Case of Tubercular Meningitis, with Measure- 
ments of Cranial TemperatureSj/^yDfcgg 
Mary Putnam-Jaoobi, M. D. 
[Reprinted from the Journal of Nervous and Mental Disease, Jan.,1 
1~N the child, an infant of 22 months, upon whom the 
ing observations were made, a general miliary tuberculosis 
as developed from the broncho-pneumonia of measles, of 
which there was an attack about the middle of August. It was 
under observation for a month, with general and pulmonary 
symptoms, but without any cerebral symptoms whatever. 
These first, appeared on the 9th of October, and consisted in 
drowsiness, vomiting, retractions of the head with rigidity, 
hard irregular pulse, Cheynes-Stokes respirations; apathy suc- 
ceeding to restlessness and constant crying; beginning retrac- 
tion of the abdomen instead of the tympanitis hitherto exist- 
ing. 
The first cranial temperatures were taken the day following 
that on which these symptoms were first observed at the dis- 
pensary. They are compared with the normal average, as 
given by Dr. Gray: 
Right vertical, - - - 95^° 
Left “ - - 95£ 
Normal average, 91.67° 
Right frontal, - - - “ “ 93.71 
Lett “ - - “ “ 94.36 
Right occipital - - “ “ 91.94 
Left “ - - - 99} “ “ 92.66 
On this day the parietal temperatures, just above the ear, 
were not taken. 
On the 12th of October, the following temperatures were 
obtained : 
Right frontal, - - - 98f° Normal average, 93.71° 
Left “ - - 97i “ “ 94.36 
Right parietal, - - 97£ “ “ 93.59 
Left “ - - 96} “ “ 94.44 
Right, occipital, - - 96} “ “ 91.94 
Left “ - - 96 “ “ 92.66 
Right vertical, - - - 95£ 
Lett “ - - 95} 
“ “ 91.67 2 
Putnam-Jaoohi— Tubercular Meningitis. 
Rectal temperature still 102. On the 14tli the temperatures 
were taken for the third and last time. 
The meningitis was then passing into the third or paralytic 
stage, and paralysis of the right arm occurred in the evening. 
In the morning of that day the rectal temperature was 95). 
The pupils dilated, but equal. 
Right frontal, - - - 95£° Normal average, 93.71' 
Left “ - - 934 “ “ 1 94.36 
Right parietal, - - - 944 “ “ 93.59 
Left “ - - 944 “ “ 94.44 
Right occipital, - - “ “ 91.94 
Left “ - - 92£ “ « 92.66 
Right vertical, - - - 924 
Left “ - - 94 
“ “ 91.67 
The child died the next day; an autopsy revealed the ex- 
pected generalized miliary tuberculosis, and the following 
lesions in the brain which I alone transcribe: 
EXAMINATION OF THE J5RAIN. 
Dura adherent in several places to skull. Internal surface 
adherent in several places to visceral arachnoid. 
About £ pint sanguinolent serum escaped during removal 
of brain from skull. Much escaped upon first opening dura, 
showing that it came from meshes of pia on convexity. 
In removing dura, the surface of the brain was found pale, 
shining, soft, evidently highly (edematous. The surface was 
less rather than more vascular than usual; convolutions slightly 
flattened. 
The arachnoid connecting the convolutions was in sev- 
eral places opaque, but generally not adherent; on cutting it, 
the pia lining the sulci was everywhere found injected with 
fine arborizations of varying intensity. Of all examined, 
tbe sulcus between the first and second frontal convolutions 
on the left side, was found the most intensely injected. 
A very large vein was observed to run horizontally around 
the extremity of the frontal convolutions in botli hemispheres. 
The left vein was the largest, and reached backwards as far as 
the external extremity of the anterior central convolution. 
On the left side the three frontal convolutions were tolerably 
firm. But at the anterior tip of the inner part of the first Putnam-J a Gobi—Tnl>ercular Meningitis. 
3 
were several minute patches of opacity in the arachnoid. An 
inch further back, in the first subsulcus, were opacities extend- 
ing all along a blood vessel lying in the sulcus, and three dis- 
tinct yellowish patches crossing it. 
The posterior extremity of this first frontal convolution pre- 
sented a group of radiating opacities just at the edge of the 
longitudinal fissure of the brain, and extending back to the 
anterior central convolution. External to this, an intensely 
injected patch about £ inch square with a minute hemorrhage 
extending into the praecentral sulcus. 
The inner extremity of the anterior central convolution was 
injected, and with two or three quite distended vessels, for a 
distance of one inch from margin of fissure. 
In the fissure of Rolando, and in the sulcus praecentralis, 
the arachnoid was opaque, the pia, injected, adherent, and 
with minute tubercles along vessels. 
In the sulcus calloso-marginalis and over the gyrus forni- 
catus, the pia was infiltrated with minute elevated opacities. 
The superior lobule of the parietal lobe, also superior part 
of the occipital lobe, were free from injection, opacities, or 
softening. 
Right Hemisphere.—Anterior tip of the first frontal convo- 
lution presented a patch of softening, occupying the entire 
breadth of the convolution. This was followed by about an 
inch of relatively firm brain substance. Posteriorly to this, 
was another patch of softening extending from the longitudi- 
nal fissure to the superior frontal sulcus. All this portion of 
brain was paler than normal. 
But from the posterior patch of softening, two large veins ex- 
tended backward to the transverse sulcus anterior to the sulcus 
praecentral is. The anterior extremity of the most internal 
of these veins was covered with thickened yellowish opacities, 
presumably tuberculous. Similar deposits infiltrated the pia 
of the sulcus. 
The sulcus praecentralis was occupied by a distended vein, 
immersed in yellowish deposit. Another deposit, the largest 
observed on the convexity, was at the inner extremity of the 
fissure of Rolando. Internally to it, was a patch of infiltration 
extending over the border of the longitudinal fissure. In this 4 
P utn am-J ago hi— T'ubereuldr M eningitis. 
patch, about an inch square, there were no blood vessels, but 
the arachnoid was smooth, white, opaque. 
There was a small amount of infiltration along the middle of 
the inter-parietal fissure. 
On separating the hemispheres, the corpus callosum was 
found to be completely softened and broken down, so that it 
tore at the least touch, exposing the ventricles. These con- 
tained little serosity, this having probably escaped. The ven 
tricles were somewhat dilated. The fornix was completely 
softened. The third ventricle was full of sanguinolent serum. 
The head of the right corpus striatum was very soft. The 
left was tolerably linn. 
The thalami were firm. 
The corpora quadrigemina were firm, as also the peduncles 
passing from them to the cerebellum. 
The superior surface of the cerebellum was firm and not 
injected. There were no tubercles evident in the choroid 
sulcus or in the tsenia semicircularis. 
The brain was then laid on one side, and the lateral convo- 
lutions examined on the 
Left Side.—The pia was infiltrated over the secondary sulci 
of the lateral part of the third frontal convolution. Nothing 
observed over ascending ramus of fissure of Sylvius, nor over 
the superior or middle temporal fissures. 
Right Side.—A patch of softening was found at the angle 
of the supra-marginal convolution, where it curves around the 
Sylvian fissure to meet the inframarginalis of the temporal 
lobe. The primary occipital gyrus of the cuneus was the 
seat of a patch of intense injection, but no infiltration. Entire 
right hemisphere softer than left. 
Base of Brain.—Arachnoid was everywhere thickened and 
opaque, but not injected. Similarly the arachnoid on inferior 
surface of cerebellum. This surface was extremely soft. Right 
olfactory tract and bulb destroyed. The left softened. Pia 
along both Sylvian fissures adherent. On separating the tem- 
poral from the anterior lobes, the Sylvian fissures were found 
occupied by a fibrinous exudation, infiltrated with a viscid 
amber colored fluid. 
The tip of the left temporal lobe—i. e., the anterior part P utn am- J a com-— Tubercular Meningitis. 
of the second temporal convolution—was completely softened, 
over a space the size of a walnut. In the anterior part of this 
softened patch was a cavity, which might have contained a 
filbert. This cavity was completely empty, but evidently of 
recent origin and probably contained pus, which had escaped 
with the other fluids during the removal of brain. The 
cavity was lined by no membrane. This was the only focal 
lesion found. There were not even any agglomerations of 
pus around cranial nerves; no yellow tubercle at base; no 
pus. A section was made along the left peduncle, through 
the left corpus striatum to corona. The entire tract was 
found healthy. A band of fibres passed from tip of temporal 
lobe into the corpus striatum, and were easily to be distin- 
guished. This was evidently the band described by Meynert 
as the second form of his first projection system : “ A bow 
shaped bundle, passing from the cortex of the tip of the tem- 
poral lobe, which runs the length of the inner wall of the 
corpus striatum, until it passes into the anterior territory of 
its head as the stria cornea.” {Strieker''s Handbuch, Bd. I., 
p. 725.)* 
Comparing the details of the autopsy with those of the 
thermometric measurements, we find : 
That on the fourth day of manifest cerebral symptoms, the 
temperature of the right frontal region, which, according to 
our standard, should be 0.65 lower than the left, was 0.75 
higher than the left, and 3.29 higher than normal. On the 
fifth day the temperature in this region was a degree and a 
half higher still, while the temperature of the left had risen 
only £ of a degree. On the sixth day—two days before death 
—when the rectal temperature was slightly subnormal, and 
collapse evidently beginning, the temperature of the frontal 
region, though fallen, still remained higher on the right side 
than on the left, and 1.79 above normal; while on this day 
the temperature of the left frontal region had fallen 0.86 
below normal average. At the autopsy was found a patch 
of softening at the anterior extremity of the frontal lobe 
*Ferrier’s destructive and electrical experiments were made on the 
superior temporo-sphenoidal convolutions, and not on the middle nor at 
the tip of the lobe. 6 
1 VtnaM-fl acobi— Tubercular Meninyitis. 
(see nt supra)' indicating a localized encephalitis, that corres- 
ponded very well to this high temperature. 
Again, on the fourth day of the cerebral symptoms, the 
temperature in the occipital region on both sides was 99.£, an 
excess of 7.31 and of 6.59 over the normal. This excess cor- 
responded well with the inflammation of the pia, covering 
the inferior surface of the cerebellum, at the base around 
the chiasma, and in the Sylvian Assures. The temperature of 
the vertical regions, on the other hand, was lower than any 
other part of the head, being 95£ and 95£, until the com- 
mencing collapse at the time of the third measurement. This 
fact corresponded well with the moderate degree of inflam- 
matory lesion on the convexity of the brain discovered at the 
autopsy. It would have been interesting to have examined 
the temperatures at various parts of the convexity, and have 
compared them with those obtained at a point presumed to be 
near the Assure of Rolando, where was present the maximum 
of convexity lesion (excluding the encephalitis of the right 
frontal lobe). 
Tt is noticeable, however, that on the flrst two days, the 
right vertical region was hotter than the left by half a degree, 
although normally it should be a trifle cooler. 
But when the general collapse of temperature, accompany- 
ing the cerebral effusion, set in, the right vertical temperature 
fell to H degree below the left. 
In view of the abscess of the tip of the left temporal lobe, 
it is much to be regretted that the parietal temperatures were 
not taken on the first day. But on the second (four days 
before death) the temperature was elevated much above the 
normal—3.91 on the right side and 2.06 on the left. Thus 
the highest temperature, and the greatest excess of temper- 
ature, did not correspond to the side on which existed evi- 
dences of the most marked inflammation. It seems probable 
that from the situation of the abscess, its temperature could 
not have been ascertained by measurements on the surface of 
the skull.