Diagnosis of Chronic Abscess of the Brain, 
BY 
J. T. ESKRIDGE, M.D., 
OF DENVER, COL., 
* PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF 
THE UNIVERSITY OF COLORADO; NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
August and September, 1896. Extracted from The American Journal of the Medical Sciences, August and 
September, 1896. 
DIAGNOSIS OF CHRONIC ABSCESS OF THE BRAIN. 
By J. T. Eskridge, M.D., 
OF DENVER, COL., 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF COLORADO ; NEUROLOGIST TO THE ARAPAHOE COUNTY 
AND ST. LUKE'S HOSPITALS. 
Chronic abscess of the brain may, for the sake of convenience of 
description, be divided into two varieties. The one is the result of acute 
or subacute focal intracranial suppuration in which the symptoms have 
become more or less latent; while the other begins with symptoms so ill- 
defined and unobtrusive as scarcely to attract attention, if, indeed, they 
do not escape observation entirely during the early stage of the morbid 
process. It would aid in preventing confusion in the study of abscess of 
the brain if all those cases that begin with more or less pronounced cere- 
bral symptoms, and continue with unmistakable and progressive signs of 
brain-disorder, were regarded as acute or subacute, no matter what may 
be the duration of their course. It may be argued that it would be 
more definite to call those abscesses of the brain that begin with acute 
or subacute symptoms, and are followed by a latent period, as latent, 
leaving the term chronic to apply only to those whose early period is 
insidious. It does not matter much which course is followed so that it 
is distinctly understood what is meant to be conveyed by the word 
chronic as employed to designate certain varieties of abscess of the 
brain. A chronic abscess is essentially latent from its commencement 
to the beginning of its terminal period, and the so-called latent abscess 
is usually one whose duration is more or less prolonged. An abscess of 
the brain whose early symptoms have been so unobtrusive as to place it 
in the category of the chronic variety may run a much shorter course 
than the one ushered in by pronounced symptoms and followed by a 
latent period. 
Wide differences of opinion are held to-day by physicians and sur- 
geons of recognized ability regarding the difficulties encountered in the 
diagnosis of chronic abscess of the brain. Much of this discrepancy is 
due, it seems to me, to many accepting all intracranial suppuration as 
the result of an acute process. At the Surgical Congress held in Berlin 
April 17,1895, the distinguished surgeon, Professor von Bergmann, in a 
paper entitled " Progressive Cerebral Surgery," stated : " Cerebral ab- 
scess must always be operated on. Its diagnosis is easy if the etiology 
is considered. The principal cause of cerebral abscess is inflammation 
of the middle ear ; it is usually situated iu the temporal lobe." Leube, 2 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
than whom few have attained to greater distinction as careful and pains- 
taking diagnosticians, says : " The diagnosis of subacute and chronic 
abscess of the brain is, on the whole, easy." According to Professor 
Murri: " He (Leube) gives the most important indications of cerebral 
abscess, intermittent fever associated with rigors, and attributes great 
value to the absence of optic neuritis and etiological considerations." 
(Lancet, January 12, 1895.) 
Gowers, in his work on Diseases of the Nervous System, begins the para- 
graph on diagnosis of cerebral abscess with " The extreme variability 
and frequent latency of the course of cerebral abscess often render its 
diagnosis difficult and even impossible." 
Spitzka, in Pepper's System of Medicine, after making the statement 
that " there is little difficulty in recognizing the existence of cerebral 
abscess in which well-marked focal and constitutional symptoms coin- 
cide, or where a distinct abscess-producing cause, such as an ear-trouble, 
a head-injury, or a putrid bronchiectasis, coexists, adds, " but there are 
a number of cases, varying from the latent form to forms with obscure 
general symptoms, whose recognition is impossible or at best a matter 
of conjecture." (Vol. v. p. 799.) 
Professor Murri states that Martins has made a study of seventeen 
cases of cerebral abscess occurring in the German hospitals during the 
past few years, and not one of them was recognized during life {Lancet, 
January 5, 1895, p. 12). I might continue at great length to quote 
from various writers concerning the difficulties of recognizing, during 
life, chronic cerebral abscess, and I might add mistake after mistake in 
diagnosis, not a few of which would be my own, but I have no need to 
extend my remarks in this direction, as you are aware, I have no doubt, 
from personal experience, of the uncertainties attendant upon the diag- 
nosis of intracranial suppuration, especially of the chronic variety. I 
do not wish to underestimate the difficulties that are sometimes encoun- 
tered in diagnosticating acute cerebral suppuration. These not infre- 
quently prove insurmountable, but they are, on the whole, less than are 
met with in diagnosis of chronic abscess. Many of our text-books are 
content with a description of abscess of the brain, as though it always 
originated in acute cerebral suppuration. 
The importance of recognizing the essential difference between acute 
abscess and chronic abscess of the brain will justify a rather lengthy 
quotation from Professor Murri's admirable " Address on Experimental 
Craniotomy and Diagnosis of Cerebral Abscess" (Lancet, January 12, 
1895, p. 79) : 
" Abscess of the brain, which, when clinically considered, seems to be an 
essentially unique morbid process, resolves itself into two varieties which 
differ utterly in diagnosis, viz.: acute abscess and chronic abscess. Writers 
aiming at the unity of the process lose sight of the clinical side, and do not 
bring into sufficient relief the practical differences which exist between the ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
3 
two varieties. What they say of abscess applies chiefly to the acute form. 
Bacterial analysis might throw more light on the causes of the differences 
which are developed in the process of suppurative inflammation of the brain. 
At present what we chiefly know is the intensity of the exciting causes ; the 
duration of the process depends much on these. If a considerable cerebral 
artery is closed by an embolus ; if a wound on the head causes disturbance, 
contusion, or hemorrhage in a zone of the brain ; if a suppurative otitis 
media violently affects the bony substance and gives rise to a thrombus in 
the cranial sinuses, or excites inflammation in the adjacent meninges, the 
nutritive process of the cerebral tissues near cannot avoid deterioration, the 
pyogenic agents find a field well prepared, and their devastations are in con- 
sequence very rapid. But here, besides the rapidity of the disease, there 
arises another clinical distinction. These occurrences, being more intense, 
cannot easily happen without being perceived by both the patient and his 
medical attendant. Moreover, the succession of phenomena aroused by 
them is not so disconnected as to lose the evidence of their reciprocal rela- 
tion and the unity of the process they reveal. Finally, even the reaction of 
the brain provoked by rapid and great intracranial changes is more evident 
and appreciable to the practitioner. If to all this we add that the rapid 
diffusion of suppuration causes fever, and even a special fever, as a phe- 
nomenon revealing the nature of the morbid process, then it is easy to com- 
prehend how the clinical idea assumes a form so distinct that the diagnosis 
of acute abscess naturally follows. 
" When we come to the chronic forms of cerebral abscess, the description 
and opinions of pathologists inspired by the observation of such facts no 
longer correspond to the facts themselves. In these the exciting causes are 
less intense or less apparent. It is one thing, for example, if an embolus 
from a pulmonary, vein closes the artery of Sylvius, and another if pus pen- 
etrate unperceived into the brain by one of those narrow ways which lead 
there from without. The slightness of the latter is not only marked by the 
absence of disorders perceptible to the patient, but it also causes a slower 
succession of changes around itself; the surrounding tissues, not previously 
affected and violently attacked, have time to organize themselves for the 
defence, and in time circumscribe with a solid barrier (pseudo-membrane) the 
hostile element (pus) which tends to destroy it. This mysterious faculty 
which the brain possesses of adapting itself to the most serious lesions as 
long as they are gradual has full opportunity to act completely. Thus it 
follows that, from ignoring or forgetting the primary cause, it seems as 
though no external cause exists; and here we have the idiopathic abscess, 
which is almost always chronic. Even where the primary cause is known, 
if it be not violent, the process which succeeds follows with less rapidity, 
and hence the slight changes of the brain may not arouse perceptible func- 
tional disorders. Here we have the latent abscess or the latent period of the 
chronic abscess. The slowness with which brain-alterations proceed proves 
that a length of time is required for their development, and here we see the 
abscess become chronic. The perception of these internal processes is often 
defective, as is frequently seen in the doctrinal works of the pathologists and 
in the reasoning of clinical physicians who write and think of cerebral 
abscess as though it existed only in the acute form. But the abscess exists 
also in the chronic, idiopathic, latent, or semi-latent form, and this, though 
less frequent than the acute, is by no means as rare as statistics would make 
us believe." 
A small number of cases of chronic cerebral abscess, from their incep- 
tion to the beginning of the terminal period, and a few others in their 
most latent stage, may not present pronounced symptoms of organic 
brain disease until there are manifestations of the terminal period, but 
a careful study of cases of obscure brain diseases will reduce this num- 
ber to a minimum. The symptoms of abscess of the brain are common 4 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
to several forms of organic brain disease, and a correct interpretation of 
them will depend upon the experience, diagnostic skill, and thorough- 
ness of the medical attendant. Professor Murri's precaution to bear in 
mind the possibility of the presence of chronic cerebral abscess in in- 
vestigating cases of obscure brain disease might be advantageously ob- 
served by all. The frequency of this form of cerebral abscess is not 
great, but the presence of chronic cerebral suppuration is too often over- 
looked for the credit of medical science or the welfare of the unfortunate 
sufferer. 
Conclusions reached by an analysis of the most accurate history may, 
in some cases, lead from the truth; but in the vast majority of in- 
stances information thus obtained, together with a thorough examina- 
tion of the mental and physical condition of the patient, when all the 
modifying circumstances of the case are carefully considered, will greatly 
aid in arriving at an accurate diagnosis. Not infrequently the history 
of some condition that is known to be favorable to abscess-formation in 
the brain will be obtained from the patient. Months, and in rare cases 
years, may have elapsed since the cause was apparently active, and at 
the time of the examination it may have been forgotten both by the 
patient and his friends, and memory of it is only revived by a careful 
and intelligent line of questioning. It may have been a blow on the 
head ; a fall from a height and lighting on the feet or buttocks without 
striking the head ; a painful condition of one or both ears, either with 
or without otorrhoea ; suppuration in some portion of the body ; or some 
exhausting disease, possibly influenza, diphtheria, rheumatism, or typhoid 
fever, from which recovery has never seemed complete. In typical cases 
the history will develop the fact that headache, intermittent or constant, 
has been a prominent feature for a greater or less part of the time that 
has occurred since the time of the illness that left the patient's health 
impaired. In some cases irregular febrile phenomena, dimness of vision, 
vertigo, failing nutrition and strength, and sometimes mono-spasm, 
mono-paresis, hemiplegia, or general convulsions have been experienced. 
In the majority of instances, on examination of persons suffering from 
chronic cerebral abscess, we shall find evidence of organic brain disease ; 
but occasionally the patient may present a vigorous appearance, and 
death may occur without warning, as was the case in Professor Murri's 
experience (Lancet, January 12, 1895, p. 80). The most careful and 
exhaustive examination of the motor apparatus and of the general sen- 
sory phenomena may yield negative results. The reflexes may be nor- 
mal or slightly exaggerated. If the motor cortical areas or the moto'- 
tracts of the brain are affected, either directly or indirectly by the ab- 
scess, symptoms of paresis, paralysis, or muscular rigidity will be pres- 
ent, corresponding to the extent and situation of the abscess and the 
softening resulting from its presence. Nutrition and muscular strength ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
5 
usually fail in the course of the disease, but in some cases these are 
unimpaired. Mental failure, especially slow action of the mental faculties, 
and difficulty in maintaining mental concentration for a length of time, 
and lessened power of memory, together with irritability of temper, are 
not infrequent results of chronic cerebral abscess. Recurring convul- 
sions, sometimes mistaken for those of idiopathic epilepsy, are occasion- 
ally found in cases whose other symptoms of cerebral disease are most 
obscure. 
Individual Symptoms. Among the special symptoms of chronic 
abscess of the brain headache is the most important. Its significance is 
that its beginning dates from exposure to certain conditions that are 
known to be capable of giving rise to abscess of the brain. It is rarely 
constant, but there are very few cases of this disease in which headache 
has not been more or less pronounced during some portion of their course. 
At times the headache is severe, and at others it amounts simply to a 
dull or uncomfortable cephalic sensation. In some instances the head- 
ache, if present at all, has been so slight as to escape attention entirely. 
When the terminal period, caused by softening, oedema, or extension of 
the abscess, is reached, headache, even if absent before, often becomes a 
very prominent symptom, and its severity marks the beginning of the 
end. The seat of the pain does not always correspond to that of the ab- 
scess. If the terminal period is short and the symptoms tumultuous, the 
obscured consciousness often prevents any voluntary complaint of head- 
pain being made, although, even in such rapid cases, if the patient can 
be aroused and his attention engaged for a few moments, the fact that 
headache exists can, not infrequently, be obtained from the patient in 
answer to a direct question. The typical temperature of chronic ab- 
scess of the brain, if the morbid process is sufficiently large to exert 
much depression, is normal or slightly subnormal. At times there may 
be slight intermittent febrile processes which are frequently attended by 
cool and clammy perspiration. Optic neuritis, when present, is*a symp- 
tom of great importance. Some observers seem inclined to think that 
it is of infrequent occurrence, while others have observed it in a suffi- 
ciently large proportion of cases to regard it as a valuable aid in the 
diagnosis. In the cases that I have observed it has been present more 
frequently than absent, but the extreme degree of swelling so commonly 
seen in association with tumor of the brain I have not observed as a 
symptom of abscess. 
Terminal period. This period may extend over several weeks or a 
few days, and, possibly in some cases, may last only a few hours. Its 
duration depends upon the manner in which the abscess causes death. 
The latent period may end suddenly by the abscess bursting into the 
lateral ventricles and giving rise to all the symptoms of intra-ventricu- 
lar hemorrhage. The rupture may occur on the surface of the brain 6 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
and cause local, or, more commonly, general lepto-meningitis, which 
proves rapidly fatal. When the pus finds its way to the surface of the 
brain in the posterior fossa, both by the meningitis and the direct irrita- 
tion of the pons and medulla, the cardiac and respiratory centres are 
interfered with. In the latter case, if the patient survives the shock, 
the symptoms will be those of cerebro-spinal meningitis, prominent 
among which will be retraction of the head, rigidity of the muscles of 
the back of the neck, and sometimes of the spine, with manifest opisthot- 
onus and shock-like convulsive rigidity of the muscles of the limbs, es- 
pecially of the arms. CEdema and softening of the brain-substance are 
the causes of death in about one-half the cases of abscess of the brain. 
In many of these in which the motor and sensory areas of the brain are 
not especially affected, either directly or indirectly, by the abscess, the 
softening may take place so gradually that no symptoms of it may be 
detected until sudden collapse or death results from the apparent arrest 
of cerebral function. It is probable, however, that if these cases that 
end suddenly from softening and oedema were carefully watched, symp- 
toms of failing brain-power and general vigor, together with increased 
headache, irritability of temper, and a tendency to depression, might be 
detected weeks before the fatal end. In all the cases of chronic abscess 
of the brain except one which have come under my observation during 
the terminal period the symptoms of this stage have developed in a 
subacute manner. The prominent symptoms have been headache, usu- 
ally dull and heavy in character, but at times attended with severe par- 
oxysms of pain, failure of nutrition, energy, and strength ; mental dul- 
ness and slowness, and irritability of temper; vomiting only when 
associated with severe paroxysms of pain in the head ; optic neuritis in 
a number of instances ; slow or normal pulse when the patient is quiet, 
but sometimes easily accelerated by exercise ; subnormal temperature in 
nearly every case ; convulsions occasionally at the beginning or ending of 
the terminal period ; paralysis, usually hemiplegic in character, or pare-' 
sis, with rigidity of the affected muscles from pressure on the motor 
fibres of the brain, in more than one-half the cases, and in a number 
hemiansesthesia with hemianopsia. As the terminal period progresses 
the symptoms increase in gravtiy ; the sensory functions become more 
and more blunted, the patient's apathetic condition increases, and finally 
stupor, followed by coma, sets in, and the patient dies after remaining 
unconscious several hours to several days. It is rare after symptoms 
of the terminal stage become prominent for the patient to show more 
than temporary improvement. 
Localizing Symptoms. Percussion has afforded me little or no aid 
in diagnosticating a chronic abscess. The localizing symptoms of ab- 
scess of the brain may vary from those of tumor because pressure-symp- 
toms are sometimes less marked in the former than in the latter, and on ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
7 
ccount of the more complete destruction of tissue and greater cedemaa 
and softening found associated with abscess. We must remember, how- 
ever, that a tumor may exert no more pressure than abscess, and that 
it may as effectively destroy brain-substance as the latter. Definite 
focal symptoms are less frequent from abscess than from a morbid 
growth, because the most common seats of the former are in those por- 
tions of the brain, the cerebellum, frontal and temporo-sphenoidal lobes, 
whose functions are not definitely known. It is probable that distinct 
localizing symptoms are as frequently absent as present from abscess of 
the brain. 
Frontal lobe. A large abscess may exist unsuspected in the anterior 
portion of the frontal lobe, and a small one may be situated just anterior 
to the motor region without giving rise to symptoms indicative of its 
location. It is only when softening or oedema extends backward to the 
motor area of the cortex or the white substance beneath it, or pressure 
is exerted on this portion of the brain, that localizing symptoms develop, 
except in a few cases in which pupillary symptoms are found when 
the abscess is in the posterior and lower portion of the frontal lobe. If, 
with general symptoms of abscess of the brain following a blow on the 
front of the head, a septic embolus from the lungs or associated with an 
infective process in the frontal sinus, a gradual increasing paresis or 
paralysis of the face or arm on one side should occur, preceded, or 
not, by convulsive movements of the affected muscles, pupillary symp- 
toms would indicate one frontal lobe as the seat of the abscess. If the 
pupil on the side opposite to the one on which the muscles are involved 
should become sluggish or inactive, while its fellow responded normally 
to light and accommodation, it would aid in locating the abscess in the 
posterior portion of the frontal lobe. It must be borne in mind, how- 
ever, that the same pupillary phenomena may be present when the an- 
terior portion of the temporo-sphenoidal lobe is the seat of the abscess, 
as occurs from a similar lesion in the posterior portion of the frontal, 
but suppuration in the former situation usually results from middle-ear 
disease. Macewen's observations in relation to the pupillary phenom- 
ena may be quoted in full: " When the abscess is situated in the tem- 
poro-sphenoidal lobe or the frontal lobe, the pupil on the same side as 
the abscess may either become myotic or mydriatic, accompanied by a 
degree of stability. When the abscess is small and produces cerebral 
irritation the pupil on the affected side may be more or less contracted 
and sluggish. When the abscess is large and exercises considerable 
pressure the pupil on the affected side is prone to stabile mydriasis. 
An abscess which is small and produces a stabile myosis to begin with, 
may, as it augments in bulk, produce a stabile mydriasis in the same 
eye. Occasionally, the only difference detectable is sluggishness of one 
pupil to both light and accommodation, while its neighbor acts freely. 8 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
In a case of cerebral abscess a sluggish pupil with either mydriasis or 
myosis on the same side as an infective injury to the skull, or a uni- 
lateral otitis media, affords further evidence of the abscess being on the 
corresponding side of the brain." (Pyogenic Infective Diseases of the 
Brain and Spinal Cord, p. 145.) In five cases of abscess of the frontal 
lobe observed by me the pupillary phenomena described by Macewen 
were present in only one, but this was the only one of the five in which 
the abscess was located in the posterior portion of this lobe. 
Temporo-sphenoidal lobe. A small abscess, and even one of consider- 
able size, may be situated in the temporo-sphenoidal lobe without giving 
rise to any distinct localizing symptoms. In the case of chronic ab- 
scess of this lobe the history, most likely otitis media on the same side 
as the abscess, might afford the only clue to localization. A large ab- 
scess, on the other hand, would probably develop localizing symptoms 
from the effects of pressure on the surrounding structures, and if exten- 
sive softening and oedema should occur, regions of the brain whose func- 
tions are fairly well known would become involved. If the abscess were 
on the left side in the posterior portion of the temporal region, so as to 
affect the first and second temporo-sphenoidal convolutions, sensory 
aphasia would be present. On either side of the brain a large ab- 
scess in the anterior portion of this lobe might cause paresis or paraly- 
sis, first in the face, and secondly in the arm of the opposite side, with 
pupillary symptoms, such as sometimes occur in abscess situated in the 
posterior portion of the frontal lobe. Macewen has observed in cases 
of abscess in the anterior portion of the temporo-sphenoidal lobe paraly- 
sis of the third cranial nerve of the same side, thus producing crossed 
paralysis, the third cranial nerve on the same side as the abscess being 
affected and paralysis of the face and arm of the opposite side result- 
ing. A careful study of the direction in which the paralysis extends 
after the first group of muscles is involved will often afford valuable 
information upon which to base a localizing diagnosis. Not infre- 
quently the middle-ear disease which leads to acute abscess of the brain 
paralyzes the facial nerve as it passes through the Fallopian canal, but 
this rarely occurs in chronic abscess. 
Occipital lobe. In three cases1 of chronic abscess of the occipital lobe 
observed by me paresis and muscular rigidity, nearly complete hemi- 
anaesthesia, and hemianopsia of the opposite side existed. In each case 
the abscess was large and situated in the white substance, so as to exert 
pressure on the fibres of the posterior half of the internal capsule. It is 
probable that the fibres coming from the cortical centre of sight in the 
cuneus were rendered functionless, either by pressure or softening, as 
the cortical substance of this region did not seem to be directly involved. 
1 The Medical News. July 27, 1895. ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
9 
A small encapsulated abscess, in all probability, might remain in the 
white substance of the occipital lobe for a long time without giving rise to 
any localizing symptoms. It should be borne in mind that chronic abscess 
of the so-called idiopathic variety (probably due to suppuration in distant 
portions of the body) is most commonly situated in the occipital lobe. 
Cerebellum. An encapsulated abscess of considerable size situated in 
the posterior portion of one lateral lobe of the cerebellum might cause 
no definite symptoms so long as it remained more or less latent. An 
abscess in the anterior portion of either lateral lobe or one in the middle 
lobe would likely give rise to pressure-symptoms on the pons and me- 
dulla, in which case cerebellar ataxia would be manifest. The cardiac 
and respiratory phenomena, together with yawning, observed in acute 
abscess of the cerebellum, would probably not occur in the chronic 
abscess until the terminal stage develops. 
Differential Diagnosis. Other organic lesions than abscess of 
the brain are attended by symptoms common to intracranial suppura- 
tion, so that one of the most difficult problems encountered by the clini- 
cal physician in the diagnosis of chronic cerebral abscess is differentiating 
it from other diseases that so nearly resemble it, both in their clinical 
history and apparent etiology. 
The following case illustrates the similarity of the symptoms of cere- 
bral softening following thrombotic occlusion of an artery to those of 
cerebral abscess : 
A man, aged twenty-two years, an Austrian by birth, a miner by occu- 
pation, living in Colorado four years, was admitted into the Arapahoe 
County Hospital, March 25, 1895, completely paralyzed in the left leg 
and arm and lower side of the face of the same side, the upper portion 
of the latter being paretic. His family history was negative, and he 
had always enjoyed good health up to the beginning of his present 
illness. He denied indulgence in alcohol further than an occasional 
glass of beer, and said that he had never exposed himself to venereal 
poison. Abdut two months before coming under my care he suffered 
for two or three weeks from pain in the left side of the head and the 
left ear. Bleeding by the application of leeches over the left mastoid 
process seemed to relieve the pain, both in the head and ear. About 
four weeks ago he felt weak in the left arm for a day or two. The 
arm seemed all right on the third day, but on the fourth it became 
quite weak, and he began to suffer from pain in the left side of the head 
in the parietal region, and occasionally in the anterior temporal. Two 
days later the left leg was weak and awkward, and the day following 
the left side of the face was observed to be smooth and the mouth drawn 
to the right. Seventeen days ago, when he first came to Denver, from 
Idaho Springs, he could ascend and descend stairs, but the whole of the 
left side was weak, yet he could still use the left arm some, although not 
so well as the left leg. Two days later, or on the 10th of March, the 
left arm and leg and the lower portion of the left side of the face be- 
came completely paralyzed, and remained in this condition until he en- 
tered the hospital on the 25th day of March. Consciousness had never 
been affected. 10 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
Examination on admission. There was complete flaccid paralysis of 
the left arm, left leg at ankle and knee, and lower half of the left side of 
the face. The upper portion of the face and the hip were paretic. He 
could not close the left eye as tightly as he could the right. The tongue 
was protruded slightly to the left, and when the face was at rest the 
mouth was drawn a little to the right. The left side of the face seemed 
equally weak both for voluntary and emotional movements of the af- 
fected muscles. The deep reflexes were slightly increased ou the left 
side, but the superficial were absent. It was impossible to make a satis- 
factory examination of the sensory phenomena in the absence of an in- 
terpreter. The fundi and disks of the eyes were normal. Both pupils 
were dilated, the left being larger than the right, and both acted feebly 
to light and accommodation. The axillary temperature was 98.6° F.; 
pulse 72 ; respiration 20. His mind seemed clear, and he appeared to 
appreciate what occurred around him. Three days later, or on the 28th, 
I began having the temperature registered in each axilla thrice daily, 
at 6 a.m., 12 m., and at 6 p.m. ; and this was continued until April 
12th, the time of the operation. At noon of the 28th the temperature 
was R. 99.8° F., L. 99.6°. It remained about the same until the next 
day at noon, when it was found one degree below normal, and the 
same in each axilla. On the 30th the temperature was found to be 
100° F. in each axilla and the next two days it was normal. The 
pulse varied from 70 to 72, and respiration from 18 to 24: 
On April 1, 1895, assisted by an interpreter, I made a more careful 
examination. At that time he could raise his left leg from the bed and 
hold it straight at the knee, but there was absolute paralysis of the mus- 
cles below the knee. The arm and face remained about the same as on 
the former examination. The left trunk-muscles were weaker than the 
right, but still retained considerable power. Dyn. : R,, 120 ; L., 0. 
Knee-jerks : R., absent; L., increased. Ankle-clonus : R., absent; L., 
present and continuous. Tendo Achillis: R., absent; L., increased 
and attended by clonus. Plantar reflexes : R., present; L., absent. 
Cremaster and abdominal reflexes: R., present; L., absent. The deep 
reflexes of the right forearm were slightly increased ; the left were 
exaggerated. All the sensory phenomena were lessened on the left 
side, the temperature-sense being the most impaired ; on the right, sen- 
sation normal. Taste and smell present on each side and-about equal. 
Hearing with watch: R., 10/12; L., 8/12; with tuning-fork hearing 
better in left ear. Eyes : R., V. = 20/30(?) ; fields-temporal normal, 
nasal absent up to median line; and fundus and disk presented nothing 
abnormal. L., V. = 20/30(?) ; fields-nasal preserved, temporal ab- 
sent up to median line. Some obscuring of the nasal side of the disk 
by congestion and recent exudate. Beginning neuro-retinitis was ap- 
parent. The next three or four days the axillary temperature was about 
normal or slightly subnormal. On one occasion it was nearly two de- 
grees below normal. On April 4th the left fundus and disk remained 
about the same as on the 1st, and the right were still normal. Power 
seemed to be returning in the left leg, but no change could be detected 
in the arm and face. Bilateral left homonymous hemianopsia was still 
absolute. Sensory function was greatly lessened throughout the left 
side, but it was most impaired in the arm. During the entire time he 
had been in the hospital he had complained of considerable pain in the 
right side of the head, extending from the anterior temporal region back 
to the posterior parietal. Just how long he had had pain in the right ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
11 
side of the head I could not ascertain. It will be remembered that at 
the beginning of his illness the pain was in the left side of the head. 
The head-temperature had been persistently slightly elevated, and the 
rise was sufficient to lead me to diagnosticate an irritative lesion in the 
brain. From the 4th to the 12th of April the patient remained in nearly 
the same condition that he had been in from March 25th to April 4th, 
except that headache became more troublesome, and was limited to the 
right parietal region. The axillary temperature remained practically 
normal, was about equal in each axilla, but occasionally it was 0.1° to 0.2° 
higher in the left than in the right. As time wore on the tendency was 
for the temperature to be slightly continuously higher on the paralyzed 
side, but the difference was never more than a few tenths of a degree. 
On April 10th he made a slight correction in the history of his illness. 
In the original history he had stated, or the interpreter had made him 
state, that he had pain in the left ear, and this, together with the head- 
pain, had been relieved by leeches applied over the mastoid region ; but 
in his revision he said it was four months ago when he had pain in the 
left parietal and frontal regions of the head, and there was no pain in 
the ear. He reaffirmed the former statement that the pain in the left 
side of the head ceased on the application of leeches to the left mastoid 
region. About this time (or April 3d) it was observed that anaes- 
thesia of the left side, including the face and scalp, was becoming more 
pronounced, and the special senses, taste and smell, were less acute than 
on the right side. Repeated registration of the surface-temperature of 
the head showed the head-temperature to be about two degrees above 
normal. This indicated an irritative lesion of the brain. The urine 
had been examined a number of times and found free from albumin and 
sugar, and no cardiac murmur had been detected. The young man's 
age was against the idea of hemorrhage ; there was no cause, so far as 
I could detect, for embolism, and his repeated and positive assertion 
that he had never exposed himself so as to contract syphilis made me 
inclined to disregard the vascular lesions, although, in a clinical lecture 
on this case delivered the day before the patient was subjected to an 
operation, I stated that thrombotic occlusion of arteries of syphilitic 
origin would best explain the symptom-group. The localizing symp- 
toms indicated two separate and distinct lesions, one in the Rolandic 
region on the right side, involving primarily the arm-centre, and the 
other in the centrum ovale of the temporo occipital region of the same 
side. I argued that a single lesion in the centrum ovale so situated as 
to cause anaesthesia of the opposite side would affect the leg as much 
or more than the arm, and the face would be involved to a less extent 
than the leg or arm; but in this case, the face and arm being more 
affected than the leg, indicated that we should find two lesions. Ex- 
cluding a vascular lesion, the probabilities were in favor of a tumor or 
an abscess. Multiple tumors in the centrum ovale are uncommon, and 
the absence of choked disks was decidedly against the diagnosis of 
tumor. In favor of abscess we had the gradual onset of the paralysis 
involving one group of muscles after another, and the seat of one of the 
lesions in the centrum ovale of the occipital lobe was the common loca- 
tion of abscess of pytemic origin. No distinct cause could be found for 
abscess, but I consented to recommend an operation for the relief of the 
patient in hopes that we should be fortunate enough to find and evac- 
uate one or more abscesses. 
On the 12th of April Dr. Edmund J. A. Rogers removed a button of 12 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
bone from the skull over the arm-centre on the right side and found the 
brain-substance, including the cortex immediately beneath the trephine- 
opening, soft and diffluent, looking very much like pus. Ou exploring 
the centrum ovale in the occipital region another area of softening was 
found. Dr. Leonard Freeman, pathologist to the hospital, examined the 
material as it was taken from the brain, and his report is as follows : 
" The soft, white material removed from the brain by Dr. Rogers 
closely resembled pus to the naked eye, but under the microscope no pus- 
corpuscles could be seen. A few red corpuscles were detected, but they 
probably came from the blood that mixed with the material during the 
operation. The corpuscles of Gluge were quite numerous, and some small 
fat-globules were observed here and there. The mass of the substance 
was composed of disintegrated nerve-fibres, which were rather short, and 
could be distinctly seen and accurately studied as they floated in the cur- 
rent of the fluid across the field. There were no gliomatous or other tumor- 
cells, and no crystals of any kind. There was no reticulated structure." 
The operation was carried no further than to remove the most diffluent 
of the broken-down brain-substance. The wound was carefully dressed 
and the patient regained consciousness, and said his head felt better. 
About twelve hours after the operation he began to exhibit evidences of 
failing, and the temperature rose to 100° F. After this he lost rapidly, 
and died fifty hours after the operation, the temperature reaching 106° F. 
just before death. 
Autopsy, six hours after death, performed by Dr. Leonard Freeman : 
On removing the iodoform gauze from the wound softened brain-substance 
and yellowish-whitish particles resembling disintegrated brain-substance 
ran out. The middle meningeal vessels on either side arose from the oph- 
thalmic vessels. Great oedema existed at the base of the brain, espe- 
cially around the cerebellum, pons, and medulla. The arteries at the 
base of the brain presented no evidence of disease, except on the right 
side, where the middle cerebral was thickened and its calibre was occluded 
by a thrombus at the point where the nutrient vessels to the basal gan- 
glia are given off'. The cortex of the middle and lower Rolandic region 
and temporo-sphenoidal lobe was softened. The cortex of the left hemi- 
sphere was negative. On cutting into the right cerebral hemisphere a large 
area of softening, about three inches by two in size, occupied the cortex 
of the middle and lower Rolandic region and the white substance beneath. 
The occipital lobe was the seat of a large area of softening which occu- 
pied nearly the entire white substance of this lobe. The softening in the 
occipital lobe reached the cortex postero-laterally. The entire corpus 
striatum and thalamus were softened but not diffluent. The interior of 
the left hemisphere presented no pathological appearances. Cerebellum 
and ventricles negative. The microscope showed the change in the arte- 
rial walls to be syphilitic. ' 
Ill the light of the autopsy the clinical history is clear, and had not 
syphilis been so strenuously denied, no other diagnosis than that of arte- 
rial occlusion would have been seriously considered. It is useless to 
speculate whether the man knew he had syphilis ; whether he had con- 
tracted it without sexual intercourse and did not know it; or whether 
the condition of his cerebral bloodvessels was due to hereditary syphilis. 
The latter is very improbable. ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
13 
The following case,' coming on after an attack of influenza, a possi- 
ble cause of cerebral abscess, and presenting symptoms of meningitis, 
was due to an unsuspected vascular lesion which proved fatal : 
J. N., aged thirty years, white, a boiler-maker by occupation, whose 
family and personal history was not obtainable, suffered from la grippe 
about four weeks before. He was greatly reduced by the attack, but 
no localized lesion was found. He had gradually recovered, so that he 
anticipated returning to work in a day or two, but he was still weak and 
languid. On the morning of the 17th of April, 1895, about thirty-six 
hours before I saw him, he awoke and was talking with his wife, when 
suddenly he put his hand to his head and cried, " Oh, my head !" Soon 
after this he lost consciousness, but he rallied in the course of a few 
hours and talked some during the day, but seemed dull and stupid and 
complained of pain in his head. The next morning he was nearly un- 
conscious, but in the afternoon he was able to talk with his wife, and 
seemed rather bright. The temperature, Dr. Richmond reported, had 
appeared normal, although he had not registered it. When I entered 
the room, at 5 P.M., he observed and spoke to me, and said that his 
head was paining him. He looked depressed and appeared to be suffer- 
ing. Pupils were small, but responded to light. The posterior cervical 
muscles were rigid and the head slightly retracted. After I had been 
in the room examining him for two or three minutes he became uncon- 
scious, and I found it impossible to arouse him The temperature was 
98.3° F. in each axilla ; pulse 72 ; respiration 16. The knee-jerks were 
slightly increased. The ophthalmoscope showed no ocular change, and 
there was no evidence of paresis or paralysis of any muscles. The his- 
tory of la grippe, the prolonged convalescence following it, and the sud- 
den development of head-pains with normal temperature made me ap- 
prehensive of cerebral abscess, although no discharge was observed from 
either ear, and his wife stated that he had had no ear-trouble. On re- 
moving him to the County Hospital two hours later, his temperature 
was found to be 100.4° F. in the right axilla, 100.2° F. in the left, and 
100.4° F. in the rectum. The rise in temperature was thought to be 
due to the disturbance caused by removing him to the hospital. He 
did not seem to be totally unconscious ; his eyes would follow me or the 
lamp around the room ; when asked his name he endeavored to give it, 
and succeeded in doing so in an indistinct manner. I asked Dr. Rogers, 
the attending surgeon at the hospital, to see him with me at 9 p.m. 
The temperature then registered 99° F. in the right axilla and 99.2° F. 
in the left; pulse 60 ; respiration 16 ; retraction of the head was well 
marked, and on my attempting to bring the head forward, it seemed to 
give some pain. The diagnosis at this time seemed to rest between menin- 
gitis and cerebral abscess. The retracted condition of the head indicated 
irritation of the meninges in the posterior cerebral fossa, but the normal 
temperature at the time of my first visit, and its again descending after 
he had been resting a few hours in the hospital, seemed to militate against 
the presence of meningitis. That night his temperature was registered 
in each axilla every two hours, and the average temperature for the 
night was 98.4° F., being about the same in each axilla. At 9 o'clock 
1 Irrigation of the Posterior Cerebral Fossa for the Relief of Basilar Meningitis. Journal of 
Nervous and Mental Disease, Nov. 1895. 14 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
the next morning the temperature in each axilla was 99° F.; pulse 64 ; 
respiration 18. He was becoming more stupid, pulse was occasionally 
irregular and respiration at times intermittent. At noon, when Dr. 
Rogers again saw him with me, his condition remained about the same 
as it had been during the morning, but we could find no indications for 
operative procedure. During the afternoon his temperature varied from 
98.6° to 99.4° F.; pulse 63 ; respiration 18. It was quite evident that 
there was pressure in the posterior fossa, especially around the pons and 
medulla. The low temperature contraindicated meningitis, although 
normal or subnormal temperature is sometimes observed in this disease. 
Abscess of the brain did not seem likely, as the temperature had been 
found constantly a little above normal most of the time for the twenty- 
four hours he had remained in the hospital. During the afternoon he 
seemed to be sinking into a deep comatose condition, and it was evident 
that life could not be prolonged many hours unless relief of pressure 
on the pons and medulla was effected by surgical means. I could be 
positive of but one thing, and that was pressure at the base of the brain 
in the posterior fossa. A button of bone was removed from the pos- 
terior cerebral fossa of this patient, and the parts irrigated for the relief 
of cerebral pressure, the patient subsequently dying. 
Autopsy eleven hours after death by Dr. Leonard Freeman, patholo- 
gist to the .hospital: The wound had healed without the formation of 
any pus, and no abnormal adhesions between the dura and the bone 
were detected. The external surface of the dura presented a healthy 
and glistening appearance. The pia over the convex surface exhibited' 
no marked changes except engorgement of the veins. No clots were 
found in the venous sinuses. The arteries at the base of the brain pre- 
sented evidences of disease in their walls, and in the main branch of the 
left middle cerebral artery, just before the cortical vessels are given off, a 
clot was found which blocked up the entire calibre of the vessel. In 
the centrum ovale of the left frontal lobe a considerable quantity of 
semi-fluid blood was found, which, after ploughing up and destroying a 
considerable portion of this part of the brain, ruptured into the lateral 
ventricle and filled the lateral, third and fourth ventricles. The corpora 
striata were softened A slight hemorrhagic extravasation was found in 
the right frontal lobe. The remainder of the brain presented a normal 
appearance. There was no evidence of any meningitis, nor of abscess. 
The pathological condition was one of hemorrhage into both frontal lobes, 
the greater in the left, the blood finding its way into the lateral ven- 
tricles, and filling these, together with the third and fourth ventricles. 
The case just reported presented symptoms before death that were 
difficult to interpret. At the time of my first visit the normal tempera- 
ture, dazed appearance, and retraction of the head, following a prolonged 
convalescence from an attack of la grippe, suggested the possibility of 
cerebral abscess complicated with cerebro-spinal meningitis. It may be 
thought that the sudden onset of the cerebral symptoms should have sug- 
gested cerebral hemorrhage; but we know how common it is for a cere- 
bral abscess to be unsuspected until it ruptures into the ventricles, when 
the symptoms simulate those of hemorrhage into the cavities of the 
brain. A large hemorrhage into the ventricles is so commonly attended ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
15 
with a subnormal temperature at first, and a few hours later by a consid- 
erable rise of the temperature, that the case did not appear like one of 
cerebral hemorrhage. Further, the man's age was against the proba- 
bility of hemorrhage. The subsequent history of the case after the 
patient was admitted into the nervous wards of the hospital soon made 
me give up all thoughts of a cerebral abscess and led me to regard it as 
a case of cerebro-spinal meningitis. The sudden loss of consciousness, 
followed an hour or two later by a return to a conscious condition, and 
after this consciousness and unconsciousness alternating one or more 
times, were difficult to explain before death. 
The normal temperature at the time of my first visit may probaoly 
be explained by the irritating influence of the blood in the lateral ven- 
tricles counteracting the depressing effect of the hemorrhage into the 
anterior lobes of the brain. The condition of alternating consciousness, 
in the light of the post-mortem results, is probably explicable from the 
fact that hemorrhage first took place in the substance of the left anterior 
lobe, which probably gave rise to loss of consciousness. After reaction 
from this consciousness probably returned, and subsequently when the 
blood burst into the lateral ventricles, consciousness was again lost. 
As this process of filling the ventricles was evidently a gradual one, from 
the fact that depression was no greater, consciousness returned while this 
was going on, and it was not till the lateral ventricles became completely 
distended and the blood had found its way into the fourth ventricle that 
consciousness was finally lost. 
Hemorrhage into the frontal lobes of the brain is of extremely rare 
occurrence, and hemorrhage in a man so young as the patient whose 
case has just been reported is extremely infrequent. A hemorrhage 
into the centrum ovale external to the great ganglion, and then burst- 
ing into the lateral ventricles, would have found its way so readily into 
the cavities of the brain as to overwhelm the vital forces of the patient 
and cause a profound shock, such as is commonly witnessed in ordinary 
intraventricular hemorrhage. The retraction of the head was due to 
blood in the fourth ventricle, and the serum of the blood which had 
found its way around the pons and medulla into the posterior fossa came 
from the blood in the fourth ventricle. 
The case throughout its clinical history was a most puzzling one, and 
a positive diagnosis was not attempted. It was quite evident that there 
was irritation in the posterior fossa, and that in this portion of the brain 
pressure was increased; but beyond this I would not be positive, though 
the most likely thing that would account for it seemed to me at the time 
to be a basilar meningitis with exudation around the pons and medulla. 
We meet with cases whose symptoms are apparently best explained 
by a vascular lesion, but at the autopsy an unsuspected cerebral abscess 
may be found, as occurred in a man whose history is as follows: 16 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
J. S., aged seventy-five years, white ; widower for a number of years ; 
born in Ireland ; by occupation a laborer ; of large physique ; in Colo- 
rado since 1870, was admitted to the Arapahoe County Hospital, Janu- 
ary 22, 1895. Family history, so far as I was able to learn, was unim- 
portant. His health in childhood was good, and he had no serious illness 
until his seventieth year. He had indulged rather freely in alcohol, but 
during the last five years he had rarely drank. He denied syphilis, but 
suffered from gonorrhoea twenty years before. He received a bullet- 
wound in the left shoulder while in the army, in 1861. With the ex- 
ception of the time during which he was disabled on account of the 
wound, he said that he was never sick a day in his life until twelve years 
ago, when he was kicked on the left shin. The injury to the left leg was 
followed by great pain, and later a large ulcer developed, which nearly 
healed at times, but for a number of years he had had a large open sore 
on this leg. One month before coming to the hospital, however, the ulcer 
completely healed, leaving a large dark-colored, rough cicatrix which 
was very tender to pressure. For some years he had suffered from vague 
rheumatoid pains in the legs, especially in the knees and ankles, and in 
the entire left leg he had had a feeling of numbness for about five years. 
This leg seemed to him awkward, but he was able to walk with the use 
of a cane. For a number of months there had been a partial inability 
to control the bladder; frequently he would soil the bedding and his 
clothes, and had to evacuate the bladder several times during the night. 
The patient said that he was struck over the lower portion of the back 
and nates by a cable-car early in January of the present year. He was 
able to rise and walk immediately after, and he did not think he had 
sustained much injury, although pressure over the lower portion of the 
back gave him considerable pain. Since the accident he had lost all 
control over the bladder, and the left leg had been very weak. The left 
arm, he had noticed, was weaker than the right. He had been obsti- 
nately constipated for a number of months. The condition of the right 
pupil, which was widely dilated and immobile, was the result of an injury 
which he had received eleven years ago to this eye. 
Examination, January 22, 1895. He is unable to stand on account of 
the weakness of the left leg, and the examination has to be made while 
the patient is lying in bed. An old scar is observed on the anterior sur- 
face of both legs below the knees. They are evidently the result of old 
ulcerations. The arteries of the extremities are hard and unyielding. 
The left leg is very weak, but he can move this leg at all the joints, 
although the power is feeble and the movements are ataxic. The ankle- 
muscles of the left leg are weaker than those of the knee, and the latter 
are weaker than those of the hip. Muscular power seems to be fairly 
good in the right leg; the left arm is weaker than the right: Dyn. R., 
100 ; L., 40. There is slight rigidity in the left arm, with tendency to 
hold the arm close to the side of the chest, and flexed at right-angles at 
the elbow. His mental condition seems feeble, concentration of his mind 
is very difficult, and it is almost impossible to keep his attention on one 
subject more than a few minutes at a time. There is considerable loss 
of sensation throughout the left side, apparently more pronounced in the 
arm and leg than in the face. The knee-jerks are present; the left 
slightly increased, while the right is less than normal. Plantar reflexes 
and tendo Achillis are present; ankle-clonus absent; cremaster and 
abdominal reflexes are absent. The external ocular muscles seem to act ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
17 
noimally. The right eye is cataractous, the pupil being widely dilated 
and does not respond to light or accommodation. The left pupi 1 is very 
small and does not respond to an active mydriatic, so that an examination 
of the fundus of either eye is impossible. There is apparent hemianopsia 
of the left eye ; the fields could not be tested in the right eye on account 
of the presence of a cataract. The mental hebetude was too great to 
permit of an accurate examination of the special senses. The tempera- 
ture is 98.2° F.; pulse 60 ; respiration 24. During the first week of 
his stay in the hospital his temperature varied from 98° to 99.2° F., 
usually being about 98.4° F. in the morning, and 98.8° to 99° F. in the 
evening ; the pulse ranged from 54 to 90, only falling to 54 on one occa- 
sion, to 60 on three, and to 66 on two, the usual variation being from 
72 to 88 ; respiration varied less than the pulse, ranging, except on two 
evenings, from 18 to 20. A record of the temperature, pulse, and respi- 
ration was made twice daily. During this week he gradually failed, 
both mentally and physically. He soon lost all continuity of thought, 
and his mind was a complete blank for any event of recent occurrence. 
He ate but little ; he emaciated rapidly, and passed the discharges from 
the bladder and bowels into the bed. The second week, from January 
29th to February 4th, there was a gradual failure. The temperature 
ranged between 98° and 99.4° F.; pulse between 60 and 80 ; respiration 
between 18 and 20. During the third week prostration increased rap- 
idly, and his mind became a total blank. The temperature was a little 
lower than during the preceding week, rising above 98.4° F. only once, 
when it reached 100° F. one evening, but most frequently it registered 
98° F. The pulse varied from 70 to 96, averaging about 80, and was 
weak and compressible ; respiration ranged from 20 to 36. The rigidity 
of the left arm- and leg-muscles became more pronounced. On Febru- 
ary 12th he passed into a deep comatose condition, and the muscular 
rigidity began to relax, and at 5 p.m. the temperature was 99° F.; pulse 
100 ; respiration 24. The next morning at 7 o'clock the temperature had 
reached 101.4° F.; pulse 120 ; respiration 40 ; and at 5 p.m. the tempera- 
ture was 105° F.; pulse 130 ; respiration 36. He died during the night. 
Autopsy. The post-mortem examination was made about twenty hours 
after death by Dr. Leonard Freeman, pathologist to the hospital. The 
dead-room was cold and the body thoroughly frozen. Unfortunately, 
only the contents of the cranial cavity were examined. The adhesion 
of the dura to the bone was not abnormal. The membranes and cortical 
surface of the brain, neither on the convex nor on the basilar surface, 
showed any evidence of disease. The vessels were atheromatous, but not 
to a pronounced degree for one seventy-five years old. On sectioning the 
left cerebral hemisphere, no gross pathological changes were found, but 
in the right hemisphere an encapsulated cavity about two inches in 
diameter, containing a foreign substance presenting almost the identical 
appearance of orange water-ice, was found in the centrum ovale of the 
parieto-occipital region. The greater portion of the pathologic process 
had taken place in the occipital lobe. The lateral ventricle had not been 
broken into, but only a very thin partition of brain-substance intervened 
between the cavity and the posterior horn of this ventricle. None of the 
cortical substance of the brain had been directly involved by the foreign 
substance, which occupied a position so as to exert pressure on the right 
internal capsule. No evidence of gross disease was found in any other 
portion of the brain. In the frozen state it was impossible to determine 18 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
whether the lesion was a cyst or an old abscess. On melting the icy con- 
tents of the cavity they presented the appearance of a watery straw- 
colored liquid, and seemed to be the result of a cyst; but the microscope 
showed numerous granular and broken-down pus-cells, proving the lesion 
to be a chronic abscess. There was no odor. After warming the brain 
the right hemisphere was found to be much softer than the left; but the 
extent of the ante-mortem softening could not be determined, as brain- 
substance softens so rapidly on warming it after it has been frozen. 
Although I had an opportunity to study the above case for a period 
of three weeks, the presence of an abscess of the brain had not been sus- 
pected before death, and finding one at the autopsy was a great surprise 
to me. The age of the patient, the atheromatous condition of the radial 
arteries, and the comparatively sudden onset of the symptoms of cere- 
bral softening, led me to suspect and to diagnosticate arterial thrombosis. 
The temperature was normal or nearly so, as is common to abscess or slow 
necrotic softening taking place after occlusion of a cerebral artery. I 
regret that I did not make a careful comparison of the temperature in 
each axilla. It is probable that the temperature would have been found 
higher on the paralyzed than on the unaffected side. In hemiplegia 
from necrotic softening it is likely that this difference of temperature 
in the two axillae does not exist to a marked degree, and when present 
is not persistent, except possibly when the lesion causing the softening 
is an irritative one, as sometimes happens in acute softening from obstruc- 
tion of large vessels. The history of a fall did not militate against 
thrombosis, as the head did not appear to have been injured at the time, 
and it is not infrequent for occlusion of a cerebral artery in the aged to 
be preceded by increased physical exertion, which may or may not be a 
determining factor in the final closure of a narrowed vessel. As it was 
impossible to obtain a view of the ocular fundi, the condition of the disks 
could not be ascertained. The absence of headache was in favor of a 
vascular lesion, and against abscess or tumor. In a- man seventy-five 
years of age the sudden occurrence of a hemiplegic lesion, without head- 
ache preceding or following it, in the absence of a growth, or the history 
of one, in other portions of the body, the presence of tumor of the brain 
is not suspected. While no age is probably exempt from abscess of the 
brain, the infrequency with which it occurs in extreme old age made it 
improbable that I should meet with it in a'man seventy-five years old. 
Of 223 cases of abscess of the brain tabulated by Gowers in his work 
on the Diseases of the Nervous System only one was found at the seven- 
tieth year or over. There was no discoverable cause for cerebral suppu- 
ration. There was no discharge from the ears, or history of any; the 
nose appeared to be free from infective material; and no evidence of 
purulent substance in the thoracic or abdominal cavity was detected 
during life. In reviewing the history of the case, after the autopsy re- 
vealed an abscess of the brain, it has occurred to me that the large open ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
19 
sore on the leg might have furnished infective material with which the 
brain-substance became infected. The ulcer had troubled him for a 
period of twelve years, but it had entirely healed, he said, a month 
before he came to the hospital. The appearance of the cicatrix indi- 
cated that the sore had been healed several months. As his memory for 
recent events was greatly impaired on his entering the hospital, it is 
probable that events that occurred months or years before appeared to 
his mind of a later date. This loss of time-sense is common in dementia, 
especially of the senile variety. We must remember that the left leg 
had appeared numb, weak, and awkward for a period of five years, and 
for a number of mouths he had lost partial control of the bladder. The 
capsule and its contents indicated that several months, at least, had 
elapsed since cerebral suppuration took place. What part the blow to 
the lower portion of the spine had to do with causing the abscess, it 
was impossible to say. No tenderness of this portion of the spine was 
detected at the time of my examination. If the blow occurred only two 
weeks before he entered the hospital, as he stated, it is quite evident that 
it played no part in the causation of the cerebral suppuration; but, as 
before stated, his time-sense for recent events was impaired, and no re- 
liance could be placed upon his statements relating to time, especially 
for things of comparatively recent date. Had the diagnosis of cerebral 
abscess been made on the patient's admission to the nervous wards of the 
hospital I should have recommended and urged a surgical operation, as 
no hope could be entertained without the evacuation of the abscess, 
although the extreme age and prostration of the patient would have less- 
ened the probability of recovery. 
Not infrequently the history obtained from the patient is sufficiently 
inaccurate to be misleading. In such cases the corroborative testimony 
of the friends may aid in arriving at a correct diagnosis. 
A man, aged about thirty years, came under my care a few months ago, 
and reported that he had been suffering from headache for two or three 
months. His habits had been dissipated ; he had indulged in alcohol and 
venery to excess, and had contracted syphilis some years before. He gave 
no history of a fall, a blow to the head, otorrhcea, or injury of any kind. 
He had been treated for typhoid fever for a number of weeks previously 
to my seeing him, and had emaciated considerably. On examination I 
found the left arm and leg wrere weak, and that his mind was clouded. 
There was lessening of all sensory phenomena on the left side, and a 
complete left bilateral homonymous hemianopsia. The Wernicke pupil 
was absent. A few hours later he became stuporous, soon passed into a 
comatose condition, the left leg and arm became rigid, and the flexor 
muscles contracted. The left side of the face soon appeared paretic, and 
the tongue was protruded slightly to the left of the median line. He 
lived about three days and died in a comatose condition. The first two 
days his temperature was normal or subnormal; the pulse and respiration 
were exceedingly slow. The day of his death the temperature was quite 20 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
high, reaching 104° to 105° F., and the pulse and respiration were fre- 
quent. With this history it seemed to me that the most probable con- 
dition was one of syphilitic growth in the brain, especially when taken 
in connection with the choked disk which was present in each eye, but 
the swelling was not extreme. Thrombosis of a cerebral artery was 
excluded on account of the presence of the optic neuritis, and nothing 
but the subnormal temperature and the peculiar rigidity suggested an 
abscess of the brain. The lesion was located in the centrum ovale, involv- 
ing the occipito-sphenoidal region. After the patient's death, and before 
the autopsy was held, it was learned through his brother that some time 
preceding his fatal illness he had had a fall and struck upon the head ; after 
this he was dizzy and suffered from headache for a time, and even after 
returning to work his head felt uncomfortable. With this additional 
history an abscess was made probable, and at the autopsy a large encap- 
sulated abscess was found in the centrum ovale on the right side, involv- 
ing the occipital and temporo-sphenoidal lobes. The whole of the right 
side of the brain was oedematous. 
It is well known that trauma of the brain may excite into activity 
latent syphilis of the brain, and the diagnosis between abscess and syph- 
ilis of the brain may become a most difficult problem to solve in syphilitic 
ubjects who suffer from an injury to the head. In this case the paresis 
of the left leg and arm when I first saw the patient, followed by the 
rigidity of the muscles, indicated an abscess rather than a tumor, as the 
rigidity denoted extensive softening, which is more common to the former 
than to the latter. 
Some cases of brain-lesion may improve under antisyphilitic treat- 
ment for a number of months, and then relapse after the treatment is 
suspended, and again improve from the same treatment, and yet at the 
autopsy an abscess and not a tumor will be found. 
A case of this kind came under my care more than a year ago. The 
patient was a man, a tailor by occupation, whose habits had been bad. 
He was a free drinker ; had suffered several times from gonorrhoea, and 
had contracted a hard chancre about ten years before. He had never 
been the subject of traumatism. About eighteen months before I saw 
him he suffered from a severe cold, which was followed by purulent bron- 
chial expectoration. Soon after this he began to complain of headache ; 
his general health failed, he lost flesh and strength, and his mental power 
was lessened. On consulting a physician, because of his syphilitic history 
and head-pains, he was placed upon potassium iodide for a number of 
months ; his headache decreased, but did nbt entirely disappear; he con- 
tinued rather weak ; appetite poor and vacillating; bowels constipated ; 
and he was unequal to his work, both mentally and physically. He con- 
tinued in this condition of impaired health for more than a year, when 
his headache again increased, mental confusion became greater, and he 
felt a sense of physical prostration almost continually. He slept poorly, 
became very much emaciated, and his headache at times was agonizing. 
He was again treated for syphilis of the brain, and again temporarily, 
but only slightly, improved in health. His condition became miserable, 
but he did not especially attract the attention of the remainder of the 
lodgers in the house where he was staying. After passing a restless ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
21 
night, he arose in the morning to dress himself, but before his toilet was 
completed he fell to the floor, and when found a few hours later he was 
mentally confused and unable to rise to his feet, the entire left side being 
almost completely paralyzed. When I saw him, a few hours later respi- 
ration was slightly stertorous ; his temperature was about 1° F. sub- 
normal in the right uxilla, and one-half degree subnormal. in the left; 
pulse 60, full and strong ; respiration 12 per minute. On arousing him 
he seemed for a moment to appreciate what was said to him, but if left 
alone he almost immediately relapsed into an unconscious state. The 
left arm and leg were almost completely paralyzed, the paralysis being 
deeper in the leg than in the arm ; the face did not seem to be affected. 
The tongue was protruded in the median line. No satisfactory test could 
be made of the general sensory phenomena on account of his blunted 
mental condition, but, so far as I was able to determine, sensation was 
less acute on the left side than on the right. The knee-jerks were in- 
creased, the left to a greater extent than the right; plantar reflexes were 
absent; ankle-clonus was slight on the right and well marked on the left 
side ; cremaster and abdominal reflexes were barely perceptible on the 
right side and absent on the left; pupils were equal in size, rather widely 
dilated, and reacted to light feebly; there was no paralysis or paresis of 
the external ocular muscles ; both optic nerves were slightly atrophied, 
with some swelling of the disks ; the choking of the disk was greater on 
the right side than on the left; there was apparent left bilateral homony- 
mous hemianopsia, but it was difficult to test the visual fields accurately ; 
the urine was free from albumin and sugar; the heart presented no evi- 
dence of disease ; and mucous rales were heard in the lungs. No head- 
ache was complained of spontaneously, but on arousing him ana asking 
him if he had any pain, he said " Yes," and pointed to his head. Stupor 
gradually deepened into coma, and he died a few hours later. At the 
autopsy an encapsulated, chronic abscess in the centrum ovale of the 
right side was found, involving the occipital and temporo-sphenoidal 
lobes. Tne pus was thick, greenish and offensive, and the entire right 
side of the brain presented an oedematous appearance. No pathological 
changes beside these were found in the brain. Permission was not ob- 
tained to examine any portion beside the head. 
It is impossible to discuss the probabilities of arriving at a diagnosis 
soon after the formation of the abscess, which possibly dated back some 
fifteen or eighteen months before the patient's death, and about the time 
of the beginning of the head-symptoms, following a purulent discharge 
from the lungs. When I first saw the man, a few hours previous to his 
death, the diagnosis lay between a vascular lesion, tumor, and abscess. 
The eye-symptoms were sufficient to exclude a vascular lesion. The 
syphilitic history and the marked amelioration of symptoms from the 
use of potassium iodide pointed to a tumor of syphilitic nature ; but the 
choked disks presented less swelling than is commonly observed in cases 
of progressive tumor of the brain. In the Medical News for March 10, 
1894, I reported a case whose history was somewhat similar to that 
of this. In it the swelling of the optic disk was well marked and a 
tumor was diagnosticated, and the accuracy of the diagnosis was verified ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
22 
by the autopsy. In the present instance, notwithstanding the strong 
probabilities of a syphilitic growth, the history of a purulent bronchial 
discharge immediately preceding the development of cerebral symptoms, 
and the slight swelling of the optic disk, determined me to venture the 
diagnosis of a chronic abscess. 
Quite recently I put on record the case1 of a little girl who was referred 
to me by Dr. McN aught. She was eleven years of age ; had suffered for 
a length of time from otorrhoea, suppuration in the groin, probably a 
psoas-abscess, and had sustained a severe injury to the head from a fall, 
all causes of cerebral abscess. She became the subject of epileptic seiz- 
ures during which she did not lose consciousness ; the convulsive attacks 
were attended with retraction of the head, at times with opisthotonos, 
tetanic rigidity of the arms, and frequently with shock-like movements 
of the arms. There was complete atrophy of the optic nerves, and no 
evidence of an exudate was apparent in the eyes when I saw her, which 
was several years after the head-symptoms first became manifest, and 
some time after blindness, almost complete, had developed. At the 
autopsy a large cyst, connected with a small tumor of the left lateral 
lobe of the cerebellum, was found. A more definite diagnosis than that 
of organic disease affecting portions of the brain in the posterior fossa 
was not ventured during life. The history of the seizures without loss 
of consciousness, talking and throwing the arms wildly around through- 
out the attack, with distinct clonic convulsive movements and opisthot- 
onos, at first suggested hysteria ; but this was easily excluded by the optic 
nerve atrophy and certain vascular changes in the fundi. If these had 
not been sufficient to enable me to diagnosticate an organic lesion, the 
attacks that I witnessed would have been ample evidence of such changes. 
The posterior neck-muscles were rigid as cords ; the head was retracted, 
the spine arched backward, and the masseters, at times, were firmly con- 
tracted, so that when she attempted to speak her teeth, which she was 
unable to separate, were simply uncovered by the lips, and the arms, 
rigidly extended, were thrown wildly around, with shock-like convulsive 
movements. Three morbid processes were considered in the diagnosis, 
namely, abscess, tumor, and the results of an old basilar meningitis. 
The history of a bilateral otorrhoea with a very offensive discharge from 
the ears, occurring about the time of the commencement of her first 
symptoms, which were attended by a convulsion ; the suppuration in the 
right groin, the origin of which could not, when I saw her, be deter- 
mined, as there had never been any further evidence of caries of the 
spine ; and the blow to the head received just previously to the convul- 
sive seizures becoming frequent, from an etiological standpoint, were 
about as strong evidence in favor of cerebral suppuration as one expects 
to find. The subnormal temperature during the first few days of my obser- 
vation of the case was in favor of chronic cerebral abscess. The otorrhoea 
had ceased for a period of nearly ten years, and during this time the 
child had never complained of pain in the ears. It seemed to me, then, 
that, if the little patient was suffering from abscess of the brain, the prob- 
abilities were against the ears having been the source of the septic poison, 
as even chronic abscess due to ear-infection rarely runs a very prolonged 
1 Tumor and Large Cyst of the Cerebellum, with Symptoms Extending over Several Years. 
Medical Record, August 17, 1895. ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN 
23 
course. Headache is common to all the pathological processes under dis- 
cussion. The optic nerve atrophy, without any swelling of the disks, was 
in favor of chronic meningitis and against the presence of a growth or 
abscess. I felt inclined to exclude intracranial suppuration, but I con- 
fessed to the physician with whom I saw the patient in consultation, that 
I had not sufficient reason to be positive in my opinion. Between men- 
ingitis and tumor I was unable to decide. One of these morbid processes 
would have accounted for some of the symptoms, while the second was 
necessary to explain the others. Almost total loss of sight, with optic 
nerve atrophy and seizures attended with opisthotonos, rigidity of the 
muscles, tonic extensive spasm of the extensors of the limbs, especially 
of the superior ones, and the shock-like movements of the arms, are 
found in meningitis of the posterior fossa when the surface of the pons 
is irritated. So far the symptoms and theory of meningitis harmonized, 
but I was at a loss to account for other cranial nerves than the optic 
escaping. That the child at times should feel quite well, and be entirely 
free from headache or any apparent discomfort, and that there should 
be no rigidity of the posterior neck-muscles, except during the parox- 
ysms, seemed to me inconsistent with the theory of an old meningeal 
exudate in the posterior fossa. A tumor in the cerebellum so situated 
as to produce remittent pressure on the pons, with distinct paroxysms 
of increased pressure, is common to the experience of every one who has 
studied and observed persons suffering from cerebellar growths; but for 
the pressure-symptoms to be apparently completely intermittent, and to 
recur with as much regularity as epileptic seizures, without loss of con- 
sciousness or mental dulness, was new to me in my experience of cere- 
bellar growths. 
In the light of the autopsy, which revealed the presence of a large cyst 
and a small tumor in the posterior three-fourths of the left cerebellar 
hemisphere, are the symptoms explicable ? It is possible, owing to the 
watery contents of the cyst, that the pressure exerted by the cyst after 
it became chronic, on the adjacent structures, was not so great as results 
from a more solid and unyielding tumor, so that, while there might have 
been a papillitis during the early stages of the growth, the lessened pres- 
sure after the formation of the cyst and the breaking down of the growth 
allowed this to subside with the resulting atrophy of the optic nerves, 
and time had permitted all intraocular exudate to be absorbed. We 
know that a growth in the cerebellum, from its effects upon the circula- 
tion of the veins of Galen and adjacent veins and sinuses, disturbs the 
function of the pons and medulla, usually to a slight extent, continu- 
ously, and, when it has reached sufficient size to exert pressure on the 
respiratory and neighboring centres, by paroxysms, threatening life by 
increased pressure, which probably results from temporary oedema of 
the parts. In the case of a cyst, with yielding contents which may vary 
in quantity from time to time, the pressure-symptoms probably may be- 
come intermittent. The peculiar tetanic spasms were most likely due to 
temporary irritation of the pons and medulla. 
With the information gained from the clinical and pathological obser- 24 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
vations of this case, could error be prevented in the diagnosis of a some- 
what similar one ? If a large cyst of the cerebellum is attended with more 
varying pressure-symptoms than a tumor, a problematic diagnosis might 
be ventured, and it might, or might not, be correct. The only unilateral 
symptom in the case was the tendency of the right arm and leg to be- 
come a little more rigid than the left, with, at times, a turning of the head 
and eyes to the right; but this was inconstant and of little localizing 
value in determining which hemisphere of the cerebellum was affected. 
Had it been possible to localize accurately the lesions, the tumor, in all 
probability, could have been removed, the contents of the cyst evacu- 
ated, and the life of the patient saved. A careful study of the case just 
reported demonstrates how meagre and unsatisfactory are the symptoms, 
even of an extensive lesion in one lateral hemisphere of the cerebellum, 
and that ataxia from lesions of this portion of the brain probably only 
occurs when they are situated so as to exert pressure on the pons, usually 
through the medium of the middle lobe of the cerebellum. 
It will be seen by a careful study of the cases that I have reported 
in this paper that, in the diagnosis of chronic cerebral abscess, while 
one must be careful to study every symptom, together with the apparent 
etiology, too much stress must not be laid upon either. Chronic otor- 
rhcea, a blow to the head, and suppuration in a distant portion of the 
body, were found in one of my cases, yet the patient died from cyst and 
tumor of the brain. In another the symptoms were distinctly indicative 
of arterial thrombosis, yet the patient died of intracranial suppuration. 
Hitz observed a case in a man twenty-nine years of age who had suffered 
for sixteen years from otorrhoea, and had, besides, received a blow on 
the head, both being distinct causes of abscess, yet death occurred from 
tumor of the brain {Lancet, January 12, 1895, p. 82, Murri). One 
of Professor Murri's cases of abscess of the brain occurred in a man who 
had never received a blow or any apparent injury to the head, nor had 
been the subject of suppuration in distant portions of the body, nor had 
he suffered from any disease that is likely to cause cerebral abscess, yet 
death occurred, and the autopsy revealed intracranial suppuration. In 
another one of his cases there had been suppuration in the tissues which 
surround the bones of the cranium, suggesting that the organic brain 
disease was due to suppuration, yet the patient died from sarcoma and 
encephalic tuberculosis. And again, in another one, the symptoms 
and apparent etiology pointed to tubercular meningitis, but the patient 
succumbed to intracranial suppuration. 
In the diagnosis of chronic abscess of the brain the morbid processes 
from which the suppuration must be differentiated are tubercular menin- 
gitis, softening, hemorrhage, and tumor. 
Tubercular Meningitis.-Theoretically it does not seem that there 
should be much danger of mistaking a cerebral abscess for meningitis; ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
25 
but theory fails, and preconceived opinions of the value of symptoms 
weaken in the stern reality of clinical facts and post-mortem results, not 
always because the theory is wrong or the opinions have been based on 
false premises. There is no portion of the human organism the destruc- 
tion or irritation of whose tissues gives rise to so clear, invariable, and 
definite symptoms as that of certain portions of the brain when the lesion 
is limited and uncomplicated. Irritation of a given portion of the brain 
will be attended by the same symptoms, no matter how often the irritant is 
applied, provided the conditions and modifying circumstances are always 
the same ; but the extent of pathological lesions varies, and the degree of 
irritation or the amount of loss of function from a similar lesion depends 
upon so many inscrutable causes, that no two cases will be attended by 
precisely the same symptoms. Besides, the results of irritation of a por- 
tion of the brain, whether it be due to meningitis, softening, hemorrhage, 
or tumor, may give rise to the same general character of symptoms that 
occur from the presence of an abscess. The majority of cases of tuber- 
cular meningitis, even in the adult, run their course in a few weeks, are 
attended by a febrile process, and present symptoms of cranial-nerve 
involvement. While these are the usual symptoms that serve to distin- 
guish tubercular meningitis from chronic abscess of the brain, unfortu- 
nately for the diagnostician they often vary greatly. The duration of 
some cases of tubercular meningitis is longer than that of some cases of 
chronic cerebral abscess. I reported a case of tubercular meningitis, with 
continuous symptoms, in a child, to the College of Physicians of Philadel- 
phia, in 1883, in which the disease extended over a period of more than 
eight months. In the same paper are collected numerous cases, in some of 
which the duration of the symptoms was a year or more from the time of 
the first evidence of tubercular disease of the brain to the death of patient 
(see Transactions for 1883). Professor Murri, in the Lancet of January 
26, 1895, p. 206, reports a case in a man thirty-three years of age, who 
had suffered horribly from headache for a period of five months immedi- 
ately preceding his death from tubercular meningitis. In this connection 
he says : " Kratmer refers to a case which lasted four months, and speaks 
of those of Leitz of forty-two and fifty-four days' duration ; Gatti of 
Milan, observed one lasting seventy-nine days ; and Dickinson noted 
one of eight months' duration." Rise of temperature is not always found 
in fatal tuberculosis of the cerebral membranes. It seems to me that 
we must make a distinction between tubercular meningitis and tubercu- 
losis of the membranes unattended by inflammation. Two years ago I 
saw and studied with Dr. McLauthlin a case of tuberculosis of the men- 
inges in a man about thirty years of age. He had been suffering from 
tuberculosis of the lungs for a number of years, and for several weeks 
before I saw him he had been depressed in spirits'and'experienced severe 
headache, but he had not been attended by any physician. During the 26 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
week immediately preceding his death, covering the time during which he 
was seen by Dr. McLauthlin and myself, the temperature was slightly sub- 
normal until a day or two before his death, when it registered from 97° 
to 100° F. At the autopsy the pia at the base of the brain, especially in 
the Sylvian fissures and over the optic chiasm, was studded with masses 
of tubercles, but the microscope showed no evidence of recent inflamma- 
tion. In Murri's case, above referred to, and those of others in which 
inflammatory products were quite abundant, although probably not of 
recent date, the temperature was normal or subnormal for a period pre- 
ceding death. Cranial-nerve symptoms are not invariable in basilar 
meningitis, and some cases of abscess of the brain are attended by irri- 
tation of the cranial nerves. 
A condensed report of one of Professor Murri's cases (Lancet, Jan- 
uary 26, 1895, p. 207) will illustrate this point: 
A male, aged thirty-five years, was admitted to the clinic, August 16, 
1890. He was in a state of delirium and some stupor. His wife stated 
that up to his present illness he had never suffered from illness. About 
two weeks before this, or in the beginning of August, he began to com- 
plain of headache, which became so intense that he could not leave his 
bed after August 7th. His strength gradually failed ; his mental con- 
dition from the beginning was abnormally irritable, and soon became 
dull. On the night of the 15th, a few hours before admission to the 
clinic, delirium and stupor first appeared. The patient seemed well 
nourished. Occasionally there would be muscular twitching, when he 
would give vent to cries of pain in his head. There was slight rise of 
temperature. Examination on admission to the clinic: Pupils were 
equal in size ; reacted slowly ; tongue deviated toward the left; sensory 
phenomena everywhere dull; spasms and contractions occurred in all 
the limbs ; pulse was 86 ; respiration 20 ; temperature does not seem to 
have been registered ; stupor was variable and spasms continued during 
sleep. Six days later the left pupil was dilated. On the next day, or 
the 23d of August, the muscles of the back of the neck were rigid and 
the head retracted ; there were ptosis of the right eye and deviation of 
the eyes and head to the right; reflexes were normal everywhere ; gen- 
eral sensory phenomena continued obtuse ; smell was absent. On the 
25th there was convergent strabismus of the left eye from weakness of 
the external rectus muscle, and the ball of this eye was painful ; the 
muscles of the left side of the face were weak, and he was unable to pro- 
trude the tongue. On the 27th the left leg and arm showed evidence 
of weakness, but muscular and posture seilses were everywhere good ; 
the pulse was regular ; there was nystagmus of the left eye, and tonic 
spasm of the right arm with flexion of the forearm upon the arm 
and of the hand upon the forearm ; reflexes of cornea and pupil 
of the left eye weak and slow ; the right eye presented normal re- 
flexes ; deglutition occurred with difficulty, owing to lessened reflex 
action of the pharynx ; the headache continued intense ; stupor deep- 
ened each day, and by September 12th the patient was absolutely com- 
atose. The pulse at that time varied from 120 to 130, and breathing 
increased from 24 to 28, and the temperature reached and went above 
100.2° F. on several occasions. He was almost always feverish, with the ESKRIDGE: CHRONIC ABSCESS OF THll BRAIN. 
27 
exception of two periods, from August 25th to 29th, and from Septem- 
ber 3d to 11th, during which times the temperature remained at 96.6° F. 
Death occurred on the 14th of September. At the autopsy all the 
meninges presented a normal appearance. There were three abscesses ; 
one pinhead in size, on the anterior right side of the pons in the vicinity 
of the nucleus of the sixth nerve ; another, small, in the anterior part of the 
left temporo-sphenoidal lobe ; a third and largest, occupied part of the 
right optic thalamus, internal capsule, and lenticular nucleus ; the lateral 
ventricle was not broken into. The abscess was rather large and com- 
pletely encapsulated, and contained inodorous, greenish pus. The parts 
around the large abscess, including the cranial nerves, were greatly com- 
pressed. 
This case presented the typical cranial-nerve symptoms so commonly 
witnessed in tubercular meningitis, and as no cause could be found that 
would have made one suspect intracranial suppuration, the diagnosis 
must have been difficult, if not impossible. 
It will be seen that the ease with which tubercular meningitis and 
chronic abscess of the brain may be mistaken for each other is much 
greater than what at first sight would appear. It is less difficult to 
point out the dangers of mistakes in diagnosis than to lay down rules 
by which they may be avoided, but the more we are on our guard the 
less likely will we be to commit unpardonable blunders. 
Cerebral Softening and Focal Encephalitis. I am not aware 
that any one, either in journal articles or text-books, has pointed out the 
danger of mistaking cerebral softening from thrombosis of a cerebral 
artery for chronic abscess of the brain. Professor Murri reports a case, 
in the person of a girl, seventeen years of age, of grave chlorosis with 
chlorotic thrombosis of the lateral sinus and of the cerebral veins. This 
distinguished observer had made the diagnosis of " Chronic abscess of 
the left temporal lobe," and from a careful study of the clinical symp- 
toms it is difficult to see how this mistake could be prevented in a sim- 
ilar case. It was not until recently, when I encountered a case of focal 
encephalitis, due to thrombosis of an artery, in a young man who pre- 
sented symptoms which simulated those of abscess, that my attention 
was called to it. This case is reported at some length in this paper. 
About twelve years ago, while practising in Philadelphia, I was en- 
gaged in an elaborate series of observations of the temperature of each 
side of the body in cerebral lesions, and on the surface-temperature ot 
the head and body in health and disease; but the development of pul- 
monary tuberculosis in my own person compelled me to abandon the 
work for a number of years. During the past two years I have resumed 
the study of the comparative temperature on each side of the body in 
cerebral lesions, and within the past six months, with the kind and intel- 
ligent assistance of trained nurses, both in the St. Luke's and Arapahoe 
County Hospitals, I have made numerous and interesting observations 28 
ESKEIDdE: CHRONIC ABSCESS OF THE BRAIN. 
along this line. It is premature as yet to undertake to arrive at definite 
conclusions, but the following provisional statements may be made : In 
paralysis from brain-lesions the temperature on the paralyzed side is equal 
to or greater than on the unaffected side, when the lesion in the brain is 
an irritative one; but less on the paralyzed side when the brain-lesion is 
a destructive, non-irritating one. In cases of hemiplegia from cerebral 
hemorrhage the temperature on the paralyzed side is lower than on the 
opposite side during the stage of depression immediately following the 
hemorrhage ; but as soon as reaction has become well established the tem- 
perature rises on the paralyzed side to a point about half a degree to a 
degree Fahrenheit higher than it does on the unaffected side, and remains 
so for a few weeks, or until, from atrophic changes, the paralyzed parts be- 
come cooler than the normal side. In case of hemiplegia of thrombotic 
origin the difference in temperature of the two sides of the body at first is 
less than occurs from hemorrhage ; but if encephalitis results from the arte- 
rial occlusion, the temperature on the paralyzed side will equal or exceed 
that of the normal side for weeks, months, or even years, and probably 
as long as the irritation in the brain remains. In one case under my 
observation at present, the patient having been paralyzed without loss 
of consciousness two years ago, although great trophic disturbances have 
become manifest in the paralyzed limbs, yet the temperature on the 
affected side remains constantly above that of its fellow. In hemiplegia 
from tumor or abscess of the brain the temperature may be elevated on 
the paralyzed side from 0.5° to 2° or 3° F. beyond that of the other, 
the amount of the heightened temperature on the affected side depending 
upon the degree of irritation in the brain. Theoretically we should 
expect to find the difference in the temperature of the two sides of the 
body greater when the paralysis is due to tumor than when it results 
from abscess, but I have as yet been unable to determine this point. 
Slight differences in temperature always in favor of the same side of the 
body, extending over a considerable period, are significant; but greater 
differences may occur for a short time and denote nothing of importance. 
Thrombosis of the cerebral vessels may take place in persons who 
have been subjected to causes that are known to be capable of giving 
rise to cerebral abscess. If this occurs in young subjects, and is fol- 
lowed by encephalitis, headache, paralysis of one group of muscles 
after another, and a temperature on the paralyzed side equal to or 
greater than on the unaffected side, the lesion may be mistaken for 
abscess, especially if the patient denies syphilis and presents no posi- 
tive evidence of it. Under such circumstances it is probable, although I 
do not w'ish to make this point too prominent until further observation 
enables me to speak more positively, that a temperature on the paralyzed 
side equal to that of the normal side, or elevated only a few tenths of a de- 
gree Fahrenheit above it, would be in favor of thrombosis, while a persist- ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
29 
ent increase of heat on the paralyzed side of one-half to one or more degrees 
Fahrenheit would be in favor of abscess. Further, the temperature in cases 
of thrombosis of a cerebral artery is, as a rule, less variable, and is more 
commonly normal than that of chronic abscess. The mental condition 
in cases of focal softening from thrombosis, while it is blunted, is more 
nearly normal when the patient is aroused than in the cases of chronic 
abscess that have come under my care. There was one observation made 
in the case of thrombosis reported in this paper that seemed to point 
strongly against abscess, and I called attention to it in a clinical lec- 
ture the day before the operation. When the patient's leg was first par- 
alyzed the paralysis was complete in all the muscles of the leg and hip, 
but during the next few weeks paralysis began to lessen in the hip-mus- 
cles, and before the patient was subjected to an operation he was able to 
lift the leg from the bed and hold it straight at the knee. From what 
we know of the effects of abscess on the surrounding structure of the 
brain, from cedema and softening, which have a tendency to increase 
rather than to diminish, it seems very improbable that the degree of 
paralysis caused by an abscess will lessen before the pus is evacuated. 
If optic neuritis, with swelling of the disks, were to occur, a thrombotic 
lesion might be excluded, although hypenemia of the papilla, with some 
slight neuro-retinitis, was evident in the eye opposite to the side of the 
brain-softening in the case reported in this paper. No choking of the 
disk was observed. 
Cerebral Hemorrhage. It seems useless to discuss the differential 
diagnosis between abscess and hemorrhage of the brain The condition 
presented by the case observed by me of hemorrhage into both anterior 
lobes of the brain, with gradual filling of the ventricles without paral- 
ysis, convulsions, or change of temperature to any extent from the nor- 
mal, must be exceedingly rare. The case was the more confusing because 
the hemorrhage followed an illness (la grippe) which has given rise to 
abscess of the brain. 
Tumor. The diagnosis between chronic abscess of the brain and 
tumor is sometimes very difficult or even impossible. Professor von Berg- 
mann and many others lay great stress upon etiological considerations 
and the presence of fever in favor of abscess; but, as we have already 
seen, the history of middle-ear disease, which Bergmann considers the 
principal cause of abscess, does not preclude the possibility of tumor. 
Hitz, as already mentioned, saw a man who for sixteen years had suf- 
fered from otorrhcea, and besides had received a blow on the head, yet he 
died of tumor of the brain. The case of the little girl, eleven years of 
age, reported in this paper, illustrates the fallacy of laying too great 
stress upon etiology. She had suffered from otorrhoea, had had an abscess 
in the right groin, and had received a severe blow to the head, all possi- 
ble causes of abscess, yet she died from tumor and cyst of the cerebellum. 30 
ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN 
Instead of the presence of fever being a symptom of chronic abscess, a 
subnormal temperature extending over a considerable period is more 
commonly the rule. There may be periods of febrile processes in abscess, 
but we find also the same condition in tumor. Neither tumor nor chronic 
abscess free from complication, such as meningitis and distention of the 
lateral ventricles, is, as a rule, attended by fever. If the temperature- 
record is any aid in the differential diagnosis between these two morbid 
processes, it is that a prolonged subnormal temperature, in a case of 
organic brain-disease, associated with evidences of great prostration, such 
as loss of flesh, strength, appetite, and, at times, a yellowish-pale hue of 
the skin, is in favor of abscess rather than tumor. We must remember 
that while a traumatism to the head is a frequent cause of abscess of the 
brain, it is also capable of giving rise to tumor. In cases of old injuries 
to the head, dating back more than a year, in which no evidence of 
inflammation of the brain immediately followed the trauma, the devel- 
opment of organic disease of the brain, supposing the diagnosis to lie 
between abscess and tumor, the probabilities, other things being equal, 
will be in favor of the latter. Well-pronounced swelling of the optic 
disks, amounting to to of an inch (requiring +3 I) to 4 I) to 
see the centre of the disk) is always against abscess and in favor of 
tumor. It is conceivable that an extreme degree of choked disk might 
occur from abscess, but I have never observed it, and I am not aware that 
it has been met with by others. Complete blindness is not an infrequent 
result of tumor, and well-advanced amaurosis is very common. In ab- 
scess I have never met with marked amaurosis, and my personal experi- 
ence in this direction is but confirming the observations of Gowers, Murri, 
and others. Optic neuritis, limited to the same side of the brain as the 
abscess, is said to have occurred. It must be exceedingly rare, and as 
the same eye-phenomenon has been observed in tumor, it has no practical 
diagnostic value. In a case of distention of the right lateral ventricle 
from accumulation of a straw-colored watery fluid, observed by me some 
years ago, well-pronounced optic neuritis was found on the right side, 
while on the left the eye was normal. Hirt calls attention to the diag- 
nostic value of paralysis of groups of muscles consecutively involved in 
abscess. This undoubtedly is of frequent occurrence in this disease, but, 
as paralytic symptoms are found in only about one-half the cases of 
abscess of the brain, and as the muscular involvement from tumor of the 
brain sometimes takes place by groups, the phenomenon loses much of 
its supposed significance in a differential diagnosis. A steady but grad- 
ual increase of symptoms of organic disease of the brain, with the devel- 
opment of one nerve-root symptom after another, is in favor of tumor, 
so are prolonged periods during which the symptoms make but little 
progress. 
The only conclusion at which one can arrive after a study of all the ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 
31 
symptoms of chronic abscess of the brain, is that the diagnosis is often 
a most difficult one, and sometimes is an object of impossible attainment. 
The nearest approach to accuracy in diagnosis in obscure cases is to 
arrive at a conclusion which amounts to a problematic diagnosis between 
two or more morbid processes. To recommend an operation for the relief 
of chronic abscess of the brain only in those cases in which the diagnosis 
is certain, is to sacrifice many lives that might otherwise be saved by 
judicious boldness. The physician who has not the courage to recom- 
mend an exploratory operation in a strongly probable case of abscess of 
the brain, lest he may be wrong in his diagnosis, is more solicitous for 
his own reputation than for the welfare of his patient. 
In conclusion, if we are ever to reach positiveness and certainty in the 
diagnosis of obscure brain-diseases, it will be attained only by a careful 
study of minute symptoms and what often seems unnecessary and tedious 
detail. Tfye Journal 
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