The treatment of brain abcess by the induction of protective adhesions between the brain cortex and the dura berfore the establishment of drainage / Charles E. Dowman.

  • Dowman, Charles E.
Date:
1923
Catalogue details

Licence: In copyright

Credit: The treatment of brain abcess by the induction of protective adhesions between the brain cortex and the dura berfore the establishment of drainage / Charles E. Dowman. Source: Wellcome Collection.

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    Brain fungus can hardly occur unless an opening is made in the skull and dura, of a size sufficient to allow the brain to protrude. If the necessary opening is made just large enough to permit the entrance of the exploring needle and for the small drains to follow, the brain meets a natural barrier instead of an opening and cannot, therefore, escape. TECHNIC OF OPERATION Before selecting the point of attack, every reasonable method for accurate localization should be used. An entrance through contaminated areas (frontal sinus or mastoid) should be avoided for two reasons: First, the diagnosis of abscess may prove wrong; second, the abscess, if present, may not be reached with the exploring needle. By taking this precaution, the danger of producing an infection of the cranial contents will be obviated. The incision should be just long enough to permit the entrance of a perforator and small burr. It should be made as nearly as possible over the suspected site of the abscess. After a small opening has been made through the skull, the dura is incised, the incision being just long enough to assure the operator that a cortical vessel will not be injured by the exploring needle. An ordinary straight ventricular puncture needle, with centimeter markings, is then inserted in the direction of the suspected abscess. As soon as the abscess is reached and a few drops of pus have escaped into a sterile test tube, the needle is with¬ drawn slightly until the pus ceases to appear. The exact depth and direction of the needle are then calculated. The prevention of the free escape of pus at the time of operation cannot be too strongly emphasized. In the first place, a contamination of the wound is to be avoided, a condition which can hardly be pre¬ vented if the pus is allowed to escape freely through and around the needle. In the second place, the thorough evacuation of the contents of the abscess at this time may relieve the increased intracranial pressure to such an extent as to allow the brain cortex to lose its firm contact with the dura at the point of incision and to permit infection of the neigh¬ boring meninges. Such a spread of the infection can be prevented if the cortex becomes firmly adherent to the dura around the dural opening before free drainage is established. After the depth and direction of the abscess have been calculated, the needle is entirely withdrawn, and a small filiform drain of folded rubber tissue is inserted down the track of the needle in the direction of, but not into, the abscess. The wound is then covered with a properly fitted dressing, which is not changed for two or three days. During this time, the rubber tissue wick, acting as a foreign body, stimulates the formation of adhesions between the brain cortex and the dura, forming a well-defined ring around the drain. At the first dressing, the wick