954 THE ORGANS OF DIGESTION. 



The nerves are derived from branches of the right and left semilunar ganglia, 

 and from the right pneumogastric nerve. 



Surface Form. The spleen is situated under cover of the ribs of the left side, being 

 separated from them by the Diaphragm, and above by a small portion of the lower margin of 

 the left lung and pleura. Its position corresponds to the eighth, ninth, tenth, and eleventh 

 ribs. It is placed very obliquely. " It is oblique in two directions, viz., from above downward 

 and outward, and also from above downward and forward " (Cunningham). " 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 midaxillary line " (Quain). 



Surgical Anatomy. Injury of the spleen is less common than that of the liver, on account 

 of its protected situation and connections. It may be ruptured by direct or indirect violence, 

 torn by a broken rib, or injured by a punctured or gunshot wound. When the organ is enlarged 

 the chance of rupture is increased. The great risk is haemorrhage, owing to the great vascu- 

 larity of the organ, and the absence of a proper system of capillaries. The injury is not, how- 

 ever, necessarily fatal, and this would appear to be due in a great measure to the contractile 

 power of its capsule, which narrows the wound and prevents the escape of blood. In cases 

 where the diagnosis is clear and the symptoms indicate danger to life laparotomy must be per- 

 formed ; and if the haemorrhage cannot be stayed by ordinary surgical methods the spleen must 

 be removed. The spleen may become displaced, producing great pain from stretching of the 

 vessels and nerves, and this may require removal of the organ. The spleen may become enor- 

 mously enlarged in certain diseased conditions, such as ague, leukaemia, syphilis, valvular dis- 

 ease of the heart, or without any obtainable history of previous disease. It may also become 

 enlarged in lymphadenoma as a part of a general blood-disease. In these cases the tumor may 

 fill the abdomen and extend into the pelvis, and may be mistaken for ovarian or uterine disease. 



The spleen is sometimes the seat of cystic tumors, especially hydatids, and of abscess. 

 These cases require treatment by incision and drainage ; and in abscess great care must be taken 

 if there are no adhesions between the spleen and abdominal cavity, to prevent the escape of any 

 of the pus into the peritoneal cavity. If possible, the operation should be performed in two 

 stages. Sarcoma and carcinoma are occasionally found in the spleen, but very rarely as a 

 primary disease. 



Extirpation of the spleen has been performed for wounds or injuries, in floating spleen, in 

 simple hypertrophy, and in leukaemic enlargement ; but in these latter cases the operation is 

 now regarded as unjustifiable, as every case in which it has been performed has terminated 

 fatally. The incision is best made in the left semilunar line : the spleen is isolated from its sur- 

 roundings, and the pedicle transfixed and ligatured in two portions, before the tumor is turned 

 out of the abdominal cavity, if this is possible, so as to avoid any traction on the pedicle, which 

 may cause tearing of the splenic vein. In applying the ligature care must be taken not to 

 include the tail of the pancreas, and in lifting out the organ to avoid rupturing the capsule. 



