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Brain abscess; heart block; syphilis
BRAIN ABSCESS; HEART BLOCK; SYPHILIS* JOSEPH
E.
BRAUNSTEIN,
M.D.
Attending Surgeon, Greenpoint Hospital BROOKLYN,
T
HIS case of an acute subcortica1 brain abscess of otitic origin in the Ieft temporosphenoida1 lobe, is reported because of an evident cure obtained by the institution of a simpIe surgica1 procedure done despite the grave co-existing complications of heart block and syphilis. H. I?., a married female, twenty-five years of age, was admitted to the Greenpoint Hospital, March 3, 1936, complaining of a generalized headache and discharging left ear. Past History. She had had measIes during childhood. There had been one miscarriage at two months and one child had died at the age of five and one-half years. She used aIcoho1 and tobacco in moderation. The history reIative to her left ear was very indefinite and unsatisfactory, but she recalled having had some trouble beginning at the age of fifteen years but couId not describe the character; she also believes she had some trouble three months prior to admission to the hospital. Present illness began one week before her admission with pain in her left ear and two days before admission it discharged a IittIe. She had a generalized headache and had vomited twice. Physical examination revealed an apathetic drowsy individua1, fairIy we11 nourished, respondmg poorIy to questions. There was a questionable facial weakness of the right Iower haIf and the tongue deviated to the right. The pupiIs were equa1 and reacted to Iight and accommodation. There was some weakness of right hand and a questionabIe adiadochocinesis. All abdomina1 reflexes were absent; the knee jerk was diminished on the right but there was no ankIe cIonus, Babinski or neck rigidity. A smal1 ny-stagmus on Iooking to the right and to the left was present. The right eye showed a beginning papilledema; the left eye was normal. There was no past pointing. Some
N. Y.
sweIIing of the right buccal region and pyorrhea alveoIarus were evident. The nasal cavities contained some free pus. The right ear drum was intact but was retracted anteriorIy, with a caIcified area and scar in the posterior aspect. Left ear had a foul pulsating discharge, showed an otitis externa. The drum couId not be visualized entireIy. No cholesteatoma was seen but there was a question of a dehiscence in the anterior superior quadrant of the drum. Hearing apparently was good on both sides. A normal response was obtained when the Ieft ear was douched with ether. The lungs were clear. Systolic and presystohc
murmurs were heard at the apex of the heart. The pulse rate was 32 beats per minute; temperature 99.2 F., and respiratory rate 20. Clear spinal fluid was obtained under marked pressure and the cell count showed 18 Iymphocytes. The bIood count reveaIed 5,050,000 erythrocytes with go per cent hemogIobin; 23,500 leucocytes with 94 per cent poIymorphonuclear and 6 per cent Iymphocytes. Roentgenogram of the paranasa1 sinuses showed slight cloudiness of t’he right frontal sinus. The right mastoid was sclerotic; the left mastoid was impossible to examine but no fracture was demonstrabIe. There was no suggestion of increased intracerebra1 pressure. The seIIa turcica fossa was of medium size and showed no abnormality. One hour after admission an eIectrocardiogram showed an auricular rate of 50 and a ventricular rate of 30. The main finding in a11 four leads was a compIete dissociation of the auricIe from the ventricle. Examination. On March 5 a11 symptoms became more marked. The Ieft pupi was diIated and the right appeared contracted; doubIe choked disc but greater on the Ieft. There was marked stupor and apathy; the patient couId not raise her right arm or hoId it up in position. Her temperature was 99.6 F., puIse rate 28 and blood pressure 150/80. The
* Presented at the Otolaryngological Section, Kings County MedicaI Society and to the Staff Conference at the Greenpoint Hospital, May 21. 1936. From the OtoIaryngoIogicaI Service of Greenpoint HospitaI, Brooklyn. 609
610
American
Journal
of Surgery
Braunstein-Brain
spinaI tap about go/60 C.C. of a cIear fluid was obtained under pressure; count showed 30 cells; globulin 3; Kline test positive; sugar
FIGS. I
AND
2.
Abscess
to the skin. Another catheter was placed within the outside dressing for daily irrigation with Dakin’s solution. Additiona treatment insti-
FIG. 2. FIG. I. Roentgenogram of skull (after operation) showing circuIar area of decompression parietat region. Drainage tube in situ extending into abscess cavity.
74.1 mgm per I00 c.c.; Wassermann 4 PIUS; and cuIture showed no growth. The urine was negative except for I + albumin. Diagnosis. Right chronic adhesive otitis media; Ieft chronic puruIent otitis media with an acute exacerbation; Ieft temporosphenoida1 compIete heart bIock with brain abscess; severe myocardia1 damage. Operation. On March 5 a vertica1 incision over the Ieft temporoparieta1 region was made about one inch above the tegmen region through the soft parts which were then eIevated and retracted. A round defect in the bone was created with a one inch trephine exposing the dura which was under pressure but not necrotic. A strip of iodoform gauze was packed tightIy around the circumference where the edge of the bone met the dura. The dura was incised for about fs inch. A brain cannuIa was introduced for about 4 or 3 cm. forward and inward. No resistance was encountered, and pus made an immediate exit. The abscess cavity was allowed to empty itseIf sIowIy of about 4 or 5 oz. of a fou1 creamy pus, aiding it by moving the head from side to side. The dura incision was then Iengthened to about ?i of an inch. A smaI1 herniation occurred and the protruding brain tissue was removed. Two inches of a 14 F. rubber catheter with fenestrated end was introduced into the abscess cavity and an overhang of about one inch was spIit and sewed
MARCH,,937
in left
tuted Iater, consisted of six injections of bismuth in oiI and protoiodide of mercury by mouth. ImmediateIy after the operation Progress. the puIse rate was 48, temperature was 100.6F., respirations 16. An eIectrocardiogram postoperatively showed the presence of a complete A.V. dissociation. A cuIture of pus obtained from the brain abscess grew Streptococcus non-hemolyticus and StaphyIococcus aureus. A direct smear showed gram-positive cocci in short chains. CuItures made from March IO and ending ApriI 13, showed the foIIowing types of bacteria: Staphylococcus aIbus, gram-positive cocci in chains, StaphyIococcus aureus, streptococcus and gram-positive baciIIi. The patient improved immediateIy foIIowing the operation; she responded to questions, and although she couId not name objects she would describe their use. This aphasia Iasted about a month. The right Iower facia1 weakness continued to be present, but less marked, unti1 it became very questionabIe by May I I. Deviation of the tongue Iessened graduaIIy and disappeared entirely. The Ieft pupi was diIated no Ionger; both pupiIs were equa1 and responded to light and accomodation; choked disc was more marked on the right side with hemorrhages in the Ieft but a11 disappeared by ApriI 20. The patient was now able to raise
NI..~
Sm,ts
Vo..
XXYV,
No.
Braunstein--Brain
3
the right arm, except for a slight weakness which disappeared Iater. Hearing was fair. On March 8, an electrocardiogram was taken and three-quarters of an hour Iater atropine suIphate grain j is” was administered and another electrocardiogram taken. The first one taken on this day resembIed that of March 5, but the one foIlowing atropine showed an increase in the ventricuIar rate 40/60, but compIete dissociation of A.v. was stiI1 present. Another eIectrocardiogram on April 2 showed that the dissociation was not apparent as readily but the widened and prolonged P.R. interval and irreguIar T waves showing T and P waves confined and superimposed indicated the dissociation. No pus drained from the wound unti1 three days postoperativeIy, after which there was a scant sanguinopuruIent or a sanguinous discharge. At times some brain tissue was expeIIed. This was sectioned and reported to be edematous and infiItrated by poIymorphonucIears, and in one area showed an overIying puruIent exudate. The Iaboratory diagnosis was brain tissue with inflammatory changes. A tract was established graduaIIy within which the catheter drain couId be moved in and out without difficuIty. An x-ray picture after the operation (Figs. I and 2) of the Ieft IateraI and anteroposterior views showed a circuIar area of bone removed from the Ieft parietal area with a shadow of one rubber drainage tube extending downward and inward for about 2 inches into the crania1 cavity, and was reported by L. P. Vanwinkle. This drain was changed every other day, using a 13 and then an 18 F. catheter. The drain was shortened to one inch and finalIy removed on ApriI 13. Temperature was then 99.2 F., pulse rate 60, and on ApriI I 8 the patient was discharged from the hospita1 with a norma temperature, puIse rate 46 and respiration 18. The Ieft ear had no discharge, but a smaI1 granuIomatous mass was seen in ShrapnelI’s area. The Iast eIectrocardiogram taken on May 8, after the patient was discharged from the hospita1 still showed compIete A.V. dissociation. DISCUSSION
AND
CONCLUSIONS
KapIan* suggests the foIIowing fundamenta1 ruIes in the treatment of brain *
KAPLAN,
(April)
1935.
ABR.
Arch.
Otolar,yngol.,
21:
385-405
Abscess
Amrrir:rrr
Junrd
of Sur~crv
61
I
abscess: (I) evacuation of abscess; (2) proper seaIing of subarachnoid space with coaguIating current; (3) Mosher drain; (4) accurate visuahzation; (3) aHowing herniation according to King; (6) the initia1 and compIete remova of primary focus of infection. I. “Complete evacuation of the abscess” is essential. This is onIy assumed to have been accompIished for smaI1 pockets of pus may remain without symptoms, and a deIayed death may occur; aIcoho1 and trauma may reIight the process. Empty-ing of the abscess may be aided by moving the patient’s head from side to side, whiIe the cannuIa is stiI1 in situ, and during the dressings. Drawing off the pus with a syringe, shouId be avoided, for it tends to sea1 the waIIs of the abscess. 2. “Sealing,” according to our best knowIedge a protective meningitis usuaIIy occurs in the subarachnoid space and in the presence of a high Ieucocyte count as in this case, makes it very IikeIy that this occurred. The appIication of the coaguIation current is of vaIue. In the absence of a coaguIation apparatus, a strip of iodoform gauze can be easiIy packed around the edge where the bone meets the dura, thus setting up a IocaI inflammation with adhesion formation between the dura1 Iayers in about twenty-four hours, wiI1 answer the same purpose and give equaIIy as good a resuIt as coaguIation. The packing may have an additiona advantage, preventing an immediate overff ow of puruIent materia1 from invading uninvoIved subarachnoid space. In one of the cases reported by Kaplan, twenty-three days after seaIing with the coaguIation current, meningeal inflammation occurred, which was possibIy a true meningitis. 4. “Accurate Vis3. “Masher Drains”; ualization “; 4. “ Herniation According to King.” The Mosher drain has some advantages over any other but the incision in the dura must be Ionger, thereby permitting greater herniation. If sealing has not occurred spontaneousIy or it has not been induced by the coaguIation current or
612
American Journal of Surgery
Braunstein-Brain
the iodoform packing, there is a great possibiIity for the pus to roI1 over the edge of the dura and start an acute meningitis. 6. “The Initial and Complete Removal of the Primary Focus of Infection.” The idea1 treatment of brain abscess, according to EagIeton, is through a stalk, but unfortunateIy we have no method for predetermining-its presence. In a case simiIar to the one here reported, we first proceeded with the mastoid operation in an attempt to remove the source of infection. Our findings of scIerotic bone, a forward sinus and an obhterated antrum, required consumation of time in that preIiminary surgica1 procedure, but no bone erosion or puruIent invading tract was found. Hence, in the presented case, surgica1 shock was avoided and time saved by omitting the mastoid operation and proceeding directIy to relieve the pressure symptoms by evacuating the abscess. We feIt that if channels of infection existed from the mastoid, the protecting exudate which Nature provides, combined with the surgica1 coIIapse of the abscessed cavity wouId aid to obIiterate them. The radical mastoid operation can await decision as to whether or not it shouId be done at some future date, thus giving the patient a breathing speI1. We feel that the evacuation of the abscess shouId receive first consideration. Extradura1 abscess, as we11as temporosphenoida1 abscess, give aphasia. The fact that the aphasia cIeared so rapidIy postoperativeIy in this instance without mastoid operation indicates that no extradura1 abscess was present and that we were justified in eIecting to deIay the mastoid surgery. In Jackson Coates (1929) the foIIowing by EagIeton appears under “Non-IocaIizing ParaIysis.” “An inequaIity of the pupils is of IittIe IocaIizing value. It is evidence of cerebra1 invoIvement, but a contracted pupi of the homoIatera1 side from irritation may be of assistance.” The writer’s experience has been that a diIated pupi on the side of the involved ear is of significance and is an important sign of cerebra1 pressure in a temporosphenoida1 brain abscess. The DuDi is suD&ed bv the
Abscess
MARCH, 193,
third nerve and when it is invoIved by pressure onIy the sphincter fibres are affected giving a uniIatera1 mydriasis. A diIated pupi is an important IocaIizing sign of a temporosphenoida1 abscess and occurs on the side of the Iesion. SyphiIis and meningitis must be excIuded by the presence of the Iight reffex. Because of the pressure paraIysis of the sphincter muscIe of contraction the sympathetic nervous system diIates the pupi and a contracted pupi means a Ioss of sympathetic action. The question of a broken down gumma may be disregarded because of the presence of the Iight reflex, Iabyrinth response to caIoric stimuIation and fair hearing. In syphiIis the cochIear branch is the one invoIved most frequentIy. Encapsulated or Non-encapsulated Abscess. KapIan assumes that it takes about six weeks for a capsuIe to form. A. capsuIe wouId have given some resistance to the entrance of a cannuIa but since none was encountered it is fair to assume that this was an acute non-encapsuIated abscess of short duration. An encapsuIated abscess is prone to give IocaIized headaches, which were not present in this case. The bradycardia continued to exist postoperativeIy and was due to syphilis, but the difference between the p&e of 28 before operation and 48 after operation, was due to the cerebra1 pressure. In the presence of a very sIow puIse, syphiIis of the heart shouId be considered as part of the etioIogica1 factor which is causing the bradycardia. SUMMARY
A patient with a history of chronic ear suppuration was admitted to the otoIogica1 service. A diagnosis of Ieft temporosphenoida abscess was established and it was operated upon within twenty-four hours. Pressure symptoms graduaIIy abated unti1 at the time of discharge the sensorium was functioning normaIIy. The patient has since gained twenty-four pounds, and had no complaints when examined on August zq, 1936.
E.
BRAUNSTEIN,
M.D.
Attending Surgeon, Greenpoint Hospital BROOKLYN,
T
HIS case of an acute subcortica1 brain abscess of otitic origin in the Ieft temporosphenoida1 lobe, is reported because of an evident cure obtained by the institution of a simpIe surgica1 procedure done despite the grave co-existing complications of heart block and syphilis. H. I?., a married female, twenty-five years of age, was admitted to the Greenpoint Hospital, March 3, 1936, complaining of a generalized headache and discharging left ear. Past History. She had had measIes during childhood. There had been one miscarriage at two months and one child had died at the age of five and one-half years. She used aIcoho1 and tobacco in moderation. The history reIative to her left ear was very indefinite and unsatisfactory, but she recalled having had some trouble beginning at the age of fifteen years but couId not describe the character; she also believes she had some trouble three months prior to admission to the hospital. Present illness began one week before her admission with pain in her left ear and two days before admission it discharged a IittIe. She had a generalized headache and had vomited twice. Physical examination revealed an apathetic drowsy individua1, fairIy we11 nourished, respondmg poorIy to questions. There was a questionable facial weakness of the right Iower haIf and the tongue deviated to the right. The pupiIs were equa1 and reacted to Iight and accommodation. There was some weakness of right hand and a questionabIe adiadochocinesis. All abdomina1 reflexes were absent; the knee jerk was diminished on the right but there was no ankIe cIonus, Babinski or neck rigidity. A smal1 ny-stagmus on Iooking to the right and to the left was present. The right eye showed a beginning papilledema; the left eye was normal. There was no past pointing. Some
N. Y.
sweIIing of the right buccal region and pyorrhea alveoIarus were evident. The nasal cavities contained some free pus. The right ear drum was intact but was retracted anteriorIy, with a caIcified area and scar in the posterior aspect. Left ear had a foul pulsating discharge, showed an otitis externa. The drum couId not be visualized entireIy. No cholesteatoma was seen but there was a question of a dehiscence in the anterior superior quadrant of the drum. Hearing apparently was good on both sides. A normal response was obtained when the Ieft ear was douched with ether. The lungs were clear. Systolic and presystohc
murmurs were heard at the apex of the heart. The pulse rate was 32 beats per minute; temperature 99.2 F., and respiratory rate 20. Clear spinal fluid was obtained under marked pressure and the cell count showed 18 Iymphocytes. The bIood count reveaIed 5,050,000 erythrocytes with go per cent hemogIobin; 23,500 leucocytes with 94 per cent poIymorphonuclear and 6 per cent Iymphocytes. Roentgenogram of the paranasa1 sinuses showed slight cloudiness of t’he right frontal sinus. The right mastoid was sclerotic; the left mastoid was impossible to examine but no fracture was demonstrabIe. There was no suggestion of increased intracerebra1 pressure. The seIIa turcica fossa was of medium size and showed no abnormality. One hour after admission an eIectrocardiogram showed an auricular rate of 50 and a ventricular rate of 30. The main finding in a11 four leads was a compIete dissociation of the auricIe from the ventricle. Examination. On March 5 a11 symptoms became more marked. The Ieft pupi was diIated and the right appeared contracted; doubIe choked disc but greater on the Ieft. There was marked stupor and apathy; the patient couId not raise her right arm or hoId it up in position. Her temperature was 99.6 F., puIse rate 28 and blood pressure 150/80. The
* Presented at the Otolaryngological Section, Kings County MedicaI Society and to the Staff Conference at the Greenpoint Hospital, May 21. 1936. From the OtoIaryngoIogicaI Service of Greenpoint HospitaI, Brooklyn. 609
610
American
Journal
of Surgery
Braunstein-Brain
spinaI tap about go/60 C.C. of a cIear fluid was obtained under pressure; count showed 30 cells; globulin 3; Kline test positive; sugar
FIGS. I
AND
2.
Abscess
to the skin. Another catheter was placed within the outside dressing for daily irrigation with Dakin’s solution. Additiona treatment insti-
FIG. 2. FIG. I. Roentgenogram of skull (after operation) showing circuIar area of decompression parietat region. Drainage tube in situ extending into abscess cavity.
74.1 mgm per I00 c.c.; Wassermann 4 PIUS; and cuIture showed no growth. The urine was negative except for I + albumin. Diagnosis. Right chronic adhesive otitis media; Ieft chronic puruIent otitis media with an acute exacerbation; Ieft temporosphenoida1 compIete heart bIock with brain abscess; severe myocardia1 damage. Operation. On March 5 a vertica1 incision over the Ieft temporoparieta1 region was made about one inch above the tegmen region through the soft parts which were then eIevated and retracted. A round defect in the bone was created with a one inch trephine exposing the dura which was under pressure but not necrotic. A strip of iodoform gauze was packed tightIy around the circumference where the edge of the bone met the dura. The dura was incised for about fs inch. A brain cannuIa was introduced for about 4 or 3 cm. forward and inward. No resistance was encountered, and pus made an immediate exit. The abscess cavity was allowed to empty itseIf sIowIy of about 4 or 5 oz. of a fou1 creamy pus, aiding it by moving the head from side to side. The dura incision was then Iengthened to about ?i of an inch. A smaI1 herniation occurred and the protruding brain tissue was removed. Two inches of a 14 F. rubber catheter with fenestrated end was introduced into the abscess cavity and an overhang of about one inch was spIit and sewed
MARCH,,937
in left
tuted Iater, consisted of six injections of bismuth in oiI and protoiodide of mercury by mouth. ImmediateIy after the operation Progress. the puIse rate was 48, temperature was 100.6F., respirations 16. An eIectrocardiogram postoperatively showed the presence of a complete A.V. dissociation. A cuIture of pus obtained from the brain abscess grew Streptococcus non-hemolyticus and StaphyIococcus aureus. A direct smear showed gram-positive cocci in short chains. CuItures made from March IO and ending ApriI 13, showed the foIIowing types of bacteria: Staphylococcus aIbus, gram-positive cocci in chains, StaphyIococcus aureus, streptococcus and gram-positive baciIIi. The patient improved immediateIy foIIowing the operation; she responded to questions, and although she couId not name objects she would describe their use. This aphasia Iasted about a month. The right Iower facia1 weakness continued to be present, but less marked, unti1 it became very questionabIe by May I I. Deviation of the tongue Iessened graduaIIy and disappeared entirely. The Ieft pupi was diIated no Ionger; both pupiIs were equa1 and responded to light and accomodation; choked disc was more marked on the right side with hemorrhages in the Ieft but a11 disappeared by ApriI 20. The patient was now able to raise
NI..~
Sm,ts
Vo..
XXYV,
No.
Braunstein--Brain
3
the right arm, except for a slight weakness which disappeared Iater. Hearing was fair. On March 8, an electrocardiogram was taken and three-quarters of an hour Iater atropine suIphate grain j is” was administered and another electrocardiogram taken. The first one taken on this day resembIed that of March 5, but the one foIlowing atropine showed an increase in the ventricuIar rate 40/60, but compIete dissociation of A.v. was stiI1 present. Another eIectrocardiogram on April 2 showed that the dissociation was not apparent as readily but the widened and prolonged P.R. interval and irreguIar T waves showing T and P waves confined and superimposed indicated the dissociation. No pus drained from the wound unti1 three days postoperativeIy, after which there was a scant sanguinopuruIent or a sanguinous discharge. At times some brain tissue was expeIIed. This was sectioned and reported to be edematous and infiItrated by poIymorphonucIears, and in one area showed an overIying puruIent exudate. The Iaboratory diagnosis was brain tissue with inflammatory changes. A tract was established graduaIIy within which the catheter drain couId be moved in and out without difficuIty. An x-ray picture after the operation (Figs. I and 2) of the Ieft IateraI and anteroposterior views showed a circuIar area of bone removed from the Ieft parietal area with a shadow of one rubber drainage tube extending downward and inward for about 2 inches into the crania1 cavity, and was reported by L. P. Vanwinkle. This drain was changed every other day, using a 13 and then an 18 F. catheter. The drain was shortened to one inch and finalIy removed on ApriI 13. Temperature was then 99.2 F., pulse rate 60, and on ApriI I 8 the patient was discharged from the hospita1 with a norma temperature, puIse rate 46 and respiration 18. The Ieft ear had no discharge, but a smaI1 granuIomatous mass was seen in ShrapnelI’s area. The Iast eIectrocardiogram taken on May 8, after the patient was discharged from the hospita1 still showed compIete A.V. dissociation. DISCUSSION
AND
CONCLUSIONS
KapIan* suggests the foIIowing fundamenta1 ruIes in the treatment of brain *
KAPLAN,
(April)
1935.
ABR.
Arch.
Otolar,yngol.,
21:
385-405
Abscess
Amrrir:rrr
Junrd
of Sur~crv
61
I
abscess: (I) evacuation of abscess; (2) proper seaIing of subarachnoid space with coaguIating current; (3) Mosher drain; (4) accurate visuahzation; (3) aHowing herniation according to King; (6) the initia1 and compIete remova of primary focus of infection. I. “Complete evacuation of the abscess” is essential. This is onIy assumed to have been accompIished for smaI1 pockets of pus may remain without symptoms, and a deIayed death may occur; aIcoho1 and trauma may reIight the process. Empty-ing of the abscess may be aided by moving the patient’s head from side to side, whiIe the cannuIa is stiI1 in situ, and during the dressings. Drawing off the pus with a syringe, shouId be avoided, for it tends to sea1 the waIIs of the abscess. 2. “Sealing,” according to our best knowIedge a protective meningitis usuaIIy occurs in the subarachnoid space and in the presence of a high Ieucocyte count as in this case, makes it very IikeIy that this occurred. The appIication of the coaguIation current is of vaIue. In the absence of a coaguIation apparatus, a strip of iodoform gauze can be easiIy packed around the edge where the bone meets the dura, thus setting up a IocaI inflammation with adhesion formation between the dura1 Iayers in about twenty-four hours, wiI1 answer the same purpose and give equaIIy as good a resuIt as coaguIation. The packing may have an additiona advantage, preventing an immediate overff ow of puruIent materia1 from invading uninvoIved subarachnoid space. In one of the cases reported by Kaplan, twenty-three days after seaIing with the coaguIation current, meningeal inflammation occurred, which was possibIy a true meningitis. 4. “Accurate Vis3. “Masher Drains”; ualization “; 4. “ Herniation According to King.” The Mosher drain has some advantages over any other but the incision in the dura must be Ionger, thereby permitting greater herniation. If sealing has not occurred spontaneousIy or it has not been induced by the coaguIation current or
612
American Journal of Surgery
Braunstein-Brain
the iodoform packing, there is a great possibiIity for the pus to roI1 over the edge of the dura and start an acute meningitis. 6. “The Initial and Complete Removal of the Primary Focus of Infection.” The idea1 treatment of brain abscess, according to EagIeton, is through a stalk, but unfortunateIy we have no method for predetermining-its presence. In a case simiIar to the one here reported, we first proceeded with the mastoid operation in an attempt to remove the source of infection. Our findings of scIerotic bone, a forward sinus and an obhterated antrum, required consumation of time in that preIiminary surgica1 procedure, but no bone erosion or puruIent invading tract was found. Hence, in the presented case, surgica1 shock was avoided and time saved by omitting the mastoid operation and proceeding directIy to relieve the pressure symptoms by evacuating the abscess. We feIt that if channels of infection existed from the mastoid, the protecting exudate which Nature provides, combined with the surgica1 coIIapse of the abscessed cavity wouId aid to obIiterate them. The radical mastoid operation can await decision as to whether or not it shouId be done at some future date, thus giving the patient a breathing speI1. We feel that the evacuation of the abscess shouId receive first consideration. Extradura1 abscess, as we11as temporosphenoida1 abscess, give aphasia. The fact that the aphasia cIeared so rapidIy postoperativeIy in this instance without mastoid operation indicates that no extradura1 abscess was present and that we were justified in eIecting to deIay the mastoid surgery. In Jackson Coates (1929) the foIIowing by EagIeton appears under “Non-IocaIizing ParaIysis.” “An inequaIity of the pupils is of IittIe IocaIizing value. It is evidence of cerebra1 invoIvement, but a contracted pupi of the homoIatera1 side from irritation may be of assistance.” The writer’s experience has been that a diIated pupi on the side of the involved ear is of significance and is an important sign of cerebra1 pressure in a temporosphenoida1 brain abscess. The DuDi is suD&ed bv the
Abscess
MARCH, 193,
third nerve and when it is invoIved by pressure onIy the sphincter fibres are affected giving a uniIatera1 mydriasis. A diIated pupi is an important IocaIizing sign of a temporosphenoida1 abscess and occurs on the side of the Iesion. SyphiIis and meningitis must be excIuded by the presence of the Iight reffex. Because of the pressure paraIysis of the sphincter muscIe of contraction the sympathetic nervous system diIates the pupi and a contracted pupi means a Ioss of sympathetic action. The question of a broken down gumma may be disregarded because of the presence of the Iight reflex, Iabyrinth response to caIoric stimuIation and fair hearing. In syphiIis the cochIear branch is the one invoIved most frequentIy. Encapsulated or Non-encapsulated Abscess. KapIan assumes that it takes about six weeks for a capsuIe to form. A. capsuIe wouId have given some resistance to the entrance of a cannuIa but since none was encountered it is fair to assume that this was an acute non-encapsuIated abscess of short duration. An encapsuIated abscess is prone to give IocaIized headaches, which were not present in this case. The bradycardia continued to exist postoperativeIy and was due to syphilis, but the difference between the p&e of 28 before operation and 48 after operation, was due to the cerebra1 pressure. In the presence of a very sIow puIse, syphiIis of the heart shouId be considered as part of the etioIogica1 factor which is causing the bradycardia. SUMMARY
A patient with a history of chronic ear suppuration was admitted to the otoIogica1 service. A diagnosis of Ieft temporosphenoida abscess was established and it was operated upon within twenty-four hours. Pressure symptoms graduaIIy abated unti1 at the time of discharge the sensorium was functioning normaIIy. The patient has since gained twenty-four pounds, and had no complaints when examined on August zq, 1936.