1. INSPECTION.

In examining the abdomen by the sense of sight, it is necessary, in the majority of cases, that it be uncovered and exposed to a good light, which may be carefully done without any offence to the patient's delicacy. The person to be examined may be in the erect or recumbent posture, with the arms hanging loosely by the side. When the abdominal walls and viscera are healthy, the general form of the abdomen is gently convex, both sides being symmetrical, and presenting here and there slight rounded projections and depressions. Partial abdominal enlargement will be manifested by unnatural fulness or bulging of any part of the abdominal parietes, the situ ation depending upon the cause: in general enlargement, the whole abdomen will bulge forward, to a slight degree, when the enlargement is due to a general increase in the thickness of the parietes of the abdomen; more so when the abdominal organs are increased in bulk; and most of all when there is an accumulation of gaseous, liquid, or solid matters within the intestines, or within the cavity of the peritoneum. Fæculent accumulations take place mostly in the large intestines, and in the lower part of the ileum, causing distension of the colon and cæcum, manifested by irregular prominence in the right iliac, both hypochondriac, and left iliac regions. Disease of the liver gives rise to enlargement of the right hypochondriac and epigastric regions; while enlargement of the spleen produces a projection of the lower left ribs at the side, and a tumor in the left hypochondrium. Tubercular disease of the mesenteric glands is generally accompanied by enlargement of the whole abdomen, and by deviations from its natural form and symmetry. In ascites, the smooth roundness of the abdominal swelling is peculiar, so that when the fluid is abundant the abdominal cavity is expanded into a large, smooth, and almost polished globe; while in pregnancy and in encysted ovarian dropsy the tumors can be traced deeply into the pelvis.

2. MENSURATION.

In measuring the abdomen, a common tape measure will be found the most useful. The measurements are usually made at the margin of the lower ribs and the umbilicus, and when the abdomen is partially distended, at and around the most prominent region.

3. PALPATION.

For accurate palpation, the hand should be applied directly to the surface, using more or less pressure as we wish to

determine the condition of the walls or of the deep-seated viscera, and according to the existence or non-existence of tenderness; occasionally the whole of the palmar surface of the hand should be used, occasionally only the tips of the fingers, which are very sensitive. In health the abdomen is generally soft, and the walls are moderately elastic in each region. Tumors are discovered by their resistance to pressure, by their hard feel to the touch, and by the contrast which the parts occupied by them present to the healthy regions. Care must be taken not to mistake-as is often done the contraction of the central portions of the recti muscles for ovarian and other tumors. This error may be avoided by keeping the flat hand firmly and steadily applied, while the patient's attention is attracted to other matters, when the muscles will be found to relax, or so much to vary their degree of tension as to show the cause of the hardness. The right rectus is often more tense than the left, especially if there be any tenderness of the liver.

The practice of palpation is eminently useful in the diagnosis of the following diseases:

Acute Inflammation of the Liver is signalized by pain, more or less severe, in the region of the liver, increased on pressure, deep inspiration or cough; inability to lie on the left side; a yellow tinge of the conjunctiva, sometimes jaundice; dyspnoea; cough; vomiting; and hiccough. When the pain is of a sharp, lancinating character, it is supposed to indicate inflammation of the serous covering of the gland; when dull and tensive, the parenchyma is the part affected; when the convex surface of the organ is the seat of the inflammation, the chest symptoms will predominate; when the concave, the stomach symptoms will be the most marked.

In Acute Inflammation of the Peritoneum the pain is generally very severe, soon spreads over the whole abdomen, and is aggravated by any movement which calls the abdominal muscles into action, or by pressure-even the weight of the bedclothes being insupportable: the patient consequently lies quiet on his back, with his knees bent, and legs drawn up. Ôn careful examination, a sensation of friction will often be communicated to the hand, which has been likened to a gentle vibration under the fingers, or to a sensation of creaking, or grating, or crepitus. The abdomen is tense, hot, and frequently tympanitic; the bowels are constipated; there is often nausea and vomiting; the skin is hot and dry; the pulse rapid and weak; the respiration hurried; the tongue furred; and the countenanee is expressive of suffering and great

anxiety. After a time the belly ceases to be tympanitic, but remains somewhat enlarged from the effusion of serum. When a fatal termination is approaching, the abdomen often becomes much distended, the pulse very quick and weak, the countenance ghastly, and death occurs from exhaustion.

Ascites, or Dropsy of the Peritoneum, arises from many causes, but most frequently from cirrhosis. The extent of the abdominal enlargement will of course depend upon the quantity of liquid present, but the distension will always be uniform; fluctuation will generally be distinct; and there will, in most cases, be resonance over the higher parts of the belly on percussion, owing to the floating of the intestines, thus prominently distinguishing ascites from ovarian dropsy. I say, in most cases, for the distension may be so great that the breadth of the mesentery may be insufficient to allow the intestines to reach the surface of the fluid; dulness will then, of course, result. I have noticed, however, that where there is any difficulty in the diagnosis of ascites and ovarian dropsy, the mere fact of difficulty may be taken as presumptive evidence in favor of the case being one of ascites. Ovarian dropsy very rarely simulates ascites. In both diseases there will be dyspnoea, which will be urgent in proportion to the distension.

Ovarian Dropsy consists in the conversion of the ovary, or of parts of it, into cysts; generally perhaps by enlargement of one or more of the Graafian vesicles. Under the same name, simple serous cysts formed in the broad ligaments, and dropsy of the Fallopian tubes arising from closure of their extremities, have been included.

The first symptom of an ovarian tumor is enlargement of the lower part of the abdomen-generally of one or the other iliac regions. If palpation be practised, a tumor may be felt; but patients rarely apply for advice until the cyst has obtained considerable size. Fluctuation will then be distinguished with ease or difficulty, according to the nature of the tumor and its contents. In all cases there will be a dull sound on percussion over the tumor.

An ovarian cyst may be single or multilocular; that is to say, it may consist of one sac only, or it may be made up of a variable number of small cysts. All ovarian tumors run their course much more rapidly than is generally supposed. Cases of fibrous tumors of the uterus, which often exist for years without any suffering, are repeatedly mistaken for ovarian tumors. So also are concretions arising from the accumulation of various indigestible matters in the bowels,

especially when they occur in the ascending or descending portion of the colon, and when they are large and slightly movable. Adhesions often form between ovarian tumors and the peritoneum; I believe that they may be distinguished by every physician possessing the tactus eruditus.

Dilatation of the Stomach is a curious disease, to which attention has lately been directed. It is due generally to some affection of the pyloric orifice, which, causing contraction, prevents the food from readily passing into the duodenum. Hence the stomach slowly and gradually dilates, until at last it comes to occupy almost the whole of the abdominal cavity, giving rise to appearances as if a tumor were present. These appearances are the more deceitful when the stomach is full, because fluctuation may then be present; when this viscus is empty, there will be a tympanitic sound on percussion.

Abscesses of the Liver sometimes attain a great size, and, in extreme cases, may contain several pints of pus. Fluctuation will then be perceptible, but only over the region of the liver, where also a tumor will be felt. They may burst into the peritoneum, and give rise to fatal peritonitis; most frequently, however, when the matter gets near the surface of the gland, adhesive inflammation it set up in the portion of peritoneum immediately above it, and lymph is poured out, which glues the organ to adjacent parts to the abdominal parietes, the diaphragm, stomach, or some part of the intestines; the pus is then discharged externally, or into the lung or pleura, or stomach, &c.

Abnormal Pulsations.-The pulsatory movements of the abdominal aorta are generally lost to the touch, although they may become evident both to the sense of touch and of sight when the parietes are wasted, and the movements violent, as in anæmia, or in disease of the coats of the vessel, or when a tumor or a cancerous mass lies directly over the artery. The pulsations are usually best seen at the epigastrium, and sometimes at the umbilicus; on applying the hand, a jerking, quick, strong, forward impulse is felt; while auscultation often discovers a bellows-murmur, especially if anæmia coexists. I have found this pulsation not uncommon in cases of uterine disease; it has also been frequently noticed in hypochondriacs, in those whose digestive organs are deranged, in chlorotic females, &c.

4. PERCUSSION.

In the diagnosis of abdominal diseases, mediate percussion is for the most part employed, the middle finger of the left

hand forming an excellent pleximeter. Over the region of the liver the sound elicited is dull: over the stomach, when empty, slightly hollow; or when filled with gas, tympanitic: over the colon, when distended with air, resonant; when loaded with fæces, dull: while over the small intestines there is generally resonance. Over all the intestines a sense of elasticity is imparted to the percussing fingers. When the liver is increased in size, or when the spleen or the kidneys are enlarged, or when any solid tumor occupies the peritoneal cavity, there will be dulness on percussion in proportion to the extent of the solid matter. When, owing to perforation of the intestines, there is air in the peritoneum, the sound on percussion will be tympanitic, while the elasticity of the abdomen will be increased; when fluid or fæcal matter has been effused, there will be dulness. The great pain and constitutional disturbance, however, will prevent any examination but a cursory one.

Obstruction of the Bowels is a disorder, the diagnosis of which will be much facilitated by the careful practice of percussion, aided by palpation. This fearful accident-so to speak-may arise from several conditions, which I shall briefly consider on accouut of the great importance of the subject, premising that it may occur at any part of the bowels from the duodenum to the rectum, and that when there is obstruction with fæcal vomiting the disease is called ileus. Strangu lated hernia is perhaps the most frequent cause of obstruction; consequently, in every case of obstinate constipation with sickness, the practitioner should make a careful examination of those parts of the abdomen, thigh, hip, and in women, of the vagina, at which the intestines may descend. Intestinal concretions or calculi will also produce obstruction, and so will polypi. In the museum of the Westminster Hospital there is a preparation, showing a polypus entirely blocking up the jejunum. Intussusception, which consists of a slipping of a superior portion of the intestinal tube into an inferior, will also give rise to it. A part of the bowel may become strangulated by preternatural bands, the result perhaps of previous peritonitis, or by elongations of the peritoneum. Dr. Watson says he has twice seen the appendix vermiformis prove the cause of fatal internal hernia. In one case, the free end of the appendix became adherent to the mesocolon, forming a loop, through which a portion of the gut passed and became constricted. In the other instance the appendix was literally tied round a piece of the intestine. In a case which I saw at King's College Hospital, a diverticulum from the