TUMOR OF THE BRAIN SIMULATING A 
VASCULAR LESION; 
TO WHICH IS ADDED AN ACCOUNT OF THE 
AUTOPSY, WITH REMARKS 
BV 7 
J. T. ESKRIDGE, M.D., 
OF DENVER, COLORADO J 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT 
OF THE UNIVERSITY OF COLORADO J NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS. 
FROM 
THE MEDICAL NEWS, 
March io, 1894. [Reprinted from The MEDICAL NEWS, March 10, 1894.] 
TUMOfi OF THE BRAIN SIMULATING A VAS- 
CULAR LESION; TO WHICH IS ADDED 
AN ACCOUNT OF THE AUTOPSY, 
WITH REMARKS.1 
BY J. T. ESKRIDGE, M.D., 
OF DENVER, COLORADO; 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL 
DEPARTMENT OF THE UNIVERSITY OF COLORADO J NEUROLOGIST 
TO THE ARAPAHOE COUNTY AND ST. LUKE'S HOSPITALS. 
The case which I wish to study with you to-day is of 
especial interest, because the most obtrusive symptoms 
point to an entirely different lesion than the one from 
which the patient is suffering. 
Michael P. K., twenty-seven years of age, of New 
York, a waiter, single, white, living in Colorado for the 
past seven years, was admitted into the nervous wards 
of the hospital about 2.30 p.m. yesterday in a semi- 
conscious condition. His temperature was 98.4°, the 
respirations 22, and slightly stertorous when he was not 
aroused; the pulse full, and 64 per minute. The 
resident physician does not know whether any paralysis 
was present at the time of his admission or not, as he 
did not make any examination to determine the point. 
During the afternoon, owing to the kind perseverance of 
the nurse, she succeeded in arousing him sufficiently to 
get some points in his history. He came of a family of 
hard drinkers, and he had five brothers, all of whom 
indulged freely in the use of alcohol. The patient 
1 A Clinical Lecture delivered at the Arapahoe County Hospital, 
Denver, Col. 2 
stated that he had always enjoyed good health until 
about six months ago, when he contracted a severe cold. 
Since then he has not been very well; at times he has felt 
all right, and at others he has complained of a numb 
pain in the head, and a confused sensation, which pre- 
vented his thinking connectedly. 
It was ascertained from his acquaintances that up 
to the time of the occurrence of his present trouble 
he had been occupying a room in a lodging-house, and 
nothing wrong was noticed by any of the lodgers until 
yesterday morning, when he arose, apparently as well 
as usual, and began to dress himself, but before he had 
completed his toilet he fell to the floor. When found, 
a short time afterward, he seemed confused and was 
unable to rise. 
At the time of my first visit, at 8 P.M., a few hours 
after his admission into the hospital, he was lying 
quietly and sleeping, but his respiration was slightly 
noisy when left to himself. His temperature was 
normal, and equal in each axilla, the pulse 72, and 
rather full and strong. He was easily aroused from 
his stuporous sleep, and for a few moments seemed to 
realize what was said to him ; but if left alone, he imme- 
diately relapsed into an apparently unconscious condi- 
tion. His left arm and leg were almost completely 
paralyzed ; the face was apparently unaffected, and he 
protruded the tongue in the median line. Sensation 
seemed to be normal. The right knee-jerk was slightly 
increased; the left a little greater than the right. 
The plantar reflexes were absent, and no ankle-clonus 
could be elicited. The cremaster and abdominal 
reflexes were slight on the right side and absent on the 
left. The pupils were equal and widely dilated, but 
reacted slightly to light. There was no paralysis or 
paresis of the external ocular muscles. On examining 
the fundi of the eyes a condition of bilateral optic 
neuritis was found. The disc was more swollen in the 3 
right eye than in the left, but the latter had reached a 
more advanced stage, and presented distinct atrophy of 
the optic nerve, with arteries very small. The other 
special senses, so far as I was able to determine, were 
normal. The urine was free from albumin and sugar, 
and the lungs seemed to be in a normal condition. 
Headache was not complained of unless the man was 
aroused and asked about it, when he would say that his 
head pained, but his appearance did not indicate much 
suffering. His bowels were freely evacuated, and he 
slept during the night, unaided by a hypnotic. 
His stuporous condition has deepened since my visit 
last night, and I have brought the patient before you 
to-day so that we may study his condition together, 
hoping that I may be able to bring out some points 
in connection with this case which may aid you, even 
in the absence of a history, in dealing with persons 
found in a state of partial or complete unconsciousness. 
On reexamining our patient to day we find him in a 
condition very much the same as that in which I found 
him at my first visit some sixteen hours ago, with these 
exceptions : that the paralysis of the left arm and leg 
has deepened, so that their muscles are now nearly 
flaccid ; that the left side of the face, from the nose 
downward, is slightly paretic ; and that the state of 
stupor is rapidly passing into coma. You see that I 
cannot get any intelligent response from him. When I 
call to him he simply opens his eyes and moves his 
lips, and immediately sinks into a condition of blissful 
unconsciousness of his impending fate. 
You must remember that a condition of partial or 
complete unconsciousness may be produced by syncope, 
from heart-failure ; by chloral, opium, or alcohol poison- 
ing ; by uremia, epilepsy, or hysteria ; or by an apoplec- 
tic state caused by apoplectiform attacks occurring in 
cerebral congestion or paralysis of the insane; by 
" simple apoplexy " in the aged, or by apoplexy from 4 
embolism, thrombosis, abscess, cerebral hemorrhage, or 
tumor of the brain. 
You see, then, that we may have a more or less 
sudden disturbance of consciousness, from perversion of 
brain-function, and that this may be due either to direct 
or indirect causes acting upon the brain. In some cases 
of suddenly induced unconsciousness, even from struc- 
tural.brain-disease, there are but slight, if any, localizing 
symptoms, so that, in the absence of a consecutive and 
reliable history, you may at times be sorely puzzled to 
determine the cause of the unconsciousness. When 
persistent paralysis exists, especially if it is associated 
with optic neuritis, all such general causes of uncon- 
sciousness as syncope from heart-failure, chloral, opium, 
alcohol, and uremic (?) poisoning may be excluded. 
The bilateral optic neuritis, excluding lead-poisoning, 
uremia, and profound anemia, is positive proof that the 
trouble is organic, and therefore hysterical and epileptic 
coma, as well as " simple apoplexy," may be disre- 
garded in the diagnosis of the lesion in the patient 
before us. 
Having excluded all causes, except those of an organic 
nature, to which of the numerous organic brain-lesions 
may we attribute this man's condition ? 
For diagnostic purposes, these lesions may be divided, 
as regards the time consumed in their development, 
into sudden, acute, and chronic. 
The sudden lesions are vascular in their nature, and 
are due to embolism, thrombosis, or cerebral hemor- 
rhage. You must all realize the importance of a con- 
secutive and reliable history of the patient prior to the 
development of the prominent symptoms of the disease, 
and an intelligent account of the mode of invasion of 
the disease. In the absence of such a history it is some- 
times utterly impossible to make a diagnosis. With the 
light which a reliable history throws on a case, positive- 
ness in differential diagnosis may be obtained by care- 5 
ful analysis and comparison of all the symptoms. Un- 
fortunately, in the history of the present case, the 
information is meager, and it is questionable to what 
extent it may be relied upon. Prior to the development 
of the paralysis yesterday morning but little is known, 
except that for the past few months the man found it 
difficult to think, owing to what he called a confused 
feeling in his head. Pain in the head was only com- 
plained of as a heavy sensation. When I first saw him 
he made so many contradictory statements that I was 
unable to learn whether he had ever had syphilis. He 
was not seen until several minutes after he fell on the 
floor while dressing in the morning, and when found 
he was unable to rise and seemed stupid. He could 
give no account of this attack. It is fair to presume 
hat the paralytic symptoms and mental confusion came 
on comparatively suddenly, although we must bear in 
mind that he might have gotten out of bed with im- 
paired motility and mental power, and that these 
simply increased while he was trying to dress himself. 
In embolism there are usually no head.-symptoms ante- 
dating the attack, and to justify the diagnosis of cerebral 
embolism we should be able to find a cause for the 
embolus, such as acute or chronic endocardial trouble. 
No such cause exists in this patient. In rare instances 
embolism gives rise to optic neuritis, but it is evident 
that this could not occur until several days had elapsed 
after the occurrence of the brain-lesion, so that we can 
exclude embolism in this case. Without going into a 
detailed account of the symptoms of thrombosis and 
cerebral hemorrhage, a consideration of these may be 
discarded in the diagnosis of our patient's trouble, as 
insufficient to account for the presence of optic neuritis, 
which does not arise from either of these vascular 
lesions. 
You see, then, that a sudden or vascular lesion, although 
the paralytic attack was undoubtedly more or less sudden 6 
in its onset, will not account for all the symptoms which 
this man presents ; I wish you to bear in mind, how- 
ever, that while a vascular lesion will not account for 
all the symptoms, it would account for the rapid develop- 
ment of paralysis, and such a lesion may occur as a 
result of a more chronic malady and give rise to sudden 
symptoms, thus making a diagnosis, in the absence of a 
reliable history, exceedingly difficult. Of this I may 
have something to say later, in explanation of some of 
the symptoms presented by our patient. 
The acute lesions of the brain are inflammatory in their 
nature, and require from a few days to a week or more 
to reach their height. They are all, as a rule, attended 
with some rise of temperature and considerable head- 
ache. Whilst optic neuritis may appear early (fifth day, 
Gowers), atrophy, such as is found in the present case, is 
not seen until after the second week. So that normal 
temperature, absence of marked head-pain, the sudden 
onset of the main symptoms, a few hours ago, and the 
presence of optic neuritis, with beginning atrophy, 
enable us to exclude the acute organic brain-lesions. 
We have left, to account for our patient's condition, 
which seemed on superficial observation to be due to 
some sudden lesion, one of the chronic organic brain- 
diseases. We can exclude the scleroses, and in the 
light of what history was obtainable at the time ot 
the patient's admission into the hospital, together with 
the symptoms found on examination, we need to con- 
sider only two lesions, viz., tumor and chronic abscess. 
The diagnosis between tumor and acute abscess of 
the brain is usually easy, but between tumor and chronic 
abscess it is sometimes most difficult, if not impossible, 
especially if we find ourselves laboring under the diffi- 
culties encountered in the present case, in which a reli- 
able history and accurate observation of symptoms, 
prior to the sudden development of the apoplectic 
symptoms, are entirely wanting. 7 
In chronic abscess there is usually the history of a 
cause of suppuration, such as chronic ear-disease, infec- 
tive disease of the nose or of the bones of the skull, or 
suppuration in the lungs or elsewhere. In abscess of 
the brain one of these causes is found in about three- 
fourths of the cases. After the first disturbance, caused 
by the formation of pus, a latent period of several 
weeks, months, or years may follow, during which the 
patient may complain of slight or no brain-symptoms. 
The latent period is sometimes cut short suddenly by 
terminal symptoms resembling apoplexy, such as par- 
alysis, convulsions, coma, and death. 
Most tumors of the brain run a gradually increasing 
course, with decided head-symptoms, without a latent 
period, and with final symptoms in accord with the pre- 
vious history of increasing gross organic brain-lesion. 
But we must remember that gradually-growing tumors 
in a portion of the brain, the destruction of which gives 
rise to no definite focal symptoms, may run a compara- 
tively latent course, and finally bloodvessels may be 
encroached upon and occluded, giving rise to symptoms 
resembling thrombotic apoplexy. Again, in the course 
of tumor of the brain we may have the occurrence of a 
vascular lesion, in every way independent of the morbid 
growth. One such case was observed by me in this hos- 
pital about a year ago. The patient was suffering from a 
slowly-growing tumor attached to the dura on the right 
side of the brain, and a large hemorrhage occurred into 
the left corpus striatum and proved fatal in a few hours. 
The autopsy revealed advanced degeneration of all the 
large arteries at the base of the brain. The hemor- 
rhage that sometimes occurs in the substance of vascular 
tumors rarely proves fatal. 
Finally hemiplegia may occur in the course of brain- 
tumor, and death result; and the autopsy may afford 
no explanation of the suddenly-developed symptoms. 
Some years ago, Gowers (Brain, 1879, v°l- b P> 4&) 8 
reported a number of cases of sudden paralysis occur- 
ring in the course of cerebral tumor. 
The points in the case of the patient before us in 
favor of chronic abscess are: excluding a vascular 
lesion, as we have done already, terminal symptoms 
resembling apoplexy in a case of latent chronic brain- 
trouble, and optic neuritis. 
Evidences in favor of tumor rather than abscess are: 
absence of a cause for the development of abscess (this 
is always a strong point against abscess) ; intense optic 
neuritis, as evidenced by considerable swelling of the 
right optic disc, and absence of rigor and fever, which 
so commonly attend the terminal stage of chronic 
abscess. All these symptoms, except optic neuritis, are 
negative ones in favor of tumor, but very positive against 
abscess. 
The weight of the evidence is in favor of tumor of the 
brain, and I venture this diagnosis in view of the prob- 
ability of being able to verify or disprove it by an 
autopsy in a few hours or days. 
I wish to call your attention to the fact that, outside 
of gross organic brain-disease, renal trouble, lead-pois- 
oning, and profound anemia will give rise to optic neu- 
ritis, but it has not been necessary to consider these, 
because of the positive evidence of a brain-lesion to 
account for the patient's condition, although, as a mat- 
ter of fact, the urine is free from albumin, there are no 
evidences of chronic lead-poisoning, and the patient is 
not anemic. 
Having made the diagnosis of tumor, is it possible in 
the present case to localize it ? The base of the brain 
can be excluded, from the fact that the cranial nerves 
have not been affected; and the cortex of the convex 
surface is probably not the seat of the growth, in the 
absence of convulsions ; and a growth in the cerebellum 
would not give rise to distinct hemiplegic symptoms, 
without interfering with the functions of the medulla or 9 
pons. In all these situations headache would probably 
have been a prominent symptom, and you remember 
that, on the patient's admission into the hospital, he 
stated that he had not suffered much from head-pain. 
Excluding, then, these situations as the probable seat 
of the growth, we have left the centrum ovale in the 
right hemisphere. The growth did not have its origin 
in that portion of the centrum ovale occupied by the 
fibers of the corona radiata which connect the anterior 
two-thirds of the posterior half of the internal capsule 
with the cortical motor region, else paralysis would have 
been an early, instead of a late, symptom. The tumor 
has had its origin either anteriorly or posteriorly to the 
radiating fibers of the motor region, and these fibers 
have been encroached upon by a sudden extension of 
the morbid process to them. Whether the disease began 
anteriorly or posteriorly to the fibers of the motor region 
is not an easy matter to determine-especially so in the 
absence of a complete history. We learn that there 
was some difficulty in mental concentration for months, 
but this was not sufficiently marked to attract the atten- 
tion of the man's friends. Lesions in the centrum ovale 
posterior to the radiating fibers passing to the motor 
region might run an almost completely latent course, 
but when the anterior lobe of the brain is the seat of 
tumor we should expect to find mental disturbance, 
such as apathy, inability to concentrate the mind, with, 
probably, more or less moral obtuseness. In the present 
case, in the absence of a reliable history, I must confess 
that I am unable to make a more definite diagnosis as 
to localization than the centrum ovale of the right 
hemisphere. 
In regard to the treatment of the present case little or 
nothing can be done. The patient is now comatose and 
he will not live more than a few hours, or a day or two 
at the most. It is too late to attempt to get the effects 
of medicine, and were we sure as to the exact location 10 
of the morbid process, the physical depression is too 
great to justify an effort for its removal by surgical 
means. I shall not discuss at length the probable 
nature of the tumor, but it is most likely syphilitic or 
gliomatous; although, as the patient dated the beginning 
of ill-health from a " cold on the lungs," it may be tuber- 
culous. I will report further on this case at our next 
clinic. 
(After the lecture the patient continued to sink into a 
deeper state of coma and died about twelve hours later.) 
At the autopsy, made ten hours after death, by Dr. 
Axtell, in the presence of Drs. McLauthlin, Mack, and 
Hull, and myself, the brain only was examined. No 
abnormally firm adhesions of the dura to the bone 
existed. The sinuses and the veins of the dura were 
distended with dark, fluid blood. No clots were found. 
The veins of the pia were everywhere filled with dark, 
fluid blood. There were no signs of inflammation of 
any of the membranes, and the pia readily stripped 
from the brain. The arteries at the base were empty 
and showed no evidence of disease. The left cerebral 
hemisphere appeared normal throughout. The cen- 
trum ovale of the right hemisphere, from near its pos- 
terior portion in the occipital lobe to a point opposite 
the middle of the fissure of Rolando, showed evidence 
of disease. This entire area was occupied externally 
by what appeared to be ragged brain-substance, some 
portions of which were softer than the normal brain- 
tissue, whilst others presented an increased resistance 
to the finger. The parts anteriorly and internally 
(toward the lateral ventricle) appeared quite soft. In 
the interior of this tumor-like mass was found, in one 
portion, one or two ounces of yellow, watery fluid, and 
in another, which was separated from the cavity contain- 
ing the watery fluid by a portion of the growth, a san- 
guino-purulent gummy-looking material. Considerable 
of the yellowish, watery fluid was found in the right 11 
lateral ventricle. It is impossible to say whether this 
found its way there before death or during the dissection. 
Great care was used in examining the brain, yet, on 
account of the fluctuating condition of the whole of the 
posterior portion of the right cerebral hemisphere, a rup- 
ture of the wall of the lateral ventricle could easily have 
taken place. None of the fluid had gravitated to the 
fourth ventricle, making it probable that the fluid had 
escaped into the lateral ventricle during the dissection. 
A microscopic examination was made by Dr. Axtell, 
whose report is appended. 
The softened material surrounding the cavity contain- 
ing the fluid showed nothing but granulation-tissue ; no 
connective-tissue elements were found; leukocytes and 
red blood-corpuscles were found in abundance. It was 
simply softened, broken-down brain-substance. 
Of the gummatous substance, a large amount of gran- 
ular material, composed principally of granular leuko- 
cytes, and containing numerous red blood-corpuscles, 
was found. The hardened portion of the brain-sub- 
stance posterior to the semi-liquid material showed the 
usual appearance of gummatous infiltration. 
With the additional light which the autopsy revealed in 
the foregoing case, a few points can be more intelligently 
discussed now than during the patient's life. What 
was the cause of the sudden and grave symptoms and 
the speedy death ? What part did suppuration play in 
this man's case ; was it primary or secondary ? Do not 
syphilitic growths infiltrate the surrounding brain-tissue ? 
. It seems to me that the extensive softening and hem- 
orrhagic infiltration, which were undoubtedly of recent 
date, prior to the syphilitic growth, and involving the 
coronal fibers going from the internal capsule to the 
motor region of the brain, were sufficient to account for 
the sudden paralysis. It is probable that the liquid 
material, which, before the sudden breaking down of the 
brain prior to the syphilitic growth, had been enclosed 12 
in a circumscribed cavity, after the softening was allowed 
greater freedom of motion, and thus, by its pressure on 
the external wall of the lateral ventricle and on the great 
ganglia at the base, added to the shock already set up 
by hemorrhagic infiltration and brain-softening. 
After the man's death it was learned that he had 
been under treatment for a number of weeks for sup- 
posed syphilis of the brain, prior to his admission into 
the hospital, and had taken potassium iodid during this 
time. The treatment accounts for the yellowish liquid 
found in the interior of the growth. I have observed, 
post-mortem, several cases of syphilitic tumor which 
had been treated by potassium iodid, and in most of 
these, especially when large doses of the medicine had 
been used, a considerable amount of a straw-colored 
watery fluid has been found. I have not seen this state 
of affairs in cases that have not received anti-syphilitic 
treatment. 
What part did the suppuration play in this man's 
case; was it primary or secondary ? So evident were 
the characteristics of pus found at the autopsy, that at 
first I was inclined to regard the case as one of chronic 
abscess; but the induration of portions of the surround- 
ing brain-substance and the microscopic examination 
both showed the presence of a growth; besides, the 
pus was not of the distinct greenish color so commonly 
met with in abscess of the brain. Moreover, there was 
no odor to the pus-appearing substance. Since, then, 
it is not likely the formation of pus antedated the 
growth, it must have been secondary to it and in all- 
probability due to the destructive process of the rapidly 
growing tumor. This is the first case of tumor of the 
brain in connection with which I have found pus. I 
see no reason, however, why we should not have the 
formation of aseptic pus from the acute softening that 
may take place as the result of blocking up of blood- 
vessels from the encroachment of a growing tumor. 13 
The third and last question that I will consider is: Do 
not syphilitic growths infiltrate the surrounding brain- 
tissue ? Gowers, in the second edition of his Diseases of 
the Nervous System, vol. ii, p. 493, under the heading 
" Syphilitic Growths," says : " The adjacent brain-sub- 
stance is softened and more or less displaced, but it is 
not infiltrated by the growth." 
On the other hand, Bramwell, in his work on Intra- 
cranial Tumors, p. 216, in quoting from Heubner on 
the appearances of syphilitic growths of the brain, says : 
" This form of tumor is never sharply defined; on 
examining the edges by the microscope, one may see at 
points apparently normal a strongly-marked cellular 
infiltration, which gradually passes into the healthy 
tissue." 
Ziegler, Special Pathological Anatomy, sect, ix-xii, 
p. 311, beautifully illustrates diffuse cellular infiltration 
(syphilitic) of the cortical substance of the brain in a 
case of gummatous syphilitic meningo-encephalitis, and 
on page 312, after describing, in connection with this 
illustration, the tendency of syphilis of the membranes 
to involve the adjacent brain-substance, he states : " The 
same holds for the nodes which develop independently 
in the substance of the brain and cord." 
Delafield and Prudden, in their work on Pathological 
Anatomy and Histology, in speaking of gummy tumors, 
to which they devote but a few lines, only refer to coag- 
ulation-necrosis and degeneration as taking place in the 
surrounding tissue. 
In a case of syphilitic growth of the brain, operated 
on for me by Dr. Parkhill about two years ago, in a 
man about thirty years of age, a cavity containing about 
four ounces of a yellowish, watery fluid was found, and 
microscopically the brain-substance was indurated and 
softened around this cavity for some distance, making 
the size of the growth, from naked-eye appearances, 
four and a half inches in its longest dimensions, by three and a half and three inches in its shorter. The 
hemisphere of the brain from which this tumor was 
taken at the autopsy was examined by a competent 
microscopist and found to be infiltrated with gummatous 
tissue around the growth, even in portions which ap- 
peared macroscopically to be normal. 
It seems to me that since surgical operative procedure 
is recommended for the removal of syphilitic growths, 
it is of the first importance to recognize the fact that 
these growths affect the surrounding brain-tissue, both 
by necrotic softening and gummatous infiltration, and 
that in many cases of long-standing tumors of this 
nature the brain-tissue has been so extensively infiltrated 
that but little or no good results can be reasonably 
expected after the excision of the old tumor-mass. I 
believe that Mr. Victor Horsley is right in urging 
early operation for the removal of syphilitic growths, if 
symptoms do not rapidly disappear under vigorous 
anti-syphilitic treatment. 
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