Joseph Buford Pennybacker, C.B.E., M.D., F.R.C.S. (1907-1983): Continuing Sir Hugh Cairns' Oxford Legacy and Pioneer of the Modern Management of Cerebral Abscesses.

The authors examine the life and contribution of Joseph Buford Pennybacker to British neurosurgery and the modern management of cerebral abscesses. Pennybacker's inspirational journey began with him aspiring to follow in the footsteps of the pioneering surgeon, Ephraim McDowell. It saw him cross the Atlantic, learn medicine at Edinburgh, train in neurology at Queen Square in London, and study neurosurgery under Sir Hugh Cairns in Oxford. Pennybacker navigated a successful career through World War II and together with Cairns established the Radcliffe Infirmary in Oxford as a highly esteemed neurosurgical unit. By increasing the operative tempo yet uncompromising the meticulousness of his operative technique, Pennybacker challenged the Halstedian and Cushing traditions. The pioneering Pennybacker system of managing cerebral abscesses stood the test of time and the ethos of preoperative imaging, intervention, and postoperative monitoring-clinically, biochemically, and with imaging results-remains today. Pennybacker contributed significantly to British neurosurgery and the training of both home-grown and international neurosurgeons and he was also a remarkably kind-hearted and calm individual. These qualities inspired many of his contemporaries and junior colleagues, and we hope will continue to do so for generations to come.

The last ride of Henry II of France: orbital injury and a king's demise.

Jousting was a popular pastime for royalty in the Renaissance era. Injuries were common, and the eye was particularly at risk from the splinters of the wooden lance. On June 30, 1559, Henry II of France participated in a jousting tournament to celebrate two royal weddings. In the third match, Gabriel de Montgomery struck Henry on the right shoulder and the lance splintered, sending wooden shards into his face and right orbit. Despite being cared for by the prominent physicians Ambroise Paré and Andreas Vesalius, the king died 10 days later and was found to have a cerebral abscess. The wound was not explored immediately after the injury; nevertheless, wooden foreign bodies were discovered in the orbit at the time of autopsy. The dura had not been violated, suggesting that an infection may have traveled from the orbit into the brain. Nostradamus and Luca Guarico, the astrologer to the Medici family, had prophesied the death of Henry II of France, but he ignored their warnings and thus changed the course of history in Renaissance Europe.

Management of brain abscesses. I: Drainage and antiseptics.

Listerian antisepsis opened the way to surgical treatment of brain abscesses, at a time when advances in neurology made it possible to localize many of these lethal infections. William Macewen, a pupil of Joseph Lister, published in 1893 a remarkable monograph on pyogenic diseases of the brain and spinal cord. He recognized that these were caused by bacterial infection, and reported a series of 20 cerebral and cerebellar abscesses, treated by surgical drainage with antiseptic precautions. His mortality was amazingly low, but later surgeons were less successful. The causes of failure included inability to control microbial infection of the brain. Various chemical antiseptics and also serotherapy were tried, but mortality remained very high.

Management of brain abscesses. II: Antibiotics and computed tomography.

The discovery of the sulphonamides in 1935 was followed by the dramatic introduction of penicillin, first used in the management of a brain abscess in 1942 by J.B. Pennybacker of Oxford. He integrated antimicrobial drugs in a system of diagnosis, local and systemic antibiotics, and operative treatment, which was widely accepted. However, the mortality from brain abscess remained high until the advent of computerized tomography in 1973 made diagnosis safe and easy. During the next two decades, Pennybacker's system of management was modified, and applied with better results to all forms of brain abscess, including opportunistic infections associated with impaired immunity. These modifications have been studied historically in the management of 140 patients with brain abscesses treated in South Australia in the years 1955-95.

Eduard Hitzig's experiences in the Franco-Prussian War (1870-1871): the case of Joseph Masseau.

It is well known that Fritsch and Hitzig published the results of their experiments on cortical stimulation in 1870, the year in which the Franco-Prussian War (FPW) broke out. Several tall stories are found about Hitzig's role in the FPW; stories that have not been well documented. During this war, he worked at the military hospital in Nancy, where he was allowed to admit to his ward soldiers with head wounds. He made a close observation of the 20-year-old French soldier Joseph Masseau, who suffered from a right-sided cerebral abscess following a gunshot wound sustained during the Loire campaign on December 10, 1870 and was looked after in the military hospital of Nancy in January and February 1871. Hitzig related the clinical and autopsy observations to his recent experimental findings. A translation into English of part of the case report is provided.

Taming an old enemy: a profile of intracranial suppuration.

Intracranial suppurative disorders (ICSDs; brain abscess, empyema, and purulent ventriculitis), have been a scourge through the ages and attempts at curative surgery, as for cranial trauma, are considered to be one of the first true neurosurgical interventions performed. ICSDs, seen initially as a consequence of poor socioeconomic conditions and neglected otorhinogenic infections, predominantly manifest today as postsurgical complications, and/or in immunocompromised patients where they continue to result in significant neurologic morbidity and death. The reduction in the incidence of "old world" classic ICSDs can be attributed to the modernization of society, driven inter alia by a shift from an agricultural to an industrial economic society. It can also be coupled with pivotal achievements in public health and the dramatic developments in medicine in the 20th century. This trend was first noted in developed countries but now, with improved socioeconomic circumstances and globalization of medical technology, it is occurring in the developing regions of the world as well. Although ICSDs have undergone a metamorphosis in their clinical profile and despite their rarity in contemporary "developed world" neurosurgical practice, they still have undoubted potential for fatal consequences and continue to pose a significant challenge to the 21st-century neurosurgeon.

A neurologist in the origin of European and International neurosurgery: Clovis-Julien-Désiré Vincent (1879-1947).

Vincent Clovis began his carrier as a neurologist and finally became neurosurgeon at an advanced age. He is considered the founder of French neurosurgery, and after Harvey Williams Cushing, Europe's first neurosurgeon. He was mainly interested in pituitary tumors, in cerebral abscesses and in cerebral oedema.

Primer reporte de cirugía cerebral en Cuba / First report of cerebral surgery in Cuba

Objetivo: Profundizar en el decursar histórico de nuestra especialidad a través de la revisión de fuentes bibliográficas y documentales ubicadas en prestigiosas instituciones provinciales, nacionales e internacionales, relacionadasfundamentalmente con las neurociencias.Desarrollo: La trepanación del cráneo es el más antiguo de los procederes quirúrgicos que se conoce. Los primeroscráneos trepanados fueron encontrados en el Perú 500 o más años antes de Cristo, desde entonces ha existido un largo camino en la realización de reportes sobre procederes neuroquirúrgicos en la historia de la humanidad. En Cuba desde la primera mitad del siglo XIX comenzaron a aparecer artículos sobre pacientes con patologías neurológicas, pero no fue hasta 1891 en que la realización de un proceder neuroquirúrgico figuró en la prensa médica cubana como un suceso memorable.Se indago acerca del primer trabajo de carácter científico, aparecido en la literatura médica cubana referente a un proceder sobre el cerebro. Su autor es el Dr. Manuel Moreno de la Torre y la discusión clínica del caso, así como los pormenores de la intervención quirúrgica aparecen en el volumen 17 de la Revista “Crónica Médico–Quirúrgica de La Habana” de 1891 bajoel título: “Abceso cerebral, trepanación, curación, recidiva y muerte”.Conclusiones: Se espera que esta investigación motive a médicos e historiadores a calar en las raíces de cada una de las especialidades médicas, hermoso e instructivo método de respetar a nuestros predecesores(AU)

Objective: Our interest is to investigate through the history of our specialty by the review of bibliographical sources anddocuments in prestigious provincial, national and international institutions related fundamentally to the neurosciences.Development: Skull trepanation is the most ancient surgical procedure that we know. The first skull trepanations were found in Peru 500 or more years B. C. Since then there´s a long way about neurosurgical report cases in the history of humankind.In Cuba since the first half of the XIX century began to appear articles about patient with neurological pathologies, but it was not until 1891 that the fact of a neurological procedure was published in the Cuban medical press as a remarkable deed. We searched about the first work of scientific character, appeared in the Cuban medical literature dealing with a procedure on thebrain. His author is Dr. Manuel Moreno de La Torre and the clinical discussion of the case, and the details of surgicalprocedure are in volume 17 of the magazine “Crónica Médico–Quirúrgica de la Habana” of 1891 under the title·”Abceso cerebral, trepanación, curación, recidiva y muerte”.Conclusions: We hope that our investigation will be a source of motivation for doctors and historians to go deep in the roots of each of the medical specialties, a lovely and instructive way to respect our predecessors(AU)

Did one ear infection in France change the history of Britain? The illness and death of Francis II (1544-60).

The middle ear has long been considered a continuum of the upper respiratory tract and modern physicians recognize the impact of upper respiratory tract pathology on the middle ear and are familiar with the possible neurosurgical complications of any resultant chronic or acute middle ear infection. In the 16th century, lack of this knowledge may have led to a sequence of events and one of the most important turning points for the British monarchy. This paper on the illness and death of King Francis II of France uncovers interesting aspects of ENT practice from the French Renaissance period and the intrigue surrounding this royal patient's well-documented but little discussed illness.

On the report of the first successful surgical treatment of brain abscess in the Ottoman Empire by Dr. Cemil Topuzlu in 1891.

IN 1891, Dr. Cemil Topuzlu operated on a brain abscess that originated as a complication of a depression fracture of the cranial inner table. The patient presented with Jacksonian seizures on his left side after a sharp trauma resulting in a 15 cm-long scalp laceration and underlying linear cranial fracture in the right parietal bone. Dr. Topuzlu attributed Jacksonian epilepsy to the fracture irritating the motor area in the right hemisphere and attempted a craniotomy based on his measurements to localize the Rolandic fissure. The operation was complicated by a brain abscess, and Dr. Topuzlu reoperated to drain the abscess. He successfully treated the brain abscess and Jacksonian seizures and then presented this case in the Royal Society of Medicine of the Ottoman Empire and in the International Surgery Congress in Lyon in 1894. The case report was published in his surgery book in 1905. The case was not only the first case of brain abscess to be treated successfully with surgical intervention in the Ottoman Empire, it was also one of the first cases of neurological surgery performed using contemporary anesthesiological and surgical techniques, which reveals the importance of neurological examination and cerebral localization techniques in the era before x-rays. Dr. Topuzlu was the founder of modern surgery in the Ottoman Empire and deserves to be credited for his novel applications in the 19th century.

Intracerebral abscess in children: historical trends at Children's Hospital Boston.

OBJECTIVES: A previous study performed at Children's Hospital Boston describing the natural history of intracerebral abscess between 1945 and 1980 demonstrated a decline in mortality after 1970. This current study examines the occurrence of intracerebral abscess at Children's Hospital Boston between 1981 and 2000, inclusive, and compares the results with the previous study. Our objectives were to determine whether there had been a change in the predisposing factors, whether there were changes in the microbiology of intracerebral abscesses, and whether mortality rate had continued to decline. METHODS: To ensure that all occurrences of intracerebral abscess treated at Children's Hospital Boston between 1981 and 2000 were identified, we searched 4 separately maintained databases for the keywords "brain" or "abscess" or the International Classification of Diseases, Ninth Revision code 324.x. This search yielded the names of 386 patients. Of these 386 patients, a solitary intracerebral abscess or multiple noncontiguous intracerebral abscesses could be confirmed in 54 patients on the basis of cranial imaging (computed tomography or magnetic resonance imaging) or autopsy reports. The complete retrospective review of the medical records of these 54 patients constitutes the basis for this study. RESULTS: Congenital heart disease was the most common predisposing factor during both eras. Compared with the previous era, important historical trends identified include a reduction in the number of abscesses that occurred in the settings of sinus or otitic infection (11% during 1981-2000 vs 26% during 1945-1980), an increase in number of intracranial abscesses in infants (18% vs 7%) and in the setting of immunosuppression (16% vs 1%), an increase in the number of children who were treated with antibiotics alone (22% vs 1%), a stable overall mortality rate (24% vs 27%), and the identification of Citrobacter and fungus as causes of intracranial abscess not observed during the previous era of 1945-1980. Citrobacter was observed only during the neonatal period. Fungi were the causative organisms predominantly in the setting of immunosuppression. CONCLUSIONS: Intracerebral abscess in children continues to be associated with high rates of neurologic impairment and death. Because earlier detection may reduce morbidity and mortality, intracranial abscess should be considered when evaluating children with new-onset neurologic signs or symptoms, especially in children who have acute immunosuppression and disseminated fungal disease or fungemia.

The death of Henry II of France: a sporting death and post-mortem.

In 1559 Henry II King of France was wounded in a tournament and died. A broken lance entered his right orbit, destroying his eye and leaving behind many splinters. The skull was not penetrated but infection spread intracranially. Both Ambroise Paré and Vesalius saw him and predicted death. Nine days after wounding, both attended the King's post-mortem. The story shows how difficult life was without antisepsis, anaesthesia, antibiotics or investigations. The King's stubbornness highlights the dangers of continuing to play after concussion.

[Oscar Wilde. Medical observations on the 100th anniversary of his death 30 November 2000]. / Oscar Wilde. Medizinische Betrachtungen zu seinem 100. Todestag am 30. November 2000.

BACKGROUND AND BIOGRAPHICAL ANNOTATIONS: Oscar Wilde, the brilliant poet, essayist and playwright, son of the famous oculist and aurist William Wilde in Dublin, died on November 30th 1900 at the age of 46 of an otogenic cerebral abscess. By way of introduction the biographical stations are briefly outlined. In 1895 Wilde at the summit of his career was found guilty of homosexual intercourse and sentenced to two years of imprisonment and forced labour. THE CASE HISTORY: As a sequence of the circumstances in the prison and diarrhoea Wilde lost 30 lbs weight during the first months and became very weak. Although one Sunday early in October 1895 he felt very sick and begged to be allowed to stay in bed the doctor of the prison taking him for a malingerer forced him to get up and attend the service in the chapel. There he collapsed and suffered a fracture of the skull involving the right ear, and a concussion with temporary unconsciousness. Previously there had been a mild deafness of this ear, probably a bland type of chronic otitis media. After the accident there was bleeding from the ear and suppuration which lasted for many months often associated with heavy pain. After the discharge from prison in 1897 for a while the complaints were slight and Wilde travelled around France and Italy accompanied by friends. Finally he settled down in a hotel in Paris. In September 1900 heavy earache recurred and Wilde was confined to bed. Several doctors were taking care of him. At October 10th 1900 a Parisian surgeon performed an operation on Wilde's right ear, probably of the kind that had been suggested by his father William Wilde: Wilde's incision. The lethal outcome could not be averted. DISCUSSION: The case history is reported in detail based on the extant documents, analysed and put in relation to the medical knowledge and therapeutical means available around 1900. A successful treatment would not have been possible at that time, even under more favourable circumstances.

The death of Thomas Wolfe: a 60-year retrospective.

It seems likely that an old tubercular lesion of the lung had been activated during Wolfe's acute pneumonia and that the disease had spread to the brain. The chest x-ray with the right upper lobe infiltrate was certainly typical of pulmonary tuberculosis, and the spinal fluid findings were characteristic of tuberculous meningitis with 230 cells, 75% of which were mononuclear, which Dandy felt "practically made the diagnosis." Tuberculosis was so prevalent worldwide in the early 20th Century, around the time of Wolfe's birth, but began to decline dramatically in the early 1950s with the introduction of modern chemotherapy and isoniazid (INH). In the U.S. the number of reported cases of TB decreased from 84,304 to in 1953 to 22,201 in 1985. Unfortunately, however, the number of cases has been increasing since 1985, due to a variety of factors including decline in public funding for TB control, HIV infection, immigration, homelessness, substance abuse, and incomplete therapy. Today, Wolfe would have been easily treated and probably cured. Would earlier diagnosis of his condition have made any difference in the outcome? The answer is uncertain, since sanatorium therapy (rest and environment) and surgery were the only available treatments at the time of his illness. Had he lived in a later generation, he might not have met his death at the age of 37.

Troy, Mycenae, and the otologic demise of Herr Heinrich Schliemann.

Heinrich Schliemann (1822-1890) was a self-made man with a remarkable aptitude for language and an excellent business mind. He was also the founder of Aegean archeology, providing a factual base for the writings of Homer, which until then had been considered merely a collection of mythologic poems. During his life, Schliemann suffered from ear trouble, ultimately dying from an otogenic temporal lobe brain abscess. He consulted many of the most famous 19th century otologists and was eventually operated on by the famous Professor Schwartze. We present the life and death of arguably the most famous man of his day as drawn from a number of biographic sources and speculate on the ear pathology that ultimately lead to his demise.

Abscesos encefálicos

Se presentan 103 casos de abscesos cerebrales atendidos en nuestro Servicio en los últimos 25 años. 64 casos correspondieron a hombres y 39 a mujeres. Se dividieron en dos grupos: a uno de ellos se le dio tratamiento médico y quirurgico convencional; los pacientes del segundo grupo fueron tratados médicamente, al igual que el primer grupo, pero el tratamiento quirúrgico ademas de la escisión capsular incluyó la colocación de un sistema de irrigación continua con antibióticos en la cavidad del absceso. Se describen los resultados