Tuberculous abcesses of the brain secondary to tuberculosis of the cæcum / Carl W. Rand.

  • Carl W. Rand
Date:
[1935], ©1935
Catalogue details

Licence: In copyright

Credit: Tuberculous abcesses of the brain secondary to tuberculosis of the cæcum / Carl W. Rand. Source: Wellcome Collection.

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    Reprint from SURGERY, GYNECOLOGY AND OBSTETRICS, February, 1935, Vol. 60, 229-235 TUBERCULOUS ABSCESSES OF THE BRAIN SECONDARY TO TUBERCULOSIS OF THE CAECUM CARL W. RAND, M.A., M.D., F.A.C.S., Los Angeles, California THE central nervous system is not infre¬ quently invaded by tuberculosis. This in¬ vasion usually occurs as tuberculous menin¬ gitis, miliary tuberculosis, or less frequently as single or multiple tuberculomata. Tubercle or tuberculoma formations may become confluent and involve relatively large areas of the brain, caseation and breaking down of tissue with secondary infection resulting. On the other hand, true tuberculous abscesses of the brain are very rare. Their pathology differs from that of tuber¬ culous abscesses elsewhere in the body in that it does not involve the various stages of granulo¬ matous change to be expected from an infecting or¬ ganism of this nature. Apparently these abscesses are blood-borne infections from a chronic tuber¬ culous process elsewhere in the body. The method of abscess formation resembles that of other cerebral abscesses caused by pyogenic in¬ fecting organisms when these are blood-borne. There is probably a primary period of localized encephalitis, a secondary period of softening, and a final period of capsule formation, in the develop¬ ment of a true abscess. The case here reported is of such a type. CASE REPORT Tuberculous abscess of the cerebellum and right frontal lobe, complicating a tuberculoma of the ccecum, in a Japa¬ nese 46 years old. M. Y., Japanese male, fish merchant, aged 46 years and single, referred by Dr. K. Tashiro, of Los Angeles, on October 23, 1933, for symptoms resembling those of a tumor of the brain. He was born in Japan, coming to this country at the age of 18. He is said to have had an attack of acute appendicitis in 1925 for which he was not operated upon. He was a heavy smoker and drinker. There was no history of chronic cough, chills, fever, expectoration, or loss of weight. On May 12, 1932, he was examined by Dr. Walter Wessels of Los Angeles, who obtained a history that during the previous 2J2 months he had developed slight pain in the abdomen morning and evening. A month prior to Dr. Wessel’s examination he had had an attack of colic which lasted 1 day; this was followed by constipation which was relieved by taking some “gas powders.” There had never been any nausea or vomiting. His physical examination was entirely negative except for 3 devitalized teeth, a slightly enlarged heart and a tumor mass in the right lower quadrant. This mass was described as being about the size of a lemon, rather hard, freely movable, smooth, occupying a position 3 centi¬ meters to the right of the umbilicus and extending from the level of the umbilicus downward for 5 centimeters. The right kidney could be felt above and was distinct from the mass. A gastro-intestinal study was negative except that the ascending transverse and descending colon was found to be narrow and spastic. The ascending colon was inter¬ fered with by the palpable mass which moved with it upon manipulation. The caecum was filled. The bowel ap¬ peared to be pushed to the extreme right. No appendix was seen. The blood Wassermann was negative. Urinalysis and examination of the stool were negative. Blood count: haemoglobin 80 per cent, red blood cells 4,480,000, white blood cells 14,000, differential: lymphocytes 26 per cent, polymorphonuclears 57 per cent, large lymphocytes 9 per cent, mononuclears 5 per cent, eosinophils 3 per cent. The diagnosis at that time seemed to rest between: (a) perity¬ phlitis, (b) Meckel’s diverticulum, (c) omental cyst, (d) hydatid cyst, and (e) carcinoma of the caecum. An ex¬ ploratory laparotomy was recommended but was not car¬ ried out. When first seen by me on October 22, 1933, a different picture presented. There was a large movable tumor in the right lower quadrant of the abdomen which was not painful or tender on pressure but which was now about the size of a man’s fist. The patient gave a history also of periodical attacks of partial intestinal obstruction. Roent¬ genological studies following a barium meal test showed a marked filling defect in the region of the caecum. There was a further history of headaches dating back about 4 weeks. The pain was most marked in the right suboccipital region. There had been a great deal of nausea and frequent vomiting. The patient had lost weight. He had been unsteady on his feet and apparently very ataxic. He preferred to lie on the right side, becoming very dizzy if he turned to the left side. One made out no evidence of tuberculosis in the chest. The sense of smell was present on the right side but lost on the left side. His discs showed no choking. There was a slight horizontal nystagmus on looking to the right, none on looking to the left. There was slight weakness of the right lower face. The Romberg symptom and gait could not be tested, but when propped up in bed the patient fell backward and to the right. There were no abnormal reflexes of the Babinski group on either side. No ankle clonus was present. Blood Wassermann was again negative. A spinal fluid examination showed a clear fluid, containing one cell, marked increase in globulin, negative Wassermann. Colloidal gold curve 0000000000. No tubercle bacilli or other organisms were seen. The presence of an expanding lesion in the right cere¬ bellar lobe was suspected. The question arose as to whether this was secondary to the tumor in the abdomen and an exploratory laparotomy was suggested. On October 28, 1933, the patient was operated upon by Dr. K. Tashiro. At operation the mass proved to be an extensive tubercular lesion involving a very movable cae¬ cum and the adjacent terminal ileum, with regional mesen¬ teric and omental changes. The caecum and lower portion of the ascending colon were quite thickened and moderately indurated as was also a portion of the terminal ileum about 3 inches long. The appendix was retrocaecal and bound down in a mass of adhesions. An extensive resection of the caecum and ascending colon as high as the hypatic flexure and also including 6 inches of the terminal ileum was carried out. An isoperistaltic side-to-side bowel anas¬ tomosis was then done, uniting the transverse colon to the terminal ileum. The wound was drained with a cigarette