REPORT OF THE TRANSACTIONS OF THE OTOLOGI- MEETING OF JANUARY 8, 1903. THE PRESIDENT, EDWARD B. DENCH, M.D., IN THE CHAIR. scar. Dr. W. P. EAGLETON (Newark) presented a case of cerebellar abscess with the following history: Boy, æt. fourteen, always in good health, but always had poor memory and did not get along well at school. Six years ago had discharge of pus from the right ear for three weeks followed by abscess of uncertain locality; no Mother said at times a whitish mass protruded from the ear, which was very sensitive to touch. On May 29, 1902, the boy waked in the night with severe pain which lasted three days. On June 1st, was struck on the head by a ball, knocked down but not rendered unconscious. Two days later the ear pain returned radiating over the head, followed in three more days by a flow of foul pus from the ear which lasted a week. During this week he suffered from pain in the head and ear, occasional vomiting, slight attacks of screaming without apparent cause. Probably dizzy, as he would catch at articles in going about the room. Lost flesh rapidly. Indistinct history of a chill; at the end of seven days he became drowsy, and in the next three days seemed dazed and yawned frequently. On the 18th day he was found lying on his right side on the floor, his eyes wide open and apparently blind, in which condition he remained all night and was several times thought to be dying. It was noticed that his arm and leg of the opposite side frequently twitched. The next morning, though still in stupor, he could be roused; he was emaciated, tongue coated, yawned frequently, eyes were wide open, temperature 99.3°, pulse There was slight lateral deviation of the eyes to the opposite side. Pupils were equal and responded promptly to light. The pupil on the unaffected side was observed to dilate more widely 62. than that on the side of the lesion. There was marked right optic neuritis with beginning left optic neuritis. Absence of both patellar reflexes. Operation.-Half an ounce of pus was found in cerebellar tissue near the posterior surface of the petrous portion of the temporal. The finger was introduced. Cavity held open by the forceps when the latter accidentally slipped and the flow of pus stopped. Careful search failed to rediscover the cavity. A drainage tube was introduced along the tract. During the next week the boy did well; was rational, no deviation of the eyes, co-ordination normal, but at times he would cry out and there was involuntary defecation and urination. Optic neuritis increased in the left eye and there was nystagmus when the eyes were moved toward the side of the lesion. Seven days after operation, the pulse and temperature being normal, paresis of the arm of the same side developed; the eyes deviated to the opposite side. On the tenth day the wound was explored with the finger but nothing found. On the fourteenth day after operation he was in the same condition as primarily; pulse 60, respiration 14, complete paralysis of arm and hand of the same side. A second operation was undertaken and on exposing the original sinus tract a large abscess cavity was found running towards the median line, from which two ounces of pus were evacuated. After this the hernia, which had developed through the original wound during the first week, disappeared. During the following three weeks the patient was so violent as to require restraint; screamed frequently. On October 2d, he was discharged; the sinus was healed and has remained so, though twice a small opening has developed over the site of the wound. His mental condition is very poor, though his mother says he is as bright as he ever was. Discussion. Dr. JOSEPH COLLINS said it was always gratifying to hear of recovery from brain abscess, whether cerebral or cerebellar, particularly so in the latter as the difficulties surrounding the operation are considerable. He stated that it was the belief and teaching of the neurologist that brain abscess offered a wider field for operative surgery than any other disease upon the central nervous system; in fact, in other diseases of the central nervous system the field of surgery was getting narrower, but in the matter of dealing with brain abscesses it was becoming broader; it still had room to grow. He thought that the conditions that indicated operative interference were fairly well recognized for abscess, but he wished to emphasize that operation should not be deferred until the appearance of highly pathognomonic symptoms. This, he thought, was frequently impressed upon the neurologist. Speaking of three cases he had recently seen, the first in consultation with Dr. McKernon, he said that in one case the patient had for over a week given signs of brain abscess though there were no definite focal symptoms. An operation was done that same night but the general condition of the patient was too bad then to look for any good result. He thought that if the operation in this case had been done earlier a fairly favorable prognosis might have been made. He brought out the point that the exact localization of the abscess is of secondary importance. From 65 to 70% of all cases show that the abscess is either in the temporal lobe, on a site corresponding to the cause, or it is in the cerebellum. If not found in one place there is nothing else to do but enlarge the opening and proceed to search in the other locality. This was a good rule for brain abscesses except those secondary to lung infection and more rarely those secondary to suppurative processes in remote parts of the body. Dr. Collins further spoke of the fact that otologists did not operate boldly enough in these cases; he thought they, as a rule, made too small an opening in the skull. He cited two cases to illustrate this fact. This he considered a mistake, as nothing was to be gained and much might be lost; a large opening gave better access, was no more dangerous than a small one, and was very little more liable to be complicated with cerebral hernia. The general surgeon, on the other hand, takes away as much of the skull as is necessary, and this procedure Dr. Collins thought should be pursued, so if the abscess is not found in the cerebellum there is already a sufficient opening through which to attack the temporal lobe, and vice versa. He thought the following points should be emphasized : 1. Abscess of the brain, wherever situated, is practically a fatal disease, although there are a few recorded cases of spontaneous recovery; these are the exceptions that prove the rule. 2. As all cases die, operation gives the only chance of recovery. There is but one way of dealing with them: enter the skull, evacuate the abscess, cleanse and thoroughly drain the cavity. 3. The cardinal symptoms of localization should not be awaited before subjecting the patient to operation. Operation should expose the most probable seat of the abscess, always bearing in mind that the location of brain abscess stands in determined relationship to the origin of its causative factors. 4. If necessary, one should "go it blind" rather than wait for focal symptoms, once the mind is made up that there is a circumscribed septic process within the cranial cavity. In regard to Dr. Eagleton's remarks as to the immediate cause of the abscess in the case presented, he did not think that made much difference, but in regard to his explanation that if due to trauma the abscess was the result of "lowered vitality of the brain," Dr. Collins could not agree with this unless by it Dr. Eagleton meant stasis of the lymphatics. In regard to the best instrument for opening an abscess cavity in the brain, he thought there was nothing better than the clean finger, and he deprecated the use of sharp or pointed instruments. He considered that Dr. Eagleton had dwelt sufficiently upon the necessity for draining these abscesses. Dr. GORHAM BACON spoke of a case reported in the American Fournal of Medical Sciences, August, 1895. Male, æt. thirty-one, with chronic otitis media of five years' standing. The drum membrane was destroyed. An attempt was made to secure drainage by removing the granulations, but eventually the patient had to be admitted to the hospital, as he complained of nausea, vomiting, vertigo, lessened discharge, and a tendency to fall to the left. Bone-conduction was almost absent. Mastoid operation was performed, granulations removed from attic and antrum, and drainage established. There was improvement for a week, when vomiting occurred with severe pain in the left side of head from vortex to occiput; slight oedema of right optic nerve; partial nystagmus on turning to either side; stagger to the left; knee-jerks normal; pulse 50-60, temperature not over 99.6°. Cerebellar abscess was diagnosticated and an operation performed. The sinus was normal; the temporo-sphenoidal lobe was also investigated. For five days the symptoms were less pronounced, then severe headache with vomiting and restlessness occurred, the vomiting later becoming projectile. The patient tore off bandages, became very noisy; Cheyne-Stokes respirations set in; twitching of left side of face, left arm, and leg with retraction of the head. There was then a remission followed by an exacerbation of symptoms; the patient had lost sensation and motion in the left arm; pupils contracted, double neuro-retinitis. On division of the right cerebellar hemisphere at the autopsy an abscess 4.5 x 3 cm was found, with a wall 3 mm thick, obliterating the corpus dentatum and encroaching on the middle cerebellar peduncle. The third and eighth nerves were compressed. No meningitis. No spot of carious bone was found. The most prominent symptoms in this case were: pain on the left side, on the side opposite the ear trouble; sudden diminution in discharge; vertigo, vomiting, staggering, falling to opposite side, slow pulse, facial paralysis, optic neuritis. In regard to Dr. Eagleton's case, he wished to ask if the mastoid had been investigated; he thought that in all cases of brain abscess where the patient's condition allows the mastoid should be investigated, first of all and particularly the antrum and attic. After opening the antrum, the bone should be cut away rapidly so as to explore the sigmoid sinus and lay bare the cerebellum. Dr. PHILLIPS briefly referred to a case he had recently reported in the ARCH. OF OTOLOGY, No. 2, vol. xxx., 1901, p. 85. The patient was seen in February, 1900, with a streptococcic mastoid infection. The mastoid operation was done, but later developments required a second operation. The case did well for a few days when he developed severe cerebral symptoms with coma, severe pain, and crying out. There were no signs of optic neuritis and no facial paralysis. The case was considered inoperable, but after twenty-four hours, when the dressings were changed, some pus was discovered at the angle of the knee of sinus, and on slightly pressing the wound with a probe it "slipped into" a cerebellar abscess from which a quantity of pus was evacuated. The opening was enlarged and abscess cleaned out, and without an anæsthetic, as the man was comatose. The wound was kept irrigated with hydrogen peroxide, a proceeding which the Doctor said he could not recommend, and the patient recovered consciousness and became greatly improved and was soon up and about the hospital apparently entirely well. On May 18th he left the hospital and went to work. Some time later he returned to the hospital with high temperature, very violent, and in eight hours after admission was dead. The autopsy showed the correctness of the diagnosis, but scattered over the brain surface were broken-down deposits of pus containing streptococci. The immediate cause of death was, therefore, a general meningitis. Dr. CHARLES L. DANA said that from the paper presented and from his own reading of other cases of cerebellar abscesses it seemed that there had not been much attention paid to the |