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.

    8/18 page 48
    especially tests of ocular movements and of the visual fields, that cannot be made. Much may be discovered in these cases by patient observation at frequent intervals, but, in some cases, and particularly in children, the diagnosis and localization of the abscess cannot be made with certainty by clinical methods. X-ray examination of the skull is particularly valuable in this type of case. Abscesses of the brain very often contain gas. How often, when the brain needle enters the abscess cavity, do we not first observe a little puff of offensive gas before the pus wells out ? This gas will show in the skiagram and it indicates exactly the position of the abscess. Differential diagnosis.—In this series of cases confusion in diagnosis has arisen between brain abscess and the following conditions : Encephalitis, cerebral throm¬ bosis, cerebral aneurysm, tuberculous meningitis, purulent pachymeningitis, purulent leptomeningitis, arachnoiditis (serous meningitis), and intracranial tumour. I do not propose to go into the clinical differentiation of these groups. Indeed, this is often impossible in the present state of our knowledge, especially when the intracranial disturbance affects an individual who incidentally suffers from a chronic running ear. In many cases a diagnosis is only reached by doing an exploratory puncture of the brain. The following case may be cited as an example :— Case I.—Meningo-encephalitis simulating brain abscess. Otitis media and chronic mastoiditis. Mastoidectomy. Exploratory puncture of the brain, with findings that excluded brain abscess. Recovery. History.—A boy, aged 8, was admitted to the London Hospital in a semi-conscious condition on December 26, 1928. Six days before he had come home in the evening complaining of feeling tired. On the following afternoon he had complained of frontal headache, and had vomited several times without warning. The next day he gradually became unconscious. Past History.—There were several points that were likely to be of importance in the diagnosis. He had had bronchitis and pneumonia at the age of five months, and from that time onwards he had had much chest trouble, and for four years before admission had attended a tuberculosis dispensary. At the age of two he had had discharge from both ears, and this had continued for twelve months. A week before the onset of the present illness the left ear had begun to discharge again, and then the right ear had begun to discharge. Those who saw him at the time of his admission were thus prepared to consider a diagnosis of tuberculous meningitis or of brain abscess. Examination.—The boy was semi-conscious and had some head retraction. Tempera¬ ture 100*6°. Pulse-rate 112. Internal squint of the left eye. Slight right facial weakness. Bilateral extensor plantar responses. On clinical examination there was no evidence of any disease of the lungs. Examination of the right ear showed no abnormality. There was profuse offensive discharge from the left ear, and the left drum was perforated anteriorly and elsewhere reddened. Lumbar puncture showed clear fluid under raised pressure. The fluid contained twenty white cells per cm., 0*035% protein, no tubercle bacilli. Progress.—After admission the patient became more unconscious and gradually developed a right hemiparesis. The pulse-rate became slower. First Operation.—December 28,1928. An incomplete left mastoidectomy was performed. In the region of the antrum there was a polypoid mass of soft, red tissue, and this contained a little mucopurulent fluid, which was subsequently shown to be sterile. No pus was found. The dura of the middle fossa was exposed over an area about one-half inch in diameter. It did not bulge unduly. Histological examination of the fragments of bone removed at operation showed fibrosis of the marrow. Post-operative Notes.—On the following day there was slight papillcedema and the right hemiparesis was rather more pronounced. The boy continued in a semi-conscious condition, and the pulse-rate slowed to 44, the respiration rate to 16. Second Operation.—-January 2, 1929. Through a separate incision above and in front of the mastoidectomy incision, the left temporal lobe was tapped for abscess, but none was found. When the subarachnoid space was opened a free escape of cerebrospinal fluid occurred. This observation was considered to be strongly against the presence of an abscess. In addition the small fragment of brain tissue that was removed in the brain needle after tapping of the temporal lobe looked to the naked eye normal—quite unlike the soft, glistening
    digitised image 1
    digitised image 2
    digitised image 3