CHAPTER XXXVI DIAGNOSIS OF ABDOMINAL SWELLINGS (Part 3)

conTour largely depends upon f -ct^^^^^^^^^^^^^^^ Hip liver— if on the surface it forms a globulai pio ection from Z organ; if deep in the Bubstance o .e gland the whole liver becomes enlarged. There is no fever, and the patient's general health is not IS no . . ^ examination of the blood seriously clistuioeu. When a imnrexia, and there is pam m tne iigut XXXVI] GALL-BLADDER TUMOURS 515 and a heavy dull pain referred to the liver, and especially if the patient has sufi'ered from amoebic dysentery, or the specific amoeba can be found in the stools, the diagnosis of abscess of the liver must be made. The enlargement of the organ may be chiefly upwards, bulging up the diaphragm ; the abscess may be so large as to give a sense of fluc- tuation, or it may be actually pointing. In many cases it is only when pus is evacuated that the diagnosis is assured. Leucocytosis is not constant in liver abscess. When the liver is moderately enlarged, tender to the touch, perhaps tender at certain spots only, and the patient has a pycemic temperature with rigors and profuse sweats, and wastes rapidly, it is a case of suppurative pylepJtlebitis. In these cases there is some source of infection in the area draining into the portal vein, e.g. appendicitis, or ulceration of stomach or intestine or gall-bladder ; the know- ledge that such a lesion exists, of course, aids in the diagnosis. An irregular, bossy enlargement of the liver occurring in a child who bears evident marks of congenital syphilis, or in an adidt who is suffering from tertiary syphilis, is a gumma. A positive Wassermanu reaction confirms this diagnosis. 2. Tumours of the gall-bladder. — If an enlarged gall- bladder is firm, or even hard to the touch, only slightly tender, and the patient has long suffered from dyspepsia with more or less local discomfort, the case is one of gall-stones. The gall-stones may be visible in a sldagram. But if with such a history the gall-bladder is found tense and rounded, and there' is acute tenderness on deep pressure at the epigas- trium, but no jaundice, it is a case of a gall-stone impacted in the cystic duct with mucous distension 516 SURGICAL DIAGNOSIS [chap. of the gall-bladder. In most cases there is pain often severe pain, but this may gradually subside withou removal of the obstruction ; there may be sbght jaundice, from projection of the impacted ^tone mto ov a second stone lying n., the common bile-duct A history of attacks of biliary colic in the past o course, aids the diagnosis. When a gall-stone s impacted in ihe common Ule-duct it causes com- ;Tete jamidice, but the gall-bladder is not distended unless there is simultaneous impaction of a stone iu the cystic duct. But p-essure upon the common bUe-duct from without causes comp ete jaundice with distension of the gall-bladder. Such pressure is most oCdne to enlar'gement of the head of tl^e P^^^^^^^^^^^ to cancer of the pylorus, or to adhesions lound the duct very rarely to a large calculus in the pancreatic duct Persistent complete jaundice which has come on abruptly, without enlargement of the gall-bladdei , and is assoc ated with tenderness at the epigastrium frregular fever, and rigors, is evidence ot wipactwn of a stone ^n the common cZ«d / persistent jauBdice with distension of the gall-bladder is evidence of compression of the common Ue-dud. If a distended gall-bladder is found ^o h^ '^ quisitely tender and the seat of severe tbiobbmg E aid the patient's temperature is high, acute PnTammation, llecysii^s, I:t:ittll, later on the viscus becomes adherent and does not move with respu-ation. A progressive nodular, solid enlargemen of the .aimadder with gradual loss of its mobih ty and tl^^ of cachexia, P7^J. ^^«[;^, UaddJ. The growth extends ^^If ^f^^; ^^^^^ ' and n,ls., ca,use,s secondary deposits in that oigan. xxxvi] SPLENIC TUMOURS 517 3. Renal tumours.— For the diagnosis of these tumours, see p. 702. 4. Splenic tumours. — A splenic tumour that can be entirely replaced beneath the left ribs, and that then, by deep inspiration, or by standing up or turning on to the right side, falls downwards and forwards from benea,th the ribs, is a ivanclering sfleen. An enlarged spleen in a patient who has suffered from malaria will readily be recognized as a malarial or ague spleen ; the occurrence of the typical febrile attacks, and duringr one of them the detection of the Plasmodium in the blood, will confirm the diag- nosis. A steadily enlarging spleen, with progressive anremia and great increase in the polymorphonucleai cells of the blood, is due to sfleno- medullary leucocy- thcBinia. But if the enlarged spleen is unconnected with ague or with torsion of its pedicle, and there is no leucocytosis, but progressive ansemia w^ith diminution in the number of the red blood-cells and in the percentage of haemoglobin, it is a case of sflenic ancBinia. If a splenic tumour with these characters is associated with enlargement of the liver and ascites, the condition is known as Banti's disease. There are also cases of chronic enlarge- ment of the spleen, in children and young people, which are associated with periodic attacks of jaun- dice without the presence of bile in the urine — • acholuric jaundice of childhood ; the disease, which often attacks several members of a family, is curable by splenectomy. A chronic globular, tense, fluctuating tumour of the spleen is a hydatid tumour. Malignant tumoxir and abscess are occasionally met witli in the spleen. Uterine tumours. — In every case of uterine tu- mour the question of pregnancy is to be first con- sidered, and it must be remembered that the obvious 518 SURGICAL DIAGNOSIS [chap. existence of other uterine disease, sucli as libroid tumour or cancer of the cervix, does not exclude pregnancy. A solid tumour of the uterus, of slow growth, perhaps remaining stationary in size for years, or diminishing at the menopause, either uni- form in shape or coarsely lobed, either causing no symptoms except from its size, or attended with menorrhagia, or metrorrhagia, or leucorrhoea, is a uterine fibroid. A globular mass of the tumour pro- jecting from the surface, or movable over it, will be easily"recognized as a siihjocritoncal fibroid tumour. A uterine tumour appearing at middle life or later, grosving steadily but not attaining to a great size and attended with pain,, a sero-sangmneous vagmal discharge, and increasing cachexia, is careinovia oj Ihc fundus uteri. An examination of the interior of the womb and of a portion of the growth removed by a curette is usually necessary to establish the diagnosis before the late stage of the disease. A rapidly growing tumour of the uterus with uneven surface diminishing mobihty, and later on cachexia and ascites, is probably a sarcoma of the uterus. _ ^ 6 Broad-ligament tumours. — A tumour springing from the broad ligament, which has a smooth even surface and fluctuates throughout, particularly it it has slowly and painlessly developed and has but little mobility, is a parovarian or hroad-ligament cyst. But if the tumour has an uneven surface, fluctuates in one or more places, and consists of more than one cyst, or of cyst and solid matter combmed it is an ovarian cyst. If the tumour is freely movab e, evidently liavmg a distinct or even a long pedicle, tliis shows that it is ovarian rather than parovarian. Mobility of the tumour, and evidence of somethmg in addition to a single thin-walled cyst, arc the SNMnpl.nns by wliich an alidonunal ovarian tumoui XXXVI] OVAEIAN TUMOURS 519 is difierentiated from a broad-ligament cyst. A rapidly growing solid tumour witli nodular uneven surface, becoming more and more fixed, and asso- ciated with ascites, vomiting, wasting, and cachexia, is a malignant tumour of the ovanj. This may be a primary or a secondary growth. A very slowly growing, firm, solid tumour of the ovary, or one that is known to have remained sta- tionary for some time, may be a fibroma. A slowly growing, soft, solid, coarsely lobulated tumour of the broad ligament, unassociated with symptoms other than those due to its bulk, is a lifoma of the broad ligament. When after tapping an ascites an irregular firm tumour is fomid in one or both broad ligaments, it is a ■papillary cy.^t of one or both ovaries. Rapid re-collection of the ascitic fluid will certainly occur ; the Huid may be blood-stained. The general health sulfers but little, if at all, and these cases, if not recognized and properly treated, may go on for years with repeated tappings and the removal of very large quantities of fluid. A solid or partly solid tumour, with very limited mobility, occurring in a girl or young woman, is most probably a dermoid ovarian tumour. These tumours are liable to sup- purate, and if the abscess is opened or bursts the escape of sebaceous matter, hair, or teeth reveals at once the nature of the original tumour. A der- moid tumour, although congenital, may not give rise to any symptoms or grow to any size until adult life. 7. Tumours of the pylorus. — A tumour of the py- lorus, of small size, which is observed to remain stationary in size and smooth in outline, is a fibrous stricture of the pylorus. Chronic dilatation of the stomach, and a history of pain some time after taking food, perhaps of vomiting and htematemesis — symp- 520 SURGICAL DIAGNOSIS [chap. toms pointing to ulcer at or near the pylorus — would confirm the diagnosis. But if the tumour is known to have appeared quite recently and is noticed to enlarge, if it has an uneven or nodular contour and its mobility is lessening, and if it is associated with recently developed and progressive dyspepsia, vomiting, delay in emptying and altered gastric secretion, revealed by a test-meal, wasting and an- aemia, it is carcinoma of the fylorus. {See p. 576.) A small, firm, barrel-shaped tumour, not exceeding in size a hazel-nut, felt in the region of the pylorus in an infant, usually a male, a few weeks old, and accom- panied by visible peristaltic waves in the stomach, loss of weight, forcible if not frequent voinitiug, and constipation, is congenHal Jnjpeiirojihy of the pylorus. 8. Tumours of the pancreas. — A solid fixed tumour in the head of the pancreas, with persistent jaun- dice, enlarged gall-bladder, rapid emaciation and cachexia, is a carcinovia of or involving the pancreas. There may be vomiting, fatty stools, glycosuria, and a great increase in the diastase in the urine. A tense globular tumour of the pancreas is probably a pancreatic cyst, and if it attains a considerable size and fluctuation can be detected in it, or if there is a history of injury preceding its development, the diagnosis is assured. A chronic moderate enlarge- ment of the whole pancreas, with pain in the back and local tenderness, is probably caused by pan- creatic calculi ; this may lead to persistent jaundice, with a distended gall-bladder. {Sec p. 573.) Pan- creatic calculi arc demonstrable by X-rays. 9. Tumours of the omenta.— A tense globular mov- able tumour of the omentum is probably an liydalid cyst ; if there is eosinophilia and if fluctuation can be obtained the diagnosis is certain. A very chronic solid tumour witli an uneven or lobed surface, and xxxvi] INTESTINAL TUMOUES 521 not attended with ascites and cacliexia, is a lipoma of the omentum. But a rapidly growing solid tumour, firm, nodular, attended with ascites and cachexia, is a malignant tumour of the omentum. Myxoma may be met with in the omentum, but is only distinguished from a lipoma after its removal. 10. Mesenteric tumours. — A globular tense tumour is a cyst. If small, chronic, and symptomless it is almost certainly a lymphatic cyst, or a chylous cyst. If larger and firmer it is most probably a thick- walled cyst containing putty-like material, the nature of which is not definitely ascertained. Some believe these cysts to be tuberculous, others think they are congenital in origin and allied to dermoids. They may be painful at times and a little tender. A soft, sohd, irregularly lobed tumour of very slow growth is a lipoma. 11. Tumours of the intestine. — The first thing to determine in regard to any tumour of the intestine is whether it is fcBcal in nature. The signs by which a feecal accumulation can usually be recognized are a firm consistence, a nodular outline, no diminution in the mobility of the bowel, the possibility of in- denting the mass by firm pressure with the fingers, and above all its movement along the course of the colon and its ultimate disappearance after repeated free evacuations of the bowel. The tumour is not dull on percussion, owing to the admixture of flatus with the faeces. The history may be misleading, as there may even be irritative diarrhoea associated with fa3cal accumulation. The most common seats of fa3cal tumours are in the caecum and at the hepatic, splenic, and sigmoid flexures of the colon. A fcecal tumour may be the result of the obstruction of the bowel by a malignant stricture, and this possibility must always be remembered. A firm nodular 522 SURGICAL DIAGNOSIS [chap. tumour of the intestine with signs of ulceration of the mucous surface and of obstruction to the easy passage of fasces along the colon-mucous and bloody diarrhoea, griping pains, smal broken-up motions, distension of the bowel on the proximal side of the tumour— is a carcinoma of the colon. As the disease advances the tumour becomes f^xcd, and secondary growths may be found m the liver, tlie abdominal wall, etc. Sudden complete obstruction may be the first symptom noticed by the patient Fsecal vomiting without other signs of intestinal obstruction indicates ulceration between the colon and the stomach. . , A firm tumour of the sigmoid flexure m a tat person, associated with chronic constipation and the passage of small scybala like sheep-droppings, or more definite signs of chronic intestinal obstruction, may be due to chronic diverticulitis. A small smooth or lobulated tumour m the in- testine, not increasing in size, not lessemng tlie normal mobility of the bowel, and associate with a certain amount of griping pam, is probably a lipoma, poly f us, or myoma of the hoivcl. i he exact nature of the tumour can only be determined by an operation. An elongated tumour of the colon which becomes firmer and clearer in outline when handled, and then after a few minutes softer and less distinct, associated with griping pains, tenesmus, and the passage of mucus or blood with sma 1 broken-up motions, is a <hronic intussusception. In very laic cases the right iliac fossa and right loin arc unusually empty, and the end of the intussusceptu.n can be felt in the rectum. . 12. Retroperitoneal tuinours.-The special featur s to determine in these cases are the mobility of the tumour, its rate of growth, its outlme, the presence, xxxvi] ABDOMINAL ANBUEYSM 523 in it of fluctuation or pulsation, and signs of disease of the spine. If the tumour is absolutely fixed to the spine or ilium, grows steadily or rapidly, is solid, and is uneven on the surface, it is a malignant tumour. This may be a primary sarcoma of the bone, most often seen in the ilium, or a secondary carcinoma, most often met with in the lumbar glands in con- nexion with carcinoma of the testicle. A very firm chronic tumour absolutely fixed to the bone, with a lobnlated surface, is an exostosis ; it may be felt to have a stalk-like attachment to the bone ; a skiagram will show its outline and nature quite clearly. A very chronic tumour, soft in con- sistence, uneven in outline, and with a slight degree of mobility over the spine, is a lifoma. A chronic retroperitoneal swelling with well- defined outline, tense, smooth, and fluctuating, is a tuberculous abscess ; the position and shape of the swelling will determine whether it is a fsoas or an iliac abscess. {See also p. 667.) A pulsating swelling may be an aneurysm. Such a case must be examined with great care {see Chap. XX.). If the pulsation can be felt along a line passing from epigastrium to navel and, when the patient kneels up and completely relaxes the ab- dominal muscles, pulsation is not felt by a hand laid lightly on the part, the case is one of pulsating aorta. The pulsation is felt solely on account of thinness and loss of tone of the abdominal wall, and the condition is most often met with in women. A very vascular sarcoma may pulsate. An aneurysm will be diagnosed only when a tumour which pre- sents an expansile pulsation and a bruit can be identified; the bruit may be chiefly audible poste- riorly ; there may be severe pain from pressure upon 524 SURGICAL DIAGNOSIS the spinal nerves, or jaundice from pressure upon the bile-ducts, or hasmorrhage from stomach or intestine, or sudden profuse htemorrhage into the peritoneal cavity, from rupture of the aneurysm into the mucous canal or serous cavity. 13. Abdominal abscesses.— The diagnosis of an ab- dominal abscess may be attended with very great diiiiculty. The symptoms are a swelling more or less well defined and clearly outlined, fixed to the surrounding structures, painful, tender, of recent and rapid formation, associated with fever, rapid pulse, and leucocytosis. Such an abscess in con- nexion with a'lrpencUcUis may be met with in the right iliac fossa, the right loin, the pelvis, and even in the left iliac fossa or central part of the belly. Similar abscesses in connexion with ulceration of the ca3cum (tuberculous), sigmoid flexure (diverti- culitis), or descending colon may be met with in the left iliac fossa and loin. It is when the sup- puration occurs in the upper part of the abdomen just beneath