SYMPTOMATOLOGY AND COURSE.—When the rupture is of traumatic origin there may be no marks of external violence: the symptoms usually are those that follow sudden and great losses of blood, faintness, pallor following intense pain in the splenic region, frequency and weakness of pulse, sighing, coldness of the extremities, and the rapidly developing signs of profound prostration. A fatal termination usually quickly follows the rupture. Where the hemorrhage is not immediately great the patient may not succumb at once, but may live for hours, even days—nay, may even recover, as has occurred in the experience of some observers. Wilks and Moxon saw a case of splenic laceration where five ounces of laminated clot in process of absorption were found lying upon the spleen, death having occurred eighteen days after the accident in consequence of abscess of the brain. In cases where rupture has taken place, perhaps from very slight violence, in a spleen enlarged and softened from disease, the above-mentioned symptoms may have been preceded by pain and a sense of weariness in the splenic region, and by distinguishable enlargement of the organ.
PATHOLOGICAL ANATOMY.—Except in injuries caused by the penetration of foreign bodies or fractured ribs the rupture will usually be linear, and either straight, curved, angular, or stellate. If the rupture have occurred spontaneously it will probably be single, but in the event of its following violence it will most often have resulted at several places. In cases of traumatic splenic rupture in persons suffering from chronic malarial poisoning, Konaraloff14 invariably found the rents in the lower portion of the organ, the greater ones on the outer surface, the smaller ones mostly on the inner surface near the hilum. They were widely gaping and deep. In ruptures consequent upon disease alone or slight violence to a diseased organ the spleen will usually be found enlarged, sometimes to three or four times its normal volume, with its substance softened and of a cherry-red color. In such cases signs of bruising or injury to the integument will not usually be discoverable. Splenic hemorrhage has been known to occur from the rupture of varices and aneurism, in which case characteristic appearances have been found after death. After death from rupture of the spleen the abdominal cavity will be more or less filled with blood, dark and coagulated. Though the contrary has been held, it is doubtful if multiple rupture of the spleen can be regarded as certainly indicative of a traumatic origin.
14 Lond. Med. Rec., No. 97, 1883, p. 259.
Tubercle of the Spleen.
Tubercle not unfrequently attacks the spleen, but only as secondary to general tuberculosis. Wilks and Moxon indeed think the larger nodules of tubercle may be primary, but there seems to be no evidence in support of this opinion. As a symptom of general tuberculosis, splenic enlargement from congestion, simply and quite without any specific deposit, is observed as a form of acute splenic tumor. It is at the later stages of general tuberculosis that distinct deposits of tubercle are formed in the spleen, and these are consequently almost always crude. They are generally scattered throughout the pulp, and, according to Billroth, they but rarely affect the Malpighian corpuscles. They are of very small size, and may be present in great numbers; their color is grayish and they are translucent, and only the largest show the yellow tinge of commencing fatty degeneration. According to Orth, they are not always easily distinguishable from the Malpighian bodies. Occasionally, and especially in scrofulous children, larger nodules are formed by the confluence of several tubercles that may equal a pea in size and present numerous yellow points of caseation.
It is usually impossible to diagnosticate the existence of splenic tubercle during life. After death the general splenic tissue will be darkened from hyperæmia and the tubercles surrounded by a vascular halo. When incised the tubercles will stand out from the tissue in which they are imbedded, unlike the Malpighian bodies, and when exposed to a stream of water the latter will disappear, while the tubercles will remain unaffected.
Tumors of the Spleen.
The spleen is very rarely invaded by new growths other than those already mentioned, and then almost exclusively either from direct extension from other parts or by metastasis. In pseudo-leukæmia or Hodgkin's disease the spleen is usually enlarged by a hyperplastic process quite like that of leukæmia. In that variety of this disease that has been called lympho-sarcoma, in which the spleen is invaded subsequently to the implication of the lymphatic glands, especially those of the cervical region, the Malpighian follicles may become enlarged, and even attain the size of walnuts. They contain spindle-cells and connective tissue. The trabeculæ likewise participate in the enlargement. Apart from the hyperplastic follicles thus occurring and also seen in leukæmia, small-pox, scarlatina, etc., lymphoma has been observed by Virchow, Weichselbaum, and others. The tumors consist of bright grayish-red or reddish, not sharply defined, nodules projecting from the dark-red mass of the spleen. Primary sarcoma is said to have been observed in the spleen, but malignant tumors of this organ are usually secondary growths, and even thus occurring are exceedingly rare. They are soft and very rapidly-growing sarcomata and carcinomata. As a rule, they depend upon malignant disease of the liver or abdominal glands through metastasis or by extension of growth. They sometimes grow with almost incredible rapidity. The symptoms are very obscure, and the presence of the malignant infiltration cannot be detected unless hard nodulated masses are formed, which become perceptible through the abdominal wall, as in hepatic cancer. The prognosis is always bad, and depends generally upon the existence of splenic cancer only in so far as this indicates the dissemination of the primary affection and becomes the forerunner of the cancerous cachexia. Fibroma and angioma have also been encountered in the spleen: they are both exceedingly rare. The latter has been known as a pulsating tumor (Langhans).