JACKSON: Thrombosis of the Cavernous Sinus.
365
THROMBOSIS OF THE CAVERNOUS SINUS. BY EDWARD JACKSON, M.D., DENVER, COLO.
The sympteom-picture of this condition must necessarily vary somewhat with the general disease that it may attend, and the local conditions, particularly the point- at which the thrombotic process begins. Since, in the following case, the anatomical condition was ascertained by post mortem examination, it seems worthy of record. J. C., male, aged .26, a native of Ohio, suffering from pulmonary tuberculosis, was admitted to the Arapahoe County Hospital, medical service of Dr. H. B. Whitney, January 3, I901. He had suffered from a pulmonary hemorrhage in I897, and with a cough and expectoration since that time. He had been somewhat worse the last few months - was weaker, and had suffered from asthma. But he was not greatly emaciated, and gave no indication of an early fatal termination of his case. During the first five days in the hospital his temperature did not rise above 99.50. Respiration ranged from 24 to 42, and pulse from IOO to I38. His urine was rather concentrated, specific gravity I030, but otherwise normal. On the night of January 8th the lids of the right eye began to swell. There was slight muco-purulent conjunctival discharge, and severe pain in the region of the right orbit. January gth. The patient was transferred to my charge, and when I saw him in the afternoon there was great swelling of the right lids, some protrusion of the eye, severe muco-purulent conjunctival discharge, no marked impairment of the ocular movements, corniea normal, and vision apparently unaffected. The left eye had already been protected by a Buller's shield. It appeared normal in all respects, and remained so throughout the case. The temperature, which had risen the preceding
366
JACKSON: Thrombosis of the Cavernous Sinus.
night to IO, had dropped again to normal; pulse I30; respiration 30. Repeated microscopic examinations of the conjunctival discharge failed to reveal either the gonococcus or the Klebs-Loeffler bacillus. The patient made no complaint except of severe aching in the region of the orbit. January ioth. The swelling of the lids, chemosis, prominence of the eyeball and conjunctival discharge had increased. Temperature rose to Ioo.05 in the afternoon, with pulse io8, respiration 20. January iith. The swelling still greater. The cornea remained clear, vision apparently good, and no impairment of the ocular movements, other than would be accounted for by the general swelling. The temperature, IOI.4 in the morning, rose to 102.5 in the evening. There was continued complaint of pain, and slight delirium. The patient died on the I2th, quite suddenly, shortly after midnight, having responded rationally to questions a few minutes before. The treatment employed was frequent washing of the eye with a two per cent. solution of protargol, and the application of a twenty per cent. solution of protargol once daily. Internallv, calomel and a saline were given, with morphia to diminish the pain. The post mortem examination was made fourteen hours after death by Dr. J. A. Wilder, pathologist to the hospital. It showed old lesions and scattered tubercles in the upper lobes of both lungs, with moderate recent congestion and cedema. The heart, spleen, and kidneys were normal; there was a nutmeg liver. The cerebral meninges showed miliary tubercles scattered over both hemispheres, but none at the base of the brain. In the right cavernous sinus was an organized clot, about one-eighth of an inch in diameter, extending into it from the orbital vein. In the early part of its course this case looked more like one of purulent conjunctivitis than anything else, although the excess of swelling and rather moderate discharge caused me at first to think it might be diphtheritic. The movements of the
CHENEY. Inflammatoty Hyp4etropky of Lid Margins. 367 eye showing no impairment, except such as would be expected from the swelling, at first seemed to exclude thrombosis of the cavernous sinus. Later, the swelling of the orbital tissue, showed that it was in some way involved; but not until the case had run its course did I conclude that it'was a case of sinus thrombosis. The clot found extended into the cavernous sinus from the orbital vein.. But even allowing for post mortem-contraction it had probably not filled the sinus, an'd it presented no prolongations extending into other cerebral sinuses. It seems probable that the process began in some vein in the orbit. This would account for the'absence of'any early paralysis of the extraocular muscles. The vision retained until the time I last saw him, a few hours before his death, showed that the thrombosis had not then involved the retinal vessels.
AN UNUStJAL CASE OF CHRONIC INFLAMMATORY HYPERTROPHY OF THE LID MARGINS. By FREDERICK E. CHENEY, M.D., * BOSTON, MASS.
The pati'ent whose case I have to report is a boy twelve years of age, .born in Germany, and -of Jewish extraction. He entered the Massachusetts Charitable Eye and Ear Infirmary April 8, I9oI. The history obtained from the father is as follows: In' his second year the boy'developed a skin trouble, described as pimples varying in size froni a pin's head to a silver dollar, and distributed over the entire body. These pimples continued to form for -about six years and some of the larger ones on the back of the neck were- operated upon. Four years ago, at about the time the skin 'trouble ceased, a pimple was noticed on the right upper lid and also that the lid was enlarged. It has gradually increased in size up to the present time and now falls over the front of the eye and interferes with vis;on. There have been
365
THROMBOSIS OF THE CAVERNOUS SINUS. BY EDWARD JACKSON, M.D., DENVER, COLO.
The sympteom-picture of this condition must necessarily vary somewhat with the general disease that it may attend, and the local conditions, particularly the point- at which the thrombotic process begins. Since, in the following case, the anatomical condition was ascertained by post mortem examination, it seems worthy of record. J. C., male, aged .26, a native of Ohio, suffering from pulmonary tuberculosis, was admitted to the Arapahoe County Hospital, medical service of Dr. H. B. Whitney, January 3, I901. He had suffered from a pulmonary hemorrhage in I897, and with a cough and expectoration since that time. He had been somewhat worse the last few months - was weaker, and had suffered from asthma. But he was not greatly emaciated, and gave no indication of an early fatal termination of his case. During the first five days in the hospital his temperature did not rise above 99.50. Respiration ranged from 24 to 42, and pulse from IOO to I38. His urine was rather concentrated, specific gravity I030, but otherwise normal. On the night of January 8th the lids of the right eye began to swell. There was slight muco-purulent conjunctival discharge, and severe pain in the region of the right orbit. January gth. The patient was transferred to my charge, and when I saw him in the afternoon there was great swelling of the right lids, some protrusion of the eye, severe muco-purulent conjunctival discharge, no marked impairment of the ocular movements, corniea normal, and vision apparently unaffected. The left eye had already been protected by a Buller's shield. It appeared normal in all respects, and remained so throughout the case. The temperature, which had risen the preceding
366
JACKSON: Thrombosis of the Cavernous Sinus.
night to IO, had dropped again to normal; pulse I30; respiration 30. Repeated microscopic examinations of the conjunctival discharge failed to reveal either the gonococcus or the Klebs-Loeffler bacillus. The patient made no complaint except of severe aching in the region of the orbit. January ioth. The swelling of the lids, chemosis, prominence of the eyeball and conjunctival discharge had increased. Temperature rose to Ioo.05 in the afternoon, with pulse io8, respiration 20. January iith. The swelling still greater. The cornea remained clear, vision apparently good, and no impairment of the ocular movements, other than would be accounted for by the general swelling. The temperature, IOI.4 in the morning, rose to 102.5 in the evening. There was continued complaint of pain, and slight delirium. The patient died on the I2th, quite suddenly, shortly after midnight, having responded rationally to questions a few minutes before. The treatment employed was frequent washing of the eye with a two per cent. solution of protargol, and the application of a twenty per cent. solution of protargol once daily. Internallv, calomel and a saline were given, with morphia to diminish the pain. The post mortem examination was made fourteen hours after death by Dr. J. A. Wilder, pathologist to the hospital. It showed old lesions and scattered tubercles in the upper lobes of both lungs, with moderate recent congestion and cedema. The heart, spleen, and kidneys were normal; there was a nutmeg liver. The cerebral meninges showed miliary tubercles scattered over both hemispheres, but none at the base of the brain. In the right cavernous sinus was an organized clot, about one-eighth of an inch in diameter, extending into it from the orbital vein. In the early part of its course this case looked more like one of purulent conjunctivitis than anything else, although the excess of swelling and rather moderate discharge caused me at first to think it might be diphtheritic. The movements of the
CHENEY. Inflammatoty Hyp4etropky of Lid Margins. 367 eye showing no impairment, except such as would be expected from the swelling, at first seemed to exclude thrombosis of the cavernous sinus. Later, the swelling of the orbital tissue, showed that it was in some way involved; but not until the case had run its course did I conclude that it'was a case of sinus thrombosis. The clot found extended into the cavernous sinus from the orbital vein.. But even allowing for post mortem-contraction it had probably not filled the sinus, an'd it presented no prolongations extending into other cerebral sinuses. It seems probable that the process began in some vein in the orbit. This would account for the'absence of'any early paralysis of the extraocular muscles. The vision retained until the time I last saw him, a few hours before his death, showed that the thrombosis had not then involved the retinal vessels.
AN UNUStJAL CASE OF CHRONIC INFLAMMATORY HYPERTROPHY OF THE LID MARGINS. By FREDERICK E. CHENEY, M.D., * BOSTON, MASS.
The pati'ent whose case I have to report is a boy twelve years of age, .born in Germany, and -of Jewish extraction. He entered the Massachusetts Charitable Eye and Ear Infirmary April 8, I9oI. The history obtained from the father is as follows: In' his second year the boy'developed a skin trouble, described as pimples varying in size froni a pin's head to a silver dollar, and distributed over the entire body. These pimples continued to form for -about six years and some of the larger ones on the back of the neck were- operated upon. Four years ago, at about the time the skin 'trouble ceased, a pimple was noticed on the right upper lid and also that the lid was enlarged. It has gradually increased in size up to the present time and now falls over the front of the eye and interferes with vis;on. There have been
