ENLARGEMENT OF TILE' SPLEEN.
is common in early life, and is found in the course of a diseases.. The symptom is alluded to incidentally in the descriptions of the various forms of illness in which the phenomenon occurs ; but the subject is of sufficient importance in a clinical point of view to deserve a special chapter for its consideration.
A splenic tumour may be of acute or chronic growth. Acute enlarge ment is seen in typhoid fever and ague, sometimes in acute tuberculosis, and, it is said, in cerebrospinal fever ; also the enlarged spleen found in cases of leucocythemia may be included in this class, for in early life leukhwmia often runs an acute course. Rapid increase in size of the organ is also oc casionally met with as a result bf splenic embolism in the course of ulcera tive endocarditis.
Chronic enlargement of the spleen may be the consequence, and some times the only manifestation, of the cachectic condition induced by mala rious poison. It occurs in some cases of ainyloid degeneration, although a spleen so affected is not always increased in size. It is a common symp tom of lymphaclenoma, is not unfrequently a consequence of atrophic cirrhosis of the liver, and may be met with in cases of old-standing dis ease of the heart. Lastly, it may be due to a simple hyperplasia. Hyper trophy of the spleen may occur in rickets and syphilis, especially the latter ; but is also found in cases where syphilis may be positively excluded, and in cases, too, where there is no reason to suspect any malaiious origin of the swelling.
In the child a spleen is not necessarily diseased because its lower edge is within reach of the finger. The healthy organ is sometimes pushed down, so as to be felt. This displacement may occur in cases of copious effusion into the left pleura, and is common in rickets where there is much retrac tion of the ribs.
In determining the existence of enlargement of the spleen it is not suf ficient merely to ascertain the position of the lower edge ; for considerable of the organ may be present although its inferior border does not project below the margin of the ribs. In the child the spleen often extends backwards and upwards as well as downwards, and may reach posteriorly to the spinal column. By percussion in such cases we can often detect dulness in the axilla reaching upwards as far as the fourth or fifth rib, and in the back extending as far upwards as the inferior angle of the scapula. In all
cases where a splenic tumour is suspected the size of the organ should be estimated by percussion as well as palpation. When the lower part of the organ projects below the ribs into the abdomen it is easily felt by laying the hand flat upon the belly and pressing gently with the finger tips. That the swelling thus discovered is due to increase in size of the spleen is indi cated by the superficial position of the tuniour, by the comparative thinness of its inner border, and by the notch which can often be distinctly perceived by the finger.
An enlarged spleen is usually firm and resisting to the touch, especially if the enlargement is a chronic process. In typhoid fever, however, the substance of the swollen organ is unusually soft, and on this account can sometimes be only felt by a practised finger. In acute forms of swelling the increase in size is accompanied by some tenderness on pressure. In chronic enlargements there may be also tenderness, but this is commonly due in such cases to the presence of local peritonitis.
In the present chapter it will be unnecessary to refer again to all the forms of splenic tumour met with in the child. It will be sufficient to con sider the chronic enlargement which occurs as a consequence of a simple hyperplasia of the organ.
Simple Hypeiplasia of the spleen is a not uncommon condition in in fancy and early childhood. Often the patient may bear traces of inherited syphilis or show some symptoms of rickets ; but this is not always the case, and sometimes no sign of diathetic disease or constitutional weakness is anywhere to be detected. When the enlargement is thus present in a child of apparently healthy constitution its etiology is difficult to establish. In some of the cases which have come under my notice the enlargement has been preceded by gastro-intestinal derangement. In others the child has been subject to frequent attacks of pulmonary catarrh. Sometimes the splenic tumour was first discovered shortly after an attack of measles ; but it is difficult to admit a connection between these derangements and the splenic hyperplasia.