THE PAINS OF CEREBRAL ABSCESS.
Cerebral abscesses is, fortunately, a rare disease; but the very fact of
its rarity makes the resemblance of the pain it causes to that of
neuralgia the more likely to lead us into serious errors. We are apt to
forget the possibility of suppuration of the brain on account of its
infrequence.
Pain in the head is present as an early symptom of abscess in the brain
in a large proportion of cases in which there is pain at all. [Of
seventy-five cases of cerebral abscess analyzed by Gull and Sutton
(Reynolds's "System of Medicine," vol. ii.), pain was a symptom in
thirty-nine, and most frequently an early symptom.] Many cases are
recorded in which it preceded every other morbid sign by a considerable
period. It is usually more or less paroxysmal, often strikingly so; in
the latter case, it bears a great similarity to neuralgia. On the other
hand, it sometimes takes the shape of a fixed burning sensation, much
less resembling neuralgia. The situation of the pain by no means always,
nor even usually, corresponds to the situation of the cerebral abscess;
on the contrary, abscess in the cerebellum has often caused pain
referred to the anterior part of the head, and so on. So long as the
disease remains characterized only by pain, more or less, of a
paroxysmal character, the diagnosis must be very uncertain; but in the
great majority of cases certain more distinctive symptoms soon become
superadded; either convulsions (sometimes hemiplegic), vertigo, coma,
paralysis, vomiting, or a combination of some of these.
In the stage in which there is as yet no conspicuous symptom but severe
pain, the diagnosis of cerebral abscess from neuralgia must rest on the
following points of contrast:
_Cerebral Abscess._ _Neuralgia of Head._
Often occurs secondarily to caries Rarely appears before puberty.
of internal ear, and purulent
discharge the result of scarlet
fever, measles, etc., in
childhood.
Frequently follows a blow or Comparatively seldom caused by
injury. blow, or other external
injury or caries of bone.
No true "points douloureux." If severe, soon presents, in most
cases, the "points douloureux."
Usually the pain does not Intermissions of pain complete,
completely intermit. and of considerable length.
Pain often excruciating from a Pain usually not very violent at
very early period. first.
Pain often limited in situation, Pain superficial; follows
seems deep-seated, though, as distribution of recognizable
often as not, it has no relation nerve-branches belonging to
to the site of the abscess. the trigeminus or the great
occipital.
No well localized vaso-motor or Usually there are lachrymation,
secretory complications. congestion of conjunctiva, or
other vaso-motor and secretory
complications, such as are
described in Chapter III.
Very rare in old age; then Severe and intractable neuralgia
usually traumatic. is commonest in the
degenerative period of life.
Relief from stimulant narcotics Relief from opium, etc., is much
very transitory. more considerable and
permanent.
The only case of cerebral abscess that I have personally seen, in which
the above points of distinction would have been insufficient, was that
of a boy of sixteen, in whom the only discoverable symptom, for nearly
three months, was pain, very strongly resembling ordinary migraine,
recurring not oftener than once in ten days or a fortnight, lasting for
some hours at a time, and nearly always ending in vomiting, and
disappearing after sleep. At the end of the three months, acute pain in
the left ear set in, and this was followed, soon, by right hemiplegia,
coma, and death. It was then discovered, although it had formerly been
denied, that the boy had suffered from discharge from the left ear,
following a febrile attack which had been marked by sore-throat, and
followed by desquamation of the cuticle--evidently scarlet fever. In all
cases of severe pain in the head, it is a golden rule to inquire most
carefully as to the possible existence, present or past, of discharge
from the ear, or other signs of caries of the temporal bone; and, even
if no positive history of this kind be given, we should still regard
with great suspicion any case in which there has been scarlet fever
followed by deafness.