cerebral metastasis in intrathoracic · february i948 davidson: cerebral metastasis in association...

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CEREBRAL METASTASIS IN ASSOCIATION WITHINTRATHORACIC DISEASE

BY MAURICE DAVIDSON, M.A., D.M., F.R.C.P.Physician, Brompton Hospital for Diseases of the Chest; Consulting Physician, Miller General Hospital for

South-East London

The following case reports seemed to me to beworth recording; the phenomena with whichthey deal, though well recognized in medicalliterature, are not so commonly encountered ingeneral practice; in one, especially (Case 3), thedifficulty in diagnosis in the earlier stages of theillness was not inconsiderable and gave rise tomuch interesting discussion.The association between bronchiectasis and

cerebral abscess has always been admitted;reference to it is to be found in most standardworks on general medicine. Jex-Blake (1920) in asurvey of iio cases records intracranial abscess asthe cause of death in I5, i.e., in 13.63 per cent.Kent and Blades (1942) refer to metastatic abscessin connection with intrathoracic suppuration asoccurring almost exclusively in the brain, rarely inother organs. Collis (I944) discussing a series ofcases collected from the Brompton Hospital, froman E.M.S. chest centre, and from the BirminghamUnited Hospitals, reviews some of the literatureon the subject. His own figure of three cases ofcerebral complication in 54 deaths frombronchiectasis at Brompton, between I933 and1938 only, gives an incidence of 5.5 per cent.;with empyema he found that the cerebral com-plications occurred in I.9 per cent. of cases andaccounted for i6 per cent. of the mortality of thecondition, and with lung abscess the correspondingfigures were 4.5 per cent. and 20 per cent. Heagrees with Schorstein as saying that 20 per cent.of bronchiectatic patients eventually develop acerebral complication; it must be remembered,however, that in the earlier days of the work atBrompton, before the introduction of broncho-graphy, many cases of bronchiectasis, in whichinfection played but a negligible part, must havepassed unrecognized, and that therefore the earlierstatistics are probably to some extent misleading.Nickerson (1935) in a record of 10,502 unselectedautopsies found 12 instances of cerebral abscessassociated with thoracic disease. Russell Brain(I947) dealing with the causes of cerebral abscessputs these in order of frequency as (i) In-fection of the middle ear, mastoid and nasalsinuses; (2) pyaemic states; (3) metastasis from

intrathoracic suppuration; (4) head injury; astatement which is generally. corroborated byother neurological authorities.Enough has been said by way of introduction to

indicate the importance of this aspect of chestdisease, though it may, perhaps, be observed inparenthesis that brain abscesses do not occur inconnection with acute empyema, but only afterthe chronic variety of at least three months dura-tion and usually much more, and that in fatalcases death takes place with considerable rapidity(Schorstein notes the occurrence of death within anaverage period of io days, and Collis within'3 days).

Case 1. Chronic Empyema-CerebralAbscessThis was a man aged 59 who, in I9I6, had an

empyema following an attack of acute lobar(pneumococcal) pneumonia. The usual operationof thoracotomy with rib resection had been per-formed for drainage of the empyema, withapparently complete recovery. In 1920 astaphylococcal abscess developed under the oldoperation scar, and it wV then found in the courseof routine examination that a broncho-pleuralfistula was present. He again made what seemedto be a complete recovery, but for the next threeyears he suffered from occasional attacks ofhaemoptysis, which did not, however, constitute aserious disability or prevent him from carryingout his ordinary duties, which were of a fairlystrenuous character.

In the early part of 1933 he began to expectoratea small quantity of sputum, which was occasionallyblood-stained, and about this time he began tocomplain of a certain amount of lassitude. Onclinical examination it was evident that the drain-age of the original empyema had been inadequate,and surgical exploration was considered advisable.A large exploring needle was introduced undergeneral anaesthesia just above the middle of theoriginal scar; an extremely thick and tough pleuralmembrane was pierced and a little thick pus waswithdrawn. An incision was then made along theline of the scar and about an inch of rib was re-sected. The pleura when incised was found to be

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about an inch thick; a small pocket about thesize of a tangerine orange, or rather less, wasfound. From the escape of air through the woundduring expiration it was evident that there was abroncho-pleural fistula. A short rubber drainagetube was inserted into the cavity, and the woundwas closed.

After this operation the patient improved, thecough becoming less, with only a trace of mucoidsputum in the morning. About three weeks later,however, the temperature, which had been normalfor some time, rose again to io00 at night, and thedischarge from the tube increased somewhat. Thesinus was dilated by the introduction of bougies,a large drainage tube being subsequently intro-duced. The discharge now amounted to an ounceto two ounces a day; the bronchial fistula wasstill evident from the escape of air whenever thepatient coughed or made a forced expiration.A second operation was undertaken with the

object of establishing more satisfactory drainage.The old scar and the mouth of the sinus were ex-cised with the diathermy cautery, the incisionbeing prolonged backwards. It became evidentthat the cavity extended well back and about aninch and a half above the sinus. The bronchialfistula was demonstrated, two small bronchi beingseen opening into a thin portion of the cavity wall.The cavity, which extended from the mid-axillary line to the costo-vertebral angle, wasfinally packed with gauze soaked in flavine-paraffin.

Five days after this last operation it was ob-served that the patient had some little difficulty inhis speech; he had a slight degree of mental con-fusion, and there was some clumsiness in themovements of the right hand, though nd loss ofpower was noticed (a similar phenomenon hadbeen observed about a year previously, the symp-toms lasting about a week). The following dayaphasia was more marked, and right-sided facialweakness was apparent, with some loss of powerin the right arm and leg; the abdominal reflexeswere absent, and the plantar reflexes showed anextensor response on both sides. Next dayaphasia was extreme and the patient's generalcondition was obviously much worse; the dayafter this his respirations became shallow and thepulse was weaker, and he died early the nextmorning. No autopsy was permitted in this case,but from the clinical course of events it is obviousthat death was due to a metastatic abscess in theleft side of the brain, succeeding a chronic pyo-genic infection of the pleural cavity.

Case 2. Chronic Pulmonary Tuberculosis-Cerebral AbscessThis patient, a medical practitioner, died at the

age of 74 of cerebral abscess. The clinical history

is of considerable interest, since no objective signsof disease, either of the lungs or of the centralnervous system, had ever manifested themselvesuntil a few weeks before death occurred. Thepatient had retired from active practice about tenyears before his decease, and had been leading acomparatively quiet life devoted to medical andgeneral literary study. The first sign of anyserious disturbance of normal health was a suddenslight aphasic manifestation. He had noticed acertain lack of mental orientation while doing acrossword puzzle; he had also had difficulty inreading his favourite Greek authors, the sequenceof thought and the significance of words andphrases being suddenly interrupted, an experiencewhich, since he was a classical scholar of out-standing ability, caused him considerable mentaldistress.

It was shortly after this that I was asked to seehim on account of general malaise and slight fever,which eventually ended in a terminal pneumoniawhich was the immediate cause of death.Throughout the last illness persistence of theaphasia was a prominent feature. It took the formof an obvious disorientation of cerebral associa-tion, certain words being invariably substituted forothers in a sentence, though the ability to main-tain intelligible conversation was more or less un-impaired. Examination of the central nervoussystem showed no localizing signs of a cerebrallesion, and consciousness and intelligence weremaintained to within a few days of death, which,as already mentioned, was due to an acute terminalpneumonia.Autopsy on this patient revealed a large abscess

cavity in the left temporo-sphenoidal lobe. Thiscavity contained several ounces of pus of a brightgreenish-blue colour, suggestive of infection withB.Pyocyaneus. Examination of the lungs showedpneumonic consolidation of both lower lobes, butthere was evidence of old chronic fibro-caseoustuberculosis at both apices, with racemose tuber-culous lesions of more recent date in the upperzones of both lungs below the apical regions. Atno time during life had this patient ever sufferedfrom any symptoms suggestive of a pulmonasylesion, the only indication of ill-health being thegradual onset of such general symptoms as arecommonly associated with the decline of advancingyears.

It was evident that the cerebral abscess musthave been present for some considerable time.The conclusion reached by myself and the patholo-gist who conducted the autopsy was that theoriginal lesion in the brain must have been atuberculoma, secondary to clinically silent tuber-culous lesions of the lungs, and subsequently in-fected by the B.Pyocyaneus.

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Case 3. Bronchiectasis - EmpyemaCerebral Abscess i

This was a girl of i8 whose clinical history and'course were so eventful and who presented suchan interesting and difficult problem in differentialdiagnosis that I have felt it worth while to recordthe case in considerable detail.

She was originally sent to me for advice in 1945with a history of long standing respiratory catarrh.In early childhood she had had an operation forthe removal of tonsils and adenoids, since whichshe suffered each winter from recurrent colds withmuch cough and expectoration. In 1941 she wasseen by a surgical specialist w4o found evidenceof a pan-sinusitis and drained both maxillaryantra, which were full of pus. During this opera-tion she was observed to cough up a mass of thickgreenish pus from the lower respiratory tract.Bronchiectasis was suspected, and X-ray examina-tion of the chest confirmed this suspicion. Shewas treated by postural drainage, and an auto-genous vaccine, prepared from a culture of the-sputum, was also employed; the resulting im-provement in her symptoms, however, fell shortof expectations. Her family were anxious to sendher to Switzerland, but the possibility of surgicaltreatment had been considered, and I was askedto see her with a view to bronchography so thatthe whole question might be adequately ventilated.

Figs. 3 and 4 illustrate the condition of thebronchial tree on the left side in November, 1945.The branches to the lower lobe show undoubtedsaccular bronchiectasis, the branches to the middlelobe are also dilated. Bronchograms of the rightside appeared more or less normal, but carefulscrutiny of the lower lobe bronchi showed that theposterior basic branches were by no means beyondsuspicion, some distortion and slight dilatationbeing evident. For this reason it was felt that theprospects of satisfactory results from a left lowerlobe and lingula lobectomy were not altogetherfavourable, and it was decided to allow the patientto go to Switzerland to a moderately high altitude,with the proviso that the question of operativeintervention at a later date might have to beconsidered.

Eventually she went to Arosa early in 1946, andcontinued her studies there; she improved con-siderably in general health and her catarrhalsymptoms cleared up. In February, 1947, shewas taken ill with acute fever and respiratory dis-tress following an attack of varicella. I was notable to get a very accurate account of her clihicalpicture at this time, but so far as I could gatherfrom the rather inadequate notes available, sheappears to have had a pneumonia (sic), and X-rayexamination showed bilateral pleural effusion. Ex-ploration of the right pleural cavity revealed the

presence of clear fluid, and this exudate eventuallyresolved completely. Since abnormal physicalsigns persisted on the left side, and it was thoughtthat fluid was present here also, the left side of thechest was explored on several occasions, at firstwith negative result; later, however, a smallamount of pus was withdrawn; despite this fact,no further steps seem to have been taken for nearlya month. The patient was removed from Arosain April and was transferred to a clinic in Zurichwhere further exploration of the left side of thechest revealed a pyothorax, and intercostal drain-age was effected by insertion of a rubber catheter.There was evidence of a broncho-pleural fistula,and the drainage tube was left in situ and thepatient returned to England. The condition ofthe chest just prior to drainage is shown in Fig. 5.Towards the end of June, 1947, I was asked to

see her urgently in consultation with her owndoctor, who was anxious about her as she hadbegun to complain of headache and photophobiawith occasional vomiting; her temperature hadrisen to I03°. The possibility of a cerebral abscesswas, naturally, very much in her doctor's mind.When I saw her she, was obviously very toxic;she was still complaining of some headache,though the temperature was not then so high;although worried with the pain and obviously ill,she had no mental confusion, and careful examina-tion of the central nervous system at that time re-vealed no localizing signs. There was very slightblurring of the nasal edges of the optic discs, butno definite papilloedema. The intercostal tubewas still in situ, but drainage of the pleural cavitywas intermittent, the total amount of dischargebeing quite small. The X-ray appearances of thechest at this stage are shown in Fig. 6. I was un-able to satisfy myself at this time that there weresufficient grounds for a diagnosis of cerebralabscess, and felt that with adequate drainage of theinfected pleural cavity the general toxaemia, towhich I attributed the cerebral symptoms, mightwell clear up completely. Arrangements weremade for her transfer to the Brompton Hospital assoon as a bed was available.

Within a few days of this her condition becamesuddenly much worse and after an urgent com-munication from her doctor she was brought toLondon by ambulance and admitted to Bromptonas an emergency on July 6. She stood the longambulance journey well, but on arrival at thehospital was somewhat exhausted. No definitesigns of any local lesion of the central 'nervoussystem were apparent, but she was extemely toxicand examination of the urine showed markedacetonuria. A glucose drip saline (intravenous)was started and 50,000 units of penicillin weregiven by intramuscular injection.

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The following day she was conscious andrational, but complained of severe frontal head-ache radiating backwards to the occiput; therewas also some pain and stiffness of the back of theneck. The general condition at this time wassuggestive of a severe disturbance of the nervoussystem, and, despite the presence of definite focalsepsis in the chest, the possibility crossed my mindthat this might be a case of tuberculous meningitiswith a long prodromal period. On lumbar punc-ture there was no increase in the pressure ; thecerebro-spinal fluid was opalescent. Penicillin(io,ooo units) was introduced into the spinalcanal. Examination of the fluid showed 360 cellsper c.mm. (polymorpho-nuclears 37 per cent.,lymphocytes 6i per cent., monocytes 2 per cent.).The protein content was i8o mg. and the chlorides710 mgm. per cent. The fluid was sterile.Although there was no characteristic diminutionof the chlorides, yet the presence of so manylymphocytes in the fluid in conjunction with theclinical picture of meningeal irritation and the longhistory of increasing toxaemia (which seemed in-commensurate with the degree of focal sepsispresent), appeared to fit in with a diagnosis oftuberculous meningitis. It had been alleged bythe medical authorities at Arosa that on oneoccasion tubercle bacilli had been recovered in aspecimen of the sputum; I had no really satis-factory proof of this and could only regard suchevidence as circumstantial and of doubtful value.On July i i a second lumbar puncture was done.

The fluid was still opalescent. There were I50cells per c.mm. (polymorphonuclears 30 per cent.,lymphocytes 70 per cent.). The protein was8o mgm. and the chlorides 640 mgm. per cent.The following day she complained of slight dip-lopia; there was still no definite papilloedemathough the edges of the discs were not quite sharpand clear. The same evening I asked Dr. RussellBrain to see her with me. He agreed that in viewof the lymphocytic content of the spinal fluid, thepersistent fever, and the long and rather indefiniteclinical history, tuberculous meningitis could notbe excluded; he was, in fact, inclined to favourthis diagnosis in spite of the absence of bac-teriological proof, though as a possible alternativehe suggested there might be a condition of super-ficial venous thrombosis following the focal sepsisin the chest. The headache continued for somedays with varying severity, as did also the diplopia,and by July 20 she was extremely drowsy andrestless,-later becoming delirious. She lay partlycurled up in bed, resenting interference, withdefinite rigidity of the neck muscles and with apositive Kernig's sign; she gave a frequent andcharacteristic cry at intervals, her whole con-dition presenting a classical picture of tuberculous

meningitis. Lumbar puncture was again done thesame afternoon, io cc. of fluid being removed withslight resulting improvement in the patient'scondition. This fluid contained 700 cells perc.mm. (polymorphonuclears 32 per cent., lympho-cytes 68 per cent.). The protein content was120 mgm. and the chlorides 68o mgm. per cent.(one acid-fast bacillus was found on examination of adirect smear).

For a few days after this there was a markedimprovement in her general condition, the head-ache being less and consciousness having returned,though diplopia was still present. On July 28she had two epileptiform attacks, one at 8.30 a.m.,the second at I I.30 a.m. The fits commenced inthe left leg and spread to the left arm and then tothe right side of the body; there was associatedloss of consciousness, cyanosis, and biting of thetongue. This was the first suggestion of anylocalizing symptoms, and Dr. Russell Brain, whokindly saw her again with me on the following day,then thought that the evidence seemed much lessindicative of tuberculous meningitis and more infavour of a cerebral abscess occurring as a bloodborne metastasis from the pyogenic infection inthe chest. We agreed that examination by ventri-culography was indicated and the next day shewas seen by Mr. Wylie McKissock who had beencalled in in consultation.

After the usual trephine he explored the regionof the right occipital lobe and aspirated 4 or 5 cc.of pus. He then inserted i cc. of thorotrast andpenicillin into the abscess cavity and the woundwas closed in three layers. The site of the abscessis illustrated in Figs. 7 and 8 (radiograms taken onJuly 30, shortly after operation). The patient'sgeneral condition following this exploration re-mained satisfactory, no marked disturbance of thenervous system being observed. Bilateral papil-loedema was now noted, chiefly in the nasal halvesof the discs. Cultures of the pus aspirated re-mained sterile for 48 hours, after which a fewpyogenic cocci were grown. Sulphamezathineand penicillin were given daily. On September 9the condition of the abscess cavity was as seen inFigs. 9 and io, and on September 14 Mr.McKissock again operated and removed theabscess sac by gentle dissection. The patientstood the operation well, and thereafter made un-interrupted progress, rapidly resuming her normalcerebral functions, and exhibiting no further signsof untoward disturbance, though slight papil-loedema persisted. The condition of her chestremained more or less the same, the last two radio-grams (July i6 and September i6) being shown byFigs. i i and 12. On September zo it was notedthat air was still blowing in and out of the empyematube.

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FIG. i .-Radiogram of chest from Case i postero- FIG. 2.-Same Case as Fig. i after injection of neo-anterior view). hydriol to show extent of sinus.

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FIG 3.-Bronchogram of Case 3 (7/I1/45) (postero- FIG. 4.-Same Case as Fig. 3 (7/11145) (lateral view).anterior view).

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FIG. 5.-Radiogram of chest from Case 3 (9/5/47) FIG 6.-Radiogram of chest from Case 3 (3/7'47)before aspiration. drainage tube-in left pleural cavitv.

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FIG. 7.-Radiogram of skull from Case 3 (30/7/47) after FIG. S.-Same as Fig. 7 (lateral view).introduction of thorotrast into abscess cavity.


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Fic.. g.-Radiograin of skull from Case 3 (9/9/47) Fic. io.-Sanme as Fig. 9 (lateral view'showing abscess cavity well outlined.

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iri.ii.-Radiogram of chest from Case 3 (x6/7/*t7) FIG. 12.-Radiogram of chest from Case 3 (i6/9,47).


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Since then the intercostal drainage tube hasbeen removed. The patient's recovery from thecerebral operation has been entirely satisfactoryand it is proposed to deal with the condition in thechest later on after a suitable period ofconvalescence.

CommentThe primary object of this article was the re-

cording of the above three cases, the first of whichis a fairly typical example of a brain abscessoccurring after many years as a complication ofchronic empyema, the other two presenting certaininitial difficulties in diagnosis sufficiently outsidethe average clinical experience to be worthy ofmention. Several other points, however, arise,especially from the anatomical standpoint, re-garding the metastasis of intrathoracic lesions tothe central nervous system.The autopsy findings in Case 2 came as some-

thing of a surprise. I have postulated the existenceof a tuberculoma of the brain, secondary to old-standing pulmonary tuberculosis, since this ap-peared on the whole the most reasonable hy-pothesis to fit the clinical and anatomical facts.Kinnier Wilson (I940) noted the diminishing in-cidence of brain tuberculomata and gave a tableshowing their incidence among brain tumoursaccording to various authors. Out of a total of2,I90 tumours classified, the tuberculomata num-bered 79, i.e., 3.6. per cent., against which Wilsonhas quoted Starr's compilation in I890. of 500brain tumours which yielded a percentage oftuberculomata as high as 32.2. They are generallyunderstood to be isolated tuberculous lesions.According to Vines (I940) they are unassociated atfirst with any generalized tuberculous process,though it is supposed that they may occasionallylead, after a long interval, to tuberculous meningitisor to miliary tuberculosis of general distribution.It will be remembered that in this case the pul-monary lesions were of different dates, the apicalfibrosis being obviously of very long standing whilethe discrete lesions in the upper and middle zonesof the lungs were undoubtedly more recent.Whether the spread to these areas of the lungs andto the temporo-sphenoidal lobe of the brain wasmore or less simultaneous, and what was the dateof its occurrence, can only be a matter of con-jecture; no objective symptoms of manifestdisease were observed in this patient until a com-paratively short period before his death fromcerebral abscess with a terminal pneumonia.The clinical story of Case 3 was distinctly un-

usual. It seems hardly likely that this girl wouldhave developed an abscess of the brain as a resultof the bronchiectasis pure and simple; when shefirst went abroad she had no constitutional dis-

turbance, and there was little or no evidence ofany active suppurative lesion within the chest.The exact nature of the acute phase which followedan attack of one of the milder exanthems is un-certain. I cannot help feeling that the infection ofthe pleural cavity, which led to the formation of anempyema, must have been a result of injudiciousneedling of the chest in circumstances in whichsuch a procedure was really contraindicated. Fromthe dates of her movements it is evident that theempyema cannot have been present for more thantwo or three months at most before the onset ofthe cerebral symptoms; it can hardly be describedas belonging to the chronic variety in the ordinarysense of the term. It was partly for this reason,and partly because of the absence of any definiteneurological signs when I saw her soon after herreturn to England, that I hesitated to concludethat she had an infective cerebral metastasis,though the history of headache and vomiting wassuspicious enough in the light of what had beenhappening during the preceding two months.When I examined her at the end of June, 1947,she was, despite the toxaemia, mentally alert andable to give a clear and intelligible account of mostof her experiences abroad; such a picture is instriking contrast to that usually observed in casesof cerebral abscess.Walshe (I947) lays stress on the change in

mental alertness and emotional tone as one of themost striking early indications of the formation ofan abscess in the brain. ' The patient,' he says,' tends to be an ineffective witness when questionedas to his illness, his memory is poor, and hiscapacity for sustained attention manifestly im-paired; he is apathetic and may even be drowsy;he may confess to headaches, but no very preciseaccount of his symptoms can usually be obtainedfrom him.' Even later, when the increasingpyrexia and vomiting made evident the urgency ofher condition, the state of the cerebro-spinal fluidwas more suggestive of meningitis than of cerebralabscess, and the suspicion of tuberculousmeningitis raised by the insidious history and thelymphocytic cellular content of the fluid was tosome extent strengthened by the allegation (forwhich I had no adequate proof), of the finding oftubercle bacilli in her sputum on one occasion inthe clinic at Arosa.

In the three cases just qioted the primary lesionwithin the chest was inflammatory. It remains tosay a few words about the secondary lesions in thebrain in connection with primary bronchogeniccarcinoma. That the brain is a frequent site forsecondary deposits in this condition is well known.Oschner and DeBakey (I942) give a graphic re-presentation of metastasis of primary lung cancerbased on 3,047 collected cases in which the brain,

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which they list eighth out of I7 different organs,accounts for I6.5 per cent. Dosquet (1921)quoted by Frissell and Knox (I937) gives figuresfrom autopsies in the pathological departments inBerlin and Kiel showing metastasis in the brainin 3 I .4 per cent. of a series of I09 cases of-broncho-genic carcinoma; in contrast with this he refers to2,5I9 cases of cancer of other 6rgans, among whichcerebral metastasis was found in only i.6 per cent.of the Berlin cases and o.6 per cent. of the Kielcases. Fried and Buckley (1925) found metastasisin the central nervous system in I5 out of 37patients with bronchogenic carcinoma, i.e., inapproximately 40 per cent. The prominence ofneurological symptoms from secondary cancer inpatients in whom a primary bronchial growth hasbeen silent and entirely unsuspected is a strikingphenomenon to which attention has been fre-quently called in neurological literature. Fergusonand Rees (1938) emphasized this in a record ofnine cases observed at the National Hospital overa period of ten years. In five of these casesneurological symptoms were the first manifesta-tion of disease; in the remaining four, neurologicaland chest symptoms appeared almost simul-taneously. The nine cases were taken from a totalseries of 29 tumours of which the secondarydeposits were causing signs or symptoms (i.e.,31 per cent.). The frequency of cerebral metastasisin bronchogenic cancer is such that in mostneurological clinics X-ray examination is nowrecognized as a necessary part of the routine in-vestigation in all cases showing symptoms or signssuggestive of tumour.

In conclusion it may be of interest to considercerebral tumour and intrathoracic suppuration to-gether in connection with the aetiology of cerebralmetastasis and especially with reference to thepaths by which the secondary deposit reaches thebrain. Cerebral abscess secondary to bron-chiectasis or chronic empyema is generally re-garded as due to the passage of a septic embolus,and some uncertainty has been felt as to the routeby which such passage occurs. When a septicclot is detached from some distant focus in thebody and enters the venous circulation, the usualfilter in its path is the pulmonary vascular bed-theoccurrence of pulmonary infarction after pelvicoperations for example is well known. How is itthen that in cases such as we have been consideringparticles reach the brain without being caught by 'the pulmonary capillaries ? Oschner and DeBakey,discussing this in case of lung cancer pointed outthat when the lesion was primarily in the lung, nosuch barrier was present when once the tumourcells had entered the pulmonary veins, when theroute to the arterial circulation and so to the brainbecame direct. Simpson (1929) noted thrombosis

of veins by tumour cells in 29 out of 139 cases(approximately I7 per cent.), and found thatthe pulmonary vein3 were often affected bothby thrombosis and by direct invasion of thegrowth.A good deal of experimental work has been

carried out in order to elucidate this point, es-pecially by Batson (1940) who lays considerablestress on the part played by the vertebral veins inthe spread of secondary lesions. After injection ofopaque material in solution into the breast veins ofa female cadaver he found the material in theclavicles, the intercostal veins, the head of thehumerus, the cervical vertebrae, the transversecranial venous sinus, and in the superior longi-tudinal sinus; some of it also appeared in theazygos vein and in the superior vena cava. Hehas suggested that the vertebral veins should berecognized as a definite system in addition to theportal, caval, and pulmonary systems. He pointsout that after straining, coughing, etc., the blood ispressed out of the thoracic cavity, and that tumoursand abscess of the thoracico-abdominal wall, aswell as tumours of the lung, having connectionswith this venous system may give rise to metastasisat any point in it without involvement of theportal, caval, or pulmonary systems. His con-ception of the application of this in cases ofbronchogenic carcinoma is particularly fascinating.' The primary lesion,' he says, ' provides thetumour cells, and the stimulus for the cough whichcauses a flow from the bronchial veins, especiallythe posterior one, into the spinal veins rather thaninto the veins of the right heart.' The same ex-planation holds good for the occurrence ofabscess in the brain secondary to lung abscess;' the posterior bronchial vein and vertebral veins,with the ever-present cough, appear to present theplausible route of extension.'

Martin (I941) in his observations on superiorlongitudinal sinus thrombosis following child-birth quotes Batson's work and concludes thatfragments of clot may be carried up to the superiorlongitudinal, sinus by way of the vertebral venoussystem and there act as a nucleus for the clot whichforms in the sinus.

Collis (I944) in a summary of the literature onthis subject, to which he has added observationsfrom his own cases, makes the point that forthrombosis to extend from an inflammatory pro-cess in the lung or pleural cavity to the vessels ofthe chest wall, the adhesions between lung andchest wall must have become vascularized. Whenthe thrombosis reaches the walls of larger veins,he says the emboli are likely to affect the inter-costals mainly since the distribution of thebronchial veins is relatively limited. He regardsthe ultimate distribution of the embolus as de-


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pending on whether or not conditions favour areversed flow of blood in the spinal veins, in whichcase it may enter this system and be carried to thebrain-otherwise it may be carried by the azygosveins to the superior vena cava, and so be caughtin the pulmonary network, where it is relativelyharmless.

SummaryThree cases are described in which a metastatic

abscess in the brain developed secondary to focalinfection in the chest.

Difficulties in differential diagnosis in two ofthese are described and briefly discussed.The occurrence of secondary deposits of growth

in the brain in cases of bronchogenic carcinoma isreviewed, and reference is made to recent observa-tions on the anatomical paths by which metastaticdeposits from intrathoracic lesions travel to thecentral nervous system.

BIBLIOGRAPHY

BATSON, 0. V. (1940), Ann Surg., 112, 138.BRAIN, W. R. (I947), 'Diseases of the Nervous System,' 3rd

edition. Oxford Univ. Press.COLLIS, J. L. (I944), Journ. Thor. Surg., I3, 445.DOSQUET (I921), Virch. Arch. f. path. Anat., 234, 48I.FERGUSON, F. R., and REES, W. E. (I938), Lancet, I, 738.FRIED, B. M., and BUCKLEY, R. C. (I925), Arch. Int. Med.,

35, I.FRISSELL, L. F., and KNOX, L. C. (I937), Amer. Journ. Cancer,

30, 235.JEX-BLAKE, A. J. (1920), Brit. Med. Yourn., I, 59I.KENT, E. M., and BLADES, B. (1942), J7ourn. Thor. Surg., 2, 434.

MARTIN, J. P. (I94i), Brit. Med. Journ., 2, 537.NICKERSON, D. A. (I935), New Engi. Journ. Med., 213, 228.OSCHNER, A., and DEBAKEY, M. (I942), Journ. Thor. Surg.

2, 357.SIMPSON, S. L. (1929), Quart. Journ. Med., 22, 4I3.VINES, H. W. C. (1940), 'Green's Manual of Pathology,' s6th

edition, p. I099. Baltimore. The Williams & Wilkins Co.WALSHE, F. M. R. (I947), 'Diseases of the Nervous System,' sth

edition, p. 89. Edinburgh. E. & S. Livingstone, Ltd.WILSON, S. A. K. (I940), 'Neurology,' Vol. 1, p. 593. London.

Edw. Arnold & Co.

SOME CLINICAL AND SOCIO-MEDICAL ASPECTSOF CARDIOVASCULAR DISEASE

By EDMUND FINSTERBUSH, M.D. (VIENNA), M.R.C.S. (ENG.), L.R.C.P. (LOND.)Consulting Cardiologist to the Ministry of Pensions

The present state of affairs in respect of diag-nostic, remedial, preventive, and socio-medicalarrangements for cardiac patients is comparableto that regarding tuberculosis prior to the in-stitution of tuberculosis dispensaries and tuber-culosis officers in this country some 40 years ago.A few historical data may briefly illustrate the

development of tuberculosis services which con-trasts so strikingly with the complete lack ofsimilar arrangements for cardiac cases.The control of tuberculosis was initiated by a

voluntary system of notification of -phthisis bythe Metropolitan Borough of Finsbury in I900under the then Medical Officer of Health, Dr.George Newman. The compulsory notificationof all forms of tuberculosis followed in I912under the Public Health Regulations.The departmental Committee under the chair-

manship of Mr. Waldorf Astor, M.P., in one oftheir reports (1913) advised that ' the aim should

be that not a single case of tuberculosis should beuncared for in the community, and that whatso-ever services the scheme provides should be avail-able for all cases of the disease.' Up to that time,the scheme consisted of tuberculosis dispensaries,the first one founded by Dr. Robert Philip (after-wards Sir Robert Philip) in I887, sanatoria,hospitals, farm colonies, open air schools, etc.Under the Public Health Act (Tuberculosis

Act) 1921 the local authorities were directed toarrange treatment, aftercare, and supervision oftuberculosis patients.The remarkable progress in the anti-tuberculosis

services is evident from the following figures. InI9II there were 5700 sanatorium beds for tuber-culosis; in 1923 there were 442 tuberculosis dis-pensaries in England, and 249 tuberculosisofficers; in 1936 there were 459 tuberculosisdispensaries, some 400 tuberculosis officers, and26,773 sanatorium beds.


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