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362                                       THE EAR


The patient generally lies curled up, his head turned towards the side of the
lesion. When sitting up or standing he tends to hold his head inclined to
this side. Often there is considerable rigidity of the neck, and persistent
nuchal rigidity is considered the most constant and earliest sign of an acute
cerebellar or cerebral abscess of otogenic origin when it is combined with
a cell content in the cerebrospinal fluid of chiefly under 100 lymphocytes.
The patient complains of dizziness when sitting up, and when erect he
stands with a wide base. Although the headache is usually occipital it is
well to remember that in cerebellar abscess there may be complaint of
headache in the frontal region. Yawning and hiccough may be symptoms
suggestive of pus in the posterior cranial fossa. The speech may resemble
that in disseminated sclerosis, i.e. scanning speech. Vomiting and papill-
oedema are more common in cerebellar than in cerebral abscess. Cerebellar
ataxia may also be present, the patient staggering or falling towards the
diseased side as a rule. Further, the direction of the fall on Romberg's test
(backwards and to the diseased side) is not influenced by cold syringeing
of the ear or by altering the position of the patient's head. As cerebellar
control is homolateral, the signs of cerebellar abscess are on the same side
as the lesion. Movements of the homolateral limbs are asynergic, and the
patient is disinclined to use the limbs on this side when he is irritated, e.g.
by holding his nose. The deep reflexes may be increased on the side of the
lesion. A valuable localizing sign is 'dysdiadochokinesia'. In testing for this
the forearms are alternately and quickly pronated and supinated; if the
sign is present, fatigue is rapidly induced in the arm on the diseased side.
When the patient raises both hands in the position of surrender the arm
on the suspected side starts to fall gradually. Nystagmus is usually present
and is coarser and of greater amplitude than that due to labyrinthitis; it is
generally directed towards the affected side and becomes more noticeable
as the disease progresses. The variability of the nystagmus of cerebellar
abscess is characteristic. At one time it is directed to the affected side and
at another to the sound side, or it may be absent for short periods. This
is in marked contrast to the conditions found hi labyrinthitis in which the
nystagmus is always directed to the healthy side and gradually diminishes
in intensity, passing from the third to the second, and later to the first,
degree before disappearing. It will thus be seen that in labyrinthitis the
symptoms and signs gradually diminish and pass off, whereas in cerebellar
abscess they show a progressive increase. The pointing test may be found
useful. In cerebellar abscess there is usually deviation in the pointing test
and as a rule it is outwards on the site of the lesion, but, like the nystagmus,
may show considerable variation from day to day. There may be distinct
tremor on the affected side in the *finger-nose' test. Complete hemiparesis
of the limbs is occasionally met with, and is due to compression of the
pyramidal tract below the decussation of the pyramids. Respiratory para-
lysis occurs not infrequently in cerebellar abscess, and is caused by coning
of the foramen magnum by the brain stem.

COURSE AND TERMINATION. If untreated, a brain abscess invariably ends
fatally. The patient at first becomes stuporous but can still be roused although
his response to external stimuli is very slow; he may even fall asleep while