The modern treatment of brain abscesses is needle aspiration and simultaneous broad spectrum antibiotics for weeks. The treatment has evolved to antibiotic treatment alone if the abscess cannot be drained or extirpated. Total resection may only be considered for superficially located abscesses [1]. Extreme caution has been a neurosurgeon’s characteristic in the treatment for some deep brain abscesses.

There is a long history of convincing arguments against any surgical intervention, starting in 1856 when Herman Lebert, based on his own assessment of the literature and collecting 80 cases, felt surgery should not be an option [2]. There is also a long history of neurosurgical approaches, and the first successful operation for brain abscess has been attributed to the French surgeon Sauveur François. Morand he has been bravoed as the first surgeon to perform a successful surgery on an abscess located in the mastoid sinus and temporal bone [3]. Dr. James F. Weeds, a frontier military surgeon, operated on a cavalry lieutenant who had been shot in the right frontal area of the head. After meningitis, he developed a brain abscess around the original gunshot wound and presented with papilledema, focal seizures, and hemiparesis. Dr. Weeds trephined the cranium and drained the abscess, and the patient recovered [4]. Gowers and Barker removed a temporal lobe abscess in 1886 [5]. However, these were incidental success cases, and the overall zeitgeist was that surgery for a suspected brain abscess was dangerous.

The first comprehensive work on the subject came from the Scottish surgeon William Macewen with his book Pyogenic Disease of the Brain and Spinal Cord, Meningitis, Abscess of the Brain, Infective Sinus Thrombosis published in 1893 [6, 7]. Macewen was a devotee of Joseph Lister, who markedly improved surgery by introducing antisepsis and other groundbreaking techniques to reduce infections. It may explain why Macewen was attracted to the best treatment of infections and his choice of neurosurgical infectious diseases in his book.

William Macewen advised draining the abscess and treating the underlying causative sinus infections. Macewen recorded 25 cases of brain abscess, and he saw 19 of these patients for surgery (Fig. 1), resulting in 18 recoveries. All five of his patients with extradural abscess recovered [6, 7]. He summarized his approach as follows:

First, eradication of the source of infection. Second, an opening into the abscess sufficiently large to permit escape of pus and for this purpose a quantity of brain tissue existing between the abscess and the surface of the brain may require removal. Third, irrigation of the abscess cavity with an antiseptic solution to cleanse the cavity. Fourth, drainage in some cases, and in other instances no drainage. [In chronic abscesses he used a decalcified chicken bone drainage tube with the inner end just within the abscess cavity and stitched to the skin; and India rubber, glass, or other non-absorbable drain, removed after 24 to 48 hours when pus formation still existed]. Fifth, daily changing of dressing, with irrigation of the abscess cavity, and sixth placing iodoform gauze against the reflected dura and brain to prevent extension of infection into the meninges.

Necrotic brain abscess in temporal lobe (from Macewen’s book [7])

He wrote in the preface of his book:

Though not sharing the hopelessness of the opinion expressed in 1833 by a distinguished neurologist [not identified] as to the inutility of operations on the brain undertaken for abscess, the author was then inclined to take a more some sombre view of the prospects of recovery from such operations than his subsequent experience has proven to be necessary. He now regards an uncomplicated cerebral abscess, early recognized, accurately localized, and promptly operated on, as one of the most satisfactory of all intracranial lesions, the patient being at once relieved from a perilous condition and usually restored to sound health.