SYMPTOMATOLOGY.—Long-continued or frequently-recurring attacks of splenic hyperæmia, occurring under the stimulus of chronic malarial poisoning or of leucocythæmia or pseudo-leucocythæmia, will ultimately induce those structural changes that result in new formation. Enlargements from the two latter diseases will be more appropriately considered elsewhere. After repeated attacks of remittent or intermittent fever or other forms of malarial intoxication the symptoms of acute will gradually merge into those of chronic congestion. They will usually prevail to a more intense degree. The dragging weight of the tumor will excite pain, and may render rest upon the right side too uncomfortable to be indulged in. Hemorrhage from the stomach and bowels may occur, and at times will be excessive. The patient may be reduced to an extreme degree by the profuse and repeated losses of blood. In the intervals of the malarial attacks the temperature will be unelevated, and the pulse may be slow and irregular, though oftener feeble and rapid. All the symptoms will be, however, commingled with those from other causes. Those of malarial cachexia will sometimes be very pronounced. The pale, sallow complexion, the pallid lips, the extreme anæmia and generally unhealthy aspect, and the general symptoms accompanying such states, the history of miasmatic fevers, of characteristic neuralgias, etc., will generally be present. Oedema may be observed, but will usually be hydræmic in origin. Anomalous symptoms due to the systemic condition will be often developed when the enlargement arises from other than malarial causes.
Under the influence of the latter cause the spleen may acquire many times its normal dimensions, and may easily be felt below the border of the ribs, where its irregularly curving and notched border will serve to identify it. The tumor sometimes becomes so large that it reveals its presence by causing a bulging and asymmetry appreciable by the patient. Here, however, congestion will have been supplanted by hypertrophy. The tumor may vary greatly in size. It may fill the left part of the abdominal cavity, reaching to the pubes and distending the belly-wall with its dense enlargement, dull upon percussion, and perhaps moving within narrow limits under the hand of the examiner. This tumor may attain a size and weight many times greater than the normal. Hypertrophy once established, it may remain more or less pronounced for years, directly occasioning unimportant symptoms. It is difficult to determine the exact influence exerted by these tumors upon the duration of life.
PATHOLOGICAL ANATOMY.—In simple hypertrophy there is both hyperplasia of the pulp and of the trabecular connective tissue. The spleen is enlarged, sometimes to an extreme degree, equalling fifteen or sixteen times its normal weight.3 Such enlargement is not observed in any other form of splenic disorder, excepting in some rare cases of leucocythæmia and tumor. Its density is also increased. The capsule is thickened, and adhesions to the surrounding parts may be quite intimate. The color of the surface is darker than normal. Upon section the structure appears dense, smooth, of a dark color (from deposit of pigment), and showing to the naked eye great increase of the trabecular tissue. The pigmentation more especially observed in malarial intoxication occurs in the intervascular cords of the pulp (Rindfleisch), where it can be seen as black, flaky masses of hæmatin (the origin of melanæmia). According to Friedreich,4 there may be a circumscribed splenic hypertrophy, consisting of little points of granulation imbedded in the pulp. In ordinary diffuse hypertrophy all the elements are involved, though the trabeculæ show the greatest increase and encroach more or less upon the pulp. The Malpighian corpuscles may show little or no enlargement. The processes are indistinguishable from those of chronic inflammation. In hypertrophy from obstructed portal circulation the organ will be dark red and very full of blood. It sometimes happens that obstructive hypertrophy terminates in fibrotic contraction, when the connective tissue will be found to have almost completely crowded out the pulp.
3 Hertz, Ziemssen's Cyc., vol. ii.
4 Virchow's Archiv, xxiii., 1865; Ziemssen's Cyc., viii., Mosler.
DIAGNOSIS.—Decided enlargement will usually be recognized with but little difficulty. A tumor in the left hypochondrium, occupying and transgressing the normal splenic boundaries, will probably be of splenic origin. Occasionally enlargement may be simulated by a spleen of normal size displaced downward by intra-thoracic growths or effusions or by that remarkable abnormality known as wandering spleen. The course of the primary affection in the one case, and the free movability of the organ in the other, will suffice generally to guard against error. Rarely, the tumor may be due to cancer of the stomach, enlargement of the left kidney or of the left lobe of the liver, omental tumors, fecal accumulations in the colon, or ovarian tumors. The concomitant symptoms will suffice to distinguish cancer of the cardiac end of the stomach. Percussion will reveal the presence of subjacent gases, and palpation will detect the greater hardness of the gastric tumor. Enlargement of the left kidney may be due to cancer, abscess, or other causes, and may simulate splenic hypertrophy. The renal tumor may be traced farther backward, and will not present the characteristic outline of the spleen. The clinical history and symptoms will here, again, prevent error. Omental tumor is usually separated from the splenic region by an area of resonance. Enlarged liver may be traced toward the right side of the body, becoming more noticeable as the spleen is receded from. Fecal accumulation may closely resemble splenic tumor, as it does other abdominal enlargements. The doughy consistency of enlarged spleen may be like that of the fecal mass, but one may often permanently alter the shape of the latter by the pressure of the fingers, and in any case doubt may be dispelled by the use of purgatives. Ovarian tumors may be traced into the pelvis, as may also, for the most part, fibro-cystic and fibroid tumors of the uterus and its appendages.
On the other hand, recognition of splenic tumors may be prevented by gaseous distension of the stomach and bowels, by abdominal dropsy, diffuse or encysted, by fecal distension of the colon, and may, indeed, be impossible until these conditions have been remedied. Enlargement of the spleen from simple hyperplasia must also be distinguished from other forms of splenic enlargement—from splenitis, from lardaceous degeneration, from tumors, from leukæmia and pseudo-leukæmia, from syphilitic and tuberculous spleen, etc. In such cases the diagnosis will rather depend upon concomitant symptoms than upon the physical characters of the enlarged organ. Percussion and palpation will not seldom enable one to determine the presence of tumor (cancer), hydatids, etc. Pressure will often serve to elicit expressions of great tenderness in splenitis; enlargements with fluid contents will be revealed by fluctuation. In the greater number of cases where the enlargement is evident, but is without distinguishing characteristics, the general condition of the patient and the history of his illness will disclose its true nature. Lardaceous degeneration will have been anteceded by prolonged suppuration, by tubercle, by scrofula, or by syphilis, and will generally be associated with the same processes in other parts. Syphilitic disease may be indicated by the history of the patient, though in this case, of course, lardaceous degeneration could only with difficulty be excluded. Tubercle, rarely giving rise to an appreciable tumor, can only be conjecturally diagnosticated from the history and general condition of the patient. The condition of the blood and of the lymphatic system in leukæmia and pseudo-leukæmia will suffice to determine the nature of the splenic enlargement. The ague-cake of chronic malarial poisoning is usually accompanied by a degree of cachexia, as is shown in the earthy pallor of the complexion. This is often sufficient to enable one to discriminate between several forms of enlargement, for it differs from the intense pallor of leukæmia by its sallow hue, and is not at all like the hue of the complexion in lardaceous disease. The cancerous cachexia, it is true, may closely resemble it, but here the history and symptoms assist in avoiding mistakes.
PROGNOSIS.—When the hyperplastic processes have amounted to true connective-tissue formation, a complete return to normal conditions will not occur after the removal of the stimulus. The permanence of the enlargement will be proportionate to the extent of organization of the hyperplastic elements. In ague-cake some reduction in size will follow the exhaustion of the malarial influence, though the spleen probably never ceases to be appreciable as a distinct enlargement. At the same time, the enlarged organ may not, of itself, exert any specially unfavorable effect upon its bearer. Not a few persons will live for years with it, and eventually die from other causes. It may be assumed, however, that the presence of ague-cake is indicative of profound malarial cachexia, by which the powers of life are much less resistant to unfavorable influences. It may be said, in a general way, that the larger the spleen the less favorable is the prognosis. It should be remembered that a considerable proportion of persons suffering from leucocythæmia have also suffered from chronic malarial poisoning, and that the enlarged spleen of this affection may possibly have begun its morbid course under the influence of malaria.
TREATMENT.—In passive congestion relief is often secured through the use of remedies that diminish portal engorgement or enable the heart to find compensation for a damaged mitral valve—conditions in which the splenic disorder is really an unimportant concomitant. In the enlargement that has for its cause chronic malarial intoxication cinchona and its alkaloids are preferable to all other remedies, not only in arresting the new growth otherwise progressive under the stimulus of the poison, but by neutralizing the latter and facilitating the absorption of the hyperplastic elements that have not already become converted into more highly-developed tissue. To effect these objects the agents must be given in fair doses (twenty grains of sulphate of quinia daily) until the malarial cachexia shall have been overcome—until the bulk of the enlarged spleen shall have been reduced to the smallest possible proportions. To bring about the desired result the treatment may have to be continued during several months, occasionally suspended upon the supervention of symptoms of cinchonism. A drug of deserved repute (probably through its anti-malarial influence) is arsenic. This should be given for protracted periods. Many remedies possessing anti-malarial properties have also been recommended and employed in these conditions. Eucalyptus and eucalyptol have recently been used with promising results, though the sanguine expectations of some will hardly be realized. Iron, preferably as a sulphate or as the tincture of the chloride, is invaluable in correcting the profound anæmia always present in these cases, though its influence in reducing the splenic bulk immediately is, at best, doubtful. Remedies competent to reduce hepatic and portal engorgement will often prove beneficial. Salines and vegetable cathartics may more especially be employed, but the use of mercurials, except for occasional administration, is almost universally condemned as productive of evil consequences.
Local Treatment.—The systematic application of cold by effusion or by ice-bags will at times undoubtedly reduce the size of an enlarged spleen. Alleviation will often be afforded by solutions of nitric acid to the splenic region, and counter-irritants are of occasional service, either by means of the tincture of iodine persistently employed or by blistering fluids or plasters. These, however, should be used with great caution in debilitated subjects, as gangrene has been known to follow their application. Mosler thinks that the practice of injecting tincture of iodine, carbolic acid, etc. into the substance of the spleen is sufficiently promising to justify further experiment. The continuous electric current and electrolysis have also been recently recommended as of advantage in reducing the splenic bulk. In cases of excessive enlargement, where accompanying or consequent cachexia threatens to end in death, extirpation of the spleen has been advised and practised. While the removal of the leucocythæmic spleen is so constantly followed by death that the operation cannot be considered justifiable, it seems that the spleen enlarged from other causes may sometimes be removed with safety. In the Lancet of Feb. 11, 1882, Herbert Collier tabulates all (until then) known cases of removal of the spleen for disease, 29 in number: 16 of these operations were upon leukæmic subjects, and had a fatal termination; 8 of the remaining cases recovered. Crédé5 concludes from an analysis of 30 cases of extirpation of splenic tumor that the adult spleen may be removed without detriment; that its removal causes temporary derangement of the blood-making function; and that this is compensated for by activity of the thyroid body and red marrow of the bones. As bearing further upon the question of the practicability of splenectomy, should surgical art succeed in reducing the dangers immediately dependent upon the operation, are the highly interesting experiments of Tizzoni6 and Griffini,7 wherein extirpation of the spleen in dogs was followed by reproduction of true splenic tissue.