Two Abscesses of the Brain 
Caused by Septic Emboli resulting from an 
old Gunsnot Wound of the Right Lung 
inflicted Thirty-two Years before. 
Evacuation of One Abscess ; Improvement; 
Reath from Exhaustion, caused by Primary 
Abscess and Old Lung Trouble. 
BY 
J. T. ESKRIDGE, M. D., 
D1NVIB, COL., 
Professor of Nervous and Mental Diseases in the Medical De- 
partment of the University of Colorado; Neurologist to the 
Arapahoe County and St. Luke's Hospitals; 
and CLAYTON PARKHILL, M D., 
D1NVKB, COL., 
Professor of the Principles and Practice of Surgery and Clinical 
Surgery in the Medical Department of the University of 
Colorado ; Surgeon to the Arapahoe County and St. Luke's 
Hospitals; Consulting Surgeon to the Colorado State In- 
sane Asylum; and Surgeon General of the Colorado Na- 
tional Guards. 
REPRINTED FROM THE 
Neto York JBeDical 
for August 10, 1895. Reprinted from the Neto York Medical Journal 
for August 10, 1805. 
TWO ABSCESSES OF THE BRAIN 
CAUSED BY SEPTIC EMBOLI 
RESULTING FROM AN OLD GUNSHOT WOUND OF THE RIGHT LUNG 
INFLICTED THIRTY-TWO YEARS BEFORE. 
EVACUATION OF ONE ABSCESS ; IMPROVEMENT ; 
DEATH FROM EXHAUSTION, 
CAUSED BY PRIMARY ABSCESS AND OLD LUNG TROUBLE. 
By J. T. ESKRIDGE, M. D., 
DENVER, COL., 
PROFESSOR OF NERVOUS AND MENTAL DISEASES 
IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF COLORADO ; 
NEUROLOGIST TO THE ARAPAHOE COUNTY AND ST. LUKE'S HOSPITALS; 
and CLAYTON PARKHILL, M. D., 
DENVER, COL., 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY 
AND CLINICAL SURGERY 
IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF COLORADO ; 
SURGEON TO THE ARAPAHOE COUNTY AND ST. LUKE'S HOSPITALS ; 
CONSULTING SURGEON TO THE COLORADO STATE INSANE ASYLUM ; 
AND SURGEON GENERAL OF THE COLORADO NATIONAL GUARDS. 
HISTORY AND NEUROLOGICAL REPORT BY DR. ESKRIDGE. 
I wish to express my thanks to Dr. Miller and Dr. Levy, 
the attending physicians, for their invariable courtesy and 
for their kindness in giving me points in the history of the 
case about to be reported. Unfortunately, some symptoms 
that might have aided in diagnosticating the primary ab- 
scess were not known to me or either of the attending 
physicians until after the death of the patient. 
Captain E. (retired), fifty-two years of age, born in Ohio, 
married, white, living in Colorado about thirty years, a mining 
engineer by occupation, had been a semi-invalid for thirty-two 
years. The family history is excellent. The patient in child- 
hood was healthy and strong, and continued so until his 
Copyright, 1895, by D. Appleton and Company. 2 
TWO ABSCESSES OF THE BRAIN. 
twentieth year, when, while in the United States army during 
the war of the rebellion, he was wounded by a Minie ball. 
The missile struck and fractured the seventh rib on the right 
side, just external to a perpendicular line drawn from the 
nipple downward, and lodged in the lower lobe of the right 
lung. The bullet was not extracted, and soon after he be- 
gan to suffer from cough, pain in the lower portion of the 
right chest, and repeated haemoptysis. Two years later, or in 
1865, he sought the climate of Colorado on account of the pul- 
monary trouble. After his coming here his physician, Dr. Els- 
ner, informs me that at that time he had as many as eight haem- 
orrhages from the lung in one day. After a while the bleeding 
from the lung lessened, but did not entirely cease. He was 
troubled with a persistent cough, and expectorated considerable 
muco-purulent material, especially on arising in the morning 
and after exposure to cold. Consolidation of the lower portion 
of the right lung and bronchial dilatation, with bronchitis, and 
at times a rather profuse bronchial excretion of offensive muco- 
purulent material, frequently stained with blood, were evident 
up to the time of his fatal illness. 
At times months would pass during which he was fairly 
comfortable, but these periods would be followed by a slight 
pulmonary haemorrhage and increased bronchial excretion. 
During the summer of 1894 he began to complain of headache, 
usually frontal, physical weakness, inability to maintain mental 
concentration as well as was his wont, and it was observed that 
he was losing flesh, although his appetite was still good. His 
digestive powers, which had not been very vigorous for a num- 
ber of years, became more impaired. Some time in October or 
November, 1894, he began to complain of pain in the right 
frontal region of the head. The pain was nearly constant, 
rarely severe, but was often spoken of as a gnawing sensation. 
He said that he could compare it to nothing else that would de- 
scribe it more accurately than an imaginary feeling caused by 
the gnawing of a rat in this region of the head. The seat of 
the greatest intensity of the pain was invariably located about 
opposite the right posterior angular process of the frontal bone. 
The discomfort was not superficial, but appeared to be seated TWO ABSCESSES OF THE BRAIN. 
3 
deep witbin the substance of the brain. An account of this 
pain I did not succeed in obtaining until after the patient's 
death. He continued at his duties as president of an important 
and rather harassing business enterprise until the day when 
he was seized with acute cerebral symptoms which confined 
him to his bed. 
February 16, 1895.-He felt as well as usual on the morning 
of this day ; he remained at his place of business until 1 p. m., 
when he ate a hearty luncheon. He felt comfortable until 
about 5.30 p. m., when, without any appreciable cause to him, 
the muscles of the left side of the face and pharynx began to be 
affected with a clonic contraction. Dr. Miller, Dr. Levy, and 
Dr. Hersby were hastily summoned. I saw him in consulta- 
tion with these gentlemen about 7.30 p. m. The muscles of the 
left side of the face were constantly slightly contracted and 
the face drawn a little to the left, but at periods of every 
ten or fifteen minutes the affected muscles would clonically 
contract rather violently for two or three minutes. One of 
these paroxysms was just beginning as I entered the room, and, 
as it was said to be similar in every respect to the preceding 
ones, I will describe it as it appeared to me. 
The frontal portion of the occipito-frontalis muscle was con- 
tracting on both sides, more markedly on the left than on the 
right. The left eye was constantly opening and shutting, while 
the right eyelids moved slightly at each violent contraction of 
the muscles of the left eyelids. The movements of the eyeballs 
were slightly affected. All the muscles of the left side of the 
face were contracting rather strongly; occasionally the corner 
of the mouth on the left side was drawn downward, and the 
platysma myoides muscle contracted quite vigorously. At the 
same time there was contraction of the pharyngeal muscles 
which produced more or less of a gurgling sound and caused at- 
tempts at swallowing. The laryngeal muscles seemed to be 
affected slightly with the twitching. None of the muscles of 
the right side of the face, with the exception of a slight move- 
ment of the muscles around the right eye and on the right side 
of the forehead, were affected. It was found very difficult for 
him to swallow during the convulsive seizures. The paroxysm 4 
TWO ABSCESSES OF THE BRAIN. 
lasted four or five minutes, during which he was perfectly con- 
scious, as he had been from the first. He was asked at the 
time if he had any pain. He pointed to the front of the right 
side of his head and said " Yes." After the paroxysm ceased 
the muscles of the face on the left side were slightly contracted, 
and the face was drawn a little to the left. Occasionally there 
was a slight winking of the left eye, and not infrequent con- 
traction of the platysma myoides on the left side. The remission 
lasted from ten to fifteen minutes, when the clonic contraction 
began again. Owing to the excitement and number of peo- 
ple in the room it was impossible to obtain a detailed history 
of the case, and a hurried examination revealed but little. It 
was impossible to examine the fundi of the eyes on account of 
the lids opening and shutting so frequently. All the reflexes 
seemed about normal, and no muscles were affected except 
those of the face, especially on the left side, and those of the 
pharynx, and to a slight extent of the larynx. 
The diagnosis seemed to me to rest between embolism and 
thrombosis, with the probabilities in favor of thrombosis, on. 
account of the age of the patient and the absence of any car- 
diac murmur. Had I been aware at the time of the character 
and extent of his lung trouble my diagnosis would have been 
an infective embolism. The patient was given a quarter of a 
grain of morphine hypodermically, with the result of relieving 
the convulsive movements and giving him a quiet and comfort- 
able night. On seeing him next morning, in consultation with 
Dr. Miller, there had been no return of the muscular spasms on 
the left side of the face, but these muscles now seemed slightly 
paretic and the tongue was protruded a little to the left. Deglu- 
tition was still a little difficult, and on attempting to swallow 
water a paroxysm of coughing was produced and some of the 
water was regurgitated through the nostrils. There was no 
distinct aphasia, but speech seemed to be a little indistinct on 
account of the paretic condition of the muscles of the tongue,, 
lips, and pharynx of the left side. Sensation was normal. 
During the next three or four days the patient was fairly 
comfortable, with the exception of headache in the right frontal 
region, but he was urged to remain in bed. During this period TWO ABSCESSES OF THE BRAIN. 
5 
there was still observed to be some weakness of the muscles of 
the left side of the face and of deglutition. 
On February 21st I was asked to see him again in consulta- 
tion and found the left side of the face almost completely para- 
lyzed, deviation of the tongue to the left, slight drooping of the 
left eyelid, and considerable difficulty in swallowing, especially 
for liquids. The left arm was nearly as strong as the right. I 
was informed that the temperature since the occurrence of the 
facial spasms had been normal or subnormal. His mind at that 
time was perfectly clear, but he looked depressed and seemed 
to be losing flesh. The deep reflexes were slightly below nor- 
mal. While his answers to questions were always correct, yet 
there was observed a mental slowness which was foreign to 
him in his normal condition, and when asked to press the dyna- 
mometer he would always hesitate and look at the instrument 
in his hand a few seconds before grasping it. 
I gave the opinion at this visit that an embolus of an infect- 
ive nature from one of the pulmonary veins had found lodg- 
ment in one of the branches of the middle cerebral artery on 
the right side, and expressed some apprehension of abscess of 
the brain. 
On the 27th of the month, when I saw him the next time, 
the paralysis of the left side of the face was absolute, and the 
patient presented an aspect indicating great prostration. The 
bowels were obstinately constipated and the mind was obtunded 
and acted slowly. The face presented a dusky hue and was a 
little more yellowish than natural. He was still somewhat rest- 
less and uneasy about himself, but the anxiety seemed to be less 
than at my former visits. 
On March 5th, when I again saw7 him, there was a decided 
change for the worse Mental hebetude was well pronounced ; 
he was more or less apathetic, and prostration was much more 
profound. The temperature, as it had been throughout, was 
about normal or subnormal. The pulse at this time varied 
from 70 to 80, but I was informed that a few days before it had 
been down as low as 60. The left arm was decidedly paretic 
and two days later became completely paralyzed. 
On the 8th he was in a semi-conscious condition, and was 6 
TWO ABSCESSES OF THE BRAIN. 
apparently unable to maintain any continuity of thought. The 
temperature in the right axilla was about normal, while it was 
from a half to one degree above normal in the left axilla. The 
left arm was absolutely paralyzed, and the left foot and ankle 
muscles seemed to be weaker than normal. On account of his 
mental dullness it was impossible to test accurately the special 
senses or the general sensory phenomena, but, as far as I was 
able to determine, sensation was as good on one side of the body 
as on the other. The deep reflexes were nearly normal on the 
right side, but lessened on the left. By the 10th of the month 
paralysis in the left leg was nearly complete, and on the 11th it 
was absolute, when an operation for the evacuation of an ab- 
scess in the lower Rolandic region was recommended and 
urged, but this was not consented to until the 13th. In the 
mean time all evidences of intracerebral suppuration became 
more and more pronounced, the pulse showing evidence of 
weakness rather than of brain pressure, and the temperature 
remained normal or subnormal on the right side and slightly 
elevated on the left. He remained in a semi-conscious condition 
during most of the time for three or four days before the opera- 
tion, but seemed to recognize his wife and attending physician 
momentarily when aroused, but all other persons were called by 
the name of his attending physician. When a different name 
was suggested to him he would seem to realize it for a moment, 
but it rapidly faded from him. 
The following record of temperature, pulse, and respiration 
has been kindly furnished by the attending physician, Dr. 
Miller: 
March 11th.-9 a. m. : Temperature, right axilla, 98-4°; 
left, 99 4°; pulse, 72. Evening: Temperature, right axilla, 
98'6° ; left, 100° ; pulse, 78. 
12th.-Morning: Temperature, right axilla, 98° ; left, 99'4° ; 
pulse, 84; respiration, 24. Noon: Temperature, right axilla, 
98'6°; left, 100°. Six p. m. : Temperature, right axilla, 99° ; 
left, 100°; pulse, 84; respiration, 24. 
13th.-Temperature, right axilla, 99° ; left, 100° ; pulse, 99 ; 
respiration, 24. Noon : Temperature, right axilla, 98'8° ; left, 
100°; pulse, 84; respiration, 20. TWO ABSCESSES OF TI1E BRAIN. 
7 
The eyes were carefully examined with the ophthalmoscope 
on several occasions, but no changes in the fundi or discs were 
discovered. 
A surgical operation for the relief of the patient was agreed 
to about 3 p. m. of March 13th, when he was becoming rapidly 
comatose, and all the physicians in attendance were of the opin- 
ion that life, unless radical measures were adopted, could not 
be prolonged more than twenty-four hours. 
For reasons which I shall explain later, I marked the point 
about midway between the lower end of the fissure of Rolando 
and the horizontal branch of the fissure of Sylvius for the cen- 
tre of the trephine. 
OPERATION AND SURGICAL REPORT BY DR. PARKHILL. 
The skull having been mapped out by Dr. Eskridge, the 
Parkhill brain marker was used to transfer these landmarks to 
the bone. A semilunar flap was made with its base downward. 
This brought into view the markings over the mouth, lips, 
tongue, throat, and larynx centres. A three-quarter-inch tre- 
phine was employed. The bone proved to be exceedingly hard, 
with scarcely a trace of diploic structure. When the button 
was removed, the membranes were found bulged somewhat into 
the opening, but no pulsation either on palpation or inspection 
could be detected. The dura was then incised and seemed to 
be normal, as did also the arachnoid and pia, together with the 
cortex brought into view. After the suggestions of Macewen, 
I used a small trocar and cannula with which to make the ex- 
ploration. This was passed first forward and slightly down- 
ward, but discovered no pus. It was then withdrawn to the 
cortex and passed backward, inward, and slightly downward 
from the same puncture. At a depth of about half an inch 
from the surface of the brain considerable resistance was ap- 
parent. This was evidently the wall of the abscess, for when 
it was passed the pus immediately made its appearance. From 
an ounce to an ounce and a half of pus was obtained. The tro- 
car was attached to the nozzle of a fountain syringe which was 
filled with normal salt solution. A glass tube, having twice the 
calibre of the cannula, was inserted into the abscess cavity by 8 
TWO ABSCESSES OF THE BRAIN. 
the side of the original instrument. This was in order to give 
a larger opening for the exit than for the entrance of the fluid. 
When the water ran out from the abscess cavity perfectly clear 
this instrument was removed and a small rubber tube passed 
into the cavity. The external end of this was brought out 
through a puncture in the middle of the flap. The flap was 
was then sutured in place, and the usual sterilized dressing 
applied. There was hardly any shock following the operation, 
and four hours afterward bis temperature was 98'4°, pulse 92. 
At eight o'clock the following morning his temperature was 
98'8°, pulse 98. From that time onward his temperature gradu- 
ally rose, until at the time of his death, four days after the oper- 
ation, it had reached 102'2°, and his pulse was 132. I have no 
doubt that, if the second abscess had been discovered and 
drained, the patient would have perfectly recovered. The origi- 
nal puncture of the trocar and cannula must have gone within 
a hair's breadth of this abscess, and yet if that had been dis- 
covered the result would have been the same, because I should 
not have explored for another. 
This case brings up the very interesting question 
whether one would be justified, after discovering one ab- 
scess of the brain, in exploring for another. The danger 
of infection of sound tissue would have to be taken into 
consideration, and yet this case would seem to indicate that 
under certain conditions it might be justifiable. 
SOME POINTS IN THE HISTORY OF THE CASE SUBSEQUENT TO 
THE OPERATION, AND AN ACCOUNT OF THE AUTOPSY, 
WITH REMARKS BY DR. ESKRIDGE. 
It is of importance that some of the symptoms subse- 
quent to the operation should be given in detail in order to 
compare them with those of other recorded cases of the 
same nature in which all the pus has been evacuated and 
recovery followed. By this method it may be that we shall, 
after a more extended experience, be able to determine by 
the symptoms whether, when the contents of one abscess TWO ABSCESSES OF THE BRAIN. 
9 
have been got rid of, we have yet another that has not been 
reached. 
On the morning of the day of the operation the temperature 
in the right axilla was 99°; in the left, 100'2°; pulse, 99; res- 
piration, 23. At noon the temperature in the right axilla was 
98'8°; in the left, 100°; pulse, 84; respiration, 20. About one 
degree higher had the temperature been found in the left axilla 
than in the right for several da\s immediately preceding the 
operation. 
A few minutes after the patient was removed from the 
operating table the temperature was equal in each axilla, and 
registered 98'4°. The pulse and respiration for that hour are 
not recorded on the chart. 
March 13th.-8 p. m. : Temperature, right, 98'8° ; left, 99° ; 
pulse, 92 ; respiration, 23. 10 p. m. : Temperature, right, 99'2° ; 
left, 99'4°; pulse, 91; respiration, 23. 
llfth.-2 a. m. : Temperature, right, 100'2° ; left, 100°; pulse, 
91; respiration, 26. 4 a. m. : Temperature, right, 99'4°; left, 
100'2°; pulse, 91; respiration, 24. 
A careful record of temperature, pulse, and respiration was 
made every hour by a trained and careful nurse. The tempera- 
ture during the remainder of the forenoon registered about 99° 
in each axilla; pulse varied from 85 to 97, and respiration from 
24 to 30. Physical prostration was intense, but apparently less 
than before the operation. Mentally he was decidedly brighter, 
but attempts to answer questions soon exhausted his mental 
power. From 2 p. m. of the 14th to 4 a. m. of the 15th the 
temperature ranged from 100° to 100'8°, being nearly the same 
in each axilla, occasionally a little higher on the right side than 
on the left, but more commonly its difference was in favor of 
the latter. The difference during this time did not amount at 
any time to more than four tenths of a degree, and usually to 
only two tenths of a degree. 
The pulse varied from 97 to 100, and respiration from 24 to 
32. It was still difficult for him to swallow liquids, as it had 
been before the operation. Although he seemed to be getting 
an abundance of nourishment and stimulants, yet it was evident TWO ABSCESSES OF THE BRAIN. 
10 
that the patient was getting weaker. At 6 a. m. of the 15th it 
was reported that he had passed a comfortable night; the tem- 
perature in the right axilla was 99'8°; left, 99'4°; pulse, 97; 
respiration, 27. From 8 a. m. to 8 p. m. of the 15th the patient 
seemed to be doing well, and once during the day he smiled at 
his wife and made a pleasant remark. While Dr. Parkhill was 
dressing his head, he took a cigar from the doctor's vest pocket 
and put it in Dr. Miller's pocket, and seemed to enjoy the pleas- 
antry, as he knew Dr. Miller did not smoke or use tobacco in 
any form. About 11 p. m. he had a slight pulmonary haemor- 
rhage, and at midnight the temperature was: right, 100'4°; left, 
100'2° ; pulse, 124; respiration, 44. Four hours later the tem- 
perature remained about the same, but respiration was 49. 
During the forenoon of the 16th the temperature was about 
101°, or a fraction of a degree below ; pulse, 114 to 120; res- 
piration from 34 to 49. Physical prostration was increasing, 
and it was with difficulty that he could swallow any food. 
During the afternoon the temperature registered 103'4° ; pulse, 
142; respiration, 53. It was impossible for him to swallow, 
and be was nourished both by the rectum and by the nasal 
tube. Rectal enemata had been resorted to throughout his stay 
in the hospital. From 11 p. m. of the 16th to 3 p. m. of the 17th, 
when death occurred, the temperature ranged from 101° to 
102'4", being lower than it had been the day previously. 
Autopsy, March 17, 1895, at 8 p. m., five hours after death, 
by Dr. E. R. Axtell, pathologist to the hospital. The skullcap 
was very thick, with very little diploic structure. The adhe- 
sions of the dura to the bone were very firm over the vertex. 
The trephine opening in the skull was found to correspond to 
the junction of the upper with the middle third of an imaginary 
line drawn from the lower end of the fissure of Rolando to the 
point where the fissure of Sylvius bifurcates into the vertical 
and horizontal branches. No adhesions existed between-the 
pia and the dura. Over the left hemisphere some recent exu- 
date was found on the pia over a space about two inches square 
in the region of the vertex. Membranes, vessels, and brain 
presented a normal appearance over the base. The left hemi- 
sphere showed no evidence of disease in the cortex, white sub- TWO ABSCESSES OF THE BRAIN. 
11 
stance, or ganglia. The left lateral ventricle contained about 
the normal quantity of fluid. 
Right Hemisphere.-In the frontal lobe there was an ab- 
scess. It had a firm capsule and occupied the place of and had 
destroyed nearly all the white substance of the lower and an- 
terior two thirds of this lobe. It extended backward to about 
an eighth of an inch of the anterior tip of the lateral ventricle, 
from the cavity of which it was separated both by its own cyst 
wall and by an adhesive obliteration of the anterior third of the 
cavity of the ventricle. The abscess did not directly interfere 
with the motor region. The pus, of a dirty, greenish-brown 
color, was viscid and extremely foetid. There were about three 
ounces of it. The capsule seemed very firm. A second ab- 
scess, smaller than the first, but also encapsulated, was found in 
the white substance immediately beneath the lower portion of 
the ascending frontal and parietal convolutions, and the,parts 
around the lower end of the fissure of Rolando (third frontal). 
Its sac, which had been pierced by the trocar of the surgeon at 
the time of the operation, was less firm than that of the large 
abscess. Its cavity was capable of containing about a fluid- 
ounce and a half and was about half full of foetid pus. No 
connection existed between the first and second abscesses. The 
brain substance around the abscess was softer than normal. 
Chest.-The left pleura was free from adhesions, except for 
a slight area over the diaphragm. The right pleura was uni- 
versally adherent by firm fibrous tissue which could be broken 
down only with great force. Beneath the sixth and seventh 
ribs, at a point where they had been resected thirty years before 
in the axillary line, the fibrous bands were so strong that they 
had to be cut with a knife. These strong adhesions also existed 
over the diaphragm for a space of two or three inches from the 
ribs. The left lung presented evidence of extensive catarrhal 
pneumonia throughout the lower lobe. Section of the bronchi 
in this lung showed the mucous membrane in a state of subacute 
inflammation. The right lung was normal in the upper third. 
The lower third was a solid mass of fibrous tissue, and the 
bronchi here, as well as in the middle lobe, presented a well- 
marked condition of bronchiectasis and the cavities were filled 12 
TWO ABSCESSES OF THE BRAIN. 
with pus and mucus. In the lower lobe ot the right lung there 
was found a large Minie bullet which was greatly flattened at 
the conical end. The bullet rested in a dense white capsule of 
connective tissue which in places was fully four tenths of an 
inch thick. The heart and pericardium were normal. The 
spleen was small, but showed no evidence of disease. Both 
M 
Fig. 1.-Horizontal section, showing both abscesses. 
kidneys were healthy. The liver was normal. The gall bladder 
was distended with gallstones of two varieties, the black and 
the pink. The cystic duct was obstructed by a soft, crumbling 
stone. The spinal cord was not examined. The bone of the 
right arm was exposed just above the elbow joint. At this 
point the bullet of thirty years before had plowed its way 
through the bone. A resection had been made and good union 
obtained, with but slight bulging of the callus anteriorly. TWO ABSCESSES OK THE BRAIN. 
13 
Examination by Dr. II. C. Crouch of the contents of brain 
abscess No. 2, removed at operation on March 13th: ''Micro- 
scopically the direct examination showed the material to con- 
sist of pus cells (the majority of which were more or less in 
a condition of fatty degeneration), and the debris of such, with 
some fat crystals and many fat globules; a few broken down 
nerve cells, red blood-corpuscles, and a small amount of pig- 
ment, apparently heemogenic in origin. A search for pigment 
of pulmonary origin (anthracosis) failed to give any positive 
results. 
"Cover-glass preparations stained for bacteria showed the 
presence in considerable numbers of what were apparently 
streptococci. These stained according to Gram, which meth- 
Fig. 2.-Pre-frontal section, showing primary abscess, or abscess No. 1. 
ods gave the best results. Seen thus, the micro-organisms were 
mostly in chains, some of them being of considerable length, 
and would correspond in general appearance to the Strepto- 
coccus pyogenes. The individual cocci varied in size. Their 
general appearance seemed to indicate degeneration and invo- 
lution forms. The cultures seemed to confirm this. Gelatin 
tubes were inoculated and plates prepared therefrom. Stroke 
cultures were made on glycerin-agar in tubes and dishes. The 
cultures remained sterile, however, in spite of the apparent 
abundance of the cocci in the cover-glass preparation." 14 
TWO ABSCESSES OF THE BRAIN. 
Microscopical report of the cyst wall and of the contents of 
the primary abscess by Dr. Axtell: 
" The microscopical examination of the pus taken from the 
abscess shows pus cells and granular matter. The pus cells 
were much less distinct than they are usually seen. They all 
presented granular disintegration. No crystals and no calca- 
reous matter could be found. 
Fig. 3.-Frontal section, showing abscess No. 2. 
" The examination of the capsule surrounding the abscess 
showed it to be about a sixteenth of an inch thick, of some 
firmness, with a smooth inner surface. Under the microscope 
it was found to be composed of loose connective-tissue elements 
and granulation tissue with a limited blood supply. The brain 
substance adherent to it was infiltrated with lymphoid cells, and 
the cerebral elements presented fatty degeneration." 
After learning the full extent of the patient's lung 
trouble and its character, the diagnosis of cerebral abscess TWO ABSCESSES OF THE BRAIN. 
15 
following a septic embolism from the lungs was the only 
rational conclusion that could be reached. Had I known 
the full extent of his head symptoms during the months 
preceding the beginning of his fatal illness, I am inclined 
to think that I should at least have suspected an abscess 
of older date than the one which was diagnosticated. 
From the time of the first manifestations of the facial 
spasm to the death of the patient, only twenty-nine days 
elapsed, yet at the autopsy the second abscess was found 
surrounded by a capsule whose walls were fibrous. From 
the study of traumatic abscesses of the brain it is believed 
that such a capsule will not form before the end of the 
second month. If such a length of time is required for 
the formation of a fibrous capsule, we must conclude that 
the more recent abscess was of older date than one month, 
and that the symptoms that were thought to be due to em- 
bolic occlusion of an artery were caused by the destruc- 
tive irritation of the abscess in its extension backward and 
involving the motor region. There seems to be nothing 
inconsistent with such an explanation for the terminal 
symptoms. It would seem improbable that a person 
should be able to attend to his business with two large ab- 
scesses in the frontal lobe of his brain, but equally as great 
a destruction of brain tissue has been observed in this re- 
gion of the brain unattended by obtrusive symptoms. 
A study of the meagre temperature record that was 
kept of the case prior to the operation did not throw much 
light on the nature of the intracranial mischief, for the 
reason that the brain symptoms were complicated by those 
of the lung trouble. The three days immediately preced- 
ing the operation, the only time during which frequent 
temperature observations were made and careful records 
kept, the temperature was normal or subnormal on the 
right or non-paralyzed side, except on one occasion, when 16 
TWO ABSCESSES OF THE BRAIN. 
it reached 99° F., while the same thermometer registered 
one degree higher in the left axilla than in the right. 
These observations were made with great care, the ther- 
mometer being held in the axilla whose temperature was 
first taken ten minutes, and in the second axilla five, the 
instrument still being warm from the first axilla when it 
was placed in the second. To prevent any possibility of 
error, the temperature was taken in the right axilla first at 
one time, and in the left axilla first on registering the tem- 
perature the next time, and thus alternately obtaining the 
temperature of right or left axilla first. Subsequent to the 
operation the temperature was found nearly the same in 
each axilla, the difference in the axillae never being more 
than four tenths and usually only two tenths, and the differ- 
ence was not always found in favor of the left side. The 
temperature being about the same in each axilla after the 
removal of the pus from the right motor region of the 
brain would seem to corroborate the observation made by 
me in a case observed in Philadelphia in 1882, and com- 
municated to the College of Physicians in that city in 
1883, in a paper entitled Report of Three Cases of Ab- 
scess of the Brain {Transactions of the College of Physi- 
cians, 1883, p. 77). In one of the cases there reported 
in full, the temperature was found from five tenths to three 
degrees and four tenths, Fahrenheit, higher on the para- 
lyzed than on the unaffected side, extending over a period 
of more than two months, and only on one occasion was it 
observed to be equal or greater on the unaffected side of 
the body. I have made similar observations in numerous 
other cases of abscess or tumor of the brain involving the 
motor region. If this result should be substantiated by 
future observations, it may serve a useful purpose in differ- 
entiating ordinary vascular from irritative focal lesions of 
the brain. TWO ABSCESSES OF THE BRAIN. 
17 
Tn endeavoring to select a point for the removal of the 
button of bone from which the abscess might be most eas- 
ily reached, it was necessary to take several things into 
consideration. The entire left side, including face, arm, 
and leg, was completely paralyzed. Tf the trephine open- 
ing had been made over the arm centre, as is often done in 
operating for the relief of complete hemiplegia due to the 
presence of a tumor, it would have been very difficult to 
reach the abscess from this point and impossible to have 
kept it well drained. Even if the centre of the trephine 
opening had been over the middle of the face centres, 
thorough drainage of the abscess cavity would not have 
been easy to maintain. It is a well-recognized fact that 
abscesses of the brain are most commonly situated in the 
white substance, and that much of the loss of function re- 
sulting from their presence is due to pressure and oedema 
of adjacent structures. In the case under consideration, as 
the early symptoms were attended by involvement of the 
muscles of the larynx and pharynx, the platysma myoides, 
as well as the muscles of the face, and in the subsequent 
progress of the disease the muscles innervated by the cor- 
tical centres below the lower end of the fissure of Rolando 
were seriously affected, it was thought that the lower por- 
tion of the abscess was situated nearly on a level with the 
horizontal branch of the fissure of Sylvius. The autopsy 
showed that the button of bone had been removed from a 
point where the abscess was most easy of access and thor- 
ough drainage the least difficult to accomplish. In the 
case reported in this paper there were two abscesses ; the 
contents of one were evacuated, while the other abscess re- 
mained undetected. If we compare the symptoms subse- 
quent to the operation in this case with those of brain ab- 
scess in which all the pus has been got rid of at one 
operation, are there appreciable differences that will enable 18 
TWO ABSCESSES OF THE BRAIN. 
us in a similar case to the one here reported to determine, 
when one abscess has been evacuated, whether another yet 
remains in the brain ? 
We must remember that the symptoms of most cases 
of abscess of the brain are complicated by those of the 
morbid condition that has given origin to the infective 
material that has found a lodgment in the brain and given 
rise to the abscess. In the case under consideration it was 
impossible to determine how much the prostration and 
general depressed condition were due to the serious lung 
trouble and how much to suppuration in the brain. In un- 
complicated abscesses of the brain the temperature is usu- 
ally normal and often subnormal, the pulse slow, and respira- 
tion infrequent; but very soon after the pus has been evacu- 
ated the temperature ascends to about 100° to 101°, the pulse 
to 100 or more, and respiration to 16 or 20. In the case 
now under consideration, the temperature on the paralyzed 
side fell about one degree to normal, and was the same as 
that of the right side both before and after the operation ; 
and for the next six hours it was about half a degree 
above normal in each axilla, and did not reach 100° until 
eight hours after the operation. After this it ranged from 
99° to 100° for six hours more. The pulse remained about 
the same in quality and frequency for twenty-four hours 
subsequent to the operation as it had been before it. Res- 
piration also showed no perceptible effect from the opera- 
tion. These symptoms were considered at the time, but 
the purulent condition of the lungs prevented their attract- 
ing attention to lead me to suspect another brain abscess. 
The patient's mental condition was so much better forty- 
eight hours after the operation than it was before it that, 
although he was failing physically, I was inclined to attrib- 
ute this to the condition of the lungs rather than to that of 
the brain, especially as respiration became so rapid. TWO ABSCESSES OF THE BRAIN. 
19 
Death finally took place by the lungs rather than by the 
brain, as the patient did not become entirely comatose 
until about twelve hours before death, although the respi- 
ration was 50, the pulse from 130 to 135, and he was 
deeply cyanotic for thirty-six hours before death. Un- 
doubtedly the presence of the large unevacuated abscess 
in the brain contributed to his death. It hastened it, and 
would have caused death irrespective of the lung trouble ; 
but it is more than probable that had the lung difficulty 
not been so serious he would have made a temporary and 
imperfect recovery after evacuating one abscess, as the 
brain was not found markedly cedematous around the old 
or primary abscess, whose capsule was firm and unyielding. 
It may not always be possible to determine by the 
symptoms the presence of another abscess in the brain, 
after one has been evacuated, if the brain symptoms are 
complicated by those of the primary morbid process ; but 
in the uncomplicated cases a careful study of the pulse and 
temperature will greatly aid in the diagnosis, and even in 
such a case as the one reported in this paper an analysis 
of the symptoms will put the physician upon his guard, 
and with accumulated experience may lead to an accurate 
diagnosis of the most complicated cases. We have much 
to learn in regard to abscess of the brain, and every case 
should be exhaustively studied and the symptoms recorded 
until we have a fund of information sufficient to guide us 
in the analysis of the symptoms of the most obscure dis- 
eases of the brain. The New York Medical Journal. 
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