LATERAL SINUS THROMBOSIS AND CEREBELLAR ABSCESS.*

BY J. P. MORTON, M.D., HAMILTON, ONT.

Our purpose is to compare two cases one of lateral sinus thrombosis with one of cerebellar abscess.

These cases were under our care at the same time and offered us opportunities for contrast. We found it difficult to steer ourselves through them without mistakes.

The lateral sinus case was in a man of 45 years, who had suffered from right chronic otorrhoea for three years. He was well nourished, of decidedly lymphatic temperament, and was a very heavy drinker.

When we saw him first he was in bed with a T. of 101 degrees and P. 110. He was not complaining much, and his wife thought he was much worse than he pretended to be. He seemed dull, but had been out on a spree for two or three days before. He looked very sick to us and was perspiring heavily. There were no pupillary disturbances. He was constipated, with furred and coated tongue. Slight tenderness was present over mastoid very high up. There was no sagging of walls, and a perforation through Shrapnell's membrane seemed to be plugged with dried matter.

We immediately enlarged this opening down as far as meatal floor and curetted the middle ear and otic, which seemed filled with cholesteatomatous substance, and there seemed to be very little free matter. During the next three days he was much better, T. being 99.5, the ear-ache and tenderness over mastoid disappeared. We used ice over mastoid. On fifth day his temperature rose to 101 and he was perspiring profusely. Mastoid tenderness was very difficult to elicit. He seemed drowsy, although in this connection you must remember his natural apathetic condition and his alcoholic condition. He answered intelligently, but slowly. We sent him to the hospital and watched him for two days. Perspiration continued to be profuse; his temperature went to 103.5 on second day in hospital. He seemed to be duller mentally. There was twitching of facial muscles. No pupillary disturbance and fundus normal. No tenderness in neck over internal jugular vein. There was now profuse discharge from middle ear, but if there had been tenderness over mastoid he now would admit of no more on the

* Read at annual meeting of Ontario Medical Association at Hamilton.

right than on the left. This was very disconcerting, and the diagnosis was between intercranial abscess and lateral sinus trouble. Operation revealed a very much sclerosed mastoid, a middle ear and antrum with well-formed cholesteatomous formation. On uncovering the sinus, we found a discolored dura, no pulsation of vein, the walls were not smooth or yielding to touch. An incision. 1-4 inch long brought no bleeding, and instead pus was found in sinus and behind it. We extended the incision to 1 inch in length, and by means of a blunt curette endeavored to secure bleeding from above and below. We were successful at the torcular end, but the bulbar end, which we would rather have had bleed, remained closed. We now proceeded to excise the jugular from clavicle to above the entrance of facial vein, but our anaesthetist informed us that the patient was in very bad condition and asked to be allowed to stop anaesthetic.

Temperature remained normal for two days and mental condition was improved. On third day after operation T. rose to 112 degrees, with profuse perspiration. The nurse said she had "never seen such sweating." In evening T. dropped to 99. This seemed to indicate severe systemic infection from internal jugular, and was shown even more distinctly on sixth day, as T. went to 105 in morning and dropped to 97 at night. We advised removal of internal jugular very persistently, but one of us as a consultant advised against this, and so it was not done. During the next week the patient was very sick. The ear was dressed each day; no syringing was done. The T. dropped to 96 and 97, and this seemed to predominate, but now and again it would rise to 104, 105, and once to 106. He lay on his left side and would not turn to right. Cerebration was very slow, and often he would never answer. He seemed to be very deaf. No aphasia. Pupil on right was dilated slightly, and they both reacted very sluggishly to light and accommodation. He felt dizzy. There was marked twitching of facial muscles, with ptosis of right side. Fundus was normal. The muscle power seemed normal. Slight nystagmus was present when he looked to left side. Urine normal, and blood count showed leucocytosis.

We were pretty sure the patient was going to die. We warmly discussed the probability of brain abscess, and one of us advised exploring for cerebellar abscess. Weight of opinion was against this, chiefly for three reasons:

1. The lateral sinus condition was known to be so bad that it would account for the condition without supposing the other. 2. Absence of optic nerve trouble.

3. The T. did not remain subnormal, but rose every now and again to as high as 106. This was a very important deciding point.

4. Indefiniteness of what cerebellar or cerebral symptoms there were. Nystagmus was only found on having patient look to left for quite a while, and might be due to exhaustion. Slight pupil dilation might be due to his always lying to left side; I have read that this occurs. (In Allbutt, System of Medicine.).

His alcoholic condition and natural apathy, with the toxine, would easily account for his sluggish pupil reflexes and his dull mental condition and the poor reflexes, knee, elbow, Babinsky, etc. If his T. had stayed subnormal, operation would have been done.

Extra dural abscess was ruled out because of the freedom with which we opened things up at time of operation. The tegmen tympani was removed and no abscess could have been near the sinus without having been opened; in fact, there was an extra dural abscess opened; it lay around the sinus. We were correct in our judgment, for the patient gradually improved, and is drinking as hard as ever to-day.

Permit me to say that, although the internal jugular was not excised in this case, some of us believe that the patient was allowed to run an unjustifiable risk.

Our second case was in a child of fifteen, and when first seen she had a typical right suppurating mastoid. T. was 105 when we operated, showing very extensive bone destruction, as the case had been badly neglected. We uncovered 3-4 inch of lateral sinus and found it normal. The T. was normal for four days after the operation, and then for three days it went to 99, 100, 101. The child seemed to be getting dull, although when its parents came it seemed as bright as ever.

During following week we noticed these points: T. went to normal, with slight variations, and then to subnormal, with slight variation, but it never went above 99. The child always wanted to turn on its left side and keep its right cheek up. If turned in any other position she would immediately turn back, and there seemed to be retraction of the neck muscles, but this was probably due to action of opposing sterno mastoid, the right muscle now having no mastoid attachment. One of us made the diagnosis of meningitis, but this was ruled out on account of T. and mental condition. There was no nystagmus, even in long trials to either side. No pupillary disturbances. No fundus indications. aphasia. No vomiting, except once on eating some sweets. Severe diarrhoea. Muscles of right arm were weaker than those of left. Leg muscles equal in strength. Cerebration was undoubtedly slow.

No profuse perspiration. She felt like turning around and could hardly stand up. When we handled her she was very irritable and wanted us to go away, and would cry. All reflexes were exaggerated, chiefly on right side. There were no paralyses, although the eye muscles seemed slow in action. Sensation was normal, although it always elicited irritability. Different diagnoses were here made:

Lateral sinus thrombosis.

Cerebellar abscess.

Temporo sphenoidal abscess.

Extra dural abscess.

Meningitis.

These were held to by different consultants.

We ruled out some of these as follows:

Lateral sinus thrombosis was ruled out because there was no rise in temperature after it became subnormal, and there was no profuse perspiration.

Extra dural abscess, on account of expectation that it would have found exit at site of operation.

Meningitis was ruled out because of continuous subnormal temperature and absence of Kernig's sign, no crying out and recognition of neck retraction as being due to antagonistic sterno mastoid action.

This left temporo sphenoid abscess and cerebellar abscess to trouble us. We decided in favor of cerebellar abscess for the following reasons:

1. Age of patient; 10-20 most common age.

2. Forced position in bed; right side persistently up; curled

up in bed.

3. Marked paresis of upper limb on same side as lesion.

4. Exaggerated reflexes on right side.

5. Rotation; fall away from the lesion.

Operation showed a large cerebellar abscess. Patient improved for a few days after operation and then all the symptoms of cerebellar abscess and purulent meningitis became very prominent and patient died. Post-mortem showed diffuse purulent meningitis.

Physician's Library.

Poisoning By Arsenuretted Hydrogen or Hydrogen Arsenide. Its Properties, Sources, Relations to Scientific and Industrial Operations, Symptoms, Post-Mortem Appearances, Treatment and Prevention. With a record of one hundred cases by different observers. BY JOHN GLAISTER, Doctor of Medicine of the University of Glasgow, etc., etc. Price, 5 shillings net. Edinburgh: E. & S. Livingston.

From various sources the author has compiled the histories of several cases, which with those occurring under his own observation, number one hundred and twenty. As there has not been, prior to this, any single volume on the subject, this may be accepted as the standard to go by and will make a distinct addition to Forensic Medicine and Toxicology.

Borderland Studies. Miscellaneous, Addresses and Essays pertaining to Medicine and the Medical Profession, and their Relations to General Science and Thought. Volume II. BY GEORGE M. GOULD, M.D. Price, $1.50. Philadelphia: P. Blakiston's Son & Co.

As the sub-title implies this is a collection of essays, lectures and addresses which from time to time have been put forth by that energetic and forceful writer, Dr. Gould, who is well and favorably known to the medical profession of Canada. It forms a unique volume in medical literature and will be read with great interest.

Medical Gynecology. BY S. WYLLIS BANDLER, M.D., Adjunct Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital. Octavo of 675 pages, with 135 original illustrations. Philadelphia and London: W. B. Saunders Company, 1908. Cloth, $5.00 net. Half Morocco, $6.50 net. Canadian Agents: J. A. Carveth & Co., Limited, Toronto.

There were surgeons and gynecologists who not so very long ago denied there was such a thing as medical gynecology. The author