Discussion on the diagnosis and treatment of abcess of the brain : opening papers.

Date:
[1934?]
Catalogue details

Licence: In copyright

Credit: Discussion on the diagnosis and treatment of abcess of the brain : opening papers. Source: Wellcome Collection.

    21/44 (page 1663)
    of smell which occurred daily, aud attacks of falling without warning, which com¬ pletely interfered with his work. When he came under our care he had evidence of intense scarring at the site of the old abscess with a traction diverticulum of the frontal horn of the left lateral ventricle (fig. 13). Free excision of the left frontal pole failed to relieve his fits. Mistakes in Diagnosis and Treatment In certain cases, owing to the intensity of the infection and low resistance of the patient, the chances of a successful result from surgical treatment are probably extremely poor from the very beginning. Thus, cases in which the pus shows a free and abundant growth of bacteria, and cases in which most of the accessory sinuses are heavily infected fall inro this group. But there are many cases in which death is due not so much to the inability of the patient to localize and limit the infection as to our inability to find and deal adequately with the abscess. Undoubtedly the greater number of failures of this type are due to mistakes in diagnosis, but we will first consider errors of treatment. Errors of Treatment Assuming that the surgeon approaches an operation for brain abscess with a clear idea of how abscesses of varying types should be drained, and that he is reasonably gentle in his handling of the brain, the mistakes that he can make in treatment are relatively few. For, though after a death in a case of brain abscess he may feel that some detail has been responsible for a bad result, yet in the light of the post-mortem examination and later reflection this often proves to have been false. If an abscess has been operated on at the right time and the right type of operation has been done there is a good chance of recovery. (1) The wrong type of operation is performed. — Thick-walled multilocular abscesses cannot be treated satisfactorily by drainage but require dissection and total removal, or marsupialization. Abscesses in which the pus is very thick are probably best treated through an osteoplastic flap. (2) The abscess is missed ivith the exploring needle.—This happened in one of our cases of chronic recurrent frontal abscess in which the correct diagnosis was made. At necropsy the abscess was a thick-walled abscess containing a little thick pus, and it was so low in the frontal lobe that its capsule presented on the inferior surface of the brain. The patient was comatose from cerebral oedema at the time when he came into hospital, and there is little doubt that the only possible chance of success would have been an immediate osteoplastic exploration with dissection of the abscess and a wide decompression. If the abscess had been found with the exploring needle, the major operation would probably have been performed. In one of our cases treated by an osteoplastic flap the exploring needle entered the abscess cavity but no pus escaped. When the needle was withdrawn a plug of fibrino-purulent material was found in its eye. The material in a needle after exploratory puncture of the brain always repays examination. (3) The tube is blocked.—Coleman considers that pus can usually escape around the sides of a blocked tube, but in one of our cases of frontal abscess blockage of the tube undoubtedly contributed to the patient’s death. Gauze became plugged against the opening of the tube. It is preferable to cover the drainage tube with sheet guttapercha which will not stick. (4) Oblique drainage.—Abscesses that are drained obliquely, instead of at right angles to the skull at the point where the abscess is nearest the surface, do not ' drain satisfactorily. (5) Operation too early will produce an unfavourable result in a case that otherwise might end well if operation was delayed until a capsule formed. Thus in a patient with a streptococcal frontal abscess following infection of the maxillary