CHAPTER I ABDOMINAL AND OTHER TUMORS (Part 1)

CHAPTER I ABDOMINAL AND OTHER TUMORS Tue diagnosis of abdominal tumors is in most cases either easy or impossible; but it is never easy unless one has a considerable knowledge of what tumors are likely to occur in each of the regions of the abdomen, unless one has taken a careful history and made the ordinary manual exploration of the mass. In addition, laboratory examinations and x-ray exposures are sometimes of importance. Of these methods, direct palpation of the tumor may be the most or the least important of all. Sometimes it tells us a good deal, but usually what it tells us is interpreted and enlarged very considerably by what we have learned to expect. For example, an epigastric tumor is almost always cancer of the stomach. Should such a tumor occur in a child, we should, of course, seek some other diagnosis; but, then, such a tumor very rarely does occur in a child. Certain regions of the abdomen are much more prone to contain tumors than others; in other words, the diseases which produce tumor in the abdomen are chiefly those of the pelvis and pelvic or- gans, those of the stomach, liver, and kidneys. Tumors of the left hypochondrium are comparatively rare, and almost invariably turn out to be connected with the spleen or left kidney. In the right hypochondrium we have not only those connected with the liver and gall-bladder, but those connected with the hepatic flexure of the colon, with the pyloric end of the stomach, with the right kidney, as well as retroperitoneal and glandular masses which often push the liver forward and are hidden behind it. It should always be remembered that a doubtful tumor, seemingly springing from the liver, may, in fact, be a normal liver pushed downward and forward by some growth behind it. Some of the most humiliating mistakes that I have known have been due to forgetting this point. If ascites is present, our diagnosis is much simplified, as there are comparatively few tumors often associated with ascites. Such Vou. 2 7 ABDOMINAL TUMORS SPLENIC TUMOR IN TYPHOID SALPINGITIS UTERINE FIBROMYOMA OVARIAN CYST HERNIA ENLARGED GALL-BLADDER IN CHOLELITHIASIS NEOPLASM OF STOMACH SPLENIC TUMOR IN MA- LARIA, ACUTE STAGES CIRRHOTIC LIVER SPLENIC TUMOR IN CIR- RHOSIS OF LIVER NEPHROPTOSIS TUBAL PREGNANCY SOLID TUMOR OF OVARY a [eee racecar NEOPLASM OF INTESTINES NEOPLASM OF LIVER TUBERCULOUS PERITONITIS CYST OF BROAD LIGAMENT ABSCESS OF ABDOMINAL WALL MALIGNANT NEOPLASM OF UTERUS HYPERTROPHY OF SPLEEN ‘unknown | CAUSE) MALIGNANT NEOPLASM OF KIDNEY MALIGNANT NEOPLASM OF PANCREAS AND BILE- DUCTS ENLARGED LIVER IN PER- NICIOUS ANEMIA | — \ —— }— } — \ — Diacram I. 3519 2515 1539 1282 1099 1095 Bit 753 428 370 348 272 224 201 163 132 131 129 121 119 17 ABDOMINAL TUMORS—Continued TUMOR OR HYPERTROPHY OF LIVER (UNKNOWN es 113 CAUSE) ENLARGED GALL-BLADDER IN CHOLECYSTITIS —_ 105 PYONEPHROSIS. = 103 TUBERCULOUS KIDNEY E> Ss 101 NEOPLASM OF PERITONEUM i 95 SPLENIC TUMOR IN PER- NICIOUS ANEMIA }- 20 CARCINOMA OF GALL- BLADDER } = 88 SPLENIC TUMOR IN MY- ELOID LEUKEMIA } = 88 ENLARGED LIVER IN MY- ELOID LEUKEMIA } = 84 ENLARGED LIVER IN cHRronic Pericarpitis J = HYDRONEPHROSIS = 73 SPLENIC TUMOR IN HODG- , KIN’S DISEASE } = 70 RENAL CALCULUS (WITH) gg HYDRONEPHROSIS) J ABSCESS OF LIVER = 66 ENLARGED LIVER IN RICKETS Ml 63 ENLARGED LIVER IN HODG- KIN’S DISEASE ba 60 PARANEPHRITIC ABSCESS. a 59 ACUTE INTESTINAL OB- STRUCTION } Ls 57 ENLARGED LIVER IN LYM- ry 61 PHOID LEUKEMIA MALIGNANT NEOPLASM OF | 49 ABDOMINAL WALL HYPERTROPHY AND TUMOR OF OVARY tune} . 48 KNOWN CAUSE) ENLARGED LIVERIN SUPPU- )_ . 48 RATIVE PYLEPHLEBITIS J SPLENIC TUMOR IN LYM-\ é PHOID LEUKEMIA 2 INTUSSUSCEPTION ' 45 Dracram I—Continued. 20 DIFFERENTIAL DIAGNOSIS are cirrhosis of the liver, syphilis of the liver and spleen, tuberculous peritonitis with omental or glandular masses presenting as tumor, retroperitoneal cancerous metastases from neoplasm of the stomach, gall-bladder, or pelvic organs. Lastly, a small percentage of the cases of uterine fibroid and ovarian cyst are complicated by ascites. The list just given is not a very short one, but it has this character- istic, that a majority of its members can, as a rule, be easily excluded and thus a diagnosis of the cause of ascites arrived at. The most important inquiries in relation to abdominal tumors are the following: (1) Duration and present symptoms, including pain, soreness, and the various disturbances of function (gastric, intestinal, biliary, urinary). (2) The location of the tumor, with especial reference to its con- nection with one or another abdominal organ. (3) Its size, shape, and consistency. (4) Its mobility and respiratory mobility. (5) The determination of its relation to the stomach and colon: (a) through inflation of these organs, (6) through the observation or history of peristalsis and intestinal noise. Aside from these five methods of examination we must study: (a) The urine. (b) The blood, especially in relation to the Wassermann reaction, the presence of anemia, leukemia, or leukocytosis. Rarely one must also search for the complement fixation in relation to hydatid disease or gonorrhea. (c) The stomach contents. (d) The x-ray findings after a bismuth meal, a bismuth enema, or the injection of a silver salt to the pelvis of the kidney. (e) The temperature chart. In the urine the most important points are the presence of blood or of pus. In the feces, the presence of blood, pus, or parasitic eggs. A knowledge of the relative frequency of abdominal tumors is an essential part of their diagnosis. Some guides to such a knowl- edge may be obtained from the diagrams which follow. (See Dia- grams I, TI, III, IV, V. VI, VII.) Combining the knowledge thus obtained with a careful history of the case, and especially with the direct and indirect evidence touching the function of the differ- ent abdominal organs, we may arrive at a diagnosis in the majority of cases. Causes OF Tumors INVOLVING THE ABDOMINAL WALL HERNIA Ea a aS ee re ABSCESS ee 91 MALIGNANT NEOPLASM Ja 34 ACTINOMYCOSIS. = 14 HEMATOMA = 1 LIPOMA = 9 FIBROMA a 6 TUBERCULOSIS i] 2 Dracram IE 21 Tumors OF THE KIDNEY NEPHROPTOSIS Sa aa 870 MALIGNANT NEOPLASM a 119 PYONEPHROSIS as 103 TUBERCULOUS KIDNEY 101 HYDRONEPHROSIS = 73 CALCULUS (WITH HY- DRONEPHROSIS) } a SE PARANEPHRITIC AB- eeege | 59 CYST = 22 Diacram IIL. 22 Tumors OF THE LivER GALL. CIRRHOSIS SSS sy ie NEOPLASM Ts, 201 PERNICIOUS ANEMIA ers 117 HYPERTROPHY OF LIVER) gape " (UNKNOWN CAUSE) J 8 MYELOID LEUKEMIA rT 84 CHRONIC PERICARDITIS 82 ABSCESS ec] 66 RICKETS = 63 LYMPHOBLASTOMA (HopekiN’s oIsEAse) SS 60 SUPPURATIVE PYLE-) PHLEBITIS. i —_ ae LYMPHOID LEUKEMIA —_ 45 CHOLANGITIS, ACUTE OR} SUPPURATIVE j — 3 CATARRHAL JAUNDICE 29 CONGENITAL SYPHILIS ill 26 HYDATID CYST = 18 ACQUIRED SYPHILIS = 17 Dracram IV, a3 Tumors Invotvinc THE Uterus, Ovaries, OR TUBES SALPINGITIS SSS 25 UTERINE FISROMYOMA se a 1639 OVARIAN CYST a . 1282 TUBAL PREGNANCY [Ty 348 SOLID TUMOR OF) OVARY (CANCER, | 109; ADENOMA, 105; FIBROMA, 31; PA, — 272 ILLOMA, 15; SAR- | COMA, 12) J CYST OF THE BROAD) ‘o8 LIGAMENT j MALIGNANT —_NEO-» PLASM OF UTERUS, SM OF UTERUS, goa 109 (CANCER, 124; SAR- COMA, 5) HYPERTROPHY OR UNSPECIFIED; © 48 TUMOR OF OVARY Dracran V. Causes OF Tumors INVOLVING THE INTESTINES AND PERITONEUM NEOPLASM OF |NTEST|NEO TS 1S 1 TUBERCULOUS PERITON| |S S/S 146 NEOPLASM OF PERITONEUM 84 ACUTE INTESTINAL OB-) pps a STRUCTION ip ANEURYSM OF ABDOMINAL) guy AORTA 36 INTUSSUSCEPTION — 31 CHRONIC INTESTINAL O8-| guy STRUCTION! 30 NEOPLASM OF OMENTUM 7 21 “FECAL IMPACTION’? = 12 NEOPLASM OF RETROPER- ITONEAL GLANDS \— W DIVERTICULITIS. = 7 luding cases known to be of neoplastic origin. ? Cause unknown; some organic cause (stricture, tumor) is almost invariably present. Dracrax VI. Causes OF Splenic Tumor TYPHOID 3519 MALARIA, ACUTE STAGES 763 CIRRHOSIS OF LIVER SS ees |) HYPERTROPHY, UNKNOWN —EE 461 CAUSE PERNICIOUS ANEMIA Sas 90 MYELOGENOUS LEUKEMIA = 88 HODGKIN’S DISEASE ————— 70 BANTI'S DISEASE AND SPLENIGiY — se ANEMIA LYMPHATIC LEUKEMIA [an 51 CONGENITAL SYPHILIS zs 28 ACQUIRED SYPHILIS = 19 POLYCYTHEMIA Fay 19 CHRONIC MALARIA = 13 HEMOLYTIC FAMILY JAUNDICE 7 MALIGNANT NEOPLASM o 7 ABSCESS ' 4 AMYLOID DISEASE f] 3 FLOATING SPLEEN a 2 1 ANEMIA INFANTUM PSEUDO-1 LEUKAMICA J Dracraw. VIL. ABDOMINAL AND OTHER TUMORS 27, Yet, as I said at the outset, there are a number of cases which will utterly escape us despite the use of all the methods and pre- cautions above suggested. I have seen, for instance, a tumor of the tail of the pancreas which could not by any possibility have been recognized during life. Such baffling tumors are, fortunately, not very common, but they will occur in the experience of every one who sees many patients. Among pelvic tumors diagnosis is frequently impossible, partly because several of the alternative possibilities may give precisely the same history, the same data on palpation, and the same laboratory findings; partly also because these supposed alterna- tives may all be present at once. One breaks one’s heart to distin- guish a fibroid tumor from a ic ovary, or a salpingitis from an extra-uterine pregnancy, and then at operation finds both the dis- eases present at once. Such mistakes are not often very serious, for what we have chiefly to decide is whether an exploratory operation sary or not. Case 1 A waitress of twenty-seven entered the hospital March 29, 1909. The patient has two children, the younger four years old. She had a miscarriage two years ago, and was operated on at that time; she has never felt well since. She had typhoid in the Massachusetts General Hospital two years ago. Her menstruation comes every twenty-four days. The last period was three weeks ago. ‘Three days ago she fell, striking the right side. At 9 o’clock last night, without warning or pain, there was a gush of bright blood from the vagina. She went to.bed and had continuous flowing for an hour or more, with slight staining since then. Physical examination was negative, save for a tumor above the pubes, firm, smooth, rounded, not tender, about the size of a grape- fruit. There were no masses or tenderness in either culdesac, but the mass described was easily felt and was apparently continuous with the cervix. It was freely movable. The urine, temperature, and pulse normal. Dr. Brewster thought the patient probably pregnant and advised waiting a month. She left the hospital April 2d, but re-entered April 15th, having been at the Waverley Con- valescent Home until the day before, when she thought she felt a lump drop down in her abdomen. She also said she felt as if she was “going to bust.” On examination, the tumor reached from just above the umbilicus to the pubic bone; it was freely movable from side to side, dull on percussion. The vagina was bluish, the 28 DIFFERENTIAL DIAGNOSIS cervix soft and “taken up.” There was no demonstrable milk in the breasts. Discussion.—With no cessation of menstruation, one naturally does not consider pregnancy in this case until other and more obvious alternatives have been ruled out. A distended bladder is the first possibility to be excluded. Such a condition is not common in women except after anesthesia or other causes of coma. In the present case the use of a catheter promptly made us certain that the bladder was not distended. Fibroid tumors are not common in women of this age, are rarely so smooth and symmetric, and are often well recognized by the patient herself as of Jong duration before it seems necessary to consult a physician. Fibroid tumors are often associated with metrorrhagia, such as was present in this case, and this possibility cannot be ruled out. There is no way of being any surer as to diagnosis unless Ab- derhalden’s test can be tried. When the present case w en Ab- derhalden’s work had not been published, but it is in cases such as this that the serum diagnosis of pregnancy is most valuable. Outcome.—On the zoth it seemed that parts of the fetus could be distinctly felt, and being assured that there was no tumor, but only pregnancy, the patient felt better, slept well, and was able to leave the hospital on the 23d. During most of her stay the tempera- ture ranged between 99° and 993° F. In due time she gave birth to a normal child. Case 2 A Greek of twenty-seven, employed in an automobile shop. en- tered the hospital December 23, 1909. The patient came here from Greece seven years ago. He has never been sick until the present illness, and denies the use of alcohol. About a month ago he felt a little pain in the region of the liver and noticed a very consider- able mass in that region. The mass has steadily increased in size ever since, and for two weeks he has had enough pain there to disable him from work and disturb his sleep. The pain is worse at night. Physical examination shows marked bulging of the: lower right ribs, and a smooth, firm mass, dull on percussion, extending from the fourth intercostal space in the nipple line to the umbilicus and as far as the left nipple line. No thrill or crepitus is felt over the mass. There is no edema. Blood and urine negative. Discussion.—The essentials of this case are as follows: A m which appears to be an enlarged liver, has been noticed for a month ABDOMINAL AND OTHER TUMORS 29 by a young Greek. He has watched it grow considerably within that time. He is unusually young for cancer or any other malignant disease of the liver. Moreover, we have no evidence of disease in the stomach or in any other organ whence the neoplasm could have been carried to the liver by metastasis. Syphilis or cirrhosis of the liver are possible diagnoses, but neither of these diseases often causes as much pain as appears to have been present here. There is no reason to suppose that the mass is due to leukemic, amyloid, or fatty infiltration. If these diseases are excluded, it is natural to consider the pos- sibility of hydatid disease, especially as the patient is Greek. For the association of Greeks with sheep and sheep dogs, in their own country, is well known to be a potent source of hydatid disease. Nevertheless, nothing better than a tentative diagnosis could have been made in this case, unless additional evidence could be obtained by testing for deviation of the complement. The absence of eosino- philia is notable. Outcome.—Operation, January 6th, showed presenting in the wound a large liver, in which there was a cyst the size of a lemon. This cyst was shelled out whole. A 4-inch incision was then made in the anterior surface of the liver and another large cyst with a thick white wall bulged through the wound and ruptured, with the escape of a large quantity of yellow fluid. This cyst turned out to be about the size of a grape-fruit and was removed entire. A third cyst, bulging against the diaphragm from the upper surface of the right lobe, was about the size of a baseball. This cyst was ruptured into the cavity of the larger cyst and its sac was removed through the original liver wound. On further examination, a fourth cyst, about the size of a baseball, was felt in the left lobe of the liver, but was not removed. The fluid removed at operation from the cyst looked like serum, but contained no albumin. The patient recov- ered fairly well from the operation, but developed pneumonia and died January 14th. The autopsy, January 16th, showed echinococcus cyst of the liver, double chronic pneumonia, and purulent bronchi- tis; fibropurulent pleuritis on the right, obsolete tuberculosis of the bronchial lymphatic glands, enlargement of the spleen, and chronic perisplenitis. Case 3 A housekeeper of fifty-seven entered the hospital January 21, 1908. Three years ago the patient began to have indigestion and simul- 30 DIFFERENTIAL DIAGNOSIS taneously uterine flowing at very irregular intervals. About three months ago she noticed that her lower abdomen was hard. For many years she has had varicose veins in the right leg and for ten years has worn an elastic stocking. A week ago she woke up in the night with severe pain in the right Jeg. This pain has continued since and has disturbed sleep. For three days it has confined her to bed. Physical examination was essentially negative except as related to the abdomen, in the lower part of which was a large, nodular, tender, rounded mass, extending from the pubic bone to a point 3 inches above the umbilicus, <Eucecnemen and from the right flank to a ers 4 point 4 inches to the left of the median line. It was dull on percussion and slightly mov- able. The rest of the abdomen | was negative. On the inner surface of the right lower leg was an area of redness and swelling, extending from the | shin around to and past the } median line behind, and from the ankle nearly to the knee. On the inner portion of this were several large blue veins; within the area firm, venous trunks could be felt and could be traced from there up past the Fig. 1.—Chart of Case 3. knee; on the inner side. The urine was negative. The blood showed a leukocytosis varying from 20,000 at entrance to 36,000 on the 5th of February and accompanying a slight febrile reaction (Fig. 1). After that it gradually declined, although on the 12th of March it was still 19,000. On the 21st of March it was 10,000. On the 23d a vein, large, firm, and slightly tender, could be traced from the Jef kriee to the groin. There was a good deal of