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:
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.