Rosenthal speaks of the necessity of diagnosticating brain tumor from the chronic cerebral softening of Durand-Fardel, from acquired cerebral atrophy, and the cerebral hypertrophy of children. An elementary knowledge of the general symptomatology of intracranial tumors will, however, be sufficient to prevent mistakes of differentiation in these cases. Neither of these affections presents the violent paroxysmal symptoms, the affections of the special senses, or the severe motor and sensory phenomena of intracranial growths.
Acute mania and paretic dementia are sometimes confounded with intracranial growths. A case of brain tumor is more likely to be regarded as one of acute mania than the reverse. In some comparatively rare instances in the course of their sufferings the cases of tumor become maniacal, but even a superficial study of general symptomatology in such a case will be sufficient to clear up the doubt.
Paretic dements are occasionally supposed to be cases of brain tumor, because of the epileptiform attacks and isolated pareses which occur as the disorder progresses. It is only necessary to refer to this matter, as the mistake would not be likely to be made by one having any familiarity with dementia paralytica.
L. J. Lautenbach, in a recent communication to the Philadelphia Neurological Society, which embodied a large number of ophthalmoscopic examinations of the insane at the State Insane Hospital, Norristown, Pennsylvania, and the Insane Department of the Philadelphia Hospital, and also the results of the investigations of the fundus of the eye in cases of insanity by other observers, showed that about 16 per cent. of cases of acute mania presented well-defined papillitis—a condition which he described as one of swelling and suffusion of the disc, corresponding to cases reported as choked disc, descending neuritis, and severe congestion of the optic nerve. No reports of post-mortem examinations were made of these cases, but they did not present the clinical history of meningitis or brain tumor. It therefore follows that the existence of papillitis in a case of acute mania does not necessarily point to a gross lesion, such as tumor or meningitis.
In the early stage of posterior spinal sclerosis some of the symptoms of the initial or middle stage of intracranial growths in certain positions are likely to be present; more particularly, such eye symptoms as diplopia from deficiency or paresis of the ocular muscles and disorders of the bladder may mislead. In posterior spinal sclerosis, however, some at least of the pathognomonic symptoms of locomotor ataxia, such as lancinating pains, absent knee-jerk, or Argyle-Robertson pupil, will almost invariably be present. Those tumors of the cerebellum, pons, tubercular quadrigemina, etc. which give rise to ataxic manifestations are usually readily discriminated from posterior spinal sclerosis by the headache, vomiting, and other general symptoms of brain tumor, which rarely occur in ataxia. It is far more difficult to separate non-irritative lesions of certain cerebellar and adjoining regions from the spinal disorder.
Strange to say, one of the most frequent mistakes of diagnosis is that which arises from confounding brain tumor with grave hysteria. In several of our tabulated cases the patients at different periods of the disease and by various physicians had been set down as suffering from hysteria. One of Hughes-Bennett's cases (Case 30), a wayward, hysterical girl of neurotic family, had had her case diagnosticated as hysteria by one of the highest medical authorities of Europe, and yet after death a tumor the size of a hen's egg was found in the cerebrum. In a case reported by Eskridge (Case 76) hysterical excitement and special hysterical manifestations were of frequent occurrence, and misled her physicians for a time. Eskridge remarks, in the detailed report of this case, that to such a degree was the emotional faculty manifest that had no ocular lesion been present there would have been great danger of mistaking the case for one of pure hysteria; and, indeed, a careful physician of many years' experience, not knowing the condition of the eyes, pronounced the woman's condition to be pregnancy complicated by hysteria. A close study of such objective phenomena as choked discs and paralysis will usually be of the most value.
Even malaria has been confounded in diagnosis with brain tumor. Holt37 reports a case which presented the history of a fever, at first periodical, with marked splenic enlargement, great muscular soreness, and incomplete paralysis, which was diagnosticated to be chronic malarial poison. The patient for a time improved under quinine, but eventually grew worse, and on an autopsy a glioma-sarcoma was found on the inferior surface of the cerebellum. Several years since a physician about fifty years of age was brought to one of us for consultation, and in his case a similar mistake had been made. The case was a clear one of tumor, probably cerebellar, with headache, neuritis, vertigo, and other general symptoms, which pointed to an organic lesion. This patient, who came from a malarial district in the West, had doctored himself, and had been treated by others with enormous doses of quinine and arsenic.
37 Med. Record, March 1, 1883.
LOCAL DIAGNOSIS.—Niemeyer would hardly say to-day that the brilliant diagnoses where the precise location of a tumor is fully confirmed by autopsy are not usually due to the acumen of the observer, but are cases of lucky diagnosis. It can be asserted with confidence that the exact situation of a tumor can be indicated during life in at least two or three locations. Great caution should be exercised, as insisted upon by Nothnagel,38 in the localization of tumors of the brain, because, among other reasons, of the frequent polypus-like extension of such tumors.
38 Wien. Med. Bl., 1, 1882.