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Splenic transplants following traumatic rupture of spleen and splenectomy
SPLENIC TRANSPLANTS RUPTURE J.
T.
Chief Surgeon,
FOLLOWING
OF SPLEEN AND SPLENECTOMY
KRUEGER, M.D. Lubbock Genera1HospitaI
AND
LUBBOCK,
A
of the Iiterature reveaIs SEARCH that such extensive trauma to the normal spIeen as to require spIenectomy is moderateIy rare; to demonstrate the deveIopment of functiona spIenic tissue foIlowing such an injury and splenectomy is of sufficiently rare occurrence as to warrant the report of this case. CASE
TRAUMATIC
REPORT
On March I 2, 1936, an eleven year old boy was brought to the hospital compIaining of abdomina1 pain and shortness of breath. The boy’s parents were both living and wel1, one sister had died of mastoiditis and meningitis, and another sister and a brother were Iiving and in good heaIth. The boy himself had had measles, chickenpox, whooping cough and pneumonia. His onIy surgical experience had been a tonsiIIectomy at the age of five. About three hours before he was brought to the hospital, he had injured himself in a bicycIe accident. Riding his bicycIe at fuI1 speed, he coIIided with a parked automobiIe. The rubber grip of one handlebar struck him forcibIy in the Ieft upper quadrant. It was reported that the bIow “knocked the breath” out of him. He was carried to his home. Some two hours foIIowing the accident, the patient compIained of increasing abdomina1 pain, painfu1 respiration and shortness of breath. His parents then took him to the hospital. Physical examination was as foIlows: The patient was a weII developed, we11 nourished white boy of eleven, in acute pain and having respiratory difficulty. The skin was paIe and dry. The scalp and cranium showed no abnormality. The pupils were moderateIy diIated, equa1 in size and reacted to Iight. The ears, nose, teeth, gums, tongue, pharynx, thyroid and cervica1 Iymph gIands were al1 examined with negative hndings. The heart was not enIarged, the rhythm was reguIar, there were no murmurs and the rate was seventy-two. The
H. E. MAST, M.D. Attending Surgeon,Lubbock GeneralHospital TEXAS
Iungs were clear to percussion and auscultation, but the patient had much pain in his Ieft Iower chest at each inspiration. No pleura1 friction rub was audible. The Iiver edge was not palpable, though there was moderate tenderness in this area. There was considerabIe abdominal distention, and a fluid wave couId be demonstrated. There was tenderness in the costolumbar angle on each side. The spleen was not paIpabIe. No masses were paIpabIe. There was generalized abdomina1 tenderness and rigidity, both being most pronounced in the Ieft upper quadrant. There were no pa1pahIe Iymphnodes. The extremities showed no evidence of injury beyond abrasions. Rectal examination revealed no unusua1 tenderness nor any masses. The externa1 genita1 organs were norma and there was no hernia. Urinalysis showed 2 pIus albumin, no sugar, no acetone, an occasiona granuIar cast, a fair number of red bIood ceIIs, and a few white blood ceIIs. Blood studies showed 3,900,000 red blood ceIIs, with a hemogIobin of 75 per cent. The white bIood ceII count was 13,200; 83 per cent polymorphonucIear neutrophiIs, I I per cent small Iymphocytes, 4 per cent Iarge lymphocytes, I per cent eosinophiIs and I per cent monocytes. The patient’s bIood was type IV. From the history of severe injury and from the physica Iindings, it was thought the patient had a ruptured viscus with intraabdomina1 hemorrhage. X-ray fiIms were made of the chest and abdomen. Both diaphragm shadows were clear. There was no evidence of fluid in either side of the chest. The heart and aorta were within norma Iimits as to size, shape and position. There was no evidence of pulmonary tubercuIosis or other infiItration or ConsoIidation. A singIe fiIm of the abdomen showed no abnormaIity except a generaIized Iack of detai1. The roentgenologist’s concIusions were that the chest was negative and that the Iack of detail over the abdomen suggested the presence of IIuid in the peritoneal cavity.
289
290
American Journal of Surgery
Krueger,
Mast-SpIenic
A pproximately two hours after admission and five hours after the accident the patient was given a genera1 anesthetic and his abdomen
TranspIants
NOVEMBER,,942
in two pIaces and microscopic evidence of hemorrhage in the body of the spleen near the points of rupture.
FIG. I. Photomicrograph of a representative area of one of the sections taken from splenic transplant. A spIenic artery can be seen in the edge of a spIenic node or maIpighian body, and the relationship of the node to the surrounding pulp tissue can be seen. On one edge of the section a fragment of trabecula can be distinguished. A few inflammatory ceIIs and eosinophites are scattered throughout the section. There is a large amount of bIood pigment. Fairly Iarge venous sinuses may be seen.
was opened. A one-inch incision was enIarged upward and downward to five inches and dark blood was encountered within the abdomina1 cavity. The spIeen was found to be ruptured so that it was made up of two equa1 large pieces and a smaI1 piece. Seven or 800 cc. of free bIood was present in the abdomen; this was removed by aspiration. The pedicle of the spleen was cIamped and Iigated and the three pieces were removed. FoIIowing cIosure of the wound, a transfusion of 575 cc. of whole bIood was given by the direct method. The operation required forty-one minutes. The pulse rate had risen from 120 at the beginning of the operation to 132 at the finish. The patient was in moderate shock before receiving the blood transfusion. The pathoIogist reported that the spleen was normal, except for rupture through the capsule
The patient enjoyed an uneventfu1 convalescence and was discharged in good condition on his tenth day. He led a normaI, active boy’s Iife and did not require medical attention again unti1 May 17, 1938, when he suffered simpIe transverse fractures of the Ieft radius and ulna, at the junction of their middIe and Iower thirds. These fractures heaIed SatisfactoriIy, except that on JuIy 20, 1938, he had the misfortune to refracture his Ieft radius at the site of the previous fracture, necessitating an additiona period of immobilization. ApproximateIy two years ago, in the earIy part of 1940, he was operated upon by another surgeon at another hospita1 for chronic appendicitis. His doctor teIIs me that onIy a smaI1 incision was made, and that no attempt was
NEW SERIESVOL. LVIII, No. 2
Krueger,
Mast-SpIenic
made to expIore the previous site of the spIeen or any area other than the cecum, appendix and termina1 ileum. A chronicalIy infIamed appendix was removed. No nodules were noted in the abdomen, though no specia1 search. was made for them. In October, 1940, the patient was seen in the cIinic compIaining of cramping abdomina1 pain and discomfort in the Ieft upper quadrant. He was toId to use minera oi1, eat soft foods and to report monthly. He was further advised that, if he faiIed to improve under this treatment, it wouId be necessary to perform a Iaparotomy for reIief of adhesions. He was subsequentIy seen on several occasions, stiI1 complaining of cramping pains, “puIIing” in the left upper quadrant and a Ioss of eight pounds of weight. On February 23, 1941, the patient entered the hospital for operation. He was then sixteen years oId. PhysicaI examination reveaIed no abnormaIities except a functiona mitral systoIic murmur and slight tenderness in the Ieft upper quadrant beneath the oId operative scar. A urinaIysis was normaI. BIood Wassermann was negative. His blood counts showed 4,770,ooo red ceIIs and 14,000 white ceIIs; hemogIobin was go per cent. There were IO per cent staff ceIIs, 70 per cent segmented neutrophiIs and 20 per cent lymphocytes. No pathoIogica1 forms of red blood ceIIs were seen in the stained smear. On February 24, 1941, under ether anesthesia, the patient was operated upon. A high Ieft rectus incision was made, excising the previous scar. There were many adhesions from the omentum to the anterior abdomina1 waI1, from the omentum to the cecum, from the stomach to the anterior abdomina1 waI1 and from the liver to the anterior abdomina1 wall. These adhesions were a11carefuIIy separated. Attached to the omentum on both its surfaces were twenty or thirty brownish-red, soft, encapsuIated noduIes ranging from I to 2 cm. in diameter. No noduIes were found attached to intestines, mesentery or peritoneum. The surface appearance and coIor resembled spIeen. Two of these noduIes were removed for microscopic study. No remnant of the spIeen couId be found at its former norma location. The pathoIogist, Dr. May Owen, describes the biopsies as foIIows: “The specimen submitted consists of two rounded, fairIy firm, smooth, dark reddishbIue tumors. The Iarger tumor measures 2 by
TranspIants
American Journal of surgery
29 I
1.3 by I cm. and the smaIIer 1.3 by I by .8 cm. SmaII tags of fat are attached to the capsules. The cut surfaces are dark reddish-brown. “Microscopical sections show the capsuIes to be irreguIarIy thickened. On the outer surface of the capsuIes there are tags of Ioose vascuIar fibrous tissue. The tumors show Ioose diffuse fibrous stroma with many varying sized bIood spaces, a Iarge percent of which are filled with blood. There are a few germ renters and an occasiona MaIpighian body: A few inffammatory ceIIs and eosinophiles are scattered throughout the sections. The inff ammatory ceIIs are particuIarIy noticeabIe in sections from the smaIIer biopsy. Sections from both tumors contain a Iarge amount of bIood pigment. “Findings: InfIammatory smaI1 accessor) spIeens.” A photomicrograph made from a representative area of one of these sections shows a spIenic artery in the edge of a spenic node or MaIpighian body and shows the reIationship of the node to the surrounding puIp tissue. On one edge of the section a fragment of trabecuIa ma) be distinguished. FoIIowing operation, the patient did niceIy and was abIe to go home on his tenth day. At an offIce visit two months foIlowing his operation, he stated that he had gained twenty pounds since operation, but that he stiI1 occasionaIIy had some discomfort in his Ieft upper quadrant, though never so severe as previousIy. Since his visit he has reported at intervaIs and has had graduaIIy decreasing abdomina1 discomfort. BIood counts made February 26, 1942, showed 4,96o,ooo erythrocytes and IO, IOO Ieukocytes; hemoglobin was g6 per cent. There were 3 per cent staff ceIIs, 64 per cent segmented neutrophiIes, 23 per cent Iymphocytes and IO per cent monocytes.
In 192 I, EccIes and Freer reported a case of ruptured spIeen in a twenty-one year oId man. The spIeen was removed in its entirety. Ten years Iater, during the course of an operation for incisiona hernia, an organ resembIing a norma spIeen in a11 outward appearances was found in the usua1 Iocation of the spIeen. No abdomina1 noduIes were described. The authors considered this to be an enIarged spIencuIus, hypertrophied under the impetus given by the remova of the main spIenic body.
292
American Journal of Surgery
Krueger,
Mast-SpIenic
Marine and ManIey did the earIiest successfu1 work on autotranspIantation of spIenic tissue and concluded that surviva1 and growth are the ruIe. Silberberg, in 1935, demonstrated that hemopoietic organs have no marked resistance to transpIantation, though surviva1 is not as good as epithelial organs and ceIIs or connective tissue. He concIuded that autotranspIants of spIeen manifest positive growth and fuI1 regenerative abiIity. PerIa, in 1936, reported his work on regeneration of autopIastic spIenic transpIants in mature albino rats. He concIuded that there was compIete regeneration of Iarge transpIants in from tweIve to twentyone days, and that the morphoIogica1 structure of aduIt spIeen tissue is present in the transpIant, with we11 deveIoped capsuIe and trabecuIas. His studies indicated to him that the reticuIar ceI1 of the aduIt spIeen retains its potentiaIity for differentiation and may be the precursor of the structura1 eIements of the spIeen. In 1939, Buchbinder and Lipkoff report in detai1 the case of a twenty-eight year oId Puerto Rican woman who had suffered rupture of her spleen in I g I g as the resuIt of being struck by an automobiIe. At operation many purple-red noduIes were found on the parietal peritoneum, greater omenturn, ileum, ascending coIon and sigmoid. The histoIogic characteristics were those of spIenic noduIes. The authors concIuded that these noduIes arose from autotransplantation of spIenic tissue throughout the abdomina1 cavity foIIowing trauma of the spIeen. They pointed out the possibiIity of confusing such noduIes of spIenic tissue with endometria1 imprants. They offered the term “ spIenosis ” to describe this condition. The authors were able to coIIect from the Iiterature onIy nine other cases which they considered paraIIeIed their own. These were reported by AIbrecht in 1896, SchiIIing in rgo7, Von Kuttner in 1910, FoItin in IgI I, Von Steubenraush in 1912, OItman in IgIg, Lee in 1923, Kupperman in 1936, and Shaw and Shafi in 1937.
TranspIants
NOVEMBER, ,942
In 1941, RousseIot and IIIyne discussed traumatic rupture of the spIeen, stressing treatment and sequeIas. the diagnosis, Among other aspects, they studied the bIood pictures of seventeen patients who had had spIenectomy for traumatic rupture. They found that, aIthough severa patients showed anemia for a short whiIe foIIowing operation, this anemia couId be expIained on the basis of hemorrhage. There was no persistent anemia. They did find persistent Ieukocytosis, thrombocytosis and reIative Iymphocytosis, Their findings of no anemia, but persistent Ieukocytosis and reIative Iymphocytosis are in accordance with the bIood findings of the case I am reporting today. Of the seventeen cases reported by these authors, one was found at autopsy one and one-haIf years Iater to have many implants of splenic tissue scattered over the Ieft Iobe of the Iiver. The Ieft dome of the diaphragm, the stomach, Iesser omentum, transverse colon, right kidney, peIvis, anterior waI1 of the rectum and posterior waI1 of the bIadder. This same case was described by Jarcho and Anderson, in 1939, and in addition another simiIar case was reported. Jarcho and Anderson were interested chiefly in the source from which these splenic noduIes came. SeveraI hypotheses propounded by other authors were examined and discarded. Among these were the ideas that: (I) the spIenic noduIes existed prior to the injury to the spIeen, (2) that the noduIes are formed from preexisting Iymphoid tissue or spIenic anIage, and (3) that the noduIes are formed by the peritoneum, perhaps under the stimuIus of In support of their own spIenectomy. theory of transpIantation or “seedIing” of the peritoneum from the pulp of the traumatized spIeen, they observe that the occurrence of wideIy disseminated spIenic noduIes in any considerabre number has never been reported after splenectomy in cases of nontraumatic disease of the spIeen. This suggests that the determining factor is not splenectomy but trauma.
NEW SERIESVOL. LVIII, No. 2
Krueger,
Mast-SpIenic
This theory of transpIantation of particIes of spIenic pulp is in accordance with my own view and is offered as explanation of the presence of noduIes of spIenic tissue in the omentum of the case I have reported. REFERENCES I. BUCHBINDER, J. H. and LIPKOFF, C. J. Surgery, 6: 927,
1939.
TranspIants 2. 3.
A m&can Journalof Sul-gery 293
ECCLES, W. M. and FREER, G. D. Brit. M. J., 2: 5 I 5, 1921. JARCHO, S. and ANDERSON, D. H. Am. J. Pd.,
15: 5,
‘939.
4 5.
MARINE, D. and MANLEY, 0. T. J. Esper. Med., 32:
113, 1920. PERLA, DAVID. Am. J. Patb., 12: 665, 1936. L. M. and ILLYNE, C. A. S. Clin. Norrh 6. Roussmor, America, 21: 455, 1941. 7. SILBERBERC, MARTIN. Arch. Path., 20: 276-221, ‘935.
OBSTRUCTION of the smaII bowe1 can usuaIIy be readiIy distinguished by the occurrence of frequent and copious vomiting and by the distended loops of smaI1 intestine seen in the skiagram. One of the most diffrcuIt differentiations to make, and one which occasionaIIy cannot be made without recourse to operation, is that of distinguishing a spastic obstruction of the coIon from a mechanica bIock. From-“ IntestinaI Obstructions” by Owen H. Wangensteen (Charles C. Thomas).
T.
Chief Surgeon,
FOLLOWING
OF SPLEEN AND SPLENECTOMY
KRUEGER, M.D. Lubbock Genera1HospitaI
AND
LUBBOCK,
A
of the Iiterature reveaIs SEARCH that such extensive trauma to the normal spIeen as to require spIenectomy is moderateIy rare; to demonstrate the deveIopment of functiona spIenic tissue foIlowing such an injury and splenectomy is of sufficiently rare occurrence as to warrant the report of this case. CASE
TRAUMATIC
REPORT
On March I 2, 1936, an eleven year old boy was brought to the hospital compIaining of abdomina1 pain and shortness of breath. The boy’s parents were both living and wel1, one sister had died of mastoiditis and meningitis, and another sister and a brother were Iiving and in good heaIth. The boy himself had had measles, chickenpox, whooping cough and pneumonia. His onIy surgical experience had been a tonsiIIectomy at the age of five. About three hours before he was brought to the hospital, he had injured himself in a bicycIe accident. Riding his bicycIe at fuI1 speed, he coIIided with a parked automobiIe. The rubber grip of one handlebar struck him forcibIy in the Ieft upper quadrant. It was reported that the bIow “knocked the breath” out of him. He was carried to his home. Some two hours foIIowing the accident, the patient compIained of increasing abdomina1 pain, painfu1 respiration and shortness of breath. His parents then took him to the hospital. Physical examination was as foIlows: The patient was a weII developed, we11 nourished white boy of eleven, in acute pain and having respiratory difficulty. The skin was paIe and dry. The scalp and cranium showed no abnormality. The pupils were moderateIy diIated, equa1 in size and reacted to Iight. The ears, nose, teeth, gums, tongue, pharynx, thyroid and cervica1 Iymph gIands were al1 examined with negative hndings. The heart was not enIarged, the rhythm was reguIar, there were no murmurs and the rate was seventy-two. The
H. E. MAST, M.D. Attending Surgeon,Lubbock GeneralHospital TEXAS
Iungs were clear to percussion and auscultation, but the patient had much pain in his Ieft Iower chest at each inspiration. No pleura1 friction rub was audible. The Iiver edge was not palpable, though there was moderate tenderness in this area. There was considerabIe abdominal distention, and a fluid wave couId be demonstrated. There was tenderness in the costolumbar angle on each side. The spleen was not paIpabIe. No masses were paIpabIe. There was generalized abdomina1 tenderness and rigidity, both being most pronounced in the Ieft upper quadrant. There were no pa1pahIe Iymphnodes. The extremities showed no evidence of injury beyond abrasions. Rectal examination revealed no unusua1 tenderness nor any masses. The externa1 genita1 organs were norma and there was no hernia. Urinalysis showed 2 pIus albumin, no sugar, no acetone, an occasiona granuIar cast, a fair number of red bIood ceIIs, and a few white blood ceIIs. Blood studies showed 3,900,000 red blood ceIIs, with a hemogIobin of 75 per cent. The white bIood ceII count was 13,200; 83 per cent polymorphonucIear neutrophiIs, I I per cent small Iymphocytes, 4 per cent Iarge lymphocytes, I per cent eosinophiIs and I per cent monocytes. The patient’s bIood was type IV. From the history of severe injury and from the physica Iindings, it was thought the patient had a ruptured viscus with intraabdomina1 hemorrhage. X-ray fiIms were made of the chest and abdomen. Both diaphragm shadows were clear. There was no evidence of fluid in either side of the chest. The heart and aorta were within norma Iimits as to size, shape and position. There was no evidence of pulmonary tubercuIosis or other infiItration or ConsoIidation. A singIe fiIm of the abdomen showed no abnormaIity except a generaIized Iack of detai1. The roentgenologist’s concIusions were that the chest was negative and that the Iack of detail over the abdomen suggested the presence of IIuid in the peritoneal cavity.
289
290
American Journal of Surgery
Krueger,
Mast-SpIenic
A pproximately two hours after admission and five hours after the accident the patient was given a genera1 anesthetic and his abdomen
TranspIants
NOVEMBER,,942
in two pIaces and microscopic evidence of hemorrhage in the body of the spleen near the points of rupture.
FIG. I. Photomicrograph of a representative area of one of the sections taken from splenic transplant. A spIenic artery can be seen in the edge of a spIenic node or maIpighian body, and the relationship of the node to the surrounding pulp tissue can be seen. On one edge of the section a fragment of trabecula can be distinguished. A few inflammatory ceIIs and eosinophites are scattered throughout the section. There is a large amount of bIood pigment. Fairly Iarge venous sinuses may be seen.
was opened. A one-inch incision was enIarged upward and downward to five inches and dark blood was encountered within the abdomina1 cavity. The spIeen was found to be ruptured so that it was made up of two equa1 large pieces and a smaI1 piece. Seven or 800 cc. of free bIood was present in the abdomen; this was removed by aspiration. The pedicle of the spleen was cIamped and Iigated and the three pieces were removed. FoIIowing cIosure of the wound, a transfusion of 575 cc. of whole bIood was given by the direct method. The operation required forty-one minutes. The pulse rate had risen from 120 at the beginning of the operation to 132 at the finish. The patient was in moderate shock before receiving the blood transfusion. The pathoIogist reported that the spleen was normal, except for rupture through the capsule
The patient enjoyed an uneventfu1 convalescence and was discharged in good condition on his tenth day. He led a normaI, active boy’s Iife and did not require medical attention again unti1 May 17, 1938, when he suffered simpIe transverse fractures of the Ieft radius and ulna, at the junction of their middIe and Iower thirds. These fractures heaIed SatisfactoriIy, except that on JuIy 20, 1938, he had the misfortune to refracture his Ieft radius at the site of the previous fracture, necessitating an additiona period of immobilization. ApproximateIy two years ago, in the earIy part of 1940, he was operated upon by another surgeon at another hospita1 for chronic appendicitis. His doctor teIIs me that onIy a smaI1 incision was made, and that no attempt was
NEW SERIESVOL. LVIII, No. 2
Krueger,
Mast-SpIenic
made to expIore the previous site of the spIeen or any area other than the cecum, appendix and termina1 ileum. A chronicalIy infIamed appendix was removed. No nodules were noted in the abdomen, though no specia1 search. was made for them. In October, 1940, the patient was seen in the cIinic compIaining of cramping abdomina1 pain and discomfort in the Ieft upper quadrant. He was toId to use minera oi1, eat soft foods and to report monthly. He was further advised that, if he faiIed to improve under this treatment, it wouId be necessary to perform a Iaparotomy for reIief of adhesions. He was subsequentIy seen on several occasions, stiI1 complaining of cramping pains, “puIIing” in the left upper quadrant and a Ioss of eight pounds of weight. On February 23, 1941, the patient entered the hospital for operation. He was then sixteen years oId. PhysicaI examination reveaIed no abnormaIities except a functiona mitral systoIic murmur and slight tenderness in the Ieft upper quadrant beneath the oId operative scar. A urinaIysis was normaI. BIood Wassermann was negative. His blood counts showed 4,770,ooo red ceIIs and 14,000 white ceIIs; hemogIobin was go per cent. There were IO per cent staff ceIIs, 70 per cent segmented neutrophiIs and 20 per cent lymphocytes. No pathoIogica1 forms of red blood ceIIs were seen in the stained smear. On February 24, 1941, under ether anesthesia, the patient was operated upon. A high Ieft rectus incision was made, excising the previous scar. There were many adhesions from the omentum to the anterior abdomina1 waI1, from the omentum to the cecum, from the stomach to the anterior abdomina1 waI1 and from the liver to the anterior abdomina1 wall. These adhesions were a11carefuIIy separated. Attached to the omentum on both its surfaces were twenty or thirty brownish-red, soft, encapsuIated noduIes ranging from I to 2 cm. in diameter. No noduIes were found attached to intestines, mesentery or peritoneum. The surface appearance and coIor resembled spIeen. Two of these noduIes were removed for microscopic study. No remnant of the spIeen couId be found at its former norma location. The pathoIogist, Dr. May Owen, describes the biopsies as foIIows: “The specimen submitted consists of two rounded, fairIy firm, smooth, dark reddishbIue tumors. The Iarger tumor measures 2 by
TranspIants
American Journal of surgery
29 I
1.3 by I cm. and the smaIIer 1.3 by I by .8 cm. SmaII tags of fat are attached to the capsules. The cut surfaces are dark reddish-brown. “Microscopical sections show the capsuIes to be irreguIarIy thickened. On the outer surface of the capsuIes there are tags of Ioose vascuIar fibrous tissue. The tumors show Ioose diffuse fibrous stroma with many varying sized bIood spaces, a Iarge percent of which are filled with blood. There are a few germ renters and an occasiona MaIpighian body: A few inffammatory ceIIs and eosinophiles are scattered throughout the sections. The inff ammatory ceIIs are particuIarIy noticeabIe in sections from the smaIIer biopsy. Sections from both tumors contain a Iarge amount of bIood pigment. “Findings: InfIammatory smaI1 accessor) spIeens.” A photomicrograph made from a representative area of one of these sections shows a spIenic artery in the edge of a spenic node or MaIpighian body and shows the reIationship of the node to the surrounding puIp tissue. On one edge of the section a fragment of trabecuIa ma) be distinguished. FoIIowing operation, the patient did niceIy and was abIe to go home on his tenth day. At an offIce visit two months foIlowing his operation, he stated that he had gained twenty pounds since operation, but that he stiI1 occasionaIIy had some discomfort in his Ieft upper quadrant, though never so severe as previousIy. Since his visit he has reported at intervaIs and has had graduaIIy decreasing abdomina1 discomfort. BIood counts made February 26, 1942, showed 4,96o,ooo erythrocytes and IO, IOO Ieukocytes; hemoglobin was g6 per cent. There were 3 per cent staff ceIIs, 64 per cent segmented neutrophiIes, 23 per cent Iymphocytes and IO per cent monocytes.
In 192 I, EccIes and Freer reported a case of ruptured spIeen in a twenty-one year oId man. The spIeen was removed in its entirety. Ten years Iater, during the course of an operation for incisiona hernia, an organ resembIing a norma spIeen in a11 outward appearances was found in the usua1 Iocation of the spIeen. No abdomina1 noduIes were described. The authors considered this to be an enIarged spIencuIus, hypertrophied under the impetus given by the remova of the main spIenic body.
292
American Journal of Surgery
Krueger,
Mast-SpIenic
Marine and ManIey did the earIiest successfu1 work on autotranspIantation of spIenic tissue and concluded that surviva1 and growth are the ruIe. Silberberg, in 1935, demonstrated that hemopoietic organs have no marked resistance to transpIantation, though surviva1 is not as good as epithelial organs and ceIIs or connective tissue. He concIuded that autotranspIants of spIeen manifest positive growth and fuI1 regenerative abiIity. PerIa, in 1936, reported his work on regeneration of autopIastic spIenic transpIants in mature albino rats. He concIuded that there was compIete regeneration of Iarge transpIants in from tweIve to twentyone days, and that the morphoIogica1 structure of aduIt spIeen tissue is present in the transpIant, with we11 deveIoped capsuIe and trabecuIas. His studies indicated to him that the reticuIar ceI1 of the aduIt spIeen retains its potentiaIity for differentiation and may be the precursor of the structura1 eIements of the spIeen. In 1939, Buchbinder and Lipkoff report in detai1 the case of a twenty-eight year oId Puerto Rican woman who had suffered rupture of her spleen in I g I g as the resuIt of being struck by an automobiIe. At operation many purple-red noduIes were found on the parietal peritoneum, greater omenturn, ileum, ascending coIon and sigmoid. The histoIogic characteristics were those of spIenic noduIes. The authors concIuded that these noduIes arose from autotransplantation of spIenic tissue throughout the abdomina1 cavity foIIowing trauma of the spIeen. They pointed out the possibiIity of confusing such noduIes of spIenic tissue with endometria1 imprants. They offered the term “ spIenosis ” to describe this condition. The authors were able to coIIect from the Iiterature onIy nine other cases which they considered paraIIeIed their own. These were reported by AIbrecht in 1896, SchiIIing in rgo7, Von Kuttner in 1910, FoItin in IgI I, Von Steubenraush in 1912, OItman in IgIg, Lee in 1923, Kupperman in 1936, and Shaw and Shafi in 1937.
TranspIants
NOVEMBER, ,942
In 1941, RousseIot and IIIyne discussed traumatic rupture of the spIeen, stressing treatment and sequeIas. the diagnosis, Among other aspects, they studied the bIood pictures of seventeen patients who had had spIenectomy for traumatic rupture. They found that, aIthough severa patients showed anemia for a short whiIe foIIowing operation, this anemia couId be expIained on the basis of hemorrhage. There was no persistent anemia. They did find persistent Ieukocytosis, thrombocytosis and reIative Iymphocytosis, Their findings of no anemia, but persistent Ieukocytosis and reIative Iymphocytosis are in accordance with the bIood findings of the case I am reporting today. Of the seventeen cases reported by these authors, one was found at autopsy one and one-haIf years Iater to have many implants of splenic tissue scattered over the Ieft Iobe of the Iiver. The Ieft dome of the diaphragm, the stomach, Iesser omentum, transverse colon, right kidney, peIvis, anterior waI1 of the rectum and posterior waI1 of the bIadder. This same case was described by Jarcho and Anderson, in 1939, and in addition another simiIar case was reported. Jarcho and Anderson were interested chiefly in the source from which these splenic noduIes came. SeveraI hypotheses propounded by other authors were examined and discarded. Among these were the ideas that: (I) the spIenic noduIes existed prior to the injury to the spIeen, (2) that the noduIes are formed from preexisting Iymphoid tissue or spIenic anIage, and (3) that the noduIes are formed by the peritoneum, perhaps under the stimuIus of In support of their own spIenectomy. theory of transpIantation or “seedIing” of the peritoneum from the pulp of the traumatized spIeen, they observe that the occurrence of wideIy disseminated spIenic noduIes in any considerabre number has never been reported after splenectomy in cases of nontraumatic disease of the spIeen. This suggests that the determining factor is not splenectomy but trauma.
NEW SERIESVOL. LVIII, No. 2
Krueger,
Mast-SpIenic
This theory of transpIantation of particIes of spIenic pulp is in accordance with my own view and is offered as explanation of the presence of noduIes of spIenic tissue in the omentum of the case I have reported. REFERENCES I. BUCHBINDER, J. H. and LIPKOFF, C. J. Surgery, 6: 927,
1939.
TranspIants 2. 3.
A m&can Journalof Sul-gery 293
ECCLES, W. M. and FREER, G. D. Brit. M. J., 2: 5 I 5, 1921. JARCHO, S. and ANDERSON, D. H. Am. J. Pd.,
15: 5,
‘939.
4 5.
MARINE, D. and MANLEY, 0. T. J. Esper. Med., 32:
113, 1920. PERLA, DAVID. Am. J. Patb., 12: 665, 1936. L. M. and ILLYNE, C. A. S. Clin. Norrh 6. Roussmor, America, 21: 455, 1941. 7. SILBERBERC, MARTIN. Arch. Path., 20: 276-221, ‘935.
OBSTRUCTION of the smaII bowe1 can usuaIIy be readiIy distinguished by the occurrence of frequent and copious vomiting and by the distended loops of smaI1 intestine seen in the skiagram. One of the most diffrcuIt differentiations to make, and one which occasionaIIy cannot be made without recourse to operation, is that of distinguishing a spastic obstruction of the coIon from a mechanica bIock. From-“ IntestinaI Obstructions” by Owen H. Wangensteen (Charles C. Thomas).