Rupture of the Spleen from a Phlebolite, 
With Consequent Death.—Uterus 
Unicornis. 
BY CHARLES F. DARNALL, M. D., 
O K W A1. N V T, IbwA ' 
Read befWe the Iowa State Medical Society, at Cedar 
Rapids, May 20, 1885. 
A'*printed from the Journal of the American Medical 
Association, August JJ% 
t HtCAGO: 
I’kinTf.o at the Office of the Association. Rupture of the Spleen from a Phlebolite, 
With Consequent Death.—Uterus 
Unicornis. 
CHARLES F. DARNALL, M. IX, 
OF WALNUT, IOWA. 
Read before the Iowa State Medical Society, at Cedar 
Rapids, May 20, 1885. 
Reprinted from the Journal oj the American Medical 
Association, August 22, iSSj. 
CHICAGO: 
Pit 1NTED AT THE OFFICE OF THE ASSOCIATION. 
1885. RUPTURE OF THE SPLEEN FROM A PHLEBOLITE, 
WITH CONSEQUENT DEATH.—UTERUS 
UNICORNIS. 
The subject of pathology being especially import- 
ant to the physician, I take pleasure in contributing 
a mite to our accumulation of knowledge upon that 
topic; and it is done with the confession that wher- 
ever the writer has been wrong in his deductions and 
conclusions, it is for the reason that he has followed 
a rather obscure path, and not from the fact that the 
approval of others has been the incentive. 
My subject, as indicated above, is the result of a 
post-mortem examination, and the conditions therein 
existing were so new, that they have been investigat- 
ed and formulated with the belief that the presenta- 
tion will excite at least a momentary interest. 
I was called on the morning of January 30, 1885, 
to see a German woman, ait. 36, Vl-para, who had 
been attacked at four o’clock that morning with sud- 
den pain in the bowels, followed by shock and syn- 
cope. The pulse was 120, temperature 96° F., and 
respiration 30, with prolonged expiratory efforts and 
much general suffering. There was no history of 
malaria, typhus or typhoid fevers, or any of the dys- 
crasia;, nor of rheumatism or disease of the muscles 
or joints. She had never experienced any pulmon- 
ary or hepatic trouble; her nervous system had al- 
ways been supposed to be in good condition, her 
menstrual periods easy and regular, without any 
ovarian or uterine difficulty. She had always occa- 
sional attacks of indigestion, unaccompanied with 4 
much pain, and her bowels were usually in a consti- 
pated condition. Her principal cause of sickness 
was in her kidneys, and her physician had treated 
her for “Bright’s disease” a few months before her 
death. She was confined to her bed for several 
weeks with the supposed albuminuria, and only par- 
tially recovered. From her subsequent symptoms 
it is to be conjectured that she was afflicted with 
acute idiopathic cystitis. For a few weeks previous 
to the time when she was first seen, her physician, in 
treating her for her constipation, exhibited jalap, rhu- 
barb, and other drastics, meeting with no success, as 
their effect was unable to correct her condition. 
When she was first seen by the writer there was 
pain on pressure over the spleen and also in the right 
iliac region, and the omentum gave on palpation a 
peculiar brawny sensation, with no tympanitis or per- 
itonitis. No absolute diagnosis being made other 
than that of a possible perforation of the bowel, an 
enema was ordered, with alcohol, quinine, and opium, 
hot poultices to the abdomen and dry heat to the ex- 
tremities. Reaction did not follow, and death en- 
sued on the morning of Feb. 2, three days afterwards. 
Twelve hours later a post-mortem examination was 
held. The intestines were found empty, congested, 
and distended with gas. The omentum was inject- 
ed, dry, and cedematous, with little serum or blood 
being present in the peritoneal cavity. The first 
thing that came to our notice was the half-filled blad- 
der, the whole tissue of which seemed injected and 
hyperaemic. The uterus was found prolapsed, and 
the right ovary as large as a hen’s egg, while the fim- 
briated extremity of the Fallopian tube was of a 
black, gangrenous condition, enlarged and infiltrated. 
The entire broad ligament was congested up to its 
attachment to the uterus. The ovary was opened, 
and discovered to be in a state of cystic degenera- 
tion, filled with clear albuminous liquid. Search was 
made for the left ovary, but it was entirely missing, 5 
as was also the round ligament, ovarian ligament, and 
usual blood-vessels, forming the anomaly known as 
uterus unicornus. The unilateral development char- 
acteristic of this rare condition of the uterus so far 
as the fundus pointing toward that side in which the 
ovary was present, was obliterated, being found in 
its highest state of perfection in the virgin • and as 
this woman had given birth to a child a few months 
before, the body of the uterus seemed not to have 
yet returned to that period of involution when this 
feature would be especially prominent. 
The broad ligament was present, and between its 
folds was found the organ of Rosenmiiller. As men- 
struation had taken place three weeks before death, 
the remaining ovary was further examined. A por- 
tion of it was found to be of normal tissue, full of 
Graafian vesicles, and corpora lutca in various stages 
of development and disappearance. The latter were 
of different sizes, lined with the duplicature of yel- 
low granules of fat, and in the centre of one or two 
were blood clots. Surrounding them the tissue was 
of the natural type—not congested—and extended 
over upon the sides of the main cyst, showing it had 
sprung from one of them, and was of recent growth. 
Externally the walls of this cyst were of a white 
fibrous nature, internally of the peculiar bluish color 
common to ovarian tumors. The degeneration be- 
ing multilocular, several very small cysts were in the 
parenchyma of the ovary, adjacent to the largest 
cyst, all filled with brownish or straw-colored liquids. 
Proceeding in the search for the cause of death, 
the stomach was found to be in a rather congested 
state, the liver dark colored with spots of atrophy or 
contraction, and the kidneys injected, enlarged, and 
flabby. The spleen was atrophied, and upon the 
external surface near the superior edge we discov- 
ered a rent or laceration, large enough to admit the 
finger, from which exuded a small quantity of clotted 
blood. 'I'he solution of continuity was transverse to 6 
the length of the spleen, about two centimetres long, 
and in depth nearly three centimetres. Upon the 
internal surface was found what appeared to be a 
spot of fatty degeneration, as large as a silver dollar, 
covered by a tough yellow-covered serous mem- 
brane, which being opened gave vent to a discharge 
of lymph or detritus. The bottom of the laceration 
was contiguous to this diseased spot, there being only 
about a centimetre of tissue intervening. In mak- 
ing this cursory examination of the abdominal vis- 
cera, a glimpse was caught of a foreign substance 
laying among the folds of intestine, and our next 
discovery was this same body in Douglas’s fossa, 
whence it had gravitated during our manipulations. 
This was of a hard nature like a renal calculus, 
nearly the size of a horse bean, curved on the Hat, 
rough, no facets, and in weight about one gramme. 
Naturally we linked together this concretion and 
the rupture in the spleen, but doubt being expressed 
that a calculus could come from a ductless gland, 
careful search was made of the intestines, gall-cyst, 
kidneys, and ureters, in the hope of finding an open- 
ing whence it could have escaped into the abdomen; 
but with no success. The rupture in the spleen was 
of such a nature as showed the spontaneous expul- 
sion of the body, and upon a second search being 
made with the same result, the conclusion was forced 
upon us that this unpretending organ in the human 
economy was the habitat of the nodule, and that its 
presence, or rather its liberation, was the cause of 
rupture and death. 
I have been unable to find on record such a thing 
as a splenic calculus, but our standard medical lexi- 
cographer (Dunglison) says in his definition of the 
word that a calculus may form in the substance of a 
body or organ, as the result of nutritive irritation, 
and be expelled spontaneously. Prof. Fitz says, in 
the new “American System of Medicine,”1 that path- 
I. 1885, p. 89. 7 
ological deposits, in the form of calculi, occur in 
those organs which convey in canals their peculiar 
secretory fluids, and that these are formed of the pre- 
dominating inorganic matter in them; as, for in- 
stance, a renal calculis in the pelvis of the kidney, 
which on analysis will be found to be composed of 
the urates of sodium, potassium, calcium, magnesium, 
or ammonium, or their phosphates or oxalates. The 
spleen having no duct, the question of this being a 
calculus is excluded and disposed of. 
The next thought is of tuberculous origin, but we 
may differentiate that idea. There was no evidence 
of a tuberculous deposit in the mesentery, liver, or 
intestines, and where the abdominal cavity is invaded 
it is more apt to become general, and does not attack 
a small portion of one organ, leaving the balance of 
the viscera alone. Besides, the deposits are of the 
miliary type at first, small minute bodies, and in con- 
sistence are not hard like the one under consideration, 
but of a soft waxy nature, easily cut, and showing 
the presence of earthy deposit. They are never of 
such hardness as to cut out of a tissue spontaneously, 
making a free and clean incision. There can be 
tuberculous calcific degeneration, but the agglomera- 
tion of single tubercles and consequent calcification 
cause a mush or cheese-like substance to form, and 
never hard or stony, which excludes this thought, and 
we now turn to the next theory, which probably is 
more correct. 
The cpiestion of concretion presents itself as a 
plausible one, when we understand that cretaceous 
degeneration may take place in any portion of the 
body. Calcification is a deposit of salts, previously 
held in solution in the blood, under abnormal circum- 
stances, in and upon organic matter, as the result for 
instance of an inflammation. This inexplicable fact 
is well known, and Strieker says, in the “International 
Encyclopaedia of Surgery,”1 that “tissues have the 
*Vol. I, 1881, p. 62. 8 
property of depositing lime-salts. ... As cartilage 
is converted into bone, it must deposite lime-salts in 
its basis-substance. But cartilage calcifies sometimes 
(as for example under the influence of slight inflam- 
matory stimuli) without being converted into bone. 
Of pathological calcifications of other tissues, too 
little is known beside the mere fact that they do oc- 
cur, to warrant my considering them here. ” Fitz 
says further that concretions occur in the tissues of 
organs, and are collections of inorganic salts, chiefly 
the carbonate and phosphate of calcium, hence de- 
posited through the agency of the blood. It is not 
necessary that these calcifications take place in the 
solid portion of an organ, for veins are often found 
with a concretion, or phlebolite, and this is the devel- 
opment of my investigation. That this is a concre- 
tion an analysis showed it to be carbonate of lime, 
while the laceration in the spleen terminated in the 
splenic vein, enlarged and dilated, into which the 
vein stone I present seemed to fit quite naturally. 
The absolute cause of this strange formation is of 
course speculative, but so far as a general review of 
literature has to do with forming an opinion, the 
preponderance is in favor of hemorrhagic infarction, 
according to Cohnheim,1 or coagulation-necrosis, as 
it is termed by Ziegler.2 
An embolus being arrested in a small artery, in- 
ducing extravasation and a secondary thrombus in 
the splenic vein in consequence, or a primary throm- 
bus arising from a similar source in the vein, under- 
went transformation, interfering with the necessary 
blood-supply of the surrounding area, and caused 
upon the surface of the spleen what Ziegler calls the 
“opaque yellowish-white conical patch.” Guillebeau8 
endorses this opinion, saying that splenic infarcts are 
hemorrhagic, quickly becoming decolorized and de- 
generated. Green4 says that infarcts are usually 
IZiegler’s Path. Anat., Wood’s Library, July 18, 1883, Art. 36. 
-Ibid, Art. 36. 3Ibid. 
4Pathological Anatomy, Phila., 1881, p. 192. 9 
found in the spleen, wedge-shaped, with the apex of 
the cone toward the centre of the organ, rapidly 
undergoing softening and disintegration, by regurgita- 
tion from the veins into the capillaries 
The theory of Rokitansky1 regarding phlebolites 
is that they are caused by a retarded flow in the 
veins, coagulation and incrustation following, and 
that within the concretion is an irregular brownish 
fissure,—the clot, which is found within the one under 
consideration. He writes :s “We not unfrequently 
find the sheath of the spleen indurated and cartilagin- 
ous, or ossified, and at the same time ossification of 
the arterial ramifications and free calcareous concre- 
tions (Phlebolithes) in the veins of the organs.” In 
Medinische Encyclopadie he says that in atrophy of the 
spleen as a result of perverted nutrition small con- 
cretions are found in the walls of veins, which are 
free and chalky. They show no symptoms and con- 
sequently are not amenable to treatment. Ziegler3 
says of petrifaction that the process is derived from 
the salts in the blood, not simply precipitated and 
retained, but formed as a solid compound. He 
mentions that large infarcts of the spleen are some- 
times imperfectly reabsorbed, so that the cicatrix 
incloses a necrotic caseous patch. 
Ponfick attributes4 the formation of these bodies 
to thrombi in the veins, but says it is an hypothesis. 
Delafield and Prudden say that the contents Qf an 
abscess of the spleen as the result of embolism may 
dry, shrink, and become calcified. Orth, in his 
“Lehrbuchder Pathologischen Anatomie,” states that 
phlebolites of the spleen are occasionally found, 
mentioning no case, and speaks of the frequency of 
degeneration of an infarct from embolism. He says 
they may become absorbed and contain lime-salts. 
Kirch-Hirschfild4 claims that phlebolites are occas- 
•Path. Anatomy, Syd. Kd., Vol. IV, p. 356. 
*1 bid, Vol. II, p. 167. 3()p. Cit., Art. 64. 
♦Path. Anat., p. 363. 6Lehrbuch der Path. Anat., p. 140. 10 
ionally found in the spleen, resulting in each case 
from calcification of the thrombus in enlarged veins. 
Morgagni1 records a case in which a phlebolite of 
the spleen was discovered, in an autopsy, weighing 
twenty-one drams. Bristowe2 has found them in the 
spleen and various organs of the body, and attributes 
their presence as the result of an adherent blood 
clot, undergoing degeneration. Callender3 calls them 
loose calculi, producing no inconvenience. Bichat4 
thought they occurred in veins wherein there was 
slow circulation. Hasse3 found them in varicose 
veins, which also is Paget’s theory.6 Aitken7 calls 
them products of petrifaction of blood-clots in en- 
larged veins. Quain8 says they form from a clot in a 
vein, and are perfectly harmless. Gross2 states that 
ten, twenty, or thirty phlebolites may be found in 
enlarged veins of the spleen and pelvic organs. 
Merbach10 repeats that they are found in cirsoid or 
varicose veins, usually in the pelvis, composed of 
blood and inorganic matter Cruveilhier’s11 theory is 
that they are developed in a clot of blood. Druitt12 
in his surgery shows an illustration of a female who 
had several phlebolites in irregularly dilated veins 
under the' lower jaw, which were removed with the 
knife. 
The only other case I can find on record of a 
knowledge of their presence ante mortem is reported 
by Gould,13 who found in a female patient a concre- 
tion over two inches long, laying in a dilated vein 
transversely across the tendon of the semitendinosis 
muscle in the popliteal space, and its formation he 
attributed to a thrombus. It was not removed. 
Wyeth14 says that phlebolites are found in cutaneous 
1Wardell, Reynold’s Syst. of Med., Vol. Ill, p. 471. 
2Hristowe, ibid, Vol. II, p. 883. 3Holmes’ Surg., q. v. 
4Anat. Gen., par Bdclard. &Vide Holmes, Art. by Callender. 
6I.ecture 29, p. 488. 7 Aitkin’s Practice, Vol. I, p. 127. 
8Quain, Diet, of Med. 9Gross’ Surg., Vol. I, p. 817. 
lcMedinisch Encyclopadie, Art. Milzkrankheiten. 
J1Vide Callender, op. cit. li!Page 320. 
13Phila. Medical News, Vol. XLIII, No. 9. 
Enclycopaedia of Surgery, Vol. Ill, p. 372. 11 
venous tumors, and in opposition to what has been 
cited, says that the circulation is active. Our various 
works of surgery mention phlebolites, and the opinions 
are circumstantially as given above. I can find also 
that these concretions are found in haemorrhoids, as 
well as in the external genital organs. 
Nearly sixty cases of rupture of the spleen can be 
tabulated, so far as my study has gone, and about 
one-fourth occurred spontaneously after unusual mus- 
cular exertion, for instance after vomiting, straining 
at stool, or a sudden twist of the body. In all these 
cases the viscus had previously suffered from disease, 
as malaria, typhus or typhoid fevers, or some malady 
resulting in softening of its tissue. Traumatic causes 
make up the other three-fourths, and are usually gun- 
shot wounds, blows, and falls. Of all cases of rup- 
ture, none is recorded as being caused by a concre- 
tion, and as death in the patient undoubtedly ensued 
from rupture in consequence of liberation of the 
phlebolite induced by hard straining at stool, this is 
placed on record as perhaps the first case of the kind. 
In a communication from Surgeon-General Billings, 
librarian of the Army Medical Museum and Library, 
he says, “I have had our index references to rupture 
of the spleen examined. There are many cases of 
rupture of the spleen reported, but I have not found 
any due to or connected with a phlebolite.” 
The malformation of the uterus and appendages 
is another rarity, and want of time forbids a lengthy 
discussion of the condition. The text books all 
speak of uterus unicornis, but Tait1 in his book says 
he has been able to find on record only one case of 
this singular development. This he credits to Chaus- 
sier as quoted by Busch. 
•Diseases of the Ovaries, N. \\, 1883, p. 36.