XXVIII.

ANATOMIC RELATIO~S OF THE TO OTHER STR1JCTlJRES, WITH CO~­ SIDERATION OF VARIOUS PATHOLOGIC PROCESSES BY WHICH IT ::\1 AY BE­ COME INVOLVED.*

By HENRY GLOVER LANGWORTHY, l\J. D..

DUBUQUE, IowA.

The object of this paper is to present as c1e'J.r a picture as possible of the anatomic relations of the cavernous sinus to adjacent structures, and to' index in one article, as far as pos­ sible, the scattered data of pathologic affections available in the literature of the past fifteen years, together with the im­ portant addition of unpublished information obtained from question-letters sent to prominent general surgeons through­ out the country. The idea of instituting a search of this kind grew out of the fact that in reading a paper on "Cavernous Sinus Thrombosis and the Future," before the Chicago Oph­ thalmological Society, November, 1914, the discussion s

-Read before the Chicago Laryngologlcal and Otological Society. December 21, 1915.

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ANATOMY. The cavernous sinuses, two in number, one on each side of the ,* are a part of the general venous system at the base of the . Like the other large venous channels, they are situated between two layers of the dura (splitting of the dura), are lined by endothelium continuous with that which lines the veins generally, and serve to drain the blood anteriorly from about the orbits, and anterosuperiorly from the brain itself. These sinuses carry the bulk of this venous flow backwards through the petrosals to the internal jugular veins, the great outlet for the cerebral circulation. Their anatomic importance depends upon their location in the , just lateral to the body of the sphenoid , extending from the sphenoidal fissure in front to the apex of the petrous portion of the behind, containing venous blood, and being traversed by certain other (transient) structures and being connected internally with each other by communi­ cating small intercavernous sinuses which at the same time surround the hypophysis cerebri. The cavernous sinuses are so named because they present the picture of a reticulated structuret traversed by numerous interlacing filaments which divide the sinus cavity into irreg­ ular compartments. The sinuses are larger behind than in front and measure from two to two and one-fourth centimeters in length, and have a diameter of about one centimeter. A cross section shows these sinuses to be of such shapes as :juadrilateral, shallow S outline, or distinctly tooth shaped. As l expressed by Piersol : "Its external diameter does not repre- ·Sella turcica (Turkish saddle)-the depression within the three clinoid processes of the lodging the pituitary body. t As a clear mental picture of the sinus Is important for proper clinical application in disease, It is worth repeating with Halstead that anyone "who has dissected the cavernous sinus w1ll realize that It Is not a single cavity, but it is a ainus made up of a number of cavities-from one to fourteen separate cavities, con­ nected by a very small opening, so that you may open and scrape out one of these cavities and st1ll leave others that are infected and continue to spread infection." J. C. Beck has also emphasized the fact that In attempted drainage of the sinus we must take this partition idea into consideration, for in instituting any drain­ age which might be successful the sinus must be drained as thor­ oughly as any other thrombotic vessel and that It would be ex­ tremely doubtful whether a small slit or puncture in one of these partitions would really accomplish much good.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 556 HltNRY GLOVER LANGWORTHY. sent the actual capacity of the lumen, since this is greatly reduced in size: (a) by being traversed by numerous trabeculae from which fringe-like prolongations hang freely in the blood current, a section of the sinus having very much the appear­ ance of a section of the corpus cavernosum of the penis, whence the name bestowed upon it by Winslow; and (b) by the fact that the and abducens nerve tra­ verse it, while other cranial nerves are imbedded in its outer wall." Anteriorly each cavernous sinus receives as tributaries the ophthalmic vein (through the sphenoidal fissure), spheno­ parietal sinus, lodged in the dura on the under surface of the lesser wing of the sphenoid, and a smaller cerebral vein (vena cerebri media and sometimes vena cerebri inferior). An­ teriorly the sinus is in direct communication with the angular vein at the inner angle of the orbit through the superior oph­ thalmic vein. Posteriorly the cavernous sinuses tenninate by opening into the superior and inferior petrosal sinuses at the junction of the petrous and sphenoid (foramen petrosphenoidale). The cavernous sinus communicates with the lateral sinus by lJ1eans of the superior petrosal sinus; with the internal jugu- . Jar vein through the inferior petrosal sinus, and through a plexus of veins on the internal carotid artery (Gray'); and with the pterygoid plexus through the . Internally the two sinuses communicate with each other by means of the intercavernous sinuses (anterior and posterior intercavernous sinuses, with at times a third or inferior inter­ cavernous sinus). The. internal surface has anywhere from three to seven openings by which it communicates with its fellow on the opposite side and also with the hypophysis cere­ brio On the inner wall within each sinus is found the internal carotid artery, accompanied by filaments of the carotid plexus and the abducens nerve. The communication also between the two anterior ends of the inferior petrosal sinuses at the pos­ terior extremity of the cavernous by the plexus basillaris (or so called transverse sinus) is another anastomotic connection which tends to equalize and distribute blood pressure for the larger cavernous. The external or outer wall of the sinus is occupied by the oculomotor, trochlear, ophthalmic and superior maxillary

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divisions of the trigeminal nerve. All such structures, how­ ever, are separated from the blood flowing through the sinus by the endothelial lining membrane continuous with the inner coat of the veins previously mentioned. Summing up it may be said that the transitional structures of the cavernous sinus number seven in all-i. e., internal car­ otid artery, carotid plexus, abducens, oculomotor, trochlear, ophthalmic, and superior maxillary nerves. The upper three-fourths of the external surface of the sinus is in relation to the internal part of the temporosphenoidallobe, while the lower one-fourth is in relation to the inferior maxil­ lary nerve (mandibular branch). The superior border of the cavernous sinus is in relation in the posterior four-fifths with the dura covering the cavern­ ous portion of the oculomotor nerve, and in the anterior one­ fifth with the lacrimal nerve. The inferior border is said to be "formed posteriorly by endothelial lining membrane being reflected on the intracranial portion of the nervus maxillaris." S (Hoeve. ) Relation of Structures in the Cavernous Sinus.-As out­ lined by Hoeve,s in the posterior four-fifths of the sinus, from above downward, the oculomotor, trochlear and ophthalmic nerves rest against the internal surface of the outer wall. The carotid artery, surrounded by the carotid plexus and the nervus abducens, rests against the internal wall, and the plexus cav­ ernosus lies internal to the carotid artery. In the anterior one-fifth of the sinus the oculomotor nerve and the ophthalmic (first division of the fifth) divide into their branches within the sinus at the junction of the posterior four­ fifths with the anterior one-fifth, and this breaking up into .branches is the cause of the difference in relations in the sinus and the fissura orbitalis superior.* -Dissection (trom Manual of Dissection and Practical Anatomy of the Head and Neck, Hubertus J. H. Hoeve, edition 1910, pages 347-3~9) : (1) Incise dura carefully along the superior border of sinus cavernosus, but do not cut the llgamentum petrosphenoldale at the posterior extremity of the sinus, which bridges over the Interval between the apex of the petrosK and the base of the processus cl1noldeus posterior, and which II covered only by dura In that reglon. (2) Redect the llap of dura outward and downward and expose the Interior of the sinus, and by breaking down carefully some of

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Variations of the Cavernous Sinus.-According to Quain (as quoted by :\losher): "The cavernous sinus is represented in a child by a venous plexus in the dura mater, which by en­ largement and fusion of its channels is converted into the char­ acteristic sinus of the adult. In old age the trabecul~ diminish and the cavity becomes simpler." This is also confirmed by von Lauger,tll based on corrosion and other preparations from infantile subjects. Instances have been noted where one cav­ ernous sinus is quite rudimentary, leaving practically but one functionating vessel. Relations of Cavernous Sinus and Transient Structures to Sphenoidal Sinus.-The cavernous sinus in a considerable part of its course overlaps slightly the roof of the sphenoidal cavity and is separated from this air cavity by the thinnest of bony partitions. According to Gibson,· from an examination of eighty-five sphenoidal sinuses, the roof of this sinus varies from 0.25 millimeter to two millimeters, averaging approxi­ mately one millimeter in thickness. Bony dehiscences have been observed by J. C. Beck and others between the sphenoidal sinus and , in which the internal carotid arterv might easily have been injured by too forcible instrumentatio;l in the sphenoidal cavity. In most specimens the casing of the bony carotid canal is plainly. seen bulging into the cavity of the near the posterior external angle. For the most part, therefore, it may be said that the cavernous sinus occupies a fairly constant position above and lateral to the body of the sphenoid bone (junction of roof and external wall of the sphenoidal cavity), and given a large sphenoid cavity, not only will the cavernl>us sinus be almost in contact, but also with any kind of a posterior prolongation in the body of the bone the basillar plexus may be in relation to the sphenoidal sinus as well. Indeed, diverticula are so frequently present in many sphenoids examined that through them quite a part of the cir­ cumference of the cavernous sinus region may be affected, bringing at times most all of the transient nerve trunks of the the trabecullil find the t:.ervus abducen8 and the 81nus petr08us Inferior as they pa88 through the foramen petrosphenoidale infe­ rior to the ligamentum petrosphenoidale. (3) Find that all the structure8 pas8ing through the sinus are co\"ered by the lining epithelium of the sinus, and 80 not- in contact with the venOU8 blood.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 JUtI.A'tIONS OF CAVER.NOUS SINUS TO OTHER STKUcrulltS. 559 cavernous sinu~ or even the Vidian canal (Sluder&) and Gas­ serian ganglion (Mosher) in relation to the sphenoidal cavity.

CONSIDERATION OF INDIVIDUAl, STRUcrU~. Intercavernous Sinuses (Circular Sinus).-The circular sinus (anterior, posterior and frequently inferior intercavern­ ous sinuses), which connects the two cavernous sinuses, is found in the sella turcica, surrounding the hypophysis cerebri and within the attached border of the diaphragma seltz. It is formed most often by the three sinuses mentioned: the an­ terior intercavernous sinus, usually the largest, passing in front of the pituitary body; the posterior intercavernous sinus be­ hind, and the inferior intercavernous sinus below this body. These sinuses receive branc.hes from the pituitary body and from the dura mater. The intercavernous sinuses, together with that portion of the cavernous sinus between their ter­ minations, form what is usually termed the circular sinus, al­ though in reality it represents only a part of the extensive venous system around the body of the sphenoid bone.* Basillar Sinus (Plexu!t basillaris--Transverse Sinus).-The basillar plexus consists of several interlacing veins resting on the dorsum sellce (mostly basillar process of the ), connecting the two anterior ends of the inferior petrosals, close to the posterior extremitY of the cavernous sinus. They lie between the posterior clinoid processes and the anterior margin of the , and· communicate also with the an­ terior spinal veins. The basillar plexus can be detected by its bluish color when the dura is carefully removed in this region. Like the cavernous sinus, the basillar sinuses11l are persistent channels of what was originally, in the fetus, an extensive venous plexus. . Superior Petrosal Sinus.-The superior petrosal sinus lies along the superior border of the petrous portion of the tem­ poral bone (superior petrosal sulcus), in the anterior part of

-The two middle cranial fOlBae are connected with ~ch other by the lelia tllrclca. which contalDl the hypOphYIls cerebrl and fl tirldged over ~J the 4laplll'&l!Da eeUle. T_ little O'fal opell1q ill Its middle Ie the tnoll1U'& dlaphragmlll Selllll. through which paasell the k1t11nMbulum. '!'he eat1re hYllop}lYlls II surrounded by venoul siDa.. (lDt8l'ean~ aiDaMs) located 1a the walll of ua. lano­ ~1a.nea1 ro.a.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 560 HENRY GLO~R LANGWORTHY. the attached margin of the tentorium cerebelli. It is small and narrow and serves to connect the posterior extremity of each corresponding cavernous and the bend or knee of the lateral sinus. It is a little above the petrosphenoidal foramen and trigeminal nerve. It receives some cerebellar and inferior cerebral veins, and veins from the tympanic cavity. According to Page,23 the superior petrosal is frequently found to empty itself into the lateral sinus, not by a single opening, but through a series of openings three or four millimeters apart, extending along the sinus wall at a distance of two or more centimeters. Inferior Petrosal Sinus.-The inferior petrosal sinus, larger but not as long as the superior, forms the shortest connections between the cavernous sinus and internal jugular vein. It is situated in a groove (inferior petrosal sulcus) formed by the petrooccipital suture. The inferior petrosal passes anteriorly through the foramen petrosphenoidale along with the abducens nerve, and behind through the anterior compartment of the jugular foramen, ending in the commencement of the jugular vein. The anterior ends of the inferior petrosals are connected with each other' by the interlacing vessels of the plexus basil­ laris. The inferior petrosals receive as tributaries some in­ ferior cerebellar veins, veins from the internal ear, pons and medulla. . Sphenoparietal Sinus.-The sphenoparietal sinus and oph­ thalmic veins may be regarded as the anterior beginning of each cavernous sinus. The sphtnoparietal sinus is lodged in the dura below the inferior surface of the lesser wing of the sphenoid. It is located above the oculomotor nerve, and has as tributaries small veins from the diploe and the middle meningeal. Ophthalmic Veins.-(a) The ophthalmic veins, superior and inferior, according to Gerrish,e have no valves, and the blood, under certain conditions, may flow from behind forward into the angular vein or its branches, and thus obviate pressure in the veins of the retina when the cavernous sinus is obstructed. The superior ophthalmic, beginning as the nasofrontal, com­ municates with the angular at the inner angle of the orbit. It also anastomoses with the inferior ophthalmic. Forming a short single trunk, it passes through the inner extremity of the sphenoidal fissure to the cavernous sinus. The swollen end of

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 RtI.ATIONS OF CAVERNOUS SIN.US TO OTHERSTRUCTUR£S. 561 the superior ophthalmic, just before it enters the cavernous, has been dubbed sinus ophthalmicus. (b) The inferior ophthalmic vein receives veins from the region of the floor of the orbit, and either passes through the sphenoidal fissure to join the pterygoid plexus of veins, or more directly backward through the sphenoidal fissure to the cavernous, either separately or by forming a common trunk with the superior ophthalmic. Emissary Veins.-The emissary veins are vessels which pass through foramina in the skull wall to connect the cranial sinuses with the veins of the diploe and veins external to the brain (as in and about the scalp). These are important, in that they may serve as possible channels along which infection may be carried occasionally from the surface to the interior of the cranium. They are not always constant as to presence or location. The cavernous sinus, through emissary veins, is connected with the pterygoid plexus through the foramen ovale and Vesalius, as well as through the inferior ophthalmic vein; with the pharyngeal plexus through the foramen lacerum medius, and with the internal jugular vein by the carotid plexus 8 through the carotid canal (Gerrish ). Carotid Artery.-The second or petrous portion of the carotid is within the carotid canal, while the third or cavernous portion is that part of the vessel lying within the cavernous sinus along the side of the sella turcica. The artery first enters the bony carotid canal in the petrous portion of the temporal bone, and follows its windings, first upward a short distance, curving forward and inward, and again ascends to enter the cranial cavity in its cavernous portion. In the cavernous por­ tion the artery follows the carotid groove or sulcus along the lateral body of the sphenoid extending from the posterior clinoid process behind to the in front, at which latter point it again curves upward and slightly backward to perforate the dura forming the roof of the sinus. After piercing the dura it passes between the optic and oculomotor nerves and runs to the internal extremity of the fissura lat­ eralis cerebri, where'it finally divides into terminal branches. Just at the point where the artery turns backward and internal to the anterior clinoid process, it may be easily mistaken for 3 the ophthalmic artery (Hoeve ). The abducens nerve passes

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 H~It.Y Gt.O~ LAl'fGWOJt'ffty. aloftg with the carotid in the cavernous portion and external to it. Sympathetic filaments from the carotid plexus also pass with the carotid artery. In the cavernous portion the distribu­ tion of the carotid branches are as follows: Few small arteries to the hypophysis cerebri, Gasserian ganglion, arteriae recep­ taculi, anterior meningeal and ophthalmic. According to Piersol/ where the internal carotid enters the cavernous sinus at the internal orifice of the carotid canal, the sinus projects downward around the artery in a funnel-shaped manner, and from it there arises a close network of veins, the carotid plexus or carotid sinus, which completely invest~ the artery through­ out its course through the carotid canal, at the lower opening of which it is continued into one or two veins which open into the internal jugular. Carotid Plexus.-The carotid plexus of nerves, situated on the outer side of the internal carotid artery, communicates with the Gasserian ganglion, sphenopalatine ganglion, sixth nerve, Jacobson's nerve, glossopharyngeal, and distributes fila­ ments to the wall of the carotid artery and to the dura. Fila­ ments of the carotid plexus may occasionally fonn a small ganglion (carotid ganglion) on the under surface of the artery. The relationship of these portions of the sympathetic nervous system to other adjacent structures of this region has been well worked out by Haskins.T Cavernous Plexus.-The cavernous plexus of nerves is located below and internal to the carotid artery within the cavernous sinus. It communicates with the third, fourth, ophthalmic division of the fifth, sixth, ophthalmic ganglion, besides distributing filaments to the wall of the carotid artery. It is formed chiefly by the internal division of the ascending branch of the superior cervical ganglion. Its physiology be­ longs to the physiology of the sympathetic nervous system.

PATHOLOGIC AFFECTIONS OF THE CA~RNOUS SINUS. The following data relating to diseases of the cavernous sinus have been obtained from question.-Ietters sent to mem­ bers of the American Surgical and Western Surgical Associa­ tions, and from the !\cattered monographs of affections avail­ able to me in the literature of the past fifteen years. While the information is not especially voluminous, it may serve as

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 RELATIONS OF CAVERNOUS SINUS TeD OTBD" STRUcrUJlJtS. lMI& a basis to build apon ia attempting the study et the· ca'ft1'l1CNl' sinus as a distinct and, one mi~ht say, separate ofPI' flf tbe body. As illustrating the difticulty and disappoinbnent in gath­ ering material, I would quote an extract from Itt letter from Dr. Louis B. Wilson, director of labOratories at the Ma,o Clinic, Rochester, Minnesota, who reports that "No specimen, either from operation or autopsy, showing pathologic: affec­ tions of the cavernous sinus has come into the laboratocy since I have been connected with it, now ten years." Out of two hundred and eighty-four letters mailed to mem­ bers of the American Surgical and Western Surgical. Asso­ ciations, one hundred and twenty of the men responded, but of the number responding only forty-four were able to cite cases either directly or indirectly concerning the sinus. The classification of affections from the replies received from these letters is as follows: (1) Septic thrombosis, (2) gun shot wounds, (3) involvement from fracture of the skull, (+) arb!­ riovenous aneurism, (5) injury during miseellaneous opera­ tions, (6) involvement by malignant growths, (7) congenital affections. To this from the literature gone over must be added (8) marasmic or socalled aseptic thrombosis and for the present (9) intermittent exophthalmos, both of which last are rare conditions. The foregoing admits, therefore, of a classifi­ cation of nine separate and distinct parts, all worthy gf atten­ tion, and is so far as I know practically the first attempt of its kind to systematize, and it is only a beginning.

( 1) SEPTIC THROMBOSIS. This subject has been pretty well thrashed out of late, so far as the ordinary avenues·of infection are concerned, and the few case reports yearly do not add a great deal to our present knowledge. The principal question at issue concems itself with early reasonably positive diagnosis, and whether success­ ful treatment by direct operation with the many difficulties which attend, is feasible or not. So far, attempt'S in this dine!­ tion have rather dismally failed. From the question-letters sent out, which means< Mostly: un­ published information, twenty-nine cases we~ reported to me of septic thrombosis, with recovery in three cases (Scholz, Kanavel, Halstead-see Table 1), or 9.6 per ant. Of theM

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 564 HENRY GLO~R LANGWORTHY. calles Qfrecovery,. one from the ear recovered through en­ ergetic and -thorough aural surgical procedures alone-i. e., radical mastoid and jugular ligation operation; another, neck infection, recovered through local neck drainage, and the third, complicating an ethmoid operation with syphilis, got well on expectant, purely medical treatment. A direct operation was not attempted by anyone of the twenty-one general surgeons upon whose data part of this report is based. (Table 1.) In forty-four cases of septic thrombosis selected from the index of literature here appended (Johnson,29 Adair-Dighton,·· 107 Bircher ) three recovered, or a percentage roughly of seven. Jackson!' also gives a percentage of recoveries of about seven per cent, while Dwight-GermainlO' place their recoveries in a total of cases looked up as 7}1 per cent; which seems to be not far out of the way and settles, I think, from the statistical point, that a patient does have some chance to recover, which some of us have scarcely thought possible. To cQntinue the subject farther. While it is not my purpose to present a too lengthy discussion of this topic, this article would be incomplete without some general consideration of the condition and some statement as to just how thinking men are beginning to view the matter of septic thrombosis about the body of the sphenoid bone. As has been alluded to elsewhere, physicians have felt and are feeling the need of more definite moral support, both in the matter of fairly early reasonable positive diagnosis, as well as from the standpoint of any line of treatment which might be contemplated when confronted with this disease. It may be mentioned also at this time that the problem of septic thrombosis is a borderland one, belonging to various fields, with, however, the striking features chiefly ocular. In consultation, therefore, we should, first of all, in­ clude the ophthalmologist for his eye findings, even though the actual charge of the case be placed in the hands of the general !!urgeon doing a good deal of head or pituitary body work, or of the rhinootologist specializing on the anatomy of the sphenoid region. This certainly, with some acquaintance with literature, would probably provide the best basis to work upon for intelligent future investigation. Rarity of.Cases.-The study of cavernous sinus thrombosis has betn limited in the past (1) because the cases are rare and

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 UJ.A'l'lONS OF CAVERNOUS SINUS TO OTHER STRUcruRtS. 565 the average physician, even in a lifetime, will scarcely see more than two or three sufferers with the disease; (2) being surgi­ cally less approachable perhaps than almost any other structure in the body, few men really consider the sinus available for surgical interference, especially when the patient may seem already in a septic moribund condition and the cavernous sinus itself only one of a number involved. Etiology.-For practical working purposes we may consider infection of this sinus as arising from two general directions: 1, posteriorly from about the mastoid or ear region from a thrombosed lateral sinus, the infection spreading directly for­ ward against the blood current along one of the petrosaIs; 2, anteroinferiorly and a little less common_ by the infection from a carbuncle or wound of the face, jaws or nose, being carried backward, upwards and internally to the interior of the cranium along the drainage system of the ophthalmic vein or by anastomozing veins directly upward from about the throat. The origin of infection at a remote region of the head or neck is one of the most important and tangible clues in diagnosis.* Symptoms for Reasonably Early Positive Diagnosis.-The very first question that confronts us is the necessity of making a reasonably positive diagnosis fairly early in the disease, so as to make it worth while. As the findings of the ophthalmol­ ogist are always awaited with a good deal of expectancy by the other consultants, any opinion 6f value must needs show considerable acquaintance with the literature, a watchful look­ out for just such a possibility under certain conditions, and, most important of all, getting every bit of information which is possible to obtain in any way about the patient before ren­ dering a decision as to what is clearly taking place. Since the later classical signs with which many of us are familiar are among nature's last efforts, not until we have the most careful analysis of earlier symptoms, combined with almost intuitive judgment, can we expect to improve in diagnosis-and im­ prove we must, if we would expect hopes of any future success­ fulline of treatment. While medical men are naturally averse ·The literature ot septic thrombosis Is well covered (successive articles) in numbers 10f, 72, 68, 54, 37 of the index and the present paper.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 566 R~lUY GI,OV!R LANGWORTHY. to taking the pol!itive side in medicine, the fact that so many physicians stand by without feeling sure of their ground until autopsy, even after unmistakable symptoms are presented, often a number of days before death, makes the positive position for the skilled diagnostician all the more necessary just at present. One thing perhaps that has caused a g@od deal of confusion has been variations in the earl}" onset of the disease, according t

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 UI.ATIONS OF CAVEIUlOUS SINUS TQ OTHER STRUCTUtu:s. H7 of beginning lid edema or exGJ>hthalmos o-f the epposite eye, we are safe in saying that the later positive symptoms of the cavernous sinus thrombosis are present beyond a doubt. A fairly early diagnosis in cases where the infection OJ'iginaHs posteriorly about the ear or back of the neck is cQmparatively easy, and should present no difficulty. Cases arisinc. anteriQrly about the face, nose or jaws, however, present at times "-Oft­ siderable difficulty, especially if the focus of infection is in or very close or the orbit. In some instances where the trouble started anteriorly even, yet owing to our lack of individual clinical experience, it is practically impossible to be certain of the diagnosis until the second or opposite eye begins to show some slight involvement by lid chemosis and exophthal­ mos. It is in these instances, however, where intuitive jUdg­ ment points out what might very well happen wuler suspicious' circumstances, as much as any reliance upon ophthalmoscopic evidences of bilateral venous stasis within the eyeball. While the condition is t6 be differentiated from septic infection of the , beginning erysipelas, orbital cellulitis ancl a few sphenoidal conditions, in reality these shoWd be ruled out without much difficulty. Prognosis.-The prognosis is bad, and the m&rtality for all working purposes, under present conditions, should be consid­ ered much higher than our statistics of seven pu cent would indicate. Indeed, for all practical purposes in: an individual case we tlave little reason to hoJ>e for a recovery. Medical science has not as yet attempted a syst~matic camJ*g'n to solve the problem of earlier diagnosis or pt'actital trea.t1Dent. In literature of recent years and from private S8!Stces (Table No.1, and References Nos. 29, 3S, t07) I ha..e 4lbtained six instances where a diagnosis of septic thromboais of this sinus has been made and nature was able to overC(jIJ1e the infection and the patient lived. 1n these instances attentioo was given solely to the original infecting focus, and not to the 4Zav~mous sinus itself. Of seven further rdtemptM operations of any kind to drain the sinus by direct surricai precechtre (Bircher,Jor VOSS,1OI H. Knapp/OG Dwight-Germain,!" C. A; BallaRce, Ballance-Hobhouse,·' and M~sher,1lI all bft failed tc. aCCdm­ push the purpose, and two at l~t we koow failed even to eet to and open the sinus toward which t.k Of)erat.ien was directed.

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In correspondence last year with five each of our prominent general surgeons, pituitary body workers, otorhinologists, anatomists and neurologists, eleven reported no personal ex­ perience with the disease and would make no comments; five believed the sinus might be amenable to treatment, and nine were most skeptical and expressed themselves as against any operative procedure orreal hopes for the future along this line. As possible operative routes to attack the sinus or methods of treating same the following were mentioned as still to be per­ fected: Mosher's proposed anterior route through the orbit, Hartley-Krause11l Gasserian ganglion route through the side s1 of the skull, Luc -Langworthy88 routes upward through one side of the nose and sphenoidal cavity, and lastly, in certain otitic cases, energetic treatment of the original focus alone from behind-namely, by opening the lateral sinus and jugular bulb thoroughly and resecting the internal jugular vein. Recognition of Factors Necessary fo~ Real Progress.­ From the foregoing it must frankly be stated that no substan­ tial support can be deduced from past experience. What little there is in literature is all against expected saving of life by any special operative endeavor on our part beyond thorough operative exposure of the site of original infection. In reality, reports would seem to indicate that such cases "represent organisms which are ruined and in which all science loses its right to interfere." In'the face of this, however, the few men who have studied the question most thoroughly and attempted something in the way of relief seem loath to accept such an unalterable dictum, but cling to the hope, even though not very .well founded, that little will be lost by following a more active and logical operative plan until future systematic demonstra- .tion of failure--:-not in one or two scattered instances, but from dozens· of attempts made all over the world and under all kinds of conditions-has settled the question more finally. It certainly is time, if we are to progress in our handling of so baffling a: disease, that we must tenaciously adhere· to three car­ dinal points connected with it: ( 1) Standing fiat footed upon a reasonably positive diagnosis as early in the disease as pos­ sible; (2) viewing the sinus as we would any other large ves­ sel which has become thrombotic; (3) following routinely thatoperative path which would seem to the surgeon in charge

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 lUtI.A'l'IONS OF CAVERNOUS SINUS 'l'0 OTHER STRUCTUlUtS. 669 as best fitted for drainage. This last will naturally vary, oper­ ators preferring methods as selected and reported by -them­ selves. Limitations of Deductions From Purely Cadaver Work.­ Last year the writer endeavored by systematic work on the cadaver to once more approach the matter of practical ana­ tomic access in as unbiased a manner, and choose, if possible, the best, if one be here allowed such a term, of the three routes offered so far-i. e., (a) Hartley-Krause Gasserian ganglion route through an osteoplastic resection of the side of the skull ; (b) Mosher's proposed anterior orbital exenteration and chisel­ ing through the orbital plate of the great wing of the sphenoid; and (c) the nasosphenoidal route as outlined by Langworthy," but which the pituitary body workers alone have indirectly demonstrated as containing any real practicability on a living subject. From the foregoing it may be stated that the sur­ geon, having specially prepared himself for the operation, is able to tap the cavernous sinus from anyone of the three above directions, but not by any means easily. Under favorable con­ ditions my own selection, in addition to thorough opening of the original focus of infection, would certainly be as follows, if given an actual case: Writer's Proposed Operation.-Light ether v,apor anesthe­ sia. Plugging of posterior nares on one side an.d free injection of adrenalin chlorid solution about the operative region. Quick removal of obstructing ethmoid labyrinth,'middle turbinate and anterior sphenoidal wall by the use of ethmoid curette, tur­ binate forceps, sphenoidal curette, punch, and long narrow­ handle gouge and hammer. Once in the sphenoid cavity the author's straight and angular blunt curettes with overhanging edge" can be pushed through the roof of the sphenoidal sinus, close to the junction of its roof and external wall. The blunt ends of these curettes will push the carotid artery aside without damage, and by rotating the spoon in a forward direction away from the carotid artery, the overhanging edge of the curette catches bone and a hole of some size can be made leading directly into the sinus. This can be further enlarged by use of curettes, assisted, as mentioned, bya long narrow chise1and hammer. The chief danger of the operation here, I would say, is not quite $0 much the thick walled large carotid artery,

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 i70 . H&NItY GLOVER LANGWORTHY. but cathec some unexpected small branches given off frequently in thiscqioo which when accidentally tom by instrumentation might prove troublesome or opening only a partially throm­ bosed sinus-;nuch of this, however, is at present pure specu­ lation:· Cavernous Sinus Thrombosis and the Future.-In conclud­ ing the subject of !ieptic thrombosis, I would repeat that the future alone must detenn.ine the real practicability of attempted earlier diagnosis and direct operation. At the present time, and looking fearlessly into the future, it would seem wise, until more evidence to the contrary is produced, to look upon these a.ses with increasing hopefulness and as offering at least occa­ sionally surgical opportunities which should not be ignored. (2) CUN SHOT AND OTH£R PENlt1'RATING WOUNDS.

Eight cageS of gun shot wounds were reported by letter in which the sinus had been penetrated and otherwise badly in­ jured. Six cases died, and two (Raymond, Halstead) recov­ ered. (Table 2.)

(3) INVOLVEMENT BY SKULL FRAcTun;. Fracture at the base of the skull, with moderate laceration

.Luc, of Paris (1906), proceeded by making a large opening thi'OGP tlle UtterIor wall of the maxillary sinus OIl the same side :as tke c&ftlUOnSmu8. wh1eh he wisheel, to open. and another smaller._ ID_ the DOlle, to Jocat8 tJae anterior wall of the sph8ll0ld. l1slng a straight cblsel, howeTer, he was unable to penetrate the latera1 wall or the sphenoidal canty on that side, and so came to the concluaion that the caTernou sinus should be approached through the muUlary antrum on the opposite side of the head. This gave him the desired angle (oblique), and he was able on the 'cadanlr to open the side of the sella turcica and penetrate the sinus wtthoMt'1DJuring the important stI'1ictur8ll. . Brunert also seems to have had a clear'ldea of some time opening the cavernous sinus through ita' relation8hip with the accessory sinuses of the face. 'My own, tnter~ i,n this subject dates fro~ seeing my ftrst case In nOf, aJll4fefpUng that the linu. might pos8ibly be drained (gravity metbOd~ 'by wa, 'of the sphenoidal cavity through the same 8ide 'Of the 'nose: J. ,C.· Beck, hi 1912, In Investigating the subject of apprl)aCll1}1g ;th.e hypophysi8. from ,Tariou8 routes, developed a met1lollof. ~4ng the bypophysis by way of the antrum follOWing 'the 'lal1"l1 ,open.t!on, lind o1)8rateclsuccessfully two cases of hypo­ llhrseal tumor:·"· From cadanr work. havinr; in mind also at the '1Iame UJDe the eavernous stnUIi. both. Beck and J. R. Fletcher ~~~ize the treme~4olls iUfftculty of reaching this sinus through the

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 R£I.A'J'IONS OF CAVUNOUS SINUS TO OTHG STRUcruR£S. 611 or comp1eterupture of the sinus, was t'cported in liix cases. Two C&.!ies (Ochsner, Bevan) recovered, one by tampooiDg the sinus and the other by expectant treabnent with, however, the fina1loss of the eye itself. (Table 3.)

(~) AJtTEIUO~NOUSANEURISM (RUPTURf; OF INT~RNAI. CAROTID ARTERY INTO CA~RNOUS SINOS). Fifteen cases of rupture of the internal carotid artery in the cavernous sinus, producing arteriov~us aneurism with pulsating exophthalmos, for which ligation of the common carotid or internal carotid became necessary, were reported by letter. Improvement or full recovery ensued in twelve, death in three cases. The principal causes as given were syphilitic weakening of the wall of the artery and trawnatism as by fracture or a blow on the head. In one of these cases (Hal­ stead) thrombosis of the cavernous sinus took place after ligat­ ing the internal carotid artery with, however, good recovery from the cavernous sinus thrombosis. (Table 4.) Rupture of the carotid into the cavemous has been extensiYely reviewed in literature the past f~w years. {5) INJURY TO CA\'SRNOUS SINUS DURINC MISCELLAN!tOUS OPERATIONS. Three cases were reported by letter in which the cavernous sinus was quite badly injured-two during a Gasserian gan­ glion operation with, however, good recovery, and one during an hypophysis opention (Halstead), with death from intra­ cranial hemorrhage. In the literature appended, Emersontl reports serious injury of the sinus with death from curette­ ment of the sphenoidal sinus. Cushing12 reports a case of injury to the sinus during a Gasserian ganglion operation, fol­ lowed by cavernous sinus thrombosis and recovery. The at­ tention which the pituitary body is receiving, with operative attempts at treatment, must surely in time throw much more positive light on the cavernous sinus and its transient struct­ ures. (6) MAI.ICNANT GROWTHS INVOLVING CAnRNOUS SINUS. Two cases of sarcoma w·ith death (Benjamin) were-re­ ported in my list of question"letters, but reported without any

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 572 HtNRY GLO\'tR LANGWORTHY. further data. In litesature appended, Knappl05 reports a case of orbital sarcoma followed by aseptic thrombosis of the cav­ ernous sinus, with successful sinus operation by Hartley, in which the patient lingered for over two months. Macewen101 mentions a case of septic thrombosis and death from carcino­ matous involvement.

(7) CONGtNITAL AFF£CIIONS. One congenital growth (fibrocystic) was reported by Veer (Table 7), in which the zygoma and malar bones were resected in order to reach the area, and many vessels surrounding the cavernous litigated. The patient made a good recovery. I have not obtained as yet a detailed report of this case. One might well expect here also the possibility of some of the rarer forms of congenital angiomata deep within the orbit, in which a correct diagnosis is difficult, to involve the cavernous sinus in some of its ramifications.

(8) MARASMIC (AS&PTIC) THROMBOSIS. No cases of purely marasmic thrombosis were reported in the question-letters sent out. A few instances are on record in literature, however, occurring during the course of debilitat­ ing or marasmic diseases, such as pregnancy, typhoid fever, of socalled marasmic thrombosis of this vessel. Zentmayer­ Weisenburg71 report such a case associated with menstrual dis­ turbances and pregnancy, and Knappl05 presents a case of aseptic thrombosis from sarcoma of the body of the sphenoid bone and apex of the orbit originating in the cavernous sinus.

(9) INTERMITTENT EXOPHTHALMOS. This is a most interesting condition, new, I think, to most of us, and its exact relationship to the cavernous sinus, if any, still a little unsettled. For the present, as mentioned, it seems permissible to mention it here. No cases of this affection were mentioned in the question­ letters, so that the literature of the subject had to be consulted for the information. True intermittent exophthalmos, a rare condition, is fully reviewed by Posey80 and Alger," and must not be confused with pulsating exophthalmos, which last is due \0 rupture of the internal caroti$1 artery in the cavernous sinus.

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In a case of true intermittent exophthalmos, owing to changes in the orbital veins, one eye will be pushed forward out of the orbit, but quickly recedes as soon as venous pr~ssure in the orbital veins and cavernous sin,,!s becomes normal. In a typical case the eye proptoses in a few seconds whenever the head is in a dependent position, as in stooping, or whenever a venous congestion of the cranium is produced by a great- muscular exertion or by a local pressure on the neck. The explanation of the phenomenon seems to be that under certain conditions which produce increased muscular tension in a very tortuous ophthalmic vein, a sudden kink or constriction results, com­ pletely stopping the return of blood from the orbit to the cavernous sinus. As soon, however, as the venous pressure is lowered in the cavernous by a change of posture or relief from muscular strain, the kink or bend is relieved from press­ ure posteriorly, the vein emptied and the eye sinks back into its natural position in the socket. As there seems to be no rec­ ord of an autopsy on a case of intermittent exophthalmos, our knowledge of this pathologic condition is largely theoretic. In concluding thi!\ paper and especially from a study of the many artices comprising the index it is difficult to refrain from commenting on the gradual signs of progress being made year by year with reference to our better understanding of the anat­ omy, pathology and diagnosis of affection of the cavernous sinus.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 ~ TABLE 1

Downloaded from Septic Thrombosis of Cavernous Sinus

Doctor submitting . Information DiagnQsls EtlololY Treatment R~ult Purulent disease of nasal sl· aor.sagepub.com Collins, A. N. Septic thrombosis Frontal sinus opened' aad Death Duluth, Minn. nuses drained II .l1l Strout, E. Septic thrombosis Accessory slnuws Not liven Death ~ Minneapolis, Minn. ~ Hitz, H. B. atBobst Library,New YorkUniversity onMay 8,2015 Septic thrombosis Not given Not give" Deatb Milwaukee, Wis. Blair, V. P. Septic thrombosis Suppurative ethmoiditis Accessory cavities dralMd Death ~ St. Louis, Mo. O~nhelmer,S. (1) Septic thrombosis Aural Net given Death " ew York City (2) Septic thrombosis Aural Net glvell Death f; Sudler, M. T. ~ Aural ~otgiven Death Lawrence, Kan. Septic thrombosis Patton, J. M. Septic thrombosis Boil of neck Not given Death ; Omaha, Neb. (1) Septic thrombosis Chronic ear dlscharcc Not liven Death ~ Geller, Jacob (2) Septic thrombosis Aural Not given De,ttl St. Louis, Mo. (3) Septic thrombosis Aural Not liven Deat" Wlther.poon, T. C. Butte, Mont. Septic thrombosis Typheld fever-no details Not given Death (1) Septic thrombosis Not given E"ploratory craniotomy Death Lilienthal, H. (Z) Septic thrombosis Osteomyelitis 10werJaw Not given Death New York City (3) Septic thrombosis Furuncle vestibule nose Not given Doatb @ >-I Rixt...~ E. SeptIc thrombosis Ascendlntt Infection Pte~gOldNot given Death S Downloaded from I... ruel~o,Cal. muscle and ba!le of s ul1 Z tI) Gifford, H. Aural Deattl Omaha, N.b. Ise'ticthrombesis Not given o ------.------'lIl. Cotto G. F. Septic throlQbosls Aural Death Buffalo, N. y. Not &tven aor.sagepub.com - Death Hamann C. A. (1~Se~th~= Peridental abscess Not given Clew laltd, Ohie ~2 Septic thro Frontal and maxillary Inf.ctlon Not given Death i ('Nne",R. C. (1) Septic thrombosis Aural Not given Death OWOrleus, La. (2) SePtic thlOlllbosls Aural Not gjven Death

atBobst Library,New YorkUniversity onMay 8,2015 I R~ond,Alfred (1) Septk thrombosis Accessory sinuses Not given Death t! attie, Wash. (3) Septic thrombosis Acute tonsllitls Not given Death ~ o ~e;J. J. ieptlc tbro_bl*s Aural Not given DeNJa {jI AQleles, Cal. ~ J'$9P, Wm. Septic thrombo6ls Accessory sinus disease Not given Death loux City, .owa SCholZ, R. P. tbrom~&Aural Radical mastoid and IIga- Recovery St. Louis, Mo. iSePUc tion lateral sinus I GILIve),A. B. C/lI<:III0, III. !septic thrombosis Neck Infection Local neck dr.i1nage Recovery Ethmoiditis and syphilis fol- ~ N.leteaa; A. E. Septic thrombosis Recovety Chicago, III. lowing ethmoid operation Expectant treatment ~ e~

~ ~ ~ TABLE Z 0) Gun Shot and Penetrating Wounds of Cavernous Sinus Downloaded from

Doctor submitting Treatment Result information Diagnosis aor.sagepub.com II: Babler E. A. I-Gun shot wound No operation Death l"1 St. Louis, Mo. Z- Gun shot wound Not given Death Z ~ atBobst Library,New YorkUniversity onMay 8,2015 Yates, J. L. Gun shot laceration Death Milwaukee, Wis. ~ lIll !: Basham. D. W. Gun shot wound z Wichita. Kan. Death c;) ~ I-Gun shot wound ~ Ras;mond, Alfred right optic nerve and sinus torn across. Not given Death 2-lnjury, Fron- Tamponade II: eattle. Wash. tal lobe destroyed Recovery ~

I-Gun shot wound through ear, lodging In sinus cavity. Death Halstead, A. E. Developed sinus thrombosis and brain abscess. Sinus oper- Chicago, III. ated by Gasserian ganglion route and bullet removed. Z-Gun shot wound Recovery, loss of both eyes TABLE oS @ ..."'I Downloaded from Involvement From Fracture of Skull o Z II>

Doctor lubmlttln, ~ Information Dlarnosis Treatment Result ~ aor.sagepub.com

~ 1lI Babier E. A. Z St. Louls, Mo. Fracture of base with rupture cavernous sinus Nof given Death o c: atBobst Library,New YorkUniversity onMay 8,2015 II> fI>... Ochsner. A. J. Compound fracture with laceration cavernous sinus Cavernous sinus tam- Recovery In ten Z Chlcqo, III. poned days c: fI> g Pause. H. E. Fracture base with laceration sinus wall Operative removal Death-menln- Kansas City, Mo. of clot tis ~ rl III I: BubaJll, D. W. Wichita, Kan. Fracture with injury to cavernous sinus Not given Death i ~ Bevan, A. D. I-Fracture of base causlnl cavernous sinus thrombosis Not given Death c: Chlcalo, 111. Z-Fracture of base causlnl cavernous sinus thrombosis Not given Recovery- loss of eye ~ Ot :J TABLE 4 ~ ~ Rupture Int.rnal Carotid Artery In Cavernous Sinus Arteriovenous Aneurism

Downloaded from 5 , I , l d I , , •• d ,I " C 1 , Doctor submitting Olagnosls EUoloty Treatment Result Information " « (11 . '" r

aor.sagepub.com Cured now six SGbWyzet, A. Pulsating rxophthalmos-arterlo- Not given LIgation common car- St. "~I,Minn. venous aneurism otld years Dennis, W. A. Lieatlon common caro- Relief, but not St. Paul, Minn. Pulsating exophthalmos frlKture tid and ophthalmic vein (omplet. I atBobst Library,New YorkUniversity onMay 8,2015 Vaucbaft, G. T. Lilation right Internal Ar'tef1ovenolis aneiitlsJfl Not 4ennltely lS(ertalned (.arotld Death l-Art~lovenous'aneutlsM Ttaum.tk Uttation orbital veint Mattln, edward Relieve4 i and calotld Philadelphia, Pa. Z-ltrteriovenot2S aneuriMn Not Jiven Not'liven e Lilienthal, H. Pulsatlnr exophthalmos Followed mastoid opera- Ligation both common Death New Yark City tlon carotids -- Grffflth, J.' O. Arteriovenous aneurism Not given Ligation common car- I Death Kansas, City, Mo. , otid , =~ Dean, L. W. Pulsating exophthalmos Shot through orbit Common carotid Iiga- Improved , Iowa City, ~owa te

atBobst Library,New YorkUniversity onMay 8,2015 III Doctor submitting Diagnosis Treatment Result ...III Information Z t.mlKlnade controlling e: Hurls, M. L. During Gasserian gang~onoperation Good; recovery Ul Chlcain, 1lI. theproJuse hemorrhage ~ Davis, G. G. During Gasserian ganglion operation Philadelphia, .... Packing Reco\'ery Halstead, A. E During an hypophysis oPeration Not linn Death from Intracranial ; Chicago, III. hemorrhage Il

ae: ~ c:

~ ~ .., 680 HENRY GLOVltR LANGWORTHY.

TABLE 6 Malignant Growths Involving Cavernous Sinus

Doctor submitting Information Diagnosis Treatment Result

Benjamin, A; E. I-Sarcoma Details not given Death Minneapolis, Minn. 2-Sarcoma Details not given Death

TARLE 7 Congenital Affections of Cavernous Sinus

Doctor submlttinc Information DI_llIosls Treatment Result

vanderveerNA. Congenital growth Resection zygoma Good re- Albany, • Y. Flbrocystic and malar bone. L1. covery gatlon of many veins surrounding cavernous

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REFERENCES. 1. Piersol: Human Anatomy. 2. Gray: Anatomy. 3. Hoeve: Manual of Dissection and Practical Anatomy of the Head and Neck. 4. Gibson, J.: The Sphenoidal Sinus. Jour. A. M. A., December 19,1908. 6..Sluder, G.: Some Anatomic and Clinical Relations of the Sphenoid Sinus to the Cavernous Sinus and the Third. Fourth; Fifth, Sixth and Vidian Nerves. Annals. Otol., Rhlnol. and Laryngol., Sep­ tember, 1913. 6. Gerrish: Textbook of Anatomy by American Authors. 7. Haskin, W. H.: Ocular Manifestations in Nasal and Aural Diseases Which Probably Indicate Involvement of the STDlPathetic Nervous System. Annals. Otol., Rhinol. and Larrngol., June, 11113. 8. Sobotta: Atlas and Textbook of Human Anatomy. 9. Macewen, Wm.: Atlas of Head Sections. 10. Cunningham: Textbook of Anatomy. 11. Morris: Human Anatomy. 12. Toldt: Anatomischer Atlas. 13. Testus, Jacob: Traltfl D'ADatomie Topol!'&phlQue. U. Zuckerkandl: Atlas der topograph1schen Anatomle 4el Menschen. 15. Buchanan: Manual of Anatomy. 16. DaTis: Applied Anatomy. 17. Woolsey: Applied Surgical Anatomy. 18. BchMer: Textbook of Microscopical Anatomy. 19. Campbell: Textbook of Surgical Anatomy. 20. Gordinier: Gross and Minute Anatomy of the Central Nerv­ ous System. 21. Deaver: Surgical Anatomy. 22. Visual Disturbances Showing a Causal Relation to Disease In the Sphenoidal Sinuses, With the Report of a Case, Together With Coronal and Sagittal Sections Demonstrating the Relations Exist!q Between These CaVities. 23. Pa:ge, J. R.: Hemorrhage From the Superior Petrosal Sinus. Jour. A. M. A., Aug. 8, 19U, p. 468. 24. Hunt. J. R.: Mle of the Carotid Arteries In the Causation of Vascular Lesions of the Brain. Amer. Jour. Med. Sciences, May, 19H. %5. Mosher, H. P.: Orbital Approach to the Cavernous Sinus. The Laryngoscope, August, 1914. 26. Braun. Alfred: Case of Cavernous Sinul Thrombolla Compli­ cating Suppurative Labyrinthitis. Annals Otol., Rhlnol. and Laryn­ gol., June, 19H.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 582 IIJIX1lY Gl.OQ'R UNGWVIlTJlY•. 27. 1l'rteaner, I.: Cue 01...... BUateral CaTerDOU8 Sinu Thrombosl8 Tweln Ho1U'8 After & Simple Kaalold OperaUo.. AD­ naIe otol., RhlDol. and LarJDgol., June, 1914. 28. Pooley. T. R.: Canmous B1aua Tlarombo81s. Cue Report anel Surgical Study. N. Y. State Med. Jour., AUIWlt, 1914. 29. 100800, H. R.: C&II& ef Cavernous i1lnus Thrombosis of otitic Origin, With Beconl")'. Laryng08COpe, February, 1913. 10. Horn. ~DZ'J: CaYerDOUB B1DUI Thrombosle Due lo Organ· .... ~ the Btreplothrix Group.. ADDala Otol., Rhlnol. Uld r.r,n­ pl., December, 1111. 31. M088gron. J. B.: Cue of Septic Thrombosl8 at Both Oph­ thalmic Velas and C.veraoUl S1DwJea.. Ohio State Meel. Jour.• AUPBt.191a. &2. Bull. A. C.: Cue ef Caven10U Smus ThromboRJi Reaulua. FIIom & Small Abscels in SkiD of . Vaccine Treatment. Amer. Ophthalmol. Soc1et~ TraD8actJ.ona, 1813. 33. McKinney, R.: CaMl'DOUI sinua Thrombos1a, Report of a Cue. UJ')'ngoscope, November, 1913. . 84. Maher. W. 0.: Two Unusual Cues of Pulsating Ezophthal­ mos. OphthalmoloD', AprU, 1914. 36. BertUch. H.: Thromboala ot Ca1'81'BOus ill a Five MOiltlas' Old Bab!. Muench. meet Woch., 1913, LX, 1U6. 36. Io'erron. M.: Anatomy of Sinus CaverDosus. Jour. de Mu.e­ cine de Bordeaux, Febru&J')' 9, lil3, XLIII, No. 6. 37. Ballance-H"obhouse: Case of Selltle Tbombosls of Left Sig­ moid. Left CanrDOU8 aDd. Left mter1~ Petrolal Sinuses, With a Suggestion for Treatmenl·lD Futue C..es. AaDall Otol., RJainol. and LarJugoI.. December, U1I. Noa-TltJa utlcle CODtal•• a &ben review of a number of impor­ tant cues and brief blbUocr&phr. 88. Adalr-Dlpton: CanrDous SlnUI Thrombosis of OtItic 0rJ· liD. Beeo"e~. AnnaIa. Olel.. RhlDoL and LI..J')'Dcol., June, 1912. J.I8o Practitioner, IADdoD, March. XC. No.3. a Roope. .A. P.: Anomaloua Internal Carotid ArterT. lndlaaa State Med. Assoc. Jour., April, 1913. M. BuJatel. 1'. c.: Treatmeat of Pulsatlag Exepllthalm08. With Cue Report. Ophthalmic Recor4l, J'ebl'UU7. 1913. 'l. B&eIll. C.: Acceu to Bnopbra18 and Sinus CavemOWI by ~ol6 PhaQlltCotollly. ZeDtralblalt fir Chlrurcle. ,Janu&JT. 1t12. U. HIJU, W.: TbroJilboBla of Cavema.. Slault-Unuaual Compu­ cation of PrepanC7. Australulan 1IiIcl. QueUe, June, 1912, XXJa, No,U. U. lam...... : Two eaa.. of PulMUq Ezopb.thalma. in WhIch Carotid Artery W.. ligated. Lancet, Ju1" UU.

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... RoY. J. N.: ReTolnr B~let III the Chluma; CouecUU.... BlnGCUlar Blladnesl. Ophthalmolou'. October. 11111. 46. Ibsen, J.: Case of Pulsating Exophthalmos Cured bJ tqa,. UoIl of Common Carotid. HOlpltalstldende, September. 1812 (CoPeD­ hagen). 46. Otto. K.: Thromboels of Canrnous Sinus Not of Otitic Ori­ gin. Deutsche Zeltschrlft far Cilirurgle. June. 11111. CX. 47. Eischnlg, A.: Consequences for the Retina of Ligation of the Carotid Artery. Medl&inlsche Kllnlk. September 24. 1911. 48. Zeller. 0.: Operative Treatment of Pulsating Exophthalmos. Deutsche Zeltschrlft filr Chirurgie, AIJIUSt. 1911. 49. Reber, W.: DUferential DlagnosJa of Orbital Cond1tiou Caused by Sinuitis, Including Thrombosis of Cavernous Sinus. PeIlD. Med. Jour., 1910. DO. Coffin, L. A.: Cavernous Sinus ThrombosJa. Annals Otol.• Rhlnol. and Larrngol., December, 1910. 61. Bender·Halstead: Pulsating Exophthalmos; !4atlon of in­ ternal Carotid. Surg., GJ]lecoi. and Obstetrica. January. 1910. 52. McMullen, C. G.: Aneurism of Internal Carotid Treated bJ Matas' Method. Annals of Surgery. January. 1910. 53. Barrett-Orr.: Traumatic Pulsating Exophthalmos. later­ colonial Med. Jour.. of Australasia, 1910. 54. Jackson, Edward: Ocular and Orbital Symptoms of Throm­ bosis of the Cavernous Sinus. Ophthalmology• .January, 1909. . Note.-This paper is based on two cales of the author; on twenty­ five cases published lince Dwight·Germain paper on Thrombosis of the C....ernous Sinus (Boston Moo. and Surg. .Jour., May 1. 1902); on the four cases of Dwight-Germain as preseDted by them, and on their studied records of one hundred and seventJ-eight Cas88 pr. viously reported in literature. 66. Thomas. J. J.: Fatal Phlebitis of Cerebral Sinulas and Veins in a Child Fourteen Months Old. Cleveland lied. .Jour.• September. HI09. 56. Neuman, D. S.: Cale of Thrombosll of the Cavernous Sinus Following Mastoiditis. Colorado lied. lour.• April. 1909. 57. Gallaher, Thomas J.: Thrombosla of the Intracran1al Veaous Sinuses of Otitic Origin. Colorado Med. Jour.• April, 1909. 58. Lowe, L.: Access Throqh the Throat to the SpJaeDoYal Sblus and the Sphenoid Segment of the BMe of the BraID. zentral­ blatt fur Chlrurgie, April, 1909. 69. Hlrd-Haslam: Spontaneous Pulsating Emphtha1JDoll. LaD­ cet, February. 1909. 60. Ranken, D.: Cue of Traumatic ~phtJaalmgl. LaDcet•.o.­ cember, 1909.

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61. Roy, Dunbar: Report of Probable Case of Sarcoma of Sphe­ noidal Binus With Remarks. Annals Otol., Rhinol. and Laryngol., June,1909. 62. Emerson, Francis P.: Developmental Absence of the Outer Right Sphenoidal Wall Occupied by a Vein Communicating Directly With the Cavernous Sinus; Operative Fatality and Autopsy. Annals Otol., Rhinol. and Laryngol., June, 1908. 63. Syme, W. S.: Operative Procedures in Relation to Disease of the Frontal and Sphenoidal Sinuses. Glasgow Med. Jour., March, 1908. 64. Simpson, W. L.: Septic Thrombosis of the Cavernous Sinus, With Report of a Case. Archiv. of Ophthalmology, VoL 37, No.4, 1908. 65. Thomson: Ophth. Review, October, 1908. 66. Lewis, F. P.: Pulsating Exophthalmos; Ligation of Orbital Artery; Recovery. Ophthalmic Record, February, 1907. 67. Langworthy, H. G.: Optic Neuritis in Thrombosis of Cranial Sinuses and Internal Jugular Vein. Laryngoscope, January, 1907. 68. Langworthy, H. G.: Thrombosis of Cavernous Sinuses, With Report of Four Cases. Boston Med. and Surg. Jour., April 25,1907. 69. Fridenberg: Trans. Amer. Acad. of Ophthalmol. and Oto- laryngology, 1907. 70. Henderson: Amer. Jour. of Ophthalmology, March, 1907. 71. Beggel: KIin. Monatsbl. f. Augenh., August-September, 190'1. Note.-Referred by Jackson. 72. Thomson, St. Clair: Cerebral and Ophthalmic Complications in Sphenoidal Sinuitis. Trans. Med. Soc. of London, Vol. 29. 1906. Note.~omplete bibliography to date, including brief abstract of forty cases representing complications in sphenoidal sinuitis. Thrombosis of cavernous sinus in seventeen cases. 73. Zentmayer-Weisenburg: Primary Cavernous Sin1l.s Throm­ bosis-With Involvement of All Cranial Nerves of One Side, Except the Auditory, and With Peculiar Menstrual Disturbances. Report of a. Case. Amer. Jour. Med. Sciences, February, 1906. 74. Langworthy, H. G.: Proposed Operative Measure for Throm­ bosis of the Cavernous Sinus. Laryngoscope, 1906. 75. Alger, Ellice M.: Intermittent Exophthalmos, With Report of a Case. New York Med. Jour., January 27, 1906. 76. Knapp, Arnold: Primary Cavernous Sinus Thrombosis Bec· ondary to Osteomyelitis of the Petrous Pyramid. Archiv. of Otol., Vol. 36, No.6, 1906. 77. Langworthy, H. G.: Cavernous Sinus Thrombosis in Children Following Mastoid InflammaUQn. Laryngoscope, October, 1906. 78. Ranschofr, Joseph: Pulsating Exophthalmos. Surg., Gyne­ col. and Obstetrics, August, 1906.

Downloaded from aor.sagepub.com at Bobst Library, New York University on May 8, 2015 RELATIONS OF CAVERNOUS SINUS TO OTHERSTiwCTURts. 585

79. Hansell;H.F.: J:'ulsating Exophthalmos; Suc~es8ive ,L!ga­ tionof Both Common Carotid Arteries; Death. Jour.A.. M, A.. Fel>' ruary 18, 1905. (Bibliography.) 80. Posey, William Campbell: Intermittent Exophthalmos, .With Report of a Case. Jour. A. M. A., June, 1904. Note.-Contains a complete bibliography to date. 81. Luc, H.: La Voie d'Acc~s Vers l~ Sinus Caverneus. Bulletin et Memoir de la SocHit~ francaise d'Otologie de L.aryngologie et de Rhinologie Congr~s, 1905. 82. Cushing, H.: Surgical Aspects of Major Neuralgia of the Trigemin.al Nerve. Jour. A. M. A., 1905. (Serial article.) 83. Werner: Ophthamoscope, May, 1905. Quoted by Jackson. as having recovered from cavernous sinus thrombosis with perfect eye. 84. Snell: Trans. Ophth. Soc. United Kingdom. Vol. 36. Re­ ferred to by E. Jackson in bibliography appended. 85. Hanna, H.: Fatal Case of Cavernous Sinus Thrombosis Fol­ lowing Chronic Purulent Otitis. Jour. Laryngol., Rhinol. and Otol. (London), July, 1908. 86. Stucky, J. A.: Septic Thrombosis of Cavernous Sinus FollOW­ ing Radical Mastoid Operation on Seventh Day. Jour. Laryngol., Rhinol. and atol., October, 1908. 87. Bronner; Adolph: Notes on a Case of Thrombosis of the Cavernous Sinus Due to Empyema of the Sphenoidal Sinus. British Med. Jour., November 12, 1904. 88. Ellett, E. C.: Septic Thrombosis of the Cavernous Sinus. Report of Three Cases. JC;lUr. A. M. A., May, 1904. 89. Roth, Henry: Thrombosis of the Cavernous Sinus, With Re­ port of Three Cases. N. Y. Med. Jour., February 27. 1904. 90. Miles: Trans. Sec. on Ophthalmol. A. M. A., 1904, p. 156. 91. Oliver, C. A.: Cerebellar Neoplasm in a Subject With Renal Disease. Amer. Jour. Med. Sciences, June, 1904. 92. Grunert: Die operative Ausriiumung des Bulbus venae jugu­ laris, in Fiillen otogener Pyriimie. Leipsig, Vogel, 1904. 93. Finley, C. E.: Case of Thrombophlebitis of the Cavernous .Sinus Complicating an Empyema. Archiv. of Otol., December, 1903. 94. Lodge, S.: Case of Thrombosis of the Cavernous Sinus. Annals Dtol., Rhinol. and Laryngol., September, 1903. 95. Preston, R. J.: Rupture of Carotid Artery. Virginia Med. Semi-Monthly, May, 1903. 96. Chance: Amer. Med., June, 1903. 97. Day, E. W.: Annals of Otol., Rhinol. and Laryngol., 1902, Vol. 11, p. 520. (Abstracted by Jackson as having recovered from cavern­ ous sinus thrombosis with, however, the eye badly damaged.) 98. Jackson: Trans. Amer. Ophthalmol. Soc., Vol. 9. Ibid. 99. Prefontaine: Trans. Sec. on Ophthalmol. A. M. A., p. 150. 100. Risley: Ibid., p. 155. (Referred by Jackson.)

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MI. 9toek8l': Ateh. ef OplrtllalmoF., Vol 35, p. 1m. (Quoted b7 Jaeba &It having reeeveredfrom cave!'1!WUl> sinus thrombosis witJl; loss of central vision.) 18!. Maeeweu, Wm.: PyogeDie Iafeetive Diseases of the Brain and Spinal Cord. (Ed. 1893.) 103. Jack, E. E.: Case' of CaTemous Sinus Thrombosie Following Grippe. Arehtv. of Ophthalmol., 1902, p. 545. 104. Dwight, E. W., and Germain, H. H.: Thrombosis of the CaT­ ernousSinus, With Report of Four Cases, Including One Cranial Operation. Boston Med. and Burg. Jour., May I, 1902, p. 456. Note. ,-Complete bibliography to date, with analysis of 178 cases gath- ered from literature preeedmg them. ' 105. Knapp, Herman: Case of Traumatic, at First Doubtful, Orbi­ tal Sarcoma, Followed by Alileptic Thrombosis of the Cavernous Sinus. Archiv. of Ophthalmol., 1900, p. 77. Note.-Cnernous sinult operation by Hartley, following Gasserian ganglion route. Patient lived two montl1s. 106. Morax, V.: Ocular Disturbances Observed in Case of Epithe- lroma of the Sphenoidal Sinus. Annals D'Oeulistique, June, 1896. 101. Bircher: CentramIatt fik Chirurgie, 1893, No. 22. 108. Voss: Centralblatt fitr Chirurgie, No. 47, November, 19&2. 109. Langworthy, H. G.: Amer. Eneyelop. and Diet. Opbthalmol. (Ed. by Wood), Vol. 3, 191+. Ocular Relations of the Cavernous Sinus, p. 1794, 1809. 110. cary, E. H.: Gunshot Wound of Caverno1!ls Ple~us, Report of Case. Texas State Jour. Med., October, 1914. 111. Reference Handbook of Medical Scienees, Vol. VIII, liP. 2ft· 242. 112. Hartkly.Krause Operation for ExpOsure of Gasserian Ganglion and Three Divisions of Fifth Nerve Through TempOral Fossa b7 Osteoplastic Flap. Bickham's Operative Surgery, 3rd Ed., p. 177.

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