7.3.2: From the *Report of the Henry Phipps Institute Vol. 2*

From Report of the Henry Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis. (Philadelphia: Henry Phipps Institute, 1906). 94-99.

No cases of tuberculosis of the bones of the “skull with secondary involvement of the meninges” have come under our observation during this year.

ACUTE LEPTOMENINGITIS.

Number of brains upon which report is based—78

Number of cases—5

In three of these cases tuberculous meningitis was restricted to one area of the brain.

// the differences in methods //

// between the sources cited in this project //

// is bewildering //

In two of the three cases the meningitis was restricted to the posterior fossa, affecting the cerebellum, the pons, and the medulla. One case was the usual type of extensive tuberculous meningitis affecting the base and the convexity. One case presented a proliferative type affecting the meninges of the brain and the spinal cord.

// between case study and statistical analysis //

// between personal account and polemic //

The occurrence of localized forms of meningitis in advanced cases of tuberculosis is of considerable interest. One of the cases of tuberculous meningitis restricted to the posterior fossa of the brain was described in last year’s report.

// i cannot quite grok the meaning //

// as the molecular examination of a specific case //

// is extrapolated to this study of 83 brains //

The other case follows the same type. A thick plastic exudate was present over the superior surface of the cerebellum, with an inflammation of a minor degree over the inferior surface, the pons, and medulla. The symptoms produced in both cases were not so distinct as would naturally be expected from the extent of the lesion. It should be remembered, however, that both cases were bed cases, in a very advanced stage of tuberculosis, and that disturbance of gait, position, etc., would not be so manifest under such circumstances as they would have been had the cerebral lesions been uncomplicated by the intense weakness and toxemia of the pulmonary condition. Persistent occipital headaches, rigidity of the muscles of the neck, increased reflexes, marked fatigue, and terminal delirium were present in both cases. Neither of the two cases were diagnosed ante-mortem.

TUBERCULOUS MENINGITIS RESTRICTED TO ONE CEREBRAL HEMISPHERE.

This case presented the lesions of a typical tuberculous meningitis confined to one cerebral hemisphere and more particularly to the distribution of the Sylvian artery. The case is of considerable interest both from a clinical and pathological standpoint. It represents, from a pathological standpoint, a method of infection of the cerebral meninges from a pulmonary lesion. The localization of the inflammation in this case to the distribution of one cerebral artery is evidence of the transmission of the infection through the arterial circulation. The case is as follows:

Case No. 3440. Age, twenty-six. Admitted 6–14—’05. Died 8—11—’05.

Two sisters had died of pulmonary tuberculosis. The patient had had the usual diseases of childhood; pleurisy sixteen months ago; and gonorrhea five years ago.

// genetic discourses tied to history //

He had had pulmonary tuberculosis for the last sixteen months, and presented miliary involvement of the entire right lung and of the upper lobe of the left lung.

// the usual, of course, needs to be further investigated //

The pulmonary condition advanced during the two months at the Institute, with, however, gradual reduction in temperature, which varied between 101° and 102°F.

// treatment is cast next to measurement //

// to attune to successes //

The examination of the urine showed acidity, specific gravity 1022, a slight trace of albumin, no sugar, diazo reaction positive, and a few granular and wax-like casts.

// but also to prod, extract, and inspect all aspects //

// of the ill subject //

The patient had two slight hemorrhages, one on July 12th and one on July 24th.

Dover’s powder had been administered on August 1st. On August 2d he had convulsions, Jacksonian in type, beginning in the left arm. He did not complain of headaches, and rested in fairly good condition until August 3d, when he had another convulsion. On August 4th there is a record of four convulsions;

// the inscriptions are so simple //

on August 5th, seven; August 6th, nine; August 7th, thirtyseven; August 8th, fifty; August 9th, fifteen; August 10th, twenty-five, and August 11th, thirty.

// and yet //

On August 7th complete paralysis of the right arm and leg developed, with complete loss of power in the right face. The notes of the examination are as follows:

// i read them with heartache //

“The patient is conscious, understands what is said to him, and obeys simple commands, such as protruding the tongue, closing the eyes, lifting the arm, etc. He is able to repeat simple words, such as ‘yes’ and ‘no,’

// the case study could be another kind of history //

but is unable to hold articulate conversation. The right arm and leg are completely paralyzed and flaccid. The left arm and leg have apparently normal power. The knee-jerk on the paralyzed side is present and quick and weak. There is no ankle clonus on either side.

// but as i read it, I, too, feel sick //

The Babinski reflex is present on the right side. There is some hyperesthesia of the right side. Flexing the arm or the leg produces pain. The pupils are unequal, both more than middle wide, and the left larger than the right. There is no rigidity of the muscles of the neck to-day (slight rigidity was noted in the examination on August 8, 1905).

// because all i can do is reinscribe is pain //

Immediately after the examination the patient had a convulsion which began with slight moaning and clonic jerkings beginning in the right hand and extending rapidly to the face and leg of the right side. The head was turned to the right and the right eye was closed

// because i cannot separate the case //

by a clonic spasm of the orbicularis. Both eyes were rotated to the right. During the convulsions he placed his left hand on the twitching mouth. There is some question as to whether consciousness was entirely lost on account of this movement.

// from the insistence to its publicity //

There were slight twitchings of the muscles of the face. He responded to simple commands immediately after the convulsive movements ceased. If consciousness was lost, it was only momentary. In an attempt to close the eyes in response to a command immediately after a convulsion, the right eye did not close entirely, showing some weakness.

// in the annals of this institute (the henry phipps institute) //

“The diagnosis rests between a localized infiltrating tuberculous lesion confined to the left hemisphere, cerebral hemorrhage, and uremia. The history of the onset points to uremia. The examination of the urine at this time showed only a slight trace of albumin, specific gravity 1026. The mental condition, pulse, and general examination are also against the diagnosis of uremia. The onset, the mental condition, and the localized convulsions are against the diagnosis of cerebral hemorrhage, and therefore in favor of a diagnosis of a localized inflammatory infiltrating tuberculous process of the left cerebral hemisphere.”

AUToPsy REPORT.-Examination of Brain and Spinal Cord.—“On gross examination of the spinal cord there is a localized fibrinous exudate over the entire cervical part of the cord. Examination of the brain shows an acute tuberculous meningitis extending over the upper portion of the temporosphenoidal lobe and over the entire motor area of the left side.

// i had hoped //

The frontal area is edematous; the occipital lobe is not at all involved. The base of the brain is practically normal.

// in this study to do as doctors did to this subject //

There is considerable edema of the left hemisphere. The right hemisphere is normal.

// to cut into the discourse //

Microscopic examination shows inflammatory infiltration of the meninges, with tubercle bacilli in large numbers in the tissues.

// and see how it works //

A careful study of the clinical picture in this case will show the difficulty of making a positive diagnosis. The case, as stated in the clinical notes reported at the time, was at first thought to be one of uremia, on account of the onset of the symptoms after the administration of opium to a patient who had previously shown evidence of kidney disease.

// how perhaps is the wrong term //

The further study of the case led to the rejection of this diagnosis and the consideration of the possibilities of cerebral hemorrhage, cerebral thrombosis, brain tumor, and meningitis.

// to do a postmortem on a postmortem //

While hemiplegia with complications is of frequent occurrence in uremia, and especially where the uremia occurs in individuals with cerebral arteriosclerosis, it is always associated with other evidence of deficiency of kidney function. A careful quantitative and qualitative analysis of the urine reveals evidence of deficiency of elimination.

// to look for traces in whatever residual inscription //

The total quantity of the urine or of its solid constituents (urea, etc.) is diminished. Albumin may or may not be present. Its presence is frequently in small quantities, and often only periodical.

// in the bodies and writings //

This is especially true in contracted states of the kidney. There is also evidence of uremic intoxication in the circulatory system, in the action of the heart, and the high tension of the pulse.

// in the blood, urine, sputum //

The examination of the eye-grounds will sometimes show an albuminuric retinitis. The mental condition of the patient is always an important factor in the diagnosis of uremia. Consciousness is practically never retained when the convulsions are so frequent as they were in the case under discussion. The hemiplegia of uremia, if carefully studied and kept under close and continuous observation, will often be found to be intermittent.

// at best, i suspect, is a scattershot inspection

There will be a diminution or complete disappearance of paralytic symptoms from time to time. In the absence of practically all these symptoms with the exception of the convulsions, the diagnosis of uremia was excluded.

// an exhumation of the subject and not an incision //

The gradual onset of the symptoms, the increasing frequency of the convulsions of a Jacksonian type, the retention of consciousness, and the condition of the heart and pulse excluded cerebral hemorrhage.

// in the obdurate flesh of the systems //

// that sees these people as data //

The frequency and the character of the convulsions excluded the diagnosis of cerebral thrombosis.

The symptoms of brain tumor develop much more slowly and are more frequently associated with changes in the eye-grounds than in this case.

// do i see them as any different? //

The retention of consciousness is of much interest in view of the pathological findings. Consciousness is lost in tuberculous meningitis relatively early in the course of the disease. It is also lost, as a rule, in uremia. It is invariably lost in extensive cerebral hemorrhage.

// do you? //

The retention of consciousness in this case, therefore, becomes of considerable diagnostic value. It indicates that we are not dealing with the usual type of tuberculous meningitis. The convulsions, the hemiplegia, the aphasia, localize the lesions to the left cerebral hemisphere, and especially to the motor area. The rapid development of the symptoms complicating the advanced pulmonary tuberculosis led to a final diagnosis of a localized inflammatory condition of the meninges of the left cerebral hemisphere.

// there is blood on my hands //

// red, it is not mine //

The transmission of the infecting agent from localized tuberculous foci to the meninges has been a matter of discussion for a long time. Where a tuberculous focus is in the immediate neighborhood of the meninges, the transmission may be by direct extension of the inflammatory process or by lymphatic transmission.

// what is there to do? //

Such foci are found in the bones of the skull—the mastoid, middle ear, ethmoid, nasal, and frontal sinuses. Lymphatic transmission in this class of cases is much more frequent than infection by direct extension. When tuberculous meningitis immediately follows operation upon a tuberculous joint, it is difficult to understand how the infection could be otherwise than by direct blood transmission.

// what is there to do? //

Infection of the meninges complicating slight tuberculous lesions of the chest, such as tuberculosis of the peribronchial glands, etc., might be the result either of blood or lymphatic transmission. In very advanced cases of pulmonary tuberculosis with extensive cavity formation various types of tuberculous meningitis may occur.

// what is there to do? //

The presence of tubercles from the size of a millet seed to that of a split pea, in many tissues of the body, in a large number of cases (see pathological report), points to a tuberculous bacteremia. It is surprising that tuberculosis of the meninges is not found with more frequency in such cases. The subacute leptomeningitis described later on cannot be considered as a tuberculous process, but rather as a result of continuous toxic irritation.

In miliary tuberculosis of the meninges the tubercles are found in the greatest number along the course of the blood-vessels. Hektoen has described them within the blood-vessels.