A CASE OF 
METASTATIC ABSCESS OF THE BRAIN 
Operation — Death. 
BV v/ 
a. L. WALTON, iVl.n., 
Physician to the Neurological Department of the Massachusetts 
General Hospital; Clinical Instructor in Neurology, 
Harvard University. 
Reprinted from the Boston Medical and Surgical Journal 
of November 77, i8q2. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1892. A CASE OF METASTATIC ABSCESS OF THE 
BRAIN ; OPERATION ; DEATH.1 
BY Q-. L. WALTOWTm.D., 
Physician to the Neurological Department of the Massachusetts Gen- 
eral Hospital; Clinical Instructor in Neurology, 
Harvard University. 
T. F., thirty-five years of age, a brakeman, was first 
seen by me in consultation with Dr. Duff, of Charles- 
town. The history given by Dr. Duff was as follows : 
He was well up to last July. On the 22d of July he 
went to bed with pulmonary symptoms, remaining 
there two days. On the 28th he was in bed again, 
with symptoms of pneumonia of a fetid character. The 
convalescence was fair up to August 17th, when he 
came home reeling, and dropped upon the sofa uncon- 
scious (embolus). There was frothing of the mouth 
and twitching of the hands and feet. He had three or 
more of these attacks in the course of that day, uncon- 
sciousness lasting in the first one about twenty minutes. 
A numbness of the right arm supervened, which quickly 
passed away. He was treated with carbonate of am- 
monia, digitalis, brandy, and warmth to the feet and 
cold to the head. He had another attack at midnight. 
Examination of the urine proved negative. The next 
morning at five another seizure occurred. From all 
these attacks he recovered without loss of power or 
permanent loss of sensation. On the fourth day he 
had another attack, and within the following week 
three more. The history of all those attacks was the 
same with the exception of the last. In all except the 
last he had a peculiar sensation, which started at the 
ribs on the right. The patient described this as a 
1 Read before the Section for Clinical Medicine, Pathology and 
Hygiene of the Suffolk District Medical Society, October 19, 1892. 2 
tickling sensation. This rose to the shoulder, then 
spread down the arm to the hand, when he lost himself. 
Severe headache followed the last attack. After the 
first attack there was copious bloody expectoration. 
In the last the sensation went first down the leg, then 
up to the shoulder and down the right arm. Both legs 
and both arms twitched in all these attacks, but in 
some the twitching began in the right arm, and in all 
the right arm has been most affected. For the last 
two days there has been severe headache, principally 
on the left side. 
The physical examination at this time showed a pa- 
tient with considerable emaciation, of good intelligence, 
complaining of a dull headache, principally in the left 
temporal region. There was no loss of motion or 
sensation, no irregularity of pupils or reflexes — a 
normal tendon reflex on the left, an exaggerated re- 
flex on the right — and no drawing of the face, or other 
sign of affection of the cranial nerves. Examination 
of the heart was negative. 
That night an attack followed of more serious nature 
than any preceding. The right arm and right foot 
were attacked with violent convulsive movements with- 
out any loss of consciousness. A motor paralysis of 
the right arm followed, which lasted a few hours. The 
patient was then recommended to enter the hospital 
with a question of operation, the diagnosis of abscess 
being assured. He entered the hospital on September 
2d in the service of Dr. M. H. Richardson. The pulse 
was at this time 52, full; the temperature 97.4° • and 
the mind clear. There was profuse sweating. The 
patient continued to complain of pain in the temporal 
and occipital regions, principally on the left. The 
pupils, which the day before were equal and moderately 
dilated, were now considerably contracted and reacted 
to light. The knee-jerk was very active on the right, 3 
with a tendency to ankle-clonus. On the left the re- 
flex was normal. The movements of the right leg 
were somewhat impaired, and very decidedly ataxic. 
The sensation of the left leg was normal, as of the 
right. There was no absolute paralysis of any mus- 
cle or group of muscles in the legs. The movements 
of the right hand were decidedly ataxic. He could 
not button his shirt with this hand, nor touch his nose, 
excepting by fumbling. This difficulty was apparently 
in part through lack of coordination, and partly through 
numbness. That there was absolute loss of power 
was shown by the feeble grasp, although there was no 
complete paralysis of any muscle distinguished. No 
paralysis of the face was noticed at this time. There 
was a decided loss of tactile sensation over the 
hand to the wrist.. Although his mind is apparently 
clear and he answers questions with intelligence, his 
mental processes appear somewhat sluggish. 
Examination of the lungs by the house-officer : The 
examination is difficult on account of pain in the head 
increased by movement. Respiration very superficial 
in the right lung ; fine and coarse rales at the apex 
and in front under the clavicle. The rest of the lung 
is dull, with no evident respiratory murmur. A ques- 
tion of pleuritic effusion on account of flatness and 
absence of voice-sounds low down in the axillary line 
in this side. Examination of the left lung is negative. 
Examination of the heart negative. 
Urine normal, acid, 1,022, a trace of albumen, calcic 
oxalate, normal and abnormal blood, a few fatty renal 
cells, leucocytes. 
An ice-bag applied to the head and hot water to the 
feet, and the patient put upon liquid diet. A sixtieth 
of a grain of sulphate of strychnia four times a day 
was given. In the afternoon eight grains of phenacetin, 
with fifteen grains of bromide. The patient rested 
quietly all night. 4 
Operation was seriously considered at this time, but 
it was thought best by Dr. Richardson, Dr. Carter and 
myself to postpone interference until more urgent 
symptoms appeared. These symptoms appeared on 
the following day, in the afternoon, when vomiting 
began at about three o’clock with intense headache, 
described by the patient as if the bones were splitting, 
and sufficiently severe to cause him to cry out. His 
pulse dropped to thirty during this attack, and he was 
covered with profuse perspiration. A quarter of a 
grain of morphia subdued the pain, and his pulse rose 
to sixty. He was comfortable until nine that evening, 
when another similar attack occurred, with pain and 
vomiting. During the night he vomited three times, 
and complained of intense headache. Two injections 
of morphia, each an eighth of a grain, were required 
to stop the pain, whereas the night before eight grains 
of phenacetin sufficed. 
There was obstinate constipation after, as well as 
before entrance to the hospital. During the night the 
patient was dull and apathetic. His four hourly tem- 
perature varied little from 97°. His pulse varied 
from 50 to 60, once only rising to 80. When 1 saw 
him the following morning, the pulse was 52. The 
patient was lethargic; the numbness in the right arm 
extended to the elbow ; and the movements of the 
right arm were very weak and fumbling, he being hardly 
able to find his nose at all with his right hand. The 
right corner of the mouth drooped slightly, and when 
one of the fingers was inserted between the lips they 
were not so firmly compressed upon the right as upon 
the left. The wing of the nose was not elevated as 
well upon the right as upon the left; the patient could, 
however, whistle. There was no affection of the upper 
branches of the facial nerve. Dr. Cheney’s examin- 
ation of the fundus showed no optic neuritis. A con- 5 
sultation with Doctors Gannett, Cutler, and Conant 
was held, in which the question was considered whether 
the urgency of the symptoms did not demand immedi- 
ate operation, Dr. Richardson being away. It was 
decided best to operate at once, and this was done by 
Dr. Conant, who was substituting at the time. 
OPERATION (dr. CONANt) 
The patient was shaved ; the scalp scrubbed with 
green soap, permanganate of potash and oxalic acid. 
A corrosive poultice was applied of 1-1000. The 
fissure of Rolando was marked out, a point was chosen 
at about its middle, and a circular flap turned down, 
The haemorrhage was arrested with forceps and 
sponges. The periosteum was retracted and a one- 
inch trephine applied. The bone was not very thick. 
There was no notable bleeding from the skull. The 
dura mater was found tense and bulging, dull in color, 
non-pulsating. There was a small haemorrhagic spot 
in the dura mater. A circular incision was made at 
the lower segment of the opening; and upon raising 
the dura mater, the brain bulged out, was non-pulsa- 
ting, and revealed distinct fluctuation. There were 
minute haemorrhagic spots in the pia mater. There 
was no sign of meningitis. A flue aspirating needle 
was plunged directly down, without result. It was 
then withdrawn and passed more forward, with the re- 
sult of withdrawing a suspicion of fluid. Pressed 
more deeply in the same region, aspiration was fol- 
lowed by free evacuation of puriform fluid, with 
broken-down brain-tissue and a little blood. There 
was about an ounce removed. The opening in the 
skull was enlarged downwards and forwards by the 
Rongeur forceps. The brain, which previously to the 
evacuation of the pus protuded freely and was non- 
pulsating, receded and pulsated normally. The pulse 6 
rose from 40 to 100. A portion of the gray matter 
was removed with the scissors to allow of more com- 
plete drainage. This was followed by a lively haemor- 
rhage, which required the ligation of a branch of the 
middle cerebral artery. The finger being introduced 
a large cavity was distinctly felt. The wound was 
packed with sterilized gauze, which led through the 
opening. The dura was then coapted around the 
gauze with two fine silk sutures and the skin flap co- 
apted with interrupted silk sutures. The drainage 
was left at the posterior end of the incision. A ster- 
ilized absorbent dressing was applied. The patient 
after operation was in fair condition ; pulse 90, strong ; 
respiration good. 
The operation lasted an hour and a half. After it 
the patient was given a sixth of a grain of morphia 
suppository. The pulse was strong and full, but 
slightly intermittent. 
5.30, p. M. : The ice-bag has been kept to the head. 
Respiration 40, irregular. 6 p. M.: Inhalations of oxy- 
gen, five minutes in every twenty. 7.15, p. m. : Began 
to be very restless. Complains incessantly of feeling 
cold. An enema of brandy, warm milk, salt and lau- 
danum. 8 p. m. : A subcutaneous injection of a sixth 
of a grain of morphia ; five minutes later a sixtieth of 
a grain of atropia. 11.30, p. M.: Seemed to be fully 
conscious and would answer questions. One minim of 
croton oil. 11.45, p. m. : Vomited about a drachm. 
September 4th. 12.30, a. m. : Respiration became 
very labored and superficial. The face is drawn, and 
the eyes show a tendency to roll upwards. A sixtieth 
of a grain of strychnia subcutaneously. 2 a. m. : Vom- 
ited two ounces. 2.15, a. m. : Respiration less labored. 
3 A. M.: Enema of peptonized milk, brandy and Carni- 
peptones. 4.30, A. m. : Vomited three ounces. Con- 
dition improved. Respiration easier; color better. 7 
During the night slept about two hours in short naps. 
Was restless most of the time. 9 A. M.: Gradually 
losing ground. Intellect much less clear. Dressing 
changed; very little staining. Some free blood escaped 
in removing the superficial packing. The gauze drain 
was not touched. 10.45, a. m. : An enema of pepton- 
ized milk, brandy and Carui-peptones. 1p.m.: An 
enema of Epsom salts, glycerine, aloes, turpentine and 
water, given high, was retained three-quarters of an 
hour and voided in bed, with a little faecal matter. 2 
p. m. : Seemed to rally for a short time. During the 
latter part of the afternoon the respirations became 
shallow and irregular, color match cyanosed, and strong 
odor to breath. Took no notice of anything. 7.10, 
p. m. : Nitro-glycerine, two minims subcutaneously. 
7 p. m. : Enema repeated. Became comatose; sank 
slowly; died at 10.40, P. M. 
During the time after operation, motion was con- 
fined to the left arm and leg. The reflexes at the 
knee were normal on both sides. The pulse full and 
strong to the end. No autopsy allowed. The finger 
introduced through the wound showed the abscess-cav- 
ity and another abscess higher and towards the median 
line from the wound, apparently situated near the as- 
cending frontal convolution, the cavity the diameter 
of a robin’s egg, and running from that downwards, 
inwards and backwards. The index finger could just 
reach the end of the cavity. 
Examination by Dr. Whitney showed pus-cells and 
disintegrated brain-tissue in the substance evacuated at 
the operation. 
The literature on the subject of operation for metas- 
tatic abscess in the brain is very meagre, this being, 
as far as I can ascertain, the first recorded case of suc- 
cessful diagnosis and evacuation of this variety of ab- 8 
scess. The operation has, however, been successfully 
performed in abscesses resulting from trauma, as well 
as from middle-ear disease, a result which renders op- 
erative procedure in metastatic abscess imperative 
where such a diagnosis has been arrived at. By far 
the most satisfactory treatise of this subject in its sur- 
gical bearing is that of von Bergmann,2 from which I 
draw largely in the following resume. 
Probably a quarter to a half of all cerebral abscesses 
are due to extension of suppurative process from the 
skull, more especially resulting from middle-ear dis- 
ease. Of the remainder, a large portion are due to 
trauma, leaving only a comparatively small number 
resulting from either tuberculosis or from metastatic 
processes. In a certain number of thesfe cases the pus- 
formation in the brain is a part of a general process, 
as in pytEmia, there being a similar deposit in the joints, 
the lungs, the liver and the kidneys. In the latter 
case the cerebral lesion forms so small a part of the 
general clinical picture as to render operative proced- 
ure hardly worthy of consideration. In the case of 
tuberculous abscess the promise is hardly greater. As 
regards the metastatic abscesses, with which we have 
here immediately to do, these were first demonstrated 
by Virchow as resulting from gaugreue of the lung. 
Biermer demonstrated similar trouble after bronchi- 
ectasis, and Nather8 reported cases as following pul- 
monary abscess, gangrene, impaction, pneumonia, 
wound of the lung with exudative pleurisy, and ernpy-. 
ema. The latter author found these eight cases by 
autopsy among one hundred cases of pulmonary gang- 
rene, fetid bronchitis and bronchiectasis. 
The chief difficulties in the way of operating for 
metastatic abscesses are, in the first place, the difficulty 
2 Archiv. f. klin. Chirurgie, 1837, xxxiv, p. 759. 
3 Ueutsch. Archiv. f. klin. Med., bd. 34, 8. 169. 9 
of diagnosis and localization; in the second place, the 
probability that such abscesses are multiple. 
Nather found in only one of the eight cases above 
mentioned a solitary abscess. The fact, however, that 
we may hope to find such a condition in one out of 
eight cases renders the operation not only justifiable 
but imperative when we consider the absolutely hope- 
less prognosis of abscess of the brain when treated 
expectantly or in any way other than by operative 
procedure. The hope that an abscess may become 
encapsulated, and hence become indefinitely latent, or 
that it may undergo cheesy degeneration and become 
innocuous, is practically mV, the tendency of abscess of 
the brain being in all cases either eventually to burst 
into the ventricle or into the vault, or to set up a dif- 
fuse meningitis. Even where the abscess has become 
encapsulated the tendency, as von Bergmann states, is 
to eventually break into the ventricle none the less. 
The futility of the hope that spontaneous evacuation 
may occur, either through the skull or into the ear, 
nose or other cavity, has been also dwelt upon by the 
same author. We have here, then, every reason for 
resorting to operation when the disease has become 
recognized and its localization made evident as being 
within the reach of the knife. We can offer, of course, 
very little encouragement in a case of this sort as 
regards the eventual result. Without operative inter- 
ference, however, we can offer absolutely no encourage- 
ment, the fatal prognosis being practically certain. 
As regards the diagnosis of abscess, the most impor- 
tant point is that of etiology. The number of idiopathic 
abscesses reported have been so greatly narrowed that 
it may be considered that the authentic cases are re- 
duced almost to nothing, and even in those cases which 
are apparently idiopathic a more or less remote injury 
to the skull may be probably traced as the cause, if 10 
not one of the other sources already mentioned. Yon 
Bergmann was sufficiently assured upon this point to 
decline to operate in a case referred to him for oper- 
ation by a distinguished neurologist, simply upon the 
ground of lack of etiology, an opinion which proved to 
be justified by the autopsy, which showed a diffuse 
inflammation, inaccessible to the knife. 
In our case the etiology was evident. It is true 
that tumor or other disorder might chance to arise at 
this time and give somewhat similar symptoms. The 
burden of proof, however, would rest upon any other 
diagnosis thau that of abscess. The diagnosis rests 
principally between abscess and new growth. In 
favor of abscess were the sub-normal temperature, the 
absence of choked disc, which, to be sure, occurs ex- 
ceptionally in abscess, but far less frequently than in 
tumor. Certain authors have denied that subnormal 
temperature is characteristic of abscess, but it seems 
to me that a sufficient number of cases have been re- 
corded io justify the opinion that this is an extremely 
characteristic symptom. The presence of chill and 
marked variations of temperature would have been 
even more diagnostic. These, howev r, failed com- 
pletely in our case, the temperature running a more or 
less even course varying from subnormal to normal 
(from 97° to 98.5°), although it was taken every four 
hours to show variations had they occurred. The 
factor in diagnosis upon which almost absolute reliance 
was placed was the etiology, and the result certainly 
proved the wisdom of being thus guided. With regard 
to the size of the abscess, it could not be, of course, 
determined accurately whether a large or small one 
existed hefore operation. The chances were, however, 
in favor of a fairly large one, inasmuch as an abscess 
of this sort is apt to have grown to considerable dimen- 
sions before any localizing symptoms are produced, 11 
even though it may be directly in or very near the 
motor region. I remember one case in which the au- 
topsy, after a case of gangrene of the lung, revealed 
an abscess occupying nearly the whole of the white 
matter of one hemisphere, in which absolutely no cere- 
bral symptoms had appeared, the patient dying of the 
pulmonary affection. 
Senator 4 has reported a case as similar to ours as 
any with which I am familiar. In that case lung 
trouble had existed for six months previously, with 
dulness of the right upper lobe and copious expecto- 
ration with evening fever. There was a paralysis of 
the right arm ascending from the fingers to the upper 
arm; five days later an epileptiform attack, beginning 
in the right hand and spreading to the arm, without 
loss of consciousness; on the eighth day paresis of the 
right lower facial branches; on the ninth day, of the 
leg, especially in the foot; on the thirteenth day 
marked ataxic aphasia ; and on the seventeenth, death. 
Autopsy revealed several cavities in the lung and 
numerous peribronchitic foci of inflammation. In the 
left hemisphere there was an abscess containing fifty 
grammes of pus, without any marked capsule. This 
nearly broke through the cortex. The convolutions 
from the fissure of Rolaudo forward into the frontal 
region were flattened and of a greenish discoloration, 
especially in the posterior part of the third frontal 
lobe. Von Bergmaun in quoting this case states that 
operation was omitted on account of the rarity of 
single abscesses of this nature. The autopsy, how- 
ever, showed that a solitary abscess really existed in 
this case, although the post-mortem results showed 
that the operation would have been futile on account 
of the still-existing pulmonary lesion. 
* Berl. klin. Wocli., 1879. Nos. 4-6. S. J. PARKHILL A CO., PRINTERS 
BOSTON