[Extracted from the Transactions of the American Medical Association for 1880.] 
CASE OF RECOVERY FROM OCCLUSION OF ONE OR 
MORE OF THE CEREBRAL SINUSES. 
By M. O'HARA, M.D., 
PHILADELPHIA, PA. 
On March 1,1880,1 was called to see Miss M., a romist'W'hfte 
person, twenty-two years of age. She had been complaining 
since February 22d of general and local pains which she called 
neuralgia, but now her complaint was especially of oedematous 
swelling about the eyes and face and atrocious pains in the head ; 
the pain was constant and tensile, but with exacerbations of 
severity. The pains and swelling were most marked in the 
face, temporal and frontal regions, and more manifest on the 
right side. The pains in the temporal region seemed to alter- 
nate in severity with the changing appearance of venous disten- 
sion in the forehead, nose, eyes, temples, and the whole orbital 
region. There was internal strabismus of the right eye; the 
pupils were normal; the eyes were protruded, the right eye 
more than the left; there was ecchymosis of both conjunctivae. 
Negative points were the absence of sweats and vomiting, 
though nausea was present. No definite motor paralysis could 
be made out, but the grip of the right hand seemed weaker than 
the left. 
On having her to stand and walk a few feet with eyes shut, 
she fell unless supported. There was hypersesthesia of the left 
cutaneous surface, and anaesthesia of the right. The recognition 
of impressions on either side was uncertain. Vision was not 
impaired. The hearing was defective on the left side, but this 
she stated to have been the case for years. The tendon reflexes 
were normal. Iler mental condition was unaffected. There was 
general fever, pulse 100, and respiration more frequent than 
normal. 
The only history afforded as to causation was that she had 
fallen eighteen months previously, and had struck upon her 
right knee; since, she had pains and swelling in the right and 2 
OCCLUSION OF THE CEREBRAL SINUSES. 
left knees and ankles, and pains in the leg bones, which remained 
continuously in the right tibia. There were present periosteal 
inflammation and thickening of the right tibia. 
The diagnosis was made of complete or nearly complete occlu- 
sion of one or more of the basal cerebral sinuses either from in- 
ternal or external causes, and was based on the local appearances 
and the history given by the patient; the circulation being so 
obstructed as to cause a damming backward of the blood in the 
ophthalmic veins into the facial veins, which ought to have 
been emptied into the cavernous sinuses. 
The treatment ordered was cupping, free purging, the use of 
bromides and ergot in large quantities, morphia to relieve pain 
and procure sleep. 
On March 2d Dr. C. K. Mills met me in consultation, and 
concurred in the diagnosis. He co-operated with me afterwards 
in-the management of the case. The pain was greater and more 
diffuse over all the region before mentioned; the conjunctiva 
was more ecchymosed; the strabismus was decided; there was 
very marked collateral venous distension over the whole face, 
nose, and temples. Urination was less free. 
The same treatment was continued, and it was deemed pru- 
dent, lest there be some blood contamination, to add the use of 
iodide of potassium and bichloride of mercury. 
On the third, there was an amelioration of all the head symp- 
toms. She required morphia for sleep, as the insomnia was dis- 
tressing without it. No change was made in the treatment. 
Severe purging by senna and salts appeared to have a happy 
effect. 
On the fourth, she complained of a throbbing pain in the right 
side of the head, with each beat of the heart; the headache was 
very distressing, but was relieved by morphia frequently given. 
She had annoying pruritus and formication over the whole body, 
which was palliated somewhat by washes of borax and muriate 
of ammonia. 
On the fifth, she had very much pain, as if the head would 
burst; she was delirious, and had illusions, but no permanent 
hallucinations. The squint had disappeared. Her pulse was 
108, and her temperature 103°. Her local head temperatures 
were taken at three stations-a central frontal in the middle of 
the forehead, and a lateral frontal just above and behind each 
external angular process of the frontal bone. The results were- OCCLUSION OF THE CEREBRAL SINUSES 
3 
Central frontal 99£° 
Right lateral frontal 98 
Left lateral frontal 96| 
Her right knee was painful and swollen; the left was also pain- 
ful. Her grip was equal in both hands. 
On the sixth, she showed a remarkable improvement which 
came on in the course of a few hours. She slept well and with- 
out any narcotic for four hours, and made no complaints until 
later in the day, when swelling and pains in the left knee and 
scattered pains over the body appeared. She was now kept on 
bromide and reduced quantities of the iodide, with mercury. 
On the seventh, she slept tolerably well and continued better. 
The superficial sensibility of the body was normal. The knee 
was less swollen. The ecchymotic condition of the eyes was 
disappearing. The temperature record was- 
General temperature (axilla) ..... 102° 
Central frontal 98| 
Right frontal 98^ 
Left frontal 98^ 
She complained of a beating sensation on the right side of the 
head anteriorly. There was a purplish blotch on the right molar 
bone, one and a half inches in diameter, of irregular outline be- 
tween the eye and ear. The conjunctival ecchymosis, the ocular 
protrusions and nasal swelling, present the day before, had all 
left. 
On the eighth, she w'as doing well, but had some slight deli- 
O' O' o 
rium. The pulse was 82 and temperature 100J°. 
On the tenth, she vomited occasionally, was melancholy and 
complained of flying pains. 
Up to the twentieth she steadily improved, but on this day 
she complained of gastric distress and a smothering feeling in 
breathing. 
On the twenty-third, she had neuralgic pains in the left side 
of the body and a rectal abscess was opened. 
On the twenty-fourth, she felt quite stupid; the left side of 
the body, particularly the leg and foot, felt weak. The rectal 
abscess was discharging. 
On the twenty-ninth, she had much pain in various joints, 
and felt mentally enfeebled. Her left arm and fingers felt weak. 
She could not cut with the scissors (her usual occupation). 
On April 3d, the last day she was seen, the symptoms noted 4 
OCCLUSION OF THE CEREBRAL SINUSES. 
had all disappeared; though weak, she was otherwise well and 
at work. 
The chief features of this case may be summarized as follows : 
The patient had suffered for several weeks with scattered neu- 
ralgic pains, when she was taken down suddenly with great pain 
in the head and oedema of the right side of the face, temples, 
and orbital region, with conjunctival ecchymosisand ocular pro- 
trusion ; the left side soon became involved in the same condi- 
tion. Paralysis of the right sixth nerve occurred, and the patient 
suffered from throbbing pain in the right side of the head, weak- 
ness of the limbs, and want of co-ordination, and varying con- 
ditions of sensation in the two sides of the body were present. 
General fever, accompanied by local increased temperature, 
persisted until the sudden disappearance of the severe head 
symptoms and the paralysis of the sixth nerve. 
How can we account for these phenomena and their fortunate 
and unexpected disappearance? It would seem to me that a 
blockage of the intracranial venous circulation could alone ac- 
count for the train of symptoms, which were undoubtedly those 
of venous stasis; the parts exhibiting this stasis were those 
drained by the ophthalmic veins and the portions of the facial 
vein communicating with it. The facial vein communicates at 
the inner angle of the eyes, by the angular vein which receives 
the blood of the veins of the alae nasi and superior palpebral 
veins. The ophthalmic veins terminate in the cavernous sinus; 
and the cavernous sinuses on each side are in communication with 
the circular sinus,so as to completely surround the pituitary body. 
It seems to me that the blockage of the right cavernous sinus 
subsequently extending by way of the circular sinus to the left 
cavernous sinus might account for the local manifestations pres- 
ent in this case. The paralysis of the right sixth nerve could 
be explained by pressure upon it either in its course through the 
cavernous groove or in its passage through the sphenoidal 
fissure. 
If a thrombus were present in the right cavernous sinus, this 
might have accounted for the condition, or the distended oph- 
thalmic vein passing through the sphenoidal fissure may have 
pressed upon the nerve. 
Thrombosis of the transverse sinus is said to occur with more 
frequency than thrombolic disease in any other intracranial 
location. This is owing to the fact of its being more likely to OCCLUSION OF THE CEREBRAL SINUSES. 
5 
become involved in local disease of the ear and of the petrous 
portion of the temporal bone; but no evidences of local disease 
or injury were present. Undoubtedly, however, involvement of 
the cavernous sinuses with the transverse, would explain the 
manifestations almost as well as the view of the conjoint impli- 
cation of the circular and cavernous sinuses. This, after all, 
however, is not a matter of great moment. 
The history, course, and termination of this case favor the 
idea that it was one of true phlebitis, and that the probable oc- 
clusion was not of the nature of a marantic thrombosis. It is 
well known that most of these cases of phlebitis sin num arise 
from special local causes, as disease of the cranial bones, the 
latter accompanying suppurative inflammation of the middle 
ear. No evidence of this kind was discoverable. According to 
Nothnagel,1 proof is wanting for the fact that phlebitis of the 
sinuses can arise as a spontaneous and primary affection. Under 
the influence of some specific condition of the blood, however, I 
see no reason why inflammation of the inner walls of the cere- 
bral sinuses might not occur. 
No furuncles were present about the face or body. I am in- 
clined to think that the rectal abscess indicated depressed vital- 
ity in the patient, rather than that it had any relation to the 
cerebral condition. 
The case was certainly not one of erysipelas. The erysipela- 
tous appearance did not precede the ocular and intracranial mani- 
festations. We had, in fact, a "pseudo-erysipelas," as Rosenthal 
calls it, but no true erysipelas. The recovery of the patient 
precludes the supposition of an intracranial abscess. 
Pressure upon the sinuses, arteries, and certain of the cranial 
nerves by a tumor or exudation, might have given rise to most 
of the symptoms presented, but the symptoms evolved in such 
a case would not have arisen with such rapidity. 
Congestion of the brain would hardly remain so persistent as 
in this case; there was passive congestion from stasis due to ob- 
structed circulation from the apparent thrombosis of the sinuses. 
If there were acute congestions of the brain, we should have had 
apoplectic symptoms, which did not appear in the history of the 
case. 
The result of the treatment instituted would seem to bear out 
the view that the case was one of phlebitis. 
1 Ziemssen's Cyclopaedia of the Practice of Medicine, vol. xii. p. 211. 6 
OCCLUSION OF THE CEREBRAL SINUSES. 
Authors of American text-books have paid comparatively 
little attention to the subject of cerebral thrombosis. Da Costa's 
Medical Diagnosis finishes the matter in six lines, thus: "Throm- 
bosis of the sinuses of the brain may occasion partial palsies, and 
the symptoms of cerebral pressure, like those of tumors, and 
cannot be distinguished except in those instances in which we 
can find distension of the collateral circulation and injection 
and oedema of the forehead and eyelids. Convulsions, further, 
are very rarely among the symptoms." 
Flint is taken to task by the Dublin Medical Journal, Jan. 
1880, p. 183 (Review of "Clinical Medicine"), for giving, among 
the symptoms of thrombosis of superior longitudinal sinus, ex- 
ophthalmia due to post-ocular venous congestion. The reviewer 
thinks the exophthalmia should be regarded as evidence of block- 
age of the petrosal sinuses, one or both, or of the corresponding 
lateral sinuses, into the former of which the cavernous sinus 
debouches; not into the superior longitudinal sinus, with which 
it has no anatomical connection whatever. 
Hammond1 expresses his doubt that cerebral thrombosis (ve- 
nous) possesses a symptomatology so as to admit of its being 
identified during life. He mentions as symptoms, headache, 
convulsions, paralysis of different parts of the body, particularly 
of the ocular muscles, squinting, double vision, etc. etc. Again, 
at p. 137 he says: " if the clot is small (of vein or sinus) and 
removable, the case may be favorable, depending upon our judg- 
ment of the course of the affection and the severity of the 
symptoms." 
Nothnagel2 has a fair article on cerebral thrombosis. He says: 
" The relations of the sinus cavernosus to other veins are such 
as to give rise, under the fitting conditions, to pronounced and 
characteristic symptoms. These were noticed by some of the 
earlier observers, but especial stress has been laid upon their 
diagnostic importance, within the last few years particularly, by 
Corazza Heubner, Huguenin, Genoivelle, and others. The oph- 
thalmic veins are the ones through whose agency these symptoms 
are brought about. Thus, in case of thrombosis of the sinus 
cavernosus, venous hypersemia of the fundus oculi has been ob- 
served, as well as oedema of the eyelids and the conjunctiva, toge- 
ther with prominence of the eyeball, due to hyperaemia of the 
retro-bulbar veins and of the vena frontalis. These symptoms 
2 Ziemssen, vol. xii. 
1 Diseases of Brain, p. 133. OCCLUSION OF THE CEREBRAL SINUSES. 
7 
may persist until the death of the patient, or they may disap- 
pear during life. In cases of thrombosis of the cavernous sinus, 
one important symptom may be present which is peculiar to the 
affection of that vessel, and is due to the fact that, in its walls 
and neighborhood, various nerve trunks are disposed which are 
liable to be irritated or paralyzed by the pressure of the throm- 
bosis (or the swelling of the peri-venous connective tissue), an 
accident from which important symptoms must result; these 
nerves are the first division of the trigeminus, the trochlearis, 
the abducens, and the oculo-motorius. In this way a paralysis 
of the motor nerves may arise, and in a case reported by Lebert 
there was neuralgia in the distribution of the upper branch of 
the fifth nerve and a trophic disturbance of the eye, such as may 
be produced experimentally by section of this nerve. 
"In the presence of the conditions just described, which admit 
of being objectively recognized, and by a careful consideration 
of all the attendant symptoms in the case, it might certainly be 
possible to arrive at a diagnosis which would have more than 
probability in its favor. It is evident that all the symptoms 
due directly to venous stasis may be present as well in cases of 
phlebitic thrombosis as in those of the simple marantic throm- 
bosis." 
In the Transactions of the American Ophthalmological Society for 
1875, is an article by Dr. Geo. C. Harlan, of Philadelphia, on 
two cases of vascular disease of the orbit; in which the view 
is strongly presented that many cases of supposed orbital aneu- 
rism are in reality cases in which the return of blood through 
the ophthalmic vein is prevented by some pathological condition. 
The strong assertion is made that with the exception of one 
case recorded by Guthrie, we are without positive proof that 
such a thing as an aneurism of the orbit has ever existed. Brief 
notes are given of fourteen cases. " Competent observers had 
committed themselves to the diagnosis of orbital aneurism in 
nearly all the cases, and in the remainder the same conclusion 
could hardly have been resisted by any surgeon whose attention 
had not been particularly called to the subject. In only five 
cases was there anything like an aneurism, and in them the 
arterial lesion was so situated that it would be the cause of the 
orbital symptoms only in the same manner as any other obstruc- 
tion to the venous flow might be." Four were cases of venous 
clot from phlebitis, and in three cases malignant growths were 
present. 8 
OCCLUSION OF THE CEREBRAL SINUSES 
I have referred at some length to Dr. Harlan's paper to im- 
press the fact that obstruction of the cerebral sinuses, and par- 
ticularly of those which communicate with the ophthalmic veins, 
is, comparatively speaking, not uncommon. The cases here 
collected were chiefly instances of chronic conditions; the case 
which I have just reported was acute in character; but the rea- 
soning in regard to the possibility and probability of obstruction 
of the sinuses at the base of the cranium, will apply equally to 
acute or chronic cases.