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NOTE ON A CASE OF ACUTE CEREBRAL ABSCESS.
1783 normal as it was traced towards the body of the organ. The incision was prolonged into the duodenum, which was normal in thickness, until its whole length was about one and a half inches. The operation of pyloroplasty was difficult to perform because of the thickness and friability of the stomach wall. Two rows of sutures were used, the first through all the coats and the second Lembert fashion. The latter were the most difficult to apply, for the line of incision could only with difficulty be tucked in on account of the thickness of the stomach wall. At the end of the operation the line of suture looked very secure ; the pylorus was sufficiently wide but was flattened as if the anterior and posterior walls were approximated. The abdominal incision was closed with through-and-through silkworm gut sutures. The operation took about 25 minutes and was attended by very little shock. As soon as the effect of the ansesthetic passed off mouth feeding was begun. Vomiting recommenced and occurred about e, ery half-hour until the patient died 30 hours after the operation. When examined post mortem the body was found to be very greatly emaciated. The stomach was distended and contained some curdled milk. The suture line was secure and did not allow any leakage. The pylorus was almost occluded, being represented by a vertical slit that would only admit a probe. When the stomach was distended with water none escaped through the pylorus. This was obviously due to blocking by the thick tucked-in pyloric ring. On the anterior wall one and a half inches from the pylorus there was a small excavated ulcer about one-sixteenth of an inch in diameter. It extended to the muscular coat and the mucous membrane immediately surrounding it was infiltrated with blood, so that it looked as if the ulcer had arisen in a if blood extravasation ; there were no other ulcers. A microscopic examination of the pylorus showed the thickening to be composed entirely of unstriated muscle. The other abdominal viscera were normal; there was no examination of the chest or head.
I
Newcastle-on-Tyne.
and the overlying temporo-sphenoidal lobe was explored ; no abscess was found. A similar operation was performed on the right side with the same negative result. The boy was much collapsed after the operation and was only kept alive by oxygen and strychnine. On the following day, Jan. 28tb, he was very restless, his arms and legs moving constantly, and there was some retraction of the neck. The pulse was 120, very feeble, and his temperature was 97°. The loss of consciousness was complete. On the two following days his condition remained the same. Cerebro-spinal fluid drawn off through a lumbar puncture was examined and reported to be perfectly normal. On the 31st while dressing the wound I noticed that the exposed dura mater on the left side looked quite healthy but on the right side was of a dirty grey colour and bulged outwards. A pair of dressing forceps pushed about an inch through the cerebral cortex at once evacuated a considerable quantity of blood-stained semi-purulent fluid, together with fragments of necrosed brain substance. On the following day he was quite rational and talked with his friends. Convalescence was uneventful but slow, being retarded by an attack of pleurisy without effusion. The abscess was drained for three weeks, at first a large quantity of pus coming away daily. At the end of a month the discharge had ceased and the mastoid cavity was grafted on both sides with a good result, ordinary conversation being now heard without any
difficulty. Undoubtedly in was
this
case an
acute
suppurative
cerebritis
present at the time of the exploratory operations but
no
formed the exploring tube simply brain substance. The subthe softened through passed sequent operation evacuated the pus and the necrosed brain matter. The diagnosis was rendered more difficult by the presence of bone disease in both mastoid processes and there were no guiding signs or symptoms to indicate the affected side. Otorrhoea, vomiting, intense headache, and drowsiness passing into coma were the only definite grounds on which a diagnosis of cerebral abscess could be based. The more collection of pus
having
symptoms, including constipation, optic neuritis, pulse, subnormal temperature, hemiplegia, &c., were NOTE ON A CASE OF ACUTE CEREBRAL entirely absent. In many cases of cerebral abscess, even after the most careful study of all the symptoms, it is often ABSCESS. most difficult to arrive at a correct diagnosis and in some BY A. L. WHITEHEAD, M.B., B.S. LOND., cases absolutely impossible with any approach to certainty. OPHTHALMIC AND AURAL SURGEON TO THE GENERAL INFIRMARY, In numerous instances a problematical diagnosis between LEEDS. common
slow
ALTHOUGH chronic cerebral abscess, latent for an indefinite period but ultimately giving rise to acute symptoms, is not uncommon, acute abscess secondary to ear disease is rare. The case now recorded occurred in a lad, aged 14 years. Apart from some deafness associated with a chronic purulent discharge from both ears for 12 months the boy had enjoyed perfectly good health up to Jan. 26th, 1904. At three in the afternoon of that day he left school complaining of severe headache. The pain grew rapidly more intense and the boy became very irritable, crying out constantly of pain in the head, chiefly in the frontal region, and never referred to one or the other side. During the next 24 hours he vomited twice and became drowsy but resented interference and was at times delir:ous. When seen by his medical attendant, Dr. P. S. Bird, on the evening of the 27th he could not be roused, looked very ill, and had a temperature of 1030 F. He was sent to the hospital the same night and was admitted under my care. His temperature was then 101’ 8°, his pulse was 120, and his respirations were 32. He was in a state of partial stupor, resented interference, and could not be roused to answer questions, but during the examination constantly complained of pain in the head and repeatedly placed his left hand to the left side of the head. The knee-jerks could not be elicited, but there were free movement of all the limbs and no obvious paralysis of any muscles. The pupils were equal and reacted to light ; there was a tendency to divergent strabismus. Both auditory meati were full of pus, the membrane tympanorum were destroyed, and the tympanic cavities were full of granulation tissue. There were no external signs over the mastoids but apparently some tenderness to pressure on both sides. Chloroform was administered half an hour after his admission and the left mastoid was explored; very extensive bone disease with much pus, granulation tissue, and debris was found ; the dura mater was exposed by the disease and was found to be covered with granulations ; it was opened
two or even more morbid conditions is the utmost which can be attained. Exploratory operation should be urged in all cases where symptoms are urgent even if signs are somewhat
indefinite. To recommend an operation for the relief of cerebral abscess only in those cases in which the diagnosis is certain is to sacrifice many lives which might ultimately be saved. Leeds. _________________
Medical Societies. PATHOLOGICAL SOCIETY OF LONDON. on the Grafting of the Thymus Gland in Anivrals.-The Production of Lellcocl/to8’Ís by Colchicine.Alterations in the Systeniie Circulation rvMch tend to produce Engorgement of the Lung Capillaries. A MEETING of this society was held on Dec. 20th, Dr. F. W. PAVY, Vice-President, being in the chair. Mr. L. S. DUDGEON and Dr. A. E. RUSsELL communicated a paper on the Effects of Intraperitoneal Grafting of the Thymus of Young Animals into other Animals of the and the same Litter. same Species One kitten, one rabbit, and four puppies were grafted. In three of the puppies the thymus glands from two puppies were inserted into the peritoneal cavity. Control animals were used and in one case (Dog H) the animal was anassthetised and a negative operation was performed, the abdomen being opened and forceps moved about in the peritoneal cavity. From an examination of the red cells, the htemcglobin, a differential count of 500 leucocytes, and from the results of the post-mortem examination in the case of the cat, the rabbit, and three of the dogs, it was concluded : (1) that intraperitoneal grafting of thymus gland tissue did not affect the health of the grafted animal ; (2) that it did not
Experimcnts
I
Newcastle-on-Tyne.
and the overlying temporo-sphenoidal lobe was explored ; no abscess was found. A similar operation was performed on the right side with the same negative result. The boy was much collapsed after the operation and was only kept alive by oxygen and strychnine. On the following day, Jan. 28tb, he was very restless, his arms and legs moving constantly, and there was some retraction of the neck. The pulse was 120, very feeble, and his temperature was 97°. The loss of consciousness was complete. On the two following days his condition remained the same. Cerebro-spinal fluid drawn off through a lumbar puncture was examined and reported to be perfectly normal. On the 31st while dressing the wound I noticed that the exposed dura mater on the left side looked quite healthy but on the right side was of a dirty grey colour and bulged outwards. A pair of dressing forceps pushed about an inch through the cerebral cortex at once evacuated a considerable quantity of blood-stained semi-purulent fluid, together with fragments of necrosed brain substance. On the following day he was quite rational and talked with his friends. Convalescence was uneventful but slow, being retarded by an attack of pleurisy without effusion. The abscess was drained for three weeks, at first a large quantity of pus coming away daily. At the end of a month the discharge had ceased and the mastoid cavity was grafted on both sides with a good result, ordinary conversation being now heard without any
difficulty. Undoubtedly in was
this
case an
acute
suppurative
cerebritis
present at the time of the exploratory operations but
no
formed the exploring tube simply brain substance. The subthe softened through passed sequent operation evacuated the pus and the necrosed brain matter. The diagnosis was rendered more difficult by the presence of bone disease in both mastoid processes and there were no guiding signs or symptoms to indicate the affected side. Otorrhoea, vomiting, intense headache, and drowsiness passing into coma were the only definite grounds on which a diagnosis of cerebral abscess could be based. The more collection of pus
having
symptoms, including constipation, optic neuritis, pulse, subnormal temperature, hemiplegia, &c., were NOTE ON A CASE OF ACUTE CEREBRAL entirely absent. In many cases of cerebral abscess, even after the most careful study of all the symptoms, it is often ABSCESS. most difficult to arrive at a correct diagnosis and in some BY A. L. WHITEHEAD, M.B., B.S. LOND., cases absolutely impossible with any approach to certainty. OPHTHALMIC AND AURAL SURGEON TO THE GENERAL INFIRMARY, In numerous instances a problematical diagnosis between LEEDS. common
slow
ALTHOUGH chronic cerebral abscess, latent for an indefinite period but ultimately giving rise to acute symptoms, is not uncommon, acute abscess secondary to ear disease is rare. The case now recorded occurred in a lad, aged 14 years. Apart from some deafness associated with a chronic purulent discharge from both ears for 12 months the boy had enjoyed perfectly good health up to Jan. 26th, 1904. At three in the afternoon of that day he left school complaining of severe headache. The pain grew rapidly more intense and the boy became very irritable, crying out constantly of pain in the head, chiefly in the frontal region, and never referred to one or the other side. During the next 24 hours he vomited twice and became drowsy but resented interference and was at times delir:ous. When seen by his medical attendant, Dr. P. S. Bird, on the evening of the 27th he could not be roused, looked very ill, and had a temperature of 1030 F. He was sent to the hospital the same night and was admitted under my care. His temperature was then 101’ 8°, his pulse was 120, and his respirations were 32. He was in a state of partial stupor, resented interference, and could not be roused to answer questions, but during the examination constantly complained of pain in the head and repeatedly placed his left hand to the left side of the head. The knee-jerks could not be elicited, but there were free movement of all the limbs and no obvious paralysis of any muscles. The pupils were equal and reacted to light ; there was a tendency to divergent strabismus. Both auditory meati were full of pus, the membrane tympanorum were destroyed, and the tympanic cavities were full of granulation tissue. There were no external signs over the mastoids but apparently some tenderness to pressure on both sides. Chloroform was administered half an hour after his admission and the left mastoid was explored; very extensive bone disease with much pus, granulation tissue, and debris was found ; the dura mater was exposed by the disease and was found to be covered with granulations ; it was opened
two or even more morbid conditions is the utmost which can be attained. Exploratory operation should be urged in all cases where symptoms are urgent even if signs are somewhat
indefinite. To recommend an operation for the relief of cerebral abscess only in those cases in which the diagnosis is certain is to sacrifice many lives which might ultimately be saved. Leeds. _________________
Medical Societies. PATHOLOGICAL SOCIETY OF LONDON. on the Grafting of the Thymus Gland in Anivrals.-The Production of Lellcocl/to8’Ís by Colchicine.Alterations in the Systeniie Circulation rvMch tend to produce Engorgement of the Lung Capillaries. A MEETING of this society was held on Dec. 20th, Dr. F. W. PAVY, Vice-President, being in the chair. Mr. L. S. DUDGEON and Dr. A. E. RUSsELL communicated a paper on the Effects of Intraperitoneal Grafting of the Thymus of Young Animals into other Animals of the and the same Litter. same Species One kitten, one rabbit, and four puppies were grafted. In three of the puppies the thymus glands from two puppies were inserted into the peritoneal cavity. Control animals were used and in one case (Dog H) the animal was anassthetised and a negative operation was performed, the abdomen being opened and forceps moved about in the peritoneal cavity. From an examination of the red cells, the htemcglobin, a differential count of 500 leucocytes, and from the results of the post-mortem examination in the case of the cat, the rabbit, and three of the dogs, it was concluded : (1) that intraperitoneal grafting of thymus gland tissue did not affect the health of the grafted animal ; (2) that it did not
Experimcnts