A. CASE 
OF 
Disease of the Ear, 
FOLLOWED BY 
ABSCESS OF THE BRAIN. 
BY 
EDWARD H. CLARKE, M.D., 
Boston, Mass. 
HE PRINTED FROM 
Dr. Brown-Seqnard’# Archive* of Scientific and Practical Medicine. 
J a nu ary, 1873. 
J. B. LIPPIN OOTT & CO., 
25 Bond Street, New York, 
AND 
715 & 717 Market Street, Philadelphia. DISEASE OF THE EAR, FOLLOWED BY ABSCESS OF THE BRAIN. 
47 
VIII. 
A CASE 
OF 
DISEASE OF THE EAR. 
FOLLOWED BY 
ABSCESS OF THE BRAIN. 
BY 
EDWARD H. CLARKE, M.D., 
BOSTON, MASS. 
In the following case, the disease of the brain was probably the 
result of the inflammation of the middle ear, which attacked the peri- 
osteum of the tympanum. The inflammation then passed through 
that portion of the petrous bone lying near the upper wall of the tym- 
panum to the dura-mater, and thence to the brain. The moisture and 
redness of the portion of bone described, and the adhesion of the 
dura-mater at that point, serve to mark the track of the disease. 
This case illustrates the dangers attendant upon internal otitis, 
and the necessity of an early and vigorous treatment. If it had been 
possible to arrest the disease when it first attacked the ear, and 
before the bone, or rather the periosteum was invaded, the life of 
the patient would probably have been saved. Early and free 
leeching, with decided and continued counter-irritation, offer the 
greatest chance of safety in cases like the above. 
The existence of so large a lesion of the brain without marked 
derangement of sensation or motion, is of considerable physiological 
interest. A portion of the right hemisphere, of the size of a hen’s 
egg, was destroyed, without destroying motion or sensation of either 
half of the body. The slow pulse—48 in the minute—and the slow 
and intermittent respiration, which existed simultaneously for several 
days after the attack of April 5th, made me suspicious of disease of 
the cerebellum. The patient appeared as if the action of the heart 
and lungs was nearly paralyzed. At the autopsy the elevations of EDWARD H. CLARKE. 
the medulla oblongata were flattened by the pressure of the abscess 
upon them, and this was the probable cause of the slow pulse and 
breathing. 
The treatment produced no result except the important one of 
relieving suffering. It is very likely that the paroxysms of intense 
pain, which appeared periodically for a few days when the pulse and 
respiration were the slowest, and which were apparently controlled 
by quinia, would have subsided of themselves. They were probably 
induced by an extension of the disease in the head, perhaps by the 
formation or increase of pus, and subsided as the brain became ac- 
customed to the pressure. The bromide of potassium seemed to 
control the restlessness and delirium in a marked degree. 
A. T., an American lad, aet. 15, was attacked, while at school in the country, 
with severe otalgia of the right ear, during the last week in January, 1867. The 
pain was intense and persistent, and, according to his own report, accompanied with 
tenderness and swelling of the right meatus, and pain in the ear with deglutition. 
He was confined to his bed for a week or more, and treated by a physician of the 
neighborhood. After a few days of suffering, the ear poured out a moderate dis- 
charge, and he obtained some relief. The relief, however, was not complete, and 
he came to Boston for advice. I saw him on the 16th of Feb., 1867. He was 
able to come to my house. The hearing and appearance of his left ear were nor- 
mal. His right meatus contained a moderate amount of purulent matter. The 
walls of the meatus were red, and the surface of the membrana tympani presented 
a radiated, red appearance. Inflation of the cavity of the tympanum through the 
Eustachian tube produced, momentarily, a sharp pain in the affected ear. He 
heard the ticking of my watch only when it was pressed on the ear. He was then 
suffering from otalgia, especially at night, so that his sleep was disturbed. Two 
leeches were applied to the orifice of the right meatus. He was directed to instil 
into the ear a solution of a grain of sulphate of atropia in an ounce of water 
every hour or two, if there was pain; the solution to be warmed before applying 
it. He was put on a restricted diet, and kept quiet. Counter-irritation by 
means of croton oil was kept up on the mastoid process, directly after leeching. 
At the same time he was ordered the iodide of potassium internally. The 
meatus was syringed often enough to keep it clean. He gradually and steadily 
improved. The membrana tympani assumed a normal appearance, and the pain 
disappeared. By the 7th of March he heard the ticking of my watch two or three 
feet from his right ear. He slept and ate well, and complained of no pain or dis- 
comfort. Excepting weakness, he seemed to be well. During this apparent con- 
valescence, he had three short attacks of severe pain in the right side of the head 
and face. One took hold of the trifacial nerve, and yielded to the local application 
of aconite. Another seized the right supraorbital nerve, and yielded to veratria, 
not to aconite. The third attack showed itself back of the ear, and was accom- 
panied with tenderness and swelling over the right mastoid process. This required 
leeching. All of these attacks were short, though severe. Excepting the weakness 
just referred to, he seemed to be fully convalescent by the 7th of March. On the 
morning of March 10th, he -was attacked, without apparent cause, with intense 
headache, intolerance of light and sound, nausea and frequent vomiting. His DISEASE OF THE EAR, FOLLOWED BY ABSCESS OF THE BRAIN. 
pulse soon became irregular, not intermittent, and feeble. His respiration was 
also slow, sometimes not more than eleven or twelve per minute. He had no 
cough. His respiration was vesicular. There was no tenderness over the liver or 
bowels. The latter were costive. The above symptoms persisted through the 
loth, 11 th, 12th, and 13th of March. They were apparently controlled, though not 
stopped, by the subcutaneous injection of morphia. During this period he was 
supported by enemas of beef-tea. Every form of nourishment, liquid or solid, 
that was tried by the stomach, he rejected. His pulse averaged about 60, though 
it was several times as slow as 48 and 50. The pupil of each eye acted normally. 
He had no delirium or intellectual disturbance. 
The nausea began to abate on the 14th of March, and on the 17th he got and 
Tetained a little beef-tea with pepsin in it. He had a free dejection on the 17th 
after taking citrate of magnesia, the first for a week. He had another dejection 
on the 18th. At this time he seemed to be convalescing again. The intolerance 
of light had so far abated that he bore easily a subdued light in his chamber. He 
had no nausea or headache. He retained light food and took it with a relish ; all 
opiates were omitted; and he slept quietly. During the night of the 19th he 
slept less easily than usual. Early in the morning of the 20th he complained of 
faintness, difficulty of breathing, and sharp pain in the back of his head and the 
upper part of his spine. These symptoms increased till they become violent, and 
were followed by delirium. One-fourth of a grain of sulphate of morphia was 
injected into his arm, and he became quiet in less than fifteen minutes, and fell 
asleep. Previous to the injection there was a return of nausea, vomiting, and 
intolerance of light and sound, in addition to the other symptoms enumerated. When 
asleep, his pulse was 64 and regular, and his respiratory movements normal. He 
awoke, after sleeping several hours, in a much more quiet condition, without delirium 
or pain in his head or back. He still had frequent nausea, and was abnormally 
sensitive to light and sound. He was kept very quiet, put upon a diet of crust 
coffee with milk and lime-water, and ordered 20 grs. of bromide of potassium 
every four hours. His bowels were moved by enemas. 
From this time he seemed to convalesce again. He got the bromide every four 
hours for three days, then every five hours for two days, then every six hours for 
two days, and then twice in every twenty-four hours. His bowels were moved 
every other day. He slept an average of eight hours every night. His tongue, 
which had never been much coated, became clean. His diet was cautiously 
increased, and he was able to eat bread, meat, and milk. His appetite for hearty 
food was strong. Early in April, he walked moderately about his chamber, bore a 
sufficient amount of light, had a good pulse of 84, and complained of no sort of 
discomfort. He went to bed at his usual hour in the evening of April 5th, ana 
went to sleep. A serenade from a band of music, under the windows of a 
neighboring house, which continued for about an hour, aroused him from sleep at 
1 a.m. He soon complained of intense headache; in a short time he became 
delirious, and soon after began to vomit. He got 60 grs. of bromide of potassium 
in divided doses in the course of two or three hours, and then became quiet 
and went to sleep. He had a dejection during the day, ate very little, and by 
night was comfortable again. He went quietly to sleep in the evening of April 
6th, and was awakened with intense headache and delirium at 1 a.m. of the 
7th, almost exactly twenty-four hours after the previous attack. Presently he had 
nausea and then vomiting. His pulse was irregular and 48 in a minute. His res- 
piration was also slow and abnormal (saccade). I injected his arm with 
VOL. I.—4 50 
EDWARD H. CLARKE. 
half a grain of sulphate of morphia, and he directly fell asleep. Twenty 
grains of bromide of potassium were ordered every four hours; a cathartic of 
citrate of magnesia, and a diet of gruel. He got a long and quiet sleep> 
and awoke refreshed. His bowels moved freely. On the following morning 
he had another but less violent access of pain at about 2 A.M. After its 
subsidence the bromide of potassium was omitted and quinia was given. The 
first day he got 18 grs. in 12 hours, without any subsequent tinnitus, and with a 
moderate paroxysm of pain at about 2 A.M. The next day he got 24 grs. in 12 
hours, with slight tinnitus and no paroxysm of headache in the morning. After 
this the quinia was gradually diminished, and at the end of a week it was discon* 
tinued. The pain in the head did not return. From this time he seemed to im- 
prove again. He had a good appetite ; ate freely of ordinary food; slept well; 
the action of bowels and kidneys was .normal. He began to ride out, and about 
the 20th of April he went to his sister’s house in the country, two or three miles 
from Boston. He often said that, excepting weakness, he felt perfectly well. He 
had not, at that time nor previously, any paralysis of sensation or motion. In two 
or three days, however, he began again to complain of pain in his head. At this time 
the pain came on in irregular paroxysms, and was not severe. He fell down once, 
while walking out, but got up again easily. Fie got quinia and bromide of potas- 
sium again, but without relief. He referred the pain chiefly to the back of his 
head. It was accompanied with nausea and occasional vomiting. His pulse 
dropped from the neighborhood of eighty to between fifty and sixty. His respira- 
tion was slow and irregular. He had no delirium, and the pupil of each eye acted 
normally. His urine was normal, and his bowels were moved sufficiently by an 
enema. 
Indeed, throughout his whole sickness, a dejection rarely occurred, except after 
an enema or a laxative. Soon after taking an enema, in the evening of April 25th, 
he apparently fell asleep, and died. 
His death occurred about eleven weeks after I first saw him, and about fourteen 
weeks after the commencement of the difficulty in his ear. 
Autopsy.—The head was examined thirty-six hours after death, by Dr. Calvin 
Ellis, who sent me the following report of the examination :— 
“ Dura mater much more vascular than usual. Arachnoid without the ordinary 
moisture. Convolutions of the upper surface of the brain flattened, as were also 
the elevations of the medulla oblongata. After the removal of the dura mater, 
the portion of the right hemisphere above the temporal bone bulged out in a re- 
markable manner, and was very soft to the touch. An incision showed white 
softening, which extended nearly to the posterior part of the hemisphere, and quite 
extensively in all directions around an abscess situated above the petrous portion 
of the temporal bone, of sufficient size to hold about two ounces of thick pus. 
The lateral ventricles contained considerably more serum than usual. The septum 
lucidum and walls were softened. 
“At the base of the petrous portion of the temporal bone, on the right side, 
the inner table, to a limited extent, was destroyed, and at this point the dura mater 
adhered. The cells in the interior of the bone contained more moisture than those 
of the opposite side, and had a reddish tinge. The tympanum and ossicula re- 
mained.” 
My own notes of the examination say that the portion of diseased bone above 
described was adjoining or nearly over the tympanum, and that the aspect of the 
tympanum was healthy. The brain, except around the abscess, was normal. ARCHIVES 
OF 
Scientific and Practical Medicine. 
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Physicians and Surgeons—will appear on the 15th of every month, in numbers of 
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Papers by the Editor, on the following subjects, will appear in rapid suc- 
cession : 
On Asphyxia, Syncope, and Collapse. 
Ear Affections, and their Relations with Brain Disease. 
Mechanism of Production of Symptoms in Diseases of the Brain. 
Morbid Influences of the Nervous System on Organic Functions. 
Physiological and Pathological Proofs of Attraction of Blood by Tissues. 
Amaurosis and Deafness in Diseases of the Brain. 
Rational Treatment of Poisoning by Organic Substances. 
On the Various Kinds of Hemiplegia. 
On Counter-Irritation : Its Importance and Rational Use. 
Physiology and Pathology of Epileptiform Affections. 
On Pneumonia and other Lung Affections in Diseases of the Brain. 
On Reflex Paralysis and other Affections produced by a Reflex Influence. 
Analogies and Differences between several Remedies (Belladonna, Digitalis, the 
Ergot of Rye, and the various Bromides). 
Artificial Epilepsy in Animals, and what it Teaches for the Treatment of Epilepsy 
in Man. 
On Transfusion of Blood : New Methods and Proper Conditions for its Use. 
On Differences between Americans and Europeans, as regards Diseases and Power 
of Resisting Injuries.