complications, recovery would have taken place had the sutured
laceration been the only source of hemorrhage. Lamarchia
frankly states that had the hidden laceration been discovered, he
would have removed the spleen wthout hesitation.
A fatal termination is to be expected in those cases where the
hemorrhage continues until the patient is exsanguinated. That
the hemorrhage sometimes spontaneously ceases, however, is
proved by a number of cases in which the patient had died from
some associated lesion, where the laceration in the spleen has been
found firmly closed by thrombus, as well as by other cases, in
which, at the time of operation, the hemorrhage had ceased, and
recovery had followed the removal of the clotted blood from the
peritoneal cavity without disturbing the site of laceration. In
such favorable circumstances, in the absence of operation, the
extravasated blood would either be absorbed and disappear, or if
present in large quantity, it might form a sharply defined cystic
tumor in the left side of the abdomen.
The symptoms of subcutaneous rupture of the spleen depend
upon the extent and rapidity of the hemorrhage. In a consider-
able number rapid loss of blood is fatal within a very short time.
In a larger number, several hours may pass before there is any
evidence of internal hemorrhage. Occasionally the first indica-
tion of hemorrhage will be delayed from twenty-four to seventy-
two hours, or even longer, a clinical picture that can be explained
by a sudden renewal of bleeding, temporarily checked shortly after
the trauma, through some inadvertent movement of the abdominal
wall or diaphragm, or possibly by the fact that the hemorrhage, at
first confined within the limits of an untorn capsule, eventually
ruptures that barrier and escapes freely into the peritoneal cavity.
It is needless to emphasize the importance of accurate diagnosis
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ELIOT: RUPTURE OF THE SPLEEN 339
before exsanguination takes place in all cases that are not immedi-
ately fatal. Hence, a careful consideration of the objective symp-
toms seems justifiable, for valuable time is often lost through
error in diagnosis, and published reports of cases seem to indicate
that, not infrequently, the strength of the patient is subjected to
the additional strain of needlessly long and erroneously placed
incisions in an effort to recognize the source of the hemorrhage.
During the first hours after the accident, the patient, in a con-
dition of shock, complains of severe pain in the left hypochondrium,
that is intensified by attempted movement of the body and by deep
inspirations. Similar symptoms are observed in fracture of the
ribs, differing, however, in the fact that in rupture of the spleen
the shock is more intense, while the pain is more constant, severe,
and of increasing intensity. There is frequently one or more
attacks of vomiting. The position of the patient is usually dorsal
with marked disinclination to move to either side, especially to
the right. Respiration is chiefly thoracic, the descent of the
diaphragm being scarcely perceptible in the upper abdominal
segment, especially on the left side. There is no asymmetrical
distention* or bulging of the abdomen.
There is well-defined tenderness in the region of the spleen ex-
tending from that point a variable distance downward according
to the extent of the hemorrhage. Muscular rigidity is nearly
always constant and pronounced. Although present over the
entire abdomen, it is much more marked over the upper part of the
left rectus, involving, to a lesser extent, the lower part of the same
muscle. It is also very prominent in the lower part of the costal
arch, and any attempt to press the unbroken eleventh and twelfth
ribs toward the vertebral column is not only painful, but meets
with great resistance. In cases with extensive hemorrhage, the
normal area of dulness is greatly enlarged in a downward and for-
ward direction, the left flank giving a particularly dull, if not almost
flat, note. The area of dulness is said by many to shift according
to the position of the patient, but under such circumstances the
rapid coagulation of the blood, together with the natural restric-
tion of adjacent omentum and loops of intestine, must frequently
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340 ELIOT: RUPTURE OF THE SPLEEN
retard any sudden movement of the clotted blood as a whole to
another segment of the abdomen. Theoretically, as Ballance has
suggested, such a change should not influence materially the posi-
tion of the coagulum, but only of its expressed serum. Practically,
however, the quantity of serous exudate within the first twelve
hours after the accident is so small that it could have possibly no
effect on the percussion note, and for that reason the not infrequent
presence of shifting dulness in these cases must be ascribed to the
fact that the rapidity of hemorrhage favors the accumulation of a
considerable amount of fluid blood in the peritoneal cavity. The
propriety of eliciting this symptom must, however, be seriously
questioned. The necessary change in the position is a great
hardship, and might very easily increase the severity of the hemor-
rhage or bring about its renewal when it had spontaneously
ceased. In both cases, reported in this paper, no attempt was
made to turn the patient over to the opposite side, as the diagnosis
and consequent operation seemed to be justified by the other
symptoms. Small amounts of blood can sometimes be detected
by auscultatory percussion, the stethoscope being placed over the
centre of the suspected area and relative dubiess being elicited by
gently tapping, with the extremity of a finger, the adjacent abdom-
inal wall. This should always be practised at the first examina-
tion in order that any change in subsequent examinations,
repeated at frequent intervals, may be immediately recognized.
Considerable information may sometimes be gained by placing
the end of the stethoscope in close contact with the abdominal
wall and then quickly but gently depressing it toward the abdom-
inal cavity. The accumulated blood is thereby sufficiently dis-
turbed to yield a rubbing friction sound that is conveyed to the
examiner's ear. The end of the stethoscope should be small and
connected by tubing to the ear-pieces. This physical sign, elicited
by what may be called "dipping" percussion, has been practised
by the writer during the past six months, and during that time has
yielded a positive result in several cases of extravasation of blood
into the joint and connective-tissue planes, as well as in one case of
ectopic gestation. It has also been of considerable value in deter-
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ELIOT: RUPTURE OF THE SPLEEN 341
mining the early presence of a fibrinous exudate in inflammation
of the appendix.
Of these different symptoms, the most important, and those on
which chief reliance must be placed in making a correct diagnosis,
are undoubtedly the muscular rigidity and the dulness or flatness in
the flank. The writer wishes especially to call attention again to
the value of costal resistance, or the force encountered in depressing
various segments of the costal arch toward the vertebral column.
This has been repeatedly tested in inflammatory processes of the
Uver, gall-bladder, stomach, pancreas, and kidney, and in both
cases reported in this paper its well-marked development mate-
rially aided in the diagnosis. It is also essential to keep this physi-
cal sign in mind in distinguishing between damage to the costal
arch or ribs only, and damage to the spleen as well. If the lower
part of the costal arch is the site of fracture or of dislocation, the
eleventh and twelfth ribs are not usually involved, and, inasmuch
as they are not connected with the costal arch, pressure directed
against them will neither intensify the existing pain nor meet with
any decided resistance; the reverse, however, is found to be the
case, if in addition to the damaged arch, rupture of the spleen has
taken place.
The writer has also been interested in the behavior of the rectus
muscle in uncomphcated cases of single or multiple fracture of
the ribs from the costal cartilages of which it springs. A number
of observations during the past year have shown that, if present,
the rigidity is confined to the uppermost part of the muscle. An
associated fracture of the femur in the second case directed the
writer's attention to the possibility of abdominal rigidity in this
condition, but observation of several cases of isolated fractured
femur have shown that, ordinarily, abdominal rigidity is absent,
or, if present, is Umited to the lower abdomen.
That the presence of rigidity after trauma is not always an indi-
cation of some serious intra-abdominal lesion is well illustrated in
the following case :
Male, aged thirty years, admitted to the Presbyterian Hospital
April 14, 1907. This evening, while crossing the street, patient
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342 ELIOT: RUPTURE OF THE SPLEEN
was struck in the sacral region by an automobile and was thrown
a distance of several feet, striking the lower abdomen against a
lamp-post. * He was brought to the hospital in an ambulance
and was unable to walk or stand upright. He had considerable
shock.
Examination, shortly after admission, revealed the physical
signs of contusions over the lumbosacral joint and over the lower
anterior abdomen, with general tenderness, with but Uttle if any
rigidity. This latter symptom soon appeared, however, and
thirteen hours after the accident a personal examination showed
diflFuse rigidity, especially in the lower part of the abdomen,
slightly more marked on the left than on the right side. A dis-
tinct swelling, evidently that of a hematoma, could be felt in the
left groin above Poupart's ligament. There was no rigidity of
either costal arch, and pressure on the floating ribs caused no
pain. No focal symptoms could be eUcited, and the patient's
pulse was under loo and his general condition was very satisfac-
tory. Although a rupture of an abdominal viscus was considered
unUkely, yet the rapid development and spread of the rigidit)',
together with a general increase in leukocytosis to 23,600, seemed
to warrant an exploration. An extensive properitoneal extravasa-
tion of blood was found through a mid-incision below the umbili-
cus, and, on opening the peritoneum, retroperitoneal hematomata
were detected in both iUac fossae and loins, especially on the left
side. There was no rupture of any \iscus, although an ecchy-
motic area, the size of a twenty-five cent piece, was observed in
the posterior wall of the bladder just below the fundus. The
wound was completely closed without drainage and primarj'
union secured. By the end of the first week the rigidity had
entirely disappeared. It is also interesting to note that for eight
days the patient had to be catheterized, the inability to void urine
being either due to some functional derangement of the lumbar
enlargement, or, possibly, to the contusion of the bladder wall.
Rupture of the spleen is most satisfactorily treated by splenec-
tomy. Suture of the laceration has been attempted, but is un-
certain in that the soft consistency of the organ favors the cutting
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ELIOT; RUPTURE OF THE SPLEEN 343
through of the sutures and prevents an approximation of the
divided edges with sufficient tightness to check the hemorrhage.
Moreover, the laceration may be so situated that the insertion of
the sutures is either difficult or impossible. Furthermore, the
suture of multiple lacerations requires much more time than the
ligature of a pedicle, and the condition of the patient is such that
the operation should always be concluded in the quickest possible
way. Finally, as in the case of Lamarchia, a laceration from
which hemorrhage may continue in sufficient quantity to prove
fatal may be overlooked. The pressure of the spleen by a care-
fully inserted tampon against the diaphragm and costal wall has
been employed, but such a tampon does not always check the
hemorrhage, and its subsequent removal may dislodge the clots
and lead to a renewal of that alarming symptom. Moreover,
this method is totally inapplicable in cases where one or more of
the splenic vessels are torn at the hilus, for the reason that the degree
of pressure necessary to check the hemorrhage would xmques-
tionably, even although it were successful, be followed by necrosis
of the organ. As the use of the Pacquelin or galvanocautery
does not yield desirable results, splenectomy is evidently the only
satisfactory method of treatment, and the value of that procedure
is amply demonstrated by numerous successful cases with a
steadily decreasing mortaUty.
The questions involved in this operation include the situation
and extent of the incision, the treatment of the pedicle, the re-
moval of the accumulated blood from the peritoneal cavity, and
the problem of drainage.
A review of the Uterature seems to show that the wide variance
of incision is to be ascribed to the uncertainty in diagnosis, and
hence to the fact that the incision at first was chiefly exploratory.
In cases where the diagnosis is made, a vertical incision parallel
to the upper outer border of the left rectus, above the level of the
umbilicus, supplemented by a second incision extending from its
upper extremity outward along the costal margin, is preferable,
in that the former provides sufficient space to rapidly explore the
adjacent viscera for possible rupture, while the latter permits
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344 ELIOT : RUPTUKE OF THE SPLEEN
adequate exposure of the splenic pedicle and accurate inspection of
the source of the hemorrhage.
Such an incision is also less likely to be followed by subsequent
hernia. All incisions which necessitate the application of the ped-
icle clamp by touch are to be condemned, for the pedicle, even
imder normal conditions, may be attached to the fundus of the
stomach or colon, and portions of those viscera would then be
included within the grasp of the clamp. Through an incision par-
allel to the costal arch, the application of the clamp may readily
be preceded by the liberation of any portion of an adherent viscus.
Should its deep position or adhesion to the diaphragm or parietes
render the exposure of the spleen unusually diflSicult, additional
space may be provided by the resection of one or more of the over-
lying costal cartilages.
After removal of the spleen, its pedicle, if not too broad, may be
transfixed and tied with catgut. In both cases here reported,
the pedicle was so broad that it was feared an attempt at ligature
might easily result in partial failure, and that a renewal of the
hemorrhage would seriously prolong the operation and jeopardize
the chances of recovery. In both cases, therefore, two clamps
were left in situ and the wound closed, with the exception of a
small opening in the lower part, through which the handles of the
clamps protruded. Prior to the closure of the wound the accu-
mulated blood remaining in the peritoneal cavity was rapidly
washed away by a warm saline solution, the slightly elevated por-
tion of the lower extremity permitting the rapid escape of the
clotted material from the wound. The clamps thus applied
acted not only as hemostats, but also as drains, and were removed
at the end of two and four days, respectively. The leaving of
these instruments in situ did not prove uncomfortable, and their
removal was painless. The leaving of the pedicle clamps in
situ after splenectomy has been practised ynth good results in
several instances. So iFar as the writer can ascertain, it was first
done with success by Pauchet, in 1903. It was also suggested in
1904 by Auvray as a substitute for the customar)'^ chain ligature,
and in another case, reported by Fontoynont, in 1905, the splenic
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ELIOT: RUPTURE OF THE SPLEEN 345
pedicle, together with a portion of the tail of the pancreas, were
similarly treated. The use of the clamp in this way has long been
practised in vaginal hysterectomy, and similar treatment of the
splenic pedicle seems justifiable, for the artery, near its termination,
is practically without collateral branches, and the resulting throm-
bus should be as secure as that which forms after the apphcation
of the usual ligature. The fact that the clamp or clamps may
become accidentally unlocked, especially during an attack of post-
operative vomiting, and lead to a fatal renewal of the hemorrhage,
is the only valid objection to their use; but this accident can
scarcely happen if the clamps are carefully selected. That some
form of drainage should be employed seems rational, if for no other
reason than to provide for the possible contingency of damage to
the adjacent pancreas. The tail of that organ is in close prox-
imity to the spleen, and may simultaneously be injured by the
force of the trauma. Under such circumstances, a drain for
several days, or even longer, would prove desirable, especially if
pancreatic fistula seemed inevitable.
Such a comphcation was observed in the cases of Fontoynont
and Bardenhauer and Boger. In the former, a woman, aged
twenty-eight years, splenectomy was done two hours after the
accident. The adjacent tail of the pancreas was also torn. The
clamps on the splenic pedicle were left in situ and were removed
on the third day. A tampon was also introduced, a pancreatic
fistula forming, which eventually closed spontaneously. In the
latter case a tear in the tail of the pancreas was sutured after
the spleen was removed for rupture. Recovery.
A successful case of splenectomy for rupture is also reported by
Morison, in which there was damage to the tail of the pancreas.
This case was drained through a stab puncture in the left loin, the
abdominal wound being closed completely. Primary union was
secured, but there is no mention of a subsequent pancreatic fistula
through the counteropening.
The only possible objection to splenectomy for rupture of the
spleen consists in the fact that, in the absence of accessory spleens,
which, by their hypertrophy, could easily and satisfactorily con-
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346 ELIOT: KUPTURE OF THE SPLEEN
tinue the splenic functions, it necessitates the sacrifice of an organ
which, unquestionably, is important to the body economy. That
its preservation is not essential, however, to a condition of per-
fect health is, of course, proved by the numerous cases of com-
plete recovery after its removal. That, on the other hand,
some temporary constitutional disturbance may follow splenec-
tomy is clearly shown by the cases in which a long persistent
anemia, with general emaciation, has been observed, as well as
occasional instances of delay in the repair of associated lesions,
particularly in the long bones. Thus in NotzePs case, there was
no evidence of callus formation in a fracture of the shaft of the
humerus three months after the accident, and an operation, done
at that time, for non-union, proved a total failure. Six months
later union was secured by a second operation of an osteoplastic
character. In the first case, reported by the writer, a simple
fracture of the shaft of the femur imited with no special delay,
although with rather more shortening than usual.
The following instances may be cited in illustration of the
disturbance of the body economy that sometimes follows splen-
ectomy.
Ballance reports a case of a female, aged forty-five years, who
made good progress during the first week after a splenectomy.
Then the pulse became 120 to 130; the temperature 100° to 101°.
There was threatened anorexia, pain in the limbs, especially
along the tibia, and little urine. The patient showed a tendency
to sleep all day. She fainted on changing her position in bed.
The patient was fed on grilled spleen and on extract of spleen,
with ultimate recovery.
The same observ-er also reports a second case, in a man aged
thirty-six years. Two weeks after the operation this patient be-
came cachectic, with loss of flesh and sunken face. There was
weakness and thirst and the patient continued to lose ground for
four weeks. He was given cod-liver oil and marrow on toast, but
finally improved, and ultimately recovered on the use of arsenic.
At the end of four months sUght enlargement of the lymphatic
glands could be detected.
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ELIOT; RUPTURE OF THE SPLEEN 347
Von Beck reports a case of slow recovery from SLa acute anemia
following splenectomy, without any appreciable enlargement of the
lymphatic glands or thyroid.
Heaton reports a case in a boy in whom anemia persisted
for six months after operation.
Lewerenz reports a case of a man, aged twenty-seven years, in
whom some psychical disturbance, with hallucinations, persisted
for two months after operation.
That nature endeavors to provide a substitute for the loss of the
splenic reparative power, if it may be so called, is shown in a con-
siderable number of cases by a moderate hypertrophy of the
lymphatic glands or of the thyroid, or of the marrow of the bones,
the last mentioned indicated by a general soreness along the
shafts of the long bones. Such an enlargement, which must be
regarded as compensatory, probably follows all cases of splenec-
tomy, although it may not be sufficiently pronounced to be demon-
strated by palpation. The questions naturally arise whether
complete restoration of the body economy depends upon the satis-
factory adjustment of such compensation, and whether such a
state of compensation can be disturbed or overthrown by the advent
of any sudden infection or other grave illness. Unfortunately, the
evidence relating to the latter question is very scant. It has been
shown experimentally that the removal of the spleen in animals
seems to increase their powers of resistance to various infections,
but Horz rightly states that, from that fact, no trustworthy analogy
can be appUed to the human race. Racovicco reports a case of
tj-phoid fever which ran a mild course, in an epidemic of unusual
severity, in a splenectomized female, aged nineteen years, and a few
scattered cases of prompt uneventful recovery after operation for
a subsequent ventral hernia, and in one case, that of Roeser, for
acute ileus, due to a band formation, five years after splenectomy,
are also mentioned. On the other hand the patient operated on by
Roeser, after a persistent anemia, developed a pneumonia of the
lower left lobe six months after the splenectomy. At the end of
four weeks the patient convalesced slowly, and although prior to
the pneumonia the blood count had been normal, yet after it had
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34^ ELIOT: RUPTURE OF THE SPLEEN
run its course there was a considerable increase of the lympho-
cytes, especially of the larger varieties, though slowly decreasing,
yet which persisted for many months after recovery had taken
place, NStzeFs sixth case of splenectomy for a bullet woimd of
the thorax and abdomen is interesting in that in the absence of a
peritonitis an empyema developed, and although drained by the
excision of a rib, yet persisted to discharge imder general pyemic
symptoms masses of lung tissue, until it was thought that the
major portion of the lower left lobe had come away. The re-
covery of the patient imder such circumstances would indicate
unusual reparative power, while, at the same time, the extensive
sloughing of the lung would not probably have taken place had
the damage been limited to the thoracic cavity.
The necessarily small amount of clinical evidence dealing with
this subject certainly justifies the following interesting report of
the sequel in the second case. The clinical histories of the tw^o
cases are first given.
J. B., aged twenty-eight years, male. Admitted to the Presby-
terian Hospital May 28, 1906. There is an indistinct history of
malaria. While falling a distance of five stories down an elevator
shaft this morning the patient struck the left side against a bar.
When brought to the hospital, shortly afterward in the ambulance,
the patient complained of ihirst, shortness of breath, and of pain in
the left side and lower part of the chest.
Examination revealed a fracture of the ninth rib in the mid-
axillary line, with cutaneous emphysema over the left side of the
chest. The abdomen was full, but not distended, moving more on
the right side in respiration. There was marked rigidity of the
left flank and of the lower left costal arch. In the left flank there
was dulness merging with the normal area of splenic dulness