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Cornell University Library 
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 Brain abscess, its surgical patliology and 
 
 3 1924 003 490 541 
 
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BRAIN ABSCESS 
 
 ITS SURGICAL PATHOLOGY 
 
 AND 
 
 OPERATIVE TECHNIC 
 
THE MACMILLAN COMPANY 
 
 NEW YORK • BOSTON • CHICAGO • DAIXAS 
 ATLANTA • SAN FRANCISCO 
 
 MACMILLAN & CO., Limited 
 
 LONDON • BOMBAY ■ CALCUTTA 
 MELBOURNE 
 
 THE MACMILLAN CO. OP CANADA, Ltd. 
 
 TORONTO 
 
Fig. 1. — Frontispiece. The Osteoplastic Flap fur Exploration for Abscess of Middle Fossa. 
 
BRAIN ABSCESS 
 
 IT8 SUBOIGAL PATHOLOGY 
 AND OPERATIVE TEOHNIO 
 
 BY 
 
 WELLS P. EAGLETON, M.D. 
 
 NEWAUK, N. J. 
 M.-Colonel, M. B. C. 
 President of the American Otolo^cal Society — 1931; Medical Director, Newark 
 Eye and Ear Infirmary, Newark, N. J.; Chief of the Division of Head 
 Surgery, Newark City Hospital; Attending Craniolog^t, Newark 
 Presbyterian Hospital; Consulting Cranlolo^st, St. Barnabas Hos- 
 pital and St. Michael's Hospital, Newark, N. J., Muhlenberg 
 Hospital, Plainiield, N. J., Mountainside Hospital, Montclair, 
 N. J.; Chief of the Section of Surgery of Head, 
 Base Hospital, Camp Dix, N. J., 1917-1918. 
 
 THE MACMILLAN COMPANY 
 1922 
 
 All rights reserved 
 
 n 
 
FBINIXD IN THE UNITED STATES OF AMERICA 
 
 OorTRiSHT, 1922, 
 
 bt the macmillan company. 
 
 Set up and printed. Published July, 1922. 
 
 Press of 
 J. Little Je Ives Company 
 New Yorlc, U. S. A. 
 
To the 
 
 Memory of My Father 
 
 who taught me "If all were frankly to record 
 
 their thoughts and experiences, even 
 
 of one day, humanity would be 
 
 advanced centuries," and 
 
 TO MY WIFE 
 
 the inspiration of the book. 
 
FOEEWOED 
 
 This monograph, is the result of considerable intradural experi- 
 ence, associated with many bitter disappointments and failures ; some 
 animal experimentation; and of observations during post-mortem 
 examination of cases in which death had resulted from varied intra- 
 cranial lesions. Eecognizing that surgical as well as pathological 
 and diagnostic information is obtainable from post-mortems, a 
 personal effort invariably has been made to obtain an autopsy on 
 all cerebral cases coming under my observation. The fatal cases 
 previously examined or operated upon, on which post-mortems were 
 not performed, are very few. 
 
 The laity are anxious to assist the surgeon in obtaining whatever 
 knowledge may be derived from an examination of their dead, pro- 
 vided they feel that the surgeon has striven earnestly to assist them, 
 and that the post-mortem will be reverently conducted. 
 
 Gushing, whose genius has transformed non-suppurative intra- 
 cranial surgery into comparatively safe, delicate, almost bloodless 
 physiological procedures, has long contended that the ordinary 
 surgical technic applicable to other parts of the body is insufficient 
 to combat successfully the unique physiological factors and patho- 
 logical changes presented within the dura; and it is Cushing's tech- 
 nic which the author largely has used in operating for intracranial 
 suppuration. 
 
 Surgically considered, intracerebral abscess stands in a class by 
 itself, the problems presented in its surgical treatment differing 
 from those of suppuration in other parts of the body and distinct 
 from those encountered in the treatment of non-suppurative lesions 
 of the brain. As many of the technical problems presented still 
 remain far from solution, it is proposed to call attention to some 
 of these physiological factors, their alteration by pathological proc- 
 esses, and the technic which, to the author's mind, most satisfactorily 
 meets them. The success of intradural surgery always will depend 
 upon utilizing every advantage offered by the preventive and reactive 
 efforts of nature, while a single technical error may mean the loss 
 of the patient's life or at least of his subsequent usefulness. 
 
 vii 
 
viii FOREWOED 
 
 In this monograph, the writer has attempted to correlate the 
 surgical treatment of the different pathological lesions of brain ab- 
 scess, for he believes that, although pathology and treatment usually 
 are dealt with in separate chapters, they are in reality one and 
 should be so considered. Certain it is that if one is to meet with 
 even a moderate degree of success in the treatment of brain abscess, 
 the surgical manipulation in each individual case must be adapted 
 to the exact pathological condition present. 
 
 With this object in view emphasis is laid upon the pathology 
 and on mechanical changes, and a classification is adopted which is 
 capable of individual clinical recognition, because the author believes 
 that our present knowledge should enable us not only confidently 
 to diagnose the presence of brain abscess, but also in a large pro- 
 portion of the cases to determine its location and whether or not 
 it is surrounded by a capsule. 
 
 To accomplish this the surgeon must divest himself of certain 
 ideas inherent in the old classification of aural and nasal origins, 
 and must conceive of them not according to their immediate origin, 
 but pathologically, according to the causative lesion of entrance into 
 the central nervous system; that is, whether extension is by direct 
 tissue suppuration or by retrograde thrombophlebitis, for which the 
 author suggests the terms Adjacent (Secondary), and Intercurrent 
 (Tertiary) , when immediately occasioned by a secondary gross lesion 
 such as sinus thrombosis, to differentiate both from abscesses origi- 
 nating from the deposit of infected bacterial virus circulating free 
 in the blood stream, the latter being pathologically metastatic, even 
 though the original focus of infection may be in the ear or the nose. 
 One of the chief objects of this work is to enable the surgeon to apply 
 a pathological nomenclature to the subject and thus approach the 
 treatment of brain abscess in a pathological as well as a technical 
 mental attitude. 
 
 ITo apologies are offered for the personal character of the book. 
 It is largely an account of experience in more than fifty cases of ad- 
 jacent brain abscess which have come under the author's observation. 
 It has been written because he recognizes that many deaths might 
 have been avoided had he earlier been in possession of the knowledge 
 he has gained by his failures. He has analyzed his cases, making an 
 effort in each particular case to learn why the patient recovered or 
 died. 
 
 In the chapter on Diagnosis the writer voices many opinions 
 which must be regarded as purely speculative, much of which doubt- 
 less will be demonstrated to be fallacious as our physico-pathological 
 
FOREWOED ix 
 
 understanding of the clinical manifestations of suppurative cerebral 
 lesions increases. For this he offers no eixcuse, believing that a better 
 understanding of disease often may be obtained by speculation, pro- 
 vided the speculation is founded on the available clinical and experi- 
 mental evidence. 
 
 Nor does he apologize for the minutely detailed technic. He has 
 emphasized the technic, rather, because he has learned from personal 
 experience to regard it as equally important with diagnosis. "While 
 the opinions expressed are his own, he has endeavored whenever 
 possible to substantiate them by reference to recorded opinions and 
 observations. When an unsubstantiated opinion is cited, the author- 
 ity for it is cited in the text. 
 
 In the preparation of the book the author's thanks are due to 
 Dr. Frederick A. Sutton and Dr. Harrison S. Martland for the 
 pathological examinations and sections; to the staff of the Newark 
 Eye and Ear Infirmary for placing at the author's disposal the 
 records of cases under their care ; to Dr. F. Kobbins for compilation 
 of the cases of frontal and cerebellar abscess and for other valuable 
 cooperation ; to Mr. Edward B. Mead for helpful mechanical aid in 
 the construction of instruments, and to the author's secretary, Miss 
 Catherine Fideles Casey, for indispensable assistance in the prepara- 
 tion of the manuscript. 
 
 Wells P. Eaglbton. 
 Newark, N. J., January 2, 1922. 
 
TABLE OF CONTENTS 
 
 FAOB 
 
 FOEEWOBD vii 
 
 PART I.— GENERAL CONSIDERATIONS IN INTRACRANIAL SUR- 
 GERY. 
 
 CHAPTER 
 
 I. PftEFAEATION' 1 
 
 Mental Attitude of the Surgeon 1 
 
 Importance of Proper History Taking Before Exploration . . 1 
 History Taking and Complete Neurological Examination Prior 
 
 to Appearance of Severe Cerebral Symptoms 2 
 
 Time of Operation 3 
 
 Assistants 4 
 
 Anesthesia 4 
 
 II. GeWEEAI, STTBGICAL TeCHNIO of INTBACEANIAL OPBaiAIIONS ... 6 
 
 Position of Patient 6 
 
 Utilization of Gravity 6 
 
 Head-rests 7 
 
 Elevation of Head 7 
 
 Limitation of the Field 7 
 
 Control of Hemorrhage 7 
 
 Hemorrhage from the Scalp 8 
 
 Technic of Controlling Hemorrhage 8 
 
 Tourniquets and Compressors 8 
 
 Perforation of Skull and Formation of Osteoplastic Flap ... 9 
 
 Instruments 9 
 
 Sacrifice of bone 9 
 
 Control of Moderate Bleeding from the Diploic Vessels' during 
 
 the Perforation of the Skull 9 
 
 Bulging of the Dura into the Perforation Opening .... 10 
 
 Technic of Ventricular Puncture 10 
 
 Cutting the Osteoplastic Flap 10 
 
 instruments 10 
 
 Technic 10 
 
 Control of Hemorrhage from Interior of Skull before Dura 
 
 is Opened 10 
 
 Control of Hemorrhage from the Dura Itself 11 
 
 Control of Hemorrhage from the Pial Vessels 11 
 
 Control of Hemorrhage from the Brain Substance .... 12 
 
 Closure of Dura 12 
 
 Additional References to Operative Technic 12 
 
 PART II.— SURGICAL PATHOLOGY AND OPERATIVE TECHNIC OF 
 BRAIN ABSCESS. 
 
 III. Pathological aisTd Subgical Considbeations 13 
 
 Histopathology of Cerebral Tissue 13 
 
 xi 
 
xii CONTENTS 
 
 CHAPTER PAGB 
 
 Factors Peculiar to Cerebral Tissue which Demand Surgical 
 
 Recognition 13 
 
 Acute CEdema from Trauma of Operation; Sudden Increase 
 
 within Contents of Dural Envelope 15 
 
 Summary 15 
 
 References 16 
 
 General Surgical Classification 17 
 
 Surgical Pathology 17 
 
 Surgical Classification According to Position and Relationship 
 
 to the Brain and Encircling Membrane 19 
 
 Clinical Classification of Brain Abscess 21 
 
 Chronic Brain Abscess 21 
 
 Intracerebral Abscess with a Capsule and Stalk .... 22 
 Intracerebral Abscess without Cortical Involvement Discov- 
 erable Macroscopically 23 
 
 Subdural Abscess 24 
 
 Metastatic Abscess 25 
 
 Traumatic Brain Abscess 25 
 
 Meningeal Abscess — ^Intrapiarachnoid 26 
 
 General Surgical Principles 27 
 
 Surgical Factors 28 
 
 General Technic 28 
 
 Injury to the Brain from Its Own Pressure 29 
 
 Lumbar Puncture; Its Dangers 29 
 
 Ventricular Puncture 29 
 
 Technic of Incision of the Dura 29 
 
 Classification of Brain Abscess According to Location ... 30 
 
 IV. Abscess of Middle Fossa 31 
 
 Adjacent (Secondary) Abscess of the Middle Fossa — ^Temporo- 
 
 sphenoidal 31 
 
 Location; Pathological and Anatomical Considerations . . 31 
 Intercurrent (Tertiary) Abscess of the Middle Fossa, Secondary 
 
 to Thrombosis of the Superior Petrosal Sinus or a Dural Vein 31 
 
 Adjacent Meningeal Abscess (Intrapiarachnoid or Subdural) of 
 
 the Middle Fossa 32 
 
 Localized Serous (Protective) Meningitis 32 
 
 Clinical Diagnosis 33 
 
 Extension of Intrapiarachnoid Abscess 34 
 
 Adjacent Intracerebral Abscess of the Temporo-sphenoidal Lobe 
 
 without Macroscopical Manifestations of Cortical Involvement 36 
 
 Temporo-sphenoidal Abscess with a Stalk 36 
 
 Considerations Prior to Operation for Adjacent (Secondary) Ab- 
 scess of Middle Fossa 37 
 
 Principles of Operative Treatment 40 
 
 Exposure 40 
 
 Exposure for Suspected Localized Intradural Suppuration of 
 
 the Middle Fossa 40 
 
 The Osteoplastic Flap for Exploration for Abscess of Middle 
 
 Fossa 41 
 
 Inspection of Brain with the Dura 42 
 
CONTENTS xiii 
 
 OHAPTBR PAGE 
 
 Herniation of Brain upon Incision of Dura in Temporo- 
 
 sphenoidal Abscess 42 
 
 Obliteration of Homolateral Ventricle 42 
 
 Puncture of Opposite Ventricle for the Eeduction of Brain 
 
 Herniation Sufficient to Admit of Elevation of Brain . . 44 
 
 Inspection by Elevation of Brain ; 44 
 
 Teclmic of Elevation of Brain 44 
 
 Protection of Exposed Piarachnoid Prior to Exploration . . 44 
 
 Exploration within Cerebral Substance 45 
 
 Site of Adjacent Intracerebral Abscess without Maorosoopical 
 
 Evidence of Cortical Involvement of Middle Fossa ... 46 
 
 Selection of Site for Exploration 46 
 
 Chronic' Adjacent Intracerebral Abscess with a Capsule ... 47 
 
 Surgical Pathology 47 
 
 Surgical Principles Underlying the Intradural Technio in 
 Suspected, Adjacent (Secondary), Abscess of the Middle 
 
 Fossa (Temporo-sphenoidal) 49 
 
 Technic Following Elevation of Brain 50 
 
 Surgical Significance of Areas of Adhesive Inflammation of 
 
 Piarachnoid to Dura 50 
 
 Chronic Adjacent Intracerebral Abscess of the Middle Fossa . 51 
 Surgical Principles and Specific Factors Involved in the Treat- 
 ment of Encapsulated Adjacent Intracerebral Abscess of the 
 
 Middle Fossa 51 
 
 Eradication 51 
 
 Drainage 52 
 
 Selection of Cases 52 
 
 Difficulties of Complete Evacuation 52 
 
 Importance of Thorough Primary Evacuation 53 
 
 Technio of Surgical Treatment of Chronic Adjacent Intracere- 
 bral Abscess with Capsule 55 
 
 Complete Evacuation; Difficulties 55 
 
 Cleansing and Obliteration of Cavity of Abscess with Stalk or 
 
 Near Cortical Surface 56 
 
 Drainage 57 
 
 Technic of Drainage Following Incomplete Evacuation . . 57 
 
 Secondary Compression 58 
 
 Principles in Teehnic of Decompression 58 
 
 After-treatment 59 
 
 Second Abscess, or Double and Secondary Abscess 59 
 
 Case of Double Cerebellar Abscess 60 
 
 Acute Brain Abscess • 61 
 
 Pathology 61 
 
 Surgical Pathology 62 
 
 Surgical Treatment 62 
 
 Closure 65 
 
 Additional Eeferences to Double Abscesses 66 
 
 V. Mbtastatio Abscesses 68 
 
 Classification "° 
 
 Development 
 
 Adjacent Abscesses 68 
 
xiv CONTENTS 
 
 CHAPTER '■*'"' 
 
 Metastatic Abscesses 69 
 
 Metastatic Vascular Occlusion 69 
 
 Metastatic Abscesses of Venous Origin 71 
 
 Origin of Thrombotic Nidus 71 
 
 Frequency , 72 
 
 Location 74 
 
 Multiple Metastatic Absces"ies 75 
 
 Limitation of Metastatic Abscess by Capsule 76 
 
 Formation of the Cspsule 76 
 
 Case of Metastatic Brain Abscess of Otitic Origin, the Result of 
 an Infective Vascular Occlusion, with Involvement of the 
 Internal Capsule, Clinically Simulating Cerebral Apoplexy 
 and Presenting Unusual Psychic (Toxic Delirium) Phe- 
 nomena; Operation; Recovery 77 
 
 Additional References to Metastatic Abscess 82 
 
 VI. Cebebellak Abscess 84 
 
 Section 1 84 
 
 Origin 84 
 
 Immediate Occasion 84 
 
 Surgical Anatomy of the Posterior Fossa 84 
 
 Surgical Classification of Adjacent Cerebellar Abscess .... 85 
 
 Surgical Considerations 85 
 
 Herniation in Exploration for Cerebellar Abscess; Anatomical 
 
 and Physiological Factors 86 
 
 Pathological Factors . . , 87 
 
 Surgical Importance of Direction of Maximum Intracerebellar 
 
 Pressure 87 
 
 Routes of Infection 88 
 
 Surgical Importance of Determining the Probable Path of Infec- 
 tion, Whether Through the Petrous Pyramid or the Lateral 
 
 Sinus 88 
 
 Influence of Path of Primary Infection on Situation of Abscess 88 
 
 Routes of Invasion of Cerebellum in 125 Cases 89 
 
 SBCiroiT II. — ^In the Anterior Portion of the Cerebellum Originating 
 
 from Infection of the Petrous Pyramid 91 
 
 Origin 91 
 
 Infection of Cerebellum from Bony Caries or Necrosis ... 91 
 Frequency of Different Forms of Labyrinthine Suppuration 
 
 Causing Cerebellar Suppuration 94 
 
 Abscess in Lateral Cisterna 95 
 
 Secondary Serous Labyrinthitis 95 
 
 Clinical Classification 95 
 
 Principles of Surgical Treatment 95 
 
 Operative Approach to the Cerebellum 95 
 
 Exposure of One or Both Lateral Lobes of the Cerebellum, with 
 
 Exploration and Drainage Behind the Lateral Sinus . . 96 
 
 Incision and Evacuation in front of Lateral Sinus .... 96 
 Destruction of the Labyrinth Followed by Exploration of the 
 Cerebellum in Front of the Sinus: Enlargement of the 
 Dural Opening Following Application of Two Closely Allied 
 
CONTENTS XV 
 
 HAPTSB FAOI 
 
 Encircling Ligatures to the Sinus and Incision Between 
 
 Them 96 
 
 Primary Exposure of the Lateral Sinus from Behind . . 97 
 
 Anatomy of the Lateral Sinus on Cross Section 97 
 
 Physiological and Anatomical Factors. Blood Pressure Within 
 
 the Sinus 98 
 
 Surgical Obliteration of the Lateral Sinus 98 
 
 Technic Obliteration of the Lateral Sinus by Invulsion of Its 
 
 Outer Wall into the Lumen 98 
 
 Section III. — From Sinus Thrombosis Frequently Situated on One 
 of the Surfaces in the Posterior Two-thirds of the Cerebellar 
 
 Fossa 101 
 
 Irregular Shape of Cerebellar Abscess: Its Surgical Importance 101 
 
 Surgical Principles in Treatment of Adjacent Cerebellar Abscess 101 
 Abscess of Sinus Origin Situated in or on Posterior IVo-thirds 
 
 of Cerebellum 101 
 
 Cerebellar Abscess with Secondary Sinus Thrombosis . . . 102 
 Intercurrent (Tertiary) Abscess Secondary to Sinus Throm- 
 bosis 102 
 
 Traumatic Abscess, Acute or Chronic 103 
 
 Metastatic Abscess, Acute or Chronic 103 
 
 Treatment of Abscess in or on the Posterior Two-thirds of the 
 Cerebellum Following Thrombosis of the Lateral Sinus and 
 
 Its Communicating Veins 103 
 
 Incision through Inner Sinus Wall 103 
 
 Exploration Behind the Sinus over the Lateral Lobe of the 
 
 Cerebellum 103 
 
 Influence of Displacement of the Affected Hemisphere Beyond 
 
 the Median Line 104 
 
 Ventricular Puncture 104 
 
 Technic of Exposure Behind the Sinus 104 
 
 Situation of Abscess Secondary to Sinus Thrombosis .... 104 
 
 Situation of Abscess in Cerebellum in 125 Autopsy Records . . 105 
 
 Surgical Requirements for Systematic Exploration and Evacuation 105 
 
 Association of Extradural with Cerebellar Abscess 105 
 
 VII. Feontai Lobe Abscess , 107 
 
 Introductory Note 107 
 
 Anatomical and ' Pathological Considerations Peculiar to the 
 
 Frontal Region; Their Surgical Importance 107 
 
 Influence of Trauma 109 
 
 Relationship Between Osteomyelitis, Extradural and Intra- 
 dural Abscess 110 
 
 Surgical Classiflcation 112 
 
 Adjacent Frontal Abscess 112 
 
 Occurrence 112 
 
 Origin of Infection 114 
 
 Paths of Infection 115 
 
 Adjacent Frontal Lobe Abscess Associated with Osteomyelitis 117 
 
 Types of Adjacent Frontal Lobe Abscess 117 
 
 Adjacent Meningeal, Subdural 118 
 
 Adjacent Piarachnoid Abscess 119 
 
xvi CONTENTS 
 
 CHAPTER FAGB 
 
 Adjacent Abscess with Stalk 119 
 
 Adjacent Intracerebral Abscess without Macroscopical Evi- 
 dence of Cortical Involvement 120 
 
 Traumatic Frontal Lobe Abscess 121 
 
 Immediate Occasion of Adjacent Abscess 121 
 
 Situation of Adjacent Frontal Lobe Abscess 122 
 
 Presence of Capsule 122 
 
 Operative Results in Recorded Cases of Adjacent Abscess . . 122 
 
 Treatment 123 
 
 Termination 124 
 
 Surgical Aims of Operation for Adjacent Abscess of Frontal Lobe 124 
 Puncture of Dura and Evacuation of Abscess through Posterior 
 
 Wall of the Frontal Sinus 125 
 
 Chronic Encapsulated Frontal Lobe Intracerebral Abscess with 
 Stalk, Following Trauma and Secondary Infection of Frontal 
 Sinus 125 
 
 VIII. Heenia Cbbebbi 127 
 
 Etiology 127 
 
 Circulatory Factors 129 
 
 Surgical Pathology and Physiological Factors 131 
 
 Surgical Treatment 132 
 
 Prevention of Hernia; Site of Dural Defection 182 
 
 Protection 133 
 
 Reduction of Increased Intracranial Pressure 134 
 
 Case of Hernia Cerebri Following Operation for Temporo-sphe- 
 
 noidal Abscess 135 
 
 IX. Peotectivb Mechanism op the Brain 137 
 
 Prevention of Infection 137 
 
 Pathological Processes in Infection 138 
 
 Protective Mechanism of the Brain 139 
 
 The Dura 139 
 
 The Subdural Space 140 
 
 The Subarachnoid Spaces 140 
 
 Anatomy of the Cerebro-spinal Fluid System 141 
 
 Impregnability to Infection of Cerebro-spinal Fluid System . . 142 
 
 Infection of Cerebro-spinal Fluid System from Blood Stream . 144 
 
 Brain Abscess from Meningitis 144 
 
 Report of Case XXV, Streptococcus Meningitis 144 
 
 Elimination of Bacteria from the Subarachnoid Space .... 145 
 
 Immunization 145 
 
 Susceptibility of Cerebral Tissue to Bacterial Virulence . . . 146 
 
 Sensitiveness of Brain to Toixio Influences 147 
 
 Protective Mechanism in the Brain Itself 147 
 
 Varying D^rees of Sensitiveness to Infection 148 
 
 Limitation of Suppuration within the Brain 148 
 
 Extension of Infection 148 
 
 Removal of Dead Tissue 149 
 
 Repair 149 
 
 Recrudescence of Latent Infection 149 
 
CONTENTS xvii 
 
 PAGE 
 
 Conclusions 150 
 
 Relationship between Suppurative Meningitis with Brain Abscess 
 
 and Protective Meningitis 150 
 
 Report of Case XXVI, General Suppurative Meningitis . . . 151 
 
 Additional References for Protective Mechanism ..... 153 
 
 PART III. SURGICAL DIAGNOSIS. 
 
 X. Diagnosis of Brain Abscess in Gbneeal 155 
 
 Evidences of Cerebral Suppuration 157 
 
 Initial Vague Chill 157 
 
 Headache 157 
 
 Vomiting 157 
 
 General Malaise 157 
 
 Bisproportion 158 
 
 Positive Evidences of Cerebral Suppuration 160 
 
 Protective Meningitis 160 
 
 Convulsion 161 
 
 Subnormal Temperature 163 
 
 Absence of Lymphatics; Autolysis 164 
 
 Symptoms of Cerebral Compression 165 
 
 Specific Symptoms of Compression 166 
 
 Slow Pulse 166 
 
 Blood Pressure 166 
 
 Pulse Pressure 167 
 
 Projectile Vomiting 167 
 
 Ocular Paralysis 167 
 
 Coma 167 
 
 Papilloedema 168 
 
 Influence of Increased Intracranial Pressure . . . 168 
 
 Interference with Venous Return Circulation .... 169 
 
 Influence of Location of Lesion 171 
 
 Influence of Alterations in Composition of Parenchyma- 
 tous Fluid 172 
 
 Intracellular Pathways of Optic Nerve and Retina . . . 172 
 
 Induced Stupeur Arterielle 174 
 
 Diagnostic Deductions from Presence or Absence of Nerve-Head 
 
 Changes in Brain Abscess 175 
 
 XL Diagnosis of ADJACJafT Tempoeo-sphenoidal Lobe Abscess . . 176 
 
 Localizing Symptoms 176 
 
 Localizing Value of Primary Focus of Infection 176 
 
 Pathognomonic Symptoms in Temporo-Sphenoidal Lobe Abscess . 177 
 
 Aphasia 177 
 
 Word Deafness 178 
 
 Hemianopsia — Transient or Fixed 180 
 
 Facial Paralysis of Opposite Side 181 
 
 Paralysis of Contralateral Arm '. 181 
 
 Contralateral Hemiplegia 181 
 
xviii CONTENTS 
 
 CHAPTEB TXBH 
 
 SjTnptoms of Assistance in Diagnosing Temporo-Sphenoidal Lobe 
 
 Abscess 183 
 
 Pain in Teeth 183 
 
 Pain Behind the Eye 183 
 
 Convulsions — ^Localizing Value 184 
 
 Dreamy State 184 
 
 Psychic Manifestations of Toxic Delirium 185 
 
 Uncinate Symptoms 185 
 
 Past Pointing 187 
 
 Roentgen Ray Diagnosis 188 
 
 XIL Diagnosis op Ceekbhllak Abscess 190 
 
 Localizing Value of a Known Iiabyrinthitis or Lateral Sinus 
 
 Thrombosis 190 
 
 Symptoms More or Less Characteristic of Cerebellar Abscess . 191 
 
 Classification 191 
 
 Manifestations of Impaired Cerebellar Function Exclusive of 
 
 the Vestibular Tract 192 
 
 Partial or Complete Obliteration of a Symptom the Result of 
 
 Cerebellar Compensation 194 
 
 Cerebellar Paralysis 194 
 
 Cerebellar Ataxia 194 
 
 Hypermetria — Failure of Inhibition 194 
 
 Cerebellar Convulsions 195 
 
 Forced Cerebellar Attitude 195 
 
 Speech Defects 195 
 
 Vestibular Manifestations 196 
 
 Differential Value of Mode of Onset 196 
 
 Spontaneous Nystagmus 197 
 
 Lateral Deviation of the Eyes 197 
 
 Vertigo, Spontaneous Falling and Spontaneous Past Pointing 197 
 
 Induced Abnormal Vestibular Reactions 198 
 
 Changing Character of Abnormal Spontaneous or Induced Ves- 
 tibular Manifestations 199 
 
 Diagnosis of Increased Intracranial Pressure, Especially of the 
 
 Posterior Fossa, by Induced Vestibular Reactions . . . 199 
 Cerebellar Cortical Localization in Relation to Vestibular 
 
 Reaction 200 
 
 Induced Vestibular Manifestation from Pressure upon the Cere- 
 bellar Cortex 200 
 
 Local Symptoms from Direct Pressure Presumptive of Cerebellar 
 
 Origin 201 
 
 Pupillary Disturbances 201 
 
 General Symptoms Suggestive of Cerebellar Involvement . . . 201 
 
 Suboccipital Tenderness 202 
 
 Yawning 202 
 
 Rapid Loss of Flesh 202 
 
 Knee Jerks 202 
 
 Vomiting 202 
 
 Psychic Disturbances 202 
 
 Symptoms Due to an Accompanying Internal Hydrocephalus . 203 
 
CONTENTS xix 
 
 OHAPTEB PAOB 
 
 Report of Case XXXI — Cerebellar Abscess with Vagueness of 
 
 Early Symptoms 203 
 
 XIII. Diagnosis op Fbontal Lobe Abscess 206 
 
 Orbital Abscess, Osteomyelitis and Extradural Abscess — ^Dispro- 
 portion 206 
 
 Symptoms of Cerebral Suppuration 207 
 
 Convulsions 207 
 
 Diabetes Insipidus 207 
 
 Symptoms of Cerebral Compression 207 
 
 Coma 207 
 
 Papillcedema 208 
 
 Post-Neuritic Retrobulbar Neuritis 208 
 
 Localizing Symptoms 208 
 
 Loss of Smell 208 
 
 Aphasia 208 
 
 Loss of Abdominal Reflexes of the Same Side 209 
 
 Sudden Paralysis of Arm of Contralateral Side 209 
 
 Hemiplegia of Contralateral Side 209 
 
 Mental Disturbances 209 
 
 Change of Disposition 209 
 
 Symptoms Due to Association Between Frontal Lobe and Cere- 
 bellum 210 
 
 Additional References 210 
 
 XIV. Complications and Results 211 
 
 Complications after Evacuation 211 
 
 Differential Diagnosis 211 
 
 After Effects 211 
 
 Results 212 
 
 Appendix. I. Guide for Detailed Neurological Examination .... 213 
 
 Appendix II. Cerebellar Abscess: Analysis of Pathological Condition in 
 
 Reported Autopsies of 125 Cases 220 
 
 Appendix III. Frontal Lobe Abscesses; Analysis of 140 Reported Cases 244 
 
 Index of Authors 283 
 
 Index of Subjects 289 
 
PART I. 
 
 GENERAL COlSrSIDERATIONS IN INTEAOEANIAL 
 
 SURGERY. 
 
CHAPTER I. 
 
 PEEPAEATION. 
 
 Mental Attitude of the Sttbgeon. 
 
 In approaclimg the problems involved in localized, intradural 
 suppuration the surgeon must cultivate a peculiar mental attitude 
 which will render him sensitive and attentive to the minute details 
 of diagnosis and of surgical procedure. In no other branch of sur- 
 gery may the advisability of a major operation depend upon such 
 apparently trivial manifestations; in no other part of the body will 
 neglect of slight hemorrhage play so important a part in the recovery 
 or in the future well-being of the patient; in no other branch of 
 surgery is preparedness for operation more important or team work 
 more essential. The surgeon who postpones an operation for brain 
 abscess to suit his personal convenience starts with a handicap that 
 too often results in the death of his patient — a death frequently 
 avoidable. 
 
 Impoetancb of Pbopeb Histoby Taking Bbfoee Exflobation. 
 
 Many patients suffering from brain abscess are brought to the 
 hospital in a dazed condition, unable to furnish a reliable account 
 of their illness. The possibility of a brain abscess, then, may rest 
 upon the presence of a purulent discharge from the ear or nose, a 
 bronchiectasis, or the scar of a previous head injury, and the diag- 
 nosis or elimination of such abscess can only be made by the expendi- 
 ture of time and patience in interviewing persons who are in pos- 
 session of accurate information about the patient prior to the appear- 
 ance of pronounced cerebral symptoms. This has been accom- 
 plished many times, and has resulted in the greatest personal 
 satisfaction. 
 
 The following apparently trivial, yet really important, diagnostic 
 details have thus been ascertained: — The presence and exact date 
 of the initial "vague chiU," from which could be calculated the prob- 
 able duration of the abscess, and whether it was acute without limit- 
 ing membrane, or chronic with limiting membrane ; the occurrence of 
 attacks of uncontrollable vertigo, knowledge of which has largely 
 
3 BEAIN" ABSCESS 
 
 influenced tlie selection of the cerebellum as the site for exploration ; 
 transient periods of a "dreamy" state; transient or permanent 
 aphasia; complete motor, sensory, or "naming" ataxia; the gradual 
 or sudden onset of hemiplegia — ^the involvement of the hand, leg and 
 face being separated by appreciable intervals; and the presence of 
 an unrecognized hemianopsia. Some or all of these symptoms always 
 occur in the development of an abscess of the brain, and a knowledge 
 of their presence is of incalculable value to the surgeon in making 
 his diagnosis. 
 
 HiSTOET Taking and Complete Nedbological Examination Peioe to Appbab- 
 
 ANCE of SevEEE CeEUEBBAI. SYMPTOMS. 
 
 It is the practice among many surgeons when treating suppura- 
 tive diseases of the ear or nose associated with slight but suspicious 
 symptoms — ^vague chill, headache, dizziness, slight subnormal tem- 
 perature, slow pulse — to await the appearance of outspoken cerebral 
 symptoms before making a complete neurological examination. (See 
 Appendix I, "Guide for Neurological Examination.") This fre- 
 quently results in the performance of an intracranial operation with- 
 out that minute and accurate information, previously obtainable, 
 upon which depends the adoption of the correct exploratory procedure. 
 
 Examination of the recorded cases ^ of brain abscess shows that 
 a very large proportion had been operated upon previously for mas- 
 toid disease, accessory sinus suppuration, or compound fracture of 
 the skull. The radical mastoid operation has frequently been per- 
 formed for symptoms — ^headache and dizziness — ^the intracranial 
 origin of which was not apparent until some time after the operation. 
 
 In the presence of a wound or scar from a suppurative lesion of 
 a cranial bone, or any suppurative disease capable of causing meta- 
 static brain abscess, a chill, no matter how vague, followed by a 
 slightly subnormal temperature, demands not only a complete neu- 
 rological examination, but repeated blood cultures ; while slight cere- 
 bral symptoms, such as persistent headache, attacks of dizziness, slow 
 pulse, subnormal temperature and slight psychic changes, call for the 
 removal of the patient to a hospital and the performance of a lumbar 
 puncture, repeated if necessary until a positive diagnosis is obtained. 
 
 The association of brain abscess and sinus thrombosis demands 
 the early recognition of the blood-stream contamination in order to 
 differentiate between the symptoms due to sinus thrombosis and to 
 intracerebral suppuration. On more than one occasion, in the pres- 
 
 > See Appendix II and Appendix III, recorded cases of cerebellar and frontal 
 lobe abscess. 
 
PEEPAEATION 3 
 
 ence of a papilloedema secondary to occlusion of tlie venous return 
 circulation by a thrombus, one positive blood culture was the decid- 
 ing factor against intradural exploration. On the other hand, in a 
 number of instances the operative finding of an occluding sinus 
 thrombosis has caused the author to overlook an abscess of the cere- 
 bellum. In one case, at least, the thrombus was undoubtedly aseptic 
 and secondary to the abscess. Repeated negative blood cultures dur- 
 ing the period of observation would have indicated exploration of 
 the brain. 
 
 The diagnosis of a secondary "protective" (aseptic) menin- 
 gitis ^' ^' *■ ^' * — a frequent manifestation of the effort of the intra- 
 cranial contents to wall off the suppuration — is of the greatest value 
 in the early recognition of the localized intradural suppuration, while 
 the early diagnosis of a general streptococcic and pneumococcic 
 meningitis, both of which may exist for some time without producing 
 marked symptoms, has frequently prevented a useless exploration. 
 
 Time for Operation. — Brain abscess, once the diagnosis has 
 been made, permits of no delay or temporizing; it demands the im- 
 mediate sacrifice of all other interests. Two cases illustrate the im- 
 portance of prompt surgical intervention. 
 
 CASE I, B. F. 
 
 Cerebellar Abscess. Male, age 34; running ear for fifteen years. Seen 
 at eleven a. m. on the tenth day of illness. Temperature 100°; pulse 54; severe 
 dizziness; intense pain in occiput; occasional vomiting; double optic neuritis. 
 Had been delirious previous night. No tenderness over mastoid; no discharge 
 from ear. 
 
 Diagnosis. Cerebellar abscess. Ordered to hospital and preparations made 
 
 for operation. Patient did not report as ordered. Late in the day he arrived in 
 good condition; walked up two flights of stairs, needing only the help of the 
 balustrade because of dizziness. Operation appointed for next day. Less than 
 four hours after admission the patient suddenly became maniacal, had a convul- 
 sion, and expired within a few minutes. The abscess had ruptured. 
 
 CASE II, C. M. 
 
 Cerebral Abscess. Girl; chronic discharging ear; headache for several 
 weeks; vague chill; attacks of dreamy state; papilloedema; paresis of external 
 ocular muscle; heminapsia. Wvhen examined in excellent condition, rational 
 and strong. 
 
 Diagnosis. — Cerebral abscess. Operation advised. Attending physician un- 
 willing to consent without permission of family, who did not regard girl as 
 seriously ill. Delay in obtaining consent. Next morning physician reported 
 that patient was so much better there must be doubt of brain abscess, but family 
 
 2 "Meningitis Aseptica" : Eeisehlg; Zeit, f. Ohrenheilkunde, 1913, Bd. 69, p. 78. 
 
 ' "Meningitis Sympathetica" : Plaut una Schottmiiller ; Leitfaden xur Untersuchung 
 der OerebrospmalfliissigkeU , 
 
 » "Meningitis Sympathetica" : Strauss, Israel ; Amer. Jour. Med. Soo., November, 
 1917, Vol. CLIV, No. 5, p. 748. 
 
 » "Protective Meningitis" : Martland, Harrison S., Personal Communication . 
 
 • Case XVII, M. D., Metastatic Abscess, Chapter Five, p. 77. 
 
4 BKAIN ABSCESS 
 
 consented to operation. Afternoon appointed for operation. Suddenly severe 
 rigor and convulsions and patient passed into coma. Strong pulse but respiratory 
 paralysis. Artificial respiration failed to sustain pulse while hasty prepara- 
 tions for operation were being made. 
 
 Autopsy. Large temporo-occipital lobe abscess with capsule which could 
 
 have been drained by proposed operation with an excellent chance of recovery. 
 
 Four other fatal cases have come to the author's attention in 
 which the surgeon allowed external circumstances to occasion a post- 
 ponement of the operation after the diagnosis of brain abscess had 
 been made. In these four cases one abscess was temporo-sphenoidal, 
 one occipital, one frontal and one cerebellar. 
 
 While it is well recognized that sudden death results from rupture 
 of a cerebellar abscess, it is not sufficiently appreciated that ab- 
 scesses in other parts of the brain frequently cause death without 
 warning. 
 
 Assistants. — In no branch of surgery is trained team work 
 as necessary as in intradural surgery. In many hospitals the oper- 
 ator is assisted by a house surgeon and a nurse and the anesthetic is 
 administered by a junior house surgeon — a system which frequently 
 results in the neglect of small details on which the success of an 
 intradural operation essentially depends. To be prepared to meet 
 the technical difficulties which may be encountered during any intra- 
 dural operation, a team of not less than four persons trained in brain 
 surgery is required — ^operator, assistant, anesthetist and chief nurse. 
 Furthermore, it is desirable to have two assistants skilled in apply- 
 ing artificial respiration and direct blood transfusion. The first 
 assistant and the chief nurse should have an understanding of the 
 operator's technic, inasmuch as the assistant must anticipate every 
 surgical need. To allow an assistant imperfectly trained in intra- 
 dural surgery to participate actively in the operative work is to 
 invite disaster. I have more than once "lost" an abscess before its 
 complete evacuation because the assistant was not sufficiently trained 
 to respond quickly to the emergency. Likewise, I have had an as- 
 sistant well trained in general surgery but without intradural expe- 
 rience, and consequently not appreciative of the extreme delicacy of 
 the wall of a non-capsulated brain abscess, cause the searching canula 
 which had been placed within the abscess cavity to perforate the 
 delicate wall between the abscess and the adjacent lateral ventricle. 
 
 Anesthesia. — ^Ether is the anesthetic of choice except when the 
 patient is in such deep coma that no anesthetic is required. The 
 frequency of embarrassed respiration with its associated increased 
 bleeding demands that aU intradural operations be conducted under 
 
PEEPAEATION 5 
 
 anesthesia/ administered by an expert with an apparatus capable 
 of exact dosage. Horsley^ used a mixture of chloroform and 
 oxygen. The author has not adopted this as it does not appear 
 to him that the hemorrhage would be lessened by this method though 
 theoretically it should be advantageous. Gushing ® advocates a local 
 anesthetic for cranial war injuries and experience with local anes- 
 thesia va. the highly sensitive area of infected mastoids convinces the 
 author that many cases of brain abscess may be explored under local 
 anesthesia. 
 
 Technic. — The success of local anesthesia in cranial bone surgery depends 
 upon: (1) Systematic infiltration; (2) avoidance of pulling by instruments — 
 retractors, artery clamps, etc.; (3) avoidance of all transmitted shocks — chisel- 
 ing or hammering; (4) performance of all bone work by cutting or biting instru- 
 ments such as electric or hand-driven burrs, rongeurs, gauges, GrigU saws, etc. 
 The dura is not a sensitive structure; it requires only the application of a 
 local anesthetic. The author has frequently slit the dura even without a local 
 anesthetic. The brain tissue itself is non-sensitive. 
 
 ' Heuer and Dandy : "A Report of Seventy Cases of Brain Tumor" ; Johns Bopkitia 
 Hospital Bulletin, August, 1916, p. 333. 
 
 » Horsley, V. : "On the Technic of Operations on the Central Nervous System" ; 
 Brit. Med. Jour., 1906, II, p. 411. 
 
 » Cushlng, H. : "Concerning Operations for the Craniocerebral Wounds of Modern 
 Warfare" ; MiUtary Burgeon, 1916, Vol. 38, p. 601. 
 
CHAPTEE II. 
 
 GENEKAL SUEGIOAL TEOHNIO OE IlfTEACEANIAL 
 OPEEATIONS. 
 
 GENEEAOii SUEGIOAL TECHNIC. 
 
 Position of Patient.-^Iii all intradural explorations the field 
 mapped out by the original incision should be horizontal with the 
 operating table and provision should be made for its maintenance 
 without muscular strain on the patient. " 
 
 Technic. — The table should be flat and covered by a thick mattress with a 
 rubber casing. A sloping table renders impossible the proper position of the 
 iiead. The neck allows a certain degree of latitude by which the head can be 
 rotated from the perpendicular of the body. This position can be maintained by 
 the patient without strain or interference with respiration. The extent of the 
 rotation varies with the individual patient and can be determined only by placing 
 the patient on the table before administering the anesthetic, finding the degree of 
 rotation available, and then adapting the supporting and restraining apparatus 
 to the individual requirements. 
 
 In a tempororsphenoidal lobe exploration the patient's body lies on the table 
 with the head rotated sufficiently for the occipito-bregmatio line to be exactly 
 horizontal with the plane of the table. The position is maintained by padding 
 with sandbags under the head and neck, thus elevating the shoulders, back and 
 buttocks. While the patient is under the anesthetic occasional slight pressure of 
 the hand of the anesthetist applied to the jaw will prevent the backward rota- 
 tion of the patient's head. In frontal lobe exploration the patient lies prone. 
 In cerebellar abscess, if the exploration is to be behind the sinus, the patient is 
 supported by his abdomen and shoulders with chest and face pointing directly 
 downward, an "outrigger" being used. If the exploration is to be in the anterior 
 portion of the cerebellum one shoulder of the patient is elevated more than the 
 other and the head slightly rotated so that the face points dovraward forty-five 
 degrees from the vertical — Sims' chest position. 
 
 Utilization of Gravity. — A device permitting the rapid con- 
 version of the operative field to admit of complete evacuation of a 
 brain abscess by gravity is of material assistance. In one case of 
 encapsulated intrapiarachnoid abscess, after the evacuation of as 
 much pus as would flow, the patient, a small child, was elevated by 
 the feet and the operated side turned downward. This was followed 
 by the escape of an additional large quantity of pus. 
 
 Failure to utilize gravity has resulted in numerous instances in incomplete 
 evacuation, the abscess having been punctured at its uppermost extremity. In 
 
 6 
 
GENEEAL SUEGICAL TECHNIC 7 
 
 such a condition the elevation of the foot of the table causes a recurrence of the 
 flow of pus after its cessation — always desirable and frequently the deciding 
 factor for success. For complete primary evacuation the table should be 
 equipped with a device to allow of depression and elevation of the head and 
 rotation of the patient to one side or the other. 
 
 Head-rests. — The author has tried head-rests attachahle to a 
 general operating table hut they have not proved thoroughly satis- 
 factory. F. Krause, of Berlin, while performing an occipital opera- 
 tion, had the patient in a sitting position, the head inclined forward, 
 resting against the chest of an attendant who steadied the patient's 
 head between his hands. 
 
 For cerebellar operations the "outrigger," with shoulder supports 
 to allow of free respiration, is most satisfactory.^- ^' ^ 
 
 Elevation of the Head. — Elevation of the patient's head during 
 the operation lessens hemorrhage. Some surgeons operate with the 
 head and shoulders elevated at an angle of about thirty degrees. 
 This, however, necessitates a constrained position for the operator 
 which, especially in a "temperamental" man, seriously interferes 
 with his efficiency, particularly toward the end of a long operation. 
 
 Technic. — ^The operating table should be at least twelve inches higher than 
 the standard tables used for abdominal operations. The operator and assistants 
 should stand squarely on their feet, without strain, thus enabling them to work 
 for several hours without unnecessary fatigue. Each should attain the height at 
 which he works best, by an individual platform. 
 
 UMITATION OP THE FIELD: 
 
 Technic— After marking the proposed incision with a, knife, the head is 
 covered with gauze, the operative field being left exposed and surrounded by 
 toweling pinned to the scalp, a wall of toweling being erected between the anesr 
 thetist and the operator so that it is impossible for the anesthetist's hand to 
 invade the operative field or for the operator to go beyond it.* By pinning the 
 toweling to the skin with delicately constructed clips an area with a margin of 
 one-half inch may be walled off. 
 
 Control of Hemorrhage. — One of the imperfectly solved prob- 
 lems of cranial surgery is the control of hemorrhage. The number 
 of operations which result fatally, directly or indirectly from bleed- 
 ing, is still large. Many surgeons, chiefly because of failure to con- 
 trol hemorrhage, divide all intradural operations associated with 
 marked increase of the intracranial pressure into two stages — at one 
 
 » BYazler, C. H. : "Problems and Procedures in Cranial Surgery" ; Jour. Am. Med. 
 Aseoo., June 5, 1909, Vol. 52, p. 1805. 
 
 " Smitli, H. B. : "An Apparatus for Supporting and Holding the Head and Shoul- 
 ders In Cerebellar and High Spinal Operations"; Jour. Am. -Med. Assoc, Nov. 26, 
 1910, Vol. 55, p. 1859. 
 
 ' Cushing, H. : "Tumors of the Nervus Acustleus" ; 1917, W. B. Saunders Co., 
 Phlla. and London, p. 252. 
 
 * Cushing, Harvey : "Technical Methods of Performing Certain Cranial Opera- 
 tions" ; Burg. Oyn.. and Ois., 1908, March, Vol. 6, No. 3, p. 22T. 
 
8 BRAIN ABSCESS 
 
 operation turning down tlie osteoplastic flap, and at a later time 
 opening tlie dura. With proper attention to hemostasis this should 
 rarely be necessary. 
 
 Hemorrhage from the Scalp. — ^In cases with greatly increased 
 intracranial pressure bleeding from the scalp may be very severe. 
 In addition to the many spurting points there is a general oozing 
 which, though temporarily of little moment, may seriously militate 
 against the patient's recovery if allowed to continue. Over both 
 cerebrum and cerebellum the hemorrhage can be controlled by firm 
 manual pressure against the skull and the subsequent reflection of 
 the galea over the cut surface. 
 
 The excessive general oozing so frequent during operations for 
 brain tumor does not occur during exploration for cerebral or cere- 
 bellar abscess, because in the presence of intradural suppuration, 
 long before the development of the excessive increase of intra- 
 cranial pressure so frequently associated with tumors, the patient 
 has expired. Continued excessive increase of intracranial pressure 
 is not compatible with life in the presence of suppuration. 
 
 Technic of Controlling Hemorrhage.— The assistant, with the finger tips 
 of both hands, presses the scalp firmly against the bone while the surgeon cuts in 
 the small area between them, checking the hemorrhage by catching the galea with 
 fine artery forceps and reflecting it over the cut surface. The artery forceps 
 controls the hemorrhage, not by actual compression, but by pulling the galea 
 over the vessel. 
 
 The assistant must not remove the pressure until the hemorrhage is com- 
 pletely controlled. The number of forceps necessary is very large. The clamps 
 are dropped into the open palm of an assistant, for if allowed to hang they will 
 become detached by their own weight or during manipulation. The assistant 
 keeps the forceps absolutely flat and in proper relation to «ach other. Straps of 
 gauze wrapped around or through the handles of bundles of ten or twelve forceps 
 allow the assistant to control a large number. After the application of the 
 forceps a band of flat gauze pulled tightly over the cut surface controls the re- 
 maining ooze and protects the forceps from displacement. Sufficient attention 
 to this simple method prevents loss of blood and shortens the time of operation. 
 
 The author has attempted ligation of the clamped vessels before closure; but 
 it has been found to consume time and is of very little value. 
 
 During closure, with the exception of actual spurters, the hemorrhage must be 
 controlled by exact and careful approximation of the cut surfaces by suturing, 
 layer by layer, no dead spaces whatever being allowed to remain. Because of the 
 adhesion of the galea to the pericranium and subcutaneous tissue the soft parts 
 must be pushed, not pulled, together by an assistant, all traction by sutures 
 being avoided. The process is long and tiresome, but it is the only one that is 
 uniformly attended with success. 
 
 Tourniquets and Compressors. — ^When applicable in abscess well above the 
 floor, metastatic or following trauma, a rubber tourniquet' materially lessens 
 
 • Gushing, Harvey : "Pneumatic Tourniquets, with Special Beference to their Use 
 in Craniotomies" ; Medical News, Marcli 26, 1904, Vol. 84, p. 577. 
 
GENERAL SURGICAL TECHNIC 9 
 
 the bleeding. On several occasions, however, the tourniquet interfered with 
 the proper exposure of the abscess which, being subdural, had gravitated down- 
 ward. Removal of the tourniquet with an open dura is associated with annoying 
 bleeding which may be difficult to control. 
 
 Heuer^s temporo-muscular clamp, a modification of an intestinal clamp, mate- 
 rially lessens the bleeding but in temporo-sphenoidal abscess, as the exposure 
 must be low down, it cannot be employed. 
 
 The spring clips of Makkas are distinctly useful when respiratory or circu- 
 latory troubles necessitates very rapid exposure. They slip, however, if applied 
 near the edge of the wound rendering closure difficult. They also severely bruise 
 the tissue, frequently causing local necrosis. 
 
 Heidenhain's method of using deep sutures of heavy silk or silkworm gut 
 passed with a large, full curved needle through skin to bone, one overlapping the 
 other, does not control the hemorrhage but seriously interferes with the closure 
 and is followed by stitch abscesses. 
 
 Kredel's plates, likewise, have similarly failed. 
 
 PEKFORATION OF SKTJIL AMD FORMATION OF OSTEOPLASTIC FLAP : 
 
 Instruments. — Hudson's perforators save time, but it requires a little experi- 
 ence to recognize correctly the sensation when the skull is perforated; otherwise 
 it is possible to injure the dura and damage the brain substance with them. 
 Hartley and Kenyan's perforator," driven by an electric motor, is somewhat dan- 
 gerous, but properly used it makes possible a rapid and safe perforation of the 
 skull. Frazier's electric fraise' neither works rapidly nor allows a proper bevel. 
 
 SACKIFICE OF BONE: 
 
 Instruments. — ^When a large area of bone is to be sacrificed, as in cerebellar 
 abscess, the usual gauges and chisels are too small. The author is using more 
 and more very large chisels, rongeurs and heavy hammers. A large chisel properly 
 placed is not so dangerous an instrument as a small one, but it requires a heavier 
 hammer to drive it. Herman Bleyle has made a well-balanced hammer weighing 
 nearly twelve ounces; but the author has not yet found the rongeur strong 
 enough and powerful enough to cut bone as rapidly as is necessary. The French 
 bulldog rongeurs and the long-handled rongeurs devised by Bryant ' are the most 
 satisfactory. 
 
 contbol of modeeate bleeding from the dlploio vessels dueing the 
 Pebfokation of the Skull. 
 
 Disregard of moderate bleeding results in unnecessary loss of 
 blood. Moderate hemorrhage can be controlled by cotton or wax 
 until the dural opening is enlarged, when the venous hemorrhage 
 generally ceases entirely. 
 
 Technic. — Horsley's wax must be of the proper consistency. There is a little 
 knack required for its successful application. It must be WIPED, not pressed, 
 into the bony foramen. The proper pressure to be exerted comes with experience. 
 Attempts to control hemorrhage by all forms of stiff plugs — ^Krause's hooks, ivory 
 
 " Hartley and Kenyon : Experiences in Cerebral Surgery ; Annals of Surgery, 
 April, 1907, Vol. 45, p. 481. 
 
 ' Frazier, C. H. : Problems and Procedures in Cranial Surgery ; Journal American 
 iledUsal Aaaodation, June 5, 1909, Vol. 52, p. 1805. 
 
 • Bryant, William Soliier : An Improved Rongeur for Mastoid Operations ; Journal 
 American Me4ical Association, August 6, 1910, Vol. 55, p. 502. 
 
10 BEAIK ABSCESS 
 
 or wooden plugs — are useless as they are constructed on a wrong principle, 
 namely, that the bleeding has to be overcome by force whereas in reality it re- 
 quires complete occlusion of the vessels. The slightest pressure completely stops 
 bleeding. A frequent cause of failure is the attempt to wipe wax into a vessel 
 which is still partially outside of the bony foramen. 
 
 BULGING OF THE DtfBA INTO THE PEEFOKATION 0PBININ6S : 
 
 If the intracranial pressure is greatly increased on making the initial opening 
 the dura bulges forcibly into the opening and it is with difficulty that a director 
 can be passed from one to the other. The proper use of the dural separators is 
 acquired only after a little experience. A large number of dural separators of 
 different sizes and shapes is required. The instrument should be advanced 
 carefully, by gentle pressure and a to-and-fro movement. The introduction of the 
 protected guide for the Gigli saw is facilitated by bending its tip. The bulging 
 of the dura through the opening can be prevented by the performance of a lumbar 
 puncture. This is frequently attended with severe hemorrhage, which can be 
 completely controlled only after the bone flap has been elevated. 
 
 TECHNIC OP VENTRICULAR PUNCTURE: 
 
 A trephine opening is made in the occipital bone about three-quarters of an 
 inch above the transverse sinus and three-fifths of an inch from the median line; 
 the dural opening need only be large enough to admit the searcher. The searcher 
 is passed directly forward; if two or three punctures fail to reach the ventricle 
 the opposite hemisphere should be similarly trephined and punctured, as obliterar 
 tion of one lateral ventricle from pressure is a frequent occurrence. 
 
 THE CUTTING OF AN OSTEOPLASTIC FLAP OF THE SKULL: 
 
 Instruments. — The spaces between the openings are cut with a Gigli saw or 
 with a narrow Marentz rongeur. 
 
 Technic. — The saw should be held tense, with the handles wide apart so that 
 the cutting angle of the saw will be as obtuse as possible. The movements of 
 the saw should be transmitted partially by rotation of the operator's body rather 
 than by a to-and-fro movement of his arms alone. If the arms alone are used the 
 operator is apt to allow his hands to approach each other, thus breaking the saw. 
 Properly used a Gigli saw will out through any skull without difficulty, making 
 H, bevel upon which the flap can rest. It is the best and safest instrument at our 
 command. (See Part II, p. 41.) 
 
 Control of Hemorrhage feom Interior of Skull Before Duea is Opened. 
 
 After the elevation of the flap, or sacrifice of the bone, consid- 
 erable blood occasionally comes from beneath the edge of the bone. 
 The crowding into the bleeding area of a very small roll of cotton 
 with a black thread attached generally controls the bleeding. The 
 hemorrhage is frequently quite profuse at first, but later the small 
 compress can be slowly removed, generally without recurrence of the 
 hemorrhage. 
 
 In hemon-hage from a venous sinus the accurate placing of a 
 piece of fascia lata over the rent — ^the postage-stamp method — will 
 control the bleeding. Its proper application, its unfolding and tuck- 
 ing away with forceps, requires considerable experience. 
 
GENBEAL SURGICAL TECHNIC 11 
 
 CONTBOL OF HeMOEBHAGE FBOM THE DtJBA ITSELF. 
 
 In cases of increased intracranial pressure there is a constant 
 oozing from the small vessels of the dura which, while of slight im- 
 portance before opening the dura, is extremely annoying later, and 
 is most difficult to control. 
 
 Oozing is readily stopped by placing over the oozing points 
 strands of dry cotton, in the meshes of which the blood will coagulate. 
 Upon the removal of the cotton, however, at the end of the operation, 
 the oozing is apt to recur with increased persistence. A properly 
 applied piece of muscle is very effective. It should be placed flat over 
 the bleeding point and the blood pressed from under it. The muscle 
 acts by occlusion and as a chemical hemostatic. Applied blood clot 
 also at times will control a very troublesome oozing. When obtain- 
 able, the application of fibrin paper is of the greatest advantage. *• ^** 
 
 The larger vessels of the dura are encircled with a needle and 
 ligated in two places, or "double-clipped," before incision. In liga- 
 tion by a needle-passed suture I have frequently injured a pial vessel, 
 with resultant annoying hemorrhage. 
 
 OONTEOL OF HBMOEKHAGE FBOM THE PlAI, VESSELS. 
 
 All hemorrhage must be controlled before the closure of the dura, 
 for if a single point is left bleeding at the primary closure it will 
 continue to ooze, with resulting degeneration, the pressure from the 
 brain itself being insufficient to stop the hemorrhage. The pial ves- 
 sels — endothelial tubes — run in the substance of the piarachnoid, 
 which itself hugs the cortex, dipping down into each convolution. 
 The pial vessels anastomose freely with each other, and furnish the 
 superficial vessels of the cortex. They cannot therefore be caught 
 and elevated without tearing the adjacent piarachnoid and injuring 
 the superficial cortical vessels ; they must be encircled without eleva- 
 tion or laterally occluded by pressure. 
 
 Technic.-^-The application of the finest hemostat only increases the bleeding, 
 since it is impossible to elevate the piarachnoid or pial vessels sufficiently to 
 ligate by the forceps. The pial vessels may be ligated by passing a needle ligature 
 around them, but passing the needle and tying the ligature without tearing the 
 tissue is a most delicate procedure. Cashing "double-clips" all pial vessels and 
 cuts between the dips. Horsley double-ligated all pial vessels before cutting. 
 Hartley stopped bleeding by applying with a slight pressure a thick layer of 
 
 • Harvey, S. C. : Fibrin Paper as an Hemostatic Agent ; AnncUs of Swgery, 1918, 
 Vol. 63, p. 66. 
 
 " Cushlng, Harvey : The Control of Bleeding In Operations for Brain Tumors ; 
 ArmaJa of BurgerVi 1911, Vol. 64, p. 1. 
 
13 BRAIN ABSCESS 
 
 vaseline spread on a piece of gauze. If the gauze is raised the vaseline adheres 
 to the bleeding points and seals them. The use of adrenalin, also, will stop pial 
 bleeding, but the hemorrhage will recur later from the relaxation of the con- 
 striction unless pressure is applied. 
 
 CiONTEOL OF HEMOKBHAGE FEOM THE BRAIN SUBSTANCE. 
 
 This is generally slight and is stopped spontaneously hy the sur- 
 rounding tissue. If not, a piece of fascia, or, even better, of temporal 
 muscle, or the fibrin paper plates of Harvey, -"^^ must be smoothly ap- 
 plied to the bleeding surface. The immediate control of hemorrhage 
 by the smooth application of autogenous tissue over the bleeding part 
 is one of the most beautiful and delicate procedures in surgery. It is 
 rarely necessary in operation for brain abscess to destroy the con- 
 tinuity of the brain substance, for, unlike brain tumors, which must 
 be removed from the place where they are embedded in the brain, 
 an abscess is drained from within without disturbing the surrounding 
 tissues. 
 
 OLOSUKE OF DUEA: 
 
 Technic— Approximation by catgut suture is most unsatisfactory, but in the 
 presence of suppuration the author uses it. Waxed fine silk gives a much better 
 approximation of the dural edges. 
 
 In increased intracranial pressure it may be impossible to close the dura with- 
 out injury to the brain substance. Suturing a transplant of fascia lata into the 
 dural defect makes an excellent cerebral covering. 
 
 Additional References to Operative Teohnio. 
 
 Bahm, Hans: Die Meohanik der Gehirnerschiitterung; Oentralblatt fUr 
 Ohirurgie, February 14, 1920, No. 7, p. 146. 
 
 Barany: Die offene imd geschlossene Behandlung der Schussverletzungen des 
 Gehims; ZeitsoJirift fur AerztUche FortWldvng, 1917, Bd. XIV, S. 397. 
 
 Masland, Harvey C.: Cutting the Boae Flap in Cranial Surgery; Armals of 
 Surgery, October, 1920. 
 
 Midgeville, Een6: Mnde de Topographie Cranio-Cfirebrale pour la Eecherche 
 des Abcfes Oto-Enc6phalique; 1919, Vigot Frtres, Paris. 
 
 Di5jerine, Mme. et Landau, M. E.: M^thode de Topographie Cranio-En- 
 cephalique simple et pratique pour prdciser, dans les Blessures du Crane par 
 Pi-ojectileB de Guerre, la partie du Ceirveau 16s6e par le Projectile et le Si^e 
 de ce dernier; Revue Neu/rologique, Mars, 1916, Tome XXIII, No. Ill, pp. 
 425-447. 
 
 ^Loo. elt. 
 
PAET II. 
 
 SUEGIOAL PATHOLOGY AND OPERATIVE TECHNIO 
 OF BRAIN ABSCESS. 
 
CHAPTEE III. 
 PATHOLOGICAL AND SURGICAL CONSIDERATIONS. 
 
 HISTOPATHOLOGY OF CEEEBEAL TISSUE. 
 
 Histologically, cerebral tissue is composed of neurons — the 
 functioning cells of the brain, the most highly specialized tissue in 
 the body. Between the neurons is the supporting tissue of the brain, 
 the neuroglia — ^the glial cells and fibres. The neuroglia plays only 
 an inactive part in the nervous mechanism; with the small amount 
 of connective tissue from the pia and alongside the blood channels it 
 forms a framework, as it were, in which the nerve cells functionate. 
 
 Under stress, such as infection, certain cells of the neuroglia take 
 on amoeboid activity and are instrumental in the removal of waste 
 products from the brain. ^ 
 
 Following the law that the more highly specialized the cell the 
 more it depends upon nutrition for its life, and the less able it is to 
 regenerate itself, nerve cells die easily and do not regenerate; glial 
 tissue, on the other hand, while more resistant, regenerates. The re- 
 generation of glial tissue, however, plays no active part in the restora- 
 tion of nerve function. Thus, in traumatic epilepsy, if unrelieved at 
 an early date, a general gliosis, or proliferation of the glial tissue, 
 occurs, in the presence of which any operative procedure for the cure 
 of the epilepsy is useless. 
 
 FACTOKS PECULIAR TO CEREBRAL TISSUE WHICH DEMAND 
 SURGICAL RECOGOTTION. 
 
 Upon, opening the dura the following factors peculiar to cerebral 
 tissue are encountered: 
 
 (1) In the normal state the dural envelope is completely filled 
 by its contents. During pathological processes, inflammatory or 
 traumatic, the bulk of the intradural content is greater than can be 
 contained within the dural envelope without alteration and com- 
 pression. Normally, the intracranial tension, being of circulatory 
 origin and varying with the tension of the cerebral veins and capil- 
 
 * Alzheimer, Alois : BeltrSge zur Kenntnlss der Fathologtscben Neuroglia tind 
 llirer Beziehungen zu den AbbauTorgSngen im Nervengewebe ; HUtologiache »»d Hitto- 
 pathologische Arbeit Uier QraesMrn/rinie ; Jena, March, 1910. 
 
 13 
 
14 BEAm ABSCESS 
 
 laries, is variable in degree; in the dog tlie brain functions witbin 
 a wide range of intracranial pressure ^ from zero to 50 mm. Hg. In 
 the presence of a localized intracranial suppuration (abscess) addi- 
 tional space within the dural envelope is obtained by (a) obliteration 
 of the venous sinuses; (b) displacement of the cerebral tissue, not 
 only of the affected but also of the unaffected hemisphere; and (c) 
 obliteration of the cerebro-spinal fluid circulatory systean spaces. 
 These factors, by interfering with the delicate circulatory systems — 
 hemic, cerebro-spinal fluid, and intracellular — ^increase the liability 
 to extension of infection even before the appearance of actual com- 
 pression of the cerebral tissue. 
 
 (2) The over-filling of the dural envelope is partially due to the 
 cerebro-spinal fluid system. In abscess, not only is the amount of 
 the cerebro-spinal fluid increased from the irritation, but there is 
 an associated internal hydrocephalus due to diminished exit off 
 cerebro-spinal fluid by the cortex, and definite obstruction in the 
 main cerebro-spinal fluid circulatory system by displacement of the 
 hemispheres. 
 
 (3) The blood vessels of the brain are endothelial tubes, easily 
 ruptured. Every drop of blood effused into the cerebral tissue causes 
 shock by over-stimulation of the cerebral cells. The writer has seen 
 paralysis lasting for days and convulsions continuing for hours as the 
 result of small hemorrhages and pressure on the cortex caused by 
 subdural injections of an autogenous serum. 
 
 (4) Injury to cerebral tissue, no matter how slight, has a deeply 
 depressing effect upon the organism as a whole. 
 
 (5) Death of ganglionic cells and neurons (the functioning cells 
 of the brain) is not followed by regeneration. 
 
 (6) Cerebral tissue, the seat of infection, does not tolerate 
 manipulation and injury as well as normal cerebral tissue; the sup- 
 purative process with the associated compression of cerebral tissue 
 so lowers its resistance that slight trauma may occasion extensive 
 oedema or encephalitis. This is of the greatest surgical importance. 
 
 (7) The micro-organisms of an encapsulated brain abscess gen- 
 erally are of low virulence while within the abscess cavity ; but placed 
 upon the normal piarachnoid they may cause a rapidly fatal sup- 
 purative meningitis. 
 
 (8) After the evacuation of the brain it must be realized that 
 the piarachnoid and cerebral tissue must be entirely and firmly 
 covered by dura, bone, fascia or skin, as failure to provide a tight 
 
 • Hill, Leonard : "Physiology and Pathology of the Cerebral Circulation" ; London, 
 1896. 
 
Fig. 2. — Brain, with large tumor, which presented few symptoms for over a 
 year after decompression. Death 2% years after operation. (This case at no 
 time developed a papillcedema.) 
 
 Fig. 3. — Brain, with large tumor. Spontaneous decompression, followed by 
 marked improvement in symptoms. 
 
 Fig. 4. — Sections of cerebrum with extensive infiltrating glioma. Decom- 
 pression followed by such relief of symptoms that one year after operation 
 patient, through deception, successfully passed an "inspection" for industrial 
 life insurance. 
 
PATHOLOGICAL AND STJEGICAL CONSIDERATIONS 15 
 
 covering in the presence even of mild suppuration, witli associated 
 increased intracranial pressure from oedema, frequently is followed 
 by fungating hernia, -whicli almost invariably terminates in a fatal 
 meningitis. (Witness the fungating hernia following a small "leak" 
 from improper closure or stitch abscess, in a subtemporal decom- 
 pression.) 
 
 AouTE CEdema feom Teaitma op Oeeeahon : Sttdden Inckeasb within Contents 
 
 OF DuEAL Envelope. 
 
 Sudden death may result from acute oedema of the brain, with- 
 out marked gross changes, as is frequently shown at post mortem. 
 
 CASE ni, P. 
 
 Labyrinthitis. Male, 58 years of age. Undoubtedly serous meningitis, as 
 shown by papilloedema, and excessive pressure of fluid from lumbar puncture, but 
 no micro-organisms in cerebro-spinal fluid. Operation: long chiseling process; re- 
 peated shocks. Death in coma eighteen hours after operation. Autopsy: cortical 
 contents flattened from pressure against skull; excessive amount of cerebro-spinal 
 fluid; no micro-organisms. 
 
 This case illustrates a condition which is but an exaggeration of 
 the acute oedema of the brain which occurs with acute abscess, or as 
 the result of trauma. 
 
 Cases are not uncommon in which death rapidly follows a cerebral 
 trauma or hemorrhage into a slowly growing glioma, in which at 
 post-mortem, the amount of the hemorrhagic infiltration into the 
 brain is not sufficient, of itself, to cause death, were it not for the 
 rapidity of its effusion. 
 
 CASE IV, L. 
 
 Glioma. Adult male. Always well. Several months previously headache 
 followed by convulsion and irregular attacks of "dreamy state." In intervals 
 apparently perfectly well but listless; later irregular headache for two weeks, 
 followed by convulsions, slight aphasia, loss of memory, slight papilloedema; six 
 weeks later suddenly became unconscious. Death within eighteen hours. 
 Autopsy : Two gliomatous masses in left temporo-sphenoidal lobe. One, old under- 
 going cystic degeneration with evidences of former blood extravasation. Second, 
 filled with recent blood extravasation. 
 
 In contrast with these cases consider the enormous brain tumors 
 of slow growth, which, when given a vent by decompression, cause' 
 few symptoms because the intracranial contents have time to re- 
 adjust themselves. (See Figs. 2, 3, and 4.) 
 
 Summary. — The increase in the intracranial contents from sup- 
 puration, and the associated protective meningitis, with the possibility 
 of the blocking of the fluid within the ventricles in cerebellar abscess, 
 are all to be considered in the surgical treatment of brain abscess. 
 
16 BEAIN ABSCESS 
 
 In brain abscess tbe cerebral tissues, as a result of the toxemia 
 from the suppuration and of the increased intracranial pressure, 
 perform their proper functions with diiBculty. If, in addition to 
 these, trauma, oedema, or hemorrhage into the cerebral tissue from 
 manipulation should occur, a fatality is apt to result, — a fatality 
 for which the surgeon is largely responsible. How frequently have 
 patients who, prior to operation, were in excellent mental condition, 
 immediately following operation passed into deep coma or active 
 delirium ! 
 
 REFERENCES. 
 {Pathology of Brain Abscess) 
 
 (1) Miodowski, F. : Beitrage zur Pathogenese und pathologischen Histologie 
 
 des Hirnabszessen; Arch, fiir Ohrenheilkunde, 1908, B. 77, Case I, S 239. 
 
 (2) Tylor: In "Pathology of Encephalic Infection in Otitis"; Brain, 1912, 
 
 Vol. XXXV, p. 109. 
 
 (3) Homen, B. A.: Experimentelle und Pathologische Beitrage zur Kenntniss 
 
 der Hirnabazesse; Arbeiten was dem, Patholog. Institut d. Universitat 
 Eelsingfors, 1913, B. I, H. 1-2, S. 1. 
 
 (4) Friedmann, M. : Der Himabszess (Encephalitis purulenta) ; Handbuoh der 
 
 Pathol. Anat. des Nervensystems, 1904, B. 1, S. 504. 
 
 (5) Kolpin: Zur Symptomatologie und pathologischen Anatomic des Hirn- 
 
 abazesses; Deutsche Zeitschrift fiir Nervenheilkimde, 1903-04, B. XXV, 
 S. 365. 
 
 (6) Topley, W. C: A Case of Generalized Streptotrychosia with Extensive 
 
 Lesions in the Central Nervous System; Brain, 1912, Vol. XXXV, p. 26. 
 
 (7) Korner, Otto: Die Klinischen Erkrankungeu des Hirns, der Hirnhaute und 
 
 der Blutleiter; 1902. 
 
 (8) MacEwen, Wm. : Pyogenic Infective Diseases of the Brain and Spinal 
 
 Cord; 1893, pp. 972-991. 
 
 (9) Politzer, Adam: Diseases of the Ear; Fifth Edition, p. 636. 
 
 (10) Wittmaack: Ueber die Beziehungen der pneumatisation Storungen zur 
 
 Bntwickelung endokranieller Komplikationen; Archiv fiir Ohrenheil- 
 kunde, B. 97, No. 1. 
 
 (11) Hegener, J.: Labyrinthitis und Himabszess; Passow wnd Sohdfer'a Beir 
 
 tr&ge zur Anat., Phys., Pathol., und Therap. des Ohres, der Nase und 
 des Balse&, 1909, B. II, S. 359. 
 
 (12) Hassin, G. B. : Histopathological Studies on Brain Abscess; Medical 
 
 Record, January 19, 1918. (Gives description of cells and a bibliography.) 
 
 (13) Westphal, A.: Ueber Gehirnabszesse; Archi/v fiir Psychiatrie, 1900, B. 
 
 XXXIII, S. 206. (Gives detailed pathological and microscopical report 
 with microscopical illustrations.) 
 
 (14) Beck, K. ; Zur Entstehung und Ausheilung von otitischen Kleinhirnab- 
 
 szessen; Zeitschrift fiir Ohrenheillcvmde,^. 64, 1911-12, S. 262. (Gives 
 note on discovering route of infection.) 
 
 (15) Essick, C. K. : Pathology of Experimental Traumatic Abscess of the 
 
 Brain; Archives 'Neurology and Psychology, 1919, Vol. I, p. 673. 
 
 (16) Macklin and Macklin: A Study of Brain Repair in the Eat by the Use 
 
 of Trypan Blue; Archives of Neurology and Psychiatry, April, 1920, 
 Vol. 3, p. 353. 
 
 (17) Mayman, L. : Zur Pathologic und Klinik der otogenen Grosshirnabszesse; 
 
 Munohener med. Woohenschrift, 1913, No. 2-3, S. 65. 
 
PATHOLOGICAL AND STJEGICAL CONSIDBEATIONS 17 
 
 (18) V. Hibler, E.: Zur Kenntniss der pathogenen Anaeroben. Bin Kleinhirn- 
 abazess bei chroniBcheT eiterig-emsiger Otitis, Sinus Thrombose und Car- 
 cinom-Entwickelung im rechten Felsenbein; Oentralilatt fiir Bakteriol- 
 ogie, 1913, B. 68, S. 257. 
 
 GENERAL SURGICAL CLASSIFICATION. 
 
 Brain abscess, from the standpoint of surgical pathology, con- 
 stitutes a group of surgical problems, separate and distinct, yet so 
 intertwined that they pass imperceptibly from one to another, as 
 nature (or the surgeon) undertakes to limit or eradicate the patho- 
 logical process. It is by an appreciation of the fundamental patho- 
 logical differences, by availing himself of favorable conditions, and 
 by the creation of favorable and the avoidance of the creation of 
 unfavorable conditions, that- the surgeon may guide a localized intra- 
 dural suppuration to a successful termination. 
 
 From a surgical standpoint, brain abscess may be divided into 
 four general classes, each based on pathological and etiological fac- 
 tors, which are utilizable by the surgeon during the operative treat- 
 ment. 
 
 I — Chronic Adjacent {Secondary) ; (temporo-sphenoidal, frontal, 
 or cerebellar) with a capsule. The abscess is secondary and adjacent 
 to a known focus of extradural suppuration, such as the mastoid 
 or nasal sinuses, while its slow growth has permitted its limitation 
 by a capsule and has facilitated a readjustment of the disturbed 
 intracranial contents. 
 
 II — Acute Adjacent {Secondary) ; (temporo-sphenoidal, frontal, 
 or cerebellar) without limiting membrane. The rapid formation of 
 the abscess, and its accompanying oedema, have caused a sudden 
 increase in the intracranial contents before the protective mechanism 
 of the brain could have time to erect a macroscopically demonstrable 
 limiting membrane. 
 
 Ill — Intercurrent {Tertiary) to a gross lesion, namely, sinus 
 thrombosis or progressive osteomyelitis. 
 
 IV — Metastatic, which includes: (a) Chronic, without a capsule, 
 (b) Chronic, with a capsule, and (c) Acute. 
 
 V — Traumatic. 
 
 SURGICAL PATHOLOGY. 
 
 A large proportion of brain abscesses, (with the exception of the 
 truly traumatic), belong to types I and II, being secondary and 
 adjacent to suppuration within the ear or nose, the infection extend- 
 ing within the dura either by direct continuity of tissue, or what is 
 
18 BEAIN ABSCESS 
 
 much, more frequent, in my experience, by retrograde thrombo- 
 phlebitis, with or without an intercurrent sinus thrombosis. 
 
 In my series, excluding all truly traumatic cases, out of the first 
 forty-four brain abscesses, forty, or over ninety per cent., belonged 
 to the secondary adjacent types, chronic or acute. 
 
 Metastatic abscesses originate from embolic septic occlusion of a 
 cerebral vessel, the primary foci being generally far distant from the 
 brain, the most frequent site being the lungs, from a bronchiectasis. 
 Occasionally, a true embolic septic occlusion originates from an 
 infected mastoid or petrous bone, in which case as the septic embolus 
 has passed freely through the circulation prior to its lodgment in the 
 brain, the cerebral invasion is distinctly apoplectiform in onset, 
 while the brain abscess is not adjacent to the ear, but is lodged either 
 in the frontal or occipital lobes, deep within the cerebral tissue, or 
 in the opposite hemisphere.* An examination of the clinical and 
 post-mortem histories of the recorded cases of brain abscess, not 
 traumatic, whose situation is not adjacent to the site of infection, 
 demonstrates their embolic origin.* 
 
 Of the author's forty-four brain abscess cases three were meta- 
 static, one from bronchiectasis, one from suppurative endocarditis, 
 and one, while originating from a sinus thrombosis and mastoiditis, 
 was undoubtedly embolic in origin.^ 
 
 There still remains a small number of so-called "idiopathic" 
 brain abscesses,^' "^ in which the site of the original suppuration is 
 unknown. The demonstration of the fusiform bacillus as the caus- 
 ative micro-organism in certain of these abscesses and in the tonsils 
 has greatly limited the number. (See Metastatic Abscess, p. 68.) 
 
 In types I and II of intracerebral abscess secondary to adjacent 
 suppuration the pathological process is a nutritional death of cerebral 
 tissue following a retrograde thrombophlebitis. While direct exten- 
 sion of tlie infection through the dura, piarachnoid and brain in the 
 writer's opinion but rarely occasions intracerebral abscess, it is un- 
 doubtedly the causative factor in localizing intrapiarachnoid suppura- 
 tion. 
 
 • Lombard, Bloch, A., and Moulouguet, A. : TJn cas d'abac6s du lobe frontal du 
 c8t£ oppos€ & une otite suppur£e chronlgue ; Annal dea Maladies de I'Oreille, etc., 1914, 
 Tome 90, p. 749. 
 
 • Berens, T. P. : Abscess of the Frontal Lobe of the Brain of Otitic Origin ; Trana. 
 Amer. Otol. Soq^ 1913, Vol. 13, p. 66. 
 
 ' Quimby, Wm. O. G. : Personal Communieation. (Observed at a post-mortem, a 
 temporo-sptaenoldal lobe abscess in the opposite hemisphere to the originating aural 
 suppuration.) 
 
 " Casamajor, L. : Brain with Double Frontal Abscess ; Medical Record, 1915, 
 Vol. 87, p. 412. (Report of case and exhibition of specimen autopsy findings. New 
 York Neurological Society meeting December 1, 1914.) 
 
 ' Climenko, H. : A Case of Brain Abscess ; Journal Nervoua and Mental Diseaaea, 
 1918, Vol. XLVII, P. 444. 
 
PATHOLOGICAL AI^D SUEGICAL CONSIDEEATIONS 1? 
 
 In either case long before the micro-organisms have entered the 
 cerebral tissue, — in one case being confined within the walls of the 
 vessels and in the other because of the continuity of structure — the 
 protective forces of the brain have become active in the affected area. 
 Chief among these, as we have seen, are the leucocytes and endothelial 
 cells from the blood vessels, the cells lining the arachnoid spaces, and 
 the macrophage from the neuroglia, each contributing towards com- 
 batting the invading micro-organisms, and the limitation and subse- 
 quent repair of the inflammatory septic process by the formation of 
 new connective and the removal of dead tissue. The same applies, 
 to a limited extent, in metastatic abscess because of the temporary 
 limitation of the invading organisms within the lumen of the 
 occluded cell.* 
 
 In traumatic abscess, on the contrary, the immediate death of 
 cerebral tissue from trauma, associated with the transplantation of 
 micro-organisms in unprepared cerebral tissue, furnishes favorable 
 conditions for the rapid extension of the suppurative process before 
 the limiting protective reactions of the brain can be marshalled; 
 while the associated oedema and hemorrhage of extensive trauma so 
 increases the intracranial pressure that the protective reactions of the 
 brain are actually prevented from playing an active part in the 
 limiting process. 
 
 SUEGICAIi CLASSIFICATION ACCORDING TO POSITION AND RELATION- 
 SHIP TO THE BRAIN AND ENCIRCLING MEMBRANE. 
 
 Intradural abscess may be divided, surgically, according to its 
 position within the brain or piarachnoid, and its relationship with 
 the encasing dura and piarachnoid, through which its evacuation must 
 be conducted, into: (a.) Intracerebralj without macroscppical evi- 
 dence of cortical involvements (&) Intracerebral, with a cortical 
 "stalk"; (c) Meningeal, either intrapiarachnoid or subdural. 
 
 (a) Intracerebral abscess without macroscopical evidence of 
 cortical involvement originates from retrograde thrombophlebitis, or 
 from perivasculitis from an adjacent area of suppuration — ^lateral 
 sinus thrombosis, mastoiditis, or sinusitis, — or from the deposit of 
 a septic embolus in metastatic abscess. 
 
 (6) Intracerebral abscess with a cortical "stalk," probably origi- 
 nates from a combination of direct extension and associated retro- 
 grade thrombophlebitis or perivasculitis from an adjacent suppura- 
 tion. In my opinion the direct extension advances more frequently 
 
 • See Chapter 9, Protectlye Mechanism. 
 
20 BEAIN ABSCESS 
 
 outward from the abscess cavity itself toward the dura than inward 
 from the dura to the abscess, the "stalk" being always a late mani- 
 festation. The "staUc" is nature's effort to evacuate spontaneously 
 an encapsulated intracerebral abscess through the original site of iu- 
 fection. The literature contains numerous instances of the spon- 
 taneous evacuation and cure of intracerebral abscess by the develop- 
 ment of a stalk followed by a secondary necrosis of the dura. 
 
 As the perivascular spaces of the brain contain cerebro-spinal 
 fluid, not lymph, and histologically and embryologically are not 
 lymph channels, the term "perivascular" should be substituted for 
 the frequently employed and incorrect "lymphatic" path of infection 
 in the brain substance." 
 
 (c) Meningeal Abscess j (either intrapiarachnoid — limited to 
 the meshes of the piarachnoid — or subdural — limited to the subdural 
 space — results from a direct extension from an adjacent infective 
 process — osteitis, phlebitis, extradural abscess or trauma.-'*' 
 
 As far as the author is aware, subdural and intrapiarachnoid 
 abscess have not previously been differentiated clinically. In a case 
 in which death resulted from leptomeningitis, following the evacua- 
 tion of a temporo-sphenoidal intracerebral abscess, the post-mortem 
 disclosed a large flat collection of pus and organized fibrin, entirely 
 limited to the subdural space; it was very yellow and resembled the 
 exudate frequently seen covering the appendix, the exudate being 
 about half an inch in thickness and apparently undergoing resolu- 
 tion. It was not entirely a reparative process, however, as it ex- 
 tended underneath the whole frontal lobe of the affected side. It 
 was possibly of traumatic origin from infection of the subdural 
 space during evacuation of the intracerebral abscess, although its 
 appearance and the clinical history would point to its having existed 
 prior to the operation. 
 
 The exact site of an abscess in or on the different lobes of the 
 brain depends largely upon its origin and mode of invasion. If the 
 abscess originates from an adjacent suppuration in the ear or 
 nose, it is situated in or on the temporo-sphenoidal lobe, the cere- 
 bellum, or the frontal lobe. 
 
 An adjacent abscess is almost invariably single, the multiple 
 abscesses reported being generally of traumatic or embolic origin. 
 
 • Weed, L. H. : An Anatomical Consideration of the Cerebrospinal Fluid ; jlna- 
 tomtcal Record, May, 1917, Vol. 12, p. 492. 
 
 " In offering the above claeslflcation the author is fully aware of its pathological 
 imperfections. Exact pathological knowledge of the relative frequency of brain 
 abscess from direct extension, from improperly called "lymphatic" Infection, from 
 thrombophlebitis, and from septic thrombi by occlusion, is not available since but 
 few microscopical examinations to ascertain the exact route of infection into the 
 brain are recorded in the literature. 
 
PATHOLOGICAL AND SUEGICAL CONSIDEEATIONS 21 
 
 An adjacent abscess may be chronic or acute, witli or -without a 
 distinct limiting membrane, depending upon its age. 
 
 If the abscess is of metastatic origin, following a vascular occlu- 
 sion by a septic embolus or thrombus freed from a distant focus, it 
 may be situated in any part of the cerebrum or cerebellum. It is 
 apt to be multiple, but not so frequently as is generally believed; it 
 is apt to be subcortical, but may be cortical, never, however, possessed 
 of a true stalk; and it may be meningeal. (See lieport of Case XVI, 
 T. v., Chapter V, Metastatic Abscess, p. 75.) A metastatic abscess 
 is rarely encapsulated, the limiting membrane being thrombotic, not 
 the formation of new connective tissue. 
 
 If the abscess is traumatic, originating from compound fractures 
 of the skull, or from traumatized and infected cerebral tissue during 
 the exploration and evacuation of an adjacent or metastatic abscess, it 
 may be situated in any part of the brain traumatized, a subcortical 
 "abscess frequently being associated with a meningeal abscess. 
 
 CLINICAL CLASSIFICATION OF BRAIN ABSCESS. 
 
 The importance of a thorough understanding of the origin, mode 
 of infection, relationship with the dura and piaraohnoid, and the 
 probable exact site and duration of the intradural suppuration, must 
 be fully appreciated by the surgeon before entering the dura, as each 
 may occasion such variations in the mechanical, pathological and 
 physiological factors as to call for specific surgical reco^ition. 
 
 Exploration into cerebral substance when the abscess is situated 
 entirely within the meshes of the piarachnoid, may result fatally; 
 while the attempted evacuation of a meningeal abscess through a 
 small dural opening — sufficient in an acute intracerebral abscess — 
 is bound to be followed by failure. 
 
 If now the surgical types. Chronic {Secondary) Adjacent Abscess 
 with a capsule; Acute Adjacent Abscess without limiting membrane; 
 Metastatic, and Traumatic Abscess; be combined with the specific 
 surgical types: — Intracerehral Abscess without macroscopical evir 
 dence of cortical involvement; Intracerebral with a cortical "stolh/' 
 and Meningeal Abscess ; from the clinical point of view the following 
 varieties in intradural abscess may be recognized surgically, each 
 presenting individual technical problems : — 
 
 CHBONIO BBAIN ABSCESS: 
 
 1 (o), Intracerebral with Capsule, without Macroscopical Evidence of Cortical 
 Involvement; Origin; Adjacent, Metastatic, or Traumatic. 
 
 Tliis is the most frequent type of adjacent (secondary) abscess, 
 exceptionally of traumatic or metastatic origin. 
 
22 BBAIN ABSCESS 
 
 1 (&), Intracerebral without Limiting Membrane; Origin; Metastatic, or 
 Adjacent. 
 
 To this type belong most of the metastatic abscesses, but a certain 
 proportion of otitic and rhinologic abscesses, although of long dura- 
 tion, have no capsule. 
 
 2, Adjacent Intracerebral with Capsule and "Stalk"; Origin; Adjacent 
 
 (Secondary), or Traumatic. 
 
 The stalk extending through the cortex and attached to the inner 
 surface of the dura over the site of original infection. In exceptional 
 cases the stalk may extend through the dura. 
 
 3, Meningeal; Origin; Adjacent, Traumatic, or Metastatic. 
 
 ACUTE BEAIN ABSCESS: 
 
 1. Intracerebral without Limiting Membrane, but whose fluid contents are 
 
 distinctly circumscribed: Origin; Adjacent, Metastatic. 
 
 2. Meningo-Cerebral, associated with an active surrounding encephalitis: 
 
 Origin; Traumatic. 
 
 3. Meningeal; Origin; Adjacent, Traumatic. 
 
 Metastatic abscess and abscess originating from sudden vascular occlusion 
 are classified together, and "acute abscess with a stalk" is omitted, the 
 stalk not being macroscopically recognizable and consequently cannot be 
 utilized surgically. 
 
 INTRACEREBRAL ABSCESS WITH A CAPSULE AND "STALK." 
 
 In the author's experience abscess with a stalk is not so frequent 
 as intracerebral abscess without maoroscopical cortical involvement, 
 although Komer states that forty-two per cent, of all brain abscesses 
 are from direct extension. However, in the reports of 131 cases of 
 brain abscess analyzed by the author, a sinus leading to the abscess 
 was found in but four. The abscess situated in both the cortex and 
 the subcortical tissue is attached by its stalk to an adjacent area of 
 suppuration in either the temporal bone or the accessory sinuses of 
 the nose. It is a chronic process, the entire abscess and stalk being 
 distinctly encapsulated. 
 
 There is reason to believe that intracerebral abscess with a stalk 
 is a late stage of intracerebral abscess without maoroscopical evidence 
 of cortical involvement. The stalk develops after the formation of 
 the abscess cavity by a continuation of tissue necrosis from the abscess 
 cavity toward the cortex, following in reverse order the path of in- 
 fection originally taken by the causative thrombophlebitis, the nutri- 
 tional disturbances of the cerebral tissue, plus the pressure of the 
 abscess from above, causing the necrosis. 
 
 Those who have viewed through a large dural opening throm- 
 bosis of a cortical cerebral artery ; who have seen how distinctly the 
 area of improper blood supply is demarked, and yet how normal it 
 appears until compared with the surrounding cortex, can understand 
 
PATHOLOGICAL AND SITEGICAL CONSIDBEATIONS 23 
 
 How the area surrotindiiig a retrograde throm'bophle'bitis is the seat 
 of an extension of the suppurative process from the abscess. 
 
 The writer's reasons for believing that the stalk is frequently a 
 secondary process after the development of the abscess itself are: 
 that abscesses with stalk are much less frequent than intracerebral 
 abscesses without macroscopical evidence of cortical involvement; 
 that the stalk is found only in old abscesses; that post-mortem ex- 
 aminations show a large number of extensive abscesses with a per- 
 fectly normal cortex ; and that there is sometimes seen at post-mortem 
 an area of necrosis of the surface of the cerebral tissue, not extending 
 from the dura. 
 
 In the abscess with a stalk from direct extension of tissue necrosis, 
 the suppuration having advanced from the adjacent site of infection, 
 firmly uniting the piarachnoid with the inner surface of the dura 
 and extending through the cortex, furnishes a direct route into its 
 interior without injury to the subarachnoid or subdural spaces. 
 
 During operation, if the dural opening is large the stalk is easily 
 located by the area of adhesions of the piarachnoid to the dura. 
 This type of abscess, if evacuated early, should give a high percent- 
 age of recovery. Many cases of brain abscess have recovered spon- 
 taneously by evacuation through the stalk and the formation of a 
 fistula in the dura. This — Jbfature's method — the establishment of 
 an encapsulated tract through the dura, piarachnoid and cerebral 
 tissue into the abscess cavity — should be one of the first principles 
 to be followed in surgical treatment. 
 
 In like manner in adjacent abscess the surgeon should attempt 
 to convert an intracerebral abscess with a limiting membrane but 
 without macroscopical evidence of cortical involvement into a cap- 
 sulated abscess with a stalk; i.e.j to convert an acute abscess without 
 limiting membrane into an encapsulated intracerebral abscess. 
 
 INTRACEREBRAL ABSCESS WITHOUT CORTICAL INVOLVE- 
 MENT DISCOVERABLE MACROSCOPICALLY. 
 
 This type is generally caused by a retrograde thrombophlebitis 
 of a cerebral vessel.^^ TTpon opening the dura no evidence of dis- 
 ease is discoverable in the piarachnoid or the cortex, the abscess being 
 situated entirely within the cerebral substance at a depth of from one 
 to four centimeters beyond the cortex, but adjacent to the primary 
 infection. 
 
 Although at operation the cortex usually appears normal, in one 
 
 " Preysing, H. : Neun Gehirnabszesse im Gefolge von Obren-und Nasenerkrank- 
 nneen ; ArcMv Jilr Ohrenheilkunde, 1900-01, B. 61, S. 262. 
 
24 BEAIN ABSCESS 
 
 instance in a metastatic abscess secondary to bronchiectasis the writer 
 found a small thrombosed vessel running from the dura through the 
 arachnoid space, the abscess being located directly under the affected 
 vessel. The author is not familiar with a similar observation during 
 life/^ but surgically it suggests a careful inspection of all vessels 
 running from the dura into the brain for surrounding infiltration or 
 thrombosis.-^* 
 
 The peculiar blood supply of the brain accounts for the formation 
 of the abscess entirely beyond the cortex.^* The blood vessels of the 
 pia run horizontally upon the surface of the cortex and anastomose 
 freely; consequently, thrombosis of a pial vessel but infrequently 
 interferes with the nutrition of the cortex sufficiently to produce 
 extensive local necrosis. On entering the cerebral tissue, however, 
 the blood vessels run vertically and become terminal; infective 
 thrombosis of a cerebral vessel, therefore, is rapidly followed by local 
 nutritional death of cerebral tissue with abscess formation. 
 
 The cerebral necrosis from lack of proper nutrition, following 
 infective vascular occlusion of a terminal and intracerebral vessel, 
 explains the frequency with which intracerebral abscesses grow in- 
 ward toward the ventricle — rupture into a ventricle being a frequent 
 termination — and the futility of leaving the dura open "so that the 
 pus may follow the line of least resistance," in case of failure to locate 
 an abscess. 
 
 "The line of least resistance" in nutritional death is really in- 
 ward. If a capsule is not formed the brain offers but little resist- 
 ance until the abscess approaches the ventricle, when, according to 
 Miodowski,^^ the choroid plexus may take on a definite protective 
 action, becoming thickened by several layers of exudate. (This 
 observation has not been confirmed in the writer's experience, 
 although he has repeatedly examined the choroid plexus at post- 
 mortems.) 
 
 SUBDURAL ABSCESS." 
 
 Subdural abscess rarely exists except as a traumatic complica- 
 tion of intracerebral abscess. The literature contains but a few ref- 
 
 " MacEwen, W. : "Pyogenic Infective Disease of the Brain and Spinal Cord" ; 1893, 
 p. 90, Fig. 39. (Depicts a thrombophlebitis over the area of a brain abscess at post- 
 mortem.) 
 
 " The vessels that normally enter the dura directly from the cerebral cortex are 
 comparatively few and consequently may be rapidly investigated. 
 
 "Plersol: Textbook of Human Anatomy, III Edition, 1911, p. 1206. 
 
 ■■ Mlodowski, F. : BeitrSge zur Pathogenese und pathologischen Histologie des 
 Hirnabszesses ; Archie fiir OhrenheUkunde, 1908, B. 77, S. 239. 
 
 >• There exists confusion in the anatomical nomenclature. Some authors regard 
 the smooth, glistening lining of the dura as the parietal layer of the arachnoid, and 
 consequently would call It the arachnoid instead of the subdural space. (Santfie, H. B. : 
 "Anatomy of the Brain and Spinal Cord," 1915, p. 9.) 
 
PATHOLOGICAL AND SUEGICAL CONSIDBEATIONS 25 
 
 erences to collections of pus confined to the subdural space.^'^ The 
 author's own experience is limited to the case referred to on page 
 73, which, it is believed, originated from the exploration and 
 evacuation of an intracerebral abscess through a small dural opening. 
 The frequency of subdural abscess as a complication of eixperi- 
 mentally produced traumatic intracerebral abscess would make it 
 appear that trauma is the usual cause. ^*' ^®' ^^ 
 
 METASTATIC ABSCESS. 
 
 This is usually situated within the white substance of the brain, 
 secondary to septic vascular occlusion, the infection having been 
 brought from a distant focus by the circulation. All possess the 
 two characteristics of metastatic abscess — the situation away from 
 the site of original infection, and an apoplectic onset. 
 
 Metastatic brain abscesses are frequently secondary to bronchiec- 
 stasis, pyemia, and endocarditis, but are rarely associated with aural 
 suppuration, although a personal experience has convinced the writer 
 of their occurrence. ^^' ^^ From an operative standpoint metastatic 
 abscess belongs to the group having no macroscopical cortical involve- 
 ment ; the frequency of multiple metastatic brain abscesses, however, 
 should be recognized. (See Metastatic Abscess, p. 68.) 
 
 TRAUMATIC BRAIN ABSCESS. 
 
 Prior to the development of otology and rhinology, and before 
 the recognition of aural and nasal suppuration as the cause of adja- 
 cent brain abscess, trauma was regarded as the most frequent cause 
 of intradural suppuration. Although its importance has been much 
 neglected in recent years, an examination of the recorded cases dem- 
 onstrates that, in the presence of a chronic or acute adjacent suppu- 
 ration, trauma still may be regarded as playing an active part. Many 
 
 " Strelt, Herman : Weltere Beitrage zur Histologie una Pathologle der Meningitis 
 nnd Slnusthrombosis ; Ardhvo filr Ohrenheilkunde, 1912, Bd. 89, S. 177. (Gives 
 analyses of reported cases.) 
 
 " Esslek, C. R. : Pathology of Experimental Traumatic Abscess of the Brain ; 
 AffiKi. Neurol, (md Pgychol., 1919, I, p. 673. (States that during the experimental 
 production of brain abscess, "in one-third of the animals the infection entered the 
 subdural space, forming a subdural abscess.") 
 
 "» Heine, B. : Zur Kenntniss der subduralen Biterungen. Beitrage aur Ohren- 
 heilJcundej Featscti/Hft Lucae, Julius Springer, Berlin, 1905. (Contains an excellent 
 colored illustration of a subdural abscess.) 
 
 ™ Hinsberg, v. : Ueber dem Infections Mechanismus bei Meningitis und Stlrn- 
 hohleneiterung ; Verhandlungen der Deutsche Otol. Oesenachaft, 1901, S. 191. (Gives 
 microscopical findings of path of invasion by blood vessels and lodgment in subdural 
 space, with microscopical Illustrations.) 
 
 =1 Jobson, G. B. : Contralateral Otitic Brain Abscess ; Laryngoscope, Vol. 25, 
 1915, p. 7. 
 
 >= Bagleton, W. P. : Report of a Case of Brain Abscess Resulting from an Infec- 
 tive Vascular Occlusion of Otitic Origin, with Involvement of the Internal Capsule, 
 clinically Simulating Cerebral Apoplexy, and Presenting Unusual Psychic (toxic de- 
 lirium) Phenomena. Operation — Recovery — Subsequent History. (Reported at the 
 annual meeting of the Medical Society of New Jersey, held at Spring Lake, N. J., 
 June, 1915.) 
 
26 BEAIN ABSCESS 
 
 oases of clironio otitis first present cerebral symptoms following a 
 blow or fall on the head. (See Case XII, W. K., Chapter IV, page 
 60.) Likewise, in many recorded cases the first symptoms of 
 brain abscess followed a surgical manipulation, such as a radical 
 operation, on a neighboring bony structure. Such cases are so 
 numerous that the inference is forced that the trauma of the opera- 
 tion was the direct cause of the brain abscess, or lighted into activity 
 a long dormant intracerebral suppuration. (See Analysis of post 
 mortem examination of cerebellar abscess, p. 105.) 
 
 Traumatic brain abscess may be defined as a collection of pus, 
 the result of death of cerebral tissue in the presence of infection, the 
 tissue death resulting not from the infection, as in secondary adja- 
 cent brain abscess, but from trauma coincident with the infection. 
 
 Traumatic infective encephalitis passes imperceptibly into trau- 
 matic brain abscess. Infective encephalitis is a diffuse septic process, 
 whereas traumatic brain abscess is a partially- — but only partially 
 — ^limited one. The difficulty of limiting the process is the distin- 
 guishing feature between traumatic and adjacent abscess. In the 
 latter the protective mechanism of the brain has been marshalled, 
 the bulwarks of resistance have been prepared before the actual en- 
 trance of the invading micro-organisms. In the former the trauma, 
 by killing cerebral tissue, has furnished a most favorable medium 
 for the grovTth of micro-organisms before provision for combating 
 them has been made ; and the secondary oedema following the trauma, 
 — ^by blocking the nutrient channels of the brain, by the induction 
 of thrombosis and hemorrhage into its substance, and by increasing 
 the brain's bulk and thus causing compression — ^has established a 
 vicious circle which not only favors extension of the infection, but 
 actually paralyzes all attempts at limitation. 
 
 These specific factors of traumatic abscess (death of cerebral 
 tissue prior to preparation; secondary oedema with associated hem- 
 orrhage and thrombosis; increase in the brain's bulk, all causing 
 compression with further death of tissue, and paralysis of the brain's 
 protective mechanism) should forewarn the surgeon because an en- 
 capsulated adjacent abscess — which has been fully walled off — 
 may be converted during operation into a traumatic abscess with its 
 associated encephalitis. 
 
 MENINGEAL ABSCESS. 
 
 Intrapiarachnoid. — This type, the result of direct infection 
 through the dura, is at first a protective process of the piarachnoid in 
 
^^s^ 
 
 JCi 
 
 
 a^"': 
 
 ■ ^^ 
 
 ^ 
 
 ^■-^ 
 
 ^^i.'- 
 
 i^J*^ 
 
 ^ 
 
 y^ 
 
 &^>^' 
 
 pf-i 
 
 M 
 
 1 ,-^ 
 
 ^tt 
 
 tm 
 
 :?# 
 
 ■•?^. \, 
 
 ^S 
 
 mM¥ 
 
 ■'►'' 
 
 K^' »^-- 
 
 \ :^m 
 
 m 
 
 ■' ^a 
 
 
 in 
 
 Fia. 5 (a) 
 
 Fig. 5 (b 
 
 Fig. 5 (a) and (1>). — Brain abscess situated In meshes of piaradmoid; super- 
 ficial necrosis from pressure. E.Kpioration .and evacuation tlirougli small open- 
 ing. Death from nreningitis. Autopsy disclosed a further brain necrosis and 
 abscess contiguous to dural opening. Osteoplastic flap and dural incision would 
 have exposed the entire intrapiarachnoid abscess ancl prevented the cutting off 
 by brain pressure of tlie undiscovered portion. 
 
PATHOLOGICAL AND SUEGICAL CONSIDBEATIONS 27 
 
 its attempt to prevent general infection of the meninges.^' The 
 delicate cells of the piarachnoid take on great activity when ap- 
 p^roached by infection, and offer a very efficient barrier to the inva- 
 sion of micro-organisms from either the dural or the cerebral sur- 
 face. While our knowledge of the function of the cells lining the 
 subarachnoid spaces is still very meagre, they play an active part 
 m the brain's protective mechanism. In the presence of an adja- 
 cent suppuration, a large collection of cerebro-spinal fluid is fre- 
 quently localized around the infected area, which later may become 
 a localized collection of pus. 
 
 As our present knowledge but rarely admits of a positive differ- 
 ential diagnosis between cortical and subcortical lesions, the surgeon, 
 before exploring the brain substance, should examine the brain sur- 
 face in all directions accessible to the dural opening. If the abscess 
 is situated within the meshes of the piarachnoid, exploration into the 
 brain tissue is not only unnecessary, but may seriously militate 
 against the patient's recovery. In three cases after an unsuccessful 
 exploration of the cerebral substance, the post-mortem disclosed an 
 abscess localized entirely within the meshes of the piarachnoid. In 
 each instance I failed to locate the intrapial abscess because I was 
 working through an insufficient opening. All of these cases, though 
 ending fatally, were favorable cases for recovery, had they been 
 properly treated. (See Fig. 5 a and b.) These experiences con- 
 vince me that exploration through an intact dura, as so frequently 
 practised, is fundamentally wrong. 
 
 GENERAL SUEGICAL PRINCIPLES. 
 
 Clinical experience and experimental observation abundantly 
 teach that one of the prime objects in the surgical treatment of intra- 
 cerebral abscess, secondary to adjacent suppuration, is the utilization 
 of the already organized protective reactions of the brain. Surgical 
 manipulations should be so conducted as not to paralyze this protec- 
 tive mechanism. If the operative trauma to the brain is not the 
 minimum necessary to meet the individual requirement — the eradi- 
 cation and obliteration of the abscess in an encapsulated abscess 
 with a stalk — ^the complete or partial evacuation in an encapsulated 
 intracerebral abscess, or simply the partial evacuation of the abscess 
 for the relief of increased intracranial pressure in an acute abscess, 
 (a localized collection of pus — localized either actually if a capsule 
 has been formed, or potentially if the abscess is acute) will convert 
 
 " Kllppel, D. : Mfinlngites Chroniques : Nouvecm Traiti de Midedne de Thera- 
 pmtigue, 1912. Tome 35, p. 274. 
 
28 BEAIN ABSCESS 
 
 such abscess into a traumatic abscess, with almost inevitable rapid 
 extension of the infection, cerebral necrosis, and death. 
 
 Surgical Factors. — The factors to be considered in surgically 
 approaching a brain abscess are: (1) the duration of the cerebral 
 suppuration, (2) the presence or absence of a limiting membrane, 
 and (3) the extent of the disturbances in the brain substance, out- 
 side the abscess. The different pathological processes not only call 
 for variations in the operative technic to be adopted, but markedly 
 influence the possibility of successful surgical intervention. 
 
 Irrespective of the pathological condition and because of the 
 factors peculiar to cerebral tissue, the surgeon on entering the dura 
 must endeavor to prevent all injury to the brain from its own pres- 
 sure; to lessen, as far as possible, injury to the brain tissue by 
 manipulation thereby converting the abscess into an unlocalized 
 traumatic process; to prevent the spread of the infection to tissues 
 as yet not infected, especially the meshes of the piarachnoid ; to con- 
 trol compression, which of itself favors extension of the suppurative 
 process, and to convert an unfavorable into a favorable type of abscess 
 whenever this is possible. 
 
 General Technic. — Slow, painstaking work, from tlie first nick in the dura 
 to its complete closure, is of primary importance. The intradural work should 
 be performed with as much delicacy and attention to detail as are required dur- 
 ing the extraction of a cataract. Each drop of blood effused into the piarachnoid 
 or the cerebral tissues, each separate trauma, hemorrhagic or manipulative, 
 lessens the probability of the patient's recovery. 
 
 Essick " believes that there is experimental evidence that whole blood limits 
 the spread of infection to the meninges. If this is substantiated, it will revolu- 
 tionize our ideas of the treatment of the subarachnoid spaces during the evacua- 
 tion of brain abscess. 
 
 The experiments of Flexner ^ and Weed,'" however, demonstrate that any 
 disturbance of the protective mechanism of the brain — ^the withdrawal of cerebro- 
 spinal fluid, the production of an aseptic meningitis by the injection of sera, or 
 the infusion of blood within the subarachnoid spaces — greatly predispose to a 
 general infection of the meninges in the presence of a blood stream infected by 
 certain micro-organisms. Of course Essick's experiments approach much nearer 
 to the conditions present during the evacuation of a brain abscess than the 
 induced blood stream infections of Weed and Flexner. The latter, however, dem- 
 onstrate how delicate the protective mechanism of the nervous system is and 
 how easily it is disturbed, while clinical experience teaches that hemorrhage into 
 the subdural spaces in the presence of infection actually facilitated its spread. 
 Until Essick's observation has been amplified, the surgeon must be careful to 
 avoid all effusion of blood within the meninges or brain. 
 
 " Essick, C. E. : Pathology of Experimental Traumatic Abscess of the Brain ; 
 li^h. Neurol, ana Psychol., 1919, I., p. 673. 
 
 =' Flexner, S., and Amoss, H. L. : The Relation of the Meninges and Choroid 
 Plexus to Poliomyelltlc Infection ; Jour. Exper. Med., 1917, Vol. XXV, p. 525. 
 
 2" Weed, L. H., Wegeforth, P., Ayer, J. B., and Felton, L. D. : Meningitis Pro- 
 duced by Intravenous Inoculation ; Monographa of RooTcefeller Institute Jor Medical 
 Beseareh, No. 12, March 25, 1920, pp. 67-112. 
 
PATHOLOGICAL AND SUEGICAL CONSIDEEATIONS 29 
 
 Injxjbt to the B&ain fbom Its Own Fbessuse. 
 
 Upon, opening the dura excessive internal pressure may cause 
 cerebral herniation, with injury to the arachnoid, associated with 
 slight hemorrhage into its substance. In acute abscess, the tension 
 within the dura is always excessive ; consequently, if the dura appears 
 very tense, before opening it a lumbar or ventricular puncture, de- 
 pending upon whether the suppuration is in the cerebrum or in the 
 cerebellum, may be performed, although the early withdrawal of 
 cerebro-spinal fluid is to be avoided if possible. 
 
 LuMBAB Puncture; Its Dangees: 
 
 Lumbar puncture, with the withdrawal of a small amount of fluid prior to 
 the incision of the dura in abscess of the cerebrum, will allow the brain, to 
 fall away from the dura so that it can be incised without injury to its contents. 
 The performance of lumbar puncture is not without danger, especially if there 
 be an abscess below the tentorium, as, by the removal of the cushion of the 
 cerebro-spinal fluid from below, the increased pressure above may drive the 
 medulla through the foramen magnum, herniating it, with resulting immediate 
 paralysis of the respiratory centre. I have seen death on the table following a 
 lumbar puncture; while the fluid was still flowing, the patient stopped breathing, 
 and although the heart continued to beat for ^ome time, during which artificial 
 respiration was continuously performed, the patient from the time of the accident 
 gave no evidence of voluntary respiration. 
 
 VENTEICULAB PUNCTURE: 
 
 In cerebellar abscess the intracranial pressure is not only increased by the 
 abscess, but also by an internal hydrocephalus, — a usual complication of cere- 
 bellar abscess. (See Appendix, Part IV.) 
 
 In abscess of the brain, with its complicating internal hydrocephalus, the 
 increased intracranial pressure may obliterate the lumen of the large venous 
 sinuses, the blood, ordinarily carried by the sinuses, leaving the skull by the 
 normally small diploic vessels. Extreme venous obstruction, so frequent in 
 tumors of the posterior fossa, is not encountered, however, during operations for 
 cerebellar abscess, as death will have supervened long before an advanced stage 
 is reached. 
 
 Sufficient venous obstruction to obliterate the lateral sinus of the affected side, 
 giving rise to a mistaken diagnosis of a sinus thrombosis, has been observed by 
 me during operation. When venous obstruction is present the removal of bone 
 over the cerebellum may be accompanied by considerable hemorrhage, and the 
 opening of the dura without immediate prolapse of the brain and rupture of the 
 piarachnoid will be impossible, especially if only one hemisphere is exposed. 
 If, however, a ventricular puncture is performed before the dura is opened, the 
 sinuses again become patent, the bleeding stops and the cerebellum drops back, 
 permitting dural incision without prolapse of the brain. 
 
 Technic of Incision of the Dura: 
 
 To avoid possible injury to the piarachnoid. Gushing originally caught and 
 elevated the dura with two fine silk ligatures, cutting between them. Later he 
 employed a small, sharp, half-curved membranous cataract hook for the primary 
 opening. By either method the dura can be incised without injury to the 
 
30 BEAIN" ABSCESS 
 
 piarachnoid. When the dura is not excessively tense, it can generally be safely 
 incised by cutting superficially with a knife, scraping a little from side to side, 
 and then cutting a little deeper and scraping again. In several instances, how- 
 ever, I have injured the piarachnoid during this procedure. The small dural 
 opening may be enlarged safely by cutting on a flat brain spatula, the dural 
 vessels being "clipped" by Cuahin^s silver wire" or ligated before incision. 
 
 CLASSIFICATION OF BEAIW ABSCESS ACCORDING TO LOCATION. 
 
 The anatomical and physiological relationships of suppuration 
 in the frontal, temporo-sphenoidal, occipital lobes and cerebellum 
 occasion great differences, not only in symptomatology, but in surgi- 
 cal considerations. A useful clinical classification, however, is into : 
 Abscess of the Middle Fossa (Temporo-sphenoidal), Frontal lobe 
 abscess and Cerebellar abscess. The occipital lobe is in such inti- 
 mate relationship with the temporo-sphenoidal lobe that surgically 
 they are considered together, suppuration confined to the occipital 
 lobe alone occurring only in abscess of metastatic or traumatic origin. 
 
 " Gushing, Harvey : The Control of Bleeding In Operation for Brain Tumor, 
 with the Description of Silver "Clips" for the Occlusion of Vessels Inaccessible to the 
 Ligature ; Trams. Amer. Surg. Assoc, 1911, XXIX, p. 389 ; Annals ot Surgery, 1911, Vol. 
 LIV, pp. 1-19. 
 
CHAPTEK IV. 
 ABSCESS OF MIDDLE EOSSA. 
 
 ADJACENT (sECONDAEt) ABSCESS OF THE MIDDLE FOSSA 
 
 TEMPOBO-SPHENOrOAL, 
 
 LOOATIOK; PATHOLOGICAI AND ANATOMICAL CONSIDERATIONS: 
 
 During the early stages of brain abscess, the symptoms as a rule 
 are so vague tbat they do not warrant a positive diagnosis of intra- 
 cranial suppuration, much less its definite localization. Consequently 
 any operative procedure vrhich may be undertaken at an early stage 
 must be largely exploratory and must be so conducted that in case 
 of failure to locate the suppuration as little damage as possible, im- 
 mediate or remote, wiU be caused by the exploration. 
 
 The usual sites of intradural suppuration of the middle fossa 
 secondary to aural disease, are, 
 
 (1) in the meshes of the piaraohnoid, directly above the tegmen 
 of either the antrum or the middle ear; such an abscess is probably 
 preceded by, and results from, an extensive but still localized menin- 
 gitis, a pathological condition which lumbar puncture and post- 
 mortems lead the author to believe is of greater frequency than, is 
 generally recognized :^ 
 
 (2) in the substance of the temporo-sphenoidal lobe itself, in the 
 second temporo-sphenoidal convolution, or 
 
 (3) an extension from one or other of the above. 
 
 INTERCURRENT (TERTIARY) ABSCESS OF THE MIDDLE FOSSA, 
 
 SECONDARY TO THROMBOSIS OF THE SUPERIOR 
 
 PETROSAL SINUS OR A DURAL VEIN:' 
 
 As thrombosis of the lateral sinus is often the immediate mode 
 of transmission to distant portions of the cerebellum, away from tiie 
 petrous, so thrombosis of the superior petrosal is in rare cases the 
 transmitting agent of the temporo-sphenoidal lobe; for it is to be re- 
 
 >Brleger: In Blau'a EneuelopeeUe der Ohrenheflkimde, 1900, S. 245. 
 ' See Case XXVIII ; Chapter XI, page 182. 
 
 31 
 
33 BKAIN ABSCESS 
 
 membered that one of the main venous efferents of the basal por- 
 tion of the brain — one of the medio-cerebral veins, often called the 
 temporal sinus — empties into the superior petrosal sinus.*' * 
 
 ADJACENT MENINGEAL ABSCESS (INTBAPIAEACHNOID OE SUB- 
 DUEAL) OF THE MIDDLE FOSSA.' 
 
 Post-mortem examinations lead the writer to believe that an 
 abscess primarily situated in the meshes of the piarachnoid, the 
 result of direct extension through the tegmen, is apt to remain con- 
 fined to the meshes of the piarachnoid. As it increases in size, the 
 intrapiarachnoid abscess frequently involves the cerebral cortex, by 
 direct pressure causing "superficial brain necrosis," but never re- 
 sulting in an intracerebral abscess. 
 
 Localized Sebous (PKOTEca^vE) Meiningitis. 
 
 To this group belong the cases of so-called "serous meningitis," 
 with localizing symptoms, aphasia, paralysis, etc., which recover 
 after the removal of the focus of infection within the temporal bone 
 without opening the dura. Serous meningitis is probably primarily 
 a sterile, localized collection of cerebro-spinal fluid of toxic origin, 
 which later may become easily infected — the primary stage of an 
 intra-piarachnoid or subdural abscess.®' ''• ®' ® 
 
 The experimental work of Essick, in which the presence of bac- 
 teria in the adjacent tissues without invasion of the subarachnoid 
 space itseH causes a large increase in the amount of cerebro-spinal 
 fluid and leucocytes, explains the frequency of serous meningitis 
 and its operative treatment, viz.; — 
 
 (a) The removal of the adjacent infected area of the mastoid 
 cells or the petrous pyramid, and (b) , the prevention of compression 
 by decompression through a clean area, lumbar puncture or the 
 evacuation of the fluid by incision of the dura through the infected 
 area. The latter method is frequently successful, but it allows the 
 evacuation of only a small quantity of fluid, with the liability of 
 infection of an uninfected area. 
 
 « Browning, W. : The Veins of the Brain and Its Envelopes : Their Anatomy and 
 Bearing on the Intracranial Circulation ; Monograph, Brooklyn, 1884. 
 
 * Whitehead, A. L. : Some Points in the Diagnosis of the Complications of Tem- 
 poral Bone Disease, Based upon a Study of 135 Fatal Cases ; Journal oj Lwryngology, 
 Otolagu and RMnoiogy, 1906, Vol. XXI, p. 269. 
 
 » See p. 17, Surgical Classification of Brain Abscess. 
 
 ' Boenninghaus, Georg : "Die Meningitis Serosa Acuta" ; Wiesbaden, Verlag von J. 
 F. Bergman, 1897. (Reviews cases reported prior to 1897.) 
 
 ' Warrington, W. B. : Intra-cranlal Serous Effusions of Inflammatory Origin, 
 Meningitis, or Ependymitis Serosa; Quarterly Journal of Medicine, January, 1914, 
 Vol. 7, No. 26, p. 98. (Reviews the literature.) 
 
 ' Knapp, A. : Serous Meningitis ; ArcMves ot Otology, 1906, No. 1, p. 10. 
 
 » Emerson, Linn : A Case of Serious Meningitis Mistaken for Brain Abscess ; Opera- 
 tion ; Recovery ; Reprint from Laryngoteope, July, 1906. 
 
ABSCESS OF MIDDLE FOSSA 33 
 
 CASE r, B. B. 
 
 Sinus Thrombosis. Male. Chronic otitis media, left ear. Frequent attacks 
 of pain and lieadache; chills. Admitted to hospital suffering from mastoiditis, 
 left side. Mastoidectomy done. Sinus thrombosis discovered; jugular not ligated 
 because of condition of patient; thought to be dying. Eecurrence of symptoms. 
 
 Operation: Ten days after mastoid operation, ligation of jugular. On open- 
 ing vein it was found to contain free pus for a distance of about three inches, 
 running down below the clavicle. The pus was not in the fascia around the 
 vein, but was in the vein itself. 
 
 Immediately after the second operation the man complained of dizziness. Ten 
 days later chill; violent headache, repeated at regular intervals during the day. 
 Patient gradually became violent from pain, which passed as suddenly as it 
 came. Had two chills. Marked papilloedema of both eyes. Labyrinth dead. 
 Spontaneous deviation of both hands to right. Fell to right. No spontaneous 
 nystagmus. Slight area of anesthesia along third branch of trifacial. One 
 attack of vomiting. Lumbar pimcture revealed cloudy fluid under pressure; 
 cell count 160; increased globulin. 
 
 Spontaneous deviation to right and falling to right, both away from lesion, 
 pointed to involvement of cerebellum over posterior surface of petrous portion of 
 temporal bone. This was also confirmed by cerebro-spinal fluid, which gave 
 symptoms of protective meningitis. 
 
 Cerebellum exposed in front of sinus. Incision of dura through sinus region; 
 in front of this evacuated large amount of cerebro-spinal fluid. 
 Diagnosis: Serous meningitis. Uneventful recovery. 
 
 CASE VI, J. G. 
 
 Aseptic Meningitis. Male, 26 years of age. Eight ear had been discharging 
 for past three years, with attacks of pain, which, however, were not severe. 
 Never any dizziness except when he had grippe about one year before coming to 
 hospital; but did not think it was associated with any exacerbation of his ear 
 trouble. About three weeks before admission to hospital had an ulcerated tooth; 
 after extraction tlie pain continued for a time and then subsided. At the same 
 time he began having pain in his ear, and dizziness ; pain in ear was not steady — 
 it was sometimes severe and sometimes not. It was associated with pain in the 
 head in the right temporal region, running forward toward the frontal region. 
 During these three weeks he had dizziness — ^ran into things but did not fall. 
 Swayed at times, but could not tell to which side he was inclined to fall. Had 
 two attacks of vomiting, not influenced by food. 
 
 When first seen had no facial paralysis, but three or four days later was 
 found to have a right-sided facial paralysis, and the discharge in the ear was 
 very much increased. Examination of his ear showed a large mass of polyp 
 coining from roof. Had a slight convergent strabismus; was totally deaf in 
 right ear; complained of chilly sensations; no patella reflexes; no sense of taste. 
 Operation: A radical operation was done, following which the cochlea was 
 opened and the vestibule entered. The external semicircular canal had necrosed 
 through. The dura over the internal auditory meatus was opened, evacuating 
 cerebro-spinal fluid; no increaseji tension. For several weeks patient had con- 
 siderable temperature, pain in his head, stiff neck, and high cell count. Some 
 weeks later patient, discharged sequestra of cochlea. It was then seen that 
 protective meningitis had followed operation. Uneventful recovery. (The case 
 is recorded in The La/rynffosoope, for January, 1922.) 
 
 Clinical Diagnosis. — ^With a high temperature without chills 
 but with symptoms of compression, such as papilloedema, if repeated 
 
34 BEAIIT ABSCESS 
 
 blood cultures have been negative or the sinus has been explored and 
 found to be uninfected, or if the infection has been thoroughly elimi- 
 nated, and especially if cytologieally an aseptic meningitis is pres- 
 ent — see Case V, K. B. — ^we are warranted in suspecting an aseptic 
 meningitis of the irritation type. In which case, before exploration 
 within the dura it is justifiable — (1) to thoroughly evacuate all 
 infected areas, mastoid, labyrinth or sinus, and (2) to control the 
 increased intracranial pressure by decompression through a dean 
 area, ventricular puncture or liunbar puncture. The procedure to 
 be adopted for the control of compression depends somewhat upon 
 the site of the suppuration, for it must always be doubtful if an 
 intracerebral abscess is not also present. If the labyrinth and 
 sinus are both intact the decompression should be a subtemporal one, 
 while if either the labyrinth or sinus is known to be involved, and 
 consequently a cerebellar abscess is possibly present, a ventrictilar 
 puncture or a cerebellar decompression should be performed. The 
 danger of a lumbar puncture causing sudden death from respiratory 
 paralysis in cerebellar abscess is so great that it should only be re- 
 sorted to in case a ventricular puncture for some reason is not 
 advisable. 
 
 Extension or Intrapiabachnoid Abscess. 
 
 In its growth a localized meningeal collection of pus, starting 
 from just above the tegmen, usually extends externally along the 
 under surface of the temporo-sphenoidal lobe; then upward and for- 
 ward, along the external surface of the temporo-sphenoidal lobe in 
 which direction it may travel a considerable distance. A meningeal 
 abscess so situated is always very shallow, due to the firmness with 
 which the temporo-sphenoidal lobe is held to the floor and sides of 
 the middle fossa by the weight of the brain, the exit of the nerves 
 and vessels toward the median line, and the veins entering the lateral 
 sinus. An abscess so situated is frequently divided into several 
 compartments communicating with each other — the so-caUed "oyster- 
 shaped abscess." 
 
 Earely the localized meningeal collection of pus extends directly 
 backward, inward and upward, along the upper surface of the ten- 
 torium cerebelli, below the occipital lobe. When the abscess is situ- 
 ated above the tentorium, the purulent collection is apt to be very 
 large in amount but of very thin consistency, being in reality simply 
 a large localized collection of purulent oerebro-spinal fluid, not 
 thick pus. 
 
ABSCESS OP MIDDLE FOSSA 35 
 
 In evacuating a meningeal abscess on the external surface of tlie 
 temporo-sphenoidal lobe, a part of the abscess may be easily over- 
 looked because the internal pressure of the brain forces it firmly 
 against the edge of the dural flap, thus cutting the abscess in two. 
 In meningeal abscess over the tegmen, a similar accident is not in- 
 frequent, the brain descending before the abscess is completely evacu- 
 ated. This is illustrated by the following case : 
 
 CASE VII. J. J. o. 
 
 Brain Abscess. Steam fitter, well developed and nourished, admitted to hos- 
 pital November 18, 1912. Diagnosis: Brain Abscess. 
 
 Two months previously, patient "got cold in ears" while swimming, and two 
 days later became almost totally deaf first in right, then in left ear. Abscess 
 developed in both ears and broke in right. No discharge from ears. The right 
 ear gradually got better, but pain continued in both ears. About two weeks 
 before admission to hospital pain increased in left ear, and patient became very 
 deaf in that ear. There was never any discharge from either ear. Eight days 
 before the patient was seen, intense pain developed in head and in left ear, with 
 dizziness, and the man was obliged to stop work. Tym.panic membrane lanced. 
 For three days previous to admission had been almost totally deaf in left ear, 
 with intense pain; also had peculiar frontal headache and pain in eyes. He 
 suddenly felt something break in head which soimded in left ear like cannon 
 shot, and since explosion had word deafness; vomiting three days before and 
 during explosion. There was a previous history of pneumonia in childhood, and 
 typhoid 11 or 12 years ago. Use'd neither tobacco nor alcohol. 
 
 Examination revealed right sided hemianopsia, paresis of right arm, and 
 Wernicke's aphasia. Could recognize family and his own doctor, but could not 
 understand their names. There was word deafness, slight dizziness, absence of 
 right-sided abdominal reflexes, exaggerated knee-jerks, especially the right, exag- 
 gerated plantar reflexes, and tendency to ankle clonus on right side; no Oppen- 
 heim, no Babinski, no nystagmus, but increased P. K. on right side. Tongue very 
 eoateid; no tremors. Left ear: could hear watch on contact; deaf to aerial con- 
 duction. Eight ear: could hear watch at 2 inches. 
 
 Operation.—^ large flap was made above the left ear and the skull exposed 
 and trephined; mastoid not opened. Some pus was found in the external audi- 
 tory canal. Dura found to be adherent and covered with granulations; no pus 
 in dural cavity. Upon exposing the temporo-sphenoidal area of the brain an 
 oyster-shaped abscess was discovered in posterior portion of lobe, with distinct 
 limiting membrane. Brain surface was irrigated with warm saline, the dura 
 closed and rubber drain inserted. The scalp was closed with interrupted sutures 
 of plain catgut. 
 
 The following day patient appeared confused, but was able to recognize names 
 of objects shown to him. Temperature 102°. A lumbax puncture was done and 
 about 300 c.c. of fluid withdrawn under tension. Paresis of right arm still 
 present, and probahly hemianopsia of right aide. Patient unable to talk, and 
 upon attempting to read printed numbers tried to make them; usually made 
 them inverted. 
 
 Nine days later patient had two severe convulsions, lasting about five minutes 
 each. Temporo-sphenoidal region again explored, but no abscess found. Eubber 
 tissue placed over brain and a drain passed through soalp. Patient then turned 
 on abdomen and incision made in median line of neck down to base of skull, 
 bone chiselled away and medulla exposed. Dural and basal cisterns opened and 
 
36 BKAIN ABSCESS 
 
 rubber drain inserted into the latter. Gauze drain inserted down to base of 
 wound. 
 
 The next day patient had convulsion which lasted one minute, and on follow- 
 ing day convulsion and chill. The day after, he had convulsion at 2.30 a.m. 
 which lasted one minute, and another at 4.45 p.m., with incontinence. Death 
 occurred at 1.00 a.m., on the thirteenth day after operation. 
 
 Post-mortem examination showed that this man originally had infection of 
 the left middle ear, which was followed by the extradural abscess disclosed at 
 operation. The abscess was walled off from the dura by firm granulations, and 
 was followed by an intradural, extrapial abscess, which at operation appeared 
 to be intracerebral ; the covering, however, proved to be simply a thick membrane. 
 Patient subsequently developed suppurative meningitis. The infection was evi- 
 dently one of low virulence, as no bacteria were found in the cerebro-spinal fluid 
 or in the pus examined. Local collections of pus at post-mortem exhibited a 
 tendency to recede under the occipital lobe in the position of normal drainage 
 from gravity. Nothing abnormal was found in the ethmoidal, sphenoidal, or 
 lateral sinuses, or in the opposite ear. 
 
 ADJACENT INTRACEREBRAL ABSCESS OF THE TEMPORO- 
 SPHENOIDAL LOBE WITHOUT MACROSCOPICAL MAN- 
 IFESTATIONS OF CORTICAL INVOLVEMENT. 
 
 Abscess of the temporo-sphenoidal lobe, without macrosoopical 
 evidence of cortical involvememt is the most frequent variety of brain 
 abscess. It develops either from a retrograde thrombophlebitis, or 
 from direct extension of tissue suppuration from the beginning of 
 the mastoid antrum or of the middle ear. When it originates from a 
 retrograde thrombophlebitis because of the anatomical vascular con- 
 dition, it is situated in or near the second temporo-sphenoidal con- 
 volution, which, being a silent area, produces no outstanding localiz- 
 ing symptoms on the right side in right-handed patients ; but if situ- 
 ated on the left side it frequently produces a "naming" aphasia, 
 which latter may at first be of but transient duration and of im- 
 perfect extent. 
 
 Adjacent abscess may, however, be situated entirely within the 
 occipital lobe — (H. Knapp) — ^the author having seen one such case 
 where the abscess was secondary to a lateral sinus thrombosis, or 
 thrombosis of the superior petrosal sinus. Its situation may also be 
 entirely removed from the temporo-sphenoidal lobe. 
 
 This type of abscess may attain great size, having a tendency to 
 extend inward from nutritional disturbances. Rupture into the 
 ventricle is a frequent termination. 
 
 TEMPORO-SPHENOIDAL ABSCESS WITH A STALK. 
 
 "Abscess with a stalk" is located almost invariably in the second 
 convolution of the temporo-sphenoidal lobe, directly above the teg- 
 men in the cerebral substance, generally from one-half to one and a 
 haK inches above the tegmen. (Figs. 6 and Y.) The external sur- 
 
Fig. 6. — Position of three temporo-splienoidal abscesses with a stalls, above the 
 ■tegmen tympani and antrum, showing uniform position of adjacent abscess. 
 Illustration copied from Preysing drawing in Korner's "Die otitischen Erkran- 
 kungen des Hirns, der Hirnhiiute und der Blutleiter," .3d Edition, 1902. 
 
 assfiiiUi 
 
 LA ■ 
 
 "*n t^l*Manraro MO 
 
 Fig. 7. — Horizontal section of head with temporo-sphenoidal abscess with 
 stalk, showing uniform position of adjacent abscess within cortex, low down in 
 temporo-sphenoidal lobe, above antrum or middle ear. Illustration copied from 
 Preysing drawing in Korner's "Die otitischen Erkrankungen des Hirns, 
 Hirnhaute und der Blutleiter," 3d Edition, 1902. 
 
 der 
 
ABSCESS OF MIDDLE FOSSA 37 
 
 face of tibe dura is frequently adherent to the bone and covered with 
 granulations, and the dural inner surface is always united to the 
 brain. 
 
 Considerations Pbiob to Operation fob Adjacent (Secondary) Abscess of 
 
 Middle Fossa. 
 
 A diagnosis of a probable adjacent (secondary) temporo-sphe- 
 noidal lobe abscess having been made, (based upon the presence or 
 history of an adjacent suppuration within the mastoid or petrous 
 portion of the temporal bone; the general symptomatology of the 
 intracranial suppuration ; localizing symptoms varying between nega- 
 tion and the pathognomic "naming" aphasia; elimination of cere- 
 bellar suppuration), a definite opinion must be formed prior to op- 
 eration, whether the abscess is chronic with a probable capsule, or 
 acute without limiting membrane. This is of prime importance, as 
 the technic to be adopted is fundamentally different, and failure 
 properly to visualize the surroundings of the abscess may lead to an 
 irreparable blunder. 
 
 The operation must not be simply an effort to find and evacuate 
 pus, irrespective of its surroundings ; it roast be a procedure adapted 
 to existing conditions, the most important being the presence or ab- 
 sence of a limiting membrane. This is in opposition to the dictum 
 that "brain abscess, as pus in other parts of the body, is to be treated 
 by free drainage." Eeviewing my many failures in the light of 
 post-mortem findings, I am convinced that to avail himself of everj' 
 advantage, the surgeon must be fairly sure before he operates whether 
 a capsule does or does not limit the abscess. 
 
 Histories of two cases of temporo-sphenoidal lobe abscess improp- 
 erly treated because of incorrect diagnosis as to pressure or absence 
 of capsule. 
 
 CASE vm. 
 
 Temporo-sphenoidal Lobe Abscess — Chronic. A. M. M. Male. Progressive 
 muscular atrophy of left side, beginning about a year before admission to hos- 
 pital. Four weeks before admission he began to have neuralgia on left aide of 
 face, with pain in teeth, continuing after paracentesis of membrana tympani of 
 left side. Ear continued to discharge. One week before admission became un- 
 able to talk. On admission had typical "naming aphasia." Mild papilloedema 
 of left eye. Occlusion of left aural canal. Slight paralysis of lower portion of 
 right side of face, seen chiefly on emotional movement. Eight-sided hemianopsia; 
 right hand slightly weak; no Babinski; no clonus; apparently deaf in left ear. 
 Cerebration rather slow. Lumbar puncture gave apparently normal fluid; culture 
 revealed microorganisms. 
 
 Operation: — Believing it to be an acute abscess, temporo-sphenoidal region 
 exposed over an area of an inch and a half in diameter. A small dural incision 
 made through which the brain protruded. Gangrenous. Free pus evacuated 
 
38 BEAIN ABSCESS 
 
 through small needle. No capsule felt. Following operation slow pulse, patient 
 in good condition, apparently disorientated. 
 
 Autopsy Findings. — On removing the skullcap by the Washburn method the 
 whole anterior lower inner surface of the anterior fossa between dura and brain 
 was found to be covered with a yellowish exudate which looked like chicken-fat, 
 the thickest portion being several millimeters thick; it was smooth, glistening, 
 and extremely yellow. This covered the whole of the frontal lobe of the left side. 
 The abscess itself was in the temporo-sphenoidal lobe, was about one inch in 
 diameter and had a beginning membrane, the margins of which were becoming 
 sharply defined. Its inner surface was red, undoubtedly from hemorrhages which 
 had undergone absorption. There was no free pus in the abscess. There were 
 many areas of slough or moisture in the abscess which, as a whole, was round 
 with very few pockets. The area around the abscess was yellow, taking on the 
 character of the exudate. There was typical lepto-meningitis in several parts of 
 the brain. The lateral ventricle of the left side was much displaced over and 
 beyond the median line and was slightly distended. The opposite lateral ven- 
 tricle was markedly distended. The left middle ear showed an extensive area of 
 degeneration, bluish-yellow from acute necrosis. The anterior wall of the middle 
 ear was apparently entirely gone, leaving a fistula. The inferior petrosal sinus 
 contained an exudate in the portion before it enters the cavernous sinus; the 
 cavernous sinus was free. The mastoid cells were not markedly involved; the 
 ethmoids and sphenoid not involved. On removing the dura over the tegmen 
 the bone looked bare — ^no communication was seen between the area of the abscess 
 and the tegmen. No adhesions between the dura and the brain. 
 
 Comment. — In making a small dura! incision and trying to pass a small 
 Whiting's encephaloscope through the small opening nothing was accomplished 
 except to incite a traumatic encephalitis, as was shown afterwards by the gan- 
 grenous hernia. The man had an acute abscess which should have been simply 
 evacuated through a large or a small opening in the dura, but nothing else 
 should have been done. On evacuation the pus was first watery and then floccu- 
 lent. This should have warned us that this was an acute abscess. The opening 
 made was large enough to permit herniation but too small to permit inspection. 
 
 Three days after operation the pulse was only 88, although the temperature 
 was as high as 104° The patient was restless. Systolic blood pressure was 100. 
 Five days after the operation the pulse was 68, temperature 102°, and the patient 
 apparently better. After operation there was marked papilloedema of both 
 eyes — not present before operation — indicating compression. 
 
 CASE rx. 
 
 Temporo-sphenoidal Abscess (Chronic). G. W. Male, seven years of age. 
 Admitted to hospital March 1, 1920. Running ear three months before; mastoid 
 operation February 8, 1920. 
 
 Operation: Operated on March 3, 1920, for temporo-sphenoidal abscess. 
 Evacuation through a small opening in the dura with a very small needle. No pus 
 was withdrawn, but a large quantity of clear fluid having the appearance of 
 cerebro-spinal fluid evacuated. On introduction of the needle resistance was 
 encountered, but on the assumption that we were dealing with an acute abscess, 
 this was not recognized as due to the capsule of a chronic abscess. Strabismus 
 was noted at this time. The patient did very well for three days following opera- 
 tion. The strabismus almost entirely disappeared, but recurred. Six days after 
 operation paralysis of the rectus of the opposite eye appeared and the patient 
 became sleepy and drowsy, growing gradually worse until the fourteenth day 
 after operation, when death occurred. 
 
 Autopsy Findings. Very extensive encephalitis surrounded an encapsulated 
 
 abscess which was adherent over the tegmen. The encephalitic tissue was soft, 
 
Fig. 8. — 'Jcinporo-splieuoidiil lobe abscess caA'itj' with displacement of hemi- 
 sphere beyond median line. Showing increase in size of brain bulk. Death 
 from extension of suppurative process and compression after several weeks of 
 apparent freedom from s.Mnptoms. Aljsccss erroneously treated as an acute 
 a,bscess by small opening wlien it was a chronic abscess with capsule. 
 
ABSCESS OF MIDDLE FOSSA 39 
 
 with numerous hemorrhages. The abscess had approached the cortex in many 
 places, causing gangrenous areas. The capsule was distinct, firm, and in some 
 places several millimeters thick. It was so firm that it was covered with blood 
 vessels and by taking hold of it the whole abscess was lifted out intact. The 
 pus surrounding the capsule was thin, such as is developed from an acute 
 encephalitis, while that inside the capsule was thick, such as is seen in chronic 
 brain abscess. (Fig. 8.) 
 
 Comment. — From the clinical course after operation and from the autopsy 
 findings this was evidently a case of chronic (encapsulated) brain abscess, which 
 was treated as an acute abscess. The death of the patient was probably the out- 
 come of this failure to differentiate the acute from the chronic condition, and 
 of the traumatizing of the brain tissue in the effort to drain the abscess, the 
 procedure followed being likewise the outcome of this error in diagnosis. 
 
 At the time of operation, it will be remembered, a large quantity of perfectly 
 clear fluid was drawn away which looked like cerebro-spinal fluid and was found 
 to contain streptococci. At that time it was thought that this might be a large 
 collection of cerebro-spinal fluid outside the brain, the abscess being intra- 
 arachnoid. The clearness of the fluid also suggested that the abscess was acute. 
 It is unfortunate that it was not recognized that the resistance encountered in 
 the efforts to evacuate the abscess was due to the encapsulation of a chronic 
 abscess, and that this encapsulation accounted for the absence of chill after the 
 patient was admitted to the hospital. The chill probably had occurred at the 
 time of the mastoid operation, seven weeks before, at which time, doubtless, the 
 abscess had begun to form. The autopsy showed that the clear fluid drawn off 
 at the time of the abscess operation was probably from the top of the abscess, 
 the pus having settled below. The exploring needle being so small, only the 
 clear fluid could pass through it. When the encapsulation was encountered 
 during the exploration, a larger needle should have been used, on the theory that 
 the abscess was chronic and the pus too thick to pass through a small needle. 
 
 This case may be contrasted in that respect with that of Mrs. H., Case XIII, 
 Chapter Four, p. 63, in which the abscess was easily evacuated through a small 
 needle. However, the question arises whether, at the time of the operation on 
 the boy, it could have been determined that the abscess was chronic and not acute. 
 
 In the diagnosis reliance must be placed upon the difference between the 
 symptoms of compression from chronic abscess and those of brain destruction 
 from acute abscess. In an acute abscess there probably is brain destruction 
 going on, with symptoms of sepsis, as shown in Case XIII, Mrs. H., to which 
 reference has just been made. One of the symptoms of compression is slowing 
 of the pulse. The fact that this boy had an irregular pulse should have called 
 attention to the probability of the extension of the process, but not necessarily 
 to compression. The increase in the optic neuritis was also signiflcant. The 
 temperature was of little assistance. A second lumbar puncture might have 
 been of assistance in the diagnosis. 
 
 An error in technic involved the improper anchorage of the stylet tube in 
 the capsule. The cotton must be placed in pledgets close up to the tube itself, 
 touching it in all its parts, building a pyramid which comes from the side of 
 the apex where the tube is. Over this must be placed a dressing and the bandage 
 must go around the neck. Failure to observe these two essential proceedings 
 caused the tube to become displaced in this case and also in Case XIII. 
 
 Furthermore, failure to place the drainage tube within the abscess capsule, 
 which, as stated, was not recognized as such at the time of subsequent dressing 
 and exposure of the wound, was an error in technic, giving rise in manipulation 
 to undue traumatization of the tissues and setting up the encephalitis found at 
 autopsy. In other words, this chronic brain abscess was converted into an acute 
 abscess which caused the patient's death. If the compression caused by the 
 
40 BKAIN" ABSCESS 
 
 chronic abscess had been relieved by a decompression operation, the encephalitis 
 might not have developed, the chronic process would not have been converted 
 into an acute one, and the final outcome of the case might have been very different. 
 
 Pkinciples of Operauve Trea.tment. 
 
 Exposure. — Exposure of the under surface of the temporo- 
 sphenoidal lobe through the roof of the tympanum and antrum, fol- 
 lowed by puncture of the dura and brain, and introduction of drain- 
 age material, has resulted in a larger proportion of recorded cures 
 than any other method. Were it possible to make a positive diag- 
 nosis of an encapsulated intracerebral abscess of the temporo-sphe- 
 noidal lobe, with a stalk, this would be the method of election, as the 
 surgeon thus enters the abscess through the walled-off area of primary 
 infection at its nearest approach to the cortex. Such a diagnosis is 
 infrequent except on finding a fistulous tract during or subsequent 
 to mastoid operation. Many such cases are on record. 
 
 In the greater proportion of cases, if the surgeon is to operate 
 early enough to offer a fair chance of recovery, the operation must 
 be largely explorative. Exposure and exploration through the teg- 
 men has the following objections : (a) It is througb an infected field ; 
 if the abscess is not located, death from meningitis is almost inev- 
 itable, (b) The exposed area is so limited that an intrapiarachnoid 
 abscess may be entirely overlooked ; if exposed, its ramifications are 
 obliterated by the brain pressure, (c) The surgeon, seeing a few 
 drops of pus, cannot know it to be part of an extended, thin layer of 
 extra-cerebral suppuration, but realizing that a larger collection 
 of pus must exist to account for the symptoms, he is tempted to ex- 
 plore the brain substance, creating a traumatic intra-cerebral sup- 
 puration, (d) An intra-cerebral abscess without macroscopical evi- 
 dence of cortical involvement, an abscess with a stalk, and a menin- 
 geal abscess cannot be differentiated, and consequently cannot be 
 differently treated, (e) Compression cannot be provided for except 
 by enlargement of the dural opening into a clean area after an 
 operation in a highly infected area — the reverse of a properly 
 planned surgical procedure. 
 
 Exposure for Suspected Localized Intrordural Suppuration of 
 the Middle Fossa. — The operative procedure is planned to form an 
 osteoplastic flap sufficiently large to admit of complete inspection 
 and exploration of localized intra-dural suppuration of the cerebrum, 
 without involving the infected middle ear and mastoid, and if an 
 abscess is not located, to allow complete aseptic closure of the dura 
 and replacement of the flap. (See Frontispiece.) If an abscess is 
 
Fig. 9. — Outline for formation of osteoplastic llap for exploration for sus- 
 pected abscess of the temporo-splicnoidal lobe. 
 
ABSCESS OF MIDDLE EOSSA 41 
 
 located, especially one contiguous to tlie middle ear, tlie flap permits 
 of drainage tlirougli the middle ear, tlie primary route of infection. 
 
 The OsTEX)PiiASTic Flap fob Exploration roB Abscess of Middle Fossa. 
 
 See Frontispiece. 
 
 Technic. — ^Preparation. The osteoplastic flap, irregularly trapezoidal in 
 shape, has its base upwards. The limits of the proposed flap are first outlined 
 by a very superficial skin incision; the area is covered by moist gauze, and Lake's 
 semi-circular incision is then made. This incision, which surrounds the upper 
 one-half of the ear, begins posterior to the auricle in the auricular fold in front 
 of the mastoid, hugs the attachment of the cartilage to the skin, and ends 
 anteriorly at the lower level of the epitragus in front of the ear. The incision, 
 carried through the fascia and muscle to the bone, allows of a forcible refiection 
 of the external ear, with an evulsion of the membranous canal downward. 
 
 A small piece of cotton to which is attached a black string is now placed 
 in the space between the exposed superior auricular bony wall and the reflected 
 canal in order to absorb whatever purulent secretion may be expressed from 
 the middle ear by pressure. 
 
 After covering with another layer of moist gauze, the reflected aural flap may 
 be held in position downward by a narrow, flexible tourniquet, so placed that 
 its upper edge exposes the superior wall of the external auditory canal, and con- 
 sequently is below the level of that portion of the middle fossa formed by the 
 superior surface of the petrous pyramid. Cushing's canopy is then applied, 
 limiting the operative area. 
 
 If, as is usual, th« mastoid has previously been opened, the whole procedxire 
 is considerably complicated, as the walling off of the infected area of the previous 
 operation. Lake's incision, the downward reflection, and the fllling of the whole 
 cavity with iodoform gauze, must be treated as an entirely separate procedure 
 preparatory to the aseptic exposure of the brain above. 
 
 Technic of Formation of Bone Flap." — The skin incision for the lower border 
 is from three and a half to four inches in length. It begins one inch in front of 
 and three-quarters of an inch above the external auditory meatus, on an imagi- 
 nary line perpendicular to the center of the eminentia articularis, runs horizon- 
 tally backward for two inches to an imaginary line perpendicular to the posterior 
 border of the base of the mastoid, and then turns sharply upward at an angle of 
 30 degrees and runs one and one-half inches to the posterior inferior angle of 
 the parietal bone, just above the parieto-occipital suture. The anterior incision, 
 three and one-half to four inches in length, is at right angles to the anterior 
 section of the inferior border. (Figure 9.) The skull is perforated at both 
 superior angles (Holes 1 and 2) ; then at the center of both anterior and 
 posterior borders (Holes 3 and 4). The superior halves of the anterior and pos- 
 terior borders, (Line "a," between holes 1-3, and Line "b," between holes 2-4), 
 
 '» See Chapter Two, p. 10. Tbe formation of the flap Is described In detail 
 because, while osteoplastic resections in this region have been frequent (Krause, 
 Surgery of tlie Brain, Vol. 3, p. 900, English edition, 1912), the author is not aware 
 that a replaceable osteoplastic flap has previously been devised which automatically 
 aims at utilizing all available space as near tbe floor of the middle fossa as pos- 
 sible without Injury to the sinus and without entrance into the infected areas of 
 the middle ear and mastoid. During the last few years the author has made many 
 of these bone flaps, and must confess that the majority have become infected when an 
 abscess has been located because of their close proximity to an infected ear. How- 
 ever, In a case in which an abscess is not located the whole flap can generally be saved 
 even if a local area of Infection may have occurred. 
 
 With this disadvantage the osteoplastic flap has served a most useful purpose and 
 the author believes that with strict observance of technic it will commend itself for 
 all cases of suspected temporo-sphenoidal lobe abscess. 
 
42 BEAIN ABSCESS 
 
 are then formed by the Gigli saw, making the bevel outward, after which, under 
 the skin, the bone of the base of the flap, (Line "c," between holes 1-2), is par- 
 tially sawed so as to insure the flap breaking properly. The formation of the 
 lower border of the flap, which is three and one-half inches in length, is the 
 most important, the object being to have it reach as near as possible to the 
 floor of the middle fossa, where the principal investigation will be held. 
 
 The bone of the lower border is perforated, (Hole 5), at the junction of the 
 anterior (horizontal) and posterior (elevated) portions in the squamous portion 
 of the temporal, directly over the root of the mastoid, about one inch behind and 
 three-quarters of an inch above the external auditory meatus, and above and 
 slightly in front of the root of the temporal ridge, which here makes a sharp 
 bend upward. The bone over the anterior inferior angle, (3-5-6), being deep 
 under the temporal muscle, can be sacrificed as well as the bone below it as far 
 as the floor of the middle fossa. The remainder of the anterior border is then 
 cut with a Gigli saw. The posterior half of the inferior border is then elevated 
 to avoid the knee of the lateral sinus, which here rises very high. The posterior 
 inferior angle, (Hole 7), one and one-half inches above Eeid's line, is in the in- 
 ferior angle of the parietal bone, just above the parieto-occipital sutures, two 
 inches behind the end of the horizontal portion of the inferior border of the 
 anterior section. In making the posterior inferior angle, (Angle 4-7-5), hemor- 
 rhage is frequently encountered from external diploic vessels running directly 
 into the sinus, which may necessitate the rapid completion and elevation of the 
 flap to control the hemorrhage. Consequently the perforation at the posterior 
 inferior angle, (Hole 7), and its connection with the anterior sector of the 
 inferior border, (Line "d," between holes 5-7), and the posterior border, (Line 
 "e," between holes 7-4), is left until all other parts of the flap have been made. 
 (Fig. 10, Elevation of Flap.) 
 
 Inspection of Brain within the Dura. — ^Free incision of the 
 dura exposes the external surface of the temporo-sphenoidal lobe, 
 frequently the site of oyster-shaped localized intra-arachnoid abscess. 
 
 Hebniatioii of Brain topon Incision of Ddba in Tempobo-sfhenoidai, 
 
 Absoess. \ 
 
 While moderate herniation of the brain occurs immediately upon 
 incision of the dura, in my experience the excessive uncontrollable 
 herniation associated with rupture of the piaraohnoid and hemor- 
 rhage, which frequently accompanies exposure of the cerebellum, 
 especially when but one cerebellar hemisphere is exposed, does not 
 occur. Making a large dural opening greatly lessens the chief dan- 
 ger from the herniation, viz., rupture of the piarachnoid. If threat- 
 ened, this calls for reduction of the internal cerebral pressure by 
 lumbar puncture. However, if the abscess is large and so situated 
 that it compresses the ventricles with displacement of the hemi- 
 sphere, lumbar puncture may liberate but a few drops of cerebro- 
 spinal fluid apparently not under tension. 
 
 Obliteration of Homolateral Ventricle. — ^As the abscess in- 
 creases in size, the lateral ventricle gradually becomes compressed; 
 
■> ''- -T-,-- 
 
 Fig. 10. — Bone flap elevated. (See Frontispiece.' 
 
Fig. 11. — Section of brain in skull, slio\\'ing' tcniporo-spbenoidal hemorrhagic 
 infiltration and l\erniation, with displacement of liomolateral hemisphere beyond 
 the median line and almost complete obliteration of lateral ventricle aldiouoh a 
 large dural opening liad been made. Prior to tlie diiral opening the displace- 
 ment and the oljlitcration must have Ijcen extreme. 
 
 Figs. 13 (a) and (b). —Acute 
 eerelielhir aliseess in lateral lobe 
 of cerebellum — a frequent position 
 vlien secondary to sinus tlirombosis. 
 
 During evacuation pus passed over 
 piarachnoid; prior to evacuation a 
 careful exaniinalion of cerebro- 
 spinal lluid gave no evidence of sup- 
 ])urating meningitis; immediately 
 following operation fulminating 
 meningitis. Death within thirty- 
 six hours. 
 
 Fro. 13 (b) 
 
ABSCESS OP MIDDLE FOSSA 43 
 
 this is followed by a partial displacement of the cerebral hemispliere 
 beyond the median line, probably with actual obliteration of the 
 aqueduct of Sylvius. 
 
 Obliteration of the ventricle of the affected side, with displace- 
 ment of the hemisphere beyond the median line by abscess, is a 
 matter of great surgical importance to which attention has not 
 hitherto been directed. Gushing has long recognized that subcortical 
 tumors frequently obliterate the ventricle of the affected side, pre- 
 venting its location by ventricular puncture. Of the frequency of 
 obliteration of the lateral ventricle and partial displacement of the 
 hemisphere the writer has post-mortem evidence in one case of cere- 
 bral abscess (Fig. 11), in two cases of subcortical tumor of the 
 temporo-sphenoidal lobe, and, clinically, by repeated failures to find 
 the ventricle on puncture. ^^ 
 
 The following case demonstrates obstruction in the main cerebro- 
 spinal fluid channel by cerebral abscess, the compression and dis- 
 placement of the hemisphere probably causing a "block" at the 
 aqueduct of Sylvius and the restoration of the channel by the evacua- 
 tion of the abscess. 
 
 CASE X, C. H. 
 
 Temporo-sphenoidal Lobe Abscess. Girl. Diagnosis: Abscess of tem- 
 poro-sphenoidal lobe. On incising dura great herniation of brain. Lumbar punc- 
 ture liberated but a few drops of cerebro-spinal fluid, dropping slowly at inter- 
 vals of several seconds. Exploration within brain by canula; partial evacuation 
 of abscess through canula. Upon relief of excessive pressure cerebro-spinal fluid 
 in large quantities under pressure began to flow from the lumbar puncture 
 canula, the partial evacuation of the abscess having removed an obstruction 
 which prevented the free flow of the cerebro-spinal fluid. ( Of. Case XXIV, Chap- 
 ter VIII, p. 135, Hernia Cerebri Following Temporo-sphenoidal Lobe Abscess.) 
 
 Failure to locate the lateral ventricle by puncture would seem 
 to indicate that if, during an explorative operation for suspected 
 brain abscess, free incision of the dura is associated with marked 
 herniation, and lumbar puncture fails to reveal the excessive hernia- 
 tion which threatens rupture of the piarachnoid, the surgeon should 
 immediately explore the temporo-sphenoidal lobe and partially evacu- 
 ate the abscess, if located. On several occasions evacuation of abscess 
 has converted an uncontrollable cerebral herniation into an apparent 
 collapse of the affected hemisphere, the brain no longer completely 
 filling the skull. 
 
 Puncture of the Opposite Ventricle for the Reduction of Brain 
 
 ^' Reynolds, C. B. : Journal American Medical AasociaUon, 1914, Vol. LXII, 
 p 449, contains illustration showing obliteration of ventricle and displacement of 
 hemisphere beyond median line by a brain abscess. 
 
44 BRAIN ABSCESS 
 
 Herniation Sufficient to Admit of Elevation of Brain. (See Lum- 
 bar and Ventricular Puncture, p. 29.) The post-mortem and 
 clinical evidence of obliteration of the lateral ventricle vpith displace- 
 ment of the affected hemisphere would indicate that, in the presence 
 of marked herniation, if lumbar puncture liberates but a few drops 
 of cerebrospinal fluid, or cerebral exploration fails to locate the 
 abscess, puncture of the opposite lateral ventricle, through an inde- 
 pendent opening, may reduce the intracranial pressure sufficiently to 
 permit of inspection between the dura and the brain. 
 
 Inspection by Elevation of Brain. — Inspection of the under 
 surface of the temporo-sphenoidal lobe, as far as the tegmen is de- 
 sirable, because upon the presence or absence of adhesions between 
 the dura and brain will depend the surgical procedure to be adopted. 
 
 Technic of Elevation of Brain. — On first opening the dura over the external 
 surface of the temporo-spheno-idal lobe, it is generally impossible to inspect the 
 area of limited adhesions about the middle ear by elevation of the brain, as the 
 internal pressure of the brain is so great that it is jammed tightly against the 
 cut edges of the dura. Although a lumbar puncture lessens the herniation, the 
 reduction of the pressure is usually not sufficient to allow of inspection by dis- 
 placement of the brain upwards. Reduction of the intracranial pressure by 
 puncture of the opposite ventricle, or by partial evacuation of an intracerebral 
 abscess, usually permits elevation of the brain in the anterior portion of the 
 flap, allowing inspection of the under surface of the temporo-sphenoidal lobe above 
 the tegmen antri and tympani — the most frequent location of intrapiarachnoid 
 abscess and abscess of the second temporo-sphenoidal convolution "with a stalk." 
 
 By elevating the brain in the posterior portion of the flap above the hori- 
 zontal portion of the sinus, the upper surface of the tegmen cerebelli, as it rises 
 upward and inward, and the under surface of the occipital lobe, may be inspected. 
 
 Inspection of this area is difficult, as the margin of the dural opening, and 
 the elevated postero^inferior border of the bony flap are both considerably 
 above the outer limit of the tentorium. Introduction of the spatula between the 
 dura and the brain is accompanied by considerable hemorrhage from injury to 
 the posterior-inferior cerebral veins entering the sinus directly from the tem- 
 poro-sphenoidal region of the brain in the triangle between the superior border 
 of the temporal containing the superior petrosal sinus, the knee of the lateral 
 sinus and the transverse sinus. 
 
 Protection of Exposed Piarachnoid Prior to Exploration. — In all 
 cases of suspected brain abscess, before exploring the brain substance, 
 the piarachnoid exposed by the dural opening should be covered with 
 wet cotton to protect it from drying and from possible infection dur- 
 ing the sudden liberation of pus through the exploring canula. The 
 piarachnoid is a mesh of endothelial cells and fine blood vessels. It 
 offers great resistance to trauma while moist. The brain, as long as 
 its piarachnoid covering is intact, may be displaced and handled 
 without injury or hemorrhage, except at the comparatively few 
 places where blood vessels run directly from the arachnoid into the 
 
Fig. 12. — Uemorrlmgic infiltratioii into substance of piaraclmoid from tear- 
 ing small pial vessels during operative manipulation. Note multiple minute 
 hemorrhages, partially due to surgical manipulation and cerebral herniation. 
 
ABSCESS OP MIDDLE EOSSA 45 
 
 dura, or outside the cranium.^^ When the piarachnoid becomes dry, 
 however, it tears easily; even the weight of the brain, itself, may 
 cause rupture, and, as the piarachnoid is largely made up of blood 
 vessels, tearing is accompanied by hemorrhage. Hemorrhage into 
 the piarachnoid is largely infiltration into the cortex itself, because 
 of the close adhesions of the pia to the cortex. How frequently do 
 we see the beautiful glistening surface of the cerebral cortex become 
 dry, lustreless, and almost black with hemorrhage, as the surgeon 
 proceeds with his operative manipulations. (See Fig. 12.) 
 
 Horsley operated within the dura under a stream of warm, weak 
 bichloride solution. Absorbent cotton saturated with warm normal 
 salt solution, as employed by Gushing, is much better, as it may be 
 used to control any slight hemorrhage and, at the same time, to pro- 
 tect the meninges from infection. 
 
 Many cases of brain abscess, after evacuation, end fatally from 
 meningitis, the otologist frequently giving less consideration to the 
 protection of the piarachnoid from the pus of the abscess than the 
 abdominal surgeon gives to the peritoneum in draining an appen- 
 dicular abscess. As a matter of fact the arachnoid is much more 
 susceptible to infection than is the peritoneum, the peritoneum pass- 
 ing its existence in the neighborhood of infection, whereas tbe arach- 
 noid, normally, is remote from infection. (See Fig. 13, a and b.) 
 
 Technic. Before searching within the brain, the piarachnoid should be cov- 
 ered Tvith wet cotton, that the first gush of pus from the searcher may not soil 
 it, after which the remainder of the pus should be removed by a suction appa- 
 ratus, as it presents in the searcher." 
 
 Explwwtion within C&rebrcd Sichstance. — Exploration into the 
 brain substance should be performed with a hollow semi-blunt 
 searcher. This is of the greatest importance. Exploration with a 
 knife is generally associated with hemorrhage from the interior of 
 the brain. The vessels within the cerebral substance run perpendicu- 
 lar to the surface; consequently a blunt searcher passing parallel to 
 a vessel pushes it aside, whereas a knife cuts it. 
 
 The disadvantage of exploration with a semi-blunt searcher is 
 that the capsule of the abscess may be so dense that penetration by 
 the searcher is impossible (Fig. 18) — a very rare condition. 
 
 '= In exploring over the temporo-sphenoidal lobe with the spatula, after the brain 
 has been caused to "fall back" by the withdrawal of the cerebrospinal fluid by lumbar 
 or ventricular puncture, one large and one or two small venous communications wiU 
 be seen passing directly into the sinus. Care should be taken not to tear them before 
 the application of "silver clips" ; otherwise, hemorrhage sufficient to interfere seri- 
 ously with further inspection may result. ^ , ^ ^ . ^. ... ... . 
 
 >" A suction apparatus with the tip at least twice the calibre or the searcher 
 should catch the pus as it presents itself in the searcher, or in the cavity of the 
 encephaloscope. The tip should never, of course, touch the brain tissue itself. 
 
46 BRAlSr ABSCESS 
 
 In Blake's case" it was one-sixth, and in Knapp's*" one-flfth inch thick, while 
 in a personal case it was so dense it could not be perforated with a sharp 
 chisel.'" The pus may be too thick to run through the lumen of the searcher. 
 The contents in Bacon's case" had "almost the thickness of chewing gum"; in 
 Manasse's"' it was necessary to use a curette to remove it; while in Kopke^s" 
 the abscess cavity was filled with blood. 
 
 Difficulty in evacuating is encountered only in chronic abscess. 
 
 Technic: Exploring Instrument. — In abscess of recent formation a smooth, 
 graduated, soft rubber catheter, lubricated, with a well fitted metal stylet, 
 should be employed for exploration. If simple evacuation is decided upon it may, 
 without withdrawal, be utilized as a drainage tube and for the formation of a 
 tract. If a firm capsule is suspected, Cushing's metal searcher should be sub- 
 stituted, as the capsule may be impervious to the rubber searcher. 
 
 SITE OF ADJACENT INTEACEEEBRAL ABSCESS WITHOUT MACKO- 
 
 SCOPICAL EVIDENCE OF CORTICAL INVOLVEMENT OF 
 
 MIDDLE FOSSA: 
 
 Post-mortem examinations and clinical experience have demon- 
 strated that the vast majority of adjacent intracerebral abscesses 
 originating from the ear are situated primarily in the white sub- 
 stance of the third temporal convolution, directly above the tegmen 
 tympani et antri.^"' ^^ It ia the involvement of this area on the left 
 side, containing as it does the "naming" center of Mills, that gives 
 the localizing symptoms of a pathognomonic "naming aphasia." ^^ 
 
 From this original site the abscess extends either (1) inward and 
 upward, causing a paresis, first of the lower face, then of the arm, 
 and later of the leg; or (2) downward, towards the cortex over the 
 tegmen. 
 
 Selection of Site for Exploration. — Because of the uniform 
 appearance of the abscess in the white substance of the third temporal 
 convolution, the site of the exploration should be as low down as 
 possible toward the floor of the middle fossa, just above the tegmen. 
 Otherwise the abscess, if small, may be overlooked; — this occurred 
 to the writer in one of his earlier cases. 
 
 CASE XI., D. D. 
 
 Abscess Lovr Down in Middle Fossa. Male, 45 years of age. History; 
 chronic alcoholism; left-sided otitis media of three months' duration; constant 
 pain in head; vague chill for several weeks, with loss of fiesh; coated tongue; 
 
 » Blake : Lancet, I, March 31, 1900, p. 439. 
 
 « Knapp, H. : Archives of Otology, Vol. 29, 1900, p. 46. 
 
 " See Chapter Five, Metastatic Abscess, p. 68. 
 
 " Bacon : Trema. Amer. Otol. Soc, May, 1900, p. 404. 
 
 >»Manasse: Arch. Otol., Vol. XXVII, 1898, p. 115. 
 
 » Ropke : Arch. Otol., 1901, Vol. XX:x, p. 30. 
 
 " MacEwen : Pyogenic Infective Diseases of the Brain and Spinal Cord ; 1893, 
 p. 72, Fig. 30. 
 
 "■ MacEweu : Atlas of the Head Sections ; 1893, Plate 8. 
 
 2» Mills' Naming Center Is "located In the Inferior temporal gyrus, Just anterior to 
 the middle of the Inferior lateral border of the hemispheres." Santfie : Anatomy of the 
 Brain and Spinal Cord ; 1915, p. 192. 
 
■p''i'. 
 
 •'. " 
 
 A. ' t 
 
 
 
 
 
 
 Fig. 14- a 
 
 ^/■^■Ar';v;' 'W' /' ■':r/ ^'v. .''/:•'. /■;,:,' ,:(,'^ 
 
 •^■•>.'^' 0-^- '':*ll"'' i('''/( W']ff^^ 
 
 Fig. 14-B 
 
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 V 
 
 
 
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 • *.«. 
 
 
 
 
 
 Ftg. 
 
 14-C 
 
 
 4". • 
 
 
 
 Fic 14 A B C ^Micropliotograph made from sections taken from encapsu- 
 lated al.scess'ol brain of 'iV-i months' duration. (Dr. Harrison Martland.) bee 
 
 '^ A— Inner tliird of abscess capsule; showing shaggy tissue composed of 
 necrotic, sloughing and disintegrating brain tissue containing hemorrhage, fabrm, 
 nus ( poly nucTear leucocytes) and bacteria. „,,,,. j.- = 
 
 B— Middle third of abscess capsule; showing fibroblastic tissue forming a 
 dense fibrous protecting wall with scattered polynuclear and endothelial leuco- 
 cytes. Fibroblastic proliferation is in this instance due to stimulation of fabro- 
 b'lasts by the presence of fibrin in the disintegTating bram tissue. 
 
 C— Outer third of abscess capsule; showing endothelial leucocytes around 
 dilated blood-vessels and in the surrounding oedematous brain tissue. JNote 
 absence of polynuclear leucocytes. 
 
ABSCESS OF MIDDLE EOSSA 47 
 
 indefinite history of inability to name objects, which had entirely disappeared 
 at time of examination. 
 
 Mastoid Operation: For one week apparently recovering, but headache con- 
 tinued. Later, attacks of transient and incomplete "naming aphasia"; slight 
 paresis of lower portion of right face, only elicited by spontaneous emotional 
 movements, namely, smiling or laughing. 
 
 Second Operation: Exploration through clean area above the ear; no abscess 
 located. Marked improvement followed operation; patient insisted upon leaving 
 bed; suddenly, a few days after operation fell while walking; became cyanosed; 
 paralysis of respiration, and death. 
 
 The exploration low down toward the floor of the middle fossa 
 has the advantage that, being adjacent to the infected mastoid area, 
 the piarachnoid is punctured through the area of inflammatory 
 protective changes which are always present. And puncture through 
 a "prepared" area is much less frequently followed by leptomenin- 
 gitis than through one which is "unprepared." 
 
 CHRONIC ADJACENT INTRACEREBRAL ABSCESS WITH A 
 
 CAPSULE. 
 
 Surgical Pathology. — The pathological processes in chronic 
 brain abscess are the same as in abscess formation in other parts of 
 the body, viz., death of tissue and the changes due to the tissues' 
 protective reactions, the latter being governed, however, by the 
 special tissue involved. 
 
 Microscopically, a chronic braia abscess with a capsule is com- 
 posed of : (1) A cavity filled with detritus and pus (Mg. 14A) the 
 end result of complete death of tissue from bacterial action and 
 nutritional disturbances, and (2) a limiting capsule, formed by the 
 irritation of the bacteria and their toxins on the tissues, and the 
 tissues' protective and reconstructive reactions. The capsule in a 
 general way may be divided into three zones, all closely intermingled, 
 the destructive bacterial action having predominance nearest the 
 cavity, while in the external zones the tissues' reconstructive and 
 protective powers are chiefly manifest; although far beyond the cap- 
 sule, bacterial action can always be demonstrated. 
 
 Just external to the cavity and projecting into it is (1) the 
 "necrobiotic zone," in which the tissue now dead is undergoing lique- 
 faction from the action of the toxins. To insure the ideal surgical 
 result, namely, the eradication of the infection, the surgeon must 
 remove this zone, as far as possible, using the utmost delicacy. Merg- 
 ing into the necrobiotic zone is (2) the granulation tissue zone, with 
 connective tissue developing from it — the capsule (Fig. 14B) ; and 
 external to both in the otherwise normal brain tissue is (3) a round-, 
 cell infiltration in the perivascular sheath of the vessels, showing that 
 
48 BEAIN ABSCESS 
 
 the inflammatory or the protective process is still active well beyond 
 the capsule. (See Figs. 140, 15 and 16.) 
 
 The capsule of connective tissue is the result of two factors — 
 the resistance of the tissues and the virulence of the infection. With 
 a high resistance and a low virulence, nature attempts a complete 
 encapsulation of the abscess by a wall of new connective tissue, 
 which grows denser with time. 
 
 The connective tissue reaction of the body is simply the attempt 
 of the orgajiism to limit the extent of the inflammatory process. 
 In most parts of the body, subcutaneous, muscular, etc., if the infec- 
 tion is not virulent, an encapsulation rapidly follows, partly because 
 the tissues in general are freely supplied with connective tissue 
 which, being of a low order of cell, rapidly propagates itself. In 
 the brain, however, the formation of a connective tissue capsule is a 
 considerably slower process; partially because practically all the 
 new cells making up the capsule must be brought to it by the newly 
 formed blood vessels. These blood vessels, consisting at first of only 
 an endothelial tube, soon develop an outer connective tissue layer, 
 and from this layer is formed the connective tissue of the capsule. 
 (See Fig. 14B.) The connective tissue of the piarachnoid also 
 plays a part, but the glial cells, the framework of the brain, being 
 highly specialized connective tissue, plays little or no part in the 
 encapsulation. 
 
 In the formation of a capsule the type of micro-organism is 
 thought by some) to play a large part, Neumann ^* stating that "dip- 
 lococci cause an abundant secretion of fibrin, and so form a capsule, 
 but when anerobio micro-organisms are preseoit, a firm capsule is 
 not formed." 
 
 While, microscopically, the formation of connective tissue can 
 be demonstrated within a short period, the development of a capsule 
 firm enough to be appreciable macroscopically and consequently of 
 great surgical assistance, is a slow process. Friedmann ^* found 
 microscopically a distinct membrane, composed of two layers, be- 
 tween the eighth and the twelfth day after the cerebral infection. 
 The resistance to the advance of the searcher offered by such a cap- 
 sule would not be appreciable to the surgeon. Westphal ^^ found a 
 delicate encapsulating membrane seventeen days after the onset of 
 the cerebral symptoms. In such a case it is probable that, with 
 very delicate handling of the searcher the surgeon would be aware 
 
 '^ Neumann, H. : Cerebellar Abscess, Bngllsb Ed., 1907, p. 14 ; Polltzer : A Text- 
 book of Diseases of the Har, 5tb Ed., 1909, p. 66. 
 
 "' Filedmann : Handbucb der Pathologlechen Anatomle des Nervensystems, 1905. 
 » Westphal : AroMv fUr PaycJdatrie, 1900, Bd. 33, S. 206. 
 

 
 v^ 
 
 
 
 
 
 Fig. 15. — Section (Dr. Fredk. Sutton) ; low power: through granulation 
 layer of chronic brain abscess of about 14 days' duration. To right, new con- 
 nective tissue: perivascular infiltration. To left, normal brain tissue. 
 
 
 Fig. 16. — Same case as Fig. 15. Section; high power: perivascular infil- 
 tration. 
 
Fig. 17. — Section through streptococcic brain abscess of 105 days' duration. 
 Firm capsule % to % inch in thickness. (For microphotographs of sections 
 see Fig. 14.) 
 
ABSCESS OF MIDDLE EOSSA 49 
 
 of a slight resistance at the moment of perforation. Uchermann *' 
 estimated that it probably takes about 24 days to form a capsule of one 
 millimeter thickness; about 38 days for one of two millimeters. 
 The latter condition would offer considerable resistance to a semi- 
 blunt searcher and would be impervious to a blunt instrument. 
 (Fig. 17.) 
 
 Although several clinical observers ^''' ^®' ^^ contend that a capsule 
 is not formed until between the third and eighth week, the author 
 has recognized the presence of a capsule as early as the seventeenth 
 day.*" After the incision of the piaraehnoid the consistency of the 
 brain tissue is so uniform that, by delicate handling, very slight 
 resistance is appreciable. 
 
 Stirgicai, Principles Undeelying the Intradubal Technic in Suspected, 
 
 Adjacent, (Secondaet) Abscess of the Middle 
 
 Fossa ( Tempoeo-sphenoidal ) . 
 
 As the diagnosis of brain abscess must of necessity be more or 
 less provisional, and as cortical and subcortical suppuration can 
 rarely be differentiated, all explorations must be conducted through 
 a clean area, and adequate exposure must be provided for. 
 
 In no field of surgery is it more important that the surgeon 
 keep an open mind. Because of the uncertainties of the diagnosis, 
 he must prepare to assume a "shifting policy," depending upon 
 whether the exploration reveals, in chronic abscess, an intracerebral 
 abscess without macroscopical evidence of cortical involvement, with 
 a stalk, or meningeal; and in acute abscess, an intracerebral or 
 meningeal abscess. 
 
 He must not adhere to a particular procedure simply because 
 it resulted successfully in a former operation. He must adapt each 
 act of his technic to the condition found, preserving the protective 
 structures erected by nature, and availing himself of their assistance. 
 Compression, because it favors extension of suppuration and paralyzes 
 the protective mechanism, must be controlled or prevented. 
 
 In the treatment of individual clinical types of abscess (see 
 p. 21), existing pathological conditions and clinical experience both 
 suggest that the surgeon follow the method adopted by nature in its 
 efforts to cure spontaneously an adjacent brain abscess. 
 
 In encapsulated adjacent abscess with a stalk, as nature has 
 
 " TJchermann : ZeitacJiHft Jii/r Ohrenheilkunde, 1904, Bd. 46, S. 306. 
 " Lebert : ArcMv fiir Pathol. Anat. und Physiol., 1856, Bd. 10, S. 78. 
 2» Schott : WUmburg. Med. Zeitschrift, 1861, Bd. 2, S. 462. 
 » Huguenin : Handbuoh der spes. Pathol, und Therap., 1876, Bd. 2, S. 331. 
 '» See further discussion of formation of capsule, Chapter Five, Metastatic Abscess, 
 p. 76. 
 
to BEAIN ABSCESS 
 
 erected a walled-off tract througli the piarachnoid into the cavity of 
 the abscess, the surgeon should utilize this tract for the complete 
 evacuation, cleansing, and obliteration of the abscess and the intro- 
 duction of necessary drainage. In adjacent intracerebral abscess 
 with capsule, but without macroscopical evidence of cortical involve- 
 ment, the abscess should be completely evacuated and an attempt made 
 to form a walled-off area through the piarachnoid, after which it may 
 be completely evacuated, cleansed and obliterated. In acute abscess, 
 as compression is favoring the extension and preventing the limita- 
 tion of the suppuration — as well as being the cause generally of most 
 of the clinical symptoms — the abscess should be evacuated as com- 
 pletely as possible through a small searcher and the dura closed, or 
 at least the brain completely covered. In several instances I have 
 firmly anchored the small searcher to facilitate the formation of a 
 tract. Later, after the formation of the capsule, it niay be treated 
 as an encapsulated intracerebral abscess. A meningeal abscess, 
 chronic or acute, should be fully exposed in all directions, no mat- 
 ter how extensive the sacrifice of bone or dura, the area should be 
 thoroughly cleansed by irrigation, adequate drainage provided at a 
 distance from the dural margin through "stab" wounds, and the brain 
 completely covered. 
 
 Technic Following Elevation of Brain. — i lumbar or ventricular puncture 
 of the dilated opposite ventricle, or the partial evacuation of the abscess, through 
 the cortex, having caused sufficient "falling back of the brain" to allow an intra- 
 dural inspection over the roof of the tegmen if adhesions are seen above the 
 middle ear, all of the exposed external surface of the temporo-sphenoidal lobe 
 should be covered with wet cotton, the bone rongeured away down to and includ- 
 ing the middle ear and antrum, and the dura opened from below. 
 
 If the stalk of the abscess is short so that the abscess cavity is separated by 
 only a few millimeters from the under surface of the temporo-sphenoidal lobe, it 
 may be possible to eradicate it, viz., to evacuate, cleanse, obliterate and introduce 
 drainage material through the lower dural opening, in which case the upper 
 dural opening should be tightly closed and the bone flap replaced. 
 
 In cases in which the protective inflammation is very limited, this area may 
 be increased by placing strips of moist cotton, from the upper wound, between 
 the dura and the brain on as many sides of the adhesive area as possible, before 
 opening from below. 
 
 Stteoical Significance op Areas of Adhesive Inflammation of 
 plaeachnoid to dura. 
 
 When elevation of the brain with the spatula discloses, on the 
 under surface of the temporo-sphenoidal lobe, adhesive inflammation 
 uniting the brain with the dura, it may be inferred that if the area 
 of adhesion is extensive, the abscess is probably in the meshes of 
 the piarachnoid ; and that if the adhesions are limited to the tegmen, 
 
ABSCESS OF MIDDLE FOSSA 61 
 
 the abscess is probably in the brain substance, a "stalk" uniting the 
 abscess with the area of primary infection. 
 
 Both forms of abscess offer excellent prospects of recovery, for 
 nature has walled off the infected tract from the meshes of the 
 piarachnoid, and established a tract' from the dura to the furthest 
 extremity of the abscess, while the adjacent tissues have become 
 largely immunized during the limitation of the infection. 
 
 CHRONIC ADJACENT INTRACEREBRAL ABSCESS OF THE 
 MIDDLE FOSSA. 
 
 It is recognized that a larger proportion of recoveries have fol- 
 lowed evacuation and drainage from below through the middle ear 
 and antrum than through the external surface of the temporo- 
 sphenoidal lobe, because in abscess with a "stalk" the tegmen per- 
 mits entrance into the abscess at its nearest approach to the dura, 
 and through an immunized tract of protective adhesions. Conse- 
 quently, in operating, a definite attempt should be made to evacuate 
 the abscess at its nearest approach to the dura, — the antrum and 
 middle ear,- — and to utilize the area of protective adhesions, — ^for it 
 is through this tract that the abscess may be entered, thoroughly 
 evacuated, and drainage material introduced with the least danger 
 of inciting a suppurative meningitis, or of injuring and infecting 
 the neighboring cerebral tissue, with its accompanying oedema, en- 
 cephalitis and fungating hernia. 
 
 SUBOICAI. PEINCIPtES AND SPECIFIO FACTOES INVOLVED IN THE TBEATMENT OF 
 
 Encapsulated Adjacent Intbacebebeal Abscess of the Middle Fossa. 
 
 In the surgical treatment of encapsulated intracerebral abscess 
 one of two principles is employed: (1) Attempted eradication of 
 the suppuration, and (2) drainage. 
 
 Drainage, while efficiently controlling suppuration in other parts 
 of the body, is generally inadequate in cerebral suppuration (see 
 p. 57), and may be the direct cause of secondary infection of the 
 meninges, the development of the so-called secondary abscess, and of 
 hernia cerebri. 
 
 On the oliier hand, an attempt at eradication, except in selected 
 cases, will be associated with cerebral trauma, resulting in the 
 presence of infection in traumatic encephalitis. 
 
 On the proper selection of the principle to be adopted in each 
 individual case, largely depends the life of the patient. 
 
 Eradication. — In the treatment of chronic intracerebral abscess 
 with a capsule with a stalk, the surgical aims should be the same as 
 
52 BRAIN ABSCESS 
 
 in the surgical treatment of low grade infection in other soft tissues, 
 viz.: (1) thoroughly to remove all pus and detritus, thus largely 
 eliminating the infection; (2) to reduce as far as possible the sup- 
 purative surface by the collapse and obliteration of the cavity; 
 (3) to convert the granulating surface of the obliterated cavity into 
 an active reparative process, the subsequent discharge being then 
 largely the discarded products of healing, and not, as formerly, the 
 result of the destruction of tissue. In addition to this the surgeon 
 must endeavor, (4) to accomplish the above without spreading the 
 infection to the susceptible adjacent piarachnoid; and (5) to do so 
 with a minimum of operative trauma. 
 
 Drainage. — In encapsulated intracerebral abscess without 
 macroscopical evidence of cortical involvement, complete evacuation, 
 cleansing, and obliteration are impossible, because wide entrance into 
 the abscess is apt to be followed by meningitis (there being no area 
 of protective adhesion) and traumatic encephalitis from injury to 
 cerebral tissue. 
 
 Selection of Cases. — When the falling back of the brain reveals a wide 
 stalk leading into an abscess cavity, an attempt should be made at complete 
 evacuation, cleansing, and obliteration of the cavity. Again, if exploration of 
 the under or lateral surface of the temporo-sphenoidal lobe reveals an encapsu- 
 lated intracerebral abscess without macroscopical evidence of cortical involve- 
 ment, within one or at most two centimeters of the cortex, attempted eradication 
 is justifiable, although vpithout a stalk a systematic effort at complete evacua- 
 tion, cleansing and obliteration, increases the danger from meningitis and 
 traumatic suppuration. 
 
 With an intracerebral abscess without a stalk, situated beyond two centi- 
 meters from the corteK, an attempt at eradication is associated with great tech- 
 nical difficulties and prohibitory trauma to the brain. The surgical effort should 
 be limited to as complete an evacuation as is possible through the searcher, and 
 the formation of a tract through which the abscess is drained and later, possibly, 
 cleansed. 
 
 Difficulties of Complete Evacuation. — Certain anatomical 
 and physiological factors peculiar to cerebral tissue make difficult 
 the complete evacuation of the pus and obliteration of the cavity : — 
 (1) the brain substance has a specific gravity of 1036,^^ 78.9 per 
 cent, of it being water; (2) the brain substance is practically a 
 semisolid, homogeneous mass of nerve cells and glial tissue, while 
 the blood vessels within the substance are comparatively small ; ** 
 (3) the brain is largely held in shape by the enveloping piarachnoid 
 — (witness its distortion upon removing the fresh brain from the 
 calvarium and stripping off the piarachnoid). 
 
 " Santee, H. 3D. : Anatomy of the Brain and Spinal Cord, 1915, p. 49. 
 "Mallory: Principles of Pathology and Histology, 1914, p. 625. 
 
ABSCESS OF MIDDLE FOSSA 53 
 
 The mechanical factors inherent in the abscess itself which in- 
 fluence the operative procedure and modify the surgical aims, are: 
 (1) the thickness of the enveloping capsule; (2) the distance of its 
 outer wall from the point of puncture on the cortex; and (3) the 
 consistency of the pus. 
 
 Taken in its entirety, cerebral substance within the piarachnoid is 
 approximately of the consistency of mush contained within a deli- 
 cate gauze bag. If now a raw egg with the shell removed is placed 
 within the mass and an effort is made to remove the entire yolk 
 with little disturbance of the mush, we have a fair model of the 
 mechanical difficulties of thoroughly evacuating an intracerebral 
 abscess with a delicate encapsulation. Puncture through the mush 
 into the egg will cause the liberation of some of the yolk, but col- 
 lapse of the surrounding mush will uniformly prevent the evacua- 
 tion of the larger part of the semi-liquid contents of the enveloping 
 membrane. 
 
 Upon entering an intracerebral abscess with the searcher, sudden 
 expulsion of a portion of the pus is caused by the tension of the 
 surrounding cerebral substance; but as soon as the tension between 
 the abscess contents and the surrounding cerebral tissue is equalized, 
 further evacuation of the pus is accomplished by gravity, and the 
 weight of the surrounding cerebral tissue. Muscular contraction of 
 surrounding tissue — so powerful a factor in the evacuation of the 
 pus of an abscess in the soft structures — plays no part. 
 
 The nearer the pus approaches the density of the surrounding 
 cerebral tissue, the greater the mechanical difficulty of complete 
 evacuation. Pus of thin consistency will be much more completely 
 evacuated by the brain than thicker pus. 
 
 The firmer the envelope, the greater the possibility of entrance 
 into the abscess cavity of an instrument which will insure complete 
 evacuation, cleansing, and obliteration of the cavity. 
 
 Importance of Thorough Primary Evacuation. — Complete 
 evacuation, cleansing and obliteration of the cavity whenever feasible 
 without trauma to normal cerebral tissue, should be carried out at 
 the time of the primary aperation. In recent years I have realized 
 more and more that, having once located the collection of pus with 
 the exploring searcher, thorough evacuation and obliteration of the 
 cavity greatly lessens the liability of subsequent re-filling, or second- 
 ary abscess from inadequate drainage. 
 
 The literature of the treatment of chronic brain abscess shows 
 how frequently reliance is placed on partial evacuation, with the in- 
 troduction into the cavity of some form of drainage material to allow 
 
54 BKAIN" ABSCESS 
 
 of subsequent drainage of pus. I am convinced, towever, that not 
 only is incompleite primary evacuation, preventing obliteration of the 
 cavity, generally followed by inadequate drainage (because of the 
 collapse of the opposing walls shutting off portions of the abscess 
 with the frequent formation of an apparently new cavity), but that 
 the retained pus favors an extension of the encephalitis. Many fail- 
 ures to locate pus at a secondary operation, in which primary incom- 
 plete evacuation had failed to stop the suppurative process, and in 
 which at post-mortem the drainage material was found outside the 
 abscess cavity, have persuaded me that the surgeon, in chronic brain 
 abscess with a capsule, has but one major chance to combat infection, 
 namely, cut the time af the primary operation. 
 
 The importance of primary complete evacuation is supported by 
 two clinical observations of great prognostic value, which have long 
 been recognized : (1) if following an operation for brain abscess, the 
 disappearance of the symptoms is accompanied by alm,ost com/plete 
 cessation of the discharge, — complete primary evacution — relapse 
 and refilling of the abscess cavity but rarely occurs ; (2) on the other 
 hand, continuation after the first few days of a profuse discharge 
 from the drainage tube — incomplete primary evacuation — ^frequently 
 results in recurrence of the symptoms associated with a sudden cessa- 
 tion of the discharge, cleansing of the tube showing that the ces- 
 sation of the discharge is not due to "plugging" of the tube ; the new 
 area of encephalitis being apparently not connected with the region 
 drained. 
 
 Evacuation through puncture of the dura is recommended by 
 Lemaitre.^* This gives a large percentage of recoveries because 
 it evacuates the abscess with but a slight ajnount of trauma. How- 
 ever, it has the great disadvantage that a subtemporal and piarach- 
 noid abscess either will be entirely overlooked or imperfectly 
 evacuated. 
 
 The method fulfills the surgical requirement for the successful 
 treatment of acute brain abscess; it results in evacuation and the 
 formation of a tract. However, before the method is employed care 
 should be taken to be assured that the abscess is not chronic, as other- 
 wise the operation will fail. In several of the vn-iter's cases with an 
 abscess with a capsule which approached the surface it was evacuated 
 in this way, mistaking it for an acute abscess. Post-mortem revealed 
 that, had the abscess been properly eradicated, the patient undoubt- 
 edly would have recovered. 
 
 " Lemattre, F. : Exclusion of Subarachnoid Space ; Bevue de CMrurgle. 1919, 
 Tome 57, p. 497. (Abstracted In Jour. Am. Med. Boo., June 12, 1920, Vol. 74, No. 24, 
 p. 1680.) 
 
Fig. 18.— Part Two. 
 Collapse of abscess, 4, 6, 7, 8. Difficulty in entrance by blunt instrument, 
 3, 4, 6. Capsule holders in place, 6, 6, 7, 8. 
 
ABSCESS OP MIDDLE FOSSA 55 
 
 Teohnio of Subgioal Treatment op Cheonio Adjacent Inteacerebbal Abscess 
 
 WITH Capsule. 
 
 Complete Evacuation; Difficulties. — The teclmic depends 
 upon -whetlier eradication — complete evacuation, cleansing and oblit- 
 eration of the cavity — or simple drainage is to be attempted. In 
 evacuating a chronic intracerebral abscess vpith a limiting membrane 
 situated fairly near the surface, after the first nish of pus has been 
 removed care should be taken to evacuate only a small quantity of 
 pus through the exploring searcher. Unless this precaution is taken 
 the exploring searcher, having entered a small abscess or perforated 
 a dense capsule, the partial withdrav^al of the pus vpill result in the 
 collapse of the opposing cavity walls from the external pressure of the 
 surrounding brain tissue, thus locking in a quantity of pus and ren- 
 dering difficult the proper placing of the encephaloscope. The more 
 pus evacuated the greater the flaccidity of the portion of the abscess 
 vrall impinged upon by the blunt encephaloscope; consequently, by 
 preserving the distention of the abscess the difficulty of perforating 
 the capsule by the encephaloscope and placing the instrument within 
 the abscess cavity is lessened. The fact that the encephaloscope is 
 correctly placed is shown by the free escape of pus through the 
 lumen. 
 
 This locking in of pus invariably happens in all intracerebral 
 abscesses, chronic or acute, when evacuation is attempted through 
 the exploring searcher, unless the searcher has entered the abscess 
 cavity at its most dependent portion and has passed well into the 
 cavity itself. If l^e searcher has entered the upper portion of the 
 abscess (especially if the abscess is multilocular in shape), the partial 
 evacuation of the abscess with the collapse of its walls, will leave the 
 remainder of the pus at such an angle from the exploring searcher's 
 tract, that if it is necessary that another instrument, such as an 
 encephaloscope or forceps carrying drainage material be passed 
 along the searcher it may not enter the cavity, this portion of the 
 cavity having now become a mere slit between two opposing walls 
 and away from the remainder of the still pus filled cavity, to which 
 it is united by an obliterated tract at right angles to the exploring 
 searcher. This tract can be followed if the abscess is held by the 
 retaining searcher, by lifting apart its collapsed walls, thus allowing 
 entrance into all parts of the remaining cavity. (Fig. 18.) 
 
 The writer has frequently failed to find the cavity of the abscess after the 
 evacuation of a quantity of pus through the exploring instrument, although' 
 
56 BEAIK ABSCESS 
 
 considerable pus was still locked in an extremity, the position of the remaining 
 pus being distant perhaps by several centimeters from that portion of the cavity 
 obliterated by the partial evacuation. 
 
 An abscess once entered by an exploring instrument shovM never 
 be lost. This is of tlie ixtmost importance. As soon as pus is 
 definitely located ty the searcher its flow should be stopped, because 
 when the abscess becomes flaccid greater difficulty is experienced in 
 finding it with the abscess holder, and in entering it with the in- 
 specting instrument. In the case of a chronic intracerebral abscess 
 with a firm capsule, if the capsule is of delicate structure, on passing 
 the encephaloscope over it pus will appear in the instrument at the 
 recorded depth. If, however, the limiting membrane is of more than 
 three weeks' duration, it may be dense enough to resist the entrance 
 of the encephaloscope, in which case, although the cavity of the 
 encephaloscope remains free from pus, the pressure will appreciably 
 increase the flow of pus through the exploring canula. The abscess 
 is again perforated by the abscess holder and if on withdrawing the 
 stylet pus flows from it the inspecting instrument is passed over it. 
 
 Although Whiting's encephaloscope'' is invaluable for the complete evacua- 
 tion, cleansing and obliteration of the cavity and for the introduction of drainage 
 material, on many occasions the writer has been unable to place it properly 
 within the abscess cavity because, ( 1 ) it is introduced heside the searcher and, 
 consequently, if the searcher has perforated an extramity of the abscess (Fig. 18, 
 Diagram 3), the encephaloscope may miss it entirely; and, (2) because, being 
 blunt, the instrument may simply indent a, firm abscess capsule (Fig. 18, Dia- 
 gram 4). Both accidents have occurred in the writer's experience. 
 
 To obviate the former accident the author has devised a modiflcation of 
 Whiting's encephaloscope, which is to be introduced over the exploring searcher, 
 whose track occupies the center of the inspecting instrument. (Figs. 19, 20, 21.) 
 
 Cleansing and Oblitebation op Cavitt of Abscess with "Staik" ob Near 
 
 COETICAL STJETACE. 
 
 A brain abscess with a capsule, if near the cortical surface, should 
 be thoroughly evacuated, its walls inspected and cleansed, and its 
 cavity obliterated, so that on withdrawal of the inspecting encephalo- 
 scope, the surgeon should know that no recess of the abscess has been 
 overlooked. Examination of recorded cases of "second" brain 
 abscess demonstrates that separate and distinct multiple brain 
 abscesses (excepting those of metastatic or traumatic origin) are very 
 rare — "second abscess" simply being a prolongation of the original 
 
 " Whiting, F. : The Differential Diagnosis of Acute and Chronic Brain Abscess 
 by Means of the Encephaloscope. Traneactions Americcm Otological Society, 1903, Vol. 
 VIII, p. 285, 
 
Fig. 19. — Author's modifi- 
 cation of Wliiting's enceplial- 
 oscope. Allows of passage 
 of encephaloscope over 
 searcher ; aimed to prevent 
 the "losing" of the abscess 
 after its partial evacuation 
 — a frequent and disastrous 
 accident. This instrument 
 is adapted only to cases 
 which, from their compara- 
 tively short duration, are 
 believed to be surrounded by 
 a delicate capsule. 
 
 Fig. 20. — Author's 
 capsule retaining 
 searcher and enceplialo- 
 scope (closed). 
 
 Fig. 21. — Author's capsule re- 
 taining searclier and enceplialo- 
 scope ( open ) . Adapted only to 
 cases surrounded by a very firm 
 capsule Avhicli will allow of 
 manipulation and traction out- 
 ward from the interior of the 
 capsule. 
 
ABSCESS OF MIDDLE EOSSA 67 
 
 abscess united to tlie main cavity by a narrow entrance which has 
 been obliterated by the collapse of the surrounding cerebral tissue 
 during evacuation. 
 
 Technic. — Complete illumination of all hidden recessea is of primary im- 
 portance; a Klaar's headlight worn by the operator has proved moat satisfactory. 
 
 All instruments used within the brain should be held by the operator himself, 
 whose eyes should never for an instant leave the enoephaloscope, the obturator or 
 a cleansing instrument being placed in his hands by an assistant. The re-intro- 
 duction of an obturator, with the slightest forward or lateral movement of the 
 instrument, will prevent tearing and consequent confusing hemorrhage. In the 
 latter part of the thorough evacuation, cleansing by absorbent cotton on appli- 
 cators and moistened with salt solution, furnishes the greatest assistance. If the 
 abscess is superficial, situated within two centimeters of the surface, the entire 
 cavity may be cleansed by this method. 
 
 Drainage. — In a chronic abscess, with a firm limiting membrane, 
 some form of drainage is desirable, although in my experience the 
 subsequent discharge in carefully cleansed abscess has been so slight 
 that with our present understanding of tissue disinfection and control 
 of localized infection by the tissues themselves, many cases of chronic 
 brain abscess do not require drainage. Personally, however, the 
 writer never has had the courage to omit drainage. If the evacua- 
 tion has been thorough, the very slight subsequent discharge is sim- 
 ply the product of tissue repair ; "free drainage," in the sense of com- 
 bating infection, plays no further part. 
 
 Technic. — Before withdrawing the encephaloscope, a wick of rubber tissue 
 should be placed within the cavity. Gauze in any form is very irritating, as is 
 shown by the invariable hemorrhage which accompanies its removal. The irrita- 
 tion of its presence favors the development of hernia cerebri. 
 
 Technic of Drainage Following Incomplete Evacuation. — If the external 
 wall of the abscess cavity is more than two centimeters from the surface of the 
 cerebral cortex, the abscess is to be as completely evacuated as is possible through 
 the exploring instrument, assisted by gravity. 
 
 After the stoppage of the flow of pus, turning the patient in different direc- 
 tions, to the right or left, lowering or elevating the head, may liberate addi- 
 tional pus. 
 
 Because of collapse of the absceas walls and the attending diflBculty of intro- 
 ducing drainage material within the cavity (see p. 55), the exploring instru- 
 ment (graduated soft rubber catheter) should be utilized for subsequent drain- 
 age and the formation of a tract, and firmly anchored to the soft parts. 
 
 In one instance, in a deeply situated abscess, as it was imposaible to enter 
 the abscess cavity with an investigating instrument, the writer used the metal 
 searcher as a permanent drain by cutting it off a little beyond the cortical sur- 
 face. Rubber drainage tubing is much better, as later, if the abscess is deeply 
 situated, and if its limiting membrane is firm enough to have offered considerable 
 resistance to the passage of the searcher, cleansing by irrigation through the 
 searcher offers the best prospect of cure. The filling of the abscess cavity ia 
 accomplished by the weight of the syringe piston, and it ia emptied by means of 
 suction." 
 
 "Muck has demonstrated cUnically that during the dressing of a brain abscess 
 the rotation of tlie head in tlie sitting position markedly influences the size of the 
 
68 BKAIN ABSCESS 
 
 Secondary Compression. — Compression favors suppuratioQ 
 and prevents the protective and nutritive mechanisms of the brain 
 from functioning. With a closed dura, excessive action of any of 
 the processes — infective, traumatic, or reparative — ^may cause in- 
 crease of the intracerebral pressure, the compression being followed 
 by extension of any remaining infection ; consequently, after evacua- 
 tion, the decision must be made whether the dura shall be more 
 or less tightly closed or whether a subsequent enlargement of the 
 brain's bulk demands a large dural opening. 
 
 In deciding whether the dura is to be closed, the most important 
 consideration is: Has the suppuration been completely controlled, 
 and if so, will the secondary reactive oedema be excessive ? 
 
 Without complete primary evacuation, there will be extension' 
 of the suppuration from refilling of the abscess or its extension into 
 the already infected adjacent area, thus causing compression. 
 
 With compression from excessive secondary oedema, especially 
 when associated with injury to normal cerebral tissue such as 
 may accompany attempts at eradication, the remaining slight infec- 
 tion is given a new start. Even with complete evacuation the normal 
 reactive forces of the brain are to be considered, for if excessive 
 they may give rise to compression. 
 
 In brain abscess, especially acute abscess, the nutritive and pro- 
 tective mechanisms of the brain are greatly disturbed by the infec- 
 tion itself, by limitation, and by operative trauma. Following evacua- 
 tion these mechanisms, in their efforts at re-establishment, may 
 occasion such excessive re-active changes as to give rise to compres- 
 sion. (Fig. 22.) 
 
 In a review of the author's cases he is convinced that three 
 resulted fatally from subsequent compression — ^probably preventible 
 — ^which caused extension of the suppurative process (Case VIII, 
 A. M. N"., Chapter Four, p. 37, and Case IX, G. W., Chapter Four, 
 p. 38) ; while in at least two others (Case XIII, Mrs. H., Chapter 
 Four, p. 63, and Case XVII, Miss M. D., Chapter Five, p. 11), 
 the large dural opening, one resulting in a large hernia cerebri, 
 probably became the saving factor. (See also Case X, C. H., 
 Chapter Four, p. 43.) 
 
 Principles in Technic of Decompression. — To leave the dura 
 open is to risk a most distressing hernia cerebri, with its attending 
 
 abscess cavity and consequently Its drainage. The size of the cavity Is altered, he 
 believes, by the hindering of the escape of the venous blood from the head through 
 pressure Induced by rotation of the head. 
 
 Muck, V. : Wle soil der Hlrnabszesskranke nach der Operation gelagert werden ? 
 (Position of Patient after Operation for Brain Abscess) ; ZeUschritt fUr OhrenheU- 
 kunde. 1920, Vol. 79, p. 86. 
 
Fig. 22. — Original drawing from brain containing a temporo-splienoidal lobe 
 abscess whicli had been almost completely evacuated. Shows obliteration of the 
 posterior horn of ventricle on abscess side and the dilatation of tlie ventricle of 
 the opposite side; shows, also, extension of infiltration and increase in size of 
 hemisphere. 
 
ABSCESS OF MIDDLE FOSSA 59 
 
 danger of secondary infection, and yet not to provide for compression 
 may be fatal. Decompression, by displacement of the brain sub- 
 stance, is in itself a cause of secondary oedema. If tbe dura is to 
 be left open a wide opening must be provided ; otherwise the hernia- 
 tion through a small opening may cause strangulation of the brain. 
 With a decompression the brain must be entirely covered by soft 
 parts. 
 
 The sewing in of a large piece of fascia lata furnishes a most 
 efficient protection for the brain in non-suppurative cases. Its 
 similarity to the dura renders it less irritating to the cortex than 
 either muscle or skiu. 
 
 Immediate After-treatment. — Following operation the patient 
 should remain on the operating table for many hours, preferably until 
 the next morning, or at least until complete consciousness has been 
 regained. To move a patient immediately after a profound operative 
 disturbance of his cerebral tissue adds an unnecessary tax to his en- 
 durance which may result disastrously. Since attention has been 
 called to this important detail by Gushing,^® the writer has been 
 impressed by the frequent collapse of patients after being trans- 
 ported to the ward, not only in cerebral cases but in other types of 
 serious operation. 
 
 If the hospital routine cannot permit the brain abscess cases to 
 remain in the position operated upon, the institution is not a proper 
 place for the operation. 
 
 Continued After-treatment. — ^After thorough efvacuation, 
 most delicate cleansing, and complete obliteration of the cavity, the 
 dura and the external wound should be almost entirely closed, and 
 no matter how great the temptation to do so, the brain itself should 
 not again be disturbed for many days; if possible, not for several 
 weeks. In the author's experience further manipulation invariably 
 militates against the patient's recovery. The drain may be allowed to 
 be gradually expelled from the brain itself. In most of the suc- 
 cessful cases re-introduction of drainage has been unnecessary. 
 
 "Second Absckss," oe Dotjbu! and Secondaky Abscess. 
 
 In traumatic brain abscess (secondary infection of necrotic cere- 
 bral tissue, blood detritus, etc.), two or more separate abscesses fre- 
 quently occur. 
 
 In abscess from direct extension from adjacent suppurativa 
 
 " Gushing, Harvey : Tumors Nervus Acusticus ; 1917, W. B. Saunders Company, 
 Pbiladelpbia and London, 
 
60 BEAIN ABSCESS 
 
 lesions or from retrograde thrombophlebitis with nutritional death, 
 two or three abscesses must of necessity be of infrequent occurrence. 
 Most of the abscesses recorded as "second," or "double," are in reality 
 secondary, though a few cases of double adjacent abscess are re^ 
 ported.*^ A second abscess, originating from the original brain 
 abscess is, however, of frequent occurrence, but from an etiological 
 standpoint such are rather secondary to the original adjacent abscess 
 and should be so designated. 
 
 Secondary abscess is due, in order of frequency, to (1) "loss 
 of abscess" before complete evacuation, or by collapse of its walls; 
 (2) encephalitis induced in surrounding tissue by the trauma of 
 exploration or evacuation; (3) encephalitis by direct extension from 
 the primary abscess, the path of infection, though frequently small, 
 being discoverable by careful examination. 
 
 W. K. : Double Cerebellar Abscess, the second abscess resulting from loss of 
 primary abscess associated imth cerebral trauma; operations; recovery. 
 
 Boy, aged 14, always in good health, but had poor memory. Six years ago 
 had discharge of pus from right ear for three weeks. Mother said at times a 
 whitish mass protruded from the ear, which was very sensitive to touch. 
 
 History. — Awakened in the night with severe pain which lasted three days. 
 He was then struck on the head by a ball, knocked down, but not rendered un- 
 conscious. Two days later the ear pain returned, followed in three more days 
 by a flow of foul pus from the ear, which lasted a week. During this week he 
 suffered from pain in the head and ear, occasional vomiting, slight attacks of 
 screaming without apparent cause; probably dizzy, as he would catch at articles 
 in going about the room. Lost flesh rapidly. Indistinct history of a chill. At 
 the end of seven days he became drowsy and in the next three days seemed dazed 
 and yawned frequently. On the eighteenth day he was found lying on his right 
 side on the floor, his eyes wide open and apparently blind, in which condition ha 
 remained all night and was thought to be dying. It was noticed that his arm 
 and leg of the opposite side frequently twitched. The next morning, though still 
 in stupor, he could be aroused. He was emaciated, tongue coated, yawned fre- 
 quently, eyes wide open, temperature 99.3 degrees, pulse 62. There was slight 
 lateral deviation of the eyes to the opposite side. Pupils were equal and re- 
 sponded to light. The pupil on the unaffected side was observed to dilate more 
 widely than on the side of the lesion. There was marked right optic neuritis, 
 with banning left optic neuritis. Absence of both patellar reflexes. 
 
 Operation. — Half an ounce of pus was found in cerebellar tissue near the 
 posterior surface of the petrous portion of the temporal bone. The finger was 
 introduced. Cavity held open by the forceps, when the latter accidentally slipped, 
 
 " Coates, G. M. : Temporo-sphenoidal Abscess, Double ; Annals oj Otology, RMn- 
 olotgu and Laryngoloffy, June, 1917, Vol. 26, p. 408. 
 
 Two cases: 
 CASH I 
 
 Temporo-sphenoidal ; no symptoms whatever ; discovered by accident by bulgine 
 of dura ; sterile pus ; chronic. 
 
 CASB III 
 
 Two abscesses ; no stalk ; 1 em. of cerebral tissue between two cavities • both 
 apparently acute. History not explicit enough to eay whether or not it was 'meta- 
 static ; could not have been caused by trauma as patient died on table. 
 
ABSCESS OP MIDDLE FOSSA 61 
 
 and the flow of pus stopped. Careful search failed to re-disoover the cavity. 
 A drainage tube was introduced along the tract. During the next week the boy 
 did well, was rational, no deviation of the eyes, co-ordination normal, but at 
 times he would cry out, and there was involuntary defecation and urination. 
 Optic neuritis increased in the left eye, and there was nystagmus when the eyes 
 were moved toward the side of the lesion. Seven days after operation, the pulse 
 and temperature being normal, paresis of the arm of the same side developed; 
 the eyes deviated to the opposite side. On the tenth day the woTind was ex- 
 plored with the finger, but nothing was found. On the fourteenth day after the 
 operation he was in the same condition as primarily; pulse 60, respiration 14, 
 complete paralysis of the arm and hand of the same side. 
 
 Second Operation. — On. exposing the original sinus tract a large dbsoeaa 
 cavity was found, rimning toward the median line; two ounces of pus were 
 evacuated, after which the hernia, which had developed during the first weeh, 
 disappeared. During the following three weeks the patient was so violent as to 
 require restraint, and screamed frequently. 
 
 Discharged from hospital; the sinus was healed and remains so though on 
 two occasions a small opening has developed over the site of the wound. His 
 mental condition is very poor, though his mother says he is as bright as he 
 ever was. 
 
 Present Condition. — Perfectly well; complains of headache. Served with 
 American Expeditionary Forces in France. 
 
 ACUTE BRAIN ABSCESS, 
 
 In acute intracerebral abscess the outstanding pathological process 
 is acute cerebral tissue death, with intense oedema, and but slight pro^ 
 tective limitation, the rapid formation of the abscess precluding the 
 formation of a protective capsule. As the technic of the surgical 
 treatment of chronic brain abscess with a capsule utilizes the capsule 
 in the thorough evacuation, cleansing and obliteration of the abscess, 
 the surgical technic of acute brain abscess must be largely modified 
 to adapt itself to differences in the pathological processes. 
 
 Recovery in acute intracerebral abscess is much rarer than in 
 brain abscess with a capsule, and yet I am persuaded that. with a 
 proper operative regard for the differences in processes, the mor- 
 tality from acute abscess should not be much higher than in chronic 
 cases. 
 
 Pathology. — The pathological changes in an acute brain abscess 
 are the same as those occurring in an abscess formation in any part 
 of the body, altered only by the special structure involved. Fol- 
 lowing the infection we have the same death of tissue and the same 
 protective processes that occur elsewhere. 
 
 A microscopic specimen exhibits an inner zone of dead tissue 
 and pus, necrosis from strangulation, and leucooytosis. If the infec- 
 tion is virulent enough to break dovm completely any attempted 
 resistance of the part, there follows an extension of this process — 
 
62 BEAIN ABSCESS 
 
 an extending death of tissue — and beyond, in tlie still living cerebral 
 tissue, an intense oedema with thrombosis of the vessels, and hemor- 
 rhage. In such a case death of the patient occurs within a few 
 hours of the original infection : fulminating infective encephalitis. 
 
 When the infection is not so virulent, protective processes are 
 present. In the microbiotic zone, in which the bacteria and their 
 toxins have caused a disappearance of the nerve cells, the glial cells, 
 although altered, are still present, and external to this zone there 
 is an area of round cell infiltration — from which iJie leucocytes have 
 been called from the blood vessels to the brain for its protection — \ 
 associated with vascular thrombosis and with a meshwork of fibrin.^* 
 
 The microscopical picture of an acute brain abscess gives the gen- 
 eral impression that the chief limiting process is thrombosis of the 
 vessels, and hemorrhages, just as the formation of a new connective 
 tissue is the chief limiting process in chronic brain abscess. 
 
 In this area of infiltration from the lymphocytes, the nerve cells 
 are also dying or dead, but the neuroglia on the other hand show a 
 certain amount of proliferation. Blood vessels now rapidly bud in 
 this zone, each blood vessel simply being a blind endothelial tube from 
 which fibroblasts spring. 
 
 Surgical Pathology. — If an acute abscess is now attacked by 
 the surgeon, and during the evacuation and the subsequent intro- 
 ^uption of a drain hemorrhage from the vessels occurs, the delicate 
 protective mechanism is broken down, the oedema of the adjacent 
 cerebral tissue is greatly increased, the inflammatory process acquires 
 a fresh momentum from the trauma of the operation and the irrita- 
 tion of the drain, and death is apt to follow rapidly. (See Figs. 
 23, 24.) 
 
 The Surgical Aims should be limited to, (1) the location of 
 the abscess; (2) the relief of compression by as complete evacuation 
 of the abscess as possible without trauma to the cerebral tissue; and, 
 where the suppuration is intracerebral, to (3) the establishment of 
 an area of protective adhesions into the abscess cavity. 
 
 Methods of Treatment. — A clinical diagnosis of acute abscess 
 without capsule having been made, one of two methods must be 
 adopted. Either, (1) exploration through a large dural opening, 
 followed by complete evacuation if a piarachnoid abscess is located, 
 or, if an intracerebral abscess, by as complete evacuation as is pos^ 
 sible through the searcher, with tight closure of the dura excepting 
 such as is sufiicient to admit of the exit of the searcher ; or, (2) a 
 
 •• HasBln, G. B. : Hlstopathologlcal Studies In Brain Abscess ; Medical Record, 
 January 19, 1918, Vol. 93, p. 91. 
 
%' 
 
 Fig. 23. — Microjihotograph showing intense oedema, round cell infiltration 
 and multiple hemoirhages in an acute cerebral abscess. Death 24 hours after 
 evacuation, without return of consciousness. 
 
 Fig. 24. — Microphotograph showing areas of hemorrhagic encephalitis, fol- 
 
ABSCESS OF MIDDLE FOSSA 63 
 
 hollow needle puncture through the intact dura, the primary aim of 
 the puncture being the location of the abscess and the establishment 
 of a tract of protective adhesions through the piarachnoid into its 
 cavity. 
 
 Were it possible uniformly to differentiate acute non-capsvlated 
 introrcerehral, from piarachnoid abscess prior to operation, the punc- 
 ture method would be preferable, since in acute intracerebral abscess 
 the puncture, with but slight damage to the cerebral tissue, partially 
 relieves the compression by the partial evacuation. 
 
 Unfortunately our diagnostic methods do not allow of such accu- 
 rate differentiation, and if the puncture method is uniformly adopted 
 many superficial piarachnoid abscesses will fail of localization, 
 as has been the author's repeated experience. Consequently he has 
 for years advocated and practised a dural opening large enough to 
 admit a thorough inspection of the adjacent piarachnoid; and in case 
 a piarachnoid abscess is not found, exploration into the brain sub- 
 stance without injury to a cortical vessel, with partial evacuation of 
 the abscess and tight closure of the dura around the exploring instru- 
 ments, which may or may not necessitate a second operation for com- 
 plete evacuation, cleansing, and obliteration after the capsule has 
 been found. 
 
 In 1914, before the New York Academy of Medicine, the author recorded: — 
 "I am persuaded that the operation for acute intracerebral abscess, especially if 
 situated more than two or three centimeters from the surface, should be con- 
 ducted in two stages. My opinion is based upon almost a complete failure to 
 effect a cure by means of exploration and introduction of drainage material into 
 the brain in cases of acute, subcortical, intracerebral abscess. 
 
 Post-mortem examinations of acute intracerebral abscesses so treated re- 
 vealed intense cedema and multiple punctate hemorrhages, while the drain was 
 invariably found lying in the brain itself, entirely outside the abscess cavity, thus 
 only exaggerating a previously bad condition. In my opinion it is better not 
 to introduce drainage material at all than to damage brain tissue in an un- 
 successful attempt to drain the cavity. When the operation is undertaken in 
 two stages the first procedure should consist simply of the evacuation of the 
 cavity with a minimum of traumatism." 
 
 CASE xrn. 
 
 Mrs. H.: — Acute Adjacent Temporo-sphenoidal Lobe Abscess. Eight 
 middle ear disease, without discharge two weeks previously. 
 
 Present History. — Fourteen days previously suddenly had a severe pain in 
 the right ear, accompanied by a chill. No discharge. Pain lasted twenty-four 
 hours and then stopped. Temperature about 102 degrees. Few days later: — 
 temperature ranged from 102 to 105 degrees; respiration, 32 to 36; pain in back 
 
 " Lemaltre, P. : "L'Bxclusion des especes sous-arachnoldiens" (Bxcluslon of the 
 Subarachnoid Spaces; application to the treatment of cerebral and cerebellar abscesses 
 of otitic origin, and in a general way to brain surgery) ; Revue de Ohirurgie, 1919. 
 Tome LVII, p. 497. 
 
64 BEAIN ABSCESS 
 
 of head recurred and persisted. Consolidation of lung was diagnosed, although 
 no cough was present. 
 
 A few days before examination there were mental symptoms; pulse slow; 
 patient delirious at times, at other times more or less lethargic; temperature 
 normal. No vomiting, hut nauseated once — thought to be due to tobacco smoke 
 in the room. No dizziness. Temperature irregular, ranging from normal to 103 
 degrees. 
 
 Examination on fourteenth day of illness: — patient more or less lethargic; 
 can be aroused and answers questions well — it seems as if she answers too well, 
 for although she keeps her eyes closed she is conscious of all that goes on around 
 her. Eight optic disc margin slightly indistinct, veins full; left margin clear, 
 but veins full. Hears well with both ears. 
 
 Slight weakness of left arm, which appeared for first time at this examina- 
 tion. Has a very bad odor to her breath. The membrane of her mouth is 
 swollen. She has no Kernig; no Babinski. Temperature which had ranged 
 from normal to 101 degrees in last few days, suddenly rose to 103: slight chill. 
 Lumbar puncture gave high cell count; no bacteria. 
 
 Two Days Later. — ^In deep coma; cannot be aroused; incomplete paralysis 
 of left arm. During last two days several attacks of choking and cessation of 
 respiration. 
 
 Operation on Sixteenth Day of Illness.— As there was some doubt whether 
 patient was suflfering from encephalitis lethargica or brain abscess, the only ear 
 symptoms recorded having been pain which lasted twenty-four hours and had 
 never been followed by discharge, it was decided to explore the mastoid first, and 
 if evidence of disease was found, then to explore the brain. The mastoid antrum 
 and a few cells were found to contain granulations and a few drops of pus. 
 (Smear and culture from cells and antrum negative.) 
 
 Through a clean field above the mastoid and ear the bone under the temporal 
 muscle and over the squamous portion of the temporal was removed and the dura 
 exposed for an area about two inches in length by one and one-half inches in 
 breadth. A small opening through the dura failed to reveal pus in or on the 
 surface of the brain. A puncture of the brain through the opening, with hypo- 
 dermic needle at depth of one inch from the cortex revealed thin pus. On 
 account of small size of needle the flow was very slow and soon stopped 
 altogether. 
 
 Needle left, and held in position by numerous small pledgets of wet cotton 
 pyramided around it. Muscle and skin closed except for pyramided area. 
 
 At the beginning of the operation the blood pressure was 170, rising to 190 
 and falling immediately to 155 upon the partial evacuation of the abscess. Cul- 
 ture from pus from brain revealed streptococcus. 
 
 Two Days after Operation. — Patient has regained consciousness, recognizes 
 objects and talks, but is still very lethargic. Left arm and leg both almost com- 
 pletely paralyzed. Slight papillcedema of both eyes. No drainage through the 
 needle, but considerable over and around it, as if it had discharged for some 
 time and then stopped. On passing wire through needle there was no pus. 
 Patient gradually improved. Moved fingers of left hand and toes of left foot for 
 first time in several days. 
 
 Subsequent History. — During the subsequent treatment of the abscess it was 
 twice lost, and refound because of filling again with pus. A larger drainage 
 tube was at last properly placed within the abscess cavity. The papillcedema 
 persisted for over six weeks after the operation. The patient ultimately com- 
 pletely recovered. 
 
 Comments. — In this case we caused (1) slow evacuation, thus relieving the 
 compression; then (2) the establishment of a small tract; later (3) the en- 
 largement of the tract and again evacuating. During this treatment there waS 
 
ABSCESS OF MIDDLE FOSSA 65 
 
 opportunity for the acute abscess to be converted into (4) a chronic abscess with 
 a capsule. The continuation of the papilloedema may have been due to the lack 
 of a wide decompression, or a displacement of the brain bulk may have been a 
 factor. 
 
 The abscess was certainly touched at its side and not in the center — the 
 collapse of its walls twice causing the loss of the cavity, which was not found 
 again until it had refilled with pus, thus demonstrating the necessity of as com- 
 plete evacuation as possible in acute as well as in chronic abscesses. 
 
 The leucocytosis three days after the operation was 24,000, with 83% pqly- 
 morphonuclears. It rapidly fell to normal — 6200 to 8800 — in spite of the abscess 
 refilling twice, showing that routine cell counts are of very limited value after 
 evacuation as to the progress of the case. 
 
 The object of the operation is the evacuation of the abscess and 
 the collapse of its walls, with the least possible associated trauma to 
 the cerebral tissue. By the evacuation some of the infective material 
 is removed and this, with the associated relief of tension, may allow 
 time for the tissue to develop resistance and the formation of a 
 capsule. Later, should the symptoms recur, the area of suppuration 
 being now limited, the abscess may again be explored, when, as in 
 one of my cases, the meninges will be found walled off — a very 
 important aid. The abscess may now be fully evacuated and drain- 
 age material introduced. 
 
 Technic. — In exploring for an acute abscess, three inches of the end of a soft 
 rubber catheter containing two holes, with a flexible metal stylet, should be 
 used. The stylet should occupy but a small part of the lumen of the catheter, 
 so as to allow the thin pus to flow through the catheter with the stylet in 
 place. On locating the abscess the greatest care must be taken not to displace 
 the catheter. All pus presenting is collected by a suction apparatus. After pus 
 has ceased flowing the stylet is removed and the catheter cut off flush with the 
 skin, to which it is attached by a silk suture. The patient should then be in- 
 verted. If the abscess is very acute the catheter may be withdrawn; if of longer 
 duration, the dural opening should be entirely closed except for the small open- 
 ing through which the catheter passes and which it should entirely flU. The skin 
 opening should be tightly closed, except for a similar opening. 
 
 The technic of the second complete evacuation is that adopted in chronic 
 intracerebral abscess. 
 
 CLOSUKB. 
 
 In all cases of brain abscess, chronic or acute, the abscess having 
 been entirely evacuated, the brain should be as completely covered 
 as possible. If the technic of evacuation has been perfect, the dura 
 can be almost closed, the small area which carries drainage into 
 the abscess cavity alone being unprotected by the dura. 
 
 Many otologists and surgeons disregard the fact that all drain- 
 age material within the dura is dangerous, especially if it is absorbent. 
 To place dry gauze over an exposed area of piarachnoid over which 
 
66 BEAIN ABSCESS 
 
 a dressing is introduced, is simply to invite disaster, As a proof of 
 this, witness the very extensive superficial brain necrosis often found 
 at autopsy after so-called "free" drainage. 
 
 If a drainage tube or strip of rubber tissue has been introduced 
 into the abscess cavity, a tract for the drainage material should be 
 made to the nearest external surface, through dura, bone, and skin. 
 Over all the remaining area, dura, bone and skin should be covered, 
 unless the soft parts are so wet that it is thought advisable to place 
 a drain between the dura and the bone. 
 
 It is not an uncommon experience to find, at the end of an intra- 
 dural manipulation, that the protruding brain prevents the complete 
 closure of the dura. When it does occur, the piarachnoid should 
 be covered with a piece of fascia lata stitched firmly to the dural 
 defect, over which as much as is possible of the bone flap should 
 be placed, and the fascia, muscle and skin lightly closed. 
 
 It is best to leave all drainage undisturbed for several days, dur- 
 ing which an organized wall is being built along the tract, thus plac- 
 ing the tract in reality outside the brain tissue. Further manipula- 
 tions along this tract, such as the re-introduction of drainage or of 
 the encephaloscope, should be conducted, if at all, without the slight- 
 est injury to this wall. During recent years, in my successful cases, 
 the drainage material has been left entirely alone for rather long 
 periods. As it is slowly expelled by the brain, it is carefully cut 
 off, care being taken to anchor the end. After a period of from 
 two to five weeks, depending upon the depth of the abscess, its size, 
 duration and amount of discharge, the last piece of drainage is 
 removed. 
 
 Additional Referenoes to Double Ahsoess. 
 
 Miiller, R. : Doppelter otitisoher Schlaf enlappenabszess ; Zeitsehrift filr Ohren- 
 heillcunde, 1910, Bd. LXI, S. 183. 
 
 Urbantschitsch, E. : Zweifacher rechtsei tiger Schlaf enlappenabszess : Opera- 
 tion: Heilung; (Double Right-sided Temporal Lobe Abscess; Operation; Re- 
 covery) ; Wiener Klimsche Wochensehrift, 1916, Bd. XXIX, No. 47, S. 1507. 
 
 Additional References to Tem/poro^ Sphenoidal Brain Absoess. 
 
 Ruttin, E.: Schlafeulappenabszess mit Infektion des rechter Unterhoms, 
 Pyocephalus, Meningitis, Exitua; International OentraXhlatt filr Ohrenheilkunde, 
 1909-10, Bd. VIII, S. 379. 
 
 Voss, F.: Encephalitis hemorrhagica und Schlafeulappenabszess nach Otitis 
 media; Zeitsehrift filr Ohrenheilkunde; Bd. LXI, S. 323. 
 
 Beliuoff, S. ; Ein Beitrag zur Kasuistik des otitischen Hirnabszesses; Klim- 
 ische Beitrage emr Ohrenheilkunde, 1919, p. 89. (Adjacent abscess lighted into 
 activity by trauma.) 
 
 Urbantsohitsoh, E.: Eitrige Meningitis und Schlafeulappenabszess; (Puru- 
 
ABSCESS OP MIDDLE FOSSA 67 
 
 lent Meningitis und Temporo-sphenoidal Lobe Abscess) ; Wiener Klmisoher 
 Woohensohrift, 1918, Bd. XXXI, S. 794. 
 
 Mlygind, S. H. : Haemorrhagia Meningea, resembling cerebral abscess of 
 otitic origin; Ugesk. for Laeger K0henh., 1919, Vol. LXXXI, pp. 1836-38. 
 
 Bodkin, H. : A Case of Cerebral Abscess of Otitic Origin; British MecUoal 
 Journal, 1917, I, p. 510. 
 
 Nauwerck: Zur Kenntniss des chronischen, traumatischen Hirnabszesses; 
 Miinohener medisinisoher Wochensohrift, 1917, Bd. LXIV, S. 109. 
 
OHAPTEK V. 
 METASTATIC ABSCESS. 
 
 CLASSIFICATION. 
 
 The accepted classification of brain abscess of otitic, rhinitic, 
 or metastatic origin calls for modification. Many abscesses orig- 
 inating from the ear and the nasal sinuses are pathologically and 
 clinically metastatic and should be so classified, their symptomology 
 permitting differentiation from the usual adjacent (secondary) 
 abscess of aural or nasal origin. 
 
 The classification of brain abscess into Adjacent (secondary to 
 aural or nasal suppuration), and Metastatic (from lungs, heart, ear, 
 etc.), as suggested elsewhere in this monograph (Chapter III., 
 p. 17), is based upon two distinct types of pathological process: — 
 the adjacent type, invading the brain by direct extension either 
 through tissue suppuration, or by way of a thrombophlebitis, or 
 perivasculitis, and the metastatic form, which is of hematogenous 
 origin. 
 
 Erom a pathological standpoint a brain abscess which originates 
 from an infection free in the blood stream is truly metastatic 
 whether the primary focus be situated in the ear or in the lung. 
 The classification into Adjacent, Metastatic and Traumatic will 
 explain many reported cases otherwise enigmatic — such as abscess 
 of otitic origin of the opposite hemisphere^ — ^while clinically it will 
 prove of assistance in diagnosis and surgical treatment. 
 
 DEVELOPMENT. 
 
 Adjacent Abscess. — Adjacent brain abscess, as the name im- 
 plies, is anatomically adjacent to the primary focus of infection, viz., 
 mastoid antrum and middle ear, labyrinth, or nose, to which it is 
 directly connected by a pathological process. Its position within 
 the brain, therefore, must be more or less definite, being prescribed 
 by anatomical relationship. The infection from the ear or nasal 
 sinus extends into the cerebral tissue by continuity of tissue sup- 
 puration, or necrosis, or by contiguous extension through a venous 
 
 68 
 
METASTATIC ABSCESS 69 
 
 wall or a perivascular space — retrograde thrombophlebitis or peri- 
 vasculitis. 
 
 Eetrograde thrombophlebitis of a cerebral or pial vein follows 
 the course of thrombotic formation in general; it advances in the 
 wall of the vein — a phlebitis — or in a perivascular space. The 
 phlebitis or perivasculitis is followed first by a parietal, and later 
 by an obliterating thrombus. A blood-stream infection, if present 
 at all, is secondary to the thrombus formation. In accordance with 
 thrombotic formation in general, the process is comparatively slow. 
 
 The chief surgical and diagno&tic difference between the forma- 
 tion of an abscess from retrograde thrombosis and from a metastasis 
 is based on the fact that in the former the protective mechanism 
 of the brain has time to assert itself while the circulation is still 
 ■ active and before the death of cerebral tissue takes place. If the 
 symptoms are present at all at this time, they must of necessity be 
 trivial since they are due to a normal reactive process. Likewise, 
 the clinical symptoms of adjacent abscess develop gradually; they 
 are never apoplectiform. 
 
 Metastatic Abscess. — ^Metastatic abscess follows the occlusion 
 of a cerebral vessel by an infected nidus circulating freely vnthin 
 the blood stream itself. Bacterial infection of the blood stream 
 alone apparently is not sufficient to produce a brain abscess. In the 
 numerous experiments of Weed and his associates ^ with direct blood- 
 stream infection, only one superficial abscess (from infection of a 
 perivascular space) developed. The blood stream is intolerant of 
 the presence of micro-organisms within itself. EoUowing injections 
 of micro-organisms into the blood stream, the blood soon eliminates 
 them and rapidly becomes sterile again. An additional factor, 
 apparently, is necessary ; this is probably supplied by a minute septio 
 nidus small enough to pass through the capillaries. Toxaemia causes 
 great damage to the intima of the blood vessels because of the slow- 
 ness of the venous circulation, and a toxsemic nidus finds a favorable 
 condition in the intima for the rapid growth of a thrombus which 
 soon may become of embolic nature. 
 
 Metastatic Vascular Occlusion. — The onset of metastatic 
 brain abscess is sudden, apoplectiform, because the bacteria, sud- 
 denly closing the vessel, cause apoplectiform symptoms — a sudden, 
 violent headache, transient dizziness, projectile vomiting. These 
 symptoms may be slight, and apparently transient, but the sudden 
 
 J Weed, D. H., Wegeforth, P., Felton, J. B., and L. D. : Meningitis Produced by 
 Intravenous Inoculation ; Monographt Bookefeller Institute for Ue^ical Reieareh, 
 Marcb 25, 1920, No. X2, pp. 57-112. 
 
70 BEAIN ABSCESS 
 
 vascular occlusion causes immediate nutritional death of the cerebral 
 tissue.^ 
 
 The focus of original infection is generally distant from the 
 brain — in the lungs, the heart, or the pleura — ^but numerous cases 
 are on record of the infecting nidus originating from blood vessels 
 contiguous to the ear. In a case reported by Berens,* infection 
 originated from thrombus of the internal carotid artery; in one of 
 the writer's from the lateral sinus. Oases resulting from abscess 
 at the surface of the body are not of common occurrence, but 
 Kutzinski and Marx * report one in which abscess of the frontal lobe 
 apparently resulted from a purulent process in the finger. All such 
 cases should be classified as metastatic. The usual explanation that 
 metastatic abscess is always of embolic arterial origin has not been 
 substantiated by the author in an examination of the post-mortem 
 records.^' ® 
 
 Won-suppurative arterial occlusion is comparatively frequent, 
 but it does not occasion abscess formation although the symptoms may 
 simulate those of abscess when associated with a suppurative process. 
 
 CASE xrv. 
 
 A. S.: Thrombosis of Cerebral Vessels. Child, aged seven months. 
 
 History. — The father died from tuberculosis when the child was only a few 
 months old. The child seemed perfectly well until one day it suddenly cried, 
 had a convulsion, and was brought to hospital with twitching of its right upper 
 lid, corner of mouth, and right arm and leg, with a lateral deviation of its eyes 
 to the left. O. E. negative. On following day spastic paralysis of right arm and 
 leg. Developed otitis media in left ear; right ear began discharging about four 
 days after admission to hospital, with swollen area over mastoid. Nystagmus to 
 left, continued lateral deviation of eyes to left. Continued twitching of right 
 arm and leg; facial paralysis; frequent slight convulsions, followed by profuse 
 perspiration. Increasing coma. Temperature normal until three or four days 
 before death, when it ran to 105 and 108 degrees. Child died three weeks after 
 admission to hospital. 
 
 Diagnosis. — Inherited tuberculosis from father, . followed by acute tubercu- 
 losis, with thrombosis of cerebral vessels from tuberculous infection. 
 
 Autopsy Findings. — On opening skull the left frontal lobe was found soft- 
 ened — not an abscess, but nutritional disturbance from vascular occlusion. The 
 softening extended over to right frontal lobe, with portions of infiltration where 
 blood had been effused into the brain. The right hemisphere showed signs of 
 increased intracranial pressure. Embolus in anterior cerebral artery, causing 
 degeneration of the whole frontal lobe. Around the place where the thrombus 
 
 ' Moore, John T. : Blastomycosis. With Report of Case Dying from Abscess of 
 the Brain ; Sur., Oyn. and Ots., December, 1920, pp. 590-594. 
 
 " Berena, T. Passmore : Atmale of Otology, RMnology and Laryngology, 1913, Vol. 
 XXII, p. 448. 
 
 * Kutzinski, A., and Gerlchtsarzt, Marx : Hirnabszess als Polge peripherer KBrperei- 
 terung naeh einem UnfaU ; MonatschHft fUr Paychiatrie und Neurologle, October, 
 1914, S. 255. 
 
 ■ Schorsteln : Lancet, 1909, II, p. 843. 
 
 " Cayley : Abscess of the Brain Associated with Bronchiectasis ; TratuacHons of 
 the Pathological Sooiety of London, 1884, Vol, XXXV, p. 12. 
 
METASTATIC ABSCESS 71 
 
 occurred there was hemorrhagic infiltration. Examination of right ear showed 
 grumous material in the middle ear and antrum; area of bone around seemed 
 softened. The left ear also contained grumous material. 
 
 Metastatic Abscess of Venous Origin. — The vast majority of, 
 if not all, metastatic brain abscesses are undoubtedly of venous origin, 
 for bere, as in embolus of thrombotic origin in general, conditions are 
 favorable for its development, while the rapidity of the arterial flow, 
 assisted by the brain's protective mechanism, tends to prevent the 
 lodgment and growth of a small infected nidus in the arterial circula- 
 tion. This view explains and is substantiated by the relative infre- 
 quency of brain abscess in ulcerative endocarditis, in which large 
 numbers of infected nidi are carried to the brain by the arterial cir- 
 culation. 
 
 Origin of Thrombotic Nidus. — Parietal venous vegetations 
 are more frequently associated with mastoiditis and sinus phlebitis 
 than is generally supposed, the vegetations grossly resembling those 
 of the heart in acute endocarditis. 
 
 CASE XV, B.; 
 
 Meningitis from Labyrinthitis; with Beginning Thrombi and Vegetating 
 Thrombus in Ixjngitudinal Sinus ; Male. 
 
 History.— Always subject to headache. Had had an attack of influenza, fol- 
 lowed by sharp pain in right ear. Spontaneous rupture of drum membrane. Ear 
 continued to discharge for about six weeks; during entire time patient swayed 
 to right and complained of pain on right side of head. Lost considerable flesh. 
 Attended to his business until physician ordered him to country. While away, 
 had a distinct chill and severe headache, and vomited during the night. Lumbar 
 puncture gave an excessive amount of fluid imder pressure, slightly turbid or 
 yellowish, looking like urine and containing a large number of polymorpho- 
 nuclear leucocytes; apparently sterile. Totally deaf in right ear. Examination 
 revealed no discharge from this ear. A teat-like projection was seen in lower 
 quadrant. Marked nystagmus at outer comer. 0. E. gave fulness of the veins; 
 no spontaneous pointing deviations. 
 
 Operation. — Mastoidectomy. The whole mastoid was sclerosed, being abso- 
 lutely solid. Exploration of the cerebellum negative. 
 
 Patient was in deep coma the day following operation, and died three days 
 later with marked symptoms of suppurative meningitis. 
 
 Autopsy Findings. — The bone was hardly cancellous to the naked eye and 
 was sawed with great difficulty. The piarachnoid was infiltrated with pus. The 
 Pacchionian bodies were prominent alongside the longitudinal sinus. On opening 
 the superior longitudinal sinus the cavity was found to contain a cluster of 
 vegetations posteriorly to a plane corresponding to the occiput. These vegeta- 
 tions were not unlike those seen in the valves in bacterial endocarditis. Some 
 were friable and could be torn off easily, the majority were fibrous, were well 
 organized and could not be stripped off. They almost obliterated the lumen of 
 the sinus. The right labyrinth, converted into one large, mouse-eaten cavity, 
 contained a thick film of foul-smelling pus. 
 
 Smears made from the right middle ear, labyrinth, meninges, and some of the 
 vegetations in the longitudinal sinus, showed streptococci. Sections of the longi- 
 
72 BEAIN ABSCESS 
 
 tudinal sinus where the vegetations occurred showed the wall to be thickened 
 by fibrosis. The vegetations sprang from the intima and consisted of a stem 
 of connective tissue in which there was a marked infiltration of small and large 
 mononuclears and polyblasts. In some of the more recent ones polynuclears were 
 abundant. 
 
 Comment. ^Undoubtedly the severe pain in the back was due to lodgment of 
 
 embolic portions of the sinus in the small vessels of the cord. Without having 
 obliterated the sinus, the vegetations were being given off into the circulation 
 all the time. 
 
 A venous sinus vegetation, if detached, need not necessarily go 
 through the entire circulation before again entering the cerebral 
 venous circulation. Arnold "^ has demonstrated experimentally that, 
 on injection of bran into the large veins of the neck in case of inter- 
 ference with the normal intrathoracic negative pressure, particles of 
 the bran are found in the opposite venous sinus. According to his 
 experiments the venous circulation from the head toward the heart 
 is reversed when a positive intrathoracic pressure is encountered. 
 Mechanically, then, disturbance of the return venous circulation, such 
 as an occluding thrombus or temporary compression from a tampon, 
 may cause a reversal of the current from one venous sinus to that of 
 the other side, there being no obstructing valves.® These factors, asso- 
 ciated with a disturbance of the protective mechanism of the brain, 
 render possible the lodgment and growth of the embolic thrombus. 
 The protective mechanism of the brain is easily interfered with by 
 circulatory disturbance, as demonstrated by Weed,® by the produc- 
 tion of meningitis from a blood-stream infection by jugular decom- 
 pression. Arnold's ^^ observation provides an explanation of abscess 
 of the brain on the opposite side from the ear lesion, such as that 
 referred to by Japha,^^ Quimby,^'^ Lossen,^^ and Maier,^* or of any 
 of the unusual sites of abscess formation in the frontal or occipital 
 lobe from ear suppuration,^^ or in the parietal from nasal infection. 
 
 Feequenot. 
 
 Abscesses of the brain of metastatic origin, while of relatively 
 rare occurrence, are much more frequent than is generally recognized. 
 
 'Arnold, J.: tJeber RUckiauflgen Transport; ArcMv. fur Pathol., Anat.. und 
 Physiol., 1891, Ba. 124, S. 385. 
 
 • EJQOtt, J. F. : The Cerebral Sinuses and their Variations ; Trans. Int. Med. Con- 
 gress, London, 1881, Vol. I, p. 191. 
 
 • Weed, L. H. : Production of Meningitis by Release of Cerebro-spinal Fluid : Jour. 
 Am. Med. Assoo., 1919, Vol. 72, p. 191. 
 
 w Arnold, J. : Loo. cit. 
 
 " Japba, A. : Zur Diagnostil£ der Herderkranlsungen des Gehirns : Zeit. fur Prak. 
 Aerate, 1898, VII, 701. 
 
 " Qulmby, Wm. O. G. : Personal Communication. 
 
 "Lossen, W. : BeitrSge zur Diagnose und Therapie der Kleinhirnabszesse (Case I) ; 
 BeitrUge z. KUih Chvrurgie, 1903, Bd. 39, S. 804. 
 
 "Maier, M. : Erfahrungen iiber den otitischen Hlrnabszess : Arohiv filr Ohren- 
 heiVmnde, 1914, Bd. 95, S. 163. / ' " «">"' 
 
 "Berens, T. Passmore: Abscess of Frontal Lobe of the Brain, with Exhibition 
 of Specimens; Tr<ma. Amer. Otol. 8oo., 1913, Vol. XIII, Part I, p. 66. 
 
METASTATIC ABSCESS 73 
 
 About twelve per cent, of these abscesses are caused by suppurative 
 pulmonary disease; ^* approximately an equal percentage have their 
 origin in pyemic foci other than those situated in the lungs ; and a 
 small number are due to amcebic dysenteric disease of the liver; ^''' ^* 
 vrhile in a certain proportion of cases the cause is unknown.^* A 
 number of so-called "idiopathic" brain abscesses have been re- 
 ported,^''' ^^ in vphich a careful post-mortem examination failed to dis- 
 close a primary cause in any other organ (see page 110), although 
 the demonstration of the fusiform bacillus in the tonsils ^^ and of the 
 fusiform bacillus and anaerobic streptococci in the lungs has recently 
 diminished the number. 
 
 In 1915 the author reported a metastatic abscess originating in the 
 ear ; since that time an analysis of recorded cases of brain abscess has 
 confirmed the opinion that certain abscesses originating from the ear 
 and nose are of a clinical type different from the usual adjacent 
 abscess. In common with all metastatic, abscesses of the lungs, the 
 liver or the heart they have an apoplectiform onset, and, not being 
 limited by the anatomical relationships that more or less restrict an 
 adjacent abscess, they may be situated in any part of the brain. 
 
 Examination of cases of abscess of the frontal lobe of aural origin, 
 of the temporo-sphenoidal lobe of the opposite side of the cerebellum 
 of nasal origin — in fact of all the cases of abscess not adjacent to 
 the suppuration — substantiates this view.^^' ^*' ^^ Groth ^* collected 
 thirty-three cases of abscess of the brain due to pulmonary affections, 
 and in his review he endeavors to explain the frequency of brain 
 abscess in suppurative pulmonary disease on the one hand, and its 
 relative infrequency in suppurative endocarditis on the other, by 
 attributing it to mechanical conditions in the circulation. This, how- 
 
 " Meyer, E. : Bin Fall von gangranoser LungentzUnduog mit metastlschen Abszes- 
 sen in Leber und Hlrn und Bemerkungen zur Symptomatologie and Diagnose des Hirn- 
 abszesses ; Berlin Klin. Woohenschrift, 1868, Bd. 5, S. 429. 
 
 " Couteaud : Absc6s metastiques de I'encfiphale en rapport avec les suppurations 
 hfipato-pulmonalres ; Revue de Chirurgie, July, 1913, Tome XXXIII, No. 7, p. 91. 
 
 " Armitage, P. L. : Amoebic Abscess of Brain ; Journal Trap. Med. and Hyg., April 
 15, 1919, p. 69. (States that 43 out of 45 cases followed liver abscess.) 
 
 " Gowers, W. R. : Diseases of the Nervous System ; London, 1893, Vol. II, p. 
 470. (States fifteen per cent.) 
 
 2° Henderson, J. : A Case of "Idiopathic" Cerebral Abscess ; Lancet, London, May 
 31, 1913, I, p. 1525. 
 
 '^ Reynolds, Cecil E. : A Case of Brain Abscess ; Jour. Amer. Med. Assoc., Feb- 
 ruary 7, 1914, Vol. 62, p. 449. 
 
 " Dick and Bmge : Brain Abscess Caused by Fusiform Bacilli ; Jour. Amer. Med. 
 Assoc, February 7, 1914, Vol. 62, No. 6, p. 446 ; Trans. Chicago Path. Soo., 1914, IX, 
 p. 995. 
 
 ^ Tyler, Christopher : The Paths of Encephalic Infection In Otitis : Brain, London, 
 1912-13, Vol. XXXV, p. 109. 
 
 " Berens, T. Passmore : Brain Abscess with Unusual Features ; Annals Otol., 
 RMnol., Laryngol., 1910, Vol. 19, p. 218. 
 
 "■ Lombard, Bloch A., Moulouguet, A. : Un cas d'abscSs du lobe frontal du c6t6 
 opposfi a. une otite suppurfie chronique; Armal des Maladies de I'Oreille; 1914, Tome- 
 90, p. 749. 
 
 '» Groth, W. : Beltrag zu den Metastatischen Himabszessen pulmonalen Ursprungs ; 
 InaugureA DU/sertatiom, Berlin, 1910. 
 
U BEAIN ABSCESS 
 
 ever, may be more satisfactorily explained by assuming a throm- 
 botic, not an embolic origin. 
 
 It is a clinical fact of great importance that while suppurative 
 diseases of the lungs, particularly bronchiectasis,^'^' ^* frequently 
 cause abscess of the brain, suppurative endocarditis rarely does so, 
 although the size and directness of the arteries from the heart to the 
 brain would lead one to expect abscess of the brain to be a frequent 
 complication of suppurative endocarditis. Such, however, is not the 
 case;^® while metastatic abscess of the kidneys and spleen are com- 
 mon in suppurative endocarditis, brain abscesses only infrequently 
 occur, but one case having come under the author's observation. Ac- 
 cording to Sperling,^" in seventy-six cases of endocarditic emboli 
 from the left heart, metastatic abscess occurred in the kidneys in 
 fifty-seven, in the spleen in thirty-nine, and in only fifteen in the 
 brain. 
 
 Abscess of the brain secondary to suppuration in the lungs would 
 appear to be primarily thrombotic or venous in origin, the brain 
 being peculiarly susceptible to such infections ; whereas abscess result- 
 ing from suppurative endocarditis may be primarily embolic, against 
 which the brain may possess a resistance not present in the spleen 
 and kidneys. EouUand's successful case ^^ demonstrates that 
 prompt surgical procedure offers a fair prospect for recovery in 
 metastatic abscess of pleuro-pulmonary origin. 
 
 Location. — In pulmonary disease the left side of the brain is 
 the site of metastatic abscess three times more frequently than is the 
 right (Gowers), and the frontal lobe is especially apt to be the site 
 of the abscess.*^ 
 
 In proposing exploration in metastatic brain abscess the surgeon 
 is confronted with a question of the greatest importance in relation 
 to the future surgery of this condition : — "In the event of an abscess 
 being found, will the paralysis be cured ?" 
 
 If the pathology of metastatic brain abscess is that of an infective 
 embolus carried from a distance and deposited in a terminal cerebral 
 artery, acting simply as a local embolus with a secondary infection of 
 the surrounding tissue, and if the suppurative embolus involves the 
 
 " Sehorsteln : Cerebral Abscess in Diseases of Lung : Lancet, London, September 
 18, 1909, p. 843. 
 
 2* Menetrier, P., et Durand : AbscSs <Ju cerveau localise par une traumatlsme chez 
 un sujet porteur de dilatations bronchiques; Bull, et Mim. Sae. MM. des H6p., 1920, 
 III, Series No. 27, p. 1066. 
 
 =» Krause : "Surgery of the Brain ; 1900, Vol. Ill, p. 924. 
 
 '" Sperling : Inaugural Dissertation ; 1872. 
 
 ■1 EouUand, H. : Abscfis mStastique <3u cerveau au cours d'une suppuration pleurale. 
 Trepanation, drainage de VabscSs, Gu6rison. Paris Ohirurgical, 1917, Tome IX. p. 
 613. 
 
 "" Couteaud : Trois cas d'abscSs du cerveau consficutifs a des absc6s du foie : 
 Bulletin de I'Acadimie de Midecine, 1011, Tome 65, p. 359. 
 
METASTATIC ABSCESS 75 
 
 same vessel from whicli hemorrhage generally occurs, — ^the so-called 
 "artery of cerehral hemorrhage"^ — then the draining of the abscess 
 will not relieve the paralysis, as these branches, being terminal, 
 have no anastomotic communication in non-suppurating vascular 
 disease. 
 
 In answering this question it should be realized that the paralysis 
 or loss of function caused by abscess of the brain from direct exten- 
 sion from adjacent suppurative lesions invariably disappears after 
 evacuation; and if metastatic abscesses of the brain are thrombotic 
 and deposited in the veins and not in the arteries, then drainage 
 should have a decided effect on the relief of the paralysis. 
 
 Oadwalader ^^ has shown that in apoplexy the spontaneous 
 intracerebral hemorrhages are apt to be large, and that when this 
 is so they almost invariably cause death; while complete recovery 
 from cerebral vascular occlusions and later softenings frequently 
 takes place. 
 
 Multiple Metastatic Abscesses. — Metastatic abscess may be 
 multiple, due to the involvement of the blood stream itself. In 
 this respect it differs from adjacent abscess which, from its etiologi- 
 cal pathology is single, at least originally, unless complicated by 
 another process, such as trauma. On account of the tendency of 
 suppuration to extend along the white fiber tracts, leaving the better 
 nourished gray matter, the abscess may have prolongations which 
 have frequently been mistaken for separate abscesses. It has been 
 frequently observed, however, that metastatic cerebral abscesses 
 secondary to suppurative disease of other parts of the body are 
 usually multiple. This has been the author's experience. 
 
 CASH XVI, T. v.: 
 
 Autopsy 1280. Specimen: Section of brain, showing small abscess beneath, 
 cortex; very little attempt at encapsulation. A similar small abscess was found 
 in cortex, extending to piarachnoid and producing a suppurative meningitis. 
 
 Cause of Death: Multiple abscess of brain, due to pneumococcus bronchiec- 
 tasis. 
 
 The author has seen as many as five brain abscesses at post- 
 mortems, and separate abscesses to the number of thirty have been 
 reported. Belief in the multiplicity of such abscesses has deterred 
 surgeons from operating and consequently the number of operations 
 undertaken for their relief has been very limited. Examination of 
 the literature of the last twenty-five years shows, however, that forty- 
 
 " Cadwalader, William B. : A Comparison of the Onset and Character of the 
 Apoplexy Caused by Cerebral Hemorrhage and by Vascular Occlusion ; Jmir. A. M. A., 
 May 2, 1915, Vol. LXII, p. 1385. 
 
76 BRAIN ABSCESS 
 
 five per cent, of all metastatic brain abscesses were solitary.'* In 
 view of this it is justifiable for the surgeon to explore the brain in all 
 cases of general pyemia presenting localizing apoplectiform cerebral 
 symptoms, especially if the original focus of infection can be drained, 
 as when the abscess is secondary to empyema, psoas abscess,®* 
 or abscess of the liver, phlebitis of the lateral sinus, or similar 
 conditions. 
 
 Treatment. Surgicallyj then, metastatic abscess should be 
 divided into two classes: (a) abscesses in which the original infection 
 is removable — all such abscesses should be operated upon ; — and (b) 
 abscesses in which the primary cause is strictly hematogenous, and 
 which are beyond surgical intervention. 
 
 Limitation of Metastatic Abscess by Capsule. 
 
 It is a frequent statement that metastatic abscesses are charac- 
 terized by absence of capsule. A superficial examination of the re- 
 ported cases would apparently substantiate this, as a large number 
 are without limiting membrane; but a careful analysis will demon- 
 strate that the absence of a capsule is in no way inherent in the 
 pathological process itself. The capsule is absent because in a large 
 proportion of cases there is not sufficient time for its development 
 before the death of the patient. Especially is this the case in meta- 
 static abscess of pulmonary origin, in which death generally follows 
 within a few days the appearance of cerebral symptoms.®* 
 
 Even in cases of slightly longer duration the suddenness of the 
 cerebral involvement would necessarily allow insufficient time for the 
 formation of a limiting membrane, whereas in an adjacent abscess 
 of equal duration the forces for protection and limitation are 
 marshalled long before the actual involvement of the cerebral 
 tissue. 
 
 Formation of the Capsule. 
 
 The thickness of the capsule will depend upon the age of the 
 abscess, and — what is of equal importance — upon the virulence of the 
 micro-organism and the tissue reaction necessary to limit the advance 
 of the suppuration. In certain cases the extension of the suppuration 
 apparently is easily limited. Cases have been reported in which, 
 
 ^ Bibrowicz, W. : Beitriige zur Klinik und Chirurgie der Hirnabszesse ; Beitr&ge 
 zur KUnik und Chirurgie, 1905, Bd. 47, S. 407. 
 
 •■ Saelhof, Clarence C. : Multiple Brain Abscesses Secondary to Bronchiectasis and 
 Kyphoscoliosis ; Jour. Nerv. and Ment. Diseases, April, 1920, Vol. 51, No. 4, p. 330. 
 
 " In Schorstein's nineteen cases death occurred in from three to twenty-eight 
 days — an ayerage of ten days. All of Schorstein's cases over seventeen days had a 
 capsule. Fraukel, Krause, and Saelhof's cases — twenty-four days — all had capsules. 
 
METASTATIC ABSCESS 77 
 
 althougli the abscess was of long duration, tlie capsule consisted simply 
 of a thin membrane. In a case referred to by Kolpin,*'' an abscess 
 of three months' duration was bounded by unchanged tissue, and had 
 not a capsule in the true sense. In this case, however, the man in 
 the beginning had symptoms of cerebral involvement which persisted 
 for a few days and then disappeared. The abscess, therefore, was 
 probably a metastatic abscess of only seven days' duration and could 
 not have had a capsule. 
 
 All the symptoms of cerebral involvement must be taken into 
 account in a consideration of the existence of a capsule. In Kolpin's 
 case the abscess, even if it were of three months' duration, might or 
 might not have had a firm capsule. However that may be, the pro- 
 tective tendency of the brain is toward the formation of a capsule, 
 and in brain abscess continuity of cerebral symptoms, or the return 
 of cerebral symptoms after a period of quiescence, generally means 
 an encapsulated abscess. 
 
 A great deal has been written about the encapsulation of brain 
 abscess. Komer *® gives it as his opinion that the presence or absence 
 of a capsule has no significance with regard to the age of an abscess, 
 but a study of the cases in the literature would confirm the author's 
 experience that the formation of a microscopically demonstrable cap- 
 sule begins at about the seventeenth day of the cerebral involvement 
 and in a rough way progresses with the age of the abscess.^® 
 
 Cassirer **• cites cases in which the capsule was found in from 
 two to five days, although he admits that these were exceptional. His 
 conclusion is that while the exact time of the formation of the capsule 
 probably never will be settled definitely, a localized cerebral suppura- 
 tion always means encapsulation. 
 
 Urbantschitsch *^ reports a case of temporo-sphenoidal lobe abscess 
 which, probably after rupture into the first horn, was followed by an 
 encapsulated empyema of the posterior horn. 
 
 CASE XVII, M. D. : 
 
 Metastatic Brain Abscess of Otitic Origin, the Result of an Infective Vas- 
 cular Occlusion, vpith Involvement of the Internal Capsule, Clinically Simulating 
 Cerebral Apoplexy and Presenting Unusual Psychic (Toxic Delirium) Phenomena. 
 Operation. Recovery. 
 
 " Kolpin : Zur Symptomatologie und pathologischen Anatomic des Hirnabszesses ; 
 Deutsche Zeitschrift fur Nervenheilkunde, 1903-04, Bd. XXV, S. 465. 
 
 ^' Komer : Die otitischen Erkrankungen des Hlrns, der Hirnhiiute und der Blut- 
 leitcr. 
 
 '"See further discussion of formation of capsule, Part II, Surgical Pathology and 
 Operative Teehnic, p. 47. 
 
 " Cassirer, Richard : Archiv fur PsycMatrie, 1902-03, Bd. 36, S. 191. 
 
 " Urbantschitsch, E. : Schlafenlappenabszess mit abszesaaktem Bmpyem des 
 Hinterhons des linken Seitenventrikels ; Internatiomal Oentralblatt fiir OhrenheUkunde, 
 1909-10, Bd. 8, S. 554. 
 
78 BRAIN ABSCESS 
 
 The salient features of this case may be summarized as follows: (1) Right- 
 sided acute otitis media; (2) Mastoid operation, perisinus abscess with necrosis 
 of the sinus wall and accidental opening of the sinus; followed by (3) Severe 
 dizziness — probably serous labyrinthitis — ^and within thirty-six hours by an 
 apparent "apoplectic stroke," with complete motor and sensory paralysis of the 
 left side; (4) Erysipelas; (5) Gradual improvement and two weeks later a sud- 
 den increase in the symptoms; (6) Toxic delirium. 
 
 History. — Female, 53 years of age, unmarried. Previous good health. Jan- 
 uary 15, 1914, pain in right ear and dizziness; January 16, spontaneous rupture; 
 January 18, paracentesis; chill. January 19, severe chill, temperature 101 to 105 
 degrees. January 20, two severe chills, followed by a temperature of 101 to 103 
 degrees. 
 
 Diagnosis. — Probable sinus thrombosis. 
 
 Operation. — On January 20 ( five days after first pain in ear ) . Opera- 
 tive findings: Acute mastoiditis, with perisinus abscess; necrosis of sinus wall; 
 free hemorrhage. 
 
 Subsequent History. — On the following day, January 21, great restlessness; 
 temperature of 100 to 101 degrees, accompanied by dizziness and vomiting. Dur- 
 ing the night, when the patient attempted to raise a bowl of soup to her face 
 with the right hand, she complained of a sharp pain in left (opposite) wrist and 
 knee; According to the nurse she was able at that time to move the hand. A 
 few hours later she was discovered to be completely paralyzed in the left arm 
 and leg, with complete loss of sensation on that side. 
 
 January 23, temperature 101% to 102 degrees. Fifty-four hours after opera- 
 tion, erysipelas extending on to face from region of affected ear. January 24, 
 temperature 97.3 to 99.4 degrees. Erysipelas spread rapidly to opposite side of 
 face and then subsided. January 25 to 29, temperature 98.3 to 100 degrees. 
 Delirious at times. Violent pain in head, especially at night, necessitating the 
 administration of morphine. Pain in right eye. Throbbing in left ear. Slight 
 improvement in paralysis of arm and leg, enabling patient to raise arm to head. 
 Slight delirium at times; irregular vomiting. 
 
 January 30 to February 3, temperature between normal and 101 degrees. 
 Paralysis of arm considerably improved; arm raised to head with difficulty. 
 Still severe pain in head and in right eye. February 4, fifteen days after opera- 
 tion, the temperature, which had been normal for five days, fell to 97.4 imme- 
 diately rising to 101 degrees. Vomiting; sudden increasie of paralysis, so that 
 the arm and leg could not be moved; mental condition much worse. At this 
 time the nurse noticed a loss of sensation in the left side of the face, the patient 
 not feeling a basin when pressed against it, as she had previously done. Involun- 
 tary movement. Difficulty in swallowing. 0. E. negative. 
 
 On February 6, seventeen days after operation, the patient was examined 
 with the following findings: Cordplete motor paralysis of the left arm and leg. 
 Paresis of upper part of right side of face (which may have dated from 
 the time of operation, but which had been obscured by the erysipelas ) . Com- 
 plete sensory paralysis of the left side (of face, left arm and leg). Left 
 abdominal reflex absent. Left-sided hemianopsia. 0. E. negative. Apparently a 
 lateral deviation of the eyes toward the right side, although the patient moved 
 eyes to left. Slight nystagmus on looking toward left. Right ear totally deaf; 
 complained of "noise" in that ear and in the head, resembling "raining," 
 "pounding," or "sea sounds." At times there were sounds in the left ear like 
 the puffing of a locomotive. The right vestibular apparatus non-reactive to 
 cold. 
 
 Patient drowsy, but could be easily aroused, when she recognized oljjects 
 which, however, she was slow in naming. Although she heard with the left ear, 
 she apparently did not hear promptly, as, when asked a question, she did not 
 
METASTATIC ABSCESS 79 
 
 answer for a few seconds. (It is difficult accurately to describe this "delayed 
 hearing": it suggests, but differs from the "slow cerebration" so frequently 
 associated with brain abscess. It impressed one as a physical defect, such as 
 ordinary deafness; while "slow cerebration" is obviously a mental defect.) 
 
 During the examination the patient was apparently perfectly normal men- 
 tally, but on being left to herself she gradually wandered into semi-delirium. 
 She was garrulous and disorientated as to time and place. She tried to leave 
 the bed with the desire to return home, from which she repeatedly asserted she 
 had been removed for "white slave" purposes and taken to different places where 
 proposals of a sexual nature had been made to her." When told that she was 
 at home she agreed, but insisted that she had been away. The paralysis of the 
 arm also formed the basis for another fixed delusion. She asserted that she 
 had lost her arm, or that it had been placed in a bureau drawer, and she fre- 
 quently asked the nurse to bring it to her. 
 
 Blood pressure, 115 mm. Heart negative. Urine contained a slight amount 
 of albumen; no sugar; specific gravity 1018. 
 
 February 8, Examination: Negative blood culture. Spinal fluid pressure 
 slightly increased. Transparency, clear, watery. No sediment after centrifugal- 
 ization. Globulin; moderate increase. Twenty-one cells, mostly polynuolears. 
 Fehling's reduced. Bacteriological examination, sterile. Conclusion: Secondary 
 protective meningitis, probably from brain abscess. 
 
 Remarks. — The cause of the paralysis, judging from its sudden onset, was 
 apparently an apoplexy from hemorrhage or embolism, totally independent of 
 the previous infective process. This view was further strengthened by the age 
 of the patient — fifty-three years — and also by the fact that, so far as the writer 
 is aware, there is no case in the literature of sudden involvement of the internal 
 capsule of otitic origin. The more he thought of the case, the more apparent 
 became the fact that the patient had had a virulent infection, which had rapidly 
 caused involvement of the sinus. wall, upon which had been superimposed an 
 erysipelas with, probably, complete destruction of the inner ear. While the sud- 
 den onset of the paralysis pointed clinically to a vascular lesion, it was con- 
 ceivable that such a virulent infection might cause a metastatic septic occlusion 
 of one of the vessels to the internal capsule. The exact point of involvement 
 in the posterior limb of the internal capsule was easily determined by the 
 hemiplegia and hemianesthesia, associated with hemianopsia, and what was 
 apparently hemianaciisia. 
 
 An exploration was undertaken, largely because the sexual delusions were 
 apparently becoming more firmly fixed day by day. 
 
 Operation, February 11. The still open mastoid wound was filled with 
 gauze and the auricle freed by an incision above and in front, so that it could 
 be turned downward. Flexible steel tourniquet applied, exerting its pressure 
 along the lower edge of the middle fossa. A large osteoplastic flap, about three 
 Inches square, made. Lumbar puncture performed to allow the brain to fall 
 back. A dural flap turned down, and the brain explored with a Gushing 
 explorer. The cortex punctured 1^4, mches above the external auditory meatus 
 and the searcher carried inward horizontally to a line running from one external 
 auditory meatus to the other. At a depth of Gy^ cm. from the cerebral surface, 
 the searcher encountered firm resistance, on overcoming which apparently clear 
 fluid escaped under pressure. Mistaking the fluid for cerebrospinal fluid from 
 the ventricle, I slowly withdrew the searcher. A d/rop of thick pus followed 
 along its track. Re-introduction of the searcher was followed by evacuation of 
 from a half to three-quartersi of an ounce of thick pus. The effort to pass a 
 thick instrument alongside the searcher for the purpose of facilitating the 
 
 « The patient's family stated that sht recently, had been Interested in white slave 
 tales in the daily papers and in the discussions at meetings of the King's Daughters. 
 
80 BRAIN ABSCESS 
 
 Introduction of drainage simply resulted in forcing pus out of the searcher; 
 and as more damage would be done by injury to the brain tissue in attempting 
 permanent drainage, the searcher was withdrawn and dura, bone and skin 
 tightly closed in layers. 
 
 In a short time it was realized, however, that the failure to open the 
 cavity of the abscess with a blunt instrument, at this great depth from the 
 surface, was due to the presence of a firm, limiting membrane, which latter had 
 been perforated with the semi-sharp searcher, but which was too dense to allow 
 its perforation by a blunt instrument. 
 
 Postoperative History. — Following the operation the patient's condition 
 greatly improved. The paralysis of the arm and leg partially disappeared; the 
 mental state underwent marked improvement; the distressing sexual delusions 
 entirely disappeared, but the delirium and some disorientation and severe head- 
 ache continued. 
 
 March 1, seventeen days after evacuation, condition much the same. Com- 
 plete paralysis of arm and leg. Mental state much clearer. Slight disorienta- 
 tion and delirium at night; fairly rational during the day. Complained of 
 "horrid dreams" at night, but knew they were dreams. Knew nothing of brain 
 operation and refused to consent to another, as she remembered the mastoid 
 operation. Slight suppuration from upper edge of wound, thought to be due to 
 stitch abscess. 
 
 March 19 (two months after primary trouble), the patient requested that 
 something be done to relieve pain in the head. 
 
 Examination, March 20: "Left lower extremity slightly spastic; a moderate 
 Babinski, and a few clonic twitches on testing Achilles reflex. Left knee jerk 
 active; right knee jerk active. No Babinski; slight clonus. Left upper extrem- 
 ity, wrist, supinator and triceps jerks double plus; spasticity most marked 
 distally. Gross movements in shoulder and elbow fairly good. Loss of passive 
 motion in left upper extremity. Hemianesthesia most marked in upper extrem- 
 ity. Left abdominal reflexes diminished. Eight very active." 
 
 Mental Status. — The patient is generally active and bright, and talks freely 
 and readily. There is a moderate degree of psychomotor restlessness, and occa- 
 sional delirium. Patient is well orientated as to place, but says: "I have not 
 the least idea of the time of the day. I haven't seen a newspaper for several 
 days to keep track of things. This must be about supper time; it is towards 
 midnight." When told that it was 10:30 A. M., she replied : "I have lost 
 track of things these last few days." She had a good insight into her condi- 
 tion, and gave no evidences of hallucinations,, or other sensory perversions. 
 Says, "I had another hand — I don't know what became of it. This one has no 
 grip at all. I have lost the grip in my left hand. I have spent lots of time 
 and energy trying to get it back. It is worth it to get the use of your hand." 
 Keeps fumbling and searching with right hand over bed for the limb she imagined 
 she had lost. Memory good for recent events. 
 
 Previous history showed partial disorientation in space and time, but not as 
 to person. The space orientation is most affected. 
 
 Dreams, pleasant and disagreeable (both). Not lengthy. For example, 
 "Last winter in a snow storm, walking up a little hill there was a white casket 
 filled with white flowers and this casket began to roll down the hill. I don't 
 know what started it — ^whether there was a body in it, I do not know. It was 
 simply a dream, a disagreeable one." (Dr. O. Beling. ) 
 
 Conclusions. — Hemianesthesia, hemiplegia, and moderate delirium (toxic). 
 
 Operation, March 21. The osteoplastic and dural flap again turned down, 
 disclosing an area of granulations, which apparently follows the original ex- 
 ploration tract into the cerebral substance and communicates externally with the 
 supposed stitch abscess. Following with a searcher the granulating tract inwards, 
 
METASTATIC ABSCESS 81 
 
 at a depth of 6% cm. from the surface, a dense capsule was again encountered; 
 on perforating this the searcher entered the abscess cavity. Through the searcher 
 the cavity was now completely evacuated and irrigated by alternately filling 
 with normal salt solution and emptying with a suction apparatus. A Whiting 
 encephaloscope, which is but 4^^ cm. in length, was then introduced as deeply 
 as possible over the searcher; the opening in the capsule made by the searcher 
 was enlarged by the introduction and expansion of the blade of nasal alligator 
 forceps, and through the opening thus made a rubber drainage tube, nine centi- 
 meters long, was introduced. The lower end of the tube lay in the cavity of 
 the abscess, and the outer end was sutured to the skin through an opening 
 rongeured out of the osteoplastic flap, the skin portion of the flap being horizon- 
 tally stripped for that purpose. All the rest of the wound now tightly closed in 
 layers. 
 
 March 22, the day following the operation, temperature 101 degrees. March 
 25, three days later, the condition was excellent; temperature normal. Involun- 
 tary movements of bowels at times. Still occasional delusions. Garrulousness 
 much less. March 28, able to move arm and hand, to her great delight. Appar- 
 ently normal mentally during the day, but had slight delirium at night. 
 
 April 11, paralysis of both arm and leg greatly improved. Hemianopsia 
 greatly improved; with rough test with hand, apparently normal. Mental con- 
 dition apparently normal. 
 
 June 29, still walked with cane. Used hand and arm almost normally. Mental 
 condition absolutely normal. Had no recollection whatever of occurrences be- 
 tween the sinus operation and the first evacuation of the abscess. No memory 
 of delusions, but remembered occurrences subsequently to first evacuation of 
 the cerebral abscess. 
 
 November 15, mental condition normal. Remembered delusions and dreams 
 well. No anesthesia left side. Walked with slight hemiplegic gait; used cane, 
 but could go without. Used arm as well as ever. Slight spontaneous nystagmus 
 in both comers, especially toward the affected side. Low voice heard at one 
 foot with noise apparatus. Cold caloric test gave increased nystagmus, nausea 
 and dizziness. 
 
 Remarks. — The case is of importance: first, because of its 
 undoubted tbrombotic origin, the abscess having been caused by vas- 
 cular occlusion, as was evidenced by the "apoplectic" character of 
 the onset of the paralysis, and not by direct extension of the suppura- 
 tive process from the ear; secondly, because of the unusual psychic 
 symptoms present, to vrhieh little attention has been paid in brain 
 abscess ; thirdly, because of its deep position, it being, so far as the 
 writer knows, the only abscess of the internal capsule which has been 
 successfully dealt with surgically.** 
 
 In cases of abscess of the brain from direct extension from con- 
 tiguous suppurative lesions, paralysis, when present, is evidenced first 
 by paresis of a part, generally the arm, then of the leg, and ulti- 
 mately, with the development of the abscess, a complete paralysis 
 
 " MacBwen : Pyogenic Diseases of the Brain and Spinal Cord ; 1893, p. 152. 
 (Makes the statement that "There are no cases recorded in which there is undoubted 
 evidence of secondary Involvement of the internal capsule from abscess of the temporo- 
 sphenoidal lobe")' 
 
82 BEAIN ABSCESS 
 
 ensues. In no record is to be found the history of a sudden paralysis, 
 such as is common in apoplexy. 
 
 In the case here reported it was the sudden onset of the paralysis 
 which led to the diagnosis of a vascular lesion, the probability of 
 which was further strengthened by the age of the patient. However, 
 a low blood pressure and the absence of a heart lesion, associated with 
 an infection that has been sufficiently virulent to cause a perisinus 
 abscess with disease of the sinus wall and complete suspension of 
 the labyrinthine function was evidence that such a virulent infection 
 might have caused a suppurative thrombus which at last found lodg- 
 ment in the central ganglia. It is possible that this thrombus was 
 thrown off twenty-four or thirty-six hours before its lodgment in 
 the brain, or what is more probable, that it was a retrograde embol- 
 ism causing vascular occlusion of one of the large deep veins of the 
 brain. 
 
 It may be said, on the other hand, that the internal capsule was 
 never directly involved; that the abscess simply pressed against it, 
 and much can be said in favor of this latter supposition. However, 
 the sudden onset of the paralysis, the location at which the abscess 
 was found, exactly at the depth, from the cerebral surface, of the 
 internal capsule, would seem to support the former contention. 
 
 Anatomical studies before operation have demonstrated that the 
 internal capsule is situated, in the average brain, one and one-fourth 
 inches above the centre of the external auditory meatus, and six centi- 
 meters inwards, on the line toward the opposite side. It was this 
 exact anatomical position that made successful exploration possible at 
 such a depth for such a small cavity. 
 
 We must assume, theoretically, from this case, that septic throm- 
 bus involving the internal capsule, with subsequent abscess, does 
 not cause a permanent paralysis if drained. 
 
 Additional References to Metastatic Absoess. 
 
 Klessens, J. J. H. M. : Abscess in de Linker Hemisplieere der Groote Herse- 
 nen, Bij Rechtazijdige Otitis Media; N ederlandsoh Tijdsohrift, April 10, 1920, 
 Erste Helft, No. 15, p. 1269. 
 
 Kutzinski, A. and Marx: Hirnabszesa als Folge peripherer Korperaeiterung 
 nach einem Unfall; M onatsohrift filr Psychiatrie, 1914, Bd. XXXVI, S. 255. 
 
 Urbantachitsch, E. : Contralaterale Hirnabszesse; Wiener klinisohe Wochen- 
 sdhrift, 1918, Bd. XXXI, S. 290. (Alao published in Milita/rarzt, 1918, Bd. LII, 
 S. 12801.) 
 
 Bouchez, F.: Dea Absc6s du cerveau consecutifs k la pneumonie; TMse de 
 Paris, 1906. 
 
 Condat, M. : Abscfes multiples du cerveau &. pneumocoques ; Archiv. de M4de- 
 (Me des Enfamis, 1917, Tome XX, p. 92. 
 
METASTATIC ABSCESS 83 
 
 Moore, John T. : Blastomycosis — ^with Eeport of Case Dying from Abscess of 
 the Brain; Surgerjf, Gyneoology amd Obstetrios, December, 1920, pp. 590-594. 
 
 Effler, Louis R. . Brain Abscess Following Streptococcus Sore Throat; 
 Laryngoscope, February, 1921, pp. 31-94. 
 
 Pogany, E. : Himabszess mit ungewohnter Lokalization ; Gyogyaszat, 1920, 
 No. 30 — (Hungarian). Nmrologisches Centralblatt, 1921, Bd. XI,, S. 215. 
 
CHAPTEE VI. 
 
 CEREBELLAE ABSCESS. 
 
 SECTION I. 
 
 Origin — Surgical Anatomy — Classification — 
 Surgical Considerations. 
 
 ORIGIN. 
 
 The vast majority of cerebellar abscesses originate from aural 
 infection. In 117 recorded post-mortems analyzed by the author, 
 the abscess was of otitic origin in 99 cases, from sphenoid sinus 
 suppuration in 2, metastatic in 2, traumatic in 2, tuberculous in 2, 
 carcinomatous in 1, and syphilitic in 1. 
 
 Immediate Occasion. — In adjacent cerebellar abscess, while 
 acute exacerbation of a chronic suppuration is generally the imme- 
 diate cause, trauma plays an important part. Many cases are re^ 
 corded of cerebral symptoms immediately following a radical mastoid 
 operation, or during the dressing of the wound, the inference being 
 that the cerebellar abscess was either the direct result of the surgical 
 manipulation, or was occasioned by secondary infection during the 
 dressing. 
 
 Operative manipulation apparently induces different types of 
 intradural suppuration, dependent upon the acuteness or chronicity 
 of the suppurative bone lesion. Operations during acute mastoiditis, 
 which occasionally induce a suppurative meningitis, apparently do 
 not cause cerebellar abscess, without at least the intermediary of a 
 sinus thrombosis. In chronic suppurative otitis, however, operative 
 manipulation, or secondary infection may originate a retrograde in- 
 fective thrombosis within the vessels of the bone from which the 
 infection may be carried into the cerebral tissue itself. 
 
 SuBGicAi Anatomy of the Postebiok Fossa. 
 
 The descending portion of the lateral sinus divides the intradural 
 contents of the posterior fossa into two unequal portions: (1) The 
 
 84 
 
CBEEBELLAK ABSCESS 85 
 
 anterior one-third, inclosed witllin the inaccessible triangle of the 
 petrous pyramid, the basilar portion of the occipital bone in front, 
 and the lateral sinus behind, contains the anterior one-third of the 
 cerebellum, the pons and most of the medulla; (2) the posterior 
 two-thirds, contains the lateral lobes of the cerebellum and the pos- 
 terior portion of the medulla. 
 
 The more forward the sinus the greater the surgical inaccessibility 
 to the contents of the anterior triangle of the posterior fossa. 
 
 SURGICAL CLASSIFICATION OF ADJACENT CEREBELLAR 
 
 ABSCESS. 
 
 From an operative standpoint, therefore, cerebellar abscess should 
 be divided into two general classes, according to its location: 
 (I) cerebellar abscess situated on or near the anterior surface of 
 the cerebellum, the infection entering through the posterior surface of 
 the petrous pyramid; (II) cerebellar abscess situated m or on the 
 posterior two-thirds of a lateral hemisphere, the infection originating 
 in the lateral sinus. 
 
 An abscess in either location, according to its position and origin, 
 may be: (1) meningeal, limited by meshes of the piarachnoid and 
 the inner surface of the dura; the suppuration resulting from an 
 adjacent infective process by direct extension; (2) intracerehellar, 
 without macroscopical evidence of cortical involvement; originating 
 from retrograde thrombophlebitis, perivasculitis or metastatic vas- 
 cular occlusion; and (3) intracerehellar, with a cortical "stalk." 
 
 SuEGicAL Considerations. 
 
 In every case of suspected cerebellar abscess, before exploration 
 within the dura, the following physiological and pathological factors 
 should be considered : 
 
 (1) The small size of the cerebellar fossa and the position of the 
 lateral sinus, which render difficult an exposure through a clean area 
 of sufficient size to permit of inspection and complete evacuation. 
 
 (2) The increase in the bulk of the affected cerebellar hemi- 
 sphere, and its displacement with the contiguous brain stem beyond 
 the median line, and with possible herniation of the brain stem into 
 the foramen magnum. 
 
 (3) The cerebellar displacement which may obstruct the cere- 
 bro-spinal system circulation, causing acute obstructive internal 
 hydrocephalus. 
 
 (4) The expulsive and uncontrollable herniation resulting from 
 
86 BEAIN ABSCESS 
 
 the increased brain bulk;, and disturbance of tbe cerebro-spinal cir- 
 culation system. 
 
 (5) The possible immediate fatal effect of further herniation or 
 displacement. 
 
 (6) The location of the abscess in or on the different lobes and 
 surfaces of the cerebellum, dependent upon the path by which the 
 infection enters the dura. 
 
 To meet these factors successfully the operation must be planned : 
 (1) to evacuate the abscess at its nearest approach to the dura, 
 so that the operative manipulations will cause the least possible dam- 
 age to the cerebral tissue; (2) to reduce the increased intracranial 
 pressure; (3) to prevent excessive cerebellar herniation which, other- 
 wise, may pause rupture of the piaraehnoid, injury to the cerebellar 
 tissue, and sudden dislocation of the brain stem, already abnormally 
 displaced. 
 
 Hebniation in Exploration for Cekebellab Abscess: Anatomical and 
 Physiological Factors. 
 
 The tegmen cerebelli rises dome-like (MacEwen's Atlas,^) from 
 the superior border of the petrous pyramid, the upper limit of the 
 dome reaching the plane of the floor of the anterior fossa, the third 
 ventricle, and the central ganglia, and rising above the lower level 
 of the descending horns of the lateral ventricle (MacEwen's Atlas, 
 Eig. 49). Externally, the plane of the upper limit of the cerebellar 
 dome is marked by a line extending from the level of the roof of the 
 orbit to the upper border of the auricle. 
 
 In cerebellar abscess from infection of the labyrinth, a large part 
 of the cerebellar substance is above the plane of the primary infection, 
 viz., the posterior surface of the petrous pyramid. 
 
 The intracerebellar pressure is largely influenced by the cerebro- 
 spinal circulatory system, the fluid passing through the aqueduct 
 of Sylvius into the fourth ventricle with its communications with the 
 basal and lateral cistema, situated near or on the anterior and 
 inferior surfaces of the cerebellum. The fluid acts as a water-bed 
 for the brain, lifting the brain stem and cerebellum upwards. The 
 maximum intracerebellar pressure is exerted normally backward and 
 outward, in the axis of the lateral lobes of the cerebellum, and upward 
 and outward, toward the tegmen cerebelli, away from the median 
 line and the internal portion of the posterior surface of the petrous 
 pyramid. 
 
 " MacBwen, William : "Atlas of Head Sections," Glasgow, 1893. 
 
CEKEBELLAE ABSCESS 87 
 
 Patholosicai, Pactobs. 
 
 Increase in cerebellar bulk, displacement beyond tbe median line, 
 and obstruction to tbe cerebro-spinal system circulation, are the 
 pathological factors to be considered. Intracranial pressure is enor- 
 mously increased. This increased pressure is the result of the 
 mechanical increase in the cerebellar contents from the abscess; an 
 associated increase in the amount of the cerebro-spinal fluid from 
 irritation of the inflammatory process ; and the mechanical displace- 
 ment, by the abscess, of the affected lobe beyond the median line into 
 the cerebellar fossa of the opposite side, blocking the normal cere- 
 bro-spinal fluid pathway and causing an obstructive internal hydro- 
 cephalus. (See Internal Hydrocephalus, appendix to Cerebellar 
 Abscess.) 
 
 When a hemisphere is the seat of an abscess its bulk is greatly 
 increased; it gradually encroaches on the opposite cerebellar fossa, 
 displacing the mid-line of the cerebellum and brain stem, causing 
 compression of the opposite hemisphere. The cerebro-spinal circula- 
 tory system, in its effort to protect the vital centres by lifting the 
 brain, presses the lateral lobes firmly against the dura — ^the place of 
 maximum intracerebellar pressure — in the line of the dural incision. 
 
 The cerebro-spinal fluid, passing through the aqueduct of Sylvius 
 and into the fourth ventricle with lateral branches to the basal cis- 
 terna, exerts a direct pressure on the brain, forcing it backward and 
 upward. If now the displacement of the affected hemisphere is suf- 
 ficient to obstruct the small opening for the third ventricle into the 
 fourth, an acute obstructive internal hydrocephalus will result at 
 once, adding enormously to the already increased intracranial pres- 
 sure, and causing herniation of the brain stem into the foramen 
 magnum. 
 
 SUBGIOAL IMPOETANOB OP DIRECTION OF MAXIMUM InTRACEEEBELLAB PEESSUBE. 
 
 During increased intracerebellar pressure, the direction of the 
 maximum pressure is unchanged, viz., upward and outward, away 
 from the third and fourth ventricles, and the basal and lateral cis- 
 terna. As a result of this increased pressure the cerebellum itself is 
 forcibly crowded backward and outward against the occipital bone, 
 and upward and outward against the tentorium cerebelli (See Mac- 
 E wen's Atlas, Fig. 42). This direction of maximum pressure ia 
 maintained until the increase of the intracranial pressure becomes so 
 great that the normal resistance to displacement downward is over- 
 come, when the medulla is herniated into the foramen magnum, with 
 
88 BEAIN ABSCESS 
 
 sudden death from pressure upon the vital centres, — a frequent ter- 
 mination of cerebellar abscess. 
 
 It is the direction of the maximum pressure that explains the 
 long recognized operative observation, that in cerebellar abscess in- 
 cision of the dura over the lateral lobe is frequently associated with 
 uncontrollable herniation, •while incision of the dural covering of the 
 anterior surface of the cerebellum behind the posterior surface of 
 the petrous pyramid is unattended by herniation. In cerebellar 
 abscess of the anterior third, if the dural incision is over the lateral 
 lobe, the herniation and the operative injury to the mass of cerebellar 
 tissue intervening between the abscess and the dural opening, wiU 
 add unnecessarily to the shock of the operation, and prevent complete 
 primary evacuation or subsequent drainage of the abscess cavity 
 (Figs. 25 and 26). 
 
 ROUTES OF INFECTION. 
 
 SUEGIOAL ImPOETANCB OF DeTEHMININQ THE PEOBABLE PATH OF IlTFEOTION, 
 W'HETHEB ThEGTJGH THE PeTEOTJS PYRAMID OR THE LATBBAL SiNUS. 
 
 Before operating the surgeon should endeavor to ascertain the 
 probable path of infection of the suppuration, for on it generally 
 depends the position of the abscess in (1) the anterior one-third of 
 the cerebellum, or (2) the posterior two-thirds. The probable 
 positio"n of the abscess will largely determine the operative method to 
 be adopted. 
 
 The importance of approaching the abscess at its nearest point 
 to the surface was exemplified in a case in which, having exposed 
 posterior to the sinus, because of a functionating static labyrinth, the 
 herniation of the brain through the dural opening, in spite of ven- 
 tricular puncture, made it impossible to depress the cerebellum far 
 enough toward the median line to allow inspection of its anterior 
 surface. Exploration through the cerebellar tissue located an abscess 
 at a considerable depth from the dural opening. At the post-mortem 
 the abscess was found situated within the meshes of the piarachnoid 
 entirely anterior to the cerebellar substance. In such cases com- 
 plete evacuation anterior to the lateral sinus (following the path of 
 infection and using the walled-ofE piarachnoid) should be followed 
 by a high percentage of recoveries. 
 
 Influence of Path of Peimaet Infection on Situation of Abscesses. 
 
 Examination of the post-mortem reports of cerebellar abscess 
 shows ths-t in a general way the location of the abscess in or on the 
 
Fig. 26. — Intraiiiaiachnoid abscess situated on the anterior surface of the 
 cerebellum. Technical error was made of exposing only one hemisphere, and 
 this behind the lateral sinus, necessitating exploration and evacuation of abscess 
 through the substance of the cerebellum, followed by extensive brain hei-niation 
 and necrosis; whereas, if the sinus had been obliterated, the abscess could 
 have been evacuated without cerebral injury. A part of the normal cerebellar 
 tissue was torn awaj' in removing the brain, after death, from the dura. Note 
 the displacement of the braiir stem and the displacement of the diseased hemi- 
 sphere beyond the median line. 
 
CEREBELLAR ABSCESS 
 
 89 
 
 cerebellum is dependent upon tlie path of extension into the cere- 
 bellum from the original site of infection. Determination of the 
 route of infection, then, becomes of the greatest surgical importance ; 
 and as experience teaches that exploration and drainage through the 
 original route of infection results in the largest proportion of recov- 
 eries in cerebellar abscess, the diagnosis of the exact route of infection 
 into the cerebellum will largely determine the operative procedure. 
 
 The routes of infection in the -cerebellar abscesses are: (1) around 
 or through the labyrinth; (a) through caries of the cells within the 
 bony capsule of the petrous pyramid — ^the cancellous tissues sur- 
 rounding the bony semi-circular canals and cochlea; (b) through 
 caries or necrosis of the capsule of the semi-circular canals ; (c) from 
 suppurative labyrinthitis by "pre-formed ways," namely, the ductus 
 endolymphaticus, the internal auditory meatus, or the aqueductus 
 cochleae; ^ (2) through thrombosis of the lateral sinus and its com- 
 municating veins. 
 
 An examination of the records of post-mortems of cerebellar 
 abscess reported in the literature shows the path of infection to the 
 cerebellum in only 128 cases. So far as the writer is aware no syste- 
 matic research from post-mortem records has previously been made to 
 ascertain the relative frequency of the individual paths of infection 
 into the cerebellum. 
 
 ROUTES OF INVASION TO CEREBELLUM IN 125 CASES' 
 Labyrinth: No. of Cases. Percent. 
 
 Labyrinth ■ 19 
 
 Semicircular canals 6 
 
 Vestibular aqueduct 11 1 
 
 Retrograde thrombosis from empyema of 
 
 the vestibular aqueduct 1 1-17 
 
 Ductus endolymphaticus or sacculus en- 
 dolymphaticus 5 
 
 Internal auditory meatus 7 
 
 Facial nerve 1 
 
 Subarcuate hiatus 4 
 
 Fold passing from dura to mastoid cells, 
 
 probably subarcuate hiatus 
 
 Undetermined, but thought to be by "pre- 
 formed way" 
 
 4 
 
 56 
 
 44.8 
 
 "Mackenzie, G. W. : Labyrinth Papers; Philadelphia,- 1913, 222, p. 8. 
 • Eagleton, Wells P. ; Cerebellar Abscess ; Jour. Amer. Med. Assoc., Oct. 4, 1919, 
 Vol. 73, pp. 1060-1062, 
 
90 BEAIK ABSCESS 
 
 No. of Gases. Percent. 
 Total Forward, 56 44.8 
 
 Caries of Petrous Bone 22 17.6 
 
 (There can lie no doubt that many of 
 these were labyrinth cases.) 
 
 Sinus Thrombosis: 41 32.8 
 
 (Associated sinus thrombosis and laby- 
 rinthitis). 
 Of 97, the total number of cases of in- 
 fection from the labyrinth and sinus 
 thrombosis, 13 (or 13.3 per cent.) had 
 both labyrinthitis and sinus throm- 
 bosis; showing the intimate association 
 of the blood stream infection with cere- 
 bellar abscess. Cerebellar abscess with 
 labyrinthitis need not necessarily be 
 situated in the anterior one-third of 
 the cerebellum, as an associated sinus 
 thrombosis may be the immediate 
 origin of the abscess. 
 
 Necrosis of Mastoid 3 2.4 
 
 Metastatic 1 .8 
 
 (From Pulmonary Suppuration.) 
 
 Fistula of Dura from Extradural Abscess, 
 
 probably Perisinus from description 1 
 
 Fistula of Neck. 
 
 :} 
 
 1.6 
 
 125 100.0 
 
OEKEBELLAK ABSCESS. 
 
 SECTION II. 
 
 In tlie Anterior Portion of the Cerebellum Originating from 
 Infection of the Petrous Pyramid. 
 
 OEIGIN. 
 
 , The labyrinth is so frequently the cause of cerebellar abscess 
 that the first step towards localization in a suspected brain abscess 
 is the investigation of its function. As sensory aphasia, not of vas- 
 cular origin, but accompanied by a left-sided dural suppuration, is 
 strongly suggestive of temporo-sphenoidal abscess, so a dead laby- 
 rinth, associated with symptoms of brain abscess, presumably localizes 
 the lesion within the posterior fossa. On several occasions I have ex- 
 plored for and evacuated a cerebellar abscess in patients brought to 
 the hospital in coma, regarding whom no previous history was obtain- 
 able at the time of operation, the diagnosis resting solely on a chronic 
 suppurating otitis, evidences of cerebral compression, and a non- 
 reacting static labyrinth. 
 
 Infection of CEKBBEiiTJM: feom Bony Caeies oe Nbcsbosis. 
 
 The probability of the infection extending to the cerebellum de- 
 pends largely on the anatomical structure of the individual petrou^ 
 bone involved, i.e., the presence or absence of perilabyrinth cells — 
 the small cancellous cells within the bony capsule of the petrous pyra- 
 mid, — especially along the inferior and posterior surfaces. 
 
 From operative findings I would place the path of infection from 
 the labyrinth to the cerebellum in the following order of frequency. 
 (See Eoutes of Infection, p. 88) : 
 
 (1) By way of the cells surrounding the bony semicircular canals 
 and cochlea. These can be subdivided into two groups, through 
 which infection occurs: (a) the cells surrounding the compact bony 
 labyrinth (perilabyrinth cells) in the posterior portion of the petrous 
 pyramid; (b) the cells in Trautmann's triangle, the outermost of 
 the posterior perilabyrinth cells. 
 
 91 
 
93 BRAIN ABSCESS 
 
 (2) Through nutritional necrosis and caries of the bony labyrinth 
 capsule itself. 
 
 When the infection goes around, not through the labyrinth, the 
 cells of Trautmann's triangle are affected ; but they are not as gen- 
 erally the direct cause of infection of the cerebellum as is supposed. 
 The deeper cells, however, (from which the direct point of entrance 
 of the infection to the brain occurs) are involved through the cells in 
 Trautmann's triangle. 
 
 The reports of the post-mortem examinations * of cerebellar 
 abscess show that the dura is frequently adherent over the posterior 
 surface of the petrous pyramid, associated in a small proportion of 
 cases with a fistulous opening marking the site of the entrance of the 
 suppuration into the cerebral substance. 
 
 CASE xvin. 
 
 F. C. i Intrapiarachnoid Abscess. Girl, aged eight years. Hypertrophy of 
 adenoids and tonsils, which had been imperfectly removed. Tuberculosis of left 
 lung. Hematuria. Chronic otitis media, left ear, with discharge, purulent and 
 in large amount. Adenoids and tonsils removed, and mastoid operation. Since 
 then had had several hemorrhages from kidneys and had been passing little 
 urine. Had vomited considerably. 
 
 Symptoms. — Spontaneous nystagmus, vomiting, mild papilloedema in both 
 eyes of three weeks duration. Vomiting originally thought by attending physician 
 to be due to kidney lesion. Thought to hear well, but the peevish, restless con- 
 dition of child made this unsatisfactory. Urine contained pus, blood and albu- 
 men; specific gravity 1026. W«ber referred to left. Thorough examination 
 Impossible because of child's peevish condition. Chronic nephritis. Symptoms 
 now pointed to cerebellar abscess. 
 
 Operation. — In spite of the suppression of urine ether was administered and 
 the patient placed in left lateral position on operating table. When under 
 anesthetic she was turned on right side and the head placed in a movable forward 
 carrier. She was then rotated on the chest with sandbags under each shoulder. 
 Incision in left side, extending from mastoid to median line and from median line 
 downward about three inches; the flap was rapidly turned outward. Difiiculty 
 encountered in controlling hemorrhage from the large accessory veins. 
 
 The dura being very tense an opening was made over the occipital lobe and 
 the searcher passed in an attempt to find the ventricle. The first passage of 
 the searcher failed to reach the ventricle after passing to a depth of six centi- 
 meters. The direction probably was too far outward. The second passage appar- 
 ently was straight forward toward the nose. A large amount of clear cerebro- 
 spinal fluid was evacuated. On withdrawal of the trocar more fluid followed. 
 Closure of dura over ventricular puncture opening. 
 
 Immediately after ventricular puncture the dura over the cerebellum became 
 much softer. Dura incised. Immediately herniation through large dural opening 
 prevented inspection. Searcher passed through substance of cerebellum toward 
 posterior surface of petrous portion of temporal bone at a depth of four centi- 
 meters from the cortex. Thick pus evacuated, caught by suction apparatus. Pus 
 ran slowly on account of its thick character, being first muco-pus followed by 
 
 'For Analysis of Post-Mortem Records, see "Condition of Dura over Sito nf 
 Infection." Appendix II, Cerebellar Abscess. 
 
CBREBELLAE ABSCESS 93 
 
 pure pus. No capsule was felt during passage of searcher, although, a capsule 
 was expected because from the history cerebellar symptoms had lasted from 
 three to four weeks. Introduction of drain. Death two days later. 
 
 Autopsy Findings. — On reflecting the dura the brain well filled the cranial 
 cavity and there was exposed a very light, grayish-white brain substance. On 
 the left side of the posterior fossa was an opening in the dura opposite to the 
 trephined opening, about one inch in diameter, and a small amount of softened, 
 purulent brain matter was found clinging to the dura over the posterior sur- 
 face of the petrous portion of the left temporal bone. The base of the skull 
 after removal of the dura was everywhere clear and free except in the following 
 places: — in the posterior fossa on the left side, over the posterior surface of the 
 petrous portion of the left temporal bone, where there was an oval, reddened, 
 suppurating mass about one centimeter in diameter, which was firmly adherent 
 to the dura. On tearing off the dura from the bone there was exposed an 
 oval area of bone necrosed about one centimeter in diameter on the posterior 
 surface of the petrous portion of the left temporal bone. The dura on the inner 
 surface was smooth and glistening over this area of necrosed bone. The cortex 
 of the bone around this area was entirely gone, leaving a pale, reddened granular 
 tissue beneath. The rest of the left half of the posterior fossa showed the two 
 openings and was quite clear. 
 
 On removing the brain there was seen in the middle fossa a considerable 
 amount of fiuid, slightly cloudy, and what appeared to be a purulent exudate 
 around the r^ion of the pituitary body and the tips of the temporo-sphenoidal 
 lobes. (See Fig. 26.) 
 
 The anterior and middle fossse and the posterior fossa on the right side were 
 everywhere clear and free. In the foramen magnum there was a small amount 
 of purulent exudate around the upper part of the cord. The ethmoid cells were 
 slightly moist, but everywhere clear and free from suppuration. The inferior 
 surface of the pituitary was clear and free. The sphenoid cells showed a small 
 amount of mucoid material, but were free from suppuration. Both lateral 
 sinuses were clear and free. 
 
 Comment. — In spite of the hemorrhage and the weak condition of the patient, 
 the cerebellum over both hemispheres and forward to the sinus should have 
 been exposed, as it is impossible to inspect both cerebellar hemispheres through 
 an opening over one of them. The patient had been suffering from symptoms 
 of labyrinthine irritation for at least three weeks. In view of the fact that 
 there was negative blood culture, the sinus should have been ligated and the 
 abscess evacuated in front and through the sinus. The abscess was entirely 
 intrapiarachnoid. 
 
 The operative demonstration of a fistulous opening, or of ad- 
 hesions between the dura and cerebellum, is of the same surgical 
 importance as similar lesions on the roof of the antrum and middle 
 ear, and should in like manner influence the treatment. 
 
 Intrapiarachnoid abscesses are most frequent on the posterior 
 surface of the petrous pyramid near the apex, as it is here that all 
 the cellular tracts of the labyrinthine cells coalesce.^ This also 
 accounts for a large number of intra-cerebellar abscesses which at 
 operation have been found located deep within the cerebellum, near 
 the median line. 
 
 » Glrard, L. : Perllabyrlnthlne Cells : Socliti de Laryngol., d'Otol. et de Rfiinol. 
 de Pcuria, December 9, 1911 ; Also, Intemutional Centralilatt fUr Ohrenheilkunde, 
 1912, B. X., p. 156. 
 
94 BEAIN ABSCESS 
 
 In tlie selection of the proper approach to the cerebelliam a func- 
 tionating labyrinth does not necessarily exclude the posterior surface 
 of the petrous pyramid, as with infection of the peri-labyrinthine cells 
 the labyrinth itself may not be involved. A carefully taken history, 
 however, will always reveal a previous "irritation" of the labyrinth. 
 
 Hepe * reports a case of deep-seated epidural abscess, without 
 labyrinthitis. 
 
 The histological findings cleared up the genesis of the leptomeningitis; it 
 originated through the rupture of a deep-seated epidural abscess derived from 
 the pneumatic cells. 
 
 Feeqtobnot op Different Foems of Labykinthine Suppueation Causing 
 Ceeebellab Suppubation. 
 
 Cerebellar suppuration may follow any one of the four types 
 of intralabyrinthine suppuration, namely, (a) suppurative laby- 
 rinthitis with closed empyema within the bony labyrinthine cavity, 
 the vestibule, the semi-circular canals and cochlea ; (b) caries of the 
 compact bony waUs of the semi-circular canals, vestibule, or cochlea, 
 associated with secondary circumscribed or diffused labyrinthitis with 
 granulation tissue replacement of the membranous labyrinth ; (c) ne- 
 crosis of the petrous pyramid from nutritional disturbance with 
 secondary labyrinthitis; and (d) infective labyrinthitis through "pre- 
 formed ways," the ductus endolymphaticus, aqueduct cochlea;, along 
 the perineural sheaths of the internal auditory meatus (West),'' or 
 between the layers of dura of the saccus endolymphaticus (Horne).^ 
 
 Cerebellar abscess, in the author's experience, most frequently 
 follows caries of the capsule of the posterior semi-circular canals. At 
 operation, the compact bony wall on the posterior surface of the 
 petrous pyramid is found to be perforated. This process is generally 
 associated with obliteration and absorption of the other semi-circular 
 canals. 
 
 Closed empyema of the labyrinthine cavities frequently causes 
 intrapiarachnoid suppuration in the neighborhood of the internal 
 auditory meatus, but rarely intracerebellar suppuration. 
 
 Labyrinthine necrosis with the formation of a sequestrum as a 
 result of nutritional death — a condition frequently seen in tubercu- 
 losis, the sequestra often involving the whole petrous pyramid, — 
 
 • Hepe : Bin Beltrag zur Kasuistik der tlefgelegenen epiduralen Abszesse ohne 
 LabryinthentzUndung ; Zeitechrift filr Ohrenheilkimde, 1916, Bd. 74, S. 91. 
 
 ' West and Scott : Operative Surgery of the Labyrinth ; Proceedings Royal Med- 
 ical Society, April, 1908, p. 918. 
 
 ' Home, Jobson : Formation of a Circumscribed Intradural Abscess at the Site 
 of the Saccus Endolymphaticus ; Transactions Sixth International Otologieal Congress, 
 London, August, 1899, p. 393. 
 
CEEEBELLAE ABSCESS 95 
 
 is but rarely associated with cerebellar abscess, tbougb it frequently 
 causes death from meningitis. 
 
 In acute infective labyrinthitis the infection may extend along 
 the perineural arachnoid sheaths of the nerves of the internal audi- 
 tory canal, distending them with turbid or hemorrhagic fluid. 
 
 Abscess in Lateral Cistebna. 
 
 Acute suppuration extending through the internal auditory 
 meatus along the perineural arachnoid sheaths of the facial and audi- 
 tory nerves, while usually causing diffuse suppurative meningitis, is 
 not infrequently followed by a circumscribed collection of purulent 
 cerebro-spinal fluid in the lateral cisterna. 
 
 Secondaet SEBOtrS Labteinthitis. 
 
 From the proximity of the caries of the deep perilabyrinth cells 
 to the delicate structure of the labyrinth, there is generally an asso- 
 ciated serous labyrinthitis, as evidenced clinically by a non-reacting 
 static labyrinth. 
 
 Abscess secondary to sinus involvement, although associated with 
 petrous pyramid infection, is not necessarily situated in the anterior 
 one-third, or adjacent to the petrous pyramid, but may be in any 
 part of the cerebellum. 
 
 Clinical Classification, — Abscesses of the following clinical 
 varieties may be siiiuited in part or wholly in the interior one-third 
 of the cerebellum: (1) Adjacent, Meningeal, chronic or acute, lim- 
 ited by the meshes of the piarachnoid and the inner surface of the 
 dura: the intradural suppuration resulting from an adjacent in- 
 fective process by direct extension from infection of the petrous 
 pyramid. (2) Adjacent, intracerebellar, without macroscopical evi- 
 dence of cortical involvement j chronic with capsule, or acute without 
 limiting membrane. (3) Adjacent intracerebellar with capsule or 
 "stalk." 
 
 Principles of Surgical Treatment. — Physiological and mechan- 
 ical factors and clinical experience require that the exploration of a 
 cerebellar abscess, originating from infection of the petrous pyramid, 
 be made through a dural opening, situated as far forward as possible 
 in order to follow the route of infection, and to lessen the cerebral 
 herniation. The dural opening must also be large enough to permit 
 of adequate inspection and evacuation, and it must be made through 
 a clean field. (See Surgical Factors, p. 85.) 
 
 Operative Approach to the Cerebellum. — Two routes of ap- 
 
96 BEAIIT ABSCESS 
 
 proach to the cerebellum are followed by surgeons, the choice resting 
 largely upon the operator's attempt to explore through a clean area, 
 or to follow the path of infection. 
 
 In exploration through a clean area the method involves : 
 
 A. Exposure of one or both lateral lobes of the cerebellum, with 
 exploration and drainage behind the lateral sinus. 
 
 Exposure of one lateral lobe and incision of the dura through 
 the opening is fundamentally wrong, as the lateral displacement of 
 the affected lobe beyond the median line causes immediate uncon- 
 trollable herniation which prevents all inspection. ISTumbers of cases 
 of abscess, however, have been successfully explored and drained by 
 this method. 
 
 JB. Incision and evacuation in front of lateral sinus. 
 
 The route anterior to the sinus is especially advantageous if the 
 abscess is located in the meshes of the piarachnoid, in contact with 
 the petrous pyramid. In this case the abscess is united by protective 
 adhesions to the dura over the petrous pyramid; evacuation and 
 drainage in front of the sinus follow the path of infection, and per- 
 mit of preservation of the protective adhesions, while the abscess is 
 approached at its most superficial point. 
 
 Exploration in front of the sinus, however, presents the following 
 disadvantages: (1) if the abscess is not found, meningitis is almost 
 sure to follow, as the operation is conducted through the infected 
 area of the mastoid; (2) the area between the sinus and the pos- 
 terior pyramid is too small to allow of proper exploration, complete 
 evacuation, or attempt at eradication. 
 
 The supposition that an abscess which originates from the laby- 
 rinth or petrous pyramid is located in the anterior one-third of the 
 cerebellum, and consequently may always be reached in front of the 
 sinus, is not borne out by post-mortems. Intracerebellar abscesses, 
 situated in the substance of the cerebellum itself, are not uniformly 
 near enough to the posterior surface of the petrous pyramid to be 
 successfully explored and completely evacuated through the small 
 space in front of the sinus. A large number of unsuccessful explora- 
 tions are recorded. Intrapiarachnoid abscesses originating from the 
 posterior surface of the petrous pyramid are connected with the 
 original focus of infection. However, they may extend great dis- 
 tances either upward under the tentorium, or downward along the 
 under surface of the cerebellum. 
 
 0. Destruction of the labyrinth followed by exploration of the 
 cerebellum in front of the sinus: Enlargement of the dural open- 
 
CEREBELLAE ABSCESS 97 
 
 ing following application of two closely allied encircling ligatures 
 to the sinus and incision between them: (Bourguet).® 
 
 While disturbance to the return circulation by obliteration of the 
 lateral sinus is generally slight/"' ^^ the mechanical difficulties of 
 occlusion by ligation of a pervious large sinus are so great that it 
 has been practised hitherto in but two recorded instances.^ *°* ^^ 
 
 D. Primary exposure of the lateral sinus from behind j oblitera- 
 tion of Us lumen, above by invulsion of its outer wall into its cavity, 
 and below by. an encircling ligation ; followed by free incision through 
 the walls of the sinus, with enlargement of the incision anteriorly 
 into the contiguous dura surfaces. 
 
 By this method the exposure and exploration may be conducted 
 through a dean field, away from, although adjacent to the primary 
 site of infection, the petrous pyramid. The dura is incised away 
 from the plane of maximum intracerebral pressure, and consequently, 
 the herniation is reduced to a minimum, and the junction of the an- 
 terior and lateral surfaces of the cerebellum is freely exposed. 
 
 If associated with ventricular puncture, this method allows of 
 inspection of the anterior surface of the cerebellum — the situation of 
 adjacent intrapiarachnoid abscesses of the posterior fossa, and of ex- 
 ploration of the anterior one-third of the cerebellum — ^the usual loca- 
 tion of adjacent intracerebellar abscess from infection of the petrous 
 pyramid. If an abscess is located, it provides ample room for its 
 thorough inspection, cleansing and obliteration. 
 
 Anatomy of the Lateral Sinus on Cross Section. 
 
 The lumen of the descending portion of the lateral sinus, opposite 
 the middle ear, is an irregular oval with its greatest convexity out- 
 ward, the sinus tunneling, as it were, between the layers of the dura 
 (MacE wen's Atlas, Fig. 39).^* The inner wall of the siaus is flush 
 with the contiguous dura, while the outer wall projects considerably 
 beyond the surface of the dura. Obliteration of the sinus by an 
 encircling ligature is difficult, because in its horizontal diameter it 
 presents two fixed points of dural surface that cannot be approxi- 
 mated. Beaching the knee, the sinus becomes distinctly pear-shaped, 
 
 • Bourguet : Absc6s du cervelet et labyrinthine suppurge ; trepanation ; gu6rison ; 
 Toulouse Medieal, Tome 15, p. 289. 
 
 '0 Eagleton : Circulatory Disturbances Following Ligation of the Internal Jugular 
 Vein in Sinus Thrombosis, with Report of a Case; Arohmea OtoXogv, 1906, Vol. XXV, 
 2 D 991 
 
 ' '" Stolz : Ueber die TJnterblndung der Vena Jugularis Interna ; Correspondens- 
 Blatt fUr BchuieUier Aerete, 1918, Bd. 48, No. 13, S. 415. 
 
 " Ballance : Personal Communication to Dr. Edward B. Bench. 
 
 "Mall, F. P.: On the Development of the Blood Vessels of the Brain in the 
 Human Embryo; Amer. Jour, of Anatomy, 1905, Vol. IV, p. 1. 
 
98 BRAIN ABSCESS 
 
 witli its inner wall still flush with the contiguous dural surfaces of the 
 cerebellum and cerebrum. The superior petrosal sinus enters at an 
 oblique angle, emptying into the inner wall at its posterior margin. 
 This is of surgical importance. After passing the knee, the hori- 
 zontal portion of the lateral sinus assumes a triangular shape, with 
 three fixed points, the dura of the tentorium cerebelli being inter- 
 posed (MacE wen's Atlas, Fig. 10) . Because of the three fixed points 
 of dural attachment, to completely obliterate a large transverse 
 sinus by an encircling ligature is difficult ; the tightening of the liga- 
 ture tears the dural attachments, with resulting hemorrhage. 
 
 In both the transverse and the descending portions of the sinus^ 
 however, it is possible to invidse the outer wall into the cavity, thus 
 completely obliterating the sinus. 
 
 Physiological and Anatomical Factoes. Blood Pressure within the Sinus. 
 
 The blood pressure in the descending portion of the lateral sinus, 
 normally but a few millimeters of mercury, is negative during each 
 inspiration, the collapse of the sinus being frequently witnessed dur- 
 ing its operative exposure. The volume of blood, although under low 
 pressure, is large. This low or negative pressure permits the control 
 of hemorrhage, following injury to the sinus wall, by bridging the 
 gap, the lumen of the sinus remaining permeable. The gloved finger, 
 a small piece of cotton, or the "postage stamp method" (in which 
 a piece of fascia lata is placed over the rent, the fascia adhering to 
 the injured sinus) , controls the hemorrhage without stopping the cur- 
 rent of blood within its lumen. The control of hemorrhage from the 
 sinus by compression is more difficult because of the large volume of 
 blood and the triangular shape of the sinus. 
 
 Surgical Obliteration of the Lateral Sinus. — A device^* 
 holds the two ends of suture apart so as not to compress the fixed 
 dural attachment, while the descent of a metal obturator causes an 
 invulsion of the outer wall of the sinus into its cavity, obliterating the 
 lumen. The obliteration of the sinus frees the approach to the an- 
 terior triangle of the cerebellar fossa. Through the enlarged triangle, 
 the anterior surface of the cerebellum (the most frequent site of 
 cerebellar abscess) can be inspected. (Figs. 2Y, 28.) 
 
 Technic of Obliteration of the Lateral Sinus by Invulsion of its Outer 
 Wall into the Lumen. — A small opening is made in the dura, on each aide of 
 the sinus, using a. triangular dural knife or eystotome. A ligature is passed 
 
 " Bagleton, W. P. : An Original Device for the Control of Hemorrhage from the 
 Large Sinuses of the Brain, by Involution of the Outer Wall into the Lumen : Medical 
 Reoord, February 15, 1919, p. 274. 
 
Fig. 25. — Temporal bone and cerebellum with abscess in situ, almost one- 
 third of the afl'ected hemisphere being displaced beyond the median line. 
 
 S — Sagittal plane ; d — drain in evacuated abscess, with surrovuiding zone of 
 encephalitis. (Copied from Hegener's Labyrinthitis und liirnabszess ; Beitrdge 
 zur Anatomie, Physioloqie. Pathologie mid Therapie des Olires, der Nase und des 
 Raises, 1901, Bd. 2, S. 461.) 
 
 Fig. 27. — Author's sinus obliterator and carrier in position. 
 
 "Crn OB — flliH+pva+Ar dptacbed from Carrier. 
 
CEEEBELLAE ABSCESS 99 
 
 from one dural opening to the other, using a full curved needle with the point 
 blunted, damage to the cerebral tissue being avoided by hugging the dural sur- 
 face. One side of the ligature is knotted at its centre and the suture placed in 
 the slot of the carrier and of the obturator on the same side. The other side of 
 the ligature is then placed in the opposite slot, using the knotted point of the 
 ligature as a fulcrum, and tightened sufficiently to cause a slight indentation of 
 the sinus, when the ends of the ligature are tied in a bow knot over the cross 
 arm of the carrier. Tightening the upper screw of the carrier will cause the 
 descent of the obturator into the sinus, obliterating its cavity. The slots in the 
 soft metal arms of the obturator are pressed firmly against the suture holding it 
 in position; the suture above is then loosened and removed from the slots of the 
 carrier, and the obturator liberated from the carrier by unscrewing the lower 
 screw. The suture is now tied over the obturator. If the ligation is to be made 
 above the knee it will be necessary, in addition, to perforate the tentorium cere- 
 belli vidth the needle. In passing the needle the entrance of the superior petrosal 
 sinus into the lateral sinus may be injured. Hemorrhage from the petrosal sinus 
 can be controlled by tucking under it a small piece of cotton with a black silk 
 carrier. 
 
 The upper portion having been obliterated and all downward current of blood 
 stopped, the lower portion of the sinus is easily ligated, by an encircling liga- 
 ture, as the sinus walls are here compressible; or, if the bony exposure is low 
 enough, the lower portion of the sinus may be obliterated by the pressure of a 
 tampon against its firm bony wall. Between the two ligatures the sinus can be 
 freely incised. 
 
 CASE XIX. 
 
 S. B. : Cerebellar Abscess." Male, adult. Influenza followed by acute otitis 
 media in right ear. Mastoid operation performed, neither dura nor sinus being 
 exposed. Three weeks later wound had practically healed; no symptoms. Five 
 weeks after operation, dull, boring pains commenced behind right eye and in 
 right frontal region. Paroxysm of pain was followed by vomiting, and for two 
 weeks there was headache of varjdng intensity on the right side and frequent 
 projectile vomiting which was influenced by the position of the patient, who 
 could take food when lying on the right side but would vomit upon turning on 
 his back. 
 
 Two weeks later the patient was much improved and could walk about the 
 room, although when he first attempted to walk he staggered and had a ten- 
 dency to fall to the right. No strength in right arm; used left. Became dizzy 
 on sudden change of position. Headache subsequently increased in severity, 
 right-sided weakness became more marked, and the patient became slightly 
 confused mentally. Examination showed the mastoid scar to be healed. No dis- 
 charge from ear. Patient could hear with right ear. Cold caloric in right ear 
 produced nystagmus, but not nearly so marked as that produced in left; com- 
 plained of blurred and troubled vision. Ophthalmoscopic examination revealed 
 congestion and slight cedema of both discs and fixation nystagmus. Mentality 
 dull; BO aphasia. Pulse 60; respiration irregular, bordering on Cheyne-Stokes. 
 Cerebro-spinal fluid clear under pressure. 
 
 Movements of pronation and supination were overdone. Asynergia more 
 marked on the right side, as shown in his inability to coordinate the various 
 muscles and joints. Asked to put his right hand back of his head, his arm 
 would apparently wobble in every direction until he got it in place, or he would 
 
 " Eagleton, W. P. : Report of a Successful Operation for Cerebellar Abscess by 
 Obliteration of tbe Lateral Sinus and Exploration and Drainage through Its Inner 
 Wall and Anterior Surface of Cerebellum : Medical Record, February 15, 1919, Vol, 95, 
 p. 274. 
 
100 BRAIN ABSCESS 
 
 raise the right hand with the left. The right hand was much weaker than the 
 left. 
 
 Second Operation. — The old mastoid cavity was therefore re-opened and the 
 sinus exposed, but no trace of infection was found. 
 
 Third Operation. — Cerebellar: Three days later, May 12, a cerebellar opera- 
 tion (W. P. E.) was performed, hemorrhage from scalp being controlled by 
 von Hayden's instruments. The whole cerebellar fossa was exposed on the right 
 side, and the posterior surface of the petrous pyramid removed as far as the 
 internal auditory meatus. Difficulty was experienced in locating the sinus on 
 account of granulations; but it was found by approaching from behind forward. 
 A blunt needle threaded with heavy silk was passed just below the sinus knee 
 encircling the dura from behind forward and out on the anterior wall of the 
 cerebellar fossa. On first passing it the sinus was undoubtedly perforated. The 
 sinus was obliterated by the instrument above at the knee, and was again 
 tied with an encircling ligature as low down toward the bulb as possible. 
 Between the ligatures the external wall of the sinus was then opened without loss 
 of blood, and the incision was continued through the inner wall to the cere- 
 bellum. This incision was afterwards enlarged, the opening into the cerebellar 
 fossa being directly at the angle of the anterior and external surfaces. There 
 was no prolapse of the brain. Exploration with searcher at distance of 3 cm. 
 located the abscess with capsule, pus flowing freely. On introduction of Whit- 
 ing's instrument ( encephaloscope ) , pus again flowed. The capsule could be felt 
 at the bottom of the encephaloscope, and pressure expressed more pus. The 
 abscess was thoroughly cleansed and wiped out. There was slight herniation 
 of the brain. A rubber tissue drain was inserted and the wound closed. 
 The obliterating obturator was removed on the tenth day. Uninterrupted 
 recovery. 
 
CEEEBELLAK ABSCESS. 
 
 SECTION III. 
 
 From Sinias Thrombosis Frequently Situated on One of tlie Surfaces 
 in the Posterior Two-thirds of the Cerebellar Fossa. 
 
 Ieeegulab Shape of Ceeebmxae Abscess; Its Surgical Importance. 
 
 Many charts depict cerebellar abscess as round or oval; post- 
 mortem examinations, on the contrary, show it frequently to be very 
 irregular in shape, with prolongation from the main cavity, the open- 
 ing into the prolongation at times being so small that it is frequently 
 mistaken for an independent abscess cavity.^* 
 
 The irregular shape of the cerebellar abscess is explainable by 
 the recognized tendency of suppuration to follow white fibre tracts, 
 avoiding the more freely nourished gray substance. 
 
 Surgical Principles in Treatment of Adjacent Cerebellar 
 Abscess. — ^With adequate and properly selected exposure the prin- 
 ciples outlined above may be applied as in the treatment of adjacent 
 abscess of the middle fossa. In cerebellar abscess, complete evacua- 
 tion or, if possible, eradication, is especially important ; because with 
 drainage alone the irregular shape of cerebellar abscess is frequently 
 followed by refilling and extension of the suppuration. (See Sec- 
 ondary Abscess, p. 59.) 
 
 Attempts at eradication are necessarily attended with especial 
 danger because of injury to the neighboring vital medullary centres 
 during operation, or from subsequent compression. 
 
 ABSCESS OF SINUS ORIGIN SITUATED IN OR ON POSTERIOR 
 TWO-THIRDS OF CEREBELLUM. 
 
 Abscess in this location is secondary to sinus thrombosis and may 
 result from retrograde thrombosis of a cerebellar vein entering the 
 sinus,^'' or from necrosis of the sinus wall itself. 
 
 " Neumann, H. : Cerebellar Abscess ; English EcUtion, 1907, p. 11. 
 
 " Some of the Inferior cerebellar veins empty Into the transverse sinus, while the 
 sigmoid portion receives the internal auditory and some of the veins of the medulla 
 And pons, 
 
 lOX 
 
103 BEAIN ABSCESS 
 
 When secondary to a retrograde thrombosis the abscess is gener- 
 ally situated in the lateral lobe, and as the thrombosis is frequently 
 very extensive any portion of the cerebellum may be involved in the 
 abscess. ^^' ^'' ^^ 
 
 When the cerebellar suppuration is secondary to a necrosis of 
 the sinus, the abscess is on the lateral lobe — "superficial brain 
 necrosis" from direct extension. 
 
 I. CEREBELLAR ABSCESS WITH SECONDARY SINUS THROMBOSIS. 
 
 Cerebellar abscess may be the primary cause and not the result 
 of a thrombosis of the lateral sinus. 
 
 With increased intracranial pressure the sinuses, on account of 
 the low venous pressure, are early obliterated, and, according to 
 Wolbach,^^ multiple small areas of brain tissue are herniated into 
 the yielding points of the entrance of the arachnoid villi within the 
 sinuses. The herniation is frequently followed by an occluding 
 thrombus which, in the presence of infection, may undergo septic 
 degeneration. The author has seen such an occlusion of the lateral 
 sinus during an operation for cerebellar abscess. On opening the 
 sinus no bleeding resulted, although no clot was present, the inner 
 sinus wall being pressed firmly against the outer by the increased 
 intracranial pressure of the abscess. 
 
 II. INTERCURRENT (TERTIARY) ABSCESS SECONDARY TO SINUS 
 
 THROMBOSIS. 
 
 Abscess secondary to sinus thrombosis may be: (a) cortical or 
 meningeal, chronic or acute, from infection of the inner wall of the 
 sinus, or of the lateral veins entering it. The situation may be on 
 any surface adjacent to the infected sinus (Kg. 13) ; (b) intror 
 cerebellar, without macroscopical evidence of cortical involvement, 
 with capsule, or without limiting membrane, from retrograde 
 thrombophlebitis of the cerebellar veins. The situation may be 
 in any part of the homolateral hemisphere.^^ Thirteen per cent, of 
 all cases of cerebellar abscess with labyrinthine involvement are asso- 
 
 " Neumann, H. : Der Otitische Kleinhlmabszess ; 1907, S. 5. 
 
 "• Euttin, E. : A Clinical Study of the Serous and Purulent Abscesses o( the 
 Labyrinth ; Ay,thorlzed translation by H. Newhart, 1914, p. 183, Case 68. 
 
 " Martin, H. H., Savannah, Ga., and Crowe, S. J., Baltimore : Lateral Sinus 
 Disease — Case Keport ; Larynffoaoo^e, December, 1920, Vol. XXX, No. 12, p. 817. 
 
 '^ Wolbach, S. B. : Multiple Hernia of the Cerebrum and Cerebellum, Due to 
 Intracranial Pressure ; Jmir. Med. Res., Vol. XIX, No. 1 ; New Series July, 1900, Vol. 
 XIV, p. 159. (Eeports two cases of occluding thrombus in lateral sinus; Case I, 
 associated wth acute otitis. Case VIII, unassociated, both just external to the torcular.) 
 
 " Jones, H. E. : Some Unmanageable Complications of Suppurative Middle Ear 
 Disease, Liverpool Med. Chir. Jour., 1899, Vol. XIX, p. 43 ; British Medical Journal, 
 II, 1898, p. 1235 ; Transactions International Otological Congress, 6, London, 1899. 
 
CEREBBLLAE ABSCESS 103 
 
 ciated ■with sinus thrombosis. The position of the abscess will thus 
 depend upon whether it originated directly from the petrous pyramid 
 or from the sinus. 
 
 III. TEAUMATIC; ACUTE OR CHRONIC. 
 
 IV. METASTATIC; ACUTE OR CHRONIC. 
 
 TREATMENT OE ABSCESS IN OR ON THE POSTERIOR TWO-THIRDS OF 
 
 THE CEREBELLUM FOLLOWING THROMBOSIS OF THE LATERAL 
 
 SINUS AND ITS COMMUNICATING VEINS. 
 
 Incision Through Inner Sinus Wall. — If the diagnosis of cere- 
 bellar abscess is positive, and the abscess is secondary to a sinus 
 thrombosis, and consequently is probably situated in the lateral 
 lobe of the cerebellum, exploration and evacuation may be conducted 
 through the inner wall of the sinus, thus following in a general 
 way the course of infection. On several occasions subsequent to a 
 sinus thrombosis operation, the writer has drained a cerebellar abscess 
 through the inner sinus wall.^' 
 
 CASE XX. 
 
 J. J.: Perisinus Abscess. Male. Acute Otitis. Six weeks previously symp- 
 toms of mastoid involvement. Operated. Perisinus abscess found. Sinus not 
 opened. Did well for eight days, but headache upon moving head. Then irregular 
 vomiting and occasional subnormal temperature. Later, rapid loss of flesh and 
 gradually semi-comatose. Operated on twelfth day. Thrombosis of lateral sinus 
 found and evacuated. Next day deep coma. Without an anesthetic a cerebellar 
 abscess was evacuated through the inner sinus wall. Relief instantaneous. The 
 patient, who had not spoken for two days, and who, during twenty-four hours 
 had been in deep coma, opened his eyes and became entirely rational. Did well 
 for three days, but abscess did not drain well because of small size of opening. 
 Fourth day chill with high temperature, which was repeated. Internal jugular 
 ligated. No clot found. Death ten hours later. 
 
 Comment.— Although it was not recognized at the time, the thrombus was 
 probably secondary to the abscess, as there were no symptoms of sinus throm- 
 bosis. The subsequent chill with high temperature was due to a septic lepto- 
 meningitis. 
 
 In another case without sinus symptoms, the removal of the bone 
 over the sinus uncovered a localized collection of pus apparently on 
 the sinus; examination revealed the inner surface of the abscess to 
 be the cerebellar cortex, the sinus walls having undergone necrosis. 
 
 Exploration Behind the Sinus Over the Lateral Lobe of the 
 Cerebellum. — If the abscess is in the lateral lobe of the cerebellum, 
 
 " Eagleton, W. P. : Brain Abscess of Otitic Origin, with Report of Two Cases, and 
 an Analysis of 131 Cases Reported In Literature ; Transactions of Medical Society of 
 New Jersey, 1902, p. 194. 
 
104= BRAIF ABSCESS 
 
 - the duxal exploration may be made tehind the sinus, uncovering 
 hoth cerebellar hemispheres. 
 
 Cerebellar abscesses originating from thrombosis of the lateral sinus, while 
 generally located on or in the posterior two-thirds of the cerebellum, are fre- 
 quently so situated, on either the upper or the under surface of the cerebellum, 
 as not to be accessible by puncture from behind the sinus. 
 
 Influence of Displacement of the Affected Hemisphere Be- 
 ' yond the Median Line. — Failure to appreciate the abnormal posi- 
 tion occupied by the affected hemisphere has led me on several oc- 
 casions to attempt investigation of the cerebellar surfaces after 
 uncovering only the affected hemisphere. Opening the dura was in- 
 variably accompanied by herniation of the brain to a sufficient 
 degree to prevent thorough inspection. 
 
 Ventricular Puncture, by reducing the increased intracranial 
 pressure will prevent destructive herniation, but displacement of the 
 affected lobe beyond the median line necessitates incision of the dura 
 over both lobes, to allow of proper inspection. 
 
 Technic of Exposure behind the Sinus. — If the cerebellum, over the lateral 
 lobes is to be exposed, the opening in the bone must extend horizontally from 
 the posterior edge of one lateral sinus to the opposite sinus; and laterally, 
 from below the superior curved line to the foramen magnum. In removing the 
 bone troublesome hemorrhage from the mastoid emissary and diploic veins may 
 occur. In cerebellar abscess the intracranial pressure is not only increased by 
 the abscess, but also by an internal hydrocephalus — a usual complication of 
 cerebellar abscess." The increased intracranial pressure frequently obliterates 
 the lumen of the large venous sinuses ; the blood, ordinarily carried by the sinuses, 
 leaving the skull by. the normally small diploic vessels. It is impossible to open 
 the dura without immediate prolapse of the brain and rupture of the piarachnoid. 
 If, however, a ventricular puncture is performed before the dura is opened, the 
 sinuses become patent, the bleeding stops and the cerebellum drops back, permit- 
 ting dural incision without uncontrollable prolapse of the brain. The dural 
 incision, to admit of inspection, must uncover loth cerebellar hemispheres, 
 extending from one lateral sinus to that of the opposite side. 
 
 Situation of Abscess Secondary to Sinus Thrombosis. — 
 No absolutely uniform relation that may be utilized surgically, 
 exists between the point of infection and the situation of the abscess. 
 
 Intracerebellar and intrapiarachnoid abscesses are rather uni- 
 formly distributed over all surfaces and in all parts of the lateral 
 hemispheres of the cerebellum. The middle lobe, however, is only 
 infrequently the site of an abscess. Metastatic abscesses from pul- 
 monary suppuration occur within the middle lobe, but of the other 
 
 "See examination of the pathological findings In 125 cases of cerebellar abscess, 
 
CEREBELLAE ABSCESS 105 
 
 four recorded cases of middle lobe abscesses none are above suspicion 
 of not being either metastatic in origin, or of having originated from 
 explorative punctures of the cerebellum. 
 
 SITUATION OF ABSCESS IN CEREBELLUM IN 125 
 AUTOPSY RECORDS. 
 
 No. of Oases. 
 
 On or near Anterior Surface of Cerebellum 30 
 
 Whole of Lateral Hemisphere 11 
 
 Not Stated 36 
 
 In Posterior Two-thirds of Cerebellum 23 
 
 On or near Lower Surface 6 
 
 On or near Lower and Mesial Surface 3 
 
 On or near Posterior and Mesial Surface 1 
 
 On or near Upper Surface 1 
 
 Lateral Surface 1 
 
 Opposite Lobe 2 
 
 In Middle Lobe 3 
 
 Total 117 
 
 Multiple Abscesses 10 
 
 Bilateral 2 
 
 Surgical Requirements for Systematic Exploration and Evacuor 
 tion. — In the treatment of cerebellar abscess secondary to sinus 
 thrombosis, to meet the surgical requirement that the operative pro- 
 cedure may be attended by a systematic exploration which will admit 
 of a uniform operative localization of the suppuration and its com- 
 plete evacuation, or eradication, it would be necessary in all cases : 
 
 (1) To obliterate and doubly ligate the descending portion of the 
 lateral sinus. 
 
 (2) To expose the dura of the whole cerebellar fossa of the 
 affected side, and as the affected hemisphere occupies a position 
 beyond the median line, the bone over the unaffected hemisphere 
 should be freely removed. 
 
 (3) To perform a ventricular puncture in order to relieve the 
 internal hydrocephalus. 
 
 (4) Then to incise the dura, as far forward as possible, the 
 incision extending backward through the obliterated sinus and con- 
 tinued in whichever direction is necessary. 
 
 Because of the variety of situations of cerebellar abscess, as found 
 at post-mortem, no other surgical manipulation promises uniformly 
 to locate the abscess or to allow of its complete evacuation or eradica- 
 tion. 
 
 Association of Extradural with Cerebellar Abscess. — At the com- 
 
106 BEAIN ABSCESS 
 
 pletion of the intradural operation, the adjacent surface of the petrous 
 pyramid should be inspected. Friedrich ^^ and Hegener ^* assert 
 that extradural abscess is the most frequent cause of cerebellar 
 abscess. Although the author's experience does not substantiate this, 
 he must confess to having on two occasions overlooked an associated 
 extradural abscess during operation. 
 
 2= Frledrich : Die Eiterungen des Ohrlabyrinthes. Monograph. Wiesbaden. 
 " Hegener : Verhandlungen der Deutschen Otologischen Gesellsehaft ; 1907. 
 
OHAPTEE VII. 
 FEOl^TAL LOBE ABSCESS. 
 
 Introductory Note. 
 
 The author's experience with frontal lobe abscess is limited to several cases 
 of adjacent abscess and several of traumatic origin. 
 
 The number of adjacent frontal lobe abscesses coming under the observation 
 of any one man necessarily must be so limited as to preclude authoritative state- 
 ment from him. This section, therefore, is based upon a review of the 145 or 
 150 cases reported in the literature of the subject, with application to their 
 treatment on the lines of the principles expounded in the body of this work. 
 
 Having been begun with only a few pages recording the personal observations 
 of the writer, this part of the book has expanded to its present proportions 
 after a survey of the literature had revealed repeated errors and hitherto unap- 
 preciated viewpoints, and brought to the author's mind a realization of the neces- 
 sity for an exhaustive study of frontal lobe abscess. 
 
 Anatomioai and Pathological Consideeations Pectjllar to the Feontal 
 Region; Theib Sttbgical Impobtakce. 
 
 Abscess of the frontal lobe presents surgical problems different 
 from those involved in abscess situated either in the temporo-sphe- 
 noidal lobe, or in the cerebellum. 
 
 The following anatomical and physiological peculiarities of the 
 frontal bone influence its occurrence and course: 
 
 (1) The mechanism of the nose and paranasal sinuses is for the 
 protection, not only of the upper respiratory tract, but of the brain 
 as well. By the aid of its ciliated epithelium, its mucous glands, 
 and its adherent elastic-tissue tunica propria, it adequately prevents 
 the invasion of the bone by repeated adjacent infections within the 
 nose and accessory sinuses. 
 
 (2) When the protective mechanism of the nose is overcome, the 
 protective mechanism of the brain tends to limit the infection, first 
 to the dura — pachymeningitis externa — and, failing in this, to the 
 subdural space — ^pachymeningitis interna. Both protective mechan- 
 isms must be overcome before an abscess develops. Thus, in spite 
 of the frequency of nasal suppuration, intracranial complications of 
 nasal origin are very rare. 
 
 (3) The compact bony structure of the roof of the orbit, of the 
 
 107 
 
108 BRAIN" ABSCESS 
 
 ethmoid, sphenoid, and inner plate of the frontal sinuses, without 
 diploic tissue, contributes to the protection, the compact bony plates 
 offering a bulwark against infection. The absence of cancellous tis- 
 sue eliminates a harbor for the growth or latency of micro-organisms, 
 such as is furnished by the mastoid. If, however, the infection in- 
 vades the compact bony plate, extensive nutritional death from ne- 
 crosis, not caries, results. Necrosis of the compact tissue of the 
 posterior frontal wall of the roof of the orbit or ethmoid is frequently 
 accompanied by the formation of an extradural abscess which, clinical 
 experience teaches, is frequently followed by or associated with an 
 adjacent abscess of the frontal lobe. Anatomically, this association 
 would be expected in this region. 
 
 (4) Direct vascular paths run from the mucosa of the accessory 
 sinuses through the bone into the dural plexus, communicating with 
 the veins of the cortex and the longitudinal sinus. 
 
 ■ (5) There exists, in addition, an intimate vascular and nutritional 
 relationship between the frontal bone and the dura, covering the 
 frontal lobe.^ Consequently, infection of the vessels of the diploe 
 of the frontal bone — osteomyelitis — is associated with subperiosteal 
 and extradural abscess, frequently with sinus thrombosis, and occa- 
 sionally with intradural abscess. 
 
 Isolated irritation of the inner layer of the dura stimulates the 
 bony growth of the. overlying skull, as shown clinically by the fre- 
 quency with which dural endothelioma is covered by a bony exostosis. 
 The presence of an exostosis of one of the flat bones of the skull 
 warrants a diagnosis of an adjacent dural endothelioma. 
 
 These anatomical conditions render the frontal lobe a unique 
 field, which — ^when infected — gives rise to pathological changes and 
 clinical manifestations not common in other parts of the skull. 
 
 The frontal lobes of the brain also possess anatomical and 
 physiological peculiarities which markedly influence suppuration 
 within the dura, and which render the diagnosis and treatment of 
 frontal lobe abscess especially difficult : 
 
 (1) The position and anatomical relationships of the frontal 
 lobes make them especially liable to trauma. 
 
 (2) The frontal lobes form the "silent area" of the brain. This 
 largely accounts for their remarkable tolerance of trauma. 
 
 (3) The frontal tips are attached to the dura by minute blood 
 vessels, which assist in holding it in position. These are easily rup- 
 
 " SklUem, Penn G., Jr.: Kib Cartilage Transplant for Saddle Back Nose; Annals 
 of Surgery, 1918, Vol. 68, p. 580 — "The frontal lobe receives Its nourishment largely 
 from the dura." 
 
Fig. 29. — Frontal lobe aliscess and perforation into lateral ventricle, with 
 subsequent cerebral bernia. Area of infiltration extending from the hernia into 
 the ventricle. Lateral ventricle of affected aide was filled with pus, which was 
 completely encapsulated within the lateral ventricle — "encapsulated empyema of 
 one lateral ventricle." 
 
FEONTAL LOBE ABSCESS 109 
 
 tured by trauma, causing hemorrliage into the pia and subarachnoid, 
 and rendering the frontal lobe especially liable to infection whenever 
 the protective mechanism of the nose and dura is broken through. 
 
 (4) The limited area of the frontal lobe admits of the formation 
 of only a small collection of pus without involving the cerebral 
 ganglionic masses, or perforating into the ventricles or the sub- 
 arachnoid space. Perforation into ventricle or subarachnoid space is 
 rapidly followed by death. In guarding these structures nature gen- 
 erally succeeds in limiting frontal lobe suppuration to a small com- 
 pass. "While a few large ones are recorded, the vast majority of 
 frontal lobe abscesses are of small size and low virulence, being 
 frequently latent, remaining dormant for a considerable period before 
 presenting outstanding symptoms — frequently not until rupture into 
 the ventricle or piarachnoid ushers in the fatal termination. (Kg. 
 29.) 
 
 The protective mechanism of the brain apparently Bucceeds in attenuating 
 the virulence of many micro-organisms which have entered the brain substance, 
 as a certain proportion of the brain abscesses are sterile on evacuation, and the 
 great majority of frontal lobe abscesses are of low virulence. 
 
 (5) The anterior portion of the frontal lobe derives its blood and 
 nourishment from the branches of the anterior cerebral artery, which 
 is, itself, a loop. In the presence of localized suppuration in the 
 frontal region, the reactive forces, having been already subjected 
 to strain in its encapsulation, the development of meningitis, general 
 or localized, is a much more frequent occurrence than during the 
 formation of brain abscess in the temporo-sphenoidal lobe. There- 
 fore, when adjacent frontal lobe abscess has developed, any additional 
 disturbance — extension of the abscess or injury to the cerebral tissue 
 during its evacuation — is badly borne because of the poor blood sup- 
 ply of the frontal lobe: — ^witness the high mortality following 
 operations for frontal lobe abscess. 
 
 Influence of Trauma. 
 
 Trauma plays a much more important part in the production of 
 frontal lobe abscess than of abscess in any other part of the brain. 
 Given symptoms of increased intracranial pressure, with history of 
 trauma in the frontal region, abscess of the frontal lobe is to be sus- 
 pected. The explanation for this may be found in the relatively 
 frequent disturbance of the vascular supply of the frontal lobe. 
 Throughout the skull the dura is held firmly to the bone by fibrous 
 connective tissue; the brain, however, is attached to the dura by the 
 
110 BEAIN ABSCESS 
 
 blood vessels and nerves. In the frontal region tlie anterior poles 
 of the brain are attached to the dura by small veins which, after 
 ramifying on the cerebral cortex, become part of the dural plexus. A 
 certain amount of movement of the brain as a whole is allowable 
 between the brain and the dura, the movement being in the sub- 
 dural and subarachnoid spaces and in the brain itself. 
 
 In severe concussion or contrecoup violence, however, the dis- 
 placed brain's weight is thrown against the frontal poles, causing suf- 
 ficient displacement to rupture the minute vessels holding it to the 
 dura and causing pial and subarachnoid hemorrhages. With milder 
 forms of injury the anterior frontal poles of the brain are fre- 
 quently the site of hemorrhage in the pia and subarachnoid space; 
 while a violent injury to the skull is generally productive of a dis- 
 organization of the cerebral tissue of the region affected. The writer 
 does not recall a case of a fractured skull which did not show hemor- 
 rhage into the pia and piarachnoid space of the frontal poles. 
 
 Similar hemorrhage occurs, though much less frequently, in the 
 temporo-sphenoidal tips. On the other hand, the vessels of the dura 
 itself are not injured without direct violence because of its firm 
 attachment to the bone. A rupture of the middle meningeal artery 
 is always associated with a tear in the integrity of the bone. 
 
 Trauma of the frontal lobe, however, does not give rise to abscess 
 unless associated with infection, although recently cases have been 
 reported in which transmitted trauma from shell shock with but slight 
 external injury has produced frontal lobe abscess. This is of the 
 greatest surgical importance, demonstrating that transmitted trauma 
 without bodily injury, may give rise to such a degree of cerebral 
 disorganization of the frontal lobe as to cause abscess formation. 
 The lowered resistance permits the micro-organisms from a distance 
 to be deposited by the circulation.^ While trauma alone is well 
 borne, the frontal lobes are unusually susceptible to a combination 
 of infection and trauma; thus compound fracture of the skull, with 
 involvement of the frontal sinus, is followed by suppurative menin- 
 gitis in a larger proportion of cases than in other regions. 
 
 Relationship Between Osteomyeutis, Extkaditral and Intbadural 
 
 Abscess. 
 
 As there exists an intimate nutritional relationship between the 
 diploe and the dura of the frontal bone, and through it with the cere- 
 bral tissue itself, any disturbance of the nutrition by infection or 
 
 ' Damaye, Henri : AbscBs ft ataphylocoque du lobe frontal lavorlsfi par la fatigue 
 et le bombaidement ; Le Progr&a Midicai, Sine. S&ie; 1918, Tome 33, p. 402. 
 
FHONTAL LOBE ABSCESS 111 
 
 trauma of the frontal region is apt to be associated with extradural 
 and frontal lobe abscess. 
 
 The following pathological associations are of surgical import- 
 ance: (1) Osteomyelitis of the frontal bone, originating from para- 
 nasal suppuration, is comparatively frequent, although it is almost an 
 unknown condition in the other flat bones of the skull. I have seen it 
 attack the temporal bone from aural infection in but one case. It 
 follows extension of infection from the frontal sinus, or more fre- 
 quently trauma during a frontal sinus operation. 
 
 (2) Intradural abscess is associated with extradural abscess in a 
 considerable proportion of cases of infection from the nasal sinuses, 
 from the orbit, or from a complicating osteomyelitis of the frontal 
 bone. In the temporo-sphenoidal region, although an extradural 
 abscess is of frequent occurrence, it is but rarely complicated by a 
 brain abscess. 
 
 In the process of limiting the suppurative focus external to the 
 dura, the resisting powers of nature, as a rule, prevent its spread 
 into the cranial cavity. In the frontal region, however, the associa- 
 tion of extradural with intradural abscess is so frequent, that it would 
 appear as if an extradural collection either favors or is coincident 
 with the formation of a brain abscess itself.^ 
 
 The uncovering of an extradural abscess during an operation 
 around the mastoid never in itself suggests the advisability of open- 
 ing the dura; but operative experience has taught the author that, 
 having found an extradural abscess of the frontal region, an intra- 
 dural abscess is to be suspected. He has therefore come to regard 
 the operative finding of an extradural abscess adjacent to an infected 
 sinus a distinct indication for the exploration of the brain itself. 
 
 CASE XXI. 
 
 D. McS. Male; Adjacent Frontal Lobe Abscess Following Frontal Sinus 
 Disease, Orbital Phlegmon, or Osteomyelitis, and Associated with Extradural 
 Abscess. 
 
 Previous History. — Pneumonia five years before; always had some "nose 
 trouble," with slight discharge, since childhood; had lost sense of smell for past 
 three years. 
 
 About three weeks before admission to hospital suddenly had pain and 
 swelling of right eye; swelling extended to other eye and then subsided; two 
 weeks later pain in head, with recurrence of swelling of right eye. 
 
 Examination. — Slight exophthalmos of right eye, with beginning chemosis 
 and diplopia; limitation of motion toward nasal side. Polypoid degeneration 
 
 " Gerber, P. H. : Die Kompllkationen der Stlmhohlenentziindungen ; Beitr&ge sur 
 Anatomie, Pathologie, und KUnik der StirnhSMen. Berlin, S. Karger, 1909. (Collected 
 65 frontal lobe abscesses, 25 or 40 per cent, of which had an associating extradural 
 abscess. He found but 28 cases reported of extradural abscess alone.) 
 
112 BRAIN ABSCESS 
 
 of mucous membrane of nose, polyps filling botli nostrils; creamy pus in both 
 nostrils, apparently from ethmoids. 
 
 X-Ray Findings. — Frontal sinuses moderate size, multilocular, deficiency of 
 illumination both sides, more marked on right; haziness right ethmoid. 
 
 Diagnosis. — Orbital abscess from ethmoid suppuration. 
 
 Operation. — Right-sided orbital abscess evacuated; caries of orbital wall of 
 anterior ethmoid cells; ethmoids and frontal sinus filled with pus; pus 
 evacuated. 
 
 Examination of pus from sinus revealed large Grram-negative bacilli. 
 
 Patient did well for three weeks. Exophthalmos slowly receded. Discharged 
 from hospital. 
 
 Subsequent History. — Several days later profuse discharge from wound, with 
 severe pain in head, starting from bridge of nose and extending over top to back 
 of head. Temperature and pulse normal; forehead pufify and tender; no ten- 
 derness over wound, which was now almost entirely closed. 
 
 X-Ray Findings. — Frontals, right post-operative, left, marked deficiency of 
 illumination. 
 
 Second Operation. — Left frontal sinus opened; found to contain pus; thor- 
 ough removal of mucous membrane, followed by tight closure; right frontal sinus 
 re-opened; large area of osteomyelitis of frontal bone found, osteomyelitis ex- 
 tending into orbit, with necrosis of roof of orbit; small sequestra removed; 
 dura beneath osteomyelitis covered by fiattened granulations. 
 
 Following second operation patient did well for a few days; suddenly intense 
 headache. Lumbar puncture; smear negative; culture negative — no bacilli. Fol- 
 lowing day, acute delirium, deep coma and sudden death on second day. 
 
 SURGICAL CLASSIFICATION. 
 
 Frontal Lobe Abscesses, like abscess of the cerebellum, should be 
 divided into: I — Chronic Adjacent (Secondary) ; II — ^Acute Adja- 
 cent (Secondary); III— Intercurrent (Tertiary) to sinus thrombosis 
 or progressive osteomyelitis ; IV — Traumatic ; V — Metastatic. 
 
 Adjacent Feontal Lobe Abscmss. 
 
 Occurrence. — Adjacent frontal lobe abscess is of very infre- 
 quent occurrence, there being not more than 150 cases reported in 
 the literature of the subject, while there are records of over 900 
 cases of adjacent abscesses of the middle fossa. 
 
 It ynll be asked why it is that, with nasal suppuration almost 
 universal and aural suppuration comparatively infrequent, the num- 
 ber of adjacent brain abscesses of otitic origin are many times more 
 numerous than those of nasal origin. 
 
 The explanation is simple — the nose and accessory sinuses are 
 essentially a mechanism for the protection, not only of the upper 
 respiratory tract, but of the underlying bone of the nose and para- 
 nasal sinuses. On the other hand, the mucous membrane of the 
 antrum and the mastoid cells is merely a cellular covering of the 
 
FEONTAL LOBE ABSCESS 113 
 
 bone, which is easily destroyed, thereby allowing invasion of the 
 bone. 
 
 Histologically the lining structure of the bony cavities of the 
 nose and paranasal sinuses is made up of mucous glands and vascular 
 erectile tissue containing lymphatic tissue or vessels covered by cili- 
 ated columnar epithelium, with a connective and elastic tissue 
 stroma firmly adherent to the underlying periosteum. Each of these 
 elements is designed for the prevention or removal of infection, — 
 the secretion from the glands for encapsulation and attenuation of 
 micro-organisms and foreign substance, the lymph tissue for theii' as- 
 similation, the erectile tissue for the mechanical obstruction to their 
 entrance, and the cilia for their removal. Even after infection of this 
 lining structure itself, the hypoplastic mucoid degeneration, so-called, 
 carries on the process of protection, while the elastic lamina propria, 
 with its firm adhesion to the bone, prevents the micro-organisms from 
 attacking the bone. 
 
 Other factors must be added to the usual infective diseases of the 
 nasal sinuses before the brain can be involved from the sinuses. 
 These factors are trauma, from blow or fall, or coincident with opera- 
 tion on the sinuses ; infection by virulent micro-organisms ; and acute 
 exacerbation of a chronic process by re-infection, or the assuming of 
 virulence by attenuated micro-organisms, when they reach or are 
 transplanted on previously unaffected tissue, such as compact tissue 
 of the bone, the dura, or the piarachnoid. 
 
 Trauma and renewed virulence generally act together, as during 
 operation or in fracture of the inner plate. 
 
 Virulent infection, or greatly lowered resistance such as follows 
 scarlet fever or diphtheria, may cause a complete disorganization 
 of the soft tissue lining the sinuses, with perforation of the outer wall 
 of the ethmoid cells or of the anterior wall of the frontal sinus, 
 associated with bony necrosis, with or without extension into the 
 cranium. 
 
 In a large number of reported cases frontal lobe abscess was pre- 
 ceded by an acute suppuration of sufficient intensity to cause redness, 
 or a bony necrosis of the outer frontal sinus wall and the lamina pro- 
 pria of the ethmoid, with an associated orbital phlegmon. 
 
 If, during operation, the frontal sinus is forcibly curetted, thereby 
 not only removing the chief barrier, but liberating micro-organisms 
 which have been attenuated by encapsulation in the mucous secretion 
 and tissue, and transplanting them into the vascular spaces and 
 lacunae of healthy bone, whereby they assume virulence, there may 
 
114 BRAIN ABSCESS 
 
 result osteomyelitis, perivasculitis, or retrograde thrombophlebitis, 
 eventuating in pachymeningitis interna, suppurative leptomeningitis, 
 sinus thrombosis, or brain abscess. 
 
 Milligan,* in forty frontal sinus operations, encountered frontal 
 lobe abscess in two, or five per cent. 
 
 In abscess following acute virulent infection, the intense pain of 
 bony involvement is of diagnostic value, as it will precede the clinical 
 manifestations of cerebral extension. When the abscess follows the 
 trauma of an operation, the pathological process being perivascular, 
 there may be no complaint of pain. 
 
 Origin of Infection. — In adjacent frontal lobe abscess the orig- 
 inal site of infection is from the nasal accessory sinuses or the orbit, 
 or from a complicating osteomyelitis of the frontal bone itself, origi- 
 nating from either the sinuses or the orbit. 
 
 Of the adjacent frontal lobe abscesses originating from the nasal 
 sinuses, the vast majority follow suppuration of the frontal, or of the 
 frontal and ethmoids together ; a few are reported as originating from 
 the ethmoids and sphenoid, but none from infection of the sphenoidal 
 sinuses alone. 
 
 As the ethmoid mucous membrane is separated from the dura 
 only by a thin layer of compact bony tissue, suppuration of the eth- 
 moids would naturally be regarded as a frequent cause of brain 
 abscess or meningitis ; in reality the ethmoids alone but infrequently 
 cause intracranial complications, despite the fact that the ethmoids 
 are the frequent site of operative procedure. This immunity is main- 
 tained because the nutritional supply of the superior surface of the 
 ethmoid bone itself is not easily disturbed, necrosis of the ethmoid 
 roof being very rare. The operative procedure must be of a gentle 
 character, since perforation of the ethmoid plate is attended with a 
 high mortality. In removal of the mucous membrane it is to be re- 
 membered that the attachment of the lamina propria to the bone is 
 loose, the lining membrane being easily removed, while the absence 
 of diploic tissue prevents latent infection. 
 
 Ethmoid suppuration, however, by necrosis of the lamina propria, 
 is frequently the cause of an orbital phlegmon. An orbital abscess is 
 the direct cause of frontal lobe abscess in a large proportion of cases 
 — about 12 per cent. 
 
 * Milllgan, Sir William : Some Practical Points In the Treatment, Operative and 
 Non-operative, of Frontal Sinus Suppuration, with an Analysis of the Ultimate Eesults 
 Obtained in Forty Cases; Journal Laryngology, August, 1904, Vol. 19, p 439. 
 
 , Milligan, Sir William: Suppurative Frontal Sinusitis; British Medical Journal, 
 
 1905, I, p. 171. 
 
FEONTAL LOBE ABSCESS 115 
 
 Paths op Intection. 
 
 In adjacent abscess, infection extends either by (1) — direct con- 
 tinuity of tissue suppuration; (2) — ^through, thrombosis of veins in 
 the mucosa (thrombophlebitis) ; (3) — through a combination of con- 
 tinuity of tissue suppuration and thrombophlebitis; or, (4) — ^through 
 a complicating osteomyelitis. 
 
 (1) — Infection hy Continuity of Tissue Suppuration: (a) Exam- 
 ination of the reported cases of frontal lobe abscess shows that in 
 numerous instances the diseased mucous membrane of the frontal 
 sinus was in direct contact with the brain itself through necrosis of 
 the dura and of the posterior sinus walls (an intracerebral abscess 
 with a stalk). 
 
 With an intact dura a piarachnoid abscess may be formed, adja- 
 cent to a necrotic posterior wall ; the intrapiarachnoid abscess being 
 the result of an infection of the cerebro-spinal fluid, called by the 
 toxic irritants in the infected area to protect the brain. 
 
 On account of the anatomical peculiarities of the nasal sinuses, 
 while the mucous membrane is frequently infected, the bone itself is 
 comparatively rarely involved ; when attacked, however, it is the seat 
 of necrosis from nutritional death — not caries — as the structures 
 are made of one firm layer of compact bony tissue, and not, as in the 
 temporal bone, of cancellous tissue with compact tissue boundaries. 
 In consequence of this absence of soft, medulla-filled cancellous tis- 
 sue, the frontal bone does not furnish a harbor for bacterial growth as 
 does the temporal bone, the structure of which favors caries and 
 latent infection. For the same reason ebonization, a reparative, but 
 pathological process of the mastoid, is not encountered in the nasal 
 accessory sinuses. 
 
 The mucous membrane of the frontal sinus is more firmly held to 
 the periosteum of the bone by the tunica propria than is that of the 
 ethmoid, while the mucous membrane of the sphenoid is compara- 
 tively loosely attached. Therefore bacterial invasion into the tunica 
 propria itself is much more apt to be followed by necrosis in the 
 frontal than in either of the other sinuses, although the free venous 
 drainage of the sphenoidal mucous membrane into the adjacent 
 cavernous tissue is its chief protection. 
 
 (&) Onodi describes "half ethmoidal canals," through which 
 the ethmoidal vessels pass and in which the mucous membrane of the 
 nose comes in direct contact with the dura and with the periosteum 
 of the orbit, thus favoring extension by continuity.^ 
 
 ' Onodi, A. : Ueber die okulo-orbital intrakraniellen nnd cerebralen Kompllkatlonen 
 nasalen Ursprungs; Mediminische KUnVh, 1914, No. 17, p. 719. 
 
116 BEAIN ABSCESS 
 
 (c) Dehiscence in the bony structure of the cells themselves 
 likewise favors extension of infection by this path. 
 
 (2) — Infection hy Retrograde Thrombophilias or Perivascu- 
 litis of the minute veins in the mucosa of the frontal sinus which 
 communicate freely with the dural and pial veins and with the venous 
 sinuses. This, i. e., thrombophlebitis, is the path of infection in a 
 large proportion of cases. It is associated with an intact posterior 
 wall of the frontal sinus, and within the dura the abscess is sepa- 
 rated from the overlying dural membrane by apparently normal 
 cerebral tissue; or it occupies the subdural space. 
 
 Although a certain proportion of the recorded cases give the 
 lymph vessels as the path of infection, this claim is not substan- 
 tiated by microscopical evidence.*' '' 
 
 (3) — Infection by a Combination of Tissue Suppuration and 
 Thrombophlebitis: In this case the tissue suppuration causes an 
 involvement of the posterior wall of the frontal sinus, while the 
 thrombophlebitis is the originating cause of the intracerebral 
 abscess. 
 
 (4) — Infection by a complicating Osteomyelitis j when the frontal 
 lobe abscess may be either an adjacent paranasal sinus brain abscess, 
 or, what is more frequent, secondary to osteomyelitis. In the latter 
 case the abscess may be far removed from the nasal sinuses. Osteo- 
 myelitis of the frontal bone, following acute infection or operation 
 upon the frontal sinuses, is primarily a thrombotic process involving 
 the soft vascular layers of the diploe. In its extension both the inner 
 and outer tables are involved. Consequently osteomyelitis is always 
 associated with a sub-periosteal and extradural abscess ^ and with 
 necrosis of the compact bone of the roof of the orbit. The involve- 
 ment of the veins themselves is generally far beyond the apparent 
 area of bony involvement. Failure of complete eradication of the 
 process during operation on the skull is largely responsible for its 
 subsequent recurrence. 
 
 ' Turner, Logan A. : The Lymphatic Apparatus of the Nose and Nasopharynx 
 in Its Relation to the Rest of the Body ; Y&rhamdlungen dea Sten, Intemationalen 
 Laryngo-Rhinologiachen Kongremes^ Berlin, 1911, S. 65. (Reviews literature and 
 finds no positive evidence of Invasion of the brain by lymphatica) 
 
 ' Zwillinger, Hugo: Experimentelle tJntersuchungen zur Mechanik der intra- 
 kranlellen und cerebralen Komplikationen der StirnhShlenentzundungen ; Arch, filr 
 Laryngologie und BMnologie, 1913-14, Bd. 28, S. 271. (Zwillinger, by experimental 
 injection of the subdural space, demonstrated certain irregular vascular channels run- 
 ning from it into the mucosa of the frontal sinus and ending in irregular buds in 
 the mucous membrane. These he regarded as lymphatic channels. Experimentally 
 he failed to demonstrate a lymphatic plexus in the frontal sinus, or to show whether 
 the channels ran through the separate openings in the bone or not. An examination 
 of his paper and Its accompanying drawings is far from convincing that the injected 
 channels were lymphatic.) 
 
 » Schilling, R. : Ueber die Osteomyelitis des flachen Schadelknochens und des Mit- 
 telohres; Zeltaehrlft fOr Ohrenheilhunde, 1904, Bd. 48, S. 52. Brganzungsheft. 
 
FEONTAL LOBE ABSCESS 117 
 
 AdJaobstt Feontal Lobe Abscess Associated with. Osteomtexitis. 
 
 The dura offers firm resistance to infection of the intracranial 
 contents; but my experience teaches that when osteomyelitis leads 
 to necrosis of the bone of the orbit or the posterior sinus wall, because 
 of the intimate nutritional and vascular supply of this region the 
 development of extradural abscess in this area is apt to be associated 
 with adjacent intradural suppuration. 
 
 Intercurrent (^Tertiary) Brain Abscess, Associated with Paror 
 sinoidcd Suppuration but Secondary to Osteomyelitis, Longitudinal, 
 or Cavernous Sinv^ Thrombosis, and Situxited at a Distance from 
 the Priwiary Site of Infection: In osteomyelitis from nasal infection 
 a thrombophlebitis of the diploic and dural vessels occurs at a con- 
 siderable distance from the area primarily infected. This thrombo- 
 phlebitis may extend inside the dura, causing either a brain abscess 
 or, more frequently, longitudinal or sinus thrombosis, which in turn 
 may be the immediate origin of a localized intradural collection of 
 pus. The immediate origin of the brain abscess determines its loca- 
 tion within the cerebral substance, just as thrombosis of the lateral 
 sinus, when the direct cause of cerebellar abscess, determines the site 
 of the abscess, placing it on any surface or on any part of its tribu- 
 taries, possibly remote from the original site of the primary infec- 
 tion, on the petrous bone. 
 
 In the determination, then, of the location of a brain abscess, the 
 immediate originating pathological process— osteomyelitis, longi- 
 tudinal or cavernous sinus thrombosis— should be considered as if it 
 were secondary to a complicating condition. The abscess may be 
 situated at a great distance from the nasal sinuses. In a case re- 
 ported by Knapp a brain abscess secondary to a longitudinal sinus 
 thrombosis was situated near the torcular, although the primary in- 
 fection was in the accessory sinuses.^ 
 
 Types of Frontal Lobe Abscesses. 
 
 I — Chronic Adjacent (Secondary) ; 
 
 (a) Intracerebral without macroscopical evidence of cortical involve- 
 
 ment; 
 
 (b) Intracerebral with a stalk; 
 
 (c) Meningeal. 
 
 II — ^Acute Adjacent (Secondary) ; 
 
 (a) Intracerebral without macroscopical evidence of cortical in- 
 
 volvement; 
 
 (b) Meningeal. 
 
 • Enapp, Arnold : Osteomyelitis of the Skull with Empyema of the Nasal Acces- 
 sory Cavities; Sinus Thrombosis; Pyemia; Death; Autopsy; Archives of Otology, 1903, 
 VoL 32. p. 181. 
 
( 
 
 118 BRAIN" ABSCESS 
 
 III — ^Intercurrent (Tertiary) to progressive osteomyelitis or longitudinal 
 or cavernous sinus thrombosis; 
 
 (1) Chronic; 
 
 (2) Acute. 
 IV — ^Metastatic. 
 
 V — Traumatic. 
 
 ADJACENT MENINGEAL, SUBDURAL. 
 
 There is clinical evidence that subdural adjacent abscesses are 
 more common in the frontal region than in any other portion of 
 the brain. (See Case VIII— A. M. M., p. 37.) The subdural 
 space apparently possesses great resistance to infection, subdural 
 abscess being infrequent. In frontal sinus disease, however, there is 
 microscopical evidence (Streit)^" that once the mucous membrane 
 barrier is overcome and the vessels of the bone invaded pachymenin- 
 gitis interna and small subdural collections of pus are frequently 
 present. 
 
 Pachymeningitis interna and small subdural abscesses are na- 
 ture's effort to limit the process. Either process may not give rise to 
 clinical symptoms sufficient to excite suspicion of it^g existence ; when 
 present, however, any trauma, such as in an operation on the frontal 
 sinus, may occasion a virulent leptomeningitis, an unexpected, fre- 
 quently terminal development. 
 
 von Hinsberg ^^ examined microscopically a case in which death 
 from meningitis rapidly followed an operation for frontal sinus dis- 
 ease. He found that without microscopic evidence of necrosis the 
 bone was traversed by numerous small vessels, some of which were 
 thrombosed, the process evidently being of long standing. Between 
 the dural layers were several large cavities filled with albuminous 
 fluid and microorganisms. Two of these cavities communicated with 
 the subarachnoid space, a direct connection between the outer sinus 
 wall by way of the thrombosed vessels being demonstrated. One 
 focus remained encapsulated against the subdural space while others 
 perforated it, occluding the subdural and the subarachnoid spaces and 
 thus preventing infection. At the operation these were broken down, 
 causing a purulent leptomeningitis. 
 
 Streit ^^ demonstrated experimentally that a subdural abscess 
 limited to the subdural space can be produced under favorable con- 
 
 '" streit, Herman : Weitere Beitrfige zur Histologie and Pathologle der Meningitis 
 und Sinusthrombose ; Archw fiir Ohrenheilkunde, 1912, Bd. 89, S. 177. 
 
 i> von Hinsberg, V. : Ueber flen Infektionsmechanlsmus bei Meningitis nach Stlrn- 
 Mhleneiterung : Verhandhmgen ier Daiischen Otologischen Oesellsahaft, 1901, Bd. 10, 
 S. 191. 
 
 " Streit, Herman : Weitere BeitrSge zur Histologie und Pathologle der Meningitis 
 und Sinusthrombose ; ArcMv Jiir Ohrenheilkunde, 1912, Bd. 89, S. 177. 
 
FRONTAL LOBE ABSCESS 119 
 
 ditions, the subdural space itself being generally skipped in the ex- 
 tensive infective process from the frontal sinus to the subarachnoid. 
 He presumes that a subdural abscess probably is the second stage in 
 the development of leptomeningitis. The value of Streit's and von 
 Hinsberg's microscopical and experimental work lies in its demon- 
 stration that pachymeningitis interna and small foci of subdural pus, 
 which have not given rise to symptoms and whose presence is con- 
 sequently unsuspected, may exist, and, by the trauma of operation on 
 an infected frontal sinus, may give rise to virulent leptomeningitis or 
 brain abscess. 
 
 Adjacent Piabachnoid Abscess. 
 
 The reported cases make it appear that this type of meningeal 
 abscess is not as frequent in the frontal as in the temporo-sphenoidal 
 region, nor does it attain as large a size. These characteristics are 
 probably accounted for by the absence of cancellous tissue in the 
 nasal region, an irritating area of bony caries, consequently, being 
 much less frequent in this region than in the temporal. 
 
 Piarachnoid abscess is originally of toxic origin from the irrita- 
 tion of an adjacent bony inflammation — serous meningitis — ^which 
 later becomes infected by the invasion of micro-organisms into the 
 protective collection of cerebro-spinal fluid. 
 
 As in the temporo-sphenoidal region, if the irritating cause is re- 
 moved before the infection occurs, the collection of cerebro-spinal 
 fluid will disappear. Cases are recorded of the disappearance of the 
 cerebral symptoms by sinus operation alone, without the opening of 
 the dura. 
 
 ADJACENT ABSCESS "WITH STALK." 
 
 This type of abscess is of relatively more frequent occurrence in 
 the frontal lobe than in either the middle or the posterior fossa. As 
 with temporo-sphenoidal abscess, and for the same reason, abscess 
 with a stalk offers the best prospect of recovery. Although only 
 twenty cases of frontal lobe abscess have recovered, three have been 
 spontaneously cured by rupture and evacuation through a stalk. The 
 establishment or utilization of a stalk — ^nature's method of cure — in 
 frontal lobe abscess, as in temporo-sphenoidal abscess, should be the 
 fundamental surgical aim. With a stalk present the operative mor- 
 tality should be low. 
 
120 BEAIN ABSCESS 
 
 ADJACENT INTRACEREBRAL ABSCESS WITHOUT MACRO- 
 SCOPICAL EVIDENCE OF CORTICAL INVOLVEMENT. 
 
 This type of abscess is generally situated in the white medullary 
 substance, about one-half inch from the cortex. It is usually of a 
 small size and of very low virulence, remaining latent for long pe- 
 riods of time. The literature records a few cases of the abscess 
 growing backwards, involving the speech area on the left side, and 
 then the face and arms. 
 
 Metastatic Abscess is relatively more frequently encountered in 
 the frontal lobe than in other portions of the brain, and the left 
 frontal lobe is attacked more frequently than the right. -^^ 
 
 The special predilection of metastatic foci to find lodgment in the 
 frontal lobes would favor the view that the return circulation through 
 the veins of the frontal lobe furnishes a favorable condition for 
 thrombotic-embolic formation — slowness of current and ebbing with 
 poor resistance.^* This latter condition may be assisted by the 
 anatomical peculiarity of the arterial supply of the frontal lobe, 
 coming as it does from a loop of a loop — the anterior cerebral artery ; 
 and therefore the arterial supply, while ordinarily ample, is easily 
 disturbed by traumatic or inflammatory influence. 
 
 Among metastatic abscesses should be included all frontal lobe 
 abscesses of otitic origin, as a careful examination of the literature — 
 Lombard,^ ^ Berens,'^* Schwabach,^'' Nonne,^® von Hinsberg^® — will 
 demonstrate that they all possess the diagnostic peculiarities of meta- 
 static abscess, namely, an apoplectiform onset, which although often 
 so mild as to escape notice, still can be elicited by careful examina- 
 tion and location of the abscess at a distance from the primary in- 
 fection, to which site it has been conveyed by an intercurrent osteo- 
 
 " Couteaud : Metastatic Abscess in the Brain ; Hevue de Chirurgie, Paris, 1913, 
 Vol. XXXIII, No. 7, pp. 1-172. (States that "The left side and the frontal lobe are 
 most frequently involved.") 
 
 " Browning, In an examination of 200 cases of supracerebral veins, found 59 in 
 the frontal region, jumping over from the piarachnoid to the dura at 3-4 cm. 
 from the longitudinal sinus, and only 9 in the posterior, superior and central; thus, 
 he thinks, favoring infection. Browning, W. : The Veins of the Brain and its 
 Envelopes : their Anatomy and Bearing on the Intracranial Insulation ; Monograph, 
 Brooklyn, 1884. 
 
 '= Lombard, Bloch A., and Moulouguet, A. : Un cas d'abscfts frontal du c6t6 opposS 
 fi une otite suppurfie chronique (Frontal Lobe Abscess of Otitic Origin) ; Awnalea iet 
 italades de I'Oreille, etc., 1914, Tome 90, p. 749. 
 
 '» Berens, T. Passmore : Abscess of Frontal Lobe of Otitic Origin ; Armala of 
 Otology, RMnology and Laryngology, June, 1913, Vol. XXII, p. 433. 
 
 " Schwabach, D. : Beitrag zur pathologlschen Anatomic des inneren Ohres, und 
 zur Frage vom primaren Hirnabszess ; Beltrdge stur Ohrenheilkunde, Lucae Festschrift, 
 1905, S. 55. 
 
 '" Nonne, M. : Ueber FBUe von benignen Himhauttumoren ; ueber atyplsch ver- 
 laufene FUlle von Hirnabszess, sowie weitere klinische und anatomisehe Beftrage zur 
 Frage vom "Pseudo-tumor Cerebri" ; Deutsche Zeitachrift fiir Nervenhellkunde, 1907, 
 Bd. 33, S. 316-357. 
 
 " von Hiusberg, V. : Ueber den Infections-Mechanismus bei Meningitis und Stirn- 
 hShleneiterung ; Terhandlungen der Deutsohen Otologiechen Oeaellachaft, 1901, S. 191. 
 (Gives microscopical findings of path of invasion by blood vessels and lodgment In 
 glib^ural space, with pilcroscoplcal illustrAtions.) 
 
FEONTAL LOBE ABSCESS 121 
 
 myelitis or the involvement of a large venous cliannel, sucli as the 
 longitudinal sinus. 
 
 The surgical importance of the relative frequency of metastatic 
 abscess being situated within the frontal lobe, especially on the right 
 side, should be more generally appreciated, as in a case in which a 
 metastatic abscess is suspected (with symptoms of cerebral suppura- 
 tion but without localization), the operative exposure should be large 
 enough to admit of exploration of the frontal lobes, especially of 
 the left. 
 
 TRAUMATIC FRONTAL LOBE ABSCESS. 
 
 As would be expected from its exposed position, traumatic abscess 
 is relatively common in the frontal lobe, and for the reason that this 
 area is silent, the encapsulated suppuration is apt to be overlooked 
 until a fatal meningitis has developed. (See Case XXII, p. 125.) 
 Experience has taught the author that, given a history of trauma of 
 the frontal region, especially if a fracture of the frontal bone is 
 known to have occurred, slight but continued symptoms — such as 
 headache, slight changes in disposition, dizziness, etc. — call for an 
 exploration of the frontal region. In the author's experience the 
 results of operative treatment of localized frontal lobe abscess of 
 traumatic origin are most satisfactory, the operative mortality being 
 very low, in contradistinction to the high recorded mortality in adja- 
 cent frontal lobe abscess. 
 
 Immediate Occasion of Adjacent Abscess. 
 
 In a large proportion of the reported cases the adjacent frontal 
 abscess has been preceded by operative trauma on an accessory sinus. 
 So uniformly has this occurred that it is necessary to assume either 
 that the operation on the sinus was the immediate occasion of the 
 intradural suppuration, or that the intracranial origin of the symp_- 
 toms was not appreciated by the surgeon at the time of the sinus 
 operation.^" 
 
 While the latter supposition indubitably explains many of the 
 cases, the writer is of the opinion that undue trauma during a sinus 
 operation is also frequently responsible. The forcible curetting of 
 
 " Iieegard, Fiithjof : Cerebral Abscess of the Frontal Lobe ; Annals of Otology, 
 Rhinology and Laryngology, March, 1919, p. 115. ("Often the mode of procedure 
 Is to operate for the sinusitis. If the symptoms do not disappear, as had been 
 expected, if they continue and increase, it gradually becomes clear th^t there exists 
 something more than an inflammation in the frontal sinus, and then finally the 
 cerebral abscess is diagnosed. Such a state of affairs is so typical that on reading 
 through the history of cases we find these conditions recurring again and again, 
 almost with the regularity of a law.") 
 
132 BRAIN ABSCESS 
 
 the firmly adherent membrane from the posterior wall of the frontal 
 simis produces a condition similar to an acute virulent infection hy 
 liberating into the damaged bony tissue micro-organisms which have 
 been attenuated by the protective mechanism of the accessory sinuses; 
 these organisms again become virulent, attack the blood vessels of the 
 denuded bones and produce a thrombophlebitis with extension into 
 the central tissue by their transplantation into new soil, finding here 
 a favorable medium from the damage done to the tissues by the 
 operator. 
 
 Situation of Adjacent Feontai Lobe Abscess. 
 
 The situation depends upon the point of infection. As the frontal 
 sinus has great variations in its size, the abscess may be situated in 
 any part of the frontal lobe. It is consequently of great importance 
 that a roentgenogram be taken, depicting at least the limitations of 
 the frontal sinus. Among the recorded cases such a high proportion 
 present necrosis of the posterior wall adjacent to which the abscess 
 was situated, that the writer is led to believe that such an inflam- 
 matory defect is of greater surgical assistance than is the operative 
 finding of a defect of the posterior. Either in itself is more or less a 
 guide to the location of the abscess. Where the abscess is due to com- 
 plicating osteomyelitis, longitudinal, lateral or cavernous sinus throm- 
 bosis, it may be situated at a great distance from the infecting sinus. 
 
 Presence of Capsule : Adjacent frontal lobe abscesses follow the 
 same rule as regards capsule formation as do abscesses of the middle 
 fossa; although, on account of the low order of the virulence, the 
 limiting membrane is frequently slight in spite of the long duration 
 of the abscess. 
 
 Opeeative Eesult in Eecoeded Cases op Adjacent Abscess. 
 
 An exceptionally high mortality — disproportionately much 
 greater than abscess in any other region of the brain — attends frontal 
 lobe abscess. 
 
 Of the 87 cases collected by Boenninghaus,^^ only 15, or 17 per 
 cent, recovered, a mortality of 83 per cent. Of the 15 that recovered 
 three are reported as having been evacuated spontaneously, leaving 
 but twelve out of the 87, or about 14 per cent, of the total number 
 as successfully operated upon. Boenninghaus's compilation thus 
 demonstrates that the surgical means adopted had been inadequate, 
 
 " Boennlngliaus : CWrurgle der NebenhBhlen inkl. Chlrurgle der Dndokranlellen 
 Kompllkationen ; Haniiuch aer spex. Ohirurgie dee Ohres und der oteren Luftwege, 
 Bd. Ill, Part II, S. 239. 
 
FEONTAL LOBE ABSCESS 123 
 
 or had been misdirected, especially as nature, unaided, successfully 
 evacuated 20 per cent, of the total recoveries ; whereby the inference 
 is forced that with proper technic the mortality should not be high. 
 Treatment. — As in a large number of the reported cases of 
 frontal lobe abscess the patient died suddenly before a positive diag- 
 nosis had been made, operation must be performed while the diag- 
 nosis is still largely problematic, and consequently must be more or 
 less exploratory. 
 
 Principles of Exploratory Intradural Operation. — Surgical pro- 
 cedure must meet two requirements of all intradural explorative 
 operations. It must be through a clean field, so that, with failure to 
 locate the abscess, the dura may be tightly closed; it must be so 
 conducted that direct 6r indirect damage to cerebral tissue is most 
 improbable. 
 
 Operative Intradural Policy. — ^In proposing a policy of surgical 
 procedure for frontal lobe abscess the surgical observations previously 
 described should receive consideration. As the operative results in 
 adjacent frontal lobe abscess have been much poorer than in adjacent 
 abscess of the middle or posterior fossa, while post-operative papiU- 
 oedema and hernia cerebri are frequent; and as traumatic secondary 
 compression is frequently the cause of the fatal result ; and, moreover, 
 while nature, unaided, has cured one-fifth of all the cases that have 
 recovered by spontaneous evacuation — ^for few deaths result after 
 spontaneous evacuation — ^therefore, any operative procedure should 
 be planned to evacuate the abscess as nearly as possible after the 
 method of nature. 
 
 Technic of Operations for Suppurative Lesions of the Accessory 
 Nasal Sinuses. — ^All operations on the paranasal sinuses should con- 
 sist of simple drainage through the nose, or of an external operation 
 with delicate but thorough eradication of the diseased mucous mem- 
 brane, simple drainage being insufficient and forcible curetting dan- 
 gerous. Streit,^^ von Hinsberg,^^ and Zemann ^* have demonstrated 
 microscopically that pachymeningitis interna and small subdural foci 
 may be converted into a general septic meningitis. 
 
 Termination. — Cases of adjacent frontal lobe abscess rarely de- 
 velop compressive symptoms — coma, slow pulse, papilloedema — death 
 generally occurring suddenly while the patient is still active. The 
 
 22 Streit, Herman : Weltere Beitrage zur Histologie und Pathologle der Meningitis 
 und Sinusthrombose ; ArcMv. fiir Ohrenheillmnde, 1912, Bd. 89, S. 177. 
 
 " von Hlnsberg : Ueber den Infektions-Mechanismus bel Meningitis nacb Stern- 
 hohlenelterung ; Verhandlung der D&utscTven Otologischen Oeaellschaft, Bd. 10, S. 
 191. 
 
 " Zemann, W. : Beltrag zur Kenntniss der endokranlellen Komplikatlonen nach 
 chronlscber Nebenhiihleneitemng ; Zeitsohrift fiir Laryngol., Bhinol., und ihre Qrern- 
 geblete, 1913-1914, Bd. VI, S. 545. 
 
134 BEAIN ABSCESS 
 
 absence of compression symptoms until but a few hours or even 
 minutes before death accounts for the large number of unrecognized 
 frontal lobe abscesses, the patients dying without intradural explora- 
 tion. The immediate cause of death is either unknown or is trace- 
 able to rupture of the abscess through the piarachnoid or into the 
 lateral ventricle. With rupture into the piarachnoid space death may 
 be almost instantaneous, convulsions ushering in the demise; or it 
 may be preceded by a virulent meningitis, lasting but a few hours. 
 (See Case, p. 125.) (Fig. 30.) 
 
 Sudden death frequently occurs without rupture into the ven- 
 tricle or the subarachnoid space. For some reason, brain abscess in 
 any part of the brain frequently terminates suddenly, the post-mor- 
 tem failing to reveal either a leak into the ventricles or any other 
 apparent cause for the sudden termination. It is probably due to an 
 acute toxaemia which paralyzes the vital centers, as death is preceded 
 by a sudden elevation of tanperature, with respiratory failure. 
 
 According to Gerber's ^^ collection of recorded cases of frontal 
 lobe abscess, 65 in number, eight recovered. Of the remaining 57, in 
 21 cases, or 37 per cent., the cause of death was unknown. Of the 
 remainder, with known cause of death, 36 in number, the great ma«- 
 jority ruptured into the subarachnoid space. In 13 per cent, of the 
 total number the lateral ventricle was involved. Of the fatal cases 
 in which the cause of death was stated, 88.8 per cent, died of purulent 
 leptomeningitis. 
 
 In MoUer's case a latent abscess caused death in five hours.^* 
 
 In Pfingst's case, without symptoms of brain abscess, excepting 
 head pains on the side of an orbital suppuration, the patient died 
 suddenly in convulsion. Autopsy showed a large encapsulated ab- 
 scess, frontal lobe, entirely within the cortical surface.^'' 
 
 Surgical Aims of Operation for Adjacent A bscess of Frontal Lobe. 
 — The osseous flap should be large enough to permit of inspection of 
 the intradural surface over the posterior wall of the frontal sinus, 
 the roof of the ethmoid, and the orbit, as adhesions between the dura 
 and the brain call for evacuation through the protected area.^' ^* 
 
 The intracerebral manipulation should be confined to, (a) the 
 
 2=Gerber, P. H. : Die Komplikatlonen der Stirnhohleneutziindungen : Monograph, 
 Berlin, S. Karger, 1909. 
 
 2" Schausboe : Bin Fall von Empyema Sinus Frontalis mit Stirnlappen-Abszess ; 
 Trang. Danish Otal. Laryngol. Sooiety, March, 1915 : Inter. Oentralhlatt filr Lan/naol.. 
 1915. Bd. XXXI, No. 12, S. 396. J » 1/ , 
 
 "Pflngst, A. O. : Brain Abscess (circumscribed purulent encephalitis). Its Course 
 and Pathology; Miss. YaMey Med. Jour., Ijoulsville, 1918, Vol. 25, p. 193. 
 
 ^Elschnlg: Der orbitogene Hirnabszess ; Prager med. Wochemschritt. 1914 Bd. 
 XXXIX, S. 37. J ' • 
 
 " Piffl : Zur Kasulstik der rhinogenen Stirnabszesse : Prager med. Wochenachrift. 
 1914, Bd. XXXIX, S. 39. 
 
Fig. 30. — Chronic encapsulated intracerebral frontal lobe abscess with stalk, 
 unrecognized although present for months. Sudden death from acute lepto- 
 meningitis. No rupture into ventricle. The cause of sudden death in cases of 
 brain abscess without rupture into the ventricle has not as yet been fully 
 explained. 
 
PEONTAL LOBE ABSCESS 135 
 
 thorough evacuation of the abscess; (b) the utilization or the estab- 
 lishment of a tract ; (c) the accomplishment of both without trauma 
 or infection of the normal cerebral tissue; and (d) the avoidance of 
 secondary compression. 
 
 Technic. — The osteoplastic flap should be as large as possible and low down 
 over the frontal avoiding, if possible, the diseased frontal sinus; its base 
 should be external. Ventricular puncture before opening the dura will allow the 
 dura to be incised without prolapse. After incision of the dura the placing 
 of the head over the edge of the table will permit the brain to fall upward and 
 toward the opposite side sufficiently to allow of elevation and inspection of the 
 under surface of the frontal lobe. If adhesions exist between the brain and the 
 dura, the abscess should now be drained through the area of protective ad-v 
 hesions, into the frontal sinus, as reconuuended in detail in the discussion of 
 temporo-sphenoidal lobe abscess. 
 
 In intracerebral abscess without macroscopieal evidence of cortical involve- 
 ment the abscess should be thoroughly evacuated and a tract established, as 
 recommended in the location of temporo-sphenoidal lobe abscess. No attempt 
 at eradication should be made, as the frontal lobe does not stand trauma 
 well on account of the poor circulation. 
 
 At the completion of the operation, if the slightest doubt exists that trauma, 
 has been occasioned, a large dural opening should be left by the sacrifice of the 
 bony flap, the brain being covered by fascia lata. 
 
 Puncture of Dura and Evacuation of Abscess through Posterior 
 Wall of the Frontal Sinus — 
 
 This is advisable only when an extradural abscess or a defect in the 
 posterior wall is accidentally found at an operation for frontal sinus disease. 
 It is apt to be associated with cerebral trauma, does not admit of complete 
 evacuation of either subdural or intracerebral abscess, or of decompression for 
 secondary oedema. 
 
 CASE 
 
 Chronic Encapsulated Frontal Lobe Intracerebral Abscess with Stalk, follow- 
 ing Trauma and Secondary Infection of Frontal Sinus. 
 
 Chief Complaint. — ^Headache, dizzy spells and defective vision of right eye. 
 
 History. — Had skull fractured from explosion of stone three months pre- 
 viously. Speaks but little English. 
 
 Examination.— Old wounds across forehead: Eyes: right cornea, dense scar 
 across centre; Vision 10/70; left cornea, media and fundus normal; Vision 20/20. 
 Ears: hearing, — right, whisper, 20 feet; left, whisper 10 feet. Bone conduction 
 apparently shortened. Rotation to right; past-pointing, — right arm, no past- 
 pointing; left arm, past-pointing to left. Rotation to left; past-pointing,— 
 right arm, past-pointing to right; left arm, no past-pointing. Rotation to right; 
 nystagmus 24 seconds, falling normal. Rotation to left, nystagmus 20 seconds, 
 falling normal. Examination unsatisfactory. 
 
 Three months later re-admitted to hospital. 
 
 Chief Complaint. — ^Hiccough. States that "'nothing bothers him." Head- 
 aches; no dizziness. Has been unable to work well since accident. 
 
 Examination. — Patient speaks but little English, is very unintelligent, and 
 at times appears drowsy. Hiccough at irregular intervals. Temperature and 
 pulse normal. Reflexes normal; no paralysis or anesthesia; no aphasia. Eyes: 
 
126 BEAIK ABSCESS 
 
 Papilloedema bilateral; edges of discs indistinct; veins tortuous. No hemor- 
 rhages. 
 
 X-Ray Examination. — "Old fracture of frontal bone." 
 
 Following day hiccough disappeared. Following day vomited, seemed 
 brighter. Suddenly chill followed by convulsions. Temperature suddenly ele- 
 vated from normal to 105. In deep coma. Lumbar puncture. Fluid turbid. 
 Cell count 19,000. Streptococci. Death within a few hours. 
 
 Post-Mortem Examination. — ^Leptomeningitis; abscess of brain of right 
 frontal lobe, with very thin capsule surrounded by several areas of small second- 
 ary pus formation. Both frontal lobes degenerated; tip right frontal lobe 
 forced into defect in posterior wall of right frontal sinus, result of old fracture. 
 Mucous membrane of frontal sinus thickened. 
 
 Remarks. — From the post-mortem examination it would appear that the 
 fracture extended through the posterior wall of the frontal sinus, and was asso- 
 ciated with injury to the frontal lobe and herniation of the brain into the 
 frontal sinus. An infection of the mucous membrane of the sinus being now in 
 direct contact with the brain, resulted in the formation of the brain abscess and 
 the development of a purulent leptomeningitis. 
 
CHAPTEK VIII. 
 HEENIA OEEEBEI. 
 
 In tlie treatment of all intradural lesions the introduction of any 
 drainage material is dangerous. OusMng's painstaking tight closure, 
 in layers, of the operative wound has contributed largely to his low 
 mortality following operation for brain tumor. He has long taught 
 that "backing out," being a reconstructive process, must of necessity 
 consume at least as much time as the destructive approach. In non- 
 suppurating intradural lesions failure of water-tight closure fre- 
 quently results in hernia cerebri of the fungating variety, which ter- 
 minates in death from meningitis. 
 
 Since it is but rarely possible in operating for brain abscess com- 
 pletely to eradicate the suppuration, some form of drainage is neces- 
 sary. In a considerable proportion of cases drainage of whatever 
 kind is followed by hernia cerebri. This is particularly apt to occur 
 if the evacuation is not complete,^ if the trauma of the operation ex- 
 cites severe reactive oedema, or if the dural opening is improperly 
 placed. 
 
 The problems involved in the causation, pathology and treatment 
 of hernia cerebri have recently attracted renewed attention because 
 of the frequency of hernia from shell injuries during the world war. 
 
 Etiology. 
 
 In the presence of a dural defect hernia cerebri will follow any 
 increase of the brain's bulk, or increase in the intracranial but ex- 
 tracerebral pressure. Increase in the intracranial pressure per se, 
 although generally followed by hernia, is not necessarily the cause 
 of this condition ; the increased bulk may be outside the brain itself, 
 as in serous meningitis when, if the dural defect is directly over the 
 serous effusion, no herniation results, whereas if away from it, her- 
 niation follows. 
 
 In abscess of the brain, hernia cerebri may result from: (1) In- 
 
 » Molllson, W. M. : Case of Cerebral Abscess ; hernia cerebri ; avulsion of abscess 
 wall : complete homolateral ophthalmoplegia ; recovery ; Proceedmgs Boy. Soc. Med., 
 London, 1917-1918, Vol. II, Sec. Otol., p. 61. 
 
 127 
 
128 BEAIN ABSCESS 
 
 crease in the cerebral tissue bulk, viz., tbe abscess and its surround- 
 ing suppuration and reactive changes, — capillary thrombosis, hemor- 
 rhages, perivascular infiltration, round-cell infiltration and associated 
 oedema — to which is added, after operation, cerebral death from 
 trauma, secondary reactive oedema, extension or. re^fiUing of abscess, 
 and encephalitis. (2) Obstruction in the exit of the cerebro-spinal 
 fluid from the ventricles. (3) Increase and alteration in the amount 
 of the fluid produced, the alteration probably seriously interfering 
 with exit (such as occurs in the eye in acute secondary glaucoma), 
 although this has not been demonstrated.^ (4) Strangulation, death, 
 suppuration, and secondary oedema of the hernia itself. By the 
 reaction of these factors, one upon the other, a vicious circle is 
 established. 
 
 Post-mortem reports show that in a very large proportion of 
 cases brain abscess is associated with internal hydrocephalus. In 
 an examination of 124 post-mortems of cerebellar abscess internal 
 hydrocephalus was recorded as present in 27 cases. The vast ma- 
 jority of the reports, however, contain no mention whatever of its 
 presence or absence, the association between the two apparently not 
 being recognized. (See Appendix II, Cerebellar Abscess.) 
 
 A certain degree of internal hydrocephalus probably accompanies 
 all brain abscesses. The brain abscess and suppurative meningitis 
 experimentally produced by Weed * in cats were invariably associated 
 with internal hydrocephalus, although no obstruction existed.* The 
 affected hemisphere is frequently displaced beyond the median line, 
 the displacement obstructing one of the main channels of the cerebro- 
 spinal fluid system, thus causing obstructive hydrocephalus. (See 
 p. 129.) 
 
 In the production of increased intracranial pressure — an over- 
 filling of the dural envelope — the various factors are so dependent 
 the one upon the other that they should not be considered separately. 
 The intradural suppuration by bacterial, chemical and mechanical 
 irritation induces an associated cerebral oedema and is accompanied 
 by an increased production of cerebro-spinal fluid. At the same time 
 its rapid removal from the interior of the brain is prevented by a 
 mechanical obstruction of the large cerebro-spinal fluid circulatory 
 channels from mechanical displacement of the brain substance — ob- 
 
 ' Rawling, L. B. : Cerebral Edema (Excess Cerebrospinal Fluid) ; Brit. Med. Jour., 
 May 4, 1918, p. 499. 
 
 ' Weed, L. H., Wegeforth : Meningitis Produced by Intravenous Inoculation ; 
 Monographs of Rockefeller Institute for Medical Besearoh, March 25, 1920, No. 12, 
 pp. 57-112. 
 
 * Dandy, W. E. : Extirpation of Choroid Plexus of Lateral Ventricles In Com- 
 municating Hydrocephalus; AnnaU of Surgery, December, 1918, 68, p. 569. 
 
HEENIA CEREBRI 129 
 
 structive hydrocephalus, — or from occlusion of the eliminating chan- 
 nels of the cortex, (the subarachnoid spaces) — from the associated 
 meningitis — communicating hydrocephalus. 
 
 Argot,^ from observation of forty cases of hernia cerebri follow- 
 ing war injuries, contends that infection is always the cause, and that 
 the infection induces a localized or general meningitis, with or with- 
 out abscess formation, with the production of an excessive amount of 
 cerebro-spinal fluid. He describes a localized meningitis with cyst 
 formation around the dural opening, and contends that if the infec- 
 tion can be combated the hernia will recede. 
 
 Argot's observations have been substantiated experimentally by 
 the frequency with which traumatic brain abscess is complicated by 
 subdural abscess situated away from the dural defect.* 
 
 CiRCULATOBY FACTORS. 
 
 Anything that obstructs the return circulation from the head will 
 cause increased intracranial pressure and herniation, if a dural defect 
 exists. The writer has seen ligation of the jugular vein followed 
 immediately by longitudinal sinus thrombosis and intense optic neu- 
 ritis with total blindness. The blindness, after persisting for several 
 days, was relieved by rupture of the dura and by development of a 
 hernia cerebri. At autopsy the lateral sinus on the opposite side was 
 found to be of very small calibre. The following case illustrates the 
 circulatory disturbances that may follow ligation of the internal 
 jugular vein in sinus thrombosis, with the development of hernia 
 cerebri : "^ 
 
 CASE XXIII. 
 
 D. S. : Hernia Cerebri. Boy, 9 years. 
 
 Previous History. — Scarlet fever five years ago, followed by left otitis media 
 purulenta; this subsided and was followed by fair-sized dry central perforation 
 of membrana tympani, which several times had discharged and subsequently 
 became absolutely dry, remaining so for several months at a time. 
 
 Present History. — Suddenly slight pain, redness, and tenderness over mastoid, 
 accompanied by very profuse discharge. Temperature 100 degrees. Vessels of 
 left optic disc rather full. Following day all mastoid symptoms had disap- 
 peared, discharge much less, follicular tonsilitis, although no complaint of 
 throat. Perfectly well in three days. Five days later, sudden dizziness and 
 rise of temperature to 104 degrees. Temperature rapidly fell again to normal, 
 and patient appeared to be perfectly well. Same sudden rise of temperature 
 repeated next day. Following day temperature 104 degrees, which fell in five 
 
 ' Argot, G. : Pathogfinie et Traitement des Hernles Cfir^brales ; Lyon Annates de 
 Chirurgie, 1917, Tome 14, p. 814. 
 
 • Esslck, C. R. : Pathology of Experimental Traumatic Abscess of the Brain ; 
 AreMoes of Neurology ani Fathologv, 1919, Vol. 26, p. 1083. 
 
 » From ArohMes of OtologVi 1906, Vol. XXV, No. 2, p. 91. 
 
130 BEAIN ABSCESS 
 
 Lours to 100.2 degrees, and rose again in five hours to 103.4 degrees, and again 
 fell in six hours below normal, 98.1 degrees. 
 
 Blood examination showed numerous plasmodia malarias. Quinine given in 
 large doses, but in spite of this there was a further sudden rise on following 
 day. 
 
 Operation. — ^Mastoid absolutely normal; no bleeding from diploic veins. 
 Sinus exposed at knee; normal appearance, but blackened well down towards bulb, 
 and small opening in wall very low down through which drop of pus oozed. 
 Jugular ligated; immediately followed by a profuse flow of blood from upper 
 wound, both from soft parts and from bone. On passing probe into opening in 
 sinus, profuse hemorrhage, which was controlled by pressure from above. Free 
 bleeding thought to come from below. Firm tamponage necessary to control 
 hemorrhage. 
 
 Following day general condition good, but mfirked double optic neuritis, 
 although none had heen present one-half hour prior to operation; chilly sensa- 
 tion, rather restless. 
 
 Two days later: Temperature 100-103.4 degrees; pain in back of neck oij 
 moving eyes; retinal veins enormously dilated and tortuous, arteries smallT 
 Numerous hemorrhages in retina. Ether given; again very profuse hemorrhage, 
 supposed to come from below as well as above. Very firm tamponage necessary 
 to control bleeding. 
 
 Four days later: Veins over whole of sioalp and upper part of chest very 
 much distended. 
 
 Eleven days later: General condition very much improved, but can see very 
 little. The enlarged veins in the scalp have felt like irregular cords imder 
 the finger, as if filled with firm thrombi, but now are gradually disappearing. 
 Has had two lumbar punctures during past weelc. Fluid clear, under pressure, 
 microscopical examination negative, first puncture apparently improved vision 
 somewhat. Great difficulty has been experienced in changing dressings because 
 of the hemorrhage which succeeded any disturbance of the firm packing. 
 
 Nineteen days later: Very free discharge of clear cerebro-spinal fiuid, escap- 
 ing from small opening in inner wall of sinus. Dressings soaked several times 
 daily. 
 
 Twenty-four days later: Hernia cerebri. 
 
 During the next month symptoms of cerebellar abscess, irregular projectile 
 vomiting, vertigo, on left side loss of coordination of both arm and leg, but 
 chiefly of arm. Deviation of tongue, but no loss of flesh. 
 
 During this time the cerebellum was twice explored; nothing found. 
 
 Thirty-four days later: liapid rise in temperature; delirium; inability to 
 swallow; collapse; death. 
 
 Report of Autopsy. — "Nothing abnormal noted over the surface of the 
 brain. The optic nerves and vessels cut and the medulla divided and the brain 
 lifted out. It separated easily except at the site of the hernia cerebri, which 
 was the left side of the cerebellum. 
 
 "On opening the sinuses, the left lateral, the torcular, the inner one-fourth 
 of the right, nearly the whole of the superior longitudinal, were all thrombosed. 
 The cavernous and the petrosals were normal. 
 
 "The hernia cerebri involved nearly the whole of the left lateral lobe of the 
 cerebellum; extending from it was an area of softening involving the left 
 lateral portion of the pons. 
 
 "Two specimens were taken for microscopical study; one, the lateral por- 
 tion of the pons and the other the medulla. The specimen taken from the medulla, 
 on cross-section in its upper part, showed in the median line of the floor of the 
 fourth ventricle a hemorrhagic area extending inwards and slightly to the left. 
 The floor of the fourth ventricle showed microscopically extensive round-celled 
 
HERNIA CEEBBEI 131 
 
 infiltration. Medulla: both specimens show evidences of rather extensive menin- 
 geal inflammation." 
 
 Examination of the wet specimen of this dura several months later showed 
 the free right lateral sinus to be only about one-half the size of the thrombosed 
 left lateral sinus. 
 
 Stxegical Pathology and Physiological Factors. 
 
 Hernia cerebri from a surgical standpoint may be divided into 
 two groups: (1) non-vlcerative, and (2) ulcerwtive or fungating. 
 
 Non-ulcerative hernia cerebri, even in the presence of infection, 
 may serve a useful purpose, as by its development, compression 
 whicb is favoring an extension of the suppuration may be relieved, 
 the protective forces of the brain being enabled thereby to limit the 
 suppurative process, which otherwise will prove fatal. A non-ulcer- 
 ating hernia cerebri is covered with piarachnoid; it is smooth and 
 glistening, and pial vessels run over it. It occurs with large dural 
 defects. The surgical treatment calls for the preservation of this 
 normal piarachnoid. 
 
 Unfortunately, in the presence of suppuration, non-ulcerative 
 hernia cerebri generally becomes ulcerative or fungating. Fungat- 
 ing hernia is not covered with piarachnoid, its surface is ulcerative or 
 gangrenous. It occurs in small dural openings, and is partly the 
 result of strangulation of cerebral tissue. 
 
 Fungating hernia cerebri, examined microscopically, is found to 
 contain little normal cerebral tissue, even when the hernia is of large 
 size. In the presence of suppuration a large part of the cerebral 
 tissue protruding from the dural opening rapidly degenerates and is 
 replaced by vascular inflammatory exudate, with the formation of 
 granulation tissue. The area of oedema and granulation tissue passes 
 imperceptibly into the area of normal cerebral tissue, so that if the 
 hernia is excised, the irritation of the operation is sufficient to start 
 the process afresh.* Several painful experiences have impressed this 
 upon the writer. Moreover, it is impossible to stop the growth of a 
 hernia by pressure, as the irritation of the compression increases its 
 size. 
 
 Normally, the cerebral tissue is bathed in warm, mildly alkaline 
 cerebro-spinal fluid. If a non-ulcerative cerebral hernia is exposed to 
 the air for but a few minutes, its surface becomes dry from evapora- 
 tion,' the pathological fluid of the cedema coagulating rapidly. Dry- 
 ing of the surface of a cerebral hernia results in local areas of gan- 
 grene, a frequent and to a large extent unavoidable complication of 
 
 ■ Sargent and Holmes : The Treatment of the Cranial Injuries of Warfare : Brit. 
 Uei. Jour., 1915, I, p. 537. 
 
132 BEAIN ABSCESS 
 
 cerebral hernia. This superficial gangrene continues uninterruptedly 
 whenever any absorbent material is used on the hernia.® 
 
 SXJRGICAL TREATMENT. 
 Pehventiok of Hernia ; Site of Dural Defection. 
 
 Experimental evidence and clinical experience demonstrate that 
 dural defects over the vault of the cerebrum or the lateral lobes of 
 the cerebellum are much more frequently followed by herniation than 
 over the under surface of the temporo-sphenoidal lobe, the inner and 
 lower angle of the forehead, or the anterior surface of the cerebellum, 
 the dura and the brain, at the latter points, being held firmly together 
 by vessels and nerves, and the intracerebral and intracerebellar pres- 
 sure being minimized. Consequently, drainage should be at the site 
 of the dural defect, unless a protective non-ulcerative hernia is de- 
 sired for the control of compression. 
 
 An effort should be made in every case of hernia cerebri to de- 
 termine the causative factor or factors. As the underlying cause 
 in many cases of hernia cerebri following abscess formation is an 
 incomplete evacuation of the abscess, if a fistulous tract in the abscess 
 cavity can be located without injury to the cerebral tissue its complete 
 evacuation will be followed by a recession of a large part of the 
 hernia. 
 
 (See Case XII, W. K., Chapter TV, p. 60, of Double Cere- 
 bellar Abscess, in which hernia, probably from "second abscess," 
 was relieved by evacuation.) 
 
 Likewise, the evacuation of a meningeal abscess or retention cyst, 
 situated near the edge of the dural defect, — ^both frequent complica- 
 tions,- — will promptly relieve the hernia. 
 
 The treatment of hernia cerebri involves the avoidance of irri- 
 tation from surgical interference or dressings; the protection of the 
 hernia from injury, dryness, cold, or secondary infections ; and pos- 
 sibly the reduction of increased intracranial pressure. 
 
 It has long been recognized clinically, as previously noted, that 
 excision of the hernia is invariably followed by its reappearance and 
 that, in many cases, it ushers in a fatal meningitis, the rapid increase 
 in the hernia resulting from the mechanical irritation of the opera- 
 tion itself. Surgeons have learned to leave the protruding tissue 
 alone, confining their efforts to attempts at covering the protruding 
 mass. The observation of Essick, Weed and Wegeforth ^" in experi- 
 
 » steed, KeUogg : Gunshot Fracture of the SkuU ; Jour. A. U. A.. ; May B, 1917, 
 Vol. LXVIII., p. 1299. 
 "ioo. cif. 
 
HERNIA CEREBEI 133 
 
 mentally produced brain abscess of a fatal meningitis from recrudes- 
 cence of a latent infection, following operation for the closure of 
 cranial defects, in abscesses wMch have been healed for several 
 months, explain the complicating meningitis, and should make most 
 cautious the slightest surgical intervention. Even attempts to probe 
 apparent fistulous tracts in the hernia should be avoided, unless 
 instillation with a bismuth solution, followed by X-ray examinations, 
 shows that the fistula leads to a definite cavity within the dura] 
 opening. ^^ 
 
 Protection, — During exposure for dressing, the hernia should 
 be continually but gently flooded with warm salt solution containing 
 a small quantity of calcium salts. (Gushing has found that sterile 
 normal salt solution without calcium salts is toxic to normal cerebral 
 tissue.) The hernia should be irrigated but infrequently, to avoid 
 all unnecessary irritation of the cerebral tissue and to facilitate the 
 growth of new connective tissue over the hernia.-^ ^ During the war 
 Dakin's solution was used freely on cerebral tissue; its apparent 
 harmlessness must be because the hernia no longer consisted of cere- 
 bral tissue, although Argot washes out the cerebral wounds with 
 Dakin's solution immediately after the injury. Gushing ^® instills 
 dichloramin-T in the cerebral tract ; its use, however, can be justified 
 only by extensive destruction of cerebral tissue. The writer has seen 
 a hernia become gangrenous with rapidly fatal result, following ap- 
 plication to its surface of a weak formalin solution. 
 
 After irrigation with normal salt solution, the hernia should be 
 thoroughly covered with sterile wet rubber tissue coated with vase- 
 line, over which a dressing is placed. As the rubber tissue prevents 
 the evaporation of the fiuid, it should be changed only at infrequent 
 intervals — ^not more than once every ten days or two weeks — even 
 though the discharge from contiguous suppuration be irritating to 
 the skin and surrounding parts. 
 
 In the case reported (page 135) the odor from the eczema 
 induced in the surrounding skin by the non-changing of the dressings 
 permeated the whole floor of the hospital, but the attendants were 
 not permitted to disturb the hernia unnecessarily. The outer dress- 
 ing was changed once or twice weekly, and a non-irritating ointment 
 applied to the surrounding skin, but the dressing on the hernia itself 
 was removed only every fourteen days. At these times the hernia 
 was merely flooded with a warm salt solution. 
 
 " Tobey, Dr. G. L. : Personal OoinmunieaUon. 
 
 " Adami and McCrae : Text Book of Pathology, 1914, II Edition, p. 124. 
 " Gushing : Notes on Penetrating Wounds of the Brain : Brit, Jf erf, Jour., Feb. 83, 
 J918, p. 321, 
 
134 BRAIN" ABSCESS 
 
 Several months later a small piece of rubber tissue, wbicb had 
 been lost under the osteoplastic flap at the time of the operation, 
 came away followed by a piece of the bone of the flap. Slight re- 
 cession of the hernia followed ; from which it would seem that the 
 irritation from the foreign bodies was responsible, in part at least, 
 for the hernia. 
 
 Under non-operative treatment the granulating mass gradually 
 assumes a very even appearance and begins to shrink; later, islands 
 of epidermization appear in it, gradually covering the hernia. 
 (Figs. 31, 32.) 
 
 All the cases of hernia cerebri which the writer has known to 
 recover have been treated without operative interference upon the 
 hernia itself. 
 
 Reduction of Incbeased Intkacranial Pressube. 
 
 Smith,^* and Sargent and Holmes ^^ advise frequent lumbar 
 punctures, using a saline solution manometer to measure the degree 
 of pressure of the cerebro-spinal fluid. 
 
 Technic. — "Normally we have found that the column of saline thus sup- 
 ported varies from 15 to 25 cm. The amount of fluid to be withdrawn will 
 roughly depend upon this reading and varies from four to eight fluid drachms, 
 according to the initial pressure recorded. Even where the initial pressure is 
 very high — in one of our cases it amounted to 108.5 cm. — it is not necessary 
 to remove more than from 4 to 8 fluid drachms, as the pressure recorded after 
 the removal of this quantity will rarely register much above the normal. It is 
 important, too, that the fluid be withdrawn slowly, almost drop by drop, as 
 otherwise the hernia, with too much sudden relief of pressure, may sink back 
 through the bony opening into the brain, leaving a deep cavity where before 
 there was a large hernia. This is dangerous, for adhesions may be broken down 
 and a septic meningitis lighted up." " 
 
 Although the writer has no personal experience with lumbar 
 puncture in cerebral hernia, such a procedure is based upon sound 
 mechanical and clinical grounds provided the hernia is of cerebro^ 
 spinal fluid origin. The author has seen a marked papilloedema, the 
 result of traumatism, quickly disappear under one lumbar puncture. 
 In another cage, following an operation for compound depressed frac- 
 ture without injury to the dura, the patient, through failure on the 
 part of the medical attendant to appreciate the condition, continued 
 
 " Smith. S. : Notes on the Treatment of Hernia Cerebri ; British Medical Jmimal, 
 July 22, 1916, p. 103. 
 
 >= Sargent and Holmes ; Treatment of Penetrating Wounds of the Skull ; British 
 Journal of SurgetV, 1916, Vol. Ill, No. 11, p. 475. 
 
 '" Cassidy and Page : A Method of Determining the Absolute Pressure of the 
 Cerebro-spinal Fluid ; Proo. Boy. Med. Soc, 1910-1911, Vol. 4, pt. 1, Clinical Section, 
 p. S6. 
 
Fig. 31. — Cerebral hernia following evacuation of temporo-sphenoidal lobe 
 abscess. Note outline of osteoplastic flap, all of which is slightly elevated and 
 the lower part of which had been sacrificed. The wide decompression thus 
 furnished was the deciding factor in the recovery. Some months later a small 
 bony sequestrum was spontaneously expelled, but in spite of this loss the 
 patient has a good bony covering over the whole region except just above the 
 ear. 
 
 Fio. .32. — The same case as Fig. 31, three years after the evacuation of the 
 abscess, showing recession of hernia and its complete covering by skin without 
 operative intervention or the application of pressure. 
 
HEE"NIA CEEEBEI 135 
 
 in a state of active delirium for three weeks and when seen was ap- 
 parently dying from exhaustion. One lumbar puncture, however, 
 was followed by almost immediate return to consciousness and rapid 
 recovery. The writer also has seen several cases of fracture with 
 intradural hemorrhage in which each lumbar puncture was followed 
 by marked and immediate improvement of the patient's mental con- 
 dition. In fact the results of repeated lumbar puncture in traumatic 
 cases have been so satisfactory that witb the author it is a routine 
 practice if the operation on the skull is not followed by immediate 
 and continued improvement.^'' 
 
 Argot, ^* as the result of his large experience in cerebral hernia, 
 condemns lumbar puncture as being apt to cause a dissemination of 
 the localized infection, meningitis, or rupture of a localized abscess 
 internally. 
 
 CASE XXIV. 
 
 J. G. : Bernia Oerebri Following Operation for Temporo-splienoidal Aiscess. 
 
 Woman. Admitted to hospital December 23, with history of chronic relapsing 
 otitis media for many years. Of nervous disposition; subject to night terror. 
 
 Operation on mastoid showed acute exacerbation of chronic process. Dis- 
 charged January 1, doing well. Hearing: voice, 7 inches; whisper, 3 inches; 
 watch, 2 minutes. Weber referred to left. 
 
 Three days later, January 4, became delirious at night, singing, more or less 
 irrational. Ee-admitted to hospital the next day. Examination: no nystagmus, 
 could hear with left ear, no spontaneous pointing deviation. 
 
 January 6, patient able to walk and execute all movements; irregular con- 
 tractions over body; active abdominal reflex; no neck stiffness; mastoid wound 
 re-opened; dura over middle fossa found covered with granulations. Sinus 
 accidentally opened; profuse bleeding. The following day there was spontaneous 
 nystagmus on looking towards right side, and aphasia, — ^naming centre was 
 slightly involved, but the aphasia seemed to he rather a carrying over of a 
 previous impression. Shown a pencil, named it and said it was something to 
 write with; shown a knife, called it a knife; shown a bunch of keys, called it a 
 knife and said it was something to whistle with. Shown a match, she said it 
 was something to light a fire with; shown a pad called it a piece of paper; 
 shown a hospital card, said it was a piece of paper to put your name on. 
 
 Convulsive seizures, in which both hands rotated on themselves inward. 
 Lateral deviation of the head and of eyes to the left. The left pupil gradually 
 became much larger than the right, the right apparently becoming much smaller. 
 On coming out of the convulsion undoubtedly had a Bahinski, especially on left. 
 The face was drawn to the left as if there were paresis of the right side. As 
 patient became further conscious the left pupil became widely dilated; the right 
 pupil becoming small. At this time there was marked rotary nystagmus to the 
 right. Between convulsive seizures left patellar reflex absent, no hemianopsia. 
 Named objects well for a few minutes and then gradually relapsed into a drowsy 
 condition, repeating one word to everything, although she undoubtedly named the 
 use of things better than the name itself. 
 
 " lioblnger, A. S. : Cerebral CEdema in Intracranial Trauma ; Calif ortda State 
 Journal of Medicine, June, 1918, Vol. 16, p. 303, 
 u Argot : Loc. at. 
 
136 BEAIH ABSCESS 
 
 Caloric producing nystagmus not associated with any dizziness or vomiting 
 and apparently no pointing deviation, although of this cannot be sure, because 
 of stuporous condition of patient. 
 
 January 9. Several convulsive seizures. Eight hand cold, left warm; slight 
 double papilloedema, especially on left disc. Toxic delirium. Internal squint, 
 left eye. 
 
 Diagnosis. — Temporo-sphenoidal lobe abacess, without capsule as length of 
 time since initial cerebral symptoms is too short to allow of formation of 
 capsule. 
 
 Operation. — Large osteoplastic flap turned upwards. Incision of dura 
 showed cortex to be normal. There was marked prolapse of brain through dural 
 opening. Lumbar puncture was done but resulted in a few drops only of cerebro- 
 spinal fluid; canula left in position. Exploration of temporo-sphenoidal lobe 
 was followed by a gush of pus and the immediate free discharge of cerebro- 
 spinal fluid from trocar in lumbar region. The greatest delicacy in cleansing 
 abscess. No hemorrhage. Rubber drain. Replacement of flap. Almost tight 
 closure. 
 
 February 11. Large hernia about half the size of a tangerine orange directly 
 above ear. Under slight pressure, small amount of pus observed at upper edge. 
 Hernia not gangrenous, kept covered by rubber tissue. Pus seen in two or three 
 places along edge of hernia. Patient apparently perfectly well; able to name 
 objects correctly. Hernia could be reduced by one-third by pressure; it was 
 soft, perfectly smooth, and cystlike in appearance, not like brain; probably com- 
 posed of granulated or (Edematous tissue. 
 
 Some weeks later. Hernia, which had been carefully protected, was very 
 much smaller. A piece of rubber tissue was discovered which had been lost 
 during drainage. Loose sequestra of bone removed and hernia gradually reduced. 
 Patient made a complete recovery. 
 
 Comment. — It was undoubtedly the irritation from the lost drain that caused 
 the hernia. 
 
CHAPTER IX. 
 PROTECTIVE MECHAmSM OE THE BRAIN. 
 
 The protective mecliaiiism of the brain is one of the functions of 
 the delicate, anatomical and physiological relationship which exists 
 between the cerehro-spinal fluid circulatory system and the circula- 
 tory system of the blood, by means of which bacterial invasion is 
 prevented, or, having occurred, the invading toxins are eliminated. 
 The brain is unable to function properly when it is the seat of suppu- 
 ration ; it is also profoundly influenced by toxemia ; consequently na- 
 ture has furnished especial protection both from external infection 
 and from the blood which circulates through it. In addition to the 
 bony cranium an external protection — the dura — is essential, not only 
 because the cranium is liable to injury, but because it contains an 
 organ,- the nose, which is the natural habitat of many forms of bac- 
 terial life, while another organ, the ear, is the frequent site of infec- 
 tion, both of these being contiguous to the cranial cavity itself. Eur- 
 thermore, as the blood stream, which circulates through and nourishes 
 the brain, is constantly invaded by micro-organisms (one of its func- 
 tions being to devour them) there must be a special mechanism whose 
 purpose it is to guard the brain, not only from the organisms them- 
 selves, but as far as possible from the influence of the toxins which 
 may be contained within the blood. 
 
 Prevention of Infection. — Consequently the brain normally is 
 protected from infection from without by (1) the dura; and from 
 within by (2) the normal Encephalo-Chorio-Meningeal Mechanism, 
 consisting of an intimate anatomical and delicately adjusted physi- 
 ological relationship between the blood circulatory system and the 
 cerebro-spinal fluid circulatory system within the dura, the chief 
 function of which is the nutrition of the brain from the circulating 
 blood (the same as all other tissues of the body) . At the same time 
 it affords protection from any mechanical or bacterial irritant that 
 may be circulating within the blood, and from the toxins in waste 
 products discharged into the blood stream again. 
 
 In this mechanism the chief protective elements are furnished 
 by (a) the blood in the blood vessels, (b) the blood vessels them- 
 
 137 
 
138 BEAIN ABSCESS 
 
 selves, (c) the pia and the external layer of the subarachnoid space, 
 (d) the eerebro-spinal fluid, and (e) the glial tissue of the brain. 
 
 Surgical Application: It is the presence of a special internal protective 
 mechanism which explains the fact that although abscess of the kidneys, skin, 
 etc., is frequent in suppurative endocarditis, abscess of the brain is of very rare 
 occurrence, and then generally as a terminal manifestation, in spite of the fact 
 that the blood infecting micro-organisms have a straight-away course from the 
 heart to the brain. 
 
 In the presence of infection the brain repels the invasion (1) by 
 the incorporation of bacteria and deleterious products within the sub- 
 stance of the phagocytic cells, which in the brain substance come from 
 two sources, (a) the leucocytes and (b) the polynuclears from the 
 blood vessels (as in other tissues) and (c) the macrophages from the 
 cerebral tissue itself. These macrophages — a cell peculiar to the 
 nervous system and produced from the external layers of the piarach- 
 noid, the pia and the glia — play a most important part in combating 
 suppuration and in repair. Their chief function, apparently, is 
 (2) the transference and removal of dead and deleterious matter 
 from the central nervous system by incorporating it within their sub- 
 stance and discharging it (a) into the blood vessels and (b) into the 
 perivascular spaces of the eerebro-spinal fluid circulatory system, by 
 which all waste or deleterious material is conveyed into the sub- 
 arachnoid space, and thence discharged into the venous sinuses or 
 the extracranial lymphatics. During this process there occurs (3) 
 an immunization of the eerebro-spinal fluid in the subarachnoid and 
 perivascular spaces, while at the same time elements are produced 
 from the blood vessels and the brain tissue which (4) limit the sup- 
 puration by (a) the production of polymorphonuclear cells (b) the 
 proliferation of glial tissue, and (c) the formation of new connective 
 tissue. 
 
 Pathological Peocesses in Infection. 
 
 Infection enters the brain by four methods : 
 
 (1) By the extension of contiguous tissue suppuration, causing 
 a necrosis of the dura, an intrapiarachnoid abscess, a superficial brain 
 necrosis, or a suppurative meningitis ; 
 
 (2) From the blood vessels, (a) through retrograde thrombo- 
 phlebitis of the veins of the ear or nasal sinus which perforate the 
 dura and enter the brain, thus causing adjacent (secondary) brain 
 abscess ; or retrograde thrombophlebitis of the veins which enter the 
 large venous sinuses from the brain substance, thus causing inter- 
 current (tertiary) brain abscess ; (b) by invasion of the perivascular 
 
PEOTECTIVE MECHANISM OP THE BEAIN 139 
 
 channels surrounding tlie blood vessels — perivasculitis ; (c) through 
 bacterial embolus within the vessels — the method of cerebral invasions 
 of all infections that primarily are of blood-stream origin (cerebro- 
 spinal meningitis, streptococcsemia with secondary meningitis, 
 pneumococcus meningitis, metastatic abscess from the lungs, etc.) ; 
 
 (3) By invasion of the prolongations of the subarachnoid spaces 
 which surround certain nerves — chiefly the olfactory, the optic, and 
 the auditory nerves — ^by means of which the subarachnoid spaces be- 
 come extracerebral. (The filtrable virus of poliomyelitis probably 
 enters the nervous system from the nasal mucosa by way of the 
 perivascular prolongations which surround the olfactory nerves) ; 
 
 (4) By interference with the normal operation of the meningeal 
 protective mechanism, which, in the presence of blood-stream infec- 
 tion, may allow entrance into the meninges, the perivascular spaces, 
 or the cerebral substance itself, of micro-organisms from the blood 
 stream. This latter method probably is a frequent factor in the pro- 
 duction of streptococcus meningitis and pneumococcus meningitis of 
 aural and nasal accessory sinus origin. 
 
 PROTECTIVE MEOHA:sriSM OF THE BRAIN. 
 
 I.— By the Dura. 
 
 Surgically the chief function of the dura is to prevent the en- 
 trance of micro-organisms into the brain. On the approach of an 
 adjacent infection the dura fortifies itself and combats the poison 
 by the formation of granulation and subsequently of new connective 
 tissue, both on its external and internal surface — a pachymenin- 
 gitis externa and interna. In the development of the latter process 
 the central protective mechanism, especially the arachnoid cella, 
 takes an active part. 
 
 Points of Vulnerability of the Dv/ra: Although the enclosing dura is the 
 chief protection of the brain against direct invasion by micro-organisms, it con- 
 tains areas of vulnerability, especially where it is perforated by certain nerves 
 and blood vessels. The subarachnoid space prolongations surrounding these 
 blood vesels extend well into the foramina through which the nerves and blood 
 vessels enter and leave the cranium. At these sites the subarachnoid space ac- 
 tually becomes intracranial; The subarachnoid prolongation around the nerves 
 causes a perineural space in three places ; ( 1 ) along the nerve of the special 
 sense of hearing and orientation, where the intralabyrinthine fluid is part of the 
 eerebro-spinal fluid; (2) along the nerve of the special sense of smell — the olfac- 
 tory nerve — ^where the perineural sheaths descend into the nasal mucous mem- 
 brane, and (3) along the nerves of the special sense of sight, where the subarach- 
 noid space is continued for a certain distance along the optic nerve as the inter- 
 vaginal space. 
 
 It is more than a coincidence that all these prolongations of the subarachnoid 
 space are directly connected with three of the organs of special sense. There is 
 
140 BEAIN ABSCESS 
 
 experimental evidence tliat it is through the extradural or extracranial prolonga- 
 tion of the perivascular spaces of the vessels and of the perineural spaces of the 
 nerves that infection frequently enters the brain, and that within these recesses 
 micro-organisms long continue to persist after their elimination from the general 
 subarachnoid space. 
 
 II — By the Subdural Space. — 
 
 The subdural space apparently is very immune to infection, as 
 it offers especial resistance to the growth of bacteria. In meningitis 
 or brain abscess it generally is unaffected, altiiough as a brain 
 abscess approaches the cortex the subdural space may become com- 
 pletely obliterated; but in cases of pachymeningitis interna the in- 
 fecting micro-organisms may project well into the subdural space 
 without involving it, as demonstrated by Streit.^ In this situation 
 they may remain more or less dormant for long periods of time. 
 If trauma is now added, breaking down the adhesions, a general 
 fulminating meningitis may follow, as has occurred in many cases 
 following an operation for a chronic aural or nasal sinus suppura- 
 tion. 
 
 Surgical Application: Although meningitis or abscess primarily confined to 
 the subdural space is a very rare occurrence from aural infection,* it apparently 
 is more common in nasal sinus suppuration, probably because of the communica- 
 tion of the subdural space with the mucosa of the frontal sinus by way of the 
 perimeningeal spaces." However, in experimentally produced traumatic abscess,' 
 large subdural abscesses were frequent, and microscopic examination found the 
 adjacent subarachnoid space to be free from micro-organisms, demonstrating the 
 extreme degree of resistance of the external layer of the arachnoid and explain- 
 ing the clinical experience that a subdural abscess is a frequent complication of 
 hernia cerebri following evacuation of an intracerebral abscess. The occurrence 
 of a hernia should always awaken suspicion of its origin in a localized collection 
 of pus in the subdural space, and should cause the surgeon carefully to expose 
 the regions adjacent to the hernia before again entering the brain surgically. 
 
 Ill — By the Subarachnoid Spaces. — 
 
 In the normal state the subarachnoid spaces, in which the cere- 
 bro-spinal fluid circulates, are kept free. On the approach of bac- 
 teria to the dura the subarachnoid space fortifies itself by an over- 
 production of cerebro-spinal fluid containing a large number of 
 phagocytic cells — ^polymorphonuclears. 
 
 Swrgical Application: Serous meningitis is a protective process. In aseptic 
 meningitis the perivascular spaces apparently are not involved, but the velum 
 
 1 Streit, Hermann : Weitere Beltrage zur Hlstologie und Pathologie der Menln^tia 
 und Slnusthrombose ; Archvo fUr Ohrenheilkunde, 1912, Bd. 89, S. 177. 
 
 ' Case VIII, Chapter Four, p. 37. 
 
 " ZwilUnger, H. : Experimentelle Untersuchungen zur Mechanlk der Intrakranlellen 
 und cerebralen Komplikationen der Stirnhohlenentzundungen. (From the Anatomical 
 Institute of the University of Budapest.) ArcMv fur Laryngologie und RMnologie, 
 1914, Bd. XXVIII, S. 271. 
 
 * Bssick, Charles B. : Loc. cit. 
 
PEOTECTIVB MECHANISM OF THE BRAIN 141 
 
 interpositum and choroidal stroma are infiltrated with polymorphonuclears. The 
 high polymorphonuclear count without organisms in lumbar puncture is simply a 
 sign of a protective meningitis. Later, as the process becomes quiet, mononuclear 
 cells and lymphocytes predominate.' 
 
 On the entrance of bacteria into the subarachnoid spaces of the cerebro-spinal 
 fluid circulatory system, the meningeal protective mechanism combats infection 
 chiefly by the action of macrophages coming from the glial tissue and from the 
 piarachnoid cells. 
 
 ANATOMY OF THE CEREBRO-SPHSTAL FLUID SYSTEM.' 
 
 Tlie cerebrospinal fluid circulates within closed cavities and 
 tubes — the ventricles, the cisterna and the subarachnoid spaces con- 
 stituting the cerebro-spinal circulatory system — ^just as the blood 
 circulates in the blood vascular system; and like the vpaUs of the 
 venous system, the walls of the cerebro-spinal circulatory system 
 are normally impermeable to the contained fluid. 
 
 The cerebro-spinal fluid finally empties into the blood stream 
 after performing its functions in the brain, passing by osmosis into 
 the venous sinuses of the head, and at certain points where the sys- 
 tem has passed outside of the cranium, communicating again by 
 osmosis, with the extracranial lymphatic system. This communica- 
 tion occurs along the arachnoid prolongations around the sheaths 
 of certain nerves, especially the olfactory and the auditory. 
 
 Thus, while the cerebro-spinal fluid circulatory system is a closed 
 system without an apparatus for the puriflcation and return of its 
 fluid such as the vascular system has in the heart and lungs, it 
 utilizes both the vascular and the lymphatic system for its dis- 
 carded material much in the same way as the blood vascular system 
 utilizes the kidneys; with this difference, however, that while the 
 blood discharges through the kidneys only its deleterious material 
 the entire cerebro-spinal fluid constantly is being discharged into the 
 blood or the lymphatic system. 
 
 Viewed then in a large way, both anatomically and physiolog- 
 ically, the cerebro-spinal fluid circulatory system must be of impor- 
 tance to the cerebral functions.'' *° ^' 
 
 ' Ayer, J. B. : Loo. eit. 
 
 ' Bagleton, W. P. : Operative Treatment of Suppurative Meningitis wltli special 
 reference to Irrigation of the Cranial and Spinal Subarachnoid Spaces, and the Impor- 
 tance of Protective Meningitis from a Prognostic and Therapeutic Standpoint ; Trans- 
 actions American Otological Society, 1921. 
 
 ' Weed, Lewis H. : Studies on Cerebro-Spinal Fluid ; Journal of Medical Beaecurch, 
 September, 1914, Vol. XXXI, pp. 21-117. 
 
 8 Wegcforth, Paul, and Weed, Lewis H. : Studies on Cerebro-Spinal Fluid ; Jotimal 
 of Medieal Research, September, 1914, Vol. XXXI, pp. 167-176. 
 
 • Weed, Lewis H., and Gushing, Harvey : Studies on Cerebro-Spinal Fluid ; 
 Amerioan Jmirnal of Pht/aiology, January, 1915, Vol. XXXVI, No. 2. 
 
 "• Cushing, Harvey, and Weed, Lewis H. : Studies on the Cerebro-Spinal Fluid and 
 its Pathways; Johns Hopkins Hospital Bulletin, November, 1915, Vol. XXVI, No. 
 297. 
 
143 BRAIN ABSCESS 
 
 The circulatiiig cerebro-spinal fluid is produced chiefly from 
 the choroid plexus within the ventricles, the walls of which are 
 lined by cells, the endyma, which are impervious to the fluid. From 
 the ventricles the fluid passes by a process of overflow through the 
 aqueduct of Sylvius into the fourth ventricle and leaves it by the 
 medial foramen of Magendie and the lateral foramen of Luschka; 
 from these it spreads over the base of the brain, accumulating in 
 the large basal cistema, whence it is distributed by way of the 
 sponge-like, communicating meshes of the subarachnoid spaces over 
 the cortex, through the vessels and convolutions, and empties at 
 last by osmosis into the venous sinuses. 
 
 In its passage over the cortex there is contributed from the cere- 
 bral substance — through the prolongations of the subarachnoid spaces 
 along the vessels entering or leaving the cerebral tissue, called the 
 perivascular spaces — a small amount of cerebrospinal fluid which 
 has a somewhat different composition from the cerebro-spinal fluid 
 formed in the ventricles. These perivascular channels opening di- 
 rectly into the subarachnoid spaces of the cortex, are undoubtedly the 
 means of direct communication between the intracellular juices of 
 the brain cells — the perineural system, and the general cerebro- 
 spinal circulatory system. 
 
 The cerebro-spinal fluid acts to remove the waste products of 
 the brain, but whether it supplies any nutritive ingredient neces- 
 sary to the continued functioning of the brain is not known. It is 
 inconceivable that it does not possess some such quality, especially 
 since its normal content is a sugar-reacting subs.tance. 
 
 IMPBEGN ABILITY TO INFECTION OF CEREBEO-SPINAI. FLUID SYSTEM. 
 
 The cerebro-spinal fluid system, while anatomically composed 
 of very delicate cells, is very resistant to infection when attacked 
 either upon its external surface, or internally from the cerebral 
 tissue; and while in close anatomical proximity to the blood circu- 
 latory system — ^being separated from the pial vessels by only 
 one layer of cells and actually surrounding the vessels as perivascular 
 
 " Weed, Lewis H. : The Formation of the Cranial Subarachnoid Spaces ; The 
 Anatomical Record, May, 1916, Vol. X, No. 7. 
 
 " Weed, Lewis H. : An Anatomical Consideration of the Cerebro-Splnal Fluid ; 
 The Anatomical Record, May, 1917, Vol. XII, No. 4. 
 
 " Weed, Lewis H., and McKibben, Paul S. : Pressure Changes In the Cerebro- 
 spinal Fluid Following Intra-Venous Injection of Solutions of Various Concentra- 
 tions; Americwn Journal of Plvyaiology, May, 1919. Vol. XLVIII, No. 4. 
 
 " Weed, Lewis H., and McKibben, Paul S. : Sxperimental Alterations of Brain 
 Bulk ; Amerieam, Journal of Physiology, May, 1919, Vol. XLVIII, No. 4. 
 
 " Weed, Lewis H. : The Cells of the Arachnoid ; Johns Hopkins Hospital Bulletin, 
 October, 1920, Vol. XXXI, No. 356. 
 
 i» Maeklin, Charles Clifford, and Macklin, Madge Thurlow : A Study of Brain 
 Repair In the Eat by the Use of Trypan Blue ; ArchAmes oj Neurologjf and Psyohiatry, 
 April, 1920, Vol. Ill, pp. 353-394. 
 
PROTECTIVE MECHANISM OF THE BEAIN 143 
 
 spaces — ^the cerebro-spinal fluid system, when uninjured, does not 
 allow of invasion of the subarachnoid spaces by bacteria circulating 
 free in the blood stream. However, a very small disturbance of 
 the meningeal protective mechanism in the presence of a blood- 
 stream infection may allow the invasion of the meninges from the 
 blood stream. 
 
 The subarachnoid space bacteriologically resembles the perito- 
 neum, each being a mesothelial-lined cavity which, on account of its 
 blood supply and its contained fluid, furnishes a favorable soil for 
 the development of micro-organisms. The cells of the subarachnoid 
 space, however, both of the external layer toward the subdural space 
 and of the pial layer, are very resistant to infection; but the cells 
 lining the cavity itself possess much less resistance if once infected. 
 Likewise there is experimental evidence that the cerebro-spinal fluid 
 normally possesses to a high degree immunizing bodies which under 
 favorable circumstances may considerably increase. On the other 
 hand, anything which alters the integrity of the meningeal choroid 
 protection, or upsets the operation of the meningeal mechanism, di- 
 minishes or removes its protective function. 
 
 In suppurative processes the arachnoid membrane thus serves to 
 limit the spread of infection from the outside into the subarachnoid 
 space, or, when the subarachnoid space itself is infected, it prevents 
 infection from spreading inward into the deeper layers of the pia and 
 the substance of the brain. In abscess of the brain, although the 
 perivascular spaces may be flUed with exudate, no micro-organisms 
 and but few cells may be found in the subarachnoid space at a dis- 
 tance from the infection. 
 
 Surgical AppUoation: It is the resistance of the piaraohnoid to invasion from 
 the subarachnoid space that explains the clinical fact that while suppurative men- 
 ingitis both local and general, frequently follows intracerebral abscess, localized 
 meningitis never is followed by the latter, although frequently accompanied by 
 a superficial brain necrosis. 
 
 Note: The cerebro-spinal circulatory system seems to have resisting power to 
 infection in itself, as the infiltrable virus of poliomyelitis — ^which apparently finds 
 its path into the venous system by the nasal mucous membrane — ^probably in a 
 normal state is prevented from entering the brain by the meningeal mechanism; 
 but microscopical changes of the meningeal mechanism, such as the production 
 of an aseptic meningitis by the injection of a normal horse serum or a normal 
 salt solution — -Ringer's or Locke's solution — or slight hemorrhages which have a 
 demonstrable effect upon the meningeal mechanism, "sufSce to remove the power 
 of the intact organism to exclude the virus of poliomyelitis from the interstices of 
 the central nervous tissues." " 
 
 " Flexner, S., and Amoss, Harold L. : Relation of the Meninges and Choroid Plexus 
 to Poliomyelitie Infection ; Jmimal Experimental Medicine, 1917, Vol. 25, p. 525. 
 
144 BRAIN ABSCESS 
 
 iNTECTIOISr OF ClaiKBEO- SPINAL FLtTID SYSTEM FBOM BlOOD StEEAM. 
 
 Normally infection is prevented from reaching the brain through 
 the blood vessels by two factors: (1) the intima of the blood vessels 
 of the brain, and (2) the encephalo-meningeal protective mechanism, 
 virhich includes the choroid plexus. 
 
 Given an injury to the intima — a toxemia causing degeneration, 
 or a traumatic injury — a thrombus develops which interferes with 
 the nutrition of the cerebral tissue and, being septic, implants micro- 
 organisms in the already damaged cerebral tissues. Again, without 
 thrombosis, if the meningeal protective mechanism itself is upset — 
 as by lumbar puncture, compression of the jugular, cessation of the 
 heart, — in the presence of pathognomic micro-organisms free in the 
 blood stream at the time of the disturbance, certain micro-organisms 
 may enter the leptomeningeal spaces in sufficient numbers to occasion 
 a fatal leptomeningitis.^* 
 
 Brain Abscess from Meningitis. 
 
 In all the experimentally produced meningitis, only one brain abscess occurred 
 — this a superficial one — showing that it is not the micro-organisms in the blood 
 stream that causes a brain abscess^ — there must be another factor added to this. 
 This factor is undoubtedly thrombosis of a vessel, and the affinity of certain micro- 
 organisms for cerebral tissues. 
 
 CASE XXV. 
 
 F. v.: Case of Streptococcus Meningitis from Disturbance of the Meningeal 
 Protective Meohojnism of the Brain hy Liirnbar Puncture in the Presenos of a> 
 Blood-sttream Infection from a Suppurative Thromhophlebitis of the Leg. Male. 
 Entered hospital October 3, with chief complaint of pain in left leg and groin, 
 which caused inability to walk, sleeplessness and slight headache. 
 
 History. — Present illness dates from a week before admission to hospital, 
 when he received a blow on the head — in left parietal region. He was not un- 
 conscious and worked next day. The following day felt better. Three days be- 
 fore admission he began to have severe pain in left thigh and groin. Past history 
 negative. 
 
 Physical Examination. — Patient did not look ill; head showed no evidence 
 of injury; eyes, nose and ears, negative; slight tenderness over left hip; knee 
 jerks diminished; no paralysis or sensory changes. There were two eye-ground 
 reports, one that the discs were indistinct, the other that they were clear. X-ray 
 for fracture of skull and enlargement of sella turcica both negative; for left hip 
 injury, negative. Cell count, 18,000; polynuclears, 76%; lymphocytes, 24%. 
 Temperature, 102°. 
 
 October 4 — (Next day) — ^Lumbar puncture; spinal fluid clear, transparent, no 
 nebula; globulin, negative; cell count, 3 per cnam. That evening temperature 
 began to rise, thereafter running a typically septic course, ranging between 100° 
 and 105°. 
 
 The after-history of the case is typically a septicemia. Another lumbar punc- 
 
 » Weed, Lewie H. : Meningitis Produced by Intra- Venous Inoculation ; Mono- . 
 graph! of Rooheteller Institute ]or Medical Research, No. 12, March 25, 1920, pp. 
 57-112. 
 
PEOTECTIVB MECHANISM OP THE BEAIN 145 
 
 ture was performed October 14, which showed markedly bloody fluid, containing 
 pus cells and numerous chains of streptococci. 
 
 October 15 — Patient became delirious and remained so to the end. 
 
 Octoler 24— Death. 
 
 Autopsy : 
 
 Head. — Brain covered by plastic, purulent meningitis, having greenish-yellow 
 look; also a slight encephalitis; sinus free and clear; no fracture to be seen. 
 
 Abdomen.— X/iver slightly enlarged; all organs in abdomen show acute 
 cloudy swelling; inferior vena cava from level of fourth lumbar vertebra down, 
 and extending' into iliacs and femorals on both sides, was the seat of a purulent, 
 septic thrombosis; at most central part of involvement was an organizing clot; 
 there was an involvement of the tissues surrounding the vessels. 
 
 Chest. — ^Acute, cloudy swelling of heart, and oedema of lungs, with congestion 
 of bases. 
 
 Probable Cause of Death. — Suppurative meningitis (streptococcus), with 
 original focus a suppurative thrombophlebitis. 
 
 Secondary, or Terminal Lesions.^-Acute, cloudy swelling of heart muscle, 
 liver and spleen; pulmonary parenchymatous nephritis. 
 
 Elimination of Baotebia fbom the Subarachnoid Space. 
 
 While the protective mechanism of the brain prevents the en- 
 trance of bacteria into it from the blood stream, when the subarach- 
 noid space has actually been invaded by them the protective mech- 
 anism avails itself of the blood stream for their elimination. 
 
 Experimental injections of bacteria into the subarachnoid space 
 invariably are followed by finding the micro-organisms in the blood 
 stream.^® Experimental injection into the subdural spaces of large 
 amounts of normal solution, on the other hand, shows no changes in 
 the brain, but a severe hyperemia of both lungs, with hemorrhages. 
 
 Surgical Application : Patients in coma or convulsions frequently have a com- 
 plicating pneumonia, due to a lowering of the resisting power. 
 
 Immunization. — Immunization in general is so imperfectly un- 
 derstood — especially as comparatively few experiments in this field 
 have been made — that little real knowledge is to be expected regard- 
 ing its application to the brain and subarachnoid spaces. It is known, 
 however, that full blood contains components which retard the growth 
 of bacteria and in the majority of cases kill them. By this means 
 the blood stream constantly purifies itself. It is also known that 
 the removal of immunized blood from the body allows a continuation 
 of these components for varying times for different micro-organisms. 
 After the third day, however, these component elements of the blood 
 rapidly disappear. 
 
 " Felton, L. D., and Wegeforth, Paul : The Production of Experimental Menin- 
 gitis by Direct Inoculation into the Subarachnoid Space; Monographs of Bockefeller 
 Institute for Medioal Research, March 25, 1920, No. 12, p. 7. 
 
146 BEAIN ABSCESS 
 
 It has been proved experimentally that immunization of the 
 cerebro-spinal fluid is much more difiicult than immunization of the 
 blood, because the cerebro-spinal fluid, being constantly emptied into 
 the venous circulation, cannot very long contain the immunizing sub- 
 stances. Sera injected into the cerebro-spinal fluid are passed into 
 the blood in about twenty minutes. 
 
 Surgical Application: It is an established surgical fact that the dura can be 
 incised with greater immunity through the area of a neighboring infection — 
 over the tegmen, for instance — ^than over an area which is not the seat of an 
 infection. Immunization probably exists in the cerebro-spinal fluid and in the 
 brain area, but the immunization does not extend far nor does it last long. Under 
 such circumstances, the surgeon cannot with impunity enter the dura and explore 
 the brain for any great distance. By so doing he carries infection into an area 
 that is not immunized, while the trauma of the exploration kills cerebral tissues 
 which furnished a most favorable soil for the development of cerebral 
 suppuration. 
 
 Susceptibility of Cerebkal Tissue to Bacterial Virulence. 
 
 The ordinary pathogenic micro-organisms are from forty to two 
 hundred times more virulent in the subarachnoid space than in any 
 other part of the body structure. The toxins of tubercle bacillus, for 
 instance, apparently have a specific affinity for meningeal tissue. 
 
 Extracts of cholera bacillus are about forty times more toxic in 
 the subarachnoid space than when injected into the blood. Anthrax 
 extract produces hemorrhage into the pia, while many other forms of 
 infection — such as streptococcus capsulatus, or pneumococcus type 
 three — ^have a distinct action on the blood, causing hemorrhage into 
 the brain. 
 
 Newborn infants are subject to certain infections to which adults are less 
 liable, or not at all susceptible. During infancy the colon bacillus is a frequent 
 cause of infection of the brain tissue and of the meninges as well as of the kid- 
 neys. Artificially fed infants are much more liable to infection by the colon 
 bacillus than are breast-fed infants. In adults the colon bacillus is only feebly 
 virulent. It would seem that infants during the nursing periods acquire an 
 immunity from the mother. When deprived of this immunity they must build 
 up immunity for themselves. 
 
 Bull's™ experiments on dogs and rabbits demonstrated the pathological effect 
 on the nervous system of streptococci from the blood stream. In dogs sections of 
 the central nervous organs showed multiple abscesses in the cerebrum, the pons, 
 medulla and the white matter of the spinal cord. In some of the rabbits obvious 
 clinical symptoms were wanting, but a purulent meningitis was found at autopsy. 
 The sections showed at times focal lesions associated with the meningitis, usually 
 affecting the cerebrum, the cerebellum, and medulla and the pons. 
 
 2° Bull, Carroll G. : Pathologic Effects of Streptococci from Cases of Poliomyelltla 
 and Other Sources; Journal of Experimental Meixoine, 1917, Vol. XXV, p. 657. 
 
PEOTECTIVB MECHANISM OF THE BRAIN 147 
 
 Sensitiveness of Beain to Toxic Influences. 
 
 To function properly tlie brain must be bathed in its own normal 
 fluid and at a normal temperature. It is not only bigbly sensitive to 
 toxio influences, but it is profoundly influenced by any change in the 
 composition of the cerebro-spinal fluid wbich surrounds it; even 
 sterile normal salt solution (if it does not contain a small amount of 
 calcium salts) is highly toxic to the brain, causing irritation if in- 
 jected into the subaraclmoid space, and respiratory embarrassment 
 and death if irrigated through the cerebro-spinal fluid system. ^^ 
 
 Note: "Changes in the structure or function of the meningeal-choroid plexus 
 complex too slight to be detected by cellular or chemical changes in the cerebro- 
 spinal fluid, or by morphological alterations, are sufl[icient to diminish in an 
 essential manner its protective powers. An immune serum injected intra-spinally 
 is protective, but the degree of its efficiency is more or less proportional to the 
 freedom from injury to the meningeal structure by the irritating substances em- 
 ployed. The slighter the inflammation the more readily and quickly the injury 
 is repaired," and consequently, "Aseptic fluids which irritate, inflame, or even 
 slightly alter the int^rity of the meninges and choroid plexus, diminish or 
 remove their protective function." "Injury to the blood vessels of the meninges 
 also promotes an infection. This may be due either to the escape of the inoculated 
 virus from the blood through the injured vessels into the meninges, or, what is 
 more probable, to the entrance of the blood into the subarachnoid space, thereby 
 setting up a mild inflammatory reaction which suffices to promote the infec- 
 tion." ^ 
 
 PROTECTIVE MECHANISM IN THE BRAIN ITSELF. 
 
 The protective mechanism in the brain itself is made up of two 
 parts — (1) those structures which prevent the entrance of micro- 
 organisms into the cerebral tissue and (2) those forces which com- 
 bat, destroy, or limit infection which has gained entrance. They 
 frequently act in both capacities. The chief protective agent in the 
 brain in combating infection is the blood, the blood vessels furnishing 
 the elements which defend the cerebral substance from infection. 
 Consequently, the cortex, which is well supplied with blood, is in- 
 frequently infected, while the deep substance of the brain, relatively 
 poorly supplied with terminal blood, may easily become the seat of 
 an abscess. In the presence of infection, infiltration of blood into the 
 substance of the cerebral tissue undoubtedly favors the extension of 
 the infection, probably by causing death of the cerebral tissue by 
 pressure. 
 
 =1 Weed, Lewis H., and Wegeforth ; ioc. oi*. ^ „ „ ■ ^ ,^ „ 
 
 '^ Flexner S and Amoss, Harold L. : Relation of the Meninges ana Cnorold 
 
 Plexus to Poilomyelitic Infection ; Jmimal of Experimental Medicine, 1917, Vol. 25, 
 
 p. 525. 
 
148 BEAIN ABSCESS 
 
 Note: There is experimental eTidenc© that the red corpuscles themselves help 
 to limit the extension of infection in certain parts of the brain and under certain 
 conditions, probably by some form of mechanical protection. "A large intra- 
 arachnoid space hemorrhage completely protected the subarachnoid space from 
 infection, although the brain substance was one large abscess." Free red blood 
 cells are also found in considerable numbers in the neerobiotio zone of intracere- 
 bral abscess.^ 
 
 Varying Degrees of Sensitiveness to Infection. 
 
 The different elements of the brain possess relatively different 
 degrees of resistance to infection. The gray matter of both the 
 cortex and the central ganglia is very resistant. In traumatic 
 abscess the different zones of this gray matter also differ in their 
 susceptibility. An intracerebral abscess in its growth usually does 
 not affect the ganglionic tract, but follows the white fiber tracts. 
 
 Limitation of Suppuration within the Brain. 
 
 The blood vessels furnish the elements which encapsulate a sup- 
 puration, while by the blood are contributed the phagocytes which 
 help to remove the products of tissue disorganization. The cerebral 
 tissues — ^the arachnoid, the pia and glia — furnish the macrophages 
 which by a process of digestion assimilate into themselves the dead 
 tissue and carry it to the blood vessels and cerebro-spinal fluid system, 
 that remove it from the brain. In this process the perivascular 
 spaces of the blood vessels play a large part; consequently, in all* 
 suppurative lesions of the brain the adjacent perivascular spaces are 
 found crowded with round cells and with micro-organisms. 
 
 Note: For a detailed description of how a suppurative process into the brain 
 is limited, reference is made to Part II, page 47. 
 
 Extension of Infeotion. 
 
 The three great factors in the death of cerebral tissue, and conse- 
 quently, in the development of a cerebral abscess are (1) thrombosis, 
 (2) compression, and (3) operative trauma. 
 
 After encapsulation, a brain abscess extends by two processes, 
 (1) a seeping of infected material through the capsule and (2) an 
 extension through pressure erosion. 
 
 Extension of infection within the cerebral tissue is favored by 
 death of cerebral tissue largely because the myelin discharged from 
 its sheath furnishes a favorable soil for the growth of bacteria. 
 
 The blood vessels play such an important part in the proper 
 
 "Essick, Charles B.: Loo. dt. 
 
PEOTECTIVE MECHANISM OF THE BEAIN 149 
 
 function of tlie brain that any disturbance of the circulation in 
 the presence of infection, favors extension. Thrombosis of the blood 
 vessels furnishes a large part of the pathological picture in the early 
 stages of brain abscess. In acute abscess the first extension of the 
 abscess is entirely through thrombosis ; consequently, anything which 
 causes dislocation of the brain mass, favors thrombosis and prevents 
 the reactive forces of the brain from operating properly. Compres- 
 sion by favoring thrombosis has a similar action: thus, vdth an 
 intact dura, dilatation of the ventricles by increase of the intracranial 
 pressure is an aid to extension of the infection. 
 
 Surgical AppUoation: In the early stages of brain abscess relief of intra- 
 cranial pressure by lumbar puncture undoubtedly assists in the limiting of the 
 process, as the brain's bulk is primarily not seriously increased, the abscess 
 being due to nutritional death. It is the reactive forces of the brain itself that 
 occasion a part of the increase of the intracranial pressure. 
 
 Eemoval of Dead Tissue. 
 
 Dead tissue v^ithin the brain is taken care of by two processes: 
 (1) removal, chiefly by the phagocyte cells of the brain itself — ^the 
 macrophages — and (2) encapsulation of the dead area. In the for- 
 mer process the same exhaustion of reaction happens in the brain that 
 happens with other tissues ; namely, if suppuration is long continued 
 a limited area of suppuration is allowed to exist indefinitely. Experi- 
 ments with vital dyes show that the macrophages are able to remove a 
 certain amount of dead tissue, but, after a time they lose their 
 activity. 
 
 Surgical Application,: The surgeon must guard, therefore, against allowing 
 the activity of the protective elements to become exhausted. Aseptic meningitis 
 is dangerous, although it contains no septic factors, because it exhausts the pro- 
 tective elements in their effort to remove the cause of irritation. 
 
 Repair. — ^Repair of cerebral substance is accomplished by one 
 of two processes: (1) by cyst formation, if the lost tissue is adjacent 
 to the meninges, the pia filling the gap. This accounts for the fre- 
 quency of meningeal cysts in areas injured. The cysts are filled with 
 cerebro-spinal fluid and the degenerated elements of the blood cells; 
 and (2) by proliferation of glial tissue — a gliosis. 
 
 Recrudescence of Latent Infection. — Recrudescence of latent 
 infection is a very frequent occurrence in the nervous system. This 
 is of the greatest surgical importance because, a brain abscess having 
 been cured, there undoubtedly lurk in parts bacterial elements which 
 await opportunity again to become active ; ^* consequently, no further 
 
 " EagletOD, W. P. : Meningitis, Case 3, Tr. Am. Otological Soe., 1921, p. 919. 
 
150 BEAIN ABSCESS 
 
 surgical interference should he undertaken at least for a consider- 
 able period of time. 
 
 Weed and Wegeforth,'* after curing experimental brain abscess, found that 
 meningitis resulted on further manipulation in trying to close the dural defect. 
 
 Conclusions. — It would seem then, that it is the close and 
 delicate relationship between the cerebro-spinal fluid circulatory sys- 
 tem and the blood circulatory system, which furnishes the chief 
 mechanism in the protection of the brain substance. Both are 
 necessary for the prevention, combating, limiting, and removal of 
 deleterious matter from the brain into the subarachnoid spaces and 
 so out into the circulation. Anything, therefore, which in the pres- 
 ence of micro-organisms interferes with the capillary blood stream 
 within the brain, renders an infection of the brain liable, while any- 
 thing, operative or therapeutic, which upsets the cerebro-spinal fluid 
 circulatory system increases the likelihood of cerebral abscess or 
 meningitis. In abscess of the brain the chief causative influence in 
 infection is thrombosis of the small vessels ; for in consequence of the 
 presence of small thrombi an area of cerebral substance not only 
 undergoes nutritional death but, because of the accompanying peri- 
 vasculitis, it has eliminated from it the avenue whereby infective 
 material is removed from the brain. Thus, both the blood stream 
 and the cerebro-spinal fluid circulatory system are thrown out of 
 action in this area, while the dead cerebral tissue becomes a favorable 
 ^ soil for the growth of micro-organisms. 
 
 RELATIONSHIP BETWEEN SUPPURATIVE MENINGITIS WITH BRAIN 
 ABSCESS AND PROTECTIVE MENINGITIS. 
 
 Although suppurative meningitis is usually the terminal process 
 of brain abscess, it is an important fact that with micro-organisms 
 free in the spinal fluid (as shown by lumbar puncture) an existing 
 brain abscess is the only type which offers a probable chance of re- 
 covery, because the protective character of the process which origi- 
 nated from the abscess was already active at the time of the invasion 
 of the cerebro-spinal fluid by the bacteria. Of all the cures of true 
 suppurative meningitis, (not of blood stream origin, reported in the 
 literature) — 27 in number, over two-thirds had a protective menin- 
 gitis at the time of the invasion of the subarachnoid space by the 
 bacteria; of these, five were secondary to a brain abscess and were 
 cured by evacuation of the abscess, together with lumbar puncture or 
 the injection of serum into the spinal cavity. 
 
 '■ Weed and Wegeforth : Loo. cU. 
 
PEOTECTIVE MECHANISM OP THE BEAIN 151 
 
 "Two were preceded by brain abscess — Day : One was associated 
 with intrapiaracbnoid abscess — Held & Kopetsky; and two were 
 associated with or preceded by subdural abscess (traumatic), Kost- 
 livy & Poirier." ^e 
 
 It should be recognized that the protective meningitis which de- 
 velops to ward off the brain abscess from the subarachnoid space may 
 be the deciding factor in controlling the infection when the micro- 
 organisms actually invaded the cerebro-spinal fluid system itself. 
 Consequently, in suppurative meningitis, complicating a brain ab- 
 scess, in spite of the presence of the invading micro-organisms in the 
 cerebro-spinal fluid, evacuation of the abscess should be undertaken 
 with a fair prospect of recovery from the meningitis. 
 
 CASE XXVI. 
 
 T. p.: General Suppurative Meningitis (Streptococcic, Hemolytic) originated 
 from a latent and unsuspected cerebral abscess of eighteen rmmths' dwration 
 treated by cerebral and cerebro-spinal subarachnoid irrigation. 
 
 Resume of Case : About one and a half years previously the pati«nt attempted 
 suicide by shooting himself in the right temple with a revolver. He was brought 
 to the hospital and operated upon by the author who removed a pistol bullet 
 from the left parietal region, the ball having passed through both frontal lobes. 
 The X-ray after the operation showed small fragments of bone or bullet near the 
 wound of entrance, but the patient made a very good recovery and apparently 
 has been quite well since. It is interesting to note, however, that after this time 
 his history states that he has become a drug addict. 
 
 A few days before his death, the patient waj found by the police in a more 
 or less dazed condition and brought to the City Hospital, where he was placed 
 in the observation ward for psychopathies, little attention being paid to his 
 former cerebral injury. It was noticed that he had a stiff neck, the patient walk- 
 ing around the ward in this condition. The interne performed a lumbar puncture 
 which showed a cloudy fluid under pressure; with numerous pus cells and many 
 Gram positive cocci, many arranged in chains. A diagnosis of streptococcic sup- 
 purative meningitis was made. 
 
 Two attempts were made to wash out the subarachnoid cerebral space, and 
 anti-meningococcic serum was given intraspinously. The patient grew worse 
 after the second operation, but had appeared in much better condition after the 
 first. Post-mortem disclosed three latent abscesses, the oldest of which doubtless 
 was present from the time of the original injury eighteen months previous. One 
 abscess had perforated the lateral ventricle and slowly discharged its contents 
 into it. From this the infection had passed to the basal cisterna and the cere- 
 bellar surface, the subarachnoid spaces of the cortex remaining unaffected. 
 
 History: June 7, admitted to City Hospital. Temperature 100.2 degrees 
 and pulse 100. 
 
 Psychiatric Examination, Wednesday, June 8: "I've been here three or four 
 weeks." (Was admitted yesterday.) Does not know day, month or year. 
 Says "1821." At 10 a. m. says it is about 3 o'clock. "I don't know why I 
 
 =* Eagleton, W. P. : Operative Treatment of Suppurative Meningitis wltli special 
 Reference to Irrigation of the Cranial and Spinal Subarachnoid Spaces, and the 
 Importance of Protective Meningitis from a Prognostic and Therapeutic Standpoint ; 
 Transactions American Otological Society, 1921. 
 
152 BKAIN ABSCESS 
 
 am here. I don't know who brought me here, either. I wasn't drunk. I don't 
 know what was the matter with me." 
 
 Why do you stay here? "I don't know that, either." Using drugs? "No." 
 Anything hurt you? "No." Were you here before? "I imagine so." Have 
 any trouble? "We had quite an argument — ^my brother — a little family affair." 
 Did the police bring you in? "I don't know." Did you try to kill yourself? 
 "No." 
 
 "Harding is President; Wilson before him." 
 
 "4 X 4 = 16 4- 10 c= 26 — 8 = — ^well — " (Then no answer). 
 
 "9X9 — 814-9^81 — oh, well — " (Then no answer). 
 
 "6 X 6 = 36 -|- 8 = — well — " (Then no answer). 
 
 "20 — 1 = 19." (Correct, but slow). 
 
 "Before July comes August; before December, November; before October, 
 September — " (after some thought). 
 
 Name the months of the year. "This month — " (Then no answer). 
 
 Memory for numbers poor — "3, 4, 8, 7." 
 
 No dysarthria. 
 
 Both pupils very sluggish to light — both irregular. Suspicion of Romberg. 
 Knee jerks exaggerated. Urine dribbled during examination. Executes commands 
 sluggishly. Gait somewhat spastic. Marked tremor of fingers. 
 
 June 9: Incontinent; neck stiff. 
 
 Lumbar Puncture. — Fluid cloudy under slight pressure; Wassermann nega- 
 tive; direct smears show streptococci. 
 
 Operation. — Cerebral and spinal subarachnoid irrigation. Three trephine 
 openings made in right fronto-parietal region; in the first it was found impos- 
 sible to enter fluid because of apparent adhesion of dura to brain, although 
 the opening was away from the skull opening through which the ball had been 
 extracted, by at least one and one-half inches. Two other openings were then 
 made: opened into the subarachnoid space, and tap made into cisterna magna. 
 Needle inserted underneath dura and arachnoid and surface of brain flushed 
 out with Einger's solution and drained through needle in cisterna. Process 
 repeated twice through trephine one inch posterior to first opening on the same 
 side. Later the excess fluids were drained through a lumbar puncture. Flaps 
 closed with black silk. 
 
 June 11: Temperature 99 degrees; pulse 96. Nurse's Note: "Patient ap- 
 pears to be much better. Answers intelligently to questions. Neck still very 
 rigid and head thrown back." 
 
 Lumbar puncture; 28 c.e. withdrawn, fluid cloudy, slightly yellow, under 
 slight pressure. Anti-meningococoic serum 20 cubic centimeters injected. At 
 this time the author examined the patient; the man was in excellent condition. 
 He recalled all about the previous experiences in the hospital eighteen months 
 ago. 
 
 6 p. m. : Second subarachnoid irrigation. Anterior flap opened; stitches 
 removed; needle inserted into arachnoid and irrigation carried on as on the 
 previous day. Drained through cisterna and lumbar puncture. Fluid yellow and 
 somewhat turbid. 
 
 8 a. m. : Answered when spoken to. Pulse fair. 
 
 8:30 a. m. : Patient suddenly became cyanosed and pulseless and ceased 
 to breathe. 
 
 Autopsy and Report by Db. Habbison S. Maitland. 
 
 Head. — In the cortex of the middle of the right frontal lobe is a small, 
 cortical and sub-cortical abscess, measuring about 1.5 cm. in size and filled with 
 thick, creamy pus containing a few small fragments of bone; the wall of the 
 pavity is about 2 mm. in thickness. 
 
PEOTECTIVE MECHAmSM OP THE BEAIN 153 
 
 Situated deeper in the brain substance, its outer edge encroaching on the 
 small abscess already described, is another more recent and larger abscess, 
 measuring about 2.5 cm. in diameter, and containing a slightly greenish pus; 
 its walls are about 1 mm. in thickness. The lower and inner portion of this 
 abscess cavity, about 1.5 cm. in size, leads directly into the anterior horn of the 
 right lateral ventricle, the opening being soft and necrotic brain tissue. 
 
 The right ventricle is distended with greenish-yellowish pus, and there is an 
 extensive exudate clinging to the choroid plexus; the ependyma lining the cavity 
 contains numerous punctate hemorrhages, and the surrounding brain tissue is 
 soft, cedematous, and in places distinctly necrotic. This same condition is found 
 in the left lateral ventricle, although not to so marked an extent. 
 
 The third ventricle contains purulent exudate and fluid pus, and the inter- 
 peduncular cisterna is distended with purulent exudate. The fourth ventricle is 
 dilated, as is also the iter, and contains a purulent exudate and free pus. This 
 has leaked out through the foramina of Magendie and Luschka and infected the 
 cisterna magna, which is filled with a plastic, purulent, yellowish exudate, 
 which extends up over the inferior and lateral surfaces of the cerebellum 
 and stops. The cisterna basilis and chiasmatis contain considerable plastic exu- 
 date, which apparently comes from extension from the cisterna magna, and pos- 
 sibly also from the close proximity of the infected third ventricle. The outer 
 surfaces of the brain and the spinal cord and its meninges are practically free 
 from exudate. 
 
 Extending from the wound of entrance in the middle of the frontal lobe 
 passing across the frontal lobe on its superior surface, to the left and slightly 
 backward, through the left frontal lobe on its superior surface, and stopping 
 at the bone opening in the left parietal region, is a somewhat collapsed brain 
 tract of the old bullet wound. The brain tissue is stained a gamboge yellow 
 around this old tract and there are numerous piarachnoid adhesions over this 
 area. 
 
 Comments. — Of course, a brain abscess should have been suspected, and an 
 attempt made to drain it, possibly associated with subarachnoid irrigation. 
 Subarachnoid irrigation, however, would of course have been useless without the 
 removal of the cause. 
 
 In view of the excellent condition of the patient just prior to the second 
 irrigation — with the rapid rise of blood pressure and the sudden termination, 
 one is forced to the conclusion that death resulted from cerebral compression, 
 probably induced by the irrigation. In addition to the over-looked abscess, 
 the patient probably was over-treated both as to lumbar puncture and serum 
 injections, and subarachnoid irrigation. 
 
 ADDITIONiAL REFERENCES FOR PROTECTIVE MECHANISM. 
 
 Weed, Lewis H., Wegeforth, Paul, Ayer, James B., and Felton, Lloyd D.: A 
 Study of Experimental Meningitis. A Series of Papers from the Army Neuro- 
 surgical Laboratory; Monographs of the Bochefeller Institute for Medical Re- 
 search, No. 12, March 25, 1920. 
 
 Weed, Wegeforth, Ayer and Felton: The Production of Meningitis by the 
 Release of Cerebro-Spinal Fluid; Jowmal A. M. A., Jan. 18, 1919, Vol. 72, 
 pp. 190-193. 
 
 Wegeforth, Paul, and Essick, Charles R.; The Effect of Sub- Arachnoid In- 
 jections of Antiseptics upon the Central Nervous System; Journal of Pharma- 
 cology arul Experimwntal Therapeutics, July, 1919, Vol. XIII, No. 4. 
 
 Weed, Lewis H., and Wegeforth, Paul: Experimental Therapeutics. July, 
 1919, Vol. XIII, No. 4. 
 
 Felton, L. D. : The Intra-Meningeal Virulence of Micro-organisms; Mono- 
 
154 BRAIN ABSCESS 
 
 graphs of the Bockefeller Institute for Medical Research, March 25, 1920, No. 
 12, p. 45. 
 
 Weed, Lewis H., and Wegeforth, Paul: Experimental Irrigation of the Sub- 
 Arachnoid Space; Journal of Pharmacology and Eooperimental Therapeutiosi, 
 July, 1919, Vol. XIII, No. 4. 
 
 Ayer, J. B. : Experimental Acute Hematogenous Meningitis; Monographs of 
 Rockefeller Institute for Medical Research, March 25, 1920, No. 12, p. 119. 
 
Fig. 3.3 (a). — Cross section of left optic nerve — showing perineural infiltra- 
 tion with thrombosis of small vessels and degeneration of the nerve fibers in a 
 case of frontal lobe abscess which, after evacuation of the abscess, perforated tlie 
 lateral ventricle and was followed by a closed empyema of the ventricle, causing 
 blindness. Tlie O.E. picture was tliat of strangulatioii of the vessels — "Stupeur 
 Arterielle." (The shrinkage of the sections due to the hardening process in 
 foi'malin is proportional in both right and left optic nerves; the atropliy due to 
 pathological conditions was much greater in riglit optic nerve than in left.) 
 

 
 Fig. 33 (b). — Cross seelion riglit optic nerve — near chiasm — showing peri- 
 neural infiltration with thrombosis of small vessels and degeneration of the 
 nerve fibers in frontal lobe abscess which, after evacuation of the abscess, per- 
 forated the lateral ventricle and was followed by a closed empj'ema of the ven- 
 tricle, causing blindness. The O.E. picture was tliat of strangulation of the 
 vessels — "Stupeur Artiirielle." (Tlie shrinkage of the sections due to the 
 hardening process in formalin is proportional in both right and left optic nerves; 
 the atrophy due to pathological conditions Avas much greater in right optic 
 nerve than in left.) 
 
PART III. 
 SURGICAL DIAGNOSIS. 
 
CHAPTEK X. 
 
 DIAGNOSIS OF BEAIN ABSCESS IN GENEEAL. 
 
 In the presence of a known focus of inf ection^ either from tiie 
 ear, nose, lungs, or other organ, with cerebral symptoms, brain abscess 
 is to be differentiated from 
 
 (1) blood-stream infection, 
 
 (2) meningitis, 
 
 (3) vascular lesions, 
 
 (4) brain tumors. 
 
 The symptomology peculiar to brain abscess should be divided 
 into 
 
 I— EVIDENCES OF CEREBRAL SUPPURATION. 
 II— SYMPTOMS OF CEREBRAL COMPRESSION. 
 Ill— LOCALIZING SYMPTOMS. 
 
 In the usual descriptions aU the symptoms are intermingled more 
 or less indiscriminately. This not only causes confusion, but often 
 actually hinders an early diagnosis, for if the graver symptoms of 
 . cerebral compression — ^papilloedema, slow pulse, coma, etc. — are 
 absent in the early stages of the abscess, to include them in tiie de- 
 scription minimizes the importance of the signs of cerebral suppura- 
 tion which are always present and, while never so outspoken as those 
 of cerebral compression, are capable of yielding a diagnosis at an 
 early period if properly interpreted. 
 
 The literature is filled with records of cases where a diagnosis 
 was not made "because of the absence of the, so-called, symptoms of 
 brain abscess." Review of these cases will show that what in reality 
 prevented the surgeon from making a diagnosis was not the absence 
 of the symptoms of cerebral suppuration — ^for they were present — 
 but the absence of those symptoms which point to an increase in the 
 intracranial contents, the signs of cerebral compression. 
 
 Few cases of brain abscess present evidences of cerebral compres- 
 sion in the early stages ; the majority of them not for some time, as 
 the bulk of the brain is not increased; while a considerable number, 
 
 155 
 
156 BEAIN ABSCESS 
 
 especially those in which the frontal lobe is the site of the abscess, 
 never cause compression. The importance of this fact is not gen- 
 erally appreciated. 
 
 In a doubtful case — and most cases are doubtful in the early 
 stages — ^the surgeon should approach the subject with a broad view- 
 point. In attempting a diagnosis he should adopt a definite mental 
 policy. He should endeavor to distinguish between the manifesta- 
 tions of cerebral suppuration on the one hand and those of compres- 
 sion and localization on the other — ^though both of the' latter may be 
 absent. 
 
 In the course of his experience the author has adopted the fol- 
 lowing policy: (1) he asks himseK (a) is cerebral suppuration pos- 
 sible? and (&) if possible, is it probable? 
 
 Should these questions be answered in the affirmative, he then 
 tries to decide (2) is cerebral compression present? Then, and not 
 until then, is (3) the localization of the suppuration, to be con- 
 sidered, when in, the majority of cases the solution of the three for- 
 mer questions will have made apparent the probable site of the 
 
 (1-a) Is Cerebral Suppuration Possible? In a case that pre- 
 sents cerebral symptoms the absence of evidences of suppurative dis- 
 ease of the ear, nose, lungs, or heart at the time of examination re- 
 moves the probability of a brain abscess. Although cases of otitic 
 brain abscess are on record in which the abscess has remained 
 quiescent for a long period of time during which the ear ceased to 
 discharge, the author believes that a careful examination of the 
 history of such cases would reveal that marked cerebral symptoms 
 accompanied or immediately followed the aural suppuration. 
 
 On the other hand an accompanying focus of suppuration in the 
 ear, nose, or lungs (bronchiectasis), renders possible a localized in- 
 tradural suppuration. In such a case, although the cranial symptoms 
 may be indefinite, the patient should immediately be admitted to a 
 hospital for observation and routine examination. 
 
 (1-&) Is Cerebral Suppuration Probable? In the presence of 
 cerebral symptoms with a known focus of suppuration of the ear or 
 nose, intradural suppuration becomes not only possible, but probable. 
 In such cases an early positive diagnosis is rendered possible by at- 
 tention to a multitude of details to each of which the surgeon must 
 give careful consideration. During this stage there generally is no 
 one symptom which is pathognomonic. Too much significance should 
 not be attached to the presence or — ^more especially — ^the absence of 
 any one symptom. The surgeon must construct the picture by atten- 
 
DIAGNOSIS OF BEAIN ABSCESS IN GENERAL 167 
 
 tion to minor evidences and after its construction he must consider it 
 as a whole. 
 
 I— EVIDENCES OF CEREBRAL SUPPURATION. 
 
 (a.) Initial Vague Chill. — The "initial vague chill" indicates 
 the beginning of an intradural suppurative process. It occurs when 
 the infection invades the brain tissue. This initial vague chill gen- 
 erally is described by the patient as "not a chill, but a chilly feeling," 
 and consequently the account of it is obtained only by a systematic 
 inquiry into the patient's history. Careful questioning will establish 
 not only the occurrence of the chill, but also the fact that from the 
 time of its occurrence the health of the patient was not so good as 
 previously to it. The eliciting of the exact date of the "initial vague 
 chill" is of the greatest clinical importance, since from that can be 
 computed the probable duration of the abscess, the degree of viru- 
 lence of the suppuration, and the possible presence or absence of an 
 encapsulating membrane, all of which will greatly influence the 
 surgical procedure to be adopted. 
 
 (&) Headache. — This, in the author's opinion, is always pres- 
 ent. It will vary, from a dull headache to severe attacks in which 
 the patient may become almost maniacal from pain. No other one 
 symptom is of such uniform occurrence, or of greater assistance to 
 a positive diagnosis. Its importance frequently is minimized by the 
 patient; he "always has had headaches." Psychologically, there ex- 
 ists a disposition on the part of both patient and physician to disre- 
 gard the headache because of this previous disposition. Questioning, 
 however, will demonstrate that the headache is of somewhat different 
 type from that previously complained of. Usually it is necessary for 
 the surgeon to point out the difference to the patient. 
 
 In the presence of a known focus of suppuration in the ear or 
 nose, very severe headaches preceded by a vague chill render an in- 
 tradural suppuration extremely probable. In one of the writer's cases 
 these were the only evidences demonstrable at the time of operation ; 
 and in numerous instances no other symptoms appeared for a long 
 time, although the patients all along were suffering from encapsulated 
 brain abscesses. 
 
 It is to be understood, however, that encapsulated, aseptic serous 
 meningitis may cause this syndrome; but a localized meningitis fre- 
 quently is the initial stage of an intrapiarachnoid abscess. 
 
 (c) Vomiting. — As with headache, the importance of vomiting 
 'as a symptom of brain abscess frequently is not appreciated, espe- 
 cially if the patient heretofore has had "vomiting spells" associated 
 
158 BRAIN" ABSCESS 
 
 with headaclie. True projectile vomiting rarely occurs in the earlier 
 stages of intracranial suppuration prior to the appearance of com- 
 pression; but irregular vomiting without a definite cause is a fre- 
 quent occurrence and should always be regarded as presumptive evi- 
 dence of meningeal or cerebral suppuration. In one of the author's 
 cases a boy, nine years of age, had for several weeks following a 
 mastoid operation no symptoms of cerebral suppuration other than 
 irregular headaches, two or three intermittent attacks of vomiting, 
 and a slight peevishness of disposition, yet during this time there was 
 a large collection of pus in the temporo-sphenoidal lobe. Examina- 
 tion of the recorded cases of frontal lobe abscess shows that in a 
 large proportion of them headache and vomiting were the only 
 symptoms present until shortly prior to death. 
 
 (d) General Malaise. — Loss of appetite, coated tongue, and 
 dry skin always are present to a greater or less degree with cerebral 
 suppuration. In cerebellar abscess the loss of flesh is one of the most 
 characteristic symptoms. The combination of headache, vomiting, 
 and general malaise, each or all out of proper proportion to the mani- 
 fest local condition, preceded by a vague chill and a known focus of 
 suppuration, associated with a high cell count in the cerebro-spinal 
 fluid, calls for an exploration within the skull. 
 
 (e) Disproportion. — (Value of, in diagnosis of cerebral sup- 
 puration) : A certain disproportion always exists between the com- 
 monly recognized symptoms of cerebral suppuration. This has its 
 value in diagnosing between the symptoms that arise from the caus- 
 ative lesion — mastoiditis, or frontal sinusitis — and the symptoms of 
 cerebral suppuration. The causative agents of a brain abscess — mas- 
 toiditis or a frontal sinusitis, themselves suppurative processes — 
 produce the same general symptoms as intracranial suppuration, 
 (chills, pain, headache, vomiting, temperature, general malaise and 
 high cell count), and this complicates the problem. The symptoms 
 originating from each, however, frequently can be distinguished by 
 a study of the proportional relationship between the lesion and the 
 severity of the symptoms. 
 
 In a determination of whether the symptoms presented arise 
 from intracranial suppuration or from the mastoiditis, the surgeon 
 must visualize the possible course of the different Jjathological 
 processes. In the case of the boy referred to, he had a mastoid; an 
 extradural abscess had been found at operation, but after its evacua- 
 tion he became peevish and had irregular vomiting and headache. A 
 child of nine years, recovering from a mastoid operation, might have 
 attacks of vomiting from overeating. The disproportion was evident 
 
DIAGNOSIS OF BEAIN ABSCESS IN GBNEEAL 159 
 
 in tliis case, therefore, because children of that age rarely have asso- 
 ciated vomiting and headache without an intracranial involvement. 
 An adult, on the other hand, might be liable both to vomiting and to 
 headache, but in the boy's case the repetition of such an association 
 would signify a complication of the mastoiditis, or at least a pachy- 
 meningitis interna — itself a stage of intracranial suppuration — or a 
 serous meningitis. 
 
 But, it may be asked, is not a pachymeningitis interna gener- 
 ally harmless? And are not pachymeningitis interna and serous 
 meningitis protective processes, both self -limited ? True. And do 
 they not frequently disappear upon removal of the cause? True, 
 also. Then why not reopen the mastoid and thoroughly clean it out ? 
 The answer lies in whether, in an individual case, a pachymeningitis 
 interna or a serous meningitis could exist alone. In the case cited 
 the diseased mastoid had been thoroughly exenterated, but in spite 
 of this the peevishness, headache and vomiting subsequently ap- 
 peared. Consequently, it could not be a pachymeningitis interna, 
 because if that had been present at the time of the operation it would 
 have been cured, and it had no reason to develop subsequently as 
 the diseased bone had been thoroughly removed. The disease could 
 not have followed this sequence. If the operation had been incom- 
 plete, or if a sinus thrombosis had existed, then a pachymeningitis 
 might have been present. 
 
 A visualization of the possible intracranial course of the indi- 
 vidual lesion will reveal any disproportion between the symptoms due 
 to mastoiditis or to sinusitis alone. The following chart is offered as 
 an aid to such visualization : 
 
 Sequences in Adjacent Pathological Processes Entering the Brain. 
 
 In the case of Mastoiditis, acute; there may be an associated 
 Extradural Abscess; 
 Pachymeningitis Interna ; 
 Toxic localized leptomeningeal effusion — Serous Meningitis. 
 
 Mastoiditis, acute or chronic; may be followed by 
 (Extradural Abscess) ; 
 
 Brain Abscess from direct extension of suppurative tissue or retrograde 
 thrombophlebitis. 
 
 Mastoiditis, acute or chronic; may have caused a 
 
 Labyrinthine or Perilabyrinthine involvement; from which may originate 
 
 Cerebellar Abscess from direct extension or retrograde thrombosis. 
 
 Mastoiditis, acute or chronic ; may be followed by 
 
 Labyrinthine or Perilabyrinthine involvement; and at the same time cause a 
 
 Sinus Thrombosis; from which may originate 
 
 Brain Abscess secondary to sinus thrombosis. 
 
160 BEAIN ABSCESS 
 
 Mastoiditis; 
 Sinus Thrombosis; 
 Brain Abscess. 
 
 Frontal Sinusitis; 
 
 Pachymeningitis Externa (extradural abscess) ; 
 
 Meningeal Abscess. 
 
 Frontal Sinusitis; 
 
 Brain Abscess from direct extension of suppurative tissue. 
 
 Frontal Sinusitis; 
 
 Brain Abscess from retrograde thrombosis. 
 
 POSITIVE EVIDENCES OF CEREBRAL SUPPURATION. 
 
 (a) Protective Meningitis. — During the past few years, wiien- 
 ever infection of the ear or nose is present with cerebral symptoms, 
 the demonstration of a protective meningitis by lumbar puncture has 
 become one of the cornerstones of the author's diagnosis. A high 
 cell count in the cerebro-spinal fluid from lumbar puncture is clinical 
 evidence of intracranial involvement sufficient to warrant an intra- 
 cranial exploration. The protective meningitis may be the evidence 
 of a serous meningitis from the irritation of a neighboring infected 
 focus, but if the adjacent suppuration in the ear or nose has been 
 fully removed, the persistence of a protective meningitis is absolute 
 evidence of intracranial suppuration. 
 
 In a high cell count the character of the cells is of the utmost 
 importance. A high per cent, of polynuclears in the early stages of 
 the disease indicates that the process is an active one, such as a 
 serous meningitis from extradural irritation or from an irritation 
 caused by an intracerebral abscess which approaches the surface. 
 The cells, if largely mononuclear, show a subsiding process, for the 
 function of mononuclear cells is to remove the debris from the intra- 
 leptomeningeal spaces. In meningococcus meningitis Neal ^ has 
 shown that as the infection subsides the pus cells disappear and the 
 percentage of mononuclears increases. 
 
 In Case XVII ^ the following report of the cerebro-spinal fluid 
 examination was of material assistance in differentiating between a 
 possible brain abscess and a cerebral vascular lesion: "Pressure 
 slightly increased; transparency — clear, watery; no sediment after 
 centrifugalization ; globulin — ^moderate increase; cells — 21 to the 
 cmm., mostly polynuclears; Fehling's reduced. Bacteriological ex- 
 
 ' Neal, Josephine B. : Meningeal Conditions Noted During the Epidemic of 
 Influenza ; Department 0} Bealth of City of New York, Reprmt, Series 77, February, 
 1919, p. 4. "The mononuclear cells and the normal reduction of Fehling's solution 
 are practically never present in a pyogenic meningitis." 
 
 ^ Case XVII, Miss M. D. ; Chapter Five, Metastatic Abscess, p. 77. 
 
DIAGNOSIS OF BEAIN" ABSCESS IN GENEEAL 161 
 
 animation — sterile. Conclusion — secondary protective meningitis, 
 probably from brain abscess." 
 
 The cell count may not be increased although an intracerebral 
 abscess may be present at the time. In fact, the cell count is in- 
 creased only when the meninges themselyes are irritated, or during 
 the stage of localization of the suppurative process. In intracerebral 
 abscess from retrograde thrombophlebitis the cell count is not in- 
 creased as long as the abscess does not approach the meninges. The 
 writer's conception is that a high cell count in the cerebro-spinal fluid, 
 with increase of globulin, occurs at an early stage in nearly all cases 
 of brain abscess which originate by direct extension from the ear or 
 nose. 
 
 For an understanding of the absence of a high cell count the 
 course of the pathological process must be considered. During the 
 course of localization of a meningeal process or a cerebral suppura- 
 tion, the evidences of the protective meningeal reactions are exhibited 
 in the general cerebro-spinal fluid for a few days only, as experi- 
 mental evidence shows that after the production of an aseptic menin- 
 gitis the cell count for the lumbar fluid is high only during the active 
 stage, while the process in the cerebral meninges, although limited, 
 may still be present. After the abscess is walled off from the 
 meninges and the surrounding cerebral substance, the cerebro-spinal 
 fluid obtained by lumbar puncture is nearly normal in constitution 
 and the cell count, also, becomes normal. Later, when the abscess 
 approaches the meninges, the cell count will again increase. 
 
 A high cell count, then, is important in diagnosis, but its absence 
 should not militate against the probability of an intracerebral sup- 
 puration. In its absence the possible duration of the suppuration 
 should be considered. In one of the author's cases, ^ on the eighteenth 
 day of the disease, although an abscess was present in the cerebellum, 
 the lumbar puncture fluid was clear and escaped rapidly by drops 
 (consequently it was not under much pressure) ; reduced Fehling's, 
 and contained only flve leucocytes to the cubic centimetre. In blood- 
 stream infections there is no protective meningitis and the cell count 
 in the cerebro-spinal fluid remains normal. 
 
 (6) Convulsion. — In the author's experience a convulsion oc- 
 curring in the presence of suppuration in the ear or nose is a posi- 
 tive sign of intracranial involvement. Although a few cases are 
 recorded in which the removal of the focus of primary infection with- 
 out the opening of the dura was followed by the disappearance of 
 all symptoms, he is of the opinion that a localized serous meningitis 
 
 " Case No. XXXI, W. J. : Chapter Twelve, p. 203. 
 
162 BRAIN ABSCESS 
 
 • — the first stage of an intrapiarachnoid abscess — existed at the time. 
 In four instances in which the conservative course of removing only 
 the adjacent foci of infection vi^as adopted, all subsequently were 
 found to be suffering from brain abscess, although the primary opera- 
 tion on the mastoid or nasal sinuses was followed by a period of im- 
 provement, an improvement which in one case lasted for several 
 weeks. In the light of these experiences the author regards convul- 
 sions as positive indication of an intracranial involvement and their 
 subsidence on the removal of the infected foci should not blind us to 
 the fact that the intradural contents were affected. Association of 
 convulsions with a known focus of infection calls for exploration 
 within the dura. 
 
 In frontal lobe abscess, especially in children, convulsions are 
 frequent. In one case to which the writer was called in, consultation 
 a child had two convulsions following orbital abscess. When first 
 seen the child appeared perfectly normal. An intradural operation 
 was refused. A surgeon subsequently operated on the ethmoid alone, 
 disregarding the earlier convulsions; death followed in two days, 
 with indications of a ruptured abscess. 
 
 Convulsions are of relatively infrequent occurrence in adjacent 
 brain abscess except as a terminal manifestation of meningeal or 
 ventricular rupture. It is to be remembered, however, that irritation 
 of the temporo-sphenoidal lobe from brain tumors is much more apt 
 to be associated with convulsions than is an irritation in any other 
 portion of the brain. Especially with children it has been the 
 author's experience that the first symptom of brain abscess was a 
 sudden convulsion- — in two cases occurring while the child was at 
 play apparently in perfect health, although suffering from a chronic 
 running ear. 
 
 In an examination of the recorded cases the author has been im- 
 pressed with the comparatively frequent occurrence of convulsion in 
 metastatic abscess. The explanation probably is that in metastatic 
 abscess the cortex often is suddenly involved before a protective 
 process has had time to guard the brain from the septic invasion. In 
 adjacent intrapiarachnoid abscess such protection takes place before 
 the cerebro-spinal fluid accumulation becomes purulent. 
 
 From observation the author is inclined to regard the occurrence 
 of convulsions in brain abscess as suggestive either of (1) cortical 
 involvement by an intracerebral abscess — convulsion being the ex- 
 pression of a more or less generalized cortical instability; * (2) ab- 
 
 « MacRobert, KiisseU G., and Feinler, Laurent : Cause of Epileptic Seizures !n 
 Tumors of the Temporo-sphenoidal Lobe; Journal Amerioan Uedioat Attodation, Feb- 
 ruary 19th, 1921, p. 500. 
 
DIAGNOSIS OF BEAIN ABSCESS IN GENEEAL 163 
 
 scess of metastatic origin and consequently not apt to be situated 
 adjacent to tlie site of suppuration; ^ or (3) abscess of the temporo- 
 sphenoidal lobe. 
 
 (c) Subnormal Temperature. — During brain abscess the body 
 temperature remains irregularly subnormal — a fact which is of the 
 greatest diagnostic importance. No satisfactory explanation has been 
 offered to account for the failure of a localized suppuration within 
 the cerebral tissue to give the usual body reaction to a bacterial irri- 
 tant — i. e., rise of temperature. 
 
 The theory that failure to maintain the normal body temperature 
 is due to interference with the heat-regulating mechanism of the 
 brain by cerebral suppuration — on the supposition that the brain 
 and spinal cord possess two sets of cells which cause an increase or a 
 loss of heat according as one or the other is stimulated,* should be 
 abandoned, although importance still is to be attached to the effect of 
 stimulation of the vaso-motor center. There is experimental evidence 
 that the heat^regulating centers are situated in the basal segment of 
 the mesencephalon. It has been found that removal of the cerebral 
 hemispheres and the thalamus destroys the mechanism for regulating 
 the body temperature.'^' ^' * 
 
 The daily normal temperature curve is due to fluctuation in tonus 
 of the vegetative system, the center for the regulation of the tonus 
 being situated, it is believed, in the hypothalamus. The secretions 
 from the endocrine organs — the thyroid, pancreas, and adrenals — 
 influence the tonus by stimulating the tonus center. Over-stimula- 
 tion from over-action of the thyroid and other glands causes a mod- 
 erate rise in the temperature curve, while diminished tonus — a fatigue 
 phenomenon — is followed by a lowering of the normal daily tempera- 
 ture curve; both actions, stimulation and depression of the tonus, 
 occur irrespective of the metabolic — digestive — processes.^" 
 
 It has been established that the secretions of the brain contribute 
 
 ' Sautter, C. M. : Journal American Medical Association, February 5, 1921, Vol. 
 76, No. 6, p. 378. Also, Laryngoscope, December, 1920, p. 823. Reports a case of a 
 boy of thirteen witb a temporo-spbenoidal lobe abscess of otitic origin. Ten days after 
 a simple mastoid operation convulsions intervened and the patient sank into deep 
 coma. A decompressive operation was followed by improvement. Six days later 
 convulsions returned. Evacuation of pus from area of frontal convolutions. Recovery. 
 
 "Adami and McCrae: Textbook of Pathology, 1914, p. 146. 
 
 » Rogers, Fred T. : Relation of the Cerebral Hemispheres to Arterial Blood Pres- 
 sure and Body Temperature Regulation ; Am&rican Journal oj Phvaiology, 1919, Vol. 49, 
 p. 271. 
 
 • Rogers, Fred T. : Studies on the Brain Stem — IV : On the Relation of the Cere- 
 bral Hemispheres and Thalamus to Arterial Blood Pressure ; Am&ricwn, Journal of 
 PhysioloffV, December, 1920, Vol. 54, No. 2. 
 
 • Rogers, Fred T., and Wheat, D. S. : Studies on the Brain Stem — V : Carbon 
 Dioxide Excretions after the Destruction of the Optic Thalamus and the Reflex 
 Functions of the Thalamus in Body Temperature Regulation ; American Journal of 
 Pht/Biologv, September, 1921, Vol. 57, No. 2. 
 
 "> Mayer, A. : Pathologic Physiology of Human Body Temperature ; Deutsche 
 Uediginisohe Wochenaehrift, 1919, Bd. 452, S. 138S. 
 
164 BEAIN ABSCESS 
 
 somewliat to tlie maintenance of a normal body temperature. 
 Crile's ^^ conception is that there is a normal secretion from the 
 brain tissue itself, as well as from the pituitary and other glandular 
 bodies, which contributes to the maintenance of the body tempera- 
 ture. The easily induced subnormal temperature of old age is a cere- 
 bral tissue manifestation associated with degenerative cerebral 
 changes as shown by the cholin in the cerebro-spinal fluid. The sub- 
 normal temperature of hibernating animals is associated with an 
 under-secretion of known glandular cells during hibernation. 
 
 In a general way hibernation resembles brain abscess in its symp- 
 toms. Hibernating animals have "subnormal temperature, tachy- 
 cardia, slowed respiration, with diminished output of carbon dioxide, 
 lowered blood pressure, relative peristaltic activity and marked in- 
 sensibility to painful and emotional stimulus" — symptoms closely 
 simulating cerebral suppuration. 
 
 Additional Factors in Subnormal Temperature — Absence of Lymphatics; 
 
 Autolysis. 
 
 Cerebral suppuration being associated with an irregular sub- 
 normal temperature, the intermittent rises probably are due to a 
 slight leptomeningeal space involvement. The author suggests that 
 a factor is the absence in the brain of lymphatic channels which in 
 the body tissues in general play such a large part in the conveyance 
 and control of infection. 
 
 The delicate perivascular spaces surrounding the blood vessels 
 empty into the subarachnoid spaces and are the channels whereby the 
 dead tissue or other deleterious substances are removed from the 
 brain. The phagocyte cells either absorb them or they are emptied 
 into the blood vessels of the cerebral tissue, or are carried from the 
 leptomeningeal spaces by the arachnoid villi. The high temperature 
 in meningitis is due to the micro-organisms or toxins passing into the 
 general blood stream, probably through the subarachnoid villi. 
 Drainage into the large venous sinuses carries off the blood-stream 
 infection in a considerable proportion of the cases of meningitis. 
 
 Thrombosis of the blood vessels in the area of the cerebral sup- 
 puration not only obliterates the vessels, but causes the perivascular 
 spaces to become so filled with cells that they are no longer capable 
 of functioning, and thus the remaining connection with the general 
 circulation is removed ; for as long as they remain within the cerebral 
 substance they may remain inactive. 
 
 " Crlle, George W. : Origin and Nature of the Emotions ; W. B. Sounder* Company, 
 Philadelphia, 1916, p. 138. 
 
DIAGNOSIS OF BEAIIT ABSCESS IN GBNBEAL 165 
 
 It is a clinical fact of diagnostic importance that suppuration 
 within the cerebral tissue, at a distance from the meninges, not only 
 fails to produce the well-recognized reaction of suppuration — an ele- 
 vated temperature — but, on the contrary, frequently is accompanied 
 by an irregularly subnormal temperature. 
 
 The author suggests that possibly the absence of fever in brain 
 abscess is due to the fact that a brain abscess has little or no commu- 
 nication with the general circulation, being cut off from the vascular 
 circulation by thrombosis of the vessels, and from the cerebro-spinal 
 fluid circulation by obliteration of the perivascular spaces by exu- 
 dates; while the irregular subnormal temperature in brain abscess 
 may result from a disturbance of the heat-regulating mechanism of 
 the brain. The toxins or micro-organisms which cannot reach the 
 general circulation may depress the normal temperature either by 
 depression of the tonus center or by direct action of the heat-regulat- 
 ing center, or possibly by interference with the normal secretions of 
 the brain, as occurs in hibernation. 
 
 The resistance of the brain substance to autolysis may also play a 
 part, for of aU the soft tissues, the brain and the skin are the least 
 affected by autolysis. Cholin, which is not highly toxic, is liberated 
 by the autolysis of nerve tissues. 
 
 11— SYMPTOMS OF CEREBRAL COMPRESSION. 
 
 Nothing has done more to delay diagnosis than the habit of re- 
 garding the manifestations of compression as direct symptoms of 
 brain abscess. In many cases there is no increase in the brain bulk 
 in the earlier stages, the pathological process being largely necrotic, 
 the result of nutritional death from a retrograde thrombo-phlebitis. 
 Later there may or may not be an increase of the intradural contents 
 from the growth of the abscess, with an associated or reactive cedema 
 and obstruction to the cerebro-spinal system circulation. 
 
 It will be of assistance if we do not regard the symptoms of com- 
 pression as distinctly those of cerebral suppuration, but as the result 
 of increase in the brain bulk which may or may not be present at 
 the time of examination. 
 
 Only a limited degree of compression is possible in a brain ab- 
 scess. The extreme cerebral compression so frequently associated 
 with cerebral tumors never is present in suppurative intracranial 
 lesions. Emphasis is laid upon the distinction. A neoplasm in- 
 creases the brain bulk either by displacement of the cerebral tissue or 
 by infiltration into it ; an abscess grows by the destruction of cerebral 
 
166 BEAIK ABSCESS 
 
 tissue. The reactive forces of nature are paralyzed in the priesence 
 of suppuration by a very limited degree of the suppuration, and the 
 nutrition of still unaffected parts is so interfered with that the sup- 
 puration rapidly extends and death soon follows. Therefore, the 
 manifestations of extreme cerebral compression seen in cerebral 
 tumors are never witnessed in brain abscess. 
 
 SPECIFIC SYMPTOMS OF COMPRESSION. 
 
 In the presence of cerebral compression, all the cerebral functions 
 are lowered. We have low temperature, slow pulse, and stupor, in 
 contradistinction to the excitation of meningeal stimulation from 
 suppuration, when there is high temperature, a rapid pulse, and 
 cerebral excitement. 
 
 (a.) Slow Pulse. — A continuous slow pulse is a distinct symp- 
 tom of cerebral compression, but when present it generally is asso- 
 ciated with other signs — such as papilloedema or coma — which 
 enable a diagnosis. Of greater importance, however, in the early 
 diagnosis of brain abscess is the appearance of periods of slow pulse 
 followed by a rapid return to normal. In abscess of the brain a slow 
 pulse may be recorded for a few hours — probably due to an acute 
 oedema — only to disappear as the oedema subsides or, what is more 
 important, as compensation is established. 
 
 (&) Blood Pressure. — The blood pressure uniformly should be 
 taken at frequent intervals during the time the patient is under ob- 
 servation, chiefly because of its later value when surgical assistance 
 will be necessary. With acute cerebral compression the blood pres- 
 sure will rise, but in brain abscess, as a rule, compression develops 
 slowly, in which case no variation in the systolic pressure will be 
 recorded. It has taken the author many years to realize that hourly 
 blood pressure readings, although of the greatest diagnostic assistance 
 in acute compression with involvement of the medullary centers, are 
 of little or no value in subacute or chronic compression, the mech- 
 anism of the two conditions being unlike. 
 
 Cerebral pressure is synchronous with the pressure of the veins 
 within the skull. If the intracranial contents are suddenly increased 
 the splanchnic system is suddenly called upon to re-establish the 
 equilibrium between it and the increased intracranial contents. Con- 
 sequently, the blood pressure rises to prevent the threatened medul- 
 lary anemia and immediate death. In chronic compression com- 
 pensation is established by factors within the cranium itself, and con- 
 sequently, although the intracranial tension may be high, the blood 
 
DIAGNOSIS OF BEAIN ABSCESS IN GENEEAL 167 
 
 pressure is not greatly, if at all, elevated. In one of the author's 
 cases of acute temporo-sphenoidal lobe ahscess in which signs of com- 
 pression developed early and rapidly, the blood pressure rose from 
 130 to 170, while under ether 190 was recorded. Immediately upon 
 evacuation of the abscess the blood pressure fell to 155, and on com- 
 plete evacuation to 130. 
 
 (c) Pulse Pressure. — In acute cerebral compression not in^ 
 volving the medullary centers a rising pulse pressure is of diagnostic 
 importance, as normally there is a close connection between the sys- 
 tolic, the diastolic, and the pulse pressures. A rising pulse pressure 
 means acute cerebral compression away from the medullary center. 
 Whether it is of any diagnostic assistance in acute abscess cases the 
 author is unable to say ; but in traumatic cerebral cases it has been 
 of the greatest assistance to him. 
 
 (d) Projectile Vomiting. — This is of very infrequent occur- 
 rence in cerebral compression. It is, however, of frequent occurrence 
 in cerebellar abscess, even without marked cerebral compression. 
 
 (0) Ocular Paralysis. — Ocular paralysis is of no localizing 
 value whatever, the external rectus being the most frequently in- 
 volved in any suppurative lesion. Its value as a sign of intradural 
 suppuration is also greatly mitigated by the fact of its frequent oc- 
 currence in suppurative processes of the mastoid cells or of the apex 
 of the petrous portion of the temporal, perhaps from an exudate at 
 the base of the brain. The sixth nerve as it passes over the apex of 
 the bone may be very susceptible at this point to involvement from an 
 inflammatory exudate. 
 
 Third nerve paralysis, also, is of no localizing value — as demon- 
 strated by Gushing. It is apt to be compressed between the area of 
 transmitted intracranial pressure and the internal carotid artery. 
 It is of much more value, however, than a sixth nerve paralysis as a 
 sign of cerebral suppuration ; but both are of great value as symptoms 
 of transmitted intracranial pressure. In one of the author's cases 
 there was an external paralysis of the opposite side from a temporo- 
 sphenoidal lesion. ^^ 
 
 (/) Coma. — This generally is the terminal stage of compres- 
 sion. If we await the development of coma before exploration, the 
 mortality will be high, as cerebral compression favors the extension 
 of cerebral suppuration. If we would have a lessened mortality from 
 brain abscess, the abscess must be evacuated before compression has 
 damaged the cerebral tissues, paralyzed the reactive mechanism of 
 
 « Case IX, G. W. > Chapter Four, p. 38. 
 
168 BRAIN ABSCESS 
 
 the brain, and so damaged the surrounding tissues as to make them 
 a favorable soil for an extension of the abscess. 
 
 (g) Papilloedema. — Clinically it is seldom possible to differen- 
 tiate between an optic neuritis and a papilloedema. The nerve-head 
 manifestations of brain abscess usually are a combination of both. 
 The causes giving rise to them are not thoroughly understood. 
 
 The generally accepted view of cerebral compression as the sole 
 factor in their production is not consistent with clinical and experi- 
 mental evidence. While general cerebral compression plays a part, 
 other causes undoubtedly are operative. A better understanding of 
 the exact pathological conditions producing papilloedema becomes 
 necessary because of the widely accepted belief that it is solely of 
 mechanical cerebral compressive origin — a view which frequently 
 has occasioned the fallacious inference that an absence of papilloe- 
 dema is clinical evidence of lack of increase in the intracranial 
 pressure and has led to unnecessary delay in diagnosis. In consid- 
 ering the significance of the presence or absence of papilloedema the 
 following factors must be recognized : 
 
 (1) The Presence of Increased Intracranial Pressure; 
 
 (2) Interference with the Venous Return Circulation from the 
 Cranial Cavity (sufficient to cause nerve-head changes) ; 
 
 (3) Location of the Lesion (whether or not it interferes with the 
 cerebro-spinal fluid circulatory system) ; 
 
 (4) Alteration in the Composition of the Fluid (contained with- 
 in the piarachnoid prolongations of the cerebro-spinal fluid 
 system around the optic nerve, into which the parenchyma- 
 tous fluids of the optic papilla and nerve are discharged) ; 
 
 (5) Induced "Stupeur Arterielle" (due to an involvement of 
 the periarterial sympathetic from the action of toxemia or 
 trauma upon the central sympathetic system.) 
 
 (1) The Intluencb of Increased Intbaoeanial Peessuee in the PBODtrcnow 
 
 OF Papilloddema. 
 
 Cerebral compression is not always manifested by papilloedema. 
 The intense form of papilloedema — choked disc — is, of course a 
 symptom of greatly increased pressure, but a mild or even a severe 
 form of compression may entail no papilloedema. Choked disc oc- 
 curs when the extracranial portion of the optic apparatus suddenly 
 is filled with fluid or distended with exudates and inflammatory 
 products, as in obliteration of the iter from pressure by a cerebellar 
 tumor. ^* 
 
 " WVirrlngton, W. B. : Serous Meningitis ; Quarterly Journal of Medicine. 1914, 
 p. 105. 
 
DIAGNOSIS OP BEAIN ABSCESS IN GENERAL 169 
 
 The etiological features of choked disc are (a) distension of the 
 intravaginal sheath, (b) infiltration into the substance of the optic 
 nerve, and (c) venous stasis from interference with the return venous 
 circulation from the eyeball or from the cranium itself, such as fol- 
 lows from the ligation of an enlarged jugular, with extensive throm- 
 bosis of the intracranial sinuses — ^the cavernous and the superior 
 longitudinal. 
 
 Distension of the intravaginal space is not always accompanied by choked 
 disc. In several cases of fracture of the base of the skull involving the apex of 
 the orbit, the author has observed an immediate blanching of the nerve head, 
 and on subsequent post-mortem the optic sheath was found to be filled with 
 blood. This explains the clinical observation that hemorrhage into the sheath 
 from fracture may not occasion a papilloedema, but a primary optic nerve atrophy 
 may follow within a few weeks. 
 
 A high degree of increase of the brain bulk may be tolerated 
 without papilloedema when the position of the lesion causes no ob- 
 struction of the intracerebral portion of the cerebro-spinal fluid cir- 
 culation. If papilloedema were occasioned by increase in the intra- 
 cranial pressure alone, or even by direct pressure upon the optic 
 sheath, nerve-head changes would be an early manifestation of abscess 
 of the frontal lobe, because of the location of the abscess almost 
 directly above the optic nerve and chiasm. 
 
 In frontal lobe abscess, however, papilloedema rarely occurs, al- 
 though an abscess of large size may be present. It is this almost uni- 
 form absence of papilloedema in frontal lobe abscesses that has been 
 one of the causes of failure to diagnose them. Examination of the 
 recorded cases of frontal lobe abscess reveals the fact that although 
 papilloedema is very infrequent before operation, it frequently de- 
 velops after evacuation of the abscess, demonstrating that an increase 
 in the intracranial pressure from abscess in front of the central por- 
 tion of the cerebro-spinal fluid system is not associated with papilloe- 
 dema and that the addition of another factor is necessary. 
 
 The author has observed niimerous cases of cerebral injuries which during 
 life gave distinct evidences of increase of intracranial pressure — confirmed at 
 autopsy — but showed no nerve-head changes whatever." 
 
 (2) Inteefesiencb with Venotts Retuen Cikculation from Ckanial Cavitt in 
 
 THE PBODUOTION OF PAPILLCEDEMA. 
 
 Intense choked disc may develop from an acute obstruction of 
 the return circulation from the cranial cavity and retina, but the 
 
 " Eagleton, W. P. : Fracture of the Skull ; Archi/ves of Surgery, July, 1921, Vol. 
 Ill, pp. 140-153. 
 
170 BEAIN ABSCESS 
 
 papilloedema of brain abscess never is due to an obstruction of the 
 vascular supply to tbe nerve bead alone. 
 
 A moderate increase of tbe intracranial contents sucb as occurs 
 in brain abscess can not give rise to sufficient pressure to occasion 
 papillcedema by strangulation of tbe vessels of tbe optic nerve and 
 papilla, but wben pressure is applied to an area vpbere it obstructs 
 tbe cerebro-spinal fluid system or interferes witb tbe discbarge of 
 tbe intracellular juices of tbe nerve bead into tbe subaracbnoid pro- 
 longations of tbe nerve it will occasion a moderate papilloedema. 
 
 Increase in intracranial pressure, by a temporary obstruction of 
 tbe circulation, may occasion tbe tortuous and dilated veins and red- 
 ness of tbe disc so frequently seen in septic processes, but from tbis 
 temporary congestion tbe vessels quickly recover.^® 
 
 Congestion of tbe disc from increased intracranial pressure does 
 not lead to papilloedema. Altbougb frequently described as tbe first 
 stage, it probably bas but little to do witb tbe development of a true 
 papilloedema.^' 
 
 For tbe development of a true nerve-bead swelling it is necessary 
 tbat to a venous obstruction tbere be added an increase in tbe cerebro- 
 spinal fluid system circulation. Tbe increase in tbe amount of cere- 
 bro-spinal fluid from tbe irritation of an inflamed sinus wall, and dis- 
 turbance in tbe outflow from alteration in its composition, undoubt- 
 edly is tbe origin of tbe mild papilloedema often seen in sinus 
 tbrombosis. 
 
 Tbe writer bas seen a cboked disc witb bemorrbages and blind- 
 ness immediately follow a ligation of tbe jugular for jugular bulb 
 tbrombosis and occasion an immediate complete venous stasis. The 
 venous stasis occurred because tbe ligated jugular was tbe main vessel 
 for tbe return of blood from tbe cranial cavity — tbe opposite jugular 
 foramen being very small — or because a tbrombosis occluded tbe 
 superior longitudinal sinus.^'^ Tbe intense papilloedema probably 
 originated in part from an associated acute internal bydrocepbalus 
 due to increase of tbe cerebro-spinal fluid from irritation and from 
 interference witb tbe discbarge of venous blood from tbe cerebral 
 veins tbrougb tbe veins of Galen, its discbarge tbrougb tbe arach- 
 noid villi being at tbe same time prevented by tbe tbrombosis of tbe 
 longitudinal sinus. Tbe increased amount of cerebro-spinal fluid 
 
 '"Martin and Crowe state that pressure on the internal Jugular vein may cause 
 increase In the venous dilatation at the fundus. This observation, if verified, should 
 be of some diagnostic value. (Martin, H. H., and Crowe, S. J. : Lateral Sinus Disease 
 — Case Keport; Laryngoscope, December, 1920.) 
 
 '» Pick, L. : Pseudo Neuritis Optica — Oedem der Papilla Nervi Optici — Neuritis 
 Optica ; Zettechrift fUr Augenheilkunde, 1904, Bd. XI, S. 221. 
 
 " Bagleton, W. P. : Circulatory Disturbances Following Ligation of the Internal 
 Jugular Vein in Sinus Thrombosis — with Report of Case ; Arohwes of Otologv, 1906, 
 Vol. XXXV, No. 2, p. 91. Case XXIII, chap. VIII, p. 129. 
 
DIAGNOSIS OF BEAIN ABSCESS m GENEEAL 171, 
 
 with diminislied outflow resulted in an acute distension of the ven- 
 tricles in addition to the venous stasis/®' ^® 
 
 In another case a mild papilloedema on the homolateral side fol- 
 lowed an operation for a cervical adenitis. The papilloedema origi- 
 nated when an ascending retrograde thromhus, which developed in 
 the jugular vein in the neck, entered the cranial cavity. 
 
 (3) Influence of Location of Lesion in the Peoduotion of PApuxcedema. 
 
 Papilloedema appears at once when the central portion of the 
 cerebro-spinal fluid circulation is suddenly interfered with, causing 
 an obstructive internal hydrocephalus. Abscess of the cerebellum, 
 also frequently occasions a mild papilloedema, chiefly because the 
 pressure upon the iter between the third and fourth ventricles dis- 
 places the median line of the cerebellum and thus interferes with the 
 cerebro-spinal fluid circulatory system. The intense choking of the 
 disc so frequently seen in brain tumor, however, never occurs in 
 cerebellar abscess. 
 
 Obstruction of the central cerebro-spinal fluid system is the cause 
 of the mild papilloedema in many cases of temporo-sphenoidal lobe 
 abscess,^" while the almost uniform absence of papilloedema in fron- 
 tal lobe abscess is, primarily, due to the fact that the central cerebro- 
 spinal fluid system is not involved, papilloedema developing only 
 when the abscess attains a large size or another factor is added.^^ 
 
 Very large lesions involving the cortex alone, large hemorrhages, 
 or growths, frequently cause but little change discoverable by the 
 ophthalmoscope. Direct pressure on the optic chiasm exerted from 
 below, (as in hypophyseal tumors conflned to the sella), and conse- 
 quently not interfering with the central cerebro-spinal fluid circula- 
 tory system, do not cause papilloedema. When situated above the 
 chiasm, however, as in suprasellar growths involving the floor of the 
 third ventricle, bilateral papilloedema usually is present although 
 without great venous stasis. The author's experience with tumors 
 of the hypophysis causes him to regard the absence of papilloedema 
 as an indication either that the growth is suprasellar or that, having 
 been primarily sellar in location, it has broken through the dural 
 envelope and invaded the general cerebral cavity. 
 
 " Stolz : XTeber die Unterbindung der Vena jugularls interna ; Correspondenzblatt 
 filr Schioeixer Aerzte, 1918, Bd. XLVIII, No. 13, p. 415. 
 
 '° Ruttin, B. : Venenektasie in retra auriculSren Operatlonafeld und Stauungs- 
 paplUe naeh Jugularis Unterbindung ; International Centralblatt fik- Ohrenheilkunde, 
 1919-llj Bd. IX, S. 301. 
 
 ^ Case X, Chapter Pour, p. 43 ; in which lumbar puncture performed during 
 operation liberated but little fluid prior to evacuation, but the tapping of the abscess 
 immediately was followed by free flow from the needle — an evidence of obstruction. 
 
 " Bollack, J. : Stase Papillaire et Dilation des Ventrieules au Cours des Tumeurs 
 C€r€brales; Annates d'OcuUstique, 1919, Tome 156, pp. 538-571. 
 
172 BEAIF ABSCESS 
 
 (4) Influence of Alterations in Composition of Pabenohymatous Fluid 
 
 {of the nerve head and the optio nerve, which is discharged into the 
 
 prolongations of the cereiro-spinal fluid system surroimd- 
 
 vng the optio nerve). 
 
 Papilloedema in brain abscess frequently originates from a block- 
 ing of the pathways by which the parenchymatous fluids from the 
 nerve head and the optic nerve are discharged into the subarachnoid 
 prolongations of the optic nerve, the blocking being caused by changes 
 in the parenchymatous fluid itself, or in the cerebro-spinal fluid. 
 
 Intbacbllulab Pathways of Optic Neeve and Retina. 
 
 "The optic nerve is not an outgrowth from the brain to the ter- 
 minus as are the other cranial nerves, but a growth from the nervous 
 elements of the retina into the brain." ^^ "Histogenetically it is 
 merely an association path of the central nervous system correspond- 
 ing to the other association paths." 
 
 Primitively, the retina is a part of the cerebral cortex. If at an 
 early stage the "eyeball is removed and the optic nerve cut, the gen- 
 iculate, the pulvinar, and the anterior quadrigeminal bodies do not 
 undergo complete development." ^^ The trophic center, therefore, 
 which controls the development of these deep-lying ganglionic parts 
 is in the retina. 
 
 The intracellular fluids of the anterior part of the eye are dis- 
 charged through the ligamentum pectinatum, the canal of Schlemm, 
 and Montana's spaces ; those from the posterior part of the eye, how- 
 ever, the retina and the optic nerve — the cerebral portion of the 
 eye — discharge into the optic prolongations of the leptomeningeal 
 channels of the cerebro-spinal fluid circulatory system.^*' ^^ 
 
 Verhoeff's cases apparently would furnish evidence that if an optic nerve 
 tumor involves the subarachnoid space a papillodoema develops, while atrophy 
 alone appears when the space is not attacked. (Verhoeflf, F. H. : Primary Intra- 
 neural Tumors (Gliomas) of the Optic Nerve; Transactions American Medical 
 Association/ — Section on Ophthalmology, Boston, June 8-10, 1921, pp. 87-127. 
 
 This system of intraneural, pericapillary, and perivascular path- 
 ways of the retina and optic nerve frequently but erroneously is 
 
 " Gradle, H. S. : Development of Human Eye — Ocular Embryology ; American 
 Enovclopedia Ophthalmology, Vol. V, pp. 3862-3920. 
 
 " Ryder : Development of the Bye ; Norris and Oliver Syatem oS Disease of the 
 Eye, Vol. I, p. 60. 
 
 « Weed, Lewis H. : Dual Source of Cerebro-spinal Fluid — Studies on Cerebro- 
 spinal Fluid; Journal Medical Research, September, 1914, Vol. XXXI, No. 1 (New 
 Series, Vol. XXVI, No. 1), pp. 21-117. 
 
 " Wegeforth, Paul, and Weed, Lewis H. : Analogous Processes of Cerebral and 
 Ocular B^uids — Studies on Cerebro-spinal Fluid : Journal Medical Research, September, 
 1914, Vol. XXXI, No. 1 (New Series, VoL XXVI, No. 1), pp. 167-170. 
 
DIAGNOSIS OF BEAIN ABSCESS IN GENEEAL 173 
 
 spoken of as lympliatic,^* although there probably does exist a com- 
 munication at the apex of the orbit of this system with the true 
 lymphatic system. 
 
 Normal cerebro-spinal fluid does not coagulate, but alterations in 
 its chemical properties — ^from irritation or inflammation — causes it 
 to become coagulable to a greater or less degree. The author suggests 
 that it is the filling of the intravaginal space with a pathological coag- 
 ulable fluid,^'' or alteration of the perineural, pericapillary, or peri- 
 vascular fluids — ^thus causing obstruction in the pathways — ^which 
 is the additional factor generally operative in the production of papil- 
 loedema in abscess of the brain ; much in the same way that interfer- 
 ence — by inflammatory or hemorrhagic exudates — with the filtration 
 of fluids from the anterior portion of the eyeball by blockage of the 
 canal of Schlemm will precipitate an attack of acute glaucoma. ^^ 
 
 The most intense choked disc with hemorrhage and venous tortuosities that 
 the author has observed, having its origin from a brain abspess occurred in a 
 very small temporo-sphenoidal lobe abscess, situated adjacent to the posterior 
 horn of the lateral ventricle, and in which the ventricle fluid itself at operation 
 coagulated. Prior to the operation the intensity of the choked disc occasioned 
 doubt whether it could possibly be due to an abscess. 
 
 It is probably the cellular reaction to the toxic influence of an 
 altered cerebro-spinal fluid which is the cause of the mild papillce- 
 dema seen in many localized suppurative processes — such as that 
 associated with an involvement of the cells at the base of the petrous 
 pyramid which is accompanied by "Gradenigo's syndrome," all of 
 which symptoms disappear on evacuation of the adjacent mastoid 
 area. The toxic reaction from the altered cerebro-spinal fluid has 
 here a direct pathway into an optic nerve prolongation from the 
 interpeduncular and chiasmal cistema. This is also the explanation 
 of the frequently seen unilateral mild papilloedema associated with 
 otitic sinus thrombosis — ^thrombophlebitis.^^ 
 
 "' Behr, C. : Zur Entstehung der Stauungspapille ; v. Graefa ArcMv fUr Ophthal- 
 mologie, 1920, Bd. 101, S. 165. 
 
 =" Weed, Lewis H. : Dual Source of Cerebro-spinal Fluid ; Journal Medical Re- 
 search, September, 1914, Vol. XXXI, p. 103. (States "Intra-leptomeningeal cbannela 
 of pathological coagulable fluid probably cause obstruction of tbe perineural, pericapil- 
 lary, and perivascular system of the optic nerve.") 
 
 ^' Schiek believes from his histological examination of six cases that papilloedema 
 arises from an obstruction to the "axial output from the eye" — a lymph stasis at the 
 papillar end of the optic nerve, especially from over-filling of the intravaginal sbeath 
 with cerebro-spinal fluid. Schiek, F. : Die Genese der StauungspapiUe ; Centralblatt 
 fii/r Innere Medizm, 1910, Bd. XXXI, S. 484. 
 
 ™ Rados produced papilloedema experimentally by the cerebral inoculation of 
 extracts from virulent tumors. Rados, A. : Histologische Veranderungen an der 
 experimentalen StauungspapiUe ; Archiv filr Augenheillcunde, 1915, Bd. LXXIX, S. 
 199. 
 
 Lewlneohn demonstrated by animal experiments that the injection of glycerine, 
 oil, or liquid paraffine into the subdural space caused a delayed change in the papilla, 
 which must have originated from obstruction by the altered fluid and not simply from 
 
174 BEAIN ABSCESS 
 
 (5) Induced "Stupetjb AKTERisaxE" in the PEODUcraoisr of Papillcedema.*' 
 
 Arterial contraction from disturbance of the central sympathetic 
 nervous system in the brain — as the result of trauma or toxemia — 
 undoubtedly is a factor in the production of nerve-head changes in 
 certain cases. The author has seen a mild papillcedema from an 
 enormous frontal lobe abscess foUovs^ed, after evacuation, by oblitera- 
 tion of the arteries and veins, vs^ith blindness due to an accumulation 
 of pus in the lateral ventricle of the affected side, as shov^n at post- 
 mortem. The basal eistema was also enormously distended. (Figs. 
 33 a and b.) 
 
 Contraction of the vessels of the nerve head frequently is an 
 early manifestation of fracture of the skull from — the author sug- 
 gests — a disturbance of the fibres of the sympathetic nerves surround- 
 ing the arteries and veins. On the following day the nerve head 
 appears normal 'unless a hemorrhage of the optic nerve sheath has 
 occurred. In these cases the fracture generally passes through the 
 apex of both orbits. 
 
 In one case, following a fracture which went through both orbital 
 roofs, both discs were white, the arteries being obliterated. On the 
 following day after the removal of bone the discs were normal. In 
 spite of the normal discs, however, greatly increased intracranial 
 pressure was present, as was shown during life by the large amount 
 of fluid under great pressure in the lumbar punctures, and later at 
 autopsy by whiteness of the cortex and obliteration of the sulci. Both 
 optic nerves were tightly held and indented where they passed through 
 the orbital foramina, as if they were compressed. Microscopical ex- 
 amination of the nerve, however, failed to reveal any pathological 
 change. 
 
 In another case a white nerve head accompanied an extensive 
 hemorrhage of the head of a new-bom infant. The white disc per- 
 sisted after the removal of the clot. At post-mortem a large intra- 
 piarachnoid abscess was found, with an obstructive hydrocephalus 
 from closure of the iter. 
 
 increase of Intra-eranial pressure, as this would immediately have been manifest. 
 Lewinsohn, G. : Expcrimenteller Beitrag zur Patlaogenese der Stauungspapille ; ArcMv 
 fur OphthalmoToffie, 1912, Vol. 81, p, 15. 
 
 Klauber, from clinical and histological examinations of wounds of the head, found 
 papillcedema to be more frequent in the 'presence of infectious complications, due to an 
 endocranial lymph stasis from the toxic irritation caused by necrotic brain tissue 
 and extrayasated blood. Klauber, E. : Klinische und histologische Betrachtungen 
 iiber das Oedem des Schnorenkopfes bei Gehirnverletzten ; Klmische MonatsWatter fur 
 Augenheakunde, 1918, Bd. LX, S. 504. 
 
 »»Leriche, Rcii(? : Some Kesearches on the Peri-arterial Sympathetica: Annala of 
 Surgery, October, 1921, Vol. LXXVI, No. 4, p. 387. 
 
DIAGNOSIS OF BEAIN" ABSCESS IN GENBEAL 175 
 
 DIAGNOSTIC DEDUCTIONS FROM PEESENCE OR ABSENCE OF NERVE- 
 HEAD CHANGES IN BRAIN ABSCESS. 
 
 (1) A moderate grade of papilloedema is a frequent manifesta- 
 tion of cerebellar abscess. It originates from an obstruction in tbe 
 central cerebro-spinal fluid circulatory system (a) by cerebral dis- 
 placement at the iter, or (b) by the accumulation of a pathological 
 fluid from an associated arachnoiditis in the basal cistema ; 
 
 (2) The same explanation of displacement accounts for the 
 papilloedema frequently seen in occipital lobe abscess, the pressure 
 being applied from above, consequently necessitating the suppurative 
 process being well forward in the occipital lobe ; 
 
 (3) The presence of a papilloedema in a temporo-sphenoidal 
 lobe abscess depends (a) upon whether the abscess sufficiently dislo- 
 cates the brain to cause obstruction in the cerebro-spinal fluid system 
 by pressure, or (b) upon the toxic action of an altered cerebro-spinal 
 fluid in the nerve head. (In the latter case it primarily should be 
 regarded as a manifestation, not of compression, but of cerebral sup- 
 puration.) 
 
 (4) The usual absence of papilloedema in frontal lobe abscess is 
 due to the fact that — in spite of the greatly increased intracranial 
 pressure — ^none of the above factors are present; 
 
 (5) Although when present papilloedema is of great diagnostic 
 assistance in a case of brain abscess, its absence in the presence of 
 other signs of intracerebral suppuration should not occasion delay 
 in intradural exploration ; 
 
 (6) Intense choked disc with swelling of several dioptres of the 
 papilla and multiple hemorrhages never occurs from brain abscess 
 alone. Its presence, when brain abscess is present, signifies that 
 another factor also must be active— such as an acute, sudden obstruc- 
 tion to the venous return from the eye from thrombosis of, or pres- 
 sure upon, the cavernous sinuses; 
 
 (Y) Obliteration of the arteries of the nerve head, with blind- 
 ness out of proportion to the visible ophthalmic changes, when asso- 
 ciated with brain abscess is suggestive of involvement of the central 
 portion of the sympathetic system such as would occur from empy- 
 ema of the lateral ventricles. 
 
CHAPTEK XI. 
 
 DIAGNOSIS OF ADJACENT TEMPOKO-SPHENOIDAL 
 LOBE ABSCESS. 
 
 LOCAI-IZING SYMPTOMS. 
 
 If, from a study of a case from tlie point of view of the symp- 
 tomology of intradural suppuration in general, it is decided tliat a 
 brain abscess exists, tbe next step in the diagnosis involves the locali- 
 zation of tbe patbological process. 
 
 Localizing Value of Primary Focus of Infection. — The im- 
 portant thing to be determined in the localization of a brain ab- 
 scess in the early stages is the original point of entrance of the 
 infection, since the abscess will be found adjacent to this except 
 in the case of abscesses of metastatic character. The chief point in 
 localization, therefore, is to determine whether the infection has 
 entered the brain from the ear; whether it involves the labyrinth; 
 whether it has entered from the nose or accessory sinuses. 
 
 If the labyrinth is involved the abscess is apt to be situated in 
 the cerebellum; if there are no labyrinthine symptoms the abscess 
 probably is temporo-sphenoidal ; if the suppuration exists in the 
 frontal nasal sinus, the abscess is apt to be adjacent to the posterior 
 wall of the frontal sinus. In the latter case the X-ray is an important 
 aid in localization. 
 
 In a brain abscess following aural suppuration the elimination 
 of the cerebellum as the site of infection is of the greatest importance 
 in localization; for, in adjacent abscess from the ear the abscess, if 
 not metastatic, will be situated either in the temporo-sphenoidal lobe 
 or in the cerebellum. If, in the absence of a spontaneous nystagmus, 
 cold caloric in either ear in the upright position gives a normal 
 nystagmus and normal vertigo, the cerebellum can probably be ex- 
 cluded. The pointing deviations are so uncertain that induced point- 
 ing variations may be largely disregarded.^ 
 
 ' Barany, Eobert : Temporary Depression of the Function of the Cerebellar Cortex 
 after the Method of Trendelenburg, evidenced by the pointing test; Journal of Lanyn- 
 gology, Rhimoloay ami Otologv, August, 1911, Vol. 26, p. 444. 
 
 176 
 
ADJACENT TBMPOEO-SPHBNOIDAL LOBE ABSCESS 177 
 
 Pathognomonic Symptoms in Temporo-sphenoidal Lohe Abscess. 
 — The temporo-sphenoidal lobe is a silent area of the brain. Even 
 when it is the seat of a large collection of pus no localizing symptoms 
 may be present. Two pathognomonic symptoms, however, frequently 
 are present and outspoken — i.e., aphasia (naming), and (an easily 
 overlooked symptom) hemianopsia. 
 
 (a) Aphasia. — One of the author's cases suddenly manifested 
 a sensory (naming) aphasia which lasted for a few hours and then 
 entirely disappeared. In reviewing this case he is inclined to be- 
 lieve that in many of the adjacent temporo-sphenoidal abscesses which 
 later develop aphasia, an incomplete aphasia is present off and on 
 for several days prior to its becoming sufficiently outspoken to com- 
 mand the attention of the patient or the physician. 
 
 In a right-handed man with an abscess in the left hemisphere the 
 presence of a naming aphasia is pathognomonic. The aphasia in the 
 early stages is apt to be transient, appearing suddenly and as sud- 
 denly disappearing. At the time of the examination the patient 
 may talk very well, but his family will state that on a certain date 
 he was "out of his head." In one of the cases, careful questioning 
 showed that the patient was unable to name an object which he 
 wanted; after repeated attempts to name it, he got out of bed and 
 got it for himself; but in a few hours the aphasia had disappeared 
 entirely. 
 
 Personal experience has taught the writer not to be deceived by 
 an apparent improvement. In one case a young man, following two 
 operations on the jugular bulb, suddenly became aphasic. When seen 
 on the following evening his speech was perfect, but from the de- 
 scription of his aphasia by his physician, the author felt warranted 
 in advocating a temporo-sphenoidal exploration. On account of the 
 previous operation and the — at the time — excellent physical condi- 
 tion of the patient, his family refused. A few weeks later he pre- 
 sented himself to all appearances in perfect health. Ophthalmoscopic 
 examination revealed a slight papilloedema, however. The following 
 summer he suddenly became comatose and died within a few hours 
 from rupture of the abscess. 
 
 The reports of frontal lobe abscess contain several cases with a 
 similar history. The transient nature of the aphasia undoubtedly 
 comes from involvement by oedema of the associated tract ; later the 
 oedema is sufficiently abated to allow of complete restoration of 
 function. 
 
 A "naming aphasia" is seldom complete until signs of compres- 
 sion develop. In the presence of suppuration within the ear, pre- 
 
178 BEAIlSr ABSCESS 
 
 ceded by a vague chill, and associated with headache, exploration of 
 the temporo-sphenoidal lobe is demanded. Even when complete, the 
 aphasia disappears entirely after operation, so that the tract can not 
 have been destroyed. The "naming" character of the aphasia, how- 
 ever, although incomplete, usually can be demonstrated if properly 
 investigated. Frequently it can be elicited only by careful ques- 
 tioning. 
 
 When incomplete this type is rather definite. The patient, when 
 he names an object correctly, realizing its correctness, will repeat 
 the same name for the next object; but while he may or may not 
 know that this is the wrong name, he invariably can use or properly 
 describe the use of the object.^ 
 
 (6) Word Deafness. — The labyrinth contains, developmen- 
 tally, the end organ of one of the most primitive of the special senses 
 and one of the latest of all — the vestibular, and hearing apparatus. 
 If we except speech, audition is the most highly specialized of all our 
 special senses. In spite of the general conception that the eye is the 
 most highly specialized sense, hearing as we understand it, undoubt- 
 edly is. It is the only one of the special senses below speech which 
 has even a tendency to be localized in one cerebral hemisphere. 
 Hearing is a specialization of a special sense — that of sensation, 
 touch — and it is out of the specialization of hearing that speech has 
 been acquired by man. 
 
 While experimental and histological evidence would place the 
 cortical center for hearing bilaterally in the transverse temporal gyri 
 of Heschl and in two-fifths of the temporal convolutions,^ a total 
 deafness of the central organ is of rare occurrence for the reason 
 that the hearing centers are bilateral — situated in both temporo- 
 sphenoidal lobes — and consequently total central deafness follows 
 only upon the destruction of both lobes. 
 
 The transverse temporal gyri, probably of both sides but certainly 
 of the left side, contain the primary centers for the reception and 
 analysis of auditory stimuli ; they represent the uppermost link in 
 the chain of auditory neurons.* Interference with the functioning of 
 the cortical center for hearing such as would be caused by the pres- 
 sure of a temporo-sphenoidal lobe abscess may give rise to a complex 
 of symptoms which are of great diagnostic value. Of these, word 
 deafness — a form of aphasia — is the most important. In general, 
 
 » Gordon, Alfred : A Contribution to tlie Study of Apliasia ; New York Medical 
 Journal, January 4, 1913. 
 
 • Kennedy, Foster : Symptomology of Temporo-splieiioidal Tumors ; Archives of 
 Internal Medicine, September, 1911, Vol. 8, pp. 317-350. 
 
 ' Campbell : Histological Studies on the Localization of Cerebral Functions : 
 1905. 
 
ADJACENT TEMPOEO-SPHENOIDAL LOBE ABSCESS 179 
 
 aphasia is the inability to call a word, or the use of inappropriate 
 words. Word deafness, as defined by Laiguel-Levastine,^ is rather 
 a "syndrome characterized by the absence of adaptation of the words 
 to the ideas and of the ideas to the words." 
 
 In one of the author's cases *' "^ word deafness was a manifestation 
 of a large, left-side, intrapiarachnoid temporo-sphenoidal lobe abscess. 
 The patient, although possessing hearing in both ears, and affected 
 by a Wernicke "naming aphasia" which allowed him to use numbers 
 but not proper names, had a complete word deafness. He was un- 
 able to call, repeat, or understand any proper names, but recognized 
 and appreciated objects by sight alone. When he desired anything 
 — ^lemonade, for instance — ^he uniformly would say, "Help me — ^help 
 
 me ;" then, realizing his inability to make his want known by 
 
 words, would add, "Show me." When shown the right object — ^the 
 lemon, perhaps — ^he instantly would recognize it as the thing de- 
 sired and assent by saying "Yes." 
 
 He recognized his physician and friends but could not call their 
 names nor even understand the names when they were spoken. Com- 
 mands given him with nouns in the sentences he did not understand, 
 but commands without nouns were understood, although imperfectly. 
 When told to lie down he did so, asking, "Is this what you mean ?" 
 He was conscious of and annoyed by a paresis of his right arm and 
 described it by saying, "All in." 
 
 Following the evacuation of his abscess the word deafness imme- 
 diately disappeared, but the "naming aphasia" continued. He then 
 could understand a name and could repeat it. When shown a knife, 
 for instance, he could not say what it was, but when asked if it was 
 a knife he not only recognized it but understood the name of it. He 
 was imperfectly able to read printed numbers and letters, but appar- 
 ently did not completely comprehend the command to read, as he 
 generally tried to copy them instead of reading. He often inverted 
 the letters and figures in writing them, but as he was writing with 
 his left hand, the right still being paralyzed, this may account for it. 
 
 In the writing teats he made the figures 2 and 6 upside down; a 7 he wrote 
 9; and 8 he also wrote 9, and a 9 was written 10. For 24 he drew an indeter- 
 minate scrawl. The figure 2 he read two, but the 10 he called five. The letter 
 W he read aright, but the letter P he was unable to read. 
 
 ' Laiguel-Levastine : Aphasie et Apraxie ; Le Bulletin KMical, 1920, Vol. XXXIV, 
 D 277 
 
 » Case VII, J. C. C. : Chapter Four, p. 35. 
 
 ' Not© : Cases of brain abscess with word deafness have been reported by Brown, 
 W. G. Mastoid Disease with Cholesteatoma Complicated by a Cerebral Abscess ; 
 Medioal JaamM of Australia, 1920, I, p. 212 ; and Wiener, Alfred : A Case of Brain 
 Abscess Following Traumatism and Acute Mastoiditis — Operation — Recovery ; Archives 
 of Otology, 1906, Vol. XXXV, No. 4. 
 
180 BEAIN" ABSCESS 
 
 (c) Hemianopsia — Transient or Fixed. — ^Hemianopsia is one 
 of the most important localizing signs of temporo-splienoidal lobe 
 abscess. It is due to an involvement of tbe association fibers running 
 from the cortical optical center in the cuneus to the geniculate 
 bodies — the cuneo-pulvinar tract (Meyer's Tract) — which passed 
 through the temporo-sphenoidal lobe. Gushing* has demonstrated 
 that in temporo-sphenoidal lobe tumors this tract is caught between 
 the tumor and the distended ventricle. This undoubtedly also is the 
 explanation in temporo-sphenoidal lobe abscess cases. 
 
 In a brain abscess as well as in a brain tumor case the author has 
 seen a complete hemianopsia for colors which disappeared entirely 
 on the following day. In his experience the hemianopsia has been 
 latent in all abscess cases and he believes that a transient hemian- 
 opsia is of much more frequent occurrence in temporo-sphenoidal 
 lobe abscess than generally is appreciated, since it is not an outspoken 
 symptom and not recognized by the patient himself, even when com- 
 plete for form as well as for color. Consequently, if the surgeon is 
 to avail himself of a localizing hemianopsia in making a diagnosis, 
 it is necessary to examine the visual fields repeatedly both for form 
 and for colors. (Fig. 34.) 
 
 Hemianopsia persists long after the subsidence of suppurative 
 symptoms, and in some cases even after the abscess has been cured. 
 In a re-examination of two of the author's healed cases of temporo- 
 sphenoidal lobe abscess * hemianopsic sections of the field were still 
 found wanting after an interval of three and five years. (Figs. 35 
 and 36.) 
 
 CASE NO. XXVII. 
 
 E. L. : Hemianopsia a Deciding Factor in Exploring Temporo-sphenoidal Lobe. 
 Boy. 
 
 In the case referred to on page 177 the abscess was of many weeks' 
 duration, during which time the mastoid wound and drum membrane had 
 entirely healed, the hearing returned to normal, and no nerve-head changes 
 were present. The only suspicious symptoms during these weeks were irregular 
 vomiting and a mild form of headache — the former having been attributed to 
 errors in diet and the latter to eye-strain from a refractive error. Five weeks 
 after the prescribing of the glasses the headache became suddenly severe, the 
 vomiting frequent, an intense choked disc developed and the vision was reduced. 
 
 On examination a diagnosis of a probable brain abscess was made, based 
 upon (1) the presence of a previous aural suppuration; (2) irregular vomiting 
 and headache; localization of the pus in the temporo-sphenoidal lobe was sus- 
 pected because repeated examinations of the field for form and colors had on 
 one occasion — two days previously — shown a distinct tendency to ( 3 ) a hemianop- 
 
 ' Gushing, Harvey : American Neurological Association, Atlantic City June 
 1921. 
 
 » Case X, C, H,, Chapter Four, p. 43 ; and Case XVII, M. D., Chapter Five 
 
270' 
 
 Left Eye Right Eye 
 (Solid line shows form field, dotted line color field.) 
 
 Fig. 34. — Bilateral suggestive hemianoptie indentation of color fields in a 
 case of left adjacent temporo-sphenoidal lobe abscess. (Case XXVII, E. L., 
 Chapter Eleven, p. 180.) 
 
 (Solid line ■ 
 
 shows form field, dotted line 
 
 color field.) 
 
 Pig. 35. — Persistent hemianoptie indentation of field of right eye of patient 
 three years after operation for a left-sided adjacent temporo-sphenoidal lobe ab- 
 scess. (Case X, C. H., Chapter Four, p. 43.) 
 
Left Eye Eight Bye 
 (Solid line shows form field, dotted line color field.) 
 
 Fig. 36. — Unappreciated hemianoptio indentations of fields in a cured case 
 of metastatic abscess of right internal capsule five years after operation. (Case 
 XVII, M. D., Chapter Five, p. 77.) 
 
Left Eye Eight Bye 
 (Solid line shows form field, dotted line color field.) 
 
 Left Bye Eight Eye 
 (Solid line shows form field, dotted line • - color field.) 
 
 Fig. 37, Upper Figure. — Transient suggestive hemianoptic 'field in case of left 
 adjacent temporo-sphenoidal lobe abscess. 
 
 Lower Figure — Two days later; disappearance of hemianopsia for form, but 
 indentation for colors. 
 
ADJACEISTT TEMPOEO-SPHENOIDAL LOBE ABSCESS 181 
 
 tie contraction in the eye of the affected side and a corresponding indentation 
 in the opposite eye (Fig. 37) ; while the patient gave (4) a history of having 
 a few days hefore had difficulty in recalling several names, among them the 
 word "scapular" — a familiar word for a Roman Catholic who had worn one for 
 several years. 
 
 The abscess, which was of very small size with a very firm capsule, was 
 located near the posterior horn of the lateral ventricle. After the evacuation 
 of about two drachms of thick pus in a misguided effort at complete evacuation, 
 the searcher was forced into the adjacent lateral ventricle. The cerebro-spinal 
 fluid discharged was so viscid that it formed a cast within the searcher. As the 
 ventricle was not dilated — as shown by both ventricular and lumbar puncture — 
 it undoubtedly was the change in the character of the fluid itself which occa- 
 sioned the intense choked disc. 
 
 (d) Facial Paralysis of Opposite Side. — Generally the first 
 manifestation of involvement of the motor area of the brain by an 
 adjacent temporo-sphenoidal lobe abscess is a paresis of certain of the 
 muscles of the opposite side of the face. This facial paresis is of the 
 cortical, not of the peripheral type. It involves the lower portion of 
 the face and is elicited only by spontaneous emotional movements, 
 such as laughing, when the lower portion of the face appears flat- 
 tened, while the eye, which the patient can close on command, does 
 not close reflexly by volition so frequently nor so completely as the 
 other. 
 
 Facial paresis is of the greatest importance in diagnosis. It long 
 precedes weakness of the arm and the leg. In the presence of sup- 
 puration in the ear, with a history of vague chill and headache, a 
 cortical paralysis of the face of the opposite side to the aural suppura- 
 tion makes a diagnosis positive. 
 
 (e) Paralysis of Contralateral Arm. — A weakness — paresis or 
 paralysis — of the arm, which comes and goes, is a frequent localizing 
 manifestation of brain abscess. 
 
 (/) Contralateral Hemiplegia. — Complete hemiplegia in tem- 
 poro-sphenoidal lobe abscess is a very rare condition. When it occurs 
 it can be differentiated from a vascular lesion by the progressive na- 
 ture of the paralysis, the face first becoming involved, then the arm, 
 and last of all the leg, the involvement of the groups being separated 
 by appreciable intervals. This is in contradistinction to vascular 
 disease in which the onset is sudden and involves face, arm and leg 
 simultaneously.^ " 
 
 In the presence of a complete contralateral hemiplegia which has 
 appeared suddenly, the probability is that the surgeon is not deal- 
 ing with an adjacent temporo-sphenoidal lobe abscess, since an 
 adjacent abscess by reason of its location away from the internal 
 
 M Case XVII, M. D., Chapter Five, p. 77. 
 
182 BRAIN ABSCESS 
 
 capsule cannot cause a complete hemiplegia unless it is of enormous 
 size, but with a vascular lesion or an abscess of metastatic origin. A 
 metastatic abscess may cause a complete hemiplegia either (1) of 
 internal capsular origin — its causative retrograde thrombophlebitis 
 involving the vascular supply of the internal capsule — or (2) of. 
 cortical origin, the infecting nidus having been confined to the motor 
 area by way of a secondary thrombosis of a dural or pial vessel, the 
 intercurrent intradural or extradural abscess being situated over the 
 motor area at least three inches above the ear. 
 
 CASH NO. xxvm. 
 
 P. Q. : Case of Intercurrent Superficial Brain Necrosis\, Situated Three Inches 
 Aiove the Ear, Over the Motor Area of the Gereiral Cortex (with Necrosis of 
 Dura and Extradural Abscess) to which Point the Infection Was Carried from 
 the Original Focus in the Middle Ear by an Intercurrent Thrombosis of a Dural 
 Vein. 
 
 History: The man was brought to the hospital complaining of intense pain 
 in his left ear; dizziness, vertigo, noises in his ear. He had had bilateral run- 
 ning ear in both ears for many years, but during the past year the discharge 
 had stopped in his right ear; it had not stopped in his left. An examination 
 revealed a dead labyrinth. The headaches and dizziness gradually disappeared 
 and he was discharged from hospital. He was admitted the same day, with 
 high temperature. It was now found he had a high cell count of his cerebro- 
 spinal fluid; it was under great pressure, and cloudy. He had a leucocytosis 
 of 13,000. He was rigid and had the symptoms of meningitis. However, to the 
 surprise of everybody, this cleared up and the patient was again discharged. 
 
 Four months later he was again admitted to the hospital. He now had a 
 paralysis of the right arm. He had a slight facial paralysis of the right side. 
 He had no "naming aphasia," but apparently had some difficulty in talking. 
 He had two convulsions the night of admission and had had two or three the 
 day before. He was apparently deaf in the left ear. He was able to walk and 
 did not have a Romberg. 
 
 From the history of the case it seemed certain that the man had an encapsu- 
 lated brain abscess of the temporo-sphenoidal lobe, though it was hard to 
 account for the lack of "naming aphasia," and "how a right-handed man could 
 have a right-handed paralysis of the arm and face without a 'naming aphasia,' 
 if the abscess had extended upward from the tegmen in the ordinary way." 
 It was also certain that the abscess was near the surface, because of the 
 convulsions. For the same reason — because of the convulsions — it was judged 
 to be a metastatic abscess, the author not having seen convulsions in an 
 adult except in a metastatic abscess. 
 
 Operation. — A. large osteoplastic flap was turned up in the usual way, over 
 the middle fossa. On drilling the last hole — ^that is, the anterior hole, well up 
 toward the vertex— very profuse bleeding occurred. On passing the searcher 
 from this to the next hole there was a free discharge of pus. Another hole 
 was drilled between number one and two — on a straight line — ^because of the 
 adherence of the dura. About two drachms or half an ounce of pus was dis- 
 charged from the two holes. The abscess was found to be extradural with 
 necrosis of dura and superficial brain necrosis. A large dura vein, which was 
 thrombosed, ran directly upward in the anterior portion of the exposed area. 
 At the upper end of it, it formed the extra-dural abscess, which had been com- 
 pletely evacuated. An incision was made in the dura. Along its whole course 
 
ADJACENT TEMPOEO-SPHENOIDAL LOBE ABSCESS 183 
 
 the large thrombosed vein was firmly adhereut to the brain underneath as 
 well as to the dura. The brain was searched in the upper portion to a depth 
 of about six centimeters, but nothing was found. The entire bone flap was 
 sacrificed; tight closure and drainage from the exposed dura — ^the area of 
 exposed brain — and another drain above. 
 
 Comment. — ^The case is remarkable being a metastatic abscess secondary to 
 a thrombosis of a dural vein that originated over the whole of the arm area 
 of the same side. A lumbar puncture done at the time of the operation revealed 
 very little fluid. After the operation the paralysis of the arm gradually disap- 
 peared; temperature fell to normal; and the patient recovered. 
 
 SYMPTOMS OF ASSISTANCE IN DIAGNOSING TEMPOKO-SPHENOIDAL 
 
 LOBE ABSCESS. 
 
 (a) Pain in Teeth on the side of tlie affected hemisphere, 
 together with symptom of pain behind the eye must he due to in- 
 volvement of the Gasserian ganglion at the apex of the petrous pyra- 
 mid. In one of the author's cases of temporo-sphenoidal lohe abscess 
 which followed a chronic suppuration of the petrous pyramid,-^ ^ the 
 pain in the teeth had been so severe that a dentist repeatedly had been 
 consulted. On the development of the brain abscess the cerebral 
 symptoms were so outstanding as to overshadow the pain in the teeth, 
 although for several weeks that had been the most prominent syna.p- 
 tom. As the post-mortem showed a very extensive involvement of 
 the cellular structure of the petrous labyrinth, without destruction 
 of the auditory apparatus, the author is of the opinion that the pain 
 in the teeth was due to the bone lesion and not directly to the 
 abscess. ^^ 
 
 (6) Pain behind the Eye. — In two cases of temporo- 
 sphenoidal lobe abscess in which drainage tubes had been inserted, 
 irrigation occasioned pain behind the eye in the affected hemisphere 
 whenever the cavity was distended by the fluid, the pain disappearing 
 ■ immediately upon the release of the fluid. The pain behind the eye 
 was produced by each distension and could be uniformly produced 
 as long as the drainage tube remained in place.^^ 
 
 The author has no evidence to warrant including it among the 
 symptoms of temporo-sphenoidal abscess, but he is persuaded that 
 pain behind the eye of the affected side should be considered as a 
 localizing symptom of more or less value, depending upon the indi- 
 vidual case. The pain behind the eye probably is due to irritation of 
 the ophthalmic branch of the trifacial in the middle fossa, and not 
 to irritation of the Gasserian ganglion. 
 
 " Case VIII, A. M. M., Chapter Four, p. 37. 
 
 " Cadwalader, Williams B. : Significance of Facial Pam in Determining the 
 Location of Intracranial Tumor; Aro7i4/oes of Neurology and Peychiatrv, August, 
 1920, Vol. IV, pp. 182-184. 
 
 »» Case XIII, Mrs. H., Chapter Four, p. 63. 
 
184' BRAIN ABSCESS 
 
 Pain behind the eye of the homolateral side should not he con- 
 fused with the pain behind the eyes of both sides which, the author 
 has come to believe, is of considerable diagnostic significance; the 
 bi-lateral, post-ocular pain being caused by a distension of the lateral 
 ventricle from an obstructive internal hydrocephalus such as is seen 
 in cerebellar tumors with obstruction of the iter. The distended 
 ventricles cause irritation of the nervous distribution of the fifth 
 to the dura, and a general headache follows ; or, pressure downwards 
 on the sensory root of the fifth as it enters the middle fossa from the 
 posterior, irritates the first branch of the fifth. 
 
 (c) Convulsions — Localizing Value.^* — ^While epileptic seiz- 
 ures are of much more frequent occurrence in tumors of the temporo- 
 sphenoidal lobe than in tumors in any other location in the brain 
 — ;-noted in about fifty per cent, of all the recorded cases — they are 
 very infrequent in abscess of the temporo-sphenoidal lobe. McEobert 
 and Feinier ^^ have shown that the cause of convulsions in temporo- 
 sphenoidal lobe tumors probably is pressure involvement of the vas- 
 cular system of the middle central area. This probably also explains 
 the convulsions in Case XIV, Chapter Five, p. 70, in which con- 
 vulsion was due to something other than pressure, as the patient had 
 two convulsions after the evacuation of the abscess at operation. 
 
 (d) Dreamy State. — This occurs in a small proportion of cases 
 and often is overlooked entirely or mistaken for the semi-somnolent 
 condition which is common in cerebral compression. There is, how- 
 ever, a distinct difference between the two conditions. 
 
 In one of the author's cases there were dreamy state attacks from temporo- 
 sphenoidal lobe tumor. The patient was admitted to the hospital in a semi-stup- 
 orouB condition, accompanied by the statement that: 
 
 "About three or four weeks previously he complained of severe headache 
 and told his friends he was losing his mind. This was followed hy a con- 
 vulsion, since which time he has been unable to do any work. During the past 
 week he has been in a more or less semi-conscious condition but could be 
 aroused." 
 
 The patient being unable to make a connected statement, the following 
 account was obtained: "Had not noticed anything wrong until one month 
 previous, when the patient's tone of voice changed and he 'said some things 
 which seemed unnatural.' Later he would stop in the midst of a task and stare 
 into space. About three weeks before his admission to hospital he had a fit. 
 After that he stated frequently that he was losing his mind. For the past 
 two weeks had been ill, sometimes complaining of pain in left side of head, 
 frontal and parietal regions. Had several attacks of vomiting, not projectile. 
 
 " See p. 161, Convulsion, a Positive Evidence of Cerebral Suppuration. 
 
 " McEobert, Eussell G., and Feinier, Laurent : The Cause of Epileptic Seizures in 
 Tumors of the Temporo-splienoidal Lobe; Journal American Medical Association Feb- 
 ruary 19, 1921, Vol. 76, No. 8, p. 500. (In forty-one recorded cases bad arani mal 
 attacks, and In five minor cases lesser types of convulsions.) 
 
ADJACENT TEMPOEO-SPHENOIDAL LOBE ABSCESS 185 
 
 Lately refused to have anything to do with his friends— said he thought they 
 had something against him." 
 
 Post-Mortem. — Cortex normal; in left temporo-sphenoidal lobe two large 
 areas about two inches long and one inch wide, of gliomatous infiltration, in 
 the upper one of which were a large number of hemorrhages with secondary 
 degeneration. 
 
 (e) Psychic Manifestations of Toxic Delirium.^" — In one of 
 
 the author's cases ^'^ a toxic delirium was the most outspoken symp- 
 tom. The patient, a single woman past the menopause, having just 
 previous to her attack been impressed by accounts of the white slave 
 trade, was obsessed by this during the whole of her illness until after 
 the evacuation of the abscess. 
 
 The author has knowledge of another case in which the toxic in- 
 sanity caused the commitment of the patient to an insane asylum 
 where she remained for several months. Although the attendant 
 physicians were aware of her suffering from a discharging ear, no 
 importance was attached to it until the post-mortem revealed a tem- 
 poro-sphenoidal lobe abscess. 
 
 (/) Uncinate Symptoms. — There are no cases on record of 
 uncinate symptoms in temporo-sphenoidal lobe, but the author be- 
 lieves this is due to a combination of vague mentality on the part of 
 the patient and carelessness in the investigation of the history. The 
 anatomical site of the temporo-sphenoidal lobe must so frequently 
 involve the anterior poles of the lobe as to produce illusions of the 
 sense of taste and of smell. 
 
 CASE NO. XXIX. 
 
 M. C. : Case of Brain Abscess Illustrating Transient Nature of Aphasia and 
 Paralysis, with Apparent Complete Recovery without Operation; Sudden Exten- 
 sion of Metastatic Abscess Five Months Later; Death. Male, 18 years of 
 age. 
 
 History.^April. Had had discharging right ear for 17 years, which caused 
 no other symptoms until one month previous, when he complained of consider- 
 able headache and had fever and several chills. He was seen by an ear 
 specialist, who advised mastoid operation. Parents refused operation and family 
 physician treated patient for a month for malaria because of chills and fever, 
 although three blood examinations were negative for plasmodia. Operation; 
 diseased mastoid, pre-sinus abscess, and apparently thrombosed sinus. The 
 following day internal jugular resected and removed broken down clot from 
 the sinus. 
 
 After operation patient had two chills and persistent headache. Two 
 days after operation complained that he saw double — -had to close his eyes in 
 order to see well. (Undoubtedly had paralysis of internal rectus of left eye 
 at this time.) This gradually disappeared. Temperature returned nearly to 
 
 " Henderson, D. E., Mulrhead, W., and Fraser, J. S. : A Case of Toxic Exhaustive 
 Insanity Associated with Chronic Suppurative Otitis Media, Labyrinthitis, and Extra- 
 dural Abscess ; Review of Nearologv and PsyCMatry, Edinburgh, 1913, Vol. 17, pp. 
 565-576. 
 
 " Case XVII, Miss M. D., Chapter Five, p. 77. 
 
186 BEAIF ABSCESS 
 
 normal; boy was thought to be recovering and was allowed to leave hospital, 
 although complaining of headache. 
 
 Suddenly developed pain in left ear; mastoid was opened; some creamy mate- 
 rial found in cells. 
 
 Some time later, in May, it was noticed that patient had weakness of lower 
 portion of face on right side and that he talked with left side of face; but 
 mother said he always had done so. A few days later patient suddenly became 
 completely paralyzed on right side, both arm and leg being involved. When 
 seen a few minutes after attack, hemiplegia was complete, and patient was 
 aphasic. He knew what he wanted but was unable to name the object. When 
 
 he wanted anything he would say, "I don't — I ," but when the name was 
 
 suggested to him he recognized it. The paralysis lasted about an hour and then 
 disappeared. 
 
 When seen by the author within a few hours all signs of paralysis and 
 aphasia had disappeared. Examination showed an intense papilloedema, with a 
 swelling of 7 dioptres with hemorrhages and multiple spots of degeneration, 
 "showing it to be an old papillitis." His palate went up toward the left side 
 as if he had a, paralysis of the right palate. 
 
 Diagnosis. — Abscess of the left temporo-sphenoidal lobe. 
 
 Comment at Time of Examination. — "The patient immediately following 
 his sinus thrombosis had an extension of the infection to the opposite side, and 
 interference with the return circulation, or a free nidus was deposited in the 
 vein of Galen. This caused the intense papilloedema and also the paralysis 
 of the left rectus, from which !he then suffered,. I have never seen a 
 papilloedema of 7 dioptres from an abscess alone. The present abscess must be 
 an old one and have a capsule." 
 
 Operation refused. 
 
 July H; Patient presented himself at the office of the author, apparently in 
 perfect health. For five weeks had had no symptoms whatsoever; no headache; 
 had gained flesh and looked well. 
 
 Examination. — 
 
 Eyes. — Still has marked papilloedema of 4 dioptres — more marked in left — 
 with multiple small hemorrhages and streaked spots in the retina such as seen 
 in degeneration following a retinitis. 
 
 y 200 y 40 
 
 Talks with left side of face, but mother says patient has always done so. 
 
 Palate goes up to right side; tongue in median line; B patella reflex 
 increased. 
 
 Comment. — "The fact that the boy is now perfectly well would look as if he 
 had an encapsulated abscess, or that the whole trouble had been vascular, from 
 a plugging at the time of the original sinus thrombosis." 
 
 Subsequent History. — Early in September patient returned from a pro- 
 tracted stay in the country. He had now developed a paralysis of the left side. 
 As the author had entered the Service the patient was taken to a hospital in 
 New York City. 
 
 Hospital Record. — Septemher 12; Physical Examination. Well nourished 
 white man, age 18 years. Head; old scar over mastoids; swelling on top of 
 skull. Neclc; old scar over right jugular vein. Face; paralysis on left side of 
 face. Eyes; pupils equal and normal in size, react to light and accommodation. 
 Nose; negative. Arms; paralysis of left arm and hand. Lrnigs; no dulness, 
 breath sounds clear. Eewrt; no murmurs. AMomen; no tenderness. Blood 
 ooimt; E.B. C, 4,800,000; H., 85; W. B. C, 25,000; P., 91; L., 9. 
 
ADJACENT TBMPOEO-SPHENOIDAL LOBE ABSCESS 187 
 
 Spinal Fluid Culture. — Cell count, 100; polynuclears, 75 per cent.; lymph- 
 ocytes, 26 per cent.; Buty., 1+; Culture, Negative. 
 
 Diagnosis.^AbseesB pocket on top of head; acute mastoiditis; meningitis. 
 
 Operation. — Secondary radical mastoid; drainage of pus pocket. 
 
 "There was a scar over old mastoid with small wound, unhealed. Posterior 
 wall of middle ear found partially down from previous operation; many granu- 
 lations in this region and also in the middle ear, and some free pus. Sinus 
 was not pulsating; no definite avenue of access to the brain by infection found 
 or determined; dura looked healthy. A transverse incision made into pus pocket 
 on top of head at the junction of the coronal and parietal sutures; contained 
 about four ounces thick, white pus; abscess and necrotic tissue cleaned out. 
 
 September 13; Diagnosis, Brain Abscess. 
 
 0. D. Typical: Papillitis with change in retina suggestive of fatty change, 
 especially around the region of macula, where they assume shape of a ring 
 with the macula, the center also along the arteries. 
 
 O. S. Typical: Papillitis with similar changes in the retina, only fatty 
 degenerations are more disseminated. Changes along arteries. 
 
 Pathological Findings. — Bone over centers of arm and leg on right side was 
 softened; dura looked unhealthy and on incision much pus was evacuated. 
 
 Spinal Fluid Cell count, 250. Butyric, positive. Scalp abscess culture 
 negative. 
 
 September H; Brain abscess culture, staphylococcus albus. 
 
 8eptem,ber 15; Spinal fluid, cc. 56; butyric, positive; polynuclears, 75 per 
 cent.; lymphocytes, 25 per cent.; culture, negative. 
 
 September 17; Spinal fluid cell count, 60; butyric, positive; culture, nega- 
 tive. 
 
 September 19; W. B. C, 20,000; polynuclears, 90 per cent. 
 
 September 22; Death. 
 
 Comment. — ^This case probably had an encapsulated left temporo-sphenoidal 
 abscess and a thrombophlebitis which extended to the opposite side. Later the 
 thrombus caused a separate intercurrent cortical abscess of the opposite side, 
 which was drained, and which originated the meningitis from which he died. 
 
 (g) Past Pointing. — There is some evidence to warrant the be- 
 lief that the intracranial portion of the vestibular apparatus also may 
 have one of its cortical centers in the temporo-sphenoidal lobe, al- 
 though the evidence is so contradictory that it is possible the cortical 
 center or centers for pointing deviations is situated in the frontal 
 lobe. Temporo-sphenoidal lobe lesions give clinical manifestations 
 only by an involvement of association tracts vphich pass through it 
 in their course from the frontal lobe to the cerebellum, much in the 
 same way that hemianopsia is produced. 
 
 EoENTGEN Rat Diagnosis." 
 
 Although many cases of brain abscess have been subjected to an 
 X-ray examination, the following case is the only one recorded in 
 which the findings were definitely diagnostic prior to evacuation. 
 
 " Glegg, W., and Blacfe, H. : A Case of Roentgen Ray Diagnosis of a Chronic 
 Cerebral Abscess Secondary to Frontal Sinus Suppuration; The Lanoet, 1915, No. 1, 
 p. 124. 
 
188 BRAIlSr ABSCESS 
 
 The X-ray showed an area, semi-spherical in shape, of a shadow in 
 the temporo-sphenoidal lobe. The shadow was due to the presence 
 of gas in the upper part of the abscess, the result of micro-organic 
 growth. (See Fig. No. 38.) 
 
 ■ The X-ray was made when the patient was in a recumbent posi- 
 tion. Post-mortem revealed the presence of anaerobic micro-organ- 
 isms which produced bubbles of air and fluid, changing its shape with 
 the change in position of the patient, the straight posterior line show- 
 ing the level of the fluid. In such a condition a positive diagnosis 
 of brain abscess was possible from an X-ray alone. This one expe- 
 rience should encourage a routine X-ray examination of all cases of 
 suspected brain abscess. 
 
 Together with the experimental work of Dandy,^' moreover, in 
 the injection of air into the ventricles, it should, in the author's 
 opinion, encourage after evacuation the injection of air in different 
 positions of the head through the drainage tube, followed by a routine 
 X-ray examination in different positions of the head, to ascertain 
 whether complete evacuation of the abscess has or has not occurred. 
 as Muck ^° has demonstrated, the size of the abscess changes 
 with alteration in the position of the head while in the sitting 
 position. 
 
 J. B. : Roentgen Ray Diagnosia. Male, 42 years of age. 
 
 Patient admitted to hospital in stuporous condition; had had ©araehe for 
 several days; no history of discharging ear. When brought to hospital was 
 suffering with pain in left ear. No temperature; slow pulse. Lumbar puncture 
 showed almost clear fluid; globulin, -| — |-, and high cell count — over 200 per 
 field; many polynuclears ; direct smears showed no organisms. Slight double 
 Kemig; no marked neck rigidity. Cleared mentally after puncture, but unable 
 to talk. When seen two days later was in deep coma; Cheyne-Stokes respira- 
 tion. Temperature, 99-100; pulse, which had been 60, had risen to 160. O. B., 
 negative. Profuse discharge from left ear. 
 
 X-ray showed shadowy area, semi-spheroidal in shape, directly above external 
 auditory canal, the straight line of its base being nearly vertical to the external 
 canal although slightly in front of it. The anterior portion was oval. 
 
 Autopsy and Rbpoet by De. Haebison S. Maetland. 
 
 On removing calvarium bone quite normal; the course of middle meningeal 
 arteries had produced deep grooves in calvarium and there were a few small, 
 rarefied areas in the bone. Dura normal over the top of cerebral hemispheres. 
 On deflecting dura, which was tense, brain showed very marked picture of com- 
 pression. Convolutions markedly flattened and sulci thin. The whole brain 
 appeared dry. Small amount of subarachnoid yellowish exudate over superior 
 surface of both cerebral hemispheres, mainly confined to regions near the longi- 
 tudinal sinus and over the course of the middle cerebral arteries. 
 
 " Dandy, W. B. : Localization or Elimination of Cerebral Tumors by Ventriculo- 
 graphy; Surgery, Qynecalogy and Oiatetrice, April 20, 1920. 
 =»See Note 35, Chapter IV, p. 57. 
 
Fig. 38. — X-ray photograph showing gas of anisrobic origin in cavity of 
 temporo-sphenoidal lobe abscess. X-ray taken witjh patient in recumbent 
 position. Straight line at base in "shadow" shows level of pus in abscess cavity 
 — the gas tilling the upper (anterior) portion of cavity. Note typical location 
 of cavity of adjacent temporo-sphenoidal lobe abscess as shown by the air 
 filling its anterior one-third. 
 
Fig. 39. — Encapsulated adjacent temporo-splienoidal lobe abscess. Lower 
 surface of brain removed, exjiosing abscess cavity, the anterior tliird of wliicli 
 was filled with gas of bacterial formation, and produced a distinct shadow in 
 the X-ray picture. (See Fig. 38.) 
 
ADJACENT TEMPOEO-SPHBNOIDAL LOBE ABSCESS 189 
 
 On removing brain left temporo-sphenoidal lobe was tightly compressed into 
 left middle fossa and there were present recent fibrinous adhesions between 
 inferior surface of lobe and posterior surface of left petrous portion of tem- 
 poral bone. On breaking up these adhesions in removing brain, about 40 cc. 
 of creamy, greenish-yellow pus escaped, and several large bubbles of gas. 
 
 The large abscess cavity occupied two-thirds of left temporo-sphenoidal lobe; 
 anterior end rounded, situated 3 cm. distant from anterior tip of lobe, opening 
 1 cm. in size on inferior surface of lobe. Total antero-posterior diameter of 
 cavity 6 cm.; lateral width, 4 cm., and height, 2.5 cm. Inferior wall of abscess 
 in thinnest place about 4 mm. thick, and in thickest areas about 1 cm., this 
 being the distance separating the abscess cavity from the cortex of the brain. 
 (Fig. 39.) 
 
 Abscess cavity showed wall or capsule entirely surrounding it which had 
 internal grayish-white layer uniformly about 1 mm. in thickness; clinging to its 
 inner surface were purulent shreds which gave it a shaggy appearance; outer 
 part of wall reddish in color, about 2 mm. thick, making a total thickness of 
 3 mm. Surrounding brain substance was slightly (edematous. Dura imme- 
 diately over attic showed a small perforation, circular in shape, about 0.5 cm. 
 in size, with necrotic and blackened edges; roof of attic, necrotic; attic, middle 
 ear, and mastoids filled with fluid pus. 
 
 Cultures from abscess showed rapid formation of gas. Type of anserobe 
 not determined. Pus had distinctive odor, similar to that found in gangrene 
 of the lung, which is characteristic of anaerobic infection. 
 
CHAPTEE XII. 
 DIAGNOSIS OF CEKEBELLAK ABSCESS. 
 
 Surgically considered, the cerebellar hemisplieres are largely 
 "silent areas," as they can be extensively destroyed without produc- 
 ing outspoken clinical manifestations. Cerebellar abscess, therefore, 
 usually is much more difficult to localize than temporo-sphenoidal 
 lobe abscess, because in the majority of cases there is an absence of 
 the symptoms which justly may be regarded as pathognomonic, espe- 
 cially during the early stages. Even when the abscess has attained 
 considerable size, if its growth is slow it frequently is not associated 
 with any symptoms that properly may be regarded as pathognomonic. 
 This absence of localizing manifestation is due largely to the com- 
 pensation in function which is established in the cerebellum more 
 completely and with greater rapidity than in any other portion of 
 the central nervous system. 
 
 However, at any time during the growth of the abscess, symptoms 
 may develop which may be sufficient to localize the suppuration in 
 the cerebellum ; of these, spontaneous vertical nystagmus, spontaneous 
 pointing deviation, falling, commanding vertigo, lateral deviation of 
 the eyes, cerebellar attitude, and paresis of the arm and leg of the 
 homolateral side are the most common. Unfortunately, none of these 
 symptoms generally are present until symptoms of compression also 
 have appeared. Consequently, during the early stages,, when surgi- 
 cal interference is most promising, the diagnosis in the majority of 
 cases must rest, not on the pathognomonic symptoms, but on the 
 ability of the surgeon to combine (a) the manifestations of cerebral 
 suppuration with (&) the probability of the suppuration being in the 
 cerebellum (because of the existence of a suppurative disease of a 
 structure by way of which the cerebellum usually is invaded), with 
 (c) the exclusion of other possible sites of cerebral abscess, and (d) 
 slight symptoms of impaired cerebellar function, into enough of a 
 localizing cerebellar picture to warrant exploration. 
 
 LOCAllZINQ VALTTE OF A KNOWN LABYRINTHITIS OB LATERAL SllTOS 
 
 Thkombosis. 
 
 Post-mortem examinations show that the path through which the 
 cerebellum is invaded is by the labyrinth in 44 per cent, of the 
 
 190 
 
DIAGNOSIS OF CEEEBELLAK ABSCESS 191 
 
 recorded cases, and by tlie perilabyrintih — caries of tlie petrous 
 bone — in 18 per cent, more, making a total of 62 per cent, of all 
 tbe recorded cases. Consequently, in tbe presence of a suspected 
 localized cerebral suppuration, a non-reactable labyrinth is pre- 
 sumptive evidence tbat the abscess is situated in tbe cerebellum. 
 This is a clinical fact of the highest cerebellar localizing value. In 
 several instances the author has made a diagnosis of cerebellar 
 abscess — the patient being in deep coma — from the presence of 
 chronic running ear, a mild associated papilloedema and inability 
 to induce a nystagmus by the injection of cold water into the affected 
 ear, the absence of reaction shovring a dead labyrinth. 
 
 Again, post-mortem evidence and clinical experience both dem- 
 onstrate that another large proportion of all the cases of cerebellar 
 abscess — 33 per cent. — is secondary to a lateral sinus thrombosis.-^ 
 While a lateral sinus thrombosis may cause an abscess in the cere- 
 brum, .the proportion of such cases is very small. Consequently, 
 with a suspected brain abscess the presence of a known lateral sinus 
 thrombosis is at least suggestive that the abscess is in the cerebellum. 
 
 Symptoms Moeb oe Less Chaeacteeistic ov Cekebeixae Abscess. 
 
 Unlike temporo-sphenoidal lobe abscess, cerebellar abscess rarely 
 presents in the early stages any symptoms which are absolutely 
 pathognomonic; but careful and repeated examinations usually will 
 elicit one or more symptoms which are of more than merely suggestive 
 value. These may continue throughout the disease, or, what is more 
 frequent, they may rapidly disappear. This is especially true of 
 vertical nystagmus and lateral deviation of the eyes, both of which, 
 when present, are definite indications of cerebellar involvement; al- 
 though the former — ^vertical nystagmus — ^may occur from irritation 
 of the cerebellum from a protective meningitis, the irritating cerebro- 
 spinal fluid in the basal cisterna originating from a distant abscess 
 situated in the cerebrum. 
 
 Classificwtion: 
 Cerebellar symptoms may be divided into 
 I — ^Manifestations oe Impaieed Ceeebbllae Functions; 
 
 (a) asynergia, or inco-ordmwtion of homolateral side — adiadoJcohine- 
 
 sis; 
 
 (b) homolateral "cerebellar paresis"; 
 
 (c) forced cerehella/r attitude; 
 
 (d) cerebellwr ataxia; 
 
 (e) hypermetria. 
 
 » See Appendix II, Cerebellar Abscess. 
 
193 BEAIN ABSCESS 
 
 II — ^Manifestations of Involvement of Ceeebbixab Poetions of thk Ves- 
 TiBtTLAK Apparatus; 
 
 (a) spontaneous or 
 
 (b) induced abnormalities of (1) nystagmus, (2) vertigo, (3) past- 
 
 pointing, and (4) falling. 
 
 Ill — Manifestations fbom Direct Pressure; 
 
 (a) cranial nerve symptoms — 9th, 10th, 11th, and 12th; 
 
 (b) motor pyramidal tract sym,ptoms; 
 
 (c) sensory tract symptoms; 
 
 (d) sympathetic nerve symptoms — pupillary. 
 
 IV — ^Manifestations of Transmitted Pressure from Induced Internai, 
 Hydrocephalus. 
 
 I— MANIFESTATIONS OF IMPAIRED CEREBELLAR FUNCTION EXCLU- 
 SIVE OF THE VESTIBULAR TRACT. 
 
 A better understanding of the clinical manifestations of cere- 
 bellar abscess may be obtained by recalling a few physiological facts 
 about the cerebellum : 
 
 (A) The cerebellum is neither a motor nor a sensory, but may 
 be regarded in a broad sense as a reflex organ, as it is by way of the 
 cerebellum that certain sensory — peripheral — impulses influence 
 muscular movement. The cerebellum is "related through its va- 
 rious lobules to the various centers in the cerebrum and the tonus 
 centers in the medulla, in the same way that a posterior root ganglion 
 — sensory — is related (in a motor sense) through its motor cells in 
 the anterior horn of the cord to a certain muscle complex." ^ While 
 it does not in any way originate motion, the cerebellum exercises a 
 synchronizing influence on muscular movements of the same side, 
 largely by reacting to centripetal impulses; consequently, it acts as 
 (a) a co-ordinator, (b) a regulator, and (c) an inhibitor. 
 
 In experimental ablation of the cerebellum the primary oub 
 standing symptoms are: (1) interference with the proper perform- 
 ance of certain voluntary muscular movements of the trunk or 
 extremities, depending upon the particular part of the cerebellum 
 attacked, this interference affecting chiefly the same side as the 
 experimental removal; and (2) an associated alteration in the 
 muscles in a state of rest, especially during the early stages after 
 the ablation. Experimental ablation of the cerebellum thus causes: 
 (a) homolateral muscular asthenia or lack of strength; (b) homo- 
 lateral muscular atonia or loss of tone; (c) homolateral muscular 
 astasia or muscular unsteadiness — this being a combination of 
 tremor, titubation (tottering) and rhythmical oscillatory movementa 
 
 ' Myers, I. L. : Cerebellar Localization ; Transactions of the Section on Nervmis 
 and Mentai Diseases, A. M. A.j 1916, p. 92. 
 
DIAGNOSIS OF CEEEBELLAE ABSCESS 193^ 
 
 — and (d) hypermetria, or lack of proper muscular inhibition. 
 Whether the hypermetria is part of the general muscular disturb- 
 ance, or exists as an independent disturbance is not at yet fully 
 established. 
 
 All these cerebellar functions are intimately interwoven and 
 probably all are parts of the disturbance of one function, muscular 
 synergia — active sympathy or co-ordination.^ Consequently, a study 
 of the clinical manifestations of cerebellar abscess results in all the 
 symptoms being divided into : (a) disturbance of co-ordination, viz., 
 asynergia, or inco-ordination, of which adiodokokinesis and ataxia 
 are the best known; (b) disturbances of muscular tone, or atonia-^ 
 rhythmic oscillations, tremors, or forced positions; (c) disturbances 
 of inhibition of voluntary muscular movements — ^hypermetria. 
 
 (B) In all cerebellar destructive lesions there are two stages; 
 (1) the stage of exaltation of function, in contradistinction to the 
 effect of invasion of the cerebrum, in which a suppurative process 
 always is accompanied by a period of inhibition of function — such 
 as the transient aphasia and hemianopsia of temporo-sphenoidal lobe 
 abscess. On the other hand an invasion of any area of the cerebellum 
 is associated with exaltation of function — such as cerebellar convul- 
 sion or a sudden lateral deviation of the eyes.*' ' 
 
 As the cerebellum is of low genetic origin, compensation from 
 injury is easily established; consequently, following the stage of ex- 
 altation, there is (2) the stage of compensation by the restoration of 
 the functions in those muscular movements and position ordinarily 
 employed, whatever impairment of function that may remain being 
 manifest only on attempting little-used movements — such as balan- 
 cing on one foot — or on the induction of a reflex (as an induced 
 nystagmus). 
 
 As cerebellar abscess usually develops slowly, these two stages 
 frequently are present at the same time and it is impossible to dis- 
 tinguish one from another. Although at a given moment there may 
 be outspoken symptoms of cerebellar deficiency, the establishment of 
 compensation may cause them rapidly to disappear, with the result 
 that at the time of examination, the composite of the two stages may 
 give little or no clinical manifestation of impaired cerebellar func- 
 tion. It is the early establishment of compensation which makes the 
 
 • Mills, Charles K., and Weisenburg, Theodore H. : Cerebellar symptoms and 
 CerebeUar Localiisation ; Transactions of the Section on 'Nervous and Mental Disease; 
 American Medical Assooiation, Atlantic City, June 23-26, 1914, p. 107. 
 
 •Case XXXI, W. J., Chapter Twelve, p. 203. 
 
 "Meyers, I. L. : Loo. oit. ("The phenomena of cerebellar deficiency are accord- 
 ingly to be interpreted as phenomena of hyperfunctional and not hypofunctlonal 
 activity,") 
 
194 BEAIN ABSCESS 
 
 diagnosis of cerebellar abscess so difficult and at the same time makes 
 an altered or transient impairment of cerebellar function of diag- 
 nostic importance. 
 
 Paetiai. OB Complete Obliteea.tion' of a Symptom the Result of Ceeebedlae 
 
 Compensation.' 
 
 While it may be impossible to distinguish any one symptom as 
 the direct result of compensation, the obliteration of the symptom by 
 compensation should be regarded as the important thing in an attempt 
 to interpret a vague cerebellar manifestation in the case of a suspected 
 cerebellar abscess. 
 
 Cerebellar Paralysis. — The cerebellum undoubtedly has control 
 of the co-ordination of the muscular movements of the body as well 
 as of the tonicity of the individual muscular group. It thus acts as 
 a "reinforcing" station. For this reason the presence of a lesion 
 within the cerebellum may produce an apparent muscular paralysis. 
 Unless the pyramidal tract is invaded the paralysis is never complete 
 and affects only the side of the body on which the lesion is located. 
 Homolateral, incomplete paralysis, therefore, is an aid to the locali- 
 zation of an abscess. When a true motor paralysis occurs in a cere- 
 bellar lesion, it is due to the effect of transmitted pressure in the 
 pyramidal tracts and not to involvement of the cerebellum itself. 
 
 Cerebellar Ataxia. — Cerebellar ataxia is made up of three 
 parts: muscular asthenia — ^loss of strength, or debility; muscular 
 atonia — a lack of tone ; and muscular astasia, the latter being a com- 
 bination of titubation, or tremor, with rhythmical oscillatory move- 
 ments, and hypermetria, a lack of inhibition. 
 
 Ataxia is but infrequently seen in cerebellar abscess because long 
 before it has become of sufficient severity to be of diagnostic assist- 
 ance, marked symptoms of compression have developed. The author 
 is of the opinion, however, that a careful study of the "vertigo" so 
 frequently classed as labyrinthine, chiefly because of the presence of 
 a non-reactable labyrinth, would disclose evidences of cerebellar 
 ataxia enough to warrant at least a suspicion of cerebellar involve- 
 ment. 
 
 Hypermetria — "Failure of Inhibition." — One of the functions 
 of the cerebellum is inhibition of muscular movement. Whether this 
 
 •Lndonl, Lul^: Htimcm Phyaiologji, 1915, Vol. Ill, Muscular and Nervous Sys- 
 temEl, p. 481. ("Functional compensation Is tlie purposive and voluntary acts by 
 whicn the effects of deficient or lost cerebellar Innervation Is abrogated.") 
 
 Rossi, GUberto: AroMmio di flMologla, 1912, Vol. X, p. 251. (Tbe cerebrum 
 also assists in the establishment of compensation, as "The immediate effect of heml- 
 extlrpatlon of a dog's cerebellum Is diminution of excitability in the motor cortical 
 area of the opposite hemisphere.") Quoted by Luciaul in Human Phyaiologu, 1915, 
 Vol. Ill, p. 483. 
 
DIAGITOSIS OF CEEEBELLAE ABSCESS 195 
 
 is intimately related to, or really is a part of the other functions of 
 this part of the brain — synergia, tonia, co-ordination, and so on — 
 has not been definitely established. 
 
 In one of the author's cases a test of the past-pointing of the 
 homolateral side revealed the inability of the patient to control the 
 backward movements of his arm. He invariably brought the arm so 
 far back that it struck the bar at the top of the bed with sufficient 
 force to cause pain — an evidence of hypermetria. There was also a 
 lack of co-ordination laterally, yet he could touch the fingers together 
 fairly well. On operation it was found that the abscess was 3 cm. 
 inward and upward, probably involving the arm center; there^ 
 fore, the asynergia, or inability to synchronize the movements of 
 the joints and muscles, was in the arm or shoulder (probably in 
 the latter). 
 
 Cerebellar Convulsions. — ^Experimentally, on the removal of 
 certain parts of the cerebellum there follow oscillatory or contractile 
 movements of the homolateral side, resulting in a to and fro move- 
 ment of the head or a forced position of the trunk. On superficial 
 cauterization of the same cerebellar region, however, a similar condi- 
 tion occurs on the opposite side of the animal.'' Whether this phe- 
 nomenon is due to irritation or to the removal of inhibitions is still 
 in dispute. 
 
 While convulsions are of but infrequent occurrence in tumors of 
 the posterior fossa,^ they are frequently associated with cerebellar 
 abscess. 
 
 Forced Cerebellar Attitude. — Lying on one side in a semi- 
 flexed attitude is frequent in cerebellar abscess during the stage of 
 compression. Its presence prior to this stage is of the first diagnostic 
 importance even though it be imperfectly developed. Likewise, a 
 lateral deviation of the eyes occurring prior to compression should be 
 regarded as a forced cerebellar position. 
 
 The lateral deviation of the eyes observed in Case No. XXXI, W. J., Chapter 
 Twelve, p. 203, following a convulsion was a manifestation of the "sustained 
 tonicity" which is characteristic of cerebellar convulsive movements. In sev- 
 eral other of the author's cases a forced position on one side — has been the 
 guiding diagnostic manifestation. 
 
 Speech Defects. — A dysarthria — a scanning or ataxic speech — 
 is a frequent manifestation of cerebellar abscess. It is one of the 
 many manifestations of muscular inco-ordination. 
 
 ' Ferrier : See Luelani, Human Phygioloffv, Vol. Ill, Muscular and Nervous Sys- 
 tems, p. 434, 
 
 • McKobert, R. G., and Feinier, Laurent : Cerebellar Fits ; Archwee of Neurology 
 and Psychiatry, March, 1921, Vol. V, p. 304. 
 
196 BEAIK ABSCESS 
 
 II_VESTIBULAR MANIFESTATIONS. 
 
 Unfortunately, the same vestibular syndrome — spontaneous 
 nystagmus, past-pointing, and falling — ^wMch always accompanies 
 acute labyrinthitis, is also produced by an acute, destructive lesion of 
 the cerebellum, and as cerebellar abscess in a large proportion of the 
 cases is a complication of a suppurative labyrinthitis, differentiation 
 is thereby rendered difficult. To be fully successful the attempt to 
 differentiate must be made immediately upon the appearance of any 
 one of the symptoms common to both, for while theoretically there 
 are many points of difference between the vestibular manifestations 
 of a suppurative labyrinthitis and an intracranial involvement ^ 
 (the falling, for instance, in a labyrinthine involvement being in- 
 fluenced by a change of position of the head while in a cerebellar 
 lesion it is not), in actual practice such is the case only when the 
 cerebellar lesion is acute, limited and destructive. In cerebellar 
 abscess, however, the slow growth may allow ample time for the re- 
 establishment of compensation, with the result that at the time of 
 examination either no vestibular symptoms may be present at all 
 or they will be so modified as to have lost their distinctive cerebellar 
 characteristics. 
 
 If assistance in the early diagnosis of cerebellar abscess is to be obtained 
 from the vestibular manifestations it can be accomplished only by repeated 
 observations, and recording at the time of observation, all data as well as all 
 vestibular manifestations normal and abnormal, for in this way alone a changing 
 character will be appreciated. If to-day no nystagmus is present in the recum- 
 bent or in the erect position, and to-morrow there is a slight nystagmus to the 
 right in the same position, and on the following day it is again absent 
 or has changed to a slight nystagmus to the left, the record of the three days 
 may make an early diagnosis possible, while failure to record one or the other 
 manifestation at the moment of observation may result in doubt. 
 
 DiFFEBENTIAl, VALUE OF MODB OF OnSBI. 
 
 In acute labyrinthitis the onset of the suppuration is sudden and 
 complete, the limited area of the bony capsule causing a complete 
 inhibition of function. The spontaneous nystagmus, past-pointing, 
 and falling, all appear at the same time; and as compensation is 
 established the symptoms individually and gradually disappear, first 
 the nystagmus, then the falling, and last of all the past-pointing. 
 In cerebellar abscess, on the other hand, there is a disproportion 
 in the complete onset and the progressive disappearance of the 
 
 • Moulouquet, A. : Cerebellar Abscess of Aural Origin ; The Lancet, 1921, I, p. 283. 
 (States "In cerebeUar abscess the disturbances are more equilibrating than vertiginous, 
 Willie in labyrinth disease It Is the vertiginous character which predominates.") 
 
DIAGNOSIS OF CBREBELLAE ABSCESS 197 
 
 symptoms. Consequently, an incomplete onset is of especial im- 
 portance in diagnosing a cerebellar lesion. 
 
 Spontaiteous Ntstagmus. 
 
 The spontaneous nystagmus of cerebellar abscess is apt to be tran- 
 sient and of changing character during the early stages. It is also of 
 a somewhat different type from that of involvement of the labyrinth. 
 The nystagmus of cerebellar abscess, being due to asynergia of the 
 ocular muscles, is in consequence more or less oscillatory in nature, 
 while the nystagmus of vestibular origin is rhythmic.^** Cerebellar 
 nystagmus usually is toward the side of the lesion, with a vertical 
 tendency. Too much attention should not be paid to this, however, as 
 the ease with which the cerebellum establishes compensation not only 
 may alter the character of the nystagmus but may eliminate it alto- 
 gether. 
 
 Lateeal Deviation of the Eyes. 
 
 Lateral deviation — the cerebellar component of a nystagmus — 
 generally occurs when compression or destruction is sufficient to 
 cause an abolition of the cerebral control. The author is of the 
 opinion that compression sufficient to cause coma and lateral devia- 
 tion is much more easily induced in cerebellar than in cerebral 
 abscess. When an otitis media is the primary focus of a brain 
 abscess the appearance of a lateral deviation of the eyes should be 
 regarded as evidence that the posterior fossa is the site of the infec- 
 tion since an adjacent temporo-sphenoidal lobe abscess can not cause 
 a spontaneous lateral deviation of the eyes. 
 
 Vertigo, Spontai^eous Faixinq and Spontaneous Past-Pointing. 
 
 The combination of vertigo and falling with marked nystagmus 
 so frequently seen in cerebellar pontine angle tumors is rarely pres- 
 ent in the early stages of cerebellar abscess, or if present is so com- 
 plicated by disease of the labyrinth as to make interpretation difficult. 
 
 (a) Vertigo: While a symptom of disease of the labyrinth with- 
 out intracranial involvement, vertigo frequently is the only outstand- 
 ing indication of cerebellar abscess as it occurs as a marked symptom 
 in about one-third of the cases. ^^ Contrary to the generally accepted 
 
 '° Wilson, J. Gordon, and Pike, F. H. : Mechanism of Labyrinthine Nystagmus 
 and its Modification by Lesions in the Cerebellum and Cerebrum. An Experimental 
 Investigation ; Oxford Univeraity Presg, Henry B^owde, 1914. Also Journal American 
 Medical Aaaodatum, December 18, 1915, Vol. 65, p. 2156. 
 
 M Dench, Edward Bradford : Otitic Brain Abscess ; Reprint from, Amerioan Journal 
 of Medical ScAeneeg, November, 1907, p. 3. 
 
198 BEAIN ABSCESS 
 
 view vertigo may be entirely absent in tlie early stages of the dis- 
 ease.^^ Spontaneous vertigo may be of localizing value, as inability 
 to alter tbe vertigo by the application of caloric and rotating tests 
 is presumptive evidence that the lesion is in the cerebellum. 
 
 (b) Falling: Physiologically, it would be expected that in 
 abscess of a cerebellar hemisphere falling when present would be 
 toward the side of the lesion and would not be influenced by changing 
 the position of the head. Due to the establishment of compensation 
 by the cerebellum, however, the direction and the type, and even 
 the presence of falling may promptly be altered or abolished. In 
 one of the author's cases of adjacent cerebellar abscess the falling 
 was backward and away from the lesion; but so many cases are 
 recorded in which the falling is similarly paradoxical and even in- 
 fluenced by a change in the position of the head,^^ that, like nystag- 
 mus, it must lose its clinical localizing signiflcance. When the vermis 
 primarily is involved — a rare situation in cerebellar abscess except 
 in metastatic cases — the falling probably would be backward. 
 
 (c) Spontaneous Past-Pointing Deviations: Spontaneous point- 
 ing deviations occur in the early stages of brain abscess, but abnor- 
 malities are so frequent that they cannot be considered as symptoms 
 of great localizing value. 
 
 Induced Abnormal Vestibitlab Reactions. 
 
 Too much reliance has been placed upon the value of one com- 
 plete examination of induced vestibular reactions in locating the 
 presence of, or eliminating the cerebellum as the site of an abscess, as 
 clinical experience has demonstrated that only by repeated tests can 
 the functioning of the cerebellum be shown to be in perfect order. ^* 
 
 The tests must be made before the patient becomes dulled. The author's 
 experience has been that all patients — even small children — can be subjected to 
 the tests provided the examiner will devote sufficient time and patience to making 
 them. 
 
 " Case XII, W. K., Chapter Four, p. 60. 
 
 " Rohardt, W. : Ueber Zeige und Fallreaktionen bel Kleinhirnkranken ; Zeitachrift 
 fUr die ffes. aeuralogie und, Fsydhiatrie, 1919, VoL 49-50, p. 167. 
 
 ^* Reported Oases o/ Cerehellar Abscess &imng Spontanemis and Induced Vestibular 
 Reaction and Demonstrating their Changing and Bizarre Character. 
 
 Hohngren, G. : Opererad oeh lakt liUhjarnabseess med skada a ett ave Barany'a 
 centra ; SiiensMi LUkaresiillskapets Handlingas, 1916, Vol. XLII, p. 516. 
 
 Jones, I.: Equilibrium and Vertigo; 1918, p. 369 (Case by Pislier). 
 
 Hill, Frederick Thayer: Report of a Case of Cerebellar Abscess Following Shell 
 Wound of Skull and Showing No Symptoms for Period of Five Months; Military 
 Surgeon, September, 1919. 
 
 Rohardt, TO. : Ueber Zelge and Fallreaktionen bel Kleinhirnkranken ; Zeitachrift 
 filr die ges. Neurolagie und Psychiatrie, 1919, Vol. 49-50, p. 167. 
 
 Jessaman, L. W. : Brain Abscess as a Complication of Acute Infection of Nasal 
 Accessory Sinus; La/ryngoscope, March, 1920,' Vol. XXX, No. 3, pp. 147-149. 
 
 Martin, H. H., and Crowe, S. J. : Lateral Sinus Disease — Case Report ; Lan/nao- 
 scope, December, 1920. 
 
\ DIAGNOSIS OF CEREBELLAE ABSCESS 199 
 
 Cri^QiNG Characteb of Abnoemal Spontaneous ob Induced Veshbulab 
 \ Manifestations. 
 
 The author's experience leads him to believe that there is no set 
 formula for the diagnosis of cerebellar abscess by abnormalities of 
 the vestibular reactions alone, but that the induced reactions, like 
 the spontaneous manifestations, are apt to be of a very changing 
 nature, especially during the early stages of the disease. This 
 changing character he has come to regard as highly suggestive of 
 cerebellar involvement. 
 
 In one of his cases ^' the only symptom present at the time of examination 
 was an abnormal falling; there was no spontaneous nystagmus, and aside from 
 the falling, the vestibular reactions apparently were normal; but suddenly the 
 patient had a convulsion, followed by a lateral deviation of the eyes. 
 
 Small, acute, and destructive lesions, such as hemorrhages in- 
 volving the so-called "vestibular pathways," will produce symptoms 
 or give localizing manifestations; but cerebellar abscess is a gross 
 lesion which at the time of examination generally has progressed 
 slowly to the point of giving rise to an increased intracranial pres- 
 sure, not only of the posterior fossa but also of the whole intra- 
 cranial contents. During the slow, progressive growth of a cere- 
 bellar abscess the cranial contents have had ample time for read- 
 justment — ^the establishment of compensation. This compensation 
 the vestibular apparatus — one of the most primitive of the special 
 senses — is especially able readily and easily to accomplish; with 
 the result that at the time of examination no diagnostic abnor- 
 malities of induced vestibular reactions may be present, while the 
 vestibular manifestcdions of the increased intracranial pressure over- 
 shadow and obscure all others. For several reasons not yet fully 
 explained an increase of intracranial pressure interferes with the 
 reactability of the intracranial portion of the fibres of the vertical 
 canals of both ears long before the fibers to the horizontal canals are 
 affected. Whether this affection occurs on the auditory canal itself, 
 or in the intracranial portion, is not definitely established, but it is 
 probably in the latter. 
 
 Diagnosis of Increased Inteackanial Peessube, Especially of the Postebiob 
 Fossa, by Induced Vestibulae Eeactions. 
 
 The outspoken vestibular manifestation of increased intracranial 
 pressure — absence of reactability of the vertical canals of both ears to 
 
 " Case XXXI, W. J., Cliapter Twelve, p. 203. 
 
SOO BEAIN" ABSCESS 
 
 the cold caloric — ^first described and properly interpreted by tbe 
 author,^' while an early manifestation of increased intracranial pres- 
 sure prevents an accurate localization by the vestibular reactions 
 alone. It is of the greatest value, however, in the early diagnosis 
 of increased intracranial pressure as it appears long before and inde- 
 pendently of papilloedema. 
 
 Its assistance in the diagnosis of cerebellar abscess by demon- 
 strating an increased intracranial pressure cannot be over-emphasized. 
 As the result of many vestibular examinations and subsequent lumbar 
 punctures for diagnosing obscure nervous diseases, the author testi- 
 fies that the vestibular manifestations of increased intracranial pres- 
 sure are uniformly the earliest symptom present and consequently 
 the most valuable as yet known. 
 
 CESEBEILLAB COBTICAl liOOAlIZATIOIT IN RELATION TO VESTIBTILAB EEACHON. 
 
 Horsley and Clark ^"^ demonstrated that the cerebellar cortex con- 
 tains no areas which are irritable by the faradic current, such as 
 exist in the motor areas of the cerebrum. When muscular contrac- 
 tion occurs from such irritation it is due to involvement of the deep 
 ganglia. There is, however, considerable experimental and clinical 
 evidence to substantiate Barany's contention ^* that the cortex of the 
 cerebellum contains areas the destruction of which — or pressure upon 
 them — causes alteration in the ability to execute certain voluntary 
 movements properly. 
 
 IXDUOED VESTIBXTLAB MANIFESTATION EEOM PeESSUBE UPON THE CEEEBELLAB 
 
 COETEX. 
 
 The author has observed that pressure from a protective exudate 
 over the anterior surface of the cerebellum opposite the internal 
 auditory meatus uniformly results in (a) an immediate reduction 
 of the duration of the obtainable nystagmus from the horizontal 
 canals by turning, and (b) a great reduction, or complete absence, 
 of irritability of the superior vertical canals of both sides on the ap- 
 
 >• Bagleton, W. P. : Decompression for Kelief of Disturbances of the Auditory 
 Apparatus of Intracranial Origin — Report of Three Cases with a Previously Unde- 
 scrlbed Aural Condition ; Tramactlons American Otological Society, June 10, 1912, 
 Part III, p. 564. Also Laryngoscope, 1913, Vol. XXII, p. 592. 
 
 " Horsley and Clark : On the Intrinsic Fibers of the Cerebellum, its Nuclei and 
 its Different Tracts; Braiki, 1908, Vol. XXXI, p. 138. (Quoted by Lucianl, in Human 
 physiology, 1915, Vol. Ill, Muscular and Nervous Systems, p. 484.) 
 
 " Barany, R. : The Vestibular Apparatus and the Central Nervous System ; 
 Laryngoscope, 1912, Vol. XXII, p. 81, demonstrated that the cooling of "small areas 
 of the cerebellar cortex situated directly behind the attachment of the external ear," 
 results In a spontaneous past-pointing of the arm outward, from, he believes, a 
 paralysis of the inward pointing centre, while cooling an adjacent area causes a spon- 
 taneous past-pointing imeard. 
 
DIAGNOSIS OF CEREBELLAE ABSCESS 201 
 
 plication of the cold caloric/® the latter from increase of the intra- 
 cranial pressure. If this interpretation of the clinical observation is 
 correct, the vestibular symptom complex — viz., reduction by about 50 
 per cent, of the normally obtainable nystagmus from pressure on the 
 cerebellar cortex opposite the internal auditory — should render pos- 
 sible an early diagnosis of intrapiarachnoid abscess of the anterior 
 surface of the cerebellum (the most frequent site of intrapiarachnoid 
 abscess from labyrinth suppuration). 
 
 Ill— LOCAL SYMPTOMS FROM DIRECT PRESSURE PRESUMPTIVE OF 
 CEREBELLAR ORIGIN. 
 
 (a) Hyperesthesia, of the face and diminution of the corneal re- 
 flex on homolateral side — fifth nerve involvement; 
 
 (b) Deviation of tongue — twelfth nerve involvem^ent. 
 Deviation of the tongue may be due to direct pressure or it may 
 
 be due to involvement of the nucleus of the twelfth in the medulla 
 or of the supra-nuclear pathway. In the former case the tongue 
 will deviate away from the side of the lesion and in the latter toward 
 it. 
 
 Absence of corneal reflex probably is due to direct pressure as it 
 occurs on the side of the lesion. It probably is caused by pressure 
 of the upper fibres of the sensory root against the firm dural opening 
 where the root passes out of the posterior fossa into the Meckel's 
 space. 
 
 On the involvement of the ninth — the glosso-pharyngeal — the 
 author's only experience was in one case, in which the patient com- 
 plained of difficulty in swallowing. 
 
 The respiratory and circulatory disturbances of the tenth hardly 
 can be expected to be elicited in cerebellar abscess. 
 
 PUKLLAEY DiSTUBBANCES. 
 
 The dilatation of the pupil so frequently seen in cerebellar 
 abscess is due more to action of the toxemia upon the sympathetic 
 centers than to any direct effect of the abscess. 
 
 Geneeal Symptoms Suggestive of Cebebellab Involvement. 
 
 (a) Suboccipital tenderness and rigidity of neck; 
 
 (b) Yawning; 
 
 "(a) Eagleton, W. P.: Aural Manifestations in Surreal Intracranial Lesions; 
 Address before OlinAcal Congress oj Surgeons, Fhiladelpliia, Oct. 25, 1921. (b) Eagle- 
 ton, W. P. : Value of Vestibular Manifestations In Surgical Intracranial Conditions — 
 with Report of Four Cases; Address Annual American Laryngological, Rhinologicai 
 and OMogical Soeiety, Atlantic City, June, 1921. 
 
203 BRAIN ABSCESS 
 
 (c) Rapid loss of flesh; 
 
 (d) Alteration in Icnee jerks; 
 
 (e) Projectile vomiting; 
 
 (f ) Psychic disturbances and cerebellar fits. 
 
 Suboccipital Tenderness. — Gushing and Grey ^° have called 
 attention to the greater frequency of suboccipital tenderness in cere- 
 bellar than in cerebral tumors. The author's experience would lead 
 him to believe that this is also the case in cerebellar abscess. 
 
 Yawning. — Although yawning frequently is present in suppura- 
 tive disease of any part of the brain, in the author's experience it is 
 more marked in cerebellar abscess than in abscess in other regions. 
 
 Rapid Loss of Flesh. — Emaciation in cerebellar abscess is much 
 more rapid than in suppuration in other parts of the brain.^^ It is 
 partially due to the effect of the cerebral suppuration in disturbing 
 the general metabolism. In cerebellar cases, however, there is added 
 more or less of a specific action from the disturbance of the trophic 
 reactions presided over or reinforced by the cerebellum, which results 
 in a rapid emaciation. When the abscess becomes completely encap- 
 sulated and quiescent, the emaciation stops. In the presence of a 
 probable cerebral suppuration the author has come to regard rapid 
 emaciation as suggestive of cerebellar abscess. Experimentally, in- 
 jury to the cerebellum results in "retarded growth of the cutaneous 
 elements, particularly of the skin, and the lowering of resistance to 
 the injurious action of external agents." ^^ 
 
 Knee Jerks, — Alteration in the patella reflexes depends upon 
 the involvement of the pyramidal tracts; it generally occurs on the 
 homolateral side, but it may be bilateral. 
 
 Vomiting. — Vomiting is much more sudden and severe in cere- 
 bellar abscess than in abscess in other locations. In the author's 
 experience in the presence of a suspected localized cerebral suppura- 
 tion, continuous projectile vomiting is suggestive of cerebellar abscess. 
 
 Psychic Disturbances. — In the presence of compression there 
 always occurs a cloudiness of the sensorium — ^poor perception and at- 
 tention — and possibly disorientation for time and place.^^ In intra- 
 cerebellar abscess the author has found a certain degree of optimism 
 in the patient which is not warranted by his physical condition. In 
 
 " Grey, Ernest G. : Studies on the Localization of Cerebellar Tumors ; BepHnted 
 from Annals oj Surgery, February, 1916. 
 
 "Luclanl, Lulgl: Humcm Physiology, 1915, Vol. Ill, Muscular and Nervous 
 Systems, p. 472. 
 
 =' Lucianl, Lulgl : Loo. dt. 
 
 " Mlngazzim, G. : Abscess e Tumori del Encefalo ; Elv. di Patol., Nov., 1919, 
 Part 3-4 and 5-8. Abstracted In Arohimea of Neurology and PaycMatry, 1919, Vol. 2. 
 
DIAGNOSIS OF CEREBBLLAE ABSCESS 203 
 
 one of his cases the patient, throughout his illness aud even when 
 dying, continued to insist that he felt fairly well. 
 
 IV— SYMPTOMS DUE TO AN ACCOMPANYING INTERNAL 
 HYDEOCEPHALUS. 
 
 On account of its position in the posterior fossa, cerebellar 
 abscess is much more frequently associated with an internal hydro- 
 cephalus from obstruction by pressure and displacement of the iter, 
 than is an abscess in any other portion of the brain. Stupor, altera- 
 tions in the reflexes, epileptiform seizures, intense and paroxysmal 
 headaches, sub-occipital tenderness, opisthotonos, sugar in the urine, 
 vomiting — all are frequent and all, partially at least, originate from 
 the internal hydrocephalus; while the marked papillcedema of cere- 
 bellar abscess is, in the author's opinion, entirely of this origin, 
 the distance of the site of the suppuration away from the optic 
 nerve being best explainable by the induced internal hydrocephalus. 
 
 To this group belong also the sixth nerve paralysis, from pressure, 
 as the nerve passes over the apex of the petrous base in its separate 
 dural compartment. Third nerve paralysis probably is from pres- 
 sure exerted between the internal carotid and the distended floor of 
 the third ventricle and the intra-chiasmal cisterna. 
 
 The slight exophthalmos very rarely seen in cerebellar abscess 
 probably originates from the pressure of the internal hydrocephalus, 
 and the hyperesthesia of the fifth probably has a similar origin. 
 
 CASH NO. XXXI. 
 
 W. J.: Case of cerebellar abscess, Illustrating vagueness of early symptoms, 
 followed by remission of all symptoms ; then sixth nerve paralysis. No localizing 
 symptoms whatsoever until nineteenth day, when suffered from dizziness for 
 first time. Tempero-sphenoidal lohe exploration from, erroneous diagnosis. 
 Sudden onset of marked cerebellar manifestations; several incomplete cerebellar 
 evacuations. Changing character of vestibular manifestations. Extension of 
 abscess. 
 
 Autopsy. — ^Multilocular abscesses of cerebellum. 
 
 History. — 
 
 Boy. 
 
 March 1 : Cold, accompanied by pain in right ear, followed by discharge. 
 
 March 12: Mastoid operation. 
 
 March 23: Severe headache through forehead and back of head, thought to be 
 due from chilling from sudden change in weather. Invasion of cerebellum 
 undoubtedly occurred at this time. 
 
 Ma/rch 24-29: Perfectly well. 
 
 March 30: General malaise and "some fever." 
 
 March Sl-April 3: Again perfectly well. 
 
 April 4: Nauseated; from this date was never entirely well. 
 
 April 5: Sudden double vision; which caused slight feeling of unsteadiness 
 which disappeared upon closing one eye. Nosebleed. 
 
204 BRAIN ABSCESS 
 
 April 6: Vomited; nose bleed; felt well enough to go to physician's office 
 for dressing. 
 
 April 8: Vomited; tongue coated; severe parieto-oecipital headache; con- 
 fined to bed. For first time looks ill. 
 
 April 11: Lumbar puncture; fluid clear, not under pressure; Fehling's 
 reduced; low cell count, 5; vomited after lumbar puncture. 
 
 April 12: Admitted to hospital, complaining of headache, vomiting, double 
 vision. To-day has had first attack of real dizziness (nineteen days after cere- 
 bellar involvement). "When he turns in bed feels sick at stomach." Slight 
 aching in right shoulder and right hip. Patient thinks there is a slight weak- 
 ness in right leg, "especially since having needle inserted into him" — the lumbar 
 puncture. 
 
 Examination. — Memory good; has rather "dopey'' manner; answers ques- 
 tions intelligently but in a low voice. Brightens up on being questioned; speech 
 rather thick as though tongue were thick; patient says he has noticed change 
 himself — that he cannot pronounce words as rapidly as he should. Thinks it is 
 due to the thick coating on his tongue. 
 
 April 13: Pulse 84-90; complained of severe pain in head. Examination 
 to-day shows slight nystagmus on looking toward extreme right (this is the 
 first suspicion of any nystagmus since the beginning of his illness). Hears 
 with his right ear. 
 
 April IJf: Lumbar puncture, fluid clear. Fehling's reduced normally, cell 
 count 57 per cm.; no organisms. Diagnosis, probable abscess of the temporo- 
 sphenoidal lobe with capsule, because vestibular reactions apparently demon- 
 strated increased intracranial pressure with an intact cerebellum. 
 
 Resume: An absence of vestibular reaction of his vertical canal and a normal 
 reaction to the horizontal. 
 
 Operation. — Temporo-sphenoidal lobe exploration; no pus but accidental 
 tapping of the lateral ventricle. On account of the puncture going into the ven- 
 tricle at a very short distance, decided that patient either had a serous meningitis, 
 or that he had a cerebellar abscess. 
 
 Condition at the completion of the operation very bad; pulse very fast; 
 decided not to explore the cerebellum until he had time to recover. 
 
 April 16: Pulse 80; has vomited several times. 
 
 April 17: Restless; complains of severe pains in temples. Lumbar punc- 
 ture 15 cc. fluid clear, cell count 118; Fehling's reduced normally. 
 
 April 18: Had a convulsion. Became unconscious, following which had 
 lateral deviation of eyes to left ( away from the site of the lesion ) . Left eye 
 now looks down and out. Co-ordination, right hand not so good as left, tongue 
 apparently protrudes to the right. A Romberg; 
 
 Operation. Cerebellar Exploration. — April '18: Ligation of lateral sinus. 
 Area of caries in the posterior portion of the petrous pyramid exposed, from which 
 infection had entered the cerebellum. Encapsulated abscess, located at distance 
 of 3 cm. from cortex. Slow evacuation through small exploring canula. Smear 
 from abscess showed streptococcus and Gram positive, bacillus and sarcinse. 
 Operative comments: "The abscess is probably much larger than evacuated; 
 a larger exploring canula should have been used. The abscess was apparently 
 'lost' before complete evacuation. Patient stood the ether very well, which is 
 remarkable, as at the previous operation he nearly died on the table, and to-day 
 he is in very much worse physical condition. This may be explained by the 
 accidental tapping of the ventricle and the relief of pressure at the previous 
 operation.'' 
 
 April 21: Evacuation; marked nystagmus on looking toward the right — 
 toward the lesion, while previous to the evacuation he had a lateral deviation 
 of both eyes to the left. Patient now in excellent mental condition. 
 
DIAGNOSIS OF CEEBBELLAR ABSCESS 205 
 
 April ZS: Abscess apparently not evacuated completely. Patient in rery 
 good condition but sweats too much. Still has a marked spontaneous nystagmus, 
 which has a tendency to be vertical in character. 
 
 April 26: Patient has become more and more drowsy; has nystagmus; can- 
 not tell whether it is to the right or to the left, but it certainly has a vertical 
 tendency up and down. No choked disc, undoubtedly because he has such a 
 large decompression. Marked hypermetria of the right arm. 
 
 Operation. — Evacuation of abscess well up toward the tentorium and in the 
 anterior portion of the cerebellum. 
 
 May 1 : Patient vomited for first time since April 24th ; recurrence of head- 
 ache. No rise in temperature; pulse 82; culture from abscess streptococcus 
 proteus. 
 
 May 2: Mild papilloedema of right eye; left n^ative. Head back, slight 
 nystagmus to left in outer corner. Spontaneous past pointing both hands ele- 
 vated slightly to left spontaneously. Head erect, no perceptible spontaneous 
 nystagmus; spontaneous past pointing; tendency of right hand to deviate to 
 right; left deviates to left. 
 
 May 6: Still indistinctness of upper margin of right disc, but much less 
 than three days ago. Still incoordination of right arm, fingers to nose test. 
 Rotates right hand much slower. Spontameoiis nystagmus becomes marked on 
 changing position. 
 
 During the whole of this time patient remained in a rather apathetic con- 
 dition, saying he felt pretty well, but having a tendency to sleep, the sleep not 
 being of a natural type. 
 
 May 13: Erect position; spontaneous nystagmus on looking up, but not so 
 marked on looking to right — side of lesion, but marked on looking to left — 
 away froon lesion. Legs: touches hand with left toe, but right leg shows 
 incoordination. Astereognosis. O. E. : right eye, indistinctness toward nasal side. 
 Left eye may be slightly hazy above. Pupils large in proportion to amount of 
 light in room,, but react promptly. No Babinski, no Oppenheim. Speech slow 
 and rather cut off — ^talking somewhat like a Chinaman, without proper modula- 
 tions, in a monotonous tone. Repeats and fumbles over parts of words — 
 then repeats the word and goes on again. Tongue protrudes slightly to the 
 right side — side of lesion; when sits up sways (trunk muscles involved); slight 
 dizziness. All signs of extension of cerebellar suppuration. 
 
 May H to July 3: Abscess evacuated on several occasions. Increasing 
 stupor. Death. 
 
 Post-Mortem Notes. — ^Autopsy and report by Dr. F. A. Sutton. 
 
 Dura over right cerebellar area adherent. Considerable pus. The right 
 cerebellar lobe little more than a shell. The abscess cavity extending over beyond 
 the median line into, the left lobe and almost through the cortex on the superior 
 surface. On dissecting cerebellum there were several cavities containing from 
 one-half to a dram and one-half of pus. The abscesses resulted in almost 
 complete destruction of the right cerebellar lobe and practically one-half left lobe 
 of cerebellum. The drainage was not complete because the abscess was multi- 
 locular. 
 
 Several small harder areas near the surface of the cerebellum, consisted of 
 normal brain tissue surrounded by blood vessels. Lateral ventricles free. The 
 third ventricle slightly distended with fiuid. 
 
OHAPTEE XIII. 
 DIAGNOSIS OF FKONTAL LOBE ABSCESS. 
 
 Frontal lobe abscess is the most difficult of all types of abscess 
 to diagnose, (1) because the symptoms usually present in acute and 
 chronic frontal sinus or ethmoid disease closely simulate those of 
 frontal lobe abscess; (2) because the region of the frontal lobes in- 
 volved in adjacent abscess is a "silent area" and consequently there 
 are but seldom any definite manifestations of cerebral involvement; 
 (3) because of the small space occupied by the frontal lobe, the 
 abscess does not attain to any considerable size before it ruptures into 
 the ventricles or the subarachnoid space. 
 
 An examination of the recorded cases of frontal lobe abscess 
 (see Appendix III, Frontal Lobe), reveals that a large proportion 
 were not diagnosed during life, a sudden and fatal termination having 
 occurred as the result of rupture of the abscess. Therefore, if the 
 diagnosis is to be surgically useful, it must be made before the signs 
 of compression have appeared, since a frontal lobe abscess usually 
 does not give signs of compression, at least not until immediately 
 before the fatal termination. 
 
 An early diagnosis of frontal lobe abscess is made possible only 
 by a systematic method of reasoning, together with repeated and 
 thorough examinations, with minute attention to certain small details 
 This is especially true if the abscess is latent and of small size. 
 The diagnosis must depend largely upon: (1) the presence of a 
 known point of infection which is apt to cause an abscess of the 
 frontal lobe — in the frontal sinus, the ethmoids or the orbit; (2) the 
 history of an acute invasion or an acute exacerbation of a chronic 
 suppuration— tenderness, redness of the external frontal wall, orbital 
 phlegmon, or trauma, accidental or operative — since such irregtdari- 
 ties are more or less constantly present; and (3) the general symp- 
 toms of cerebral suppuration. 
 
 Orbital Abscess, Osteomyelitis and Extradural Abscess — Dispro- 
 portion; value of. — The presence of any one of these conditions pre- 
 supposes a possibility of a frontal lobe abscess. When associated 
 with symptoms disproportionate to the known lesion, or with symp- 
 toms of cerebral suppuration, they call for exploration within the 
 
 206 
 
DIAGNOSIS OP FRONTAL LOBE ABSCESS 207 
 
 dura. The scar of a traumatic woiiiid of the frontal sinus, followed 
 by headache, should presuppose frontal lobe suppuration. Many 
 cases of frontal lobe abscess subsequent to an injury, are on record, 
 in which careful examinations have failed to reveal any mental dis- 
 turbance or psychic effect, the only symptoms present being head- 
 ache, insomnia and anorexia — ^general symptoms of cerebral sup- 
 puration. 
 
 Symptoms of Cerebral Suppuration. — There is a certain look 
 about the patient which, to the trained eye, is very significant; the 
 tongue is coated, the skin dry, there is loss of flesh, and the leucocyte 
 count is high. Headache is uniformly present and in many cases 
 is the only symptom. It frequently dates from an acute exacerbation 
 of a chronic frontal sinusitis, and if so should be always regarded 
 with suspicion. The headache may be continuous or intermittent, but 
 it is of a more severe type than that which occurs with frontal sinus 
 suppuration alone. If, to the above, is added vomiting, and if the 
 cerebro-spinal fluid frona a lumbar puncture gives a high cell count, 
 exploration of the frontal lobe is indicated. The cerebral explora- 
 tion should precede, not follow, an operation upon the accessory 
 sinuses. 
 
 On the other hand if an extradural abscess is accidentally located 
 at the time of a sinus operation, the existence of an associated intra- 
 dural abscess would be suggested. 
 
 Convulsions.— In the author's opinion convulsions are positive 
 evidence of intracranial involvement. While it is possible that a 
 convulsion may occur from a protective piarachnoid accumulation, 
 when the sinus has been opened or free nasal drainage has been estab- 
 lished, the occurrence of convulsions should be regarded as distinct 
 evidence that the disease has extended beyond the accessory sinuses 
 themselves. 
 
 The oases of cerebral symptoms which have been cleared up by operations 
 on the frontal sinus are due to "serous meningitis" of toxic origin. 
 
 Diabetes Insipidus. — Foerster ^ calls attention to the appearance 
 and development of diabetes insipidus in serous meningitis. As it 
 cannot occur from an acute sinus disease alone, it should be classi- 
 fied among the symptoms of cerebral origin. 
 
 Symptoms of CEasEBEAL Compeession. 
 
 Coma. — The coma of frontal lobe abscess is somewhat different 
 from the coma seen in general cerebral compression. It simulates 
 
 '■ Foerster : Munich, med. Wochenschrift, 1918. 
 
208 BEAIN ABSCESS 
 
 normal sleep more than the coma of suppuration in other parts of the 
 brain. ^ 
 
 In one of the author's cases this so-called "frontal-lobe coma" was present for 
 several weeks. At the autopsy one of the ventricles was found to be distended 
 with pus. 
 
 Papilloedema. — If papillcedema were caused by direct pressure 
 it would be of frequent occurrence in frontal lobe abscess. Such is 
 not the case, however. In frontal lobe abscess papillcedema is rarely 
 present.*' *• ° 
 
 An examination of the records of over one hundred cases of frontal lobe 
 abscess shows only three to have exhibited definite nerve head changes, all 
 associated with symptoms of compression. The almost uniform absence of papil- 
 lcedema in frontal lobe abscess is due to the fact papillcedema is largely 
 dependent upon an obstruction of the central cerebro-spinal fluid circulatory 
 system. 
 
 The situation of a frontal lobe abscess causes no such obstruction. 
 It is not unusual, however, to have papillcedema appear immediately 
 upon the evacuation of the abscess, which demonstrates that the 
 trauma of the operation furnishes a factor necessary to the produc- 
 tion of papillcedema, although the increased intracranial pressure 
 had been relieved. 
 
 Post-Neubitic Retrobulbar NEURrris. 
 
 The author has seen one case of the retrobulbar neuritis described by Ken- 
 nedy" in a frontal lobe tumor; it is not recorded in any case of abscess of the 
 frontal lobe. 
 
 Localizing Symptoms. 
 
 (a) Loss of Smell. — Loss of the sense of smell on the affected 
 side probably occurs very frequently. If present it is of distinct 
 diagnostic value. 
 
 (b) Aphasia. — In frontal lobe abscess aphasia occurs only when 
 the abscess has attained considerable size. At first it is apt to be 
 transient, due probably to an extension of oedema to the Island of 
 Eeil. In many of the recorded cases of frontal lobe abscess of the 
 left side, associated with paresis or paralysis of the arm of the op- 
 posite side, motor aphasia has been the first symptom. 
 
 ' Milian, G. : Le Coma Frontal ; PaHa Medical, 1920, Vol. X, No. 40, page 256. 
 
 ' Denker, A. : Ehinogener Frontallappenabszess : ArcMv fur iMryngol, und Bhinol., 
 1900, X, S. 411. Blurring of the left disc; pulse 55-60. 
 
 ' Faunz, M. : Khlnogener Hirnabszess ; Archii,< fUr Laryngol. und Bhinal., 1902-03, 
 XIII, S. 427. (Venous hyperBemia of the outer fundus ; had compression, pulse being 
 60-66.) 
 
 ' Jessamon, L. W. : Brain Abscess as a Complication of Acute Infection of Nasal 
 Accessory Sinuses ; Laryngoscope, 1920, Vol. 30, p. 147. 
 
 •Kennedy, Foster: American Journal of Medical Science$, September, 1919. 
 
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DIAGNOSIS OP FRONTAL LOBE ABSCESS 209 
 
 (c) Loss of Abdominal Reflexes of the Same Side. — ^Absence or 
 weakness of the homolateral abdominal reflexes probably is frequently 
 present. The author, however, knows of no such observations in 
 abscess, although he frequently has observed it in frontal lobe 
 tumors. 
 
 (d) Sudden Paralysis of Arm of Contralateral Side. — ^A pathog- 
 nomic symptom of frontal lobe abscess is paralysis of the arm of the 
 opposite side to the causative accessory sinus disease. It generally 
 occurs very suddenly; the onset of paralysis from the presence of 
 frontal lobe abscess signifies an abscess of enormous size. 
 
 The author has seen a frontal lobe abscess of large size which 
 gave no paralysis whatever — although the abscess had existed for sev- 
 eral weeks — ^until suddenly the arm became totally paralyzed. (Fig. 
 40.) 
 
 (e) Hemiplegia of Contralateral Side. — Paralysis of the leg and 
 arm are probably more common in frontal lobe abscess of orbital 
 origin than in cases of frontal sinus origin. 
 
 (f ) Mental Disturbances. — So little is known of the functions of 
 the frontal lobe that it is not surprising that the clinical evidence of 
 intellectual and psychic disturbance should generally be wanting in 
 the reports of frontal lobe abscess. ''' *■ ®' ^** 
 
 (g) Change of Disposition. — Change of disposition and poor 
 memory may both be present, although they have been but infre- 
 quently observed in frontal lobe abscess. In suppuration in the 
 frontal sinus or ethmoids, however, any change in disposition should 
 be regarded as of the greatest significance. The frontal lobes will 
 stand a remarkable degree of compression without any sign of dis- 
 orientation as to time or place, but in the author's experience one 
 of the most frequent of the changes is in disposition. 
 
 In a case of large pial cyst compressing the left frontal lobe the first evidence 
 of its presence was a certain degree of apathy regarding the welfare of the 
 family. 
 
 ' Bolton, J. S. : The Brain in Health and Disease; Edtcard Arnold, London, 
 1914, p. 65. DivideB the frontal lobe from the functional aspect into posterior, or 
 psychomotor (cerebral-assoeiatlve-motor), and anterior or prefrontal (higher-cerebral- 
 associative) portions. On page 122 states "the pre-Eolandic portion of the cerebrum 
 or the frontal lobe possesses controlling and executive functions." 
 
 • Ouilllani, 6., and Libert, H., observed several cases of extensive destruction 
 of the frontal lobes without disturbance of the psychic functions. Considerations 
 cllniques sur un cas d'abscSs du lobe frontal gauche; Bulletins et Memoirs SocUti 
 Midioale des H6pitaute de Paris, No. 71, p. 680. 
 
 • Viete, Henry : Notes on War Injuries of the Frontal Lobe ; Aliany Medical 
 AnnaU, January, 1920, Vol. LXI, No. 1, p. 14. (With extensive destruction of the 
 anterior pole of the left frontal lobe the only symptom was slight incontinence of 
 urine, although he was carefully examined for psychic changes, especially defects In 
 memory, attention, Judgment, self-control. 
 
 " Bing, Kobert : Compendium of Regional Diagnosis in Affections of the Brain 
 and Spinal Cord ; New York, Bebmam Company, 1909, p. 202. (Psychic disturbances 
 are observed chiefly In lesions of the anterior portions of the frontal lobe. The lesion 
 must be bilateral, or, if unilateral, it must be capable of producing a sympathetic 
 symmetrical affection of the opposite frontal lobe.") 
 
210 BRAIH ABSCESS 
 
 (h) Symptoms due to Association between Fronted Lobe and 
 
 Cerebellum^ — There seems to be an intimate association between tbe 
 
 ' frontal lobe and the cerebellum, as both produce falling. There is 
 
 some clinical evidence to suggest that in acute lesions spontaneous 
 
 past-pointing deviations of the contralateral arm also occur.^^ 
 
 ADDITIONAL REFERENCES DIAGNOSIS FRONTAL LOBE ABSCESS. 
 
 (a) Kesdiner, Moses: Large Endothelioma of the Dura Compressing Both 
 Frontal Lobes; Journal American Medical Association, June 17, 1916, Vol. 
 LXVI, pp. 1913-1915. 
 
 (6) Kennedy, Foster: Retrobulbar Neuritis as an Exact Diagnostic, Sign 
 of Certain Tumors and Abscesses in the Frontal Lobes; American Journal of the 
 Medical Sciences, September, 1911. 
 
 (a) Sierra, A. M. : Nota previa acerca del estudio functional de los Idbulos 
 frontales; La Semama Medioa, 1920, Vol. XXVII, p. 338. 
 
 (d) Milian, G.: Le Coma Frontal; Paris Medical, 1920, No. 40, p. 256. 
 
 (e) Jessaman, L. W. : Brain Abscess as a Complication of Acute Infection 
 of Nasal Accessory Sinus; Laryngoscope, 1920, Vol. XXX, No. 3, p. 147. 
 
 (/) Nichorster, H. : Ueber Stirnhirnabszess; Inaugural Dissertation, 1917; 
 Jahreshericht fiir Neurologic und Psychiatric, 1917, Bd. XXI, S. 540. 
 
 (g) Guilliani, G., and Libert, E. : Considerations cliniques sur un cas 
 d'absc^s du lobe frontale gauche; Bull, et Mem. Soc. M4d. des Hdpitaum de Paris, 
 1920, No. 17, p. 680. 
 
 " Albrecht, W. : Debar die Beeinflussung des Baranyschen Zelgeversuchs Tom 
 QroBBhlm, speziell vom Stlrnhim aus (From Tubingen Uniyersity Clinic for Diseases of 
 ■ the Throat, Nose and Ear) ; ArcMv fiir Ohrett^, Nas&rir- und KeMkopfheilkimde. 1920, 
 Bd. 106, S. 1. 
 
CHAPTER XIV. 
 COMPLICATIONS AND RESULTS. 
 
 Complications after Evacuation. — After the evacuation of a 
 chronic brain abscess, if the symptoms continue and meningitis is not 
 present, the surgeon must decide whether the symptoms are caused 
 by a refilling of the abscess or by a suppurative encephalitis. In 
 the former case a further evacuation is called for, vrhile in the latter 
 any irritating manipulation is contra-indicated. 
 
 In acute abscess, after evacuation through a small dural opening 
 all symptoms should rapidly subside and not again recur; the paraly- 
 sis should disappear and the headaches and vomiting cease. Stra- 
 bismus and papilloedema, however, subside much more slowly ; there 
 should be no increase of the latter. 
 
 Differential Diagnosis. — Encephalitis is distinctly a septic 
 process which is in no way limited, while in a refilled abscess the 
 abscess is partly, if not completely, limited. The differential diag- 
 nosis between refilling of the abscess cavity is always difficult, but 
 in a general way a slowly developing compression signifies a refilling 
 of the abscess while exhaustion denotes an encephalitis. 
 
 Vomiting after evacuation is a most serious symptom as it usually 
 signifies an extension of the suppurative process. 
 
 Headaches may occur either from refilling or extension, but when 
 associated with great prostration they are to be taken as denoting 
 encephalitis. 
 
 Irregular pulse is a sign of extension. Progressive paralysis al- 
 ways means extension. 
 
 After Effects. — No case of brain abscess should be regarded as 
 completely and permanently cured. Cerebral tissue, once the seat of 
 suppuration, never can be regarded as fully normal. 
 
 In one of the author's cases of double cerebellar abscess the boy, although he 
 had been perfectly well for many years, when called into service and put 
 under the stress of war developed intense headaches which incapacitated him. 
 In another case, although the small hernia was completely covered and the 
 patient apparently had been perfectly well for several years, rotation in a 
 Barany chair caused a convulsion, the first since the evacuation of the abscess. 
 
 Kichardson relates a case in which brain abscess had been cured but death 
 occurred suddenly several years later. (Bichardson, Charles; Personal commu- 
 nication.) 
 
 211 
 
212 BEAIN ABSCESS 
 
 Results. — Contrary to tlie generally accepted view the mor- 
 tality of brain abscess is still very higb. In the author's cases the 
 mortality following surgical treatment of brain abscess has been 
 about 75 per cent., the recoveries only about 25 per cent. In recent 
 years, since adopting the principle of operating on an early diag- 
 nosis, of avoiding during operation all unnecessary trauma with its 
 sequence of secondary oedema, and of providing for the relief of any 
 induced compression, his operative results have greatly improved. ■'' ^ 
 
 ^ Mygind reports the results of 207 cases of intracranial disease of various kinds, 
 of otitic origin ; forty-two of them of brain abscess, only four of which recovered — 
 or less than 10 per cent. He points out that in all Intracranial suppuration the mor- 
 tality rises to a considerable degree with the onset of any added complication. Of 
 his 207 cases, 35 per cent, had more than one intracranial lesion ; of these, fifty 
 cases had two intracranial affections, 24 per cent, of them recovering; ten cases had 
 three pathological processes with 12 per cent, of recoveries, and seven cases had four 
 different intracranial lesions with no recoveries. (Mygind, H. : Otogene multiple 
 Intrakranielle Sygdrume; Ugeskrift for haeger, 1920, Vol. 82, No. 22, p. 687.) 
 
 'NlShsmann states that in all large complications of otitic brain abscess the per- 
 centage of recovery in temporo-sphenoidal lobe abscess is 33% per cent., and in cere- 
 bellar about 10% per cent. (Niehsmann, Th. : Erfahrungen uber den otitischeu 
 Hirnabszess ; ArcMv fur Ohren, Nagen wnd Kehlkopfheilkunae, 1920, Vol. 106, p. 
 83.) 
 
 The writer is of the opinion that this is somewhat misleading, as all recoveries ar« 
 apt to be reported, while those which end fatally frequently are not. 
 
APPENDIX I. 
 
 guidk fob detailed neubological examination. 
 
 The guide is designed to enable hospital internes or trained attendants, with- 
 out special training in neurology, to conduct a detailed examination by eliciting 
 and recording the details of all objective and subjective symptoms. 
 
 The examination is divided into: (I) General Neurological Symptoms, 
 (JI) General Neurological: ^Examination, (IQ) Cerebral Localization, and 
 (IV) Examination of Cranial Nerves. 
 
 Suggested terms with possible interpretations and methods of testing, as 
 well as the normal reaction, are placed in brackets. ( * ) in the margin indicates 
 examination for unconscious patients. The general sections are indexed by Koman 
 numerals, the chief symptom or manifestations by capital letters, and the 
 individual details by alternate letters and numbers. 
 
 DIEECTIONS FOB USING GDIDE. 
 
 The examination b^ins under the heading General Symptoms. 
 
 At the completion of the examination all outstanding symptoms and ab- 
 normal findings are recorded on the record sheet, followed by the index numbers 
 and letters according to the guide, enabling a ready reference to the exact 
 location of each detail. Example: "Papillcedema, IV., B. 1." When a general 
 symptom has a direct bearing upon the localization, it should be cross-indexed. 
 Example: "Dizziness, I. — d., and IV. f. 2." 
 
 GUIDE FOB NBUBOLOGICAL EXAMINATION 
 
 (to be followed by House Surgeon) 
 
 Full Name 
 
 Address 
 
 Hospital No 
 
 RiswmS of History: 
 
 R6swm4 of Outstanding Symptoms: 
 
 R4sum4 of Almormal Nev/rologioal Findings: 
 
 (Give all Index Numbers and Letters) 
 
 Signature of House Surgeon. 
 Date 
 
 I. Geneeal Symptoms: 
 
 (a) Headache: 
 
 Severity — ("mild"; "intense"; "bursting"; "throbbing"; "lacerat- 
 ing"). 
 Location — ("frontal"; "temporal"; "behind the eyes"; "pituitary"; 
 
 "occipital"; "vertex"). 
 In Attacks or Constant. 
 Initial Appearance; Date of. 
 213 
 
214 BEAIN ABSCESS 
 
 (B) Pain: 
 
 Situation — ("nose"; "eyes"; "ears"; "arms"; "legs"; etc.). 
 
 Duration. 
 
 Initial Appearance. 
 
 In Attacks or Constant. 
 
 • (c) Vomiting: 
 
 Frequency. 
 
 Type — ("projectile" or "regurgitant"). 
 
 Initial Appearance. 
 
 (d) Dizziness: 
 
 In Attacks or Constant. 
 
 Degree — ("transient giddiness"; "swaying"; "falling"). 
 
 Duration. 
 
 Initial Appearance. 
 
 Description of — ("if objects or if patient appears to move"). 
 
 Duration — ("momentary" or "continued"). 
 
 • (e) Convulsions: 
 
 General or Localized. 
 
 Part Involved. 
 
 Associated with Unconsciousness. 
 
 Preceded by Aura (Description of Aura: "visual flashes of light"; 
 
 "objects seen"; "auditory"; "tones or music heard"). 
 During Attack: 
 
 Head, to R. to L. 
 
 Eyes, toR. tpL. 
 
 Arms, to R. to L. 
 
 Legs, toR. toL. 
 
 • (/) Stupor: 
 
 Initial Appearance. 
 In Attacks. 
 
 (g) Numbness: 
 Situation. 
 In Attacks. 
 Initial Appearancie. 
 
 {h) Tingling: 
 Situation. 
 In Attacks. 
 Initial Appearance. 
 
 II. Genebal Examination: 
 
 • (a) Head: 
 
 1. Wounds: description of. 
 
 2. Bleeding from ear; R. L. 
 
 3. Bleeding from nose; R. L. 
 
 4. Scars: description of. 
 
 • ' (&) Extremities': 
 
 1. Paralysis of Arm! R. L. 
 
 2. Paralysis of Leg? R. L. 
 
 3. Anesthesia of Arm? R. L. 
 
 4. Anesthesia of Leg? R. L. 
 
APPENDIX I 215 
 
 • (o) Reflexes: 
 
 1. Superficial: 
 
 a. Epigastric. 
 
 b. Abdominal. 
 
 c. Cremasteric. 
 
 • 2. Deep: 
 
 a. Knee. 
 
 b. Anlcle. 
 
 c. Babinsld. 
 
 d. Kernig. 
 
 • 3. Sphincters: 
 
 a. Loss of Bladder Control. 
 
 b. Loss of Bowel Control. 
 4. Vasomotor: 
 
 a. Abnormal Flushing? 
 
 b. Abnormal Sweating? 
 
 III. Cebebeai. Localization: 
 (o) Frontal Lobe: 
 
 1. Memory for 
 
 a. Names — (Father's name; of street where he lives), 
 
 b. Events. 
 
 2. Orientation. 
 
 3. Affections. 
 
 • 4. Aphasia. 
 
 a. For names or other parts of speech. 
 
 b. Ability to repeat sentences after examiner. 
 
 (&) Temporal Lobe: 
 
 1. Aphasia: 
 
 a. Ability to recognize object and state use, but inability to 
 
 name. (Knife; key.) 
 
 b. Ability to recognize proper name and ability to repeat 
 
 name. 
 
 2. Uncinate Gyrus Symptoms; 
 
 a. Hallucinations of Smell. 
 
 b. Hallucinations of Hearing. 
 
 3. Hemianopsia: 
 
 a. Right-sided. Left-sided. 
 
 b. For form. 
 
 c. For colors. 
 
 4. Dreamy state, 
 (c) Parietal Lobe: 
 
 1. Sensory Symptoms: 
 
 a. Paresthesia; touch, pain, temperature. 
 
 • b. Anesthesia. 
 
 c. Astereognosis. 
 
 d. Muscle sense. 
 
 • 2. Motor Symptoms: 
 
 a. Paralysis; where; duration. 
 
 b. Paresis; where; duration. 
 
 c. Convulsive Seizures, Sec. I-e. Part involved; Consciousness 
 
 lost. 
 
216 BEAIN ABSCESS 
 
 {d) Occipital Lobe: 
 
 1. Hemianopsia: riglit-sided ; left-sided. 
 
 2. Visual hallucination: right-sided; left-sided. 
 
 (e) Cerebellum: 
 1. Dizziness. 
 
 * 2. Nystagmus. 
 
 3. Romberg. 
 
 4. Disturbances of gait. 
 
 5. Ataxia. 
 
 6. Adiadokokinesia. 
 
 IV. Cbanial Nerves : 
 
 (a) First: ("Olfactory"; Special sense). 
 
 1. Smell ("perfumery") Right nostril. 
 Left nostril. 
 
 * (6) Second: ("Ophthalmic"; Special sense). 
 
 1. Fundus examination. 
 
 2. Vision Right Eye. Left Eye. 
 
 * (c) Third; Fourth; and Sixth: (Ocular Movements). 
 
 * I. Pupils: 
 
 a. Equal. 
 
 b. Contracted. 
 
 c. Dilated. 
 
 d. React to light. 
 
 e. React to accommodation. 
 
 * 2. External Ocular Movements: 
 
 a. Diplopia. Convergent R. L. 
 
 Divergent R. L. 
 
 * b. Spontaneous Nystagmus to R. to L. 
 
 * e. Conjugate Deviation to R. to L. 
 
 ( d ) Fifth : ( "Trifacial" sensory and motor ) . 
 
 1. Sensory Portion: 
 
 (a) Anesthesia of [Supra-orbital * (Cornea). 
 
 (b) Neuralgia of 1 Iifra-orbital. 
 
 ^ ' ^ [inferior Dental. 
 
 (o) Taste in anterior two-thirds of tongue (sugar; salt). 
 
 2. Motor Portion: 
 
 (a) Buccinator. 
 
 (b) Masseter. 
 
 3. Vasomotor Portion: (Herpes of brow; of lip). 
 
 * (e) Seventh: (Facial; Motor, Sensory). 
 
 1. Motor Portion: 
 
 a. Paralysis or Paresis. R. L. 
 
 Part Involved: 
 Brow. 
 
 Lower Eyelid. 
 Mouth. 
 Cheek. 
 Palate. 
 
 2. Sensory Portion: ("Taste in anterior two-thirds of tongue"). 
 
 3. Vasomotor: ("Herpes of Ear"). 
 
APPENDIX I 317 
 
 (/) Eighth: ("Auditory'' and "Vestibular"; Special Senses). 
 
 1. Auditory Portion: 
 
 a. Deafness: R. ear L. ear 
 
 fWatch R. L. 
 
 HearlngJ Whisper R. L. 
 
 [voice R. L. 
 
 (Normal or otherwise) 
 
 b. Tinnitus: 
 
 (Special auditory tests to be conducted by specialist). 
 Tuning Forks 
 
 Weber Referred to: R. L. 
 
 Bone Conduction: Duration of (seconds) : R. L. 
 
 2. Vestibular Portion: 
 
 a. Spontaneous Nystagmus. 
 
 b. Spontaneous Vertigo. 
 
 c. Spontaneous Pointing Deviation (downward from shoulder) 
 
 R. Arm L. Arm 
 
 d. Ef.sum#. of induced vestibtji.ab reactions (to be filled in 
 
 by expert after special vestibular tests have been con- 
 ducted ) . 
 
 1. From turning to Right. 
 
 Nystagmus. 
 
 Vertigo. 
 
 Past Pointing. E. Arm L. Arm. 
 
 Falling. 
 
 2. From turning to Left. 
 
 Nystagmus. 
 
 Vertigo. 
 
 Past Pointing. R. Arm L. Arm. 
 
 Falling. 
 
 3. From Douching Right Ear 
 
 Nystagmus. 
 
 Vertigo. 
 
 Past Pointing. R. Arm. L. Arm. 
 
 4. From Douching Left Ear 
 
 Nystagmus. 
 
 Vertigo. 
 
 Past Pointing. R. Arm L. Arm. 
 
 Special Vestibular Tests (to be conducted by expert). 
 
 1. Turning to Right (reactions induced by turning to right, head 
 forward 30 degrees ) . 
 
 a. Induced Nystagmus (normal, horizontal to left). 
 
 1. Amplitude. 
 
 2. Duration (normal; 26 sec). 
 
 3. Direction (normal, horizontal to left). 
 
 b. Induced Vertigo (normal; to left). 
 
 c. Induced Past Pointing (shoulder from above; normal; to 
 
 right). 
 
 R. arm to — 
 
 L. arm to — 
 
 d. Supplementary. 
 
 1. Head forward; falling (normal, to right). 
 
218 BEAIN ABSCESS 
 
 2. Turning to Left (turning to left, head 30 degrees forward). 
 
 a. Induced Nystagmus. 
 
 1. Amplitude. 
 
 2. Duration (normal; 26 sec). 
 
 3. Direction (normal; horizontal to right). 
 
 b. Induced Vertigo (normal; to right). 
 
 c. Induced Past Pointing (shoulder from above; normal; to 
 
 left). 
 
 R. Arm to — 
 
 L. Arm to — 
 
 d. Supplementary. 
 Head back 60 degrees. 
 
 Head forward: Falling (normal; to left). 
 
 3. Caloric Bight (reactions induced by douching right ear with 
 
 cold water, head forward 30 degrees). 
 
 a. Induced nystagmus (normal; rotary to left). 
 
 1. Amplitude. 
 
 2. Direction. 
 
 3. Duration. 
 
 b. Induced Vertigo (normal; to left). 
 
 c. Past Pointing (shoulder from above; normal; to right). 
 
 R. Arm to — ■ 
 L. Arm to — ■ 
 
 d. Supplementary. 
 
 I. Head back 60 degrees. 
 
 a. Nystagmus (normal, horizontal to left). 
 
 b. Past Pointing (normal; to right). 
 R. Arm to — • 
 
 L. Arm to — 
 
 4. Caloric Left (reactions i^duced by douching left ear, head 
 
 forward 30 degrees). 
 
 a. Induced Nystagmus (normal, rotary to right). 
 
 1. Amplitude. 
 
 2. Direction. 
 
 3. Duration. 
 
 b. Induced Vertigo (normal; to right). 
 
 c. Past Pointing (shoulder from above; normal to left). 
 
 R. Arm to — 
 Ii. Arm to — 
 
 d. Supplementary: 
 
 1. Head back 60 degrees. 
 
 a. Nystagmus (normal; horizontal to right). 
 
 b. Past Pointing (normal; to left). 
 
 R. Arm to — 
 L. Arm to — 
 
 * (G) Nimth: ("Glossopharyngeal"; special sense; sensory motor). 
 
 1. Taste. 
 
 2. Swallowing. 
 
 • (H) Tenth: ("Pneumogastric"; motor and sensory). 
 
 1. Hoarseness. 
 
 2. Rapidity of Heart. 
 
APPENDIX I 219 
 
 (I) Eleventh: ("Spinal Accessory''; motor). 
 
 1. Trapezius Muscle. 
 
 2. Sternocleidomastoid. 
 
 3. Shoulder Dropping. 
 
 (J) Twelfth: ("Hypoglossal"; motor). 
 How is tongue protruded? 
 
APPENDIX 11. 
 
 CEEEBELIiAB ABSCESS: ANALYSIS OF PATHOLOGICAL CONDITION IN 
 EEPOETED AITTOPSIES OP 125 CASES. 
 
 Post-Mortem Findings in 
 Cerebellar Abscess. 
 
 Analysis of Oases Eeported from 1857 to 1919. 
 
 Dupdy: Gazette medicale de Paris, XII., 1857, p. 230. 
 
 Condition of Dura Over Site of Infection: In four cases, of cerebellar 
 abscess noted by the author in the literature, tbe dura mater connected 
 with the cerebellum was more or less altered. 
 Gull, "W. : Guy's Hospital Reports, III. Series, 1857, p. 261. 
 
 Situation: Apparently posterior, but not stated. Stalk. Abscess near 
 cerebellar surface; superficial wall of abscess adherent to dura for a small 
 space corresponding to the entrance of the vein from the vestibular aque- 
 duct. Lateral sinus thrombosis. Hydrocephalus. 
 
 Condition of Du/ra Over Site of Infection: Superficial wall of cere- 
 bellar abscess was adherent to the dura mater for a small space, corre- 
 sponding to the entrance of the vein from the vestibular aqueduct. 
 
 Capsule: The abscess (in the right lobe of the cerebellum near the 
 surface) was limited by "a highly vascular cyst." (This is an old 
 observation dating back to 1857.) 
 
 Pathological Processes in Cerebellum — (Softening, Discoloration, etc.) : 
 The nervous substance surrounding the cerebellar abscess was edematous. 
 Heusinger: Virchow's Archiv, XI., 1857, p. 92. 
 
 Situation: Double brain abscess, one in cerebellum, one in lower lobe 
 of cerebrum. Situation of cerebellar abscess probably posterior; corre- 
 sponding transverse sinus entirely obliterated by a solid thrombus. 
 Petrous bone was destroyed in an enormous circumference. 
 SoHWASTZE, H. : Archiv fiir Ohrenheilkunde, Vol. I., 1864, p. 195. 
 
 Situation: Apparently anterior, but not stated. Cerebellar abscess 
 originating through passage of pus from mastoid antrum into the in- 
 ternal ear through the oval window and through the internal auditory 
 meatus, into the cranial cavity. Hydrocephalus. No sinus thrombosis. 
 
 Condition of Dura Over Site of Infection: Dura mater over left 
 petrous bone was very loosely attached and easily removed. 
 VoLTOLiNi, E.: Yirchow's Archiv, Vol. XXXI., 1864, p. 202. 
 
 Situation: Probably anterior, but not stated. Cerebellar cortex had 
 undergone local gangrenous destruction; middle portions were greatly 
 
 220 
 
APPENDIX II 231 
 
 softened. Pia mater of cerebelluin in part infiltrated with pus. Infec- 
 tion through subarcuate hiatus. Hydrocephalus. 
 
 Pathological Processes in Gerebellwm, — {Softening, Discoloration, etc.) : 
 The cerebellar cortex had undergone a local gangrenous destruction and 
 the adjacent white substance was softened; the middle portions were very 
 soft. Pia mater of cerebellum was in part infiltrated with pus. 
 Teoeltschj Archiv flir Ohrenheilkunde, Vol. IV., 1869, p. 126. 
 
 Situation: Apparently posterior, but not stated. Cerebellar abscess and 
 a similar abscess in temporal lobe, applied to petrous bone at tegmen 
 tympani and posterior pyramid, separated by tentorium and by normal 
 brain substance. Labyrinth suppuration. Phlebitis of superior petrosal 
 sinus, in observer's opinion perhaps propagated through the subarcuate 
 hiatus. 
 
 Condition of Dura Over Site of Infection: Dura mater was discolored, 
 considerably thickened, and covered with superficial fibrinous deposits 
 over the tegmen tympani as well as at the posterior surface of the pyra- 
 mid, where the brain abscesses (cerebellar and temporal) were applied 
 to the petrous bone. 
 Gribbon, G. C. : Lancet, I., 1878, p. 712. 
 
 Situation: "On examining the cerebellum, all of the interior of the 
 organ except about the anterior third of the median and left lobes was 
 found to be an abscess ... it appeared to have begun in the right lobe, 
 of which nothing was left but the cortex. . . ." Hydrocephalus. (Case 
 of abscess of the cerebellum bursting into the ear with immediate death. 
 No operation.) 
 
 Condition of Dura Over Site of Infection: The bone was denuded of 
 dura mater and stained with pus for a quarter of an inch around the 
 auditory meatus. Pus also abounded in the mastoid cells. 
 
 Capsule: The cerebellar abscess appeared to have begun in the right 
 lobe of which nothing was left but the cortex, as here it was encased in a 
 thick lining membrane, while in the other lobes to which it afterwards 
 penetrated there was no such membrane of demarcation, but it was as if 
 the cerebellar substance were being rapidly broken down in every direc- 
 tion. 
 
 Pathological Processes in Cereiellum — {Softening, Discoloration, 
 etc.) : "On slitting up the tentorium, the surface of the cere- 
 bellum close to the right auditory meatus was seen to be discolored, and 
 pus to be lying between it and the bone. On examining the cerebellum, 
 all of the interior of the organ except about the anterior third of the 
 median and left lobes was found to be an abscess ... it appeared to 
 have begun in the right lobe, of which nothing was left but the cortex. 
 It was as if the cerebellar substance were being rapidly broken down in 
 every direction." 
 Moos, S.-Steinbrugge, H. : Zeitschrift fiir Ohrenheilkunde, X., 1880-81, 
 
 p. 87. 
 
 Situation: Abscess occupied the larger portion of the left cerebellar 
 hemisphere and a small portion of the vermis. Perforation of dura in 
 region of aperture of vestibular aqueduct. Lower end of anterior bony 
 boundary of oval window was carious and necrotic. Carious orifice in 
 promontory corresponding to beginning of first cochlear convolution. 
 
232 BEAIN ABSCESS 
 
 Extensive destruction of left pyramid. Apparently abscess with 
 stalk. 
 
 Condition of Dura Over Site of Infection: Dura mater appeared 
 thickened and discolored at posterior surface of left petrous bone and 
 presented a small round perforation in the region of the aperture of the 
 vestibular aqueduct. 
 
 Pathological Processes in Cerehellum — {Softening , Discoloration^ etc.) : 
 Pia and arachnoid of left cerebellar hemisphere, which contained an ab- 
 scess were opaque. Dura thickened and discolored, also perforated, at 
 posterior surface of petrous bone. 
 FiNNEL : Transactions New York Pathological Society, lY., 1881, p. 31Y. 
 
 Pathological Processes in Cerehellum — (Softening, Discoloration, etc.) : 
 Abscess in right hemisphere of cerebellum. Neighboring tissue was much 
 softened. 
 Eaymond, F. : Progres medical, IX., 1881, p. Y49. 
 
 Situation: Cerebellar abscess following otitis media with propagation 
 to internal ear. Abscess occupied the entire left lateral lobe which was 
 completely destroyed. Cavity was well outlined and did not communi- 
 cate with neighboring regions. Dural adhesions. No special findings in 
 mastoid cells. No remarks concerning hydrocephalus. 
 
 Condition of Dura Over Site of Infection: Dura mater of normal 
 appearance; no adhesions except at level of left petrous bone, surround- 
 ing the internal auditory meatus; in this region the cerebral meninges 
 were thickened and indurated. A portion of the dura mater remained 
 adherent at the level of the abscess around the internal auditory meatus. 
 
 Capsule: The walls of the cerebellar abscess were thickened, hardened 
 and roughened on the internal surface. 
 
 Pathological Processes in Cerehellum — (Softening, Discoloration, etc.) : 
 The cerebellar abscess occupied the entire left lateral lobe, which was 
 completely destroyed. 
 Hadden, "W. B.: St. Thomas's Hospital Eeports, N. P., Vol. XIV., 1884, 
 
 p. 297, 
 
 Case I. Situation: Not stated. Large abscess involving right hemi- 
 sphere of cerebellum and extending about a third of the way across the 
 left hemisphere. Distinct but not extensive caries of right mastoid cells. 
 
 Condition of Dura Over Site of Infection: Dura mater at base of 
 skull was healthy; no caries was seen on stripping it. 
 
 Case II. Situation: Superficial abscess involving under surface of 
 left lobe of cerebellum. Pus in mastoid cells on both sides. History of 
 a fall. 
 
 Condition of Dura Over Site of Infection: Dura mater and surface 
 of bone at base were healthy. 
 SoHULZ, E. : Deutsches Archiv fiir klinische Medizin, Vol, XXXV., 1884, 
 
 p. 477. 
 
 Situation: Anterior. Abscess was situated upwards and forwards in 
 the cerebellum. No mention of a stalk. No sinus thrombosis. Hydro- 
 cephalus. 
 
 Capsule — (Presence or Aisence) : The right cerebellar hemisphere con- 
 tained an abscess cavity larger than a walnut, lined with a discolored 
 pyogenic membrane. 
 
APPENDIX II 223 
 
 Pathological Processes in GerebeUum — {Softenmg, Discoloration, etc.) : 
 
 From the right cerebellar hemisphere, some viscid greenish pus escaped 
 
 from a small orifice with discolored surroTindings, in petrous bone near 
 
 porus acusticus. 
 
 Stallard, J. H. : Pacific Medical and Surgical Journal, Vol. XXVI., 1884, 
 
 p. 207. 
 
 Situation: Traumatic abscess; central part of right lobe of cerebellum 
 softened and reduced to the consistency of cream. 
 
 Capsule: Central part of right lobe of cerebellum was reduced to the 
 consistency of cream; the softening did not invade the gray matter or 
 approach the surface. On the inner side there was no trace of a limiting 
 membrane but on the outer side there were distinct remains of an attempt 
 at limitation in an oval spot nearly one inch in its longest diameter. 
 This membrane was covered with pus cells. (Case of traumatic origin.) 
 
 Pathological Processes in CereheUum — (Softening, Discoloration, etc.) : 
 
 Central part of right lobe of cerebellum was reduced to consistencgr of 
 
 cream; this softening did not invade the gray matter or approach the 
 
 surface. 
 
 Capdeville, p. : Journal de Medecine de Bordeaux, XIV., 1884-85, p. 37. 
 
 Situation: Abscess sequel of middle ear disease, filled the entire right 
 lobe of cerebellum. "No sinus thrombosis; sinuses were entirely intact. 
 Osteitis of petrous bone and mastoid process. Deep cavity filled with 
 pus in petrous bone, at level of angle formed by superior petrosal sinus 
 and right lateral sinus. No mention of hydrocephalus. 
 
 Condition of Dura Over Site of Infection: The sinuses of the dura 
 mater were entirely intact, free from phlebitis or thrombosis. At the 
 level of the angle formed by the superior petrosal sinus and the right 
 lateral sinus, a deep cavity fiUed with pus was found in the petrous bone ; 
 This cavity was covered by a thinned portion of dura, which however pre- 
 sented absolutely no change or solution of continuity. 
 
 Capsule : Eight cerebellar lobe was filled with greenish pus which was 
 completely enclosed in la continuous shell composed by the cerebellar 
 cortex. 
 
 Pathological Processes in CereheUum — (Softening, Discoloration, 
 etc.) : On incision of the right cerebellar lobe, a mass of greenish pus 
 (about 100 grammes) escaped, entirely filling the lobe; this pus was 
 completely enclosed in a continuous shell composed by the cerebellar 
 cortex. 
 Hanfield-Jones, M.: Brain (London), VII., 1884-85, p. 398. 
 
 Situation: Two abscesses close beneath surface, rather nearer the upper 
 than the under part of the cerebellum, separated from each other by a 
 septum of tough brain substance, % inch thick. Hydrocephalus. Case 
 probably of syphilitic origin. 
 
 Condition of Dura Over Site of Infection: (Syphilitic Cerebellar Ab- 
 scess). Eight half of cerebellum was found at autopsy to be firmly ad- 
 herent to the dura mater of the anterior portion of the posterior fossa, so 
 that the dura was removed together with the cerebellum. Dura mater 
 corresponding to site of the two abscesses was adherent to cerebellum 
 and much thickened by a probably gummatous material. 
 
 Capsule: The right lobe of the cerebellum contained two abscess cavi- 
 
224 BEAIN ABSCESS 
 
 ties lined with a pyogenic membrane, evidently not of very recent date. 
 (Case of Syphilitic origin.) 
 
 Pathological Processes in Gerehellum — {Sofiermig, Discoloration, 
 etc.) : Dura mater corresponding to site of two (syphilitic) cerebellar 
 abscesses wag adherent and thickened by gummatous material; pia 
 mater covering the cerebellum was thickened, especially near the site of 
 the abscess. 
 Hedinger, a. : Zeitschrift fiir Ohrenheilkunde, Vol. XIV., 1884-85, p. 56. 
 
 Situation: Apparently anterior, but not stated. Cerebellar abscess due 
 to propagation of pus from middle ear into cochlea and by means of the 
 vestibular aqueduct into the cerebellum. Caries of petrous bone. No 
 mention of stalk. No mention of sinus thrombosis or hydrocephalus. 
 
 Condition of Dura Over Site of Infection: No orifice was found in 
 the dura, probably because the small orifice was promptly closed by or- 
 ganized connective tissue after perforation and evacuation of pus to the 
 cerebellum had occurred. The pus in the cerebellum caused extensive de- 
 struction and after rupture of the abscess drained below the dura in the 
 direction toward the spinal canal. 
 
 Pathological Processes in Gerehellunu — (Softening, Discoloration, etc.) : 
 
 Pus in cerebellum caused extensive destruction, and after rupture of the 
 
 abscess drained below the dura in the direction towards the spinal canal. 
 
 EoTHHOLZ, H. ; Zeitschrift fiir Ohrenheilkunde, Vol. XIV., 1884-85, p. 184. 
 
 Situation: Two intercommunicating cerebellar abscesses, the foremost 
 reaching close to the fourth ventricle. Autopsy showed a distinct con- 
 tinuous chain of suppuration from the tympanum along the facial nerve 
 whose bony sheath was defective, into the posterior cranial fossa and from 
 here within the soft cerebral meninges into the cerebellum. 
 
 Capsule: Two intercommunicating cerebellar abscesses, about the size 
 of a walnut, were enclosed in a thick abscess capsule. 
 SUTPHEN, T. T. : Zeitschrift fiir Ohrenheilkunde, Vol. XVII., 188Y, p. 286. 
 
 Situation:' Not clear. Caries of temporal bone corresponding in part 
 to situation of internal auditory meatus ; orifice leading from the carious 
 cavity into an abscess in the opposite cerebellum. Adjacent to it above 
 and anteriorly was a mass of cicatricial tissue which is interpreted by 
 the observer as the result of a healed abscess. 
 
 Capsule : Corresponding to the internal auditory meatus, there was an 
 orifice which led from the large carious cavity in the temporal bone, into 
 an abscess in the opposite cerebellum. Adjacent to the abscess above 
 and anteriorly there was a mass of cicatricial tissue which occupied the 
 entire thickness of the gray matter, was hard to cut, and presented a 
 discolored roughened surface, so that there could be no doubt about its 
 being the result of a healed abscess. 
 
 Pathological Processes in Cerehellum — (Softening, Discoloration, etc.) : 
 Mass of cicatricial tissue, evidently the result of a healed abscess, was 
 found adjacent to a cerebellar abscess above and anteriorly, occupying 
 entire thickness of gray matter. 
 HuTTON, F. T., and "Weight : The Lancet, Vol. II., 1888, p. 210. 
 
 Situation: Posterior. Cerebellar abscess, in a case of otitis interna, 
 occupying posterior inferior and inner part of left hemisphere. "The 
 petrous portion of the left temporal bone was found extensively diseased. 
 
APPE:KrDIX II 226 
 
 and perforated pus appeared to track backwards between thickened and 
 adherent dura mater beneath the left temporo-sphenoidal lobe towards the 
 cerebellum." No mention of stalk. No mention of sinus thrombosis or 
 hydrocephalus. 
 
 Condition of Dura Over Site of Infection: Dura was thickened and 
 adherent, and pus passed between it and towards the cerebellum, beneath 
 the left temporo-sphenoidal lobe. 
 
 Pathological Processes in CerebeTlum — {Softeninff, Discoloration, etc.) : 
 Some hemorrhage was found at the base of the brain. 
 Smith, Th. 0. : Journal American Medical Association, Vol. X., 1888, p. 202. 
 
 Situation: Anterior. "Left hemisphere of cerebellum, anterior half, 
 converted into an abscess." Opening in posterior surface of petrous bone 
 communicated with tympanic cavity. No mention of stalk. No state- 
 ments concerning hydrocephalus. 
 
 Condition of Dura Over Site of Infection: Dura mater normal, ex- 
 cept on posterior surface of petrous portion of left temporal bone, where 
 the adhesion was a little greater than normal around an opening in the 
 bone, which communicated with the tympanic eavily. 
 
 Pathological Processes in Cerebellum/ — {Softening, Discoloration, etc.) : 
 Anterior half of left cerebellar hemisphere was converted into an abscess. 
 Hartmann, a. :■ Zeitschrift fiir Ohrenheilkunde, Yol. VIIL, 1889, p. 313. 
 
 Situation: Apparently anterior, but not stated. Cerebellar abscess in 
 a case of otitis media with caries of petrous bone. Total destruction of 
 bony wall of canal of facial nerve at its bend; two carious tracts led from 
 here backwards, one of these tracts corresponding to the hiatus sub- 
 arcuatus. Abscess with stalk. 
 Eeinhaed, and Ludewig: Archiv fiir Ohrenheilkunde, Vol. XXVII., 1889, 
 
 p. 201. 
 
 Situation: Anterior. Abscess situated in anterior segment of cere- 
 bellum, but there was purulent thrombophlebitis of transverse sinus and 
 superior petrosal sinus. Subdural abscess. Tentorium adherent to cere- 
 bellar surface. At the posterior segment of the cerebellum in the region 
 of the upper vermis was a discoloration involving only the pia. Large 
 carious defect in temporal bone; fistulous opening in wall of lower audi- 
 tory meatus. Apparently abscess with stalk. 
 
 Condition of Dura Over Site of Infection: The adherent tentorium 
 having been divided, fetid grayish green masses of pus were reached, 
 which spread between the cerebellar surface and the dura. 
 
 Capsule : Abscess fully the size of a hen's egg, in anterior segment of 
 right cerebellar hemisphere. It was separated from the healthy cere- 
 bellar tissue by a green abscess wall, which was almost entirely covered 
 with gangrenous grayish green masses. 
 
 Pathological Processes in Cereiellum — {Softerdng, Discoloration, etc.) : 
 Tentorium eerebelli on right side adherent to surface of cerebellum. 
 Masses of pus spread between cerebellar surface and dura. Large abscess 
 in anterior segment of right cerebellar hemisphere. Surface of cere- 
 bellum locally depressed, with irregular orifices in two places from which 
 pus welled up. Grayish yellow discoloration, size of a dime, involving 
 only the pia, at posterior segment of cerebellum in region of upper 
 vermis. 
 
226 BEAIK ABSCESS 
 
 MiLLiGAiT, W., and Hare, A. W.: British Medical Journal, February 1; 
 
 1890, p. 231. 
 
 Situation: Abscess situated towards middle of right lobe, in its an- 
 terior and upper part. No mention of a stalk. Temporo-sphenoidal lobe 
 •was normal. No caries of petrous bone. No hydrocephalus. Propaga- 
 tion of infective process is referred by the observers to the small venous 
 and lymphatic channels between the middle ear and the perivascular 
 lymphatic spaces of the cortex. 
 
 Gondition of Dura Over Site of Infection: Membranes and surface 
 of brain were healthy. 
 
 Capsule : There was an empty and collapsed abscess cavity in the right 
 lobe of the cerebellum, about the size of a small walnut; it was lined 
 by a distinct limiting membrane suggesting that the abscess was of old 
 standing. 
 Pitt, G. Newton : British Medical Journal, Vol. I., 1890, p. 643. 
 
 Situation: Abscess situated in upper part of posterior or semilunar 
 lobe of cerebellum; probably secondary to lateral sinus thrombosis. Sur- 
 face of abscess was adherent to torcular Herophili, where dura and bone 
 were thickened and inflamed. Abscess vrith stalk. No comments on 
 hydrocephalus. 
 
 Gondition of Dura Over Site of Infection: Dura mater and bone for 
 an inch and a half near the torcular Herophili were thickened and in- 
 flamed. (Cerebellar abscess secondary to lateral sinus thrombosis.) 
 
 Pathological Processes in Gereiellum — (^Softening, Discoloration, etc.) : 
 Acute softening around pons abscess. 
 Sohwaezb: Deutsche Milita.rarztliche Zeitschrift, Yol. XIX., 1890, p. 535 
 
 Situation: Case I. Posterior. Abscess in posterior lobe of cerebellum 
 1 cm. below surface, following otitis media. Evidence of a stalk. Forma- 
 tion of pus focus in cerebellum is explained by observer as the result of 
 phlebitic and periphlebitic processes. Perforation of dura in occipital 
 fossa and partial disintegration of posterior surface of petrous pyramid. 
 
 Case II. Situation apparently posterior. Cerebellar abscess due to 
 phlebitic and periphlebitic processes; stump of a blood vessel projected 
 from wall, closed by a plug of pus. No mention of stalk. 
 
 Gondition of Dura Over Site of Infection: Autopsy showed a slight 
 basal meningitis, probably originating from a perforation of the dura, 
 size of a i)ea, filled with thick pus ; dura slightly bulged in the surround- 
 ings of the hole and appeared considerably thickened in this region after 
 it had been detached from the skuU. Corresponding to the hole in the 
 dura, the occipital fossa also presented a superficial disintegration of the 
 inner bone plate with discoloration. 
 Panse, E. : Archiv fiir Ohrenheilkunde, Vol. XXXIII., 1891-92, p. 38. 
 
 Situation: Apparently anterior. Cerebellar abscess due to infection 
 through vestibular aqueduct. No mention of a stalk. No statement 
 concerning sinus thrombosis or hydrocephalus. 
 
 Gondition of Dura Over Site of Infection: Dura was firmly applied 
 to bone in vicinity of jugular foramen above the transverse sinus. 
 
 Pathological Processes in Gerehellutn — (.Softening, Discoloration, etc.) : 
 Left cerebellar hemisphere firmly fixed at sharp margin in vicinity of 
 
APPENDIX II 327 
 
 jugular foramen ; it contained an abscess fully the size of a pigeon's egg, 
 filled with dirty green pus. 
 Truokenbeod, C: Zeitschrift fiir Ohrenlieilkunde, Vol. XXII., 1891-92, 
 
 p. 228. 
 
 Situation: Apparently posterior. Cerebellar abscess in a ease of 
 osteitis of mastoid process. Transverse sinus thrombosis. Longitudinal 
 sinus was free from thrombosis. Disintegration of dura around cere- 
 bellar abscess. No mention of stalk which apparently existed. 
 
 Condition of Dura Over Site of Infection: Dura was involved in dis- 
 integration process around cerebellar abscess. 
 
 Pathological Processes in OereieUum — (Softening, Discoloration, etc.) : 
 Discoloration and softening beyond middle in surroundings of left-sided 
 cerebellar abscess. 
 Harrison, C. E. : The Lancet, October 1, 1892, p. 763. 
 
 Situation: Not apparent from description. Cerebellar abscess sec- 
 ondary to ear disease. No mention of stalk. No subdural abscess. No 
 extravasation of pus into meninges or ventricles. No mention of sinus 
 thrombosis or hydrocephalus. Dura over petrous bone discolored and 
 bone necrotic, with small perforation into mastoid antrum, but no evi- 
 dence of active inflammation in mastoid cells. 
 
 Condition of Dwra Over Site of Infection: Dura mater covering the 
 central part of the anterior surface and to a less extent the posterior 
 surface of the petrous bone, was discolored and under it was a large 
 piece of still undetached necrotic bone. 
 
 Pathological Processes in Gerehellum — {Softening, Discoloration, etc.) : 
 Walls of abscess cavity were mostly formed of softened brain tissue. 
 Randall, B. A.: Transactions American Otological Society, Vol. V., Part 
 
 I., 1892, p. 93. 
 
 Situation: Probably anterior, but not stated. Observer considers sup- 
 puration to have been limited to the mastoid cells and the adjacent in- 
 tracranial structures. Autopsy showed an opening from the mastoid be- 
 neath the lateral sinuses, communicating with the abscess. No mention 
 of sinus thrombosis or hydrocephalus. 
 Jansen, a. : Archiv fiir Ohrenheilkunde, Vol. 35, 1893, p. 272. 
 
 Pathological Processes in GereheUum — (Softening, Discoloration, etc.) : 
 
 Encephalitic changes in form of hemorrhagic infarction and softening 
 
 in right cerebellar hemisphere, situated directly below the surface near 
 
 the temporal bone. 
 
 Kenefick, T. a.: Boston Medical and Surgical Journal, Vol. 129, 1893, 
 
 p. 144. 
 
 Situation: Cerebellar abscess of apparently spontaneous origin. "Di- 
 viding the cerebellum at the base there was found a cavity large enough 
 to hold a billiard ball. The other organs were healthy." 
 Haebordt: Otitische Erkrankungen des Hims, etc. (See Komer), 1894, 
 
 p. 135. 
 
 Situation: Apparently posterior. Cerebellar abscess following several 
 operations for cholesteatoma of temporal bone. Phlebothrombosis of 
 transverse sinus extending into the jugular vein. Numerous metastatic 
 foci in both cerebral hemispheres, and in other organs. 
 
238 BEAIN" ABSCESS 
 
 Harrison, 0. E. : The Lancet, 1894, II., p. Y95. 
 
 Situation: Apparently posterior. Cerebellar abscess the result of 
 chronic middle-ear disease. No mention of stalk. Sinus thrombosis. 
 Patch of organized lymph on outer wall of lateral sinus, corresponding 
 on its outer surface with a piece of necrotic bone containing holes and 
 depressions through which a probe could in two places be passed into 
 the mastoid cells. 
 
 Condition of Dura Over Site of Infection: When the dura was sepa- 
 rated from the cranium at the autopsy, a patch of organized lymph was 
 found on the outer wall of the right lateral sinus, corresponding with 
 necrotic bone. 
 KoRNER, O. : Die otitischen Erkrankungen des Hirns, der Himhaiite und 
 
 der Blutleiter; Monograph, 1894, p. 118. 
 
 Situation: Abscess situated in anterior external portion of cerebellar 
 hemisphere. No mention of stalk. No second abscess was demonstrable 
 anywhere. Cerebellum was adherent to transverse sinus at its knee, and 
 the sinus at the site of adhesion was filled with a thick white partly ad- 
 herent thrombus; the other sinuses, notably the superior petrosal sinus, 
 were free. No fistula leading to the abscess. Hydrocephalus. 
 
 Condition of Dura Over Site of Infection: Dura over the petrous 
 bone was normal throughout. 
 
 Capsule : Abscess cavity size of walnut in anterior external portion of 
 right cerebellar hemisphere; it was lined with a very thin, not every- 
 where plainly demonstrable membrane. 
 Mackenzie, H. W. G. : St. Thomas's Hospital Eeports, Vol. XXII., N. S., 
 1894, p. 143. 
 
 Situation: Case I. Chronic middle ear suppuration. Large abscess, 
 almost wholly replacing the left cerebellar lobe. No mention of sinus 
 thrombosis. Hydrocephalus. 
 
 Case II. Abscess situated in outer third of right cerebellar lobe which 
 was somewhat adherent to outer part of petrous bone; at this spot the 
 dura had disappeared. Old adhesions between medulla and cerebellum. 
 No disease of mastoid cells. The sinuses contained soft non-adherent 
 clot and fluid blood. Hydrocephalus. 
 
 Condition of Dura Over Site of Infection: Case I. "Dura mater over 
 posterior portion of left petrous bone was blackened and perforated; 
 around the perforation it was adherent to the left cerebellar lobe, which 
 was almost wholly replaced by a large abscess. The bone over the pos- 
 terior and external portion of the left petrous ridge was found, when 
 the dura was detached, to be carious. 
 
 Case II. Eight cerebellar lobe was somewhat adherent to outer part 
 of petrous bone near its junction with the squamous. At this spot the 
 dura mater had disappeared and there was a small area of bare bone 
 with some loose fragments. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) : 
 Case I. Left cerebellar lobe was almost entirely replaced by a large 
 abscess. 
 
 Case II. Eight cerebellar lobe somewhat adherent and enlarged, pale 
 and softened; abscess in outer third of lobe, with well defined walls, 
 separated from surface by fairly normal white matter. 
 
APPENDIX II 239 
 
 Wallace, 0. S. : St. Thomas's Hospital Eeports, E". S., Vol. XXIV., 1895 
 
 (1897), p. 353. 
 
 Situation: Two cerebellar abscesses (case of mastoiditis), one in an- 
 terior part of lateral lobe, at a depth of 1% inches from cerebellar sur- 
 face abutting on surface at both ends and forming chord of a circle cut- 
 ting off the outer and posterior part of the lateral lobe of the cerebellum. 
 Just internal to this and parallel to it was a second abscess cavity, which 
 was elongated, but not so long as the first cavity. No sinus thrombosis. 
 No hydrocephalus. 
 Zeller: Berliner klinische Wochenschrift, 32, 1895, p. 923. 
 
 Situation: Posterior. Cerebellar abscess in the presence of transverse 
 sinus thrombosis. The site of rupture from the mastoid cavity towards 
 the posterior cranial fossa was situated in the groove of the superior 
 sinus. Fistulas behind the mastoid process, in the parotid region, and 
 in the neck. 
 
 Condition of 'Dura Over Site of Infection: The sound could be passed 
 far in between the dura and the bony floor of the posterior cranial fossa. 
 
 Capsule: Abscess size of walnut in right cerebellar hemisphere, with 
 old pyogenic membrane. 
 Woodward, J. U. : Zeitschrift fiir Ohrenheilkunde, Vol. XXIX., 1896, p. 373. 
 
 Situation: Abscess occupied entire left lateral lobe of cerebellum. No 
 lateral sinus thrombosis. Several small orifices in the sinus wall estab- 
 lished a communication with pus focus under dura mater. Hydroceph- 
 alus. Adjacent cortical portion of cerebellum was discolored, softened 
 and necrotic over a small area. 
 
 Condition of Dura Over Site of Infection: Purulent pachymeningitis 
 in area on posterior surface of petrous portion of left temporal bone near 
 opening of internal auditory meatus ; bone was carious in this area which 
 extended to below the lateral sinus ; no lateral sinus thrombosis. Several 
 small orifices in sinus wall communicated with pus-focus under dura 
 mater. 
 
 Pathological Processes in Cerehellum — {Softening, Discoloration, 
 etc.) : Cortical portion of left lateral lobe of cerebellum adjacent to 
 abscess was discolored, softened, and necrotic over a small area. Re- 
 mainder of cerebellar cortex was normal. 
 Heimann: Archiv fiir Ohrenheilkunde, Vol. 43, 1897, p. 220. 
 
 Situation: Abscess in right lobe of cerebellum and processus vermi- 
 formis, with caries of right petrous bone and general tuberculosis. 
 (The brain abscess was independent of the general tuberculosis and 
 originated at an earlier date, as the remote result of middle-ear sup- 
 puration.) 
 MiJLLER, E. : Charite-Annalen, Vol. XXII., 1897, p. 369. 
 
 Situation: Apparently anterior. Cerebellar abscess through infection 
 of posterior semicircular canal and ductus endolymphaticus. No men- 
 tion of a stalk, but left cerebellar hemisphere and its dural covering were 
 agglutinated with petrous bone by suppurating tissue strands originating 
 from vestibular aqueduct; caries of petrous bone around aqueduct. 
 
 Condition of Dura Over Site of Infection: Left cerebellar hemisphere 
 and its dural covering were agglutinated with left petrous bone by sup- 
 purating tissue-strands which originated from the vestibular aqueduct; 
 
230 BEAIN ABSCESS 
 
 these strands led from in front towards the pus cavity. Dura was greatly 
 thickened over region of abscess. 
 
 Capsule: Left cerebellar hemisphere contained a pus focus, size of a 
 walnut. Abscess membrane was in course of formation. 
 
 Pathological Processes in GereheUum — (Softening, Discoloration, etc.) : 
 Left cerebellar hemisphere and its dural covering were agglutinated 
 with left petrous bone by suppurating tissue-strands derived from vesti- 
 bular aqueduct. 
 ViOLLET, p. : Bulletins de la Societe Anatomique de Paris, Vol. 72, 1897, 
 
 p. 450. 
 
 Situation: Abscess occupied exclusively the central portions of the 
 left lobe of the cerebellum. No sinus phlebitis. No subdural abscess. 
 No mention of stalk. There was a communicating orifice between the 
 middle ear cavities and the cerebellum in front of the sinus, besides 
 granulations in the petrous bone, pointing to this route as the mode of 
 propagation from the ear to the cerebellum. 
 
 Condition of Dura Over Site of Infection: Communicating orifice be- 
 tween middle ear cavities and cerebellum through the dura in front of 
 the sinus. 
 Orne Green, J.: American Journal of Medical Sciences, Vol. 117, 1899, 
 
 p. 406. 
 
 Situation: Case I. Apparently anterior. Caries of labyrinth. Cere- 
 bellar abscess, from infection through internal meatus; at base of cere- 
 bellum opening against the posterior surface of petrous bone. Adhesion 
 between cerebellar substance and dura between internal meatus and ves- 
 tibular aqueduct. Abscess was in direct connection with the internal 
 meatus; carious perforation from tympanum to vestibule; mixed infec- 
 tion of brain from vestibule, along internal meatus. 
 
 Case II. Abscess was situated in the extreme anterior part of the 
 digastric lobe of the cerebellum. It communicated by a fistulous tract 
 with a collection of pus at the orifice of the vestibular aqueduct. Carious 
 perforation from the tympanum to the external semicircular canal, and 
 infection through this to the vestibule and thence along the vestibular 
 aqueduct to the brain. 
 
 Case III. Abscess in anterior part of digastric lobe of cerebellum; 
 cause, infection through the whole carious osseous labyrinth. Adhesion 
 of cerebellum to dura oVer vestibular aqueduct. No fistula communi- 
 cating with the bone was found. 
 
 Condition of Dura Over Site of Infection: Case I. Small area of 
 cerebellar substance was adherent to the dura, between internal meatus 
 and vestibular aqueduct; no ulceration of dura. 
 
 Case II. Petrous Bone : Dura was healthy except at vestibular aque- 
 duct, where there was in the bone a collection of pus as large as a 
 bean. 
 
 Case III. Cerebellum adherent to dura for %, inch over vestibular 
 aqueduct. 
 
 Capsule: Case III. Abscess in anterior part of left digastric lobe of 
 cerebellum, incapsuled by a thin pyogenic membrane. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) : 
 Case I. Cerebellum adherent to whole posterior surface of petrous 
 
APPENDIX II 331 
 
 bone; cerebellar convolutions somewhat flattened, probably due to excess 
 of fluid in ventricles. 
 
 Case II. Slight purulent deposit on upper surface of cerebellum; 
 more abundant deposit on its base on both sides. Pia was inflamed over 
 an area % inch in diameter on .right lower surface. 
 
 Case III. Encephalitis of cerebellum, with abscess of the left digastric 
 lobe from infection through the whole labyrinth. 
 Muck: Zeitschrift fiir Ohrenheilkunde, Yol. 3Y, 1900, p. 194. 
 
 Situation : Extradural abscess in posterior cranial fossa. Partial ulcer- 
 ation of saccus endolymphaticus. Orifice led from cavity in inner wall 
 of antrum directly into the subarcuate hiatus. No sinus thrombosis. 
 Okada, W. : Klinische Vortrage aus dem Gebiete der Otologie und Pha- 
 .ryngo-Ehinologie, Vol. III., H., 10, 1900, p. 340. 
 
 Position: Case I. Evidently anterior. Perforation of petrous bone 
 at labyrinth wall, filled with pus. Dura adherent to petrous bone and 
 cerebellum. Cerebellar abscess with punctiform hemorrhages in sur- 
 roundings. Abscess with stalk. Hydrocephalus. 
 
 Case II. Abscess situated near anterior circumference of cerebellum 
 which was adherent to the necrotic petrous bone, in surroundings of 
 vestibular aqueduct. Route of infection through oval window. Hy- 
 drocephalus. No operation. No mention of stalk which probably 
 existed. 
 
 Case III. Abscess in cerebellum at the transition of the posterior 
 upper into the anterior lower surface, laterally, where this border is 
 closely applied to the posterior petrous wall directly below the tentorium 
 cerebelli. Suppurating connective tissue strands, coming from the vesti- 
 bular aqueduct between the internal auditory meatus and the sigmoid 
 sinus, led to the abscess. Necrosis of petrous bone around opening of 
 vestibular aqueduct; the strands led to this point. 
 
 Condition of Dura Over Bite of Infection: Case I. Pachymeningitis 
 circumscripta petrosa, arachnitis adhesiva et purulenta cerebellaris. Dura 
 adherent at anterior and lateral surface of right cerebellum, to petrous 
 bone as well as to cerebellum. Purulent infiltration of dura at this 
 circumscribed spot. 
 
 Case III. Left cerebellar hemisphere was agglutinated by suppurating 
 tissue strands with the dura covering the posterior surface of the petrous 
 bone; these strands came out from the vestibular aqueduct, between the 
 internal auditory meatus and the sigmoid sinus ; they led to a pus cavity 
 in the left cerebellum. After the dura had been stripped from the 
 petrous bone, the bone appeared necrotic around the opening of the 
 vestibular aqueduct, to the extent of a lentil; the suppurating strands 
 led to this point. 
 
 Capsule: Case II. Abscess barely the size of a walnut was situated 
 near the anterior circumference of the right cerebellum, and lined with 
 a smooth, thick, granulating membrane. 
 
 Case III. Pus focus, size of walnut, in left cerebellum, at the tran- 
 sition of the posterior upper into the anterior lower surface. A true ab- 
 scess membrane was not present, but was in course of formation; the 
 abscess was sharply outlined from the surroundings. 
 
 Pathological Processes in Cerebellum — {Softening, Discolorationj etc.) : 
 
233 BRAIN ABSCESS 
 
 Case I. Punctiform hemorrhage in surroundings of abscess in right 
 cerebellar hemisphere. 
 
 Case II. Eight cerebellum adherent to petrous portion. Eight half of 
 cerebellum (Edematous. 
 
 Gase III. Left cerebellar hemisphere agglutinated by suppurating tis- 
 sue strands with dura covering the posterior surface of the petrous bone. 
 Gruneet, K., and Zeeoni, "W. : Archiv fiir Ohrenheilkunde, Yol. 51, 1900-01, 
 
 p. 262. 
 
 Situation: Apparently anterior. Abscess in right cerebellum. Avenue 
 of infection: fistula of promontory. Labyrinthine suppuration. Ves- 
 tibular aqueduct was the avenue of infection. Abscess with stalk. 
 
 Condition of Dura Over Site of Infection: Dura was adherent at pos- 
 terior surface of petrous portion of temporal bone. 
 
 Capsule: Abscess in right cerebellar hemisphere, with abscess mem- 
 brane. 
 
 Pathological Processes in Cerebellum, — {Softening j Discoloration, etc.) : 
 Cerebellar substance surrounding abscess was interspersed with extra- 
 vasates. 
 Pheysing, H. : Archiv fiir Ohrenheilkunde, Vol. 51, 1900-01, p. 262. 
 
 Situation: Old encapsulated cerebellar abscess, anterior, with stalk. 
 Situation not stated in case of cerebellar abscess. Extradural abscess in 
 immediate vicinity of trephine orifice, with fine perforation of dura ; cor- 
 responding to this point abscess in cerebellum. Avenue of infection: 
 fistula of dura. 
 
 Condition of Dura Over Site of Infection: Fistula of dura; abscess in 
 right half of cerebellum, following chronic otitis media and radical op- 
 eration; extra-dural abscess and fistula close to trephine orifice of right 
 mastoid process. 
 Gruneet, K., and Schulze, W. : Archiv fiir Ohrenheilkunde, LIV., 1901- 
 
 02, p. 63. 
 
 Situation: Apparently anterior although the sigmoid sinus contained 
 a thrombus extending as far as the bulb of the jugular vein. Extra- 
 dural abscess and another abscess at the lower surface of the left cere- 
 bellmn. The vestibular aqueduct is stated to have been the source of 
 the infection. 
 
 Condition of Dura Over Site of Infection: Dura was discolored over 
 posterior aspect of middle portion of left petrous bone. Under the dura 
 was a collection of pus and a polyp-like mass which penetrated through 
 the vestibular aqueduct into the internal ear. 
 SoHULZE, W. : Archiv fiir Ohrenheilkunde, Vol. LVIL, 1902-03, p. 67. 
 
 Situation: Apparently anterior. Abscess of right cerebellar hemi- 
 sphere. Avenue of infection: Operative (?) opening of oval window, 
 infection of vestibule and vestibular aqueduct; empyema of saccus; cere- 
 bellar abscess by continuity and contiguity. 
 
 Condition of Dura Over Site of Infection: Cerebellum adherent to 
 dura. Dura greatly thickened at posterior surface of pyramid between 
 sigmoid fossa and porus acusticus intemus. On inner surface of dura, 
 at opening of vestibular aqueduct, was a ruptured pus sac. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) : 
 Soft meninges together with cerebellum were agglutinated to abscess wall. 
 
APPENDIX II 233 
 
 Fliess, H. : Deutsche Medizinische "Wochenschrift, No. 14, 1903, p. 242. 
 Situation: Anterior. The abscess was situated at the lower surface 
 of the left cerebellum in the anterior external quadrant. The pus had 
 evidently reached the posterior cranial fossa by way of the vestibular 
 aqueduct. 
 
 Pathological Processes in Ger&bellum — {Softening, Discoloration, etc.) : 
 The outer wall of the cerebellar hemisphere which formed a portion of 
 the abscess cavity was entirely destroyed by the suppuration in its an- 
 terior half, and this segment was adherent to the petrous bone, being 
 directly agglutinated to the dura, over sac of Ootugno. 
 VON HiNSBERG : Deutsche Medizinische Wochenschrift, No. 39, 1904, p. 1245. 
 
 Situation: Case I. Anterior. No sinus thrombosis or labyrinth sup- 
 puration. Abscess in left cerebellar hemisphere could be traced to the 
 antrum through the hiatus subarcuatus, which presented well-marked 
 changes. The superior semi-circular canal — free from necrosis — con- 
 tained a number of blood vessels imbedded in granulation tissue which 
 was continuous with granulations in the antrum and could be traced to 
 the opening of the hiatus subarcuatus at the posterior edge of the 
 pyramid. 
 
 Case II. Anterior. Sinus without changes. Abscess in left cere- 
 bellar hemisphere was due to infection through the vessels of the hiatus 
 subarcuatus which carried infectious material from the diseased mastoid 
 cells with which they were directly connected, into the dura in the form 
 of emboli. 
 
 Condition of Dura Over Site of Infection: Cerebellum slightly ad- 
 herent to pyramidal surface in region of left porus acusticus intemus. 
 VON HiNSBERG : Dura here presented a thin reddish-yellow deposit and was 
 greatly thickened; centre of dural thickening was situated exactly over 
 opening of hiatus subarcuatus; vessels of canal entered directly into the 
 dura. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) : 
 Under side of left cerebellar hemisphere (which contained the abscess) 
 was covered with purulent deposits. 
 VON UoHERMANN : Zeitschrift fiir Ohrenheilkunde, Vol. 46, 1904, p. 303. 
 
 Situation: Case Y. Multiple brain abscess. Cerebellar abscess pre- 
 sumably posterior, in direction of trephining orifice just above knee of 
 thrombotic transverse sinus. Temporal lobe abscess about midway in 
 left middle temporal gyrus. 
 
 Case YII. Three cerebellar abscesses, apparently posterior; first cavity 
 just inwards of thrombotic transverse sinus; second abscess about in 
 middle of hemisphere; third cavity more mesially situated, in vicinity 
 of but not reaching the median line; extending forwards as far as the 
 flocculus. 
 BoESCH, H.: Zeitschrift fur Ohrenheilkunde, Vol. 50, 1905, p. 33Y. 
 
 Situation: Anterior. Labyrinth suppuration with right-sided cere- 
 bellar abscess. All sinuses were empty. Upper semicircular canal was 
 empty. The anterior and inferior side of the right cerebellar hemisphere 
 presented a discolored focus leading into the abscess cavity which filled 
 the entire portion of the right cerebellum above the arbor vita, extend- 
 ing to the left half. In front the cerebellar abscess was directly bounded 
 
334 BRAIN ABSCESS 
 
 by the suppurating and necrotic saccus endolymphaticus, plainly showing 
 the path of infection of the brain substance. 
 
 Condition of Dura Over Site of Infection: Dura was adherent to the 
 bone and to the pia, at site of mastoid operation; pia was adherent to 
 reddish and discolored brain-substance. 
 
 Pathological Processes in Cerebellum — (Softening, Discoloration, etc.) : 
 Anterior and inferior side of right cerebellar hemisphere presented a' 
 discolored focus, size of a bean, which led into a larger pus cavity; the 
 brain substance in the surroundings was discolored, greenish, interspersed 
 with numerous punctiform hemorrhages. 
 PoLiTZER, A. : Archiv fiir Ohrenheilkunde, Vol. 65, 1905, p. 161. 
 
 Situation: Anterior. Chronic cerebellar abscess in upper vermis of 
 cerebellum. The cochlear capsule presented several irregular gaps bound- 
 ed by eroded margins, communicating with the cochlear canal, or sepa- 
 rated from it only by the endosteum. The process of disintegration un- 
 doubtedly originated in the interior of the cochlea. There was also sup- 
 puration of the prolapsed temporal lobe, following radical operation for 
 otitis media. 
 D'Hoore: Archives Internationales de Laryngologie, d'Otologie et de 
 
 Rhinologie, Tome XXII., 1906, p. 758. 
 
 Situation: Probably anterior. Sinus apparently normal. Autopsy had 
 to be restricted to an examination through the enlarged bony gap of the 
 mastoid-operation wound. The drainage tube led into an abscess pocket, 
 but beyond this abscess extended another voluminous pouch, tapering at 
 the anterior tip of the right cerebellar lobe. (Stalk?) It was not pos- 
 sible to establish the lesion of continuity between the cerebellar focus 
 and the mastoid across the dura mater. 
 Knapp, a. : Transactions of the American Otological Society, Vol. IX.-X., 
 
 1906, p. 39. 
 
 Situation: Apparently anterior. Abscess in anterior part of right 
 cerebellar lobe. Destruction by cholesteatoma of most of the external 
 semicircular canal, with involvement of bone directly posterior to 
 canal. 
 
 Condition of Dura Over Site of Infection: On reflecting the dura on 
 the right side of the convexity of the brain, there was a patch of exu- 
 date over the motor area. The bone directly posterior to the external 
 semicircular canal was involved and corresponded to the thickening of 
 the dura, thus showing the path of infection. 
 
 Capsule — (Presence or Absence) : There was no membrane to the 
 cerebellar abscess. 
 Lannois-PereetiSee : Archives Internationales de Laryngologie, d'Oto- 
 logie et de Ehinologie, Tome XXII., 1906, p. Y58. 
 
 Situation: Anterior. Suppurative labyrinthitis with propagation of 
 pus through the internal auditory meatus; discolored area on arachnoid 
 and pia mater of cerebellar fossa directly related on visceral side to a 
 portion of the abscess at the anterior and lateral portion of the right cere- 
 bellar hemisphere, above the white central substance. Remainder of 
 hemisphere was (Edematous and softened. 
 
 Pathological Processes in Cerebellum — (Softening, Discoloration, etc.) : 
 Abscess in right cerebellar hemisphere; covered only by a thin layer of 
 
APPENDIX II 235 
 
 cerebellar cortex. The remainder of the hemisphere was oedematous and 
 softened. 
 Black, W. D. : Laryngoscope. Vol. XYII., 190Y, p. 553. 
 
 Situation: Anterior. Abscess situated near centre of right lateral lobe 
 of cerebellum; it seemed to have no connection with the lateral sinus. 
 The observer believes that the infection occurred through the lymphatics, 
 as the sigmoid sinus and the bony walls around it were healthy. 
 BoENNiNGHAUS: Zeitschrift fiir Ohrenheilkunde, Vol. 54, 1907, p. 245. 
 
 Situation: Posterior. Sinus thrombosis due to empyema of aberrant 
 pneumatic occipital cell. Autopsy showed a purulent disintegrating 
 thrombus in the sinus at a point corresponding to the situation of the 
 cerebellar abscess. 
 IsEMEB, F. : Archiv fiir Ohrenheilkunde, Vol. 74, 1907, p. 244. 
 
 Situation: Anterior. Cerebellar abscess in medullary substance of 
 right hemisphere, following extensive labyrinth suppuration. Small ex- 
 tra-dural abscess at the posterior pyramidal surface. The existing sig- 
 moid thrombosis was not responsible for the abscesses. According to 
 the autopsy findings, the brain abscess had not originated by continuity 
 from the diseased labyrinth, but the germs were carried into the depth 
 of the cerebellum through retrograde thrombosis and phlebitis of small 
 vessels opening from the brain into the pia-veins; possibly also through 
 the sheath-like lymph spaces. 
 
 Condition of Dura Over Site of Infection: Cerebellum was adherent 
 to dura, in region of old operation wound (labyrinth-suppuration). 
 
 Pathological Processes in Oereielhun — (Softening, Discoloration, etc.) : 
 Eight cerebellar hemisphere was somewhat depressed and on palpation 
 appeared very soft as if fluctuating. Small red foci of softening in sur- 
 roundings of abscess situated chiefly in the medullary substance, with 
 irregular ragged margins. 
 Voss, P. : Zeitschrift fiir Ohrenheilkunde, Vol. 53, 1907, p. 57. 
 
 Situation: Case I. Cerebellar abscess apparently posterior; pus was 
 foimd at depth of 3 cm. Old healed sinus thrombosis. Second abscess 
 situated at posterior pole of occipital lobe. 
 
 Case II. Eight-sided cerebellar abscess evidently posterior; right-sided 
 transverse sinus thrombosis. Perisinus abscess. Discoloration of adja- 
 cent dura. Abscess with stalk. 
 
 Case III. Small superficial abscess in cerebellum, mesiaUy from sinus. 
 Pus was aspirated from lateral surface of cerebellum at depth of 3 em. 
 No autopsy. 
 Bhiggs, G. N. : Lancet, II., 1908, p. 1745. 
 
 Situation: Anterior. No sinus thrombosis. In the performance of 
 
 the complete radical mastoid operation, the external semicircular canal 
 
 was found to be carious, but no fistula could be discovered entering the 
 
 internal ear through the foramen ovale or foramen rotundum. 
 
 Laurens, P. : Eevue Hebdomadaire de Laryngologie, d'Otologie, et de Ehi- 
 
 nologie. Vol. XXIX, 1909, p. 513. 
 
 Situation: Case I. Anterior. Abscess was found in left lobe of cere- 
 bellum, at junction of superior and inferior aspect. Path of infection 
 was evidently either labyrinthine (endo- or peri-lymphatic) or juxta 
 labyrinthine. Abscess with stalk. 
 
236 BEAIN ABSCESS 
 
 Case II. Apparently anterior. Old abscess in right lobe of cere- 
 bellum, at the level of tbe upper inner angle of tbe petrous bone. Sudden 
 rupture into the meninges. Abscess with stalk. 
 
 Condition of Dura Over Bite of Infection: Case I. Area of adhesions 
 between dura and pia mater on posterior surface of left petrous bone; 
 pus escaped from this area in post-mortem removal of cerebellum. 
 
 Case II. Zone of adhesions between dura and pia on posterior surface 
 of right petrous bone; old cerebellar abscess, of latent development, which 
 opened suddenly into the meninges. 
 Braun, a. : Medical Eecord, March 26, 1910, p. 535. 
 
 Situation: Probably posterior. Sinus thrombosis. Abscess was found 
 on the surface of the right lobe of the cerebellum, a short distance behind 
 the obliterated sinus. Observer does not think it likely that the cere- 
 bellum became infected after the mastoid operation by extension from the 
 infected sinus; but he comments that the cerebellar abscess may have 
 been present at the time of the mastoid operation. There was no necrotic 
 bone. 
 Flatau: Monatschrift fiir Ohrenheilkunde, 41, 1910, p. 910. 
 
 Situation: Posterior. Cerebellar abscess by way of sphenoid sinus 
 which contained another abscess. 
 TJffenorde, W. : Beitrage zur Anatomie, Physiologic, Pathologic und 
 
 Therapie des Ohres, der Nase and des Halses, Yol. III., 1910, p. 86. 
 
 Situation: Case I. Apparently posterior. Wall of right sigmoid sinus 
 was covered with a layer of pus. Defect in tegmen tympani. Purulent 
 exudate and dark red hemorrhages at lower aspect of cerebellum, extend- 
 ing in part also to the upper cortical layers. 
 
 Case II. Probably anterior. Empyema of labyrinth; saccus empyema; 
 rupture of saccus. Cerebellar floor was covered with a smeary layer 
 of pus. 
 
 Condition of Dura Over Site of Infection: Dura in posterior portion 
 of right middle cranial fossa and in anterior portion of right posterior 
 cranial fossa was covered with a fibrinous layer. Inner parietal layer of 
 dura was smooth and shiny. 
 
 Pathological Processes in Cerelellum — (Softening, Discoloration, etc.) : 
 
 Case I. Lower aspect of cerebellum showed some purulent exudate and 
 dark red hemorrhages extending in part also to the upper cortical layers". 
 
 Case II. Cerebellar floor was covered with a smeary purulent layer. 
 Pus in depth of tissues. 
 Bare, J. Stoddart : Glasgow Medical Journal, Vol. Y6, 1911, p. 50. 
 
 Situation: Posterior. Infective paralabyrinthitis and septic throm- 
 bosis of the lateral sinus; opening in sinus wall leading into abscess 
 cavity. (No mention of stalk.) 
 De Stella : Annales des Maladies de I'Oreille et du Larynx, Vol. XXXVIL, 
 
 1911, p. 999. 
 
 Situation: Probably anterior. Abscess in the vermis and in a large 
 portion of the right cerebellar hemisphere; following radical operation. 
 No details. 
 DoRTES, P. : Eevue Hebdom. de Laryngologie, d'Otologie, et de Ehinologie, 
 
 Tome XXXL, 1911, p. 145. 
 
 Situation: Anterior. Distinctly outlined abscess in anterior half of 
 
APPENDIX 11 237 
 
 left lobe of cerebellum at level of anterior third. Chronic pyolabyrin- 
 thitis complicating chronic middle ear suppuration. Osteitis of inner 
 wall and threshold of aditus. Greenish discoloration of posterior surface 
 of petrous bone behind internal auditory orifice. Slit-shaped fistula of 
 external semicircular canal. 
 
 Condition of Dura Over Site of Infection: At level of discolored area 
 on posterior surface of petrous bone, behind internal auditory orifice, 
 some pus was found under the dura and around the internal auditory 
 orifice. 
 
 Pathological Processes in Gerebellwm — {Softening , Discoloration, etc.) : 
 Left lobe of cerebellum at level of anterior third, presented a black 
 necrotic spot. 
 Jacques, P., and Ooulet, G. : Le Larynx, lY., 1911, p. 50. 
 
 Situation: Anterior. Large abscess in anterior portion near inferior 
 surface of right lobe of cerebellum, at point corresponding to thrombotic 
 lateral sinus. Focus of pachymeningitis at level of sinus thrombosis. 
 Small area of osteitis in petrous bone near floor of antrum. (No men- 
 tion of stalk.) 
 
 Condition of Dura Over Site of Infection: Pocus of pachymeningitis 
 at level of a sinus thrombosis. 
 
 Pathological Processes in Cerehellum — {Softening, Discoloration, etc.) '. 
 Inferior surface of right lobe of cerebellum presented a greenish purulent 
 spot at a point corresponding to the lateral sinus; the cerebellar cortex 
 underneath this spot was softened and peculiarly thinned, but not ulcer- 
 ated. Wide area of purulent infiltration in the form of a greenish areola, 
 around abscess cavity. 
 Kelson, W. H. : Proceedings of the Koyal Society of Medicine: Otological 
 
 Section, Vol. IV., Part III., 1911, p. 40. 
 
 Situation: "The brain shows the site of the abscess surrounded by 
 (Edema and a small lesion (abscess?) on the dorsal surface of the left 
 hemisphere of the cerebellum." (No details. Patient died from cere- 
 bellar abscess following operation (for nasal polyps) and otitis media). 
 Logan Turner, A., and Eeynolds, F. E. : Journal of Laryngology, Ehinol- 
 
 ogy, and Otology, Vol. XXVI., No. 2, 1911, p. 57. 
 
 Situation: Posterior. Large abscess in left lobe of cerebellum. Sig- 
 moid sinus thrombosis. No mention of stalk. No meningitis. 
 Beck, K. : Zeitschrift fur Ohrenheilkunde, Vol. 64, 1911-12, p. 262. 
 
 Situation : Probably anterior. Microscopical specimens plainly showed 
 the route of the infection from the original focus of suppuration in the 
 middle ear to the dura, the cerebellum, the abscess itself, and the scat- 
 tered encephalitic foci. Extradural abscess due to rupture of mastoid 
 suppuration into extradural space. The encephalitic foci were shown 
 by the specimens to have originated, not by continuity, but through 
 retrograde distribution of the infectious agents by preformed chan- 
 nels. 
 
 Condition of Dura Over Site of Infection: Strong connective tissue 
 strands passing from the dura formed part of an enormous connective 
 tissue capsule of an old abscess-cavity. Dura was entirely infiltrated 
 with pus; pia and arachnoid were indistinguishable. 
 
 Capsule: In a case of healed cerebellar abscess, the autopsy showed 
 
238 BRAIIT ABSCESS 
 
 strong connective tissue strands passing from the dura and fonning part 
 of an enormous connective-tissue capsule of the old abscess cavity. 
 
 Pathological Processes in Cerebellum — (^Softening, Discoloration, etc.) : 
 A very thin layer of greatly altered cerebellar substance was seen be- 
 tween the agglutinated hard and soft meninges and the cerebellar abscess. 
 Karsner, H. T. : Journal of Medical Eesearch, Vol. XXV., 1911-1912, p. 393. 
 Situation: Large abscess in middle lobe of cerebellum, extending 
 slightly and equally into both lateral lobes. Probably of metastatic 
 origin. 
 
 Capsule: The middle lobe of the cerebellum was almost completely 
 replaced by a non-encapsulated deeply seated abscess which extended 
 slightly and equally into both lateral lobes. 
 Brook, W. : Zeitschrift fiir Ohrenheilkunde, Vol. 66, 1912, p. 267. 
 
 Situation: Case YI. Apparently anterior. Abscess in right cere- 
 bellar hemisphere following labyrinth suppuration; pus ruptured from 
 the basal convolution into the internal auditory meatus. Cochlear aque- 
 duct was filled with pus in its entire extent, as was also the vestibular 
 aqueduct in its first portion. 
 FoRGUE, E., and Eatoiier, G. : La Provence Medicale, No. 43, 1913, p. 481. 
 
 also 
 Eauzier and Eoger: Montpellier Medical, XXXV., 1912, p. 134. 
 
 Situation: Posterior. The suppuration starting from the left mastoid 
 passed through the postero-superior aspect of the petrous bone in its 
 perisinusal portion, in front of the permeable lateral sinus, causing a 
 certain degree of meningitis and invading the left lobe of the cerebellum 
 where the pus collected in the form of a small superficial abscess. 
 
 Condition of Dura Over Site of Infection: Considerable thickening of 
 cranial meninges at level of postero-superior aspect of petrous bone. 
 Glegg, W. : British Medical Journal, I., 1912, p. 608. 
 
 Situation: Probably anterior. Abscess in middle lobe of cerebellum; 
 another temporo-sphenoidal lobe abscess, immediately adjacent to cere- 
 bellar abscess; tentorium between was intact. (Death some weeks after 
 radical mastoid operation; no details.) 
 LiNOK : Zeitschrift fiir Ohrenheilkunde, Vol. 65, 1912, p. 206. 
 
 Situation: Case II. Anterior. Abscess due to transition of labyrinth 
 suppuration to cerebellum through ductus and saccus endolymphaticus, 
 by way of a fistula in the bony labyrinth capsule. The primary entrance 
 avenue was the horizontal semicircular canal, the infection travelling 
 backwards through the vestibular aqueduct. Earefying osteitis of petrous 
 bone. 
 
 Condition of Dura Over Site of Infection: Discolored yellowish area 
 size of a pea, with irregular margins, on dural covering, corresponding to 
 saccus endolymphaticus. 
 Savariaud: Journal de Medecine de Paris, No. 9, 1912, p. 171. 
 
 Situation: Probably anterior. (No sinus thrombosis.) Eight lobe of 
 cerebellum was almost entirely occupied by a large abscess without true 
 walls. Section of petrous bone near upper posterior border showed a 
 large fistulous tract filled with granulations and communicating with the 
 tympanum. 
 
 Condition of Dv/ra Over Site of Infection: Dura mater appeared 
 
APPENDIX II 239 
 
 thickened and -wiien incised sLowed the arachnoid cavity to be filled 
 with pus, especially on right side at base, at the level of the cerebellar 
 fossa. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) : 
 Eight lobe of cerebellum was almost entirely occupied by an abscess 
 which had no true walls. 
 Spencer, F. E. : Annals of Otology, Ehinology and Laryngology, Vol. 
 
 XXL, 1912, p. 321. 
 
 Situation: Cerebellar abscess of otitic origin. Floor of abscess 3 to 5 
 cm. above inferior surface of left hemisphere, which was symmetrically 
 enlarged as a whole. Lobus biventer and lobus gracilis were apparently 
 entirely replaced by the abscess cavity and its limiting membranes. No 
 connection of the abscess could be traced with the sinuses, the mastoid 
 bone, or the inner ear. The process was presumably embolic in character. 
 
 Capsule: The abscess cavity was surrounded by a clearly defined pyo- 
 genic membrane, one-half millimetre in thickness. 
 
 Pathological Processes in Cerebellum — {Softening, Discoloration, etc.) '. 
 Inferior surface of left cerebellar hemisphere which was symmetrically 
 enlarged, showed, in the sulci, streaks of yellow purulent material shining 
 through the (Edematous pia. 
 UoHEEMANN, V. : Zeitschrift fiir Ohrenheilkunde, Yol. 66, 1912, p. 49. 
 
 Situation: Anterior. Cerebellar abscess originating from petrous por- 
 tion of temporal bone, namely, the paralabyrinthine cells, (paralabyrin- 
 thitis) without a sign of labyrinth suppuration. 
 Ukbantsohitsch, E. : Monatschrift fiir Ohrenheilkunde, Vol. 46, 1912, p. 36. 
 
 Situation: Anterior. Abscess mesially situated in upper vermis ex- 
 tending symmetrically to both cerebellar hemispheres. Eecent thrombo- 
 sis of left sigmoid sinus. Fistula of semicircular canal and labyrinth- 
 suppuration. 
 
 Capsule: Abscess size of walnut in upper vermis extending symmetri- 
 cally to both cerebellar hemispheres, with a not very thick pyogenic mem- 
 brane. 
 Bruhl : Berliner Klinische Wochenschrift, No. 19, 1913, p. 897. 
 
 Situation: Cerebellar abscess in lobus biventer at a distance of 3 cm. 
 from the surface. No mention of a stalk. 
 HiBLEE, E. : Centralblatt fiir Bakteriologie, Vol. 68, 1913, Abt. I., p. 257. 
 
 Situation: Posterior. Case of cerebellar abscess due to anaerobic in- 
 fection, in the presence of chronic middle ear suppuration, sinus throm- 
 bosis and carcinosis of right petrous bone. Propagation of infection 
 from middle ear to cerebellum presumably occurred by way of and on 
 the soil of the carcinoma which had proliferated into the dural covering 
 of the petrous bone only at this point, where the dura was badly infil- 
 trated and congested. This small area was situated directly over the 
 sigmoid sinus, where the dura of the posterior petrous surface was 
 changed and destroyed. 
 
 Condition of Dura Over Site of Infection: Dura of posterior petrous 
 pyramid was destroyed in a small area just above the sigmoid sinus. 
 (Proliferation of carcinoma into dural covering of petrous bone.) In a 
 large area of the posterior and in part also the upper surface of the 
 petrous bone, dura was infiltrated, thickened and discolored. 
 
340 BEAIN ABSCESS 
 
 Capsule: There was no trace of a pyogenic membrane (right sided 
 cerebellar abscess). 
 MicHAELSEN, tr. : Zeitschrift fiir Ohrenheilkunde, Vol. 67, 1913, p. 262. 
 
 Situation: Case VIII. Anterior. No statement is given as to the 
 site, but the cerebellar abscess had existed six months, so its location 
 must be anterior. Abscess with capsule. Internal hydrocephalus. Fresh 
 thrombosis in sigmoid sinus. Circumscribed labyrinth suppuration in 
 vestibule and semicircular canals, extending through endolymphatic duct, 
 causing saccus empyema and cerebellar abscess. 
 
 Case IX. Probably anterior. Middle ear suppuration and involve- 
 ment of labyrinth. Cerebellar abscess derived from, saccus. No mention 
 of stalk. 
 
 Case XII. Probably anterior. Eoute of infection, labyrinth; dura 
 and pia adherent. Cerebellar abscess; no statement as to stalk. Hydro- 
 cephalus. 
 
 Case XIII. Undecided. No statement as to site of cerebellar abscess 
 or paths of infection. Hydrocephalus. 
 
 Condition of Dura Over Site of Infection: 
 
 Case XII. Suppuration in left labyrinth extending to dura of pos- 
 terior cranial fossa and pia of cerebellum. 
 
 Pathological Processes in Gerehellum — {Softening, Discoloration, 
 etc.) : 
 
 Case IX. Encephalitis, especially of cerebellum, probably derived 
 from saccus. 
 
 Case XII. Labyrinth suppuration extended to pia of cerebellum. 
 Maier, M. : Archiv fiir Ohrenheilkunde, Vol. 95, 1914, p. 163. 
 
 Situation: Case III. Probably anterior. (Apparently well forward, 
 but not stated.) Abscess with stalk communicating with porus acusticus 
 internus. Serous meningitis. Should have been explored from in front 
 because of the sequestra and the stalk to porus acusticus internus. 
 
 Case IV. Probably anterior. No sinus thrombosis. Abscess with 
 stalk; from description must have gravitated downward toward floor of 
 posterior fossa. 
 
 Case VII. Cerebellar abscess; no stalk. Cannot tell location; partial 
 sinus thrombosis. Perisinus abscess. 
 
 Case XI. Cerebellar abscess with stalk. Cannot state location. Trans- 
 verse sinus thrombosis. 
 
 Case XIII. "Lateral margin of cerebellum." Eight-sided abscess 
 with stalk 1% cm. deep. No sinus thrombosis. Cholesteatoma of petrous 
 bone (left). Also apparently an intrapial abscess by extension going 
 to right side. 
 
 Case XIV. Labyrinth fistula, posterior upper portion of horizontal 
 semicircular canal. Situation of cerebellar abscess apparently lateral 
 and anterior. No stalk. (Funnel-shaped defect in lower surface of 
 cerebellar hemisphere may be stalk.) Hydrocephalus. Fresh clot in 
 transverse sinus and adhesion of sinus to cerebellum. Cannot say where 
 abscess was really situated or trace mode of invasion. The thrombus 
 may have been the cause by adhesive process. 
 
 Case XIX. Otitis interna purulenta (left). Abscess in left cere- 
 bellar hemisphere. Intrapial abscess of right side (subdural space). 
 
APPENDIX II 241 
 
 No stalk. ITo description, no location. Cause: circumscribed laby- 
 rinthitis. 
 
 Case XXI. Abscess with a stalk, -with necrosis of dura. No sinus 
 thrombosis. Situation, lower surface of cerebellum. 
 
 Case XXVI. Posterior. Sigmoid sinus thrombosis. Abscess situated 
 at posterior lower surface of cerebellum (behind). No stalk. 
 
 Case XXXI. Probably anterior. No route given. Bight cerebellar 
 hemisphere was enlarged and compressed the pons and medulla, so 
 possibly anterior. No statement as to stalk or exact position. 
 
 Case XXXIV, Sinus thrombosis. Situation of abscess, lateral half 
 of cerebellar hemisphere. "Abscess had evidently originated from sur- 
 face." Must have come from sinus thrombosis. Extradural adhesion 
 of posterior and upper surface of petrous pyramid. Abscess with 
 stalk. 
 
 Case XXXVI. Anterior. Sinus thrombosis. Cerebellar abscess; no 
 statement as to stalk; infection passed probably from sinus to brain 
 surface. Situation "at lateral margin of lower segment," so must be 
 "forward" low down towards bulb. 
 
 Condition of Dura Over Sites of Infection: 
 
 Case VII. Inner surface of tense dura mater covered with a layer of 
 thick pus ; likewise arachnoid. 
 
 Case XI. Margins of left cerebellar abscess cavity. 
 
 Case XVII. Transverse sinus passed in an adhesion between dura and 
 cerebellum. 
 
 Case XXI. Dura of left cerebellum was transformed into a thickened 
 tissue mass adherent to pia. 
 
 Case XXXIV. Pachymeninx raised from bone by purulent exudate, 
 at posterior and upper surface of petrous pyramid. 
 
 Case XXXVI. Thick layer of pus between arachnoid and pachy- 
 meninx of left cerebral hemisphere. Also pus in subdural space at the 
 base, especially in the left and right posterior cranial fossa. (Abscess at 
 lateral margin of lower segment of right cerebellar hemisphere.) 
 
 Capsule: 
 
 Case III. Large abscess in right cerebellar hemisphere, with pyogenic 
 membrane. 
 
 Case IV. A continuous membrane could be detached only from the 
 outer half of the abscess cavity in the right-cerebellar hemisphere. 
 
 Case XIII. Abscess in left cerebellum. Under tentorium on both 
 sides, there was a purulent membrane firmly applied to tentorium 
 throughout; the two cerebellar hemispheres were likewise covered by a 
 fairly adherent purulent membrane. 
 
 Pathological Processes in Cerebellum — (Softening, Discoloration, 
 etc.) : 
 
 Case IV. Eight cerebellar hemisphere adherent at its lower surface 
 to petrous bone. 
 
 Case VII. Cerebellum greatly softened in surroundings of abscess 
 cavity. 
 
 Case XI. Cerebellar substance around abscess slightly discolored. 
 
 Case XIII. Cerebellar substance surrounding abscess cavily was 
 greatly softened. 
 
MS BEAIN ABSCESS 
 
 Case XIV. Eight cerebellar hemispliere very congested and reddened, 
 especially in its lateral areas. Large funnel-sliaped defect with reddened 
 margins on lower surface of this hemisphere. 
 
 Case XIX. Pia mater at base of cerebellum infiltrated with pus. Left 
 cerebellar hemisphere consisted of a disintegrating mass and contained 
 a large cavity. 
 
 Case XXI. Dura of left cerebellum was transformed into a thickened 
 tissue-mass adherent to the pia. Lower surface of cerebellum presented 
 an orifice which led into a cavity from which the pus had been emptied 
 in an operation. 
 
 Case XXXI. Eight cerebellar hemisphere was enlarged and com- 
 pressed the pons and medulla. 
 
 Case XXXIY. At base of brain on lower side of right cerebellar 
 hemisphere, the internal meninges were purulent and infiltrated. Abscess 
 had originated from surface. 
 EUTTIN, E. : Monatschrift fiir Ohrenheilkunde, Vol. 48, 1914, p. 728. 
 
 Situation: Probably posterior. Sinus thrombosis. Cerebellar abscess; 
 no statement as to situation. No statement as to stalk. 
 Fbiesner, L : Annals of Otology, Ehinology and Laryngology, Vol. XXVI., 
 
 No. 3, 1917, p. 847. 
 
 Situation: Anterior. Abscess was entered from Trautmann's triangle, 
 "downward and backward" one inch. Sinuses normal. 
 
 Condition of Dura Over Site of Infection: Dura macroscopically nor- 
 mal ; no granulations, no exudate. 
 Stme, W. S.: Journal of Laryngology, Ehinology and Otology, Vol. 
 
 XXXn., 1917, p. 190. 
 
 Situation: Posterior. The deep wall of the lateral sinus was bulging 
 and fluctuating; it was incised and a large cerebellar abscess was opened 
 into. Infection presumably occurred through the sinus and the com- 
 municating veins. 
 
 Pathological Processes in Gerehellum — {Softening, Discoloration, 
 etc.) : Destruction of cerebellum was very extensive and was probably 
 caused by infection from several sources. 
 
 Additional Bibliography 
 
 Cerebellae Abscess 
 
 BRAtW, E.: Archiv fur Ohrenheilkunde, Vol. XXIX, 1889-90, p. 161. 
 
 PoiiLAK: Wiener Medizinische Wochenschrift, No. 47, 1894, p. 2020 (Deutsche 
 
 Medizinal Zeitung, XII, 1894, p. 1121. 
 AoLAND, T. D., and Ballance, A. A.: St. Thomas's Hospital Reports, 1894, 
 
 London, 1896, N. S., XXIII, p. 133. 
 Thigpbn, Ch. a.: Archives of Otology, Vol. XXVI, 1897, p. 253. 
 KooH, P.: Monograph, 1897, p. 24 (Otitic Cerebellar Abscess). 
 UcHERMANN, VON.: Zeitschrift fiir Ohrenheilkunde, Vol. 46, 1906, p. 303. 
 Dixon, Geoege Sloah: Transactions of American Otological Society, Vol. 
 
 IX-X, 1906, p. 282. 
 NoTJBSB: Journal of Laryngology, Otology and Ehinology, Vol. XXII, 1907, 
 
 p. 110. 
 Mjodowski, F,: Arohiv fur Ohrenheilkunde, Vol. 22, 1908, p. 239. 
 
APPENDIX II 243 
 
 Texiee, v.: Revue Hebdomadaire de Laryngologie, d'Otologie, et de Rhinologie, 
 
 XXXIX, 1909, p. 401. 
 Voss, F. : Zeitschrift fur Ohrenheilkunde, Vol. LXI, 1910, p. 323. 
 KOPEYKSKI: Monatschrift fiir Ohrenheilkunde, 41, 1910, p. 809. 
 SoHALLEB, W. F.: California State Journal of Medicine, Vol. XI, No. 7, 1913, 
 
 p. 281. 
 Eagleton, Wells P.: Medical Eecord, Vol. 95, No. 7, 1919, p. 274. 
 
APPEISTDIX III 
 
 FRONTAL LOBE ABSCESS 
 
 Analysis of 140 Beported Cases. 
 
 Total Number Frontal Lobe Abscess, 140." 
 
 I — ^Adjacent Frontal Lobe Abscess 104 
 
 From Frontal Sinus 64 
 
 From Ethmoid 23 
 
 With Orbital Complications 41 
 
 Associated with Osteomyelitis 9 
 
 II — ^Metastatic Frontal Lobe Abscess 14 
 
 In Opposite Lobe 7 
 
 Of Aural Origin 9 
 
 III — Traumatic Frontal Lobe Abscess 22 
 
 140 
 Additional Tabulations Frontal Lobe Abscess. 
 
 I — Path of Infection of Frontal Lobe Abscess 71 
 
 II — Frontal Lobe Abscess Associated with Complications 117 
 
 III — Frontal Lobe Abscess Associated with Epidural Abscess 3 
 
 rv — Frontal Lobe Abscess Associated with Extradural Abscess 14 
 
 V — Frontal Lobe Abscess Associated with Subdural Abscess 4 
 
 VI — Frontal Abscesses Associated with Meningitis 31 
 
 Adjacent Feontal Lobe Abscess. 
 
 Pbeysing : ( 1 ) Left frontal abscess following empyema of left maxillary sinus. 
 
 frontal sinus, and ethmoid cells. 
 Ebinhard: (1) Left frontal abscess with an extradural abscess. 
 SOLOWTKCZ and Kaebowski, B.: (1) Chr. latent frontal sinus suppuration with 
 
 epidural abscess at greater wing of sphenoid bone. 
 Eaglbton: (1) Case XXI — D. McS., Chapter Seven, p. 111. Orbital and extra- 
 dural. 
 Manasse: (1) Intracranial complications after acute influenza. Sinusitis. 
 
 First abscess in left frontal lobe. Then abscess in left temporal lobe and 
 
 intrameningeal abscess in left occipital lobe. 
 Zemann: (1) Multiple abscesses in rt. frontal lobe, one superficial cortical 
 
 and two communicating deep seated. 
 PiCQirt: (1) Intracerebral abscess after right mastoid symptoms and sub- 
 
 meningeal symptoms supervening on influenza. 
 
 I The cases in the following lists of Frontal Lobe Abacesaes neceasarily overlap 
 to a greater or less extent, each list containing many duplicate cases from other 
 lists, according as the varioua aymptoms complicate one with another of the different 
 manifestations. If this is borne in mind there will be no confusion in regard to the 
 140 recorded cases here given, 
 
 244 
 
APPENDIX III 245 
 
 Gbtjening: (1) Chronic Buppuration ethmoid cells and frontal sinus; osteotomy 
 for exploration of brain; inner plate orbital process removed, dura mater 
 exposed; it was discolored and perforated on under surface frontal lobe. 
 Death. 
 
 Pbbysing: (1) Left-sided frontal abscess from gangrenous purulent process in 
 left nose and its cavities. 
 
 Steese: (1) Abscess in left frontal lobe. Post-mortem showed frontal sinus 
 disease. 
 
 KoEBEL: (1) Abscess right frontal lobe after mastoid, antrum and frontal sinus 
 suppuration rt. side. Abscess referred to ear disease. Nasal condition caused 
 no disturbance. Enlarged right frontal sinus and left to a less extent filled 
 with pus. Dura detached and ulcerated. 
 
 Luo: (1) Et. frontal abscess aiter bilateral chr. frontal sinus suppuration. 
 
 Rafin: (1) Et.-sided frontal sinusitis and brain abscess. 
 
 Teeitel: (1) Abscess left frontal lobe following removal of polyps left nose, 
 and purulent discharge left nose, and pain in forehead and cheek. 
 
 SlLBX: (1) Abscess both frontal lobes after empyema ethmoid cells and frontal 
 sinus. 
 
 VON ScHEODEB: (1) Abscess rt. frontal lobe after rt.-sided retrobulbar phleg- 
 mon. 
 
 Kbeckb: (1) Left frontal abscess after nasal discharge pus, polyps, and swell- 
 ing over left eye. Frontal sinus filled with pus. 
 
 Eedtenbacher : (1) Abscess of eyelid after influenza followed by pus in frontal 
 sinus with necrosis and abscess at apex of frontal lobe. 
 
 WiLiJAMSON : ( 1 ) Abscess anterior part frontal lobe after influenza with profuse 
 nasal discharge and frontal and occipital headache. 
 
 WEtcHSELBAtrM : (1) Abscess rt. upper eyelid. Pus in rt. maxillary and frontal 
 sinus and between posterior wall of rt. frontal sinua and dura mater. Pachy- 
 meningitis and leptomeningitis and brain abscess. 
 
 SlLLAB: (1) Abscess frontal lobe and empyema left frontal sinus after long 
 standing sinusitis. 
 
 Rentoit: (1) Abscess rt. frontal lobe after obtaining pus in incision of right 
 upper eyelid for orbital cellulitis. Eight orbital plate necrosed. No commu- 
 nication between pus from orbit and cerebral abscess. 
 
 Eeineb: (1) Abscess left frontal lobe with cerebral symptoms and bone disease 
 for 2% months. Vomiting, fever, convulsions. Extensive caries frontal bone. 
 Meningitis. 
 
 BousQUET: (1) Et. frontal abscess. After acute empyema of right frontal 
 sinus, subperiosteal orbital abscess and necrosis of frontal bone. Trephining 
 of frontal bone some hours before death. 
 
 Jacubasch: (1) Large abscess frontal lobe. Second abscess further back. Pre- 
 viously sore in nose. DuU headache, vertigo, vomiting. 
 
 Maas, H.: (1) Nasal polypi and nasopharyngeal polyp removed, followed by 
 apathy and vertigo, exophthalmos, delirium, and death. Post-mortem showed 
 dura base of skull covered with pus. Abscess left frontal lobe of brain above 
 ethmoidal region. 
 
 YouL: (1) Traumatic abscess opposite wound in temporal region. (Frontal 
 lobe?) Abscess communicated with lateral ventricle. No cerebral symptoms 
 until two weeks after injury when child vomited and later had convulsions 
 terminating in death. 
 
 Stmonds, C. J.: (1) Chr. suppuration of ethmoid sinus. Death from diffuse 
 meningitis. Post-mortem showed two abscesses under surface left frontal 
 lobe. Dura mater beneath frontal lobe adherent to brain. Neither abscess 
 opened lateral ventricle. Extension to orbit. 
 
 SrwoNDS, C. J. (second case): (1) Chr. suppuration ethmoidal and frontal 
 sinuses with abscess left frontal lobe. Influenza. Nasal discharge. Opera- 
 
246 BEAIN ABSCESS 
 
 tion for suspected subdural or cerebral collection. Death. Cerebral infection 
 from ethmoid sinus. Extension to orbit. 
 
 ScHABFEB, H.: (1) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess. Destruction rt. ethmoid labyrinth rupturing through lamina 
 papyracea resulting in osteitis and periostitis of orbit. Later pachymeningitis 
 and purulent leptomeningitis. Death. 
 
 Stbutcken, H. J. L.: (1) Severe headache; pus from right nostril. Frontal sinus 
 opened. Cerebral symptoms. Puncture cranial cavity. Drainage. Recurrence 
 brain symptoms. Later a. second abscess opened. Incomplete recovery with 
 persistent amnesia. 
 
 SiBUTCKEK, H. J. L. (second case): (1) Eight-sided headache with rapidly 
 developing oedema of surroundings of rt. eye and protrusion of eyeball. Eth- 
 moid cells opened and most of them removed. Large abscess behind eyeball 
 opened. Later rigidity nape of neck. Vomiting. Later another operation 
 and another abscess found. Recovery with partial amnesia and persistent 
 loss of smell rt. side. 
 
 Manassb: (1) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after treatment. Cerebral 
 symptoms in form of vomiting, headaches and fever. Frontal sinus diseased 
 and closed ethmoid cell found attached to its posterior wall. Three operations, 
 and during last frontal lobe brain abscess found under this frontal ethmoid 
 cell. Suppurative process passed from frontal ethmoid cell to bone and then 
 to cranial contents through preformed vascular channels. 
 
 Uffenorde, W. : (1) Ozena and left-sided frontal sinus and ethmoid suppura- 
 tion leading to orbital phlegmon through fistula. Operations (2) revealed 
 extradural and frontal sinus abscess. Two months later frontal abscess; 
 meningitis; after rupture of frontal lobe abscess into ventricle. Death. 
 
 WiENEB: (1) Persistent headache; empyema frontal sinus right side with two 
 operations. Later frontal lobe abscess. Operated. Recovery. 
 
 HoscH, P. H. : (1) Bilateral maxillary sinusitis and right-sided frontal and 
 ethmoidal sinusitis. Extradural perisinus abscess and frontal lobe abscess 
 found at base of right frontal brain, only after death, because of unusual 
 location. Purulent meningitis. 
 
 Maffei: (1) Partial loss of vision followed by vomiting and severe headache. 
 Incipient neuroretinitis. Later pain in nape of neck and rise of temperature. 
 Death from asphyxia. Spontaneous discharge from left nostril and filling 
 throat. No operation. No autopsy, but author believed disease to be in frontal 
 lobe. 
 
 Metjbees: (1) Bilateral frontal sinusitis with abscess rt. frontal lobe. Sudden 
 pain left eye. Operation left frontal sinus. Recurrence severe headache and 
 sudden death under collapse. Post-mortem showed abscess rt. frontal lobe; 
 delicate membrane. Cranial sinuses free from pathological changes. 
 
 HEIMA.N, Th. : ( 1 ) Bilateral empyema antrum of Highmore and left-sided frontal 
 sinusitis. Bilateral earache. Severe headache and vomiting. Sudden death. 
 Autopsy showed extradural abscess. Right lobe and both frontal sinuses, 
 ethmoid and maxillary sinus filled with pus. Abscess with stalk, diffuse 
 meningitis. 
 
 Gbunwald, L.: (1) Ozena Empyema both frontal sinuses. Carious destruction 
 posterior sinus wall. Right-sided pachymeningitis. Abscess frontal lobe dis- 
 covered eight days after primary operation. Recovery. 
 
 MuixiN, W. v.: (1) Pain over frontal sinuses and pus from nasofrontal ducts. 
 Later pus from frontal sinuses and pain across forehead, more severe left side. 
 Sudden death. Autopsy showed abscess left frontal lobe. Necrosis extended 
 from surface all way through frontal lobe and perforated into left lateral 
 ventricle. 
 
 Bebens, T. p.: (1) Pansinusitis rt. side. Radical external frontal ethmoidal and 
 
APPENDIX III 24r 
 
 sphenoidal operation performed. Gradual recovery. Three years later frontal 
 headache. Swelling of cicatrix rt. frontal region. Incision through old frontal 
 wound revealed frontal lobe abscess. Author is convinced patient carried large 
 collection of pus for months in frontal lobe, and that this was source of nasal 
 trouble. 
 
 PiFFL, 0.: (1) Chr. left-sided frontal sinusitis and exophthalmos. Badical 
 operation. Removal orbital roof and incision of exposed dura. Frontal lobe 
 adherent to orbital roof and frontal abscess found at autopsy. 
 
 Elschnig, a.: (1) Chr. tuberculous tumor lachrymal gland right eye. Opera- 
 tion. Extirpation of tumor and temporary resection of lateral orbital wall. 
 Death four weeks after. Abscess found in right frontal lobe directly above base 
 with circumscribed adhesions of meninges. 
 
 Elschnig, a. (second case): (1) Phlegmon left upper eyelid incised. Paresis 
 right side and mental apathy. Operation left frontal abscess. Bemoval 
 orbital roof and dura. Recovery. 
 
 Elschmig, a. (third case): (1) Chr. frontal sinusitis. Incipient orbital 
 phlegmon. Radical operation after incision at upper inner orbital margin. 
 Abscess found in frontal brain; death. Autopsy showed abscess reaching to 
 area of second frontal convolution. Incipient encephalitis remainder frontal 
 lobe and , adjacent temporal lobe. Purulent meningitis entire right cerebral 
 hemisphere. 
 
 ZEMANif: (1) Chr. bilateral frontal sinusitis; fistula through left eyebrow; left- 
 sided ethmoid cell suppuration. Badical operation left side. Subperiosteal 
 abscess cavity. Two weeks later operation right frontal sinus. Death in 
 three days. Autopsy showed adhesion right frontal lobe to posterior surface 
 of frontal sinus. Two deeper abscesses in frontal lobe behind superficial cor- 
 tical abscess in white brain substance frontal pole and separated from cortical 
 abscess by layer of brain tissue. 
 
 Ltjbbebs, K.; (1) Chr. frontal sinusitis and fistula right eyebrow followed by 
 osteomyelitis, frontal bone and frontal sinus empyema. Abscess right frontal 
 lobe which author believed bad existed for 18 months. Recovery. 
 
 RiscHE, H.: (1) Headache; swelling above left eye. Incised. Pus evacuated. 
 Stupor, vomiting. External frontal sinus operation. Dura incised. Abscess 
 found in frontal lobe. Recovery. 
 
 BuTZENGEiQEB, C. : (1) Infection nasopharynx and frontal sinus; pus rupturing 
 to outside causing external abscess right side of forehead. Simultaneously 
 inward progression of infection. Operation, right frontal sinus exposed. 
 Frontal abscess found. Bight days later headache and vomiting. Wound 
 re-opened twice for re-filling abscess. Hernia cerebri. Ablation. Recovery. 
 
 White, J. A.: (1) Chr. frontal sinusitis. Dullness of intellect. Operation dis- 
 closed frontal lobe abscess. Unconsciousness. Lost use right arm and muscles 
 of face. Second abscess found in Bolandie fissure. Death. 
 
 McCoy, J.: (1) Pneumonia; swelling of eyelids one week later. Incised. Fis- 
 tulous opening showed eroded bone. Double ethmoiditis perforating both 
 orbital plates. Extension necrosis frontal and forehead regions. Osteomyelitis. 
 Epidural abscess left upper forehead. Nausea, vomiting. Cerebral symptoms. 
 Paralysis right side. Coma. Disintegration entire frontal lobe. Death. i 
 
 McCoy, J. (second case) : (1) Pain left eye; frontal sinus relieved considerable> 
 pus. Improvement, but almost constant headache and intermittent discharge 
 of pus. Swelling left forehead and epidural abscess found on incision. Head- 
 ache, drowsiness, nausea, vomiting. Osteomyelitis. Ethmoid labyrinth thor- 
 oughly removed. Convulsions. Wound re-opened and multiple abscesses 
 found. Hernia cerebri. Gradual recovery. 
 
 HUED, L. M.: (1) Chr. pansinusitis. Epidural abscess; frontal lobe abscess. 
 Meningitis. Death. 
 
 GoxTLTEB, B. J.: (1) Trauma to left orbit (piece of wood) through upper eyelid. 
 
248 BRAIlSr ABSCESS 
 
 Convergent squint and diplopia. Swelling on orbit incised. Three months 
 later apathy. Loss of memory; subnormal temperature. Both eyes proptosed. 
 Paralysis left external rectus. Choked disc. Skull trephined. Frontal lobe 
 abscess. Month later twitching right arm and leg. Second abscess tapped. 
 Keoovery. 
 
 Fagge, C. E.: (1) Empyema frontal sinus. Badical operation. Headache; 
 apathy. Subnormal temperature. Abscess left frontal lobe. Death. Post- 
 mortem showed abscess nearly to anterior horn of lateral ventricle. 
 
 ElEIMEB: (1) Acute right frontal sinus Inflammation. Three operations. In 
 third large abscess extending close to lateral ventricle evacuated. Death five 
 days later. 
 
 Laubxtb, M. p. ; (1) Chr. frontal sinusitis. Operation. Posterior bony wall 
 intact. Abscess frontal lobe. Infection of brain through venous or lymphatic 
 channels. Recovery. 
 
 Fbeudewthai., W. ; (1) Acute frontal sinusitis. Headache, nasal discharge. 
 CEdema right eye. Posterior wall of sinus eroded. Convulsions left side. 
 Death several days later. 
 
 Rawling, L. B. : (1) Frontal headache. (Edema, right upper eyelid. Coma. 
 Paralysis left side of body and face. Vomiting. Optic neuritis. Operation; 
 abscess found. Recovery. Two later operations for return of symptoms. 
 Headache. Left hemiplegia; marked hernia. Frontal sinus contained carious 
 bone. Recovery. 
 
 Mayeb, H.: (1) Radical sinus operation for left-sided frontal sinus empyema. 
 Death. Frontal abscess; purulent meningitis. Thrombosis of sagittal and 
 cavernous sinus. Bone intact. Infection occurred by way of blood vessels. 
 Veins of roof of frontal sinus filled with pus and coagulated blood. 
 
 Hammesfahb: (1) Left-sided frontal sinus empyema and frontal lobe abscess. 
 Symptoms of brain pressure eight weeks later. Operation. Abscess found in 
 posterior pole of lower frontal convolution. Recovery. Infection occurred by 
 way of venous channel. 
 
 RoEPKB: (1) Left frontal sinus and maxillary suppuration. Subperiosteal and 
 extradural abscess. Second operation frontal lobe abscess. Death. Probable 
 rupture into lateral ventricles. 
 
 RoEPKB (second case) : (1) Bilateral frontal sinus suppuration. Osteomyelitis. 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into the lateral ventricle. Death. 
 
 Gosis: (1) Chr. frontal sinusitis. Fever, vomiting, convulsions. Operation; 
 evacuation extradural abscess. Death. Post-mortem showed frontal lobe 
 abscess. 
 
 GoBis (second case) (1): Frontal sinusitis. Meningitis. Death, three days 
 after operation for extradural abscess. Post-mortem showed frontal lobe ab- 
 scess. 
 
 ClBNEBOS: (1) Frontal sinusitis. Evacuation of ethmoid. Operation for brain 
 abscess. Disintegration large portion right frontal lobe. Death from menin- 
 gitis. 
 
 Settebt: (1) Bilateral empyema frontal sinus. Removal nasal polyps. Death 
 five days later. Post-mortem showed abscess right frontal lobe. Continuity 
 infection posterior wall through lymphatics or blood vessels. 
 
 MnJJOAN, W.: (1) Left frontal and ethmoidal sinus disease. Supra-orbital 
 incisions. Nasal drainage. Abscess left frontal lobe. Extensive basal menin- 
 gitis. Death. 
 
 MmiGAN, W. (second case): (1) Left frontal and maxillary sinus disease. 
 Supra-orbital incision. Alveolar drainage. Abscess left frontal lobe. Exten- 
 sive basal meningitis. Death. 
 
 GAjnPTJT: (1) Acute frontal sinusitis. Orbital phlegmon. Two operations. 
 Death. Post-mortem showed abscess frontal lobe at level of meningeal and 
 
APPENDIX III 249 
 
 bone lesions. Microscopical abscess on cortical surface of brain. Incipient 
 osteitis orbital roof. 
 
 Eeinhabd: (1) Left-sided frontal sinus suppuration, and frontal lobe abscess. 
 Extradural abscess. Meningitis and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess, abscess 
 on floor of second left frontal convolution. Layer of healthy brain tissue 
 between. 
 
 HuBBABD: (1) Ozena. Acute mastoiditis. No operation. Two months later 
 mental dullness and headache. Mastoid tenderness: death. Post-mortem 
 showed abscess centre frontal lobe. Dura adherent to under surface right 
 frontal lobe. 
 
 Linden: (1) Empyema left frontal sinus. Brain abscess. Death. Post-mortem 
 showed dura and pia adherent. Thick-walled abscess. No direct communica- 
 tion between abscess and sinus. Path of infection — sequestration of posterior 
 wall. 
 
 PAtWZ, M.: (1) Acute left frontal sinusitis. Headache and vomiting. Dilated 
 sluggish pupils. Venous hyperemia of eyegrounds. Operation — bulging dura. 
 Incision of dura and brain substance; pus aspirated. Death. 
 
 Heezfeld: (1) Coryza. Left-sided frontal headaches. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Recovery. 
 
 Denkeb: (1) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. One month later external operation. Headaches, 
 somnolence, blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 Recovery. 
 
 Tratjtmann: (1) Empyema left frontal sinus. Perforation into orbit and 
 anterior cranial fossa. Abscess left middle frontal lobe. Caries orbital roof. 
 Death two weeks later. Post-mortem showed dura adherent to left frontal 
 lobe and brain. Perforation of posterior wall. Circular orifice in bone com- 
 municating with frontal sinus. 
 
 Wilson : ( 1 ) Abscess frontal sinus and frontal lobe. Perforation external and 
 internal wall. Death. 
 
 PEINGST, A. 0.: (1) Ethmoidal involvement. Head pains on side of orbit. 
 Convulsions. Sudden death. Post-mortem showed large encapsulated abscess 
 in frontal lobe. Path of infection through blood vessels. 
 
 Jessamon, L. W. : ( 1 ) Tenderness over left frontal sinus and ethmoids. Nasal 
 operation. Temperature. Thick speech. Aphasia. Paresis right arm. Com- 
 plete paralysis right hand. Posterior wall frontal sinus removed. Congestion 
 optic disc. Aphasia increased. Third operation subdural abscess. Death. 
 Post-mortem showed dura thickened especially over ethmoid, and discolora- 
 tion over ethmoid bone. 
 
 Adjacent Feontal Lobe Abscess feom Ethmoid Disease. 
 
 Vangehitchten : (1) Anomaly of ethmoid sinus cause of infection. 
 
 SiLEX: (1) Empyema of ethmoid cells and frontal sinus, previous to two 
 
 abscesses of frontal lobes. 
 Williamson: (1) Large frontal (right) abscess after influenza, with profuse 
 
 nasal discharge and frontal and occipital headache. Small amount of pus 
 
 in right ethmoid cells. 
 Knapp : ( 1 ) Abscess left frontal lobe after orbital phlegmon evacuated from 
 
 pus. Anterior ethmoid cells filled with offensive pus. 
 Symonds: (1) Chronic suppuration of ethmoid sinus. Death from diffuse 
 
 meningitis. Post-mortem showed two abscesses under surface left frontal lobe. 
 
350 BRAIN" ABSCESS 
 
 Dura mater beneath frontal lobe adherent to brain. Neither abscess opened 
 lateral ventricle. Extension to orbit. 
 
 Stmonds (second case) : (1) Chronic suppuration ethmoidal and frontal sinuses 
 with abscess left frontal lobe. Influenza. Nasal discharge. Operation for 
 suspected subdural or cerebral collection. Death. Cerebral infection from 
 ethmoid. Extension to orbit. 
 
 ScHAEFEB, H. : (1) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess. Destruction right ethmoid labyrinth rupturing through lamina 
 papyracea, resulting in osteitis and periostitis of orbit. Later pachymeningitis 
 and purulent leptomeningitis and death. 
 
 STRtrTCKEN, H. J. L. ( 1 ) Eight-sided headache with rapidly developing oedema of 
 surroundings of right eye and protrusion of eyeball. Ethmoid cells opened 
 and most of them removed. Large abscess behind eyeball opened. Later 
 another abscess. Operation. Eecovery with partial amnesia and persistent 
 loss of smell on right side. 
 
 Manasse : ( 1 ) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after-treatment. Cerebral 
 symptoms in form of vomiting, headaches, fever. Frontal sinus diseased, and 
 closed ethmoid cell found attached to its posterior wall. Three operations, 
 and at last frontal lobe brain abscess found imder this frontal ethmoid 
 cell. Suppurative process passed from frontal ethmoid cell to bone and then 
 to cranial contents, through preformed vascular channels. Recovery. 
 
 Uffenokde, W. : (1) Ozena and left-sided frontal sinus and ethmoid suppura- 
 tion leading to orbital phlegmon through iistula. Operations (2) revealed 
 extradural abscess and frontal sinus abscess. Two months later frontal abscess 
 and meningitis. After rupture of frontal lobe abscess into ventricle. Death. 
 
 HoscH, P. H. : ( 1 ) Bilateral maxillary sinusitis and right-sided frontal and 
 ethmoidal sinusitis. Extradural perisinus abscess; frontal lobe abscess found 
 at base of right frontal brain after death. Purulent meningitis. 
 
 Hmmajst, Th.: (1) Bilateral empyema antrum of Highmore and left-sided 
 frontal sinusitis. Bilateral earache. Severe headache and vomiting. Sudden 
 death. Autopsy showed extradural abscess. Right lobe and both frontal 
 sinuses, ethmoid and maxillary sinus filled with pus. Abscess with stalk. 
 Diffuse meningitis. 
 
 Bkeens, T. p. : ( 1 ) Pansinusitis right side. Radical external frontal, ethmoidal, 
 and sphenoidal operations performed. Gradual recovery. Three years later 
 frontal headache. Swelling of cicatrix right frontal region. Incision through 
 old frontal wound revealed frontal lobe abscess. Author convinced patient 
 carried large collection of pus for months in frontal lobe and that this was 
 source of nasal trouble. 
 
 ZBatANN, W. : (1) Chr. bilateral frontal sinusitis; fistula through left eyebrow. 
 Left-sided ethmoid cell suppuration. Radical operation left side. Subperi- 
 osteal abscess cavity. Two weeks later operation right frontal sinus. Death 
 in three days. Autopsy showed adhesion right frontal lobe to posterior sur- 
 face of frontal sinus. Two deeper abscesses in frontal lobe behind superficial 
 cortical abscess in white brain-substance frontal pole, and separated from cor- 
 tical abscess by layer of brain tissue. 
 
 McCoT, J.: (1) Pneumonia; swelling of eyelids, one week later incised. Fistu- 
 lous opening showed eroded bone. Double ethmoiditis perforating both orbital 
 plates. Extension necrosis frontal and forehead regions. Osteomyelitis. 
 Epidural abscess left upper forehead. Nausea, vomiting. Cerebral symptoms; 
 paralysis right side. Coma. Disintegration entire frontal lobe. Death. 
 
 McCoT, J. (second case) : (1) Pain left eye; frontal sinus relieved considerable 
 pus. Improvement, but almost constant headache and intermittent discharge 
 of pus. Swelling left forehead and epidural abscess found on incision. Head- 
 ache, drowsiness, nausea, vomiting. Osteomyelitis. Ethmoid labyrinth thor- 
 
APPENDIX III 251 
 
 oughly removed. Convulsions. Wound re-opened and multiple abscesses found. 
 Section of bone removed from temporal region. Hernia cerebri. Gradual 
 recovery. 
 
 HcED, L. M. : (1) Chr. pansinusitis. Epidural abscess. Frontal lobe abscess. 
 Meningitis. Death. 
 
 Stuckt: (1) Traumatic ethmoiditis. Meningitis. Abscess frontal lobe. No 
 localizing symptoms. Death. Post-mortem showed necrotic cribriform plate. 
 Fracture through table left frontal sinus. Cerebral convolutions softened. 
 
 CiSNEBOS ; ( 1 ) Frontal sinusitis. Evacuation of ethmoid operation for brain 
 abscess. Disintegration large portion right frontal lobe. Death from menin- 
 gitis. 
 
 MiLUGAN, W. (1) Left frontal and ethmoidal sinus disease. Supraorbital in- 
 cision. Nasal drainage. Abscess left frontal lobe. Extensive basal menin- 
 gitis. Death. 
 
 Denkeb: (1) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. One month later external operation. Headaches. 
 Somnolence. Blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural mass exposed. Dura incised. Brain incised and abscess evacuated. 
 Recovery. 
 
 Ppingst, a. O. : (1) Ethmoidal involvement. Head pains on side of orbit. 
 Convulsion. Sudden death. Post-mortem showed large encapsulated abscess 
 in frontal lobe. Path of infection through blood vessels. 
 
 Jessamon, L. W. : (1) Tenderness over left frontal sinus and ethmoids. Nasal 
 operation. Temperature. Thick speech. Aphasia. Paresis right arm. Com- 
 plete paralysis right hand. Posterior wall frontal sinus removed. Congestion 
 optic disc. Aphasia increased. Third operation. Subdural abscess. Death. 
 Autopsy showed dura thickened especially over ethmoid and discoloration over 
 ethmoid bone. 
 
 Adjacent Fbontal Lobe Abscess feom Fbontal Sirrns. 
 
 CiSNEEOS: (I) Latent sinusitis (acute) with complete obstruction of frontal 
 canal. 
 
 SoLOWCEJOZTK and Kabbowski: (1) Chr. latent frontal sinus suppuration with 
 intracranial complications in the form of epidural abscess. 
 
 SoHOTJSBOE: (1) Empyema frontal sinus and anterior ethmoid cells compli- 
 cated by orbital abscess and frontal lobe abscess. Improvement after opera- 
 tion. Later dull and indifferent, loss of appetite,, vomiting, retarded pulse. 
 Craniotomy. Recovery. 
 
 MOEULEE (Quoted by Schousboe) : (1) Left maxillary sinus empyema, orbital 
 abscess; ethmoid cells and sphenoid cavity evacuated. During convalescence 
 from operation sudden nausea and death. Frontal sinus empyema and frontal 
 sinus abscess quoted as cause of death. 
 
 Manasse: (1) Acute frontal sinusitis followed by left frontal, left temporal and 
 left occipital abscess. 
 
 Eckstein: (1) Subperiosteal abscess at lateral end of left supraorbital mar- 
 gin. 
 
 Grubning: (1) Chr. suppuration of ethmoid cells and frontal sinus after nasal 
 pneumococcus invasion which resulted in brain abscess. 
 
 Pbetsinq: (1) Left-sided frontal lobe abscess following empyema left maxillary 
 sinus, frontal sinus and ethmoid cells from gangrenous purulent process of 
 left nose. 
 
 Stbibse: (1) Post-mortem showed abscess in left frontal lobe and perforation 
 in posterior wall of frontal sinus. 
 
 KoEBBX: (1) Right frontal abscess after combination of mastoid, antrum, and 
 frontal sinus suppuration. 
 
353 BEAIN ABSCESS 
 
 Luc: (1) Eight frontal abscess following bilateral chronic frontal sinus sup- 
 puration. 
 
 RafiN: (1) Eight frontal abscess and right-sided frontal sinusitis. 
 
 TBeitel: (1) Purulent discharge left side of nose, pain in forehead and cheek. 
 Polyps left side of nose, and middle turbinate removed. Operation frontal 
 sinus. Post-mortem showed large abscess frontal lobe; dura adherent to brain; 
 meningitis ; hemiparesis. 
 
 SiLEX: (1) Empyema ethmoid cells and frontal sinus, followed by abscesses 
 (2) both frontal lobes. 
 
 Dmochowsky: (1) Right frontal abscess in case of antrum inflammation. 
 
 Kbeckl: (1) Left frontal abscess after discharge of pus from nose and nasal 
 polyps. Operation for swelling above left eye. Weeping fistula; frontal sinus 
 found to be filled with pus. 
 
 ZiEM : ( 1 ) Frontal lobe abscess arising laterally from optic nerve. Post-mortem 
 also showed mucosa of left frontal sinus discolored grayish black. 
 
 KOBHLER: (1) Abscess behind dura. No communication between frontal sinus 
 and nose. Forehead tender on pressure. No history obtainable. Fluctuating 
 swelling on left frontal tuberosity. 
 
 ScHiNDLEB : ( 1 ) Left-sided frontal lobe abscess following inflammation of 
 frontal sinus. Post-mortem showed abscess in second and third frontal 
 convolutions. 
 
 Williamson: (1) Influenza and profuse nasal discharge and frontal and 
 occipital headache. Progressive increasing mental dullness. Right optic neu- 
 ritis. Large abscess anteriorly right frontal lobe on autopsy. 
 
 Weichselbaum : ( 1 ) Abscess right upper eyelid and pus in right maxillary and 
 frontal sinus and between wall, right frontal sinus and dura mater. Purulent 
 pachymeningitis and leptomeningitis and brain abscess. 
 
 SiLLAE: (1) Abscess frontal lobe with empyema frontal sinus (left) after long 
 standing sinusitis. Death. 
 
 Reimek : ( 1 ) Abscess left frontal lobe with cerebral symptoms and bone disease. 
 Extensive caries frontal bone. Meningitis? Diminished hearing. Paralysis 
 left sixth nerve. 
 
 BOTJSQTJET: (1) Acute empyema right frontal sinus. Subperiosteal orbital 
 abscess and necrosis of frontal bone. Puncture of orbit. Later trephining 
 frontal bone, not sinus. Death. 
 
 Symonds ( Case 2 ) : ( 1 ) Chronic suppuration ethmoidal and frontal sinus with 
 abscess left frontal lobe. Influenza. Nasal discharge. Operation for suspected 
 subdural or cerebral collection. Death. Cerebral infection from ethmoid 
 sinus. Extension to orbit. 
 Strltyoken, H. J. L.: (1) Severe headache; pus from right nostril. Frontal 
 sinus opened; cerebral symptoms. Puncture cranial cavity. Drainage. Re- 
 currence brain symptoms. Later a second abscess opened. Incomplete recov- 
 ery with persistent amnesia. 
 Manasse: (1) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after treatment. Cerebral 
 symptoms in form of vomiting, headache, fever. Frontal sinus diseased and 
 closed ethmoid cell found attached to its posterior wall. Three operations, 
 and at last, frontal lobe brain abscess found under this frontal ethmoid 
 cell. Suppurative process passed from this frontal ethmoid cell to bone and 
 through to cranial contents, through preformed vascular channels. Recovery. 
 Uffenoede, W. : ( 1 ) Ozena and left-sided frontal sinus and ethmoid suppuration, 
 leading to orbital phlegmon, through fistula. Operations (2) revealed extra- 
 dural abscess and frontal sinus abscess. Two months later frontal abscess, 
 meningitis after rupture of frontal lobe abscess into ventricle. Death. 
 WiENBE, A.: (1) Persistent headache; empyema of frontal sinus right side, 
 with two operations. Later frontal lobe abscess. Operated. Recovery. 
 
APPENDIX III 253 
 
 HoscH, P. H.; (1) Bilateral maxillary sinusitis and right-sided ethmoidal and 
 frontal sinusitis. Extradural perisinus abscess. Also frontal lobe abscess 
 found at base of right frontal brain after death. Purulent meningitis. 
 
 Meuregss: (1) Bilateral frontal sinusitis with abscess right frontal lobe. Sud- 
 den pain left eye. Operation left frontal sinus. Recurrence severe headache 
 and sudden death in collapse. Post-mortem showed abscess right frontal lobe, 
 with delicate membrane cranial sinuses free from pathological changes. 
 
 Feeitdenthal, W.: (1) Acute empyema frontal sinus. Diffuse suppuration 
 frontal lobe. Two operations. Death after second. Catheter then introduced 
 struck only a fluid mass so that more than the frontal lobe seemed to be 
 bathed in pus. 
 
 Feeudenthai, W. (second case) : (1) Influenza; frontal sinusitis. Extradural 
 collection of pus. Abscess of frontal lobe. Two operations. Headaches. Dis- 
 colored bone. Abscess between it and intact dura. Eecovery. 
 
 Feettdenthal, W. (third case): (1) Acute empyema sphenoid sinus. Infection 
 extended to other accessory sinuses with abscess in temporal lobe. 
 
 Heiman, Th. : (1) Bilateral empyema. Antrum of Highmore and left-sided 
 frontal sinusitis. Bilateral earache. Severe headache and vomiting. Sudden 
 death. Autopsy showed extradural abscess. Right lobe and both frontal 
 sinuses, ethmoid and maxillary sinus filled with pus. Abscess with stalk. 
 Diffuse meningitis. 
 
 Gbunwald, L. : (1) Ozena; empyema both frontal sinuses. Carious destruction 
 posterior sinus wall. Right-sided pachymeningitis. Abscess frontal lobe 
 discovered eight days after primary operation. Recovery. 
 
 MuiiiN, W. v.: (1) Pain over frontal sinuses and pus from nasofrontal ducts. 
 Later pus from frontal sinuses and pain across forehead more severe left side. 
 Sudden death. . Autopsy showed abscess left frontal lobe. Necrosis extended 
 from surface all the way through frontal lobe and perforated into left lateral 
 ventricle. 
 
 Beeens, T. p. : ( 1 ) Pansinusitis right side. Radical external, frontal, ethmoidal 
 and sphenoidal operation performed. Gradual recovery. Three years later 
 frontal headache. Swelling of cicatrix right frontal region. Incision through 
 old frontal wound revealed frontal lobe abscess. Author is convinced patient 
 carried large collection of pus for months in frontal lobe, and that this was 
 source of nasal trouble. 
 
 PiFFL, O. : (1) Chr. left-sided frontal sinusitis and exophthalmos. Radical 
 operation. Removal orbital roof and incision of exposed dura. Frontal lobe 
 adherent to orbital roof and frontal abscess found at autopsy. 
 
 Elschnig, a. (third case) : (1) Chr. frontal sinusitis. Incipient orbital phleg- 
 mon. Radical operation after incision at upper inner orbital margin. Abscess 
 found in frontal brain. Death. Autopsy showed abscess reaching to area of 
 second frontal convolution. Incipient encephalitis remainder frontal lobe and 
 adjacent temporal lobe. Purulent meningitis entire right cerebral hemisphere. 
 
 Zhmann, W. : (1) Chr. bilateral frontal sinusitis; fistula through left eye- 
 brow. Left-sided ethmoid cell suppuration. Radical operation left side. Sub- 
 periosteal abscess cavity. Two weeks later operation right frontal sinus. 
 Death in three days. Autopsy showed adhesion right frontal lobe to pos- 
 terior surface of frontal sinus. Two deeper abscesses in frontal lobe behind 
 superficial cortical abscess in white brain-substance frontal pole and separated 
 from cortical abscess by layer of brain tissue. 
 
 Lttbbbes, K. : (1) Chr. frontal sinusitis and fistula right eyebrow followed by 
 osteomyelitis frontal bone and frontal sinus empyema. Abscess right frontal 
 lobe which author believed had existed for eighteen months. Recovery. 
 
 EiscHE, H. i (1) Headache; swelling above left eye. Incised. Pus evacuated. 
 Stupor, vomiting. External frontal sinus operation. Dura incised. Abscess 
 found in frontal lobe. Recovery. 
 
254 BRAIN ABSCESS 
 
 BtnzENGEiGEE, 0.: (1) Infection nasopharynx and frontal sinua, pus rupturing 
 to outside causing external abscess right side of forehead. Simultaneously 
 inward progression of infection. Operation. Eight frontal sinus exposed. 
 Frontal abscess found. Eight days later headache, vomiting. Wound re- 
 opened for reiilling of abscess. Hernia cerebri. Ablation. Recovery. 
 
 White, J. A.: (1) Chr. frontal sinusitis. Dullness of intellect. Operation 
 disclosed frontal lobe abscess. Unconsciousness. Lost use right arm and 
 muscles of face. Second abscess found in Eolandic fissure. Death. 
 
 McCoy, J.: (1) Pneumonia; swelling of eyelids one week later; incised. Fis- 
 tulous opening showed eroded bone. Double ethmoiditis perforating both or- 
 bital plates. Extension necrosis frontal and forehead regions. Osteomyelitis. 
 Epidural abscess left upper forehead. Nausea and Vomiting. Cerebral symp- 
 toms; paralysis right side. Coma. Disintegration entire frontal lobe. 
 Death. 
 
 MoCoT, J. (second case) : (1) Pain left eye. Frontal sinus operation; consider- 
 able pus. Improvement, but almost constant headache and intermittent dis- 
 charge of pus. Swelling left forehead and epidural abscess found on incision. 
 Headache, drowsiness, nausea, vomiting. Osteomyelitis. Ethmoid labyrinth 
 thoroughly removed. Convulsions. Wound re-opened and multiple abscesses 
 found. Section of bone removed from temporal region. Hernia cerebri. 
 Gradual recovery. 
 
 HuED, L. M.: (1) Chr. pansinusitis; epidural abscess; frontal lobe abscess; 
 meningitis; death. 
 
 Fagge, C. H.: (1) Empyema frontal sinus. Radical operation. Headache; 
 apathy. Subnormal temperature; abscess left frontal lobe. Death. Post-mor- 
 tem showed abscess nearly to anterior horn of lateral ventricle. 
 
 Keimer : ( 1 ) Acute right-sided frontal sinus inflammation. Three operations. 
 In third large abscess extending close to lateral ventricle evacuated. Death 
 five days later. 
 
 LAMBtra, M. P.: (1) Chr. frontal sinusitis. Operation. Posterior bony wall 
 intact. Infection of brain through venous or lymphatic chaiinels. Abscess 
 frontal lobe. Recovery. 
 
 Cabgill, Tubnek, and Thomas: (1) Orbital cellulitis incised. Later irritability 
 and optic neuritis. Frontal sinus opened. Posterior wall necrotic. Brain 
 covered with granulations. Abscess frontal lobe evacuated. Recovery. 
 
 FEEaDENTHAL, W. : (1) Acute frontal sinusitis. Headache. Nasal discharge. 
 Oildema right eye. Posterior wall of sinus eroded. Convulsions left side. 
 Death several days later. 
 
 Rawling, L. B. : (1) Frontal headache. (Edema right upper eyelid. Coma. 
 Paralysis left side of body and face. Vomiting. Optic neuritis. Operation. 
 Abscess found. Recovery. Two later operations for return of symptoms. 
 Headache. Left hemiplegia. Marked hernia. Frontal sinus contained carious 
 bone. Recovery. 
 
 Mayer, H. : (1) Radical sinus operation for left-sided frontal sinus empyema. 
 Death. Frontal abscess. Purulent meningitis. Thrombosis of sagittal and 
 cavernous sinus. Bone intact. Infection occurred by way of blood vessels. 
 Veins of roof of frontal sinus filled with pus and coagulated blood. 
 
 Hammesfahe: (1) Left-sided frontal sinus empyema and frontal lobe abscess. 
 Symptoms of brain pressure eight weeks later. Operation. Abscess found 
 in posterior pole of lower frontal convolution. Recovery. Infection occurred 
 by way of venous channel. 
 
 ROEPKB: (1) Left frontal sinus and maxillary suppuration. Subperiosteal and 
 extradural abscess. Second operation frontal lobe abscess. Death. Probable 
 rupture into lateral ventricles. 
 
 RoEPKB (second case): (1) Bilateral frontal sinus suppuration. OsteomyelitiB. 
 
APPENDIX III 255 
 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into the lateral ventricle. Death. 
 
 HoFFMAifN, R. : (1) Bilateral chr. sinus suppuration. Multiple brain abscess. 
 Left-sided traumatism. Two operations. Recovery. Recurrence five months 
 later. Death. Post-mortem showed infection by lymphatics. 
 
 GoRiS: (1) Chr. frontal sinusitis; fever, vomiting, convulsions. Operation. 
 Evacuation extradural abscess. Death. Post-mortem showed frontal lobe 
 abscess. 
 
 GoEis (second case) : (1) Chr. frontal sinusitis. Meningitis. Death three days 
 after operation for extradural abscess. Post-mortem showed frontal lobe 
 abscess (subdural). 
 
 ClSNEEOS: (1) Frontal sinusitis. Evacuation of ethmoid. Operation for brain 
 abscess. Disintegration large portion right frontal lobe. Death from menin- 
 gitis. 
 
 Seifeet: (1) Bilateral empyema frontal sinus. Removal nasal polyps. Death 
 five days later. Post-mortem showed abscess right frontal lobe. Continuity 
 infection posterior wall through lymphatics or blood vessels. 
 
 MiLLiGAN, W.: (1) Left frontal and ethmoidal sinus disease. Supra-orbital 
 incisions. Nasal drainage. Abscess left frontal lobe. Extensive basal men- 
 ingitis. Death. 
 
 MiLLiGAN, W. (second case): (1) Left frontal and maxillary sinus disease. 
 Supra-orbital incision. Alveolar drainage. Abscess left frontal lobe. Exten- 
 sive basal meningitis. Death. 
 
 Gariput: (1) Acute frontal sinusitis; orbital phlegmon. Two operations. 
 Death. Post-mortem showed abscess frontal lobe at level of meningeal and 
 bone lesions. Microscopical abscess on cortical surface of brain. Incipient 
 osteitis orbital roof. 
 
 Rbinhaed : ( 1 ) Left-sided frontal sinus suppuration and frontal lobe abscess. 
 Extradural abscess. Meningitis and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess one 
 on floor of second left frontal convolution. Layer of healthy brain tissue 
 between. 
 
 Linden : ( 1 ) Empyema left frontal sinus. Brain abscess. Death. Post-mortem 
 showed dura and pia adherent. Thick-walled abscess. No direct communica- 
 tion between abscess and sinus. Path of infection — sequestration of posterior 
 wall. 
 
 Patjnz, M. : (1) Acute left frontal sinusitis. Headache and vomiting. Dilated 
 sluggish pupils. Venous hyperemia of eyegrounds. Operation. Bulging dura; 
 incision of dura and brain substance. Pus aspirated. Death. 
 
 Hebzfeld, J.: (1) Coryza. Left-sided frontal headaches. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Recovery. 
 
 Denkee : ( 1 ) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. One month later external operation. Headache, 
 somnolence, blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 Recovery. 
 
 Tbatjtmann: (1) Empyema left frontal sinus. Perforation into orbit and 
 anterior cranial fossa. Abscess left middle frontal lobe. Caries orbital roof. 
 Death two weeks later. Post-mortem showed dura adherent to left frontal lobe 
 and brain. Perforation of posterior wall. Circular orifice in bone communicat- 
 ing with frontal sinus. 
 
 Wilson: (1) Abscess frontal sinus and frontal lobe. Perforation external and 
 internal wall. Death. 
 
256 BEAIN ABSCESS 
 
 Jessamoit, L. W.: (1) Tenderness over left frontal sinus and ethmoids. Nasal 
 operation. Temperature; thick speech. Aphasia. Paresis right arm. Com- 
 plete paralysis right hand. Posterior wall frontal sinus removed. Congestion 
 optic disc. Aphasia increased. Third operation. Subdural abscess. Death. 
 Post-mortem showed dura thickened, especially over ethmoid, and discolora- 
 tion over ethmoid bone. 
 
 Frontal Lobe Abscess with Oebitai. Complications. 
 
 NoNNE: (1) Choked disc from neuritis optica. 
 
 SCHOUSBOB : ( 1 ) Empyema frontal sinus and anterior ethmoid cells compli- 
 cated by orbital abscess and frontal lobe abscess. 
 MoELLEE: (1) Left maxillary sinus empyema and orbital abscess; ethmoid 
 
 cells and sphenoid. 
 Eagleton: (1) Case XXI, D. McS., Chapter Seven, p. 111. 
 
 Eckstein : ( 1 ) Subperiosteal abscess at lateral end of left supra-orbital margin. 
 Getjening : ( 1 ) Chr. suppuration of ethmoid cells, pneumococcic, involving nasal, 
 
 ethmoid, orbit, and brain. 
 Steese: (1) Pain in both eyes; dimness of vision and vomiting; abscess left 
 
 frontal lobe. 
 Steese (second case) : (1) Abscess at upper end of fissure of Rolando and 
 
 another in occipital lobe. 
 Le!E, J. M. : (1) Traumatic. Penetrating foreign body above eyelid (right upper) 
 
 and passed through sphenoidal fissure into frontal lobe. 
 VON Schroder: (1) Right frontal abscess after right retrobulbar phlegmon. 
 
 Incision orbital margin; voided much thick pus. 
 EIbeckl : ( 1 ) Left frontal abscess after nasal discharge of pus and polyps. 
 
 Operation for swelling above left eye and weeping fistula. Frontal sinus 
 
 filled with pus. Pain in occipital region. 
 Zdekaur: (1) Left-sided ptosis after traumatic penetrating wound of left side 
 
 of head from which pus discharged. 
 Redtejtbachek : (1) Abscess apex frontal lobe after abscess left upper eyelid. 
 ZiRM: (1) Frontal lobe abscess coming laterally from optic nerve and showing 
 
 cellular tissue of orbit congested. (Cavernous Sinus.) 
 BoRELius: (1) Traumatic puncture upper eyelid. Epileptiform seizures and 
 
 other cerebral symptoms. Twitching more marked left arm and leg. Incision 
 
 in upper eyelid. Drainage tube; recovery. 
 Williamson: (1) Abscess right frontal lobe after influenza with profuse nasal 
 
 discharge and frontal and occipital headache. Optic neuritis right eye. 
 Weichselbaum : (1) Abscess right upper eyelid. Eyeball intact. Pus in 
 
 right maxillary and frontal sinus and between posterior wall of right frontal 
 
 sinus and dura mater. Pachymeningitis and leptomeningitis and brain abscess. 
 Renton, J. C. : ( 1 ) Abscess right frontal lobe after incision with evacuation of 
 
 pus along upper eyelid for right orbital cellulitis. Right orbital plate necrosed. 
 
 No direct conjmunication between pus from orbit and cerebral abscess. 
 Knapp: (1) Abscess left frontal lobe after orbital phlegmon which was incised 
 
 and pus evacuated. Base of frontal lobe over orbital margin yellowish in 
 
 color and adherent to dura mater. Some pus flakes on dura. Orbit free from 
 
 pus. 
 BousQTJET: (1) Acute empyema right frontal sinus. Subperiosteal orbital 
 
 abscess and necrosis frontal bone. Puncture of orbit. Bone eroded. Sinus 
 
 flUed with cheesy pus. 
 Stmonds, C. J.: (1) Chr. suppuration ethmoid sinus. Death from diffuse 
 
 meningitis. Post-mortem showed two abscesses under surface left frontal lobe. 
 
 Dura mater beneath frontal lobe adherent to brain. Neither abscess opened 
 
 lateral ventricle. Extension to orbit. 
 
APPENDIX III 257 
 
 Stmonds, C. J. (second case): (1) Chr. suppuration ethmoidal and frontal 
 sinuses with abscess left frontal lobe. Influenza. Nasal discharge. Operation 
 for suspected subdural or cerebral collection. Death cerebral infection frbm 
 ethmoid sinus. Extension to orbit. 
 
 ScHAB3T», H. : { 1 ) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess. Destruction right ethmoid labyrinth rupturing through lamina 
 papyracea, resulting in osteitis and periostitis of orbit. Later pachymeningitis 
 and purulent leptomeningitis. Death. •' 
 
 Stbuycken, H. J. L. (second case): (1) Right-sided headache with rapiSly 
 developing oedema of surroundings right eye and protrusion of eyeball. Ethmoid 
 cells opened and most of them removed. Large abscess behind eyeball opened. 
 Later rigidity nape of neck; vomiting. Another operation and another abscess 
 found. Recovery with partial amnesia and persistent loss of smell on right 
 side. 
 
 Manasse: (1) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after treatment. Cerebral 
 symptoms in form of vomiting, headaches, fever. Frontal sinus diseased and 
 closed ethmoid cell found attached to its posterior wall. Three operations 
 and at last frontal lobe brain abscess found under this frontal ethmoid 
 cell. Suppurative process passed from this frontal ethmoid cell to bone and 
 then to cranial contents, through preformed vascular channels. Recovery. 
 
 Uffenoede, W. : (1) Ozena and left-sided frontal sinus and ethmoid suppuration 
 leading to orbital phlegmon through fistula. Operations (2) revealed extra- 
 dural abscess and frontal sinus abscess. Two months later frontal abscess and 
 meningitis after rupture of frontal lobe abscess into ventricle. Death. 
 
 Maffei: (1) Partial loss of vision followed by vomiting and severe headache. 
 Incipient neuroretinitis. Later pains in nape of neck and rise in temperature. 
 Death from asphyxia. Spontaneous discharge of pus from left nostril and 
 filling throat. No operation. No autopsy, but author believed disease to be 
 in frontal lobe. 
 
 Mbiueebs : ( 1 ) Bilateral frontal sinusitis with abscess right frontal lobe. Sud- 
 den pain left eye. Operation left frontal sinus. Recurrence severe headache 
 and sudden death in collapse. Post-mortem showed abscess right frontal lobe 
 with delicate membrane. Cranial sinuses free from pathological changes. 
 
 PirpL, 0.: (1) Chr. left-sided frontal sinusitis and exophthalmos. Radical 
 operation. Removal orbital roof and incision of exposed dura. Frontal lobe 
 adherent to orbital roof and frontal abscess found at autopsy. 
 
 Elschnig, a.; (1) Chr. tuberculous tumor, lachrymal gland right eye. Opera- 
 tion, extirpation of tumor with temporary resection of lateral orbital wall. 
 Death four weeks after. Abscess found in right frontal lobe directly above 
 base with circumscribed adhesion of meninges. 
 
 Elschnig, a. (second case): (1) Phlegmon left upper eyelid incised. Paresis 
 right side and mental apathy. Operation left frontal abscess. Removal orbital 
 roof and dura. Recovery. 
 
 Elsohnig, a. (third case) : (1) Chr. frontal sinusitis. Incipient orbital phleg- 
 mon. Radical operation after incision at upper inner orbital margin. Abscess 
 found in frontal brain. Death. Autopsy showed abscess reaching to area of 
 second frontal convolution. Incipient encephalitis remainder frontal lobe and 
 adjacent temporal lobe. Purulent meningitis entire right cerebral hemisphere. 
 
 Zemankt, W.: (1) Chr. bilateral frontal sinusitis. Fistula through left eye- 
 brow. Left-sided ethmoid cell suppuration. Radical operation left side. Sub- 
 periosteal abscess cavity. Two weeks later operation rt. frontal sinus. Death 
 in three days. Autopsy showed adhesion rt. frontal lobe to posterior surface 
 of frontal sinus. Two deeper abscesses in frontal lobe behind superficial corti- 
 cal abscess in white brain-substance frontal pole, and separated from corticaj 
 abscess by layer of brain tissue. 
 
258 BRAIN ABSCESS 
 
 McCoy, J. (second case): (1) Pain left eye. Frontal sinus operation; consid- 
 erable pus. Improvement but almost constant headache, and intermittent 
 discharge of pus. Swelling left forehead and epidural abscess found on in- 
 cision. Headache, drowsiness, nausea and vomiting. Osteomyelitis. Ethmoid 
 labyrinth thoroughly removed. Convulsions. Wound re-opened and multiple 
 abscesses found. Section of bone removed from temporal region. Hernia 
 cerebri. Gradual recovery. 
 
 CoTTLTEB, E. J.: (1) Trauma to left orbit (piece of wood) through upper eyelid. 
 Convergent squint and diplopia. Swelling in orbit incised. Three months 
 later apathy; loss of memory; subnormal temperature. Both eyes proptosed. 
 Paralysis left external rectus. Choked disc. Skull trephined. Frontal lobe 
 abscess. Month later twitching rt. arm and leg. Second abscess tapped. 
 Recovery. 
 
 Tatlob, F. L. ; (1) Trauma to rt. eye. Superficial abscess opened one month 
 later. Headache, apathy, emaciation, optic neuritis. Paresis left side of face. 
 Stiffness back of neck. Vomiting. Incontinence of urine and feces. Operation. 
 Et. frontal abscess. Recovery with poor vision. Following year unconscious, 
 convulsions, death. 
 
 Caequl, Tubnee, and Thomas : ( 1 ) Orbital cellulitis incised. Later irritability 
 and optic neuritis. Frontal sinus opened. Posterior wall necrotic. Brain cov- 
 ered with granulations. Abscess frontal lobe evacuated. Eecovery. 
 
 Eeis, W. : (1) Traumatic panophthalmitis. Brain abscess. Incision of eyeball. 
 Evacuation of pus. Headache, fever, coma; death from diffuse meningitis. 
 
 Gamput: (1) Acute frontal sinusitis. Orbital phlegmon. Two operations. 
 Death. Post-mortem showed abscess frontal lobe at level of meningeal and 
 bone lesions. Microscopical abscess on cortical surface of brain. Incipient 
 osteitis orbital roof. 
 
 Patwz, M.: (1) Acute left frontal sinusitis. Headache and vomiting. Dilated 
 sluggish pupils. Venous hyperemia of eyegrounds. Operation. Bulging dura. 
 Incision of dura and brain substance. Pus aspirated. Death. 
 
 Deneeb: (1) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. One month later external operation. Headache, 
 somnolence. Blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 Recovery. 
 
 FeoittaIi Lobe Abscess Assooiated with Osteomyelitis. 
 
 BcHWABACH: (1) Osteitis and osteomyelitis in petrous portion of temporal bone. 
 
 BOLOWCEJOZYK, A., and Kaebowski, B.: (1) Osteomyelitis of entire cranial 
 vault. 
 
 Metjbebs: (1) Osteomyelitis of diploe. 
 
 Reimee: (1) Caries of frontal bone; dura adherent and greatly thickened in 
 neighborhood of abscess left frontal lobe. 
 
 BotrsQTJBT: (1) Necrosis frontal bone and subperiosteal orbital abscess. Post- 
 mortem showed right frontal abscess. Sinus filled with cheesy pus. 
 
 Ldbbers, K,: (1) Chr. frontal sinusitis and fistula right eyebrow, followed by 
 osteomyelitis frontal bone and frontal sinus empyema. Abscess right frontal 
 lobe which author believes had existed for eighteen months. 
 
 McCoy, J.; (1) Pneumonia; swelling of eyelids one week later; incised. Fistu- 
 lous opening showed eroded bone. Double ethmoiditis perforating both orbital 
 plates. Extension necrosis frontal and forehead regions. Osteomyelitis. Epi- 
 dural abscess left upper forehead. Nausea, vomiting. Cerebral symptoms. 
 Paralysis right side. Coma. Disintegration entire frontal lobe. Death. 
 
 McCoy, J. (second case). (1) Pain left eye; frontal sinus operation; considerable 
 pua. Improvement, but almost constant headache and intermittent discharge 
 
APPENDIX III 359 
 
 of pus. Swelling left forehead and epidural abscess found on incision. Head- 
 ache, drowsiness, nausea and vomiting. Osteomyelitis. Ethmoid labyrinth 
 thoroughly removed. Convulsions. Wound re-opened and multiple abscesses 
 found. Section of bone removed from temporal region. Hernia cerebri. Grad- 
 ual recovery. 
 BoEPKB (second case): (1) Bilateral frontal sinus suppuration. Osteomyelitis. 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into lateral ventricle. Death. 
 
 Metastatic Frontal Lobe Abscess. 
 
 Casamajoe: (1) Idiopathic double abscess frontal lobe; no history of opera- 
 tion. Death seven days after admission. Autopsy showed double frontal 
 abscess primary on right side, extending through corpus callosum into left 
 frontal lobe. Meninges showed no evidence of involvement. No diagnosis 
 until autopsy. 
 
 Schwabach: (1) Left-sided otitis media followed by headache and vertigo. 
 Abscess in right frontal lobe found at autopsy with "granulating congested 
 capsule several mm. thick. Extensive purulent disintegration left petrous 
 bone; labyrinth extensively diseased; complete rupture labyrinth capsule. 
 Osteitis and osteomyelitis in petrous portion temporal bone. First symptom 
 hardness of hearing left ear; five weeks later headache with disturbance of 
 equilibrium in form of vertigo and tottering gait. Onset is not fully reported. 
 
 Lombard, Bloch, and Moulonguet: (1) Operation for left-sided chronic ear sup- 
 puration. Epilepsy with symptoms of intracranial hypertension suddenly five 
 years later. Squama trephined and temporo-sphenoidal lobe punctured. Next 
 day left-sided hemiparesis with hypesthesia and disappearance of cutaneous 
 and tendon reflexes same side. Five days later second intervention with tre- 
 phining of occipital bone and puncture of cerebellum. Death following day. 
 Autopsy showed abscess rt. frontal lobe. 
 
 PicQTrfi: (1) Influenza without pulmonary complications, but with severe pain 
 in right ear and profuse suppuration. Three months later pain returned with 
 great severity. Violent hemicrania, progressive loss of strength, rise of tem- 
 perature. Mastoid process slightly tender on pressure, and it was decided to 
 perform exploratory trephining operation on mastoid process. Next day rise 
 of temperature, delirium, blunted intelligence and complete left-sided hemi- 
 plegia. Mastoid process trephined; no pus. Hernia cerebri. Intracerebral 
 abscess in front of Eolandic fissure. Autopsy showed generalized encephalitis 
 and second smaller focus of pus behind first. 
 
 Stebsb: (1) Metastatic from lung. Abscess at upper end of fissure of Rolando; 
 another in occipital lobe. 
 
 Eeimeb (second case) : (1) Kickets, headache, rigidity nape of neck, contracture 
 right arm, left-sided facial paralysis, convulsions, convergent strabismus, nys- 
 tagmus, fever; idiocy. Autopsy showed frontal convolutions right anterior 
 lobe entirely flattened and almost completely transformed into abscess which 
 had already ruptured into right lateral ventricle. Left anterior lobe con- 
 tained central abscess size of walnut. 
 
 Bebens, T. p.: (1) Deafness rt. ear. Intermittent purulent discharge. Tender 
 mastoid. Radical operation. Sixteen days later profuse hemorrhage from 
 middle ear cavity. After convulsions headache, stupor, coma. Later, attack 
 of typical Jacksonian epilepsy. Incision through dura revealed pus. Hernia 
 of brain filling bone wound. Death some days later. Autopsy showed subdural 
 abscess over rt. hemisphere. Large abscess also occupying most of rt. frontal 
 lobe with spontaneous discharge into subdural space. Author believes case 
 to be of otitic origin. 
 
 HiESCHBEEG, O.: (1) Metastatic brain abscess following abscess bronchial 
 
260 BEAIN ABSCESS 
 
 glands. Fistula from broken down glands to esophagus. Death from purulent 
 meningitis. Autopsy showed abscess rt. frontal lobe and several smaller 
 abscesses. 
 
 Stdckt : ( 1 ) Acute otitis right ear. Syphilis. Metastatic abscess left frontal 
 lobe. Very chronic as shown by firm capsule. Death from meningitis. 
 
 Johnston: (1) Left-sided frontal sinusitis. Operation showed healthy bone. 
 Sudden death four weeks later. Large abscess left frontal lobe, evidently 
 present previous to operation. Membranous capsule. 
 
 ScHOKSTBiN : ( 1 ) Tuberculosis. Bronchiectatic cavities. Facial paralysis left 
 side. Muscular spasm and later hemiplegia rt. side. Death three days later. 
 Autopsy showed two abscesses frontal lobe. 
 
 ScHORSTEiN (second case): (1) Tuberculosis. Bronchiectatic cavities. Dull- 
 ness and apathy. Death. Post-mortem showed abscess rt. frontal lobe. 
 
 Lambuk, M. p. : ( 1 ) Chr. frontal sinusitis. Operation. Posterior bony wall 
 intact. Infection of brain through venous or lymphatic channels. Abscess 
 frontal lobe. Eecovcry. 
 
 Wertheim : ( 1 ) Fever ; headache ; discharge from nose. Tumor over right eye. 
 Incision voided pus. Sinus wall roughened. Death. Post-mortem showed 
 abscess right frontal lobe. Necrosis posterior wall. Circumscribed pachy- 
 meningitis. 
 
 Frontal Abscess in Opposite Lobe (Metastatic). 
 
 Casamajob: (1) Idiopathic. Primary in right frontal lobe and extending 
 
 through corpus callosum to left frontal lobe. 
 ScHWABACH: (1) Left otitis media previous to abscess in right frontal lobe. 
 Lombard, Bloch, and MouLOtrGUET : ( 1 ) Left chr. ear suppuration previous to 
 
 right frontal abscess. 
 NoNNE: (1) Left tympanic suppuration previous to right frontal abscess. 
 Meurers: (1) Left-sided frontal sinusitis previous to right-sided frontal lobe 
 
 abscess. 
 Heiman, Th. : (1) Bilateral empyema, antrum of Highmore, and left-sided 
 
 frontal sinusitis. Bilateral earache. Severe headache and vomiting. Sudden 
 
 death. Autopsy showed extradural abscess. Eight lobe and both frontal 
 
 sinuses, ethmoid and maxillary sinus, filled with pus. Abscess with stalk. 
 
 Diffuse meningitis. 
 Sttjcky, A. : ( 1 ) Acute otitis right ear. Syphilis. Metastatic abscess left frontal 
 
 lobe. Very chronic as shown by firm capsule. 
 
 Frontal Lobe Abscess of Aurai, Origin (Metastatic). 
 
 ScHWABACH: (1) Left otitis media previously to right frontal lobe abscess. 
 Extensive disease in labyrinth. 
 
 Lombard, Bloch, and Moulouguet: (1) Left chronic ear suppuration previous 
 to right frontal abscess. 
 
 NoNNE : ( 1 ) Contraction of left tympanic membrane. 
 
 PiCQufi: (1) Intracerebral abscess after right mastoid symptoms and submenin- 
 geal collections, supervening on influenza. 
 
 Berens: (1) Subdural abscess in right hemisphere and second in larger portion 
 of frontal lobe. 
 
 KoEBEL : ( 1 ) Mastoid, antrum, and frontal sinus suppuration of right side 
 previous to abscess of right frontal lobe. Abscess referred to ear disease. 
 
 Bebens (second case): (1) Deafness right ear. Intermittent purulent dis- 
 charge. Tender mastoid. Radical operation. Sixteen days later profuse hemor- 
 rhage from middle ear cavity. Convulsions, headache, stupor and coma. Then, 
 attack of typical Jacksonian epilepsy. Incision through dura revealed pus. 
 
APPENDIX III 261 
 
 Hernia of brain filling bone wound. Death some days later. Autopsy showed 
 subdural abscess over right hemisphere. Large abscess also occupying most of 
 right frontal lobe with spontaneous discharge into subdural space. Author 
 
 1 believes case to be of otitic origin. 
 
 Sttjcky, a. : ( 1 ) Acute otitis right ear. Syphilis. Metastatic abscess left frontal 
 lobe. Very chronic as shown by firm capsule. Death from meningitis. 
 
 Htibbabd: (1) Ozena. Acute mastoiditis. No operation. Two months later 
 mental dullness and headache. Mastoid tenderness. Death. Post-mortem 
 showed abscess centre frontal lobe. Dura adherent to under surface right 
 frontal lobe. 
 
 Traumatic Frontal Lobe Abscess. 
 
 Hoffmann: (1) Multiple brain abscesses (4) following bilateral traumatic 
 frontal sinus suppuration. Non-penetrating. 
 
 Steese (fourth case) : (1) Fracture base of skull. Six months later pain over 
 right eye. Apathy and left hemiplegia. Autopsy showed large abscess right 
 frontal lobe. 
 
 Steese (sixth case) : (1) Two abscesses frontal lobe. Laceration of cerebellum. 
 Fracture of skull. 
 
 Steese (seventh case): (1) Bullet removed from head. Entire frontal (rt.), 
 lobe honeycombed with abscess cavities. 
 
 KoEHLER: (1) Struck forehead against file which penetrated frontal bone. Ab- 
 scess left hemisphere. Cavity communicated with opening in frontal bone and 
 with left ventricle. Third and fourth ventricles also contained pus. 
 
 Lee, J. M. : ( 1 ) Fell on stub of weed which penetrated upper eyelid, and passed 
 through sphenoidal fissure into frontal lobe of brain. 
 
 Zdekatjee: (1) Nail penetrated left side of head resulting in right hemiplegia, 
 left ptosis; pus wound over left temporal bone. Puncture of dura. Drainage. 
 Recovery with paresis left hand. 
 
 BOKELius, J.: (1) Traumatic puncture upper eyelid; epilepsy; twitching more 
 marked left arm and leg; other cerebral symptoms. Drainage tube inserted 
 after deep incision in upper eyelid. Recovery. 
 
 Wtss, O.i (1) Traumatic abscess involving entire frontal lobe. Sudden onset. 
 Severe pain followed by twitching right arm and leg. Later paralysis right 
 arm and 1^. Fever. Enlargement of head. Coma; convulsions during which 
 child died. 
 
 YOQL: (1) Traumatic abscess after temporal wound with later cerebral symp- 
 toms. "Vomiting, convulsions and death. Brain tissue found to be disorgan- 
 ized. Abscess communicated with lateral ventricle. 
 
 Apeblo: (1) Traumatic penetrating abscess left frontal lobe; craniectomy with 
 recovery. Second operation which revealed solution of continuity. Drainage 
 with gauze and glass tube. Later cerebral hernia. Recovery. Complete cica- 
 trization. 
 
 MaoEwen, Wm.: (1) Trauma to forehead. Unconscious. Headache, somno- 
 lence, vomiting, profuse perspiration. Patellar reflexes diminished. Pupils 
 unequal. Paresis left internal rectus. Bilateral optic neuritis. Convulsions 
 both arms. Operation without narcosis. Abscess frontal lobe. Gradual im- 
 provement all symptoms. 
 
 MacEwen, WiM. (second case): (1) Trauma of forehead. Headache; wound; 
 roughened bone. Somnolence, vomiting, temperature, chills, convulsions. 
 Aphasia for an hour. Paralysis rt. side improved after several hours. Diag- 
 nosis, abscess in third convolution. Operation refused. Death. Autopsy 
 showed extradural exudate. Hyperemia of dura. Abscess frontal lobe one 
 inch from surface. 
 
 Kennedy, Fosteb: (1) Traumatic, non-penetrating, right fronto-parietal region. 
 
263 BRAIN ABSCESS 
 
 Headache and irritability. Optic neuritis left side. Slight left facial weakness. 
 Loss of smell, right side. Gradual increasing left hemiplegia. Operation 
 showed large abscess in frontal lobe. Recovery. 
 
 Sachs, E.: (1) Trauma to forehead. Dull and irritable. Paralysis right arm 
 and leg. Lumbar puncture yielded clear fluid. Unconsciousness. Convulsions. 
 Vessels left retina tortuous. Operation. Frontal lobe abscess found and 
 drained. Recovery. 
 
 Damaye, H. : (1) Frontal abscess following fatigue and bombardment. Patient 
 soldier under observation for asthenia and headache, with symptoms of shell- 
 shock. Death. Autopsy showed interlobar abscess right frontal lobe. Dura 
 adherent to pia at level of right frontal lobe. 
 
 Coulter, E. J. : (1) Trauma to left orbit through upper eyelid. (Piece of 
 wood.) Convergent squint and diplopia. Swelling in orbit incised. Three 
 months later apathy. Loss of memory, subnormal temperature. Both eyes 
 proptosed. Paralysis left external rectus. Choked disc. Skull trephined. 
 Frontal lobe abscess. Month later twitching right arm and leg. Second 
 abscess tapped; recovery. 
 
 Feeeeei: (1) Trauma left side of head. Operation showed periostitis posterior 
 wall. Sudden death four weeks later. Post-mortem showed left frontal ab- 
 scess. No symptoms during life. 
 
 Taylob, F. L.: (1) Trauma to right eye. Superficial abscess opened one month 
 later. Headache, apathy, emaciation. Optic neuritis. Paresis left side of 
 face. Stiffness back of neck. Vomiting. Incontinence, urine and feces. Opera- 
 tion right frontal abscess. Recovery with poor vision. Following year, un- 
 conscious. Convulsions. Death. 
 
 Stuckt: (1) Traumatic ethmoiditis. Meningitis. Abscess frontal lobe. No 
 localizing symptoms. Death. Post-mortem showed necrotic cribriform plate. 
 Fracture through table left frontal sinus. Cerebral convolutions softened. 
 
 HorrMANN, R. i ( 1 ) Bilateral chr. sinus suppuration. Multiple brain abscesses. 
 Left-sided traumatism. Two operations. Recovery. Recurrence five months 
 later. Death. Post-mortem showed infection by lymphatics. 
 
 Reis, W. : (1) Traumatic panophthalmitis; brain abscess. Incision of eyeball. 
 Evacuation of pus. Headache, fever, coma; death from diffuse meningitis. 
 
 Path: op Ijntection of Feontal Lobe Abscess. 
 
 Casamajor: (1) Extending through corpus callosum to left frontal lobe from 
 right. 
 
 Lombard, Bloch, and Motjlgugxjet: (1) Left otitis developing right frontal 
 abscess. Thrombophlebitis from sinus, extending along course of a cerebral 
 vein, or arterial or venous embolus from primary infectious focus. 
 
 Pbeysing: (1) Gangrenous suppurative process in left nose and cavities, caus- 
 ing a circumscribed necrosis of dura over lamina cribrosa. Pia vein passing 
 along lower side of frontal lobe became involved and probably further on 
 thrombotic. Entrance of infective process through this vein and the lymph 
 tracts into frontal lobe. 
 
 Nonne: (1) Syphilis, alcoholism, albuminuria, and left tympanic contraction 
 previous to rt. frontal abscess. Two months before admission to hospital head- 
 ache, apathy, stupor, gradual right-sided hemiparesis. Complete paralysis rt. 
 side after 3 months and death. Autopsy showed orchitis fibrosa left side. 
 
 CiSNEKOS: (1) Through lymphatic and blood route. 
 
 Hoffmann: (1) Multiple traumatic (4). Three abscesses on left side of dura in 
 brain substance — "possibly caused by way of blood vessels or lymphatics." One 
 of four frontal lobe abscesses communicated with left ventricle. 
 
 Meubees (second case): (1) Second case. Left-sided frontal sinus empyema 
 ruptured through septum and gave rise to similar empyema on rt. side. Longi- 
 
APPENDIX III 263 
 
 tudinal sinus and later parietal emissary vein were infected by way of veins 
 and frontal diploe and closed by thrombosis. 
 
 Zemaun: (1) By continuity. Case of meningitis. Three abscesses, one of right 
 lobe, superficial cortical, and two communicating deep-seated abscesses. 
 
 Vangehuchten : (1) Anomaly of ethmoid sinus through which infection oc- 
 curred. Large abscess left frontal lobe. 
 
 Gbdeninq: (1). Nasal, ethmoid cells, orbit and brain. 
 
 Pebysing: (1) Gangrenous purulent process in left nose, and cavities gave rise 
 to circumscribed necrosis of dura and pia over lamina cribrosa; pial veins be- 
 came involved in disease, and thrombosed, and infective process entered through 
 the vein, and the concomitant lymph tracts into the frontal lobe. 
 
 KoEHLEE: (1) Traumatic abscess left hemisphere. Cavity communicated with 
 opening in frontal lobe and with left ventricle. Third and fourth ventricles 
 also contained pus. Pus had penetrated through foramen of Monro into right 
 ventricle. 
 
 Leb, J. M. : ( 1 ) Traumatic penetrating foreign body, passed through upper eye- 
 lid and sphenoidal fissure into frontal lobe of brain. 
 
 SiLEX : ( 1 ) Empyema ethmoid cells and frontal sinus, followed by two abscesses 
 both frontal lobes. Perforation of posterior and lower wall. 
 
 VON ScHKOEDEB: (1) Caries of orbit or ethmoid cells. Rt. frontal abscess after 
 right retrobulbar phlegmon. 
 
 ZiBM: (1) Frontal lobe abscess. Post-mortem showed cellular tissue of orbit 
 congested and abscess laterally from optic nerve. 
 
 ScHiNDLEE: (1) Left frontal abscess following inflammation of frontal sinus. 
 Perforation of posterior upper wall. Post-mortem showed large abscess in 
 second and third left frontal convolution. 
 
 BoEELins, J.: (1) Traumatic puncture of upper eyelid. Epileptiform seizures 
 and other cerebral symptoms. No paralysis, but twitching more marked left 
 arm and leg. Incision upper eyelid and probe passed through roof of orbit and 
 frontal lobe. Drainage. Recovery. 
 
 Weichselbatjm : (1) Influenza. Swelling right upper eyelid; eyeball intact. 
 Abscess rt. upper eyelid. Pus right maxillary and frontal sinus and between 
 posterior wall of frontal sinus and dura mater. Process originated from max- 
 illary and frontal sinus where purulent pachymeningitis and leptomeningitis 
 developed with brain abscess. 
 
 Renton, J. C. : ( 1 ) Abscess rt. frontal lobe after incision with evacuation of pus 
 along upper eyelid for right orbital cellulitis. Right orbital plate necrosed. 
 Dura inflamed over this area. Abscess cavity lined with distinct membrane, 
 and there was no direct communication between the pus from orbit and the 
 cerebral abscess. 
 
 KiTApp: (1) Abscess left frontal lobe after orbital phlegmon which was incised. 
 Base of frontal lobe was adherent to dura mater; dura was bluish covered 
 with pus flakes. Orbit free from pus. Communication existed between orbit 
 and dilated frontal sinus. 
 
 Reienee: (1) Abscess left frontal lobe with cerebral symptoms, and bone dis- 
 ease. Extensive caries frontal bone. 
 
 Reieneb (second case) : (1) Abscess left anterior lobe and also abscess right 
 lobe which was flattened, and abscess had ruptured into right lateral ventricle. 
 
 BouSQTJET: (1) Acute empyema right frontal sinus and subperiosteal orbital 
 abscess and necrosis frontal bone. Perforation in cranial cavity (posterior 
 and inferior wall). 
 
 Maas, H.; (1) Nasal polypi and nasophar3mgeal polyp removed. Apathy, ver- 
 tigo. Exophthalmos, delirium, death. Post-mortem showed dura at base of 
 skull covered with pus. Abscess in frontal lobe of brain above ethmoidal 
 region. Lamina cribrosa and upper surface of sphenoid destroyed. 
 
 YouL; (1) Traumatic abscess at point opposite wound in temporal region. Sur- 
 
264 BRAIN ABSCESS 
 
 rounding brain tissue much disorganized. Abscess communicated with lateral 
 ventricle. 
 
 Stmonds, C. J. : (1) Chr. suppuration of ethmoid sinus. Death from diffuse 
 meningitis. Post-mortem showed two abscesses under surface left frontal lobe. 
 Dura mater beneath frontal lobe adherent to brain. Neither abscess opened 
 lateral ventricle. Extension to orbit. 
 
 Symonds, C. J. (second case): (1) Chr. suppuration ethmoidal and frontal 
 sinuses with abscess left frontal lobe. Influenza, nasal discharge. Operation 
 for suspected subdural or cerebral collection. Death. Cerebral infection from 
 
 , ethmoid. Extension to orbit. 
 
 ScHAEFBJB, H. : (1) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess. Destruction rt. ethmoid labyrinth rupturing through lamina 
 papyracea, resulting in osteitis and periostitis of orbit. 
 
 STBtTTCKEN, H. J. L. : (1) Severe headache; pus from right nostril. Frontal 
 sinus opened. Cerebral symptoms. Puncture cranial cavity. Drainage. Re- 
 currence. Incomplete recovery with persistent amnesia. 
 
 STEUTOKErr, H. J. L. (second case) : (1) Right-sided headache with rapidly de- 
 veloping oedema of surroundings of right eye and protrusion of eyeball. Eth- 
 moid cells opened — most of them removed. Large abscess behind eyeball 
 
 . opened; later rigidity nape of neck, vomiting. Another operation and another 
 abscess found. Recovery with partial amnesia and persistent loss of smell 
 right side. 
 
 Aperlo, Gr.: (1) Traumatic penetrating abscess left frontal lobe. Craniectomy 
 with recovery. Second operation which revealed solution of continuity. Drain- 
 age with gauze and glass tube. Later cerebral hernia. Recovery; complete 
 cicatrization. 
 
 Manasse: (1) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after-treatment. Cerebral symp- 
 toms in form of vomiting, headache and fever. Frontal sinus diseased and 
 closed ethmoid cell found attached to its posterior wall. At third operation 
 frontal lobe brain abscess found under this fronto-ethmoid cell. Suppurative 
 
 . process passed from frontal ethmoid cell to bone and then to cranial contents 
 through preformed vascular channels. Recovery. 
 
 Uffbnorde, W. : (1) Ozena and left-sided frontal sinus and ethmoid suppura- 
 tion leading to orbital phlegmon, through fistula. Operations (2) revealed 
 
 , extradural abscess and frontal sinus abscess. Two months later frontal ab- 
 scess, meningitis, after rupture of frontal abscess into ventricle. Death. 
 
 MEtTEEES : ( 1 ) Bilateral frontal sinusitis with abscess rt. frontal lobe. Sudden 
 pain left eye. Operation left frontal sinus. Recurrence severe headache and 
 sudden death, in collapse. Post-mortem showed abscess right frontal lobe, with 
 delicate membrane. Cranial sinuses free from pathological changes. 
 
 Fbeudenthal, W. : (1) Acute empyema frontal sinus. Diffuse suppuration 
 frontal lobe. Two operations. Died after /second. No autopsy. In second 
 operation catheter was introduced and struck only a fluid mass, so that more 
 than frontal lobe seemed bathed in pus. 
 
 Fbeiidenthal, W. (second case) : (1) Influenza frontal sinusitis. Extradural 
 collection of pus. Abscess of frontal lobe. Two operations. Headache. Dis- 
 colored bone. Abscess between it and intact dura. Recovery. 
 
 Fbeudenthai., W. (third case) : (1) Acute empyema sphenoid sinus. Infection 
 extended to other accessory sinuses with abscess in temporal lobe. 
 
 Meetins, P.: (1) Headache; incision for swelling of glabella. Operation subse- 
 quently showed extradural abscess. Some broken down brain tissue evacuated. 
 Anterior wall of sinus necrosed and fistulous tract from sinus to extradural 
 abscess. 
 
 GeiiNWAU), L.: (1) Ozena, empyema both frontal sinuses. Carious destruction 
 
APPENDIX III 265 
 
 posterior sinus wall. Right-sided pachymeningitis. Abscess frontal lobe dis- 
 covered eight days after primary operation. Kecovery. 
 
 MnLLi]5r, W. V. : (1) Pain over frontal sinus and pus from nasofrontal ducts. 
 Later pus from frontal sinuses and pain across forehead — more severe left side. 
 Sudden death. Autopsy showed abscess left frontal lobe. Necrosis extended 
 from surface all the way through frontal lobe and perforated into left lateral 
 ventricle. 
 
 Bekens, T. p.: (1) Pansinusitis rt. side. Kadical external, frontal, ethmoidal 
 and sphenoidal operation performed. Gradual recovery. Three years later 
 frontal headache. Swelling of cicatrix rt. frontal region. Incision through 
 old frontal wound revealed frontal lobe abscess. Author is convinced patient 
 carried large collection of pus for months in frontal lobe, and that this was 
 source of nasal trouble. 
 
 Elschnig, a.: (1) Chr. tuberculous tumor lachrymal gland right eye. Opera- 
 tion. Extirpation of tumor with temporary resection of lateral orbital wall. 
 Death four weeks after. Abscess found in rt. frontal lobe directly above base 
 with circumscribed adhesion of meninges. 
 
 Elschnio, A. (third case) : (1) Chr. frontal sinusitis. Incipient orbital phleg- 
 mon. Radical operation after incision at upper inner orbital margin. Abscess 
 found in frontal brain; death. Autopsy showed abscess reaching to area of 
 second frontal convolution. Incipient encephalitis remainder frontal lobe and 
 adjacent temporal lobe. Purulent meningitis entire right cerebral hemisphere. 
 
 Zbmann, W. : (1) Chr. bilateral frontal sinusitis; fistula through left eyebrow; 
 left-sided ethmoid cell suppuration. Radical operation left side. Subperiosteal 
 abscess cavity. Two weeks later operation rt. frontal sinus. Death in three 
 days. Autopsy showed adhesion rt. frontal lobe to posterior surface frontal 
 sinus. Two deeper abscesses in frontal lobe behind superficial cortical abscess 
 in white brain-substance frontal pole and separated from cortical abscess by 
 layer of brain tissue. 
 
 Bebens, T. p. : (1) Deafness rt. ear; intermittent purulent discharge. Tender 
 mastoid. Radical operation. Sixteen days later profuse hemorrhage from 
 middle ear cavity. Convulsions, headache, stupor, coma. Then attack typical 
 Jacksonian epilepsy. Incision through dura revealed pus. Hernia of brain fill- 
 ing bone wound. Death some days later. Autopsy showed subdural abscess 
 over right hemisphere. Large abscess also occupying most of right frontal lobe 
 with spontaneous discharge into subdural space. Case believed to be of otitic 
 origin. 
 
 LuBBBMS, K. : ( 1 ) Chr. frontal sinusitis and fistula rt. eyebrow followed by 
 osteomyelitis frontal bone and frontal sinus empyema. Abscess rt. frontal 
 lobe which author believed had existed for eighteen months. Recovery. Dura 
 was reached following fistulous tract. 
 
 HiBSCHBERG, O. : ( 1 ) Metastatic brain abscess following abscess bronchial glands. 
 Fistula from broken down glands to esophagus. Death from purulent menin- 
 gitis. Autopsy showed abscess rt. frontal lobe and several smaller abscesses. 
 
 MoCoY, J.: (1) Pneumonia, swelling of eyelids one week later, incised. Fistu- 
 lous openings showed eroded bone. Double ethmoiditis perforating both orbital 
 plates. Extension necrosis frontal and forehead regions. Osteomyelitis. Epi- 
 dural abscess left upper forehead. Nausea, vomiting, cerebral symptoms, paraly- 
 sis rt. side, coma, disintegration entire frontal lobe. Necrosis and destruction 
 of inner plate leading to epidural abscess, thence to frontal lobe by way of 
 blood vessels. Abscess enlarged insidiously invading lateral ventricle. Death. 
 
 McCoT, J. (second case) : (1) Pain left eye; frontal sinus relieved considerable 
 pus. Improvement, but almost constant headache and intermittent discharge 
 of pus. Swelling left forehead and epidural abscess found on incision. Head- 
 ache, drowsiness, nausea, vomiting, osteomyelitis. Ethmoid labyrinth thor- 
 
366 BRAIF ABSCESS 
 
 oughly removed. Convulsions. Wound re-opened and multiple abscesses found. 
 Section of bone removed from temporal region. Hernia cerebri, marked choked 
 disc. Gradual recovery. Necrosis and destruction of inner plate leading to epi- 
 dural abscess and thence to frontal lobe by way of blood vessels. 
 
 Fagge, C. H. : ( 1 ) Empyema frontal sinus. Radical operation ; headache, apathy. 
 Subnormal temperature; abscess left frontal lobe. Death. Post-mortem 
 showed abscess nearly to anterior horn of lateral ventricle. 
 
 Keimee : ( 1 ) Acute right frontal sinus inflammation. Three operations. In 
 third large abscess extending close to lateral ventricle evacuated. Death five 
 days later. 
 
 Lambue, M. p. : (1) Chr. frontal sinusitis. Operation. Posterior bony wall 
 intact. Infection of brain through venous or lymphatic channels. Abscess 
 frontal lobe. Recovery. 
 
 Cakgill, Tdbnek, and Thomas: (1) Orbital cellulitis incised. Later irritability 
 and optic neuritis. Frontal sinus opened. Posterior wall necrotic. Brain 
 covered with granulations. Abscess frontal lobe evacuated. Recovery. 
 
 Feeudenthal, W.: (1) Acute frontal sinusitis. Headache, nasal discharge, 
 ffidema rt. eye. Posterior wall of sinus eroded. Convulsions left side. Death 
 several days later. 
 
 Rawling, L. B.: (1) Frontal headache; oedema rt. upper eyelid. Coma; paraly- 
 sis left side of body and face. Vomiting; optic neuritis. Operation; abscess 
 found; recovery. Two later operations for return of symptoms. Headache, 
 left hemiplegia. Marked hernia. Frontal sinus contained carious bone. Re- 
 covery. 
 
 Stuokt: (1) Traumatic ethmoiditis, meningitis, abscess frontal lobe. No local- 
 izing symptoms. Death. Post-mortem showed necrotic cribriform plate. Frac- 
 ture through table left frontal sinus. Cerebral convolutions softened. 
 
 Mayub, H. : (1) Radical sinus operation for left-sided frontal sinus empyema. 
 Death. Frontal abscess. Purulent meningitis. Thrombosis of sagittal and 
 cavernous sinus. Bone intact. Infection occurred by way of blood vessels. 
 Veins of roof of frontal sinus filled with pus and coagulated blood. 
 
 Hammesfahe: (1) Left-sided frontal sinus empyema and frontal lobe abscess. 
 Symptoms of brain pressure eight weeks later. Abscess found in posterior 
 pole of lower frontal convolution. Recovery. Infection occurred by way of 
 venous channel. 
 
 EoEPKE : ( 1 ) Left frontal sinus and maxillary suppuration. Subperiosteal and 
 extradural abscess. Second operation frontal lobe abscess. Death. Probable 
 rupture into lateral ventricle. 
 
 EoEPKE (second case): (1) Bilateral frontal sinus suppuration. Osteomyelitis. 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into the lateral ventricle. Death. 
 
 Hoffmann, R. ^ ( 1 ) Bilateral chronic sinus suppuration. Multiple brain abscess. 
 Left-sided traumatism. Two operations. Recovery. Recurrence five months 
 later. Death. Post-mortem showed infection by lymphatics. 
 
 Seifeet: (1) Bilateral empyema frontal sinus. Removal nasal polyps. Death 
 five days later. Post-mortem showed abscess rt. frontal lobe. Continuity Infec- 
 tion posterior wall through lymphatics or blood vessels. 
 
 GaeipdY: (1) Acute frontal sinusitis. Orbital phlegmon. Two operations. 
 Death. Post-mortem showed abscess frontal lobe at level of meningeal and 
 bone lesions. Microscopical abscess on cortical surface of brain. Incipient 
 osteitis orbital roof. 
 
 Eeinhaed: (1) Left-sided frontal sinus suppuration and frontal lobe abscess. 
 Extradural abscess, meningitis, and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess one 
 on floor of second left frontal convolution. Layer of healthy brain tissue 
 between. 
 
Appendix ill ger 
 
 Linden: (1) Empyema left frontal sinus. Brain abscess. Death. Post-mortem 
 showed dura and pia adherent. Thick-walled abscess. No direct communica- 
 tion between abscess and sinus. Path of infection sequestration of posterior 
 wall. 
 
 Heezpeld, J.; (1) Coryza. I^eft-sided frontal headache. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Eecovery. 
 
 WERraEiM: (1) Fever, headache, discharge from nose. Tumor over rt. eye. 
 Incision voided pus. Sinus wall roughened. Death. Post-mortem showed ab- 
 scess rt. frontal lobe, necrosis posterior wall. Circumscribed pachymeningitis. 
 
 Denker: (1) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. One month later external operation. Headaches, 
 somnolence, blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 Eecovery. 
 
 Tbaittmann: (1) Empyema left frontal sinus. Perforation into orbit and an- 
 terior cranial fossa. Abscess left middle frontal lobe. Caries orbital roof. 
 Death two weeks later. Post-mortem showed dura adherent to left frontal lobe 
 and brain. Perforation of posterior wall. Circular orifice in bone communi- 
 cating with frontal sinus. 
 
 Wilson: (1) Abscess frontal sinus and frontal lobe. Perforation external and 
 internal wall. Death. 
 
 Pfingst: (1) Ethmoidal involvement, head pains on side of orbit; convulsion, 
 suddm death. Post-mortem showed large encapsulated abscess in frontal 
 lobe. Path of infection through blood vessels. 
 
 Fkontal Lobe Abscess Associated with Complications. 
 
 Lombard, Blooh, and Moulouguet: (1) Operation right frontal lobe which 
 yielded no pus. Day after left-sided hemiparesis with hypesthesia and disap- 
 pearance of cutaneous and tendon reflexes same side. Second operation no 
 abscess found, but autopsy showed right frontal abscess. 
 
 Nonnb: (1) Eight-sided hemiparesis of character of organic paralysis. Patellar 
 reflex and Achilles jerk absent on both sides. Choked disc from neuritis 
 optica. Disturbances in co-ordination, in standing and walking; ataxia of 
 trunk muscles; absence sense of smell. Complete paralysis of right side before 
 death. 
 
 SoLOWCYCZYK, A., and Kabbowski, B.: (1) Intracranial. 
 
 Legaaed: (4) Intracranial. 
 
 Schousboe: (1) Empyema of frontal sinus and anterior ethmoidal cells. Patient 
 became dull and indifferent. Loss of appetite; vomiting; retarded pulue. 
 
 MoEiXBat: (1) Left maxillary sinus empyema and orbital abscess. Nauseated 
 after operation. Ethmoid cells and sphenoid. 
 
 Manasse: (1) Frontal sinusitis. Intracranial complications short time after 
 acute influenza; sinusitis. Left frontal abscess, then left temporal; then intra- 
 meningeal abscess in left occipital lobe. 
 
 Eckstein : ( 1 ) Somnolence. Suppurative thrombosis of longitudinal sinus with 
 extradural abscess. 
 
 PlCQirfe: (1) Severe pains right ear. Mastoid tender on pressure. Intelligence 
 blunted. Complete left-sided hemiplegia. Cerebral hernia. Generalized en- 
 cephalitis at autopsy. Smaller focus in addition to first also foimd. 
 
 Steese: (1) Pain both eyes; dimness of vision. Mental dullness; delirium, 
 stupor. Difiiculty in swallowing and breathing. Frontal sinus disease shown 
 by post-mortem. Vomiting; urinary incontinence; constipation. Death. 
 
 Steese (second case): (1) Phthisis several months. Paralytic stroke. Left 
 
»68 BRAIN ABSCESS 
 
 hemiplegia. Occasional chronic spasm left side with spasmodic conjugate 
 deviation. Ankle clonus. 
 
 Steese (third case): (1) Fracture of skull; vomiting; shallow respiration. 
 Abscess right frontal lobe. 
 
 Steese (fourth case): (1) Abscess in left frontal lobe. Entire lobe softened. 
 Headache; malaise; and chills. 
 
 Steese (fifth case) : (1) Fracture of skull. Spasms left side of face and ex- 
 tending to leg and arm. Abscess frontal lobe. Laceration of cerebellum. 
 Pneumonia. 
 
 Steese (sixth case): (1) Bullet removed from head. Headache; stupor; 
 twitching right hand and leg. Slight paralysis left side. DiflSculty in swal- 
 lowing. Right pupil dilated and left contracted. Rigor. 
 
 Koehleb: (1) Traumatic (penetrating) abscess left hemisphere. Vomiting. 
 Coma. Swelling. Tremor left half of body. 
 
 Koebel: (1) Post-mortem showed right cerebral hemisphere distinctly en- 
 larged, as compared to left. Cavity at apex and base of medulla right frontal 
 lobe. 
 
 Lee, J. M. ; (1) Traumatic (penetrating) — foreign body. Convulsions. Spasms. 
 Bulging dura. 
 
 Rajtin: (1) Right frontal sinusitis and brain abscess. Congestion of brain. 
 
 Teatel: (1) Abscess frontal lobe after purulent discharge left nose and pain in 
 forehead and cheek. Removal of polyps left nose. Hemiparesis right side. 
 Brain hernia. Convulsions. Removal of ethmoids. Death. 
 
 VON ScHKOEDEE : ( 1 ) Rt. frontal abscess after right retrobulbar phlegmon. 
 Serous meningitis right hemisphere. Necrosis , orbital roof. Dura under ab- 
 scess inflamed. 
 
 Kbecki : ( 1 ) Left frontal abscess after discharge of pus and polyps of nose. 
 Operation for swelling above left eye and frontal sinus found filled with pus. 
 Chills, fever, left-sided headache. Pain in occipital region. Apathy. Thicken- 
 ing of dura mater. Soft meninges at base covered with pus. 
 
 Zdekauee : ( 1 ) Puncture of dura after penetrating traumatic abscess left side 
 of head. Dura found to be fluctuating. Recovery with paresis left hand. 
 
 Redtenbachee : ( 1 ) Abscess apex frontal lobe after abscess left upper eyelid 
 succeeding influenza. Chronic spasms. Headache; weakness right half of 
 body. Apathy; rigidity of neck. Pus in frontal sinus and necrosis of its 
 posterior wall. Dura adherent to this wall. 
 
 BOEELIUS, J.: (1) Traumatic puncture upper eyelid resulting in epileptiform 
 and cerebral symptoms. Twitching more marked left arm and leg. Deep 
 incision in eyelid. Drainage tube. Recovery. 
 
 Williamson : ( 1 ) Abscess frontal lobe after influenza. Nasal discharge. Frontal 
 and occipital headache. Mentality dull which became progressively more 
 marked. Optic neuritis right eye. 
 
 Weichselbaum : (1) Influenza; swelling rt. upper eyelid; eyeball intact. Head- 
 ache, vomiting, delirium. Abscess right upper eyelid. Pus right maxillary 
 and frontal sinus and dura mater. Pachymeningitis and leptomeningitis. 
 
 SiLLAK: (1) Empyema frontal sinus. Long standing sinusitis. Abscess in 
 frontal sinus operated. Abscess frontal lobe. 
 
 Renton, J. C. : ( 1 ) Right frontal abscess after incision with evacuation of pus 
 over inner side of upper eyelid for right orbital cellulitis. Later severe head- 
 ache, vomiting. Spasms left side. Post-mortem convolutions over right lobe 
 slightly flattened. Right orbital plate necrosed and dura inflamed over this 
 area. No direct communication between pus from orbit and cerebral abscess. 
 
 Knapp: (1) Abscess left frontal lobe after orbital phlegmon, which was incised 
 and pus found. Headache and vomiting. Orbit found free from pus and com- 
 munication existed between orbit and dilated frontal sinus. 
 
 Reineb: (1) Abscess left frontal lobe with rickets and cerebral symptoms. 
 
APPENDIX ill 369 
 
 Headache and anesthesia left face. Diminished hearing left side and paralysis 
 left sixth nerve. 
 
 Reineb (second case): (1) Abscess both anterior lobes. Eight was flattened 
 and abscess was ruptured into right lateral ventricle. Left contained a cen- 
 tral abscess. Headache, rigidity of neck. Contracture right arm. Left-sided 
 facial paralysis. Convulsions. Nystagmus. Dilated pupils. Idiocy. 
 
 BousQUET: (1) Acute empyema right frontal sinus. Subperiosteal orbital ab- 
 scess and necrosis frontal bone. Puncture of orbit. Bone eroded. Two weeks 
 later contractures, severe oedema, loss of consciousness. Trephining frontal 
 lobe before death. 
 
 Jactjbasch: (1) Abscess right frontal lobe. Sore in nose; dull headache; ver- 
 tigo, vomiting. Speech slow and difBcult. Apathy. Pain back of head. Left- 
 sided hemiparesis. 
 
 Wyss, 0. i ( 1 ) Traumatic abscess of entire frontal lobe. Sudden onset of severe 
 pain and twitching right arm and leg. Later paralysis right arm and leg. 
 Fever. Enlargement of head. Coma; dilated pupils. Convulsions during one 
 of which child died. 
 
 Maas, H. i ( 1 ) Removal of polypi and nasopharyngeal polyp followed by apathy, 
 vertigo, exophthalmos, delirium, death. Post-mortem showed abscess in frontal 
 lobe of brain above ethmoidal region. 
 
 YouL : ( 1 ) Traumatic abscess in region opposite temporal wound. Cerebral 
 symptoms two weeks after injury; Vomiting. Convulsions; death. Post-mor- 
 tem showed surrounding brain tissue disorganized. 
 
 Symonds, C. J. : (1) Chr. suppuration ethmoid sinus. Death from diffuse men- 
 ingitis. Post-mortem showed two abscesses under surface left frontal lobe. 
 Dura mater beneath frontal lobe adherent to brain. Neither abscesses opened 
 lateral ventricle. Extension to orbit. 
 
 Symonds, C. J. (second case) : (1) Chr. suppuration ethmoidal and frontal 
 sinuses with abscess left frontal lobe. Influenza. Nasal discharge. Operation 
 for suspected subdural or cerebral collection. Death. Cerebral infection from 
 ethmoid sinus. Extension to orbit. 
 
 ScHAEFEE, H. : ( 1 ) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess. Destruction right ethmoid labyrinth rupturing through 
 lamina papyracea, resulting in osteitis and periostitis of orbit. Later pachy- 
 meningitis and purulent leptomeningitis. Death. 
 
 Struycken, H. J. L. : (1) Severe headache. Pus from right nostril frontal 
 sinus opened. Cerebral symptoms. Puncture cranial cavity. Drainage. Re- 
 currence brain symptoms. Later a second abscess opened. Incomplete recov- 
 ery with persistent amnesia. 
 
 Steuycken, H. J. L. (second case): (1) Right-sided headache with rapidly de- 
 veloping oedema of surroundings of right eye and protrusion of eyeball. Eth- 
 moid cells opened and most of them removed. Large abscess behind eyeball 
 opened. Later rigidity nape of neck. Vomiting. Another operation and an- 
 other abscess found. Recovery with partial amnesia and persistent loss of 
 smell right side. 
 
 Apeeulo, C: (1) Traumatic penetrating abscess left frontal lobe. Craniectomy 
 with recovery. Second operation which revealed solution of continuity. Drain- 
 age with gauze and glass tube. Later cerebral hernia. Recovery. Complete 
 cicatrization. 
 
 Manasse : ( 1 ) Acute accessory sinus suppuration which led to enormous orbital 
 phlegmon. Frontal sinus revealed pus during after-treatment. Cerebral 
 symptoms; vomiting, headache, fever. Frontal sinus diseased and closed eth- 
 moid cell found attached to its posterior wall. Three operations and at last 
 frontal lobe brain abscess found imder the fronto-ethmoid cell. Suppurative 
 process passed from ethmoid cell to bone and then to cranial contents through 
 preformed vascular channels. Recovery. 
 
270 BRAIN ABSCESS 
 
 UrFENOBDE, W.: (1) Ozena and left-sided frontal sinus and ethmoid suppura- 
 tion leading to orbital phlegmon through fistula. Two operations revealed ex- 
 tradural abscess and frontal sinus abscess. Two months later frontal abscess, 
 meningitis, after rupture frontal abscess into ventricle. Death. 
 
 WiENEB, A. : ( 1 ) Persistent headache. Empyema frontal sinus, right side, with 
 two operations. Later frontal lobe abscess. Operated. Recovery. 
 
 HoscH, P. H.: (1) Bilateral maxillary sinusitis and right-sided ethmoidal and 
 frontal sinusitis. Extradural perisinus abscess. Frontal lobe abscess found 
 at base of right frontal brain only after death, because of unusual location. 
 Purulent meningitis. 
 
 Maffei: (1) Partial loss of vision followed by vomiting and severe headache. 
 Incipient neuroretinitis. Later pain in nape of neck and rise of temperature. 
 Death from asphyxia. Spontaneous discharge from left nostril and filling 
 throat. No operation; no autopsy, but author believed disease to be in frontal 
 lobe. 
 
 Metjbees : ( 1 ) Bilateral frontal sinusitis with abscess right frontal lobe. Sudden 
 pain left eye. Operation left frontal sinus. Recurrence severe headache and 
 sudden death in collapse. Post-mortem showed abscess right frontal lobe. 
 Abscess with delicate membrane. Cranial sinuses free from pathological 
 changes. 
 
 FEBtTDENTHAL, W. : (1) Acute empyema frontal sinus. Diffuse suppuration 
 frontal lobe. Two operations. Died after second. No autopsy. In second 
 operation catheter was introduced and struck only a fiuid mass so that more 
 than the frontal lobe semed to be bathed in pus. 
 
 Fbeudenthai,, W. (second case): (1) Influenza, frontal sinusitis. Extradural 
 collection of pus. Abscess frontal lobe. Two operations. Headaches. Dis- 
 colored bone. Abscess between it and intact dura. Recovery. 
 
 Fkettdenthal, W. (third case) : (1) Acute empyema sphenoid sinus. Infection 
 extended to other accessory sinuses with abscess in temporal lobe. 
 
 MBatTiNS, P. S. : (1) Headaches. Incision for swelling of glabella. Necrosed 
 bone. Operation subsequently showed extradural abscess. Some broken down 
 brain tissue. Fistula. Death two weeks after operation from pulmonary com- 
 plications. 
 
 Heiman, Th. : (1) Bilateral empyema antrum of Highmore and left-sided 
 frontal sinusitis. Bilateral earache. Severe headache and vomiting. Sudden 
 death. Autopsy showed extradural abscess, right lobe and both frontal sinuses, 
 ethmoid and maxillary sinus filled with pus. Abscess with stalk. Diffuse 
 meningitis. 
 
 MuLLiN, W. V. ! (1) Pain over frontal sinuses and pus from nasofrontal ducts. 
 Later pus from frontal sinuses and pain across forehead, more severe left 
 side. Sudden death. Autopsy showed abscess left frontal lobe. Necrosis ex- 
 tended from surface all way through frontal lobe, perforating left lateral 
 ventricle. 
 
 Bebens, T. p. : (1) Pansinusitis rt. side. Radical external frontal ethmoidal 
 and sphenoidal operation performed. Gradual recovery. Three years later 
 frontal headache. Swelling of cicatrix right frontal region. Incision through 
 old frontal wound revealed frontal lobe abscess. Author is convinced patient 
 carried large collection of pus for months in frontal lobe and that this was 
 source of nasal trouble. 
 
 PiFFL, 0. ; ( 1 ) Chr. left-sided frontal sinusitis and exophthalmos. Radical oper- 
 ation. Removal orbital roof. Incision exposed dura. Frontal lobe adherent 
 to orbital roof and frontal abscess found at autopsy. 
 
 Elschotg, a. : ( 1 ) Chr. tuberculous tumor, lachrymal gland, rt. eye. Operation, 
 extirpation of tumor with temporary resection of lateral orbital wall. Death 
 four weeks after. Abscess found in right frontal lobe directly above base with 
 circumscribed adhesions of meninges. 
 
APPENDIX III 271 
 
 Blschnig, a. (second case): (1) Phlegmon, left upper eyelid incised. Paresis 
 rt. side and mental apathy. Operation left frontal abscess. Removal orbital 
 roof and dura. Eecovery. 
 
 Elschniq, a. (third case) : (1) Chr. frontal sinusitis. Incipient orbital phleg- 
 mon. Radical operation after incision at upper inner orbital margin. Abscess 
 found in frontal brain. Death. Autopsy showed abscess reaching to area of 
 second frontal convolution. Incipient encephalitis remainder frontal lobe and 
 adjacent temporal lobe. Purulent meningitis entire rt. cerebral hemisphere. 
 
 Gkunwald, L. : (1) Ozena; empyema both frontal sinuses. Carious destruction 
 posterior sinus wall. Right-sided pachymeningitis. Abscess frontal lobe dis- 
 covered eight days after primary operation. Recovery. 
 
 Zemann, W. : (1) Chr. bilateral frontal sinusitis; fistula through left eyebrow. 
 Left-sided ethmoid cell suppuration. Radical operation left side. Subperiosteal 
 abscess cavity. Two weeks later operation rt. frontal sinus. Death in three 
 days. Autopsy showed adhesions rt. frontal lobe to posterior surface of frontal 
 sinus. Two deeper abscesses in frontal lobe behind superficial cortical abscess 
 in white brain-substance frontal pole and separated from cortical abscess by 
 layer of brain tissue. 
 
 Bekens, T. p. : (1) Deafness rt. ear. Intermittent purulent discharge. Tender 
 mastoid. Radical operation. Sixteen days later profuse hemorrhage from 
 middle ear cavity. Convulsions, headache, stupor, coma. Then attack typical 
 Jaeksonian epilepsy. Incision through dura revealed pus. Hernia of brain 
 filling bone wound. Death some days later. Autopsy showed subdural abscess 
 over right hemisphere. Large abscess also occupying most of rt. frontal lobe, 
 with spontaneous discharge into subdural space. Author believes case of otitic 
 origin. 
 
 MacBwbn, Wm.: (1) Trauma to forehead; unconscious; headaches; somnolence, 
 vomiting, profuse perspiration. Patellar reflexes diminished. Pupils unequal. 
 Paresis left internal rectus. Bilateral optic neuritis. Convulsions both arms. 
 Operation without narcosis. Abscess frontal lobe. Gradual improvement all 
 symptoms. 
 
 MacEwen, Wm. (second case) : (1) Trauma of forehead; headache; wound; 
 roughened bone. Somnolence. "Vomiting, temperature, chills, convulsions. 
 Aphasia for an hour. Paralysis rt. side improved after several hours. Diag- 
 nosis — abscess in third convolution. Operation refused. Death. Autopsy 
 showed extradural exudate; hyperemia of dura. Abscess frontal lobe one inch 
 from surface. 
 
 LuBBEBS, K.: (1) Chr. frontal sinusitis and fistula rt. eyebrow followed by 
 osteomyelitis frontal bone and frontal sinus empyema. Abscess rt. frontal 
 lobe which author believed had existed for 18 months. Recovery. 
 
 HiESCHBEEG, 0. : ( 1 ) Metastatic brain abscess following abscess bronchial glands. 
 Fistula from broken down glands to esophagus. Death from purulent menin- 
 gitis. Autopsy showed abscess rt. frontal lobe and several smaller abscesses. 
 
 Kennkdy, Fosteb: (1) Traumatic non-penetrating right fronto-parietal region. 
 Headache and irritability. Optic neuritis left side. Slight left facial weakness. 
 Loss of smell right side. Gradually increasing left hemiplegia. Operation 
 showed large abscess in frontal lobe; recovery. 
 
 Sachs, E. : ( 1 ) Trauma to forehead. Dull and irritable. Paralysis rt. arm and 
 leg. Lumbar puncture yielded clear fluid. Unconsciousness; convulsions. 
 Vessels left retina tortuous. Operation. Frontal lobe abscess found and 
 drained. Recovery. 
 
 EiscHE, H.: (1) Headache. Swelling above left eye. Incised. Pus evacuated. 
 Stupor, vomiting, external frontal sinus operation. Dura incised. Abscess 
 found in frontal lobe; recovery. 
 
 BuTZENGEiGEE, 0.: (1) Infection nasopharynx and frontal sinus; pus ruptur- 
 ing to outside causing external abscess right side of forehead. Simultaneously 
 
273 BEAIN ABSCESS 
 
 inward progression of infection. Operation. Eight frontal sinus exposed. 
 Frontal abscess found. Eight days later headache and vomiting; wound re- 
 opened twice for refilling of abscess. Hernia cerebri. Ablation. Recovery. 
 
 White, J. A. : ( 1 ) Chr. frontal sinusitis. Dullness of intellect. Operation dis-i 
 closed frontal lobe abscess. Unconsciousness. Loss use rt. arm and muscles of 
 face. Second abscess found in Rolandic fissure. Death. 
 
 Damate, H. : (1) Frontal abscess following fatigue and bombardment. Patient 
 soldier under observation for asthenia and headache with symptoms of shell 
 shock. Death. Autopsy showed interlobar abscess rt. frontal lobe. Dura ad- 
 herent to pia at level of rt. frontal lobe. 
 
 SttjckY, a. : ( 1 ) Acute otitis rt. ear. Syphilis. Metastatic abscess left frontal 
 lobe. Very chronic as shown by firm capsule. Death from meningitis. 
 
 McCoy, J.: (1) Pneumonia. Swelling of eyelids one week later, incised. 
 Fistulous openings showed eroded bone. Ethmoiditis perforating orbital plate, 
 similar condition rt. and left. Extensive necrosis frontal and forehead re- 
 gions. Osteomyelitis. Epidural abscess left upper forehead. Nausea and 
 vomiting. Cerebral symptoms; paralysis rt. side. Coma. Encephaloscope 
 showed entire frontal lobe had disintegrated. Death. 
 
 McCoy, J. (second case) : (1) Pain left eye. Frontal sinus relieved considerable 
 pus. Improvement, but almost constant headache and intermittent discharge 
 of pus. Swelling left forehead and epidural abscess found on incision. Head- 
 ache. Drowsiness. Nausea and vomiting. Ethmoid labyrinth thoroughly re- 
 moved. Convulsions. Wound re-opened and multiple abscesses found. Section 
 of bone removed from temporal region. Hernia cerebri. Marked choked disc. 
 Gradual recovery. 
 
 HuED, L. M. : (1) Chr. pansinusitis; epidural abscess; frontal lobe abscess. 
 Meningitis. Death. 
 
 Coulter, R. J. : (1) Trauma to left orbit (piece of wood) through upper eye- 
 lid. Convergent squint and diplopia. Swelling in orbit incised. Three monthi 
 later apathy. Loss of memory. Subnormal temperature. Both eyes proptosed. 
 Paralysis left external rectus. Choked disc. Skull trephined. Frontal lobe 
 abscess. Month later twitching right arm and leg. Second abscess tapped. 
 Recovery. 
 
 Fagge, C. H. : (1) Empyema frontal sinus. Radical operation. Headache. 
 Apathy. Subnormal temperature. Abscess left frontal lobe. Death. Post- 
 mortem showed abscess nearly to anterior horn of lateral ventricle. 
 
 Feereri: (1) Trauma left side of head. Operation showed periostitis posterior 
 wall. Sudden death four weeks later. Post-mortem showed left frontal ab- 
 scess. No symptoms during life. 
 
 Johnston: (1) Left-sided frontal sinusitis. Operation showed healthy bone. 
 Sudden death four weeks later. Large abscess left frontal lobe, evidently 
 present previous to operation. Membranous capsule. 
 
 Keimee: (1) Acute rt. frontal sinus inflammation. Three operations. In 
 third large abscess extending close to lateral ventricle evacuated. Death five 
 days later. 
 
 ScHOESTEiN: (1) Tuberculosis. Bronchiectatic cavities. Facial paralysis left 
 side. Muscular spasm and later hemiplegia rt. side. Death three days later. 
 Autopsy showed two abscesses frontal lobe. 
 
 ScHORSTBiN (second case): (1) Tuberculosis; bronchiectatic cavities. Dullness 
 and apathy. Death. Post-mortem showed abscess rt. frontal lobe. 
 
 Lambur, M. P. : (1) Chr. frontal sinusitis. Operation. Posterior bony wall 
 intact. Infection of brain through venous or lymphatic channels. Abscess 
 frontal lobe. Recovery. 
 
 Taylor, F. L. : ( 1 ) Trauma to rt. eye. Superficial abscess opened one month 
 later. Headache, apathy, emaciation. Optic neuritis. Paresis left side of face. 
 Stiflfness back of neck^ Vomiting; incontinence urine and feces. Operation. 
 
APPENDIX III 273 
 
 Et. frontal abscess. Eecovery with poor vision. Following year unconscious, 
 convulsions. Death. 
 
 Cakgill, TuBNESt, and Thomas : ( 1 ) Orbital cellulitis incised. Later irritability 
 and optic neuritis. Frontal sinus opened. Posterior wall necrotic. Brain 
 covered with granulations. Abscess frontal lobe evacuated. Recovery. 
 
 Feetjdenthal, W. : (1) Acute frontal sinusitis. Headache; nasal discharge. 
 (Edema right eye. Posterior wall of sinus eroded. Convulsions left side. 
 Death several days later. 
 
 Eawling, L. B. : ( 1 ) Frontal headache. CEdema rt. upper eyelid. Coma. Paraly- 
 sis left side of body and face. Vomiting. Optic neuritis. Operation. Abscess 
 found. Eecovery. Two later operations for return of symptoms. Headache, 
 left hemiplegia; marked hernia. Frontal sinus contained carious bone. Ee- 
 covery. 
 
 StuokT: (1) Traumatic ethmoiditis; meningitis. Abscess frontal lobe. No 
 localizing symptoms. Death. Post-mortem showed necrotic cribriform plate. 
 Fracture through table left frontal sinus. Cerebral convolutions softened. 
 
 Mayek, H. : ( 1 ) Eadical sinus operation for left-sided frontal sinus empyema. 
 Death. Frontal abscess. Purulent meningitis. Thrombosis of sagittal and 
 cavernous sinus. Bone intact. Infection occurred by way of blood vessels. 
 Veins of roof of frontal sinus filled with pus and coagulated blood. 
 
 Hammespahe: (1) Left-sided frontal sinus empyema and frontal lobe abscess. 
 Symptoms of brain pressure eight weeks later. Operation. Abscess found in 
 posterior pole of lower frontal convolution. Eecovery. Infection occurred by 
 way of venous channel. 
 
 EoEPKE: (1) Left frontal sinus and maxillary suppuration. Sub-periosteal and 
 extradural abscess. Second operation. Frontal lobe abscess. Death. Prob- 
 able rupture into lateral ventricles. 
 
 EOEPKB (second case): (1) Bilateral frontal sinus suppuration. Osteomyelitis. 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into the lateral ventricle. Death. 
 
 Hoffmann, E.: (1) Bilateral chr. sinus suppuration. Multiple brain abscess. 
 Left-sided traumatism. Two operations. Eecovery. Eecurrence five months 
 later. Death. Post-mortem showed infection by lymphatics. 
 
 GoBiS: (1) Chr. frontal sinusitis. Fever, vomiting, convulsions. Operation — 
 evacuation extradural abscess. Death. Post-mortem showed frontal lobe 
 abscess. 
 
 GoBlS (second case) : (1) Frontal sinusitis; meningitis. Death three days after 
 operation for extradural abscess. Post-mortem showed frontal lobe abscess. 
 
 CiSNBaios: (1) Frontal sinusitis. Evacuation of ethmoid. Operation for brain 
 abscess. Disintegration large portion rt. frontal lobe. Death from meningitis. 
 
 SlEFEBT: (1) Bilateral empyema frontal sinus. Eemoval nasal polyps. Death 
 five days later. Post-mortem showed abscess rt. frontal lobe. Continuity in- 
 fection posterior wall through lymphatics or blood vessels. 
 
 Reis, W.: (1) Traumatic panophthalmitis. Brain abscess. Incision eyeball. 
 Evacuation of pus. Headache, fever, coma, death from diffuse meningitis. _ 
 
 MlLUGAN, W.: (1) Left frontal and ethmoidal sinus disease. Supraorbital in- 
 cisions. Nasal drainage. Abscess left frontal lobe. Extensive basal menin- 
 gitis. Death. 
 
 MiLLlGAN, W. (second case): (1) Left frontal and maxillary sinus disease. 
 Supraorbital incision. Alveolar drainage. Abscess left frontal lobe. Exten- 
 sive basal meningitis. Death. 
 
 Gabiput: (1) Acute frontal sinusitis. Orbital phlegmon. Two operations. 
 Death. Post-mortem showed abscess frontal lobe at level of meningeal and 
 bone lesions. Microscopical abscess on cortical surface of brain. Incipient 
 osteitis orbital roof. 
 
 Eeinhaed: (1) Left-sided frontal sinus suppuration and frontal lobe abscess. 
 
274 BEAIK ABSCESS 
 
 Extradural abscess. Meningitis and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess one on 
 floor of second left frontal convolution. Layer of healthy brain tissue between. 
 
 Hubbabd: (1) Ozena; acute mastoiditis. No operation. Two months later 
 mental dullness and headache. Mastoid tenderness. Death. Post-mortem 
 showed abscess centre frontal lobe. Dura adherent to under surface right 
 frontal lobe. 
 
 LiKDEN: (1) Empyema left frontal sinus. Brain abscess. Death. Post-mor- 
 tem showed dura and pia adherent. Thick-walled abscess. No direct com- 
 munication between abscess and sinus. Path of infection — sequestration of 
 posterior wall. 
 
 Paunz: (1) Acute left frontal sinusitis. Headache and vomiting. Dilated 
 sluggish pupils. Venous hyperemia of eyegrounds. Operation — ^bulging dura. 
 Incision of dura and brain substance. Pus aspirated. Death. 
 
 Heezfbld, J.: (1) Coryza. Left-sided frontal headache. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Recovery. 
 
 Weethehi; (1) Eever, headache, discharge from nose. Tumor over rt. eye. 
 Incision voided pus. Sinus wall roughened. Death. Post-mortem showed 
 abscess rt. frontal lobe. Necrosis posterior wall. Circumscribed pachymenin- 
 gitis. 
 
 Denkee: (1) Pain left temple and eye. Intranasal operation for left frontal 
 sinusitis and ethmoiditis. On« month later external operation. Headaches, 
 somnolence, blurring left optic disc. Posterior wall frontal sinus removed. 
 Epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 Eecovery. 
 
 Tratjtmann: (1) Empyema left frontal sinus. Perforation into orbit and 
 anterior cranial fossa. Abscess left middle frontal lobe. Caries orbital roof. 
 Death two weeks later. Post-mortem showed dura adherent to left frontal 
 lobe and brain. Perforation of posterior wall. Circular orifice in bone com- 
 municating with frontal sinus. 
 
 Wilson: (1) Abscess frontal sinus and frontal lobe. Perforation external and 
 internal wall. Death. 
 
 Pfingst, a. O. ; ( 1 ) Ethmoidal involyement. Head pains on side of orbit. Con- 
 vulsions. Sudden death. Post-mortem showed large encapsulated abscess in 
 frontal lobe. Path of infection through blood vessels. 
 
 Jessamon, L. W.; (1) Tenderness over left frontal sinus and ethmoids. Nasal 
 operation. Temperature. Thick speech. Aphasia. Paresis rt. arm. Complete 
 paralysis rt. hand. Posterior wall frontal sinus removed. Congestion optic 
 disc. Aphasia increased. Third operation, subdural abscess. Death. Post- 
 mortem showed dura thickened especially over ethmoid and discoloration over 
 ethmoid bone. 
 
 Fbontal Lobe Abscess Associated with EPidtjbal Abscess. 
 EiTBD, L. M.; (1) Chronic pansinusitis; epidural abscess; frontal lobe abscess; 
 
 meningitis; death. 
 Heezteld, J.: (1) Coryza. Left-sided frontal headache. External operation. 
 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 
 Eecovery. 
 Denkeb: (1) Pain left temple and eye. Intranasal operation for left frontal 
 
 sinusitis and ethmoiditis. One month later external operation. Headaches. 
 
 Somnolence; blurring left optic disc. Posterior wall frontal sinus removed; 
 
 epidural abscess exposed. Dura incised. Brain incised and abscess evacuated. 
 
 Recovery, 
 
APPENDIX III 275 
 
 Frontal Lobe Abscess AssooiATia) with Exteadueai, Abscess. 
 
 Eeinhabd: (1) Extradural abscesses discovered at time of operation associated 
 with one on floor of second left frontal convolution. 
 
 Eagleton: (1) Case XXI — -D. McS., Chapter Seven, page 111. 
 
 Eckstein : ( 1 ) Subperiosteal abscess at lateral end of left supraorbital margin 
 with suppurative thrombosis of longitudinal sinus, and extradural abscess over 
 upper half left frontal lobe. 
 
 Uffenoede: (1) Ozena and left-sided frontal sinus and ethmoid suppuration, 
 leading to orbital phlegmon, through fistula. Operations (2) revealed extra- 
 dural abscess and frontal sinus abscess. Two months later frontal abscess, 
 meningitis, after rupture of frontal lobe abscess into ventricle. Death. 
 
 'HoscH, P. H. : (1) Bilateral maxillary sinusitis and right-sided frontal and 
 ethmoidal sinusitis. Extradural perisinus abscess, frontal lobe abscess found 
 at base of right frontal brain after death. Purulent meningitis. 
 
 FeeudbnthAL, W. (second case): (1) Influenza; frontal sinusitis. Extradural 
 collection of pus. Abscess frontal lobe. Two operations. Headaches. Dis- 
 colored bone. Abscess between it and intact dura. Recovery. 
 
 Meetins, p. : ( 1 ) Headaches. Incision for swelling of glabella. Necrosed bone. 
 Subsequent operation showed extradural abscess. Some broken down brain 
 tissue evacuated. Fistula. Death two weeks after operation from pulmonary 
 complications. 
 
 Heiman', Th. : (1) Bilateral empyema antrum of Highmore and left-sided 
 frontal sinusitis. Bilateral earache. Severe headache and vomiting. Sudden 
 death. Autopsy showed extradural abscess. Eight lobe and both frontal 
 sinuses, ethmoid and maxillary sinus, fllled with pus. Abscess with stalk. 
 Diffuse meningitis. 
 
 .MacEwen, Wm. (second case): (1) Trauma of forehead; headache; wound, 
 roughened bone. Somnolence, vomiting, temperature, chills. Convulsions. 
 Paralysis right side. Aphasia for an hour. Paralysis improved after several 
 hours. Diagnosis — abscess in third convolution. Operation refused. Death. 
 Autopsy showed extradural exudate. Hyperemia of dura. Abscess frontal 
 lobe one inch from surface. 
 
 EOEFKE: (1) Left frontal sinus and maxillary suppuration. Subperiosteal and 
 extradural abscess. Second operation frontal lobe abscess. Death. Probable 
 rupture into lateral ventricle. 
 
 GoEis: (1) Chr. frontal sinusitis. Fever, vomiting, convulsions. Operation. 
 Evacuation extradural abscess. Death. Post-mortem showed frontal lobe 
 abscess. 
 
 GoEis (second case) : (1) Frontal sinusitis; meningitis. Death three days after 
 operation for extradural abscess. Post mortem showed frontal lobe abscess. 
 
 EeinhAED: (1) Left-sided frontal sinus suppuration and frontal lobe abscess. 
 Extradural abscess. Meningitis and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess one on 
 floor of second left frontal convolution. Layer of healthy brain tissue between. 
 
 Hekzfeld, J.: (1) Coryza. Left-sided frontal headaches. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Eecovery. 
 
 Feontal Lobe Abscess Associated with Subdtteal. 
 Bebens, T. p. : ( 1 ) Deafness right ear. Intermittent purulent discharge. Tender 
 mastoid. Eadical operation. Sixteen days later profuse hemorrhage from 
 middle ear cavity. Convulsions, headache, stupor, coma. Then, attack of 
 typical Jacksonian epilepsy. Incision through dura revealed pus. Hernia of 
 brain flUing bone wound. Death some days later. Autopsy showed subdural 
 abscess over right hemisphere. Large abscess also occupying most of right 
 
276 BEAIN ABSCESS 
 
 frontal lobe, with spontaneous discharge into subdural space. Author believes 
 case to be of otitic origin. 
 
 GrOMS (second case): (1) Frontal sinusitis. Meningitis. Death three days 
 after operation for extradural abscess. Post-mortem showed frontal lobe ab- 
 scess (subdural). 
 
 Heezfeld, J.: (1) Coryza. Left-sided frontal headache. External operation. 
 Posterior wall frontal sinus carious and removed. Epidural abscess found. 
 Dura incised. Subdural abscess evacuated. Fistula in frontal lobe of brain. 
 Recovery. 
 
 Jessamon, L. W. : (1) Tenderness over left frontal sinus and ethmoids. Nasal 
 operation. Temperature. Thick speech. Aphasia. Paresis right arm. Com- 
 plete paralysis right hand. Posterior wall frontal sinus removed. Congestion 
 optic disc. Aphasia increased. Third operation subdural abscess. Death. 
 Post-mortem showed dura thickened, especially over ethmoid and discoloration 
 over ethmoid bone. 
 
 Fbontal Lore Abscess Associated with Meningitis. 
 
 Reinhabd: (1) Purulent leptomeningitis and frontal lobe abscess. 
 
 Manasse: (1) Death from meningitis after abscess left frontal lobe, left tem- 
 poral lobe and intrameningeal abscess in left occipital lobe. 
 
 Zemann: (1) Eight frontal lobe abscess in form of superficial cortical abscess. 
 Meningitis. 
 
 Prbtsing: (1) Left frontal lobe abscess following empyema of left maxillary 
 sinus, frontal sinus, and ethmoid cells. Meningitis. Death. 
 
 Teeitbl : ( 1 ) Abscess frontal lobe. Basal surface frontal lobe hemorrhagic. 
 Dura adherent over frontal lobe. Purulent basilar meningitis. 
 
 VON ScHROEDEE: (1) Right-sided retrobulbar phlegmon producing right frontal 
 abscess. Serous meningitis right hemisphere. 
 
 Kbeckl: (1) Left frontal abscess after frontal sinus operation, for swelling 
 above left eye. Sinus filled with pus. Previously discharge of pus from nose 
 and nasal polyps. Autopsy — soft meninges at base covered with thick greenish 
 pus. 
 
 Kohler: (1) Abscess behind dura found after fluctuating painful swelling on 
 left frontal tuberosity. Incised. Operation failed to, arrest further extension 
 of meningitis. 
 
 Hanot : ( 1 ) Abscess frontal lobe giving picture during life of tubercular menin- 
 gitis. 
 
 Weichselbaxtm : (1) Abscess right upper eyelid. Eyeball intact. Pus right 
 maxillary and frontal sinus and between right frontal sinus and dura mater. 
 Abscess opposite in frontal lobe. Purulent pachymeningitis and leptomenin- 
 gitis. 
 
 Reiner: (1) Abscess left frontal lobe with cerebral symptoms. Rickets and 
 extensive caries frontal bone. Purulent meningitis at left side of base. 
 
 Stmonds, C. J. : ( 1 ) Chr. suppuration of ethmoid sinus. Death from diffuse 
 meningitis. Autopsy showed two abscesses under surface left frontal lobe. 
 Dura mater beneath frontal lobe adherent to brain. Neither abscess opened 
 lateral ventricle. Extension to orbit. 
 
 ScHABPER, H. : ( 1 ) Orbital phlegmon with death from meningitis. Post-mortem 
 showed abscess, destruction right ethmoid labyrinth rupturing through lamina 
 papyracea. resulting in osteitis and periostitis of orbit. Later pachymenin- 
 gitis and purulent leptomeningitis. Death. 
 
 UrrENORDE, W. : (1) Ozena and left-sided frontal sinus and ethmoid suppuration 
 leading to orbital phlegmon through fistula. Operations (2) revealed extra- 
 dural abscess and frontal sinus abscess. Two months later frontal abscess and 
 meningitis, after rupture of frontal lobe abscess into ventricle. Death. 
 
APPENDIX III 277 
 
 HosoH, p. H.: (1) Bilateral maxillary sinusitis and right-sided frontal and 
 ethmoidal sinusitis. Extradural perisinus abscess and frontal lobe abscess 
 foimd at base of right frontal brain after death. Purulent meningitis. 
 HeimaM', Th. : ( 1 ) Bilateral empyema antrum of Highmore and left-sided frontal 
 sinusitis. Bilateral earache. Severe headache and vomiting. Sudden death. 
 Autopsy showed extradural abscess. Right lobe and both frontal sinuses, eth- 
 moid and maxillary sinus, filled with pus. Abscess with stalk. Diffuse 
 meningitis. 
 Gbunwald, I.: (1) Ozena. Empyema both frontal sinuses. Carious destruc- 
 tion posterior sinus wall. Right-sided pachymeningitis. Abscess frontal lobe 
 discovered eight days after primary operation. Recovery. 
 
 Elschnig, a. (third case): (1) Chr. frontal sinusitis. Incipient orbital phleg- 
 mon. Radical operation after incision at upper inner orbital margin. Abscess 
 found in frontal brain. Death. Autopsy showed abscess reaching to area 
 of second frontal convolution. Incipient encephalitis remainder frontal lobe 
 and adjacent temporal lobe. Purulent meningitis entire right cerebral hemi- 
 sphere. 
 
 HlESCHBEBG, 0. ; ( 1 ) Metastatic brain abscess following abscess bronchial glands. 
 Fistula from broken down glands to esophagus. Death from purulent menin- 
 gitis. Autopsy showed abscess right frontal lobe and several smaller abscesses. 
 
 Stuckt, J. a.: (1) Acute otitis right ear. Syphilis. Metastatic abscess left 
 frontal lobe. Very chronic as shown by firm capsule. Death from meningitis. 
 
 Htjbd, L. M. : (1) Chr. pansinusitis. Epidural abscess; frontal lobe abscess. 
 Meningitis. Death. 
 
 Stucky, J. A. (second case): (1) Traumatic ethmoiditis. Meningitis. Abscess 
 frontal lobe. No localizing symptoms. Death. Post-mortem showed necrotic 
 cribriform plate. Fracture through table left frontal sinus. Cerebral con- 
 volutions softened. 
 
 Mayee, H. : (1) Radical sinus operation for left-sided frontal sinus empyema. 
 Death. Frontal abscess. Purulent meningitis. Thrombosis of sagittal and 
 cavernous sinus. Bon© intact. 
 
 ROEPKE (second case): (1) Bilateral frontal sinus suppuration. Osteomyelitis. 
 Frontal lobe abscess. Meningitis. Three operations. Abscess had ruptured 
 into meninges and into the lateral ventricle. Death. 
 
 GoBis (second case): (1) Frontal sinusitis. Meningitis. Death three days 
 after operation for extradural abscess. Post-mortem showed frontal lobe 
 abscess (subdural). 
 
 CiSNEBOS: (1) Frontal sinusitis. Evacuation of ethmoid. Operation for brain 
 abscess. Disintegration large portion right frontal lobe. Death from menin- 
 gitis. 
 
 Reis, W.: (1) Traumatic panophthalmitis. Brain abscess. Incision of eyeball; 
 evacuation of pus. Headache, fever, coma. Death from diffuse meningitis. 
 
 MiLLiGAN, W.: (1) Left frontal and ethmoidal sinus disease. Supraorbital 
 incisions. Nasal drainage. Abscess left frontal lobe; extensive basal menin- 
 gitis. Death. 
 
 MiixiGAN, W. (second case): (1) Left frontal and maxillary sinus disease; 
 supraorbital incision; alveolar drainage. Abscess left frontal lobe. Extensive 
 basal meningitis. Death. 
 
 Reinhaed: (1) Left-sided frontal sinus suppuration and frontal lobe abscess. 
 Extradural abscess. Meningitis and brain pressure after operation. Loss of 
 consciousness. Death. Post-mortem showed behind extradural abscess one on 
 fioor of second left frontal convolution. Layer of healthy brain tissue between. 
 
 Weetheim: (1) Fever, headache, discharge from nose. Tumor over right eye. 
 Incision voided pus. Sinus wall roughened. Death. Post-mortem showed 
 abscess right frontal lobe. Necrosis posterior wall. Circumscribed pachy- 
 meningitis. 
 
378 BRAIN ABSCESS 
 
 I^ONTAL Lobe Abscess. 
 
 BIBLIOGRAPHY. 
 
 Apeblo: Abscesso del lobo frontale sinistro; Gazzetta degli OspedaU, 1917, 
 
 XXXVIII, p. 337. 
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 p. 402. 
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APPENDIX III 379 
 
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 Wochenschrift, 1875, Bd. XII, p. 505. 
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 Keimee: Personal Communication to Gerber. (See Komplikationen der Stirn- 
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 1880, Bd. IX, p. 448. 
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 Vol. XI, p. 99.) 
 
280 BRAIN ABSCESS 
 
 Kbeckl: Beitrag zur Pathologie und Therapie des chronischen Stirnhohlen- 
 
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 90, p. 749. 
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 Archiv fii/r Ohrenheilkunde, 1912-13, Bd. 90, p. 172. 
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 MacEwbn, Wm. : The Pyogenic Infective Diseases of the Brain and Spinal 
 
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 1913, Vol. XIII, p. 80. 
 
 Mabtei: Absces van de voqrhoofs des kwab der hersenen; Nederlandsoh. 
 
 Tijdschrift von Q-eneeskunde, 1910, II, p. 2302. 
 Manasse: Ueber orbitale und cerebrale Komplilcationen bei akuten Neben- 
 
 hohleneiterungen ; Verhamdlung des Vereins deutschen Laryngol., 1911-12, 
 
 p. 621. 
 Mayee: Beitrag zur Kenntniss der Sehstorung nasalen Ursprungs; Wiener 
 
 Klin. Woohenschrift, 1907, No. 31, p. 938. 
 McCoy, J. : Report of Two Cases of Brain Abscess in the Frontal Lobe Secondary 
 
 to Ethmoid and Frontal Sinusitis; Tramsactions of Am. Laryngol., Rhinol., 
 
 and Otol. 8oo., 1910; Armals of Otol., Bhinol., and Laryngol., 1910, XIX, 
 
 p. 287. 
 Mertiks, p. S. : Empyema of Frontal Sinus, Followed by Extradural Abscess 
 
 and Abscess of the Frontal Lobe; Am. Jour. Med. Soienoes, 1904, Vol. 127, 
 
 p. 684. 
 Meubees: Ueber Vier in Anschluss an eiterige Nebenhohlenerlcrankungen ent- 
 
 standene Komplikationen mit todtlichem Ausgang; Zeitschrift fur Ohrenheil- 
 
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 MiLLiGAN, W.: Suppurative Frontal Sinusijiis; British Medical Journal, 1905, I, 
 
 p. 171. 
 MuLLiN, W. v.: Abscess of Left Frontal Lobe Following Suppuration of Frontal 
 
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 NoNNE: Atypisch verlaufene Falle von Hirnabszess; Deutsche Zeitschrift filr 
 
 Nervenheilkunde, 1907, Vol. 33, p. 316. 
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 1902-03, Vol. XIII, p. 427. 
 Pfingst, A. C. : Brain Abscess; Its Cause and Pathology; Miss. Valley Med. 
 
 Jov/f., 1918, XXV, p. 193. 
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 Mai. de I'Oreille, 1890, XVI, p. 437. 
 PlCQirfi, L., and F^vbiee, C. : Absces intracraneur d'origine otique; Annal. d. Mai. 
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 Piffl: Zur Kasuistik der hinogenen Stirnabszesse; Prager med. Woohenschrift, 
 
 1914, Vol. XXXIX, p. 39. 
 
APPBKDIX III 281 
 
 Pretsing: Neun Gehirnabszesse im Gefolge von Ohren- und NaseA-Erkrankun- 
 
 gen; Archiv filr Ohrenheillcunde, 1900-1901, Vol. LI, p. 262. 
 Raj'IN: Sinusite frontale; absces du cerveau; Lyon Medical, 1897, Tome 85, 
 
 p. 236. 
 Rawling, L. B.: Case of Chronic Abscess of the Frontal Lobe; Recovery 
 
 Transactions of the Medical Society of London, 1907, XXX, p. 375. 
 Rbdtenbachee : Hirnabszesse und Eiterung im Sinus frontalis nach Influenza 
 
 Wiener Med. Blatter, 1892, XV, No. 13, p. 200. 
 Reimek: Gehimabszess : Jah/rbuch fii/r Kinderheilhunde, 1877, Vol. XI, p. 38 
 Reinhaed: Stirnhohleneiterung und Stirnlappenabszess ; Miinch. Med. Wochen- 
 
 sohrift, 1905, No. 46, p. 2245. 
 Reis, W. : Ein Abszess in der Lamina cribrose des Sch. nerven; Archiv filr 
 
 Ophthalmologic, 1904, LIX, p. 155. 
 Renton, J. C. : Note on a Case of Cerebral Abscess Subsequent to Orbital 
 
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 RoPKE: Ueber die Osteomyelitis des Stirnbeins im Anschluss an Stirnhohleflei-' 
 
 terung, und iiber ihre intrakraniellen Folgeerkranliungen ; Y erhandlu/hgen der 
 
 deutschen Otol. Gesellschaft, 1907, Vol. XVI, p. 162. 
 Sachs, E.: A Case of Frontal Lobe Abscess; Jour. Nervous and Mental Diseases, 
 
 1911, Vol. 38, p. 693. 
 SCHAEFEK: Ein Fall von ulceroser Entziindung im Bereieh der rechten Stirn- 
 
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 Schilling: Ueber die Osteomyelitis der fiaclien Schadelknochen ; Zeitschrift 
 
 filr Ohrenheillcunde, 1904, Vol. 48, p. 52. ( Erganzungshef t. ) 
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 Archiv. de Med. et de Pharm. Milit., 1892, Vol. XX, p. 241. 
 SCHOESTEIN: The Schorstein Lecture on Abscess of the Brain; Lancet, 1909, 
 
 II, p. 843. 
 ScHOUSBOB: Ein Fall von Empyema sinus frontalis mit Stirnlappenabszess; 
 
 Transt. Danish Oto-Laryngol. Society, March, 1915. Internat. Centralblatt 
 
 fur Laryngol., 1915, XXXI, p. 396. 
 VON ScHEOEDEE: Retrobulbares Phlegmon; Peterburger Med. Wochenschrift, 
 
 1895, No. 6, p. 56. 
 ScHWABACH: Beitrag zur pathologisohen Anatomie des inneren Ohres und zur 
 
 Frage vom primaren Hirnabszess; Beitrage zur Ohrenheillcunde. Lucae Fest- 
 schrift, 1905, p. 55. 
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 No. 24, p. 689. 
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 p. 1140. 
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 p. 178. 
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 Bhmol, Laryngol., 1907, XVI, p. 364. 
 
282 BEAIIT ABSCESS 
 
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 Clinio, 1912, Vol. LXIX, p. 612. 
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 1900, rV, p. 236. 
 Tatlob, F. L.: a Case of Abscess of the Frontal Lobe of Traumatic Origin; 
 
 "New York Medical Journal, 1908, Vol. 87, p. 891. 
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 XXV, p. 301. 
 Teeitei.: Ueber Hirnabszesse nach Stirnhohleneiterung; Deutsche Med. Woohen- 
 
 schrift, 1896, Vol. XXII, p. 758. 
 Uffenoedb: Complicierte Falle von Nasenhohlenerkrankung; Zeitschrift fur 
 
 Laryngologie, 1911, Vol. Ill, p. 597. 
 Vangehtjchten : Absces volumineux du lobe frontal gauche; Bull. Acad. Royal 
 
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 Weichselbaum : Influenza und Komplikationen ; Wiener med. Woohensohrift, 
 
 1890, Vol. XL, p. 223. 
 WEETHEni: Erkrankungen der Nasen Nebenhohlen; ArcMv fur Laryngol., 1900, 
 
 Vol. XI, p. 204. 
 WiENEB, A.: Abscess in the Frontal Lobe of the Brain after Chronic Frontal 
 
 Sinusitis; Medical Record, 1910, Vol. 78, p. 715. 
 White, J. A.; Discussion. Transactions American Laryngol., Rhinol., and 
 
 Otol. Society, 1910. 
 Williamson, R. T.: A Case of Abscess in the Eight Frontal Lobe of the 
 
 Brain; Medical Chronicle, 1890-91, XIII, p. 423. 
 Wilson: Abscess of the Frontal Lobe; International Oentralblatt fur Laryn- 
 gologie, 1899, No. 4, p. 149. Australian Medical Gazette, 1898, October 20. 
 Wyss: Gehirnabszess im Kindesalter; Jahrhuch filr Einderheilkunde, 1871, IV, 
 
 p. 139. 
 YouL: Abscess of the Brain in a Child; Lancet, 1847, I, p. 71. 
 Zdekauer: Hirnabszess. Heilung durch Trepanation; Jahrhuch filr Kinder- 
 
 heilkunde, 1893, Vol. XXXV, p. 297. 
 Zemaistn: Endocranielle Komplikationen nach chroniacher Nebenhohleneiterung; 
 
 Zeitschrift filr Laryngologie, 1913, Vol. VI, p. 545. 
 ZiRM: Thrombosierung beider Sinus cavernosa; Wiener Klin. Woohensohrift, 
 
 1892, No. 27, p. 394. 
 ZwiLLiNGKR: Intrakranielle und cerebrale Komplikationen der Stirnhohlenent- 
 
 zilndungen; Archiv filr Laryngologie und Rhinologie, 1914, Vol. XXVIII, p. 
 
 27L 
 
INDEX OF AUTHORS 
 
 Acland, T. D., 242 
 
 Adami, 133, 163 
 
 Albrecht, W., 210 
 
 Alzheimer, 13 
 
 Amoss, H. L., 28, 143, 147 
 
 Aperlo, G., 261, 264, 269, 278 
 
 Argot, G., 129, 135 
 
 Armltage, F. L., 73 
 
 Arnold, J., 72 
 
 Ayer, J. B., 28, 141, 153, 154 
 
 Bacon, 46 
 
 Ballance, A. A., 97, 242 
 
 Barany, R., 12, 176, 200 
 
 Barr, J. S., 236 
 
 Beck, K., 16, 237 
 
 Behr, 173 
 
 Belinoflf, S., 66 
 
 Berens, T. P., 18, 70, 72, 73, 120, 246, 
 
 250,. 253, 259, 260, 265, 270, 271, 
 
 275, 278 
 Bibrowicz, W., 76 
 Bing, R., 209 
 Black, H., 187 
 Black, W. D., 235 
 Blake, 46 
 Bloch, A., 18, 73, 120, 259, 260, 262, 
 
 280 
 Bodkin, H., 67 
 
 Boenninghaus, G., 32, 122, 235 
 Boesch, H., 233 
 BoUack, J., 171 
 Bolton, J. S., 209 
 Borchard, 278 
 
 Borelius, J., 256, 261, 263, 268, 278 
 Bouchez, F., 82 
 Bourguet, 97 
 Bousquet, 245, 252, 256, 258, 263, 269, 
 
 278 
 Braun, A., 236 
 Braun, E., 242 
 Brieger, 31 
 BriggB, G. N., 235 
 Brock, W., 238 
 Brown, W. G., 179 
 Browning, W., 32, 120 
 Bruhl, 239 
 Bryant, W. S., 9 
 Buhl, C. G., 146 
 Butzengeiger, C, 247, 254, 271, 278 
 
 Cadwalader, W. B., 75, 183 
 Campbell, 178 
 Capdeville, F., 223 
 
 Cargill, L. V., 254, 258, 266, 273, 278 
 
 Caaamajor, L., 18, 259, 260, 262, 278 
 
 Cassidy, 134 
 
 Cassirer, R., 77 
 
 Cayley, 70 
 
 Cisneros, 248, 251, 255, 262, 273, 277, 
 
 278 
 Clark, 200 
 Climenko, H., 18 
 Coates, G. M., 60 
 Condat, M., 82 
 Coulet, G., 237 
 
 Coulter, R. J., 247, 258, 262, 272, 278 
 Couteaud, 73, 74, 120 
 Crile, 164 
 
 Crowe, S. J., 102, 170, 198 
 Cushing, H., 5, 7, 8, 11, 30, 59, 133, 
 
 141, 180, 202 
 
 Damaye, H., 110, 262, 272, 278 
 
 Dandy, W. E., 5, 128, 188 
 
 Day, 151 
 
 Dejerine, 12 
 
 Dench, E. B., 197 
 
 Denker, A., 208, 249, 251, 255, 258, 
 
 267, 274, 278 
 DeStella, 236 
 D'Hoore, 234 
 Dick, 73 
 
 Dixon, G. S., 242 
 Dmoehowaky, 252, 278 
 Dortea, P., 236 
 Dreyfuss, 278 
 Dupuy, 220 
 Durand, 74 
 
 Eagleton, W. P., 25, 63, 73, 89, 97, 
 98, 99, 103, 141, 149, 151, 169, 170, 
 200, 201, 243, 244, 256, 275 
 
 Eckstein, 251, 256, 267, 275, 278 
 
 Effler, L. R., 83 
 
 Elaberg, C. A., 278 
 
 Elschnig, A., 124, 247, 253, 257, 265, 
 270, 271, 277, 278 
 
 Emerson, L., 32 
 
 Emge, 73 
 
 Essick, C. R., 16, 25, 28, 32, 129, 132, 
 140, 148, 153 
 
 Fagge, C. H.,, 248, 254, 266, 272, 278 
 
 Faunz, M., 208 
 
 Feinier, L., 162, 184, 195 
 
 Felton, J. B., 69 
 
 Felton, L. D., 28, 69, 143, 153 
 
 Ferreri, 262, 272, 278 
 
 283 
 
284 
 
 INDEX OP AUTHOES 
 
 Ferrier, 195 
 
 Fevrier, C, 280 
 
 Finnel, 222 
 
 Flatau, 236 
 
 Flexner, S., 28, 143, 147 
 
 Fliess, H., 233 
 
 Foerster, 207 
 
 Forgue, E., 238 
 
 Frankel, 76 
 
 Fraser, J. S., 185 
 
 Frazier, C. H., 7, 9 
 
 Freudenthal, W., 248, 253, 254, 264, 
 
 266, 270, 273, 275, 278 
 Friedmann, M., 16, 48 
 Friedrich, 106 
 Friesner, I., 242 
 
 Garipuy, 248, 255, 258, 266, 273, 278 
 
 Gerber, P. H., Ill, 124, 278 
 
 Girard, L., 93 
 
 Glegg, W., 187, 238 
 
 Goodman, C, 279 
 
 Gordon, A., 178 
 
 Goris, 248, 255, 273, 275, 276, 277, 
 
 279 
 Gowers, W. R., 73 
 Gradle, H. S., 172 
 Grey; E. G., 202 
 Gribbon, G. C, 221 
 Groth, W., 73 
 
 Gruening, E., 245, 251, 256, 263, 279 
 Grunert, K., 232 
 Grlinwald, L., 246, 253, 264, 271, 277, 
 
 279 
 Guilliani, G., 209, 210 
 Gull, W., 220 
 
 Hadden, W. B., 222 
 
 Hammesfahr, 248, 254, 266, 273, 279 
 
 Hanfield Jones, M., 223 
 
 Hanot, 276, 279 
 
 Hansberg, 279 
 
 Harbordt, 227 
 
 Hare, A. W., 226 
 
 Harrison, C. E., 227, 228 
 
 Hartley, 9 
 
 Hartmann, A., 225 
 
 Harvey, S. C, 11, 12 
 
 Haasln, G., 16, 62 
 
 Hedinger, A., 224 
 
 Hegener, J., 16, 106 
 
 Heiman, Th., 229, 246, 250, 253, 260, 
 
 270, 275, 277, 279 
 Heine, B., 25 
 Held, 151 
 
 Henderson, D. R., 185 
 Henderson, J., 73 
 Hepe, 94 
 Herzfeld, J., 249, 255, 267, 274, 275, 
 
 276, 279 
 Heuer, 5 
 Heusinger, 220 
 
 von Hibler, E., 17, 239 
 
 Hill, F. T., 198 
 
 Hill, L., 14 
 
 von Hinsberg, 25, 118, 120, 123, 233 
 
 Hinsdale, G., 279 
 
 Hirschberg, 0., 259, 265, 271, 277, 279 
 
 Hoffmann, R., 255, 261, 262, 266, 273, 
 
 279 
 Hohgren, G., 198 
 Holmes, 131, 134 
 Homen, E. A., 16 
 Home, J., 94 
 Horsley, 5, 200 
 Hosch, P. H., 246, 250, 253, 270, 275, 
 
 277 279 
 Hubbard, Th., 249, 261, 274, 279 
 Huguenin, 49 
 Hurd, L. M., 247, 251, 254, 272, 274, 
 
 277, 279 
 Hutton, F. T., 224 
 
 Isemer, F., 235 
 
 Jacques, P., 237 
 
 Jacubash, D., 245, 269, 279 
 
 Jansen, A., 227 
 
 Japha, A., 72 
 
 Jessamon, L. W,, 198, 208, 210, 249, 
 
 251, 256, 274, 276, 279 
 Jobson, G. B., 25 
 Johnston, 260, 272, 279 
 Jones, H. E., 102 
 Jones, I., 198 
 
 Karbowski, B., 244, 251, 258, 267, 
 
 281 
 Karsner, H. T., 238 
 Keimer, 248, 254, 266, 272, 279 
 Kelson, W. H., 237 
 Kenefiek, T. A., 227 
 Kennedy, F., 178, 208, 210, 261, 271, 
 
 279 
 Kenyon, 9 
 Kesohner, M., 210 
 Klauber, E., 174 
 Klessens, J. J. H. M., 82 
 Klippel, D., 27 
 Knapp, A., 32, 117, 234 
 Knapp, H., 36, 46 
 Knapp, 249, 256, 263, 268, 279 
 Knott, J. F., 72 
 Koch, P., 242 
 
 Koebel, 245, 251, 260, 268, 279 
 Koehler, 252, 261, 263, 268, 276, 279 
 Kolpin, 16, 77 
 Kopetsky, 151 
 Kopeynski, 243 
 Korner, 0., 16, 22, 77, 228 
 Kostlivy, 151 
 Krause,' F., 7, 41, 74, 76 
 Kreckl, 245, 252, 256, 268, 276, 280 
 Kutzinski, A., 70, 82 
 
INDEX OF AUTHOES 
 
 285 
 
 Laiguet-Levastine, 179 
 
 Lambur, M. P., 248, 254, 260, 266, 
 
 272 
 Landau, M. E., 12 
 Lannois-Perretiere, 234 
 Laurens, P., 235, 280 
 Lebert, 49 
 
 Lee, J. M., 256, 261, 263, 268, 280 
 Leegaard, F., 121, 267, 280 
 Lemaitre, F., 54, 63 
 Leriche, E., 174 
 Lewinsohn, G., 173 
 Libert, E., 209, 210 
 Linck, 238 
 
 Linden, 249, 255, 267, 274, 280 
 Loebinger, A. S., 135 
 Lombard, 18, 73, 120, 259, 260, 262, 
 
 267. 280 
 Lessen, W., 72 
 Lubbers, K., 247, 253, 258, 265, 271, 
 
 280 
 Luc, 245, 252 
 Luciani, L., 194, 195, 202 
 Ludewig, 225 
 
 Maas, H., 245, 263, 269, 280 
 MacEwen, W., 16, 24, 46, 81, 86. 87, 
 
 97, 98, 261, 271, 275, 280 
 Mackenzie, 89, 228 
 Macklin, C. C, 16, 142 
 Macklin, M. T., 16, 142 
 Maffei, 246, 257, 270, 280 
 Maier, M., 72, 240 
 Mall, 97 
 Mallory, 52 
 Manasse, 46, 244, 246, 250, 251, 252, 
 
 257, 264, 267, 269, 276, 280 
 Martin, H. H., 102, 170, 198 
 Martland, H. S., 3 
 Marx, 70, 82 
 Masland, H. C, 12 
 Mayer, H., 163, 248, 254, 266, 273, 277, 
 
 280 
 Mayman, L., 16 
 McCoy, J., 247, 250, 254, 258, 265, 272, 
 
 280 
 McCrae, 133, 163 
 McKibben, P. S., 142 
 McRobert, E. G., 162, 184, 195 
 Menetrier, P., 74 
 Mertins, P., 264, 270, 275, 280 
 Meurers, 246, 253, 257, 258, 260, 262, 
 
 264, 270, 280 
 Meyer, R., 73 
 Meyers, L L., 193 
 Michaelsen, U., 240 
 Miegeville, 12 
 Milian, G., 208, 210 
 Milligan, W., 114, 226, 248, 251, 255, 
 
 273, 277, 280 
 Mills, C. K., 193 
 Mlngazzirn, G., 202 
 
 MiodowBki, F., 16, 24, 242 
 
 Moeller, 251, 256, 267 
 
 Mollison, W. M., 127 
 
 Moore, J. T., 70, 83 
 
 Moos, S., 221 
 
 Moulouguet, A., 18, 73, 120, 196, 259, 
 
 260, 262, 267, 280 
 Muck, 57, 58, 188, 231 
 Muirhead, W., 185 
 Miiller, E., 66, 229 
 MuUin, W. v., 246, 253, 265, 270, 
 
 280 
 Myers, I. L., 192 
 M^fgind, H., 67, 212 
 
 Nauwerck, 67 
 
 Neal, J. B., 160 
 
 Neumann, H., 48, 101, 102 
 
 Nichorster, H., 210 
 
 Niehsmann, Th., 212 
 
 Nonne, 120, 256, 260, 262, 267, 280 
 
 Nourse, 242 
 
 Okada, W., 231 
 Onodi, 115, 280 
 Orne Green, J., 230 
 
 Page, 134 
 
 Panse, E., 226 
 
 Paunz, M., 249, 255, 258, 274, 280 
 
 Piingst, A. O., 124, 249, 251, 267, 274, 
 
 280 
 Pick, L., 170 
 
 Picque, 244, 259, 260, 267, 280 
 Piersol, 24 
 
 Piffl, O., 124, 247, 253, 257, 270, 280 
 Pike, F. H., 197 
 Pitt, G. N., 226 
 Plant, 3 
 Pogany, E., 83 
 Poirier, 151 
 Politzer, A., 16, 234 
 Pollak, 242 
 Preysing, H., 23, 232, 244, 245, 251, 
 
 262, 263, 276, 281 
 
 Quimby, W. O. G., 18, 72 
 
 Rados, A., 173 
 
 Eafin, 245, 252, 268, 281 
 
 Eahn, H., 12 
 
 Randall, B. A., 227 
 
 Rauzier, G., 238 
 
 Eawling, L. B., 128, 222, 248, 254, 
 
 266, 273, 281 
 Redtenbacher, 245, 256, 268, 281 
 Reinhard, 225, 244, 249, 255, 266, 273, 
 
 275, 276, 277, 281 
 Eeimer, 245, 252, 258, 259, 263, 268, 
 
 269, 276, 281 
 Eeis, W., 258, 262, 273, 277, 281 
 
286 
 
 INDEX OF ATJTHOKS 
 
 Eeischig, 3 
 
 Eenton, J. C, 245, 256, 263 268, 
 
 281 
 Reynolds, C. E., 43, 73 
 Reynolds, F. E., 237 
 Richardson, C, 211 
 Rische, H., 247, 253, 271, 281 
 Roepke, 46, 248, 254, 259, 266, 273, 
 
 275, 277, 281 
 Roger, 238 
 Rogers, P. T., 163 
 Rohardt, W., 198 
 Rossi, G., 194 
 Rothholz, H., 224 
 Roulland, H., 74 
 
 Ruttin, E., 66, 102, 171, 242 
 Ryder, 172 
 
 Sachs, E., 262, 271, 281 
 
 Saelhof, C. C, 76 
 
 Sant^, H., 24, 46, 52 
 
 Sargent, 131, 134 
 
 Sautter, C. M., 163 
 
 Savariaud, 238 
 
 Schaefer, H., 246, 250, 257, 264, 269, 
 
 276, 281 
 Schaller, W. F., 243 
 Schick, F., 173 
 Schilling, R., 116, 281 
 Schindler, 252, 263, 281 
 Schorstein, 70, 74, 76, 260, 272, 281 
 Schott, 49 
 
 Schottmiiller, 3 
 
 Schousboe, 124, 251, 256, 267, 281 
 
 von Schroeder, 245, 256, 263, 268, 276, 
 
 281 
 Schulz, R., 222 
 Schulze, 232 
 Schwabach, D., 120, 258, 259, 260, 
 
 281 
 Schwarze, 226 
 Sehwartze, H., 220 
 Scott, 94 
 
 Seifert, 248, 255, 266, 273, 281 
 Sierra, A. M., 210 
 Silex, 245, 249, 252, 263, 281 
 Sillar, 245, 252, 268, 281 
 Skillern, P. G., 108 
 Smith, H. B., 7 
 Smith, S., 134 
 Smith, Th. C, 225 
 Solowcyczyk, A., 244, 251, 258, 267, 
 
 281 
 Spencer, F. R., 239 
 Sperling, 74 
 Stallard, J. H., 223 
 Steed, K., 132 
 Steese, 245, 251, 256, 259, 261, 267, 
 
 268, 281 
 Steinbrugge, H., 221 
 Stolz, 97, 171 
 Strauss, I., 3 
 
 Streit, H., 25, 118, 123, 140 
 Struycken, H. J. L., 246, 250, 252, 
 
 257, 264, 269, 281 
 Stucky, J. A., 251, 260, 261, 262, 266, 
 
 272, 273, 277, 281, 282 
 Sutphen, T. Y., 224 
 Syme, W. S., 242 
 
 Symonds, C. J., 245, 249, 250, 252, 256, 
 
 257, 264, 269, 276, 282 
 Szulislawski, 282 
 
 Talko, 282 
 
 Taylor, F. L., 258, 262, 272, 282 
 
 Texier, v., 243 
 
 Thigpen, Ch. A., 242 
 
 Thomas, St. Olair, 254, 258, 266, 273, 
 
 278 
 Tobey, G. L., 133 
 Topley, W. C, 16 
 Trautmann, 249, 255, 267, 274, 282 
 Treitel, 245, 252, 268, 276, 282 
 Troeltsch, 221 
 Truckenbrod, C, 227 
 Turner, L. A., 116, 237, 254, 258, 266, 
 
 273, 278 
 Tylor, C, 16, 73 
 
 von Uchermann, 49, 233, 239, 242 
 Uffenorde, W., 236, 246, 250, 252, 257, 
 
 264, 270, 275, 276, 282 
 Urbantschitsch, E., 66, 77, 82, 239 
 
 Vangehuchten, 249, 263, 282 
 Verhoeff, F. H., 172 
 Viete, H., 209 
 Viollet, P., 230 
 Voltolini, R., 220 
 Voss, P., 66, 235, 243 
 
 Wallace, C. S., 229 
 
 Warrington, W. B., 32, 168 
 
 Weed, L. H., 20, 28, 69, 72, 128, 132, 
 
 141, 142, 144, 147, 150, 153, 154, 
 
 172, 173 
 Wiegeforth, P., 28, 69, 128, 132, 141, 
 
 145, 147, 150, 153, 154, 172 
 Weichselbaum, 245, 252, 256, 263, 268, 
 
 276, 282 
 Weisenberg, T. H., 193 
 Wertheim, 260, 267, 274, 277, 282 
 West, 94 
 Westphal, 16, 48 
 Wheat, D. S., 163 
 White, J. A., 247, 254, 272, 282 
 Whitehead, A. L., 32 
 Whiting, P., 56 
 
 Wiener, A., 179', 246, 252, 270, 282 
 Williamson, 245, 249, 252, 256, 268, 
 
 282 
 Wilson, 197, 249, 255, 267, 274, 282 
 
INDEX OP AUTHOES 
 
 287 
 
 Wittmack, 16 
 Wolbach, S. B., 102 
 Woodward, J. U., 229 
 Wright, 224 
 Wyss, O., 261, 269, 282 
 
 Youl, 245, 261, 263, 269, 282 
 
 Zdekauer, 256, 261, 268, 282 
 
 Zeller 229 
 
 ZemaAn, W., 123, 244, 247, 250, 253, 
 
 257, 263, 265, 271, 276, 282 
 Zeroni, W., 232 
 Zirm, 252, 256, 263, 282 
 Zwillinger, H., 116, 140, 282 
 
INDEX OF SUBJECTS 
 
 Abdominal reflexes, loss of, in frontal 
 abscess, 209 
 
 Abscess, adjacent, see Adjacent abscess 
 brain, see Brain abscess 
 capsulated, 23 
 
 cerebellar, see Cerebellar abscess 
 cerebral, see Brain abscess, and Cere- 
 bral abscess 
 double, see Double abscess 
 extradural, see Extradural abscess 
 frontal, see Frontal abscess 
 idiopathic, see Idiopathic abscess 
 intercurrent, see Intercurrent ab- 
 
 intracerebellar, see Intracerebellar 
 
 intracerebral, see Intracerebral ab- 
 scess 
 
 intradural, see Intradural abscess 
 
 intrapiarachnoid, see Intrapiarach- 
 noid abscess 
 
 in lateral cisterna, 05 
 
 losing, 56 
 
 meningeal, see Meningeal abscess 
 
 meningo-cerebral, 22 
 
 metastatic, see Metastatic abscess 
 
 of middle fossa, see Middle fossa 
 
 oyster shaped, 34 
 
 perisinus, see Ferisinus abscess 
 
 second, 59 
 
 secondary, 59 
 
 subdural, see Subdural abscess 
 
 temporo-sphenoidal, see Temporo- 
 sphenoidal abscess 
 
 traumatic, see Traumatic abscess 
 Accessory nasal sinuses, operations for 
 
 suppurative lesions of, 123 
 Adhesive inflammation of piarachnoid 
 to dura, surgical signiflcance of, 
 50 
 Adjacent abscess, 17, 20, 68 
 After effects of brain abscess, 211 
 Anesthesia, 4 
 
 local, 5 
 Aphasia, in frontal abscess, 208 
 
 in temporo-sphenoidal abscess, 177 
 
 naming, 46 
 Aseptic meningitis, case of (VI), 33 
 Assistants must be trained, 4 
 Autolysis, in subnormal temperature, 
 164 
 
 Bleyle's hammer, 9 
 Bone, sacrifice of, 9 
 
 Brain, and see Cerebral 
 abscess, see below Brain abscess, 
 Cerebellar abscess, Frontal 
 abscess, Temporo-sphenoidal ab- 
 scess 
 blood supply of, 24 
 elevation of, 44, 50 
 exploration into, 45 
 hemorrhage from, control of, 12 
 hernia of, see Hernia 
 herniation of, see Herniation 
 infection of, methods, 138 
 injury to from its own pressure, 29 
 inspection of, within dura, 42 
 necrosis of, superficial, 32 
 oedema of, sudden death from, 15 
 protective mechanism of, 137, 139, 
 147 
 additional references to, 153 
 by dura, 139 
 
 by subarachnoid spaces, 140 
 by subdural space, 140 
 removal of dead tissue from, 149 
 repair of, 149 
 sensitiveness of, to toxic influences, 
 
 147 
 suppuration within, limitation of, 
 148 
 Brain abscess, acute, 61 
 adjacent, 17 
 closure of, 65 
 exploring for, 65 
 methods of treatment, 62 
 pathology of, 61 
 surgical aims in, 62 
 surgical pathology of, 62 
 varieties of, 22 
 after effects of, 211 
 case of (VII), 35 
 
 (XXIX), with transient aphasia 
 and paralysis, 185 
 classification of, according to loca- 
 tion, 30 
 clinical, 21 
 chronic, adjacent, 17 
 closure of, 65 
 surgical pathology of, 47 
 varieties of, 21 
 complications of, 211 
 compression, secondary in, 58 
 diagnosis of, 155 
 differential diagnosis of, 211 
 evacuation of, complications after, 
 211 
 
 289 
 
390 
 
 INDEX OF SUBJECTS 
 
 Brain abscess from meningitis, 144 
 idiopathic, 18, 73 
 intercurrent, 17 
 
 metastatic, 17, 18, 25, 68, 69, 120 
 pathology of, references to, 16 
 results of, 211, 212 
 surgical classification of, 17, 19 
 surgical factors in, 28 
 surgical pathology of, 17 
 surgical principles in, 27 
 surgical technic in, 28 
 traumatic, 17, 19, 25, 121, 261 
 
 Capsulated abscess, 23 
 
 Capsule, formation of in metastatic 
 
 abscess, 76 
 Cerebellar abscess, 84 
 
 additional bibliography, 242 
 
 adjacent, surgical classification of, 85 
 surgical principles in treatment of, 
 101 
 
 analysis of pathological condition in 
 reported autopsies of 125 cases, 
 220 
 
 anatomical factors in, 86 
 
 associated with extradural abscess, 
 105 
 
 case of (I), delay in operating 
 fatal, 3 
 
 case of (XIX), 99 
 
 case of (XXXI), with vague symp- 
 toms, 203 
 
 cerebellar ataxia in, 194 
 
 cerebellar attitude, forced, in, 195 
 
 cerebellar convulsions in, 195 
 
 cerebellar paralysis in, 194 
 
 changing character of vestibular re- 
 actions in, 199 
 
 classification of symptoms, 191 
 
 clinical classification of, 95 
 
 diagnosis of, 190 
 
 double, case of (XII), 60 
 
 exploration of, 103 
 
 exposure of behind sinus, 104 
 
 failure of inhibition in, 194 
 
 falling in, 198 
 
 following sinus thrombosis, 101, 103 
 
 herniation in exploration for, 86 
 
 hypermetria in, 194 
 
 immediate occasion of, 84 
 
 irregular shape of, 101 
 
 knee jerks in, 202 
 
 labyrinth in etiology of, 91 
 
 labyrinthine suppuration in, 94 
 
 labyrinthitis in diagnosis of, 190 
 
 lateral deviation of eyes in, 197 
 
 lateral sinus thrombosis in diagnosis 
 of, 190 
 
 local symptoms from direct pressure, 
 201 
 
 obliteration of symptoms the result 
 of cerebellax compensation, 194 
 
 Cerebellar abscess, origin of, 84, 
 91 
 past pointing, spontaneous in, 198 
 pathological factors in, 87 
 physiological factors in, 86 
 post-mortem findings in, 220 
 psychic disturbances in, 202 
 pupillary disturbances in, 201 
 rapid loss of flesh in, 202 
 routes of infection in, 88, 91 
 
 in 125 cases, 89 
 secondary to sinus thrombosis, 101, 
 
 102, 104 
 situation of, 105 
 speech defects in, 195 
 spontaneous nystagmus in, 197 
 suboccipital tenderness in, 202 
 surgical considerations in, 85 
 surgical requirements for explora- 
 tion and evacuation, 105 
 surgical treatment of, 96 
 symptoms of, 191, 201 
 due to internal hydrocephalus, 
 203 
 ventricular puncture in, 104 
 vertigo in, 197 
 
 vestibular manifestations in, 196 
 vestibular reactions, changing char- 
 acter of in, 199 
 induced abnormal, 198 
 reported cases of, 198 
 vomiting in, 202 
 yawning in, 202 
 Cerebellar ataxia, in cerebellar abscess, 
 
 194 
 Cerebellar attitude, forced, in cerebel- 
 lar abscess, 195 
 Cerebellar compensation, cause of ob- 
 literation of cerebellar symp- 
 toms, 194 
 Cerebellar convulsions, in cerebellar ab- 
 
 cess, 195 
 Cerebellar cortex, pressure on, with 
 vestibular manifestations, 200 
 Cerebellar cortical localization, in re- 
 lation to vestibular reaction, 
 200 
 Cerebellar function, impaired, manifes- 
 tations of, 192 
 Cerebellar lesions, stages of, 193 
 Cerebellar operations, outrigger for, 7 
 Cerebellar paralysis, in cerebellar ab- 
 scess, 194 
 Cerebellar symptoms from direct pres- 
 sure, 201 
 Cerebellum, experimental ablation of, 
 symptoms, 192 
 exploration of after destruction of 
 
 labyrinth, 96 
 exposure of lateral lobes with ex- 
 ploration and drainage behind 
 lateral sinus, 96 
 
IITDEX OF SUBJECTS 
 
 291 
 
 Cerebellum, incision and evacuation in 
 front of lateral sinua, 96 
 infection of from bony caries or 
 
 necrosis, 9i 
 operative approach to, 95 
 physiology of, 192 
 Cerebral abscess, case of (II), delay 
 in operating fatal, 3 
 coma in, 167 
 
 compression, blood pressure in, 166 
 ocular paralysis in, 167 
 papillcedema in, 168 
 projectile vomiting in, 167 
 pulse pressure in, 167 
 pulse slow in, 166 
 symptoms of, 165, 166 
 in frontal abscess, 207 
 Cerebral suppuration, chill, evidence of, 
 157 
 convulsions, evidence of, 161 
 disproportion evidence of, 158 
 evidence of, 157, 160 
 headache, evidence of, 157 
 is it possible, 156 
 is it probable, 156 
 malaise, evidence of, 158 
 meningitis, protective, evidence of, 
 
 160 
 positive evidences of, 160 
 subnormal temperature evidence of, 
 
 163 
 symptoms of, in frontal abscess, 207 
 vomiting, evidence of, 157 
 Cerebral tissue, factors peculiar to 
 which demand surgical recogni- 
 tion, 13 
 histopathology of, 13 
 susceptibility of to bacterial viru- 
 lence, 146 
 Cerebral trauma, death from, 15 
 Cerebro-spinal fluid system, anatomy 
 of, 141 
 impr^nability to infection, 142 
 infection of from blood stream, 144 
 Chest position, Sims', 6 
 Chill, evidence of cerebral suppuration, 
 
 157 
 Chisels, 9 
 
 Chronic brain abscess, after-treatment 
 of, 59 
 drainage in, 57 
 Cisterna, lateral, abscess in, 95 
 Clamp, Heuer's temporo-museular, 9 
 Clips, spring, of Makkas, 9 
 Closure, of brain abscess, 65 
 
 of dura, 12 
 Coma, in cerebral compression, 167 
 
 in frontal abscess, 207 
 Complications of brain abscess, 211 
 Compression, secondary, in brain ab- 
 scess, 58 
 Compressors, 8 
 
 Contralateral hemiplegia in frontal 
 abscess, 209 
 in temporo-sphenoidal abscess, 181 
 paralysis in temporo-sphenoidal ab- 
 scess, 181 
 in frontal abscess, 209 
 Control of hemorrhage, 7, 8, 9, 11, 12 
 Convulsions, in cerebral suppuration, 
 161 
 in frontal abscess, 207 
 in temporo-sphenoidal abscess, 184 
 
 Dead tissue, removal of, 149 
 
 Death, sudden, from cedema of brain, 
 
 15 
 Decompression, principles in technic 
 
 of, 58 
 Delay in operating in cerebellar abscess 
 
 fatal, case (I), 3 
 Deviation, lateral, in cerebellar abscess, 
 
 197 
 Diabetes insipidus in frontal abscess, 
 
 207 
 Diagnosis, of brain abscess in general, 
 155 
 of cerebellar abscess, 190 
 of frontal abscess, 206 
 of temporo-sphenoidal abscess, 176 
 Differential diagnosis of brain abscess, 
 
 211 
 Diploic vessels, control of hemorrhage 
 
 from, 9 
 Disposition, change of in frontal ab- 
 scess, 209 
 Disproportion, in cerebral suppuration, 
 
 158 
 Double abscess, 59 
 
 additional references to, 66 
 cerebellar, case of (XII), 60' 
 Drainage, in chronic intracerebral ab- 
 scess, 52 
 Dreamy state, in temporo-sphenoidal 
 
 abscess, 184 
 Dura, adhesive inflammation of pia- 
 rachnoid to, surgical significance 
 of, 50 
 bulging of into perforation openings, 
 
 10 
 closure of, 12 
 
 control of hemorrhage from, 11 
 incision of, technic of, 29 
 herniation of brain following, 42 
 inspection of brain within, 42 
 protection of brain by, 139 
 vulnerability of, 139 
 Dural defects, in hernia cerebri, 132 
 Dural separators, 10 
 
 Eagleton's encephaloscope, 56 
 Elevation of brain, inspection by, 44 
 
 technic of, 44 
 
 technic following, 50 
 
392 
 
 INDEX OF SUBJECTS 
 
 Elevation of head, during operations, 7 
 Encapsulated adjacent intracerebral 
 
 abscess of middle fossa, 51 
 Encephaloscope, Eagleton's, 56 
 
 Whiting's, 56 
 Eradication, in treatment of chronic 
 
 intracerebral abscess, 51 
 Exploration of cerebellar abscess, 103 
 protection of piaracbnoid prior to, 44 
 site for, 46 
 
 within cerebral substance, 45 
 Exploring, for brain abscess, 65 
 
 instrument, 46 
 Evacuation, complications after, 211 
 difficulties of, 52 
 importance of thorough, 53 
 Exposure of temporo-sphenoidal lobe, 
 
 40 
 Extradural abscess, associated with 
 cerebellar abscess, 105 
 relationship of with osteomyelitis, 
 and intradural abscess, 110 
 Eyes, lateral deviation of in cerebellar 
 abscess, 197 
 
 Facial paralysis of opposite side, in 
 temporo-sphenoidal abscess, 181 
 Failure of inhibition, in cerebellar ab- 
 scess, 194 
 Falling, in cerebellar abscess, 198 
 Fibrin paper, as a hemostatic agent, 11 
 Flap, osteoplastic, formation of, 9 
 Frazier's electric fraise, 9 
 Frontal abscess, 107 
 
 analysis of 140 reported cas^s of, 244 
 anatomical considerations, 107 
 aphasia in, 208 
 
 associated with complications, re- 
 port of cases, 267 
 with epidural abscess, report of 
 
 cases, 274 
 with extradural abscess, report of 
 
 cases, 275 
 with meningitis, report of cases, 
 
 276 
 with osteomyelitis, analysis of 
 
 cases, 258 
 with subdural abscess, report of 
 cases, 275 
 bibliography of, 277 
 coma in, 207 
 
 contralateral hemiplegia in, 209 
 contralateral paralysis in, 209 
 convulsions in, 207 
 diabetes insipidus in, 207 
 diagnosis of, 206 
 
 additional references to, 210 
 disposition, change of, in, 209 
 extradural abscess in, 206 
 localizing symptoms in, 208 
 loss of abdominal reflexes in, 209 
 loss of smell in, 208 
 
 Frontal abscess, mental disturbance in, 
 209 
 metastatic, 120, 259 
 in opposite lobe, 260 
 of aural region, 260 
 operative intradural policy in, 123 
 orbital abscess in, 206 
 osteomyelitis in, 206 
 papilloedema in, 208 
 path of infection, in, report of cases, 
 
 262 
 pathological considerations, 107 
 principles of exploratory intradural 
 
 operation, 123 
 relation of trauma to, 109 
 retrobulbar neuritis in, 208 
 surgical classification of, 112 
 symptoms due to association with 
 
 cerebellum, 210 
 symptoms, of cerebral compression in, 
 
 207 
 symptoms of cerebral suppuration in, 
 
 207 
 traumatic, 121, 261 
 treatment of, 123 
 types of, 117 
 Frontal abscess, adjacent, 112 
 analysis of cases, 244 
 associated with osteomyelitis, 117 
 capsule in, 122 
 case of (XXI), 111 
 from ethmoidal disease, 249 
 from frontal sinus, 251 
 immediate occasion of, 121 
 infection by complicating osteo- 
 myelitis, 116 
 infection by continuity of tissue 
 
 suppuration, 115 
 infection by retrograde thrombo- 
 phlebitis or perivasculitis, 116 
 infection by tissue suppuration 
 
 and thrombophlebitis, 116 
 intracerebral, without macroscop- 
 ical evidence of cortical involve- 
 ment, 120 
 meningeal, subdural, 118 
 occurence of, 112 
 operative results in, 122 
 origin of infection in, 114 
 paths of infection in, 115 
 piaracbnoid, 119 
 situation of, 122 
 
 eurgical aims for operation for, 124 
 terminations of, 123 
 treatment of, 123 
 with orbital complications, 256 
 with stalk, 119 
 Frontal abscess, intercurrent with 
 
 stalk, case of (XXII), 125 
 Frontal abscess, metastatic, 120, 259 
 Frontal bone, peculiarities of in rela- 
 tion to frontal abscess, 107 
 
INDEX OP SUBJECTS 
 
 393 
 
 Gtigll saw, 10 
 Gliosis, 13 
 
 Gradenigo's syndrome, 173 
 Gravity, utilization of in evacuation 
 of brain abscess, 6 
 
 Hammers, 9 
 
 Hartley and Kenyon's perforators, 9 
 Head, elevation of during operations, 7 
 Headache, evidence of cerebral suppura- 
 tion, 157 
 Head-rests, 7 
 Heidenhain'a sutures, 9 
 Hemianopsia, case of (XXVII), in 
 temporo-sphenoidal abscess, 180 
 Hemiplegia, contralateral, in frontal 
 abscess, 209 
 in temporo-sphenoidal abscess, 181 
 Hemorrhage, control of, 7, 8, 11, 12 
 from brain, 12 
 
 from diploic vessels during per- 
 foration of skull, 9 
 from dura, 11 
 from interior of skull before dura 
 
 is opened, 10 
 from pial vessels, 11 
 from scalp, 8 
 
 postage-stamp method of, 10 
 Hemostats not to be used, 11 
 Hernia cerebri, 127 
 case of (XXIII), 129 
 ease of (XXIV), following operation 
 for temporo-sphenoidal abscess, 
 135 
 circulatory factors in, 129 
 dural defects in, 132 
 etiology of, 127 
 f ungating, 131 
 non-ulcerative, 131 
 physiological factors in, 131 
 prevention of, 132 
 protection in, 133 
 reduction of increased intracerebral 
 
 pressure in, 134 
 surgical pathology of, 131 
 surgical treatment of, 132 
 ulcerative, 131 
 Herniation, in exploration for cerebel- 
 lar abscess, 86 
 of brain on incision of dura in tem- 
 poro-sphenoidal abscess, 42 
 puncture of opposite veniiiele for 
 reduction of, 44 
 Heuer's temporo-muscular clamp, 9 
 Histological considerations, 13 
 History taking, importance of, before 
 exploration, 1 
 prior to appearance of symptoms, 2 
 Homolateral ventricle, obliteration of 
 in temporo-sphenoidal abscess, 
 42 
 Eorsley's wax, use of, 9 
 
 Hudson's perforators, 9 
 Hydrocephalus causing symptoms in 
 
 cerebellar abscess, 203 
 Hypermetria in cerebellar abscess, 194 
 
 Idiopathic brain abscesses, 18, 73 
 Illumination, necessity for, 57 
 Immunization, 145 
 
 Induced "stupeur art^rielle," in pro- 
 duction of papilloedema, 174 
 Infection, pathological processes in, 138 
 impenetrability of cerebro-spinal 
 
 fluid system to, 142 
 latent, recrudescence of, 149 
 method of entry into brain, 138 
 prevention of, 137 
 
 varying degrees of sensitiveness to 
 extension of, 148 
 Inflammation, adhesive, of piarachnoid 
 to dura, surgical significance of, 
 50 
 Inhibition, failure of, in cerebellar ab- 
 scess, 194 
 Inspection of brain within dura, 42 
 Intercurrent abscess, tertiary, 17 
 
 secondary to sinus thrombosis, 31, 
 102 
 Intracerebellar abscess, situation of, 
 
 104 
 Intracerebellar pressure, 86 
 direction of maximum, 87 
 Intracerebral abscess, 19 
 adjacent, of middle fossa, 51 
 with capsule, 47 
 
 with surgical treatment, 55 
 without macroacopical cortical in- 
 volvement, 36 
 drainage of, 52 
 eradication of, 51 
 evacuation of, 52, 53 
 selection of eases, 52 
 stalk of, 19, 20 
 with capsule, 21 
 with capsule and stalk, 22 
 with stalk, 19 
 
 without cortical involvement discov- 
 erable macroscopically, 23, 46 
 without limiting membrane, 22 
 Intracranial operations, general surgi- 
 cal technic, 6 
 position of patient in, 6 
 Intracranial pressure, increased, diag- 
 nosed by vestibular reactions, 
 199 
 influence of in papilloedema, 168 
 reduction of, 134 
 Intradural abscess, 19 
 relationship between osteomyelitis, 
 extradural abscess and, 110 
 Intradural suppuration in middle fossa, 
 exposure for in suspected cases, 
 40 
 
394 
 
 INDEX OF SUBJECTS 
 
 Intrapiarachnoid abscess, 20, 26, 32, 
 93 
 case of (XVIII), 92 
 extension of, 34 
 situation of, 104 
 
 Kenyon and Hartley's perforators, 9 
 Knee jerks in cerebellar abscess, 202 
 Kredel's plates, 9 
 
 Labyrinth, in etiology of cerebellar ab- 
 scess, 91 
 Labyrinthine suppuration, in cerebellar 
 abscess, 94 
 types of, 94 
 Labyrinthitis, case of (III), 15 
 
 in diagnosis of cerebellar abscess, 
 
 190 
 meningitis from, case of (XV), 71 
 secondary serous, 95 
 Lateral cisterna, abscess in, 95 
 Lateral deviation of eyes in cerebellar 
 
 abscess, 197 
 Lateral sinus, anatomy of on cross 
 section, 98 
 blood pressure in, 98 
 physiological and anatomical factors, 
 
 98 
 primary exposure of, 97 
 surgical obliteration of, 98 
 Limitation of field of operation, 7 
 Localized serous (protective) menin- 
 gitis, 32 
 diagnosis of, 33 
 Location of lesion, influence of in 
 
 papilloedema, 171 
 Losing abscess, 56 
 Lumbar puncture, dangers of, 29 
 Lymphatics, absence of and subnormal 
 temperature, 164 
 
 Makkas, spring clip of, 9 
 Malaise, evidence of cerebral suppura- 
 tion, 158 
 Marentz rongeur, 10 
 Meningeal abscess, 20, 22, 26 
 adjacent, of middle fossa, 32 
 adjacent subdural, 118 
 Meningitis, aseptic, case of (VI), 33 
 brain abscess from, 144 
 case of from disturbed meningeal 
 
 protection (XXV), 144 
 from labyrinthitis, case of (XV), 
 
 71 
 localized serous protective, 32 
 
 diagnosis of, 33 
 protective, evidence of cerebral sup- 
 puration, 160 
 suppurative, from cerebral abscess, 
 case of (XXVI), 151 
 
 Meningitis, suppurative, with brain 
 abscess, relation of to protective 
 meningitis, 150 
 Meningo-cerebral abscess, 22 
 Mental disturbances in frontal abscess, 
 
 209 
 Metastatic abscess, 17, 18, 25, 68, 69, 
 120 
 additional references to, 82 
 case of (XXVIII), 182 
 classification of, 68 
 development of, 68 
 frontal, 120, 259 
 formation of capsule in, 76 
 frequency of, 72 
 limitation of by capsule, 76 
 location of, 74 
 multiple, 75 
 case of, 75 
 of otitic origin, case of (XVII), 77 
 of venous origin, 71 
 treatment, 76 
 Metastatic vascular occlusion, 69' 
 Middle fossa, abscess of, 31 
 case of (XI), 46 
 adjacent meningeal abscess of, 32 
 adjacent secondary abscess of, con- 
 siderations prior to operation, 
 37 
 cleansing and obliteration of abscess 
 
 with stalk near surface, 56 
 following thrombosis of superior pe- 
 trosal sinus or dural veins, 31 
 osteoplastic flap for exploration of, 
 41 
 Mills, naming center of, 46 
 Muscle, control of hemorrhage by, 11 
 
 Naming aphasia, 46 
 
 Naming center of Mills, 46 
 
 Nasal sinuses, accessory, operations for 
 suppurative lesions of, 123 
 
 Necrosis, superficial of brain, 32 
 
 Nerve head changes, diagnostic deduc- 
 tions from, 175 
 
 Neuritis, retrobulbar, in frontal ab- 
 scess, 208 
 
 Neuroglia, 13 
 
 Neurological examination, guide for, 
 213 
 prior to appearance of symptoms, 2 
 
 Neurons, 13 
 
 Nystagmus, spontaneous, in cerebellar 
 abscess, 197 
 
 Obliteration of homolateral ventricle 
 in temporo-sphenoidal abscess, 
 42 
 
 Ocular paralysis in cerebral compres- 
 sion, 167 
 
 CEdema of brain, from trauma of opera- 
 tion, 15 
 
INDEX OF SUBJECTS 
 
 29S 
 
 CEdema of brain, sudden death from, 
 15 
 
 Oozing, control of, 11 
 
 Operating in cerebellar abscess, delay 
 in fatal, ease of (I), 3 
 
 Operation, time for, 3 
 
 Operative technic, general, 6 
 additional references to, 12 
 
 Optic nerve, intracellular pathways of 
 in papilloedema, 172 
 
 Osteomyelitis, adjacent frontal lobe ab- 
 scess associated with, 117 
 relationship between extradural and 
 intradural abscess and, 110 
 
 Osteoplastic flap, cutting of, 10 
 for exploration for abscess of middle 
 fossa, 41 
 
 Outrigger, for cerebellar operations, 7 
 
 Oyster-shaped abscess, 34 
 
 Pain behind eye in temporo-sphenoidal 
 abscess, 183 
 in teeth in temporo-sphenoidal ab- 
 scess, 183 
 Papilloedema, etiology of, 169 
 in cerebral compression, 168 
 in frontal abscess, 208 
 increased intracranial pressure in, 
 
 168 
 induced "stupeur artfirielle" in pro- 
 duction of, 174 
 influence of location of lesion in, 171 
 influence of parenchymatous fluids 
 
 in, 172 
 interference with venous circulation 
 in, 169 
 Paralysis and transient aphasia, case 
 of brain abscess with (XJQX), 
 185 
 Paralysis of contralateral arm, in 
 frontal abscess, 209 
 in temporo-sphenoidal abscess, 181 
 Parenchymatous fluids, influence of in 
 
 papilloedema, 172 
 Past pointing, in cerebellar abscess, 
 198 
 in tempero-sphenoidal abscess, 187 
 Pathological considerations, 13 
 Pathological processes in brain, se- 
 quence of, 159 
 Pathology of brain abscesses, 47 
 
 references to, 16 
 Patient, position of in intracranial op- 
 erations, 6 
 Perforation of skull, 9 
 bulging of dura in, 10 
 control of hemorrhage during, 9 
 Perforators, 9 
 Petrous pyramid, cerebellar abscess 
 
 from infection of, 91 
 Perisinus abscess, case of (XX), 103 
 Pia, blood vessels of, 24 
 
 Pial vessels, control of hemorrhage 
 
 from, 11 
 Piarachnoid abscess, adjacent, 119 
 Piarachnoid, adhesive inflammation of 
 to dura, surgical signLflcauce of, 
 50 
 protection of prior to exploration, 44 
 Plates, Kredel's, 9 
 Postage-stamp method of controlling 
 
 hemorrhage, 10 
 Posterior fossa, surgical ajiatomy of, 
 
 84 
 Preparation, 1 
 
 Projectile vomiting, in cerebral com- 
 pression, 167 
 Protection of brain, by dura, 139 
 by subarachnoid spaces, 140 
 by subdural space, 140 
 Protective mechanism of brain, 137, 
 139, 147 
 additional references to, 153 
 Protective meningitis, evidence of cere- 
 bral suppuration, 160 
 Psychic disturbances in cerebellar ab- 
 scess, 202 
 manifestations of toxic delirium in 
 temporo-sphenoidal abscess, 185 
 Pulse, slow in cerebral compression, 166 
 Pulse pressure, in cerebral compression, 
 
 167 
 , Puncture, lumbar, dangers of, 29 
 ventricular, 29 
 
 for reduction of brain herniation, 
 
 44 
 in cerebellar abscess, 104 
 technic of, 10 
 Pupillary disturbances in cerebellar 
 abscess, 201 
 
 Rapid loss of flesh, in cerebellar ab- 
 scess, 202 
 
 Reflexes, loss of abdominal, in frontal 
 abscess, 209 
 
 Repair of brain substance, 149 
 
 Results of brain abscess, 211, 212 
 
 Retina, intracellular pathway of, in 
 papilloedema, 172 
 
 Retrobulbar neuritis, in frontal ab- 
 scess, 208 
 
 Roentgen ray diagnosis in temporo- 
 sphenoidal abscess, 187 
 case of (XXX), 188 
 
 Rongeurs, 9, 10 
 
 Searcher, 45 
 Second abscess, 59 
 Secondary and double abscesses, 59 
 Sensitiveness of brain to toxie influ- 
 ences, 147 
 Separators, dural, 10 
 Serous labyrinthitis, secondary, 95 
 Sims' chest position, 6 
 
396 
 
 INDEX OF SUBJECTS 
 
 Sinus thrombosis, case of (V), 33 
 cerebellar abscess following, 101, 
 102, 104 
 treatment of, 103 
 in diagnosis of cerebellar abscess, 
 
 190 
 intercurrent abscess secondary to, 
 31, 102 
 Sinus wall, incision through, 103 
 Skull, cutting of osteoplastic flap, 10 
 perforation of, 9 
 
 control of hemorrhage during, 9 
 Smell, loss of, in frontal abscess, 208 
 Speech defects in cerebellar abscess, 
 
 195 
 Spontaneous nystagmus in cerebellar 
 
 abscess, 197 
 Stalk, development of, 22 
 
 of intracerebral abscess, 19, 20, 22 
 "Stupeur ajtdrielle," induced, in 
 
 papilloedema, 174 
 Subarachnoid space, elimination of bac- 
 teria from, 145 
 protection of brain by, 140 
 Subdural abscess, 20, 24, 32 
 
 adjacent meningeal, 118 
 Subdural space, protection of brain by, 
 
 140 
 Subnormal temperature, autolysis in, 
 164 
 absence of lymphatics in, 164 
 evidence of cerebral suppuration, 163 
 Suboccipital tenderness, in cerebellar 
 
 abscess, 202 
 Suction apparatus, 45 
 Sudden death from oedema of brain, 15 
 Surgeon, mental attitude of, 1 
 Surgical factors, 28 
 Surgical principles, 27 
 Surgical teehnic, general, 28 
 
 Temperature, subnormal, autolysis in, 
 164 
 absence of lymphatics in, 164 
 evidence of cerebral suppuration, 163 
 Temporo-muscular clamp, of Heuer, 9 
 Temporo-sphenoidal abscess, 31 
 additional references to, 66 
 adjacent, case of (XIII), 63 
 
 diagnosis of, 176 
 aphasia in, 177 
 
 case of (VIII, IX, X), 37, 38, 43 
 contralateral hemiplegia in, 181 
 convulsions in, 184 
 diagnosis of, 176 
 dreamy state in, 184 
 facial paralysis of opposite side in, 
 
 181 
 hemianopsia, case of (XXVII), in, 
 
 180 
 herniation of brain in incision of 
 dura in, 42 
 
 Temporo-sphenoidal abscess, intradural 
 teehnic in suspected adjacent 
 cases, 49 
 localizing symptoms in, 176 
 localizing value of primary focus of 
 
 infection in, 176 
 obliteration of homolateral ventricle 
 
 in, 42 
 pain behind eye in, 183 
 pain in teeth in, 183 
 past pointing in, 187 
 pathognomonic symptoms in, 177 
 principles of operative treatment in, 
 
 40 
 psychic manifestations of toxic de- 
 lirium in, 185 
 Roentgen ray diagnosis in, 187 
 
 case of (XXX), 188 
 symptoms, 183 
 uncinate symptoms in, 185 
 with stalk, 36 
 word deafness in, 178 
 Temporo-sphenoidal lobe, exposure of, 
 
 40 
 Thrombosis of cerebral vessels, case of 
 
 (XIV), 70 
 Thrombotic nidus, origin of, 71 
 Tourniquets, 8 
 Toxic influences, sensitiveness of brain 
 
 to, 147 
 Trauma, cerebral, death from, 15 
 Traumatic abscess, 17, 19, 25, 121, 
 261 
 frontal, 121, 261 
 
 Uncinate symptoms in temporo-sphe- 
 noidal abscess, 185 
 
 Vascular occlusion, metastatic, 69 
 Venous circulation, interference with 
 
 in papilloedema, 169 
 Ventricle, obliteration of homolateral 
 in temporo-sphenoidal abscess, 
 42 
 puncture of opposite for reduction of 
 brain herniation, 44 
 Ventricular puncture, 29 
 for reduction of brain herniation, 
 
 44 
 in cerebellar abscess, 104 
 teehnic of, 10 
 Ventricular reaction, in diagnosis of 
 increased intracranial pressure, 
 199 
 Vertigo, in cerebellar abscess, 197 
 Vestibular manifestation, from pres- 
 sure on cerebellar cortex, 200 
 in cerebellar abscess, 196 
 Vestibular reactions, changing char- 
 acter of in cerebellar abscess, 
 199 
 
INDEX OP SUBJECTS 
 
 397 
 
 Vestibular reactions, cerebellar cortical 
 localization in relation to, 200 
 diagnosis of by increased intracran- 
 ial pressure, 199 
 in cerebellar abscess, 198 
 reported cases of, 198 
 Vomiting, in cerebellar abscess, 202 
 
 Vomiting, in cerebral compression, 167 
 in cerebral suppuration, 157 
 
 Wax, Horsley's, use of, 9 
 Whiting's encephaloscope, 56 
 
 Yawning, in cerebellar abscess, 202 
 
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