William Macewen and the treatment of brain abscesses: revisited after one hundred years

Abstract

The year 1993 marked the centennial of the publication of Sir William Macewen's monograph, Pyogenic Infective Diseases of the Brain and Spinal Cord, and its accompanying volume, Atlas of Head Sections. As Harvey Cushing noted, the text on pyogenic diseases of the brain was a landmark in surgery of the nervous system. At the time of its publication, Macewen's work was the most comprehensive study of pyogenic brain diseases. In this paper the author reviews the state of knowledge of brain abscess existing in the 19th and 20th centuries, with particular emphasis on the late 19th century, and elucidates factors contributing to Macewen's remarkable success. His thorough knowledge of the natural history of pyogenic diseases of the temporal bone and nasal sinuses, in addition to his clear description of cranial anatomy, as illustrated in his Atlas of Head Sections, were especially important in developing his successful treatment of brain abscess. The x-ray had not yet been discovered; Macewen's diagnosis was based on clinical findings superbly illustrated by his three clinical stages of brain abscess development. His clinical observations are as relevant today as when he described them 100 years ago. Macewen recorded 25 cases of brain abscess. Nineteen of these patients came to his attention in time to undergo surgery, resulting in 18 recoveries. All five of his patients with extradural abscess recovered. These results were achieved in the era known as "the most glorious period in British surgery." Neurosurgery was in its infancy; nevertheless, even as the 20th century closes, Macewen's results still have not been surpassed.

Diagnosis and management of brain abscess and subdural empyema

“…Brain abscesses were common in the first half of the twentieth century; however, with the introduction of effective antimicrobial therapy for purulent infections of the mastoid process and paranasal sinuses, there has been a significant reduction in the incidence of all intracranial complications, including brain abscess and SDE [1,2]. Pioneering work by the English surgeon William Macewan in the 1880s, who performed surgical drainage of abscesses, led to marked improvement in survival in patients with brain abscesses [3]. Over the past three decades, advances in the management of brain abscess and SDE have significantly reduced mortality from 30% to 50% before 1980 to between 4% and 20% today [4][5][6][7][8][9].…”

Management of bacterial brain abscesses

“…Meningitis, Abscess of the Brain, Infective Sinus Thrombosis, 28 published in 1893, he advised draining the abscess and treating the underlying causative sinus infections. His principle that early diagnosis and localization are the most important factors for treatment of pyogenic brain abscesses was proved with the introduction of CT. 5 In 1918, Warrington 43 investigated the etiological factors in 2 groups: 1) infections from foci in contiguous structures; 2) infections spread through the bloodstream from a distant site. For treatment of the brain abscess, King 22 introduced marsupialization in 1924 and Dandy 8 introduced aspiration in 1926.…”

“…William Macewen was the first to make a major contribution to the management of brain abscesses; he diagnosed and proposed surgical treatment for a brain abscess in 1876. 5,33 In his classic work, Pyogenic Infectious Disease of the Brain and Spinal Cord. Meningitis, Abscess of the Brain, Infective Sinus Thrombosis, 28 published in 1893, he advised draining the abscess and treating the underlying causative sinus infections.…”

Early Multimodality Treatment of Intracranial Abscesses

“…The treatment of brain abscesses remains one of the success stories of modern medicine; what began as a nearly uniformly fatal disease at the turn of the 20th century (2) has become a largely curable ailment through operative and pharmaceutical intervention (2). Attempts at operative treatment of intracranial abscesses were documented as early as 1752 (2), and continued throughout the 19th century, with limited success (2,12).…”

“…Attempts at operative treatment of intracranial abscesses were documented as early as 1752 (2), and continued throughout the 19th century, with limited success (2,12). Common causes of abscesses included trauma, especially from gunshot wounds, and chronic otitis media.…”