THE CONTENTS OF THE ABDOMEN. 



133 



the second portion of the duodenum and the head of the pancreas, opening finally into the second 

 portion of the duodenum on its inner and posterior aspect a little behind and below the middle. 

 (4) The relatively large size of the liver in children must not be forgotten. ED.] 



The Spleen. The spleen is deeply placed in the left hypochondrium and its relations may 

 be made clear by a description of the three surfaces of the organ. The largest or convex surface, 

 jades diaphragmatica, borders immediately upon the inferior surface of the diaphragm (Plates 

 15 and 16 and also Fig. 62). In inflammations of the peritoneal covering of the spleen (peri- 

 splenitis) the practical clinician may occasionally hear a peritoneal friction fremitus, in this situ- 

 ation, produced by the respiratory movements of the diaphragm. It should, nevertheless, be 

 remembered that the pleural cavity is superimposed upon the upper portion of the spleen in this 

 situation (Plate 15 and Fig. 62), so that a peritoneal friction sound must not be confused with 

 a friction rub proceeding from the contiguous pleural surfaces above the diaphragm. The inter- 

 position of the inferior margin of the lung between the spleen and the costal wall explains the fact 

 that it is impossible to outline the upper border of the spleen by percussion (Plate 13, left). After 

 the subsidence of an inflammation the facies diaphragmatica of the spleen is frequently adherent 

 to the diaphragm. The jacies gastrica (Fig. 61 and Plate 15) is concave and is in relation with 

 the fundus of the stomach; upon this surface is the hilus for the entrance of the splenic artery 

 (from the celiac axis) and for the exit of the splenic vein. Since this vein empties into the portal 

 vein, we can easily understand the occurrence of splenic enlargement consequent upon stasis 

 within the liver (in cirrhosis hepatis, for example). The smallest surface of the spleen is the 

 long and narrow facies renalis, which is in relation with the convex border of the left kidney 

 (Plate 15 and Fig. 61). This surface may be felt in the dead body by following the facies dia- 

 phragmatica posteriorly. 



The most important clinical sign of most diseases of the spleen is an enlargement of the viscus, 

 and in order to recognize this, the topography of the spleen must be known. The spleen extends 

 from the ninth to the twelfth ribs and approaches to within two centimeters of the tenth dorsal 

 vertebra. Its longitudinal axis passes obliquely from above and behind, downward and forward, 

 so that the superior pole is also posterior and the inferior one is also anterior. This inferior pole 

 extends anteriorly to a varying degree; its normal position is at about the anterior extremity 

 of the eleventh rib (Plate 16). It is the portion of the spleen which is sometimes felt, but it is 

 not palpable under normal conditions. If this pole can be palpated beneath the costal margin, 

 the spleen is enlarged. The inferior pole of the spleen borders upon the splenic flexure of the 

 colon (Plate 17) ; if this portion of the intestine is not filled with feces, so that it gives a tympanitic 

 note, the splenic margin in the longitudinal axis of the viscus may be defined by percussion. If 

 a tumor of the spleen is present, the inflated splenic flexure of the colon may be interposed between 

 the facies diaphragmatica of the spleen and the diaphragm. It is, of course, impossible to deter- 

 mine the boundary between the spleen and the kidney by percussion; such an attempt is most 

 likely to succeed at the inferior portion of the viscus near its posterior margin in the region of the 

 "lieno-renal" angle (Plate 12). It will be observed that palpation is of more importance than 

 percussion of this organ. 



Although the spleen is attached to the diaphragm by the ligamentum phrenico-lienale and 

 to the stomach by the ligamentum gastrolienale, and is also supported from below by the liga- 



