CHAPTER XVII. THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE (Part 9)

Bd. X., p. 391. 44G CEREBKAL ABSCESS. drafts of air, or the like ; for the table of cases appended to this chapter, shows that meningitis, cerebral abscess, and pj-semia may, from such exciting causes, be the termination of a puru- lent discharge from the ear. The symptoms of brain disease are sometimes very insi- dious. At times there is a chill or a convulsion, or nausea and vomiting ; at others, only increased pain in the ear, fol- lowed in rapid order by paralysis, coma, and death. In very rare cases there are absolutely no symptoms, except those of a chronic suppurative process in the ear, until death occurs. The table of fatal cases of aural disease resulting from chronic suppurative processes, that has just been alluded to, was compiled frOm various sources, in order to show the variable character of brain symptoms supervening on otitis media purulenta, and the anxiety with which such a case, especially if united with caries or necrosis of bone, should be regarded. It is interesting to note how slowly the profession came to recognize the fact that when pus was found in the brain com- municating with the ear, that it was on its way inwards, and not making an external opening. It seems to have been hard for the medical men of a few generations back, to believe that aural disease could cause any serious affection, or that it was a matter of much account, although people were dying all about them from the results of aural disease alone. Lebert* says that Morgagni, " with his good tact and close observa- tion of Nature," discovered that the ear was often the cause of purulent affections of the circulation and brain substance ; but Itard took a step backward, and discovered a kind of cerebral abscess which broke out through the ear. Lalle- mand again placed the subject in its right light, and showed, what we now clearly see, in cases of cerebral abscesses occur- ring in connection with suppuration of the ear, that the organ of hearing was the part first affected. It is generally believed that a suppurative process in the ear is necessary for the production of an abscess of the brain, * Virchow's Archiv, Bd. IX., p. 382. PY7EMIA. 447 and this is probably the fact ; but one case that I observed, leads me to suspect tliat there may be such a thing as a chronic cerebral abscess leading to disturbing aural symp- toms, such as tinnitus aurium and pain in one side of the head, without any primary aural affection. I treated a gentleman of about twenty-nine years of age, for some months, for such symptoms as have been indicated, and when he died a cere- bral abscess was found. He could hear the watch for but three inches from the left ear, which was the affected one, and the drum membrane was sunken., I supposed the case to be one of chronic proliferous inflammation of the middle ear. The patient got no relief ; he became very despondent on account of his tinnitus aurium and pain, gave up his business, and died at Sag Harbor, L. L, of malignant pustule, about two years and a half after I first saw him, and three years and a half after his first aural symptoms. Dr. Geo. A. Sterling, of that place, made a post-mortem examination. He found " great injection of the pia mater over petrous portion of temporal bone, and an abscess about the size of a ten cent piece in the brain substance. It was bounded by inflammatory adhesions, and contained about ten drops of pus. The abscess was situ- ated on the left side, in the superior lobe, one inch from the median line and two inches from the coronal suture." This patient never had a suppurative inflammation in the ear, and it is possible that the cerebral abscess was the cause of his very distressing symptoms, although the data are not full enough to allow us to give a positive opinion. There is no account of an examination of the temporal bone. The text-books on pathology give very full accounts of cerebral abscess. The author has had but the space to plainly mark them out as one of the consequences of chronic suppuration of the middle ear. PYEMIA. The author has already (on page 292) related a case which shows that pyaemia, or metastatic abscesses, from the entrance of pus into the circulation through the mastoid veins or the lateral sinus, may result from aural disease. 448 PY2EMIA AND PARALYSIS. Mr. Prescott Hewitt,'- in 1861, related a similar case, and with the like happy result of recovery. Mr. Hewitt's case was in substance as follows : A young lady, eighteen years of age, had a discharge from the ear, as a consequence of measles. About four weeks after the occurrence of the discharge, she was seized with severe chills, which were followed by much fever, a furred tongue, and typhoid symptoms, with suppres- sion of the discharge. When Mr. Hewitt saw the patient the chills continued, the skin had assumed an earthen hue, and the fever was intense. The intellect was clear, bub there was pain extending down the side of the neck, along the course of the jugular vein, and the head was inclined to that side. There was swelling at the base of the neck. In eight days pus appeared in one of the sterno-clavicular articulations. In a few days one knee became involved, and symptoms of pneu- monia appeared, which soon subsided. In about seventeen days from the beginning of the phlebitis, swelling and pain occurred over one of the hip-joints, a deep abscess formed, but it was opened early, and the joint did not become involved. The patient ultimately recovered under treatment by wine and morphia. This case and the one already referred to, give the clin- ical features of purulent infection from suppuration in the ear. The pathological characteristics of the disease are seen in the table of fatal cases appended to this chapter. Professor Lebertf has given us the fullest account of the inflammations of the sinuses that may lead to purulent infection ; but the proper limits of this volume do not allow of a fuller discussion of this dangerous, but by no means hopeless disease. PARALYSIS. Paralysis of the seventh nerve, as it passes through the tympanic cavity, in the Fallopian canal, must of necessity be a consequence of many suppurative and carious affections of this part, and yet it cannot be said to be a frequent affection in the course of chronic suppuration of the middle ear. In * London Lancet, Feb. 2, 1861. t Virckow's Archiv, Bd. IX., p. 381. PARALYSIS. 449 the greater number of the cases in which it occurs, it is perma- nent, from the fact that the nerve tissue is destroyed by the ulcerative process ; but I have seen cases of temporary paraly- sis of the seventh, which were probably due to pressure upon the nerve trunk ; for, when the suppuration of the ear was checked, the functions of the nerve were restored, and the face resumed its normal appearance. Paralysis of other parts of the body, and complete hemi- plegia, may occur in the course of meningitis and cerebral abscess ; but these necessary consequences of the destruction of brain substance hardly require a separate notice. It is possible that a blood clot might form between the dura mater and the bone, from rupture of a branch of the middle meningeal, from caries of the temporal bone, and hemi- plegia be induced by pressure communicated to the motor tract, or as Mr. Hutchinson says, as quoted by Dr. Hughlings Jack- son,* by squeezing the blood from the corpus striatum, or tha- lamus opticus. The author has published two cases of hemi- plegia, occurring in coincidence with chronic suppuration of the middle ear,t which are here reproduced as good illustra- tions of the subject, although it is not claimed that they should be regarded as positively consequences of chronic suppuration. A boy ten years of age was brought to me for advice on May 10, 1869. He had had a discharge from the left ear since he was an infant, and about four weeks ago he was affected with a num- ber of paralytic symptoms that came on gradually. He be- came unable to speak distinctly, or to swallow his food properly, and finally he could not walk steadily. There was paralysis of the seventh pair on the left side, and of the left arm and leg, so that he could not grasp well, and he dragged his foot in walking. These symptoms came on gradually, in the course of some hours, a fact which indicated hemorrhage between the dura mater and the bone. The right membrana tympani was intact, but thickened, and it had no light spot. The left was ulcerated and perforated. Its remains were very vascular. His hearing distance was -fa" from the right ear, and ^V' from the left. Under the usual treatment the u>eiubr::i5» tympani healed, and * Reynold's System of Mf,d;cine, vol. ii., p 505. f Transactions of the America Occ'iogio. Society, 1870. 29 450 PAKALYSIS. the hearing power became normal. The paralysis was nearly gone when he disappeared from observation. June 8, 1870. — The patient was again brought to me, and his mother stated that he was seized with dizziness and loss of sight while at school. He became so affected that he was fif- teen minutes going two or three blocks, and he was stupid when he reached home, although he had complete control of all his limbs. He had sight enough to go about, but not to read. Two months after this attack, his vision was \ in the right eye, and \ on the left. The field of vision was greatly limited on the periphery. The ophthalmoscope did not detect any lesion in the fundus oculi. Under expectant treatment the boy slowly recovered his vision. The second case was that of a farmer, aged 62, whom I saw in October, 1869, in consultation with Dr. Losee, of Red Hook, N. Y. The patient had suffered from chronic suppura- tion of the right ear, since he was a child. Occasionally acute attacks would occur, culminating in abscesses of the mastoid. For sis years past, the ear had been very quiet. About six weeks before I saw the patient, he was seized with hemiplegia of the left half of the body, coming on in the course of a few hours. When I saw him he was slowly recovering from the paralysis. The hearing power on the right side was com- pletely destroyed. The cavity of the tympani was exposed and empty. There was a cartilaginous band extending across the canal, which I divided, and found that it contained small bits of dead bone, which seemed to come from the posterior wall of the canal. The patient fully recovered from the para- lysis, and is still living. Dr. Hughlings Jackson, in lecturing upon epileptic, or epi- leptiform convulsions occurring in connection with discharges from the ear, says, that arguing from the fact that cerebral or cerebellar abscess may follow disease of the ear, " it becomes legitimate to inquire if minute changes in tracts of the brain may not occasionally follow a disease of this apparatus, which changes may allow occasional discharge of nerve force." He is anxious to learn if epileptiform seizures occurring in cases * British Medical Journal, June 26, 1869. PAEALYSIS. 451 of discharge of pus from the ear, may not result from minute changes in venous tracts. There are still great gaps in our knowledge of epilepsy and paralysis dependent upon aural disease. Dr Jackson- urges that in all cases of hemiplegia in children the ear should be examined, and that in such autop- sies the possibility of venous thrombosis from aural disease should be borne in mind. The table on the next page, which I have compiled from various sources, illustrates in a striking manner the fatal con- sequences of some cases of aural disease. Taken in connec- tion with the fact already stated, that suppuration of the ear is more frequently the cause of cerebral abscess than any other one disease, these cases form a complete justification, if one were needed, for the giving up so much space to the con- sequences of chronic suppuration of the middle ear. If the table shall startle some mind hitherto inattentive to this sub- ject, into a realization of its grave importance, and lead to a more careful consideration of an ulcerated middle ear, it will have accomplished its object. * London Medical Times and Gazette, July 13, 1872. 452 CEREBRAL ABSCESS. K7* oj.8 ■a •a © a a Q) ffl r- +^ += a£ i: a! ro C 03 O 03 3 S 'Ed os'^3 « Sob ^^ -W g 02 '£, rP P P Ss 'E3 S os 03 5J oa^tf .9 £ 02 ,P ra fe P 3 £ CD O 5bg 'Sbg S o \A iJj fl g O C! H B 03 ffi^ <B 2 ^ ■ai ^ • 3 £» (i 9 j, D Td Sh =S oj Pi 1'§£ 8 ™§ 8 P IP. "S §Ja §£&£ h &ChM a J ft £ -fl = S 53 m -o -3 "S -2 -3 O^! ft® ^go? O S-. a; o o> a <b :«? &p ft P,s3 ° SSL -~^ as p £ • P ^ 0Q "i ' * ^ ® be-; pP S c2 ® "-" a £ 11 .2 & ft 53=2 B -^ a, a ill .Sfl a 03 a CEEEBRAL ABSCESS. 453 r. 03 03 C3 u 'a I a §-:-^aj •J ate I < ° P-g O g ^PQ iyj d 3 « IS g 3 >> p J3j '.si 03 & 22 T3 |3 as 3 ° a 9 ^ § crtj _ d =3 O o v '3 br en ^ .2" as d °U M . S-2 2 SI'S, .a 5 m ^•1=2 33 tb O Ph «12 a^2 2 a-3 &3 03^3^^ o <_ bfi<2 ^4 M rr, 9 > l»1 3 .SP 03 03 03^^ -.3 . ^ 03 <S fl flX) grfl rd _g "" +j O 03 0} 1.SJ 03 03 03 3} 03 O 03 03 * 02 ^^ ^ bn _, fe o 03 — d as r2 03 O D, ■5 oiSfc1 .^ _d 03 a a oJS co a oj a P. o O d 03 03 ^ Si ES g S* &CtJ ■r a Pi "S^ g "11 1 « a ^d ° ci-3 T3 rd^ 03 03 Ci S ■ ='-' if. a d B C 2 5^: a o « N r~ 03 .^ •" «S C3 r— 1 "Z C3 p, OJ « 0J Ra^-S ^a r| g a bJD * 8 ni.SE.Sca d =m £ S O oo .-£ -; s h-i s =S to O fl m a d S <o o S'm 2 2 fee .£ ^ g^ a 2 ^ -a g .CO Kj^ is ft " pi s I bJD1 o d d w W o3 >-» d Is 23 a * d O s3 ^3 . M 454 CEREBRAL ABSCESS. £a 6(3 -3 S S H W Eh 3^ 03 03 S 9 .a a H g 2 a » °- "fs w "a «3 03 cj g a t3 2 ^ 'S ""' 3 Q, 02 ^ o ^ SB'S ^2 CS p^ ft « 3^ § P u S 03 03 "3^ 03-^3 ^ ax 8.2 8 a 02 03 ^.a a a §3 m -Si fl Q3 a!" 03 O > •° 03* <»3 £» ici * A . 03 03 03 T3 sh -p- a a |1 += 03 I a 03 Cg ■^p -ttx& +3 o. rt go a o" a" Eg 0.0 «w T5 n3 fcC , St: 03 a1 C3 03 rO '8 ' o 15 8 £ ^a1 03=w 03 •2 00^ g5. 1181 sJ' a^ ce o 3i 2 5 o^ ^"3 s/Sa &'S bb Tj of o •+3 a a o £.3 o '» £P .al O •g a 8.1 a t>o | ,£3. O 03 P-» Hi .5 | r^ £» ;5 o3 "« CEEEBEAL ABSCESS. 455 "sojal •p ft 9.3 cd 3 S 2 P =4H O d © co O co — i 8.~ ■s a H- (B to n « "3 P E © d §« s &o J3 ^ d &> S £ 3 .Si'SSS So ,9 s CO o q5 cd r3 w ft a s ° & 2 " - sj g gp* g u fS-2 ° • 'd p., cd o3 A • cd rf o'd CD1^ tfi Sh -3 O -a^B e3 <! 03 "5 ^ d S ^d!-§p- . =2 * c ^.9l|f » CD CO d > .9 * 9 .9 g 5 & §3 -IS £ .2 T3 o .9 =5 Srri CD U — «* S-^'.ri 2 59 o £ si s •eP= ts „t| CD 6* 1-3 o3 c3 m Ph Ji CD P £9 CD _r CO p~, CD rd !>-. oj — ^ m © ^ ^ gg g^Sg -IS ^-d-S"3 ft9 CD^5 & "S| ! bC"1 j CO- o £ d 2 >» — CO « X S'O r2 Oh O rt 3 IS "•»S IIS £ £.9 5 rd d CD CD 2 ^§8 <*> p 2 24 ' Pk o -B d.N ^,2 '53 pO '- 1-3 51 * « S-^ CD .-S ■ d o ;S -" III a O &JD^ § c3 o3 =2 ■ . .40 S3 CD u CD M ffl I eJ-r fcJQ-o r=) 7 m '. P?hfl , CD £, H -5 ^ § -3 J> .9 ^