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BY .lA.MKS .STKWAKT, MD., Trofessor of Mi'dicinc nni-intiil from thr Montrful MnliatI Jiiiiruut. .\ijiitiilier, I'jmi. . •''•..,•'.•• m* • .••• • • t * • • • * • • • • 1 •• •• ON TIIK FOIJ.MS Ol- Al'llASiA M Kl' Wl'ill IN A15SCKSS (H- TllF- J-FIT TK.Ml'OKAIi MJUK. BY ■James Stewart, M.I)., Professor of Modifliic !m(>. Tiie oxact form of apliasiii nn-t. with is. however, rarelv tn>aled hy writers on this snhjeet with any de^n-ee of fulness or exactitude. The simple l>ut vaoin,!: all tliat. is found in tlie jrrcat majority of text-l)0()ks, even in ihoso. dcalinf: mon> especially with di,lak.' to wait for its appoaranee in any Cflsc hofore conclndini; we had to do with, an absc<>ss in tld.s situation. A pure and complete motor apliasia lias been met witli as also par- aphasia, the presence of tlie former f)oinT)e of aphasia wa.« present which differs from the forms above referred to. The conditions were so similar that I believe they tear a useful lesson in helpinfr to determine more easily what is often a dilTicult problem, i. c. the differential diajmosi; between temporal ab- sces.s and abscef»s elsewhere in the brain. • Read bef -e the Canadian Medical Association, Ottawa, September, I9()0. 55:507 2 CASE I. AbscosH ot the Tomporo-Sphonoidal Lobe Consequent on Puru lent Otitis Media Aphasia Operation-Death Three Days after from Meningitis. A ilrliciitc iiiiiii. .i-cd •-'•.'. Wii- iiiliiiillr,! \\\\n I lif \l'>\i\\ \'WUt of May. altliouj:li deaf ami Mill'crin.i: from linniliis aiirinni. Tlio livnlnMnt of tlio ciii- conliniifd.— I'olitzcr inllation Iwic- wrcMy and paintin- tlio lliroat wilh an iodinc-jriy.'criiip scliitinii. Thi> Iroatnicnl was conliniioil daily till tin- first of laly and afterward- llirco tiincs a week. On llio ir.tb of .Inly tlierc was a snddon and violoni ronirronco of tho yxiin in the eiir liuMini: for al.out ten days. On t1io ^r.tli of July lie wa.« seized witli riirors and vondfin^'. Ilio pain and tinnitn- at the sjuno tinio roasinir. At tlia.t. time liis toinperalnro rnnpod l)etwe(Mi 100° and 101..''.'' F. Tlie headaehe mMirred on n'any oorasions, however, nnd ni tho time of liis ontninee into the Imspital ho was snlTorin? vory sovoroly. The vnniitinir oocnnvd two or three timoi^ daily and was dis- tinotly rorehral in hj^o. Oil iidnii^sion, In' was found to l.e sufTerintr from nmro r>r los? oon- ptonf and -ov(>re hendaehe with vomit inL^ TTe wa.s slow in an^^worinfr questions aiid from the hisforv it would appear fhat i=ineo tlio nnsot of tho 'sudden pain. ete.. ten davs previouslv. he has had sreal dilTienlty in naniin? ohjoets. This diirienltv still persists. Tt is found that ho is unahlo to mention the name of anv nhjoct. whatever, TTe d(x^s not lnnt tho ma.stoid ; a wateh is heard at half an inch. 7i'.;/M.— The pupils nro normal in size !ind re;\c1ion. There is distiuetlv a he^inninL' douhjp optio neuritis. A diajniosis of alwooss of tho tonn'"roiS]>lienoidal loho was made and immediate operation determined on. Dr. Tiuller opened into th(> i„a-t,ui,l rrlU. llr iMinnl pu^. Dr. I'-'ll pi"........!...! m .Ai-nM' tlif Lmiii ovfi- tlif tciMiM.iu-.-|,lK'iioMliil n-iuii aiwl allcr (.li.-iun-; tlu' il'Tii, li>- I'ouml llif |)iiil.'^ biilgiiiir, ''111 ""t I'lil.-'itiiiK- With II irnnir In- was a\>\v uiiliuui any ip.iil.lc. u, liiul a |.iiri-(;..iitaiii- iiig ruvily ill Ihr 1.11 I'liipnral IhIm-. Nciiily llmv "uiiivs w.mv i.vmiiali'.l. Tlic nijiiil alliT iIm- n|MTat:on tli.- palu-nl M<1 iH'tl-'r tl'"" 1„. l,;„l ,l„iu' I'or many w.vi<.-. l.fiiij: Ir.v fr.Mi. [miii ami diM'c.ml'oil. Kvcii wiliiiii lu.Kc iinm- ail. r liir uiH-i-aliun it was ii..liiv.l by ^.■v^|■al ul.MTv.Ts that llu'fc wa.-* a (lisliiict iiiii>n.v.Mnciil. in lii^ ^l>.•l•(•h. 1" tw.'iilv-lnur Im-uis til.' iiiipi-o\.'i.H'iit \va.- m. inaii(«l \\vM it <-<.iihl 1m' sini t.liat he iia.l .•oin|-l''I.'lv frm^rwA lii- i-M ih.w.t. All kiiuU of lr,t ,,h- j,,.t.. vv.Tc prninplly ainl e .ivrily nani.'.l. ri,lurt.inat.-ly ahout thirty hours art.T the opiTatioii, syinpt..iii- «.!' iii'-iiiii;.'iti< .I.'Vc1u|h..1, whi.h pi-(,vc(l fatal I'ortv-fijilit hmiiv altiT their onstM. A pu^imortom ..xaniinatiun was iint „hlaiiha. This docs not, hovv- (v..,-. .hi met imich fru..; die clinical value of the case, us (luring life the prtscnie <4 the ahscess hail been (leiiiniistratecl. CASE 11. Abscess of the Temporo-Sphonoidal Lobe Consequent on Puru- lent Otitis Media Aphasia Sudden Death from Respira tory Failure. A girl, aged 1.^, who .^poku bolli I'reneh ami Eugiiah, wo* udiiullod ijito ihu'li.oal \ ielona nu»i)ilal au Llie lOlh ol' yubruary, VJW, cuiu- plaming of headache luul vonuling. The headaeiie diU^'S back U> Chn-liua.- of \bW. It lia» been persisleiilly pre.-eiiL and generally severe, ke.-ping her awake ai nighl^. I'lUii has been generally referred to Ihe left temporal region until a few (hiys agi>, sir.ee when it;i site hius been cont.inuou.-lv frontal. The vomit ing set, m about four weeks alter ll,. pain in thu hmd wa^ fell. It U:u. b-vn, with the exception ol iho last few days, more or lut^s persistent since its onset. A ditlieuilv in speaking has been noticed sinx.'e the headache lia.~ b'vn liixt eomplaim'd oL She .Mrmed unable f. utter the word at once which ..he wished to ^av. One of her friends expre.v-ed the dilliculty in the words that ".slio 'seemed for a few moments to have forgotten what she WiU.te.l to sav and only by an elfort would she say what .she wanted. The dillieultv of si.eech rapidly inerea.sed in severity and in the course „f a few davs reached the inti'nsity that it presented at the time of lier entrance to hospital, six months after it.s onset. During tlie iia.4 month she has had several general convulsive movement.s, hv^tmg about fifteen seconds and attended by loss of c .^- iousness. P«./ lIistor>i.-\yhvn nine months old the patient had a purulent discharc^e from each -ir lasting for three m.mths. At three years of t-r:,:;r:r;r^,:r:;;::;;:;.f';;:^;^;^- Ji ,l,n,. Ko.1. .ea...! and ..lu. ha. .vinaUK.. per -t > -U up „.. adini Jon, Ma-'wa- ImuM U. h. >n a ktharg,.. MaU, an.-wcnng cu.. JmU- ,nn,. l,..ln.v -iH. aUHu,.,. Hi. ai.u..,- ... a .......... > i-.ii is )inal>li' l.> I. .i.roMiiial.'lv 111.' tiiii.' «{ ..iiM-l, ..1 liir li'oiililt IS )inal.l.' I., i.'ii .'^'ii a .piMN , I ,, . .,1.1.. SI n,.. n,.,la.... '.l-. Al, ,1, u-'ll .•.lu.-a.-.. , M- -^ "" • ' , .,.|,..n.l .n....nlan,.,a,.. ,n,U. '-''^ "' > ^''''•; ^'^'^^ ' ^,^.,,,,,;,,. ,,,.,,,,,,,, ,|,..,v.l,..r.-im|.l.M-r.U. M.- ., aLI.. ... vm ... lu. .,^Mi iiaiM.'. I.ul ..iIp-iui.-.' 1>.i' wn.inu I" l„,ili ,lui;iliMii ami i'"!')- '•- '"•'- ,„.,■.•.... ..>,....all,......lu.a. ^^'--'-''•^^ '?;"":,. Lu.-ylr lnn.,,yn,--.l...M-/->l-wnl.s-.lan,.>. ^" - ' " „ •' ,,, ,,, .1,.. ,~.|ui.. ui.al.lf ... .viall lIuMi- .laiuo, m pen. a lx.'\. a \\atiii, 1 1< ■• ' "' ' . i, . ,.|,..ii'lv n.lr in nvn.lM,r i:n,l.-h. All M'"!-- -''''--'-^I'l-';' '^ ' ' '^ .•tt.r- .11 an in.lisi.lnal nii.l jiiTlVcllv un.l.r-l ^qval.T .liiliruUy in iv.-..,uni/.in.^' in.livi.lnal ..• ,Jll:. .„■ .1.0 n,i,. .a...al n...... Mov..,:.... n. all ...In.' !-.> >> „,,,l„.r -ul..i.'.'tiv.. (.!■ ..l.j.'.'tiv.' .li>.m'l.aiico m il„. kn.M. icrk. aiv mud. .liniini-li."l normal. Siiisiiliiiii.-'Vhi'y^' 1^ n> the lace ..!■ .'Xli'.'ini.ii'-- /.'(■//r.rrv.-SiiiM'rli.'ial mn'inal ; H Mii.l V Hv.ui ih.' n::ht lliau..n .lie left .side. ,,, |.„iK,, n.porl.'.l ..u 111.' e..n.li.i..ns ..l' the eyes and eai> ; ;.LThe right ,.u,.,l . .n.h.ly larp.r than the leit, but bo h react r..:hv.oli.hti.n.l'a... - .-■. '•''-•-^ ''^n'' iZ T-'.: ,ii,..s and ..n,..rg..m..n. ,.t .1..' v..m4s. l.u, ,. .aniianllv he sa>d that th. . . isa.lc-Hnitely.'siuhlish.Ml..i..i.'neuriii.. /.;,„. -^-Sh..h..a.—nlv ..n ...nla.-. .m h.-.h shU^s. Ihe.ei^a.np ,,,,,Hve ,,,,.,< nuMia ,.n ilie lel, >i,l.^ wi,h inv.4v.wnt .d the hon^^^^^^^ '„„. , ■ „r ,1... .,v,n,.a,.i,n,. Theiv i. a protu.e an.l hetnl d.eha.jre '■■■"rh;';:.;;l::ma, U„,„...a.e.le..nh..dr..r.veral,lays.the.mly „.>,u...al'le a.l.rm.m U, th.. ah..v.. >.vm,....u.s ben,, the development oi the ..ptie neuritis. \ A .li..uu.Mi. ..( .il..cr~* ..!■ til- u-.ni...ro*i,lu..u.iaal \.m. wa. nuuU- an.l ,„ .,...n^..n was .I..U.r,u>,u.a ..... l-.U . f- l.-.n. l...f.... .t w.. lo ha . ;:'; ll'ry .a,!...!. I ,..,.,..1 .„ I..-. Sh.nv. f..r .1... .ollow.ng ,„,... ..!■ .!,.• iM....i...t-... .■x.u....mt..... iK.i-l...-m.-.l l.y l..n. TUc n..-...l.'....- -:.-"•'! n. . I.- l-l' .....MU' I— """'^" ' ^\ ,„ark...lly th,.k..|...l. l-.....la.-ly r that ,>...;t .>M1,.. I">;;- ';' lU .,„„„,- TlH IMU, «a..aU.. r.......l .li..-.....l. t.'.t .he .....SI..U1 .. „..,•....., ...a.!. Tl... l..a,..i., .!..■. v,i.M...nl.-.. •...p.>.-allulM..mtlu. Ml I Wen' 11.11 mill. Ill- ■- ,..11 I ....r..!' .i.U. was .liMi.i.lh -U..11-.. aii.l .. .I.'.na..-..-. 1-..,^^ a. 1..... a .li..-.l U.^. ,1..M .1,.. 1..1 ■.h..vl,-M.I... Tin .•.msol......... -■.•-• llat....i.-.a'^ M.I... -hall.... ..Mai..m,.l,..K... .v.,...s. .l...l..a....a., ah-...s.-... m^ 1.. wi.h... ah..... :; ....M. ..n ..-■la..... hu,>. ah..... a .,..a.-....- ..1 a.. ... . ,,..1..„ ,1... Svlv.a,. Ii".„v wi.h .1... .■>cap.. of ah„u. 10 '•< • " ."^ - l.asin.^a r,„il ...h.n. . a ,,v..n,-h ...... a...l a., a.a.l .va........ Ah-... < > n.i.hH.. ...• .l.v .....ha M.,Ma... ... .!aMh..M .....p...-..-spl..'..'Maal ......v.. .- ,i,.„..,.. .ha. ,.a.l..r.h.. h.l... hat !..s,li.vc,..l.y..vo.-.l... ...... .' ,v„.,.....,,.. a,. a.va .,,:;.•.,.. n,h.-..a.l.h wa...h,>...h....v.la...l ...... .^ lil.Kk a..a .... .he ve.-.. .-f r..i.tu.-i..g. N-U....^; .ih.....-...al wa. to be ..... i.. a..v ..f .he ...h.r cM...v..l...i....s e.veepl in the hyp..ea...pal eo.ivol..- (ion ..f .hi- Ml ..m, ua. .h...i .livi.h'.! i".o liN^' -^-'i""^^ '">"'• """"^^"""^ "'^=' "" ■ "'^' 7 |a,io„s a...l ex.e... of .I., ahs.. >s .....1.1 m. he aee...-a...|y .hte.......... . The.'e w-e.-e f.......l f I- >-' 'li>t""t al.Mv.. .avi.h.s; ...... .h.- s.,.alh . .,r v.TV .-.na.. .•...-...a.i.... a...l h,,h.r pla...!, was sitaute.l ...a...ly ... Mu l„„,,-,„,, .,r ,l,c Hot .c....p...-al .....v..!...:..... H was ivom th.s ah^ces^ ,l,a, ,lH. p,.s l.a.l e..a|,..l .... ........vi.,,' H.e h.-ai.i. The lowe.- .il..ce.«, or ,1,.. ,,ri„.a,7 al,>ee..s. wa.. e..,..i..nl ehietly t., the mickUe a.ul lower tem- p,„.,l c.„„v..l..ti....>. .aeas...-ea .".O ....... I'ro... bet.HV l.aekwa.-,ls, 10 min_ lal.i-allv a.i.l •-•:. ....... l'r"»' "bove .lownwa.-.l ai.d held owr -10 ec. ot fluid "This abs..ess had a ii.'... .u.d thick capsule wLlh a »..i.>..th ....>er surface There was no cinmunication between the tw.. abscesses, or between either of them a..d the ventricles. The wall. ..f the upper abscess were inv{,n.lar, the tissue bei.v- necr... ic an.l disc.h.ure.l I here was .... t.nvce of n.e,nl..-an... This abscess, as al.va.ly n,e..l...ne.l. .-orros- .„„,,„, ,„ „,„ ,,„,,,. pa.-. ..!• the first temp...-.il conv..lu....n, evtend.ns l„t..n.allv IV..... a .b'p.h ..f ah,...t :5 mm. fn-m the co,-tex. .-ea.. h.nj: m fr.,i,t close to the external capsule near the base and antcn..r .... of the lenticular nucleu,., and bebind to the level of the descend.ng bo.-n ol the lateral ventricle. G Seclioii I. -IW-aiii lis.^u.> noniii.l. iln- '^^•^Liou i Broca-s middle and sui-crior IToulal convolutions. ^^ S....tion ll^-VnUTior Mirlaer : n,, disease can be .een. lu.auo ,i~»i ; •■••'■-'.z".:z^'S'z::,. ;';;;..i...a..uia,.nucu.u. ''-•''--•-'"•-;''';-';'''•';;::;.;, anu.no,- ,.ndonh..|..v..,-al...-.avnv. ' '^ ^\'''';:;''V ,';;,, ,,, ,1,,. ,,.,nporo-M,l,..n,,.dal lolu. and uo.n.u lo .in". Hi" I'l"- ot Liu iulu J,' ,,„,,., „vd..-tn,v,.d. (.nl,aadlin,tlu.M.ct,onw.can.na. ;:':L .1. d,..a.. . d.nn...u i '•-''', 7';;;:'t;i:^^^^^ ,,„nnlnnnn. of ,1,,. loin, and ,lu. ,.ra...n.ral and ,KM.-...U,alu,n. . 1. ti„n.alMAr. and i'.mca's convoluiion in Ir-nt. ,., , , , ,hc Lion 111 llo,... a.ain tl... diM-a... ,,- d,Muu-,ly couUncd to llu t... :; !.!:.da, convolnUon. Postonorly wo sec two l^ge a..c. i..l, und.d al,nv,. hv ,lu. li.-un. .d' Sylvius. >n..craaUy by th d. > :. orn of the lau.;al v..ntn.l... and i.lo. by the .woUcn hy,.. r.-.mvolu,ion. the lingual and tlu- I'u.ibe-n,. CM, the und.-r ^ui- ..„!,daW o,,.n.,.. ,- a ,,..,.o,,e a,-ea. th,. n... d..i.nd.^^^^^^^^^^ U, |,,..„ ahM.>.~. .av„v. a„d ,.l,e wall h.re ,- vu-y Hun a„d on th. Ncr c I!;,';;,;;,,:,,.. ,.nh,;id.„K.h, scetionu,t.lheMath,s,.ea.ly d(. mill, -I rated. , ,,,vi;n,>,1 llip <:ection IV.-Anterior surface: bere '>^-- '^ /' ^'^^^ ^. ,„.tefior .xtrentilie. ot the two ab.c.s. cav.tns bounded '•' '-^ '' ' ib.vo by the bi.uhr ,,t,artH- of llu. Sylvian tlssnt-e, and mtemal y b ;^Zi!.r and dc.cendin, hon.s ot the lateral ventHcle : the postenuv snffaee, -bows no trace of disclose. ,i,i,„ilu. \r,... ,i,. cxan,,,,at,on olMhe livo M.ot.,o,,s one ,> ,K.r,uadcd t ha 1 u ai' ., wa. stnctlv .nnliued ,o ih. „.n„,.n,-,h.„o,.lal .onvolnt.on. ;;;.:;,,,,, he an,ula,. ,vn,., -u,u-a,,.a,-,,nal a,,d f,-o,,,al eonvolu.,ons were 'irU ea>e. the ,y, f a,,ha.ia wa. the sa.ne. a loss of the v-- .,,,„„,.„. a, ,ets. 1" '"'th eases .he,.o wa. not sumeK.n^^^v^^^^^^^^^ ,..,„„ ,,,„ , ,i, ,„unli,s t.o „,te,-re,.e w,tl, la,rly g.-od M.ion, m.,thu h . anv .ortieal visual defect a. fa,- a. could be ascer a,ned. Zh ; ien,: veco,n,..d fully the use of objects presented to the.n^ ZyL nnder-tood without ditlicnlty spoken langituge, showtng that there was no wurd deafuosi. re The examination of tl>e l.raiu al'tur death m the ^--^ ?- ' ^ ^^^ that noitluT the posterior pan of tl.e lir.t temporal uor ^^^^^^ frontal convolution was interfered with, the destruction J-^^ ' ;] ,o,.,i„ed to the low.r and ,nor. antor.or parts ol t'- --"^^^^'^ ^"^ <„,,„„,,, c-unvolutin„s. AitlH.ugh no exanunatton ol the >>"^'>^ "^ ^^; (•c-ase was ol.auu.h it is ahnoM certain that the destruct.on of t.^ue l;:l.redin.i,es,.neareaa.n •''- -^^'^ '^ /'.-'^ ^n, ,„., „|,noM cinph'tc rcc.v.ry ..rth.. p'--r ol speech ale, 1'<-'I> ;• I ,s s,ro„. . ',d,.n..e u. .upp<>rt of the linutation ot the dest.uctue •'••;■;: ;:;:';;Zr'::!.!K:harac.risod 1, an inahilitv to nan. tlun.. ,, .;'Jlhv a, en,poraMohe lesion. ,. it due to destn.ct.. ot what ha h.,.n called the ...M., .../,v ^ '''''-• '^ V'"?'''?''',;': ; ^ in favour of ...tin, a.de a special part of the hra.n for sud a tntrc. It .as dr. ....ested hy Broadhen, and .--^-'^^y ' > supported fron> the restdts of clinical ol.scrvatn.ns hy 1 . f^; ' ' ^ of riulad.dphia. lie looks upon .i>e third t.c„M-ra.l as the .eat ot , i,,, ,.„,,, The inahili.v ,o nan.e ohjeet. may. however, he du ; U,., o,r or the asso..iat,on tracts hetween the visual cerdre am ;,,„. ,,„„li,ory Centre, on the one side, and the latter and the motor centre Cnr oiiT'ch on tiic other. . Whin,'; the two ca.cs were e.nnple. of d,roct injury to a 'namm, ..ontre" or the cultimr off of it from its connections. 1 ani utiahle to .ay : ,.v an. hoth of value, espeeiallv the second, as .how.n, that a -^ . ,,,I,a.ia characterised hv an inahildv to r mher the name of o - 'el t^ recollect nan.es. n.ay arise fnun a destruct, :e les.on con- fin d o iho ten,poro-sphenoidal lohe. This fornt of aplu.^a. present 1!::^ any suspected case of hrain ahscess, would, therefore, he of value in determining its localization. e er d. ,at STi:\VAl!T AIMIASIA. 'r.i illu-trati' til" roiiditioii-. luuiid in <';i><' No. H. i-i<;. i. TUtHI) VKlfTIiM.sr.niON. ANTIMMOU sriil'ACK Svlviiiii Fi---iir<' S> U iiiii Fis^iiit* 1-1 TfiiLpniHl I'plMT Abscess t'avil V Aiitri iurt'iiil of l.DWir Absct'js Cavity l-IC II. FdlHTll VKiniCAI. SKCTION. I'OSTKIUOU SIKKACK, SylviMH Kissuri' rpiMT All-cess ('M\it,\ l.OWt T Abscc-s Ciu il\ S\l\iim Fissure STEWAUT— AI'IIASIA. 11 V ri<;. III. SlluwillU-nllHillO oM til.' rnvU'S .■onvs|,nli,li 11- tn til.' ul.sces- ItlVlllOS. OiilliiH' of I'pp.T Alisci's^ .Cavity. Outline of r.ower Abscess Cavity. ;•■. • ••• M uiAwtrnn"*""""'^*^