TUJVIOR OR THE BRAlH- 
J. T. ESKRIDGE, M. D„ 
DENVER, COLO., 
Neurologist to the Arapahoe County, St. Luke's and 
Deaconess Home Hospitals. 
REPRINTED FROM 
The DerxVer Times 
For January, 1892. TUMOR OF THE BRAIN. 
A CLINICAL LECTURE DELIVERED AT THE ARAPAHOE COUNTY 
HOSPITAL, OCT. 31, 1891. 
J. T. ESKRIDGE, M. D., DENVER, COLO. 
Neurologist to the Arapahoe County, St. Luke's and Deaconess Home Hospitals. 
Gentlemen'.-I wish to call your attention to-day to this man 
who has been in the hospital three or four weeks, complaining, at 
the time of his admission, and since, of lameness in the right leg, 
complete paralysis of the right arm and almost total blindness of 
both eyes. I will make a systematic examination into his con- 
dition to show you the method and to demonstrate the necessity 
of it. 
J. C., aet. 30, Scotland, farm laborer, came to Colorado two 
and one-half years ago and has been engaged in tending horses 
since that time. The paternal grandmother died of paralysis and 
the paternal uncle is now suffering with paralysis which effects the 
muscles of the throat. No history of other nervous troubles in 
the family. No history of alcoholism in ancestors. Patient's health 
in youth and childhood was good. He lived in Scotland up to his 
twenty-seventh year. He occasionally indulged in alcohol, but as 
a rule only on Saturday nights, when he would become more or less 
intoxicated. Since he has been in this country he claims almost 
total abstinence. There is no history of any trouble up to his 
twenty-second year, when, after drinking the night before, he ob- 
served while engaged in plowing in the field, that the right hand 
and arm began to shake. He stopped his team but immediately 
fell over in a convulsive fit. He was told that he remained un- 
conscious for about an hour. He observed both before and after 2 
the occurrence of the fit that when he drank alcohol it seemed 
to effect his head unpleasantly. He thinks that he did notsuffer 
from headache at the time of the first convulsion. Following 
this attack he remained well for about two months, when a second 
convulsion occurred, the'same in character as the first, but it had 
not been preceded by drinking the night before. Two months 
after the second,, he had a third attack, when he began taking 
medicine and seems to have been entirely cured. Some three or 
four years ago he contracted a hard chancre, but this was not 
followed by secondary symptoms. With the exception of this he 
remained well from 1883, until July, 1890, when he was kicked on 
the right side of the head by a horse and rendered unconscious. 
The scalp was cut to the bone, but the latter apparently was not 
fractured. He does not seem to have suffered much at the time, 
as he returned to his work the latter part of the same day the ac- 
cident occurred. He says the blow on the head did not give rise 
to any headache. He remained well from July, 1890, until 
January, 1891, when, apparently after taking a cold, what was 
known at the time as "la grippe," he suffered for a week with 
severe headache. After this he remained well until the first of 
August of the present year, when, without any apparent cause, 
he noticed after the least effort made with the right hand or arm 
that this arm would be tremulous for several minutes. This 
condition continued for several days, followed by weakness of the 
hand and arm. It is just possible that this limb was affected be- 
fore he observed it as he is left handed. A few days after 
first observing the affection of the right hand he suffered with 
severe headache, lasting two or three days and attended by 
vomiting. Five days subsequently, another severe headache with 
vomiting began and lasted several days. About this time he 
noticed the right leg and foot were getting weak. From about 
the middle of August, up to the time of his entrance into the 3 
hospital, Oct. io, 1891, he suffered with more or less constant, 
dull, heavy pain in head with occasional periods of exacerbations 
of the pain. In the early part of October, about one week before 
he entered the hospital, the muscles of the right side of the 
body became stiff and rigid and remained so for a few minutes, 
but did not lose consciousness. 
Statusprase ns >-He can scarcely stand or walk without as- 
sistance on account of weakness of the right leg. The right arm 
is completely paralyzed, the right leg partially; there is a slight 
paretic condition of the muscles of the right side of the face. And 
the tongue deviates to the right slightly in protrusion. Eyelids 
are both closed at will. Knee-jerks; right, greatly exaggerated; 
left, slightly increased. Ankle clonus; right, present; left, absent. 
Planter reflexes; absent. The right foot can be flexed and. ex- 
tended at will when he is lying down, and the muscles of the 
lower portion of the leg seem to be less paralyzed than those of 
the hip and thigh. Cremaster reflexes; right, absent; left, present 
and apparently exaggerated. Inguinal reflexes; right, absent; 
left, present. Epigastric reflexes; right, absent; left, present. So 
that the superficial reflexes appear to be present through- 
out the left and absent throughout the right side. There seems 
to be almost no power of motion in the right hand, but the move- 
ments made by some of the fingers follow several seconds after 
he endeavors to move the fingers. The right deltoid and pec- 
toralis major muscles are completely paralyzed. The latter 
muscle is paralyzed for all movements, both associated and single, 
Deep reflexes of the right arm are greatly exaggerated. The 
pupils are widely dilated and respond imperfectly to light. 
Tactile sense on the right foot and leg is blunted but not ab- 
sent, but on the right hand and arm it is completely abolished. 
On the right side of the chest it is almost destroyed. On the 
face it is greatly blurred and almost completely absent, except 4 
in spots, up to the median line. On the forehead it is absent up 
to the median line. Pain sense is present but slightly lessened 
on the right foot and leg, somewhat blurred on the right side of 
the trunk, absent on the right arm and hand, and blurred on the 
right side of face and head. Temperature sense is blurred or 
abolished throughout the right side. Muscular sense is nearly 
abolished throughout the right side. Senses of taste, smell and 
hearing are all present and nearly normal. Vision: The field of 
vision is very narrow so that he can only see objects immediately 
in front of his eyes. He is unable to count fingers at a few 
inches distance from his eyes. Since he has been in the hospital 
he has suffered considerably with headache. The pain has come 
on most commonly in the morning, and at times it is quite 
severe, requiring morphia and antipyrine for its relief. 
Let us inquire into the seat and nature of the lesion from 
which this man is suffering. Is the lesion in the spinal cord or 
brain? The double choke-disc, the affection of sensation on the 
side of the face and head up to the median line, enable us to ex- 
clude lesion of the nerves orcord. In inquiring into the charac- 
ter of the brain lesion it is necessary for us to bear in mind a 
hemorrhage, embolism, thrombus, abcess, or a growth might give 
rise to symptoms more or less closely resembling those found in 
the patient before us. There are a few points of difference in the 
history and mode of onset of these various brain lesions, which I 
think will enable us to make a diagnosis by exclusion. The age 
of the man, if he had not had syphilis, would be against hemorr- 
hage, but as he has a syphilitic history, his age plays no 
part in the diagnosis. Hemorrhage into the brain substance, 
whether it occurs in a syphilitic subject or not, is sudden in its 
onset, the paralysis reaches its height in a few minutes or at the 
most a few hours. With the occurrence of the hemorrhage there 
is a period of unconsciousness, and the severity of the symptoms 5 
as a rule, lessens after the first shock of the hemorrhage; so that 
With the history.of tremor in the hand and arm, followed by gradual 
weakness of the muscles affected, and attended with severe head- 
aches, with a gradual increase of symptoms over a period of two 
or three months, and paralysis extending over the entire arm and 
slightly affecting the leg and face, enable us in the present in- 
stance to exclude hemorrhage. For the same reason we can ex- 
clude embolism and thrombus. The most important symptoms 
in the majority of cases of abcess of the brain is an association of 
cerebral disturbances in persons suffering with disease in some 
other portion of the body capable of giving rise to abcess of the 
brain. The most important of the latter are chronic ear disease, 
especially one attended with suppuration, or a suppurative pro- 
cess in some other portion of the body, as in the lungs. Injuries, 
especially of the brain, are sometimes followed by cerebral ab- 
cess. Frequently in the abcess of the brain there is a shorter or 
longer period of cerebral irritation followed by acute brain dis- 
turbances, such as we get in a case of apoplexy, attended with 
fevers and rigors. In the present instance it seems to me abcess 
may be excluded. We have left then a cerebral growth to ac- 
count for the symptoms from which our patient is suffering. To 
study the case intelligently, it is necessary for us now to take up 
the most prominent symptoms of tumor of the brain and com- 
pare them with those with which our patient is suffering. These 
symptoms for convenience sake may be divided into general or 
diffuse, which more or less point to cerebral disturbances without 
indicating any particular region of the brain; mixed, which point 
to cerebral disturbances and at the same time indicate, to a 
greater or less extent, irrigation in some particular region of the 
brain, and the localizing or focal symptoms, which enable us to 
determine with more or less accuracy the portion of the brain 
affected. This division is not entirely reliable, as the general 6 
symptoms at times may have a localizing value and those of a 
localizing nature may in other cases result from general cerebral 
irritation. One of the most common symptoms of brain t mor 
is headache. It is absent throughout the disease only in very 
rare cases. It is usually more or less constant with paroxyisms 
and remissions, and in some instances there are periods of days 
or weeks with entire intermissions. The character is very vari- 
ble. It may be by dull or acute, and sometimes patients complain 
of it as stabbing and boring, and not infrequently it is so severe 
as to materially interfere with sleep. It is increased by whatever 
interferes with the cerebral circulation; the movements of the 
patient, muscular efforts of any kind, as fits of coughing, etc. Un- 
fortunately it does not always point to the seat of the disease. It 
may be general, or located in front, at the back, or one or both 
sides of the head. In some instances the seat of the pain is 
limited to a very small area. It does have at times a more or 
less localizing value. When the growth is situated near the sur- 
face, springing from the membranes or directly or indirectly irri- 
tating them in some particular spot, the location of the pain 
usually points to the seat of the disease. With a growth situated 
in the centrum ovale, the pain is often frontal. Subtentorium 
tumors are usually attended with pain in the occipital region, ex- 
tending to the back of the neck, with tenderness over the post 
cervical muscles and more or less retraction of the head. Per- 
cussion over the head in superficial cerebral tumors elicits ten- 
derness in the region of the growth while none is found over any 
other portion of the head. Optic neuritis is found in a large 
number of brain growth. According to some authors it is found 
in four-fifths, at least, of all such cases. It is less frequent when 
the growth is over the convex surrace of the brain, involving the 
membranes, that when the brain substance is the seat of the 
tumor. Many theories have been advanced to explain the devcl- 7 
opment of optic neuritis and choke-disc, and it is probable that 
they all contain some element of truth. Mental disturbance is 
found most commonly in those cases where the circulation of the 
brain is most affected. In some, occasional delirium appears 
early and delusions may be manifested for some minutes each 
time a patient awakes from sleep. In the majority of cases, how- 
ever, there are no great mental disturbances early in the disease, 
but later, some develop delusions of suspicion and persecution, 
and seem to be in a constant condition of agitation. In a great 
number, the mind is fairly well retained until the latter stage 
of the disease, when there is a gradual blurring of the intellect, 
an ofrtunding of the mind, with a tendency to a semi-comatose 
condition. 
Hysterical manifestations are occasionally met with in the 
history of tumor of the brain. They seem to be more common 
in the female, and so far, I have only found them where the 
tumor is situated in the posterior portion of the brain, especially 
in the region of the cerebellum. These manifestations occur in 
persons who have a natural neurotic tendency, and have been 
mistaken for cases of hysteria. Fortunately, in all the cases that 
I have seen, an ophthalmoscopic examination has revealed intra- 
cranial lesions, preventing mistakes in diagnosis. 
Vomiting is not an infrequent symptom and may occur with 
growths in any portion of the brain, but it is most commonly 
met with in tumors of the medulla, middle lobe of the cere- 
bellum and in regions of the corpora quadrigemina. In cerebellar 
tumors, dizziness, optic neuritis, vomiting and headache fre- 
quently constitute the only symptoms of brain disturbance for a 
considerable length of time. Giddiness is a frequent symptom 
in tumors of the posterior portion of the brain, especially 
in the region of the pons, and in the middle lobe of the cere- 
bellum, and is sometimes manifested whether the patient is lying 
or standing. 8 
Local spasms, paresis and paralysis, have considerable sig 
nificance, and greately aid in localizing the seat of lesion. They 
are commonly met with when the Rolandic region is involved, 
and may affect at first, one side of the face, some of the 
muscles of the hand and arm, or they may begin in the muscles 
of one foot, especially of the great toe; so that mono-spasms, 
mono-paresis and mono-paralysis, affecting one group of muscles 
at first, and involving the other muscles whose brain centres are 
adjacent to those first affected, enable the neurolgist not only to 
localize the initial lesion, but the direction, course and progress 
of the disease. If the face is first involved, it is likely that in 
brain tumors of the cortex, the hand or arm centres will be 
affected before those of the legs or feet; and where the initial 
lesion affects the muscles of the feet or legs, the hand and arm 
are involved before the face. When there is an hemianaesthesia 
affecting one side of the body up to the median line, it points to 
lesion in the sub-thalmic region which not infrequently affects 
the special senses of the anaesthetic side. 
Having diagnosed tumor of the brain, it is necessary next 
to determine its location. Without going into an elaborate 
discussion of the localizing symptoms of brain lesion, let it suffice 
to-day to say that the hemiplegia with the hemianaesthesia, in- 
volving the entire right side of the body, points in this case to a 
lesion of the left sub-thalmic region, affecting the posterior por- 
tion of the internal capsule. After localizing the tumor we next 
inquire into its probable nature. Is it a sarcoma, glioma, car- 
cinoma, tubercular or syphilitic growth? The age of the patient, 
the absence of the history of cancer in the family, or of a morbid 
growth in any other portion of the body, would enable us to exclude 
the probability of cancer. For a like reason we can exclude a tuber- 
cular nodule. Sarcoma and glioma may occur at almost any time 
of life and are not infrequently found in persons about the age of 9 
our patient. The history of syphilis, and the probable location 
of the lesion in the sub-thalmic portion of the brain, not an infre- 
quent site in syphilitic growths, justify us at this stage of the dis- 
ease in treating our patient for syphilis. 
The treatment of brain tumors may be divided into curative 
and palliative. The curative may be divided into surgical and 
medical. In the vast majority of cases, brain tumors are not 
situated in regions of the brain accessible for suigical interference. 
In no case is such a procedure justifiable until a thorough course 
of medicine to get rid of the growth has been tried. In the 
present instance, should medicine fail, the seat of the lesion 
would preclude any probable good from surgical interference. 
Since he has been in the hospital he has been on anti-syphilitic 
reatment and has improved in some respects. This treatment 
to be effectual must be heroic. He was given to commence with, 
twenty grains of pottasium iodide, largely diluted thrice daily, 
and the dose has been increased five grains each day, until now 
.he is taking nearly three hundred grains of the salt dady. 
Besides inunctions of blue ointment have been used, and in addi- 
tion to this, one-sixteenth of a grain of corrosive sublimate has 
been given three times daily. The treatment will be pushed to 
the point of toleration and there maintained untill the patient's 
symptoms decidedly improve, or until after a prolonged and 
fruitless effort we shall find that no hope is to be entertained 
from anti-syphilitic treatment.