ABSCESS OF THE BRAIN. 
BT 
N. B. CARSON, M. D., 
ST. T.oris. 
REPRINTED FROM THE 
Neto ¥orfe iSeSucal journal 
for April 27, 1895. Reprinted from the New York Medical Journal 
for April 27, 1895. 
ABSCESS OF THE BRAIN.* 
By N. B. CARSON, M. D., 
ST. LOUIS. 
An eminent surgeon of London, ten years ago, is said 
by MeEwan to have asserted that to see an abscess of the 
brain, even post mortem, was an event of a lifetime. This 
seems strange, as I am quite sure there is not a surgeon in 
this city of twenty years’ experience who has not seen more 
than one case of abscess of the brain during the first ten 
years of his practice, and the opportunities afforded here 
are by no means to be compared with those of the great 
city of London. Daring twenty odd years of practice I 
have seen quite a number of abscesses in this region, aris- 
ing, some of them from injury, some of them (by far the 
greatest number) from ear disease, one from nasal trouble, 
and one, a recent case, from a most unique cause—a bite 
of a wood tick upon the scalp. 
The first case of the kind that I now call to mind was 
under my care in the St. Louis Mullanphy Hospital in the 
year 1872, during the absence of Dr. Gregory, whose case 
it was: 
* Read before the St. Louis Surgical Society, January 23, 1895. 
Coptbight, 1805, bt D. Appleton and Company. 2 
ABSCESS OF THE BRAIN. 
The patient, a boy about seven years of age, had fallen some 
months before from the third story window to the pavement 
below, striking upon the top and side of the head over the pa- 
rietal region. The skull was very badly mashed, and at the 
time of the injury and subsequently a number of fragments of 
the cranium were taken away. When he was brought to the 
hospital there was a large suppurating wound through which 
the brain substance protruded (hernia cerebri). I, at various 
times, removed pieces of dead bone and sliced off portions of 
the protruding brain substance. At one point (I think it was 
behind the Rolandie fissure), after some days, I noticed a soft 
fluctuating spot, which I accidentally opened while examining. 
As a result a considerable quantity of pus was discharged. I 
did not attempt to wash or drain the cavity; I did not even 
introduce a probe; I thought I had already done enough. 
Suffice it to say that after many weeks in the hospital the 
child made a good recovery and left with the wound almost 
closed. 
Another case occurred at the same time that the one 
described above was under my observation. 
The patient, a young man about twenty-two or twenty-three 
years of age, a waiter by occupation, had, in a quarrel, been 
struck with a fork, the prongs of which were broken off, one in 
the soft tissues, where it had formed an abscess, and two had 
been driven through the bone into the brain substance. The 
region of the injury was the left temple. I saw the case three 
weeks after the stabbing. The prong buried in the soft tissue 
had been removed by the physician first in attendance. The 
second prong I removed after I was called. This one went 
through the bone into the brain at least an inch. The third 
was removed post mortem, and, like the one I had removed, 
extended through the bone about an inch into a large abscess 
in the brain substance. There were absolutely no symptoms of 
cerebral disturbance until within three or four days of the pa- 
tient’s death, when he commenced complaining of severe head- 
ache, and it was noticed that he was more or less drowsy and ABSCESS OF THE BRAIN. 
3 
indifferent to his surroundings. This condition gradually in- 
creased until he became profoundly comatose. The diag- 
nosis of brain abscess was made by Dr. Hodgen, who saw the 
case with me in consultation a short time before the patient’s 
death. Upon removing the scalp, after death, the third prong 
of the fork was found where it had been broken off almost even 
with the surface of the bone. Upon removing the calvarium 
an abscess was found involving the frontal lobes. 
Still another case is worth mentioning, that of a child of 
four years of age, who suffered from nasal catarrh, the result 
of an injury. The infection extended through the cribriform 
plate of the ethmoid to the brain and formed an abscess which 
resulted in death. 
Besides these cases, which I saw in ante-localizing days, 
I have seen a number of abscesses of the brain the result 
of disease of the middle ear, and the majority of them 
have been in adults. Within a period extending a little 
over three years I have seen nine cases of abscess of the 
brain, and of this number eight have resulted from disease 
of the middle ear. Of all these cases, two are of particular 
interest. I deem them worthy of a detailed description: 
Last January I was called upon to open the mastoid antrum 
on account of a suppurating inflammation of the middle ear in 
a lad of fifteen years. I had not seen the case until I went 
to the house to operate, when I learned that the patient had 
had for several years, off and on, a discharge from the ear. 
Two weeks or thereabouts before I saw him he had had an 
attack of the old trouble, and Dr. Leinoine, the family physi- 
cian, sent for Dr. Jones, who treated him for some days until 
the ear symptoms were much improved. Again the pain in the 
ear became intense and Dr. Jones was called and decided that 
the antrum should be opened. I was then sent for and found 
the ear discharging freely ; while pressure over the mastoid 
caused pain, there was no perceptible swelling. The pulse was 
100; the temperature before my arrival was over 102°. The 
operation was done at once, the antrum and middle ear curetted. 4 
ABSCESS OF TIIE BRAIN. 
That evening the temperature was normal and the pulse 80. 
The night after the operation was passed well; once during the 
night he vomited, but this was attributed to the chloroform. Dur- 
ing the next day he was bright and seemed much better, except 
that he complained of pain in the hack of the head. The pulse 
was slow, only 68, but otherwise good. The temperature dur- 
ing the day was a little over 99° ; there was also more or less 
vomiting. I now began to fear abscess of the brain. The sec- 
ond night was not as good as the first, although he rested fairly 
well. The next morning he was obtuse, and it was some time 
before I could get him to notice me, but this I attributed to the 
fact that I was about to dress the wound and he had no kindly 
feelings toward me, as after I had finished he was bright and 
talkative, asking me a number of questions. I forgot to men- 
tion that I dressed the wound daily and that the washing out 
of the ear always caused severe pain in the head, which sub- 
sided immediately. 
At my evening visit the nurse told me that he had had a 
good day, seeming more like himself than he had for some time. 
The vomiting, however, had increased and the temperature fell 
below normal; the vomiting was always preceded by nausea 
and generally followed the introduction of food into the stom- 
ach, of which during the day he had taken a fair amount. He 
still complained of pain in the back of the neck. The third 
night he was very restless. I now made up my mind that we 
had an abscess of the brain to deal with. The next morning he 
was wild and very profane and vulgar in his language. The 
temperature was now most of the time subnormal, while the 
pulse varied from 68 to 78 and was small and compressible. 
The tendon reflexes were exaggerated and vomiting continued, 
and he would frequently cry out on account of the pain in the 
head. Emaciation was marked. 
That evening, the third day after the operation, I met Dr. 
Bremer, Dr. Lemoine, and Dr. Jones in consultation, and they 
agreed with me as to the presence of an abscess in the brain, 
but it was decided that the patient was too weak for any op- 
erative interference at that time. Heart tonics, nutrient ene- 
mata, etc., were ordered in hopes of improving the patient’s ABSCESS OF THE BRAIN. 
5 
condition. The next day the patient seemed somewhat better, 
while the cerebral symptoms remained unchanged. The two 
days following showed little or no change. 
After another consultation with the same gentlemen it was 
decided to operate as a forlorn hope. Everything was explained 
to the parents and their consent obtained. One week from the 
time of the first operation, an opening was made through the 
cranium an inch and a quarter behind the middle of the external 
meatus and three fourths of an inch above Reed’s base line. 
Into this opening the brain protruded and was entirely free 
from pulsation. The temporal lobes were first explored with 
negative results. The opening was then enlarged downward 
with the rongeur forceps and the cerebellum explored, when 
there was a gush of pus. 'With a forceps following the director 
this opening in the brain was enlarged, and the abscess cavity 
emptied. The abscess must have involved almost the entire 
cerebellar hemisphere, judging from the quantity of pus poured 
out. The patient was returned to bed in a very bad condition, 
and survived the operation only an hour and a half. 
This case was remarkable only in the fact that an ab- 
scess of that size conld exist and at the same time mani- 
fest comparatively few symptoms. I was assured by the 
different members of the family that they had at no time 
noticed any change in his disposition. Another remarka- 
ble feature about the case is, that he was able to go 
through, without fault, difficult gymnastic exercises, dance, 
play baseball, football, etc. 
The following very unique case came under my care at 
the St. Louis Mullanphy Hospital in the latter part of June 
last: 
The patient, a well-developed boy of eight years of age, was 
a resident of the southern portion of this State. From his his- 
tory it was learned that about the 11th day of last May he had 
been bitten on the right side of the head by an ordinary wood 
tick, common to this region. About a week later it was no- 6 
ABSCESS OF THE BRAIN. 
ticed that the part was inflamed and that the patient had fever. 
This condition lasted for three weeks, when an abscess formed 
under the scalp limited by the eyebrows in front and extending 
almost to the parietal eminence behind, the median line above, 
and the zygomatic arch below. The abscess was opened by the 
attending physician, and healed rapidly after it had been emp- 
tied. On the 8th of June he was seized with a spasm which 
involved, first the muscles about the outer angle of the left eye, 
then the angle of the mouth, then the arm, and finally the leg 
of the same side. This condition is said to have lasted five 
hours, during which time the patient was speechless, and, part 
of the time at least, unconscious. This left the entire left side 
more or less paretic, but especially about the angle of the 
mouth. 
On the 22d of June he had another spasm, not so severe as 
the preceding one. This lasted three hours, during all of which 
time the patient retained consciousness and the power of speech, 
but when it passed off, the paresis of the face was almost com- 
plete, while that of the body was decidedly increased. This 
spasm began with twitching of the angle of the mouth; from 
there it went to the eye, then to the shoulder, arm, and leg. 
About this time an abscess in the apex of the left lung was dis- 
covered which opened into a bronchial tube and discharged. I 
saw him first on the 29th of June. At that time he was much 
wasted. Upon physical examination, found the skin pale, the 
muscles soft and fiabby. On the right side of the head was a 
soft, fluctuating tumor, an abscess of about the size of a large 
hickory nut. The face and right side of the body were almost 
completely paralyzed. The family history was good, and up to 
a short time before he was bitten he had been healthy and 
strong. The mother stated that she had noticed some time be- 
fore this that he was languid and not in his usual good health, 
and complained of feeling tired, etc. The heart was healthy. 
The pupils were found to respond normally. The tendon re- 
flexes increased, more marked on the left side; ankle and knee 
clonus marked on the left side, slight on right; the senses of 
touch and sensation were unimpaired. The pulse was 81, ir- 
regular, intermitting, a beat now and then, becoming alternate- ABSCESS OF THE BRAIN. 
7 
ly fast and then very slow. He was also very impatient, not 
brooking delay, and complained of hunger continually, the 
appetite never seeming to be gratified. The mother stated that 
he had always been of a good disposition, and while he pos- 
sessed a good appetite, it was not inordinate. 
On the 4th of July the abscess on the scalp was opened by 
one of my assistants and washed. An examination of the urine 
showed hyaline casts with adherent crystals of the phosphates ; 
no albumin, crystals of the urates, phosphates, and indican. 
Dr. Le Beau and Dr. Wolfner, who kindly examined the eyes, 
report, July 6th, that when at rest the eyes were turned up- 
ward and to the left; the pupils were slightly dilated and re- 
sponded promptly to light; the fundus was normal, except the 
disc, which had a watery, suffused look suggesting oedema, but 
there was absolutely no swelling. The veins were somewhat 
enlarged, while the arteries were normal. 
On the 9th of July I operated and, upon removing the 
scalp, found that the bone at the site of the abscess, above re- 
ferred to, had been entirely destroyed so as to expose the dura; 
the opening was enlarged downward and forward. The dura 
upon its outer surface was covered with a dirty grayish exuda- 
tion ; when incised it was found to be much thickened, while 
its under surface was perfectly healthy, as were also the underly- 
ing membranes and brain surface. When the dura was incised, 
the brain substance protruded to such an extent that I feared 
it might rupture. There was an entire absence of pulsation. 
Upon introducing a small grooved director downward and for- 
ward there was a discharge of yellow, healthy-looking pus 
(about two ounces). The opening was enlarged by carrying 
forceps along the director; the pus was freely discharged, the 
cavity washed, and a drain introduced. The patient made a 
good but slow recovery, and when he left the hospital on Au- 
gust 9th he was able to walk with little assistance. The 
wound had entirely healed except at one point, from which 
came a slight discharge due to a small necrosis of the cranium. 
November 22d.—The patient visited me to-day entirely re- 
covered in general health, all signs of sickness having disap- 
peared, except that he is totally blind, a condition which has 8 
ABSCESS OF THE BRAIN. 
come on gradually since his return home. Dr. Le Beau and Dr. 
Wolfner again examined the eyes and report that they found 
the pupils widely dilated without any perception of light; the 
fundus mottled with atrophic chorioiditis spots, the disc atrophic. 
Dr. Ravold, who took the pus discharged from the abscess at 
the time of the operation, reports that he got a pure culture 
of Staphylococcus pyogenes aureus, thus confirming the diag- 
nosis of infective abscess of the brain and lung. 
Now the question presents itself as to how this infec- 
tion reached the brain, as we have seen that the under 
surface of the dura was perfectly healthy, as was also the 
underlying membrane as well as the brain surface. Was 
its position a coincidence, or was it a direct infection from 
the abscess under the scalp ? I think it was direct, and 
occurred through the communicating veins which, in foetal 
life, extend through the dura into the brain. Some of 
these veins, like similar vessels in other parts of the body* 
may have remained patulous and conveyed the micro or- 
ganism from the surface to the interior of the brain. 
In this case we also have a confirmation of the theory 
as to the location of motion and the senses of touch and 
sensation; the area in front of the Rolandic fissure being 
purely motor, while the tactile senses and sensation are said 
to be confined to the posterior regions. Here the abscess 
was, so far as it was possible to determine, limited to the 
two lower frontal convolutions, and precentral, and as a re- 
sult the motor functions were markedly involved, while 
sensation and the tactile senses remained perfect, a most 
careful examination having been made to determine this 
point. 
IIow is the resulting blindness to be explained ? There 
was evidently a certain amount of encephalitis, involving, 
in all probability, a great portion of the anterior part of 
the respective hemisphere, together with the optic commis- ABSCESS OF THE BRAIN. 
9 
sure, and the blindness was possibly a result of the inflam- 
matory changes in the commissure and optic nerves. 
A similar case is described by Williamson in the Brit- 
ish Medical Journal for February 1, 1891. 
I forgot to mention that when the patient left the hos- 
pital there was a large cerebral hernia. This hernia was 
still present when I saw him in November, but had de- 
cidedly diminished. Some time after his return home a 
small piece of dead bone was removed from the sinus, 
existing when he was discharged from the hospital, after 
which it rapidly healed. The New York Medical Journal. 
A WEEKLY REVIEW OF MEDICINE. 
EDITED BY 
FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances in 
medical science must read a live weekly medical journal, in which 
scientific facts are presented in a clear manner; one for which the 
articles are written by men of learning, and by those who are good and 
accurate observers ; a journal that is stripped of every feature irrelevant 
to medical science, and gives evidence of being carefully and conscien- 
tiously edited ; one that bears upon every page the stamp of desire to 
elevate the standard of the profession of medicine. Such a journal 
fulfills its mission—that of educator—to the highest degree, for not 
only does it inform its readers of all that is new in theory and practice, 
but, by means of its correct editing, instructs them in the very important 
yet much-neglected art of expressing their thoughts and ideas in a clear 
and correct manner. Too much stress can not be laid upon this feature, 
so utterly ignored by the “ average ” medical periodical. 
Without making invidious comparisons, it can be truthfully stated 
that no medical journal in this country occupies the place, in these par- 
ticulars, that is held by The New York Medical Journal. No 
other journal is edited with the care that is bestowed on this; none 
contains articles of such high scientific value, coming as they do from 
the pens of the brightest and most learned medical men of America. A 
glance at the list of contributors to any volume, or an examination of 
any issue of the Journal, will attest the truth of these statements. It 
is a journal for the masses of the profession, for the country as well as 
for the city practitioner; it covers the entire range of medicine and 
surgery. A very important feature of the Journal is the number and 
character of its illustrations, which are unequaled by those of any other 
journal in the world. They appear in frequent issues, whenever called 
for by the article which they accompany, and no expense is spared to 
make them of superior excellence. 
Subscription price, $5.00 per annum. Volumes begin in 
January and July. 
PUBLISHED BY 
D. APPLETON & CO., 72 Fifth Avenue, New York.