FOUR © ® © 
CASES OF 
Cerebral 
Ibemorrbage 
AUGUSTUS A. ESHNHR, JW.D. 
PHIUADEUPHIA [Reprinted from the Medical and Surgical Reporter, February 13, 1897 
FOUR CASES OF CEREBRAL HEMORRHAGE 
AUGUSTUS A. ESHNER, M.D.,* Philadelphia. 
The cases herewith reported, although 
presenting no extraordinary features, 
still are not without clinical interest. The 
diagnosis of cerebral hemorrhage, often 
easy, is sometimes extremely difficult. 
Upon the recognition of the condition 
and an appreciation of the attendant 
circumstances will depend the thera- 
peutic measures to be employed, and a 
false interpretation of the symptoms 
may lead to failure when success were 
possible. The cases were all seen at 
Howard Hospital, in the clinical service 
of Dr. Lewis Brinton, to whom I owe 
the privilege of studying them and of 
making this report. 
J. L., fifty-two years old, and engaged 
in driving a wagon, applied at Howard 
Hospital on August 7, 1896, relating 
that twelve weeks previously, while 
seated on a chair, quietly smoking in the 
evening, he was stricken with paralysis. 
His arms and legs shook and he fell 
over, striking his right shoulder. There 
was no loss of consciousness and no con- 
vulsion. For an hour there was consid- 
erable difficulty in speech, but this soon 
grew less, though it persisted in some 
degree for two or three weeks. For sev- 
eral weeks the patient was completely 
paralyzed. At the end of this time he 
began to improve and he grew gradually 
better. 
Upon application all of the members 
were stiff, especially those upon the 
right side of the body. The sphincters 
were under control. The gait was de- 
crepit and spastic-ataxic. Station was 
swaying. The knee-jerks were exag- 
gerated, almost equally. Only abortive 
ankle-clonus could be elicited. The 
♦Professor of Clyiicei M-adittiue in tlxe JiEjJadelphla 
Polyclinics; Physicjaji y 
deep reflexes in the upper extremities 
also were increased. The dynamomet- 
ric record was seven on the right as 
against thirty-two on the left. The 
facial lines were less well defined on the 
right than on the left, but the move- 
ments were active and symmetric. The 
tongue was protruded in the median 
line. The pupils were equal, regular, 
reactive to light. The action of the 
heart was rhythmic ; the first sound was 
wanting in vigor and definition; the 
second was accentuated. 
The patient admitted excessive use of 
alcohol and free use of tobacco. He had 
had gonorrhea at the age of eighteen 
years, but no history or evidence of 
syphilis could be obtained. The man 
had had measles and whooping-cough in 
childhood and tonsillitis and diphtheria 
at adult age. He complained of rheu- 
matic pains. The appetite was fairly 
good and the bowels were regular. There 
was neither headache nor vertigo and 
sleep was not disturbed. 
A prescription containing ten grains 
of potassium iodid and one thirty-second 
grain of mercuric chlorid was given 
thrice daily, subsequently increased to 
fifteen grains and one twenty-fourth 
grain, respectively, together with one- 
thirtieth grain of strychnin. At first 
there was no improvement, but after a 
time a change for the better set in, and 
slowly continued until the patient was 
lost to observation. 
Although the patient in this case 
failed to lose consciousness, a diagnosis 
of hemorrhage into the left cerebral 
hemisphere from rupture of one of the 
anterior perforating arteries was made, 
in view of the age, the abruptness of on- 
set, the absence of a cardiac lesion. 2 
The disturbance of speech was not a 
true aphasia, but was probably depend- 
ent upon destructive interference with 
some of the nerve-libers from the cortex 
concerned in the motor execution of the 
act of articulation. The primary wide- 
spread distribution of the palsy is note- 
worthy and may be dependent upon an 
unusual decussation of the fibers in the 
medulla. The pronounced spastic con- 
dition would be a natural result, attrib- 
utable to the descending degeneration 
in the crossed (lateral) pyramidal tract, 
on the side of the palsy (opposite the 
lesion in the brain), and in the direct 
(anterior) pyramidal tract on the other 
side. 
Cerebral embolism had to be excluded 
on account of the absence of a discover- 
able source of vascular plug, such as 
vegetations on the cardiac valves or 
thrombosis, and on account of the ex- 
tent of the paralysis. An embolism of 
this kind is usually swept into the left 
middle cerebral artery, and thus causes 
aphasia and epileptiform convulsions. 
Subcortical hemorrhage may of course 
give rise to the same symptoms as em- 
bolism. 
Cerebral thrombosis was excluded on 
account of the mode of onset, the prev- 
ious health of the patient, the absence of 
evidence of gross vascular disease and of 
headache and other premonitory mani- 
festations. Other possible causes ofhemi- 
plegia, e. g., neoplasm, abscess, aneu- 
rism, gumma,were excluded by the whole 
course of the case, the sudden onset, the 
further progress, the absence of head- 
ache. 
J. A., a laborer in an iron-works, 
thirty-five years old, applied at Howard 
Hospital December 4, 1896, presenting 
characteristic left hemiplegia. He re- 
lated that on June 15, after retiring to 
bed in apparently perfect health, he was 
awakened from sleep by pain across the 
anterior aspect of the chest, but he was 
unable to speak. Subsequently, he was 
told, he became delirious for a time, and 
consciousness did not return perfectly 
for four or five days or a week. It was 
then found that the left leg, the left 
arm and the left side of the face were 
paralyzed. 
The patient was unable to speak prop- 
erly for a couple of weeks. There had 
nevei' been a convulsion. Improvement 
had taken place in the state of the leg, 
but little or none in that of the arm. 
The sphincters were under control. The 
gait was the typical one. The knee- 
jerks were increased, on the left espec- 
ially, where feeble ankle-clonus could be 
elicited. At times when the foot was 
supported on the toe also a clonus was 
developed. The left upper extremity 
could not be moved voluntarily, but the 
left hand closed when the right was 
clenched and also when the teeth were 
brought firmly together; in yawning 
the left arm was raised. At times 
the left thumb was spontaneously 
drawn into the palm of the hand. 
The mouth was distorted somewhat to- 
ward the right, while the tongue, when 
protruded, was deflected toward the 
left. The pupils were equal, regular and 
reactive to light. Common sensibility 
appeared to be preserved everywhere. 
The patient complained of shortness 
of breath, with smothering spells and 
palpitation of the heart. The cardiac 
action was at first arrhythmic and no 
murmur could be heard, but after a time 
when the rhythm improved a pre-systolic 
murmur and a booming first sound were 
audible at the apex. 
There had never been hemoptysis. The 
patient had not suffered from headache, 
except immediately after the return of 
consciousness. He had used tobacco free- 
ly and alcohol moderately, but he denied 
venereal infection. He had had acute 
rheumatism as a boy, measles in child- 
hood and whooping-cough at the age of 
eighteen years. 
Although in this case the possibility 
of cerebral embolism, as a result of the 
mitral obstruction, as indicated by the 
pre-systolic murmur heard at the apex of 
the heart, cannot be positively excluded, 
hemorrhage into the brain is considered 
the more probable in view of the extent 
of the paralysis and of the absence of 
signs of cortical irritation and of evi- 
dence of embolism in structures other 
than the brain. Besides, embolism is, 
for anatomic reasons, more common 
upon the left side, and is then attended 
with right hemiplegia and aphasia. The 
onset of cerebral hemorrhage during 
sleep is not uncommon. 
The patient exhibits also associated 
movements, the occurrence of which 
lends support to the view that the mus- 3 
cles of each side of the body are inner- 
vated from both sides of the brain, 
though in preponderant degree from 
the opposite hemisphere. Additional 
evidence of allied character is to be 
found in the marked improvement that 
sometimes takes place after hemiplegia 
due to cerebral hemorrhage in infancy 
and childhood. A similar hypothesis 
applies to the gradual restoration of 
speech after destruction of the third 
frontal convolution in the left hemis- 
phere. Under these circumstances there 
is supposed to take place an education 
of the corresponding center in the right 
hemisphere. 
A. S., a tinsmith, thirty-two years 
old, presented himself at Howard Hos- 
pital, January 8, 1897, relating that on 
November 4, 1896, while on the street, 
he fell, without loss of consciousness or 
a convulsion or derangement of the 
action of the sphincters. With the aid 
of friends he was able to walk some dis- 
tance to his home. It was then found 
that the left arm and leg and the left 
side of the face were paralyzed. Speech 
was not affected. In the course of three 
weeks considerable improvement had 
taken place and the patient began to be 
up several hours each day. 
About twenty-three days after his 
first attack the patient suddenly found 
himself unable to speak. He became 
delirious at night, but no palsy was ob- 
served. The face was not drawn and 
there was no convulsion. From this 
seizure perfect recovery had taken place 
in four or five days. 
After an interval of three or four 
weeks, while seated in a chair engaged 
in conversation, the patient found him- 
self again suddenly deprived of the power 
of speech. Now the face was drawn to 
one side and saliva drooled from the 
mouth. The patient threw his head 
back, but he did not fall. With aid he 
walked some distance to his home and 
went to bed. 
When the man presented himself he 
walked fairly well, though with some 
apparent decrepitude. The station, 
though a little uncertain, was quite 
steady. The knee-jerks were greatly 
exaggerated, especially upon the left. 
Feeble ankle-clonus could be elicited on 
the left, but none on the right. Speech 
was thick and deliberate and enunci' 
ation slow. There was no apparent con- 
fusion of words or awkwardness in ex- 
pression of ideas. There was gen- 
eral weakness, but this was more pro- 
nounced on the left side. In voluntary 
movements of the face the right side was 
the more active, but in emotional move- 
ments both sides acted symmetrically. 
The pupils were equal, regular and re- 
active to light. Common sensibility 
appeared to be preserved everywhere. 
Emotional mobility was distinctly in- 
creased. The action of the heart was 
rhythmic. The first sound was clear, 
the second ringing. The radial tension 
was moderate. 
The patient admitted having had gon- 
orrhea two years previously, but denied 
other venereal history. He drank alco- 
holics moderately, though constantly, 
and he used tobacco excessively. On 
one occasion, two years before, while 
working in the sun, he became uncom- 
fortable, subsequently suffering from 
what was designated typho-malarial 
fever, which kept him in bed for nine 
weeks. 
This case well illustrates the liability 
to repetition that is present in every 
case of cerebral hemorrhage, but it is 
particularly interesting because the 
symptoms,if viewed by themselves,might 
cause embarrassment in the diagnosis. 
Objectively there is present left hemiple- 
gia with partial aphasia, an association 
that would appear paradoxic in the ab- 
sence of a history of repeated attacks. 
As it is, the onset in each instance was 
unattended with pronounced manifesta- 
tions and it is just conceivable that in a 
given case these might be so slight as 
either to entirely escape notice or not to 
have accorded to them their true sig- 
nificance. It is further to be borne in 
mind that lesions of the right cerebral 
hemisphere may be attended with more 
or less protracted disturbance of speech, 
as the second of the cases here reported 
shows. Inasmuch as each side of the 
body is, through the decussation of 
fibers in the medulla, innervated from 
both sides of the brain, though in pre- 
dominant degree from the opposite side, 
it is reasonable to infer that a lesion of 
either side of the brain would be at- 
tended with some disturbance of func- 
tion on both sides of the body. In this 
connection it is to be remembered that 4 
in exceptional instances the decussation 
may not take place in the medulla or a 
smaller number of fibers than usual 
participate in the decussation. In the 
same way, while the speech-function is 
in right-handed persons controlled from 
the left cerebral hemisphere, it is prob- 
able that the right hemisphere is also 
not without influence (latent or unde- 
veloped though this may be) upon this 
function, as is shown by its vicarious 
assumption after destruction of the 
special-center for speech in the left hem- 
isphere. In left-handed persons the 
speech-center may be primarily devel- 
oped upon the right side of the brain. 
It may, therefore, be concluded that a 
lesion in or about the third frontal con- 
volution on the right side of the brain 
may be attended with aphasic disturb- 
ance of speech, from which recovery 
will ensue with a readiness inversely 
proportionate to the education of this 
portion of the cerebrum in the processes 
of speech-control. 
As is well known, miliary aneurism 
is the condition most commonly ante- 
cedent to rupture of a cerebral vessel, 
and, as the bulging is usually multiple, 
the hemorrhage is prone to be repeated. 
The accident, apart from traumatism, is 
confined almost exclusively to the de- 
generative period of life, viz., after the 
fortieth year. Hereditary predisposition 
is not without influence in the etiology: 
but the most potent factor is to be found 
in the infections, which are so often re- 
sponsible for the disease of the vessels 
without which rupture rarely takes 
place. 
J. R., a team-driver, fifty years old, 
presented himself at Howard Hospital on 
October 2, 1896, stating that while driv- 
ing, some nine months previously, his 
horses became scared and ran away. 
He himself became giddy and fell, suf- 
fering a contusion in the left frontal 
region. He was sent to a hospital, but 
was able to walk home the same day, 
albeit somewhat bewildered and in a 
staggering fashion. There was, how- 
ever, no obvious palsy. 
After reaching home the man had a 
protracted convulsion, with loss of con- 
sciousness, general movements, and bit- 
ing of the tongue. In the course of a 
half-hour a second convulsive seizure 
took place, much like the first, although 
shorter in duration. For a week after 
these attacks the man appeared dull 
and unintelligent, and failed to control 
his sphincters. Then he began to im- 
prove, and he so continued to do for a 
period of two months. 
He now returned to work, and while 
driving became paralyzed upon the left 
side of the body, without loss of con- 
sciousness. After being brought home 
he had two convulsive seizures similar 
to his earlier ones. These attacks were 
then repeated every five, six, or seven 
weeks, but presented no special feature. 
They were usually followed by head- 
ache, without apparent focal signifi- 
cance. He was subsequently drowsy 
and apathetic, and his speech a little 
thick. 
The patient presented the usual 
symptoms of left hemiplegia. The knee- 
jerk was spastic and apparently alike on 
both sides. Ankle-clonus also was pres- 
ent, in more pronounced degree and 
longer maintained on the right. It 
appeared on the left side with extension 
of the foot, as well as with flexion, and 
it could be induced on both sides also 
by the front tap. The dynamometric 
reading was sixty on the right and forty- 
two on the left. The face was asym- 
metric, the left side of the mouth being 
relaxed (the patient said that it had 
always been so), although the left side 
of the face was at least equally active 
with the right. The tongue was pro- 
truded in the median line. There was 
no tenderness of the scalp on percus- 
sion. The left pupil was slightly larger 
than the right. Both reacted. Dr. 
Franklin D. Castle kindly examined the 
fundus and reported only slight dilata- 
tion of the retinal veins. The urine 
presented no abnormality. 
The patient was unduly emotional 
and worried a good deal about his con- 
dition, being in especial fear of a 
recurrence of the convulsions. He had 
for many years had some little difficulty 
in controlling his urine, and had also 
suffered from headache of neuralgic 
character. The radial artery was resis- 
tant and the vascular tension increased. 
The action of the heart was rhythmic; 
the first sound was booming, the second 
ringing. 
The patient had had typhoid fever, 
malarial fever, and diphtheria, but no 5 
history or evidence of venereal infection 
could be obtained. He had used tobacco 
freely and alcohol moderately. 
A prescription containing ten grains 
of sodium bromid and five grains of 
potassium iodid was given, to be taken 
thrice daily, the proportions being grad- 
ually modified until they became five 
grains of the bromid and fifteen of the 
iodid. Subsequently a prescription con- 
taining one-twenty-fourth grain of mer- 
curic chlorid and fifteen grains of potas- 
sium iodid was substituted. The patient 
made progressive improvement and had 
no convulsion during a period of four 
months, in which time the dynamomet- 
ric reading had increased to ninety-one 
on the right and seventy-four on the left. 
The interpretation of the entire series 
of events in this case is not entirely free 
from difficulty. Whether, in th$ first 
place, the patient fell in his wagon as a 
result of some cerebral disturbance, or 
whether this, together with the subse- 
quent convulsions, is to be attributed 
to the traumatism and concussion (per- 
haps laceration) of the brain attendant 
upon the accident, cannot be definitely 
decided, though I am inclined to favor 
the latter view. It is also not impossible 
that hemorrhage took place in a portion 
of the brain not in close relation with 
the motor area. The absence of focal 
symptoms would seem to exclude a gross 
lesion, such as hemorrhage or lacera- 
tion, and the temporary recurrence of 
the attacks must be related to the 
maintenance of a state of cortical irrita- 
tion induced by the accident. The 
second stage of the disease, that is, the 
left hemiplegia, is obviously to be re- 
ferred to hemorrhage into the right 
cerebral hemisphere. 
As will be noted, all of the cases 
reported are in males. Two occurred 
rather early in life, and in one of these 
a cardiac lesion was present. All had 
suffered from one or more infectious 
diseases and all had been accustomed 
to the use of tobacco and alcohol. In 
three the symptoms set in without loss 
of consciousness, and in one during 
sleep. In three of the four the palsy 
was left sided. In three also there was 
evidence of increased arterial tension, 
the fourth presenting obstruction at the 
mitral orifice, probably associated with 
myocarditis.