CHAPTER XXXVI DIAGNOSIS OF ABDOMINAL SWELLINGS (Part 1)

CHAPTER XXXVI DIAGNOSIS OF ABDOMINAL SWELLINGS The patient should lie flat on tlie back on a couch in a good light coming from above or from over the foot of the couch, and the whole abdomen should be exposed to view. The following methods of examination should be used. Inspeetiou quicldy shows the size and general contour of the abdomen, and the freedom, uniformity or otherwise of abdominal respiratory movements. Irregularities of the surface should be carefully noted, and particularly any visible peristalsis, or such an outlme as mdicates the prominence of intestinal coils, stomach, uterus, or bladder. Palpatiou.— Place the warm hand gently and quite flat on the abdomen, pass it carefully over the whole surface, and take note of the resistance ielt, and of any variation in this resistance in different parts. If any unusuf 1 or locahzed resistance is felt notice particularly the position, size, and shape of tins resistant part, its consistence, the presence or absence of fluctuation or of a fluctuation wave in It {see p. 221), and whether it can be moved by I lie liands. •' IVreus.sioii.-First percuss lightly over the whole surface and notice any change in the nor- mally resonant area or in the usual degree of rcson ance. Then percuss more deeply and notice again the same points. If any abnormal dullness is found 496 SURGICAL DIAGNOSIS [ciiai-. carefully note its extent, and whether it is con- stant or shifts under the influence of gravity as the patient moves first on to one side and then on to the other. If increased resonance is observed, it should be noted whether the accumulated gas which causes it is in the stomach, in the intestine —small or large— is free in the abdominal cavity, or is pent up in some limited space in an abscess cavity. By auscultatory percussion it may be possible to ascertain that the gas in a particular resonant area is or is not contained in the stomach or m the colon. , The relation of the resonant and dull areas must be tuli.y investigated. If this can be varied by the position ot the patient, it shows that liquid and gas are m one and the same cavity, the gas being eitlier free or con- tained in the- very mobile intestine. If the resonant area is above and the dull area below, it shows that there is some abnormal structure pushing up the intestines. If the duU area is above and the resonant area below, the pathological structure has grown fi-om above and has pushed down the stomach Ind intestines, or possibly the in'estmes only. It there is dullness in the fi-ont of the abdomen and resonance in one or both flanks over the colon, the dull structure is quite certainly within the peritonea cavity • while if the abdomen is resonant on ligtit percussion and dull on deeper percussion, there is some dull substance behind the peritoneum. Tcstiuq Ibc mobility oi the l,.mo«r.-There are three w'ays of testing the mobility of an abdominal tumour : -, ^ t. u 1. Grasp it in the hands and try to move it from side to side, from above down, and m some cases from before back. By this means not oul> the fact of ils mobility or fixity is ascertametl, but xxxvi] ABDOMINAL TUMOURS 497 also the direction and range of the mobility; and in some cases it is possible to make out that the mobility is like that of a pendulum, and that the . tumour is really fixed at one end and swings, as it were, on. that. For instance, a distended gall- bladder can be moved from side to side, but its fundus moves farther than its neck ; and an ovarian tumour can be felt to be fixed below and yet move quite notably at its upper end. The direction of mobiUty is of value in such cases as " movable kidney," where the kidney moves freely vertically but hardly at all transversely. 2. Get the patient to breathe deeply and notice whether, and to what extent, the tumour is moved by the full descent of the diaphragm. It is the movable tumoui's which lie in immediate contact with the diaphragm that are especially moved by it, such as the hver — including the gall-bladder — the kidneys, the spleen, and the stomach. 3. In certain cases we can alter the position of a particular viscus, and then notice whether the tumour is moved at the same time or not. Thus, by distending the stomach we can move a still mobile tumour of the pylorus, or a tumour of the stomach- wall, or a mass of hair lying in its cavity. By one or more of these methods the mobility of a tumour can be ascertained, and much learnt from the facts thus obtained. The studi nt must remember the natural range of movement of nearly all of the abdominal viscera, especially the great omentum and the coils of the jejunum and ileum and their mesentery, and he must bear in mind that in certain conditions this mobility may be greatly increased, as in movable kidney and wandering spleen. It must always be remen^- bcred tliat a tumour of a naturally movable part 498 SURGICAL DIAGNOSIS [CIIAT. may, by extension of its growtli, by the formation of adhesions, or even by its mere size, become fixed. Determiniii(| the oulliuc ol llie tumour. — Pass the hand carefully over the tumour and note its general outline and any projections or depressions in it. (1) This will show whether the outline of the tumour resembles that of cither of the solid viscera : e.g. the sharp lower edge of the liver, the notch in the anterior border of the spleen, the rounded lower pole and the hilum of the kidney, are quite character- istic. (2) A globular outline or globular projections are characteristic of fluid tumours ; a nodular sur- face is often met with in solid growths, and especi- ally in malignant growths. But in the abdomen we must remember that tlie nodular outline of benign tumours of the uterus, of isecal tumours, and of the solid masses in tuberculous peritonitis is very characteristic. The dimpled surface of cancerous nodules in the liver is vevy characteiistic when it can be felt. Determining the consislenee of (he tumour. — As in other parts, it is very important to distin- guish between solid and fluid tumours ; in the ab- domen we have in addition gas-coiitaining tumours " of the stomach and intestines, and gaseous abscesses. The methods of examining a tumour with this object are described at p. 221. Effects of emplylufj or dislendiufj llie hollow viseera — The stomach can be emptied by a siphon tube, or distended with carbon-dioxide ga<. The urinary bladder can be rmpiied by a catheter, or distended with gas or liquid. The rectum and colon nmy be emptied by purgatives or enemata, or distended with gas o ' liquid. The jielvis of tlic kidney may be ein])tietl liy a ure'.eial catlu'ler. By these means much may be loaint. If the em|)t}nug XXXVI] ABDOMINAL TUMOUKS 409 of a hollow viscus dissipates the tumour, its nature is at once revealed ; many a suspected abdominal tumour has disappeared when the bladder has been emptied ! The effect on the position of the tumour, and on its accessibility, of emptying or distending a hollow viscus, is sometimes vcrj^ notable. For instance, a stomach tumour may shrink up beneath the ribs or be displaced to or below the umbilicus a distended colon may almost conceal a tumour ying behind it. X-rays are used in two ways in the diagnosis of abdominal tumours. Tumours are opaque to the rays, and their exact position and relation to the other abdominal organs can be studied on the fluor- escent screen and in skiagrams. In this way an enlargement of the liver pushing upwards the dia- phragm, or a subphrenic abscess, can be seen, and even the intimate structure as well as the attach- ment of an exostosis can be studied. It is also pos- sible to pass into the aUmentary canal, the bladder, and the pelvis of the kidney substances specially opaque to X-rays, and study thereby the relation of the tumour to the various parts of the ahmentary canal and to the bladder and pelvis of the kidney. A meal containing barium can be traced as it jjasses from stomacli to rectiun, or a barium enema traced ujjwards. {See also C'iiap. XXXIX.) The bladder ajul tlic renal pelvis can similarly be filled witli solution of collargol, or sodium bromide, and the relation of its black shadow to the less (h'lisc shadow of the tumour studied. Pelvic oxsimiiiatiou. — A finger in the rectum or vagina can detect if any part of the tumour lies within the pelvis, and determine its relation to or connexion with, one or other of the pelvic viscera and to the pelvic wall. By n)cans of a ■sigmmdoscope 500 SURGICAL DIAGNOSIS [chap. the inner surface of a growtli of tlie rectum or lower segment of the pelvic colon can be seen. {See also Chap. XLII.) Examination under anaisthcsia is of great value, not only because it enables the surgeon to make his examination without causing any distress to his patient, but also because in deep aniiesthesia complete muscular relaxation is obtained and the confusing effects of voluntary or reflex muscular contraction are eliminated. Examination oi other organs. — Notice in the male whether both testicles are in the scrotum, or whether either has never descended ; or if one has been excised — if so, inquire for what reason. Any tumour o£ or about the testicle, either a malignant growth or a hydrocele, will be taken note of. In the female an examination of the breasts may be important ; if they show the mammary signs of pregnancy, or if a breast has been removed for malignant disease, it will have an important bearing upon the diagnosis of a tumour of the uterus, Uver, or ovary. In both sexes ahke the presence or his- tory of removal of a melanotic tumour, or carcinoma of the rectum, or other primary source of a secondary abdominal growth, is important. The evidence of tuberculous disease, of syphiHs, of chronic sup- puration, of renal or cardiac disease, or of disease of the lungs or pleura may have a distinct bearing upon the diagnosis of an abdominal tumom-. Examination ol the blood.— The e^ddence of primary or of secondary anajmia, of leucoc}i:osis m one or other of its various forms, and of eosinophilia may be of great assistance. Having completed the examination, the surgeon has to determine three points : (1) whether a tumour is actually present ; and if so, (2) the seat of the XXXVI] ABDOMINAL TUMOURS 501 tumour, and (3) the nature of the tumour. We will discuss the subject under those heads. I. Presence of a Tlmour There are five conditions that may po&sibiy be mistaken for actual abdominal tumour : 1. Obesity. 2. The contracted rectus abdominis. 3. Irregular contraction of abdominal muscles. 4. Flatulent distension of stomach or intestines. 5. Tumour of the abdominal wall. 1. The fact of obesity cannot, of course, be over- looked, but a great accumulation of fat in the ab- dominal wall and the omentum may easily be mis- taken for an abdominal tumour, especially when the abdomen is pendulous. To avoid this error it will be sufficient to notice— (a) the miiformity of the thick abdominal wall and the absence of definite out- line to the supposed tumour ; (6) that when the abdominal wall is grasped and moved from side to side no sense of a tumour deep to it is given ; and (c) the resonance on deep percussion over the sup- posed tumour. The " tumour " is generally thought to be in the lower part of the abdomen, and a pelvic examination, when it reveals the absence of any abnormal swelling m the pelvis, is further evidence that there is no tumour. In examining a fat abdo- men the hands must be pressed in correspondinoly deeply. It is well to bear in mind that while obesity may be mistaken for a tumour, it often conceals and renders difficult of recognition small tumours e.g. growths in the colon, ovarian cysts, uterine libr(jmata, shght enlargement of the liver : it is only by sp cial care and thoroughness in the examination and by a recogmtion of the particular difficulties that error will be avoided. 502 SURGICAL DIAGNOSIS [chap. 2. The resistance offered by a contracted rectus muscle— especially a contraction of one of the divi- sions of this muscle— may closely resemble a tumour. It will, however, be noticed that the outline of the supposed tumour corresponds to that of the muscle, and that the part is not dull on percussion; and very probably, when the shoulders are raised and the thighs flexed, and the patient's attention is diverted from the examination, the muscular rigidity may lessen or pass away altogether.. Under an anses- thetic the muscular contraction will certainly pass off and the absence of tumour be established. 3. There are cases where from irregular and un- usual muscular contraction some part — usually the lower mesial part— of the abdomen is made qmte prominent with a fairly well defined outline; the " tumour " persists for weeks together, possibly even for years. When examined, there may be some alteration in the percussion note over the sweUmg, but it is not absolutely dull, nor can it be moved beneath the abdominal wall ; it is usually entirely free from tenderness, its surface is always even. No part of the " tumour " can be felt m the pelvis When an ana3sthetic is given to the degree of complete muscular relaxation, the appearance of tumour entirely passes away. This is the condition usually spoken of as fliantom tumour. it is generally met with in women who show also signs of Wsteria. , . . 4 Flatulent distension of the stomach or intestine is readily recognized by the tympanitic percussion note over the part, and usually also by the belchmg-up of wind or the passage of flatus. In general meteorism, peristalsis is arrested and no flatus is passed. In the great majority of cases it is quite easy to |)c sure of the presence of an abdominal tumour, and, XXXVI] ABDOMINAL TUMOURS 503 where doubt exists, an examination under an ana3s- thetic will determine the point. 5. Tumours of the abdominal wall are distinguished by their special mobility, and by their becoming more prominent when the patient coughs or puts the abdominal muscles into action. [See p. 492.) II. Seat of the Tumour To know what organ or part is the seat of the tumour, attention must be paid to its exact situation m the abdominal cavity, to its relations to the resonant stomach and intestines, to its mobilitij, and to its outline, for some organs even when enlarged retain a characteristic outline. In some cases the nature of a tumour throws light upon its seat, and in other cases special symptoms are connected only with tumours of particular organs. Sometimes such symptoms as pam, vomiting, jaundice, ha^maturia. aid the diagnosis. 1. A tumour projecting fi-om under the right false ribs and at the epigastrium, which is dull on percussion, with a distinct lower edge passmg more or less transversely across the belly, and which is depressed by a deep inspiration, is a liver tumour, ihe duUness is continuous with the normal liver dullness above and entirely above the resonance ot the stomach and colon. 2. A tumour felt in the right loin projecting from beneath the ribs, with a distinct thin lowef edge, descending with inspiration, but with the fullest inspiration having no upper edge or limit and not bemg entirely "reducible" beneath the ribs by gentle upward pressure, is a Riedel's lobe of the liver. This is most likely to be mistaken for a movaWe kidney, or an enlarged gall-bladder ; both occi r "u.ch more often in women than in m.-n It L 504 SURGICAL DIAGNOSIS [cnAV. especially distinguislied from a kidney by the sharper lower edge as contrasted with the rounder edge ot the kidney, by the inability to feel any upper edge —it is merely a tongue-like prolongation of the liver —and by its not slipping up under the riljs wiien gently pressed up. There is also an absence ot the symptoms often attending a movable kidney, but this does not afford much aid in diagnosis, as even considerable mobility of the kidney may be present without subjective symptoms. The sharp lower edge, if it can be felt, also distmgmshes it from an enlarged gall-bladder, but the presence of symptoms of disease of the gall-bladder-of which Riedel's lobe is usually an unimportant sequela- adds to the Uability of this mistake being made. 3 A tumour beneath the upper part of the right rectus abdominis muscle, having a rounded lower end with a smooth rounded surface, but havmg no upper margin-the upper part of the tumour dis- appearing beneath the lower edge of the liver-which is felt to descend when the patient takes a deep inspiration, is a gall-bladder tumour This tumour is dull on percussion, the dullness bemg continuous with that of the liver: the resonant colon is below it, and may overlap its lower edge ; the tumour, if large, has some lateral -jb^/^y when the abdominal walls are relaxed. The fact tha the tumour is inseparable from the liver is of pr mary diagnostic importance. There .^^^ 1^ iaundice or a history of either or botli, to suppoit the ia'nosis If an^nlarged gall-bladder becomes adherent to the abdominal wall it loses its downward with a rounded contour, which descends with de p inspiration so that the fingers can then be passed xxxvi] RENAL TUMOURS 505 between its upper