36 LANDMARKS MEDICAL AND SURGICAL. 



the stomach, nearly half-way down to the umbilicus. Here, 

 therefore, is the best place to feel whether the liver be 

 enlarged or pushed down lower than it ought to be. If it 

 be much enlarged and much lower, even the most untutored 

 hand could detect its edge. 



Even if the edge of the liver be felt very much lower than 

 is normal below the ribs, it does not necessarily follow that 

 the liver is enlarged, since it may be pressed down by other 

 causes for instance, the habit of wearing tight stays. 



To what height does the liver ascend ? This can only 

 be ascertained by careful percussion of the chest-wall. The 

 highest part of its convexity on the right side is about one 

 inch below the nipple, or nearly on a level with the external 

 and inferior angle of the pectoralis major. Posteriorly the 

 liver comes to the surface below the base of the right lung, 

 about the level of the tenth dorsal spine. 



Roughly speaking, the upper border of the liver corresponds 

 with the level of the tendinous centre of the diaphragm ; that 

 is, the level of the lower end of the sternum. Thus a needle 

 thrust into the right side, between the sixth and seventh ribs, 

 would traverse the lung, and then go through the diaphragm 

 into the liver. 



78. Gall bladder. The gall bladder, or rather the fundus 

 of it, is situated, but cannot be felt, just below the edge of the 

 liver about the ninth costal cartilage, outside the edge of the 

 right rectus muscle. 



79. Stomach. The stomach varies in size more than 

 any organ in the body. When empty and contracted (63) it 

 lies at the back of the abdomen, overlapped by the left lobe 

 of the liver, and in front of the pancreas. When very full, it 

 turns on its axis and swells up towards the front, coming close 

 behind the wall of the abdomen, occupying most of the left 

 hypochondrium and epigastrium, displacing the other con- 

 tiguous organs, pushing in every direction, and often inter- 

 fering with the action of the heart and left lung. Hence 

 the palpitation and distressing heart-symptoms in indigestion 

 and flatulence. 



The cardiac orifice of the stomach lies to the left of the 



