SPONTANEOUS
RUPTURE OF T H E PATHOLOGIC
SPLEEN
REPORT OP TWO UNUSUAL CASES*
WILLIAM ARONSON AND ROBERT A. POX
From the Department of Pathology, Morrisania City Hospital, New York City
Schmidt 1 found that rupture of the spleen was fifteen times
more common in 1932 than it was in 1913. He pointed out that
between 1913 and 1926 he saw about two cases each year, whereas
between 1926 and 1932 he saw approximately thirty-two cases
each year. No doubt this marked increase in splenic rupture
is partially due to increased automobile and airplane travel as
well as to more frequent recognition of the condition by the
medical profession.
We report two cases of spontaneous rupture of the pathologic
spleen admitted to the Morrisania City Hospital within thirteen
days. The first case is one of spontaneous rupture of a splenic
hemangioma. The second case followed mild trauma in an
unsuspected case of leukemia.
Case 1. J. 0., aged 36, white German male admitted 8/25/39 with a history
of abdominal pain. Four days prior to admission the patient began to have
intermittent colicky abdominal pain localized to the left upper quadrant,
moderately severe in character, and unrelated to the ingestion of food. Catharsis resulted in a watery diarrhea of two days duration followed by constipation.
Twelve hours before admission two enemas were successful. Stools were never
bloody or tarry. Immediately following the enemata he experienced a severe
stabbing, constant, non-radiating left upper quadrant pain which caused him to
seek hospitalization. Just before admission he fainted while at stool. The
patient gave an indefinite history of pneumonia and a fall from a building
in 1927 sustaining no serious injury.
Physical examination revealed a well-developed, well-nourished adult male
in shock. Temperature 102.6 degrees, pulse imperceptible. Thefindingswere
localized to the abdomen which was slightly protuberant but not tympanitic.
* Received for publication January 30, 1940.
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SPONTANEOUS R U P T U R E OF
SPLEEN
869
There was marked muscle guarding in the upper quadrants, particularly on the
left, associated with considerable tenderness in the left upper quadrant and
left lumbar region. No costovertebral angle tenderness, palpable masses or
viscera. Stools were light brown in color. Hemoglobin 75 per cent (Sahli),
R.B.C. 4.2M per cu. mm., W.B.C. 19,000 per cu. mm., polymorphs 88 per cent
lymphocytes 12 per cent. A flat plate of the abdomen showed no free air
beneath the diaphragm. Electrocardiogram showed a sinus tachycardia of 166
per minute. Diagnoses of acute pancreatitis, abdominal hemorrhage and
FIG. 1. SPLENIC CAVERNOUS HEMANGIOMA
Arrow indicates rupture
mesenteric thrombosis were considered. Because of the poor condition of the
patient, surgery was deferred and shock therapy was instituted, but he failed to
respond and died 5 hours following admission.
At autopsy the abdomen was found to be filled with approximately 2000 cc.
of bright red blood, the source of which was a ragged tear in the capsule at the
lower pole of the spleen. The remaining viscera were normal. The spleen was
the usual deep red-blue color of shock, measuring 12 x 6 x 3 cm. and weighing
360 gms. At the lower pole a ruptured hemangioma, 1 cm. in diameter, was
870
WILLIAM ARONSON AND ROBERT A. FOX
located from which the hemorrhage had apparently occurred (fig. 1), burrowing
its way beneath the capsule to form a V on the superior surface.
Microscopic examination: Sections from the bleeding area revealed a ruptured capsule surrounded by a polymorphonuclear cell reaction. This area was
devoid of splenic tissue and in its place thin-walled cavernous sinuses filled
with non-clotted blood were found (fig. 2).
F I G . 2. CAVERNOUS SINUSOIDS CONTAINING UNCLOTTBD BLOOD
Case 2. A. L., aged 11, white Hebrew male, admitted 9/7/39 with a history
of epigastric pain of one hour duration. The patient received a mild blow to
the abdomen, administered by a playmate, which caused him to fall; no apparent injury was sustained. After several minutes he returned to his home
because he did not feel well and where his father found him one-half hour later
lying in bed looking very pale. Upon attempting to visit the bathroom unassisted he fainted and remained unconscious for a few seconds. Because of increasing abdominal pain, hospitalization was deemed advisable. Past history
was non-contributory except for chiokenpox in 1929, tonsillectomy in 1935 and
measles in 1939.
Physical examination revealed a well developed white male child weighing
SPONTANEOUS R U P T U R E OF S P L E E N
871
V,>.
F I G . 3. ENLARGED LEUKEMIC SPLEEN; SMOOTH GRAY SURFACE
RUPTURED ABEA
F I G . 4. SPLENIC V E I N SHOWING MANY MYELOBLASTS
SHOWING
872
WILLIAM ARONSON AND ROBERT A. POX
110 lbs., in shock. Temperature 100.4 degrees, pulse 140 per minute, respirations 42 per minute. Lungs were clear and the heart sounds were normal but
rapid. The upper quadrants of the abdomen were moderately rigid. The
liver and spleen could not be palpated. The testes were undescended. There
was no lymphadenopathy. R.B.C. 4.3M per cu. mm., W.B.C. 65,800 per cu.
mm., polymorphs 38 per cent, small and large mononuclears 62 per cent.
Diagnosis was ruptured spleen and an immediate operation was performed.
The abdominal cavity was rilled with free blood and clots. The capsule of
the spleen had been torn and blood was oozing from several lacerations in the
splenic substance. The spleen was enlarged. A splenectomy was done but in
spite of several blood transfusions and supportive therapy the patient expired
12 hours following operation.
At autopsy no tracheo-bronchial or mesenteric lymphadenopathy, or other
pathology was found. The spleen weighed 400 grams and measured 15 x 10
x 4 cm. (upper limits normally are 12 x 7 x 3 cm.) 2 . I t was grayish-red in color
and appeared to be extremely engorged. A tear through the capsule into the
parenchyma at the lower pole, 2 x 1 cm., was found. The consistency was
moderately firm (fig. 3). The cut surface was gray in appearance and congested; the substance of the parenchyma was extremely friable.
Microscopic examination: The histopathology was that of a myeloid leukemia. The myeloblasts were seen to be growing diffusely and crowded the
red pulp to the point where they had replaced the lymphocytes of the Malphigian corpuscles, giving rise to a uniform cellular appearance. The pulp
also contained red blood cells, lymphocytes, less numerous polymorphonuclears,
large monocytic cells and reticulo-endothelial cells of the stroma. Broken down
hemoglobin was also present some of which was intracellular but much more
was extracellular (fig. 4).
SUMMARY
Two cases of rupture of the spleen are reported because of the
totally unsuspected underlying pathology. Although the literature is replete with case reports of rupture of normal and malarial
spleens, we found that leukemic spleens are only rarely known
to rupture, and were unable to find any previous report of
spontaneous rupture of a splenic hemangioma.
REFERENCES
(1) MAINGOT, RODNEY: Postgraduate
Survey. Vol. 1, Part 2, page
pages 232, 245. W. Blakiston's
Sons & Co., Philadelphia, 1929.
890. D. Appleton-Century Co.,
(4) DELAFIBLD AND PRUDDEN: Text-
1937.
(2) GRAY, H.: Anatomy of the Human
Body. Lea and Febriger, Phila.,
1930, page 1277.
(3) KAUFMAN, E.: Pathology. Vol.1-,
Book of Pathology. 11th Edition, page 567, William Wood
and Company.
(5) DOWD, C. N.: Angioma of the
spleen. Ann. Surg., 62:177,1915.