Massage of Liver 341 



tumour in the right hypochondrium near the ninth cartilage. It may 

 readily be reached through the upper part of the left linea semilunaris, 

 fixed to the abdominal wound, and drained, the obstruction being re- 

 moved secundum artem. 



A distended gall-bladder may open spontaneously into the stomach, 

 duodenum, or colon, or through the abdominal wall. 



By persistent kneading, Dr. Harley has successfully dislodged 

 gall-stones which had blocked the duct. If by such artificial help the 

 torpid gall-bladder could be made to empty itself every day, there 

 would be little chance for the formation of concretions. When the 

 duct is blocked the gall-bladder is full, and its contents may be made, 

 by kneading, to play a useful part in dilating the duct and pushing 

 the concretion onward. 



THE SPLEEN 



The spleen (8 oz.) lies between the cardiac end of the stomach and 

 the ninth, tenth, and eleventh ribs, from which it is separated by the 

 arch of the diaphragm, a wedge of lung intervening between the dia- 

 phragm and the ribs. It is placed in the interval between lines which 

 continue the anterior and posterior folds of the left axilla, its long 

 axis corresponding with the length of the ribs. The tip of the spleen 

 lies beneath the apex of the eleventh rib ; its anterior border is gener- 

 ally notched. 



The external surface is convex. The inner surface is concave, and 

 is secured to the stomach by the gastro-splenic omentum, between 

 the layers of which the vessels pass to the hilum of the spleen, and the 

 vasa brevia to the stomach. The hilum is one-third nearer to the 

 posterior border than the anterior ; the inner surface behind the hilum 

 is in relation with the tail of the pancreas, the kidney and its capsule ; 

 that in front with the convex surface of the stomach. Behind and 

 above is the diaphragm, and behind and below are the kidney and its 

 capsule, and in front and below is the splenic flexure of the colon. 



Placed thus between the base of the lung, the stomach, and the 

 transverse and descending colon, the area of normal dulness of the 

 spleen varies according to circumstances, and in pneumo-thorax or 

 emphysema it may altogether disappear. When the left pleura is full 

 of fluid the spleen may descend considerably below the ribs. On 

 the other hand, when it is greatly enlarged it raises the heart and left 

 lung, and causes palpitation, coughing, and shortness of breath ; it 

 may extend also to the linea alba, and to the pelvic brim. Its 

 identity may be established by the characteristic notch in its front 

 edge ; its outline is not obscured by intestines floating in front of it, 

 as is the case with the kidney. Moreover, a suppurating or enlarged 

 kidney hides in the loin \ it does not encroach anteriorly as the spleen 

 does. Unless enlarged, the spleen cannot be felt by the fingers on 

 the surface of the abdomen, but by hooking them round the lowest 



