The sugar reaction is always absent, and the acidity is much increased as is the quantity of cholin.
The pressure or irritative symptoms as the Kernig and Babinski tests, as well as the pupillary reactions, are practically the same as in the serous meningitis, only that they soon give away to the paralytic form, namely: pupils dilate, patient is in a constant stupor or coma, and the involuntary urination and bowel movements become very manifest. The patient is, as a rule, unable to take or be given nourishment. The outcome is, in my experience, with one exception, always fatal, due to diffuse cerebritis. I have had a case of diffuse septic meningitis in the early stages of a pneumococcic type which I operated on by the Haynes’ method of drainage of the cyscterna magna, and which recovered; and I believe that the success in that case was due to the very early intervention, because I have operated by the same method on eight other cases more advanced and of streptococcic and staphylococcic type of infection, which ended fatally.
Sinus thrombosis.—This complication is the one that is recognized as giving the best prognosis because it can be very readily recognized, and even exploration is warranted to make such diagnosis. It most frequently follows, or is associated with, acute infections of the middle ear and mastoid process. The most important symptoms are the chills and fever of a distinct septic type, and, as a rule, increasing in frequency. There is invariably a blood-picture of sepsis, namely, a very high leucocyte count and the polymorphonuclear type in marked excess. Blood cultures are, as a rule, positive of a bacteriemia. If the process has extended to the bulb and internal jugular vein, then one may feel a thickening or cord-like mass along the anterior border of the sterno-cleido-mastoid muscle. The fundus examination often reveals a choked disk, especially on the side where the thrombosis is located. A symptom recently described by Beck, of Vienna, and Crowe, of Baltimore, and proven by me to be of positive value in several cases, is the production or increase of a choked disk by compression of the healthy internal jugular vein. Urbanschitch has shown in quite a number of cases of sinus thrombosis that the blood-clotting time is very much enhanced. This of course is true of any case of bacteriemia or septic phlebitis anywhere in the body. I have proven this test to be of value to me in several cases of sinus thrombosis. The exploratory exposure of the lateral sinus is of distinct value, and the only fact to remember is to expose a sufficient area so that one is able to deal with the sinus in case it be opened accidentally, because such an accident when this precaution was not taken has led to serious consequences.
The diagnosis of a thrombotic sinus when exposed is made first by its discoloration, usually of a grayish pink; secondly, it feels harder than normal and is not resilient when compressed, that is, it does not spring back. It, however, may be soft in case the thrombus has broken down; and in cases of parietal thrombosis it may spring back because there is blood circulating through it. One will at times find a small collection of pus about the sinus, a condition known as perisinus abscess, and in many instances of this condition the sinus itself is not thrombosed. The puncture of the sinus by a hypodermic needle and attempt to withdraw some blood, is not at present considered good practice owing to the danger of infecting a non-infected sinus. An incision is considered a wiser plan, and subsequently packing both sides (torcular and bulb) so they are shut off from the general circulation. There are many instances of secondary infection by embolism, either in or about the joints, and infection into the lungs, spleen, pancreas, etc., with the entire train of symptoms from such complications.
Brain Abscess.—This is most frequently associated with chronic suppuration of the middle ear and mastoid, and labyrinthine disease. As stated before, we must consider two principal types, namely, those outside the dura and those within. They may exist at the same time, or the intradural abscess may frequently follow, especially in acute exacerbations, the extradural abscess. The paramount symptom is the great pain in the head, most frequently localized at or in close proximity to the abscess. I have, however, found several instances where the patient located the pain in the anterior portion of the head, and operation or post-mortem examination disclosed it in the posterior cerebral fossa. This pain is not at all unlike that in brain tumor, and there are exacerbations in the headaches sometimes at night, other times in the mornings, and in one of my cases the patient would have about ten attacks of severe head-pains within twenty-four hours, and in the intervals be fairly comfortable.
The next group of symptoms of importance are the focal lesions, which will correspond to the anatomicophysiologic locations and actions. These focal symptoms will vary in degree in that they be either irritative or destructive. So, for instance, a small abscess pressing over the motor area will cause clonic contraction and a still larger abscess, especially if it be intradural, will produce paralysis of that portion of the body governed by that particular area. Again, if it be located in the cerebellar region it will cause a train of symptoms of imbalance and loss of interpretation of direction, which must be carefully differentiated from the irritation of the labyrinth. In this department there has been much work done by Barany, Ruttin, Neumann, and other Viennese, and many others to make it possible to make a differential diagnosis; and there is a great deal more to be done. One of the most important recent contributions in this regard is the “pointing test” of Barany in connection with cerebellar lesions; and careful study and experimenting at every opportunity is very much recommended, in order to familiarize one’s self with this test. This in connection with the various labyrinth tests makes the differential diagnosis much more easy. One must remember that both labyrinthian irritation in connection with suppuration of the ear and cerebellar irritation from brain abscess may exist at the same time.
Intracranial pressure, being increased in brain abscess, will cause the cerebrospinal fluid to be increased and found to be so by spinal puncture, although no pus cells or micro-organisms will be found, unless there is also a concomitant diffuse septic meningitis or ventricular infection present. The ocular symptoms of intracranial pressure, such as pupillary (often one large and one small) and choked disk, are usually present. The pulse rate and respiration will be affected, as in brain tumor, according to the size of the abscess. The larger the abscess the slower the pulse and respiration. The temperature, as well as the pulse and respiration, will vary as to whether the abscess be intradural or extradural. Intradural abscesses will frequently cause considerable rise of temperature, and acceleration of the pulse and respiration, and a remission when the abscess has become partially walled off. As soon as a fresh invasion of brain tissue takes place another rise of temperature, etc., occurs.
Projectile vomiting is, as in brain tumor, quite frequently encountered.
The Röntgenogram, especially a stereoscopic one, will be of some value in cases where through its chronicity a change of bone by pressure has taken place, or if one may follow the path of necrosis from the nasal accessory sinuses or the middle ear and mastoid process towards the brain. I will state, however, as I have stated on several occasions before, that not too much emphasis should be laid on the diagnostic value of the x-ray in intracranial lesions, especially abscess. I have been disappointed in this great method of diagnosis (x-ray) and much annoyed at the positiveness of some observers without sufficient evidence.
As in sinus thrombosis, so in brain abscess one should not hesitate in the exploratory operation, because waiting too long will often reduce the patient’s ability to stand an operation later on. Should one not find the abscess, then the decompression has done a great deal to prevent destruction of brain tissue by pressure, besides the patient will be very much relieved of the severe head-pains. This may be said also of spinal punctures. In this way one may wait for development of localization for another operation.