A REPORT OF FIVE CASES 
OF ABSCESS OF THE BRAIN IN INFANTS, TO- 
GETHER WITH A SUMMARY OF TWENTY- 
SEVEN COLLECTED CASES, IN INFANTS AND 
VERY YOUNG CHILDREN. 
BY 
L. EMMETT HOLT, M.D. 
York. A REPORT OF FIVE CASES OF ABSCESS OF THE BRAIN 
IN INFANTS, TOGETHER WITH A SUMMARY OF 
TWENTY-SEVEN COLLECTED CASES, IN INFANTS 
AND VERY YOUNG CHILDREN.* 
BY L. EMMETT HOLT, M.D., 
New York. 
The literature of cerebral abscess in infancy and early child- 
hood is very meagre. How rare this condition is may be judged 
from the fact that in a collection of ninety cases of abscess of the 
brain in 1867, Meyer found only three under ten years of age; in 
a collection of seventeen cases in children under fifteen, by Wyss 
in 1871, only four were under five years, two of these being in 
infants under one year. This is quite remarkable, since the two 
most potent causes of abscess, traumatism and otitis, are both 
so frequent during the first five years of life. 
The cases reported thus far have many of them been with 
very imperfect clinical histories, so imperfect, in fact, as often to 
throw little light upon the course of the disease at this early age. 
After five years, cases of brain abscess are not infrequent, and as 
a rule, the course resembles that seen in older children and early 
adult life. Four of the cases here reported came under obser- 
vation in the Babies’ Hospital in a single year, and two of them 
were under observation long enough to give an opportunity for 
careful study and record. It is the purpose of the present paper 
to furnish, together with a report of the cases mentioned, a 
collection of all that could be found in literature in children under 
five years; not, however, including any of five or over. 
Case I.—sAn abscess in the left parietal lobe containing two 
ounces of pus, with latent symptoms. 
A female child, six weeks old, was admitted to the Hospital, 
March 17, 1897. The history given was that the child was 
* Read before the American Pediatric Society, Wafhirfctdif, Hay 4 2 
Holt: Abscess of the Hrain in Infants. 
born after an easy, uncomplicated labor; that there had been no 
ophthalmia; no umbilical inflammation, and no traumatism. The 
infant was said always to have been well and healthy, and 
nothing abnormal had been noticed until four days previously, 
when swelling at the lower part of the left thigh was observed. 
The parents were not very intelligent, and no other facts could 
be ascertained. 
The child was admitted at night and no careful record was 
made of her general symptoms. She was well nourished, but 
very pale and greatly prostrated; pulse very feeble; temperature 
99.50; there was no coma. The only thing about the patient 
which attracted particular attention was, in addition to the great 
prostration, a swelling at the lower portion of the left thigh. 
This was quite prominent, and at its inner surface was an area 
of fluctuation. An erysipelatous blush surrounded the knee and 
extended up the thigh to the groin. 
The child was seen shortly after by Dr. A. L. Fisk, Surgeon 
to the Hospital, who laid open the thigh. He found no pus, but 
only a mass of disorganized blood and lacerated tissues. The 
thigh was thoroughly irrigated, and the wound drained and 
closed. No improvement followed the operation; the tempera- 
ture remained slightly elevated, and the blush extended rapidly 
upward until it reached the navel. The child grew gradually 
worse and died the following morning, eighteen hours after 
admission. 
Autopsy.—Brain: The convolutions of the left side were 
much flattened. The brain generally was firm, but quite pale, 
except over the medulla and pons, which were congested. No 
adhesions between the dura and skull, or between the dura and 
pia. There was a localized meningitis over the left hemisphere 
in the parietal region, extending somewhat on to the occipital 
and temporo-sphenoidal lobes. The pia was infiltrated with 
pus and fibrin in places, but the exudation was nowhere abun- 
dant. Occupying chiefly the left parietal lobe was an abscess 
cavity (Fig. i) measuring 7 c.m. by 5 c.m., and containing two 
ounces of thick, yellow, odorless pus. Its external wall was 
very thin, being scarcely two millimetres in thickness. In front 
the abscess was bounded by the ascending frontal, and behind 
by the anterior occipital convolution. The abscess wall was 
sharply limited, but showed no well-defined lining membrane. Holt: Abscess of the 'Brain in Infants. 
The sac communicated with the left lateral ventricle, which, 
however, was not filled with pus. 
The temporal bone on both sides was opened, and thin, 
yellow pus was found in both middle ears, but much more upon 
the left side. (No discharge during life.) 
On laying open the left thigh there was found a transverse 
laceration of the quadriceps muscle, just above the knee joint, 
with very extensive extravasation. The articular surfaces of the 
femur, fibula and tibia were reddened, and the cartilages slightly 
softened. There was some bloody effusion into the knee joint. 
Fig. I. ABSCESS OF PARIETAL LOBE IN A CHILD SIX WEEKS OLD. (Case I.) 
There was no fracture and the epiphysis was not separated. 
The other organs showed nothing of importance. 
A bacteriological examination was made with the following 
result: 
The heart’s blood, liver, left knee, thigh wound and abscess 
cavity of the brain all contained the streptococcus and staphy- 
lococcus pyogenes. The spleen and kidneys contained the 
streptococcus in pure culture. The culture from the right ear 
was contaminated; that from the left ear contained the strepto- 
coccus. 
The finding of an abscess in this case was entirely unexpected, 
for there was nothing in the history or the symptoms to point to 4 
Holt: Abscess of the Id rain in Infants. 
any serious brain lesion. Although carefully questioned, the 
parents positively stated that the child had appeared well until 
four days before admission. The condition found in the left 
thigh could only have resulted from traumatism, although no 
history of it could be obtained. It is not easy to state what the 
order of development of the different lesions was, but it seems 
most probable that the brain became infected from the ear, and 
that the thigh was a later condition infected from the brain or 
from the ear. The absence of pus from the lacerated thigh 
tissues, and the large collection in the brain, make it highly 
improbable that the thigh lesion was the primary one. 
Case II.—Abscess of both parieto-occipital lobes and the cere- 
bellum; pus in all the ventricles of the brain. 
L. K., a female child, three months old, was admitted to the 
Hospital, November 19, 1896. The family history was negative. 
One child had died at eight months of some brain disease after 
two days’ illness; one, of measles, and one of pneumonia. The 
patient was the only child living and had always been breast- 
fed. The mother was a Russian, and very little that was definite 
could be learned regarding the present illness, except that the 
child had been apparently well until three days before, since 
which time fever had been present. 
The examination on admission showed a plump, well-nour- 
ished infant; length, 23 inches; weight, 10 pounds, ounces; 
sutures still open; eyes, ears, nose and throat normal: scalp 
covered with seborrhceic eczema; tongue slightly coated; respir- 
ations shallow and irregular, almost Cheyne-Stokes; abdomen 
retracted; no rigidity of the extremities; no strabismus, drowsi- 
ness, paralysis, or stupor; liver, spleen, lungs, heart, normal. 
The temperature was 990 F., but rose the same afternoon to 
102° F. 
November 24th. The child has not done well; there has 
been continued fever and a loss of half a pound in weight. The 
child has vomited once or twice; takes food poorly. The pulse 
is strong and regular; there is slight cervical opisthotonos; 
fontanel not bulging. Unless disturbed, the child lies quietly all 
the time. No new nervous symptoms have developed since 
admission. 
December 8th. There have been very few changes during 
the last week. The fever has continued, ranging from 990 to Holt: eAbscess of the ‘Brain in Infants. 
5 
ioi° F. She has lost ground steadily, the weight having dropped 
to eight pounds and a half. The bowels move regularly and the 
stools are well digested. Once in two or three days there has 
been vomiting. The lungs are still negative. There is now 
present quite a marked degree of opisthotonos, and the abdomen 
is retracted. The pulse is rapid but regular. The child is quiet, 
but there is no stupor. 
December 10th. The opisthotonos is constant and is becom- 
ing more marked. There is a convergent strabismus which is 
not constant. The pupils are regular and respond normally; a 
slight nystagmus noticed to-day for the first time. The abdomen 
is still retracted; hands quite firmly clinched; no general rigidity; 
many rales in the right lung behind. 
December 12th. There is now distinct bulging of the fon- 
Fig. 2. TEMPERATURE RANGE IN CASE II. 
tanel; pupils are still normal; the mental symptoms have not 
increased; there is no stupor. 
December 13th. There is marked rigidity of the arms and 
hands, and moderate rigidity of the legs; also very marked 
nystagmus; general convulsive movements occurred to-day. 
The pulse is rapid, slightly irregular, at times intermittent. 
Respiration continues very irregular, almost typically Cheyne- 
Stokes. The abdomen is not now retracted; there is drowsiness, 
but no coma. The child vomited three times during the day 
and died quietly of exhaustion at 10 p.m., having been under 
observation exactly twenty-five days. 
The marked symptoms were the constant fever (see chart) 
which, during the last week, was high; continued irregularity 
of respiration and cervical opisthotonos, but with no other con- 6 
Holt: Abscess of the Tlrain in Infants. 
stant nervous symptoms; nystagmus, rigidity, retraction of 
the abdomen and vomiting,—all being only slightly marked and 
not constant. The case appeared like an irregular type of 
meningitis. 
Autopsy.—On removing the brain from the cranium, iooc.c. 
of bloody cerebro-spinal fluid escaped. There was observed a 
distinct bulging of the right parietal lobe, on opening which 
there was found a considerable quantity of green, viscid pus. 
This abscess cavity was found to communicate freely with the 
right lateral ventricle; and both lateral ventricles, as well as the 
third and fourth, were dilated and filled with pus. The abscess 
had broken across the mid-brain, and all parts about were con- 
siderably softened. On the inner side of the left hemisphere 
(Fig 3) a similar collection of pus was seen to that upon the right 
side, but it was more deeply situated. The cerebellum was 
softened, especially on its inferior surface, and was infiltrated 
with pus cells, as the microscope showed. There were nowhere 
any marked evidences of meningitis, although the pia over the 
parietal and occipital lobes was much congested. 
The sinuses were normal; a recent non-adherent thrombus 
of a dark red color was found in the lateral sinus. 
The petrous portion of the temporal bone was opened on 
both sides, the right being found normal; but on the left side a 
collection of pale green pus was found in the internal auditory 
canal. (No discharge noticed during life.) 
The spinal cord was not examined. There was a moderate 
amount of hypostatic pneumonia, and an extremely fatty liver, 
but nothing of importance in any of the other organs. 
Cultures were made from the pus on the surface of the cere- 
bellum, from the lateral ventricles, from the middle ear; and all 
showed a growth of a diplococcus, and a short, plump, motile 
bacillus. The former was identified as the pneumococcus, and 
the latter as the bacillus coli commune. The same was found in 
the lung. 
The long period of observation made it possible for many 
examinations of this child to be made, and she was seen by 
several members of the Hospital staff. The case was regarded 
during life as one of meningitis of an irregular type, and in the 
absence of definite focal symptoms, it does not seem possible 
for a differential diagnosis to have been made. The source of 
infection seems pretty clearly to have been the ears. Holt: Abscess of the Tlrain in Infants. 
7 
Case III.—Superficial abscess of the cerebellum ; diffuse pur- 
ulent meningitis. 
P. F., male, five months, admitted to the hospital, October 
5, 1896, thirty-six hours before death. The family history was 
negative; the child was reported to have been well and strong 
until seven weeks before when it was said he fell from the bed 
to the floor. How he struck could not be ascertained as not 
much attention was paid to this, and nothing of importance 
was observed until three days later when he was suddenly 
taken with sharp piercing cries and vomited several times. 
From that time he had not been well; had steadily lost flesh; 
there had been frequent attacks of trembling and muscular 
twitching, but no general convulsions. No other details that 
were reliable could be obtained. 
On admission the child was much emaciated and was in 
quite a deep stupor. There was no apparent paralysis, but a 
general spastic condition of the muscles of all the extremities; 
the neck was stiff, the head drawn back in opisthotonos; the 
hands were tightly clinched; the abdomen retracted; the pupils 
responded very sluggishly to light and, by tests, there appeared 
to be no vision. The pulse was 200 and weak. The tempera- 
ture was 100.60 F. and rose later in the day to 101.6° F. 
Fig. 3. ABSCESS ON INNER SURFACE OF RIGHT HEMISPHERE. (Case II.) 8 
Holt: of the "Brain in Infants. 
On the following day the child vomited several times a 
bloody fluid, and had several tarry stools; bleeding also occur- 
red from the left ear. There were general convulsions last- 
ing two hours. The temperature fluctuated during the day bet- 
ween 98° and 104.20 F.; the child lost steadily and died at 
eleven p.m. 
Autopsy.—There were evidences of a diffuse purulent men- 
ingitis over both hemispheres with an abundant exudation 
which was most marked at the convexity along the superior 
longitudinal sinus; the convolutions were flattened. Four 
ounces of turbid cerebro-spinal fluid were collected and meas- 
ured. On removing the brain from the skull an abscess was 
opened about 2 c.m. in diameter on the inferior surface of the 
cerebellum. This contained green viscid pus and broken down 
brain tissue, and was surrounded by quite a dense membrane. 
It extended inward into the vermiform process. Both the lateral 
ventricles and third ventricle contained the same thick pus. 
Only the upper part of the spinal cord was examined; this was 
normal. The central canal was not dilated. 
Pus from the abscess cavity was stained with gentian violet 
and acetic acid, and an organism resembling the meningo- 
coccus was found. 
This case was almost moribund at the time of admission and 
was under observation so short a time that there was no oppor- 
tunity to study it carefully. Unfortunately the middle ear was 
not examined at autopsy but there was no history of a dis- 
charge, except the bloody one mentioned. The symptoms dur- 
ing the period of observation were regarded as due to menin- 
gitis. 
Case IV. One large and two small abscesses of the cerebellum. 
F. L., female, nine months old; was admitted to the Hos- 
pital, December 7, 1896. There were four other children in the 
family; all reported healthy. The patient had never been 
strong; had measles three months ago, and was said to have 
been failing since that time. Reports regarding the duration of 
present illness were somewhat conflicting, but it appeared cer- 
tain that the child had been ailing at least six weeks. Not 
much that was reliable could be learned regarding the early 
symptoms. There had been no vomiting, no diarrhoea. 
On admission the child was fairly nourished, weighed four- Holt: Abscess of the "Brain in Infants. 
9 
teen pounds and five ounces, and had six teeth. The fontanel 
was rather large and slightly bulging. The eyes, ears, throat 
and nose were normal. There was internal strabismus; the 
pupils were dilated and responded feebly to light; knee-jerk, in- 
creased on both sides. The child was quiet but did not seem at 
all stupid; no paralysis, arms and legs being freely moved. 
Considerable cerebral irritability was manifested by grinding of 
the teeth and throwing the arms wildly about. The head was 
drawn back, but the post-cervical, muscles were not rigid; pulse 
slightly irregular; respiration shallow and very irregular; tem- 
perature normal. 
During the first few days of observation there was no special 
change in the symptoms. Marked irritability alternated with 
periods of drowsiness. The pulse at times was decidedly 
irregular and at times intermittent. The abdomen was not re- 
tracted; there was no vomiting; no constipation. 
December 11. It was noted that the child had been part of 
the time very restless and in the intervals more drowsy than be- 
fore; had vomited twice. 
December 16. The bulging of the fontanel was increasing; 
pupils moderately dilated and did not respond to light; there 
was a loss of sympathetic reflexes; there was then a very 
marked general hyperesthesia. 
December 18. The condition was about stationary; vomited 
about once each day; on account of the great restlessness re- 
-quired bromide, two or three doses daily. Lumbar puncture 
made and about io c. c. of clear fluid drawn, cultures from 
which showed the staphylococcus pyogenes aureus, and another 
organism resembling the pneumococcus. 
December 20. A very marked intermittent flush was noted 
which covered the face and neck and upper part of the chest. 
This came out rapidly and disappeared in a few minutes. When 
fully out it resembled closely the eruption of scarlet fever. It 
occurred several times a day, lasting from five to twenty 
minutes. Ankle clonus on the left side was noted. 
December 25th. The history states that the child’s general 
condition has improved in a most surprising way since her 
admission, and she has gained one pound in weight; the appe- 
tite is good, and the stools are digested. The temperature has 
been normal nearly all the time. Both the pulse and respiration 
have now become regular, but the drowsiness has rather in- 10 
Holt: of the "Brain in Infants. 
creased and opisthotonos is still present. The knee reflexes are 
still much exaggerated, and there is slight rigidity of the feet 
and legs. 
December 28. The pulse is more rapid, 160 to-day, but 
quite regular. The flushing of the face and neck is still repeated 
several times a day. 
December 29. A marked tremor of the right hand is noticed 
for the first time, and continued for the greater part of the day. 
The left hand is somewhat rigid, and when touched the rigidity 
is followed by a rhythmical tremor which lasts several minutes. 
The rigidity of the lower extremities is now marked; the feet in 
extreme extension. The child is considerably weaker. 
December 30. The rigidity of both feet and hands has in- 
creased; pulse 132, regular and strong; respiration 40 to 60 and 
very irregular; occasionally a slight tremor of the hands; right 
pupil is smaller than the left but both respond better than a few 
days ago; fontanel still tense and markedly bulging; opistho- 
tonos less marked. The mental condition is about the same; 
when undisturbed the child is drowsy and quiet but very irritable 
when touched, and cries out in a fretful way. The abdomen is 
still normal. Her general condition is not so good; she has lost 
a pound in weight. 
January 2. A second lumbar puncture made and 18 c. c. 
of clear fluid withdrawn, a bacteriological examination of which 
showed the staphylococcus in pure culture. 
January 3. The withdrawal of the fluid has not been fol- 
lowed by any depression of the fontanel or any other change in 
the symptoms. The reflexes are all greatly exaggerated. Slight 
convulsive movements of the hands occurred to-day, followed 
by tremor lasting for some time. For the past two weeks the 
child has taken large doses of iodide of potassium but without 
any apparent improvement and it is now discontinued. 
January 4. Frequent convulsive movements occur affecting 
the right hand and arm. There is paralysis now of the left side 
of the face; the mouth is drawn to one side; the naso-labial fold 
is deepened and the left eye very imperfectly closed. (This 
paralysis did not continue.) 
January 7. The general condition has improved decidedly 
during the past week and she has more than regained her lost 
weight. In other respects there is little change. She is very 
-estless much of the time but sleeps quietly at night. A puru- Holt: Abscess of the ‘Brain in Infants. 
11 
lent discharge from the ear noticed to-day, which is regarded as 
a possible explanation of the higher temperature of the last few 
days. 
Cultures from the pus of the ear showed staphylococcus, 
streptococcus and another organism which resembles the men- 
ingococcus. 
January 13. The discharge from the ear continues quite 
freely and has become offensive in spite of the frequent syr- 
inging. The pulse is weaker, quite irregular, and vaso- 
motor symptoms continue. The child is more quiet than 
formerly. 
January 14. Is growing steadily worse so far as the nervous 
symptoms are concerned. There is more dulness and less 
irritability. A careful test to-day shows that vision is present; 
pupils are still dilated and respond feebly to light; pulse irregu- 
lar but not intermittent. Respiration irregular. The rigidity of 
the extremities is constant and now marked. 
January 16. Swallowing has become so difficult that it has 
become necessary to give all food by stomach tube. Pulse is 
weaker and slightly irregular; stupor is more pronounced and 
opisthotonos less marked. There a few rales at the right apex 
behind. 
January 21. Has failed rapidly in the last few days, having 
lost a pound in weight. Pulse is rapid and regular; pupils not 
so widely dilated; vomits occasionally for a day or two but not 
in any characteristic way. Still very irritable when disturbed 
but otherwise is quiet. 
January 24. An examination of the eyes made by Dr. W. A. 
Holden, who reports a pallor of both optic discs, which, how- 
ever, are sharply outlined; the vessels are of fairly normal 
calibre; no changes in the macula. He makes a diagnosis of 
simple optic nerve atrophy. 
January 25. Rales on both sides of the chest behind. The 
bowels have been regular since admission and the stools are still 
well digested, although in general condition the child is losing 
rapidly. 
January 28. Patient moribund, but not comatose. Pupils 
smaller than a few days ago; fontanel now depressed; rigidity of 
the extremities continues; pulse very rapid but regular. Died 
quietly from exhaustion on the morning of the 29th, having been 
under observation fifty-four days. 12 
Holt: Abscess of the ‘Brain in Infants. 
The symptoms which this long case showed may be 
grouped as follows: 
l'Motor.—Opisthotonos nearly constant and generally marked; 
rigidity of all four extremities during the last four weeks only; 
tremor of the hands, especially the right, frequent during the 
last few weeks; no paralysis except a slight temporary one of 
the face; no general convulsions; ankle clonus for a time, es- 
pecially upon the left side; knee-jerk always much exagger- 
ated upon both sides. 
Sensory.—Moderate hyperaesthesia early in the illness, no 
evidence at any time of headache or other pain. 
Kaso-motor.—Tache cerebrate nearly constant; very marked 
and irregular flushing of the face and neck during the third, 
fourth and fifth weeks. 
IMental.—General irritability alternating with dulness; no 
deep stupor or coma. 
Special Senses.—Slight internal strabismus early; pupils di- 
lated throughout the attack and responded feebly to light; optic 
nerve atrophy discovered in the sixth week; purulent discharge 
from the left ear developed in the fourth week. 
General.—Pulse usually rapid and regular, occasionally irreg- 
ular but never slow or intermittent; respiration very irregular 
nearly all the time, and much of the time on the Cheyne- 
Stokes order; temperature (see Fig. 4), practically normal for the 
first two weeks, the marked rise in the fourth week, appar- 
ently from otitis; constant elevation only during the last eight 
days; vomiting occasional and never characteristic of brain dis- 
ease; the bowels always regular; abdomen never retracted; 
fontanel constantly tense and bulging. The progress was very 
irregular both as regards the nervous symptoms and the general 
condition, the child alternately losing and gaining in weight, 
and the nervous symptoms showing no steady advance for the 
first month of observation. Another factor in the diagnosis 
was the presence of pus organisms in the fluid drawn by lum- 
bar puncture in the second and third weeks. 
To summarize briefly, the symptoms which were practically 
always present were cervical opisthotonos, a tense bulging fon- 
tanel, moderate equal dilatation of the pupils, irregular respira- 
tion, a condition of mental irritability alternating with dulness, 
and increased knee-jerk. Late in the disease there were added Holt: tAbscess of the "Brain in Infants. 
pig. 4. TEMPERATURE RANGE IN CASE OP ABSCESSES OF THE CEREBELLUM. (CASE IV.) 14 
Holt: Abscess of the "Brain in Infants. 
irregular temperature, a discharging ear, rigidity of all the four 
extremities, marked vaso-motor symptoms, and optic-nerve 
atrophy. 
The case was seen by nearly all the physicians connected 
with the Hospital and by many others. At the end of the 
second week one only was willing to put himself on record as 
in favor of tubercular meningitis, the others present at this con- 
sultation regarding the case as one of basilar tumor. The latter 
diagnosis was concurred in by a prominent nerve specialist who 
saw the case late in the fourth week. However, only two 
weeks before death another prominent specialist made a diagno- 
sis of “arrested cerebral development, an atrophic cortex and 
latent hydrocephalus.” After the result of the lumbar puncture 
was known the diagnosis was thought by those watching the 
case closely to lie between meningitis and abscess, and during 
the last week the latter diagnosis was regarded as altogether the 
more probable one. 
Autopsy.—The pia mater was adherent to the dura over the 
right temporo-sphenoidal lobe and over the cerebellum; at the 
base there was a moderate amount of meningitis with purulent 
exudation; the cerebro-spinal fluid was increased in quantity, 
and the amount of fluid in the ventricles was greater than nor- 
mal although they were not distended and the fluid was not 
purulent. 
The right lobe of the cerebellum was considerably larger 
than the left, measuring i cm. more in both diameters; the 
middle lobe appeared compressed. In the right lobe of the 
cerebellum (Fig. 5), there was a large abscess which occupied 
nearly the whole lobe; this was surrounded by a sac wall 
which was dense and firm and about 1 mm. in thickness; the 
abscess contained a viscid greenish pus. A little to one side of 
this large abscess was a smaller one about 4 cm. in diameter; 
this was superficial, and though the walls of the two sacs were 
upon one side in contact, they did not appear to communicate. 
A third abscess about 2 cm. in diameter was superficially sit- 
uated in the left lobe of the cerebellum, and like the other two 
was surrounded by a dense fibrous wall. There were no col- 
lections of pus in the cerebrum and no meningitis of the con- 
vexity. The medulla was compressed and displaced to the left. Holt: of the cBrain in Infants. 
15 
There was no pus in the internal auditory canal. Nothing of 
importance was discovered in any of the other organs. 
Smears from all the abscesses showed the staphylococcus, and 
plate cultures showed the same organism, pure. A microscopi- 
cal examination of the wall of the large abscess showed a dense 
fibrous structure lined with stratified epithelium, and in places, 
some pigmentation. It appeared to have been an old cyst which 
had become infected. 
Fig. 5. abscesses of cerebellum. (Case IV.) 
Case V.—<tAcute pyocephalus, or suppurative ependvmitis 
with pus filling both lateral ventricles, complicating a spinal 
meningitis which followed the infection of a spina-kifida sac. 
This case has already been published by Dr. Ira Van Gieson 
and myself (Journal of Nervous and Mental Disease, December, 
1890.) and a brief abstract of that report will be here sufficient. 
The patient was a female infant dying at the age of three 
weeks, having been under my observation in the Hospital since 
it was three days old. It was admitted for a lumbo-sacral spina 
bifida complicated by double talipes equino-varus and para- 16 
Holt: of the "Brain in Infants. 
plegia. The spina bifida was covered with a granulating surface 
and had a very thin translucent wall. During the first two days 
the temperature was taken and found normal; it was not sub- 
sequently recorded but it did not appear elevated at any time. 
For the first two weeks the child was very quiet and slept most 
of the time, giving no sign of any cerebral disorder. During the 
last four or five days she failed rapidly and died apparently of 
innutrition, there having been no fever, vomiting, opisthotonos 
or convulsions. There was no enlargement of the head. 
At autopsy the ventricles were found greatly enlarged and 
contained five ounces of thin yellow pus. They were surrounded 
by a mere shell of brain tissue which had an average thickness 
of less than 1 cm. There was no corresponding increase in 
the size of the brain as a whole. There was suppurative inflam- 
mation of the sac of the spina bifida, which contained half an 
ounce of pus, and purulent spinal meningitis extending through- 
out the cord and evidences of inflammation throughout the cen- 
tral canal. Under the microscope the same micrococci could be 
traced from the wall of the spina-bifida sac along the surface and 
central canal of the cord to the lateral ventricles. The symp- 
toms were, therefore, entirely latent, there being no evidence of 
anything except a rapidly failing nutrition. 
While this case should not strictly be classed as an abscess 
of the brain, it still has certain features in common with such 
abscesses, and illustrates a mode, although a rare one, of in- 
tracranial infection. Evidently the primary condition was a 
patent central canal of the cord with hydrocephalus, not accom- 
panied by any enlargement of the head, and the origin of the pus 
was the access of pus germs to a previously serous fluid. That 
such an active and wide-spread infection of the central nervous 
system should occur without convulsions, fever, or any of the 
usual symptoms of brain or cord inflammation, seems most 
astonishing and serves to emphasize the fact illustrated by the 
other cases reported, that the ordinary rules of diagnosis do not 
apply in the case of young infants. 
COLLECTED CASES. 
Case VI.—Cerebral abscess following trauma (?); no symp- 
toms until a few hours before death. (Youl, Lancet, 1847. i., 71.) 
A child eight months old, no evidence of previous disease, 
received a wound in the temporal region by some sharp body, Holt: of the "Brain in Infants. 
which healed properly; no cerebral symptoms observed until 
two weeks after the injury, when child vomited and shortly 
after was seized with general convulsions and died in an hour. 
Autopsy showed abscess containing two ounces of pus in the 
hemisphere situated [in frontal lobe?] at a point opposite to the 
scar of the external wound: surrounding brain tissue much dis- 
organized; no meningitis. Abscess communicated with lateral 
ventricle. 
Case VII.—Abscess of unknown origin in the cerebellum ; pus 
in both lateral ventricles. (Hughes-Willshire, Lancet, October, 
1853.) 
Female child three months old with cerebral symptoms for 
twenty days; under observation for two weeks. Sudden onset 
with a sort of convulsive attack, very restless, nursed with diffi- 
culty; repeated convulsions during the period of observation, 
also vomiting, irregular respiration and extreme restlessness; 
temperature not mentioned. Autopsy showed brain congested, 
softened patches of meningitis over convexity; abscess cavity in 
the cerebellum which appeared to be lined by a thin 
medulla softened, about three ounces of pus in each ventricle, 
ependyma thickened and vascular, spinal cord so far as examined! 
was normal. 
Case VIII.—Abscess involving the entire frontal lobe. 
(Wyss. Jahrbuch filr Kinderheilkunde. iv., 129-139.) 
Boy ten and one-half months old, who fell several feet 
striking the head four days before the first symptoms. Sudden 
onset with crying and severe pain in the night, followed ten 
hours later by twitching of right arm and leg. Eight days after 
onset, paralysis of right arm and leg. Five weeks after onset, 
twitching of left arm and leg, fever present; circumference 
of head increased. On week later measles developed;, 
child became unconscious; pupils equally dilated; right arm 
flexed; contracture at elbow and knee. Six to eight convulsions 
daily, during one of which the child died, on the ninth day after 
onset of measles and seven weeks after beginning of illness. 
Autopsy showed left hemisphere of brain larger than right, owing 
to an enormous abscess involving almost the entire frontal lobe. 
Abscess cavity separated from surrounding brain substance by a 
membrane having smooth surface; no communication with 
ventricles, which were distended with clear serum. 
Case IX.—Abscess of occipital lobe of left hemisphere follow- 
ing a punctured wound. (Wyss. loc. cit.) 
Boy eighteen months old. Eight days before death he fell 
striking head against a frame containing nails, two or three 
of which penetrated the skull. Except for restlesness the 18 
Holt: of the Brain in Infants. 
child was well, until one day before death. He then began to 
vomit and during the following night twitching of arm and leg 
occurred; respiration became noisy and death occurred in 
about twenty-four hours. Autopsy revealed two wounds in 
occipital region around which there was slight infiltration but 
no suppuration. 
Abscess in posterior lobe of left hemisphere, the latter being 
broken down and softened as far as the roof of the left lateral 
ventricle; ventricle contained blood stained serum but no pus; 
area of softening not sharply defined. 
Case X.—Abscess of tbe entire left cerebral hemisphere. 
(JBednar. Wiener Med. Wochenschrift. 1871.) 
An infant of six weeks in whom the first symptom appeared 
on seventh day after vaccination; no traumatism. No motor 
disturbances, but the head rapidly enlarged in all directions; 
pupils contracted, and the eyes were turned inward and up- 
ward. Death on the third day. Autopsy.—Entire left hemis- 
phere hollowed out and filled with pus; cavity separated from 
cortical surface in the frontal region by a very thin wall of soft- 
ened brain matter. In parietal region, wall somewhat thicker; 
cavity communicated with left ventricle; inner wall roughened 
and fatty. Pus in the right and in the third and fourth ventri- 
cles, also in the spinal cord in the space between the dura and 
pia. Meningitis present. 
Case XI.—Encysted abscess of the right ventricle. (Warner. 
British Medical Journal. 1873. Vol. ii., p. 460.) 
The patient was fourteen months old and had indefinite 
symptoms for several months; first definite symptom was a 
convulsion lasting for three hours, followed two days later by 
another and this two days later by a convulsion in which the 
right arm and left leg only were involved. Eight days after the 
onset two more convulsions occurred during the last of which 
the child died. Head generally enlarged; anterior fontanel open 
and pulsated strongly; pupils dilated equally, disc in each eye 
normal. The autopsy revealed an apparently encysted abscess 
containing four ounces of pus in the front part of the right ven- 
tricle bulging into the anterior lobe. Abscess limited by a thick, 
tough and vascular membrane apparently of some duration. A 
slight amount of meningitis at the base of the brain; no tubercles. 
Case XII.—cAbscess of parietal lobe, following punctured 
wound : operation ; recovery. (Courvoisier. Correspondeni~ 
blatt. fur cAert{te. 'Basel. 1879. Vol. lx., No. 14.) 
Girl, two and a-half years old, who had received a penetrat- 
ing wound with a pair of shears in left parietal region. Seven 
days later the first symptoms developed, consisting of vomiting, Holt: Abscess of the "Brain in Infants. 
insomnia, headache, paralysis of right leg and arm, ptosis, and 
strabismus of left side. Later, fever and paralysis of left face, 
with paralysis of right arm and leg. Operation four days after 
onset of symptoms. Depressed fracture found and piece of bone 
removed, when thick, yellow pus escaped; incision of dura 
released a tumblerful of pus. Five hours after the operation con- 
sciousness returned and paralysis disappeared. Two months 
later the child was perfectly well, except for some paresis of 
right arm and leg. 
Case XIII.—<•.Abscess of frontal lobe following traumatism. 
{Koehler. Irrenfreund. Heilbrunn. 1879. Vol. xxi., 33-44.) 
Boy, eighteen months old, who fell, striking forehead against 
a file, which penetrated the frontal bone. Four weeks later the 
scar inflamed and a piece of file one inch long was removed. 
Subsequently the child began to vomit and passed into coma. 
A small swelling appeared at the aperture in the frontal bone, 
which pulsated and was easily reduced. Pus was removed by 
aspiration, and the patient improved. Coma again developed 
and the swelling again appeared, but upon aspiration, no pus 
was obtained. Tremor of left half of body. Death in coma, 
after an illness of a few days. Autopsy.—Abscess the size of an 
egg in left hemisphere; cavity communicated with opening in 
the frontal bone and with left ventricle. Pus had penetrated 
through the foramen of Munro into the right ventricle; third and 
fourth ventricles also contained pus. The author believes that 
the abscess had existed for several weeks without definite symp- 
toms, and that death was due to rupture into the ventricles. 
Case XIV.—Pyocephalus in a child of five months. (Transac- 
tions of the Pathological Society of London. 1881. xxxii., 6.) 
Child of five months had been in good health until one week 
previous to admission to the Hospital, when it had a convulsion. 
On admission, slight opisthotonos; thirteen days later, opistho- 
tonos had increased, and child in a convulsion. During the last 
three days the temperature ranged from ioi° to 103.4° F. Dura- 
tion of symptoms, twenty days. Autopsy.—Walls of ventricles 
injected and their cavities much distended with pus. The cen- 
tral canal of the cord, and also the subarachnoid space, contained 
pus. Signs of meningitis from the optic chiasm to the medulla; 
no tubercle in brain or other organs. 
Case XV.—{Multiple abscesses of the brain of pycemic origin. 
(Etlinger. Jahrbuch fiir Kinderheilkunde. 1881. xvii., no.) 
A child of seven weeks, which died after being under obser- 
vation twenty-four hours. Temperature 39° C.; frequent clonic 
spasms; pupils dilated; right divergent strabismus and left facial 20 
Holt: of the Ttrain in Infants. 
paralysis. Autopsy revealed diffuse purulent meningitis of the 
convexity and base of both hemispheres. Where the gray and 
white matter met, about thirty encapsulated abscesses were 
found, varying in size from a pea to a hazelnut. Phlebitis of the 
umbilical vein and of vena porta. The abscesses probably 
originated from embolism of capillaries. Meningitis was proba- 
bly caused by the bursting of some of the abscesses into the 
meninges. 
Case XVI.—Cerebellar abscess of traumatic (?) origin without 
fracture of the skull (Hadden. St. Thomas' Hospital Reports, 
London. 1884-86. xiv., 279.) 
A girl, seven months old, had received an injury to the head 
three months before the appearance of the first symptoms. 
Initial symptoms, fever and vomiting, ten days after which con- 
vulsions occurred. When first seen, the child was unconscious; 
neck and extremities rigid; respirations 60; temperature 101.20. 
Convulsions continued, and before death the pupils became 
dilated and fixed; there was nystagmus and strabismus. Death 
four weeks after the first symptoms. Autopsy revealed a super- 
ficial abscess involving the under surface of left lobe of cerebel- 
lum. Pus in the mastoid cells on both sides; acute meningitis 
of the base and spinal cord. [In this case it appears probable, 
from the presence of pus in the mastoid cells, that this may have 
been the origin of the abscess, rather than the injury to which 
it is ascribed. Ref.] 
Case XVII.—Abscess of the temporo-sphenoidal lobe secon- 
dary to ear disease. CRandall. Proceedings of Philadelphia 
‘Pathological Society. University Medical TMagagine. 1888-89. 
373-) 
A girl of four years, suffering from suppuration of the mas- 
toids and the left elbow joint and thumb. Caries of both tem- 
poral bones from which sequestra were at various times re- 
moved; thumb amputated, elbow joint excised. Though these 
operations were well borne, the child gradually sank and died 
without cerebral symptoms. At autopsy a large abscess was 
found in the left temporo-sphenoidal lobe above the opening in 
the root of the tympanum, which had evidently burst and evac- 
uated itself through the ear causing a gush of pus w'hich had 
preceded death. No meningitis; lungs filled with cheesy tu- 
bercular nodules. 
Case XVIII.—Abscess of the temporo-sphenoid lobe following 
otitis and mastoid abscess. {Dench, American Gynaecological 
and Obstetrical Journal, October, 1897, a^so New Tork Eye and 
Ear Infirmary Reports, 1897, page 121.) 
The child, two months old, brought to the Infirmary Clinic 
with a history of the symptoms of acute suppurative otitis of Holt : cAbscess of the ‘Brain in Infants. 
21 
two weeks’ duration, and a swelling behind the left ear which 
had lasted nearly as long. Patient was admitted to the hospital, 
the soft fluctuating swelling over the mastoid was incised, and 
half an ounce of thick pus evacuated. A portion of the tem- 
poral bone, above and behind, was coated with unhealthy gran- 
ulations. The dura was exposed but appeared healthy and no 
exploration of the brain was made. During the next two 
weeks the patient was in excellent condition but had fever— 
102.50 to 103.50. On the fourth day was dull; had a slight par- 
alysis of left face, refused to nurse; temperature rose to 104.50. 
Probe pushed through the dura and half a drachm of thick pus 
escaped; probe passed two inches into the brain, opening en- 
larged; no further pus found. Child brightened after operation 
but the next day developed irregular respiration, general con- 
vulsions, died; no autopsy. 
Case XIX.—Traumatic abscess of the right frontal lobe, 
operation, recovery. (Borelius. Jahrbuch filr Kinderheilkunde. 
Vol. xxxii., p. 189.) 
A boy four years old, who fell upon a splinter of wood 
which punctured the upper eyelid. One week later, the lid be- 
came swollen and epileptiform seizures and other cerebral 
symptoms occurred; no paralysis, but twitching was more 
marked in left arm and leg. After an exploratory puncture, 
deep incision was made in the upper eyelid and a large amount 
of pus evacuated. A probe would pass through roof of orbit 
into frontal lobe. Drainage tube inserted and patient recovered 
without cerebral symptoms; discharged one month after opera- 
tion. 
Case XX.—Abscess of left lobe of cerebellum following 
otitis. (Clarkson, Edinburgh [Medical Journal. 1892. Nov., 
P- 475-) 
A boy two and one-half years old who had suffered from 
otorrhoea left side for eighteen months before death. First 
grave symptoms five weeks before death when left facial par- 
alysis was observed, followed by drowsiness and vomiting 
of a cerebral type. No paralysis or contraction of any muscles 
of the limbs. Temperature normal until shortly before death, 
when it reached 103°. Operation performed by trephining over 
temporo-sphenoidal region; but abscess was not reached. Con- 
dition so bad that further operation deemed unwise. Child 
gradually lapsed into coma and died the next day; no localizing 
symptoms. Autopsy showed abscess in left lobe of cerebellum 
the size of a small egg and a localized meningitis. No other 
lesion of the brain. Middle ear was filled with unhealthy gran- 
ulations which extended into the internal ear, the bony walls of 
which were carious. 22 
Holt: of the Praia in Infants. 
Case XXI.—Abscess of temporo-sphenoidal lobe secondary 
to otitis and mastoid disease. Operation, recovery. (IMcEwen. 
Pyogenic 'Diseases of the Praia and Spinal Cord. 1893. Chap. 
II., p. 79.) 
Patient twenty-two months old when admitted to hospital 
with symptoms of cerebral disturbance and a discharge from the 
ear. For four months discharge had been profuse and very 
offensive. Paralysis of seventh nerve occurred six weeks prior 
to admission; constant pain; temperature 103 °. Operation five 
days after admission, necrosed portions of mastoid and a con- 
siderable portion of petrous bone being extracted. Abscess in 
temporo-sphenoidal lobe from which two drachms of pus were 
removed; surface of brain eroded and softened. Abscess cavity 
washed with boracic solution and drainage tube inserted. Tem- 
perature fell and continued normal; tube removed on sixth day 
and the wound closed at the end of a month; child known to be 
well six months later. 
Case XXII.—Abscess of temporo-sphenoidal lobe secondary 
to otitis and mastoid disease. Operation and recovery. {{Mc- 
Ewen, loc. cit. 1893. Chap. II., p. 79.) 
Patient two years old. Profuse, foul smelling, purulent dis- 
charge from left ear for four months; facial paralysis. Operation 
on the following day; necrosed mass removed from mastoid 
together with portion of the petrous bone, which gave vent to 
several ounces of pus. Eroded aperture found in dura mater 
leading into an abscess cavity in temporo-sphenoidal lobe. 
Cavity washed but no drainage tube inserted as the opening 
was large. Surface of the brain shaggy and softened. Com- 
plete recovery. 
Case XXIII.—Abscess of temporo-sphenoidal lobe, following 
otitis. {{McEwen, loc. cit. 1893. Chap, ii., p. 181.) 
A boy of three years had a purulent discharge from left ear 
for more than two years. A year later he had an illness lasting 
a month, probably a cerebral abscess, which discharged suddenly 
through the ear, after which he rapidly recovered. Some dis- 
charge continuing from the ear, however, a solution of nitrate of 
silver was injected, which was retained and caused excruciating 
pain, followed in two hours by delirium, and finally by coma, 
which persisted until death occurred, four days after. Exam- 
ination after death showed that the membrana tympani had dis- 
appeared, and that a probe could be passed freely into an old 
abscess cavity with firm walls in temporo-sphenoidal lobe. The 
silver solution had probably entered this cavity, causing encepha- 
litis, which resulted in death. The abscess was probably of moie 
than a year’s duration. Holt: zAbscess of the ‘Brain in Infants. 
23 
Case XXIV.—Cerebellar abscess following olitis. (eMcEwen, 
loc. cit. , p. 79.) 
A girl four years old had contracted scarlet fever. On twenty- 
first day of illness, left otorrhcea; on thirty-first day, nervous 
symptoms, with amaurosis and mydriasis; on thirty-eighth day 
an abscess behind the left ear burst and foetid pus escaped; on 
sixty-ninth day, child could see and was well for three months, 
except for a foetid discharge from the sinus. Seven months after 
onset of first illness she was seized with headache, followed by 
retraction of the head and other grave nervous symptoms, includ- 
ing convulsions. During the last days of life she became blind; 
death on the fifteenth day of the second illness. Autopsy.— 
Abscess was in left lobe of cerebellum extending into the pons; 
abscess in pons had firm walls. Pia mater over cerebrum 
involved and all the ventricles enormously distended with 
chronic serous effusion. The cord showed marked lepto-men- 
ingitis with a large amount of serum within the membrane, but 
no pus. Petrous portion of temporal bone extensively eroded 
and necrosed. The author believes that erosion of this bone first 
occurred, and through it the cerebellar fossa was invaded. The 
sinus was thrombosed and an extra dural abscess was formed, 
followed by one in the cerebellar hemisphere. The cerebellar 
abscess probably formed after the scarlet fever. 
Case XXV.—Cerebellar abscess following otitis. (dMcEwen, 
loc cit., p. 216.) 
A boy three years old. When one year old, he had measles 
followed by pertussis, during which a discharge occurred from 
the right ear; one month later abscess behind the ear. This 
was opened but for two years pus had flowed from the opening 
and from the meatus. First cerebral symptoms two weeks be- 
fore admission. Ophthalmoscopic examination showed congested 
fundi but no distinct optic neuritis; subsequently, congestion of 
the fundi became greater; when the child attempted to sit up 
he fell to the right; marked cerebellar ataxia; the temperature 
which had for some time been sub-normal or normal rose sud- 
denly to 1020; death twenty-two days after onset of brain 
symptoms. Autopsy.—Abscess involving middle lobe of the 
cerebellum projecting into the ventricle; anterior wall had dis- 
appeared: posterior wall remained and was firm and yellow; 
right lateral cerebellar lobe softened; dura thickened particularly 
over the temporal bone. Marked lepto-meningitis with miliary 
tubercles scattered freely in the sylvian fissure, acute basal and 
cerebellar lepto-meningitis; cerebral ventricles greatly distended 
with fluid; tubercle in other organs, especially lungs. The 
author believes that it is possible that the whole disease origi- 
nated from tubercle of the petrous bone spreading thence to the 
membranes of brain. 24 
Holt : zAbscess of the "Brain in Infants. 
Case XXVI.—Traumatic abscess of the frontal lobe; opera- 
tion ; recovery. (Zdekauer. Jahrbuch fur Kinderheilkunde. 
1893. xxxv., 297.) 
A boy two and three-fourth years old, who fell upon a nail 
which penetrated left side of head. Five days later, fever; com- 
plete right hemiplegia and left side ptosis; temperature 39°C., 
pulse 45. Over left temporal bone, there was a wound from 
which pus discharged. Operation performed in which the dura 
was found to be fluctuating. Puncture of dura released two 
ounces of green malodorous pus. Drainage tube inserted and 
pulse soon rose to 95 and temperature fell to 37°C. An un- 
eventful recovery followed, the paralysis having entirely disap- 
peared, with the exception of paresis of left hand. 
Case XXVII.—aAbscess of the temp or 0-sphenoidal lobe follow- 
ing otitis. {zAshby and Wright. The Diseases of Children. 
Ed. 1893. p. 430.) 
A girl two years old who had a discharge from the left ear 
for three months. Fourteen days before admission she had a 
right-sided convulsion, and four days later a second convulsion. 
Almost complete motor and sensorary paralysis of right arm and 
leg with loss of sensation on left side of face and left ptosis. 
Death eighteen days after the first convulsion. Abscess cavity 
found in left temporo-sphenoidal lobe extending into occipital 
lobe and reaching internal capsule. 
Case XXVIII. in the left middle lobe of the cerebrum 
following otitis. (fReimer. Jahrbuch fur Kinderheilk. xi., p. 58.) 
Male, four years old, admitted with general tuberculosis; no 
previous history except that he had been ill for two months. 
Was under observation seven days. On admission, a foul dis- 
charge from left ear; left facial paralysis; ptosis and external stra- 
bismus left side, both pupils dilated; partial anesthaesia of left 
face; complained of severe pain in left side of head; mind clear; 
contracture of right hand; temperature 390 C.; irregular pulse. 
Three days later became stupid; had a chill, temperature 40° C.; 
general convulsions followed by paralysis of right side; died 
quietly with subnormal temperature. Autopsy showed large 
abscess in the left middle lobe filling two-thirds of the lobe; 
purulent meningitis at the base; dura greatly thickened and 
adherent over middle fossa; ventricles dilated with serum; caries 
of the petrous bone; ossicles destroyed; pus in mastoid cells; 
general tuberculosis. 
Case XXIX. cAbscess in the left frontal lobe following 
necrosis of the frontal bone. fReimer, loc. cit., p 60.) 
Male, three years old, delicate, rachitic; under observation 
seven and a half weeks; cerebral symptoms of six weeks dura- Holt: Abscess of the "Brain in Infants. 
25 
tion. Bone disease existed for two and one-half months and 
had gone on to suppuration when brain symptoms, vomiting, 
fever and convulsions, developed. The local symptoms were 
headache of left side and later anesthaesia of left face; 
diminished hearing of left side and paralysis of left sixth nerve. 
Ten days before death, convulsions and high fever, followed by 
loss of speech and loss of consciousness; cornea ulcerated and 
perforated; death in convulsions. Fever during last two weeks 
constantly high, but pneumonia present. Autopsy showed 
large abscess occupying nearly the whole of left frontal lobe, 
containing foul pus; turbid serum in the ventricles; purulent 
meningitis at the convexity and on the left side at the base also; 
extensive necrosis of frontal bone; dura was adherent here and 
greatly thickened. 
Case XXX. Abscess in the right middle lobe of the cerebrum 
following otitis. (fRjeimer, loc. cit., p. 67.) 
Male child, four years old; delicate, rachitic; otitis of right 
side for one year; under observation for five days. Admitted 
with paralysis of right face, deafness in the right ear and a foul 
aural discharge; irregular pupils, the left being large, and severe 
pain in the head referred to the forehead, right side; very rest- 
less and irritable. Signs of tuberculosis in the lungs. Tem- 
perature during period of observation from 40° to 410 C. 
from tuberculosis) and paralysis of right arm developed. 
Died from pulmonary hemorrhage with a slight convulsion at 
the close. Autopsy showed general tuberculosis; tubercular 
meningitis, particularly at the base; caries of petrous bone and 
ossicles, and abscess in the right middle lobe, size of walnut, 
containing foul pus. [Cerebral symptoms in this case were cer- 
tainly in the main due to meningitis. Ref.] 
Case XXXI.—Two abscesses in the middle and one in the 
posterior lobe of the cerebrum. {Lloyd. [Med. Times and 
Gazette. 1861. i., p. 199.) 
Boy four years old who received wound in right side of neck, 
which bled freely. Twenty-five days later had a convulsion 
after which he was paralyzed on left side. He had no further 
marked symptoms and died ten days later. Right hemisphere 
softened with two circumscribed abscesses in the middle and 
one in the posterior lobe. Lesions supposed by author to be 
due to diminished blood supply. 
Case XXXII.—large abscess of parietal lobe following 
traumatism. {Unpublished case of C. T. Toore, M.D., referred 
to in Starr’s ‘“Brain Surgery," p. 185.) 
Male, three years old, in August fell down stairs striking 
head against heel of mother’s shoe, and causing scalp wound in 
left parietal region. One hour later convulsions, which were 26 
Holt: zAbscess of the "Brain in Infants. 
repeated in three hours. Admitted to hospital October io, 
with history that he had lately dragged right foot and not used 
right hand; was nauseated and cried out nights. On October 
20, first careful examination made showing complete paralysis of 
right arm and leg, partial of right face; right pupil larger than 
left, both respond to light; mental dulness. A scar at site of 
injury and skull felt to be depressed, no fever. Five days later 
was trephined at this point; dura found normal; incised, brain 
found normal; considerable shock and further exploration decided 
against. After operation paralysis improved, especially in arm. 
November 3, had convulsions, which were repeated frequently 
the nextten days, sometimes beginning on right side, someduring 
times more marked on leftside. Pupils contracted; died in con- 
vulsions November 17th, twenty-four days after operation and 
about three months after the injury. For two weeks after opera- 
tion temperature not above 100.4°; during next week, normal 
most of the time; on the day before death, rose to 103.50 F.; no 
deep coma, pulse 90 to 110, sometimes irregular; respiration 16 
to 20. Autopsy showed general adhesions of pia, but no acute 
meningitis. Large abscess in left parietal lobe containing eight 
ounces of pus; no communication with ventricle. 
Etiology.—Of the 32 cases, 13 were under one year of age, 
9 of these being under six months and 3 under three months; 3 
occurred during the second year, and 5 in each the third, fourth 
and sixth years, no case being included which was five years 
old or over. 
Of the 13 first-year cases, 2 were distinctly traumatic and 1 
probably so; 1 was positively an ear case and 4 others probably 
so; 1 complicated pyaemia; 1 spina-bifida, and in 3 the 
origin was uncertain. Of the cases over one year old, 10 were 
positively sequelae of otitis; 7 positively traumatic, and 1 doubt- 
fully so; 1 was secondary to necrosis of the skull. The two 
most important factors in the etiology of cerebral abscess in 
young children, as at all ages, are, therefore, otitis and trauma- 
tism. 
In three of the cases (I., II., IV.), no discharge from the ear 
had preceded the cerebral symptoms; however, in 1 there was 
an ear discharge during the course of the brain abscess, and in 
2 others pus was found in the middle ear at autopsy although 
no discharge was present during life. These last cases de- 
serve more than passing notice; the frequency with which pus 
is found in the middle ear in very young children, particularly 
infants, who have died from various forms of disease, has only 
recently been appreciated. Kossel (Jahrb. f. Kinderb. xxxvii., Holt: Abscess of the Brain in Infants. 
27 
445) found it in 8s out of 108 consecutive cases examined; 
Rasch (Jabrb. f. Kinderb. xxxvii., 319), in 45 out of 60 cases; 
Hartmann (Jabrb. f. Kinderb. xl., 28s), in 35 out of 47 autopsies, 
in 28 of which it was double. The majority of the above pa- 
tients were infants, and in a large percentage of them no symp- 
toms of otitis had existed during life. In this condition, it 
seems to me, is to be found an explanation of the origin, not 
only of brain abscess which develops without exciting cause, 
but also of very many of the cases of acute meningitis for 
which no etiology can be found. It is highly probable that in 
the 4 cases in infants of three, five, six, and fourteen months 
respectively, in which no cause could be traced, light might 
have been thrown upon the etiology had the middle ear been 
examined at autopsy, which unfortunately is not recorded. 
There were 11 cases in which an aural discharge preceded 
the brain symptoms, and in 6 of these there had been a mastoid 
abscess. The discharge from the ear had lasted two or three 
weeks in 1 case; from three to four months in 3 cases; seven 
months, fourteen months, and two years each in 1 case. In 8 of 
the 11 cases, it is positively stated that caries of the petrous bone 
existed, and in 2 others this condition seems probable from the 
history; the remaining one had a mastoid abscess. It is, there- 
fore, the old and usually the neglected cases of otitis which are 
likely to be complicated by brain abscess, and nearly always it is 
secondary to caries of the temporal bone. 
Traumatism was assigned as a cause in 10 cases; in 7 of 
these (VI., IX., XII., XIII., XIX., XXVI., XXXII.) the abscess 
followed a wound with fracture of the skull; in 3 there was his- 
tory of injury but no fracture; in 1 of these the injury was three 
months before the symptoms, but as pus was found at autopsy in 
the mastoid, this should probably be ranked as a case due to ear 
disease. In 7 of the traumatic cases decided cerebral symptoms 
developed within a week after the injury; in 4 of these there was 
fracture, and in 3 none. In 1 case the first symptoms were at 
the end of two weeks; in 1 case at the end of four weeks, and 
in 1 case without fracture, at the end of three months, this being 
a doubtful case. 
Of the remaining cases, 1 (V.) was due to infection of the 
brain previously the seat of hydrocephalus, from a spina-bifida 
sac, and one (XV.) was due to pyaemia following omphalitis in 
the newly-born; case XXI. was possibly pyaemic also. Necro- 28 
Holt: of the Brain in Infants. 
sis of the frontal bone was responsible for i case, and although 
syphilis is probable in this, the full history makes no mention 
of it. 
Symptoms.—The mode of onset.—This is of considerable inter- 
est as it is one of the points which may be of value in differen- 
tial diagnosis. In 7 cases the onset was gradual with indefinite 
symptoms; in 2, gradual with facial paralysis; in 1 with hemi- 
plegia and fever; in another with hemiplegia only, and in 1 
with fever only, making in all 11 cases with a gradual onset. 
In 15 cases the development of the cerebral symptoms was 
abrupt; with general convulsions in 7 cases; with localized 
convulsions in 3; with intense headache in 3, vomiting in 7, and 
fever with vomiting and convulsions or paralysis in only 3. In 
the remainder the mode of onset is not reported. 
In 3 cases the disease was entirely latent, and in 2 others no 
symptoms were noticed until the last twenty-four hours, so that 
in 5 the abscess practically ran its course without symptoms. 
In 27 cases constitutional and cerebral symptoms were present, 
varying much in degree and duration. 
Focal symptoms.—These depend upon the position, not the 
size of the abscess; they are very often wanting for the reason 
that parts in which the great proportion of abscesses are found 
(temporo-sphenoidal lobe, cerebellum, or frontal lobe), are not 
those which usually give rise to definite focal symptoms from 
any form of lesion. 
In only 12 cases (VIII., XII., XV., XVIII., and cases XXV to 
XXXII) were there distinct focal symptoms; in 7 of these there 
was hemiplegia, and it is interesting to note that 3 were trau- 
matic cases, 2 being instances of very large abscesses secondary 
to otitis. Of the remaining 5 cases with focal symptoms, there 
was one (XXV) of cerebellar abscess which presented quite typical 
cerebellar ataxia, but in the others they were not sufficiently 
definite to localize the disease. 
It is of interest to group the cranial-nerve symptoms recorded 
and see to what degree they aided in the diagnosis. There 
were 20 cases in which some such symptoms were present. In 
3 cases there were only dilated pupils; in one, only contracted 
pupils; in one, only internal strabismus; in one, strabismus and 
dilated pupils. 
Facial paralysis was observed in 10 cases; but in 6, as it fol- 
lowed old ear disease, it was probably peripheral, in 4 of these Holt: Abscess of the Brain in Infants. 
29 
being the only nerve symptom. In the remaining cases with 
facial paralysis (IV, XII, XV, XXXII), reference to the table pre- 
sented below will show the value of the symptom. 
Anaesthesia of the face was noted in three cases (XXVII, 
XXVIII, XXIX). 
Ptosis was noted in four cases (XII, XXVII, XXVIII, XXIX). 
External strabismus was noted but twice (XV, XXVIII). 
Optic-nerve atrophy was noted but once (IV). 
In going over these cranial-nerve symptoms it will be seen 
that in the six cases first mentioned the symptoms have no local- 
izing value, and that in those of facial paralysis following ear 
disease it has none, this being in all probability peripheral, 
although this point is not definitely stated. Such a paralysis, in 
which the whole side of the face is involved, must be carefully 
distinguished from one in which it is of central origin where only 
the lower half of the face is affected. 
There are several reasons why these cranial-nerve symptoms 
were of so little value in the diagnosis; one being that in these 
patients they were often temporary and not constant, and 
another that they were in several instances due to meningitis and 
not to the cerebral abscess. It is quite probable that many focal 
symptoms were overlooked on account of the age of the patients 
and the difficulties in the way of careful examination. 
It is hardly necessary to say in this connection that opistho- 
tonus and nystagmus are not focal symptoms, and that, particu- 
larly in infants, even localized convulsions often are not so, 
although they may continue for a considerable time. That the 
reader may see the exact relation of the symptoms to the 
situation of the abscess, they have been grouped in parallel 
columns. 
1. No cerebral symptoms. 
(6 weeks old, ear case ?) 
Large abscess in L. parietal lobe. 
II. Fever, irregular respiration, op- 
isthotonus, nystagmus, re 
traded abdomen, no focal 
symptoms. 
(3 months old, ear case ?) 
Abscess in both parieto-occipital lobes 
and cerebellum, pus in ventricles. 
111. Fever, opisthotonus, general 
rigidity of extremities,stupor, 
retracted abdomen, no focal 
symptoms. 
(S months old, traumatic.) 
Small abscess of cerebellum, pus in 
ventricles, meningitis. 30 
Holt: Abscess of the Brain in Infants. 
IV. Fever, bulging fontanel, opis- 
thotonus, dilated pupils, in- 
creased knee-jerk, vaso-mo- 
tor paralysis, irregular respi- 
ration, general rigidity of 
extremities, mental dulness, 
no coma,optic nerve atrophy. 
(9 months old, ear case ?) 
Cerebellar abscesses; large and small 
one in R. hemisphere, small one in 
L. 
V. No cerebral symptoms. 
(3 weeks old, infection from 
spina bifida.) 
Both ventricles filled with pus, men- 
ingitis. 
VI. Vomiting, general convulsions, 
no focal symptoms. 
(8 months old, traumatic.) 
Abscess in frontal lobe communicat- 
ing with ventricle. 
VII. Vomiting, convulsions, irregu- 
lar respiration, no focal symptoms. 
(3 months old; cause?) 
Cerebellar abscess communicating 
with ventricle. 
VIII. Convulsive movements of R. 
arm and leg followed by 
paralysis, blindness, equal 
dilatation of pupils, stupor, 
enlargement of the head. 
(io}4 months old, traumatic.) 
Enormous abscess of L. frontal lobe. 
IX. Vomiting and convulsions, no 
focal symptoms. 
(18 months old, traumatic.) 
Abscess in occipital lobe. 
X. Enlargement of the head, con- 
tracted pupils, internal stra- 
bismus. 
(6 months old; cause?) 
Abscess involving nearly whole of 
hemisphere communicating with L 
ventricle. 
XL Repeated general convulsions, 
once R. side only, enlarg- 
ment of the head, pupils 
equal and dilated. 
(14 months old; cause ?) 
Large encysted abscess of the R. ven- 
tricle. 
XII. Paralysis of the L. face, R. arm 
and leg, ptosis and internal 
strabismus of the L. side. 
Recovered after operation. 
(2% years old, traumatic.) 
Large abscess in parietal lobe L. side. 
XIII. Vomiting, coma, no focal 
symptoms. 
(18 months old, traumatic.) 
Large abscess in frontal lobe. 
XIV. Convulsions, opisthotonus, fe- 
ver, no focal symptoms. 
(5 months old; cause?) 
Both ventricles filled with pus, men- 
ingitis, pus in central canal of cord. 
XV. Fever, convulsions, dilated pu- 
pils, R. external strabismus, 
L. facial paralysis. 
(7 weeks old, pyaemic.) 
Multiple abscesses, meningitis. Holt: Abscess of the Brain in Infants. 
XVI. Convulsions, coma, opisthoto- 
nus, rigidity of extremities, 
fever, nystagmus, dilatation 
of pupils, strabismus. 
(7 months old, traumatic.) 
Cerebellar abscess of under surface of 
L. lobe, meningitis. 
XVII. No cerebral symptoms. 
(4 years old, ear case.) 
Large abscess in L. temporo-sphe- 
noidal lobe. 
XVIII. Fever, paralysis L. face, stupor, 
terminal convulsions, cerebral 
symptoms of lew hours only. 
(2 mos. old, ear case, unsuc- 
cessful operation.) 
Small abscess in L. temporo-sphe- 
noidal lobe. 
XIX. Convulsions especially of L. side 
and “other cerebral symp- 
toms,” but no paralysis. 
(4 years old, traumatic case; 
recovered after operation.) 
Large abscess in frontal lobe. 
XX. Facial paralysis, terminal fever 
and coma 
(2)4 years old, ear case; unsuc- 
cessful operation.) 
Abscess of the left lobe of cerebellum. 
XXL Pain, fever, facial paralysis, and 
“symptoms of cerebral dis- 
turbance ” 
(22 months old, ear case; re- 
covered after operation.) 
Small abscess in temporo-sphenoidal 
lobe. 
XXII. L. facial paralysis. 
(2 years old, ear case; recovered 
after operation.) 
Abscess in L. temporo-sphenoidal 
lobe. 
XXIII. Large discharge of pus from 
abscess through ear; severe 
pain, terminal coma. 
(3 years old, ear case.) 
Abscess in L. temporo-sphenoidal lobe. 
XXIV. Headache, opisthotonus, con- 
vulsions, blindness. 
(4 years old, ear case.) 
Abscess in L. lobe of cerebellum ex- 
tending into the pons; meningitis. 
XXV. Congested optic discs, cerebel- 
lar ataxia, fever. 
(3 years old, ear case ) 
Abscess of middle lobe ot cerebellum; 
meningitis. 
XXVI. Fever, R hemiplegia, L. ptosis, 
wound discharging pus in L. 
temporal region. 
(2]/2 years old, traumatic case; 
operation, recovery.) 
Abscess in posterior part of L. frontal 
lobe. 
XXVII. Convulsions of R. side followed 
by paralysis and anaesthesia 
of R. arm and leg, L. ptosis 
and anaesthesia of L. face. 
(2 years old, ear case.) 
Abscess in temporo-sphenoidal lobe ex- 
tending into occipital and reaching 
the internal capsule. 32 
Holt: Abscess of the Brain in Infants. 
XXVIII. Paralysis and partial anaesthesia 
of L. face, ptosis and exter- 
nal strabismus L. side, both 
pupils dilated, pain in L. side 
of head, chill, fever and gen- 
eral convulsions followed by 
R. hemiplegia. 
(4 years old, ear case.) 
Large abscess of L. middle lobe; bas- 
ilar meningitis. 
XXIX. Fever, vomiting, convulsions, 
localized headache L. side, 
anaesthesia L. face, L. inter- 
nal strabismus; later aphasia. 
(3 years old, necrosis of frontal 
bone.) 
Laige abscess of L. frontal lobe, men- 
ingitis, embolism of Sylvian artery. 
XXX. Paralysis R. face, irregular pu- 
pils, L. being large, local- 
ized headache; fever, paraly- 
sis of R. arm. 
(4 years old, ear case.) 
Abscess in R. middle lobe, tubercular 
meningitis. 
XXXI. Convulsions, L. hemiplegia. 
(4 years old, traumatic case.) 
Two abscesses in R. middle lobe and 
one in posterior lobe. 
XXXII. Early convulsions, drowsiness, 
and later R. hemiplegia, 
ptosis R. side, slight fever, 
irregular pupils, intermittent 
pulse, convulsions. 
(3 years old, traumatic case; 
unsuccessful operation). 
Large abscess in L. parietal lobe con- 
taining six ounces of pus. 
General symptoms were thus much more constant than focal 
ones, but hardly more definite, and frequently they bore no 
relation whatever to the size of the abscess,—for example, in 
case X, with an abscess filling a large part of one hemisphere, 
definite symptoms were of but three days’ duration; and in XVII, 
a large abscess existed without any cerebral symptoms. 
Of general symptoms, records regarding temperature are 
most meagre ; in 3 uncomplicated cases (II, IV, XXXI,} 
where full temperature records were kept for a long period, the 
temperature was normal much of the time, and in several the 
others constant fever existed only in the terminal stage. Two 
of these charts are given in full. In most of the remaining cases 
where the temperature is mentioned, such complications were 
present as to make it impossible to draw any inference. 
Rigors were noted in but a single case. 
Convulsions were present in 20 of the cases, usually marking 
the onset of the brain symptoms, or frequently the final stage. 
Deep coma was rare, being noted but four times, the usual Holt: Abscess of the Brain in Infants. 
mental condition being dulness or apathy, alternating with irrit- 
ability even after the development of definite cerebral symptoms. 
Enlargement of the head and bulging of the anterior fontanel 
were noted each in 2 cases. 
Pain in the head was recorded six times, but in the majority 
it was not localized on account of the age of the patients. 
The other symptoms recorded were of most variable character, 
and such as might be met with in any case of acute brain disease 
of whatever nature. 
Duration of Symptoms.— In 5 cases the symptoms were 
either entirely latent or of less than twenty-four hours’ duration; 
in the remaining cases in which the course was not influenced 
by an operation, the symptoms lasted from one to seven days in 
3; from one to four weeks in 5; from four to eight weeks in 7; 
for three months in 2, and for seven months and one year each 
in one case. In two-thirds of the non-operative cases, there- 
fore, the duration was four weeks or less. 
The Progress of the ‘Disease.—Of 26 cases, the course of 
which was not influenced by operation, there were 20 in which 
there were no symptoms until the terminal ones, these being of 
less than three weeks’ duration in 15, and over three weeks in 
5 cases. In 4 cases only was there a period of early acute symp- 
toms following otitis or injury, and then an interval of latent 
symptoms with a terminal acute stage. In 2, the course was 
prolonged and irregular, but without any interval of cessation. 
Spontaneous Opening.—In 3 cases (XVII, XXIII, XXIV) a 
cerebral abscess is reported to have discharged during life through 
the ear. In two the discharge of pus was followed by great 
improvement in the cerebral symptoms; in the third a gush of 
pus took place from the ear just before death. 
Diagnosis.—One has only to glance over the reports of the 
cases here collected to see how extremely difficult, in a very 
large number of the cases, is the diagnosis of cerebral abscess in 
very young children. Many of our most valuable symptoms in 
older patients, such as headache, tenderness of the skull, visual 
disturbances, deafness on one side, and various other sensory 
manifestations, are of no value in young children. In cases pre- 
senting only the acute terminal symptoms a diagnosis is impos- 
sible. However, with a scar on the scalp or a history of an 
injury by some sharp instrument, or of a mastoid abscess, or of 
a long standing aural discharge, followed by hemiplegia, which 34 
Holt:- Abscess of the Brain in Infants. 
develops either slowly without fever, or more rapidly with 
vomiting, fever, convulsions and other symptoms of acute intra- 
cranial inflammation, one can be reasonably sure of the existence 
of a brain abscess. In the group of cases intermediate between 
the two just mentioned, where the previous history is uncertain 
or altogether wanting, where the course is prolonged and irreg- 
ular, the fever absent or only sightly marked, and paralysis 
wanting, one must always be in great doubt, sometimes even 
though he has watched the case for a long time. On account 
of the position of most of these abscesses their symptoms are 
general rather than focal, and often only general brain symptoms 
are present, unless the motor centre of the arm or leg is invaded. 
Paralysis of the whole side of the face counts for nothing in the 
ear cases. 
In little children it is with meningitis rather than tumor that 
abscess is usually confounded, the difficulty in diagnosis being 
much increased by the fact that so often meningitis is also pres- 
ent. It is impossible to distinguish between these two condi- 
tions in the cases of abscess where definite brain symptoms are 
present only for the last week or two of the disease, whether 
they have developed without assignable cause, or have been imme- 
diately preceded by injury or by an old ear discharge. However, if 
there is an interval after an injury of a few days or weeks before 
brain symptoms begin, whether the latter come on abruptly 
with headache, vomiting, convulsions and fever, or gradually 
with paralysis and very little fever, abscess is altogether prob- 
able. In the slower and less acute cases, the progress is apt to 
be more irregular than in meningitis, and if paralysis of the arm, 
leg or lower half of the face is present, it is apt to be more com- 
plete and constant than in meningitis. Bulging of the fontanel 
and enlargement of the head are more likely to be great in 
abscess than in meningitis, unless the latter is basilar, in which 
situation it usually gives other definite symptoms. Chronic 
meningitis is distinguished by the absence of exciting causes 
such as provoke abscess, by its very slow and insidious be- 
ginning and prolonged course. 
To distinguish between abscess and tumor at this period of 
life is not usually so difficult. In tumor the cranial nerve symp- 
toms are more frequent and more prominent; irritative symptoms 
such as localized convulsions are more marked, and pressure 
symptoms usually less so, unless the tumor is so situated as to Holt: Abscess of the Bram in Infants. 
35 
cause distension of the ventricles. Tumors are generally smaller 
than abscesses, and all focal symptoms are apt to be more 
definite than abscess. Valuable assistance may sometimes be 
obtained by lumbar puncture. The discovery of pyogenic organ- 
isms in this fluid makes abscess or meningitis practically certain, 
although it does not tell us which one. Case IV. shows that 
optic-nerve atrophy cannot be depended upon as a differential 
symptom in a doubtful case, although it is much more frequent 
in tumor than in abscess. After all, it is the definite cause, the 
shorter duration and more rapid progress, which chiefly dis- 
tinguish abscess from tumor, very few of the abscess cases giv- 
ing symptoms for a longer time than eight weeks. 
Lesions.—The abscesses in this series of cases varied greatly 
in size, from very small multiple ones (XV.) to those containing 
as much as eight ounces of pus (XXXII.), and occupying a large 
part of one cerebral hemisphere. 
In 25 of the 32 cases the abscess was single; in 3, three 
abscesses were present; in one case there were many small 
abscesses; in three the pus was in the ventricle only. 
The situation of the abscess was as follows: 
Temporo-sphenoidal lobe, 6 cases, all secondary to otitis. 
“Middle” lobe (probably temporo-sphenoidal), 2 cases, 
secondary to otitis. 
Cerebellum, 7 cases: 4, secondary to otitis; 1 and possibly 
2, traumatic; 1, cause unknown. 
Frontal lobe, 6 cases: traumatic; 1, secondary to necrosis. 
Parietal lobe, 4 cases: 2, traumatic; 2, probably from otitis. 
Left hemisphere, 2 cases: 1, cause unknown; 1, traumatic. 
Multiple of cortex, 1 case, pyaemic. 
Pus in ventricles only, 3 cases: 1, infection from spina-bifida 
sac; 2, cause unknown. 
In 7 cases the abscess is stated to have communicated with 
the ventricles, and in most of these the amount of pus in the 
ventricles was large. 
In 15 cases meningitis was present; in 5 of these it was local- 
ized, and in one it was tubercular. 
There were at least two cases (IV., VII.), in which the struc- 
ture of the abscess wall makes it probable that the abscess arose 
as an infection of an old cerebellar cyst. There was another 
case in which there appears to have been a cyst of the ventricle, 
and two more where there was infection of a previously simple Holt : Abscess of the Brain in Infants. 
hydrocephalus. This is a feature in the development of brain 
abscess in very early life which merits further study. 
The Results of Operation.—Operative interference was 
resorted to in 9 cases, 5 of which recovered. The youngest 
case operated on (XVIII.) was two months old; the youngest 
successful case (XXI.) was twenty-two months old. Two of the 
successful cases were for traumatic abscesses, one in the frontal 
and one in the parietal lobe; the remaining 3 were temporo- 
sphenoidal abscesses following otitis. 
One of the unsuccessful operations (XXXII.) was for a trauma- 
tic abscess in the parietal lobe; nothing was found on opening the 
dura. Another case (XX.), complicating otitis, was trephined over 
the temporo-sphenoidal lobe, the autopsy showing the abscess 
to be cerebellar. Another case (XVIII.) was operated on for mastoid 
disease, and skull opened with negative result; later a probe 
pushed through the dura was followed by a discharge of a quan- 
tity of pus. The fourth case (XIII.) was aspirated through a 
wound with no benefit. In cases XVIII., XX., XXXII., further 
exploration of the cranial cavity wasdeemed unwise, becauseofthe 
child’s collapsed condition at that stage in the operation. Nearly 
all surgeons agree in the great shock which attends surgery of the 
brain in young children, and this should make one hesitate 
strongly in advising surgical interference in cases under three 
years old, unless there are very definite focal symptoms. 
CONCLUSIONS. 
(1) Abscess of the brain in children under five years is rare. 
(2) The principal causes are otitis and traumatism. 
(3) It rarely follows acute otitis, but most often neglected 
cases, and is usually secondary to disease of the petrous bone. 
(4) In the cases occurring in infancy without evident cause, 
the source of infection is probably the ears, even though there is 
no discharge. 
(5) The development of abscess after injury to the head with- 
out fracture of the skull is extremely rare. In nearly all of the 
traumatic cases, definite cerebral symptoms show themselves 
within the first two weeks after the injury. In cases with falls, 
as remote as several months, there is probably some other cause, 
such as a latent otitis. 
(6) In a large proportion of the cases only general symptoms 
are present, and these in very great variety. Holt: Abscess of the Brain in Infants. 
37 
17) Focal symptoms may be misleading unless they are con- 
stant, and even then they may depend upon associated lesions, 
such as meningitis. Motor symptoms only can be trusted since 
the sensory symptoms are difficult or impossible to determine in 
infants or young children. 
(8) Rapid progress, fever, and a history of injury or otitis 
generally make a diagnosis from tumor easy. In the slower 
cases with little or no fever, valuable assistance may be obtained 
from lumbar puncture. 
(9) From acute meningitis the diagnosis is more difficult, and 
in the cases in which there are only terminal symptoms the 
diagnosis is impossible. In the more protracted cases, the dis- 
tinctive points with reference to abscess are the slower and more 
irregular course and, as a rule, a lower temperature. 
(10) On account of the great amount of shock attending brain 
surgery in very young children, operation should not be urged 
unless definite localizing symptoms are present, the principal 
one being hemiplegia. 
I wish to express my indebtedness to Dr. Martha Wollstein 
for the bacteriological work done upon these cases, and to Dr. 
Louise Cordes for drawings of the pathological specimens. 
14 West Fifty-fifth Street. FROM 
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