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This case report helps doctors taking postgraduate exams, but would
not have satisfied examiners in Ancient Greece. To understand the
connection between ear disease and serious cerebral complications, rather
than the scenario offered by the two neurologists, one needs to consult
the short case (97 words in Greek) in Hippocrates [1]. This was a 20y old
playfully slapped on the head who developed fever, headache and
neurological signs. On the 7th day, a cupful of reddish pus discharged
from the right ear, whereupon she improved, but then her mental status
deteriorated and she died on day 9.
The modern formulation of such cases is that infection from otitis
media travels into the brain, whereas the ancient one proposed a
centrifugal not centripetal initial move, the old notion of cerebral
otorrhea [2]. Hippocrates often referred to physiological and pathological
drainage routes of CSF into the cranial lymphatic system via eyes, ears,
nose, etc. His case clearly invites the inference that her trigger was a
traumatic cerebral bleed, eg epidural hematoma, which decompressed via the
ear.
In the Dutch case we are expected to believe that a fit young man had
an infection from a common cold that was so virulent that in a single day
pus eroded bone and burrowed into the brain, yet did not even infect the
other ear. And where did the intracranial air come from? Three clinical
signs needed to compare the rival chains of events were not definitively
stated: the volume of aural discharge, if and when it stopped, and any
reciprocal relation between otorrhea and mental status. A simple
Hippocratic interpretation of this case is that the man had a cold, blew
his nose hard, created (or more likely enlarged) a fistula into the brain
cavity, forced air in under pressure, stripped dura and ruptured blood
vessels. When blood/pus/CSF had stopped decompressing into the ear, the
way was now open for organisms to creep back up into the brain/CSF. Modern
authors have not tested this theory, but there is plenty of good evidence
for crucial parts of it, especially in young men [2,3,4,5].
The two opposing theories can now be compared to see which best fits
the facts. Hippocratic theory explains why
1. The ear disease is usually unilateral.
2. There is no dose effect, ie chronic suppurative otitis media is
not mandatory.
3. The patients are often young and fit.
4. There is an inverse relation between otorrhea and mental status.
5. The discharge may be bloody.
6. The volume of discharge could be larger than if just of aural
origin.
7. General infections are absent, as expected if organisms had spread
via blood.
8. Air was found in the brain of the Dutch case (even without
hematoma [5]).
9. Most ear infections are harmless, only rarely lethal.
10. Minor colds or trauma can have serious consequences.
11. It is unnecessary to suppose that diffuse or mild infection
creates a fistula.
12. There is a yellow/red distinction for discharge.
The modern theory does not really explain anything, but credit is due
to the germ theory and antibiotics, and, of course, the latest case
survived. However, we should not delude ourselves that this means we
understand the disease process. Thousands are still dying from ear
disease in the developing world, so it is important we understand why not
all ear disease is the same or innocuous.
1. * Hippocrates. Vol VII. Ed WD Smith. Harvard: Cambridge,
Massachusetts, Epidemics V,50.
2. * Gordon AG. Spontaneous extradural hematoma. J Neurosurg
1983;58:794-5.
3. Omama S, Sugawara T, Oku T, Arai H, Niimura K, Higuchi H, Futai
K. [An acute epidural hematoma soon after nose blowing: a case report]. No
Shinkei Geka. 1995;23:639-42.
4. Wakamoto H, Miyazaki H, Tomita H, Ishiyama N. [The presence of air
in epidural hematoma due to congenital bone defect in the mastoid tegmen--
a case report]. No Shinkei Geka. 2000;28:731-5.
5. * L.F. Ugarriza, J.M. Cabezudo, I. Fernandez-Portales. Rapid
spontaneous resolution of an acute extradural haematoma: case report
British Journal of Neurosurgery 1999;13:604-605.
Endgame: Holland 1 Ancient Greece 12
This case report helps doctors taking postgraduate exams, but would
not have satisfied examiners in Ancient Greece. To understand the
connection between ear disease and serious cerebral complications, rather
than the scenario offered by the two neurologists, one needs to consult
the short case (97 words in Greek) in Hippocrates [1]. This was a 20y old
playfully slapped on the head who developed fever, headache and
neurological signs. On the 7th day, a cupful of reddish pus discharged
from the right ear, whereupon she improved, but then her mental status
deteriorated and she died on day 9.
The modern formulation of such cases is that infection from otitis
media travels into the brain, whereas the ancient one proposed a
centrifugal not centripetal initial move, the old notion of cerebral
otorrhea [2]. Hippocrates often referred to physiological and pathological
drainage routes of CSF into the cranial lymphatic system via eyes, ears,
nose, etc. His case clearly invites the inference that her trigger was a
traumatic cerebral bleed, eg epidural hematoma, which decompressed via the
ear.
In the Dutch case we are expected to believe that a fit young man had
an infection from a common cold that was so virulent that in a single day
pus eroded bone and burrowed into the brain, yet did not even infect the
other ear. And where did the intracranial air come from? Three clinical
signs needed to compare the rival chains of events were not definitively
stated: the volume of aural discharge, if and when it stopped, and any
reciprocal relation between otorrhea and mental status. A simple
Hippocratic interpretation of this case is that the man had a cold, blew
his nose hard, created (or more likely enlarged) a fistula into the brain
cavity, forced air in under pressure, stripped dura and ruptured blood
vessels. When blood/pus/CSF had stopped decompressing into the ear, the
way was now open for organisms to creep back up into the brain/CSF. Modern
authors have not tested this theory, but there is plenty of good evidence
for crucial parts of it, especially in young men [2,3,4,5].
The two opposing theories can now be compared to see which best fits
the facts. Hippocratic theory explains why
1. The ear disease is usually unilateral.
2. There is no dose effect, ie chronic suppurative otitis media is
not mandatory.
3. The patients are often young and fit.
4. There is an inverse relation between otorrhea and mental status.
5. The discharge may be bloody.
6. The volume of discharge could be larger than if just of aural
origin.
7. General infections are absent, as expected if organisms had spread
via blood.
8. Air was found in the brain of the Dutch case (even without
hematoma [5]).
9. Most ear infections are harmless, only rarely lethal.
10. Minor colds or trauma can have serious consequences.
11. It is unnecessary to suppose that diffuse or mild infection
creates a fistula.
12. There is a yellow/red distinction for discharge.
The modern theory does not really explain anything, but credit is due
to the germ theory and antibiotics, and, of course, the latest case
survived. However, we should not delude ourselves that this means we
understand the disease process. Thousands are still dying from ear
disease in the developing world, so it is important we understand why not
all ear disease is the same or innocuous.
1. * Hippocrates. Vol VII. Ed WD Smith. Harvard: Cambridge,
Massachusetts, Epidemics V,50.
2. * Gordon AG. Spontaneous extradural hematoma. J Neurosurg
1983;58:794-5.
3. Omama S, Sugawara T, Oku T, Arai H, Niimura K, Higuchi H, Futai
K. [An acute epidural hematoma soon after nose blowing: a case report]. No
Shinkei Geka. 1995;23:639-42.
4. Wakamoto H, Miyazaki H, Tomita H, Ishiyama N. [The presence of air
in epidural hematoma due to congenital bone defect in the mastoid tegmen--
a case report]. No Shinkei Geka. 2000;28:731-5.
5. * L.F. Ugarriza, J.M. Cabezudo, I. Fernandez-Portales. Rapid
spontaneous resolution of an acute extradural haematoma: case report
British Journal of Neurosurgery 1999;13:604-605.
* These primary sources have been read.
Competing interests: No competing interests