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Day 5 Mon 12 April, 2004

Today was a good day. My wife brought me in the laptop, which allowed me to start writing some of these experiences. The process of writing it all down was in itself a great help.

The day was quiet. A bank holiday in the UK, so not much activity on the ward, but I carried on exercising my atrophied muscles, walking around the ward with the Zimmer frame and trying to maintain some kind of muscle tone with the exercises recommended by the physio team.

A colleague from work arrived in the evening and we discussed how we would put the next issue of the magazine together. Fortunately I had written almost all the text, so that there was very little to do before sending the pages to the printer the following week. It all went well.

The spleen

Back in ancient Greece, before medicine was quite so scientific, people thought the spleen was the physical seat of ill-temper and linked it with black bile and the melancholic temperament, hence the expression 'to vent one’s spleen', means 'to display anger'.

Nowadays, people think rather differently. The spleen is part of the lymph system, and is active in the body’s defences against infection and disease. I’m not sure that the medics would like the description, but the spleen is rather like the oil sump in a car engine. It is a slow-moving storage area, lying more or less at the end of the circulatory system, just before the blood returns to the heart and lungs for another cycle around the body.

The spleen stores blood, not for the sake of storing it, but rather as a way of removing pathogens and dying red blood cells. It does this both passively, as a filter, and actively through the immune system. As the blood flows through other organs and muscles, it picks up all kinds of nasties in the body: pathogens, poisons, bacteria, virii and so on. Once the blood gets to the spleen it rests there for a while, moving slowly through the organ, which is packed full of platelets, B-cell and T-cell lymphocytes and other cells that have no purpose other than to seek out and destroy those pathogens. Perhaps surprisingly, the doctors have relatively poor understanding of exactly how this whole process works.

For those who enjoy medical jargon, there is a good factual article on the spleen at Wikipedia: http://en.wikipedia.org/wiki/Spleen

Although the spleen plays a significant part in controlling and fighting off infections, it is possible to do without it. Spleen injuries are common in horseriding accidents, motor vehicle accidents and especially motorcyclists.

The spleen itself is a purple colour from all the de-oxygenated blood contained within it. It is usually about 120mm (5 inches) long, 70mm wide (3 inches) and 35 mm (an inch or two) thick. It usually weighs about 0.2 kg (just under half a pound) and is shaped a bit like a closed fist. It is located towards the back of the body, between two of the lower ribs on the left hand side and just beneath the diaphragm.

Usually these ribs provide enough protection for the organ, but when they break, they can themselves damage the spleen. In a typical accident, the victim will fall from a height or sustain an impact which breaks one of the lower ribs. The rib does not break cleanly, but ends up with jagged, pointy bits and these in turn, puncture the spleen, leading to internal bleeding. Although the blood loss is not always immediately apparent, there is prolonged and steady leakage into the abdominal cavity, and if it is not fixed by surgery, then the patient can lose a great deal of blood.

Government advice on the treatment for those without a spleen is changing. Until recently, the best advice was to take the antibiotic penicillin as a prophylactic for the remainder of one's life. Two tablets, twice a day. Toward the end of 2003, however, the advice changed for adults, reducing this life sentence to just a couple of years. The argument for this being that in healthy adults, first there is a reservoir of immunity: the body has already come across many common diseases and has developed defences. Second, the bone marrow, liver and other centres of blood-related activity tend to take over some of the function of the spleen over time. Thus, some of the protection of the spleen gradually returns, eventually achieving the same efficacy as the original organ against certain pathogens. Children who lose their spleens are still advised to take antibiotics for life, mostly because they do not have that reservoir of immunity built up over the years.

I take penicillin daily, but I have chosen to take only one tablet instead of two. When I feel strep throat coming on, I go back to the full dose. I think the actual words my surgeon used were something like. "We give you penicillin because it won't do you any harm; it's cheap and it might do you some good, but we don't really know."

Post splenectomy, I will probably die if I catch malaria. Post splenectomy I am great risk of septicaemia, in which meningococcal bacteria poison the blood. Post splenectomy, I am especially at risk from meningitis, influenza and streptococcus bacteria. This latter is responsible for most sore throats in the world, known in the medical trade as ‘strep throat’. I have had the relevant vaccines against these bacteria, and will have to have an annual ‘flu vaccine each October.

Despite all the dangers, it is human nature to resist or forget about regular medicines, and the reality of splenectomy care is that many patients simply fail to take the penicillin tablets twice a day. We forget, or can’t be bothered, or simply run out of tablets and ‘forget’ to replenish the supply.

As a precaution, many of these people carry an emergency pack of antibiotics which they start using as soon as they feel the onset of strep throat, or other danger sign. Some pharmacists do not recommend this; others say it is the most effective way of managing the condition in the real world. The whole area seems a bit indeterminate at present, and there is certainly scope for a proper, monitored programme to look at a population of those without spleens who stop taking prophylactic penicillin at various times.

Apart from all this, I have been given a card which warns any future medical team that, “I have no functioning spleen”. I will put this in my wallet, but I doubt it will be seen if (God forbid) I end up in another emergency situation. Instead, I will buy a bracelet which has the splenectomy information engraved on the surface, together with a contact number.

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