The 10th Historical Clinicopathological Conference

A Mysterious Death

Presentation of Case

Except for intermittent ear aches (apparently bilateral), the patient had enjoyed excellent health until age 54, when he noted a marked increase in his ear pain, progressive hearing loss and “burning headaches”, sometimes agonizingly severe. His meager clinical record does not mention otorrhea, vertigo or tinnitus. The ear pain continued, although intermittently, for the remaining 13 years of the patient’s life.

The patient exercised daily and rigorously and prided himself on his physical fitness. He was particularly fond of swimming. Even on the coldest days of winter, he would ride his horse daily to the nearest body of water and swim. Although he realized seawater often exacerbated his ear pain, he continued this practice, convinced that salt-water possessed medicinal properties.

The patient had many talents, including those of a linguist, financier and classical scholar. However, his passion was archeology, a passion which led him to travel and work in diverse areas throughout much of the northern hemisphere, especially within the Mediterranean basin. His most intensive work was conducted in northern Turkey, at Hisarlik.

The patient was a native of Neubukow, Germany and the son of a protestant clergyman. He was twice married and had three children by his first (Russian) wife and two by his second (Greek) wife. None of his family members are known to have had medical problems similar to the patient’s.

The patient’s past medical history included a number of potentially severe disorders from which he recovered without sequellae. He “hemorrhaged from a weak chest” as a child. As an adult, he developed influenza while residing in Russia, yellow fever during a trip to California and malaria while working in Greece.
When the patient’s ear complaints first intensified, he ignored them and continued his work. When they remitted, he believed himself cured. However, his relief was temporary, and by the time he reached 64, it was clear that his earaches and deafness were progressing. At age 65, sudden loss of hearing and excruciating pain in the (? left) ear, caused the patient to consult Dr. Rudolph Virchow, who discovered an external ear canal occluded by swelling. Virchow advised against further sea bathing, but was ignored. He also advised the patient to consult Professor Schwartze of Halle, Germany, who was just perfecting the simple mastoidectomy as a treatment for acute suppurative mastoiditis. After several days, the pain and swelling subsided spontaneously.

Late in the patient’s 68th year, he traveled to Halle for an examination by Prof. Schwartze. Although his pain and the swelling of the ear canal had subsided temporarily, and his hearing had improved, Prof Schwartze recommended surgery. Several months later, a left “antratomy” (mastoidectomy) was performed under chloroform anesthesia. Exostoses were also removed from the right external auditory canal. The operation was completed in three quarters of an hour.

Although the surgeons declared the operation “entirely successful”, the patient complained bitterly of agonizing ear pain post-operatively. Following the procedure, the ears were irrigated daily with 2% carbolic acid solution “to evacuate the discharge”, and “a rubber drainage and lead pin” were inserted. Prof Schwartze was at a loss to explain the patient’s pain and could only assume that “the periosteum had been injured.”
Approximately a month after the procedure, the pain (at least in one ear) had subsided. Although the patient’s doctors advised further hospitalization, he discharged himself against advice in order to spend Christmas with his family in Greece. En route, he visited Virchow in Berlin, presenting him with two little boxes containing three bones removed from his ears. To Virchow, the patient appeared deaf but not particularly ill.

The patient next traveled to Paris on business. He arrived on a bitter cold December 10th. His ears, which had finally healed, once again flared up with pain and complete deafness on the left. He traveled from Paris to Naples, where on Christmas day, he suddenly collapsed in the street. Although conscious, he was unable to speak and by the next day began to exhibit signs of gradual right-sided paralysis. Surgeons called in consultation, opened his ear and discovered that “the trouble had attacked the brain.” The patient died shortly thereafter before trephining could be performed.