A CASE, DIAGNOSED AS TUBERCULAR MENINGITIS, TREATED BY TREPHINING AND DRAINAGE OF THE SUBARACHNOID SPACE; RECOVERY.1

WM. Wallis Ord, HerbertF. Waterhouse
1894 The Lancet  
ON TUBERCULAR MENINGITIS. was rough and torn at the circumferential parts, but sm oot over the thinner central region. The inner wall, generally thicker than the outer, was bulged towards the cavity and also presented at its central part a rupture, torn rather more widely than the external one; the wall around the rent was oneeighth of an inch in thickness. The valves of the heart did not present any vegetations and did not appear to be incompetent. The left coronary artery when dissected out
more » ... s found o be very atheromatous and showed many thickened patches and local bulgings ; one large branch was distinctly seen to terminate in the right upper part of the cavity ; but it was not possible to inject fluid through the vessel to this place, apparently because of the extensive thickening on account of the blood clot contained in its canal. The wall of the left ventricle, apart from the site of the lesion, was thicker than usual. The right heart was not dilated. Microscopical osmic acid preparations of a portion of the wall of the left ventricle showed fatty degeneration in parts of the sections. The lining of the aorta presented a few small, white, atheromatous patches. There were some old scars containing portions of calcareous matter at the apex of the right lung. There was no emphysema or congestion. The larynx and trachea were normal. The left kidney weighed three and a half ounces and was granular and shrunken. The right kidney weighed four and a half ounces; its capsule tore off portions of its substance on being stripped. The liver and other organs presented nothing noteworthy. Renucrks.-As to the immediate cause ot death, the appearances were those of an aneurysm of a branch of the left coronary artery, which had dissected up the substance of the heart into two layers, the outer one, as would have been expected, being the thinner of the two. In contrast to the condition of the aorta and cerebral arteries, the amount of atheroma of the coronary vessel was very marked indeed, the whole of the vessel from its origin to the aneurysm being affected. Both walls of the sac were found to be Mptured. Perhaps the explanation is that, the outer having ruptured first towards the pericardial sac, the attenuated inner one was not able to withstand the force of the next contraction of the ventricle and gave way too. The fact that the rupture in it was larger than that in the outer wall accords with this supposition. It does not seem to be so likely that the inner one should rupture first and the outer follow ; and, moreover, in such a case one should have expected the Tent in the outer wall to be the larger of the two. The changes in the kidneys, the existence of atheroma, and the hypertrophy of the left ventricle, apart from the aneurysm, -speak for themselves. Certain measurements of the skull and notes of other matters, made chiefly in connexion with the brain, are not given, nor are comments made on the apoplectiform attacks. The case is brought forward at this I time in connexion with the mode of death.
doi:10.1016/s0140-6736(01)67219-2 fatcat:2nl3oaylnvgwvloa6hyyyw6oxi