322 SURGICAL APPLIED ANATOMY. [Chap. xvn. 



discharged through a spontaneous fistula in the hypo- 

 gastric region, five inches below the umbilicus. In cases 

 where the bile duct is occluded by gall stones, or by 

 other causes, the gall bladder may become enormously 

 distended, and may form a tumour extending some way 

 beyond the umbilicus. For the relief of this condition, 

 cholecystotomy, or incision into the gall bladder, has 

 been performed. In this operation, the incision or 

 puncture is made over the most prominent part of the 

 tumour. 



THE SPLEEN 



In front. 



Stomach. 



Splenic flexure of colon. 



Outer side. Inner side. 



Diaphragm. 2 wl ***! Stomach. 



9th to llth ribs between Pancreas. 



axillary lines. L. kidney and capsule. 



The spleen. The spleen most closely approaches 

 the surface in the parts covered by the tenth and 

 eleventh ribs. Above this it is entirely overlapped 

 by the edge of the lung. It is in all parts separated 

 from the parietes by the diaphragm. " It lies very 

 obliquely, its long axis coinciding almost exactly with 

 the line of the tenth rib- Its highest and lowest points 

 are on a level, respectively, with the ninth dorsal and 

 first lumbar spines ; its inner end is distant about an 

 inch and a half from the median plane of the body, 

 and its outer end about reaches the mid-axillary line " 

 (Quain) (Figs. 31, 33, and 34). 



Injuries. Although extremely friable in structure, 

 the normal spleen is not very frequently ruptured. 

 Its connections, indeed, tend to minimise the effects of 

 concussions and contusions. It is swung up by the 

 peritoneum, rests upon the elastic costo-colic fold, and 



