The treatment of brain abcess by unroofing and temporary herniation of abcess cavity with the avoidance of usual drainage methods : with notes on the management of hernia cerebri in general / by Joseph E.J. King.

  • King, Joseph E. J.
Date:
1924?]
Catalogue details

Licence: In copyright

Credit: The treatment of brain abcess by unroofing and temporary herniation of abcess cavity with the avoidance of usual drainage methods : with notes on the management of hernia cerebri in general / by Joseph E.J. King. Source: Wellcome Collection.

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    4. Cosmetic reasons. The scalp plastic, however, should be de¬ ferred for a period of 1 year to 14 months, so as to avoid the possibility of latent infection. Cranioplasty. After a period of about ijd> to 2 years, following the original operation, the cranial defect can be repaired according to the method used by us in the neurosurgical services in the late war and also in the hos¬ pitals in civil practice. This subject will not be discussed as it was fully covered in a previous paper (5). REPORT OF CASES Case i, M. L. New York Eye and Ear In¬ firmary, No. 2838. Register No. 7558. Age 28. Russian Hebrew. Occupation, cutter of men’s clothes. Admitted to the Service of Dr. John Mc¬ Coy, on July 5, 1920. History. Four weeks ago patient had a severe pain in left ear. On the following day, the ear drum was punctured. It drained for about 10 days, when drainage suddenly ceased. The bone behind the ear then began to pain, and although discharge from the ear again appeared, the pain continued behind the ear. This condition lasted for about 12 days. On the day previous to his entering the hos¬ pital, there was swelling behind the ear. The right ear was negative on examination. The past and family history were negative. Physical examination. Bulging of tympanum, sagging of the canal wall and swelling behind the ear over the mastoid area. Temperature 101.2 degrees; pulse 84; respiration 22. July 3, 1920. Roentgenographic examination, plate No. 10102 (ordered from Dispensary). Right is fairly clear, pneumatic. Left is very cloudy and there is evidence of breaking down over the lower part of the sinus. Operation, July 7, 1920. Operator, Dr. McDou- gall. Anaesthesia, gas and ether. Simple mastoidec¬ tomy, left. Usual postauricular incision, perforation through cortex, midway between knee and bulb, cortex removed, free pusJ found. Mastoid cells broken down, filled with free pus. Dural exposure in mid-fossa, reveals epidural abscess or collection of pus. Free pus oozing from antrum. Perisinus abscess. Large area of dura exposed in mid-fossa by disease. Sinus exposed from knee to bulb. Three pieces of iodoform gauze inserted and wound closed with silk-worm gut sutures. July 9. First dressing. July 13. Discharge from canal, slight; from posterior wound, moderate. Patient complains of pain in temporal region at night; also daily, and con¬ stant headaches. July 16. Red blood cells, 5,200,000; white blood cells, 18,200; polynuclears, 90; lymphocytes, 10. July 16. Canal, almost dry. Thin purulent dis¬ charge from wound. Granulation tissue healthy. July 20. Wound in healthy condition. July 20. 10 a.m. Patient seems dull and does not answer questions. He is unable to return to bed without assistance on account of tendency to fall forward. A few minutes later he answered questions intelligently but did not remember his dressings or any of the above instances. Pupils unequal. Right larger than left; both react to light. (Atropine yes¬ terday). No vomiting; no nystagmus; no dizziness (?). Aphasia. Patient unable to name objects but can tell what they are used for; says he has trouble in remembering names for past few days. Slow cere¬ bration, astereognosis. July 20. Ophthalmological examination: O. S. A slight lateral nystagmus present. Cornea clear. Anterior chamber normal. Pupil reacts to light and distance. Lens and media clear. Fundus examina¬ tion shows myopia, about 5 diopters. There is a hyperaemia of the nerve head. The physiological cup is obliterated. The vessels are somewhat tor¬ tuous and there is a break as if it were a very small haemorrhage. O. D. A slight lateral nystagmus; Cornea clear; Anterior chamber normal depth. Pupil reacts to light and distance. Lens and media clear. Fundus examination: Myopia about 5 diopters. The nerve head is congested. The physio¬ logical cup is obliterated. The vessels are apparently normal. There may be very slight swelling of the nerve head. Diagnosis: 0. S. Beginning: neuritis. O. D. Suspicious of beginning neuritis. July 20. 4 p.m. Was called in consultation by Dr. Stuart L. Craig of Dr. McCoy’s Service. The prob¬ ability of the diagnosis of brain abscess, temporo- sphenoidal lobe, left, made by Dr. McDougall is very likely. His diagnosis was based on the following findings: (1) astereognosis, (2) sensory aphasia, (3) drowsiness and stupor, (4) constant headaches, (5) symptoms coming on following simple mastoidec¬ tomy, left, 13 days ago. However, on account of the dura having been exposed at the time of opera¬ tion, it is considered advisable to revise the wound and explore for possible extradural abscess, after further removal of bone. If no abscess is found, extradural, it is the intention to pack the wound with gauze, wet in Dakin’s solution, apply a wet gauze dressing and observe the patient for a day or two. If the patient’s condition does not improve, exploration through the cranial defect which had been enlarged above the site of the mastoid process could be performed. In the meanwhile, the dura will have become adherent to the cortex and exploration beneath the dura could be more safely done on account of the area being walled off. The pulse is not slow (80); temperature is 99.2 degrees. July 20. Lumbar puncture; cerebrospinal fluid clear, Fehlings, 1 plus; globulin. 1 plus; cells, 30 per cubic millimeter. Culture negative. Operation, July 20, 4:30 p.m. Revision of wound. Simple mastoidectomy, left. Operator, Dr. King. Assistant, Dr. McDougall. Anaesthesia: gas, oxygen, and ether. Wound was opened up, small collection of pus beneath skin flap. The cranial defect which was