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SOME POINTS
IN THE
SURGERY OF THE BRAIN AND ITS MEMBRANES
.»-
SOME POINTS
IN THE
SURGERY OF THE BRAIN AND ITS MEMBRANES
CHARLES A. BALLANCE
M.V.O., M.S., F.R.C.S.
ROYAL PRUSSIAN ORDER OF THE CROWN
CORRESPONDING MEMBER OF THE SOCIETY OF SURGERY OF PARIS
SURGEON TO ST. THOMAs's HOSPITAL AND TO THE NATIONAL HOSPITAL
FOR THE PAR.ALYSED AND EPILEPTIC, OUEEN SQ_.
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON, ETC.
WITH ILLUSTRATIONS
iLontion
MACMILLAN AND CO., Limited
NEW YORK : THE M.ACMILLAN COMPANY 1907
All rights reseyved
^^os-d
/^ a-/^-7
PREFACE
This little book contains the material prepared for the Lettsomian Lectures of the Medical Society of London for 1906. The short time devoted to a lecture, and the large amount of material available for each one, made me decide to give the Lectures as lantern demonstrations.
Previous to 1906 the Lettsomian Lectures have been delivered for fifty-five years. It is interest- ing to note that the subject chosen by me had never before been selected by a Lettsomian lecturer.
I heartily thank the many friends v^ho have been willing to let me have the use of their illustrations. I thank Dr. Charles Green for looking up many cases for me, and my brother, Hamilton Ballance, for the illustrations and notes of specimens in the Norwich Museum.
Since the Lectures were delivered some cases have been brought up to date, and a few have been added.
Fresh from a visit to the great hospitals and
vi . SURGERY OF THE BRAIN
laboratories of Philadelphia and Baltimore, I am impelled to express my admiration of the splendid work accomplished and in progress by the dis- tinguished members of the Philadelphia School of Neurology, and by Dr. Harvey Gushing of Baltimore.
It is my hope that these Lectures may be of service to many friends and other medical men who do not claim to be expert neurologists.
CHARLES A. BALLANCE.
September 1906.
CONTENTS
LECTURE I
Reminiscences of Dr. Lettsom — Some Points in the Surgery of the Cerebral Membranes
Anatomical, physiological, and physical considerations — The sub- dural and sub-arachnoid spaces — The cerebro-spinal fluid — Subdural haemorrhage in adults and infants — Traumatic encephalocele — Pathology of meningeal infections — Subdural and sub-arachnoid suppuration — Varieties of meningitis — Symptoms and diagnosis — Surgical treatment of tubercular and suppurative meningitis and of hydrocephalus interna . Page
LECTURE II
Some Points in the Surgery of Abscess of the Brain
Etiology — Morbid anatomy and pathology — Infection of brain substance — Manner of development, form, and situation — Clinical evolution — Symptoms and diagnosis — Complications — Operative treatment of the varieties of abscess — Recent im- provements in details — Concluding remarks . . Page 87
LECTURE III
SoM-E Points in the Surgery of Tumour of the Brain
Diagnosis — Difficulty of localisation — Symptom complex — Absence of all symptoms — Localisation symptoms — Relation of injury to tumour growth — Tumours of the cranium, the meninges, and the brain — Tubercular and syphilitic tumours — Endo- thelioma— Fibro-sarcoma — -Glioma, solid and cystic — Sarcoma — Psammoma — Cysts — Secondary tumours — Treatment with- out operation — Operations, curative and palliative — Pioneer work of the past, the present position, and future outlook Page 156
INDEX
397
Vll
ILLUSTRATIONS
FIG. I. 2.
3- 4-
lO.
1 1.
12.
13-
H-
17. 18, 20. 2 1.
23-
John Coakley Lettsom, M.D., LL.D., F.R.S. .
John Fothergill, M.D., F.R.S. .
Garden view of Dr. Lettsom's house at Camberwell
Destitute family relieved as a result of one of Dr. Lett som's morning walks in the Metropolis
Anterior part of cisterna magna distended by artificial in jection .....
Anterior part of cisterna magna distended with pus
Posterior basic meningitis
The brain stem .....
Portion of aorta of turtle {Chelonia Mydas) showing capa- cious lymphatic sheath surrounding the artery .
Dissection of head of turtle, with brain stem exposed
The brain stem in the embryo .
Diagram of subdural hematocele
Photograph of the outer surface of the tumour 16. Intracranial hemorrhage of the new-born
Sketch of operation for arachnoid cyst
19. Simple fracture of skull in infants
Traumatic meningocele .
Fracture of right frontal bone in a new-born infant, frac ture extending into orbit
I. Traumatic meningocele before operation. 2. Same case after operation ....
Diagram of fracture of skull in Dr, Bastian's case of trau matic encephalocele .... ix
PAGE 2
13
13 13 16
20 21 22 23 23 32
33
34' 35
36
37
37
38
X SURGERY OF THE BRAIN
FIG.
24, 25. Lumbar puncture ....
26. Sub-arachnoid space between the convolutions .
27. Sketch of complete mastoid operation
28. Arrangement of membranes around spinal cord .
29. Arrangement of arachnoid in the region of the cauda
equina .....
30. The relation of the frontal sinuses to the frontal lobes
31. The relation of the accessory sinuses to the base of the
skull ; viewed from the cranial cavity .
32. Radiogram of large frontal sinuses
33. Radiogram of suppurative disease (granulation, polypi, and
pus) in the left frontal sinus .
34. Result six weeks after the Killian operation for frontal
sinus suppuration
35. Miliary tuberculosis of pia covering the convexity of the
brain ......
36. General suppurative meningitis .
37. Posterior basal meningitis
38. Diagram of subdural drainage by an angular metal tube
39. Congenital hydrocephalus in an infant of 6 months
40. Congenital hydrocephalus treated by ligation of both
common carotid arteries
41. Traumatic meningo-cortical abscess of brain
42. Spreading septic softening of the right frontal lobe
43. Encysted abscess of left frontal lobe
44. Abscess of the right temporo-sphenoidal lobe
45. 46. The cortical centre for hearing 47, 48. The cortical centres for taste and smell
49. Diagram of the position in the cerebral cortex of th
centres concerned in the mechanism of speech
50. Tumour of the 3rd temporal convolution, indicating th
position of the naming-centre .
51. Case illustrating site of naming centre
52. Tumour of the right temporo-sphenoidal lobe bearing on
the localisation of the sense of smell
PAGE
44. 45 47 49 51
51
65
65
(^1
72
74 11 78 82
83
89
100
lOI
105 108 109
1 12
1 12 113
121
ILLUSTRATIONS xi
FIG. PAGE
53. Abscess in the temporal and frontal lobes . .124
54. Two abscesses in the brain . . . .133 55-57. Illustrating case of two abscesses in the cerebellum . 142
58. Frontal lobe abscess secondary to frontal sinus disease . 144
59. Abscess of cerebellum occupying the anterior and inner
part of the left hemisphere .... 145
60. Drawing to show the direction in which the complete
mastoid operation should be extended in order to drain
a cerebellar abscess through its stalk . . .146
61. Coronal section of left cerebral hemisphere, with small
temporo-sphenoidal abscess . . . .147
62. Glioma of frontal lobe . ^. . . .159
63. Cholesteatoma vera of cerebellum . . . 160
64. Endothelioma of meninges of temporal lobe . .161
65. Carcinomatous deposit in centrum ovale, secondary to
growth in oesophagus . . . . .161
66. Carcinomatous deposit in the skull, secondary to Scirrhus
mammae . . . . . .162
67. Sarcoma ot brain (multiple growths), secondary to sarcoma
of lung . . . . . .163
68. 69. Simple cyst of cerebellar hemisphere . 164, 165
70. Hydatid of right frontal lobe . . . .166
71. Hydatid of right lateral ventricle removed through post-
Rolandic region . . . . .166
72. Aneurism of the intra-cranial portion of the left internal
carotid artery . . . . . .167
73-76. The establishment of a cerebral hernia as a decom- pressive measure for inaccessible brain tumours . 171
77. Exposure of cerebellum (R. hemisphere) by the usual
method . . . . . .172
78. Tumour of the brain with a long history and with few
symptoms . . . . . .178
79. Photograph of psammoma (angeiolithic sarcoma) of occi-
pital lobe . . . . . .180
80. Microscopical section of tumour . , .180
81. Patient fourteen months after operation for cerebellar
tumour . . . . . . . 191
Xll
SURGERY OF THE BRAIN
82, 83. Back and side views of head, two years and nine
months after operation for cerebellar tumour . 198, 199
84, 85. Healed fracture, outer and inner surfaces of skull,
over gliomatous tumour in occipital lobe . .201
86. Cystic glioma of occipital lobe under healed fracture of
skull ....... 201
87. Photograph of supposed meningo-cortical abscess . 205
88. Tumour of frontal lobe following punctured fracture of
skull ....... 205
89-95. Illustrating the histology of the tumour . 206-210
96, 97. Parosteal round-celled sarcoma of the squama . 222
98. Periosteal sarcoma of squama .... 222
99. Cavernous angeioma (without sarcoma cells) of os frontis
projecting backwards into skull cavity and compressing frontal lobe . . . . . .223
100. Sarcoma of orbital part of os frontis displacing dura and
brain . . . . . .223
10 1. Sarcoma of outer aspect of dura mater compressing lett
frontal lobe ...... 224.
102. Sarcoma of outer aspect of dura . . . 224
103. Fibrosarcoma of cerebellar meninges . . . 225
104. Tumour (? endothelioma) of meninges in frontal region 226
105. 106. Endothelioma of meninges in frontal region . 227
107. Sarcoma ossis frontalis before and after operation . 228
108. Destruction of skull by malignant disease . . 228
109. Epithelioma of frontal region .... 229 I 10. Carcinoma of frontal region . . . . 229
111. Photograph of a child, aged 5 years, showing position of
head assumed in a lesion of the right lateral lobe of
the cerebellum . . . . . 234.
112. Child with right cerebellar tumour (solitary tubercle) . 235
113. Skew deviation of the eyes .... 247
114. Bulging right occipital fossa in a child ^h years . 250
115. Simple cyst of left cerebellar hemisphere . . 252
116. Photograph of cast of back of head, showing bulging
left occipital fossa . . . . .255
ILLUSTRATIONS
Xlll
FIG. PAGE
117. Illustration of solitary tubercle removed from left
occipital fossa with success . . . .255
118, 119, The patient fifteen months after operation . 257
120. Hemorrhage tearing up left cerebral hemisphere . 261
121. Fibro-plastic tumour of Lebert . . . . 263
122. Fibro-plastic tumour of cerebellar meninges . . 263
123. Fibro-sarcoma of cerebellar meninges . . . 264
124. Tuberculous tumour of the cerebello-pontine angle . 264
125. Upper surface of cerebellum, showing a solitary tubercle
in each hemisphere ..... 265
126. Endothelioma of cerebellum .... 265
127. Solitary tubercle of cerebellum . . . 266
128. Simple cyst of cerebellum .... 266
129. Spindle-celled sarcoma of the auditory nerve . . 267
130. Tumour of left auditory nerve . . . . 268
131. Endothelioma of cerebellar meninges . . . 269
132. Glioma filling fourth ventricle .... 270
133. Fibroma growing from the left acoustic nerve . . 271
134. A tumour the size of a bantam's egg, of a firm fibrous
consistence, in the left cerebello-pontine space . 272
135. Neurofibroma of the right acoustic nerve . . 273
136. Encapsulated sarcoma of the cerebellar meninges com-
pressing upper surface of vermis . . . 274
137. Fibro-sarcoma of left cerebellar hemisphere . . 275
138-144. Case of fibro-sarcoma of cerebellar meninges 276-281
145-148. A case of compound comminuted fracture of the
skull and laceration of the brain . . 282-285
149. Operation for simultaneous exposure of both cerebellar
hemispheres, necessitating ligation of the occipital
sinus ....... 286
150. Structures in relation to the anterior aspect of the cere-
bellar hemisphere and the posterior surface of the
petrous ...... 286
151. The reindeer of the cave of Thayngen, near Schafi--
hausen ...... 288
152. Perforated antler discovered in the cave of La Madelaine 289
XIV
SURGERY OF THE BRAIN
153. Right cerebral hemisphere from a human foetus in the
latter half of the 6th month of development . . 289
54. Sarcomatous solid tumour of (?) optic thalamus . 292
55. Spreading oedema of the centrum semi-ovale, from a
small nodule in the right prefrontal cortex, secondary
to a renal carcinoma ..... 293
56. Areas and centres of the lateral aspect of the human
hemicerebrum ..... 295
57. Areas and centres of the mesial aspect of the human
hemicerebrum ..... 295
58. Horizontal section of the occipital lobe, showing the
optic radiation . . . . .301
59. Glioma of occipital lobe .... 303
60. 161. Symmetrical atrophy and degeneration of the
occipital lobes ..... 306
62. The distribution of the middle meningeal artery . 308
63. Fibro-plastic tumour of cerebral meninges . . 308
64. The motor area and its subdivisions on the lateral
aspect of the hemicerebrum of the chimpanzee . 310
65. The motor areas and centres on the mesial aspect of the
hemicerebrum of the chimpanzee . . .310
66. Glioma of frontal lobe, microscopical section. . . 315
67. Glioma of frontal lobe . . . .320
68-170. Large glio - sarcoma of frontal lobe successfully
removed . . . . . .321
71-174. Illustrating a case of subcortical tumour . . 322
75-182. Illustrating a case of malignant growth of frontal
lobe perforating dura and skull . . 324-329
83, 184. Symmetrical cortical lesions causing hallucinations
of hearing, word deafness, and sensory aphasia . 350
85. Sketch of operation for subcortical tumour (sarcoma), growing in the centrum ovale beneath the cortex of the upper part of the precentral convolution and the superior parietal lobule . . . ,352
186-189. Illustrating the usual method of making the scalp
flap, and the drainage of a malignant "cyst" . -355
ILLUSTRATIONS
XV
190. Diagram of site of tuberculous tumour behind tlie central fissure ....
355 367 370 370
191. Large sarcoma of cerebral meninges
192. Large tumour of left parietal region 19^. Radiogram of the tumour 194-198. Tumour of frontal lobe without optic neuritis 381-385 199. Microscopical section of growth found between dura of
posterior fossa and temporal bone . . .387
200-201. Microscopical appearances of frontal lobe tumour
described under Figs. 175-182 . . 388, 389
202-206. Large sarcoma of outer surface of dura mater 392-396
LECTURE I
REMINISCENCES OF DR. LETTSOM SOME POINTS" IN
THE SURGERY OF THE CEREBRAL MEMBRANES
Anatomical, physiological, and physical considerations — The sub- dural and sub-arachnoid spaces — The cerebro-spinal fluid — Subdural hsemorrhage in adults and infants — Traumatic encephalocele — Pathology of meningeal infections — Subdural _ and sub-arachnoid suppuration — Varieties of meningitis — Symptoms and diagnosis — Surgical treatment of tubercular and suppurative meningitis and of hydrocephalus interna.
It is my duty, as it is my pleasure, to gratefully acknowledge the honour which the Council of the Medical Society of London has conferred upon me by inviting me to deliver the Lettsomian lectures.
'Reminiscences of Dr. Lettsom.
These lectures were founded to commemorate a great physician who, a century ago, was a leader of medical practice in London. It therefore seems only right briefly to recall something of his life and work before entering upon the subject matter of the lectures^
B
2 REMINISCENCES OF
John Coakley Lettsom came of a Quaker family. He was born in 1744 in the West Indies, and died in London in 18 15.
Sent at an early age to England to be educated, he chose medicine as his profession, and, in accordance with the custom of the time, was apprenticed, the master selected for him being
Fig. I.— John Coakley Lettsom, M.D., LL.D., F.R.S.
a Mr. Sutcliff then practising at Settle in York- shire. After his apprenticeship he attended St. Thomas's Hospital, where he was most diligent in his observation of the patients, of whose cases he made notes, a custom not then usual.
His first practice was in the West Indies. He had returned to the place of his birth to claim the residue of a property left to him by
DR. LETTSOM 3
his father. It consisted of a portion of land and some fifty slaves ; these latter he promptly emancipated, slavery being altogether repugnant to his nature.
He thus found himself dependent upon his profession for support, and commenced practice in Tortola. It is recorded that " in five months he amassed two thousand pounds," a financial success attending the early effbrts of very few. He gave half this sum to his mother, and with the remainder returned to England in September 1768.
He spent several months visiting the Univer- sities of Edinburgh, Paris, and other centres of learning, and took the degree of M.D. at the University of Leyden.
Soon after graduating he returned to London, and commenced practice in the City under the patronage of Dr. John Fothergill. His success was early and complete, and it is stated that for a number of years he enjoyed the largest practice in the City of London.
Of this Society he was one of the original Fellows. The memoirs of the Society bear witness to the prominent part he took in its discussions, while the freehold property from which we still derive a revenue attests the generosity of his benefactions.
4 REMINISCENCES OF
He was no less celebrated for liberality of mind and benevolence than for his skill as a physician.
The following is one of the more extra- ordinary instances of his generosity. He was attacked and robbed by a highwayman, but far from bearing any resentment, he gave the man
Fig. 2.— John FothergiU, M.D., F.R.S.
his address, and offered him further assistance. The robber responded to this invitation, and Lettsom succeeded in obtaining for him from His Majesty a commission in the army, and he served the country with distinction.
Lettsom was a voluminous writer, and did not confine himself to medical subjects. His non- medical writings were chiefly upon matters of public utility or on philanthropy, such as the properties of the tea-plant, the cultivation of the
DR. LETTSOM 5
mangel-wurzel, the abolition of slavery, and the relief of the poor.
He was not learned in the highest acceptation of the term, yet he was the friend and the patron of learning. Wherever his influence extended — and it was not narrowly circumscribed — science and useful literature flourished.
He was particularly keen on exposing quacks. On one occasion he insisted on a post-mortem examination as a " urine caster " had asserted that the disease which had caused death was in the kidneys, whereas Lettsom maintained that the symptoms — headache, vomiting, slow pulse, and vertigo — were due to disease of the brain. The autopsy showed healthy kidneys, and inflam- mation within the skull, probably the result of a former injury.
His correspondence was extensive, and many remarkable letters have been preserved, which show the variety of subjects in which he took interest, and afford many evidences of his kindly and sympathetic nature.
The amenities of medical life appear to have somewhat differed, in their forms of expression at least, from those of the present day. It is recorded that Lettsom was much angered by the discourtesy of Mr. Baker, one of the surgeons ot the hospital. Mr. Baker had a son who suffered
6 REMINISCENCES OF
from epilepsy, which somewhat impaired his understanding. His medical colleague Dr. Akenside inquired to what study he proposed to place him ; Mr. Baker replied, " I find he is not capable of making a surgeon, so I have sent him to Edinburgh to make a physician of him."
Another instance of the manners of the times is afforded by the well-known ungenerous epi- gram written of Lettsom —
When patients come to I, I purges, bleeds, and sweats 'em. If after that they choose to die. What's that to I,
I lets 'em.
Lettsom undoubtedly earned a handsome pro- fessional income, but the extent to which his private fortune must have been injured by his generosity to others may be gathered from one of his letters, dated i8th February 1783. Reply- ing to an intimate friend who had upbraided him for neglecting to take any adequate relaxation, he says, *' I have a weakness which I cannot overcome. I hope and believe it does not result from ambition or from vanity ; but so it is, how- ever, that if I hear of want, I often distress myself to obviate that want. In looking over my expenses since January last, I find I have
DR. LETTSOM
7
expended above six hundred pounds in donations ; and, like a necessitarian, I have no power to con- trol this extravagance. Thus with an income of ^5000 per annum I am always involved ; and what is still more alarming, my pensioners increase daily. I mention my extravagance as an excuse for my perpetual application to busi-
FiG. 3. — Garden view of Dr. Lettsom's house at Camberwell.
ness ; for since the year 1769, when I first settled in London, I have not taken one half- day's relaxation, and I cannot get to Grove Hill above once a fortnight."
Though there were no death duties in his time, he distributed his wealth during his life — a form of charity much more real than that commonly practised of distributing after death what can no longer be retained.
The story of the rescue of a starving family as the result of an early morning walk is typical
8
REMINISCENCES OF
of Lettsom's life. This family was saved from starvation, and with the co-operation of the churchwarden of I>ittle Greenwich in Bishops- gate Street was given a new start in life.
Lettsom writes " that he has experienced how
3^6»,
Fig. 4. — Destitute family relieved as a resvilt of one of Dr. Lettsom's morning walks in the Metropolis.
greatly the sight of real misery exceeds the description of it," and again
To pity human woe,
Is what the happy to the unhappy owe.
Physician, student of nature, and philan- thropist, Lettsom passed into the silent world, leaving behind him a host of friends and a name ever to be associated with boundless private charity and numerous projects for the public weal.
DR. LETTSOM
Of Lettsom it may be truly said —
To live in hearts we leave behind is not to die ; and,
The souls of the risihteous are in the hand of God.
In this lecture I propose to consider the posi- tion of surgical intervention in the disease, or rather group of diseases, having for anatomical basis a lesion of the meninges.
Anatomical^ Physiological^ and Physical Observations. The Subdural and Sub-Arachnoid Spaces.
We are all familiar w^ith the three-fold mem- branous investiture of the central nervous system, but the special importance of certain anatomical details is less well understood.
Axel Key and Gustav Retzius in 1875 pub- lished the result of several years' research in a beautiful monograph, w^hich, as Charpy says, has remained the classical work on this subject, though their results have not been confirmed (or corrected) by subsequent workers.
Key and Retzius showed : —
I. That there is no gross communication between the subdural and the sub-arachnoid spaces.
10 SOME POINTS IN THE SURGERY
2. That the sub-arachnoid and the subdural spaces of the brain can be completely injected from the corresponding spinal spaces.
3. That fluids injected separately into each of these spaces mix in the subdural space of the Pacchionian bodies, then pass on into the venous sinuses, and even reach the veins of the scalp,
4. That injection of the sub-arachnoid space, after death or during life, at a low pressure shows that at the base of the brain it is broken up into certain definite spaces of considerable capacity, and that over the cerebral hemispheres the sub- arachnoideal mesh-work is more abundant in the sulci than over the tops of the convolutions, so that these latter, as another writer has aptly expressed it, stand out from the general injection mass like the hedges of a flooded land.
5. That the blood -pressure in the cerebral sinuses, though diminishing during inspiration, is always positive, and that the pressure of the cerebro-spinal fluid in the sub-arachnoid space always exceeds by a few mm. of Hg. the cere- bral venous pressure, and that therefore the flow of fluid is from the sub-arachnoid space into the venous system. As the specific gravity of the cerebro-spinal fluid is less than that of the blood, any flow determined by osmosis would be, in the main, in the same direction.
OF THE CEREBRAL MEMBRANES ii
As the result of his own researches, Leonard Hill maintains that the sub -arachnoid space is " chiefly a potential rather than an actual space, except in those few places where inequalities of the brain surface are rounded off by small col- lections of fluid beneath this membrane," and that " the living brain with its circulating blood almost entirely fills the cranium, and the fluid that moistens its surfaces is little more in amount than the synovial fluid in a joint."
This latter statement is certainly true of the subdural cavity, but is less clearly applicable to the sub-arachnoid space ; and when it is stated that "the plates in Key and Retzius' mono- graph, which are copied into most anatomical works of to-day, give an entirely erroneous idea of the contents of the cranium in the living animal " ; it seems desirable to point out that these authors made their injections shortly after death, and do not suggest that the spaces are normally distended to the same degree during life, and that they controlled their results ob- tained from injections on the cadaver by ex- periments on living animals. It must not be forgotten that however little fluid there may be in the sub - arachnoid cavities at a particular moment during life, yet a considerable amount is present in the ventricles with which the
12 SOME POINTS IN THE SURGERY
sub-arachnoid cavities are in direct communica- tion.
The well-known figure of Key and Retzius, showing the sub-arachnoid spaces fully injected as they appear in a vertical median section of the head, was expressly intended to represent the relationship " of the various parts of the brain when the ventricles and the sub-arachnoid space were distended with fluid." The blood- pressure being nil, the injection would displace most of the blood from the vessels of the pia, driving it at least as far as the venous sinuses, and the sub -arachnoid spaces would therefore appear exaggerated. Artificial distension by injection is a usual and well-known method of anatomical demonstration. For example, it would scarcely be contended that Sappey's illus- trations of the lymphatics, as demonstrated by injection with mercury, were intended to repre- sent their normal state of distension during life.
Whatever the normal condition of the sub- arachnoid spaces may be, they certainly become distended during life with blood or purulent efi\isions ; of this any one who has attentively made a few post-mortem, examinations must be convinced.
In the illustration of posterior basal menin- gitis published by Dr. Lees and Sir Thomas
OF THE CEREBRAL MEMBRANES 13
Fig. 5. — Anterior part of cisterna magna distended by artificial injection. (Key and Retzius.)
The injection was made into the sub-arachnoid space of the spinal theca. The injection has penetrated everywhere beneath the arachnoid, in the interpeduncular space, and in the sulci between the convolutions.
Fig. 5. — Anterior part of cisterna magna distended with pus. (Lebert, i85i.)
From a case of suppurative meningitis in a soldier aged 24 years. Death on the fourth day. The onset was sudden, and the symptoms were fever, shivering, severe occipital pain, prostration, delirium, and finally coma.
Fig. 7. — Posterior basic menin- gitis. (Lees and Barlow.)
Child aged 5 months. Dura- tion of illness 1 1 days.
The dark shading indicates the sites of pus collection under the arachnoid. The anterior part of the cisterna magna was distended, and pus was also present over the tips of the temporo -sphenoidal lobes.
14 SOME POINTS IN THE SURGERY
Barlow, the anterior part of the cisterna magna is seen distended with pus, just as one of Key and Retzius' figures shows it distended artificially by injection.
It is a common surgical experience — for example, in operating to relieve optic neuritis — that it is easy to obtain a flow of fluid from the sub -arachnoid space of the base of the brain while it is almost impossible to do so from the vertex — opening the subdural cavity is for such a purpose a useless measure.
The only place at which, from the figures of Key and Retzius, it would be reasonable to infer that a considerable flow of cerebro-spinal fluid would be obtained is below the cerebellum. It is just here that the surgeon most easily obtains a rush of cerebro-spinal fluid and is able to establish drainage.
Imbert, in 1884, wrote: "The principle of Archimedes, in conjunction with that of Pascal, explains the manner in which certain fluids of the animal economy aflbrd protection to the organs immersed therein. The brain, for ex- ample, loses 98 per cent of its weight when immersed in cerebro-spinal fluid, for the differ- ence in specific gravity between the brain and the fluid is only 0.02. A brain which would weigh 1 500 grammes in air would only weigh
OF THE CEREBRAL MEMBRANES 15
30 grammes in the cerebro- spinal fluid : it is this weight, then, of 30 grammes which represents the whole pressure of the brain on the base of the skull. So feeble a pressure, scarcely amounting to i decigramme per square centimetre, would neither damage the extremely- delicate texture of the nervous centres nor offer the least resistance to the circulation of the blood in the interior of the brain. Further, fluid interposed between the brain substance and the cranium lessens the effect of blows and external shocks by spreading compression pro- duced at any one point over the whole surface of the brain, in accordance with the law that pressure is equally distributed in all directions."
Though it cannot be admitted that the physical conditions are anything like so simple as Imbert's description would lead us to believe, yet the almost constant escape of the brain stem in injuries of the head points conclusively to the existence of some special protective mechanism.
The sub-arachnoid cisternas, partitioned off as they are so that fluid only slowly escapes from one into another, are well fitted to act as a kind of hydraulic buffer, and notwithstanding the view that the sub-arachnoid space is a potential space only, it would appear that the cisternas are
i6 SOME POINTS IN THE SURGERY
of importance in protecting the isthmus cerebri from injury.
The weight of the brain is not wholly, or even to any considerable extent, supported by hydrostatic pressure ; its anterior and posterior
extremities rest upon planes inclined in op- posite directions, viz. the orbital plate of the frontal bone and the tentorium cerebelli ; the middle lobe fits with great accuracy into the middle fossa, and the falx cerebri prevents any side-to- side movement of the hemispheres ; a very thin layer of fluid would in ordinary circumstances prevent any injurious shock from impact of the brain substance against the resisting bone.
From the mass of the hemispheres the isthmus cerebri passes almost vertically down- wards, its lateral displacement is prevented by the sheaths of the nerves issuing from it and by bands of sub-arachnoid connective tissue, and
Fig. 8. — The brain stem. (Key and Retzius.)
Note the sub-arachnoid trabeculae which prevent movementof the brain stem against the foramen magnum.
OF THE CEREBRAL MEMBRANES 17
the amount of fluid by which it is surrounded is sufficient to give material mechanical support.
It is to the parts below the tentorium that Imbert's purely physical statement of the con- ditions present more closely applies.
Hill's experiments led him to conclude that though the amount of blood in the arteries or veins of the brain may and does vary consider- ably, the absolute amount of blood within the cranium does not vary to any great extent, the observed circulatory variations being variations in the distribution of blood and not in its total amount, and the atmospheric pressure being the chief factor in maintaining these conditions.
Sir Thomas Watson in the fifth edition of his Pj^actke of Physic observed that he formerly taught this view, and mentioned some experi- ments by Munro and Kelly which led him, though with some hesitation, to accept it ; the experiments of Burrows, however, convinced him that it was erroneous.
It would certainly be thought that if the atmospheric pressure exercised so considerable an influence on the cerebral circulation this would be profoundly modified when the dura or even the skull was opened ; surgeons do not, however, observe any profound change in
1 8 SOME POINTS IN THE SURGERY
the condition of the patient at the moment of opening the skull.
No more marked disturbance of the circula- tion is observed on opening the skull than on opening the peritoneum ; when the surgeon incises the dura mater there are no phenomena comparable to those occurring when the normal parietal pleura is incised.
The Cerebrospinal Fluid
The cerebro-spinal fluid is a secretion and not an exudation. Mott has recently laid stress on this point. He writes : " It is comparable to the amniotic fluid and the sweat for true albumin and fibrinogen are absent. (It may be noted here that one function of the amniotic fluid is protection.) At each cardiac systole it is driven from the cranium into the spinal canal. (This may in part explain the presence of blood and pus in the spinal theca when purulent and hasmorrhagic effusions occur within the cranium.) A layer of arachnoid like a sieve follows the pial vessels as they dip into the brain, and thus forms a perivascular canalicular system. The vessels are therefore always surrounded by a constant fluid pressure." The cerebro-spinal fluid is of course not lymph, but these arachnoid
OF THE CEREBRAL MEMBRANES 19
sheaths play a part in the brain that is elsewhere the sole function of the lymph sheaths. In this manner oxygen, which is necessary for the bio- chemical changes of nervous tissue, is probably carried by the cerebro-spinal fluid to all parts of the central nervous system.
On examining the great lymph sheath around the aorta of the turtle in the Royal College of Surgeons Museum, it occurred to me that it would be interesting to examine the membranes around this creature's brain. It will be noticed that the cranial subdural cavity of the turtle is not a potential but an actual space, and that delicate connective tissue bands cross it, as in the sub-arachnoid space of man, to prevent displace- ment of the brain stem (Figs. 9 and 10).
Hamatoceie of the Subdural Cavity in Adults and Infants. Traumatic Cephalhydrocele and Enceplialocele.
It has already been pointed out that the subdural and sub - arachnoid cavities are often defined and distended by effusion of blood following injury. Time will not allow a full discussion of this subject, but reference may briefly be made to cases in which a blow on the head or a fall is followed at some
20 SOME POINTS IN THE SURGERY
distance of time by obscure cerebral symptoms, among which mental disturbance and transitory
paralysis are prominent ; in some such instances a considerable haemorrhage has taken place into the arachnoid cavity, the blood has become encysted, and like a blood collection in the tunica vaginalis, has continued to increase in size, causing slow pressure on the brain.
I successfully removed such a cyst, which mea- sured seven inches in its long diameter, four and a half in its short, and one and a half in thickness, from a man aged thirty- four years, a patient of Dr. James Taylor, who had ^'?r?T^°''.'i"'^1 T'-°^'"'^' narrowly escaped being:
[C/ielonia Mydas) showing capa- J L O
cious lymphatic sheath surround- pnnc;io-nprl fo 3 ^UU^Ur
ing the artery.— (R.C.S. Museum, COUblgnCQ lO a lUUdllC
Pkvsiolozkal Series, No. SS"? c.) i i i • -i ,
^ ^ asylum, where he might
possibly have been labelled " general paralysis "* and died without relief (Figs. 12 and 13).
The following two cases of operation for
OF THE CEREBRAL MEMBRANES 21
subdural hasmorrhage I have not previously published : —
C. K., female, aged twenty -six years. Admitted December 21, 1904, into the National Hospital under Dr. Ferrier.
History (obtained from husband). — No neuroses in family. Married eighteen months. Now five
Fig. 10. — Dissection of head of turtle, with brain stem exposed.
Note the trabecula of areolar tissue crossing the wide subdural space to prevent displacement against the surrounding rigid brain case.
The turtle heads were kindly supplied by Messrs. Buszard of Oxford Street.
months pregnant. No history of injury. A month ago her husband was leaving home in the morning for his work when he heard a cry, and on going back found his wife shrieking and in a demented condition. She was violent, and tossed herself about. Next day condition much the same, but some weakness of right arm was noticed. She continued screaming, with intervals, during which she would repeat meaningless combinations of words, or point to things seen by
22 SOME POINTS IN THE SURGERY
herself apparently of a terrifying description. She remained in this state for a month. Recently paresis of right leg had been noticed.
On admission. — Patient lies on her back continually crying out and waving her left arm. She does not seem to recognise objects presented to her. On being
J
.^^'
Fig. II. — The brain stem in the embryo.
Fig. 11 a. — Drawing of section of head of human embryo (about four months). ( X 2). A large space is seen between the brain stem and the skull. In this space the basilar artery can be recognised lying nearer the brain stem than the skull. The space is crossed by delicate bands of embryonic connective tissue.
Fig. lib represents a portion of the same specimen as seen under a one-inch objective. The basilar artery and the connective-tissue bands are more plainly shown, and fine vessels can be seen penetrating deeply into the brain substance.
The specimen was prepared by Dr. Charles Green, who kindly allowed me to use it.
moved she utters loud cries. When not crying she lies in an exhausted semi-comatose condition. She has double optic neuritis, but is able to see. Pupils normal. Marked weakness of right side of face ; complete flaccid paralysis of right arm, and nearly complete paralysis of right leg. Left arm moves well. Abdominal reflexes absent on right side. Knee-jerk brisk, and ankle clonus
OF THE CEREBRAL MEMBRANES 23
present on right side. Urine retained ; fasces passed unconsciously.
Operation, December 24, 1904.- — ^The patient has been
Fig. 12. — Diagram of subdural haematocele. (Taylor and Ballance.)
Horizontal section showing the position of the " cyst " and the compression of the cerebral hemisphere, and explaining the occurrence of expansile pulsation in the tumour. The marks * * show the extent of the opening in the skull. The tumour being fluid, the pulsations of the brain were transmitted in every direction ; hence when the finger and thumb grasped the centre of the tumour (see arrows in the centre of the cyst) they were separated by an expansile pulsation comparable to that which obtains in aneurysm.
kept quiet under morphia ; she is more exhausted and her pulse is weaker. The left motor area was exposed. A subdural hasmatocele compressing the Rolandic area
Fig. 13. — Photograph of the outer surface of the tumour. (Taylor and Ballance.) (R. C. S. Museum, No. 3837 a.)
An opening has been made in the cyst wall, which exposes in the specimen a deep red clot.
was found. It extended forwards to the frontal pole and downwards towards the base, and was half an inch thick. It was removed without difficulty. Patient was
24 SOME POINTS IN THE SURGERY
much better after the operation, and all went well for ten days. On January 7 pneumonia supervened, and the patient died on January 10. There had been a little blood noticed on the dressings for a few days. This had come from cortical vessels, possibly those which had furnished the blood of the hematocele.
W. M,, male, aged forty-eight years. Admitted on March 28, 1906, into the National Hospital under Dr. Ormerod.
The family history was good ; no epilepsy nor other neuroses could be traced in it. The patient denied having had venereal disease, but admitted having incurred the risk of contracting it. He had worked hard and had had recent mental worries. Much head work, but no manual labour. In May 1905 he was struck hard on the right side of the head by the falling lid of a flush tank ; he did not lose consciousness. Since then he has suffered from headache on waking in the morning. In February 1906 he had an illness thought to be influenza, and was sick once or twice without obvious cause. Since then he has had headache, occipital and retro-ocular. When he gets out of bed his sight becomes temporarily blurred ; he has diplopia occasion- ally. No definite giddiness. Has vomited six times since the " influenza." Sight has been worse during the last four weeks. The symptoms have varied. A week before admission he was thought to be better.
On admission. — Is slightly emotional ; cerebration slow ; takes some time to answer even simple questions. No alteration of smell, taste, or hearing. Sight much impaired ; reads one inch letters at four feet. No hemianopsia ; fields not contracted. (Rough test only). Optic Discs. (Mr. Gunn.) Right : Intense fungiform
OF THE CEREBRAL MEMBRANES 25
papillitis with numerous hasmorrhages. Highest point seen with +9D. Left: Same as right. Highest point seen with +9.5 D. Pupils normal.
Tongue when protruded deviated slightly to left. Complains of dull, constant headache, occipital, retro- ocular, and frontal. No weakness of face or arms. Cremasteric reflex difficult to obtain on left side. Patellar and ankle reflex more brisk on left than on right side. Ankle clonus well marked on left, slight on right side. Gait feeble and slightly unsteady. No tenderness of cranium.
Operation in two stages. Bone removed over right frontal lobe. On opening the dura a thin layer of clot enclosed in a membrane found over the whole convex surface of the right hemisphere, from frontal to occipital region. This was removed. A cortical vein in the frontal area bled a good deal ; apparently it was attached to the clot capsule, and may have been the cause of the subdural haemorrhage. The clot was thicker (about quarter inch) over the anterior part of the frontal lobe and over part of the Rolandic area ; elsewhere it was very thin.
This matter did not escape the astute obser- vation of Richard Bright, who in 1831 v^rote : " There is a species of partial accumulation of fluid in the brain which must not be passed over without notice : I mean serous cysts forming in connection with the arachnoid, and apparently lying between its layers, or attached by thin adventitious membranes. These are occasionally discovered on dissection, and have
26 SOME POINTS IN THE SURGERY
either produced no symptoms or have been quite unsuspected till after death. These cysts vary in size from the size of a pea to that of a large orange, and may be considerably larger. They appear to be of the most chronic character, and probably never enlarge after their first formation. The brain is completely impressed by them, so that when the fluid is let out a permanent cavity remains, and even the bone of the skull is moulded to their form."
Two cases are illustrated in Bright's work.
The post-mortem appearances in one of these are thus described : " On sawing through the skull-cap a sudden gush of limpid fluid attracted attention, and examining whence this fluid escaped, a considerable oblong depression was found in the middle lobe of the right hemisphere. On minute inspection the fluid, which amounted to at least twelve ounces, had been contained in a cyst formed by the splitting of the arachnoid membrane, which had pressed on the middle lobe of the brain, and thus produced a corre- sponding depression. The membranes and sub- stance of the brain (with the exception stated) did not exhibit any morbid appearances. The thoracic viscera were quite healthy. The abdo- minal viscera showed no traces of disease, except extensive ulceration of the ileum and cascum."
OF THE CEREBRAL MEMBRANES 27
The preparation is deposited in the Museum of the Royal College of Surgeons. The patient, a male aged eighteen years, had probably died from enteric fever. No history of injury is given.
In 1897 Biroula showed at a meeting of the St. Petersburg Anatomical Society a specimen very similar to that of Bright. The patient, a soldier aged twenty-four years, died from enteric fever. A large meningeal cyst was found over the first and part of the second frontal convolu- tion on the left side. The brain was indented by the cyst. The cyst walls were formed by the meninges, and no trace of any parasite was found. There was a projection over the corre- sponding part of the skull. Shortly before death some rigidity of the right arm had been observed ; with this exception no symptoms referable to the cyst had been noticed.
Prescott Hewitt, in 1845, contributed a paper to the Royal Medical and Chirurgical Society, in which he discussed the subject with great acumen, and related several cases. In accord- ance with the views then prevalent, he held that the thin investing membranes were derived from the fibrin of the blood, and he made the in- teresting observation that he had seen similar membranes enclosing blood collections in the pleura. Curiously enough, though he referred
28 SOME POINTS IN THE SURGERY
to cases in Abercrombie's work, he made no mention of Bright's cases.
Prescott Hewitt also discussed the subject in his article on " Injuries of the Head " in Holmes's System of Surgery. Good illustrations of these cysts are there given and reference made to a particularly striking case published in full in The Lancet., 1846, vol. i. p. 416. A boy aged eight years received a blow on the head from a cricket ball and shortly afterwards showed symptoms of insanity. He had recurrent attacks of insanity with intervals of health until his death, fifteen years after the injury. The symptoms in the last attack were headache, vomiting, and drowsiness. At the autopsy a large arachnoid cyst was found.
Bearing in mind that in almost all serious head injuries blood is extravasated into the arachnoid cavity, it may well be that in cer- tain cases of intermittent headache, intermittent paralysis,, or intermittent insanity subsequent to head injury the pathological lesion present is arachnoid hasmatocele ; a condition certainly remediable by operation.
As I have mentioned successful cases of removal of large arachnoid hasmatocele, I must record one on which I did not operate and death ensued. It is noteworthy that in these cases
OF THE CEREBRAL MEMBRANES 29
of arachnoid hemorrhage there is a rise of temperature.
W. W., male, ast. 56, groom. Typhoid fever three years ago. No history of syphilis. Was kicked by a horse over the left eyebrow three months ago. Wound sutured by Dr. Halsted, who stated that there was no fracture of skull. Was said to be quite well until six weeks ago, when it was noticed that his left arm was weak and that he dragged his left leg when walking. Complete paralysis of left arm and leg four days before admission, followed in twenty-four hours by frequent vomiting and unconsciousness. Temperature 101° on morning of admission. On examination reaction to external stimuli delayed, but would answer to his name if frequently called. Speech slow and slurred. Paralysis of left arm and leg. Occasional clonic con- tractions of right arm. In the intervals the limb was held stiff ; hand-grip feeble. Right leg unaffected. Knee-jerks brisk on both sides. Ankle clonus on right side. Well-marked Babinski's sign on both sides. Pupils dilated, equal and active ; no ophthalmoscopic changes detected. No trace of albumen or sugar in urine. Constipation of four days' duration and in- continence of urine. Scar over left eyebrow ; no apparent injury to bone beneath. Temperature 99° ; pulse 60. Condition remained unchanged. Alter- nating drowsiness and lucid intervals. Troublesome constipation relieved by calomel and house mixture. Temperature ranged between 98.2° and 100° ; pulse rate gradually increased, reaching 1 20 on sixth day. Seventh day, temperature 104.4 > coma and death. P.M. — Bones of skull uninjured. Large arachnoid blood-cyst found flattening all convolutions of right
30 SOME POINTS IN THE SURGERY
hemisphere. This was definitely encapsuled and the sac could be demonstrated apart from the dura. Contents dark and fluid. Right lateral ventricle com- pressed ; left distended, its posterior horn was about the size of a golf ball. CEdema of lungs. Chronic nephritis.
During the life of the patient in St. Thomas' the symptoms did not appear to justify operation. The man was fifty-six years of age and looked at least ten years older. He was accustomed to take a good deal of alcohol. Learning more of the history of the case after death and reading the P.M. notes, it is easy to be wise after the event. It is noteworthy that the scalp wound was on the side opposite to the arachnoid haemorrhage. I may say that 1 could not be sure before the autopsy was performed that the case was not one of ordinary vascular lesion, though the alternating drowsiness and lucid interval were suggestive of sub- dural haemorrhage.
Gushing has recently drawn attention to surgical intervention for the intracranial haemor- rhages of the new^-born. Cerebral palsies, epilepsy, and other nervous disorders, which may be a permanent life disablement, are often due to these hemorrhages arising from trauma during birth. The unsupported venules passing from the brain of the infant to the longitudinal sinus and Pacchionian bodies are easily broken, and thus large blood extravasations occur in the subdural and sub -arachnoid spaces. Gushing says these extravasations are usually unilateral.
OF THE CEREBRAL MEMBRANES 31
and that they give rise to post-partum asphyxia- tion, a bulging fontanelle without pulsation, con- vulsions, unilateral palsy, a stabile pupil on the side of the hasmorrhage, irregular respiration, slowing of the pulse, a rise of temperature, inability to take nourishment, and death. Gushing gives the details of four cases on which he operated ; two were successful. I have not had the opportunity of operating on such cases, but Cushing's paper will, I believe, be a stimulant to much good work in this direction in the future. Besides the large collections of blood in the subdural cavity which run a somewhat acute course, surgeons are familiar with the localised collections of clear fluid found years after an injury in this situation and which produce mental disturbances, convulsions, and headache. The following is an illustrative case : — A man aged twenty-five was struck some years before admission to St. Thomas' Hospital on the right frontal region. Since the injury he had suffered from headache, irritable temper, and convulsions. On exploring the frontal region, a cyst of the arachnoid was discovered, containing clear but slightly yellow fluid. The headache was cured by the operation, but months after the operation he had a fit, and the epileptic condition has occasionally recurred.
32 SOME POINTS IN THE SURGERY
Fig. i+.
Fig. i(
Fig. U.
Figs. 14, 15, 16. — Intracranial haemorrhage of the new-born. (Gushing.)
Fig. 14. — Photograph of 9-day old comatose female infant. Note extreme degree of ocular proptosis and subjunctival haemorrhage and cedema. Forceps delivery ; inability to suck ; tense fontanelle ; Cheyne-Stokes respiration, and gradual onset of coma.
Fig. 15. — Lateral view to show size and position of one of the symmetrically- placed osteoplastic flaps. Operation on right side ; much blood-clot irrigated away, dura stitched under tension. To relieve tension same operation performed on left side with removal of further clot and relief of tension, as shown by recession of fontanelle.
Fig. 16. — Same patient. Photograph during sleep two months after operation. Complete retrocession of the exophthalmos.
OF THE CEREBRAL MEMBRANES ^3
Mr. Godlee read a most instructive paper at the Pathological Society in 1885, "On simple fracture of the skull in infants followed by the development of pulsating subcutaneous tumours." Similar cases have been reported by Sir Thomas Smith, Mr. Golding Bird, and others. The
Fig. 17. — Sketch of operation for arachnoid cyst at St. Thomas's Hospital.
pulsating mass may consist of blood and cerebro- spinal fluid with or without brain matter. Mr. Godlee's cases were aged five months and eight months. One of them had been also under the care of Sir Thomas Smith. Both died of septic infection. In both cases the injury was caused by a fall out of window, in one of eight, and in the other of four- teen feet. In one of the cases the brain
D
34 SOME POINTS IN THE SURGERY
cortex had been ruptured so as to open the ventricles.
Mr. Godlee writes : " When a young child receives a blow on the head the mischief is almost all spent upon the part struck and that lying immediately beneath it. The process extends little, if at all, beyond a single bone ; indeed no one of the common fractures of the
|
4~ |
\ |
|
^El |
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^^^ |
^^gk, |
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Fig. i8. — Simple fracture of skull in an infant. (Godlee, 1884.)
Male, set. 5 months. Fell 8 feet on to head. Large, soft hasmatoma right side. Slow increase in size, with impulse on coughing. Twitching of left face, arm, and leg. Vomiting. Much improvement in 2 months. Child left hospital with tumour protected by gutta-percha shield. Soon became ill, and was admitted into St. Bartholomew's with meningitis. Death 24 hours later.
skull as we meet with them in an adult can take place in its typical form in an infant, but, on the other hand, there are forms of fracture special to the young skull. There are fractures of the infant's skull, formerly described by Mr. Syme, which would have been undetected (the bone after breaking the adjacent dura and severely lacerating the brain having sprung back in place) had not actual brain matter been found in the wound, beneath the scalp, or in the pus
OF THE CEREBRAL MEMBRANES 35
(as I saw in one case) evacuated from the suppurating hematoma, which formed over it."
The following case, which was under the care of Dr. Bastian in 1902, is an example of a large traumatic encephalocele occurring later in childhood, and illustrates a method of
Fig. 19. — Simple fracture of skull in an infant. (Gocllee, 1884.)
Female, aet. 8 months. Fell 14 feet on to head. Large haematoma right parietal region. Temp. 101°. Pulse 140. Left hemiplegia. Twitching movements of right limbs. Tumour at first diminished, but then began to increase in size. Pulsation noticed loth day. Occipital bedsore formed : sepsis, death. Autopsy,.^ The tumour communicated throueh damaged dura and cortex with ventricle.
treating hernia cerebri.
A boy aged four years
fell twenty-two feet out of window. In falling it was thought he struck the left side of the head against a projecting window ledge. He was unconscious for four days. A large non-pulsating tumour formed over the left parietal region. Some three and a half weeks after he had received
36 SOME POINTS IN THE SURGERY
the injury he was brought to London and I saw him with Dr. Bastian. He had right hemiplegia, complete aphasia, and some paresis of the left third nerve. The tumour was slowly increasing in size. Operation was decided on. A large
Fig. 20. — Traumatic meningocele. (Golding Bird, Guy'i Hasp. Reports, 1889.)
Female, aged 7 months. Fell on floor 6 days before being brought to Hospital. A small swelling appeared in right parietal region immediately after injury. On admission there was a large, tense, pulsatory swelling over right side of head. The swelling was aspirated, blood and cerebro-spinal fluid being removed. It completely- disappeared in 3 weeks.
Bior other cases see Lucas, Guy's Hosp. Reports, 1876, 1878, 1881, 1884, and Silcock, C/iem. Soc. Trans, vol. xxi.
scalp flap was thrown downwards, exposing a mass of brain substance, which was protruding through a fracture of the parietal bone. The break of the parietal bone extended downwards and forwards obliquely from near the middle of the sagittal suture. The edges were so clean that they might have been cut with a knife, and
OF THE CEREBRAL MEMBRANES i^j
were separated about one-third of an inch. The fragment of parietal bone in front of the fracture
-^^IS
Fig. 21. — Fracture of right frontal bone in a new-born infant, fracture extending into orbit. (Von Bergmann, after Bruns.)
was removed by disarticulation at the sagittal and coronal sutures. A corresponding piece of
Fig. 22. — I. Traumatic meningocele before operation. (Dembowski, Saivicki' s
Essay in Chipault.) z. Same case after operation. Male, aged i6 months. Three months before being seen fell on head. Tumour appeared and grew rapidly, so as to occupy right half of skull. Operation. — Part of frontal and most of parietal bone depressed and almost detached. The posterior part of parietal displaced backwards and outwards. Through the gap in the. parietal bone the hernia cerebri protruded. Bone replaced. Gap closed by periosteal flap. Patient recovered.
bone behind the fracture was removed. It was then seen that the hernial mass of cerebral tissue protruded between the sharp edges of a rent in
38 SOME POINTS IN THE SURGERY
the dura corresponding in position and extent to the fracture in the bone. The opening in the dura was enlarged by incisions made at right angles to the tear, to the size of the aperture made in the skull. Pulsation in the extra- cranial mass at once recommenced. No further
Fig. 23. — Diagram of fracture of skull in Dr. Bastian's case of traumatic encephalocele.
The bone enclosed by the dotted lines and by the frontal and sagittal sutures was removed at the operation.
nipping of the junction of brain and hernia could then take place. The brain had been damaged to the depth of an inch along the line of fracture. The scalp flap was replaced. The patient made a good recovery ; the hernia soon disappeared. Two years later Dr. Saunders of Pembroke Dock wrote to Dr. Bastian : " Speech gradually im- proved and now almost perfect except for some
OF THE CEREBRAL MEMBRANES
39
slurring when excited. Power over left leg almost completely restored, of arm only partially — no use of hand."
Lumbar Puncture in Injury to Brain and in Apoplexy.
This seems a fitting place to point out the great value of lumbar puncture in traumatic lacerations of the cerebral substance when the patient passes into the stage of cerebral irrita- tion. A jockey, twenty-one years of age, was thrown from a horse. There was no fracture of the skull, but he was unconscious for ten days. The right arm was paralysed, and there was left ophthalmoplegia. I saw the patient with Dr. Ferrier. From unconsciousness he passed into a state of restlessness, irritability, and sleep- lessness. By lumbar puncture 2.\ to 3 oz. of red-stained cerebro-spinal fluid was drawn off; on each occasion quiet sleep was obtained after- wards for four hours. The man made a good recovery. The question arises whether in some cases of ordinary apoplexy the pressure of the clot and serum on the nervous centres might not be relieved with advantage by lumbar puncture. In extra-dural haemorrhage, from injury to the meningeal artery or a venous sinus,
40 SOME POINTS IN THE SURGERY
the fluid withdrawn by lumbar puncture is clear, while in cerebral laceration or subdural haemor- rhage it is blood-stained.
Pathology of Infection.
Infective processes may extend from a focus of disease outside the skull to the interior of the skull by —
1. The disease affecting the bone and a visible track of bone disease forming a way of com- munication.
2. Extending through a pre-formed channel, such as a foramen or canal for the passage of vessel or nerve.
3. Making its way through a congenital defect in the ossification of the bone.
4. Extending along one of the processes of dura mater, which in certain situations dip into the bone.
5. Entering the circulation.
In some injuries infective material is intro- duced directly by the injury into the interior of the skull, a " stab culture " being in fact made, and the natural resistance to penetration being directly and abruptly broken down. This is the sole difference in the pathology of the intra-cranial complications of injury and disease.
OF THE CEREBRAL MEMBRANES 41
The infective process more or less rapidly spreads within the skull from the spot where the dura has been brought into contact with infective material.
Extra-Dura! Suppuration.
At the spot where it has come into contact with the pus the dura becomes inflamed and extra-dural suppuration occurs.
This is the first stage of intra -cranial infection. The resistance of the dura mater to the further progress of the infection may be great and prolonged. The effects are then limited to the formation of a more or less considerable localised extra-dural abscess. Or, the dura may be softened and perforated forth- with, and only a few drops of pus may collect external to it.
The following case well illustrates the re- sistance of the dura : —
A man was admitted to hospital on February 2nd with ear disease, which had already extended beyond the limits of the temporal bone. This was clearly shown by the fact that, on irrigation of the ear until it was quite free from pus, the pus rapidly re-filled the entire auditory canal and overflowed into the concha. The mastoid operation was done on March 12th.
42 SOME POINTS IN THE SURGERY
The following day a fistulous track was noticed. This was enlarged with a sharp spoon. Recur- rence of symptoms took place. On April iith a free opening was made by chiselling away sufficient bone, thus freely opening the extra- dural abscess. From that time recovery was uninterrupted (Bergmann). Pus must have been in contact w4th the dura for at least nine weeks (probably longer), but no perforation of the dura took place.
At the post-mortem examination of a man who- had died from acute meningitis within forty-eight hours of the onset of illness, the temporal bones, while the dura was still in place, looked normal, but on removing the dura the roof of the left tympanum looked a little darker than that of the right. It was not perforated nor carious, but a tiny thrombosed vein was seen to issue from it. On breaking through the tegmen the tympanum was seen to be filled with a solid mass of granulation tissue, which could be picked out all in one piece with forceps. The long process of the incus was necrotic. The tympanic membrane appeared as if about to slough. There had been no otorrhcea during life.
It is easy to understand how vascular infec- tion could follow from such a condition.
OF THE CEREBRAL MEMBRANES 43
When the arachnoid is traversed the infection reaches the sub - arachnoid and the pia, and either a locaHsed or a diffused inflammation resuks. Why the inflammation should in one case be Hmited to a small or even a minute area and in another should spread rapidly over the whole surface is not difficult to understand. The answer is that it depends on the nature and virulence of the infection, just as a local infection of the hand may end in a local abscess or start a cellulitis which spreads in twenty-four hours over the whole limb. The sub-arachnoid tissue may then, like the areolar tissue of the arm, be involved in either a local infection or in a rapidly spreading cellulitis.
Infection of Arachnoid and Pia Mater.
It has long been known that effusion of serum is one of the first effects of infective irritation of the pleura, the peritoneum, the joints, and the cellular tissue, but until the publication of Quincke's papers on lumbar puncture in 1891, and on meningitis serosa in 1893, it was scarcely appreciated that the phenomena within the skull were just the same, and the term meningitis was not con- sidered applicable to any case in which purulent
44 SOME POINTS IN THE SURGERY
or at least sero - purulent effusion was not obviously present within the meninges.
Quite early, even before meningeal were distinguished from cerebral lesions, cases had been observed and recorded in which no gross
Fig. 24. — Lumbar puncture. (Chipault.) A. Method of Quincke. B. Method of Marfan. C. Method of Chipault. The simplest plan seems to be to puncture between the 4th and 5th lumbar vertebrae. The space between these vertebras corresponds to the highest part of the iliac crests. Chipault, however, maintains that the lumbo-sacral space is prefer- able since it is the largest, is surrounded by good landmarks, and is opposite the terminal enlargement of the dural sheath.
intra-cranial lesion was found after death, though the symptoms had seemed to point conclusively to its presence. That great pioneer of cerebral pathology, Thomas Willis, 1645, in relating such a case, wrote : " Wherefore in this case no other explanation seems possible but that the vital spirits within the brain were put to flight, or, so to speak, extinguished by particles
OF THE CEREBRAL MEMBRANES 45
of a malignant or narcotic or otherwise noxious nature, so that the movement of the heart, like the main - spring of a clock, being arrested, all other functions, deprived of their source of energy, immediately and absolutely ceased."
Even now suppurative meningitis is looked
Fig. 25. — Lumbar puncture. (TufRer.)
A line joining the highest part of the iliac crests bisects , the space between the 4th and 5th lumbar vertebrae. This is the best guide in lumbar puncture. A fine hollow needle, 7 cm. long, is required.
upon as a mortal disease, and some special explanation has been sought of the recovery of some patients presenting apparently un- equivocal evidence of this lesion, and of the absence of any appreciable lesion after death in other cases with quite similar symptoms ; after the vague terms pseudo-meningitis and menin- gism had been used to designate such cases, meningitis serosa was welcomed as a new fact
46 SOME POINTS IN THE SURGERY
in morbid anatomy affording an explanation of these clinical phenomena.
Even while still without the dura a focus of infection may determine an excess of fluid within the skull, just as disease of a rib may excite serous effusion in the pleura, or disease of the tibia may bring about an effusion in the knee-joint.
I have had many opportunities of observing that clear fluid collects in the subdural cavity when the dura becomes inflamed by the presence external to it of pus. This is what we should expect. Elsewhere, e.g. in the areolar tissue of a limb, an inflammatory focus is always sur- rounded by a zone of tissue tense and sodden wdth serum, and, indeed, before the pus becomes visible the site of the coming abscess is the site of serous effusion or oedema. The same sequence of events occurs in the cerebral meninges. In the subdural space, which is not divided into compartments, a pond of fluid will form, while in the sub-arachnoid space of the cortex the tissue, under normal circumstances being tra- versed by countless rivulets of fluid (like marshy ground), will become cedematous and swollen.
The following cases show the symptoms pro- duced by meningeal effusion and the beneficial effect of lumbar puncture. Probably in some
OF THE CEREBRAL MEMBRANES 47
cases the removal of fluid under pressure from the intra-dural spaces will prevent the occurrence of suppurative meningitis : — -
Case I. — J. C, aet. 19, female. — Admitted with R. chronic otorrhoea and large mass of breaking-down glands on the right side of the neck.
The radical mastoid operation was done, and all the
Fig. 26. — Sub-arachnoid space between the convohitions. (Key and Retzius.)
The sub-arachnoid space is here broken up into a number of channels, through which the cerebro-spinal fluid finds its way. At each systole the fluid in the ventricles is pumped into the spinal theca and into the great cisterns at the base of the brain. It escapes from the spinal theca along the sheaths of the nerves, and from the cisterna it passes upwards in the sub-arachnoid rivulets between the con- volutions to reach the Pacchionian bodies and the superior longitudinal sinus.
affected
glands
in the neck were removed. The
glandular disease was tubercular.
The temperature for a few days was normal and the pulse quick. The condition of the patient then changed. The temperature rose, the pulse became slower, sickness occurred, and she lay in bed in an apathetic state, with eyes closed and mouth open. Lumbar puncture was done, and with the withdrawal
48 SOME POINTS IN THE SURGERY
of 2 oz. of fluid all the symptoms disappeared. A few days later the whole group of serious symptoms returned, and were again relieved by lumbar puncture. In another week she was again in a serious condition, and, in addition to the other signs, there was now loss of the sense of smell and commencing optic neuritis. She was given chloroform, and an incision was made in the dura over the tegmen tympani, which had been removed at the first operation. This incision gave exit to pus and gas from a localised abscess in the arachnoid cavity. The patient made a good recovery.
Case 2. — A boy, aged twelve, at school, had a cold on a certain Friday ; on Saturday and Sunday he com- plained of pain in both ears. On Monday evening I saw him. He was drowsy, temperature 104°, there was oedema over the left mastoid, both tympanic mem- branes were bulging. There was no discharge from either side.
The same evening the right drum was incised, and the operation for acute mastoid suppuration was done on the left side. The lateral sinus was exposed in this operation for i inch, part of which was of a pink colour and inflamed.
The next morning patient was little if at all better, and during the afternoon he was drowsy, complained of headache, was restless and was sick. The temperature was 102°, the pulse came down to 80, the pupils were somewhat dilated and reacted slowly, tenderness was manifest over the right mastoid, and the optic discs were pinker than normal. The same evening an operation was performed on the right mastoid of an exactly similar character to that which had been carried out on the left side ; every cell of the pneumatic mastoid was full of pus, and the dura over the lateral
OF THE CEREBRAL MEMBRANES 49
sinus and beyond was red. Lumbar puncture was now done, and 2 oz. of fluid under pressure were withdrawn. The next morning there was no headache, no sickness, no drowsiness, and the pupils reacted well. Convales- cence was rapid, and on both sides practically perfect hearing was regained.
Elusion in the pleura or peritoneum gives
Fig. 27. — sketch of complete mastoid operation.
In some acute cases tlie dura when exposed is found of a bright red colour. In the figure the shaded areas over the antrum and attic, and over the sigmoid sinus, indicate the usual sites of inflammation of the dura. (The complete mastoid opera- tion is only very rarely required in acute cases ; the figure of the complete mastoid operation is used because it shows clearly the region of the tegmen.) Meningitis serosa may be induced by the inflamed dura, and can be relieved by lumbar puncture.
rise to physical signs by which its presence can be detected quite independently of any symptoms it may cause. Within the skull we are almost entirely dependent upon symptoms for our dia- gnosis, and it may be helpful to consider what was accomplished and what was missed when the diagnosis of diseases of the chest was unassisted
so SOME POINTS IN THE SURGERY
by the means of physical examination now available.
Of late years our diagnosis of diseases of the brain and meninges has been much assisted by the practice of lumbar puncture. This gives us certain and valuable information respecting the nature of the fluid in the meningeal spaces, but does not afford equally certain evidence as to its amount and distribution. It should not be forgotten that there is no direct gross com- munication between the subdural and the sub- arachnoid space ; the fluid obtained by lumbar puncture may be derived from the one or from the other, and we cannot tell from which.
In the skull, as elsewhere, the disease may be arrested in the serous stage, or other inflamma- tory lesions may arise.
Inflammation of the pia mater is neither clinically nor anatomically distinguishable from inflammation of the arachnoid, but either the subdural or the sub-arachnoid space may be the exclusive or the chief seat of the inflam- matory exudation, a fact not without significance in the treatment.
Diffuse suppuration in the subdural cavity is uncommon except as the result of direct infec- tion by injury, but I have seen it occur in in- fluenza.
i
OF THE CEREBRAL MEMBRANES 51
Certain varieties of pus seem to have but little tendency to perforate serous membranes (such as the arachnoid or peritoneum) and but little irritant effect upon them. The pus may be spread out in a sheet of greater or less thick-
Fig. 28.
Fig. 29.
Fig. 28. — Arrangement of membranes around spinal cord. (Testut.) The wide dark area is the subdural space. The light area around the cord is the sub-arachnoid space. In the spinal canal the subdural is normally an actual space ; in the cranial cavity it is a potential space.
Fig. 29." — Arrangement of arachnoid in the region of the cauda equina. (Charpy.) In lumbar puncture the sub-arachnoid cavity is usually tapped. The fluid, how- ever, in meningitis serosa may occupy the subdural space. The arachnoid will then recede from the dura, these membranes being separated by an interval wider than normal. Thus in some cases fluid may be withdrawn by the needle from the subdural space.
ness over a certain limited area of the visceral arachnoid, though there may be no visible adhesions present which have checked its spread.
In a v^oman, age forty-nine years, the subject of chronic otorrhoea, who died after three weeks' acute illness, a thick layer of yellow pus covered
52 SOME POINTS IN THE SURGERY
the visceral arachnoid exactly over the left frontal and parietal lobes.
This is quite comparable to what not unfre- quently occurs in the peritoneum and pleura. It sometimes happens that in peritonitis the exudation is apparently limited to a certain area, though there are no adhesions present, and that when the pus is wiped off the membrane under- neath it looks unaltered.
The same appearance is sometimes noticed in pleurisy with pneumonia.
When pus slowly makes its way to a serous membrane adhesion of the two layers takes place, and if the infection proceeds further it traverses both layers without causing general infection of the cavity. In the pleura and peri- toneum the serous surfaces are kept in constant lateral movement, and infective material is rubbed over a considerable area before adhesions can take place.
In the arachnoid the mechanical conditions are different, there being no appreciable lateral movement. The two layers therefore can, and commonly do, become adherent before any con- siderable area is affected, hence any collection of pus between dura and pia is commonly quite small in amount.
When the infection has traversed both layers
OF THE CEREBRAL MEMBRANES 53
of the arachnoid the sub-arachnoid space and the pia are reached ; either a locaHsed or a dif- fused inflammation may result here, or, forming a mere track through the pia, the infection may- pass on into the cerebral substance.
Varieties of Meningitis.
All intra-cranial affections, accompanied by delirium, were formerly confounded together under the name " phrenitis or phrenzy," and we doubtless now include under the term meningitis many affections which though attended in their terminal stages by inflammation of the meninges will, as our knowledge of cerebral surgery and pathology advances, nevertheless be shown to be quite distinct diseases, exactly as abdominal surgery has shown us that diffuse suppurative peritonitis is but a terminal stage in several distinct affec- tions, most of which can be recognised and arrested before that dangerous stage is reached.
For the present the surgeon classifies menin- gitis as tubercular and non-tubercular; and recog- nises that in each variety the pathological effusion may be serous or suppurative, localised or diffused.
The anatomical distinction between tuber- cular and non- tubercular meningitis is quite clear, and the diagnosis can, moreover, be usually made clinically. The various forms of
54 SOME POINTS IN THE SURGERY
non- tubercular meningeal affection cannot be distinguished without bacteriological examina- tion, though some points of difference both in the symptoms observed and in the lesions found have been noticed. Epidemic cerebro-spinal meningitis and the posterior basal meningitis of children, which are possibly the same disease, are the two forms best differentiated.
Sympto?ns and Diagnosis.
There is no one pathognomonic symptom of meningitis. The symptoms which arise are not the direct result of the meningeal lesion, but are largely due to the influence exercised by the in- flamed meninges on the brain-substance beneath, the symptomatology being, as the French writers express it, a borrowed symptomatology.
Until quite recently we had to depend for diagnosis upon symptoms alone, but within the last few years the practice of lumbar puncture has given us a valuable though indirect means of physical examination.
Though most, if not all, of the symptoms met with in cases of meningitis are also met with under other conditions, yet clinical experi- ence has taught us that a particular grouping of certain symptoms is usually associated with manifest meningeal lesions.
OF THE CEREBRAL MEMBRANES S5
In seeking to define the relation of symptoms to lesions, and to apportion to each symptom its exact diagnostic significance, we meet, as an initial difficulty, with the fact that on the one hand the symptoms are sometimes met with without demonstrable meningeal lesion, and on the other hand that gross meningeal lesions are sometimes found post-mortem which had been quite unsuspected during life.
Our present knowledge seems to show that the symptoms most directly referable to the meningeal inflammation are the three symptoms, headache, vomiting, and constipation.
These are regarded as the cardinal symptoms of meningitis ; the headache is severe and per- sistent, the vomiting apparently purposeless and not accompanied by nausea, and the constipa- tion obstinate, resisting purgatives, and neither accompanied by abdominal distension nor asso- ciated with abdominal pain.
These three symptoms appear to depend mainly upon intra-cranial effxision, whereby the pressure relations are altered and the normal power of adjustment of the intra-cranial tension impaired, but in some degree also upon absorp- tion of toxins.
Tension of fibrous tissues gives rise to pain. Incision of the dura is painful. The headache
56 SOME POINTS IN THE SURGERY
of meningitis is comparable to the eyeache of glaucoma ; both are due to tension of a fibrous envelope enclosing a nervous tissue.
With these three cardinal symptoms are associated two other groups of symptoms : —
A. Symptoms, such as fever and impaired nutrition, resulting from general infection, and depending more upon the variety of the infec- tion than upon the distribution or degree of the meningeal lesions.
B. Symptoms which are the clinical expres- sion, not of the meningeal lesions, but of the irritation of the subjacent cortex. These vary with the nature, degree, and distribution of the meningeal lesions, and with the cortical irrita- bility of the individual.
Most of the symptoms met with in cases of meningitis belong to this group. They are —
1. Psychic symptoms. — Irritability. Change of disposition.
2. Motor symptoms. — Convulsions. Kernig's sign. Exaggeration of reflexes.
3. Sensory symptoms. — Photophobia. Hyper- esthesia.
4. Sympathetic vaso-motor disturbances. — Tache cerebrale.
5. Finally symptoms due to exhaustion and death of ?7erve ceils. — Paralyses. Anesthesia. Coma.
OF THE CEREBRAL MEMBRANES c^j
This group of symptoms being, as I have already said, the clinical expression of irritation of the cerebral cortex, it is easy to understand that meningitis is by no means the only condition capable of so affecting the cerebral cortex as to give rise to them.
An actual lesion of the brain substance, the absorption of toxic substances circulating in the blood, and that still unexplained disturbance of innervation known as hysteria may all give rise to symptoms more or less closely resembling those associated with meningitis. An absent knee-jerk, a Babinski reflex, or early changes in the optic disc w^ould be pathognomonic of an intra-cranial inflammation in a case in which the delirium and fever might have led to the sus- picion of typhoid fever.
The diagnosis between these various con- ditions is sometimes difficult, and occasion- ally baffles even an attentive and experienced observer.
Examination of the cerebro-spinal fluid ob- tained by lumbar puncture affords information as to —
1. The intra-dural pressure.
2. The chemical composition of the fluid.
3. Certain physical properties, such as the freezing point.
58 SOME POINTS IN THE SURGERY
4. The cells contained therein.
5. The bacteriology.
6. The permeability of the meninges to chemical substances introduced into the blood.
Of these the cytological examination is, at present at all events, the most important.
Normally, the cerebro- spinal fluid contains few or no cellular elements, but in inflammation of the meninges the cellular elements are abun- dant ; either leucocytes or poly-nuclear plasma cells may predominate. The general indications are that leucocytosis points to a slow or subsiding inflammatory process, and abundance of poly- nuclear cells to an acute, active, and intense inflammation.
Systematic examination of the cerebro-spinal fluid obtained by lumbar puncture in a series of cases of acute diseases, whether symptoms of meningitis were present or not, has shown that —
1. Modifications of the cerebro-spinal fluid and symptoms of meningitis may be present together.
2. There may be symptoms of meningitis without modification of the cerebro-spinal fluid ; and
3. There may be modification of the cerebro- spinal fluid without symptoms of meningitis.
OF THE CEREBRAL MEMBRANES 59
Therefore it seems that there is no necessary and constant correlation between the symptoms commonly accepted as indicating meningitis, the lesions present, and the condition of the cerebro-spinal fluid.
Our knowledge of the pathological physio- logy of the symptoms is not yet sufficiently com- plete to enable us to satisfactorily explain these apparent discrepancies.
The diagnosis is then in most instances still a matter of ordinary clinical observation and judgment ; we have to determine whether the patient's symptoms are due to meningitis or to some other condition, and if we decide upon meningitis, what is its variety and extent.
The conditions most frequently giving rise to symptoms closely resembling meningitis are hysteria, organic disease of the brain, and the meningeal irritation occurring in the course of certain acute specific diseases, notably pneumonia and enteric fever.
Hysteria sometimes finds expression in symp- toms having some resemblance to those of meningitis, but a shrewd observer is not often deceived thereby ; the disease indeed assumes the mask of meningitis, but it is a mask at once incomplete and exaggerated, some symptoms being wanting, others caricatured. Other signs
6o SOME POINTS IN THE SURGERY
of hysteria are present, and the general condition of the patient does not correspond to the gravity of the symptoms.
It must never be forgotten that the neurotic temperament affords no protection against organic disease, and that the two conditions may co-exist.
The question of diagnosis between meningitis and organic disease of the brain itself chiefly arises when localisation symptoms are present. Though bearing a general resemblance to those of brain disease, these symptoms when due to meningitis are usually to be distinguished by being transient, irregular, and variable in their onset, by the outlined rather than complete, the less pure and more diffused character of their clinical ex- pression, and by their acute or sub-acute evolution.
The meningeal symptoms due to acute specific diseases very closely resemble those of suppurative meningitis, but attention to the history and the evolution of the disease usually soon enables the diagnosis to be made. In such cases the sugges- tion has been made, and seems probable, that the symptoms are due to irritation of the brain by the specific toxins of the disease.
We are usually able to diagnose clinically (i) tuberculous meningitis, (2) non-tuberculous acute meningitis, (3) the posterior basal meningitis of infants.
OF THE CEREBRAL MEMBRANES 6i
In tuberculous meningitis the onset is in- sidious, and the evolution sub-acute rather than acute ; a period of apparent remission divides the disease into the three stages so well described long years ago by Robert Whytt.
Non-tuberculous general suppurative menin- gitis has an acute onset and rapid course.
The posterior basal meningitis of infants be- gins as an acute disease, but is less rapid in its course than general suppurative meningitis, and retraction of the head is a very prominent sign.
Posterior basal meningitis is a disease of the first year of life. Tubercular meningitis is most common from the second to the seventh year (Mery and Armand Delille, 1905). While optic neuritis depends in some measure upon the site of the primary meningeal lesions, it may be affirmed to be, as a rule, a late sign in tuber- culous meningitis and an early one in suppura- tive meningitis. Tubercle of the choroid when seen is pathognomonic of tuberculous meningitis.
All forms of meningitis, if unrelieved by art, tend to cause death.
Recovery is, however, undoubtedly possible ; it has been inferred (i) from post-mortem evidence after death from other causes, (2) from the fact of recovery after clinical symptoms of meningitis, and, lastly, from the recovery of
62 SOME POINTS IN THE SURGERY
patients with a local suppurative disease and marked symptoms of meningitis after an opera- tion limited to the local disease.
We are, therefore, justified in saying that the meninges are not destitute of recuperative power, but, like the peritoneum, are quite capable of dealing with a certain amount of infective material, if the further supply is cut off.
Treatment.
Paracelsus (circa 1490- 1 541) held that " Nature was sufficient for the cure of most diseases ; art had only to interfere when the in- ternal physician, the man himself, was tired or incapable. Then some remedy had to be intro- duced which should be antagonistic, not to the disease in a physical sense, but to the spiritual seed of the disease." These remedies were termed " arcana."
Antitoxins, and substances that appear to raise the resisting power of the individual to certain infective processes, are remedies fulfilling in some degree the ideal of Paracelsus ; but such remedies have, for most diseases, still to be found.
By removing a focus of disease, or by giving free exit to infective products, surgery — though essentially a remedy " opposed to disease in a
OF THE CEREBRAL MEMBRANES 63
physical sense " — has afforded us the means of arresting many infective diseases which other- wise must destroy life ; and we must now con- sider whether surgical intervention can help us in treating meningitis, for we have no other remedy.
From this point of view we may divide cases of meningitis into two great groups — (i) those due to extension of a local infective process, and (2) those due to a general infection carried by the blood stream.
In the first group it may at once be said that the main surgical indication is the removal of the local disease, and this surely should have been carried out before the meningitis had arisen.
The importance of effectively dealing with temporal bone suppuration is now fairly well known, and the operation for its relief has slowly become appreciated, though retrograde papers on the subject continue to appear ; but in this country the radical treatment of frontal and ethmoidal suppurative disease is not always thoroughly carried out. Even acute cases are sometimes left till the patient has developed meningitis, while in chronic cases the danger of the disease is not recognised, and it is therefore apt to be left unremoved.
Chronic suppuration in the accessory cavities of the nose is exactly comparable to temporal
64 SOME POINTS IN THE SURGERY
bone suppuration, and like it should be treated strictly in accordance with the ordinary sur- gical principles applicable to the treatment of diseased bone wherever situated — namely, com- plete ablation.
Acute frontal sinus suppuration, and especially acute necrosis of the frontal bone, is, if possible, even more dangerous to life than acute temporal bone suppuration ; urgent symptoms rapidly develop, and operation is imperative. I was recently called in consultation to such a case, in which the patient's life was saved by immediate operation.
The intra-meatal aural specialist of a past generation was content to flit helplessly about his chosen canal in the manifest presence of lethal complications. Is it or is it not true that the intra-nasal specialist of the present day, with some brilliant exceptions, may at times be un- duly influenced by the traditions of his otological kinsmen instead of following the teaching of Killian and facing the operation for the com- plete removal of the disease .?
Operation for the cure of frontal and ethmoidal suppuration is now regarded in this country much in the same way as was the mastoid opera- tion twenty years ago ; hence the fatal frontal sinus cases so surprisingly frankly reported from
OF THE CEREBRAL MEMBRANES 65
time to time in our medical journals, as if the disease was inevitably mortal, and as if the lesson
Fig. 30. — The relation of the frontal sinuses to the frontal lobes. (Killian.)
The frontal sinus is opposite the base of the corresponding first or upper frontal convolution. In a large sinus the temporal recess may extend as far as the second or middle frontal convolution. An abscess of the brain arising from disease of the frontal sinuses is, as a rule, located in the anterior inferior part of the superior frontal gyrus.
Fig. 31. — The relation of the accessory sinuses to the base of the skull 5 viewed from the cranial cavity. (Killian.)
The frontal, ethmoidal, and sphenoidal sinuses are exposed. With the exception of the posterior two-thirds of the sphenoidal sinuses, all the accessory sinuses abutting on the cranial cavity lie in the region of the anterior cranial fossae.
that danger attends delay and imperfect operation had yet to be learnt.
F
66 SOME POINTS IN THE SURGERY
When the opportunity for a preventive opera- tion has gone by, and meningitis has resulted from a local cranial lesion, the chances of recovery are naturally much lessened, but even then surgery is not helpless. Many cases are recorded in which recovery has followed the removal of the local disease by an operation not opening the dura, even though symptoms of meningitis were already present.
The following is an instance of such a case : —
In April 1901 I saw with Mr. Tyrrell a boy, aged nine years, who had just returned from Paris.
There was a clear history of tubercle in his family.
Three years previously tubercular glands had been removed from both sides of his neck. A slight watery discharge from the right ear had been noticed a year before the operation on the neck, and had continued without inter- mission.
Six weeks before I saw the patient he had complained of pain in the head on running. During the two preceding weeks he had had severe pain in the head at intervals, with vomit- ing. Squint of the right eye had been noticed for a week.
OF THE CEREBRAL MEMBRANES 67
When seen he complained of constant pain in the head with exacerbations. The tempera-
c =
too (U
.2 -°
a o I f*
ture was gg F. ; the tongue was furred. There was a slight watery discharge from the right
68 SOME POINTS IN THE SURGERY
tympanum coming through a large perforation in the anterior part of the membrane. The
OJ o
so
right external rectus was paralysed. No optic neuritis.
OF THE CEREBRAL MEMBRANES 69
Complete mastoid operation forthwith. The dura covering the tegmen and a considerable area of the dura of the posterior fossa, in-
FiG. 34. — Result six weeks after the K.1I11.111 operation tor frontal sinus suppuration.
Miss D., age 27 years. When seen the right frontal sinus was obviously enlarged ; it extended upwards on the forehead for some distance and outwards, with diminishing vertical extent, as far as the external angular process. A streak of pus could be seen in the middle meatus. The antrum of Highmore was translucent, but the right frontal sinus was absolutely opaque to transmitted light.
Three years previously she had been struck in the right frontal region, and for two years had had constant aching in that situation and discharge, usually watery and without odour, from the right nostril.
Operation. — The usual vertical incision was made, with another running along the orbital margin of the eyebrow instead of along the line of the hair, where it sub- sequently causes an unsightly mark. The outer table of the skull was raised up with the forehead flap (Durante's osteoplastic flap). The sinus was full of granula- tion polypi and pus, and on displacing the tendon of the superior oblique and removing the roof of the orbit, the same condition was found in the ethmoidal cells and in the sphenoidal sinus. The disease was entirely ablated, and the various cavities were thrown into one by removing the bony partitions between them 5 this was swabbed out with chloride of zinc solution (40 grs. to i oz.). The middle turbinated bone was removed. The skin edges were then accurately sutured, and drainage provided for through the right nostril. Convalescence was rapid and complete. The patient complained of diplopia for two weeks.
Even at Freiburg patients do not escape without a slight depression in the forehead after the Killian operation by the master himself. To obviate this I made use of Durante's osteoplastic flap. This, of course, cannot be employed unless the operator can ensure complete eradication of the disease. Making the horizontal incision below, instead of through the hair of the eyebrow is, I think, also a great improve- ment. The cedema of the right upper eyelid had not quite subsided when the photograph was taken. The vertical incision can just be seen in the full-sized photograph. There is no flattening over the operated sinus.
eluding the The mastoid.
sinus wall, was granulating.
except the outer shell, was destroyed by granulation tissue, which was found by Mr. Shattock to be tubercular. The
70 SOME POINTS IN THE SURGERY
granulating dura was painted with absolute phenol.
The patient made a complete recovery. In a week the headache had ceased, and in three and a half months the sixth nerve had recovered its functional activity.
This case also illustrates the futility of removing tubercular glands of the neck and leaving mastoid disease untouched.
In such cases there must always be some doubt whether anything more than serous effusion had occurred within the dura.
When cerebral symptoms persist after the removal of local disease of the cranium the dura should be opened by an extension of the local operation, and further procedure guided by the condition found.
We have now to consider what should be done when meningitis has occurred otherwise than as a complication of some local cranial lesion.
Tuberculous Meningitis.
So fatal is this disease that even the bare possibility of recovery without permanent damage to the brain has been doubted.
It is true that certain cases have been reported as recoveries, but of these some may well have
OF THE CEREBRAL MEMBRANES 71
been localised cerebral tubercle, and in others the observer may have been deceived by a toxsemic meningitis.
The results of opening the abdomen in tuber- culous peritonitis have led to the hope that something would be accomplished by opening the skull in cases of tuberculous meningitis, but the few efforts that have been made in that direction have afforded but little encouragement.
Must we accept the results hitherto obtained as final, and conclude that no benefit is to be derived from intervention in these cases ? Before accepting defeat we should consider whether the measures hitherto adopted are those most likely to prove successful.
In operating for tuberculous peritonitis we neither remove the disease nor the source of infection, and it is by no means clear in what way the modification in the evolution of the disease is brought about, but it certainly seems that exposure of the disease and drainage of the inflammatory exudation must be the main factors. The operation is simple and easy of execution.
A problem of much greater complexity con- fronts the surgeon who seeks to deal with tuberculous meningitis in the same way. To obtain direct access to the disease and to drain the morbid exudation it would be necessary to
72 SOME POINTS IN THE SURGERY
expose and open the Sylvian lake, and also to tap the ventricles, for the tubercular disease lies in the sub-arachnoid space, mostly in the Sylvian fissure, and in the choroid plexus of the ventricles. Irrigation of the ventricles and sub - arachnoid space would be equally necessary, and these cavities cannot be irrigated the one from the other. Chipault in 1895 suggested that instead of
Fig. 35. — Miliary tuberculosis of pia covering the convexity of the brain. (Lebert.)
merely opening the arachnoid, the Sylvian lake on each side should be opened. Writing again in 1904 he says that though several surgeons have accepted his views there is as yet no practical confirmation of the value of the suggestion.
Some of the operations hitherto performed have, however, been limited to opening the sub- dural space ; consequently direct access to the disease and direct drainage have not been obtained ;
OF THE CEREBRAL MEMBRANES ^'},
the sub-arachnoid space, where the disease lies, being left untouched. This procedure is merely- opening a neighbouring cavity : opening the pleura could have little influence on disease in the pericardium.
Until more complete operations have been performed in an earlier stage of the disease we cannot say whether tuberculous meningitis is likely to be modified in the same favourable manner by operation as is tuberculous peritonitis.
General Suppurative Meningitis.
The indications for treatment are to suppress the source of infection, to give free exit to the suppurative exudation and to combat the disease with the appropriate anti-toxin.
Some remarkable and encouraging results of surgical intervention in this desperate disease have been already published. Kiimmel relates the following case : —
A man, aged thirty -three years, fell, striking his occiput ; for two days he felt pretty well, then had gradually increasing headache, especially occipital, and vertigo, together with tinnitus and deafness in the right ear. There had been a watery discharge from the nose the day after the accident. On the sixth day he was admitted to hospital as the symptoms had increased in severity. He was then still able to walk ; he complained of frontal and occipital headache. No paralysis nor
74
SOME POINTS IN THE SURGERY
eye- changes were observed. There was right-sided deafness, but no visible lesion of tympanic membrane, Cerebro-spinal fluid was discharged through the nose. On the third day after admission he became torpid, and his temperature rose to 104 ; next day there was com- plete unconsciousness, with marked rigidity of neck and squint. Lumbar puncture let out 20 cc. of purulent
Fig. 36. — General suppurative meningitis. (Cruveilhier.)
In the original beautiful drawing greenish pus is seen everywhere beneath the arachnoid ; in the sulci, and over the middle part of the upper surface of the cerebellum.
The stream of fluid passing upwards from the cisternae at the base through the sulci of the convexity to the Pacchionian bodies explains the rapidity with which pus spreads over the convexity in cases of fulminating meningitis. To relieve this condition drainage of the sub-arachnoid space is necessary.
fluid under pressure of 235 mm. Hg. Profoundly unconscious all the day, the lumbar puncture gave no relief; urine passed under him. Following day (fifth after admission) apparently moribund.
Operation as a forlorn hope. Opening made in the bone as large as a five-shilling piece on each side of the middle line low down in occipital region. Dura under pressure. Dura excised over whole extent of
OF THE CEREBRAL MEMBRANES 75
bone opening. Arachnoid deeply congested, only a small quantity of sero-purulent fluid escaped. Large plugs of gauze inserted in openings as deeply as possible into the posterior fossa, skin flap sutured, after pro- viding for drainage. The patient gradually improved, and in six weeks was discharged well.
Hinsberg refers to this and other cases in a paper published last year. It is probable that in this case the sub-arachnoid space was opened, but it is not clear from the description given that this was done as a deliberate measure. Hinsberg says that up to the present at least ten cases of recovery from meningitis after drainage of the sub-arachnoid space are known, and five in which marked improvement occurred.
Suppurative meningitis may, as we have seen, chiefly or wholly aflfect either the subdural or the sub-arachnoid cavity. When on opening the subdural space we meet with a sheet of pus we have no ready means of ascertaining how far it extends, and it is difficult or impossible to remove the pus by irrigating from one opening to another.
Continuous irrigation is conceivable, but cleansing by wiping is impossible, unless bone is removed to the full extent of the pus sheet.
In general suppurative meningitis the opera- tion aflfording the best chance of success is one
76 SOME POINTS IN THE SURGERY
which provides a free bi-lateral opening, and allows the escape of pus from the sub-arachnoid space. It has been moreover rightly suggested that the spinal theca should be opened in the lumbar region so as to permit irrigation from the cranial to the spinal cavity.
Posterior Basal Meningitis of Infants.
The main surgical indication is the relief of the internal hydrocephalus, which is apt early to arise from the effusion blocking the foramina through which the cerebro-spinal fluid escapes from the ventricles.
We have various methods for the surgical treatment of hydrocephalus, and of these I have had considerable experience at the Hospital for Sick Children, Great Ormond Street.
I. The Parkin operation I carried out many years ago in several cases under the care of Dr. Lees and Sir Thomas Barlow. In this operation an opening is made in the occipital bone, and through it the pia-matral expansion over the back of the fourth ventricle is broken through. We found it a very severe operation in infants, and it moreover fails if the Sylvian aqueduct is blocked. These operations mostly occurred in the Winter, and we kept the infants alive
OF THE CEREBRAL MEMBRANES ^-j
after operation by placing them in an incubator. In only one case was the child cured, and in this one the ventricles were tapped also
Fig. 37. — Posterior basal meningitis. (Lees and Barlow.)
Head retraction, marked opisthotonus, rigid extension of limbs. In some cases there is no opisthotonus, and there is flexor spasm of limbs. The head retraction is the characteristic sign. It is seldom so marked in tuberculous meningitis.
Child's age at onsst, 16 months. Ill 13 weeks. The 4th ventricle was dilated. The iter and the foramen of Monro were obliterated. The hydrostatic system of the brain and cord was partitioned by adhesions into four sections : the right lateral ventricle, left lateral ventricle, 3rd ventricle, and 4th ventricle, and sub-arachnoid space of cord.
The left ear contained semipurulent fluid.
through the anterior fontanelle. Unfortunately, a few months afterwards the child was re- admitted to the hospital with diphtheria and died.
78 SOME POINTS IN THE SURGERY
2. Successive tappings of the ventricles may give some relief.
3. Lumbar puncture often fails to drain the
Lateral Venencle
Fig. 38. — Diagram of subdural drainage by an angular metal tube.
The tube is sutured to the dura. The second loose suture prevents the displace- ment of the tube if the cortex sinks away from the dura. Occasionally the amount of fluid will be in excess of that which can be absorbed by the Pacchionian bodies. The internal hydrocephalus then becomes an external hydrocephalus, and the head may continue to enlarge.
The tube employed is much smaller than that shown in the figure.
ventricles of hydrocephalic infants, as the foramina of Majendie and Luschka may be congenitally absent or blocked by antenatal
OF THE CEREBRAL MEMBRANES 79
menino:itis or adhesion of the cerebellum to the medulla : the Sylvian aqueduct may also be blocked.
4. Intra-diiral drainage^ suggested by Cheyne and Sutherland, succeeds if the fluid is not too rapidly secreted to be drained off by the Pacchionian bodies, otherwise it only converts an internal into an external hydrocephalus ; a fact which I have several times observed. The plan of drainage can be carried out through the lateral angle of the anterior fontanelle, or the descending cornu of the lateral ventricle on the right side may be opened by the ingenious method of Keen. A fine tube bent at a right angle, made of gold and iridium, or of platinum, should be used.
Cases of successful treatment of hydrocephalus interna by intra-dural drainage : —
(a) Posterior Basal Meningitis and Hydrocephalus.
Male, aged three and a half, acute illness with pyrexia, head retraction, and right otorrhoea, followed by a stage of irritability, vomiting, rigidity of limbs, and emaciation.
Six weeks after admission to Great Ormond Street, intra-dural drainage was carried out by passing a number of silk threads through a fine opening in the cortex. Ten days later silk threads were replaced by a fine india-
8o SOME POINTS IN THE SURGERY
rubber tube. A fortnight" after second operation child knew his mother and spoke to her. The tube was left in situ for two months and then removed. The child left the hospital well but quite deaf. Seven years later (at age of ten and a half) child happy and healthy at a deaf and dumb school, making progress at the lip language. Like other children, but perhaps more tendency to fall when running about.
(b) Congenital Hydrocephalus.
Child, aged ten months, admitted to Great Ormond Street in December 1903. The head had been increasing in size for three or four months. The circumferential measurement is 23 inches. The eyeballs are depressed, and there is some lateral nystagmus and occasional vomiting. The child is emaciated.
January 1904. — A fine angular platinum tube was passed through the cortex into the descending cornu of the lateral ventricle on the right side.
June 1904. — Quite well ; beginning to talk. Mind, sight, hearing, and speech normal.
January 1906. — Child quite well. Head looks large ; measures 2 1 inches in circumference. It is so heavy that the infant has much difficulty in moving it.
5. The secretion of fluid may be lessened by ligature of one or both common carotid arteries. This can be safely done in hydrocephalic chil- dren, in whom the blood-supply to the brain
OF THE CEREBRAL MEMBRANES 8i
stem is of much more relative importance than that to the cerebral substance and the choroid plexus.
Congenital hydrocephalus treated by ligation of both common carotid arteries : —
George C, aged eleven months, was admitted to my ward in the Hospital for Sick Children, Great Ormond Street, on October 21st, 1905. The head had been enlarging since the age of three months. Circum- ference now 23I- inches, intermeatal measurement 17 inches. Eyeballs depressed, lateral nystagmus, tempera- ture 90° to 100°, occasional vomiting, emaciation. An- terior fontanelle very prominent and tense.
October 2 8//z. — Right common carotid tied. One ounce of cerebro-spinal fluid drawn off through the lateral angle of the anterior fontanelle by a fine trocar and cannula to relieve tension.
November \th. — Left common carotid tied. The pulse became very weak, but the respiration con- tinued. The child gradually recovered, but I thought it well to withdraw a little cerebro-spinal fluid from the anterior fontanelle early in December. About the middle of January the child left the hospital apparently quite well, and with no abnormal pressure of the fontanelle.
I have treated another case of congenital hydrocephalus in the same way. The child was under the care of Dr. James Collier of the National Hospital, Queen Square. This patient,
82 SOME POINTS IN THE SURGERY
however, died, but I ligation of the carotids
Fig. 39. — Congenital hydrocephalus in an infant of 6 months. (D. Schwartz, Cackovic's article in CAipault.)
Child aged 16 months. A litre and a half of- cerebro-spinal fluid was with- drawn through the anterior fontanelle. Head reduced in size, and eyes more freely moved. Ultimate result not known.
do not think that the was the cause of death — one of the wounds was exposed to the air and became septic and this was followed by high temperatures.
Dr. Hildesheim has recently published an admirable paper on pos- terior basal meningitis. He refers to the occur- rence of the disease after the first and second years of life, and points out that many cases of appar- ently acute hydrocephalus in adults and older children are really exacerbations of a chronic condition.
About fifteen years ago a man, twenty -six years of age, came to see me from Yorkshire. Both nostrils were full of mucous polypi. A mass of these growths projected from the posterior nares on to the soft palate. The patient answered my questions clearly, but the father, a farmer, said that his son was not mentally capable of super- vising any work on the farm. The polypi were removed by Banks' method. The operation was easy — one application of the forceps on each
OF THE CEREBRAL MEMBRANES 83
side brought away the polypus mass. The bleeding was not excessive. All went well till the third day, when the temperature rose to 103° F. ; vomiting and delirium set in, and three days later death ensued. With some difficulty an autopsy was ob- tained. All that we found was chronic hydrocephalus. The foramina in the roof
Fig. 40. — Congenital hydrocephalus treated by qJ the fourth Ven— ligation of both common carotid arteries.
tricle were blocked by old basal meningitis. There was no recent meningitis and no injury to the roof of the nasal cavity. I then saw the parents and asked them if they could recollect any illness their son had during the first year of life. To my surprise and interest they told me that their son had had a severe illness before he was a year old, lasting some months. The head increased in size, and was retracted so as to touch the back — vomiting was frequent and his life was despaired of. Gradually the symptoms had abated, but had left considerable impairment of mental power during school time and after-life.
84 SOME POINTS IN THE SURGERY
Conclusion.
Our predecessors, in dealing with acute head infections, applied vigorously those measures which they believed to be of service in treating similar affections in other parts of the body.
We have abandoned the venesection and severe purgation employed by our forefathers as remedies for acute infective disease. In parts of the body other than the cranium we have replaced them by appropriate surgical measures, but in the treatment of intra-cranial infections we have replaced the vigorous if inappropriate measures of our predecessors by an equally inappropriate inertia.
Hinsberg, in the concluding paragraph of his paper on the subject, says : — " It can no longer be doubted that in some cases of suppurative meningitis recovery may be brought about by active intervention. We are as yet quite unable to say how large a fraction this may prove to be. Personally I am not sanguine that it will be a large one, for the difficulties I have men- tioned as attending the diagnosis and localisation and the dangers of the after-treatment are still so great that a quite special concatenation of favourable circumstances is necessary for them all to be overcome."
Twenty -five years ago acute abdominal in-
OF THE CEREBRAL MEMBRANES 85
fections from the appendix, the bile ducts, and the Fallopian tubes, ruptured tubal gestation, and intestinal obstruction were almost as fatal as the acute infections of the meninges ; to-day these abdominal affections are treated surgically with considerable success, not only by those of exceptional ability and opportunities, but is a matter of ordinary practice.
I am convinced that our treatment of intra- cranial infection has been too long encrusted in conventionality, and that " we are no longer justified in regarding such cases as hopelessly lost, and in remaining with folded hands, the rather must we attempt to save them by doing the utmost within our power."
REFERENCES. LECTURE I.
Lettsom. Biographical notes, chiefly obtained from Life and Letters
of Dr. Lettsom, by T. J. Pettigrew. Key and Retzius. Studien in der Anatomic des Nerven-Systems
und des Bindegewebes. Stockholm, 1875. Charpy. Traite d'Anatomie Humaine. Poirier and Charpy. Leonard Hill. The Physiology and Pathology of the Cerebral
Circulation. London, 1896. Lees and Barlow. Simple Meningitis of Children, In Allbutt's
System of Medicine, vol. vii. Imbert. In Traite elementaire de Physique medicale. Wundt-
Monoyer. Second French edition. Watson, Sir Thos. Lectures on the Principles and Practice ot
Physic. London, 1871. MoTT. British Medical Journal, 1904. Aorta of Turtle. Specimen No. 863^, Physiological Series, Royal
College of Surgeons' Museum.
86 THE CEREBRAL MEMBRANES
Taylor and Ballance. Removal of Arachnoid Cyst. Lancet,
August 29th, 1903. •
Richard Bright. Reports of Medical Cases. BiRouLA. Societe de Psychiatrie de S. Petersbourg. Reported in
Revue Neurologique, 1897, p. 206. Prescott Hewitt. In Holmes' System of Surgery, vol. i., third
edition, 1893, and Med.-Chir. Trans, vol. xxviii. Abercrombie. Pathological and Practical Researches on Diseases
of the Brain and Spinal Cord, 1828. CusHiNG. American Journal of Medical Sciences, October
1905- GoDLEE. Pathological Society's Transactions, vol. xxxvi, 1885. Sir Thos. Smith. St. Bartholomew's Hospital Reports, 1884.. GoLDiNG Bird. Guy's Hospital Reports, 1889. Ballance. In Chipault. L'Etat actuel de la Chirurgie Nerveuse,
vol. iii. 1903. Bergmann. Die Chirurgische Behandlung von Hirnkrankheiten. Quincke. Verhand. des X-° Congress fiir innere Medizin, 1891, p.
322, and Volkmann's Klinische Vortrage. Neue Folge, No. d'] . Willis, Thos. De Anima Brutorum. Part 2, p. 276. Ernest Dupre. In Traite des Maladies de I'Enfance. Grancher-
Comby (symptoms of meningitis). Georges Guinon. In Traite de Medecine. Charcot-Bouchard-
Brissaud (for information afforded by lumbar puncture). Robert Whytt. Observations on the Dropsy of the Brain, 1768. Mery and Armand Delille. In Traite des Maladies de I'Enfance.
Grancher-Comby. Paracelsus. Ouoted from Dr. Payne's Article on the History of
Medicine in Encyclopaedia Britannica. Chipault. Traite de Chirurgie operatoire du Systeme Nerveux
and I'Etat Actuel de la Chirurgie Nerveuse. KiJMMEL. Archiv. fiir klinische Chirurgie, vol. Ixxvii. p. 930. Hinsberg. Zeitschrift fiir Ohrenheilkulide, vol. xxxviii. p. 126,
and vol. 1. p. 261. Parkin. The Lancet, 1893.
Cheyne and Sutherland. Clinical Society's Transactions, 1898. Keen. Medical News, 1888. Hildesheim. Dissertation of the Degree of M.D., Oxon. See also
Practitioner, 1905. PuRVEs Stewart. The Clinical Significance of the Cerebro-Spinal
Fluid. Edin. Med. Journal, 1906.
LECTURE II
SOME POINTS IN THE SURGERY OF ABSCESS OF THE BRAIN
Etiology — Morbid anatomy and pathology — Infection of brain substance — Manner of development, form, and situation — Clinical evolution — Symptoms and diagnosis — Complications — Operative treatment of the varieties of abscess — Recent im- provements in details — Concluding remarks.
It is now almost universally accepted that suppuration does not occur without the inter- vention of microbes ; various species of micro- organisms have been found associated with suppuration within the brain, and each of them might be spoken of as a cause of cerebral suppuration.
To the practising surgeon, however, the general or local disease of which the cerebral suppuration is a complication is the dominant etiological factor. Not because the bacterio- logical diagnosis is not of importance in treat- ment, but because it is not usually available until the clinical diagnosis has been put to the proof.
87
88 SOME POINTS IN THE SURGERY
With what diseases, then, is brain abscess associated ?
1. Injuries to the head.
2. Local cranial suppurations.
3. Certain general infections.
4. Certain local diseases other than those of the head.
Abscess of the brain complicating injuries to the head is too well known to need any exposition in this place ; I will only remark that, except when the instrument causing the injury has penetrated deeply into the brain sub- stance, the abscess is in most cases really a local meningeal suppuration with participation of the adjacent brain cortex, a meningo-cortical abscess rather than a brain abscess proper.
Less frequently injury leads to local chronic disease of bone, from which a brain abscess may subsequently arise. I have elsewhere spoken of brain abscess secondary to local cranial suppura- tion.
The general infective diseases most liable to be complicated with abscess of the brain are (a) pyaemia ; (^) tubercle ; (r) certain specific fevers, such as influenza, enteric fever, or variola.
Little need be said of brain abscess secondary to general pyaemia. The brain is one of the less common localisations of pyemic abscess, and
OF ABSCESS OF THE BRAIN 89
general pyemia is happily a disease well on its way towards becoming extinct.
It is of great interest that cases have been met with of abscess of brain, apart from any other macroscopic intra-cranial tubercular lesion, which have yielded pure cultures of the tubercle bacillus.
Cases of brain abscess following, and appar- ently caused by, the acute specific fevers, with-
FiG. 41. — Traumatic meningo-cortical abscess of brain. (Starr.)
The abscess was in the inferior parietal region, and was secondary to fracture of the skull. The thick capsule of the abscess can be seen. The patient was an infant. The injury was followed in two weeks by hemiplegia and hemianopsia.
In 22 cases of brain abscess observed at the Presbyterian Hospital, New York, 12 were due to trauma. Starr also relates 3 cases which recovered.
out any evidence of disease of the cranial bones or anything to suggest pyaemia have been from time to time reported ; for example. Dr. Bristowe in 1 891 published two such cases (to which I shall have again occasion to refer) following influenza. These cases rarely come under a surgeon's observation ; they present great diffi- culties in diagnosis, and even when brain abscess has been suspected there has usually been little or nothing to show in which region or even
90 SOME POINTS IN THE SURGERY
on which side of the brain the abscess has developed.
The local disease elsewhere than in the head which is most liable to be complicated with brain abscess is putrid inflammation or gangrene of the lung. Brain abscess supervening upon this condition has been observed and recorded for at least fifty years. Though it is clear enough that the infection is carried in the blood-stream, no adequate explanation is as yet forthcoming why it should be localised in the brain.
In 1 90 1 Clay tor collected reports of 58 cases of brain abscess secondary to disease of the lungs, most of which occurred on the left side of the brain. The particular form of lung disease was in 20 cases bronchiectasis, in 10 empyema, in 9 purulent bronchitis, in 7 gangrene of lung, in 5 tuberculous disease, in 3 abscess of lung, in 2 pneumonia, and in 2 gunshot wound of lung.
Stoll reports a case of abscess in left frontal lobe, and a cavity in the apex of the right lung 2^ cm. in diameter. A similar case to that of Stoll is reported in the Lyon Medica/e, 1904.
Blottche found pulmonary pigment in the pus of certain brain abscesses.
OF ABSCESS OF THE BRAIN 91
Examples of Brain Abscess following Pulmonary Disease.
Case I (Cayley). — Male, aged nineteen years. — Severe attack of pleurisy lasting eight weeks. Haemoptysis during the attack and, in small quantities, at intervals subsequently.
Three years afterwards. Headache, vomiting, tem- porary loss of power in left arm and leg. Renewed haemoptysis. Complained of some confusion of thought but answered questions rationally though slowly. Con- stipation, Dulness at left base with bronchial breath- ing and bubbling crepitation. Five days after com- mencement of head symptoms he had a fit with clonic spasms affecting first the left leg, then the trunk, and then the left arm ; there was no loss of conscious- ness, and he attempted to control the movements with right arm. Vomiting and headache increased. Pulse 44, temperature 96.6°. Edges of disc blurred. Died five days later. At the autopsy two abscesses were found in the brain. One in the centrum ovale of the right hemisphere as large as an unshelled walnut. " It gave off from its upper part a prolongation or loculus which reached the surface in front of the superior parietal lobule at the top of the ascending frontal con- volution, the grey matter of which was partly destroyed by it. Though in this region quite superficial the abscess had not burst on to the surface of the brain. This upper loculus communicated with the principal cavity by an aperture the size of a crow-quill." Bronchiectasis of left lung and enlarged bronchial glands without evidence of tubercle. The diagnosis during life had been tubercular tumour.
Case 1 (Pye-Smith). — Male, aged nineteen years. — Empyasma treated by simple incision, August 16,
92 SOME POINTS IN THE SURGERY
1876. Irrigated with weak iodine solution. Wound had healed and lung expanded by October 5, On October 6, vomiting, headache, and delirium. Tem- perature 1 01. 8. Left hemiplegia. Died three days later. Autopsy. Residual abscess between lobes of lung. Purulent meningitis, pus beneath arachnoid. Two abscesses in right cerebral hemisphere each as large as a marble, the one involving the gyrus forni- catus, and the back of the optic thalamus, and the other situated in front of the corpus striatum. Both abscesses had burst into the ventricles.
Case 3 (Rudolph Meyer, 1864). — Male, aged thirty- six years. — Cough and stinking expectoration three years. Temporary paresis of right hand. Four days later, shivering, right hemiplegia, aphasia. Constipation and involuntary micturition. Intense frontal headache. No vomiting ; pulse 52, temperature 98.6°. Rigidity of left arm. Died comatose. Multiple abscesses in brain. One in right occipital lobe, and two in the left hemisphere, one of which was close to the cortex.
Infectioti of Brain Substance.
In speaking of meningitis I have already indicated how infection reaches the interior of the skull ; and how the meninges react towards it. I have now to speak of the effects of infec- tion of the brain substance.
Like meningitis, brain abscess may be caused by infection reaching the brain by direct con- tinuity from an infective lesion in the head, or conveyed indirectly by blood-vessel or lymphatic
OF ABSCESS OF THE BRAIN 93
from a local lesion in the head or elsewhere, or may occur as part of a general infection of the blood.
The oft- quoted statistics of Newton Pitt show that nearly one half of all brain abscesses are secondary to local disease of the cranial bones, while only a small proportion of menin- gitis cases have a similar origin. To reach the brain by direct continuity from extension of a local infective cranial lesion infection must first traverse the meninges. In a rapidly ex- tending infective process diffuse meningitis would be the most probable result ; in the more slowly spreading infection resulting from chronic disease the meningeal infection would be localised by adhesions and time given for extension of disease to the brain.
The same point is illustrated by the fact that abscess of the brain or sinus infection is a more common complication of chronic ear disease than is acute suppurative meningitis, whereas meningitis has been the most usual result in those cases, now happily rarely met with, in which attempts to extract a foreign body from the ear have been so unskilfully made that intra- cranial infection has followed. Here the meninges are directly infected, as in accidental injury.
94 SOME POINTS IN THE SURGERY
In most cases of slowly spreading infection from chronic disease adhesions occur obliterating the cavity of the arachnoid at the site of infec- tion and binding together dura, arachnoid, pia, and cortex. The lymphatic sheaths of the numerous small blood-vessels which traverse the cortex at right angles to its surface are in direct communication with the sub-arachnoid space, and through these, as through a number of capillary tubes, infective matter easily traverses the cortex and reaches the white substance within.
The cortex is very vascular, and its connective tissue element, reinforced by numerous prolonga- tions from the pia mater, is abundantly supplied with connective tissue corpuscles. Hence it is able to offer a strenuous resistance to the bacterial attack, and does not ordinarily undergo any ex- tensive destruction. Where it is traversed by the infective material a barrier of fibrous tissue is thrown out, limiting the destructive process to the formation of a narrow track.
The white substance is much less resistant, and it would seem that the greater the distance from the cortex the more easily does bacterial action cause dissolution of brain substance.
Thus the abscess comes to assume a mush- room-like shape, with the narrow portion or stem attached to the dura at the original site
OF ABSCESS OF THE BRAIN 95
of infection from the bone. Preysing's figures admirably illustrate this important fact.
When the dura has been separated from the bone over a more or less considerable area adhesion of the meninges takes place to a much greater extent.
In a case successfully operated upon by Salzer, an area of the dura over the temporo-sphenoidal lobe measuring several square centimetres w^as in a sloughy condition. The diseased portion was excised, and the meninges were found fused into one layer, the inner portion of which, corresponding to the pia, was not necrotic. There was no abscess of brain.
In a similar case, reported by Manasse, the infection had proceeded a stage further and there was an abscess of brain, the outer wall of which was, over a considerable area, formed by fused meninges and brain cortex.
The more recent the abscess the nearer will it lie to the spot where the infection traversed the dura, and the more evident will be the stalk or its remains. The older the abscess the greater is the apparent recession from the dura and the less evident the remains of the stalk.
Such is the ordinary course of the formation of brain abscess when, as is usual, the infection gradually spreads into the brain substance by
96 SOME POINTS IN THE SURGERY
slow extension in direct continuity from the spot where the disease in the bone reached the interior of the skull ; but, as has already- been stated, the infective particles may, in the brain, as in other parts of the body, be carried by the circulation to a spot remote from the site of infection.
An abscess may thus arise in the substance of the brain without having any visible con- nection with the bone disease to which it really owes its origin. Just as an abscess in the axilla may arise from infection in the linger tip without visible intermediate lesion.
The stalked form of brain abscess is quite comparable, as to its mode of formation, to a superficial cervical abscess connected by a narrow track to a focus of disease beneath the deep fascia, and the isolated variety of brain abscess has its parallel in an abscess of liver arising from disease in the intestine.
No difficulty need therefore arise in explain- ing the pathology of a case reported by Swain, in which purulent infection of the choroid plexus in the descending cornu of the lateral ventricle occurred as a result of caries of the tegmen tympani of the same side, the inter- vening brain substance being unaffected.
The abscess may more or less rapidly increase
OF ABSCESS OF THE BRAIN 97
in size and ultimately leak, either into the ventricles or on to the surface of the brain.
Or it may run an entirely chronic course, with more or less complete latency so far as symptoms are concerned.
In these circumstances the abscess may or may not become encapsuled. Encapsulation of abscess appears to be relatively more frequent in the brain than in other parts of the body.
This is due, not to any difference in the pathological process, but to the peculiar liquid texture of the brain, allowing a sharper differ- entiation between the sclerotic tissue forming the abscess wall and the surrounding unaltered brain substance.
The statement that only acutely developing brain abscesses are free from encapsulation is too absolute, and a history of long- continued cerebral symptoms in a case of brain abscess does not necessarily point to the presence of a capsule ; for in a case of cerebellar abscess with symptoms pointing to a duration of at least eight months no capsule was found, but the whole cerebellar hemisphere was nothing but a shell of softened grey matter.
An abscess completely latent as regards symptoms for any length of time will usually be encapsuled. An abscess in the brain, as in
H
98 SOME POINTS IN THE SURGERY
other parts of the body, may tend slowly to extend, causing great local destruction of tissue. Such abscesses give rise to slight symptoms extending over a considerable period, and are not encapsuled.
A slowly growing abscess may be thought of as displacing or pushing aside fibres passing from the cortex to the internal capsule rather than causing their actual destruction, and this, view is somewhat supported by the fact that recovery from paralysis takes place after success- ful drainage of the abscess. It must, however, be pointed out that cortical impulses may some- times find new paths.
When an abscess is drained through the point of attachment to the dura, as in the case of a temporo-sphenoidal abscess opened through the tegmen tympani, though the abscess may be large, there may be but little actual damage to the cortex.
The formation of even a thick capsule does not prevent the abscess from extending; nor even from leaking into the ventricles. Acute inflam- matory softening or even suppuration has been known to arise around an encapsuled abscess. Abscesses surrounded with a thick capsule and which can be shelled out whole have run a chronic course. Complete encapsulation of an
OF ABSCESS OF THE BRAIN 99
abscess arising by extension of infection by direct continuity from bone may and does occur, the narrow track of communication being obliterated by scar tissue, just as in an aneurism, in process of cure, the narrow orifice of communication with the lumen of the artery becomes obliterated. In these cases we should find adhesion of the abscess wall to the bone.
When an abscess is found in the brain com- pletely isolated and at some distance from the meninges, the infective organisms have been carried by the blood or lymph stream, and have first multiplied at a spot in the brain some distance from the point of infection.
Many of the cases published have resulted from injury, not from bone disease, a consider- able number having followed gunshot wounds. In these, at least, it is conceivable that infec- tive particles have been driven directly into the substance of the brain, in fact that a " stab- culture " has been made.
The following is a good instance of encapsuled abscess (Bergmann) : —
A youth, aged sixteen years, received a pistol-shot wound in the right frontal region. Four months after- wards the right frontal lobe was explored for abscess, several punctures being made with a needle. No pus was reached. Three days later the abscess burst. The
loo SOME POINTS IN THE SURGERY
opening was enlarged with a scalpel. So thick and firm was the capsule that it was dragged out whole. Three days later the symptoms recurred. A second encapsuled abscess was opened and the capsule likewise dragged out. On the death of the patient, six weeks
Fig. 42. — Spreading septic softening of the right frontal lobe. (Hooper, 1826.)
Lebert gives a good illustration of the same condition in the cerebellar hemi- sphere. I think that this particular result of septic infection occurs more readily and is more dangerous in the cerebellum than in the cerebrum. The brain, just like any other soft tissue of the body, may be affected by localised or by spreading suppuration.
later, from pyelitis, the wound in the brain was found to be healing well.
Spontaneous Recovery in certain Tubercular Cases.
Inspissation and even calcification of brain abscess has been observed, but only in tuber- cular cases, the occasional spontaneous cure of which cannot be denied.
OF ABSCESS OF THE BRAIN loi
Cases are relatively common in early life which, although the symptoms are apparently only explicable by the presence of a cerebral tumour or of meningitis, either get well or run
Fig. 43. — Encysted abscess of left frontal lobe. (Hooper, 1826.)
The cyst -wall was as thick as the pericardium. The cyst contained between 2 and 3 oz. of pus. Von Bergmann's case is a good example of encysted abscesses of the frontal lobe. I have known an abscess of the frontal lobe to have so thick a wall that it could be rolled about the floor like a billiard ball.
a chronic course extending over many years, and then die from distension of ventricles.
In some at least of these cases it seems probable that there was a localised tubercular mass in the brain which has been recovered from.
In one such case, some four years after a diagnosis of cerebral tumour had been made, the autopsy showed great distension of ventricles.
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There was no visible tumour and no evident trace of tubercle in the brain, but in the mesentery there was a large calcareous mass.
Two girls, under twenty years of age, both suffered from headache, vertigo, nystagmus, and repeated purposeless vomiting ; both had double optic neuritis, unsteady gait, and absence of the patellar reflex. The diagnosis in both cases was some affection below the tentorium, probably cerebellar tumour. Both made good recoveries, but in one some impairment of sight remained.
Multiple Brain Abscess (apart from General Pycemia) .
Multiple brain abscess does not commonly occur as a result of injury, indeed the abscess which follows an injury is usually a meningo- cortical abscess.
A second abscess in the temporo-sphenoidal lobe is rare. Probably in some at least of the published cases the second abscess was nothing but a pocket of the original abscess. In Kiimmel's case, however, the autopsy showed a second abscess separated by a thick capsule from the first. In Roncali's case a temporo-sphenoidal abscess extended into the frontal lobe. In a
OF ABSCESS OF THE BRAIN 103
case of my own a temporo-sphenoidal abscess had extended into the occipital lobe.
A second or even a third abscess in the cere- bellum is by no means uncommon. The first abscess is usually situated in the anterior and outer part of the lateral hemisphere. A second abscess may be situated internal to the first and separate from it ; or posterior to it, in which latter case it has probably been originally con- nected with it, so that the apparently double abscess is really a single dumb-bell shaped cavity.
Another type of second abscess met with in the cerebellum is the oyster-shaped abscess. This forms beneath the grey matter of the upper surface. It occupies an extensive area laterally and antero-posteriorly, but in depth is very shallow.
When a second or third abscess has not arisen by infection from, or extension of, the first, it has a separate point of attachment to the dura at the site of infection.
I have elsewhere pointed out that the statistics of St. Thomas' and Great Ormond Street Hospitals show that abscess of aural origin is more frequent in the cerebellum than in the temporo-sphenoidal lobe. The following suggestions may be oflfered as an explanation of
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this, and of the fact that abscess resulting from disease of the temporal bone is more frequently multiple in the cerebellum than in the temporo- sphenoidal lobe.
In the middle fossa the site of infection is practically limited to the roof of the tympanum and antrum, while in the posterior fossa infection may occur anywhere along the whole posterior surface of the petrous or the groove of the sinus.
Not only is there a larger bone area where infection can enter, but there is a larger surface from which septic absorption can take place, for if both were spread out, the superficial area of the folia of the cerebellum, in. relation to the posterior surface of the petrous, would greatly exceed that of the convolutions of the temporo- sphenoidal lobe in relation to the tegmen.
Again, since the pia mater runs to the bottom of every fissure between the folia, and also lines the deeper fissures between the lobes, it, when infected, carries septic material deeply into the cerebellum, hence the opportunity for the branching of the track of infection or the for- mation of two distinct tracks.
Abscess has been met with at the same time, both in the temporo-sphenoidal lobe and in the cerebellum.
The great morbid anatomists of the last
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generation — Auvert, Cruveilhier, Lebert, Bright, Hooper, and Carswell — all contribute beautiful illustrations of abscess of the brain. How splendid were their labours, and how much we
Fig. 44. — Abscess of the right temporo-sphenoidal lobe. (Cruveilhier, 1830.)
Male, aged 32 years. Pain and discharge from right ear for 20 years. April 18, 1829. — Taken ill with violent headache and fever. April 29. — Seen by Cruveilhier. No affection of sensation movement or intelligence. Died suddenly May 11.
Cruveilhier states that the grasp of the two hands the day before death was equal, so there could not have been any gross hemiplegia.
Autopsy. — The ventricles were full of pus, but the encysted abscess had no con- nection with the ventricles. The last illness was probably meningitis and acute infection of the ependyma of the ventricles — a new infection — from the petrosal disease. The encysted abscess, as we often find, was not the immediate cause of death.
are indebted to them ! On the sure foundation laid by such patient pathological investigations the more perfect clinical diagnosis of the present day has been built up, and the recent advances
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of surgery have in great measure been made possible.
The Symptoms of Brain Abscess.
If we appreciate the march of the symptoms arising when abscess occurs anywhere we shall have the key to the understanding of the symptoms of abscess when situated in the brain. The symptoms of abscess in any region, as, for example, in the axilla, can naturally be grouped in three divisions : —
1. Those due to the infective process itself.
2. Those common to infective lesions of the anatomical region involved, and
3. Those due to specific functional disturb- ances caused by the local lesion or its influence on the surrounding tissues.
We may then classify the symptoms of brain abscess as follows : —
1. Those due to the mere presence in the body of deep-seated pus independent of its locality.
Such as the febrile state, with perhaps shiver- ing and vomiting.
2. Those due to increase of tension within the closed cavity of the skull.
Such as purposeless vomiting, slow pulse, torpor.
3. Those due to irritation or suppression of
OF ABSCESS OF THE BRAIN 107
function of particular parts of the central nervous system.
Such as epilepsy, anesthesia, paralysis, and perversion or loss of one or other of the special senses.
Symptoms of Extra-Dural Suppuration.
Suppuration between the bone and dura gives rise to no specific symptoms, and the first indica- tion of the presence of an extra-dural abscess is often the discovery of the pus during the course of an operation for disease of the bone.
When the pus happens to be under tension there is much local pain and fever, possibly there may be tenderness on percussion over the site of the abscess, and there is often rigidity of neck when the suppuration is in the posterior fossa. Sometimes symptoms arise from compres- sion of the brain, but there is then nothing to distinguish extra-dural from intra-dural suppura- tion. When the infection is virulent enough to rapidly make its way through the dura, the pus not being under tension, the extra-dural stage of the progress of the case is not commonly marked by any recognisable symptoms.
The symptoms of brain abscess are sometimes pathognomonic as to its situation, in others they are in this respect indefinite, and the diagnosis of
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the seat of the abscess, if possible at all, has to be made from the attending circumstances rather than from the direct effects of the abscess on the brain.
I shall not have time to deal with the localis-
FiG. 45.
Fig. 46.
Figs. 45, 46. — The cortical centre for hearing. (Ferrier.) The superior temporo-sphenoidal convolution was destroyed in both sides in the monkey, causing complete deafness. The animal was allowed to survive for more than a year, during which time it enjoyed perfect health and the full enjoyment of all its faculties, with the single exception of hearing.
ing symptoms of brain abscess, and this is the more unnecessary as I have elsewhere done so in some detail, and the subject has moreover been fully discussed by many other observers. I pro- pose only to illustrate the application of localising
OF ABSCESS OF THE BRAIN 109
symptoms to diagnosis by discussing those pro- duced by abscess or tumour of the temporo- sphenoidal lobe either by disturbance of cortical
Fig. 47.
Figs. 47, 48. — The cortical centres for taste and smell. (Ferrier.)
Lesions of right and left hemisphere, causing in the monkey loss of taste and smell. In the right hemisphere the shading indicates the extent of destruction of the grey matter. In the left hemisphere the dark shading indicates the superficial extent of the wound, and the dotted lines the extent of internal destruction of the lower portion of the temporo-sphenoidal lobe.
centres or by pressure on adjacent parts of the brain.
I. The cortical centre for hearing may be
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in part or wholly involved, causing tinnitus, hyperacusia, or absolute deafness of the opposite (healthy) ear, all of v^hich symptoms I have observed.
2. The cortical centres for taste and smell may be affected. Alteration or suppression of the sense of smell may occur in abscess, involving the anterior extremity of the temporo-sphenoidal lobe. Some cases illustrating the cortical local- isation of the sense of smell are given farther on. Jackson and Beevor published, in 1887, a remark- able case of tumour of the tip of the right temporo- sphenoidal lobe, confirming clinically Ferrier's classical experiments. Their patient suffered from fits, associated with the dreamy state (com- monly called intellectual aura), and a crude sensation of smell. I have observed the dream state in several cases of temporo - sphenoidal abscess.
3. Sensory aphasia often occurs in abscess of the left temporo-sphenoidal lobe in consequence of the cortical centres for the mechanism of speech being on the left side of the brain. The auditory word centre and the visual word centre are the ones involved in temporo-sphenoidal abscess. A temporo-sphenoidal abscess on the left side is therefore commonly more easy to recognise than one on the right.
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4. Paralysis of the opposite side of the body may be of cortical or internal capsule type. The march of the paralysis is different in the two cases. This paralysis is a frequent occurrence from pressure on the posterior end of the internal capsule, and may be associated, as might be expected, with hemi- anesthesia.
5. Paralysis of the third nerve on the side of the abscess. This is important. The paralysis is rarely complete. A stabile pupil on the side of the suspected abscess clenches the diagnosis.
6. Paralysis of the " naming centre." Certain clinical and pathological observations
point to the conclusion that the nervous mechan- ism by which the ideas of objects are correlated with their names, is located in the left tem- poro-sphenoidal lobe.
The formation of an idea of an external object is the combination of the evidence re- specting it received through all the senses ; and for the employment of this idea in intellectual operations it must be associated with and sym- bolised by a name. Broadbent and Charcot thought a naming centre necessary for the receipt and combination of the sensory impulses involved. Ross and Bastian do not think so.
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Cases Suggestive of Site of Naming Centre}
I . A woman, aged forty years, became in a high degree word blind after a cerebral seizure, though not letter blind. She could not name objects she recognised by sight and by touch. On one occasion she called the scissors "what I sew with," and the purse "what I buy
Fig. 49.
Fig. 50.
Fig. 49. — Diagram of the position in the cerebral cortex of the centres concerned in the mechanism of speech. (IVIills.)
A, Auditory centre (centre for word hearing) ; V, visual centre (centre for word- seeing) 5 N, naming centre (centre where percepts are given a name) ; B, motor- speech centre (in Broca's convolution) ; G, graphic centre ; U, utterance centre.
Fig. 50. — Tumour of the 3rcl temporal convolution, indicating the position of the naming-centre. (Mills.) A, Densest, and probably oldest portion of the growth (the cortical limit of the lesion is indicated by the dotted lines) ; B, anterior limit of the lesion beneath the cortex.
with." At the autopsy a tumour was found involving the third left temporal convolution (Mills).
2. Captain M., aged forty-four years, suffered six weeks before I saw him with an inflamed throat, pain in the left ear, and left otitis media. For ten days he had had pains in the head and vertigo. Pus could be seen oozing from a perforation in the lower part of the drum. For a fortnight hot fomentations and anti- septic irrigation were employed, and at the end of that time the patient returned without headache, but still
1 See page i 54 for another case of anomia.
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with otorrhoea and vertigo. The complete mastoid operation was then done. As the tegmen was carious it was removed. The dura over the tegmen was inflamed and not pulsating normally. For a fort- night all went well. The patient was out daily and ap- peared to be convalescing. The temperature then rose to lO] ^ and the patient was sick. Next morning he was
Fig. 51. — Capt. M. Case illustrating site of naming centre.
a. Granulating cerebral cortex seen through opening in dura covering region of tegmen tympani three weeks after operation. (From a photograph by A. C. Ballance.)
To discover the "stalk" and evaciiate the contents of a temporo- sphenoidal abscess the operator removes the tegmen tympani.
irritable, temperature ^9°, general headache, and feeling of nausea. Suddenly he was much perturbed by being unable to name anv object or person, though still able to converse in a somewhat confused manner. This condition, in its worst form, lasted about two hours. In the evening the exposed dura was bulging, headache and nausea continued, vomiting was repeated, and both discs were congested. An anassthetic was given, and
I
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the bulging dura incised. The membranes and cere- bral cortex were fused together, and on passing the little finger through the dura a cavity in the cerebral cortex was entered about the size and shape of a thimble. No actual pus was seen. The brain around the cavity was soft, and incisions were made in it. Lumbar puncture was done, the fluid contained poly- nuclear leucocvtes in abundance, and it was feared that meningitis had set in. The cavity probably occupied the temporo-occipital convolution and the adjoining part of the third temporal convolution, so interfering with Mills' " naming centre." The patient made a rapid and complete recovery.
Preysing has published a somewhat similar case.
3. A woman, aged thirty years, had had chronic sup- puration in the left ear for twenty-four years. Three days before Preysing saw her the discharge ceased suddenly, and from that time there had been severe pain behind the ear and in the temporal region. The meatus was somewhat narrowed by inflammatory swelling, and a small amount of fetid pus was found in it. Complete mastoid operation next day. A week later the middle fossa was opened by removing the tegmen tympani and antri. Dura granulating and perforated, some pus escaped from the temporo- sphenoidal lobe. Next day fever and headache per- sisted, the wound was explored, and a further extension of the abscess opened up with forceps. Some difiiculty was experienced in establishing satisfactory drainage. In the evening the fever had subsided and the patient felt well, but was astonished by finding that she was unable to give her address, she could only say " It is
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in the narrow street close by the church." She could not even recognise the name of the street when it was told her, but answered, "No, that is not the street." On investigation it was found that she was unable to name any countries, towns, or streets ; though she could describe those with which she was familiar. She did not always recognise the names when she heard them. Ordinary objects were, with few exceptions, correctly named. This partial loss of the power of naming persisted for about a week. For about another fort- night she was unable, after reading a short paragraph, to say what it was about ; the meaning of the lines being forgotten almost as soon as they were read. In three months from the time of the first operation recovery was complete.
Brissaud and Souques, in their interesting and lucid exposition of language defects resulting from brain disease, say : — " Complete inability to utter any vocal sound, articulate or inar- ticulate, is quite exceptional. Complete loss of articulate speech, with ability to make use of guttural sounds of low or high pitch, is often enough observed."
Some aphasics are only able to pronounce isolated vowels or consonants, such as A, O, R, S, or, as is most usual, only meaningless syllables or grotesque words, which they keep on repeating.-^
1 As illustrations of such syllables and words the authors give '■'■ af,far, ^Mat, cousin, akoko, monomeme?itif, iquifofoiqui " ; these with, of course, the French pronounciation aptly represent the mumbling's of certain aphasics.
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Others, again, retain nothing of their native tongue but oaths and expressions of the most objectionable nature. Some have saved from the wreck a few castaways, fragments of words, generally the first syllables ; and sometimes this partial aphemia is limited to substantives. Such was the case, related by Trousseau, of the eminent lawyer who said " Give me my um — um — um — damnation ! " " Your umbrella ? " " Ah, yes, just so, my umbrella."
Aphemia limited to one particular part of speech, the substantive, the verb, etc., is by no means rare. Most commonly it is the noun, "•' the substance of discourse," that is the most completely lost. The Abbe Perier,^ wishing to ask for his hat, could only say, " Give me my . . . what is hanging on the . . ." Loss of memory of verbs is not common, the speech then becomes a sort of " nigger language," or pidgin English. A patient of Voisin lost all the personal pronouns, which he replaced by " one " ; speaking of himself, he would say, " One would
1 Piorry, who published this case in 1838, thus described loss of memory of names as a particular form of speech defect sometimes met with in cerebral hasmorrhage : — " Some patients who have had cerebral haemorrhage recollect incidents perfectly well, have an exact memory of places, things, sounds, etc., but if asked to give the name of a person whom they know very well are unable to recollect or to pronounce the name. In a more advanced stage of the affection they cannot even assign to anything the noun used to designate it."
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like something to eat," " One is not feeling well." Aphemia generally obeys the law of progressive loss of memory, going from the particular to the general; proper nouns are first lost, then concrete and abstract nouns, adjectives, and adverbs. Some observations (Bouillaud, Winslow, Voisin) form exceptions to this rule.
" One of Charcot's patients was completely aphasic for Italian and Spanish, which she spoke quite fluently before her illness, but retained the power of speaking French, which was not her native language. That is, however, an ex- ception ; the native language is usually the last to be lost. There is likewise an aphemia for figures and numbers, for musical notes, etc., sometimes these various varieties co-exist, some- times they occur independently. A very in- teresting form of motor aphasia results from the fact that the words of a familiar song become so closely associated with the corresponding musical notes that words and music come to form one complete whole ; so that, for example, an aphasic quite unable to recite the words of the Marseillaise, would sing them without fault on hearing the music. The centre of ideation common to the words and the musical sounds being able to set in action the motor impulses for phonation."
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Brissaud and Souques do not appear to re- cognise the existence of a separate naming centre. They quote Pitres to the following effect : — " Patients affected with amnesic aphasia have not absolutely lost the power of speech, often enough they speak a great deal. They can read both mentally and aloud. They understand what is said to them. They give accurate replies to questions. But from time to time the words they desire to employ to express their thoughts escape their memory, and they are obliged to stop or make use of a paraphrase. It is quite natural that the lesions giving rise to amnesic aphasia should be sought in the immediate vicinity of the sensory word centres, but they have no absolutely fixed localisation. Indeed the symptoms seem to be caused, not by de- struction of a highly specialised centre exclusively devoted to the recall of words, but by interrup- tion of some or other of the commissural fibres uniting the special centres for verbal images with those parts of the cortex concerned in the higher psychic functions."
" Ballet thinks that amnesic aphasia is due to diminished functional activity of centres specially differentiated for the preservation and reproduc- tion of word images.
" Dejerine does not consider it a special form
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of aphasia, but merely an attenuated form of motor or sensory aphasia into which it passes by insensible gradations."
Thus it is evident that though partial defects of speech in incomplete forms of aphasia are explained by some as consequent on lesions of definite centres, yet this view remains unproved, and is not accepted by other prominent neuro- logists.
Centres for intonation, equilibration, and orientation have been located in the temporo- sphenoidal lobe. Time will not permit me to discuss them now.
Other cases illustrating the localising symp- toms of temporo-sphenoidal disease : —
1. Man, aged thirty-eight years. Operation for left petro-mastoid disease. Three days later he complained that everything given or shown to him had a bad smell. One day he asked the Sister to boil a sixpence (he had previously been in the habit of giving his wife sixpence to buy eggs). The day after this he had aphasia agraphia, alexia ; he had vomited, and there was weak- ness of face and arm with exaggeration of the knee- jerk on the contra-lateral side. At the operation the whole of the left temporo-sphenoidal lobe was found occupied by an abscess. (Case under treatment ten years ago.)
2. A woman, aged twenty, was quite unconscious of having been removed to the hospital, and repeated
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exactly the same words as when she was in bed at home. She lay quietly on her side with the limbs flexed, occa- sionally moaning, and taking no notice of anything around her. She could be roused with difficulty, and she then sat up in bed with a vacant expression of countenance, the eyes staring straight in front of her, and being apparently unconscious of her surroundings she said slowly, " Am I dying ? " " Where am I ? " Then she sank back on the pillow till again roused, when the same result followed, and the same words were repeated. The abscess was in the left temporo-sphenoidal lobe. This case illustrates the condition known as the dream state,
3. A man, aged forty-eight, was admitted to St. Thomas's some years ago with chronic otorrhoea on the right side. He had lost a son the year before from cerebellar abscess. The patient was a gardener, and said that for three weeks he had had slight headache and had once vomited. His main complaint, however, was that he had lost the sense of smell, being unable to dis- tinguish in this way between roses and violets. On examination the right pupil was found to be stabile and the right disc blurred. Operation forthwith. A large abscess was drained through the stalk, which was adherent to the diseased tegmen tympani. Rapid convalescence. No hernia cerebri. Recovery of sense of smell.
4. A man, aged thirty-eight, was seen six years ago. Hewas of considerable intellectual attainments and a good pianist. He had had left chronic otorrhoea since early childhood. Ten days previously a polypus had been removed from the ear by an otologist. Shortly afterwards he began to suffer from headache and vomiting. When seen by me pus was pouring from the left meatus in such quantity that it was obviously coming from a large
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cavity. He had also aphasia, agraphia, alexia, and amusia. The left pupil was stabile and the right face weak. Operation forthwith. Large abscess evacuated. Complete recovery, with the exception that the loss of the appreciation of musical sounds remained permanent. 5. Tumour of the right temporo-sphenoidal lobe (Beevor and Jackson), Female, aged fifty-three years.
Fig. 52. — Tumour of the right temporo-sphenoidal lobe bearing on the localisation of the sense of smell. (Jackson and Beevor.)
M'Lane Hamilton {New York Medical Journal, 1882) published a case of cortical sensory discharging lesion, in which disease involved the tip of the temporo-sphenoidal lobe. Before being convulsed, the patient, a woman aet. 40, had a peculiar aura : she suddenly perceived a fetid odour.
For thirteen months before her admission to hospital she had had epileptic fits. The patient, who was a cook, had peculiar seizures in which she saw a little black woman who seemed to be always very actively engaged in cooking. She had also the subjective sensa- tion of a horrible smell. She would stand with her eyes fixed and directed forwards (dream state) and
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then say, " Oh, what a horrible smell ! " There was some droophig of the left side of the face, and the tongue when protruded deviated to the left.
Autopsy. — The whole of the anterior end of the hippocampal lobule on the right side was occupied by a tumour. It involved the amygdaloid nucleus and the central white matter, but did not affect the grey cortex of the hippocampal convolution or of the first temporo- sphenoidal convolution. The nucleus lenticularis and the anterior end of the internal capsule were compressed. Hence the weakness of the opposite side of the face and the deviation of the tongue to the left. The left arm and leg became paralysed shortly before death.
The extreme anterior end of the temporo-sphenoidal lobe is the hippocampal lobule, which is highly de- veloped in macrosmatic animals and rudimentary in microsmatic animals like the dolphin.
6. Rone all s case. — A man, aged thirty-eight years, had severe pain in the right mastoid region following an attack of facial erysipelas. The tympanic membrane was incised. The patient had had two previous attacks of erysipelas, but gave no history of having formerly had ear disease.
Ten days after the incision of the tympanic mem- brane a severe epileptic fit occurred, leaving the patient prostrate for several days. A week or so after the fit there was high fever, and an abscess formed over the right mastoid region which soon burst externally, giving exit to a considerable quantity of pus. For a short time the occipital and frontal headache of which the patient complained were much relieved, but soon recurred with increased severity. The man then entered an hospital, where the mastoid operation was done ; this, of course, gave no relief, since the disease
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was in the brain, and when the wound had cicatrised the patient was worse than ever. The headache became more severe and vomiting occurred several times daily ; the least noise or the ordinary daylight caused intense distress, and the general health steadily deteriorated.
In this state he was sent to an aural specialist in Rome, who diagnosed brain abscess, and at once pro- ceeded to try to open it through the mastoid ; after several attempts he succeeded in finding, at the lower level of the middle fossa, a fistulous opening in the squama through which pus came. This he enlarged to the size of a sixpence and incised the dura. A hundred c.c. of pus came away. A plug of gauze was inserted into the abscess cavity through the fistula. The temperature kept high for a few days. On the third day, when the dressing was removed and the plug pulled out, 50 c.c. of pus came away. After this the patient improved, and a fortnight later he left the hospital and became an out-patient. The mastoid wound healed up very quickly. The fistulous track became partly blocked by granulations but did not close, and at every dressing a considerable quantity of pus escaped through it.
If it was not at first obvious that the opening in the skull was insufficient to drain the abscess, this was soon rendered evident by the subsequent course of the case. The discharge continued without diminution, and symptoms of local brain lesion were added. Vertigo, violent headache extending all over the right side of the head, epileptic fits beginning with movement of the toes on the left side and preceded by hallucinations of smel^, were prominent symptoms. In spite of all this no attempt was made for twenty months to open up the skull and evacuate the brain abscess. Six " opera- tions " limited to curetting the wound and irritating the
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fistulous opening with the cautery were performed. Irrigation was attempted through a tiny silver tube inserted through the little opening in the skull.
After this lamentable waste of time and opportunity the patient, then in a very feeble state, came under the care of Roncali, who came to the conclusion that there must be a large abscess in the frontal lobe extending backwards to the Rolandic area. Making a free open- ing in the skull, he found and opened the upper abscess shown in the figure. Ninety c.c. of pus were let out. The
Fig. 53. — Abscess in the temporal and frontal lobes. (Roncali, in Chipault, vol. iii.)
The sphenoidal stalk, which was irrigated daily for so long, is seen. By this treatment, no doubt, at last pus was squirted into the frontal lobe.
cavity was explored with the finger and seemed as large as an egg ; it was irrigated through the fistula and through the wound until no more pus escaped from the fistula.
For two days all went well. On the third day there was fever, followed by drowsiness. Wound dressed ; no pus came from the abscess cavity, but some was seen trickling through the old fistula. Another fit occurred that day, preceded by olfactory aura. Next day more bone removed. A knife was inserted into the fistula and brought out through the already open abscess cavity. All intervening structures were divided ;
OF ABSCESS OF THE BRAIN 125
the track was very dense and offered great resistance to the knife. On washing the track thus laid open the dilatation of the sphenoidal stalk shown in the figure was seen. Two small orifices through which pus trickled opened into the upper part of the dilatation, a probe-pointed bistoury was inserted through each into the cavity beyond and an incision made downwards. Eighty c.c. of fetid pus were let out. Improvement for three days, then rise of temperature and death on the seventh day, probably from suppurative meningitis.
This case illustrates : some symptoms of temporo- sphenoidal abscess, namely, hyperacusia, and fits preceded by an olfactory aura ; the uselessness of operation limited to a cranial bone when the brain is suppurating ; the pernicious effect of syringing a brain abscess through a small tube whereby in this patient the pus was driven from the temporal into the frontal lobe ; and the fatal result necessarily attending a case of brain abscess when dealt with in a manner contrary to the principles govern- ing the treatment of abscess in other parts of the body. When the case came under Roncali's care it was too late to save life, but the measures he adopted were conceived in the true spirit of surgery.
Clijtical Evolution and Diagnosis.
The evolution of abscess wherever situated varies greatly. The initial local infection may be quickly subdued and a small local abscess alone result, well isolated, and giving the patient little more inconvenience than an encysted sterile foreign body ; or the abscess may slowly extend and burst, with favourable or unfavourable
126 SOME POINTS IN THE SURGERY
results according to the seat of rupture ; or the abscess may extend acutely from the first with severe or even fatal general infection ; the symp- toms— both those due to the abscess as such, and those due to the local lesion — necessarily vary in these different eventualities.
So in cerebral suppuration the complexity of the symptoms is not due to any peculiarity in the pathology of suppuration in the brain, but to the complex functions of the organ involved.
As abscess of the brain is a secondary and not a primary disease, the problem of diagnosis is often rendered the more difficult owing to the presence of symptoms which are, or may be, due to the primary disease, or to some of its complications. Suppuration in the brain, like suppuration elsewhere, varies within wide limits in its virulence and local destructive effects ; there will from this cause be wide differences in the clinical course of cases. The moment when infection reaches the brain is not commonly marked by any recognisable local symptom.
We may adopt the five types of clinical evolution so well described by Brissaud and Souques.
I. A sub-acute evolution more or less distinctly
OF ABSCESS OF THE BRAIN 127
divided into three stages : the initial febrile stage, the symptoms in which are those of septic or febrile infection ; headache, vomiting, and fever. Similar symptoms occur in the initial stage of specific fevers, and the distinction may at first prove difficult. This stage lasts a vari- able number of days and corresponds to the acute stage of the suppuration.
It is succeeded by the second stage, the stage of remission. Sometimes suddenly, more often gradually, the symptoms abate and give place to a period of calm, which is the more deceptive as it is sometimes prolonged. During this period, though few or no symptoms are manifest, there is, especially, as insisted on by Okada, when the abscess is in the cerebellum, emaciation and impairment of general health ; moreover, a thorough examination would in most cases raise the suspicion that gross brain disease was present or unmask some pathognomonic localising sign.
The third or paralytic stage supervenes in most cases suddenly as an " ictus " with or without convulsion; the apoplectiform condition may pass at once into profound coma terminating fatally in a few hours, or recovery from the seizure may take place with symptoms indicating a local brain lesion.
With the onset of the third stage there is
128 SOME POINTS IN THE SURGERY
generally renewed fever. The more rapidly fatal cases are associated with rupture of the abscess, the others with more or less rapid extension of the suppuration.
The above - described evolution of a brain abscess in three stages is quite comparable to the evolution of appendicular suppuration in three stages not unfrequently observed in cases not operated on in the initial stage. First there are transient symptoms of onset, then a period of quiet during which there is localised suppura- tion, and finally renewal of symptoms due to extension or rupture of the abscess.
2. The evolution with severe general infection. — These are rapidly fatal cases — the symptoms of brain abscess are merged in those of grave general infection ; high fever and acute delirious mania are prominent symptoms. Sometimes the history or the manifest presence of one of the known causes of brain abscess will arouse a suspicion of the existence of that complication ; more often the diagnosis is made of a malignant form of some specific fever or the disease known as acute delirious mania.
3. Evolution with complete latency until the final attack of coma. — The patient dies suddenly or in a few hours, and a brain abscess, evidently having existed for a considerable time, is found
OF ABSCESS OF THE BRAIN 129
at the autopsy. In some such cases death is absolutely sudden. According to Brissaud and Souques the abscess will then be found in the centre of the frontal lobe or in the postero- external region of the occipital lobe. I should like to point out that the right temporo-sphenoidal lobe is a much more frequent and equally " silent " site of abscess.
The term " latent " must not be misused in connection with these cases ; symptoms not noticed and symptoms not present are not synonymous terms ; some of the manifestations of gross disease of the brain cause the patient but little inconvenience and are only elicited by an attentive clinical examination. In but few of the recorded cases of " complete latency " is there any evidence that such examination has been made, and in fewer still have the patients been under skilled observation for a period of several days during which pulse and temperature have been regularly taken.
We all know that an examination of the optic discs, the field of vision, and the actions of the muscles of the eye, has revealed the gravity of an illness which from the patient's complaints alone might well have been considered trivial. And, on the other hand, that the omission of such an ex- amination has often led to an error in diagnosis.
K
I30 SOME POINTS IN THE SURGERY
No one would call an axillary abscess latent be- cause there was no pressure on the brachial plexus. Is it not possible that in at least some of the latent cerebral cases the latency has been in the faculties of the observer, not in the clinical reactions of the patient ?
4. In the fourth type the clinical evolution is just like that of brain tumour. — The infection is of low virulence and the abscess produces just those symptoms which a tumour growing in the same region and at the same rate would cause.
5. The fifth type of evolution is the retnittent type. — " Here the clinical evolution is in two acts, separated by an entr'acte of greater or less dura- tion. The first act is marked sometimes by headache and fever, sometimes by an attack of mania, sometimes by acute delirium. Then all quiets down and the patient seems cured. But after a few weeks, a few months, or even a year, follows the second act, which is commonly quickly fatal."
Bristowe's influenza cases previously referred to are examples of this type of evolution.
Case I. — A man, aged twenty-four years, was ad- mitted to hospital with right hemiplegia and paralysis of the left third nerve. There was incontinence of urine. Optic neuritis was present on both sides. The patient was apathetic and did not speak or attempt to speak.
OF ABSCESS OF THE BRAIN 131
He died three days after admission. About two months before admission he had an acute illness with shivering, severe headache, and convulsions. At the autopsy there was found in the upper part of the left fronto- parietal region an encapsuled abscess as large as a Tangerine orange, containing thick greenish pus. There was no disease of the cranium.
Case 2. — A girl, aged fourteen, had, one month before admission to hospital, an acute illness with shivering, vomiting, and severe headache. From this she appar- ently recovered in the course of a few days but she did not quite lose her headache. Two months later headache increased in severity and she had vomiting from time to time. When admitted to hospital, agonising pain in the head, rigidity of neck, left pupil larger than right, no optic neuritis, no paralysis, nor anesthesia. At the autopsy an abscess as large as a Tangerine orange was found in the right occipito- sphenoidal region, containing thick greenish pus. There was a small communication between the abscess and the descending cornu of the lateral ventricle which con- tained about a drachm of pus. No cranial disease.
Another example was a case I saw with Dr. James Taylor.
A man, aged forty years, was admitted to hospital on Sept. 14th, 1895, ^'^^^ severe occipital pain, vomiting, and slow cerebration. He had paralysis of the right sixth nerve and double optic neuritis. He lay on his right side in bed. There were forced movements to the right with rotation to the right in walking. With the eyes shut he fell backwards and to the right. In the beginning of May in the same year he had a severe
132 SOME POINTS IN THE SURGERY
illness with shivering, sweating, and rigor, said to have been of influenzal origin. This had been followed by- slight loss of power on the left side, from which he had recovered. About ten days before admission the head- ache and other symptoms returned. On the day following admission (September 15th) a rigor com- menced at 5.30 P.M.; at 6.30 coma was complete; at 7.30 artificial respiration was necessary and was con- tinued until I arrived. I was told that the case was thought to be one of cerebellar tumour. Considering it almost impracticable to remove a cerebellar tumour during the performance of artificial respiration, and thinking that the history of left -sided paresis might indicate involvement of the right cerebral hemisphere, I removed a large area of bone in the right parietal region. The brain bulged under great pressure, but natural respiration did not return. A trocar and cannula was plunged in up to the hilt and impinged upon a hard mass, into which it would not penetrate. As this was thought to be a solid basal tumour which could not be removed, the operation was abandoned. The necropsy revealed an encapsuled abscess containing an ounce of thick greenish pus, replacing the right optic thalamus. The capsule was very firm and about one-fourth of an inch thick. At the present day such an abscess or tumour coming under my observation would be enucleated.
Abscess may, apart from pyemia, occur in more than one situation in the brain at the same time. Thus it has been found simultaneously in the cerebellum and the temporo-sphenoidal lobe, in the occipital and the temporo-sphenoidal
OF ABSCESS OF THE BRAIN
133
lobes, and also in the frontal and temporal lobes. The simultaneous development of abscess in more than one situation must confuse the symp- toms and will probably render an exact dia- gnosis impossible. Unless the abscesses formed
Fig. 54. — Two abscesses in the brain. (Durante, in Chifault, vol. iii.)
Patient, ast. 7 years, suffered from fracture of the right parietal bone. This was followed by abscess in the temporal lobe which was drained.
Death was caused by abscess of the middle lobe of the cerebellum, and purulent infection of the ventricles.
one after the other, and the case was most carefully observed from day to day, successful treatment would be well nigh hopeless.
Diagnosis of Brain Abscess with Complications.
I. Abscess with meningitis. — The symptoms of abscess will be modified or controlled by those of meningitis, according as the abscess or the
134 SOME POINTS IN THE SURGERY
meningitis is the more prominent disease. In abscess complicated with meningitis the tem- perature is relatively high, the pulse quick, delirium, convulsions, and optic neuritis occur early, pain in the head is severe, and retraction of the head may be present, together with vomiting, squint, and irregular respiration.
2. Abscess co?nplicated by pyamia. — The lateral sinus is often involved in cases of cere- bellar abscess, the abscess in the cerebellum being secondary to sloughing of the wall of the sinus. The symptoms therefore are first those of pyemia and secondly those of abscess. As the abscess increases, the mental state becomes impaired, and the lower temperature and slower pulse of abscess replace the oscillating tempera- ture and rapid pulse of pyaemia.
3. Abscess complicated with acute hydrocephalus. — Acute hydrocephalus is no uncommon com- plication of cerebellar abscess. If an abscess burst or leak into one of the ventricles, general purulent infection of the ependyma occurs.
In one such case a cerebellar abscess was opened and all went vv^ell for seven days. On the tenth day after opening the abscess the following symptoms were observed : temperature 96°, pulse 50, apathy, screaming fits from pain in the head, dilated and stabile pupils. Acute hydro-
OF ABSCESS OF THE BRAIN 135
cephalus was diagnosed, Keen's tapping of lateral ventricle carried out, fluid escaped under pressure, next day remission of all symptoms. Five days later without warning the following symptoms appeared : temperature 105, pulse 140, wild de- lirium, unconsciousness, squint. Acute purulent infection of the ventricles diagnosed. Diagnosis confirmed by the escape of bubbles of gas and purulent cerebro-spinal fluid on withdrawing the tiny tube that had been left in the descend- ing cornu. Irrigation of ventricles with saline solution. The pus of the original brain abscess had yielded a pure culture of pneumococcus, therefore antipneumococcic serum was given. In 36 hours the ventricles contained nothing but cerebro-spinal fluid. The wounds assumed the pink colour characteristic of successful anti- toxin injection and ceased to discharge pus. Pulse temperature and general condition greatly improved and consciousness returned. Six days later patient again became unconscious and died. At the autopsy a second cerebellar abscess was found which had not been opened.
Rupture of abscess into the ventricles causes drowsiness, rapidly deepening into coma, high fever, and speedy death.
136 SOME POINTS IN THE SURGERY
Diagnosis between Brain Abscess and certain other conditions.
(a) Tuberculous meningitis and tuberculous tumour. — The symptoms and duration of tubercul- ous meningitis vary so greatly that diagnosis is often difficult, especially in childhood. When associated with chronic purulent otorrhcea the disease has been mistaken for brain abscess, and operative treatment undertaken which, of course, failed in its object. It is important to remember how often otitis in children is tuberculous, and that symptoms of intra-cranial disease, simulat- ing brain abscess, may arise from the presence of a tuberculous mass or masses in the brain or from tuberculous meningitis. The writer has many times experienced this difficulty in diagnosis. The cases of tuberculous meningitis in which suspicion of brain abscess is likely to arise are those of ear disease with palsy. The salient features in which a case of tuber- culous meningitis differs from one of brain abscess are : the temperature is above normal, the pulse is 100 or more rapid, optic neuritis is absent or is a late symptom ; except in certain acute cases, vomiting is neither so urgent nor so frequent as in abscess, and the child is apathetic
OF ABSCESS OF THE BRAIN 137
from the onset of illness, or even before illness is suspected is dull or irritable.
The predominance of certain localising symptoms in cases of tuberculous meningitis, especially of hemiplegia, has long been well known, and before the treatment of brain abscess by operation as a systematic procedure came into practice, these symptoms were often considered in relation to the diagnosis of meningitis from tumour. Several years ago I operated upon a case in which right hemiplegia was associated with left purulent otorrhoea, under the notion that a temporo- sphenoidal abscess was present, but the case proved to have been one of tuberculous meningitis.
[b) Marantic thrombosis of sinuses. — In young children intra-cranial thrombosis as a complica- tion of marasmus is not uncommon. It not unfrequently causes paralysis, and is sometimes associated with ear disease.
The main facts which distinguish these cases from abscess are : (i) The temperature above normal ; (2) the pulse more rapid ; (3) the slight degree of ear disease, and (4) the alternating paralysis of the eyes and face.
{c) Embolism, hcemorrhage, and thrombosis. — When an elderly patient who happens to have
138 SOME POINTS IN THE SURGERY
a discharge from the ear presents symptoms of brain lesion we naturally inquire whether the cerebral condition arose from the ear disease.
In the aged the temporal bones are sclerosed, and if tympanic disease arise it cannot produce an infection of the brain until sufficient time (months or years) has elapsed for the inflamma- tory process to pass through the dense boundaries of the tympanum ; the comparatively rapid intracranial infection seen in young children with unclosed sutures and soft bone cannot occur.
Again, in abscess of the brain due to ear disease the onset of the brain symptoms is gradual, and they may not reach their acme for two or three weeks, while in vascular lesions of the brain the symptoms may be fully developed in a few hours or, at most, days. In embolism the onset is usually instantaneous, and prolonged unconsciousness is rare. In haemorrhage the patient may be a sufl^erer from chronic heart or renal disease ; the onset is usually rapid and arterial pressure is in excess. In thrombosis the manifestation of the symptoms is more gradual and may extend over a few hours or days.
OF ABSCESS OF THE BRAIN 139
Treatment '
I. General considerations. — An abscess in the brain should be dealt with surgically on the same principles as an abscess elsewhere in the body, viz. by incision so planned as to evacuate its contents and to provide for free and spon- taneous drainage, or, in the event of the abscess being encapsuled, by its complete enucleation.
In operating for brain abscess, however, the surgeon has to find out as he goes on the size and exact situation of the abscess, the acuteness or otherwise of the suppurative process, and even whether he has to deal with circumscribed or diffused inflammation or with both, facts which are readily enough ascertainable by physical examination with regard to an abscess in an accessible situation. A case of acute cerebellar abscess which was opened with relief to the symptoms, died, and at the necropsy an old encapsuled abscess was found internal to that which had been opened.
When the abscess is found and opened, the brain tissue, which is of liquid texture and enclosed in an inextensile bony capsule, at once flows together in obedience to the laws of hydro- statics, and may shut off a portion of the abscess cavity from communication with the incision.
I40 SOME POINTS IN THE SURGERY
There is thus a difficulty in maintaining free drainage. The integrity of certain parts of the brain is essential to the continuance of life, and in certain directions a limit is therefore placed on surgical interference.
These general considerations, though they in no way modify the principles of treatment of brain abscess, have an important bearing upon the details of operation.
2. Operation for brain abscess following local cranial disease. — It has been already said that in brain abscess, following frontal or temporal bone disease, the suppurative process has extended by direct continuity from the disease in the bone to the white substance of the brain. The operation for the evacuation of the abscess should there- fore be a direct continuation of the operation for the removal of the disease of the bone.
Every endeavour must be made to discover, follow out, and remove the pathway traversed by the infective process through the bone into the interior of the skull. If, for example, in the course of a mastoid operation this is not discovered, and the symptoms point clearly to the abscess being in the cerebellum or in the temporo- sphenoidal lobe, the surgeon should work his way in the one case from the inner or posterior wall of the antrum to the posterior
OF ABSCESS OF THE BRAIN 141
surface of the petrous, and in the other he should enter the middle fossa by removing the roof of the tympanum and attic. So much of the petrous or squama must be removed as is necessary to thoroughly expose the extra-dural abscess or the diseased portion of the dura re- presenting the point of attachment of the abscess to the meninges. Thus by the adoption of this route for the evacuation of the abscess, we recognise that the abscess is, in most cases, not an isolated globe within the white substance, but has a narrow portion or stalk passing through the cortex and adherent to the dura at the original site of infection.
This stalk is the track through which the infection entered. Its lumen presents a ready- made channel, with fibrous walls through which drainage can be effected and the infective material made to leave the brain. This natural tube is not liable to be obstructed by the flowing together of the liquid substance of the brain by which the efficiency of all forms of artificial drainage tube is so much impaired. If, then, the abscess can be tapped through the stalk itself without the knife passing through healthy cortex and meninges, there would be efficient drainage without risk of suppurative meningitis or hernia cerebri.
142 SOME POINTS IN THE SURGERY
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11 |
r |
-^y /A |
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Hi^-i" |
T |
'" "m |
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^^^H -" |
m |
v/^,/^/Ma^H |
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Fig. 55.
Fig. 56.
Fig.
Fig. 55. — View from above of portions of the left middle and posterior fossae. G, eroded edge of tegmen antri ; «, site of tegmen antri destroyed by disease ; f, trephine opening through which cerebellar abscess (D in Fig. 57) was drained ; r, tegmen tympani j g, remains of tegmen antri. The tympanum and antrum are enlarged by erosion. A black style projects through the opening, which leads from the antrum into the posterior fossa.
Fig. 56. — Sketch of upper surface of cerebellum, showing by a dotted line the extent of the undrained abscess. * marks the place where the stalk of the undrained abscess was adherent to inflamed dura at site of carious erosion on posterior surface of petrous. LL, line of section shown in Fig. 57.
Fig. 57. — Drawing of transverse section of cerebellum, corresponding to line LL in Fig. 56. The drawing tepresents the posterior part of the specimen seen from in front. D, track along which one cerebellar abscess was drained through the trephine opening {t in Fig. 55); MM, amygdalas ; S, undrained abscess. This abscess measured (see Fig. 56) 53 mm. from side to side, 28 mm. in the antero- posterior direction, and about 14 mm. from above downwards. After hardening the depth of the abscess appeared greater than when the specimen was fresh. The abscess was close to the upper surface of the cerebellum.
OF ABSCESS OF THE BRAIN 143
In a cerebellar abscess the point of attach- ment of the abscess to the dura is over the sinus groove, over the aqueductus vestibuli, or over the internal auditory meatus. In temporo- sphenoidal abscess the point of attachment is over the anterior surface of the petrous, and most commonly to the dura covering the tegmen. In frontal lobe abscess the point of attachment is usually on the cranial wall of the sinus. In deep abscess following injury the point of attachment of the stalk is in the region of the fracture.
Drainage through the stalk would, if successfully accomplished, remove all urgent symptoms and obviate the tendency to death. In some cases no doubt such an opening would not be sufficient to effect a cure, and the surgeon would be obliged to make a counter-opening, as he would in other parts of the body. To do this it is desirable to remove a considerable area of bone, and then to open the dura and pack the wound with gauze, so as to get the area of the brain through which an incision is to be made isolated by adhesions, on the principle so long rendered familiar by colotomy and similar operations. By doing the operation in this way a new point of attachment of the abscess to the dura is formed, and the danger of
144 SOME POINTS IN THE SURGERY
diffuse encephalitis avoided. The area of bone to be removed will be determined by the position and size of the abscess, as ascertained by a probe passed through the open stalk.
In some cases when, for example, respiration
Fig. 58. — Frontal lobe abscess secondary to frontal sinus disease. (Modified from Killian.)
Note the stalk of the abscess springing from the cranial wall of the frontal sinus. Such an abscess is commonly situated in the white matter of the basal part of the first frontal convolution. As it extends backwards it tends to involve the corona radiata and anterior end of the internal capsule, causing paresis of face, tongue, arm, and leg in the order named on the contralateral side. Killian says, " In a very instructive' case, in which recovery took place, I was able to observe motor disturbances arise and completely disappear after the operation."
has ceased, the condition of the patient is so bad that there is no time to follow a possibly tortuous route through which the disease found entrance to the brain. At all costs the abscess must be evacuated quickly. The abscess must then be reached by the most direct route and by
OF ABSCESS OF THE BRAIN 145
the most rapid method. Just as in some cases of intestinal obstruction the bowel must be emptied without reference to the cause of ob-
\.:..4
Fig. 59. — Abscess of cerebellum occupying the anterior and inner part of the left hemisphere.
a, abscess ; f, flocculus. The tract through which abscess was opened is visible. Two bristles pass into the abscess through an opening in the cerebellar cortex opposite the internal auditory meatus. The day following opening of abscess patient died.
Autopsy. — Pus in labyrinth and internal auditory meatus. Dura adherent, softened, and perforated opposite internal auditory meatus.
The illustration shows how a cerebellar abscess should not be opened. The direct route to open the stalk was through the petrous.
struction, so in certain cases of brain abscess the abscess must be evacuated before dealing with the local bone disease.
L
146 SOME POINTS IN THE SURGERY
On two occasions in my experience it has happened that with the first few inhalations of chloroform respiration ceased, and the opera- tion had to be completed during the performance of artificial respiration. In another, artificial respiration had been in progress two hours before I arrived. Neither morphia nor strychnia
Fig. 60. — Drawing to show the direction in which the complete mastoid operation should be extended in order to drain a cerebellar abscess through its stalk. The oval marked by a black line indicates the region between the sigmoid sinus behind and the facial canal in front, where bone may be safely removed. Working cautiously inwards with burr or gouge, the operator will come upon the stalk of a cerebellar abscess attached to the dura, on the inner side of the sinus, or anywhere on the posterior surface of the petrous as far inwards as the internal auditory meatus. The operation is easier when there is a visible carious track.
should be administered before the dura has been opened.
3. Discovery atjd incision of the abscess. — The abscess may burst as the dura is opened. When there is a sufficient opening in the bone and dura it may be possible to determine by palpation that the abscess is immediately sub-cortical. An incision should then at once be made through
OF ABSCESS OF THE BRAIN 147 the intervening portion of brain substance into
Fig. 61. — Coronal section of left cerebral hemisphere from a man, aged 29, displaying a small temporo-sphenoidal abscess 1 cm. in diameter, situated just above the tegmen tympani. The abscess was secondary to chronic otitis media. The rod lodged in the brain above the abscess shows the track made by the trocar at the operation performed for the relief of the disease. This track just misses the abscess cavity. The patient died of meningitis. (Norwich Hospital Museum.)
Remarks. — Compare with Fig. 59. The illustration shows how a temporo- sphenoidal abscess should not be opened. The direct route to open the stalk (attached to the tegmen) is through the tegmen.
the abscess cavity, care being taken to avoid
148 SOME POINTS IN THE SURGERY
wounding the vessels, as in other parts of the body. The use of a trocar and cannula, pus- seeker, or other special instrument is unnecessary. If the site of the abscess is not obvious it must be sought for by exploratory puncture, and in so doing it should be remembered that the site of the abscess is almost certainly close to the bone disease which gave rise to it. The best instrument to use is a sharp-pointed, long, and narrow knife. Our brains are not like Satan's —
Entrails, heart or head, liver or reins — which Milton tells us could
Not in their liquid texture mortal wound Receive, no more than can the fluid air ;
and a wound made by the surgeon's knife will not heal quite so readily as that inflicted by the sword of Michael ; yet in the brain, as else- where, clean cut wounds heal more readily than any others, and there is certainly less risk of missing an abscess with the knife than with any other instrument.
There have been cases in which the trocar and cannula has — i. Missed the abscess. 2. Passed through it without tapping it. 3. Struck the capsule but failed to penetrate it.
The use of the knife for the evacuation of an abscess of the brain is not a new operation,
1
OF ABSCESS OF THE BRAIN 149
but was taught and practised more than a century ago. Dupuytren in one of his lectures says : —
"In certain cases of deeply - seated fluid collections we must incise the dura mater, the arachnoid, the brain itself, if the focus is at the surface of this organ, and by this bold pro- ceeding patients have been saved."
And a little further on in the same lecture he continues : —
" Relying also on the success of J. L. Petit, Boyer concurs in the advice of Quesnay, and does not fear to plunge the bistoury quite deeply (assez profondemeni) into the very sub- stance of the brain in order to evacuate traumatic effusions which may have formed there, and it has fallen to my lot to do so several times with success." Like many another step in the advance of knowledge, this advice, though justified by some brilliant successes, remained for a considerable time a dead letter, for we find a great English surgeon writing nearly half a century later : " There are few surgeons who would have the hardihood of Dupuytren, who plunged a bistoury into the substance of the brain and thus luckily relieved the patient of an abscess in this situation." Dupuytren, in his account of this historical case, says simply :
150 SOME POINTS IN THE SURGERY
" I incised the dura mater, nothing came out ; I thrust a bistoury cautiously " (? so as to avoid the vessels of the cortex) " into the brain and there welled up immediately a flood of pus. That very night all the symptoms disappeared and the patient recovered."
If careful exploratory puncture with the knife fail to find the abscess, the finger inserted into the brain substance will almost infallibly detect the presence of a tense, abnormal swelling, and however deep the abscess is it may be safely opened by the knife guarded by the finger. Mistakes, however, may still be made, as in two cases I treated many years ago. In one of these one cerebellar abscess and in the other two had been opened, yet both patients died from an unopened abscess, oyster- like in shape, lying immediately beneath the cortex of the upper surface of the cerebellar hemisphere. The examining finger felt the sensation of resistance, but this was attributed to the tentorium.
The stalks of these abscesses would probably have been found and their contents evacuated had they been approached by way of the disease in the temporal bone.
OF ABSCESS OF THE BRAIN 151
Progress of the Case.
The course of brain abscess is, as I have shown, very variable.
The earlier the operation is carried out the greater the chance of success, hence the condition having once been diagnosed action should never be delayed.
I have known of cases where operation has been arranged for the following morning, but the patient died in the night.
Unless the patient is actually moribund the operation should be done. Even cessation of respiration is no bar to success in cases of brain abscess, for the operation has been carried out during the performance of artificial respiration and the patient has recovered.
After the operation the patient may rapidly convalesce or may present symptoms which will tax to the utmost the resources of the surgeon. A voracious appetite is a favourable sign.
Just as symptoms may arise after an operation for appendicitis which give rise to anxiety lest the infective process should still be in progress, but which are merely due to temporary paralysis of the gut or to some other manifestation of the functional disturbance of the abdominal contents caused by the disease or the operation ; so after
152 SOME POINTS IN THE SURGERY
an operation for the relief of an intra- cranial infection, symptoms such as vomiting, fever, and delirium may continue or newly arise during convalescence and give rise to similar anxiety, but may nevertheless be likewise due merely to disturbance of cerebral function and not call for operation. Apart from this, however, it is by no means uncommon to have definite recurrence of symptoms a few days after the evacuation of an abscess of the brain, due either to the re- filling of the abscess cavity from faulty drainage or to the formation of a new abscess in another part of the same lobe. The new symptoms are much modified by the skull being opened, and may suggest conditions, such as meningitis or acute distension of the ventricles, which are not present. The surgeon must not suflfer himself to be led astray by idle speculations as to the explanation of the symptoms, but must con- centrate his attention on the region where he has already found abscess, and whatever the symptoms may be must explore the same region of the brain.
During apparent convalescence some cases of brain abscess begin to retrograde without evident reason, and finally end fatally. A similar event occurs occasionally after the removal of large brain tumours, and depends on a general
OF ABSCESS OF THE BRAIN 153
nutritional failure. In these cases large areas of brain are involved, and the healing process exhausts the vitality of the patient.
In my surgical life the evolution of the operation for brain abscess has advanced a good stage towards perfection. Not many years ago but few surgeons had even made any attempt to operate for brain abscess ; but at the present time in every surgical clinic such operations have been performed.
Although we are at present only on the threshold of a perfect understanding of the surgical treatment of abscess of the brain, yet the labour of many workers during the last twenty years has not been in vain, and the future is bright with promise.
REFERENCES.
Bristowe. British Medical Journal, I 89 1.
Claytor. Philadelphia Medical Journal, March 2, 1901.
Stoll. American Journal of the Medical Sciences, Feb. 1906.
Blottche. Quoted from Stoll.
Cayley. Pathological Society's Transactions, vol. xxxv. (1883),
p. 12. Pye-Smith. Pathological Society's Transactions, vol. xxviii. ( i 876),
p. 4. Rudolph Meyer. Zur Pathologie des Hirnabscess, 1867. Newton Pitt. British Medical Journal, 1890. Preysing. Zeitschrift fur Ohrenheilkunde, vol. xxxv. p. 108, and
vol. xxxvii. p. 208. Salzer. Weiner klinische Wochenschrift. Band iii. No. 34, Manasse. Zeits. f. Ohrenheilk., vol. xxxi. p. 226. Swain. Zeits. f. Ohrenheilk., vol. xxxi. p. 351.
154 SOME POINTS IN THE SURGERY
Bf.rgmann. Die Chirurgische Behandlung von Hirnkrankheiten.
Third edition. KuMMEL. Zeits. f. Ohrenheilk., vol. xxviii. p. 259. RoNCALi. In Chipault, Ltat actuel de la Chirurgie nerveuse,
vol. iii. Jackson and Beevor. Brain, 1887. Ferrier. The Functions of the Brain. Mills. Article in Dercum's Text-Book of Nervous Diseases and
other papers. Broadbent, Charcot, Ross, Bastian, quoted from
Mills. Preysing. Archiv f. Ohrenheilk., vol. li. p. 266. Brissaud and Souques. In Traite de medecine, Charcot-Brissaud.
Second edition, vol. ix. Piorry. Traite de diagnostic (1838), vol. iii. p. 294. Beevor and Jackson. Loc. cit. RoNCALi. Loc. cit. Brissaud and Souques. Opus cit.
Okada. Diagnose und Chirurgie des Otogenen Kleinhirnabscess. Paradise Lost. Book vi., line 346.
DupuYTREN. Lefons Orales. Second edition, vol. vi. pp. 183-84. Erichsen. The Science and Art of Surgery. Seventh edition,
(1887), vol. i. Stephen Paget. Clin. Soc. Trans., vol. xxx., " On Cases of
voracious Hunger and Thirst from Injury or Disease of the
Brain." The suggestion is made that there are special centres
in the brain for the perception of hunger and thirst, situated
near the olfactory centres.
Note to page 112.
I have recently had another case illustrating anomia.
J. B., aged thirty-four, was admitted to the National Hospital under Dr. Beevor. He had had discharge from the left ear ever since he could remember. Last January the mastoid operation was done at a throat