1788 HUMAN ANATOMY. 



changes in position with the movements of the stomach, having its longest diameter 

 vertical when the latter is contracted and horizontal when it is distended. 



These relations sufficiently explain the difficulty not only in determining the 

 size of the normal spleen, but also in distinguishing by percussion its abnormal 

 enlargement from cases of colonic fecal impaction, of tumors of the left kidney, 

 of large plastic exudate at the base of the left pleura or lung, of hypertrophic 

 cirrhosis involving the left lobe of the liver, and of certain growths of the stomach 

 or omentum. 



In cases of hypertrophy or of swelling of the spleen, as in malaria ( ' ' ague-cake" ), 

 palpation is often of more value than percussion, the sharp crenated anterior border 

 being recognizable below the tenth costal cartilage. Physiological increase in size 

 occurs during digestion, but pathological enlargement may follow portal congestion, 

 leukaemia, malaria, typhoid, or other infectious disease, including most forms of general 

 sepsis, or may result from infection of the splenic substance. It may — as in some 

 malarial and leukaemic cases — so enlarge as to occupy most of the abdominal cavity. 

 It is then closely applied to the parietes, and is not, like renal tumors, covered ante- 

 riorly by the intestines. 



Enlargement of the spleen in infants is often due to inherited syphilis, and if it 

 occurs at the age of two or three months is usually of that character. It is of more 

 diagnostic value than enlargement of the liver, because that organ is normally dispro- 

 portionately large in infancy, and because other causes than congenital syphilis lead 

 to its enlargement. 



In all forms of enlargement of the spleen in children there is said to be more 

 relative encroachment upon the thoracic cavity than in adults, owing to the firmer 

 support of the phreno-colic ligament in young persons (Treves). Whenever it is 

 greatly enlarged, at any age, it is apt to push upward the diaphragm and compress 

 injuriously the base of the left lung and the heart. In splenic tumors, therefore, 

 irregular cardiac action and dyspnoea are often present for mechanical reasons as well 

 as on account of the associated anaemia. 



The normal movements of the spleen are not so much affected by respiration as 

 are those of the liver, which is more closely and extensively connected with the dia- 

 phragm. It rises slightly in expiration and descends during inspiration. It is 

 pushed down in emphysema and in left-sided empyema, haemothorax, or pneumo- 

 thorax. It is pushed up by ascites or by intra-abdominal new growths. 



Its relations explain why abscesses of the spleen (usually due to septic emboli, as 

 in pyaemia or septicaemia, typhoid fever, or ulcerative endocarditis) open spontaneously 

 in the following directions : ( i ) Into the general peritoneal cavity ( the most fre- 

 quent"). (2) On the cutaneous surface below the costal margin anteriorly or poste- 

 riorly. (3) Into the large intestine. (4) Into the left pleural cavity. (5) Into 

 the left kidney. 



Movable spleen {dislocated, floating, 7vandering spleeii) occurs only in adults, 

 and is especially found associated with some degree of splenic enlargement — in- 

 creasing its weight — in persons with relaxed or flabby abdominal walls. It is, there- 

 fore, often found in anaemic multiparae, as it is held in position normally not only by 

 the phreno-splenic and phreno-colic ligaments, but also by the pressure of the other 

 abdominal viscera due to the general tonicity of the abdominal muscles. 



In such cases, after elongation of the phreno-splenic ligament, the spleen falls 

 forward, lies horizontally with the hilum directed upward, and is sustained only by the 

 gastro-splenic attachments and the vessels, thus drawing the stomach downward and 

 causing serious gastro-intestinal disturbance, or possibly, if the vessels are twisted 

 and obliterated, a fatal peritonitis (Shattuck). 



In exceptional cases a movable spleen may reach the pelvis. 



From a movable kidney a wandering spleen may be distinguished by the super- 

 ficial position of the latter, its shape, the disappearance of the spleen from its normal 

 position, and the absence of urinary symptoms. 



\Vo7iyids of the spleen, if posterior, usually involve the diaphragm and the base 

 of the left pleural cavity, or, if higher, the lung itself ; if anterior, the stomach may 

 be penetrated. In gunshot wounds the kidney, colon, or pancreas may likewise be 

 involved. 



