The Surgery of the Skull and Brain

by Louis Bathe Rawling

Anosmia may be present if the patient is in a condition to respond to the tests requisite to prove the defect. In most cases, however, considerable difficulty will be experienced in applying the tests, and the results obtained are too variable. Anosmia will be associated with impaired power of taste.

Pupillary changes. ‘If the abscess is of large size, the pupil on the same side is in a state of stabile mydriasis; if small, it may be sluggish and contracted.’[56]

The TERMINAL stage.

In fatal cases death results from the pressure exercised by the expanding abscess on the bulbar centres, or from the bursting of the abscess into the ventricular or meningeal spaces. During this terminal stage the pulse becomes very rapid, the respiration irregular and Cheyne-Stokes in character, whilst the temperature rises rapidly, reaching 105-110 degrees F. Invasion of the lateral ventricle is evidenced by violent convulsions, rigidity of the extremities, opisthotonos, retraction of the head, trepidation, and prostration. The pupils become widely dilated, and remain in that condition till death ensues.

Treatment.

In the operative treatment of otitic temporo-sphenoidal and cerebellar abscess two courses are available:—(1) to trephine directly over the abscess through the squamous or cerebellar regions, postponing mastoid exploration till a later date (the two-stage operation); and (2) to carry out the complete mastoid operation, searching for the ‘stalk’ of the abscess, and draining the abscess into the now-united middle ear and antrum (the one-stage operation).

The former course is advocated by many general surgeons, the latter is the one usually pursued by the aural surgeon. The advantages claimed for the former method—the direct trephining method—are as follows:—

(1) The general condition of the patient is often of so serious a nature as to prohibit the more prolonged procedures essential to the mastoid exploration.

(2) When the exploration is conducted from the infected middle ear, an unsuccessful attempt to find the abscess carries with it an appreciable risk of meningeal and brain infection. Unsuccessful exploration through the ‘clean’ squamous and cerebellar regions presents no such disadvantages.

(3) The drainage as supplied through the trephine hole is often superior to that provided by dilating up the ‘stalk’ of the abscess into the middle ear.