symptoms of its presence depends upon varied circumstances. Small
cysts, {969} certainly, may occasion no signs, subjective or objective.
Cysts may even attain very large dimensions without exciting discomfort
to their bearer, and may consequently escape detection. Pain may
precede the appearance of a tumor, but will be irregular and
paroxysmal, increasing in severity with the growth of the cyst. The
most constant annoyance, however, is that occasioned by the size and
weight of the enlargement. The patient may detect its presence
accidentally, or his attention may first be directed to it by his
medical attendant. He may give a history of its growth during a number
of years without its having occasioned more than passing uneasiness.
The tumor may exceptionally attain a large size, nearly filling the
left side of the abdominal cavity. It may encroach upon the area of the
thoracic cavity. Upon examination, the tumor, when of sufficient size,
will be rounded, not resembling the appearance of a simply enlarged
spleen. Fluctuation will be detected, and occasionally the peculiar
hydatid thrill, upon the diagnostic importance of which great stress
has been placed. This, however, is a very inconstant sign, and in the
majority of cases is not to be discovered. Frerichs only found it where
the sac was not tense and contained other vesicles. A peritoneal
friction sound may sometimes be detected by the ear placed over the
region of the tumor. These cysts differ from other fluctuating tumors
in being of very slow growth, remaining almost without change for
years, and in exciting no constitutional reaction, unless, as is quite
possible, inflammation of the sac is developed, when rigors, hectic,
and other symptoms indicative of suppurative inflammation will be
observed. Pressure of the tumor upon the stomach may excite anorexia,
vomiting, epigastric uneasiness, and gastric catarrh. If the pressure
is exerted upon the portal vein or vena cava, dropsy may result; if
upon the bowel, constipation may be produced.
It is possible for the development of the cyst to be arrested through
the death of the echinococcus. This may occur if it is of small size.
Its walls may then become calcareous, and the mass will cease to exert
any injurious influence upon the host. In other cases, as a result of
inflammation, rupture will take place, and the contents of the cyst,
with the characteristic formations, will escape into the peritoneal,
pericardial, or pleural cavities, or into the alimentary tract, the
urinary passages, or even into the vena cava; or they may be discharged
through the body-wall. In any of these events a fatal termination is
almost inevitable. Rupture may also occur in an unaltered cyst from any
sudden or excessive violence. Death will usually speedily ensue from
collapse or as a result of inflammation of the peritoneum. Finally,
complete recovery will sometimes be secured through treatment.
DIAGNOSIS.--Echinococcus of the spleen presents no characteristic
symptoms. When the tumor is small and escapes observation, or when the
fluid nature of its contents cannot be recognized, its existence cannot
be determined. In larger tumors the hydatid thrill will, when present,
assist the observer, and the presence of fluctuation will of course
serve to exclude all solid enlargements of the spleen from
consideration. Abscess will differ in its shorter course, its rapid
increase in size, and its inflammatory symptoms, the general condition
contrasting with the excellent condition of health usually observed in
simple hydatid tumor. The diagnosis will become greatly obscured in the
event of inflammation of the cyst. Certainty can only be attained
through an exploratory puncture and examination of the contents of the
cysts. These will consist of a clear, non-albuminous fluid, rich in
sodium chloride, and revealing the echinococcus scolices and hooks and
membranous shreds when examined under the microscope. Doubt may arise
where inflammatory changes have made the fluid albuminous and where the
scolices and hooklets have been destroyed or do not accompany the
escaped fluid.
{970} MORBID ANATOMY.--The spleen may be almost destroyed by the
hydatid cysts, which, usually single, may exist in large numbers.
According to Wardell,[11] "they are seldom found in the pulp, usually
in the gastro-splenic epiploon or in the cysts constituted of the
serous investment." The cysts consist of a thick fibrous investment and
an inner parenchymatous layer, from which the little heads develop in
tiny vesicles. Compound systems, one enclosed within the other, are
thus formed, varying from the size of a pea to that of a marble, and
even very much larger. The cysts may undergo atheromatous or calcareous
degeneration. In these cases the echinococci are destroyed, and the
mass becomes encapsulated in a calcareous envelope and remains
quiescent. The microscope will reveal the remains of the echinococci,
even after long periods. Where rupture has taken place the rent in the
cyst will have allowed characteristic matters to escape into the
communicating parts, where they may be detected.
[Footnote 11: _Reynolds's System of Medicine_, vol. v.]
The PROGNOSIS of echinococcus of the spleen is always serious, usually
most unfavorable. The best results are observed in those cases where,
the cyst being small, spontaneous arrest of development has occurred.
Puncture of the cyst and partial evacuation of its contents, when
practicable, increase what would otherwise be almost hopeless chances
of ultimate recovery in cysts of moderate and large size.
TREATMENT.--The only treatment that promises good results is the
evacuation of the cyst fluid. Murchison recommends the removal of the
fluid with a very small trocar, whereby the admission of air into the
cavity is avoided. The withdrawal of the fluid is sufficient to destroy
the life of the parasite, and in favorable cases to secure the
degenerative changes of which mention has been made. The adoption of
antiseptic precautions will undoubtedly increase the chances of
recovery. Unfortunately, a certain number of cases will run into
suppuration, when all the dangers of suppurating cavities have to be
encountered, and must be treated in the usual way. Various injections
into the cyst-cavity have been recommended, but they do not seem to
afford better results than simple evacuation. These will probably most
successfully be employed in cases where the cyst has formed
inflammatory adhesions to the skin, which may be effected through the
external application of caustic agents capable of exciting inflammatory
changes in the deeper parts (Vienna paste, etc.). Injections may be
then made through incisions carried into the cyst, without danger of
exposing the peritoneal cavity. Internal medication, except for general
purposes, has no efficacy in the treatment of these tumors.
Syphilis of the Spleen.
The spleen is not very frequently affected by syphilis. Nevertheless,
this viscus may become the seat of syphilitic disorder during either
its early or late phases. It has even been asserted by Weil that the
spleen may become enlarged in the interval between the appearance of
the primary sore and the first cutaneous eruption. Whatever changes the
spleen may undergo during the course of early syphilis are essentially
of the simple congestive type, and are comparable to the acute splenic
enlargements of the ordinary specific fevers; certainly, no essentially
syphilitic changes can be detected at this stage. In fact, throughout
the whole secondary period the splenic derangement is of the nature of
simple hyperplasia. In the later stages of syphilis there is a more
permanent enlargement of the spleen, due to a chronic interstitial
inflammation that should be distinguished from that very much more
common result of old syphilis, lardaceous degeneration. The
histological characteristics of these enlargements are not known to
differ essentially from the simple chronic enlargements of the spleen
already considered.
{971} It is only toward the end of the secondary period, and during
tertiary syphilis and in inherited syphilis, that products essentially
syphilitic can be recognized. Gummy infiltrations and tumors of the
spleen have been observed by a few writers--not, however, clinically,
but for the most part in the dead-house. These tumors are found
scattered throughout the substance of the organ, but most commonly near
its surface. They vary in number within not very wide limits, and in
size from that of a pinhead to that of a pea or larger. They may be
sharply circumscribed (but not encapsulated) or more diffused. The
portions of the spleen affected become changed by the syphilitic
material into grayish-red, homogeneous masses in recent cases. At a
later stage they are "gray or grayish-yellow, homogeneous, somewhat
dry, tough, almost cheesy."[12] The spleen under these circumstances
is, as a whole, somewhat enlarged.[13] Gummy tumors of the spleen may
be confounded with tubercle and old hemorrhagic infarction.
[Footnote 12: Wagner, Mosler, _Ziemssen's Cyclop._, vol. viii. p. 485,
Am. ed.]
[Footnote 13: Gold, _Viertelj. f. Derm. und Syph._, 1880, p. 463.]
There is a form of circumscribed enlargement from new growth that is
sometimes observed in the spleens of syphilitics, and which is probably
of syphilitic origin, producing changes similar to certain forms
already described as a variety of perisplenitis. It is situated at the
surface of the spleen, and consists of hard whitish or pale-yellow
plates but slightly elevated above the normal level, but of
considerable superficial extent. When incised, these plates remind one
of cartilage.
Splenic enlargements are common in the subjects of inherited syphilis.
According to Cornil, infants syphilitic by inheritance have very
frequently enlarged spleens, the capsule being inflamed and thickened
and the splenic tissue abnormally hard. The organ may thus become
sufficiently enlarged to be detected by palpation. Sée considers that
enlargement of the spleen is present in one-fourth of all cases of
inherited syphilis, and Haslund reports splenic enlargement in 58 of
154 necropsies of such infants.
The clinical signs of syphilitic spleen are almost beyond recognition,
if indeed they can be said to exist. Circumstances of growth, etc. may
excite the suspicion that a given splenic tumor may be syphilitic.
Jullien, it is true, describes symptoms of splenic syphilis, but his
views do not seem to be well founded.
TREATMENT.--In recent enlargements therapeutics may effect much in
reducing the tumor, and the facility with which its reduction is
effected will afford a valuable indication of the success of treatment.
Gummy tumors are probably within the reach of antisyphilitic treatment,
and it is not unlikely that some of the shrunken, indurated areas often
detected post-mortem, and usually ascribed to infarctions, are in
reality due to the cicatricial remnants of old gummata. Chronic diffuse
splenic enlargements of syphilitic origin are but little influenced by
treatment.
Rupture of the Spleen.
The peculiar texture of the spleen renders it especially liable to
rupture--more so than any of the other abdominal viscera. By far the
most common cause of splenic rupture is external violence from blows,
kicks, falls, squeezing force, and wounds incised or punctured. It may
be the direct result of the injury, or the rent may be made by the
penetration of broken ribs or of foreign bodies. The rupture may even
occur spontaneously from causes located within the organ itself. It has
been previously observed that in the enlargement accompanying the acute
infectious fevers, malarial fever, etc., while the distension of the
capsule renders the spleen tense and elastic, {972} section through its
substance will often reveal a semi-diffluent condition, the exact
nature of which is not well understood, but which undoubtedly
originates in excessive vascularity. This occurs especially in malarial
fever and typhus. Rupture may here take place spontaneously, or, as is
commonly the case, a very slight degree of violence is sufficient to
produce it: a wrench, the effort to preserve a disturbed equilibrium,
an otherwise insignificant blow, may determine the lesion. Pregnancy
and the puerperal state may be the predisposing causes to the accident,
and vomiting has been known to produce it. It has also been known to
follow the softening and breaking down of a hemorrhagic infarction or
the rupture of varices and aneurism. The normal spleen is only with the
greatest rarity subjected to a degree of violence sufficient to rupture
it, while in countries where enlargement of the spleen is of common
occurrence, as from malaria, the accident occurs more frequently.
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, Konaraloff[14] 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.
[Footnote 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 {973} 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).
{974}
DISEASES OF THE THYROID GLAND.
BY D. HAYES AGNEW, M.D., LL.D.
The thyroid body occupies a very important position in the neck, being
closely related to the larynx, the trachea, the carotid blood-vessels,
the pneumogastric, sympathetic, and recurrent laryngeal nerves. These
relations render quite intelligible the phenomena which are so
frequently present when the gland becomes the subject of disease. It is
richly supplied with blood-vessels from the external carotids and the
subclavian arteries.
Notwithstanding the obscurity which enshrouds the physiological
function of the gland, there are good reasons for supposing that its
office in the animal economy is not an unimportant one: indeed, its
presence, not in the vertebrata alone, but also in birds, reptiles, and
fishes, tends to strengthen this conclusion. The experiments of Zesas
appear to show that the thyroid body plays an important rôle in
regulating the supply of blood to the brain, and also of supplementing
the work of the spleen. The place, therefore, of the gland in the body
as an appendage to the vascular system appears to be well chosen.
Congenital absence of the thyroid body is uncommon, though it has been
noted by a few writers. Curtin[1] met with one case in which the gland
was replaced by a mass of fat. Possibly in this instance the fat was
the result of a morbid change in the thyroid, and not an evidence of
the latter having never been present. Beach[2] furnishes another case
where on dissection no trace of the gland could be found. Hyrtl speaks
of the isthmus being frequently absent--a fact observed by other
anatomists.
[Footnote 1: _Lancet_, 1850, vol. ii. p. 25.]
[Footnote 2: _Medical Times and Gazette_, May 30, 1884, p. 603.]
Goitre.
Various names have been employed by different writers to designate
enlargements of the thyroid body. Among these may be named bronchocele,
tracheocele, thyrophraxia, Derbyshire neck, struma, and goitre. Among
English-speaking people the disease is generally spoken of as goitre or
Derbyshire neck.
Hypertrophy of the gland may be either general or partial; when
general--that is to say, involving the entire body--the term
symmetrical or bilateral is employed to designate the enlargement; when
confined to a single lobe, it is said to be asymmetrical or unilateral.
Not unfrequently limited portions or small areas of one lobe only are
affected, causing irregularities or nodosities which may be readily
detected by the eye or the touch.
SYMPTOMS.--The earliest evidence of bilateral goitre is the appearance
of an unusual fulness and breadth of the lower part of the neck or that
part between the sternum and the larynx. This fulness extends laterally
under the sterno-cleido-mastoid muscles, partially effacing the
suprasternal fossa, {975} and is entirely unattended by pain, heat,
redness, or other sign of inflammation. When the disease is unilateral,
the swelling is seen to extend from the side of the trachea and larynx
outward under the sterno-cleido muscle. The tumor, in consequence of
its attachment to the trachea, follows the movements of the latter, and
hence will be seen to rise and fall during the act of swallowing or of
deglutition.
The progress of the enlargement varies greatly in different cases.
After its first appearance it may remain quiescent for years, scarcely
causing any change in the appearance of the neck which could be deemed
a deformity; in other instances the growth will be progressive,
attaining to the size of a goose egg, when it may again remain
stationary. It is not common in the United States to meet with those
excessive hypertrophies of the thyroid so common in Switzerland, where
the gland extends up behind the ears, outward to the margins of the
trapezii muscles, and hangs down in front of the sternum a large
pendulous mass and imparting a most hideous appearance to the patient.
Pressure Symptoms and the Attendant Phenomena.--It is very remarkable
to what a degree hypertrophy of the thyroid may reach without giving
rise to any marked functional disturbances. This is due, no doubt, to
the character of the enlargement, the cystic and vascular causing less
inconvenience than the fibrous or more solid varieties. The pressure
symptoms which may ensue are--first, difficulty of respiration. This is
likely to follow when the central portion of the gland enlarges in
common with the lateral masses, thereby causing pressure directly upon
the trachea. This pressure may result in softening, and even complete
absorption, of one or more of the rings of the trachea. An irritative
cough may appear in the course of the hypertrophy, which is to be
referred to the encroachment by the gland on the pneumogastric nerve.
Hoarseness and a peculiar croaking voice are also sometimes witnessed,
indicating the contact of the tumor with one or both recurrent
laryngeal nerves.
Redness of the skin and elevation of temperature on one side of the
neck are occasionally present, and sometimes accompanied by dilatation
of the pupil of the eye corresponding to the affected side. These
symptoms result from pressure upon the sympathetic nerve, and may exist
in either unilateral or bilateral goitre. When associated with the
latter form of the disease, the sides of the tumor will be found
asymmetrical.