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 contiguous organs, pushing in every direction, and often interfering 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 middle line, just below the level of the junction of the seventh costal cartilage with the sternum.
80. Pylorus.—The pylorus lies under the liver, on the right side, near the end of the cartilage of the eighth rib; but it cannot be felt unless occasionally when enlarged and hardened by disease.
81. Spleen.—The spleen, if healthy, cannot be felt, so completely is it sheltered by the ribs. It lies on the left side, connected to the great end of the stomach, beneath the ninth, tenth, and eleventh ribs, between the axillary lines—lines drawn vertically downwards from the anterior and posterior margins of the axilla. Its upper edge is on a level with the spine of the ninth dorsal vertebra, its lower with the spine of the eleventh.
Its position and size, therefore, in health can only be ascertained, and not very accurately, by the extent of dulness on percussion. The greatest amount of dulness would be over the tenth and eleventh ribs; above this the thin edge of the lung would intervene between the spleen and the abdominal wall. If, therefore, the spleen can be distinctly felt below the ribs, it must be enlarged. In proportion to its enlargement, so can its lower rounded border be detected below the tenth and eleventh ribs, especially when forced downwards by a deep inspiration.[5]
82. Pancreas.—The pancreas lies transversely behind the stomach, and crosses the aorta and the spine about the junction of the first and second lumbar vertebræ. The proper place to feel for it, therefore, would be in the linea alba about two or three inches above the umbilicus. Is it perceptible to the touch?—only under very deep pressure, and very favourable circumstances, such as an emaciated and empty abdomen. It is worth remembering that it may be felt under such conditions. The pancreas of normal size, in thin persons, has been mistaken for disease—disease of the transverse arch of the colon, or aneurysm of the abdominal aorta.
83. Kidney.—The kidney lies at the back of the abdomen, on the quadratus lumborum and psoas muscles, opposite the two lower dorsal and two upper lumbar spines. The right, owing to the size of the liver, is a trifle—say, three-quarters of an inch—lower than the left. The pelvis of the kidney is on about the level of the spine of the first lumbar vertebra: the upper border is on about the level of the space between the eleventh and twelfth dorsal spines; the lower border comes as low as the third lumbar spine. During a deep inspiration both kidneys are depressed by the diaphragm nearly half an inch.
Can we feel the normal kidney? The only place where it is accessible to pressure is just below the last rib, on the outer edge of the ‘erector spinæ.’ I say accessible to pressure, for I have never succeeded in satisfying myself that I have distinctly felt its rounded lower border in the living subject, nor even in the dead, with the advantage of flaccid abdominal walls and the opportunity of making hard pressure with both hands, placed simultaneously, one in front of the abdomen, the other on the back. For these reasons, although we can easily ascertain its degree of tenderness, we cannot actually feel it unless it be considerably enlarged.
We must be on our guard not to mistake for the kidney an enlarged liver or spleen, or an accumulation of fæces in the lumbar part of the colon.