A CASE OF PROBABLE MENINGEAL HAEMORRHAGE 
WITH SYMPTOMS RESEMBLING GEN- 
ERAL PARESIS.* 
BY GEORGE .T. PRESTON, M. T>., 
OF BALTIMORE. 
Reprinted from the Maryland Medical Journal, July 29th, 1893. 
When we consider how abuudant the 
blood supply of the brain is, and how 
slight is the support afforded the vessels 
by the soft tissue in which they are em- 
bedded or upon which they lie, it is not 
surprising that we often see cases of rup- 
ture of the vessels produced by external 
violence which is not sufficient to cause 
fracture of the skull. Cases of this kind 
are often very puzzling from the lack of 
localizing symptoms. Nor is it always 
easy to decide whether we are dealing 
with a case of diffuse haemorrhage or one 
of laceration. The symptoms whether 
convulsive or paralytic, dependent upon 
injury done to the motor region of the 
cortex of the brain, are usually plain 
enough. Certain of the sensory cor- 
tical centers are sufficiently well known 
for localizing value, vision especially. 
The language center gives us another 
landmark for the left hemisphere. A 
large part of the occipital, parietal, and 
frontal cortical regions afford few 
symptoms of localizing value when in- 
jured. 
The inferences to be drawn from the 
case to be related cannot of course be re- 
garded as anything more than probable, 
since the patient has partially recovered. 
The case, however, was one of great in- 
* Read before the Medical and Surgical Society of 
Baltimore, March 23rd. terest to me, since the symptoms pointed 
to injury done both motor and psychic 
areas. The case referred to is briefly as 
follows: 
James Price, colored, aged 30, laborer, 
with good family and personal history, 
admitted to City Hospital July 14, 1892. 
On the night of the 13th he was struck by 
a freight train and rendered uuconscious, 
in which condition he was admitted into 
hospital. There was a very slight scalp 
wound and a few bruises in other parts 
of the body, but no external injury of 
any importance. The case was supposed 
to be merely one of concussion of the 
brain. There was no rise of temperature 
and at first no evidence of paralysis. 
Soon after admission the patient became 
delirious, talking in a wild, incoherent 
manner. 
A careful examination made on July 
16th showed that the patient had to a 
certain extent recovered consciousness 
but his mental condition was bad. There 
was partial paralysis of all four extremi- 
ties with greatly increased reflexes and 
ankle clonus on both sides. No loss of 
sensation. Pupil reflexes normal and 
ophthalmoscopic examination revealed 
nothing abnormal. 
After some days the patient got out 
of bed and upon attempting to walk he 
staggered and fell. He had a reeling, 
drunken gait and was not able to walk 
across the ward without support. There 
was a general tremor, intensified by any 
attempts at movement. His speech was 
thick and slurring, with a tendency to 
drop the ends of words. There was a 
slight fibrillary tremor of the muscles 
of the mouth when speaking, and also a 
spasmodic twitching of the right side of 
the face. ' 
Gradually, that is during the first 
weeks, the patient developed a well 
marked delirium of grandeur. He 
imagined that he had plenty of money; 
told me that he had $5,000, which it is 
needless to say was entirely a delusion. 
The other patients in the ward were 
greatly amused at his extravagances. His 
memory was very defective and the ac- 
counts he gave of himself utterly untrue. 
These symptoms continued without any 
very marked change for nearly two 
months, and then a gradual improve- 
ment set in. ITis grandiose delusions 
slowly disappeared, his memory became 
clearer and the expression of his face, 
which had been very silly and self com- 
placent, became more natural. The 
paralysis improved to such a degree that 
he was able to hobble across the ward 
with the aid of two canes. The muscu- 
lar weakness continued great and the re- 
flexes were still exaggerated; there was 
no muscular atrophy at any time. The 
patient left the Hospital about the mid- 
dle of November. 
The symptoms bore a striking resem- 
blance to general paresis: the general 
paralysis involving as it did all four ex- 
tremities and also the muscles of articu- 
lation, the tremor, altered reflexes, thick 
speech, muscular twitching*, loss of 
memory, and expansive delusions. 
Patient’s friends reported that he was 
perfectly sound mentally and physi- 
cally just prior to the accident. But 
for this fact and also for the fact 
that the symptoms gradually improved 
and the delusions disappeared I should 
have been inclined to regard the case 
as one of general paresis in which 
! the symptoms had been merely intensi- 
i fied and hurried up by the shock. The motor symptoms, paralysis, tremor, 
spasmodic movements, involving as they 
did all four extremities, point to a wide- 
spread, but slight lesion. The psychic 
symptoms, loss of memory and delusions 
point to the probable involvement of the 
frontal area. In all probability the 
frontal and Rolandic regions were in- 
volved to a degree sufficient to produce 
a partial but not complete loss of func- 
tion. The symptoms indicate that the 
injury was to the cortex and of such a 
nature that the tissues gradually recov- 
ered, to some degree, their normal con- 
dition. The sudden onset of the symp- 
toms, following an injury, points unmis- 
takably to haemorrhage, as does the grad- 
ual improvement due to absorption. 
The haemorrhage must have been wide- 
spread to involve the motor and probably 
the frontal regions of both hemispheres. 
The absence of fever almost precludes 
the possibility of meningitis. The most 
natural explanation of the condition is 
that as a result of the blow to the skull 
haemorrhage occurred which covered the 
under surface of the dura-mater with a 
thin layer of blood, resembling what is 
known as pachymeningitis hemorrhagica 
interna. 
The above case is interesting on ac- 
count of the widespread symptoms fol- 
lowing a traumatism and the close re- 
semblance which these symptoms bear to 
those of general paresis. If, however, 
we keep in mind the pathology of gen- 
eral paresis, the explanation given of 
the probable nature of the case related 
above—namely, that the cortex was in- 
volved to a wide extent, but a slight de- 
gree only—becomes highly probable. 
Another conclusion which may I think 
be drawn from the case is the neces- 
sity of opening the skull in all cases in 
which, following injury,unconsciousness 
is long continued, regardless of other 
symptoms, and regardless of the appar- 
ent trivial nature of the head injury. 
819 N. Charles Street.