[reprinted from medicine, may, 1895.] REPORT OF CASES OF BRAIN LES1ONS-ABSCESSES, MENIN- GITIS, AND SINUS THROMBOSIS-RESULTING FROM DISEASE OF THE MIDDLE EAR. BY J. T. ESKRIDGE, M.D., Denver, Col., Professor of Nervous and Mental Diseases in the Medical Department of the University of Colorado; Neurologist to the Arapahoe County and St. Luke's Hospitals. The following notes of cases throw some light on the clinical his- tory and diagnosis of brain lesions resulting from disease of the middle ear, and are therefore worthy of publication at this time, when cerebral suppuration is attracting so much attention both from the physician and surgeon-principally on account of the brilliant results achieved by Macewen in the relief of this trouble. The histories and examinations of some of the cases are incom- plete, and the autopsies of others are wanting; but sufficient may be gleaned from the study of each case to impress upon one the danger of neglecting a chronic otorrhoea-the importance of recognizing the early symptoms of brain complications and adopting radical measures for their relief when it becomes evident that ordinary therapeutic measures are impotent and that delay simply lessens the chances of surgical success. The following is a good example of the danger likely to result from neglected otorrhoea in childhood: I.-Disintegrating Sinus Thrombosis ; Leptomeningitis; Abscess. -A boy of 13, with negative family history, had suffered more or less with disease of the left ear since the time, ten years previous, when an attack of measles had left him with an acute otitis media. Periods of intermittence, sometimes extending over several months, had occurred, the discharge temporarily ceasing. In the summer of 1889 he contracted a cold which was followed by acute pain in the left ear and mastoid region; a week or two later the ear discharged quite freely, relieving the severe pain for a time, but the mastoid region remained sensitive to pressure. In September of the same year the discharge became very slight and somewhat offensive, and he began to experience pain radiating from the mastoid region to the superior triangle of the neck and over the left temporal region. The ear had been neglected for several weeks, and, the quantity of the discharge being greatly.lessened, the parents thought the trouble was subsiding; but pain in the head became a prominent symptom, and Dr. McLauth- lin was summoned. He found the temperature ranging from ioo° to xoi°; pulse from 90 to no; the boy irritable and restless and slightly 2 BRAIN LESIONS FROM MIDDLE-EAR DISEASE delirious during the evening; the tongue coated, bowels constipated, appetite poor, but no vomiting. Fearing the brain had become infected, he asked me to see the child. I did so and concluded that if the brain had not already become affected it was in imminent danger unless we could prevent further infection. On thoroughly cleaning the ear and keeping it as aseptic as possible by means of repeated douches of warm water and the use of peroxide of hydrogen, the symptoms soon began to abate, and within a week the boy was free from pain. The ear was treated for some time by an aurist, who suc- ceeded in curing the otorrhcea; but subsequently, when the boy took the slightest cold, he would complain of a dull, heavy sensation in the mastoid region. Early in March, 1890, on contracting a severe cold, the mastoid region became the seat of constant pain, and scant but offensive dis- charge from the ear took place. A homoeopathic physician treated the patient four weeks for typhoid fever. During these weeks the temperature varied from 990 to ioi°; the pulse ranged from 70 to 100; respiration was normal; there was pain in the head; the eyes were sensitive to light; the boy was restless; tongue coated; stomach irri- table; bowels constipated; and vomiting frequently occurred. On the 9th of April I again saw the boy in consultation with Dr. McLauthlin. We found him considerably emaciated, feverish, temperature ioi°; exceedingly restless, irritable, and complaining of constant pain in the left ear and left side of the head, the pain extending from near the forehead to the back of the neck. He lay with the head slightly retracted, but it could be brought forward without giving rise to much pain, although the posterior cervical muscles of the left side were slightly sensitive to pressure and exhibited some rigidity. The gastric irritability still continued, and there seemed to be almost complete anorexia. .The optic nerves showed slight neuro-retinitis without swelling; vision was impaired; pupils were small and not readily responsive to light. No paresis, paralysis, or twitching of any muscles. The deep reflexes were increased, and the superficial were absent. The boy was greatly prostrated and impatient of the slightest disturb- ance. There was no oedema over the mastoid, but a slightly offensive discharge from the left ear, the odor of which disappeared on cleansing the ear with peroxide of hydrogen. Meningitis, with possible cerebral abscess in the cerebellum, was diagnosticated. The symptoms grew rapidly worse, the head more retracted; the patient became listless, holding his hand to the left side of the head and giving evidence of great suffering. The temperature was constantly above normal, varying from 990 to ioi°, sometimes registering in the axilla 102°. Occasionally shock-like contractions occurred, in the muscles of the BRAIN LESIONS FROM MIDDLE-EAR DISEASE 3 arms, and at the same time the head would be considerably retracted. A semi-conscious condition ensued; deglutition was at times almost impossible; the pupils were dilated and did not respond to light; and the optic neuritis increased. On one or two occasions there were tonic convulsive movements, with a condition of opisthotonos. The boy, though apparently nearly unconscious, was restless and tossed from one side of the bed to the other, and now and then gave evidence of great suffering. The pulse varied from 120 to 140; but the respi- ration was rather slow, sometimes irregular, and at times intermittent. On the night preceding his death, which occurred early in the morning of April 14th, there was a decided convulsion, soon after which Cheyne- Stokes respiration developed, and he passed into a condition of deep coma and a few hours later died. Autopsy (four hours after death): On removing the skull-cap the membranes and cortex on the convex surface of the brain presented nearly a normal appearance, save a slight venous engorgement. The blood in the longitudinal sinus was fluid. On carefully removing the brain from the basilar cranial cavity, several pathological lesions were exposed. The dura over the left sigmoid sinus was nearly black, and over the left lateral it was dark, the color lessening toward the cere- bellum. On opening the sinuses a disintegrating thrombosis was found, extending from the sigmoid into the lateral sinus, but not into the jugular vein. A small blackened necrotic opening through the left teg- men tympani had established a pathway for free communication from the cavity of the tympanum to that of the brain. The mastoid cells and antrum contained a few drops of pus and inspissated, dark-colored material which had a very offensive odor. The petrous portion of this temporal bone, dark on its upper surface, was softened and had stained the superior petrosal sinus and adjacent part of the dura. No coagula were found in the petrosal sinus. The pia on the left side in the posterior fossa was inflamed and covered with recent exudate and con- siderable pus. Around the pons and beneath the cerebellum the pial inflammation had extended beyond the median line, but the bones, sinuses and membranes on the right side showed no further evidence of disease. The left temporo-sphenoidal lobe in its lower and poste- rior portion was the seat of a non-encapsulated abscess containing about an ounce of offensive greenish pus and broken-down brain sub- stance. A second abscess, in character like the first, was found in the left side of the cerebellum. On the left side, in the lower portion of the floor of the fourth ventricle, an ulcerated area containing a few drops of yellowish pus was found. The case just reported suggests several points worthy of elab- oration. One which cannot be too strongly emphasized is the danger 4 BRAIN LESIONS FROM MIDDLE-EAR DISEASE of a neglected otorrhoea. Another is in regard to exposing the mastoid cells and antrum. In a case of chronic otitis media with or without otorrhoea, in which pain is felt in the mastoid region whenever the patient takes cold, is it safe to defer trephining the mastoid bone, although the distressing symptoms in the mastoid disappear on treat- ing the middle ear by means of applications through the external auditory meatus and the Eustachian tube ? It seems quite evident that had the mastoid been trephined and the cells, antrum and tym- panum cleansed of all infecting material when I first saw the patient in September, 1889, the lesion which proved fatal in April, 1890, could not have occurred from exposure to cold. The danger of such an untoward result was raised and discussed with the aurist who treated the ear, but he seemed to think such heroic measures unnecessary when the inflammatory trouble rapidly subsided from his attempts at cleaning the tympanum. Macewen has called attention to the impos- sibility of cleaning even the tympanum of inspissated material by means of repeated and thorough douching from the external auditory meatus. The four weeks of "typhoid fever" which elapsed before Dr. McLauthlin was called to take charge of the patient the second time, were weeks during which an infective process was going on which finally led to the death of the patient. Would an operation for the relief of the patient five days before his death, when Dr. McLauthlin and I first saw him in his last illness, have resulted in recovery ? Surgical interference was seriously consid- ered, but the presence of basilar leptomeningitis in the left posterior fossa appeared too formidable to be controlled by surgical means. The brilliant achievements of that bold but skillful surgeon, Macewen, in similar cases, were unknown to us at the time. Case 26, on page 162 of Macewen's recent work, was almost a counterpart of the one just reported, and was operated on by the Glasgow surgeon nearly eighteen months after the occurrence of the case under consideration. Macewen's case was one of cerebro-spinal leptomeningitis; subsequent encephalitis and cerebral abscess in the right temporo-sphenoidal lobe. It required four operations to relieve the patient, after which recovery was complete. The following case illustrates the serious and fatal results that sometimes follow disease of the middle ear without the presence of otorrhoea: Case 2.-Septic Thrombosis; Probable Cerebral Abscess.-A lady about 28 years old, married, with a negative family history, suffered from la grippe in December, 1890, and following this began to experi- ence pain in the left ear. There was no discharge, but the pain BRAIN LESIONS FROM MIDDLE-EAR DISEASE 5 became quite severe in the superior posterior cervical triangle and in the neck over the jugular vein. The temperature at this time ran quite high, 103° to 104°, followed by profuse sweating and lowered temperature; the pulse rapid, and respiration slightly increased in frequency. The chills were repeated and she gradually failed in strength. I saw her in consultation the evening before her death, when she was in a semi-comatose condition, temperature 102°, pulse 140, respiration 42. Pressure over the affected ear, superior posterior cervical triangle and jugular vein corresponding to the diseased ear, caused slight wincing. Profounds coma soon supervened, and death took place a few hours later. No autopsy. The diagnosis of septic thrombosis, probably followed by abscess of the brain, was ma(le. The patient was in a dying condition when I saw her, and an operation seemed useless. The following case shows the folly of delay in operating when danger to life is imminent, and the danger resulting from timid and inexperienced physicians undertaking surgical operations requiring skill and judicious boldness: Case 3.-Septic Thrombosis; Probable Cerebral Abscess.-A male, age about 50 years, married, a contractor by occupation, had always enjoyed excellent health, with the exception of occasional pains in the right ear, until some six weeks before I saw him (December, 1890), when, after taking cold, he suffered from tonsillitis and a discharge from the right ear. The otorrhoea continued, and the pain gradually lessened for a few weeks, but on fresh exposure to cold the discharge ceased and he began to experience considerable pain in the right temporal region, in the right side of the neck, and in the right superior posterior cervical triangle. The temperature varied from 990 to 103-4°, a rise in temperature being always preceded by a chill and followed by slight sweating. He was delirious at night; appetite was lost, tongue coated, sleep disturbed. When I saw him he was semi-conscious and apathetic, but could be made to answer questions, although sustained attention was impossible. An examination of the eyes revealed nothing further than hyperaemic discs and slightly dilated pupils which responded rather slowly to light. When asked if he had head- ache he said "Yes," and indicated the location of pain by pointing to the entire right side of the head. None of the cranial nerves seemed to be especially affected, and there was no paresis or paralysis of any muscles. The deep reflexes .were about normal, but the superficial were abolished. His temperature at that time was ioo°, pulse 90, respiration 16. A septic thrombosis of the right sigmoid sinus, with possible abscess, was diagnosticated, and immediate operation, con- sisting of exploring the mastoid cells and antrum, the sigmoid sinus, 6 BRAIN LESIONS FROM MIDDLE-EAR DLSEASE and, if necessary, searching for a brain abscess, was urged. All operative procedure was postponed until the next day, when the patient was completely comatose and apparently in a dying condition. Operation: No aseptic precautions had been taken for the opera- tion, but the mastoid cavity was trephined into and found to contain some inspissated, offensive material, but no liquid pus. The sigmoid sinus was not exposed, nor was an abscess searched for. The patient died about thirty-six hours later. No autopsy. Case 4.- Thrombosis of the Right Sigmoid Sinus; Abscess and Lepto- meningitis.-Male, Italian by birth, about 36 years old; was admitted to the Arapahoe County Hospital in a semi-conscious condition in December, 1892. The only history obtainable was that he had been suffering from a discharge from the right ear for a number of months, and recently had experienced a great deal of pain in the region of this ear and over the greater portion of the corresponding side of the head. As he had, up to a short time previous, lived in a malarial district, he was thought by his friends to be suffering from malaria, for at times he would have very high temperature, perspire freely, and afterward his body seemed quite cool. He became weak and emaciated. The recurrence of chills and fever lasted a week or more, when he began to grow dull and stupid, and was taken to the hospital in a dying con- dition, death taking place a few hours after his admission, before I saw him. The autopsy revealed a disintegrating thrombosis of the right sigmoid sinus; inspissated offensive material and some pus in the right mastoid cells and antrum; a dark perforation of the tegmen tympani; the dura darkened, inflamed, and thickened over the tegmen and sigmoid and lateral sinuses; an abscess containing about one ounce of greenish offensive pus in the right hemisphere of the cerebel- lum; and suppurative leptomeningitis of the middle and posterior fossae of the right side. Case 5.-Sinus Thrombosis and Meningitis.-Male, Hungarian by birth, family history unobtainable; had, according to the statements of friends, suffered from a discharge from the left ear for a number of years. Up to one or two months previous to admission into the Arapahoe County Hospital he had been in apparently good health, but, on exposure to cold, pain developed in the region of the left ear and extended to the superior posterior triangle of the neck, and to the side of the neck in the region of the jugular vein, and over the left temporal region and forehead. He was delirious a portion of the time; had a high temperature followed by sweating, but at all times complained of intense, agonizing pain in the head. Soon retraction of the head took place, and the slightest jarring of the head or BRAIN LESIONS FROM MIDDLE-EAR DLSEASE 7 percussion over the side of the head gave rise to considerable pain. When he was admitted to the hospital both pupils were dilated and did not react well to light. He was so nearly unconscious as to make it impossible to secure satisfactory answers to questions. The coma deepened and death took place a few hours later. The temperature reached io8° before life was extinct. At the autopsy, held a few hours later, there were found suppura- tive leptomeningitis on the left side, disintegrating thrombosis of the left sigmoid sinus, necrosis of the bones of the ear, and offensive pus and inspissated material in the mastoid cells and antrum; no abscess. In the two cases reported in this paper in which abscess of the brain was found at the autopsy, this suppurative process was compli- cated with both meningitis and sinus thrombosis, and in both the temperature was elevated. It is probable that even an acute cerebral abscess, uncomplicated, after the first stage of irritation has passed, is attended by a normal or subnormal temperature. That chronic cere- bral suppuration is attended by a low temperature was demonstrated by me in some observations reported to the College of Physicians, of Philadelphia, in 1883.* I further showed that in cases of hemiplegia from cerebral abscess the temperature is higher on the paralyzed side than on the other, even when the paralysis had existed for two or three months. This is contrary to what we find in paralysis of old standing from vascular lesions. ♦Transactions of the College of Physicians, of Philadelphia, vol. vi, 1883.