598 D. W. Short

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JACKSaM w. P. u. (1950) Qsteo-dental dysplasia (cleido- cranial dysostosis). Acta Med. Scand. 139, 292-307.

JONES H. w. E. (1937) Cleido-cranial dysostosis. St Thomas’ Hosp. Gaz. 36, 193-201.

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Spontaneous rupture of the

MADDOX J. K. (1946) Cranio-cleidal dysostosis. J. R. Nau. Med. Serv. 32, 201-209.

MARIE P. and SAINTON P. (1898) Sur la dysostose cleido- cranienne hkrbditaire. Rev. Neurol. 6 , 835-838. (Cited by Abram, 1907.)

PAYNTON F. J. and DAVIS H. M. (1914)PrOC. R. SOC. Med. 8,21. SOULE A. B. (1946) Mutational dysostosis (cleido-cranial

dysostosis). J . Bone Joint Surg. 28A, 81-102.

Paper accepted 8 December 1978.

normal spleen : diagnosis by computerized tomography D A V I D BIRD, M. J. KELLY A N D R. N. B A I R D *

So contrary is it to the established conceptions of patho- logy, that there are many who doubt that a normal spleen can rupture spontaneously.

Hamilton Bailey (1930)

ATKINSON (1874) described the first case of spon- taneous rupture of the normal spleen, and reports of this rare condition appear sporadically. We report here a case which was diagnosed preoperatively by computerized tomography (CT).

Case report A 55-year-old housewife presented in December 1977 with a 3-week history of left hypochondria1 pain of acute onset, which radiated to the back and left groin. She said there was a ‘cricket ball’ under her left lower ribs. Apart from minor urinary complaints there were no other symptoms. On this and subsequent occasions no history of trauma, however minor, was elicited. On examination there was a fixed, non- tender mass beneath the lower left ribs which was at this stage thought to arise from the left kidney or the spleen.

Investigations showed that haemoglobin, white blood count, platelets, urea and electrolytes, liver function tests, urine and chest X-ray were normal. A soft tissue mass was seen on the plain abdominal X-ray and excretion urography showed medial displacement of the left kidney. A ssTcm colloid liver and spleen scan was interpreted as normal. CT scanning showed ‘a high-lying left kidney, beneath which was an enlarged spleen, the lateral part of which had a different absorption coefficient (i.e. appeared darker) suggesting a lateral subcapsular splenic haernatoma’ (Fig. 1).

Laparotomy confirmed these findings and the spleen, which contained a cricket-ball-sized subcapsular haematoma, was removed. Recovery was uneventful, and histological exami- nation of the spleen showed no intrinsic abnormality. Subse- quent review of the isotope scan suggested concavity of the lateral surface of the spleen, but the appearances had not previously been considered diagnostic.

Comment The existence of such a condition as spontaneous rupture of the normal spleen has been denied. Orloff and Peskin (1958) reviewed 71 cases of alleged spon- taneous rupture of the normal spleen and found that possible causes had not been excluded in 43 cases (61 per cent). However, in the absence of a history of trauma, perisplenic adhesions or abnormalities of the spleen, a case such as ours appears, as far as it is possible to ascertain, to be truly spontaneous.

Fig. 1. Computerized tomography scan showing subcapsular splenic haematoma.

In the diagnosis of subacute splenic rupture 89Tcm colloid liver and spleen scanning may be unreliable (Budd et al., 1976), being unable to demonstrate defects smaller than 2 cm in diameter, or to demon- strate perisplenic structures including subcapsular haematoma of the spleen. Selective arteriography has been shown to be more accurate (Drapanas et al., 1969) but is a highly skilled invasive technique not without morbidity. In the present case the diagnosis was established by CT scanning, which we suggest may quickly and non-invasively provide valuable information in the investigation of suspected sub- capsular splenic haematoma and thus lead to earlier definitive surgery.

References ATKINSON E. (1874) Death from idiopathic rupture of the spleen.

BAILEY H. (1930) Spontaneous rupture of the normal spleen. Br. Med. J . 2, 403404 .

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spleen: a dilemma in diagnosis. JAMA 236, 28862886.

drome of occult rupture of the spleen. Arch. Surg. 99,

ORLOFF M. J. and PESKIN G. w. (1958) Spontaneous rupture of the spleen: a surgical enigma. Int. Absfr. Surg. 106, 1-11.

Paper accepted 20 December 1978.

B U D D D . C., FOUTY W. J. et al. (1976) Occult rupture Of the

DRAPANAS T., YATES A. J. , BRICKMAN R. et al. (1969) The Syn-

298-306.

* Department of Surgery, Royal Infirmary, Bristol.