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Un des symboles sjivants apparaitra sur la darnlAre image de cheque microfiche, selon le caa: le symbols — ^ signifie "A SUIVRE", le symbols y signifie "FIN". Maps, plates, charts, etc., may be filmed at different reduction ratioa. Thoae too large to be entirely included in one expoaure are filmed beginning in the upper left iisrtd corner, left to right and top to bottom, as many framea as required. The following d.^agrama iiluatrate the method: Lea cartea, planches, tableaux, etc., peuvent Atre fllmte A dea taux de reduction diff fronts. Lorsque ie document est trop grand pour Atre reproduit en un seul ciichA, il est f llmA A partir de Tangle aupArieur gauche, de gauche h drcite, et de haut en baa, en prenant ie nombre d'imagea nAcessaire. Las diagrammas suivants iilustrent la mithode. ta ure, ] 1 2 3 1 2 3 4 5 6 V ll A REPORT OF TWO CASES OF ACTINOMYCOSIS OF THE BRAIN. ^ A REPORT OF TWO CASES OF ACTINOMYCOSIS OF THE BRAIN. By C. It, Martin, M.D., MGill University, Montreal. ' From the Pathological Anatmnical Institute of Professor Chiari in Prague. FoK the material from these cases, as well as for much kind advice and assistance, I am indebted to Professor Chiari, in whose institute the cases were first examined and the autopsies made. Merely a cursory glance over the total number of cases of actinomy- cosis in man, hitherto published, is necessary to convince one how comparatively rare are metastases in any form, the affected organs in most of Euch instances belonging to the thoracic and abdominal cavities. In the brain, however, metastases are peculiarly rare, and the most careful perusal of the various monographs and compilations on the disease fails to reveal more than 3, or at most 4, cases of the kind. Ponfick,^ in his well-known work, describes the oft-quoted case (Frau Deutschmann), in which, among other metastases, there were found, in the brain, abscesses containing the actinomyces fungus. Apart from this, however, the author had observed no case of a similar nature, though he further records an instance in which the disease, having comiienced in the prevertebral region, advanced jD^r continuitatem to the b - and meninges (August Barunke). J. Israel,^ who in 1885 had collected 38 cases, mentions but one other instance of actinomycotic metastases in the brain, observed and placed on record by Kiinig and 0. Israel.^ Here the disease, as viewed by J. Israel, having commenced in the lungs, was propagated through blood channels to various organs of the body, involving likewise the brain and its membranes. In this work is further cited the case observed by Zemann,* and considered by him as primary actinomycosis of the Fallopian tube, with the forniaticn of secondary abscesses in the liver, lungs, and brain. 1 Politick, "Die Aktinoniykose dos Meiisolieii ; cine neue Iiifections-kraiikheit." Berlin, 1882, - J. Israel, " Klinisclie beitriige zur Keiintniss der Actiiioniykose des Mensclien." ^Kiinig anil 0. Israel — Koiiig, "Eiu fall von Actinomycosis lioniinis." Inaug. Diss. Berlin, 1884. O. Israel, Berl. klin. Wchrschr. 1884, No. 23. ■■ Zemann, " Ueber die Aktinoniykose des Bauclifells uiid der Bauclieingeveide beim Mensclien," IVien. mcd. Jakrl. 1883. ff^l ACTINOMYCOSIS OF THE BRAIN. 79 That these abscesses, however, iiie to l)e regarded as actinomycotic is nncertiiin, in that the author failed to discover in any of these metastases the parasite which excited the primary lesions. J. Israel himself had never observed any case of actinomycosis with cerebral abscesses, nor has Bostriim,^ in his otherwise exhaustive and elaborate treatise on the subject, made any mention of their occurrence. There remains, lastly, to be mentioned the interesting article by Bollinger,'^ describing a primary actinomycosis of the brain, in which the t)nly discernible lesion was an actinomycoma, situated between the anterior pillars of the fornix. Considering, then, the marked rarity of cases such as those here mentioned, and that they, moreover, present certain peculiarities which differentiate them from others, the subjoined communication may perhaps be justifiable. -krankheit." lev.eide lieim Case 1.^ — W. W., set. 38, a blacksmith ; had been for some time under treatment in the kliiiik of Prof. Gussenbauer, on account of a phleg- monous condition of the sternum and tissues about it — of 5 months' duration. Tliis was incised and treated in the usual manner. The patient, however, became gradually worse, presented symptoms pointing to pulmonary tuber- culosis, and finally, 3 weeks after the operation, died, with evident signs of a complicating tubercular affection of the meninges. The autopsy (performed as a class exercise, November 15th, 1886) presented th following conditions : — The body was that of a medium-sized well-built man ; emaciated; post-mortem hvidity in dependent parts. Pupils somewhat contracted and equal. Thorax well developed ; on the anterior surface in the region of the manubrium sterni and corpus was a large idcerated area, 10 cm, in diameter, involving the .skin and subcutaneous tissue, and extending in several places to the subjacent bone and ribs. A sinus from here communicated with the thoracic cavity. From the right border of the ulcer was an incision 10 cm. long, exhibiting, along its deepest parts, softening tissues mtiltrated with pus. The lower portion of the manubrium sterni and part of the corpus were absent, a finger being thus readily admitted into the suppurating mediastinal tissue. The sternal end of the cartilage of- the second rib on the left side was likewise wanting, while the corresponding cartilage on the right side was stripped of perichondrium. The head. — Soft tissues of scalp pale. Skull of normal size and con- figuration. Dura ma' jr tense, its sinuses containing fluid blood and post- mortem clot. The inner meninges pale and delicate throughout, except beneath the longitudinal sinus, where a few Pacchionian granulations were found. Moderate adhesion of the meninges to the convolutions, which latter were markedly flattened, and the whole brain swollen. Basal arteries thin- walled. Cerebral substance pale, soft, and (Edematous. In the left occipital lobe were found three rounded abscesses, each about the size of a walnut and containuig thick, green, foetid pus. These, though surrounded by a definite " pyogenic " membrane, communicated with each other and occupied almost the entire Avhite substance of the lobe, encroaching, too, over its lateral surface m the * Bostiom, " Untcrsuchungen ueber die Aktinoniykose des Men.st'heii," Bdtr. z. i>ath. Anat. u. ::. aUr). Path., Jena, 1891, bd. ix. '^ Bollinger, " Ueber iiiiniiire Aktinoniykose des Geliiins beiiu llenscheii, MUnchen. ineii. iVchnsehr. 1887. 3 Demonstrated by Prof. Chiari, before the Vereiu deutsclier Arztc in Prag., Dec. 10th, 1886. 80 C. H. MARTIN. cortex. In the ventricles there was but ii Humll quantity of serum, and else- where no pathological condition beyond a small loiuUised area of intense liyperaemia on the cortex of the right middle frontal lobe. The pharynx, larynx, and trachea were normal. The iecfh, though incomplete, manifested no sign of caries ; and the alveolar process, from whicdi the lacking teeth had disappeared, showed no change other than atrophy. The tonsils were of normal size, their crypts containing a small quantity of mucus. On removal of the sternum, not only was the area about the sinus fotind involved, but, further, the whole posterior surface of the manidmum sterni and corpus, as well as the sternal ends of the first three pairs of ribs, were markedly eroded, while osteopliytic deposits, thickening of the peri- osteimi, and purulent infiltration were superadded. The mediastinal tissue was very dense and purulent, and penetrated by numerous sinuses running in various directions. Nor was the phlegmonous condition confined to these limits, but could readily be traced hence to the l)arenchyma of both lunys at their apices. Here the anterior and external portions were most involved, each lung consisting at this part of a dense mass of infiltrated tissue, in size equal to an orange. Both lungs in these areas were penetrated by numerous sinuses, the condition on the left side being more advanced, and presenting cavernous dilatations amid a compact mass of pigmented cicatricial tissue. Thickening of the large interlobular septa characterised the main changes in the right lung. Apart from these conditions were delicate apical adhesions of the pleura, hyperaemia of both lungs, and a moderate grade of lobidar pneumonia in tlie right lowest lobe. The bronchi contained mucopurulent secretion ; the peribronchial lymph glands somewhat enlarged and anthracotic. In no other organ were any definite pathological lesions to be discovered. The right tibia and femur were also examined, being sawn through in a longitudinal direction, likewise the whole vertebral column, but in none was there any evidence of pathological change. Microscopic examination of fresh specimens of the pus removed from the abscesses in the brain and lungs, as well as from the sinuses in the skin, revealed the presence of actiyiomyces in all. Pathological Anatomical Diagnosis. — Actinomycosis pulmonum, sterni et costarum ; abscessus actinomycotici mefastatici cerebri lobi occipit. sin. ; bronchitis sujypurativa ; Pneumonia lohularis lobi infer, dextri; cirrhosis hepatis f/rad. levioris. Specimens hardened in alcohol, embedded in celloidin and variously- stained with magenta, orseille, hoematoxylin, and eosin, were prepared from the affected portions of the lungs and pleura, brain, skin, and retrosternal tissue. The sections from the lungs and pleura presented a condition of extensive and advanced chronic inflammation. Where the pleural surfaces were seen there was a marked increase of fibrous tissue, con- taining in some places but few long spindle-shaped nuclei, while in others the nuclei were more numerous, short and rounded, the latter apparently representing a more recent process. In such specimens the fibrous tissue was seen to be invaded by narrow tracts of suppuration, these containing large numbers of pus cells in a state of fragmentary and fatty degeneration. The walls of these sinuses consisted of dense fibrous tissue, which likewise was infiltrated with small round cells, ACTINOMYCOSIS OF THE BRAIN. 81 extending to a greater or less distance from the margin. The actinomyces, whicli were here both large and numerous, showed distinctly the clubbed formation of their fibrils, and were surrounded on all sides by leucocytes lying within :>he suppurating tracts. Dense bands of fibrous tissue, dipping down from the pleura into the lung tissue, participated in the fibroid change. The interlobular as well as the interalveolar septa were markedly thickened and beset with anthracotic pigment In the bronchi extensive changes had likewise occurred, small round cells in various stages of degeneration filling their lumina, while in many instances there was but little evidence of epithelial lining. The walls, further, were to a marked extent the seat of purulent infiltration, which could be traced to various distances into the surrounding tissue, as well as filling the alveoli themselves. In this way suppurating tracts had evidently arisen, and according as these were cut transversely or in a longitudinal direction, different pictures would be afforded — in the former case, giving the appearance of numerous minute abscesses amid fibrous tissue, in the latter case showing definitely the sinus-like tract formed by the parasite of the disease. Sections of the hrain, at the margin of its abscesses, showed that these, for the most part, were well defined in their boundaries, their walls, though infiltrated with small round lis, making a rapid transi- tion to the normal brain tissue. In the surrounding cerebral substance, the vessels were dilated and filled with blood, presenting, further, collections of leucocytes in the tissues around their walls, where, like- wise, there was proliferation of the connective tissue elements, and swelling of the neuroglia cells. The actinomyces, which were readily demonstrated, were small, stained well, and existed chiefly, as in the lungs, amid the small round cells within the abscess cavity. Specimens from the antenor thoracic ivall, cut so as to include the simises, showed conditions where masses of pus cells, surrounded by more or less dense fibrous tissue, were the prominent feature. In addition, a moderate amount of granulation tissue was present outside the abscess cavity amid the fibrous masses. Centrally situated among the pus cells were numerous actinomyces, which, however, stained less readily than those in the brain, where apparently the process was one of much more recent date. The retrosternal cellular tissue presented changes of a similar nature to those in the thoracic wall, though with a greater preponderance of granulation tissue surrounding the abscess cavities. As in all the other sections, so here, large numbers of small round cells were found closely surrounding the actinomyces, whose stage of develop- ment was apparently of a date approximating those found in the thoracic wall. Case 2. — J. K., aet. 16, a labourer; was admitted on June 2iul, 1892, to the medical klinik under the care of Professor Dr. Pribram. From the liistory there taken it may be mentioned that in November 1891 tliere was observed HI this patient a clu-onic suppurative process, considered by liim as spon- 82 C. H. MARTIN. i taneouH in origin, on the right leg to the inner siilo of the tibia. In the following March an analogous procesH manifested itself in the superficial Btructures on the right side of the thorax. Pearly in May, while driving in a carriage, patient experienced sudden palpitation of i\w heart, followed by a left hemiplegia ; headache and occasional vomiting sujiervened. On admission the abov(! history was confirmed by clinical observations : a left hemiplegia with left facial paralysis — several sinuses in the right leg to the inner side of the tibia, and on the right side of the thorax. Physical examination revealed dulness and bronchial breathing over the lower half of the right lung. The headache and vomiting still i)ersisted. On June 10th bilateral optic neuritis was discovered, and on the following day, for the first time, rigidity of the neck muscles. Patient lost consciousness on the 11th, and died the next day at 6.45 P.M. The CLiNicAii Diagnosis was as follows : — Chronic cerebral tuberculosis of the right hemisphere, followed by basal tubercular menimjitis {double optic neuHtis) ; left hemiplegia ; tubercular osteitis of the sixth and seventh ribs of right side ; apical pidmonarg tuberculosis. Autopsy (performed June 16th, 1892, 15 hours after death). — Bodij was that of a young man, 147 cm. long, of slender build; panniculus adiposus thin ; lividity in dependent narts ; rigor mortis present ; pnpils moderately dilated and equal ; visible mncous membranes pale. The teeth were all present and in good ccmdition, with the exception of the left inner incisor of the upper jaw, which was absent, while on the anterior surface of the mucous membrane of its alveolar process there was a small area of uL jration. A probe introduced at this point could be carried along a fistulous tract 1 cm. long and leading down to bared bone. The thorax, of normal size and well developed ; on the right side in the region about the anterior axillary line, from the sixth to the eighth ribs, were the openings of several sinuses into which a probe could be passed in various directions beneath the undermined skin. Behind, at a point slightly to the right of the eighth and ninth dorsal spines, was a similar opening about 2 cm. in diameter. On slitting up the sinus leading from it, the subcutaneous tissue was found to be involved over an area about 10 cm. in diameter, while in the n.uscles were numerous greyish-red nodules varying in size from a hempseed to a Avalnut, all presenting a softened centre and in many cases intercom- municating by suppiu-ating tracts. At no point, however, was any connection vvith the vertebrae visible, nor could any of these sinuses be shown to com- municate with those in the right side of the thorax. Numerous fibrous strands traversed these areas in various directions. To the inner side of the right tibia, along its upper half, were several other orifices situated amid pale violet coloured cicatricial tissue and leading beneath the skin ; incision into the part showed the muscles on the inner side of the leg, from the knee downwards, beset with suppurating tracts running between bands o'; fibrous tissue. The tibia and fibula were found intact. The head. — Skull mesocephalic, 50 cm. in horizontal circumference ; of normal configuration ; the bones thin and containing a moderate amount of diploc. The dura mater was very tense, while in the longitudinal sinus were post-mortem clots and dark fluid blood. The inner meninges were thin and delicate throughout, moderately vascular and non-adherent. The right cerebral hemisphere was much more voluminous than the left, the cortex and inner meninges about the fissure of Kolando of a greenish colour, and presenting here distinct fluctuation. Incision over this area revealed an abscess about the size of a goose egg, filled with thick greenish tenacious pus, of a remarkably foetid odour. Around this main abscess were numerous smaller seats of suppuration, varying in size from a pea to a walnut, all containing pus of a similar character and each surrounded by a definite greyish-white capsule. ACTINOMYCOSIS OF THE BRAIN. 83 )ia. In tho suporficiul 3 driving in illowed by ii hi lulmisHion / hemiplegia inner side of ;ion revealed lung. Tho ptic neuritis of the neck next day at herculosia of double optic venth ribs of . — Uody was ilus adiposus i moderately re all present of the upper LIS membran(^ be introduced and leading t side in the th ribs, were 3d in various ghtly to the about 2 cm. aneous tissue while in the , a hempseed 308 interconi- y connection own to coni- erous fibrous r side of the ;ed amid pale incision into Dm the knee ds 0^; fibrous iiference ; of te amount of il sinus were 'ere thin and Closer examination showed that the involved areas lay in the ui)per third of tho ascending frontal ami parietal convolutions and the posterior third of the middle and superior frontal, together with a part of the corona radiata. Numerous minute ecchymoses were seen in tho cer^'bral substance aliout tho abscesses. Tlio basal ganglia were free from disease and were separated from the supi)urating areas by white substance, 1 cm. in thickness. Otherwise the cerebrum, cerebellum, and medulla, as well as their vessels, were in all respects normal, except that the cerebral convolutions were somewhat flattened. The oral cavity, phari/nx, and lari/rw were pale ; the toiisih and fhi/miil (jlaml manifested no evidence of disease. The riijlit Innij at its lowest portion was firmly adherent, the overlying pleura markedly thickened and traversed by numerous sinuses, '''roni section of this part the lung was seen to be converted into a dense thickened mass of fibrous tissue in which but little trace of alveolar arrangement remained ; no nodules were discernible. Klse- where in the organ there was no sign of disease, nor did the left lung present any abnormality beyond hypertemia and a few areas of hypostatic congestion. Heart and ]wricardin7n normal. Peribronchial lymph ijlands of the right side partially enlarged, and pre- senting numerous greyish- white areas. Abdomen had no abnormal contents. Liver normal. Spleen pale but not enl, rged. Kidneys were pale, somewhat large and friable ; numerous isolated greyish- white areas of the size of hempseed were dotted over the surfaces of both organs. The remaining portion of the genito-urinary tract normal in every respect. Stomach and intestines presented no evidence of disease. Likewise the pancreas and adrenals. Examination of fresh specimens of the pus from each of the cutaneous sinuses, as well as from tho cerebral abscessep, showed yellowish granules in which tho actinomyces were readily detected. Numerous and careful examina- tions, however, failed to reveal, in fresh specimens, any sign of tho same germ in the contents of the ulcer situate