Spleen

“ The Liver and Spleen.—There is very little of importance to note in connection with the liver except tenderness and jaundice in bilious remittent fever. The spleen, however, is the organ in which centers the infection and its tenderness and enlargement are of special diagnostic value in malaria.
Even in comatose conditions pressure on the spleen may bring about indications of pain. The liability to rupture of the friable spleen of aestivo-autumnal infections is a real danger and the patient should not expose himself to injury. ”

“ For the ordinary autopsy the following order of examination of the abdominal organs is recommended: The spleen is first examined. It is lifted up from beneath the left under-surface of the diaphragm by tearing or stretching the ligamentum phrenico-lienale and the gastrosplenic omentum. In the case of wandering spleen the technique of removal must be modified to suit the conditions. When the spleen is very soft great care must be taken not to tear or rupture it. When adhesions to the diaphragm are present these must be torn or cut. The spleen is then laid upon the left edge of the ribs. ”

“ Liebermeister, on the other hand, and Legg,130 find that the spleen is enlarged in about one-third of the cases. When the atrophic changes occur in the liver, more or less swelling of the splenic veins must occur in consequence of portal obstruction. The peritoneum, especially the omental part, is the seat of multiple ecchymoses, and the endothelium is fatty. The mesenteric glands are usually swollen. More or less blackish or brownish fluid, consisting of altered blood, is usually found in the stomach, and the same, assuming a tar-like consistence, in the large intestine. ”

“ In spleen or liver puncture the needle must be dry so that the parasites shall not suffer distortion.
Malaria.—Splenic enlargement and tenderness are important points in diagnosis of malaria.
In acute malignant tertian infections the spleen is often diffluent so that it is liable to rupture upon slight injury. One should even exercise care not to palpate the spleen too violently and the possibility of accident should be thought of in making a spleen puncture.
The typical malaria spleen is the ague cake of malarial cachexia. ”

“ 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 [p. 959] 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 ”

“ With a few people, particularly with those who have suffered from old spleen engorgements, diarrhœa sets in after using it for two or three weeks that makes them feel better. It seldom lasts more than a day, and is not weakening, but moderate. Hence it is not needful either to stop the acorn water or to lessen the dose.
[Pg 328] I could add many instructive cases of spleen-dropsies and other spleen affections in which the volatile principle of acorns proved curative, but as I have so much more to say on other subjects I dare not be too discursive on this one point ”

“ Many of the trabeculæ forming the framework of the gland become greatly hypertrophied. On section, the tissues of such a spleen are found to be moderately firm, and usually of a reddish-brown colour; but when death happens soon after or during a febrile attack, the section of the gland shows a dark surface from deposit of hæmozoin, the pulp at the same time being softened. Perhaps from over-distension some of the vessels in the interior of the gland give way, and then there is a breaking-down of the spleen pulp in patches, the remains of splenic tissue floating about in the extravasated blood. ”

“ Enlarged spleen.—— In such countries a large proportion of the population have enormously enlarged spleens. The traveller cannot fail to be struck by the number of people he sees with big bellies and spindle shanks; by their languid and depressed air; their sallow, dry, rough, unhealthy-looking skins. In many malarial cachectics the skin pigmentation is remarkably dark ”

“ When caseation has begun their centres are opaque and yellowish. Gummata are grayish-white, with opaque centers, and have a periphery of vascular granulation-tissue or hyaline scar-tissue. The most important pathologic conditions of the spleen are: acute and chronic passive hyperæmia, embolic infarctions, abscess, acute and chronic hyperplasias (typhoid, malaria, plague, pneumonia, septicæmia, leukæmia, pseudoleukæmia, splenic anæmia, hepatic cirrhosis, syphilis, Kala-azar, other forms of tropical splenomegaly, tuberculosis, rachitis, idiopathic splenomegaly of the Gaucher type, etc.) ”

“ The spleen is more liable to lardaceous or amyloid disease than any other organ of the body. And, although in the further course of the degeneration other organs and tissues inevitably become implicated (unless the patient die of some intercurrent affection) , the spleen may in the earlier stages be alone involved. In 58 cases of lardaceous disease compiled from the records of the London Hospital, the spleen was the only organ in which the degeneration was detected in 28 cases, while it remained unaffected in only 10 cases.10 ”

“ The spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. The splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. ”

“ The liver is usually enlarged, softened, friable, and as if parboiled, with many hæmorrhagic patches. The spleen is materially, often enormously enlarged, irregular in outline from extreme engorgement with blood, and in exceptional cases even ruptured. An encrease to two or three times the normal is common. The bacilli are present in great numbers in the spleen, alike in the pulp, in the blood vessels and in the trabeculæ. The lymph glands are almost always hyperæmic, hypertrophied, and softened, especially in the vicinity of the localizations of the tissue lesions. ”

“ There may be cases where a spleen will have sixty within itself against its forbidden fats, and be permitted. However, since we are dealing with a serious prohibition, one may never assume so, and the spleen must always be measured for sixty. ”

“ Pathology.—At autopsy there is noted marked emaciation with greatly enlarged spleen and liver, dropsical effusions and ulceration of the large intestine. The spleen is often enormously enlarged, rather firm but quite friable. The liver may at times show cirrhosis but the usual change is a distention of the endothelial cells of the intralobular capillaries with great numbers of parasites, as many as 100 or more parasites being at times found in a single cell. ”

“ An Eurasian friend, a doctor, says that he quite thinks cases88 might occur in which a man who had been wounded or assaulted by another would die out of spite in order to get the other hanged!—would connive with his relations and starve himself, and not try to heal the wound. He says however that the cases of ruptured spleen—of which we so frequently hear—are genuine, as frequent fevers often cause immense enlargement of the spleen, which then bursts for a comparatively slight cause, e.g. a planter and a stick. ”

“ Should, however, this residual fluid be too abundant, or the heat of the spleen be too scanty, the body becomes sickly from over-repletion with nutriment. Often, too, when the spleen is affected by disease, the belly becomes hard owing to the reflux into it of the fluid; just as happens to those who form too much urine, for they also are liable to a similar diversion of the fluids into the belly. ”

“ It is said also, that if the spleen is removed300 by an incision, animals may survive. There are some persons who think that with the spleen man loses the power of laughing, and that excessive laughter is caused by the overgrowth of it. There is a territory of Asia, known as Scepsis,301 in which it is said that the spleen of the cattle is remarkably small, and that from thence it is that remedies for diseases of the spleen have been introduced. ”

“ It seems that in a number of affections the presence of these microscopic organisms is constant and essential, and that the splenic congestion that accompanies them is a direct result of their presence in the spleen itself. The micro-organisms will be found infesting the cells of the pulp, and, so far as we have definite knowledge, they show peculiar characteristics according to the particular infectious disease to which the patient succumbed. ”

“ Obviously, when it [the spleen] is in a bad condition. Thus, just as the kidneys, whose function it is to attract the urine, do this badly when they are out of order, so also the spleen, which has in itself a native power of attracting an atrabiliary quality, if it ever happens to be weak, must necessarily exercise this attraction badly, with the result that the blood becomes thicker and darker. ”

“ In a man 44 years of age the spleen was extirpated on account of a large splenic cyst. Within two months of the operation there developed a thoroughly leukæmic condition of the blood, exclusively brought about by the increase of the lymphocytes, as is seen from the results of Credé and the table contained in his paper. ”

“ HYPERÆMIA—CONGESTION OF THE SPLEEN. Four hours after full meal in splenic diastole. In well fed, high conditioned. From obstruction of splenic or portal vein or vena cava, heart, liver, or pulmonary disease, inhibition from encephalon acting through splanchnics or vagi, microbes, ptomaines, toxins, paresis, albuminoid diet. Spleen may be seven times its normal weight. Lesions: simple blood engorgement: proliferation of pulp cells: increased friability; rupture; dark color; hyperplasia of trabeculæ—hypertrophy. Symptoms: none; or colic; palpation in ruminants ”

“ It consists of a more or less localized splenic peritonitis, and its lesions are often found at the necropsy when its existence had not been suspected during life.
ETIOLOGY.—Its commonest cause is the extension of inflammation from neighboring parts. Chronic ulcer of the stomach may be the origin of chronic perisplenitis, leading to the formation of dense inflammatory deposits. Persons who have long suffered from miasmatic poisoning frequently develop strong adhesions between the spleen and diaphragm. And from the same cause the spleen may become closely adherent to the neighboring viscera. ”

“ The food should be attenuant, acrid, and dry; little drink should be taken; but exercise, friction, and sinapisms should be had recourse to, and sometimes cupping with scarifications.
Commentary. Hippocrates describes several diseases of the spleen in his work, ‘de Internis Affectionibus.’ He states that in scirrhus the spleen is sometimes larger and sometimes smaller than natural. It is an affection which continues long, but is not fatal. Sometimes, he says, it terminates in dropsy, and sometimes in suppuration, when he approves of burning the side. ”

“ In the South and West an enormously enlarged spleen is not infrequently met with. It sometimes spreads over the whole anterior part of the abdomen, completely covering the intestines. Less frequently the liver is found similarly enlarged. ”

“ And if there's fluid in the spleen even if it's clouded or putrid if the flesh around it is intact it's kosher (N"Y in the name of Morekhai and HG"A and A"L 60:50) . 3 There's an opinion that wrote that whatever is adhered to the belly (Keres, rumen) is called the thick end and nothing else is called that.
4 The thickness of a gold dinar, we don't know its (exact) measure, but anyhow it seems it has to be less than half (the spleen's) thickness. ”

“ The common and low quality of food of the lower classes, and especially of the agricultural population, must induce a want of stamina which is unable to resist the fever in malarious districts, and this results in chronic disease of the spleen. I have already described the general protuberance of the abdomen among the children throughout the Messaria and the Carpas districts, all of whom are more or less affected by splenetic diseases. ”

“ Liability to rupture of splenic tumours.—— Another practical point is that these enlarged spleens are easily ruptured by a blow on the belly. In hot and malarious countries many a coolie goes about doing his work although he has an enormous spleen. ”

“ But vomiting of black bile taking place without fever, or any other symptom of malignity, indicates a weakness of the retentive faculty of the spleen. A weakness of the expulsive faculty will bring on anorexia, the melancholic superfluity being no longer carried to the orifice of the stomach and exciting the appetite. When the melancholic humour is infarcted in the spleen, in the first place inflammation of it occurs, indicated by heat, pain, and tightness, but afterwards it passes into scirrhus, the heat and pain having ceased, while the swelling and hardness remain. ”

“ Anamnesis, ætiology, and present state, albumen in the urine, justified the diagnosis. Patient is pale, bloated, œdema pedum, no appetite, white tongue, thin feverish pulse, swollen spleen, watery diarrhœa alternating with constipation. Every drug produced vomiting, and he perfectly abhorred the old Quinine powders. I ordered four drops Arsen. brom. and a full meat diet. Improvement followed with the continuance of the treatment. After three weeks the spleen was reduced in size, his face showed better color, hardly any œdema. ”