The sensations are not confined to the abdomen : very many of the functional disturbances of the brain (see Chap. XIII.) are only to be accounted for as results of irregularity in the digestive pro cesses ; dyspncea and palpitation, pains in the sternum or between the shoulders, that pain in the right shoulder stated to be sympa thetic of disease of the liverespecially, ially, are all of them attributable in like manner to In the abdomen itself uneasy sensations are produced by unusual enlargements of organs, by increased irritability in congestive states, and by irri tating properties of the contents of the hollow viscera ; as also by any unusual character of the secretions which prevents the normal changes, or excites others which are abnormal, or renders them unsuited to the membrane which they traverse in their passage.
As we proceed with the inquiry we shall find many of the symptoms thus cursorily alluded to come more distinctly forward as evidence of disease of the various organs contained in the ab domen • but we must first consider what aid may be derived from the application of physical investigation to diagnosis.
First we obtain very certain information from the exploration of the outlets, the mouth, the rectum, and the vagina • but, with the exception of that derived from the state of the ;olive, the extent of its application is extremely local and limited.
Secondly, the excrbtions, by their changes in appearance and characters, afford very valuable instruction. The aid of chemical analysis has been brought to bear very fully on the condition of the urine, and in fact our whole knowledge of diseases of the kidney may be said to rest upon the chemistry of the secretion; but the same progress has not yet been made in regard to the feculent discharges, and any knowledge that has been gained is inapplicable for the purposes of diagnosis.
Thirdly, the most valuable physical signs are derived from (a) inspection, (b) palpation, (c) percussion, on each of which a few words must be said. Auscultation is rarely applicable; in health no regular sounds are heard, which by their irregularity might indicate disease : its employment in abdominal aneurism we have already noticed, and it is also useful in detecting the placental bruit and the pulsations of the foetal heart in pregnancy.
a. I ion indicates deviations from the natural contour by general fulness or local enlargements, serving both to suggest and to correct other modes of investigation.
We observe a uniform and equable distension in peritonitis, which contrasts alike with the shrunken and retracted condition sometimes seen in colic and during the pain accompanying the passage of gall-stones, and with the irre gular forms of distension of an analogous kind which are noticed in enteritis and obstruction. Similarly the simple inspection of the abdomen points out in many cases a very marked difference between the distended peritoneal sac of ascites pushing out the ribs as well as the abdomen, and the prominent rounded belly of ovarian dropsy, which very frequently evidently projects more on one side than the other. No less different is the aspect of general fulness in pregnancy from local swelling in disease. In the epigastrium the outline
of a full stomach, and still more of an enlarged one, may be distinctly defined, and thus afford valuable assistance in the diagnosis of its actual condition. The uplifted ribs on the right side by enlarged liver, on the left by enlarged spleen, point out the direction in which investigation ought to proceed.
b. As a necessary adjunct to inspection, and as a means of ascer taining the cause of any deviation in form, palpation affords more information than any other means of exploring the abdominal cavity. It often indeed serves to detect deviations from health, which would otherwise escape observation altogether; and very many of the more important characters of disease in the abdominal viscera depend on its correct application. It embraces the sense of resistance or immobility of parts, their hardness and tenderness, and their relative size; it determines the value of pulsation; it indicates fluctuation.
We might here go over almost all the important diseases of the abdomen, and point out the various lessons which palpation teaches ; but they are so important, that they must be again mentioned in each particular case, and the reader is referred to the section on morbid growths (Chap. IX., Div. 2) for the details of the evidence which it affords in the varieties of abdominal tumor. In making the examination, the student has to consider whether what is felt as a deviation from natural form, consist simply of enlargement of parts, or be absolutely a new growth in so far as this is mdicated by outline ; next its form whether smooth and rounded, or nodulated and irregular ; and then its attaChments, natural and acquired.
c. Percussion may be said to be almost essential to a correct appreciation of the results of both the preceding sets of observa tions. It gives us the very valuable information whether any visible alteration in form be wholly caused by the presence of solid or fluid matter, or chiefly by the presence of the gaseous contents of the intestine; while the degree of dulness heard on percussion where a tumor is felt, determines to a certain extent its depth and thickne,ss: it is still more useful in tracing out the orig,in and connection of tumors when distension prevents our being able t,o reach their attachments with the finger, or where they take their rise under the solid covering of the ribs. It is no less important as it aids in mapping out the extent and form of organs and tumors, as, for example, the shrunken liver, the en larged uterus, or the distended bladder.
When considered, in detail, there is no question of cliagnosis, which the percussion of the abdomen tends so much to elucidate as that of ascites and ovarian dropsy. (See Chap. XXXII.) Remarkable resonance forms the chief characteristic of tympanites. The absence of dulness on percussion serves to discriminate cases of chronic peritonitis without fluid, from those in which ascites is present ; but the student must be reminded that when the patient is upon his back, a considerable amount of fluid may accumalate in the lower and posterior parts of the cavity, without manifestly altering the resonance on percustion.