infectious thrombosis the respirations are often quickened. Vomiting
now occurs relatively si'ldom, and probably only when the upright ]>osi-
tion is assumed. Vomiting accompanied by a persistent headache is
always in<licativc of intracranial miscliief. If vomiting l)e a sjtccial
feature throughout the progress of the case, there is no little j)robability
of involvement of the cerebellum. Convulsions are frequent, but not
distinctive. They are the result usually of secondary irritation of motor
areas. Maoewen states that when pus has leaked into the subdural space
or into the ventricles we are likely to note convulsive movements of
erratic character, accompanied by rigidity, and tetanoid movements are
sometimes noted. When convulsions do occur they should be carefully
observed for localizing symptoms.

Paralysis may result from destruction, and may give considerable aid
in diagnosis, since its cause is generally close to the lesion which we
seek. An odor of offensive character is usually given to the breath of
patients who suffer from cerebral abscess due to ear disease, and might be

attributed to ordinary causes did it not so nuich resemble that emanatinof

. , * . . . ~

from the ear itself. Sometimes it even taints the atmosphere of the



ABSCESS OF THE HI! A IX. 687

patient's room. During tlic latter stage of these cases rigors are less
frequent. Optic neuritis is often met with, jjarticularly in the later
periods, iiut not so often nor so comjilete as in cases of tunioi-.

A great deal of emphasis should he placed upon the results of a care-
ful aural examination. If the membrana tympani be destroyed, it may
be possible to recognize the destruction of one part or another of the
tympanic wall, or even the escape of pus from perffirations into this
cavity. The careful use of a probe under these circumstances may give
much informatinu. Swelling and redness over the mastoid are not (iften
found in ccrtiiral abscess in adults.

This disease of course tends to produce a fatal result, either by in-
creasing stupor and coma or by the rapid consequences of bursting of
an abscess into a ventricle ur into the brain-surface. Then the intiam-
matory activity is most rapid and pernicious. It is generally heralded
by acute symj)toms — vomiting, restlessness, flushing, spasms, prostra-
tion, (juick breathing, and high tenq)crature. A\'heu a ventricle is
involved the symptoms are even more clear : temperature rises with a
bound, muscular twitchings are associated with convulsions, and these
are quickly followed by coma, and by death, which frcfjuently results
within eight or ten hours from the first indication of rnptni-e.

Loca/iziiif/ Si/inpfmns. — These are only occasional in cerebral abscess,
because the majority of these lesions are situated outside the motor area.
Alterations in the pu])ils are sometimes met with. A\'ith abscess in one
temporo-sphenoitlal or frontal lobe the ])upil on the same side may cither
enlarge or diminish, but whatever size it assumes will probably remain.
Jloreover, it niav lose its motility. AVith a small abscess and cereltral
irritation it will i)robaI)ly he almormally small ; with a large abscess and
great pressin-e it will ])robably be dilated. As an abscess grows the size
of the pujiil may increase pari pax-ya. Sometimes the only difference
noted is relative .sluggishness of the pupil on the affected side. Infec-
tive thrombosis, save in the cavernous sinus, rarely affects the size of
the pupils, and when it does there is usually ptosis as well as pu])illary
change.

Macewen has laid great stress upon the inijiortance of percussion, and
ujion the fact that he elicits in these cases a different cranial jiercussion-
note. He percusses with the ordinary instruments or Ity the tip of the
middle finger, tapping lightly upon the cranium, which answers all
requirements. He ])refers immediate ])ercussion with the ear ujion the
patient's head. He claims that when the latei-al ventricles are distended
with fluid the ])ercussion-note is greatly altered, the resonance lieing
greatly increased. He reminds us, however, that the percus.sion-note
for a given spot — for in.stance, the pterion — varies according to the jiosi-
tion of the head. In children and adolescents he gets ordinarily a clear
percu.ssion-tone over the distended ventricles, and claims that the tones
over the corebelhnn generally aid in diagnosis. (Incidentally, we may
add here that he gets a characteristic craeked-jiot sound on ])ercussion
of the head in extensive fractures.) All of which would indicate that
there is a very limited field for the aj)])lic^tion of this physical sign, but
that in certain cases it may be of value. IMacewen also reminds us that
the quantity of pus issuing from the middle ear is always to be noted,
with a view to ascertaining whether or not it be greater than would



688 DISEASES AXn IS.IVrdES OF THE HEAD.

j)r()biil)Iy e.sc:i])e fi'Diii the oar alone. If distinctly greater, then there
must be an internal caA'ity from which it flows.

The particular si<i'ns of abscesses in particular localities may be
briefly epitomized as follows : In temporo-sphenoidal abscess pain usu-
ally originates in the ear on the same side as the abscess. As the brain
becomes involved we have affections successively of the lower part of
the ascending frontal and parietal convolutions ; then of the posterior anil
lower part of the third frontal ; then of tiie posterior half of the first tem-
poral ; anil, finally, the motor and sensory strands in the internal cap-
sule may be pressed on and complete local paralysis result. Hemiplegia
on the opposite side, then, is occasionally found in large temporo-sphe-
noidal aitscesses. Sometimes this is due ])urely to pressure, since resto-
ratiou of fiuiction often follows evacuation of ])us. When the order of
paralvsis is face, arm, and then leg — and particularly when sensation is
preserved — abscess in the temporo-sj)henoidal lobe is in all probal)ility
pressing from below up^vard. If, however, the order be leg, arm, and
lastly face, or if they be simultaneously affected, and particularly with
sensory paralysis, then the probal)ility of secondary involvement of the
internal capsule is nnich greater. Facial paralysis is connnon in ad-
vanced destructive lesions of the mastoid and tympanum. To distin-
guish any fiicial paralysis produced by cortical lesion from one produced
by paralysis of the facial nerve we may add that the former is seldom
so intense ; the patient can usually shut the eyelid, and there is commonly
some power of emotional expression on the affected side, while the sense
of taste in the anterior two-thirds of the tongue remains intact. In com-
plete peripheral paralysis of the facial nerve these are absent. Aphasia
is noted in some ai)scesscs on the left side. Paralysis of the third nerve
on the same side is often to be exjieeted in large abscesses. If this be
complete, we have ptosis, external strabismus, and fixed and condyloid
foramen with formation of deep cerN-ical abscess, or along the anterior



SINUS-THBOMBOSIS. 693

condyloid foramen, along the twelfth pair, and along the vein which
communicates with the vertebral plexus. On the other hand, along Avith
such involvement of the sinus-Avall we are likely to get acute lepto-
meningitis, although this may not occur faster tlian ])rotective adhesions
may tbrm A\hich shall shut off infectious products.

The result of all this disintegration within bony channels is to pro-
duce a marked eifect upon the bone itself, which becomes pigmented,
discolored, and eroded. The discoloration probably is due to the bacillus
pyocvancus. Sometimes there results deep staining along the venous
grooves, and tiie soft tissues may also participate in this stain.

Supposing the infection and resulting disturbance to be mild in degree,
there may be reaction in the direction of I'ormation of granulation tissue
aroiuid the sinus-walls, wliich will penetrate into the eroded bone on
one side and into the lumen of the vessel on the other. By a later organ-
ization of this we may get complete obliteration by tilirous tissue. This
granulation tissue may act as a barrier, autl Ibrm a most pronounced san-
itarv cordon as against tiie advance of infectious ju'ocesscs. Should it be
detached, its very object may be defeated. Hence the misfortune of
inciimplete operations.

Tlie terminal limits of most of tliese tin'ombi are protective, since dis-
integration does not usually extend so fir. Tluis in the internal jugular
a cord-like mass may be felt under the sterno-mastoid, often extending
Avell down the side of the neck. This, of course, is protective, and the
sooner such a thrombus organizes and adheres completely, the sooner
is possibility of pulmonary infiirction through the jugular shut otf.
Hence, too, the practicability of attacking the jugular in many of these
cases and washing through from aliove. It is even on record that the
superior vena cava has been completely occluded in this way and in tlie
same fashion.

By extension from the visceral side of the sinuses we may get cerebral
or cerebellar abscesses as well as purulent meningitis.

Symptoms. — Infective thrombosis does not give rise to distinct
patliognomonic symptoms. There is local iseluemia, with interference of
function an<l extracranial tedema. Tlu' general symptoms are those due
to dissemination of septic material. Headache is nearly constant, the
pain being sometimes extremely severe. Vomiting is frequent. Tem-
peratin-e usually runs high, with marked remissions. The pulse is small
and rapid, and remains so even when patients are narcotized. Chills are
frequent ; they occur early and jjerhajjs often, and the tendency is toward
greater freciuency as the condition becomes worse. Tliey are of the
pyaMuie type, followed by copious perspiration. The general appearance
of the patient is typhoid. Sometimes the lungs become involved insid-
iously ; at other times the occurrence of ])ulmonary infarction is easily
recognized. In either ease we usually have tlysniKca with cough — com-
plaint of pain in the chest whose location varies with the succession of
infarctions. At first physical examination may give negative results.
After a day or two we get ]nnuie-juice expectoration, coarse rales, fol-
lowed later by moist rales ; tlie sj)utum becomes putrid ; there is great
fetor of the breath ; and the presence of infective pneumonia cannot be
doubted.

Cerebral function is at first active and unimpaired ; intelligence often



694 DISEASES A XT) INJURIES OF THE HEAD.

lasts nearly to the end. The (Inrntidii (if the disease ordinarily is from
two to four weeks, death resultiiifi- i'roni exhaustion and se])sis.

Macewen has described u tv])hoid or abdominal type in whieli tlie
toxffimic symptoms are ])articularly manifested in the abdomen. In these
cases the skin is occasionally affected with a rash, which does not disap-
pear on pressure. The svnijitoms in many respects strikingly resemble
those of enteric fever, and experienced physicians have been misled.
This is more apt to t)ccur when otorrlia>a has not been observed or is
regarded as insignificant.

When meningitis occurs early by extension we have more violent
headache, often referred to the frontal region, frequent vomiting, per-
sistent high temperature, fewer chills, great excitement, spasms of the
upper muscles of the body, strabisnnis, with delirium and coma at the
last. If the sigmoid sinus is involved, there is usually retraction of the
head, perhaps to the aHccted side. If the leptomeningitis be diffused
down the spine as well, there are girdle-pains complained of, and there
is absolute prostration.

In certain cases, aside from the above-mentioned brain-symptoms, wo
have pecnliar disturliances due to stasis of blood in {■ertain limited areas.
For instance, we may have exophthalmos on one side or both, along
with conjunctival injection, redema of the lids, and disturbances of
vision. These symptoms occur in thrombosis of the cavernous sinus
and are produced l>y stasis in the ophthalmic vein. In these cases it is
possible for the frontal veins which empty into the o})hthalmic to be
also compromised.

Other features of deep thrombosis may also be mentioned. Thus,
Dusch noted thrombosis of the superior longitudinal sinus in a boy suf-
fering repeatedly from epistaxis. (lerhard has described a disnimilar
tilling of the external jugular veins. In thrombosis of one transverse
sinus only the internal jugular on that side will carry less blood than it
otherwise would ; so long, however, as the transverse sinus of tlie other
side is free, it will receive the current which cannot pass through the
obtitructed one, and c(mseqnently the jugular on its side will carry more.
If the contained clot extends so far as the direct communication with the
internal jugular, or even so far as the opening of the inferior petrosal
sinus, then the infernal jugular of the affected side will be almost emjtty,
while the externa/ jugular on the same side will be the more distended.
Thus, Schwartze note<l one case in which a clot extended from the
superior longitudinal into the right transverse and jietrosal sinuses clear
to the jugidar foramen, while the left transverse sinus was almost free,
the right external jugular being inordinately distended. In very young
children, as a result of the consetjuent auiemia, the large fontanelles will
usually be found de])ressed, although when a large amount of blood has
been poured outside of the membrane they will more or less protrude.

When the general signs and symptoms of sinus-thrombosis are pres-
ent, it may be possible in certain cases to determine more or less accu-
rately the site of the thrombns. When the eye is protruded, the lid
ledematous, and the frontal vein distended, it must be plain that the
cavernous sinus on that side is involved. When, as often occurs in
children, superficial veins of the scalp are distended, especially in the
neighborhood of the parietal foramen, then it will be found that the



SINUS-PHLEBITIS. 695

superior longitudinal sinus is at fault. Wiien this is seen posteriorly
or in the neighborhood of the mastoid foramen, we locate the thrombus
in the transverse sinus. When there ai'e no localizing symptoms of this
ciiaracter, we can only say in a general way that internal thrombosis has
occurred.

Prognosis is always unfavorable, although recovery is not impossi-
ble. The therapeutics are, for the most part, projihylactic. By actual
physiological rest it is possible at least to reduce tlw liability of embol-
ism of the lungs. (See Abscess following Middle-ear Disease.)

Sinus-phlebitis.
phlebitis sinuum dur^e matris ; colpitis cerebralis.

Inflammation of the cerebral veins may occur in two ways : First, as
the I'esult of throndjosis ; second, as the continuation of inflammatory or
sup])urative processes from neighlmring infectious ])rocesses.

Thromboses produce sinus-phlebitis by penetration of the infected
]>articles into the occluded sinus, by which a putrefactive condition of
the clot is brought about. On the other hand, inflammation and suppu-
ration may extend from neighboring tissue, and are more likely the
nearer such processes are going on. Even chronic inflanunation and
chronic suppuration may give rise to acute sinus-])hlebitis, aiul in these
cases the jn-imary trouble uiay be at some distance from the sinus. Acute
.suppurations spread api)arently by mere continuity of tissue without ref-
erence to the relative position of parts. They often also follow the ves-
sels and nerves, or rather work their way along the connective tissues
surrounding them, and thus penetrate from tlie dura into the sinus.
But in the great majority of instances the veins which empty into the
.sinus are directly responsible for the pro])agation of the lesion. The
(•ircumstances which must oiitaiu to produce this condition are injuries
or infections which produce phlegmon or phlegmonous erysipelas of the
scalp, or \vhich produce infectious inflanunation of the bone. Of the
former, those involving the orbital and parotid regions are the most
connnon. So also carbuncle upon the face or upon the .scalp, and sup-
purative jirocesses going on within the nasal cavities or within the vari-
ous cavities contained within the cranial bones. Oi' the chronic condi-
tions, by all means the most common are those connected with the mid-
dle ear ; and here, of course, the close proximity of the transverse sinus
to the mastoid emissaries plays a prominent role.

In sinus-phlebitis the walls of the sinus are thickened, infiltrated,
and its hmieu more or less completely filled with the breaking-down
thrombus. The veins of the brain and its membranes are overfilled, and
extravasations in the cortex often complicate these cases. In fact, too
often along with sinus-phlebitis we find apparently pachy- and lepto-
meningitis, and not rarely even an abscess in the brain-substance.
Pachymcningcal inflammations arc frequently confined to the immediate
neighiiorhood of the sinus, while leptonu'iiingitis may extend over a
large area. When the disease does not run too acute a course we are
likely to have breaking down of thi-ombi and consequent infarcts of the
lungs, which may go on to the formation of abscesses, which later may
extend to spleen, liver, and kidneys.



(JUG DISEASES AND INJURIES OF THE HEAD.

Symptoms of siiiiis-|>lilcl)itis !<(uir<;elv incliidc tliosc of fnrinntion of
tliroinlii, ami this is particuiaily the <'ase wlicii tlic priniarv iiiHaininatiou
is liiiiitcil to a very small area of tlic ovcrlyiiiii; hone. Tlioir may result
changes leading even to ])erfoi'ation of tiie sinus, without coagulation
in the same. This (constitutes, in cifeet, a destruction of the sinus-wall
without previous thrombosis, by which profuse hemorrhage may result.
This has been observed, for instance, in the transverse sinus after caries
of the temporal bone, especially in the mastoid ])ortion. But, as a rule,
thrombi form, and this Uiiid of hemorrhage is prevented. In rarer
instances there is found circumscribed thrombosis, by wiiich tlie inflamed
vein is later completely obliterated. In one case reported by Zauliil the
transverse sinus cconnected with the mastoid cells by an ojiening of con-
siderable size, and the walls of tlie transverse sinus were comj)letelv
occluded by a yellowish connective tissue. Sinus-phlebitis is more com-
mon in the transverse and cavernous sinuses, less so in the superior
longitudinal. The inflammatory ])rocess extends from its original seat
in the direction of the l)l(iod-stream. Not infre(piently it extends into
the internal jugular vein. When it depends upon a primary thrombosis
its extent is coexistent with that of the original thrombus.

The symptoms and signs are seldom of themselves absolutely
diagnostic. The sinus-iuHanunation is often accompanied by menin-
gitis or even ence]ihalitis. The ]>rincipal symptoms consist in brain-
irritation and brain-pressure, to which should be added fever, frequently
high, often with pysemic accomjianiment.

The first symptom usually comjilained of is severe headache, fre-
quently localized and made worse by pressure over the region involved.
Ijoss of appetite, with more or less mental <listnrbance, and sometimes
delirium, follows. Tliese patients sometimes vomit, and are frequently
very restless. Their delirium usually becomes aggravated into a mania,
which in quickly-fatal cases is followed by stupor and coma. Some-
times there are spasms of the cervical muscles, and often convulsions of
grou])s of muscles of the extremities, followed bv jiaralyses. In the less-
rapid eases chills frc(iuently occui', and sometimes symptoms of irritation
or paralysis along ])articular nerves, as, for instance, the oculo-niotor,
the abducens, or the vagus. Muscular paralysis usually merges into
apathy and weakness, which finally merge into coma. When pysemic
symjitoms occur they are very vague, and appear rather as j^neumonia,
pleuritis, and jaundice. When tliese appear in coniunction with aggra-
vating brain-sym]itoms they indicate a speedily fatal result. The disease
may last l)ut a few days or it may spread over several weeks. In the
most acute cases death results within a week.

The symptoms will in lai'ge measure depend ujion the jirobable sinus
most or primarily involved. They are most characteristic when the
cavernous sinus is at fault. In inflammation in this localitv we have a
numl)er of disturbances in the eye on the affected side, including con-
gestion of the orbital veins, with possible inflammation of the same and
compression of the oculo-motor nerves, perhaps also of the iir.st branch
of the fifth on the same side. There is also very likely to occur paral-
ysis of the carotid plexus of the sympathetic. At first there is pain in
the eye, and it is sensitive to light ; the pupil is small ; then the cornea
becomes cloudy, the eyelid and conjunctiva oedematous ; there is more or



SINVS-PHLEBITIS. 697

less exophthalmos ; the pupil becomes dilated ; tlie cornea loses its
polish ; the sight is lost ; the upper lid cannot be raised ; and, if these
symptoms persist long enough, we have ulceration of the cornea. In
most of these cases also we have comjilaint of j)ain in the frontal and
supraorbital region, increased upon pressure, sometimes also difficulty
in moving the tongue, and the consequent thickness of speech due to
pressure-})aralysis of the hy])oglossal nerve. This is probably to be met
^\^tll in liemorrhages beneath the pia in the region of the hypoglossal
nucleus.

When the transverse sinus is involved we have irritation, and, later,
paralysis, of the vagus, indicated by the slowing and weakening of the
pulse ; and of greatest value are certain paralytic se(pienc(>s, such as
paralysis of the muscles of the lower jaw, the tongue, the palate, and
pharynx, owing to which the mucus in the larynx and pharynx can-
not be expectorated. Also the diaphragmatic motions are interfered
with and the character of the inspiration is changed. As the trouble
extends from the transverse sinus into the internal jugular, we have
further ])aralysis of the nerves which iiave their course alongside of it.
This means paralysis of the hypoglossal nerve ]m)])er. As the lesion
extends down the jugular vein, we have tenderness in the neck, limita-
tion of motion, and frequently swelling. Very often also we have ten-
derness over the mastoid process, with acute pain in this area.

The symptoms of inflaniniation of the suju'rior longitudinal sinus
are the most vague of all, and are those rather of diffuse meningitis than
of involvement of s])ecial nerves. Pain complained of in this case is
usually referred to the temples.

As the trouble extends from one sinus to another, the symptoms are
modified accor<lingly or spread from one side to the other. Thus, when
one cavernous sinus is involved the trouble almost ahvays extends to the
other side, and the local symptoms are repeated. From the transverse
sinus lesions fre(piently extend into the petrosal, upper and lower.

Diagnosis. — It must be said that the jirimary symptoms are fre-
fpiently those which are common to this condition, to thrombosis, and to
meningitis alike. When in these instances a case presents pyremic dis-
turbances, chills, symptoms of lung-involvement, swelling of the joints,
and so on, one can with reasonable definiteness eliminate the meningeal
form. Obviously, however, diagnosis is easier when a plain reason for
sinus-phlebitis is at hand, as, for instance, the history of injury or
middle-ear trouble, of abscess, of carbuncle, etc. The farther away the
original cause is from the membrane, and the less plausible the extension
by continuity may a])]iear, the more likelv it is that we have to deal
with sinus-piilebitis. Should tiiere be a considerable amount of dis-
tni'bance of the nerves, the diagnosis is easy. Thus, oculo-motor paral-
ysis, ptosis, ])uj)illarv alteration, etc., occurring enrly, are of great im-
portance, and the history should be cai'efnlly considered. Even eye-
symptoms point primarily to the cavernous sinus, whereas lesions in-
volving the vagus or hypoglossal or the glossopharyngeal nerve point
to transverse sinus or to basal involvement. When symptoms belonging
to one of these grou])s are lacking, one may think of the convex surface
of the brain, and, if the jiatient complain of temporal or frontal ))ain
with tenderness in these regions, it may be that the superior longitudinal



698 DISEASES ANT) INJURIES OF THE HEAD.