Treatment.—Every case of brain-ab scess should be operated upon and the pus evacuated just as soon as the diag nosis can be made. In no department of brain-surgery have results been so brilliantly successful. In a great major ity of cases the abscess is easily accessible and can be readily reached. The sur ,eon should not wait for coma or cfrave symptoms of irritation or pressure, but should enter the cranial cavity, at least in an exploratory way, as soon as it seems probable that cerebral symptoms in a given case point to abscess-formation.
In trephining after traumatic brain affection it is advisable to distinguish late and early cerebral abscess. The late abscess apparently does not arise in the contused part itself, but in a healthy one, just like non-traumatic abscesses after traumatic suppuration in the bones and soft parts. These late abscesses gen erally lie deep, and are covered by nor mal cerebral cortex. The early abscesses usually arise in the injured area, into which infective material penetrates from without. Fatal meningitis is often ciated with immediate suppuration. If the suppurative process is slower, how ever, and the wound in the brain small, adhesions of tbe cerebral membranes take place in the region of the injury, and abscesses may result. These ab scesses are, to a certain extent, the re sult of retention of pus in the nests and sacs of a deep wound, and are generally superficial and cortical. They do not develop before two weeks. Very early onset of paralysis or symptoms of irrita tion are rather signs of meningitis, while the late appearance of symptoms points rather to abscess. (Nasse.) Details of sixty-seven mastoid opera tions. _Most of them were done in the usual method of Schwartze, but the later cases, to the number of about a dozen, were done by Stacke's method of dis secting off the auricle and soft tissues of the canal and laying them forward, chiseling away the posterior bony wall and anterior wall of the attic, so as to throw meatits, attic, antritm, and tyrn pannin proper ir.to one open and visible cavity, then replacing the soft parts and transplanting a flap of canal-lining into the antrum. In these methods radical removal of all diseased structures is at tempted, yet in such an open manner as to rob the operation of many of its gravest dangers; important structures cart be more surely avoided, healing is likely to be greatly expedited, and the recovery should be secured with a condi tion far less likely to relapse into cho lesteatoma or other renewed troubles.
Panse (Therap. Gaz., Apr. 15, '92).
In opening the skull for cerebral ab scess the surgeon need not be always anxious about replanting the bone re moved, considering that in three cases the gaps, without replantation, were soundly filled up.—more so than in some eases in which the replantation had been practiced. In order to drain the septic abscesses replantation had been imprac ticable, but the result was, nevertheless, a sound restoration of the bony case. Thishton Parker (Liverpool Nledico-Chir. Jour., Jan., '95).
At the present Dine it is possible to reach, and to deal successfully with, the following conditions: 1. Abscess in the cerebrum, especially in the temporo sphenoidal lobe. 2. Abscess in the cere bellum. 3. Purulent formations at the base of the skull: (0) extradural ab scess; (b) subdural abscess. 4. Infective thrombosis of the sigmoid sinus, even when secondary foci may exist.
In all these conditions it is essential to explore the cavities of the middle ear by removing the outer wall of the an trum. The partitions of the roof and sigrnoid groove separating the middle ear from the temporo-sphenoidal lobe above and from the sigmoid sinus be hind are the two great pathways by which infective matter effects its en trance into the interior of the cranium.
In operating, the path of invasion should be systematically followed up, and this may be done with safety and with efficiency by means of the rotary burr propelled by a dental engine. Thomas Barr (Archives of Otology, vol. xxiv. Nos. 3 and 4).
Case of abscess of the temporo-sphe noidal lobe opened and drained through the osseous auditory meatus.
Tbe advantages of this method of oper ating are obvious: In the -first place, we get g,00d and efficient drainage from below. The drainage-tube can, if neces sary, be kept in position for months without any discomfort. It can easily be removed and replaced, and there is no danger of not again finding the ab scess-cavity. We can also at the same time efficiently treat and cure the attic and mastoid cells, which in these eases are nearly always affected, and thus pre vent any recurrence of the disease. Only one incision and only one operation are necessary. The operation and after treatment are more difficult and tedious than in the ordi.nary method of trephin ing., but the results are certainly more satisfactory. Adolph Bronner (Brit. Med. Jour., Aug. 21, '97).