CHAPTER XXXVI DIAGNOSIS OF ABDOMINAL SWELLINGS (Part 2)

edge and the ribs, and ascends with expiration, and by gentle pressiu-e from below can be made to disappear altogether beneath the false ribs, is a movable kidney. The degree of mobility varies : it is chiefly, if not wholly, vertical, and the kidney may be found in the iliac fossa, or even as low as the brim of the pelvis. In some cases the concave hilum of the kidney can be identified. There is often a lesser degree of mobility of the left kidney, and very rarely the left kidney only is movable, or is the more movable of the two. AVhen the kidney can be moved not only vertically, but freely in a transverse direction also, transgressing the middle line, it is a floating kidney. 5. A tumour in the loin projecting from beneath the last rib and filhng out the space between it and the iliac fossa, which on bimanual examination is felt 'to project behind, or by gentle pressure on the front is made to project behind, which moves very little if at all on deep inspiration, which is dull on percussion, with intestinal (colon) resonance in front of it, is a renal tumour. As it enlarges, the tumour may encroach upon the iliac fossa, and may extend towards and even beyond the middle line, pushing the resonant colon farther and farther from the side. Changes in the urine, hsematuria, pyuria, or the subsidence of the tumour at the same time as a large quantity of urine is passed, may aid the diagnosis. 6. A tumour projecting below and in front of the left false ribs, with a vertical and notched anterior edge and smooth outer surface, which descends on deep inspiration, is a splenic tumour. Changes in the blood may strongly support the diagnosis. In some cases it is difhcult to distinguish an enlarged spleen from au enlarged left kidney. A splenic tumour does 506 SURGICAL DIAGNOSIS [chap. not fill out the loin so markedly as a renal tumour does ; by percussion it can be traced higher up on the left of the stomach, whereas the kidney is altogether behind and below the stomach, and the resonance of the stomach can be made out above it. There may be colon resonance behind the lower part of the spleen ; this is never the case in a renal tumour. By attention to these points it is possible to distinguish with certainty between these two tumours even when no changes in the blood, nor history of ague, nor renal symptoms, nor urinary changes are present. 7. A smooth, rounded, tense tumour, projecting above the symphysis pubis exactly in the middle line with a rounded dome-like outline, dull with resonance above and on each side, not moving at all freely from side to side, which is felt bulging into the pelvis n front of the uterus or beyond the prostate, and which disappears when a catheter is passed and a large quantity of urine is evacuated, is a bladder tumour. Such a tumour may easily be mistaken for a uterine or ovarian tumour imtil a vaginal examina- tion is made or a catheter passed. With one finger in the vagina or rectum, and the other hand over the hypogastrium, fluctuation can easily be de- tected. In certain uncommon cases a bladder tumour does not disappear on passing a catheter. It may be distended with a blood-clot ; then, when a catheter is passed, no urine flows, and its eye is foimd to be occluded with clot. In other cases, again, a malignant tumour of the bladder may project or be felt above the pubes. In both conditions the patient's symptoms prevent error in recognizing the seat of the tumour. 8. A tumour occupying the lower part of the abdomen inseparable from the pelvic brim below, xxxvi] ABDOMINAL TUMOURS 507 with intestinal resonance above it and on each side in the flanks, is a tumour originating in the pelvis,, and growing up into the abdomen. In the male, if it is not a bladder tumour, it will be a growth springing from the pelvic wall. In the female also it may be that, but more often it is a tumour of the uterus, or of one of the uterine appendages. An exactly median position is in favour of a uterine tumour, but small uterine tumours may be placed laterally : an ovarian tumour at first is always laterally placed, but, when large, becomes central, so that too much weight must not be attached to this point. By a careful bimanual examination it is usually possible to determine the continuity of the tumour with the uterus, or the contrary, either by the outline of the mass, or by the associated movement of the two. In tumours arising from the structures in the broad ligament the uterus may be displaced to the opposite side, depressed or raised, and the fundus uteri may be clearly felt distinct from the main mass of the tumour. The nature of the tumour in many cases goes far towards establishing the diagnosis ; evidence of preg- nancy, or the firm solid consistence of the tumour, are strong points in favour of a uterine tumour ; if the tumour consists of one great cyst, or of a multi- locular cyst, that fact is equally strong in favour of a broad-ligament tumour, usually of an ovarian tumour. An ovarian tumour may have a long pedicle, and thus be very movable within the abdomen, pass- ing across from side to side, and well up out of the pelvis. It has then to be distinguished from an equally movable cyst in the great omentum. This can be done by noticing that the mobility of an ovarian tumour is always limited in the upward direc- tion—when pressed upwards as far as it will go, the 508 SURGICAL DIAGNOSIS [chap. tense pedicle can often be lelt below it — and that the mobility of the omental tumour is always limited downwards, while it can be moved upwards without restraint. An ovarian tumour thus movable is very liable to suffer from torsion of its pedicle, causing sudden pain, vomiting, and increased size and tension of the cyst, with tenderness and perhaps severe or even fatal peritonitis. {See p. .542.) When less severe this accident leads to adhesions about the cyst, which fix it, and if it becomes fixed at a distance from the pelvic brim it may be impossible to diagnose its nature with certainty. A subperitoneal fibroid may also have a long pedicle admitting of unusually free movement, and such a tumour may become fixed by inflammatory adhesions and be difficult to diagnose, but the very firm consistence of the tumour, its globular outline, and the presence of other uterine fibroids, or a certain degree of displacement of the uterus towards the tumour, and limitation of the normal mobility of the womb, will generally reveal the nature of the case. If the pelvic tumour is fixed to the bony w-alls, and the uterus and appendages are displaced by it and are not adherent to it, it will be evident that it is a tumour of the pelvic wall, and not of any of the viscera. Such tumours, if mahgnant, may later on become attached to the viscera. 9. A tumour betw^een the umbilicus and the xiphoid cartilage may be connected with the liver, the stomach, the colon, the small omentum, or the pancreas, or be a retroperitoneal tumour other than of the pancreas. If it is continuous with the liver above both to touch and by percussion, and moves freely ^'ith the diaphragm, and has a distinct transverse thin lower edge, it will easily be recognized as a liver tumour. [See p. rm.) If," liowever, it is clearly marked ojT xxxvij ABDOMINAL TUMOURS 509 from the liver above, and moves with respiration and also from side to side, it is certainly neither hepatic nor retroperitoneal, and if there are gastric symp- toms— pain, vomiting, hsematemesis, distension of the stomach — it is certainly a pyloric tumour. A skiagram of an opaque meal will afford great assist- ance in such a case. The tumour is most often carcinomatous, and as it grows it extends to the left along the stomach, and also may become fixed to the liver, pancreas, colon, or the abdominal wall. It then loses its mobility, but the develop- ment of gastric disturbance renders the diagnosis plain. A pyloric tumour may have a great range of movement laterally ; we have known it capable of passing quite under the left ribs and well beyond the middle Hne to the right. If the tumour is clearly marked off from the liver above, moves very little with the descent of the diaphragm, but more freely laterally, has stomach resonance above it, and colon resonance to the right of it but not plainly to the left of it, it is most probably a tumour of the transverse colon. ' The absence of stomach symptoms, with distension of the cjecum and the colon to the right of the tumour, but the absence of such distension to its left side' are the special features to notice. A history of an alteration in the normal action of the bowels either m the shape of diarrhoea or of increasing constipa- tion, distmctly favours the diagnosis. ' Confirmatorv X-ray evidence is afforded by failure of a barium imxture, given as an enema, to pass up the colon beyond the tumour, or by a well-marked fillin<r defect at this point. If the tumour is fixed posteriorly, moving neither with respiration nor laterally, and there are iaundicc rapid emaciation, and fatty stools, it is a tumour of the' 510 SURGICAL DIAGNOSIS [chap. head of the pancreas. If there is jaundice from this cause the gall-bladder will certainly be distended with bile. If the tumour is small, on light percussion there will be stomach resonance over it. A tumour of the tail of the pancreas projects to the left of the middle line just in front of the left false ribs, has stomach or colon resonance in front of it, an<i is fixed to the spine. It is only distmgmshable from other retroperitoneal tumours in this situation if it is recognized^^as a cyst. If the tumour is separable from the liver, can be shown to move independently of the liver, especi- ally transversely, or if the lower edge of the liver can be felt distinct from the tumour, and with this the stomach is found by percussion and X-rays to be displaced below the tumour, it is a tumour of the lesser omentum. These tumours are excessively rare ; they may attain an enormous size; but, however large they may be, the stomach is invariably displaced below the tumour. . . 10 A tumour bidging the epigastric region, and extending downwards from beneath the left false ribs-possibly even as far as the pelvis-tympanitic on pLussion, yielding the " bell-soimd," and at tended with a succussion splash, is a dilated stomach. The emptying of the organ by a siphon, or by occa- sional veJy copious vomiting, will estabhsh the ^''!T a" tumour below the umbilical level freely movable from side to side and upwards but not Tpable of free downward displacement, with stomach and colon resonance above it, colon resonance on each side of it, and-if it docs not reach the pelvi It intestinal' note below it. is a tumour of the ^ea omentum. When very large its range of lateral mobility is corrcspondmgly limited. xxxvr] ABDOMINAL TUMOURS 511 12. A tumour below the level of the navel, with a considerable range of movement both vertically and from side to side, and which does not give the sensation of being attached either above or below, is a mesenteric tumour. If small, it lies behind coils of mtestine which give a resonant percussion note ; but if large, it may press these aside and give a dull note. 13. A tumour having the form of a transverse fold or ridge below the transverse colon, with very httle, if any, movement, is a characteristic effect of tuberculous peritonitis. Other more or less well- defined masses of tuberculous glands may be felt at the same time. The history of the case may clearly establish this diagnosis. 14. A tumour in either iliac fossa or loin may be a tumour of the corresponding part of the colon, if It is movable over the posterior abdominal wall, does not bulge mto the loin, and is not quite dull on percussion, it is a tumour of tlie colon. The sigmoid flexure has a greater range of movement than the rest of the colon. The tumour may be elongated in shape, and extend some distance along the colon ihe^re may be symptoms to support the diagnosis such as pain, constipation, irregular motions, the passage of mucus and blood, or absolute constipation. When the colon is acutely or greatly distended its cylindrical outlme may be apparent; it is then tympanitic on percussion, and sometimes period- ically hardens under examination, or loud gfirgUna sounas are heard m it. Skiagrams of an opaque meal or enema afford great assistance iT ?ho " diagnosis. '"^ 15. A tumour of the abdomen which has no de- fined outlme, and is dull on percussion, the dullness shifting with the position of the patient-in dorsal 512 SUEGICAL DIAGNOSIS [ciiAr. recumbency the flanks and hypogastrium being dull and the umbilical and ■ epigastric regions reso- nant, while with the patient lying on one side the other side becomes resonant and the level ot dull- ness rises in the dependent flank— is caused by intra- peritoneal fluid. Occasionally, when examining an abdomen, on gently but quickly depressing the finoers a firm tumour is felt through a thm layer of free peritoneal fluid. It may be a large smgle tumour such as an ovarian cyst, or a cancerous livei-, or several smaller nodules may be felt, as m diffused peritoneal cancer or tuberculous peritonitis btill more rarely, in a distended abdomen there is found an irregular distribution of dullness and resonance caused by a combination of peritoneal eftusion and adhesions leading to an encysted ascites or a loculatM ascites. If there is a single dull area m the centre of the abdomen with resonance above and below and on each side of it, this may be effitsion into the lesser veritoneal sac (bursa omentalis). 16 If a tumour in any part of the abdomen is .absolutely fixed on its deep aspect, and evidently displaces the viscera in front of it, as shomi by resonance over it, and the mobihty of tl^e -test^e and omentum over the tumour, it is a retroperitoneal If the tumour is fixed deeply, has developed rapidly, and the viscera are not displaced by it or reely^ovable over it, it is either an mtrapen on a abscels or a rapidly growing malignant tumour of the • alunentary^ca^^^^^^^^^ ^^^^ , and on the same side a tumour is found pst above the inner part of Poupart's ligament, o^Ywl^Tn our ^close to the kidney, it is most probably a tumour ol an undescended testicle. XXXVI] HEPATIC TUMOUES 513 III. Nature of the Tumour It is not necessary to discuss here all the points upon which the diagnosis of the nature of the tumour depends, as much that has been said in Chap. XVII. on the general question of the diagnosis of tumours applies as fully to tumours within the abdomen as to tumom-s elsewhere. The symptoms which lead to the distmction between solid and fluid tumours, be- tween cysts and abscesses, between inflammatory' and neoplastic swellings, and between benign and mahV- nant growths, are in the main the same, whatever the seat of the tumour. The reader is assumed to have made himself acquainted with the contents ot Chap. XVII. ; and space forbids our entering upon many details which are primarily the study of physi- cians and gyna3Cologists. Following the order ob- served in the previous section, we shall try to state the mam facts about the tumours of the various organs and parts upon which a diagnosis of their nature may be founded. 1. Tumours of the liver.-If the liver is uniformly enlarged, smooth on the surface, firm, with a well- defined edge, moving freely with the descent of the diaphragm, and the patient is the subject of chronic suppuration, it is an albuminoid liver. Moderate en largement of the spleen, a hectic temperature, night driasis"''''''^' ^"""^ "^'""^^^ tWs normal'^ wiH?'.^' ^f^^^fj enlarged, firmer than normal with a well-marked, firm edge, slic^htlv tender to the touch, with perhaps some'fHction J be telt or heard over it, and the patient is the sub- If the liver is rapidly enlarging and forms a verv solid tumour with a firm, rounded edge, and the patlnt r,i4 SURGICAL DIAGNOSIS [chap.. Is very' ill, rapidly wasting, with ^^^^/'f ^' ^J^^^^^^f ' uerlmps iaimdice, it is carcinoma of the Ivver. This r sually secondary to cancer of the alimentary canal or Vast, and often discrete -df s of th growth can be felt on the surface, and m thm sub fectl the depressed umbilicated centre of such a Snle may V recognized. Prinwy ca^-cinoma is however, not so rare as was supposed. The uime is heavily loaded with urates in carcmoma of the hver Secondary sarcoma of the liver is mdistingmshabl hi its physical characters from carcmoma, than vhi h it fs much less frequent ; it is recognized when the nature of the primary tumour, e.g. melanotic ^"TSe' W ^mour has grown slowly and has assumed a more or less globular ^V^^;^^^^!^ nniformlv tense outlme, and especially it tluctuatioii an T obtained through the tumour or hydatid fremitus or when the patient, has lived for long m . Wky where hydatll dise'ase is common, such L Au tralia or Iceland, it may be recogmzed as tj^Zmour of tUe liver The ^^^^ size from a marble to one of enormous piopoitions