Some points in the diagnosis and localization of cerebral abcess / by C.P. Symonds.
- Symonds, C. P.
- Date:
- [between 1923 and 1940?]
Licence: In copyright
Credit: Some points in the diagnosis and localization of cerebral abcess / by C.P. Symonds. Source: Wellcome Collection.
4/18 page 44
![44 Symonds: Diagnosis and Localization of Cerebral Abscess Superficial Abscess. Three years ago I showed before this Section, together with my colleague, Mr. W. H. Ogilvie, a case [2] in which, following otitis media and mastoiditis, a localized collection of pus formed upon the surface of the brain beneath the arachnoid membrane in the neighbourhood of the Sylvian fissure. This was successfully drained and the patient has since remained well. I have recently met with a similar case. A child, aged 5, was admitted to hospital with one week’s history of left otorrhoea ; a mastoid operation was done the same day. At the operation the dura in relation to the roof of the antrum was injured. For ten days after the operation the child seemed well and was allowed up. On the eleventh day after operation, at 4 a.m., she had an attack of right-sided Jacksonian epilepsy. Thereafter, at short intervals, she had many more. I saw her at 11 a.m., when she was in a constant state of right-sided clonic convulsions, so that further examination was impossible. Lumbar puncture had been done at 8.80 a.m. The fluid was clear and contained a slight excess of lymphocytes. The argument (1) from the epileptic attacks was that she had a cortical and, therefore, a superficial lesion ; (2) from the spinal fluid that the infective focus was shut off from the general subarachnoid space. Mr. Gill Carey, who operated the same afternoon, made the following note :— “ There was a small patch of granulations present on the dura in relation to the roof of the antrum (the place where the dura was accidentally injured, but not penetrated, at the original operation). Watching these granulations carefully I saw a bead of pus come out, and on enlarging the opening with sinus forceps a quantity of pus shot out under considerable pressure. The amount of pus was enough to fill the cavity of the mastoid, roughly a drachm. There was no question of opening the dura, as it was already open. I should say, however, that the collection of pus was very superficial, as the cavity was a very shallow one. At the dressing after operation the forceps met with resistance after entering about I in.” After operation there was no recurrence of the fits. The child remained unconscious for two days—presumably an exhaustion effect of the epilepsy. There were no signs of generalized meningitis. When she was fit to be examined she had a right hemiparesis with aphasia and apraxia, which gradually cleared up. The wound healed in five weeks. Six months after this she appeared in good health, but was left with slight weakness of the right arm and leg. I take it that in a case of this kind the pathway of the infection from ear to brain has for some reason become blocked at a point at which it has already become shut off from the general subarachnoid space, and would more usually progress into the cerebral substance. The infective process then spreads laterally in the plane in which it has become arrested. The process is slow, and in the neurological sense “ silent,” until it reaches above the Sylvian fissure to the face-arm area of the motor cortex. Such cases are probably rare—their immediate recognition is of obvious importance. The danger is lest the convulsions be interpreted as the first sign of a generalized meningitis, and the chance of immediate operative relief be missed. The distinguishing features are the sudden onset of convulsions or paralysis of cortical type and the findings in the cerebro-spinal fluid. Localized Non-Suppurative Encephalitis. In the course of formation of every cerebral abscess there must be a pre-suppura- tive stage of inflammation in which there are engorgement, exudation and swelling without necrosis. I would suggest that, as in other tissues, the inflammatory process may become arrested at this stage and be resolved without pus formation. That such a localized non-suppurative encephalitis may occur in relation to otitis media is perhaps doubtful. I put forward the hypothesis for discussion. It seems.](https://iiif.wellcomecollection.org/image/b30623868_0004.jp2/full/800%2C/0/default.jpg)
