CHAPTER V.

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.