One or even more hard masses in the centre of the epigastrium, or lower down towards the umbilicus, not cennected with the liver, are most commonly caused by cancer of the stomach. The general symptoms are more especially referable to that orpn, and there is almost always vomiting, which at one period or other has been grumons or like " coffee-grounds.), The sallow, ana3mic hue of malignant disease is especially marked, from the combination of cancerous growth and mal-nutrition.
In the left hypochondrium, simple enlargement of the spleen produces a tumor of an oval figure, which is perfectly even on the sur&ce. This mass has sometimes been of such size as to reach quite down into the right iliac fossa. Its attachment is in the left hypochondrium, and the diagnosis will be more or less certain, as this fact can be made out.
Occasionally a firm, hard tumor may be felt to the left of the epigastrium, which cannot be traced into the hypochondrinm. and which, though accom panied by mal-nutrition, has not been associated with symptoms clistinctly traceable to disease of the stomach ; such tumors have been found after death to be owing to scirrhus of the pancreas. The diagnosis is very difficult, and the position of the stomach is often such as to render it impossible to feel the hardened mass during life.
In the lower part of the abdomen in females the conditions of the organs of generation, the uterus, and ovaries must be considered : these will be discussed in their proper place. Tumors connected with these organs all spring out of the pelvis. In the right iliac region accumulations of feces may simulate a tumor : this, though their moat common, is not their only locality ; and I would take the opportunity of reminding my younger readers that, in all exa minations of the abdomen, care should be taken to obtain a full and free evacuation of the bowels before a diagnosis is pronounced. Similarly, in the centre of the hypogastrium, a hard round tumor may be discovered, simply due to over-distension of the bladder. By careful manipulation, fluctua tion can be discovered ; but here, too, caution must be exercised, and, in cases of doubt, a catheter should be introduced, to ascertain its exact condition.
Tumors below the level of the umbilicus, not traceable to these causes, generally have their origin in diseased conditions of the omentum, or of the lymphatic glands of the abdomen; or in local peritonitis. The two former present more decided characters of tumor, defined and indurated ; the latter 18 more diffuse, and very generally adherent to the parietes. They differ, too, in their histor Dais is associated with pain and febrile disturbance, which are not ) the others ; and while the disease lasts, the symp toms are those or a partially acute disorder. It very often terminates in abscess ; it may be caused by a blow, or by inflammation or ulceration of some part of the bowel. In females, it may be confined to the structures round the uterus, and is beat distinguished from the specific diseases of the generative organs by the fact of their having become adherent to the sur rounding parts by the undefined character of the swelling itself, and by its tenderness on pressure.
Disease of the omentum comes on gradually ; it may be associated with irregularity of the bowels, sometimes marked by constipation, and not unfre quently by some form of hemorrhage, but not attended with fever. The general state of the patient is mimic and cachectic; the tumor itself is gene rally hard, and often nodulated, and may be made to move by turning the patient in bed from one aide to the other. It often gives rise to pain, but is not essentially tender.
Disease of the glands very generally causes cedema of the feet and legs ; and sometimes also ascites, which much obscures its diagnosis; in this case, its characters are ill defined, but the tumor is generally found firmly fixed, and deeply seated towards the spine.
Almost all abdominal tumors are apt to be obscured by effusion into the peritoneal cavity. Tumors in the abdomen are very liable to pulsate ; and the question will occur whether it be aneurism. Abdominal pulsation is of comparatively little value, because all the contents of the abdomen, lying as they do above the aorta and great vessels, are liable to succussion at each systole of the heart ; neither is the presence of a " bruit" to be too much regarded, because, even in health, considerable pressure, and, in anaemic states, very slight pressure on a large vessel, is sufficient for its production. En largements of the liver and spleen are least likely to simulate aneurism. (For farther particulars the reader is referred to Chap. XXIII.) § 3. Of the Characters of Tumors.—After what has been said upon the localization of tumors, there is little to add on the sub ject of their discrimination, as that can only be dealt with on cer tain broad principles, when internal organs are concerned. To the surgeon it is all-important to be able to determine whether an external tumor belong to the class of malignant or non-malig nant disease; whether the condition of the patient be such as to lead him to recommend its removal with the knife, or to abstain from so doing ; or whether the character of the tumor be such as gives him ground to hope for its diminution or disappearance by the employment of remeditis of a less formidable character. To him, however, the question involves a great deal more than the consideration of the mere palpable characters of the tumor ; he, too, has to consider its history, its mode of growth, and its effects, as well as the condition of his patient, both with reference to cir cumstances connected with his previous life and his present state. To the physician these are the questions of real moment : many anomalous conditions are found after death which had, and could have no history during life; many which, while offering few analogies to the post-mortem inquirer, have histories scarcely dis tinguishable the one from the other ; while, again, many of which the histories differ present lesions closely corresponding.