360 SURGICAL APPLIED ANATOMY. [Chap, xvn 



Extirpation of the spleen has been very 

 successful in cases of abdominal wounds with pro- 

 trusion of the viscus. It has also been performed 

 with good results in many cases of hypertrophied 

 spleen. The operation is not considered justifiable in 

 cases of lukfemic enlargement of the organ, it having 

 proved invariably fatal in such instances. In cases of 

 wounds with protrusion, the spleen is, of course, re- 

 moved through the wound. In other instances the 

 incision is usually made in the middle line the most 

 convenient being one so arranged that the umbilicus 

 corresponds to the centre of the cut. Some surgeons 

 prefer an incision along the outer edge of the left 

 rectus muscle. The viscus is then slowly pressed out 

 of the wound. The great difficulty is with the gastro- 

 splenic omentum, which has to be divided and its 

 vessels secured. In drawing out the spleen there is 

 much risk of tearing the splenic vessels, especially the 

 vein. Special care has to be taken to avoid damage 

 to the pancreas. 



The pancreas lies behind the stomach, in front 

 of the first and second lumbar vertebrse. It crosses 

 the middle line on a level with a point about three 

 inches above the umbilicus. In emaciated subjects, 

 and when the stomach and colon are empty, it may 

 sometimes be felt on deep pressure. It is in relation 

 with many most important structures, but presents 

 but little surgical interest (Figs. 33 and 34). It has, 

 I believe, never been ruptured alone, and it could 

 scarcely be wounded without the wound implicating 

 other and more important viscera. It has been found 

 herniated in some very rare cases of diaphragmatic 

 hernia, but never alone. 



It may become invaginated into the intestine, and 

 portions of the gland have sloughed off and been 

 passed in the stools. In resections of the pylorus 

 and spleen it is undesirable that a ligature be placed 



