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Presentation of Patients.

Dr. BRANDEGEE presented a patient fifty-five years of age, upon whom he had operated for sinus thrombosis. Five weeks ago she came to the infirmary with ear trouble of ten days' standing. Temperature was 102°. At operation an abscess was found in the antrum and the sinus was unusually prominent. On exposure it appeared very black and was excised. A parietal clot was evacuated and bleeding restored from both sides. The temperature remained up on the second day. On the third day it came down only to go up again without any chill. It was then decided to operate in the neck and the jugular vein was exposed. It seemed normal except the portion from the facial junction upward where it contained a clot. The entire vein was resected and staphylococci were found in the walls. The patient made an uninterrupted recovery; the temperature after the second operation did not go up.

Discussion. – Dr. Dench wished to emphasize the fact that the temperature remained high for two days, then went down, then again on a subsequent rise it was immediately decided to ligate the internal jugular, which he thought was a very important point --namely, waiting for the second rise of temperature. He also wished to call attention to the results of the wound in the neck, which were unusually good, as the wound had healed by primary union.

Dr. GRUENING said that he was not able to get primary union in these cases of operating in the neck for jugular-vein thrombosis.

Dr. Dench thought he was generally able to obtain primary union, and thought that cases in which we failed were generally due to infection from the hands transmitted from the mastoid wound, which operation usually preceded the wound in the neck.

Dr. ARNOLD KNAPP presented a patient who had had thombosis of the jugular bulb and very severe pyæmia.

The patient was a man, twenty years of age, who had been under treatment for a mastoid fistula and external otitis when he suddenly became very ill with headache, vomiting, and great prostration. Temperature was 105.6°; pulse 130. On the following day the antrum was exposed containing granulations and pus. The tympanum was also laid bare and contained granulations. On removing the tegmen antri healthy dura was revealed. As the bone directly posterior to the antrum was honeycombed with pus, the operation was extended in this direction and some free pus was found on the surface of the sigmoid sulcus. The sinus in this region was covered with apparently healthy granulations; lower down it was normal and soft. Puncture in two places gave fluid blood. Two days later, as the pyæmic temperature remained, the jugular vein was ligated. The ligation was somewhat difficult on account of the presence of enlarged cervical glands. The vein itself was found perfectly normal. The sinus was also exposed as low down to the bulb as possible and on being incised contained fluid blood. Notwithstanding these two operations the patient proceeded to go through a pyæmia of nine weeks' duration. The greatest variation in temperature was 13", going from 108.8o in one evening to 95° the next morning. Metastatic abscesses were formed in the subcutaneous tissues of the forearms and legs, and in the deep cellular tissue beneath the recti insertion just above the symphysis, the latter focus in turn involving the perineum, the testicle, and adjoining areas of the thigh. On the whole, the patient was anæsthetized seven times. There were very few chills. There was no apparent lung involvement and no diarrhæa. Optic neuritis was present. The sensorium throughout this entire period was free and the nourishment was always well taken. Owing to the poor condition of the patient the ear wound was allowed to take care of itself; in other words, no attempt was made to tampon the tympanum and consequently the entire area filled with granulations and is covered with epithelium.

Discussion.—Dr. McKERNON asked whether the temperature curve had been influenced by the evacuation of the metastatic abscesses.

Dr. KNAPP replied that it was impossible to determine any relation between the height of tbe temperature and the suppurating process. The metastatic abscesses gave pure cultures of the streptococcus.

Dr. HARRIS inquired what the treatment, besides surgical, had been.

Dr. KNAPP replied that the patient had been given milk, as much as he would take, whiskey, and strychnine.

Dr. ARNOLD KNAPP exhibited a specimen of an unusually distended sigmoid sinus and jugular bulb obtained from a patient who had died of meningitis. The case has been described in extenso in the ARCHIVES OF OTOLOGY, vol. xxx., No. 5. The peculiarity of the sinus was that it presented an unusually distended condition and that the anterior wall was normal while the posterior was infiltrated and very much thickened, and on its surface contained necrotic tissue. There was no thrombus found at autopsy.

Dr. Whiting inquired whether a clot had shut off the jugular bulb? It had not. There was an ante-mortem clot removed at autopsy but the infiltration only involved the posterior wall of the bulb.

Dr. GRUening had met with cases of distended sinus and also remembered a case with the temperature of 105° where the sinus could not be found at operation; the dura seemed to be absent and the brain softened. At autopsy the sinus was found and there was an abscess at the posterior wall; the cerebral side of the sinus was thickened and covered with pus.

Dr. McKernon had seen a case in a patient of fourteen years, where the sinus appeared to be obliterated and could not be found at operation. Autopsy revealed a cerebellar abscess and the dura was very much thickened. The incisions which had been made in the dura could not be found as the layers of this membrane were glued together.

Dr. Dench operated on a case six or seven years ago where he could not find the sinus and thought it had become obliterated through the purulent process.

Dr. ALDERTON asked why, in Dr. Gruening's case, he did not have to deal with an abscess and sinus converted into one cavity.

Dr. GRUENING spoke of a boy with a temperature of 106° with all the clinical symptoms of sinus thrombosis. The sinus could not be found. The jugular was ligated and the patient recovered.

Dr. Dench asked if in this case the wall of the vein was examined microscopically.

Dr. GRUENING said, No.

Dr. DENCH presented a hammer and incus found lying loose in the attic of a patient on whom he had performed the radical mastoid operation some ten days ago. The hammer and incus were tightly bound together and enveloped in a mass of granulation tissue. He thought this was interesting from several standpoints: first, that it was unusual to find the two ossicles bound together; and second, that it shows the disease was limited to the attic. He said the case was one of recurrent mastoiditis apparently, and he found that the mastoid was very little involved and that there was a good deal of softening near the tympanic vault. The ordinary radical operation was completed, a Panse fiap made, and the posterior wound left open. Dr. Dench said that very many of these cases of recurrent mastoiditis are really exacerbations of a chronic otitis, and that we should, in these cases, be prepared to do a radical operation inasmuch as the mastoid operation, though relieving the symptoms of the patient, would not be followed by cure.

Discussion.-Dr. GRUENING thought this was the usual course pursued.

Dr. Whiting said he was about to operate on a case very similar where, six weeks after the onset of the otitis, during scarletfever, the mastoid had been operated. The operation did not appear to have been a radical one inasmuch as the tip had remained and the zygomatic cells were probably untouched and also that the incus was left. In this case the external wound healed. When he saw the patient there was an abscess in the mastoid again which was only kept in by a thin skin covering, and after opening this the probe encountered bare bone. The otoscopic picture showed a large perforation through which he said he could detect necrosed bone.

Dr. Toeplitz inquired whether Dr. Whiting thought he was able to ascertain by the otoscope and the aid of the probe the extent of the necrosis.

Dr. WHITING claimed that he did not think he could exactly determine the extent, but thought he was able to determine the presence of necrosis.

Dr. Toeplitz also thought it was customary in cases of acute mastoiditis supervening in the course of a chronic otitis to do a "two-time" operation, thinking it was not quite safe to do the complete operation in the presence of acute infection.

Dr. Whiting saw no advantage in this course.

Dr. Dench wished to explain that in a great many of these cases we have not really an acute process to deal with, and that we are often misled by the history.

Dr. HARRIS wished to know whether we should do the radical operation in these cases at once.

Dr. WHITING thought, as a rule, not.
Dr. ALDERTON thought that the function should be considered.

Dr. Whiting said he had reoperated on at least fifteen cases operated elsewhere and thought this was due to an insufficient operation in the first place.

Dr. Dench was surprised at the good hearing he had obtained after doing radical operation.

Dr. ALDERTON thought we must bear in mind that we cannot promise a patient that his discharge can be absolutely cured even by radical operation.

Dr. WHITING said we can at least prevent intracranial complications.

Dr. ALDERTON said we must not forget the good results that were often observed in cases left to nature, and especially the good results functionally.

Dr. Dench had recently obtained very good results in covering the mouth of the Eustachian tube with a skin graft. He thought that careful operation, especially about the region of the oval window, in the radical operation, would be followed by as good functional results as by removal of the ossicles.

Dr. HERMAN KNAPP reported a case of a patient completely deaf in one ear, who suffered from mastoiditis with sinus thrombosis in the other. The patient was operated on by a surgeon, at the same time the greatest regard was taken for the preservation of the hearing power, and an excellent result, both vital and functional, was obtained.

Dr. GRUENING thought that in most cases after radical operation the hearing was impaired, hence he had become very

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