A CASE OF RUPTURE OF THE SPLEEN DURING AN ATTACK OF MALARIA.

By P. SAVAGE, CAPTAIN, I.M.S.,

Resident Medical Officer, The Lawrence Royal Military School, Sanawar, Simla Hills.

Spontaneous rupture of the enlarged spleen in malaria is sufficiently uncommon, and cases

deserve record. Manson-Bahr in his Tropical Diseases (1919)

merely mentions it; Rogers (Fevers in the

Tropics) writes of three instances having been met with in 30,000 cases of malaria at Panama. Byam and Archibald briefly describe a case in

a European soldier in their Treatise on Tropical Diseases. The following case came to my notice when

I was Staff Surgeon, Kohat, and is published by the kind permission of the Director of Medical

Services in India.

J. K., a British soldier, aged 33, was detained in

hospital at 14.30 hours on the 6th January 1924, with a temperature of 103.6?F. He suddenly and rapidly expired on the 7th January at 15.40 hours. Previous History.?His medical sheet gave the

following information. He had had numerous admis- sions to hospital for malaria (benign tertian). His last admission was from 1st to 6th November 1923. At one time in the summer of 1923 his spleen was

"

plus plus." During 1923 he had frequently been admitted with mild relapses of malaria, accompanied by gastric pain, and attacks of dyspnoea with rales in the chest resembling asthma. On admission the temperature was 103.6?F. and he

was vomiting a good deal of bile-stained fluid. The next morning the temperature had dropped to

99.8?F., the pulse was 82 and he stated that he felt better. He spent the morning in bed reading. At 13.00 hours he became restless and complained of

pain over the stomach and made several attempts at

vomiting, without any result. Morphia i gr. was

iniected hypodermicallv.

At 14.45 hours he looked very ill and the orderly assistant surgeon was summoned. He found the

patient pale, complaining of severe gastric pain and a

sense of dizziness, and leaning over the bed attempting to vomit. At about 15.10 hours I was called. He was then

reclining in bed looking desperately ill. The face was

very pale, hands and chest cold and clammy and he was perspiring. The respirations were frequent and long- drawn. The pulse was 80 and weak, but not markedly hemorrhagic in character. The patient was conscious and understood my ques-

tions ; he said he could not see me but knew me by my voice. I commenced to examine the heart, but was

twice interrupted by his sitting up and fighting for breath, at the same time clawing his chest. A rapid examination revealed nothing, but the heart sounds were counted and confirmed the radial pulse. By_ this time the man was moribund. No abdominal tenderness could be elicited nor was any enlargement of the spleen or liver detected and in a few moments lie died during examination.

I was in doubt whether the fatal syncope was due to an internal hemorrhage, since there was no history of an injury, nor was there any bacteriological report to verify that the fever was malarial. The case at the time resembled the fatal termination

of angina pectoris. (The man looked much more than his age.) I obtained permission for an autopsy for the following day. The post-mortem findings are given here in full. Post-mortem Examination.?The body was well

nourished. Rigor mortis was still present. The usual normal patches of hypostatic congestion were present on the dependent areas of the body. No evidence of any external injuries. Brain.?A general anaemic appearance. Patches of

old meningitis on the anterior upper surface of the frontal lobes. A blood smear direct from a cerebral vein was examined for malaria parasites and young types were reported to be present in abundance. On section the brain was normal. Thorax.?The chest was fixed in a position of deep

expiration with the diaphragm on both sides compressing the lungs. Lungs.?Compressed ; otherwise normal. Heart.?A little blood-stained fluid in the pericardial

sac. The organ on removal was completely enveloped in fat and weighed 14 ozs. (396.9 grms.). The aorta showed early and slight atheromatous patches in places. Aortic valves were normal. Left ventricle.?Small ante-mortem clot. Valves

normal. Musculi papillaris hypertrophied. Ventricular wall considerably hypertrophied (twice as thick as the right ventricle). The whole ventricle was very pale. Right ventricle.?Very pale. Valves normal. Walls

not hypertrophie'd. The ventricle contained a large ante-mortem clot.

Pulmonary artery.?Contained an ante-mortem clot but not sufficient to cause death. The heart was fatty, hypertrophied. but not dilated and very pale owing to depletion of blood. The coronary arteries were not examined. The heart was not sufficiently diseased to account for

death. Abdominal Cavity.?On opening the abdomen about

a pint of pure blood escaped. The intestines were dis- tended and filled the whole abdominal cavity. Imme-

diately there was noticed a large, formed, partly adherent blood clot, running down from the left

epigastrium over the intestines into the pelvis. This clot in its upper part was 3 inches broad and con-

tinuous with the parietal surface of the spleen and tapered below to about 1 inch, where it entered the

pelvic cavity. The hand was carefully passed over this to the upper and posterior part of the spleen. This was found to be surrounded by blood clot and a rupture admitting one finger was felt. With care but with great difficulty, the spleen was

delivered and examined on the table.

Nov., 1926.] CASE OF SCORPION-BITE: LANG. 553

Spleen.?Completely surrounded by blood clot on the anterior and upper surface. Weight when cleaned 453.5 grms. (Normal spleen

weighs 160 grins.) The organ was enlarged, deeply congested, and of a

violet colour. The capsule separated easily and on

handling, the organ disintegrated at the slightest touch. The original rupture was therefore not demonstrable. The examination was not proceeded with further as

the cause of death?hemorrhage from rupture of the spleen?was clearly evident.

In the light of this knowledge I made further enquiries into his recent movements prior to admission. I learnt that a few days before being brought to hospital, he had been attending hospital with negative signs?no definite diagnosis, but merely unwell. The daj- of admission (6th) he had had a slight

fainting fit in his barrack which necessitated him lying down on his bed for a short time. He was vomiting when carried to hospital for admis-

sion but brought up nothing. His complexion was

florid, as it always was. The night orderly had reported lie had passed a good

night; slept well and taken nourishment and treatment. The day orderly (of 7th) stated he spent the morning in bed reading. He never sat up in bed, and the day previous when vomiting he had just leaned over the bed side. In the words of the nursing orderly on duty "

he was just like the other patients."

Remarks. 1. The syncopal attack on the clay of admis-

sion, which necessitated him lying: down, is sisrm- r

' ? > o

ncant.

2. Rupture had probably taken place about this time and gradual leakage had been taking place since.

3. The reflex irritation from the blood trick-

ling over the peritoneal surface of the stomach might conceivably have caused the vomiting.

4. The gastric pain complained of during the four days previous to admission must have been due to the enlarged spleen.

5. The attempts at vomiting prior to and after admission had dislodged a clot in the

rupture and caused the fatal haemorrhage. 6. The slow pulse of 80 per minute at the

time of collapse did not suggest' so serious a

complication as haemorrhage. Note.?The failure to detect the enlarged

spleen was due to the hurried examination of the moribund patient. I have once before, while on active service, seen a case of rupture of the

spleen. When stationed at Ain Tab in Syria, an

Egyptian labourer was evacuated to that place by motor ambulance from the Ak Su Valley, a very highly malarious locality about 15 miles

away over a pretty atrocious road; On arrival he was dead and a ruptured spleen

was found on post-mortem, due, I have no doubt, to the almost continuous bumpinglof the ambul- ance during the journey. I mad J no records of this case.