragment osseux libéré étant laissé adhérent a la face profonde du lambeau musculocutané, on vue de sa remiso en place ultérieure, lo reste, c'est-à-dire la portion postérieure de la paroi externe do l'orbite, est réséqué de proche on proche, a coups de pinco coupante, jusqu'au sommet de l'orbite, ou l'on atteint, la voino ophtalmique et la terminaison de ses principales bronches afférentes. Rien de plus simple ensuite que d'assurés le drainage de co foyer au moyen d'un gros drain plongeant au fond do l'orbite et que l'on fait ressortir par l'extrémité inférieure, laissée beauté, de l'incision cutanée, tandis quo lo reste en est suturé."
doi:10.1056/nejm190704251561703 fatcat:vifz3xclcnbnta674aypzj6pcm