ARCHIVES OF OTOLOGY.

ON HEMORRHAGE FROM ARROSION OF THE BRAIN SINUSES IN SUPPURATION OF

THE TEMPORAL BONES.

BY DR. H. EULENSTEIN, OF FRANKFORT-ON-MAIN.

Translated by Dr. H. KNAPP, from German Edition (Zeitsch. f. O., vol. xliii.).

TH

occur.

HOUGH by the frequent destruction of its bony sulcus the lateral sinus loses a good deal of its resistance, it is very rare that hemorrhages by arrosion of its walls The reason of it is that an obturating thrombus forms before the sinus wall gives way, a fact made known long ago by WREDEN, who, in the Monatsschrift für Ohrenheilkunde, No. 10, 1869, collected the previously published cases. The hemorrhage may be more or less copious according as the obturating thrombus is more or less complete, or the perforation of the sinus wall larger or smaller. The hemorrhage may be external or internal: the former when the blood through the opening in the sinus wall makes its way through the cavities of the petrous bone into the external ear canal and the naso-pharyngeal space; the latter when the blood enters into the middle or posterior cranial fossa. All brain sinuses that are in relation with the temporal bone may occasion the hemorrhage: the lateral, both petrosal, the cavernous, the carotid, and the jugular bulb.

'Hooper, Morbid Anatomy of the Brain, 1826, quoted by Cruveillier : Anatomie pathol. du corps humain, 1830-1842, Livr. viii., pl. 4, p. 3. Bruce, London Med. Gaz., 1841. Stokes, London Med. and Surg. Jour., vol. v., p. 676. Toynbee, Med. Times and Gaz., 1855, T. x., pp. 3, 228, 306, and Med.Chir. Trans., vol. xxxiv., 1851. Virchow, Arch. f. path. Anat., Bd. viii., p. 378. Hensinger, ibid., xi., p. 92. Griesinger, Wagner's Arch. f. Heilk., iii., p. 448. Wreden, Otit, med. neonat., Berlin, 1868.

To the seventeen cases (see below) I can add another which I deem worthy of publication.

Clinical History.- Else B., æt. five years, healthy constitution, caught scarlet fever January 8th. Earache the 14th; first seen the 15th. Mt very red, sagging in post. half. Temp. 39° C. Urine normal. R mast. proc. tender, its integument normal. Hearing, R, diminished. Immediate paracentesis draws pus and abates pain. During the next four days otorrhoea copious, temp. 37.9-39° C. Urine continues normal. Tenderness of mastoid increased, doughy swelling of its integuments.

Fan. 20th, 8.30 A.M.-Opening of the mastoid under general anesthesia. Large quantity of pus; the mastoid process markedly pneumatic, all cells filled with pus, the partition walls decayed, and also the posterior meatal wall softened. Granulations filled the antrum and beset the dura of the middle cranial fossa, which was opened. The entire outer wall of the mastoid was diseased and had to be removed to the very tip. Posteriorly the disease of the bone had advanced to the sigmoid sinus which was exposed to the extent of 3cm. Opening the posterior cranial fossa uncovered a large extradural abscess at the sinus. The sinus showed distinct respiratory motions, showing that no obturating thrombus was present in the lateral sinus. The middle portion of the exposed sinus was covered with granulations; the remainder looked healthy. Even if a parietal thrombus was in process of development we could expect that no serious harm would ensue to the patient, as she had no pyæmic temperature and no chills. The large wound cavity was filled with sterile gauze, and the usual aseptic dressing applied.

In the next three days the temperature varied between 37.5° and 39° C. General condition perfectly satisfactory.

Fan. 24th.-Change of dressing. The wound looked healthy, except the granulating patch at the sinus wall, which was covered with yellow pus.

Fan. 27th.-Change of dressing again. Granulations at many places of the wound cavity; at the posterior meatal wall and near the mastoid tip a few white, bare bone patches were visible. The purulent membrane on the sinus wall apparently a little thicker than at the first dressing.

Fan. 29th.-Dressing changed because of being soaked with

secretion.

Fan. 30th. In the afternoon the mother noticed a few drops of blood oozing from beneath the dressing; the dressing itself was not suffused with blood. Some sterile cotton-wool was shoved under the dressing; no blood made its appearance for the present. During the night had several attacks of sneezing.

Fan. 31st, 5.30 A.M.-I was called in all haste, as a profuse bleeding had occurred. I found the dressing and part of the pillow soaked with blood. There was, however, no oozing of blood at any part of the dressing. On removal of the dressing down to the tampon filling the wound, I satisfied myself on careful observation that there was no oozing now. For the sake of precautionconvinced that the hemorrhage emanated from the sinus-I pressed a tampon of sterile cotton-wool firmly on the gauze plug which lay in the wound and fastened it with a compressive bandage. The pulse of the child was good. During the day there was no more bleeding, but the temperature rose to 39.2° C. in the evening, which induced me to renew the dressing. When I raised the tampon with a forceps ever so gently at its upper edge, a broad, darkened blood stream gushed forward, flooding the neighboring parts instantaneously. Under these circumstances a change of dressing was out of the question, and I had to limit myself to press the somewhat loosened plug firmly again into the wound cavity, upon which fortunately the bleeding stopped. The situation was by no means enviable: a howling child, struggling with hands and feet to the utmost on the lap of a mother trembling and deadly pale from fear and excitement; I had firmly to compress the tampon for about twenty minutes in order to be sure that the powerful bleeding was really stopped. I put a fresh compressive bandage over the tampon and instructed the nurse to press strongly on a marked point of bandage should any bleeding again take place. The night passed without any bleeding; the child was restless, feverish, and complained of pain in the wound.

During the next three days the temperature varied between 37.8° and 40.3° C. The child was very restless, suffering greatly, pale and weak by the loss of blood, and the grave infectious disease. Its condition was very critical. The old tampon, soaked with blood, could not be removed for fear of starting a new copious, perhaps fatal, hemorrhage again, whereas its continuation threatened the child's life by retention of pus, and decomposition of the secretion of the wound, and above