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THE RELATIONSHIP BETWEEN FEEDING AND THE DEVELOPMENT OF RICKETS.
872 From the
radiological standpoint, if phleboliths Any particles of the preparation should be wiped off the back excepted, shadows in the female pelvis outside of the applicator, and the paste is then ready for application. the urinary tract are very rare. The conditions which Before doing so, a 20 per cent. solution of cocaine should be applied by a small swab to each tonsil and held in position may produce them are calcified areas in a pelvic for one minute. The tongue should now be depressed with tumour, lithopsedion, and dermoid cyst. It might a fairly and kept well out of the way. heavy depressor, be supposed that the recognition of these shadows The anterior of fauces may be drawn to one side by a pillar in a dermoid cyst would be relatively easy, and that suitable instrument, such as a long pair of forceps or heavy therefore the diagnosis ought to be made more probe ; but this is usually unnecessary as, the tongue being frequently. The shadows, however, are not always in position, the pillars of fauces are somewhat forced asunder characteristic of teeth, and, furthermore, only about I and gape, and into the gap so formed the applicator is 25 per cent. of dermoid cysts contain radio-opaque gently inserted and the handle carried towards the opposite side. are
material in the form of teeth or bone. Nevertheless It only requires ? few seconds for the paste to adhere, the occasional help which radiology may give in the and the applicator should be then withdrawn. Free salivation diagnosis of pelvic tumours should be kept in mind, takes place, and the patient should be supplied with a small especially in cases such as that reported, where no vessel for the saliva to drain into, but should be advised to tumour was palpable and the diagnosis could not avoid coughing if possible or clearing the throat. The other tonsil is now treated in a similar manner, and any particles otherwise have been made.
that may have got on to the pillar-though this is rare if the application is properly made-should be wiped away with a swab.
A NOTE ON THE
NON-OPERATIVE TREATMENT OF TONSILS. BY H. NORMAN
BARNETT, F.R.C.S. EDIN.,
SURGEON TO THE BATH EAR, NOSE AND THROAT HOSPITAL.
IN the
experience
cases
in which
of every
laryngologist there must operation-though indicated on surgical principles-for some reason cannot be proceeded with. For such cases anything like the ordinary paints and disinfectants are practically useless, but in London paste " we have an excellent be
"
The site of the application is now inspected and it will be found that a considerable area has become dark red, and there may be a drop of blood, but this is immaterial. After 24 hours a slough will appear, and then will gradually clear off tilat the end of five or six days a considerable amount of the tonsil is found to have been destroyed. The patient has a burning sensation for a minute or so after the application, and usually for 24 hours there is discomfort on swallowing and a certain amount of pain. This chiefly applies to the first application. Occasionally there is distinct constitutional reaction, and pain reaches to the ears and up and down the throat, and in one instance there was enlargement of the cervical glands. All this, however, clears up in a
alternative. Introduced by the late Sir Morell Mackenzie, it consists of equal parts of caustic soda and hydrated lime mixed with a little alcohol. This preparation day or so. The application may be given once a week, and largely dropped-into desuetude, but has been reintroduced by the work of Dr. Irwin Moore, to whom usually it takes about eight applications for an the tonsil is very large and fleshy, great praise is due for having brought to the notice average tonsil; if will be required. Care should be of his colleagues a preparation capable of giving such more than these taken before completing the course to make sure excellent results. He has also eased the way of those who wish to use it by his applicators which are most that the lacuna magna and other follicles with their contents have been destroyed, and it is sometimes admirably formed for the purpose they serve. The type of tonsil to be treated by this means is necessary to ensure this to nibble away some obstrucnot limited, but on the whole I personally prefer that ting bridge of tissue with small cutting forceps. The objective is not necessarily to destroy the the tonsil should be of the smaller buried, or semientire tonsil, but rather its septic parts, and leave a buried, type rather than of the large soft type consmall tonsil lying in its bed. healthy It much is to observe taining very interesting pus. the way in which this preparation acts. After the first application there is a distinct eating away of a considerable part of the tonsil-sometimes of the THE RELATIONSHIP BETWEEN FEEDING AND entire tonsil-the effect evidently spreading from THE DEVELOPMENT OF RICKETS. portion to portion, or as if a slice had been removed. It is well to have a pathological examination of the BY R. C. JEWESBURY, D.M. OXF., F.R.C.P. LOND., tonsil exudate before and after treatment. In my PHYSICIAN-IN-CHARGE OF THE CHILDREN’S DEPARTMENT, ST. THOMAS’S HOSPITAL; cases the streptococcus has been present before, and AND absent after, treatment, which is in itself confirmatory evidence of its value. T. M. LING, B.M. OXF., The feeling of well-being which comes to the JOHN AND TEMPLE RESEARCH FELLOW IN DISEASES OF CHILDREN, ST. THOMAS’S HOSPITAL. patient is marked, and in certain cases after even one application I have known certain rheumatic conditions to clear up in a rather remarkable manner. AN attempt has been made in this study to draw statistical conclusions between the type and method Method of Application. of feeding during the first year of life and the subIn applying the paste a great deal of care has to sequent development of rickets. Six hundred and be taken in its preparation. The powder, which is prefifty cases are considered, and these represent the pared by Savory and Moore, is shaken on to a small number of patients who have attended with a fair opal plaque, absolute alcohol is added drop by drop, degree of regularity at the Infant Welfare Departand mixed by means of a special spatula. The con- ment of St. Thomas’s Hospital during the last four sistency should be that of somewhat thin putty, years. A certain number have been excluded owing and it requires a considerable amount of working up to attendance during either the first or infrequent with the spatula to get the right consistence. No second years, or because they had left the district; hurry should be shown in preparing the paste, as if Mongolian idiots and cases showing any other gross it is not of the proper consistence not only will the are not included. action be less, but there is grave risk that the pre- deformity Method of Feeding.-As far as possible each baby paration will not adhere to the surface of the diseased has been completely breast-fed for eight or nine tonsil. months and then gradually weaned on to cow’s milk Having reached the proper consistence, the paste is now and solid food ; this has been achieved in 368, or taken up from the plaque by means of an Irwin Moore 56 per cent. of the cases. Where complete breastapplicator, which is made in various sizes, though the most useful one will be found to be the one of middle size. The feeding was not feasible, complementary feeds of cavity of this applicator is entirely filled with the paste, cow’s milk modified with water, sugar, and a 50 per and is smoothed just beneath the edge of the hollow space. cent. cod-liver oil emulsion have been given, in
873
approximately breast milk proportions. In certain unsatisfactory, in which case a modified dried milk cases, particularly where the home conditions were was advised, in both instances appropriate quantities unsatisfactory, a dried or condensed milk has been of a 50 per cent. cod-liver oil emulsion being added. used instead of fresh cow’s milk, and in all cases It was only necessary to feed 44 cases artificially the mother’s health has received any necessary from birth, and of these 16 per cent. developed clinical signs of rickets, a marked contrast to the investigation and treatment. Diagnosis of Rickets.-It is gEfuerally recognised 5 per cent. incidence among the breast-fed group. that no reliance can be placed upon any one individual It appeared immaterial whether fresh cow’s milk symptom or sign, such as pallor, sweating, flabbiness or a dried milk was used with regard to the developof muscle, or enlargement of the abdomen ; all these ment of subsequent rickets. may appear in many different conditions of ill-health. In the consideration of these cases emphasis has been laid particularly on enlarged epiphyses and the " presence of a rickety rosary," although the presence or absence of the other well-recognised signs has been considered before a definite diagnosis has been made. In a number of cases X ray photographs ofthe radial epiphyses have been taken to confirm the diagnosis, but this has not been feasible in all instances. It is admittedly impossible to diagnose the activity of the disease without radiological help, but the presence of rickets, either active or healed, can almost always be detected on clinical grounds alone. Great emphasis was laid in the Medical Research Council Report (1919-1922) on the frequency of craniotabes and its value in early diagnosis, but these cases were all studied in Vienna, and we have been struck by its comparative rarity in London ; Parsons1 is of the same
opinion
as
regards Birmingham.
Incidence of Rickets.-Figures naturally vary very much according to locality, social conditions, and the season of the year. A few years ago John Thompson2 stated that more than 50 per cent. of the children in London showed unmistakable signs of rickets, while Hess3 gives approximately similar figures for the 4 poorer districts of New York. Paterson and Darby, working in the spring of 1926, found that 32 per cent. of their cases showed gross or slight signs of the disease clinically. The cases considered here were seen over a period of four years, so that the seasonal factor has been eliminated, and 21 per cent. showed clinical signs of the disease to a varying degree. Rickets in Breast-fed Babies.-Three hundred and sixty-eight, or 56 per cent., were completely breastfed for nine months, and of these 57, or 15 per cent., developed clinical signs of rickets. At first sight this figure may seem unduly high, but appears to These be due chiefly to prolonged breast-feeding. cases attended regularly during the earlier months, particularly if there were any feeding difficulties, but subsequently their attendance lapsed, and breastfeeding was prolonged to 11 months or even longer in 42 per cent. of the cases that developed rickets. Apart from those that had left the district, every case was seen regularly, if possible, during the second year of life, and it was found that in 36 cases breastfeeding had been prolonged unduly, of whom 24, definitely more than half, developed unmistakable signs of the disease. As would be expected, it was found that rickets had been avoided in those cases where mixed feeding had been given as well as breast milk, but the high incidence of disease among those children who were completely breast-fed for this long period is in support of the general clinical impression noted by other writers. This is admittedly an unsatisfactory state of affairs, but very difficult to eradicate among hospital patients who do not appreciate the value of regular supervision during the first two years of life. Deducting these cases of prolonged breast-feeding from the total number of rickets, it appears that only 5 per cent. of the breastfed babies developed clinical signs of disease, while
the social conditions of the cases did not appear to be noticeably worse than the average for the whole group. Although it cannot be claimed that breastfeeding completely precludes the subsequent developof rickets in an urban population, the incidence ment is very much lower than for the whole group. Incidence of Rickets among Artificially Fed Babies.In cases where breast-feeding was not possible or the quantity of breast milk inadequate, cow’s milk mixtures were given unless the home conditions were
Rickets in Premature Babies and Twins.-It has been recognised for a long time that premature babies and twins were particularly liable to the development of rickets, the former owing possibly to a primary deficiency of iron in the liver, and the latter to maternal exhaustion and the subsequent impoverishment of the breast milk. Forty-three premature babies were seen, and 14, or 32 per cent., showed clinical signs of rickets, despite the fact that they had all been breast-fed for at least four months and had subsequently received adequate quantities of cod-liver oil emulsion. Sixteen twins occurred in the group, of whom six showed signs of disease. It is admittedly impossible to generalise from such small numbers, but the incidence of rickets is certainly higher than for the whole group, and suggests the advisability of supplementing the nursing mother’s diet with the fat-soluble vitamins in such cases. Bibliography.—1. Parsons, L.: Diseases of Children, Garrod and Thursfield, London, 1928, p. 110. 2. Thompson, J. : Clinical Study and Treatment of Sick Children, Edinburgh, 1926, p. 226. 3. Hess, A. F.: Abt’s Pediatrics, 1923, ii., 908. 4. Paterson, D., and Darby, R.: Arch. Dis. in Childhood, 1926, i., 36.
RUPTURE OF LEFT AURICLE. BY FREDERIC W.
LONGHURST, M.R.C.S. ENG.
RUPTURE of the auricle is so rare that a case which came under my care seems worthy of record.
recently
The patient, a cook, aged 73, led an exceptionally inactive life, and gave no history of previous illness bearing on the present fatal attack. She had certainly had no serious illness for the last six years, but suddenly felt ill while washing her hair at 10 P.M. She was not intelligent in explaining her symptoms, but complained of a sudden pain down the centre of the chest and into the upper abdomen. She was not unduly distressed or breathless. Her pulse was of good volume and quite regular, with a rate of 80. The heart did not appear to be enlarged ; there was a mitral systolic murmur, the other heart sounds being normal. The systolic blood pressure was 175. A mild
aperient only She had
a
was prescribed. fairly comfortable night,
and the next
appeared normal, with the exception of
some
morning pain, the site
of which was now more in the abdomen. The bowels had acted, and she had walked, one flight of stairs, to and from the lavatory. At noon the same day she suddenly collapsed and became grey and pulseless. Four hours later she had made a partial recovery, after taking alcohol by the mouth, and was moved in an ambulance to hospital. On arrival at hospital she was still cold and collapsed and of a pale grey colour, but was quite capable of a humorous conversation, and her radial pulse was now easily palpable with a rate of 80 and a regular rhythm, although it was very irregular in size, with an occasional dropped beat, and sometimes runs of pulsus alternans. The apex-beat was just outside the nipple line in the fifth space, and neither visible nor palpable. The heart sounds were extremely soft and muffled, with tic-tac rhythm, and only heard at the apex. During the night she became warmer and brighter for a few hours. At 8 A.M. the next day she asked for a drink, but collapsed and died while it was being fetched. ’
r
Post-mortem Examination. The body was that of a heavily built, somewhat flabby woman. The abdominal cavity contained slight excess of clear fluid. The pericardium contained at least one pint of slightly clotted blood. No ante-mortem clot was obvious. There was some effusion of blood into connective tissue around the aorta, reaching into the root the anterior wall of the left auricle was a about one inch in length. The wall of very thin and atrophied. No ulceration noted. The ventricular walls were very
of the neck.
In
large ragged tear the auricle or
atheroma
was was
soft, friable, and
radiological standpoint, if phleboliths Any particles of the preparation should be wiped off the back excepted, shadows in the female pelvis outside of the applicator, and the paste is then ready for application. the urinary tract are very rare. The conditions which Before doing so, a 20 per cent. solution of cocaine should be applied by a small swab to each tonsil and held in position may produce them are calcified areas in a pelvic for one minute. The tongue should now be depressed with tumour, lithopsedion, and dermoid cyst. It might a fairly and kept well out of the way. heavy depressor, be supposed that the recognition of these shadows The anterior of fauces may be drawn to one side by a pillar in a dermoid cyst would be relatively easy, and that suitable instrument, such as a long pair of forceps or heavy therefore the diagnosis ought to be made more probe ; but this is usually unnecessary as, the tongue being frequently. The shadows, however, are not always in position, the pillars of fauces are somewhat forced asunder characteristic of teeth, and, furthermore, only about I and gape, and into the gap so formed the applicator is 25 per cent. of dermoid cysts contain radio-opaque gently inserted and the handle carried towards the opposite side. are
material in the form of teeth or bone. Nevertheless It only requires ? few seconds for the paste to adhere, the occasional help which radiology may give in the and the applicator should be then withdrawn. Free salivation diagnosis of pelvic tumours should be kept in mind, takes place, and the patient should be supplied with a small especially in cases such as that reported, where no vessel for the saliva to drain into, but should be advised to tumour was palpable and the diagnosis could not avoid coughing if possible or clearing the throat. The other tonsil is now treated in a similar manner, and any particles otherwise have been made.
that may have got on to the pillar-though this is rare if the application is properly made-should be wiped away with a swab.
A NOTE ON THE
NON-OPERATIVE TREATMENT OF TONSILS. BY H. NORMAN
BARNETT, F.R.C.S. EDIN.,
SURGEON TO THE BATH EAR, NOSE AND THROAT HOSPITAL.
IN the
experience
cases
in which
of every
laryngologist there must operation-though indicated on surgical principles-for some reason cannot be proceeded with. For such cases anything like the ordinary paints and disinfectants are practically useless, but in London paste " we have an excellent be
"
The site of the application is now inspected and it will be found that a considerable area has become dark red, and there may be a drop of blood, but this is immaterial. After 24 hours a slough will appear, and then will gradually clear off tilat the end of five or six days a considerable amount of the tonsil is found to have been destroyed. The patient has a burning sensation for a minute or so after the application, and usually for 24 hours there is discomfort on swallowing and a certain amount of pain. This chiefly applies to the first application. Occasionally there is distinct constitutional reaction, and pain reaches to the ears and up and down the throat, and in one instance there was enlargement of the cervical glands. All this, however, clears up in a
alternative. Introduced by the late Sir Morell Mackenzie, it consists of equal parts of caustic soda and hydrated lime mixed with a little alcohol. This preparation day or so. The application may be given once a week, and largely dropped-into desuetude, but has been reintroduced by the work of Dr. Irwin Moore, to whom usually it takes about eight applications for an the tonsil is very large and fleshy, great praise is due for having brought to the notice average tonsil; if will be required. Care should be of his colleagues a preparation capable of giving such more than these taken before completing the course to make sure excellent results. He has also eased the way of those who wish to use it by his applicators which are most that the lacuna magna and other follicles with their contents have been destroyed, and it is sometimes admirably formed for the purpose they serve. The type of tonsil to be treated by this means is necessary to ensure this to nibble away some obstrucnot limited, but on the whole I personally prefer that ting bridge of tissue with small cutting forceps. The objective is not necessarily to destroy the the tonsil should be of the smaller buried, or semientire tonsil, but rather its septic parts, and leave a buried, type rather than of the large soft type consmall tonsil lying in its bed. healthy It much is to observe taining very interesting pus. the way in which this preparation acts. After the first application there is a distinct eating away of a considerable part of the tonsil-sometimes of the THE RELATIONSHIP BETWEEN FEEDING AND entire tonsil-the effect evidently spreading from THE DEVELOPMENT OF RICKETS. portion to portion, or as if a slice had been removed. It is well to have a pathological examination of the BY R. C. JEWESBURY, D.M. OXF., F.R.C.P. LOND., tonsil exudate before and after treatment. In my PHYSICIAN-IN-CHARGE OF THE CHILDREN’S DEPARTMENT, ST. THOMAS’S HOSPITAL; cases the streptococcus has been present before, and AND absent after, treatment, which is in itself confirmatory evidence of its value. T. M. LING, B.M. OXF., The feeling of well-being which comes to the JOHN AND TEMPLE RESEARCH FELLOW IN DISEASES OF CHILDREN, ST. THOMAS’S HOSPITAL. patient is marked, and in certain cases after even one application I have known certain rheumatic conditions to clear up in a rather remarkable manner. AN attempt has been made in this study to draw statistical conclusions between the type and method Method of Application. of feeding during the first year of life and the subIn applying the paste a great deal of care has to sequent development of rickets. Six hundred and be taken in its preparation. The powder, which is prefifty cases are considered, and these represent the pared by Savory and Moore, is shaken on to a small number of patients who have attended with a fair opal plaque, absolute alcohol is added drop by drop, degree of regularity at the Infant Welfare Departand mixed by means of a special spatula. The con- ment of St. Thomas’s Hospital during the last four sistency should be that of somewhat thin putty, years. A certain number have been excluded owing and it requires a considerable amount of working up to attendance during either the first or infrequent with the spatula to get the right consistence. No second years, or because they had left the district; hurry should be shown in preparing the paste, as if Mongolian idiots and cases showing any other gross it is not of the proper consistence not only will the are not included. action be less, but there is grave risk that the pre- deformity Method of Feeding.-As far as possible each baby paration will not adhere to the surface of the diseased has been completely breast-fed for eight or nine tonsil. months and then gradually weaned on to cow’s milk Having reached the proper consistence, the paste is now and solid food ; this has been achieved in 368, or taken up from the plaque by means of an Irwin Moore 56 per cent. of the cases. Where complete breastapplicator, which is made in various sizes, though the most useful one will be found to be the one of middle size. The feeding was not feasible, complementary feeds of cavity of this applicator is entirely filled with the paste, cow’s milk modified with water, sugar, and a 50 per and is smoothed just beneath the edge of the hollow space. cent. cod-liver oil emulsion have been given, in
873
approximately breast milk proportions. In certain unsatisfactory, in which case a modified dried milk cases, particularly where the home conditions were was advised, in both instances appropriate quantities unsatisfactory, a dried or condensed milk has been of a 50 per cent. cod-liver oil emulsion being added. used instead of fresh cow’s milk, and in all cases It was only necessary to feed 44 cases artificially the mother’s health has received any necessary from birth, and of these 16 per cent. developed clinical signs of rickets, a marked contrast to the investigation and treatment. Diagnosis of Rickets.-It is gEfuerally recognised 5 per cent. incidence among the breast-fed group. that no reliance can be placed upon any one individual It appeared immaterial whether fresh cow’s milk symptom or sign, such as pallor, sweating, flabbiness or a dried milk was used with regard to the developof muscle, or enlargement of the abdomen ; all these ment of subsequent rickets. may appear in many different conditions of ill-health. In the consideration of these cases emphasis has been laid particularly on enlarged epiphyses and the " presence of a rickety rosary," although the presence or absence of the other well-recognised signs has been considered before a definite diagnosis has been made. In a number of cases X ray photographs ofthe radial epiphyses have been taken to confirm the diagnosis, but this has not been feasible in all instances. It is admittedly impossible to diagnose the activity of the disease without radiological help, but the presence of rickets, either active or healed, can almost always be detected on clinical grounds alone. Great emphasis was laid in the Medical Research Council Report (1919-1922) on the frequency of craniotabes and its value in early diagnosis, but these cases were all studied in Vienna, and we have been struck by its comparative rarity in London ; Parsons1 is of the same
opinion
as
regards Birmingham.
Incidence of Rickets.-Figures naturally vary very much according to locality, social conditions, and the season of the year. A few years ago John Thompson2 stated that more than 50 per cent. of the children in London showed unmistakable signs of rickets, while Hess3 gives approximately similar figures for the 4 poorer districts of New York. Paterson and Darby, working in the spring of 1926, found that 32 per cent. of their cases showed gross or slight signs of the disease clinically. The cases considered here were seen over a period of four years, so that the seasonal factor has been eliminated, and 21 per cent. showed clinical signs of the disease to a varying degree. Rickets in Breast-fed Babies.-Three hundred and sixty-eight, or 56 per cent., were completely breastfed for nine months, and of these 57, or 15 per cent., developed clinical signs of rickets. At first sight this figure may seem unduly high, but appears to These be due chiefly to prolonged breast-feeding. cases attended regularly during the earlier months, particularly if there were any feeding difficulties, but subsequently their attendance lapsed, and breastfeeding was prolonged to 11 months or even longer in 42 per cent. of the cases that developed rickets. Apart from those that had left the district, every case was seen regularly, if possible, during the second year of life, and it was found that in 36 cases breastfeeding had been prolonged unduly, of whom 24, definitely more than half, developed unmistakable signs of the disease. As would be expected, it was found that rickets had been avoided in those cases where mixed feeding had been given as well as breast milk, but the high incidence of disease among those children who were completely breast-fed for this long period is in support of the general clinical impression noted by other writers. This is admittedly an unsatisfactory state of affairs, but very difficult to eradicate among hospital patients who do not appreciate the value of regular supervision during the first two years of life. Deducting these cases of prolonged breast-feeding from the total number of rickets, it appears that only 5 per cent. of the breastfed babies developed clinical signs of disease, while
the social conditions of the cases did not appear to be noticeably worse than the average for the whole group. Although it cannot be claimed that breastfeeding completely precludes the subsequent developof rickets in an urban population, the incidence ment is very much lower than for the whole group. Incidence of Rickets among Artificially Fed Babies.In cases where breast-feeding was not possible or the quantity of breast milk inadequate, cow’s milk mixtures were given unless the home conditions were
Rickets in Premature Babies and Twins.-It has been recognised for a long time that premature babies and twins were particularly liable to the development of rickets, the former owing possibly to a primary deficiency of iron in the liver, and the latter to maternal exhaustion and the subsequent impoverishment of the breast milk. Forty-three premature babies were seen, and 14, or 32 per cent., showed clinical signs of rickets, despite the fact that they had all been breast-fed for at least four months and had subsequently received adequate quantities of cod-liver oil emulsion. Sixteen twins occurred in the group, of whom six showed signs of disease. It is admittedly impossible to generalise from such small numbers, but the incidence of rickets is certainly higher than for the whole group, and suggests the advisability of supplementing the nursing mother’s diet with the fat-soluble vitamins in such cases. Bibliography.—1. Parsons, L.: Diseases of Children, Garrod and Thursfield, London, 1928, p. 110. 2. Thompson, J. : Clinical Study and Treatment of Sick Children, Edinburgh, 1926, p. 226. 3. Hess, A. F.: Abt’s Pediatrics, 1923, ii., 908. 4. Paterson, D., and Darby, R.: Arch. Dis. in Childhood, 1926, i., 36.
RUPTURE OF LEFT AURICLE. BY FREDERIC W.
LONGHURST, M.R.C.S. ENG.
RUPTURE of the auricle is so rare that a case which came under my care seems worthy of record.
recently
The patient, a cook, aged 73, led an exceptionally inactive life, and gave no history of previous illness bearing on the present fatal attack. She had certainly had no serious illness for the last six years, but suddenly felt ill while washing her hair at 10 P.M. She was not intelligent in explaining her symptoms, but complained of a sudden pain down the centre of the chest and into the upper abdomen. She was not unduly distressed or breathless. Her pulse was of good volume and quite regular, with a rate of 80. The heart did not appear to be enlarged ; there was a mitral systolic murmur, the other heart sounds being normal. The systolic blood pressure was 175. A mild
aperient only She had
a
was prescribed. fairly comfortable night,
and the next
appeared normal, with the exception of
some
morning pain, the site
of which was now more in the abdomen. The bowels had acted, and she had walked, one flight of stairs, to and from the lavatory. At noon the same day she suddenly collapsed and became grey and pulseless. Four hours later she had made a partial recovery, after taking alcohol by the mouth, and was moved in an ambulance to hospital. On arrival at hospital she was still cold and collapsed and of a pale grey colour, but was quite capable of a humorous conversation, and her radial pulse was now easily palpable with a rate of 80 and a regular rhythm, although it was very irregular in size, with an occasional dropped beat, and sometimes runs of pulsus alternans. The apex-beat was just outside the nipple line in the fifth space, and neither visible nor palpable. The heart sounds were extremely soft and muffled, with tic-tac rhythm, and only heard at the apex. During the night she became warmer and brighter for a few hours. At 8 A.M. the next day she asked for a drink, but collapsed and died while it was being fetched. ’
r
Post-mortem Examination. The body was that of a heavily built, somewhat flabby woman. The abdominal cavity contained slight excess of clear fluid. The pericardium contained at least one pint of slightly clotted blood. No ante-mortem clot was obvious. There was some effusion of blood into connective tissue around the aorta, reaching into the root the anterior wall of the left auricle was a about one inch in length. The wall of very thin and atrophied. No ulceration noted. The ventricular walls were very
of the neck.
In
large ragged tear the auricle or
atheroma
was was
soft, friable, and