CASE OF RUPTURE OF THE BLADDER DURING LITHOLAPAXY ; SUTURE ; RECOVERY
CLINICAL NOTES. much of what is seen in the pseudo-paralysis of Parrot. Diffuse, tender, painful swellings existed on the bones of both forearms and on both tibise ; these were said to have been present for about a week and to have caused the child a great deal of suffering. Some of the other long bones were rather tender on manipulation but no swellings other than those mentioned were noticed. There were no teeth erupted. Scurvy rickets was diagnosed and the usual treatment for that affection
... dopted, with the result that immediate improvement occurred and in a comparatively short time all the swellings, pain, and tenderness disappeared and the child appeared to be quite well. Sixteen months later the woman came again with a younger,child, aged ten weeks. The mother was then looking ill, anaemic, and apparently suffering from want of food. She stated that whilst she was pregnant with this child her husband had been out of work and they had been very badly off, with the result that she had been short of food. She had, however, had plenty of milk in the breasts and the child had had nothing whatever but this. When nine weeks old a swelling appeared about the upper end of the right tibia, which was tender and painful, and the leg became, in the mother's words, "quite paralysed." " The child was sent to me as on its first visit to the hospital sarcoma of the tibia had been suspected. When seen the child seemed to be in fairly good condition and the only part affected was the upper end of the right tibia ; here a doughy tender swelling of some size completely surrounded the bone and the child would make no effort to use the limb. Whilst in some doubt as to the diagnosis on account of the fact that the child had been entirely breast-fed, the mother reminded me of the case of her elder child who had been formerly under my care. The mother was directed to continue nursing the child but to give her as well a little orange juice twice a day, at the same time she herself was ordered a mixture containing iron and sulphate of magnesium. At this time too it must be mentioned that her circumstances had somewhat improved and that she was getting at any rate sufficient food. The result of this treatment was immediate and rapid as far as the child was concerned, the swelling on the tibia first became much less tender and in three weeks had almost completely disappeared. The mother was closely examined as to the truth of the history of the feeding and she assured me that she had looked after the children entirely herself and had never left them to the care of others, so that the possibility of their having had food other than what she herself gave them was excluded. At my request she brought the older child to be seen. This child was then healthy and strong, showing no sign of her previous or any other affection, and the mother stated that she (the child) had not ailed in any way since she was under treatment 16 months previously. CAPTAIN, I.M.S.; SUPERINTENDENT, MANDALAY CENTRAL PRISON. THE deceased was a Burman male convict, aged 24 years, In company with several other fellow convicts he was proceeding on transfer from a district jail distant from Mandalay a few hours by rail to the Mandalay central prison. According to the statements of the police escort and of his fellow prisoners he appeared to have been in his usual ,good health and to have made no complaint of indisposition whatsoever during the journey. From the Mandalay railway station the batch of convicts were marched a distance of ,about a mile to the central prison where they arrived at about 4 P.M., the afternoon not being unduly hot. While halting temporarily at the entrance of the prison it was observed that the deceased was in good spirits and was congratulating himself on his transfer to a jail in which he had previously served a term of two years ; he had been released early in 1907. The formal handing over to the jail authorities was then commenced, for which purpose the outer gate was opened and the batch of prisoners marched into the lobby between the inner and outer gates. As deceased in his turn crossed the threshold he was seen to stumble and without uttering sound or cry to fall forward on to his face and to lie motionless. The hospital assistant happened to be in the prison at the time and was on the spot in a few minutes, but life was extinct-the man had evidently died instantaneously. The post-mortem examination was carried out 20 hours after death. The body was that of an adult Burman of good physique. There were no external marks of injury. On opening the chest the pericardium was at once seen to be much distended, displacing the lungs ; on incising it the contents were found to be blood-clot. The anterior portion of the sac was carefully clipped away and the clot cleared out. There was no pericarditis. The heart was empty and appeared small and shrunken. On the anterior superior aspect of the left auricular appendix there was discovered a rent, of tri-radiate shape, through which the tip of the little finger could be readily passed into the cavity of the left auricle, the wall of which was slightly puckered in the neighbourhood, as if there had been a pre-existent bulging during life. The heart was removed and the left auricle slit open at a distance from the tear, but although no undue force was used to effect this the rent was extended, the surrounding tissues being very friable. To the inner aspect of the auricular wall around the rent some recent blood-clot was adherent, but on ' removing this it was found that the deeper layers were partly decolourised and of firmer texture, showing that deposition of fibrin had occurred some time previous to death about the spot which eventually gave way. The deepest layers of the clot were either intimately adherent to, or had entirely replaced, the endothelial coat of the auricular wall, for on gently removing the former the muscular tissue was revealed. The rest of the left auricle, the remaining chambers of the heart, and the valves were, so far as could be seen, normal; the orifices of the coronary arteries were fully patent; there was no atheromatous change visible in the roots of the great vessels ; nor was there hypertrophy or dilatation of the heart itself except in the immediate vicinity of the rupture. No gummatous deposit was found in the myocardium nor was there naked-eye evidence of subjacent fatty change. With regard to the other organs, the liver and spleen were both slightly over weight (3 pounds . 10 ounces and 9 ounces respectively) but did not present any obvious morbid change; otherwise nothing at all abnormal could be found. The brain was not examined. Rupture of the heart is a rare condition : rupture of an auricle must be a very uncommon event. Sudden death, . though not invariable, is the rule (71 out of 100 cases collected by Quain). According to Osler 1 either fatty infiltration or degeneration, acute softening following on . embolism of a branch of the coronary artery, suppurative j myocarditis, or gummatous growth is the usual predisposing, and exertion the immediate exciting, cause. Coates, however,:1 expresses a doubt as to whether fatty degeneration alone is competent to bring about a rupture of the heart. In the case described no cause for the rupture was demonstrated, though it is probable that a more detailed and fuller search might have discovered it. SURGEON TO THE MISSION HOSPITAL, DERA ISMAIL KHAN. A GIRL, aged two and a half years, nationality Jat, was admitted to hospital on Feb. 29th, 1908, for stone in the bladder. On March 2nd she was operated on ; there was not much difficulty in crushing the stone. When 10 grains had been washed out and one or two grains remained in the bladder the bladder gave way. The abdomen was opened by a two and a half inch incision, such as is made in suprapubic cystotomy. The bladder was found to be ruptured to the extent of three-quarters of an inch on the posterior aspect; this was closed by a double row of catgut sutures ; the bladder was filled with lotion and found not to leak. The abdomen was closed and two hours after the operation urine was passed naturally. The wound healed well for nine days. On the tenth day a stitch abscess was found at the lower end of the wound, and two days later another at the upper end ; these caused the wound 1 Principles and Practice of Medicine, second edition. 2 Manual of Pathology, third edition.