A Case of General Paralysis 
Apparently of Traumatic 
Origin. 
BY 
E. A. CHRISTIAN, M. D., 
Pontiac, Mich. 
Keprint 
FROM 
The American Journal of Insanity, 
Utica, April, 1888. POSTERIOR. PORTION OF INTERNAL SURFACE OF 
OCCIPITAL BONE. 
At a there was separation of the edges of the fracture with corresponding 
over-riding at b. A, the groove for the lateral sinus. F, foramen 
magnum. /, parieto-occipital suture. A CASE OF GENERAL PARALYSIS APPARENTLY OF TRAU- 
MATIC ORIGIN. 
BY E. A. CHRISTIAN, M. D., 
Assistant-Physician, Eastern Michigan Asylum, Pontiac, Mich. 
The accompanying notes of a case of extensive fracture of the 
base of the skull have been deemed of sufficient interest to justify 
their publication as a contribution to the clinical study of some of 
the more remote consequences of a traumatic basal meningitis. 
Among the points of special interest may be noted the existence 
of an external wound apparently of trifling importance, having 
little in itself to indicate the extent to which injury had been 
inflicted upon the skull; an absence at the time of the injury of 
signs of compression, such as prolonged loss of consciousness, 
paralysis, etc.; the development after a few days of acute 
delirium and fever, pointing to inflammation of the membranes, 
but without accompanying paralysis ; recovery from acute 
symptoms succeeded by a stage of mental weakness, passing slowly 
into a state of more profound intellectual disturbance, and a 
slowly developing paresis and incoordination of muscular move- 
ments; the existence of certain signs pointing to implication of 
the cerebellum, the most prominent of which was a disturbance of 
equilibrium; death five months subsequent to the receipt of the 
injury from sudden and total paralysis of voluntary motion. 
At the autopsy there were found evidences of long standing 
inflammation both of dura and pia which had finally led to com- 
pression of the cord by an abundant effusion of serum into the 
sub-arachnoid spaces in the vicinity of the medulla. There was 
also an extensive fracture with slight displacement of the occipital 
bone. Symmetrical spots of softening existed on the inferior 
surfaces of both lateral lobes of the cerebellum. These were 
probably due to the slight but prolonged pressure exerted by the 
fractured plate of bone. 
The symptoms which the patient presented at the time of his 
admission to the asylum were quite characteristic of general 
paresis, and seemed to warrant a diagnosis of paralytic dementia 
of traumatic origin ; and in the light of the subsequent history of 
the case we are tempted to wonder if after all general paresis may 
not have been the primary condition, complicated by an acute 
proces-s, and possibly hastened in its course by the injury itself. 2 
Unfortunately a microscopical examination of the brain was not 
practicable. 
L. M. T., age 53, a commercial traveler, had been a moderate 
drinker for many years. Previous to the great Chicago fire he had 
been a prosperous business man in that city, but loss of property, 
domestic infelicities and dissipated habits had combined to make 
the last ten or twelve years of his life unsuccessful. It was the 
opinion of his family physician that he had been losing mental 
vigor for several years previous to meeting with the injury. 
On May 8, 1887, he was thrown heavily upon a stone, receiving 
the force of the blow upon the left side of the occiput. He is 
said to have been unconscious when picked up by the friends who 
were with him at the time, but upon reaching home after a ride of 
an hour in a wagon, he recognized his sister and was able to speak 
to her. The physician who was summoned found him vomiting 
frequently and suffering from shock, but able to render some 
assistance to himself. An irregular scalp wound not more than an 
inch in length presented itself, at the bottom of which there 
appeared to be a slight depression of the external table. The 
doctor observed no symptoms warranting, in his estimation, 
operative interference, and at once closed the scalp wound, which 
healed kindly in a few days without suppuration. 
On the third day following the receipt of the injury the patient 
grew restless and manifested a tendency to wander in his 
conversation. This condition soon gave place to one of active 
delirium accompanied by a rise of temperature. Acute symptoms 
persisted for ten days, during which period his condition much of 
the time demanded the exercise of manual restraint to keep him 
in bed. His friends noticed at this time that his hand grasp on 
both sides was feeble, and that there was an uncertainty in his 
voluntary movements, more particularly noticeable when reaching 
for objects. As his delirium subsided he complained frequently of 
pain in the back of his head, and when occasion arose for a change 
of position he supported himself on his elbows and rotated his 
head with his body. Later he was reluctant to leave his bed, and 
seemed to distrust his ability to make proper use of his lower 
extremities. It then became noticeable that there was marked 
ataxia. As his sister expressed it, he seemed unable to " measure 
distances." He had difficulty in preserving his equilibrium, 
especially when turning around. Sudden changes of position, as 
in rising from a sitting to a standing posture, were especially 
liable to provoke staggering with subjective sensations of loss of 3 
balance. There had been constantly present more or less dis- 
comfort at seat of injury, often amounting to severe occipital 
headache. Momentary flushing of face with prominence of 
superficial veins were a frequent manifestation. 
After the subsidence of the active delirium there remained a 
condition of mental weakness associated with confusion of ideas. 
This varied in degree from time to time, but was always such as to 
require that he be kept under constant observation. He became 
self-willed and petulant, occupied himself in apparently purpose- 
less acts, and showed loss of memory, especially for recent events. 
Notwithstanding the existence of varying delusions, some of an 
expansive type, his conversation was coherent and his reasoning- 
plausible. 
At the time of his admission to the Eastern Michigan Asylum, 
in September, 1887, four months after the date of his injury, he 
was controlled by the belief that he had large bodies of troops at 
his command, and that he was attended by an invisible double 
named "Jack." His mind was also fertile in schemes for the 
invention of machinery. Physically he seemed reduced. Tem- 
parature was normal, but his pulse and respirations were accel- 
erated. The chief symptoms, however, pointed to a lesion of the 
nervous system. He spoke hesitatingly and with decided thickness 
of articulation. Gait was markedly ataxic. He walked with wide 
base of support, and experienced difficulty in moving over uneven 
places. Sudden turning of his head to the left was immediately 
followed by an abolition of equilibrium and a fall to the floor. 
He was, however, able to turn his head slowly in this direction, 
and to hold it there without loss of balance, but not without more 
or less pain. He could not lie on his left side at night without the 
development of distressing vertiginous sensations. There were 
in addition certain subjective symptoms. He complained fre- 
quently of a feeling as if cold water were trickling down his legs, 
and of a strange feeling in the left side of his brain, as if a big 
lump were there. He thought that if he could get rid of that he 
would be all right. He talked pleasantly and with some appre- 
ciation of his condition; but there was constantly present in his 
conversation a disposition to reduplicate final words. His extrav- 
agant delusions and marked ataxia, taken in connection with a 
history of previous intemperance and of a loss of mental vigor for 
some time prior to the accident, certainly justified a diagnosis of 
general paralysis in an advanced stage. But the locality of the 
injury and certain other symptoms sufficiently detailed above 4 
suggested, even at this time, the presence of cerebellar lesion. 
He improved rapidly under treatment, both mentally and phys- 
ically, so that at the expiration of a month he seemed to have 
dropped his delusions and to have gained in mental vigor. He 
was able at this time to go out with other patients to pick up 
potatoes, and felt pleased that be was able to do something useful. 
The ataxia and the distress about his head underwent little change. 
He spoke of these troubles frequently, and expressed much concern 
about them. 
On the morning of October 24th, a little more than a month 
after his admission, he complained of not feeling well. He soon 
became nauseated and had frequent calls to pass his water, accom- 
panied by a severe pain in testicles. There were also distressing 
vesical and rectal tenesmus. Two hours subsequently he was dis- 
covered by an attendant at stool, helpless and unable to rise. 
When assisted to his feet and supported for a minute, he regained 
sufficient power over his legs to support his weight. Attempts to 
dress himself were attended by such violent choreiform movements 
of his arms as to compel a discontinuance of the effort. The same 
difficulty accompanied his attempts to walk. His feet and legs 
flew about independently of efforts of the will to direct them. He 
had vomited repeatedly. The matter ejected consisted principally 
of the juices of the stomach, and was expelled in a jet without 
warning or accompanying nausea. There were no intellectual 
disturbances. A little later, as he lay on the bed, there occurred 
at intervals of a few seconds, severe clonic spasms of the flexor 
muscles, especially of the arms. The only pain complained of was 
an occasional twinge following the course of the sciatic nerve. 
He could not support himself in a sitting posture, and when raised 
from the bed he complained of intense vertigo and nausea. 
Reflexes at this stage were all normal. 
Towards evening bis temperature fell to subnormal (96° F.) 
Efforts at articulation became more labored, deglutition slowly 
failed, paralysis of voluntary movements progressed and finally 
became absolute. Owing to the difficulty in breathing, which was 
from the first thoracic, it was necessary for him to pass the entire 
night propped up in bed with his bead supported by an attendant 
to prevent its falling forward upon his chest. From the first 
sensation was intact, and the'slightest movement of his head caused 
him to cry out with pain. His intellect remained clear up to within 
a few minutes of his death, which finally resulted from failure of 
respiration eighteen hours after the appearance of paralytic 
symptoms. 5 
Post-mortem examination held four hours after death. Skull- 
cap of normal appearance. Dura generally thickened and adherent 
to inner surface of bone, and separated with difficulty, tearing in 
spots where adhesions were firmest. The superioi' longitudinal 
sinus through a portion of its extent showed evidences of an inflam- 
matory process. The walls were thickened and the inner coat had 
a pink appearance with numerous bead-like vegetations projecting 
from its surface. There were no signs of a thrombus. Along the 
vessels of the pia there was the usual milky exudate frequently 
met with in cases of insanity. An explanation of the symptoms 
of pressure upon the anterior colunms of the cord was found on 
lifting the medulla from its groove in the basilar process of the 
occipital bone, when several drams of straw-colored serum escaped 
from between the membranes. Along the floor of the skull the 
dura was even more closely attached to the bone than at the vault. 
It was every where thickened and presented a dirty white appear- 
ance. As the membrane was raised from the surface of the 
occipital bone there at once came into view the remains of an 
extensive fracture which had involved in its course the groove for 
the lateral sinus on the left side, both fossae, and the foramen 
magnum. The course and extent of the line of fracture is well 
indicated in the accompanying illustration. On the right side 
there was some over-riding of the edges of the fracture, and on the 
left side a corresponding separation easily admitting the handle of 
the scalpel. Over a corresponding area the surface of the bone was 
rough, presenting the appearance of bony granulations springing 
from the endosteum. Notwithstanding the great extent of the 
line of fracture there were no vestiges of any former laceration 
of any meningeal vessel. The inferior surfaces of both cerebellar 
hemispheres presented symmetrical spots of softening involving 
only the grey matter of the convolutions. The one on the left 
side was somewhat the larger, not more than one-half inch in 
diameter. In color the softened portions did not differ materially 
from the contiguous healthy tissue. There was no collection of 
pus visible at any point, either externally to the membrane, or 
within the brain. Cross sections of the brain were made without 
discovering further gross lesions. The intra-ventricular fluid was 
normal in quantity. There were no evidences of vascular changes.