J . Neurol . Neurosurg . Psychiat . , 1961 , 24 , 291 . SUPPURATIVE LESIONS OF THE BRAIN - STEM

In contrast to the frequency with which abscesses occur elsewhere in the brain, suppuration confined to, or extending into, the brain-stem is rare. Cassirer (1902) reported one case of pontine abscess and abstracted 10 from the literature. Further cases were added by Bregman (1906), Lichtensteinand Zeitlin (1936), Gaida (1939), and Roger, Poursines, Roger, and Tamalet (1951). Richland (1952) traced 15 cases in the literature and added a further one; of these, five were attributed to direct spread of infection from the ear, while the remainder were of metastatic origin. A further instance was reported by Sutin (1958). Weickhardt and Watts (1944), describing a case of abscess in the medulla oblongata, found nine previously recorded instances, of which only three, those of Schlesinger (1894), Moniz (1934), and Norman (1941), were confined to the medulla. In their own and other cases the lesion extended into the pons or upper cervical spinal cord. Six cases were derived from distant foci and two from the ear. The origin of the remainder was obscure, though one, that of Abercrombie (1836), is thought to have been a tuberculoma. As would be expected, the neurological manifestations vary widely, and change with progression of the pathological process, according to the cranial nerve nuclei and fibre tracts involved. Commonly, fairly accurate anatomical localization is possible. In all reported cases, the condition has progressed, usually in a matter ofdays or weeks to a fatal termination. Scalabrino and Clivio (1951) reported recovery following systemic and intrathecal penicillin therapy in a case of presumed metastatic suppurative inflammation in the midbrain. The diagnosis, however, appears not to have been established with certainty. The following cases illustrate the difficulties encountered in diagnosing this condition, even with the aid of contrast radiography.