Abcess of the brain / by Heinrich Neumann.

  • Neumann, Heinrich.
Date:
[1930?]
Catalogue details

Licence: In copyright

Credit: Abcess of the brain / by Heinrich Neumann. Source: Wellcome Collection.

    7/18 page 47
    are now fully alive to the varied symptomatology of brain abscess. But it is not many years since these cases often lay in the medical wards until they finally came to the necropsy room, where the tradition grew up among the pathologists that cases coming to them with the clinical diagnosis of cerebral thrombosis usually turned out to be cases of brain abscess ! Some mistakes in diagnosis may be assigned to neglect of ophthalmoscopy and perimetry, but it is well to emphasize the fact that many brain abscesses produce little or no papilloedema. A more frequent source of error lies in the common misconception that a brain abscess, like abscesses in other parts of the body, must produce a rise of temperature. It cannot be too strongly stressed that the tempera¬ ture in a case of brain abscess that has not been operated on is usually subnormal. In some cases the patients die because, although it may be realized that there is a brain abscess, the condition is not considered so urgent as it actually is. These, I believe, are cases in which an abscess has formed during some previous illness. A patient may have a mastoidectomy performed and the post-operative period is not entirely smooth : there is some headache and vomiting, and the temperature is not even, but shows falls to 96° and rises to 100°. However, the symptoms clear up within two or three weeks and the patient is discharged from hospital apparently well. He is walking about months later when suddenly he has violent headache, goes into coma, and dies within a few days. At necropsy an abscess is found which is surrounded by a firm capsule, that has obviously taken many weeks or even months to form. In this type of case it is probable that the abscess has formed during the disturbed convalescence from operation. The patient’s resistance at that time has been good, and the abscess (call it purulent encephalitis if you wish) has become well localized and even partially absorbed ; in this condition he is able to go about his work, apparently in good health. When convalescence after mastoidectomy is disturbed in this way, the patient should be kept under close observation for a long period, because these partially subsiding abscesses are as dangerous as volcanoes, and they erupt rapidly and without warning. It is not only after mastoidectomy that such an abscess may form, but also after mild attacks of mastoiditis and frontal sinusitis that go untreated. The localizing signs of temporo-sphenoidal abscess.—I have practically nothing to add to Dr. Symonds’ paper on this subject, but I would urge the importance of repeated daily perimetry in these cases. There is no investigation so valuable in the diagnosis of temporo-sphenoidal abscess. The finding of a homonymous quadrantic defect not only clinches the diagnosis of abscess, but it also gives valuable infor¬ mation as to the situation of the lesion. The usual type of defect is in the superior quadrants, but a homonymous inferior quadrantic defect may also be produced by a cerebral abscess secondary to mastoiditis. The discovery of this type of defect indicates clearly that it is useless to attempt to drain the abscess through the mastoidectomy wound. The exploration in such cases must be made at a higher level. By choosing a period of temporary improvement I have been able to take on the Bjerrum screen, the fields of patients who were acutely ill with brain abscess. A portable perimeter would perhaps be better, but, whatever the method employed, it is important not to rely on confrontation tests if there is the slightest chance of obtaining more accurate records. The condition of the fields in a case of abscess of .a cerebral hemisphere after mastoiditis, not only indicates the level at which the abscess should be sought, but it is also a valuable guide as to when to operate. Extension of a quadrantic hemianopia, into a complete hemianopia calls for immediate operation. If the defect is not expanding, it is safe to wait, if waiting is indicated. There is sometimes, however, a grave difficulty about examining for field defects and the other signs that Dr. Symonds has described, and that is when the patient is so drowsy that he does not cooperate sufficiently. It is the important ocular tests,
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