Brain abscess

“ Between the rapid and violent course of acute cerebral abscess detailed, and the insidious course of those which as latent abscesses may exist for many years without producing any noticeable symptoms whatever, there is every connecting link as to suddenness and slowness of onset, severity and mildness of symptoms, and rapidity and slowness of development and progress. It is the encapsulated abscesses which are properly spoken of as chronic, and which may even constitute an exception to the almost uniform fatality of the suppurative affections of the brain. ”

“ Neumann as to the differential diagnosis between meningitis, sinus thrombosis, and brain abscess: “A patient that has meningitis is one that wishes to be left alone and allowed to sleep, although when roused is not particularly irritable. If he has brain abscess then he is constantly very irritable and difficult to manage, while a patient that has sinus thrombosis when he is free from the chill and fever is very pleasant, apparently well.” ”

“ If an abscess be opened a varying quantity of pus escapes, usually evil smelling. In the more chronic cases it is thick and greenish; in the acute cases it may contain shreds of necrosed brain tissue or be intermixed with bubbles of gas. Sometimes there is also an escape of turbid cerebro-spinal fluid, which if excessive is suggestive either that the lateral ventricle has been opened inadvertently or that the abscess has already burst into it. In these cases the patient is usually comatose or in the state of muttering delirium at the time of the operation. ”

“ A chronic catarrh of the middle-ear mucous membrane results in an hypertrophy of the mucosa on one side and a chronic inflammation of the neighboring bone on the other side. Caries of the petrous bone, so caused, produces inflammation and adhesion of the dura mater, and from here as a starting-point the inflammation spreads into the brain tissue. In rare cases the brain abscess has been found connected by a fistulous tract with the diseased bone. ”

“ West, operative procedures were carried out on the mastoid region, the patient dying some days later from enteric fever. Again, the question of differential diagnosis between tuberculous meningitis, brain tumour and brain abscess is always cropping up. Thus, a short time ago, I explored both temporo-sphenoidal lobes in a boy suffering from double otitis media and presenting well-marked general cerebral symptoms, only to find that he was a subject of tuberculous meningitis. ”

“ It is also in accordance with the general law governing the influence of new formations on the cerebral functions that an acutely produced abscess will mark its presence by more pronounced symptoms than one of slow, insidious development. Indeed, there are found abscesses in the brain, even of fair dimensions, that are called latent because their existence could not have been suspected from any indication during life, while many others of equal size are latent at some time in their history. ”

“ An acute traumatic cerebral abscess is almost necessarily situated immediately beneath the site of osseous and membranous lesion, being, in fact, more a meningo-cortical abscess than a brain abscess proper. ”

“ If exploration proves negative, it may also be necessary to explore the cerebellum. If, however, the surgeon be still convinced that a temporo-sphenoidal abscess exists, he may next pierce the brain with the bistoury, in case the forceps has failed to enter the abscess cavity, perhaps owing to its walls being very thick. If all efforts fail to find the abscess, the little finger may be inserted into the brain itself to see if the resistant wall of an abscess can be felt. ”

“ The white substance is much more vulnerable to the assault of suppurative inflammation than the gray, and not infrequently the superficial part of the cortex may appear in its normal contiguity with the pia, but undermined by the cavity of the abscess, which has destroyed the subcortical tissue. Possibly the infecting agent, as in some cases of ear disease, makes its way to the brain-tissue through the vascular connections, which, however sparse at the convexity of the brain, still exist. ”

“ If a patient suffering from brain abscess is capable of answering questions, it will usually be found that he dates his illness from some particular day when he was sick, experienced a shivering attack, or suffered from a severe attack of headache. ”

“ When the symptoms are suggestive of brain abscess, when no extra-dural collection is discovered, and when the dura mater is tense and discoloured, then it becomes necessary to explore the brain. This can be carried out through an opening made in the tegmen or above the level of the supramastoid crest. Which route should be utilized depends on the local conditions. As a general rule, it is advisable to explore through the tegmen when a sinus exists in that situation, and above the supramastoid crest under all other circumstances. ”

“ Cases of brain abscess, of spinal focal lesions, and meningeal hemorrhage are in evidence, aphasias, monoplegias, Jacksonian spasm, and thalamic disease receiving consideration.
All neurologists know the difficulties in diagnosticating epilepsy in the absence of opportunities to see attacks and to receive the carefully analyzed statement of the observers of the patient. ”

“ The symptoms resulting from an acute traumatic cerebral abscess are largely dependent on the site of the abscess. In the earlier stages of development suspicion may be aroused by the presence of persistent headache—frequently localized to the region primarily affected—by mental and bodily irritability, restlessness, and pyrexia. All these symptoms may, however, be produced by the unhealthy condition of the scalp-wound—free suppuration, bare bone, and extra-dural suppuration. ”

“ The cases of abscess of the brain due to ear disease are usually found in the temporal lobe of the brain lying over the position of the ear or in the cerebellum behind it. The uncertainty of the nature and the extent of the cerebral injury in so-called contusion of the brain renders it necessary to be very careful in giving a prognosis. Any injury should be considered serious which has produced unconsciousness, for such an injury may produce enough laceration of the brain to render serious danger possible or even probable. ”

“ Acute traumatic abscess of the brain most commonly arises in connexion with an infected compound fracture of the skull. In the event of laceration of the dura mater, infective organisms have a ready means of access both to the meninges and to the brain itself, meningitis or cerebritis resulting. This liability to meningeal and brain infection is increased when hair, portions of clothing, bullets, or other foreign bodies are embedded amongst the comminuted fragments of bone, or driven into the brain substance. ”

“ If meningitis develops, the patient has headache and later it becomes very severe. Lights hurts the eyes, The patient is restless, sleepless, may have nausea and vomiting and a constant high temperature. The neck is stiff and rigid. If there is more brain involvement (phlebitis) there will be sudden rise of temperature, followed by a rapid fall of temperature and attended by profuse sweating and chills,—a dangerous condition. There can be abscess of the brain also. In abscess of the brain symptoms are less severe and localized; the rigid neck and fear of light and vomiting are absent. ”

“ Brain abscess, however, is most frequently associated with the chronic form of the ear and sinus disease; but these become more manifest following an acute attack of ear or sinus trouble. Tubercular or syphilitic meningitis is chronic inflammation per se; but these conditions are also lit up by the acute processes within the ear and sinuses.
The cardinal symptoms of any intracranial complications are—
1. ”

“ Ulcerative endocarditis, infectious osteomyelitis, pulmonary gangrene, general pyæmia, and, as is claimed by a few authors, typhoid fever, are often accompanied by multiple abscesses in the brain-substance. Usually the foci are small, as may be readily inferred from the fact that they are of embolic origin, the emboli being usually so small as to lodge in very small vessels, and that the fatality of the primary disease is so great as to cut short life before the abscess can reach larger dimensions. For the same reasons the symptoms they produce are rarely distinctive. ”

“ The most frequent cause for such abscesses is old and neglected disease of the ear. No child suffering from a “running from the ear,” which is especially apt to follow scarlet fever and other similar disorders, should be allowed to pass from under the most skilled treatment until a cure is effected. This is the commonest cause of abscess of the brain. ”

“ In other cases the person may die almost immediately on the spot where he fell, while in still others apparent recovery takes place and death occurs later either suddenly or after a reappearance [563] of symptoms. In such cases, abscess of the brain may occur and be the cause of the fatal result. These abscesses are the result of the injury, which may be almost anything from a compound fracture to a slight contusion not leaving any scar. ”

“ If, after performing the mastoid operation, the situation of the abscess be doubtful. In order to diminish the risk of infection of the brain by an exploratory puncture which may prove negative, the bone may be trephined a little beyond the mastoid wound, either above or behind, according as a temporo-sphenoidal or cerebellar abscess is suspected. If, however, it be considered advisable to make a fresh opening in the bone beyond the septic wound cavity, the aural surgeon will probably prefer to do so by means of the gouge and bone-forceps, to which he is more accustomed. ”

“ How curious and yet how intelligible is the fact that, though a headache may be induced by even a slight auto-intoxication, an abscess may exist within the brain without causing pain. When an obliterative endarteritis is threatening a leg with anemic gangrene, or when one lies too long in the same position on a hard bed, there is threatening injury from local anemia, and as a result there is acute pain, but when the obliterative endarteritis threatens anemia of the brain, or when an embolism or thrombosis has produced anemia of the brain, there may be no accompanying pain. ”

“ From these and other statistics it may be regarded as generally accepted that the majority of brain abscesses are secondary to chronic disease of neighbouring bone, and more especially middle ear disease. This being the case, it might naturally be inferred—on anatomical grounds—that the temporo-sphenoidal lobe of the cerebrum and the cerebellum are more liable to infection than any other part of the brain. From 100 cases treated at my hospital the temporo-sphenoidal lobe and cerebellum were involved in the proportion of about 2 to 1. ”

“ He may soon return to entire consciousness, but still suffer from some headache, feel wearied, and tired, and not feel like exerting himself. This may continue for some time. Occasionally the results are more serious even after a long time has passed, and an abscess of the brain should be watched for, sometimes epilepsy or insanity follows. If the patient grows worse instead of recovering, either deep seeming sleep sets in or symptoms of inflammation of the covering (meninges) or the brain itself follows. ”

“ There was profound coma for ten days and paralysis of the 1st, 2d, 3d, 4th, 6th, and 7th cranial nerves, particularly affecting the left side of the face. There was scarcely enough blood-supply left to the orbit to maintain life in the globe. The man primarily recovered, but ninety-one days from the injury he died of cerebral abscess.
There is the record of a curious brain-injury in a man of twenty-two, who was struck on the skull by a circular saw. The saw cut directly down into the brain, severing the superior longitudinal sinus, besides tearing a branch of the meningeal artery. ”

“ In accordance with the law of adaptation through natural selection, phylogeny, and association, one would expect no pain in abscess of the brain, in abscess of the liver, in pylephlebitis, in infection of the hepatic vessels, in endocarditis. This law explains why there are no nociceptors for cancer, while there are active nociceptors for the acute infections. It is because nature has no helpful response to offer against cancer, while in certain of the acute pyogenic infections the nociceptors force the beneficent physiologic rest. ”

“ Osteomyelitis of the neighbouring diploic tissue.
General meningeal infection will bring about a fatal result. Fortunately, the general rise of intracranial pressure and the formation of adhesions between the brain and the overlying membranes tend to prevent its development.
Perforation of the ventricular spaces may occur under two conditions: (1) when the abscess is associated with internal hydrocephalus, and (2) when the exploring instrument is passed too far.
Hæmorrhage is seldom serious when the operation is carried out with a light hand, all visible vessels being carefully avoided. ”

“ These symptoms are dependent on the connexion established by the posterior condyloid vein between the sigmoid sinus and the deep veins of the neck.
When the thrombus extends inwards along the meningeal veins, meningitis, meningo-cerebritis, and cerebral abscess result.
2. Symptoms resulting from toxic absorption or dependent on the transmission of infected material to other parts of the body.
Optic neuritis is present, according to Hunter Tod, in about 50 per cent. cases. It develops rapidly and attains a high degree of intensity. ”

“ The pulse rate and respiration will be affected, as in brain tumor, according to the size of the abscess. The larger the abscess the slower the pulse and respiration. The temperature, as well as the pulse and respiration, will vary as to whether the abscess be intradural or extradural. Intradural abscesses will frequently cause considerable rise of temperature, and acceleration of the pulse and respiration, and a remission when the abscess has become partially walled off. As soon as a fresh invasion of brain tissue takes place another rise of temperature, etc., occurs. ”