JOHNS HOPKINS HOSPITAL—MEDICAL CLINIC

 

LECTURES ON THE

DIAGNOSIS OF ABDOMINAL

TUMORS

BY

WILLIAM QSLER, M.D.

PROFESSOR OF MEDICINE, JOHNS HOPKINS UNIVERSITY

I. Tumors oF
IL Tcsors or
III. Tumors or
IV. Tumors or
VY. Tumors oF
VI. Tumors or

OL BU IL CY
REPRINTED FROM | Le 4
THE NEW YORK MEDICAL" JOURWAL 1894-0 ~~ t=

BALTIMORE

THE Stomaci

THE StomMacu (continued)

THE Liver

THE GALL BLappEr

INTESTINE, OMERXTUM, “MESENTERY; ETC.

;
THE KIDNEY | an

£

  

NEW YORK

D. APPLETON AND COMPANY

1894
Wr
O$2\
sq

CoPYRIGHT, 1894,
By D. APPLETON AND COMPANY.
“Tie sources to which we turn for evidence respecting
the existence and nature of abdominal tumors are: the
form and appearance presented to the eye; the form still
further discovered by the touch; the resistance ascer-
tained by pressure; the sounds elicited by percussion ;
and, in a few instances, the sounds perceptible to the ear,
either alone or by the aid of the stethoscope; and besides
these local and physical signs, we look to the general con-
dition of the system, and of the various excretions, as
rendering us most important assistance, and being fre-
quently indispensable toward the formation of a tolerably
correct diagnosis.”—(Richard Bright, On Abdominal
Tumors.)
CONTENTS.

LECTURE
I. Tumors oF THE SToMACH . .
J. Tumor FoRMED BY DitaTep Stomacu
Il. Tumor rorwep py Contractep Sromacn .
Il Noputar anp Masstve Tumors or THE Stomacu
(2) Tumors or THE PyLoric REGI0N
(0) Tcmors or THE Bopy or THe SromacH
(ce) Masstve Tumors or THE SroMACH
III. Tumors or tHe Liver . :
I, Tumor FORMED BY THE Liver ITSELF
II. Asscess
TI. Sypsrnis .
IV. Cancer .
IV. Tumors or THE GALL Biappne
(a) Ditatep Gatti BLapper .

(6) Inu-perInep Nopciar Tumors at Liven Ece

(c) CANCER oF THE GALL BLapprr
V. Miscentangovs Tumors .
I. Tumors oF THE INTESTINE
IL OmentaL Teumors .
III. Tumors oF THE PANCREAS
TV. Miscettanrous Tumors
(a) Cyst or MESENTERY .
(2) Mcirwie Tumor Masses IN Appowex
(c) Urerine Frsroip
(d) Sarcoma OF THE Appominan Wau.
(ce) Tumors or Dovsrrun Nature .
(f) ANEURYSM oF THE AORTA.
VI. Tumors oF THE KIDNEY
I. Movasie Kipnrey :
(a) Errors 1x DraGnosis or
(0) Dieti’s Crises IN . .
Il. Invermitvent HypRoNEPurosis . : -
TI, Marigvant Disease or KipNey
IV. Tusercutous KIDNEY

PAGE

45

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LECTURES ON THE

DIAGNOSIS OF ABDOMINAL TUMORS.*

 

Leorure J.—Tumors or THE Sromacn.

Guxtiemen: I propose in the following course to
pring before you the experience gleaned during a period
of twelve months in the cases of abdominal tumor which
have come before me for diagnosis. I have not included
the cases admitted under the care of Dr. Thayer (my first
assistant) during my absence in July and August, unless I
had previously or have afterward seen them. The con-
dition has been dictated at the time of examination, the
diagnosis made, when possible, and the subsequent history
of the cases has been carefully followed. I have not in-
cluded in the list instances of ascites, appendicitis, or sim-
ple enlargement of the liver or spleen; only cases in which
a definite tumor existed in connection with one or other of
the abdominal organs. We shall take up the cases in the
following order: stomach, of which there were twenty-
four, liver and appendages, intestines and peritonaum,
renal, and miscellaneous.

In the diagnosis of abdominal tumors Bishop Butler’s
maxim that “ probability is the rule of life ” is particu-
Jarly true, and the cocksureness of the clinical physician,
who formerly had to dread only the mortifying disclosures
of the post-mortem room, is now wisely tempered when the
surgeon can so promptly and safely decide upon the nature
of an obscure case.

* Delivered to the Post-graduate class, Johns Hopkins Hospital,
November and December, 1893.

1
2 THE DIAGNOSIS OF ABDOMINAL TUMORS.

With the methods of examination of the stomach you
are all familiar, having frequently seen them applied; and
as elaborate details are available both in the text-books on
physical diagnosis, and more fully in the recent special
works on diseases of the stomach by Ewald,* Boas, + Bou-
veret,[ Debove, and Rémond,* I shall proceed at once to
the consideration of the subject in hand.

Tumors of the stomach are formed (1) by the organ
itself in a condition of abnormal dilatation or contraction ;
(2) by nodular or massive outgrowths of its walls.

I. Tae Tumor rormep sy «a Drtarep Sromacn.—
There were thirteen cases of dilated stomach in the series,
in ten of which the organ itself formed a prominent tumor
visible on inspection. These will form the subject of the
present lecture. In all of the cases the existence of a
nodular pyloric tumor was also determined. In another
case, not considered here, the dilatation of the stomach was
caused by the pressure on the duodenum of a tumor of the
colon. I will first read to you the histories of the cases,
sometimes with the comments dictated at the time of ex-
amination, and then make some general remarks on the
diagnosis of dilated stomach, Though the condition is
common, I am surprised that general practitioners so fre-
quently overlook its presence, owing in large measure to
the transgression of one of. the primary rules of diagnosis,
namely, to carefully and systematically go through the rou-
tine of inspection, palpation, percussion, and inflation.

Case I. Tumor caused by Dilated Stomach; Nodular
Tumor in Right Epigastrium > Waves of Peristalsie.—George
A., aged thirty-nine, admitted September 1st, complaining of
pain in the abdomen and vomiting. Patient is a tailor by occu-
pation, and has used alcohol to excess. Present illness began
last Christmas with symptoms of dyspepsia, occasional vomit-
ing, eructations, and pain in the region of the navel. The pain
was much worse after eating and was described as of a gnaw-
ing character. The food very often turned sour. Has never

* Klinik der Verdauungskrankheiten, Dritte Auflage. Berlin,

+ Diagnostik und Therapie der Mayenkrankheiten. Theil ii,
Leipsic.

 Traité des maladies de Vestomac. Paris,

* Traité des maladies de Destomac. Paris,
TUMORS OF THE STOMACH. 8

vomited any blood. Lately the attacks of vomiting have come
on at longer intervals and large quantities of brownish, foul-
smelling material have been ejected.

Present Condition.—Patient is a medium-sized man, much
emaciated, particularly in the trunk and extremities; there are
no glandular enlargements. The tongue is thickly furred. The
abdothen is flat, somewhat scaphoid, but presents a slight promi-
nence above and to the left of the navel. At intervals of a min-
ute or two there appears in the epigastrium and upper umbili-

 

Fic. 1.—-From a photograph by Dr. Hewetson, showing undulatory waves of
peristalsis in Case I. The crosses are placed on the three prominent waves.
The letter / indicates the depression on the lesser curve.

cal region a prominent tumor, the longest diameter transverse,
and having somewhat the shape of the stomach. The chief
prominence is in the left hypochondrium, and the greater curve
emerges beneath the costal margin in the left nipple line,
passes obliquely downward to about two inches below the level
4 THE DIAGNOSIS OF ABDOMINAL TUMORS.

of the navel, and then turns upward and to the right, reaching
nearly to the ribs. The lesser curve, not so distinct, passes
two inches from the ensiform cartilage. During the promi-
nence of the tamor waves of contraction pass from left to right
and there is sometimes a well-marked depression separating the
prominent masses to the left and right of the middle line.
During the periods of contraction the masses are firm and resist-
ant; in the intervals they almost completely disappear and the
abdomen in these regions is quite soft. In the right paraster-
nal line, just below the edge of the liver, is a nodalar tumor.
Fig. 1 is from a photograph taken during the passage of the
waves of contraction, three of which are plainly to be seen at

 

Fig. 2.—Carcinoma of pylorus, showing the dilatation of the stomach as it ap
peared at autopsy. Froma photograph by Dr. Hewetson.

the situations marked with the crosses. The letter J is placed
in the depression separating the stomach into right and left.
After several attacks of vomiting, and after having [the stom-
TUMORS OF THE STOMACH. 5

ach thoroughly washed out, the distention was very much Jess
marked, and the peristaltic movements were less frequent. The
nodular tumor mass was then felt to be very much more in the
middle line. For a week or ten days before his death this pa-
tient had tetany, which is not a very nncommon event in dila-
tation of the stomach. Death occurred September 26th.

The autopsy showed at the pyloric extremity of the stom-
ach a crater-like tumor mass eight by seven centimetres, the
margins thick, elevated, and indurated. Externally there was
great thickeniog about the pylorus, with numerons nodales on
the peritoneum. At the pylorus the tumor was massed about
the orifice, through which, however, the iittle finger could pass.
The coats of the stomach were enormously thickened. Fig. 2,
from a photograph taken on the post-mortem table, shows well
the dilatation of the stomach.

Case II. Dilated Stomach, forming a Prominent Tumor ;
Lil-defined Flattened Mass in Right Umbilical Region.—John
L.. aged tifty-eight years, seen with Dr. Bryson Wood, Septem-
ber 13th, complaining of indigestion and loss of weight. The
patient is a tail, large-framed man. who has lived a life of un-
usual energy and activity, and prior to 1875 had been a hard
drinker,

Ilis mother died of some stomach trouble, the precise nature
of which he does not kuow. With this exception, his family
history is good, He has always had to be a little careful about
eating, but until within the past six months has had good
health. The present illness began with dyspeptic symptoms,
eructations of gas, feelings of distress a few hours after eating,
and occasional vomiting. The chief discomfort was at night,
five or six bours after the last meal. Lately these features
have increased very much; he has not been able to take solid
food; the eructations of gas have become very marked, and he
has had at intervals vomiting of large quantities of liquid and
undigested food. He has lost rapidly in weight and has fallen
from a hundred and ninety-five to a hundred and forty-two
pounds,

The condition on-examination was as follows: Large-framed
man, not cachectic-looking, moderately emaciated. The tongue
has a light white fur.

The abdomen is below the level of the costal margin. In
the upper zone, occupying the Jeft epigastric, the left umbilical,
and the left hypochondriac regions, there is an irregular swelling
which at intervals shows waves of peristalsis and assumes a
shape suggestive of a distended stomach. <A lesser curvature
can be distinctly seen three fingerbreadths from the ensiform
cartilage; « greater curvature about two inches below the level
6 THE DIAGNOSIS OF ABDOMINAL TUMORS.

of the navel. The most marked prominence is just beneath the
left costal margin. To the right the outline of the swelling ex-
tends beyond the nipple liae. he contrast between the upper
and lower abdominal zones is
very striking and the diagnosis
of the condition could be made
ata glance, as the organ hard-
ened when the waves of peri-
stalsis passed over it.

On palpation, the abdomen
was everywhere soft and there
was no tenderness. During con-
traction the stomach was firm
and resistant. There was no nod-
ular tumor to be felt, although
i between the navel and the right
i costal margin there was a sense

 

NX iy of increased resistance, particu-
N YY larly beneath the ribs. The area
— : . soe
of liver dullness was diminished.
| There was no enlargement of
Fig. 3.—Showing the stomach out. the superticial glands.
lines in Case II. The patient was ordered to

have the stomach washed out
every morning, and to take a diet of milk and egg-white.

October 17th.—Patient was seen again to-duy with Dr. Sal-
zer, partly with a view of determining the advisability of a
Loreta’s operation. Since the last note the patient has im-
proved considerably under the daily use of the stomach tube,
und he has been able to tuke Leube’s beef extract, meat balls,
and small quantities of milk without discomfort. He has not,
however, gained in weight; still looks very haggard and ema-
ciated, and says he at times feels very queer in his head, as it
he would go crazy.

The abdomen is a little full in the upper zone and every few
minutes the distinct outline of the stomach can be plainly seen,
forming a tumor of unusual prominence. The stomach tym-
pany can be obtained as high as the fifth interspace in the para-
sternal line.

On palpation, there is no thickening or nodular mass to be
felt in the epigastric region, nor on the deepest inspiration can
any mass be felt beneath the left costal margin. Just below
the limit of the stomach and to the right of the navel there is an
ill-defined flattened mass which does not, however, feel like a
thickened pylorus, nor is it likely that the pylorus could be felt
in this situation with the stomach tympany and the outline of
TUMORS OF THE STOMACH. 7

the stomach passing, as it does to-day, with such distinctness
beneath the right costal margin. It seems more probable that
the pylorus is covered by the distended organ.

October 26th.—Subsequent to my last visit the patient was
transferred by Dr. Salzer to the care of Dr. Simon, who tells
me that uremic symptoms developed about the 238d and the
patient died comatose on the 25th. There was no autopsy.

Casx III. Dilatation of the Stomach ; Tumors in Epigastric
and Right Hypochondriac Regions.—A. P., aged forty-seven
years, seen October 19th with Dr. Jarrett, of Towson, com-
plaining of indigestion and stomach trouble, His personal and
family history are excellent, though he states that one brother
died of a tumor inthe abdomen. For the past six months he
has been in failing health and has had distress after eating,
usually within half an hour, sometimes as soon as ten minutes.
The vomitus consists of the food he has taken, never any blood.
He has never vomited any very large quantities. The pain is
marked after eating and becomes more severe until the con-
tents of the stomach are ejected. On several occasions he has
passed blood in the stools, but he thinks this comes from
hemorrhoids which he has bad for many years.

The patient is a very well built man, looks thin, but is a lit
tle sallow, scarcely cachectic.
Tongue is red, clean, and in-
dented.

Abdomen.—Wallsthin. Oc-
eupying the left epigastric region
there is a large projection which
varies in shape and in promi-
nence. Detinite peristalsis is
to be seen, but the waves do not
pass beyond the middle line.
This bulging during peristalsis
eceupies the left epigastric and
the upper right quadrant of the
umbilical regions.

On palpation, the abdomen
is everywhere soft, very resist-
ant just below the ensiform car-
tilage and over the prominence
above noted. In the latter the Fia. 4.—Showing the position of the
resistance varies with the pres- tumor masses in Case III.
ence or absence of the peristaltic
waves. Immediately below the ensiform cartilage there isa def-
inite ridge-like swelling which is superficial, very tender, and
does not extend entirely across the space between the costal

 
8 THE DIAGNOSIS OF ABDOMINAL TUMORS,

margins. It has a boardy hardness. On drawing a deep breath
the fingers can be placed directly above it and it descends about
an inch. In the left lumbar region, just below the tenth rib
and the adjacent costal margin, there is to be felt a firm mass,
extending seven centimetres in a vertical direction. Anteriorly
in reality it can be felt within the right epigastric region, and
outward it extends to nearly the mid-axillary line. On deep
inspiration it descends and gives one somewhat the impression
of a rounded body, and on bimanual palpation it is not very
movable. .

The edge of the spleen is not palpable; neither kidney can
be felt; the edge of the liver is not palpable ; nor does there
appear to be any definite enlargement of the organ. On inflat-
ing the stomach the prominence in the epigastric and umbilical
regions becomes very marked and its lower curve extends to a
little below the navel. The upper limit of stomach tympany
is just at the sixth rib in the nipple line. There are no glandu-
lar enlargements. The patient became gradually worse and
died about Christmas time.

Case IV. Dilated Stomach, forming a Visible Tumor ; an
Oblong Mass in the Right Epigastric and Umbilical Regions.—
Annie D., aged forty-eight years, Bohemian, admitted October
ist, complaining of swelling in the abdomen, pain in the back,
and vomiting.

She knows of no hereditary disease in her family. Ter hnus-
band died of tuberculosis,

Patient was always strong and well; she has had three
children. Tler present trouble began eight months ago with
pain of a dull, aching character in the stomach, and dyspepsia,
but until recently she has had no vomiting, and has kept about and
at work up to a week ago, when she began to vomit. Prior to
this she noticed that the abdomen was swollen. The vomiting
has been chiefly after taking food, and she bas not brought up
any large quantities,

Present Condition.—Patient is thin, but the emaciation is
not extreme. The lips and mucous membranes are of a fairly
good color. Tongue is slightly furred with a white coating,
Pulse regular; temperature normal; superticial glands not en-
larged.

The abdomen is prominent, particularly in the umbilical
an left hypochondriac regions. Under observation there oc-
cur in these parts undolatory waves of peristalsis, and the out-
lines of the stomach become unusually distinct, the greater
curvature reaching fully three inches below the level of the
navel, the lesser curvature just above this point. As the waves
of contraction pass there is a vertical constriction just to the
TUMORS OF THE STOMACH. 9

left of the middle line. The peristalsis comes on spontaneously,
and any stimulus, such as flipping with a towel or even pal-
pation, at once excites it. On
palpation, except during the
time of the contraction referred
to, the abdomen is everywhere
soft. Just above and to the
right of the navel there is to be
felt an oblong mass, which takes
a direction upward and out-
ward toward the costal margin.
It is oblong, slightly movable,
firm, smooth, and not painful.

, On October 8d a test break-
fast was given at 8 a.m. At
nine o’clock the stomach tube
was introduced and about a
quart and a half of very sour-
smelling, brownish inaterial re-
moved. During the passage of
the stomach pump the patient Fie. 5.—Showing the position of the
vomited, and she felt very faint. tumor and the outlines of the
The examination for free hy- stomach in Case IV.
drochloric acid was negative.

The patient left the hospital on October 14th in much the
same condition, and has not been heard of since.

Oase V. Remarkably Movable Tumor of Pylorus ; Dilated
Stomach ; Gastro-enterostomy.—Mary M., aged fifty-eight years,
colored, admitted on October 26th, complaining of pain in the
abdomen and vomiting.

She has been a healthy woman, married twelve years; has
had six children and four miscarriages. She has always bad
very good health up to the onset of present illness, which began
in June with burning feelings in the chest and pain after eat
ing, sometimes vomiting. These symptoms have continued with
variations. At times she would be better, and then she would
have spells of belching and vomiting. Sbe had often vomited
large quantities of liquid. She makes no complaint except of
the stomach symptoms. Lately she has been very constipated.

Abdomen.—The walls are very loose, flabby, thrown into
many folds. In the right hypochondriae and right epigastric
regions there is a marked rounded prominence, which below
extends to within two centimetres of the navel, and reaches
nearly to the middle line. It descends slightly with inspiration.
On palpation, this proves to be a solid mass, which can be grasped
and fs freely movable. It is irregular, rounded, not reniform,

 
10 THE DIAGNOSIS OF ABDOMINAL TUMORS,

but is smooth at its upper and right borders, more irregular be-
low and to the left, but a definite hilum is not to be felt. To
the touch there is conveyed a sense of firm yet elastic resist-
ance, such as is given by a solid organ. On prolonged palpa-
tion no gas is felt passing through it. It is extraordinarily
mobile, and can be pushed into the epigastric region far over
into the right hypochondriac region, and below into the right
lumbar and umbilical regions to a level with the line of the an-
terior superior spines. On firm pressure, the lower margin can
even be forced into the iliac region. The diagram, which was
made with great care, illustrates the varions positions which
the mass can be made to assume. It can also be pushed into
the right hypochondriae region,
80 as to be covered almost com-
pletely by the ribs, and in subse-
quent examinations this was not
infrequently the situation in
which it was found, and from
which it could only be dislo-
cated by the. deepest inspiration
or by deep pressure in the renal
region. The mags is not tender
even on firm pressure. There
is dullness over it, but not com-
plete flatness. The patient no-
tices that the mass changes in
position as she moves about, and
when she sits up it moves far
—— down into the abdomen, while
when on her back it is frequent-
Fig. 6.—Showirg the positions into ly beneath the right ribs. When
which the tumor could be placed this mass is out from beneath
in Case V. the right costal margin the right
/ Kidney can not be felt, nor on
the left side, on the deepest inspiration, could the kidney be
palpated. Behind there are depressions in the renal regions.

The edge of the liver can not be felt; the area of splenic
dullness is not increased; the edge can not be reached even on
deep inspiration.

A test breakfast, withdrawn an hour and ten minutes after,
gave two hundred cubic centimetres of fluid in the stomach,
which contained no free hydrochloric acid. The stomach was
inflated with gas, and the outline of the greater curvature
reached almost to the navel. When the gas was in the stomach,
palpation of the most careful character gave no sensation of any
fluid passing through the tumor.

 
TUMOURS OF THE STOMACH. 11

This patient came in with a diagnosis of probable can-
cer in the stomach, which the history of repeated attacks
of vomiting and progressive loss of weight and the exist-
ence of a tumor in the abdomen seemed to justify. Ex-
treme mobility is a feature of certain tumors of the pylorus,
as in the specimen which I showed at the Philadelphia
Pathological Society of solid tumor of the pylorus, about
the size of the mass under consideration, which could be
moved readily into either hypochondriac region, and which
was sometimes completely under the ribs and out of reach.
The autopsy showed it to be a tumor of the pylorus. The
possibility of such cases has to be considered in speaking
of the nature of the present one. Here the mass is of un-
usual mobility, and can be passed into the renal Tegion on
the right side. It has not a reniform shape, but it has the
consistence and the resistance of the kidney. A point
very much in favor of its renal character is the mobility
downward, and the tumor of this sort which can be pushed
up beneath the ribs and also far down to the iliac regions
is certainly highly suggestive of floating kidney. Another
important fact is that, in a woman with such a lax ab-
dominal wall, no right kidney can be felt. The gastric
disturbance and dilatation of the stomach present are both
explicable on the view that this tumor mass has compressed
the duodenum and caused secondary dilatation.* Nor is
this, considering the history of so many cases, inconsistent
with the view that the tumor mass may be really a kidney.
On the other hand, the tumor has not the shape of a kid-
ney, and a distinct hilum can not be felt. No left kidney
can be palpated, and it may be that this is an instance of
conglomerate kidney, such as was found in Polk’s cele-
brated case.

At any rate, I have suggested to Dr. Halsted that an
exploratory laparotomy be made, and if it is found to be a
movable kidney, the organ can be stitched into position.

November 4th_—The patient has been better for the past few
days. She has had her.stomach washed out early in the morn-
ing. To-day at ward class a careful examination was again
made. The tumor mass was evident just beneath the right cos-
tal margin, and it was difficult to displace it from this point by
the deepest inspiration; bat, on turning on the left side, it
19 THE DIAGNOSIS OF ABDOMINAL TUMORS,

readily fell over toward the umbilicus, and had practically the
mobility noted before. The stomach was again inflated, and
the outlines became remarkably plain. The greater curvature
was just about the level of the navel, somewhat above the level
previously noted. The peristalsis was unusually distinct.

5th.—This morning at 10.80 Dr. Halsted operated, making
a long vertical incision over the right rectus. When the peri-
toneum was opened the tumor mass was directly exposed, and
found to be a solid growth of the anterior wall and lesser curva-
ture of the stomach in the pyloricregion. There were no adhe-
sions: the stomach was much dilated. He at first intended to
resect the tumor, but, on examining the retro-peritoneal glands,
they were found to be enlarged, and it was thought best to do
4 gastro-enterostomy. The patient died two days afterward.

Case VIL Tumor in Left Epigastrie hegion ; Dilatation or
the Stomach.—In consultation with Dr. Barclay I saw to day,
December 6th, A. B., aged sixty-four years, a German.

Patient had been in failing health for some months, and had
had dyspepsia for several years. He, however, kept about and
at his work until early in October, when he consulted Dr.
Barclay for jaundice, which seems to have been intense and to
have come on suddenly, not, however, with much pain and not
in & way suggestive of gallstones. He had never had jaundice
before, but had one or two attacks of pain resembling that of
gallstone colic. On examination, the left lobe of the liver was
found to be enlarged and a tumor mass occupied the whole of
the epigastric region. It was tender, not fluctuating, and the
doctor regarded it as an enlarged left lobe of the hver. He
had moderate fever, After the persistence of these symptoms
for some weeks he vomited a quantity of pus, the tumor mass
gradually disappeared, and the jaundice became less intense.
The gastric symptoms, however, continued and he began at in-
tervals to vomit large quantities of dark-brown material, con-
taining undigested remnants of food. The doctor has washed
out the stomach with great relief, but he has gradually failed
and has become more anemic.

Present Condition.—The patient is fairly well nourished :
face is not especially emaciated, and he has not a cachectic
look. There is no jaundice. The temperature is normal; pulse
about 96, of fairly good volume; tongue is slightly furred,

Abdomen.—Panniculus is well preserved, The upper zone
is prominent, particularly in the left hypochondriac region, and
at intervals a distinct hemispherical prominence appears below
the left costal margin, and waves of peristalsis are seen passing
from left to right. The prominence is noticeable as far as the
navel, but a definite contour of the stomach is not visible. Mid-
TUMORS OF THE STOMACH. 13

way between the ensiform cartilage and the navel and a little
to the left there is a tumor-like prominence which moves with
the descent of the diaphragm. On palpation, the abdomen is
every where soft, quite painless on pressure, and the tumor mass
just described is felt as a firm, solid body about tive centi-
metres in vertical extent and about six centimetres in trans-
verse extent. It is entirely to the left of the middle line. It is
firm, smooth, not painful, except on very firm pressure, and is
not movable. It descends about four centimetres during in-
spiration. No gurgling is felt in it. Nothing is to be felt to
the left of the median line in the pyloric region. Splashing can
be readily obtained, and on percussion the stomach tympany
extends to a finger’s breadth above the navel. The upper limit
of the liver dullness in the mamillary line is at the seventh
rib, and it does not extend beyond the costal margin. The left
lobe of the liver is not palpable; the dullness is at the junctare
of the fifth costal cartilage with the sternum, and extends three
fingers’ breadth. It can be separated from the dullness over
the tumor mass in the epigastric region. The spleen is not en-
larged. There are no superficial glandular enlargements.

The patient had had a severe attack of vomiting this morn-
ing, and his stomach was not nearly so much dilated as usual.
The vomited matter which I saw had the usual characters—
dark brown, with frothy scum. The urine was somewhat di-
minished, and he complained very much of thirst.

Two points of interest present themselves in this case,
which otherwise seems to have all the characters of ordi-
nary dilatation of the stomach from pyloric obstruction.
In the first place, the nature of the attack of severe jaundice
with the tumor mass in the epigastric region. From Dr.
Barclay’s account, there can be no question that the patient
vomited a large quantity of pus, and that subsequent to
this the tumor disappeared and the jaundice got better.
There are two suggestions in this connection: that there
was a large carcinoma of the stomach, with suppuration at
its base and about the tissues of the gastro-hepatic omen-
tum, with compression of the bile ducts. Suppuration does
occur at the base of malignant growths, more particularly
when they form adhesions with adjacent organs, and I have
placed such instances on record; indeed, there may be a
considerable collection of pus between the left lobe of the
liver and the stomach. The other suggestion is that the
jaundice and enlargement of the left lobe of the liver were
14 THE DIAGNOSIS OF ABDOMINAL TUMORS.

associated with gallstones and suppuration in the region of
the ducts, with discharge into the stomach, and subsequent
cicatricial contraction about the pylorus and dilatatio ven-
triculi. The jaundice, however, would scarcely have disap-
peared, and this is not a very likely condition. And, lastly,
it is interesting to note here the situation of the tumor mass
—not at all in the position usually felt in carcinoma of the
pylorus, but, as will have been noted in the histories of the
other cases, the tumor ig extremely variable in position.
Though in a somewhat unusual situation, it is quite pos-
sible that this really may be a tumor mass causing the steno-
sis of the pyloric orifice.

Dr. Barclay writes me that this patient died on the 29th
of December of exhaustion. The post-mortem showed an
enormously distended stomach, which covered the intestines
like an apron. The pyloric orifice was surrounded by a large
mass of cancer, which so nearly occluded it that only the
tip of the finger could enter. The cancer extended also
slightly into the duodenum and on the posterior wall of the
stomach, which showed extensive ulceration. The left lobe
of the liver was shrunken and showed soft, nodular masses
breaking down into pus. The mesenteric glands were en-
larged and cancerous. The bile passages and gall bladder
were normal.

The post-mortem does not throw much light upon the
early history of this case, the symptoms of which came on
apparently with jaundice and enlargement of the left lobe
of the liver. The tumor mass proved to be, as was sup-
posed, at the pylorus, though in a somewhat unusual situa-
tion—entirely, at the time of my visit, to the left of the
middle line.

Cass VII. Dilated Stomach ; Tumor at the Pyloric Orifice.—
October Ist. I saw to-day, with Dr. W. B. Perry, Mrs. R., aged
about sixty years, complaining of dyspepsia and vomiting. She
had been a healthy woman until about a year ago, when she
began to have attacks of dyspepsia and occasionally of vomit-
ing. These symptoms have become progressively aggravated-
and she has within the past three months lost flesh rapidly.
A marked feature in the case has been the vomiting at inter-
vals of very large quantities of a brownish liquid mixed with
portions of food.
TUMORS OF THE STOMACH. 15

Patient is a small-framed woman, much emaciated, and
looks very feeble. The abdomen is greatly distended, chiefly
on the left side and below the
level of the navel. The nature
of the trouble is at once ap-
parent by the active waves of
peristalsis which, as they pass
from left to right, bring out
with unusual distinctness the
contour of the greater and less-
er curvatures, the former pass-
ing at a level of about three
inches above the pubes, and
the latter midway between the
navel and ensiform cartilage.
The organ becomes unusually
hard and firm. Far over to the
right, just at the border of the
epigastric and umbilical regions,

 

there is to be plainly felt an ir- j

regular, nodular mass, which 18 a. 71—The position of the nodule
movable and is depressed on in- and outlines of the stomach in
spiration. No gas is felt passing ~Case VII.

through it, but the position and

characters suggest a pyloric cancer. Lavage had been already
practiced for some time, but she was in too feeble a condition to
expect much from any treatment.

Dr. Perry writes that the patient died on October 4th.

Case VII. Dilatation of the Stomach, JSorming a Visible
Tumor; Nodular Mass at the Pylorus.—January 10, 1898, Cap-
tain , of Virginia, patient of Dr. R. J. Hicks and Dr. Salzer,
came complaining of dyspepsia and discomfort after eating.

The patient has been a healthy man, a free liver, and a late
sitter; irregular in his meals. He bas not been a chronic dys-
peptic, and has only had an oecasional attack of indigestion
until the onset of the present trouble. From Christmas, 1891,
he has been ailing, though able to attend to his business. He
has had loss of appetite; no special nausea, and has never vom-
ited any large quantity. After eating, however, particularly an
ordinary meal, he has feelings of uneasiness and distress, and
rumbling and distention in the upper part of the abdomen. He
has never had any severe pain, but a sense of uneasiness when the
stomach is full and occasionally a griping pain. Ever since the
attack of diarrhq@a following the influenza he has had obstinate
constipation. There has been persistent loss of weight, from a
hundred and ninety to a hundred and forty-five pounds. Though

 
16 THE DIAGNOSIS OF ABDOMINAL TUMORS.

attending to his business, he is at times very weak and feeble,
and feels that he has lost a great part of his former vigor.

Present Condition.—Thin, not extremely emaciated, not ca-
chectic; color of mucous membrane good. Abdomen a little
below level of costal margin; marked fullness in epigastric and
umbilical regions, leaving a definite furrow along right costal
margin. During observation distention becomes much more
marked, and at intervals the outline of the stomach is unusually
distinct. Waves of peristalsis pass actively from left to right,
and the lower limit of the stomach is seen to he at least a tin-
ger’s breadth below the navel. To the right it extends almost
to the costal margin opposite the tenth rib. The peristalsis is
unusually active, waves passing every few moments, and during
their passage the stomach walls become hard. Gas can be
heard bubbling through the pylorus.

Palpation.—Every where soft; no special resistance except
over the stomach itself when in contraction. The pylorus can
be felt in the parasternal line at a point midway between the
navel and the tip of the tenth costal cartilage. Here is a firm
thickening about the size of a large walnut. Though this is a
little far out and low for the situation of the pylorus, yet the
stomach is a good deal depressed and the whole pyloric pouch
lies to the left of the middle line. There is nothing special to
be felt along the line of the lesser curvature. There is a little
resistance between the costal margin and the navel, which is
probably due to the right lobe of the liver. Gas is not felt to
bubble through this pyloric mass, nor does it seem to vary in
resistance and hardness.

January 22d.—Patient came into the private ward under
my care, chiefly to determine whether an operation, which had
been suggested by Dr. Salzer, was advisable or not. On admis-
sion, the stomach was very much in the condition mentioned in
the previous note. Ewald’s test breakfast, withdrawn an hour
after, yielded two hundred and fifty cubic centimetres of a
clear, slightly yellow fluid containing partially digested bread.
The odor was sour; the tests for free hydrochloric acid were
negative.

He had at times a great deal of distress, owing to the active
character of the peristaltic movements. He was placed on a
diet of milk, beef juice, and egg albumin, small quantities
being given every two hours. The stomach was thoroughly
emptied night and morning.

Within a few days this treatment made the greatest change
in the condition of dilatation; the organ reduced greatly in
size, the waves of dilatation were no longer evident, and he
felt much more comfortable. The reduction in the dilatation
TUMORS OF THE STOMACH. 17

made a very marked change in the tumor mass above men-
tioned. Instead of a small, nodular body to be felt far over to
the right, there was now evident to the right of the parasternal
line, in the epigastric region, a large, solid mass of the size of
an egg. In spite of the improvement in the local condition, his
general strength failed with rapidity, and on the 28th it was
thought advisable for him to be removed to his home, where he
died early in March.

Case IX. Nodular Tumor Mass in the Region of the Pylorus ;
Dilatation of the Stomach.—Rachel C., aged sixty-two years, ad-
mitted February 13th, complaining of a lump in the right side
of the abdomen. Mother died of pulmonary tuberculosis.

With the exception of pulmonary hemorrhages, of which
she has had in all nine attacks since her nineteenth year, and
an attack of transient left-sided hemiplegia of five days’ dura-
tion, she has been a healthy woman, Has had ten children.
No special history of dyspepsia.

On September 15th she had for the first time severe pain in
the upper part of the abdomen, which continued for nine days,
and was intense enough to keep her from sleep. Soon after this
she felt a lump in the right side, which has all along been pain-
ful and associated with a dragging feeling when she lies on the
left side. At intervals she has a puffed, distended feeling in
the abdomen with diffuse soreness. Her appetite has been
poor, and she has had nausea sometimes after eating, and has
several times at night had attacks of vomiting. She has had no
swelling of the legs. The urine is clear; no special diminution
in amount. Patient is emaciated, sallow : ; tongue coated, white ;
pulse is 88, regular, tension a little inoreased. There is a sott
systolic murmur at the apex; with the exception of hyper-
resonance in the front and sides, and exaggeration and pro-
longation of the expjratory murmur, there are no changes to be
noted in the lungs.

Abdomen.—There is a slight prominence in the right hypo-
chondrium, and on inspiration a tumor mass can be seen to de-
scend in the parasternal line. On palpation in this region,
just below the costal margin, there is a hard, rounded mass, the
outline of which can be pretty clearly made out toward the
median line, but toward the right it is apparently continuous
with the margin of the liver. It is superficial, nodular, hard,
and very painful. On deep inspiration, it descends almost to
the level of the navel, and the fingers can be then placed be-
tween the tumor and the liver margin, and it can be held down.
Gas can be felt bubbling through the mass. On percussion,
there is a flat tympany. When quiet and in repose no peristal-
sis can be seen as arule. When the patient turns over on the

2
18 THE DIAGNOSIS OF ABDOMINAL TUMORS.

left side the mass falls forward and to the Jeft, and can readily
be grasped between the hands. The epigastric region jis a little
flattened ; sometimes distinctly depressed. The lower umbili-
cal region, on the contrary, is full.

On dilatation with tartaric acid and bicarbonate of sodium,
the stomach is seen to be depressed and dilated. The lesser
curvature passed just at the level of the navel; the greater
curvature at a distance of seven centimetres below. Waves
of peristalsis were then seen in the stomach walls passing from
Jeft to right, and sometimes the organ showed an hour-glass
contraction.

The test breakfast showed the presence of the organic acids,
absence of free hydrochloric. Material washed out was dark in
color and smelled very sour.

The liver is not enlarged; the spleen not palpable; no en-
jargement of the external glands.

Case X. Hnormous Dilatation of the Stomach, forming a
Visible Tumor ; Ridge-like Thickening in the Pyloric Region.—
Emma H., aged thirty years, colored, admitted (to the gynecolog-
ical ward and transferred) April 28, 1893, complaining of swelling
of the abdomen, nausea, and vomiting. Nothing of any moment
in the family history. She was healthy until about eight months
ago, when she began to have dyspepsia and distress after eat-
ing. She has not infrequently had attacks of vomiting. Lately
she has been much nauseated after eating, and has had pain
and swelling of the abdomen, with much belching. Six months
ago she brought up food mixed with blood. Lately she has
only been vomiting food. She has lost in weight within the
past year, and has noticed that she passes much less urine than
formerly. The patient is moderately wasted; weight, a hundred
and five pounds; lips and mucous membranes of good color.
Temperature normal ; pulse, 112. The abdomen is flaccid, but
a little prominent, and, on inspection, very marked waves of
peristalsis are seen passing from left to right. They occupy a
considerable area, extending from just below the costal margin
to midway between the navel and the pubes. As they pass,
gbe akin is lifted in very definite prominences. On palpation,
there is very marked succussion, and, on changing from side to
side, the dullness alters as the fluid sags with the change of
position. On inflating the stomach, it is found to occupy nearly
the whole abdomen. The tympany begins above at the fifth
rib and extends to the pubes. The lesser curvature is seen just
above the umbilicus. There is very prominent distention in the
pyloric region, and the gastric sympany extends nearly to the
right anterior superior spine. No nodular masses or tumor
could be felt. With the stomach tube a large quantity of a green
TUMORS OF THE STOMACH. 19

ish-yellow liquid with remnants of food was removed. When
the’ stomach was emptied there then could be felt midway be-
tween the umbilicus and the
costal margin a ridge-like mass
about the size of the thumb,
which was freely movable and
descended with inspiration, and
which subsequent examinations
showed was extremely variable,
not being palpable when the or-
gan was very greatly distended.
With lavage and feeding at
short intervals the patient im-
proved very much and_ the
stomach reduced very materi-
ally in size and she gained in
weight,

From the prolonged history
of dyspepsia and the fact that
she had on several occasions
vomited blood, this was very Fig. 8.—Outline of the stomach in
probably an instance of dilata- Case X, showing the position of
tion from the cicatrization of an the ridge-like mass,
ulcer; and the small, elongated
nodular thickening in the region of the pylorus also suggested
this condition.

 

 

General Remarks on the Diagnosis of the Tumor caused
by Dilated Stomach.—Inspection gives most important in-
formation, the value of which may be gathered from the
fact that in these ten cases the diagnosis was made de visu.
Bear in mind, in the first place, that a dilated stomach may
occupy every region of the abdomen except the upper part
of the epigastric and may form a very prominent tumor.
The photographs (Figs. 9 and 10) which I show you illus-
trate this very well. They were taken during life from a
woman, aged sixty-five years, who was admitted to the
hospital complaining of attacks of vomiting which had per-
sisted for nearly two years, during which time she had be-
come gradually emaciated and very weak. She had at inter-
vals brought up enormous quantities of fluid. On inspec-
tion, the abdomen was greatly distended, particularly on
the left side and in the umbilical and hypochondriac re-
gions. It was uniform, but at intervals there were slight
20 THE DIAGNOSIS OF ABDOMINAL TUMORS.

irregularities and elevations ; no marked waves of contrac-
tion. On palpation, the abdomen was everywhere soft, ex-
cept at a point to the right of and just below the navel,
where there was a hard, resistant mass. At first it seemed
scarcely possible that the entire abdominal distention could
be due to a dilated stomach, but the reduction in size after
vomiting and after lavage, the depth to which the stomach
tube could pass, and the irregular waves of protrusion left
no doubt that the distention was due to an enormously di-
lated stomach. She died November 16,1889. The photo-

 

Fra. 9.—Protile view of fhe abgomen of Sarah A., aged sixty-five, showing the
tumor forme by the dilated stomach. From a photograph taken during
life.

graphs (Figs. 9 and 10) show the profile and front views
taken during life, and Fig. 11, from a photograph taken
after death, shows the position of the organ and its enor-
mous enlargement. There was cancerous stricture of the
pylorus.

The most prominent distention is usually in the left half
of the umbilical region, but it may be chiefly below the navel.
A definite stomach contour may be seen very plainly in
many instances of dilatation from stenosis of the pylorus.
At intervals, during the contraction of the stomach walls, the
outline of the greater curvature descends on the left side,
curving at a level of the anterior superior spine, and pass-
ing to the right at a variable distance above the pubes,
TUMORS OF THE STOMACH. QI

sometimes not more than three or four centimetres, some-
times midway between the pubes and the navel. Curving
upward, it ends either in the left lumbar or more frequently
in the right upper quadrant of the umbilical region, some-
times appearing to pass beneath the right costal margin.
The lesser curve is frequently much more distinct, the line
passing vertically parallel with the left border of the ster-
num or in the parasternal line, curving to the left of the

 

Fig. 10.—Tumor of the abdomen caused by a dilated stomach ; case of Sarah
A. From a photograph taken during life.

navel, and often during the contraction of the organ form-_
ing a very well marked, sharply defined contour at or a lit-
tle below the level of the navel. I have found the greatest
surprise expressed by practitioners that the stomach should
be so low, that even the lesser curvature should be below
the level of the navel; but this is frequently the case in ex-
treme dilatation. In the first place, then, the outline of
the organ may give to you at a glance the diagnosis. Sec-
ondly, inspection is of the greatest value in determining
the presence of peristalsis. Though enormously stretched,
992 THE DIAGNOSIS OF ABDOMINAL TUMORS.

there is hypertrophy of the muscular coats and great in-
crease in the activity and frequency of the movements. In
all of the cases they were present. The movements are of
two kinds, which may be seen together or separately : First,
peristaltic waves, passing slowly from left. to right, more
rarely antiperistalsis, from right to left. The mere ex-

 

Fig. 11.—Showing the position and size of the stomach in Sarah A.
From a photograph taken at the autopsy.

posure of the abdomen to the cool air is usually sufficient to
excité them. Sometimes the stimulus of palpation is re-
quired, or the flapping of the skin with a wet towel. Dur-
ing the passage of these waves the outline of the organ be-
comes evident ; sometimes, as already noted, the greater and
TUMORS OF THE STOMACH. 93

lesser curvatures are plainly to be seen. Sometimes, too,
as the waves reach the pyloric region a tumor mass may be
rendered visible or made more prominent. The stomach
may be so enormously dilated that the walls are in a condi-
tion of paralytic distention and no peristaltic waves are
seen, as in the case from which Figs. 9 to 11 were taken.

A second variety of movement to be seen in a dilated
stomach consists in a slowly performed irregular protrusion
here and there of the stomach wall, which lifts the skin of
the abdomen in a hemispherical boss or prominence.
This may develop at any point, more frequently toward the
greater curvature. They usually oceur with the peristaltic
waves and in combination may throw out in bold relief the
contour of the organ, sometimes also giving to it a some-
what hour. glass shape, owing to corresponding depressions
about the middle of the greater and of the lesser curva-
tures. The upper depression is seen in Fig. 1. These
irregular protrusions may be seen in enormously dilated
stomachs, in which the peristaltic waves are no longer visi-
ble, as in the case just mentioned, of which I have shown
you the photographs. Let me again emphasize the value
of inspection by reminding you that of the thirteen in-
stances, in ten the diagnosis was manifest on inspection
alone. ‘

Palpation.—Four points may be determined by this.
procedure. The existence of the splashing sound or suc-
cussion, the clapotage, which is always present, and which,
though in no way diagnostic, yet is of value in connection
with a prominence in the left flank and lower umbilical
region. It is of use also in determining the lowest level of
the organ. With the hand on the abdomen, as the peri-
staltic waves pass, or as the irregular protrusions develop,
you will notice that the organ hardens; and toward the
pylorus, as the wave is followed, there may be an exceed-
ingly firm contraction. After persisting for a minute or so
the muscular walls relax and are again soft and readily de-
pressed. In some instances the muscular contraction at
the pylorus is extremely firm and hard, and the relaxation
beneath the hand reminds one of that of the uterus. A
third point of importance, particularly in palpation of the
pyloric region, is the gurgling of gas through the pyloric
94 THE DIAGNOSIS OF ABDOMINAL TUMORS.

orifice. This is usually very marked when the stomach is
inflated, but it may occur spontaneously and in some in-
stances at regular intervals. In doubtful tumors of this
region this is a sign to which scarcely sufficient attention
has been paid. Its importance will be referred to again in
connection with tumors of the intestines, as in one case in
the series it saved us from a somewhat serious error, And
lastly it is by palpation chiefly that we are enabled to de-
termine the presence or absence of a pyloric tumor. And
here you have to bear in mind that in dilatation of the
stomach the pyloric tumor may be extremely variable,
readily felt to-day, scarcely palpable to-morrow, dependent
very much upon the grade of distention. You will find
this very strikingly illustrated after washing ont the stom-
ach, when perhaps a comparatively small pyloric mass may
be found to be quite large and prominent. When the
organ is extremely dilated, the tumor may be scarcely pal-
pable. This was particularly well illustrated in Case VII,
which was sent to me by Dr. Salzer for an opinion as to
the advisability of a Loretta’s operation. The tumor at the
pylorus, which at the first examination seemed not larger
than a walnut, after thoroughly emptying the stomach was
found to be a solid mass the size of an egg.

Percussion combined with palpation brings out most
clearly the splashing sound, which in cases of extreme dila-
tation may be most evident below the transverse navel line.
The extent of stomach tympany will vary with the position
of the patient. In the recumbent posture it may extend in
the nipple line from the fifth costal cartilage to within two
or three fingers’ breadth of the pubes. In the erect posture
a line of transverse dullness may be accurately defined,
which will sink as the patient is gradually placed in the re-
cumbent position. The extent of stomach tympany varies,
of course, with the amount of fluid contents, and after the
attacks of vomiting in which large quantities of liquid are
brought up it may be very much extended.

In doubtful cases inflation of the organ is a most valuable
method, and is best accomplished by the use of the bicar-
bonate of sodium and tartaric acid, from half a teaspoonful
to a teaspoonful dissolved separately and taken one after
the other, the patient being directed to refrain, as far as
TUMORS OF THE STOMACH. 25

possible, from belching. Inspection may, through thin ab+
dominal walls, at once reveal the distended stomach, dis-
playing active peristaltic movements. The percussion
limits can then be also more definitely defined. Palpation
in the pyloric region may give the sensation of gas bubbling
through into the duodenum. This method of inflation is
more satisfactory on the whole than that of pumping air
into the stomach. When gastric ulcer is suspected these
proceedings should be practiced with great caution or
omitted altogether.

Auscultation gives little information of value. One
hears the sizzling sound of the gas as the contents of the
stomach are churned about; sometimes quite loud gurgling
is heard as the fluid passes through the pylorus, often loud
enough to be heard at a distance. The succussion splash
may be obtained by placing the ear upon the abdomen, and
either shaking the patient or asking him to depress sud-
denly the diaphragm.

The characters of the contents of the dilated stomach,
the general symptoms, and special features I shall not dis-
cuss, as the subject before us is more particularly the form
of abdominal tumor caused by it. To one special point,
however, I may refer, as it is of some moment in the treat-
ment of these cases of dilatation from stenosis of the pylo-
rus. The recent experiments of von Mering show that
water is not absorbed to any extent from the stomach, but
is passed into the intestine, usually at regular intervals, by
a rhythmical opening and closing of the pylorus. Not only
is the resorption of water extremely slight, but hand in
hand with the absorption of the sugars and peptones there
is actually a secretion of water corresponding in some
measure to the amount of substances absorbed. With
these facts correspond closely certain points in the history
of dilatation of the stomach. The organ is never empty,
and even after it is pumped out as much as possible, fluid
will reaccumulate without any liquid having been taken;
and frequently patients will remark in astonishment that
the amount which they have vomited far exceeds in quan-
tity what has been taken by the mouth. This explains
also other striking symptoms in excessive dilatation of the
stomach—namely, the great reduction in the amount of
96 TILE DIAGNOSIS OF ABDOMINAL TUMORS.

urine secreted, the dryness of the skin, and the wasting,
which is proportionate to the degree and persistency of the
dilatation rather than to the nature of the obstruction. Un-
verricht has suggested to supplement this water depletion
by the use of large enemata, two litres daily of salt solu-
tion, the usg of which he states has been followed by
marked improvement in the symptoms, and in some in-
stances by an increase in weight.

And, lastly, there is the question, What conditions may
be confounded with dilatation of the stomach? Nothing,
in reality, if the examination is made systematically and
thoroughly. The physical signs alone are generally suffi-
cient, and, when taken in connection with the general symp-
toms, quite distinctive; thus there was not one of the cases
in this series about which a shade of doubt existed. Yet
mistakes have arisen, some of a remarkable nature, owing
to ignorance of the fact that the dilated organ may be
chiefly to the left of and below the umbilicus. The tumor
has been mistaken for an ovarian cyst (Detroit Lancet,
January, 1880), and even after tapping and the withdrawal
of a dark-colored fluid containing grains of rice, pieces of
potato, bread, meat, etc., laparotomy was performed for
ovarian tumor. The enormous dilatation, as shown in Figs.
9 and 10, with paralytic distention and absence of the
peristaltic waves, might, and indeed did, when the stomach
was very full, simulate ascites, but no serious difficulty
could arise in the differentiation. Tumors of the colon,
causing obstruction, lead to great distention of the large
bowel, in which active waves of peristalsis may be seen
passing from right to left. Usually the abdomen is dis-
tended more uniformly or chiefiy in the epigastric zone, and
intestinal, not gastric, symptoms have been present, and the
inflation of the stomach alone, or, if practicable, combined
inflation of the stomach and colon, will usually give infor-
mation upon which you may base a definite conclusion.

A dilated stomach, causing a prominent tumor of the
abdomen, is almost invariably due to stenosis of the pylorus.
As already mentioned, in all of the cases a tumor was evi-
dent, and in all the condition was that to which the term
dilatation of the stomach is more correctly limited. In rare
instances a prominent tumor may be caused by muscular
TUMORS OF THE STOMACH. we

insufficiency, as it is called, or atony of the stomach, and
occasionally, by change in the position of the organ, the so-
called descensus ventriculi, The differential diagnosis of
these conditions you will find fully given in the special
works #bove mentioned. J may, however, remark that only
in very exceptional instances of atony of the stomach or
of descensus ventriculi are the peristaltic waves seen. In
women who have borne many children, and who have the
extremely relaxed abdominal walls, the condition which
Glénard has termed enteroptosis may be associated with
great depression and enlargement of the stomach. In some
cases the decision is very difficult. I show you here the stom-
ach outlines of a patient who at first we thought had dilatation
of the stomach from pyloric obstruction. The organ reached
nearly to the pubes; the lower curvature was, however, at:
the umbilicus. The vertical measurements of the stomach
were twenty centimetres in the middle line, thirty-one cen-
timetres from the lower border of the eighth costal cartilage
to the middle of Poupart’s ligament, and the transverse
diameter twenty-cight centimetres and a half. Occasionally
there were to be seen peristaltic waves crossing from left
to right. No tumor was at any time to be felt. The liver
was depressed; the kidneys were movable. The examina-
tion for free hydrochloric acid was variable; sometimes it.
was present, sometimes absent. She had had dyspepsia for
some years, and within the year much belching and some
vomiting, but never of very large quantities of Hquid. With
lavage and careful dieting she improved very much, and
gained fourteen pounds in three months. We subsequently
lost sight of her.

JT. Tumor Formep By Conrracrep SToMAcn. —There
are two conditions in which the stomach itself, in a state of
contraction, may form a definite, palpable tumor—tirst, in
occlusion of the esophagus, when the organ shrinks and
may be sometimes felt as a narrow, firm cord, lying below
the margin of the left lobe of the liver; and, second, when
there is diffuse thickening of the stomach walls with con-
traction of the lumen in cirrhosis or in diffuse cancer-
ous infiltration. The following is a remarkable instance
of the latter condition, which presented a well-marked
tumor:
98 THE DIAGNOSIS OF ABDOMINAL TUMORS.

Case XI. Tumor in the Epigastrie Region, consisting of the
Stomach diffusely Injiltrated with Carcinoma.—George U., aged
sixty years, tailor by occupation, German, admitted on April 4,
1893, complaining of indigestion.

Has always been strong and well; had gonorrhea when
twent#; has been a moderate drinker; does not use tobacco.

Present illness began about five months ago with uncom-
fortable feelings in the epigastrium and constipation. Prior to
this he states that he had no dyspepsia. Svon he began to have
much distention after meals, and water brash. He has never
had any vomiting, but he spits up a great deal of mucus. There
is sometimes a sharp pain in the abdomen, but, as a rule, there
is only a heavy, uneasy sensation after eating. In January he
noticed that there was a swelling above the left clavicle. In
March he had one or two attacks of vomiting, and he has been
much troubled with hiccough.

He applied at the dispensary about the end of January, and
a stomach tube was introduced, but it brought up a little
plood. Since his illness began
he has lost forty-five pounds in
weight.

Present Condition. —Consid-
erable emaciation; lips and mu-
cous membranes of good color,
Above the left clavicle the
lymph glands are enlarged and
hard; slightly enlarged above
the right. They are also some-
what enlarged in the inguinal
region. The thoracic organs are
normal.

The abdomen is flaccid, sym-
metrical; a little full, perhaps,
in the epigastric region. On pal-
pation, a ridge-like mass is to

| be felt in the left hypochon-

drium, which extends across the

the tumor mass consisting of dif- middle line to the right side as

fusely infiltrated stomach walls far as the parasternal line. It

in Case XI. _ descends with deep inspiration

as low as the umbilicus. The

lower edge is very distinct and feels somewhat like a rolled

omentum. It can scarcely be separated above from the liver,

the edge of which is just palpable. There isa flat tympany

over the mass. On inflation of the stomach, vomiting occurred
and a good deal of distress.

 

Fig. 12.-Showing the position of
TUMORS OF THE STOMACH. 99

The urine was negative.

On April 2ist the patient had tenderness along the saphe-
nous vein and the calf of the leg, and there was cdema of the
ankle and of the leg. .

The patient left hospital on May 5th, and died two days
afterward at his home, where the autopsy was made by Dr. F.
R. Smith and Dr. F. Fincke, who brought the specimens to
the laboratory. There was nothing of special note in the tho-
racic organs except that there was some adhesion of the layers
of the pericardium.

The peritoneum was smooth. The stomach, intestines, and
mesentery were removed together. The liver was not enlarged,
was a little granular on section, and firm. The omentum was
uninvolved. The stomach was free on its anterior wall, on the
greater part of the posterior wall, and on the greater curvature,
but was closely adherent at the pyloric zone to the contiguous
parts. The organ was reduced in size, measuring in its extreme
length thirteen centimetres; transverse diameter, from four to
five centimetres. It was extremely firm and dense, and the tn-
mor mass which was felt during life corresponded to it, and the
hard, resistant edge corresponded to the greater curvature.
The orifices were not narrowed; the walls were extremely
thickened, from eight to ten millimetres at the cardia, and from
thirteen to fourteen at the pylorus. The thickening was due
partly to the great hypertrophy of the muscularis, but chiefly
to the submucosa, which measured from three to five millime-
tres. The mucous membrane was uniformly smooth, excessive-
ly thin, and showed no erosions or ulcerations.

On microscopical examination, the mucous membrane was
almost entirely deficient. The submucosa was occupied by
large groups of cancer cells between strands of connective
tissue. The layers of the muscular coat were much hyper-
trophied, and, invading the interstitial tissue and sometimes
in the muscular bundles themselves, were numerous cancerous
cells.

The pancreas was firm and hard and uniformly surrounded
by thickened peritoneal tissue, infiltrated in places with cancer-
ous new growth. The substance of the gland itself was normal.
The mesentery was enormously thickened, measuring close to
the root three centimetres. The peritoneum was thickened,
presenting in places flat areas of carcinoma, and the mesenteric
glands were uniformly enlarged and cancerous.

While we regarded this case as one of cancer of the
stomach, we certainly were not aware of its remarkable
character. The tumor so readily felt was thought to be
30 THE DIAGNOSIS OF ABDOMINAL TUMORS.

an infiltration of part of the stomach wall, whereas in
reality it corresponded definitely to the organ itself. The
diffuse infiltrating carcinoma has to be carefully distin-
guished from the true cirrhosis of the stomach, consisting
of fibrous overgrowth. The distinction can, however, only
be made by the microscope, unless, of course, there is
secondary infection of glands and neighboring organs. In
this instance the lymph glands were infected, and I would
call your attention particularly to the fact that the supra-
clavicular glands on the left side were also involved—a situ-
ation in which secondary tumors are sometimes seen in can-
cer of the stomach and of the wsophagus, and in which
their presence may be of the greatest value in diagnosis.
Not only may there be a primary infiltrating carcinoma of
the stomach not distinguishable macroscopically from cir-
rhosis of the organ, but Dr. Welch, in showing this specimen
at the Hospital Medical Society, called attention to an in-
stance which he had reported of secondary infiltrating car-
cinoma of the stomach in a woman, aged forty years, who
had double carcinoma of the ovaries. This beautiful plate,
in Carswell’s Morbid Anatomy, illustrates the condition very
well.

Lxctors II.

Noputar AND Massive Tumors oF THE STomacu.

We considered in the first lecture the cases in which
the tumor was formed by the stomach itself, either in a
state of extreme dilatation or extreme contraction. In
twenty-one cases of the series nodular growths or diffuse
thickening and infiltration were present; in three instances
a massive infiltration. And first let me remind you of one
or two anatomical facts. The only fixed portion of the
stomach is the cardiac orifice, which is covered deeply
by the left lobe of the liver, and externally corresponds to
the seventh left costal cartilage near the sternum. The or-
gan itself varies much in position with the degree of full-
ness or emptiness. The pylorus may be in the middie line,
but when the organ is distended it is from six to eight
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 31

centimetres to the right. It is usually, not always, covered
by the liver. Fully two thirds of the stomach lie beneath
the ribs in the left hypochondrium, and in contact with the
abdominal walls are only part of the body and the pyloric
region. Practically, however, we find that the organ is
often depressed and so enlarged that a much more extended
area than usually stated is exposed for palpation. Tumors
limited to the cardiac orifice can not be felt at all, even
when extensive. Those of the fundus and the posterior
wall, and a considerable part of the lesser curvature, can
only be felt when of large size. Tumors of a considerable
extent of the greater curvature and a large section of the
anterior wall are in accessible situations. It is of interest
here to note the situation of new growths in the stomach,
as determined in thirteen hundred cases analyzed by Pro-
fessor Welch. The distribution was as follows: Pyloric
region, 791; lesser curvature, 148; cardia, 104; posterior
wall, 68; the whole or greater part of the stomach, 61;
multiple tumors, 45; greater curvature, 34; anterior wall,
30; fundus, 19—so that at least three fifths of all tumors
occupy the pyloric region.

The cases which have been under observation may be
grouped into tumors at the pyloric region, tumors of the
body of the stomach, and massive tumors occupying a very
large area of.the organ.

(a) Tumors or THE PyLtoric Recion.—Of the twenty-
four cases, there were seventeen with a tumor mass of some
size or form to be felt at the distal portion of the organ.
In ten of these dilatation of the stomach was present, prom-
inent enough to itself cause a tumor and have been consid-
ered in the first lecture.

Before entering upon a description of the cases an im-
portant question arises: Is the normal pylorus palpable? It
may be answered, I think, in the affirmative, with certain
qualifying conditions. The pylorus forms a definite ring-
like muscular valve, readily to be seen and felt in the ex-
posed organ. Whether, as has been stated, it relaxes and
contracts rhythmically at definite intervals has not been
fully determined, but I would remind you of the statement
made by Beaumont, in his experiments on the movements
of the stomach of St. Martin, that when the thermometer
82 THE DIAGNOSIS OF ABDOMINAL TUMORS.

was placed toward the pyloric orifice it was at first firmly
grasped, and then, by gentle relaxation, allowed to pass.
If the stomach be exposed in a cadaver and a couple of
towels laid upon it, on palpation over them the pyloric ring
is readily felt. So also, I believe, it may sometimes be de-
tected during life. Though normally covered by the ante-
rior margin of the liver, it is freely exposed in a very
considerable number of cases, and when the stomach is
depressed or in a state of atony the pyloric ring is always
below the edge of the liver. In persons with very thin
walls, particularly in cases of enteroptosis in women, palpa-
tion in the boundary of the epigastric and umbilical regions
may discover a small, transversely placed body, varying in
position, with respiration which sometimes gives the im-
pression of a structure alternately in contraction and re-
laxation. In some cases it may even be rolled beneath the
finger. At intervals gas is felt to bubble through it. From
the pancreas, which is also sometimes palpable, it is readily
distinguished by the alternate relaxation and contraction,
and by the bubbling of gas through it. The condition is
one of some importance, as it may lead to the suspicion of
gastric cancer. Thus I saw with Dr. Salzer, in September,
1892, a woman aged thirty-two, a chronic dyspeptic, but
who lately had had very severe symptoms, and had lost
rapidly in weight, having fallen from ninety-five to sixty
pounds. At the junction of the epigastric and umbilical
regions, a little to the left of the middle line, there was a
soft, cylindrical structure, which descended with inspira-
tion. Its transverse extent was not more than three or
four centimetres. It hardened definitely under palpation.
Gas was felt escaping through it. The patient was, of
course, extremely emaciated, and the discovery of the tu-
mor, together with the pronounced stomach symptoms, led
to a suspicion of malignant disease. The case was subse-
quently under my care for seven months, and proved to be
an extremely obstinate form of anorexia nervosa; but she
gained in weight from sixty to a hundred and fifteen pounds,
and the improvement continues to date.

I believe that in very thin-walled persons, particularly
those with atony of the stomach, the pylorus, 4. ¢., the ring
and adjacent part, may sometimes be felt as a narrow, tubu-
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 88

lar structure, the distinguishing features of which are the
alternate relaxation and contraction and the bubbling of
gas through it.

Of the seventeen cases, two were instances of cicatricial
thickening and stenosis, and in fifteen there was either a
cylindrical tumor or a nodular mass.

A tumor-like formation at the pylorus may be due to a
number of causes—cicatricial contraction and thickening
about an ulcer, hypertrophy of the pylorus, and cancerous
growths—all of which conditions may lead to stenosis of
the orifice and secondary dilatation of the stomach. Again,
the first part of the duodenum and the pylorus may be in-
vaded by growths from contiguous organs, as in a case to
be subsequently mentioned, in which the tumor in the py-
loric region was caused by invasion of the duodenum by a
cancer of the colon. And, lastly, there may be mentioned
as a cause of dilatation of the stomach, stenosis of the
pylorus by dislocation. Thus adhesions may form between
the gall bladder and the pylorus, and this portion of the or-
gan is drawn up and the orifice narrowed. A remarkable
instance of the kind was operated upon in the hospital by
Dr. Finney in August last.

Tumors of the pylorus are usually, but not always, asso-
ciated with dilatation; thus there were only four out of the
seventeen cases in which the organ was not distended.
The cases of pyloric growths or thickening may be grouped
as follows :

Thickening and Induration from Healing of an Uleer.—
Two cases come in this category—Case X of the series
already given in the first lecture, which presented a very
greatly dilated stomach. There was a ridge-like mass, free-
ly movable, to be felt midway between the umbilicus and
the right costal margin. The prolonged history of dyspep-
sia, the moderate wasting, the fact that she had on several
occasions vomited blood, and the small size of the pyloric
tumor, suggested cicatrization. about an ulcer. In the
following case gastro-enterostomy was performed by Dr.
Finney, and, unfortunately, on the tenth day the pa-
tient died of an acute colitis. The nodular tumor was
very well defined, particularly after the stomach had been
emptied.

3
84 THE DIAGNOSIS OF ABDOMINAL TUMORS.

Cage XII. Dilated Stomach ; Tumor Mass at the Pylorus ;
Gastro-enterostomy ; Autopsy ; Stenosis from Uleer.—Mary G.,
aged twenty-two, colored, admitted on July 29th, complaining
of a “ gnawing in the stomach ” and “ vomiting spells.” Family
history good. Was healthy as a young girl, with the exception
of a slight attack of pneumonia about eight years ago, and ma-
Jaria a year later.

‘Her present illness began last April with loss of appetite
and weakness, and she began to lose flesh. About two months
ago she noticed a lump in the abdomen, which she thinks has
got larger. About this time she began to vomit at irregular
intervals, without any nausea or acid eructations. The attacks
gave her relief, and she says the lump seemed smaller after
them. The vomitus was copious, greenish in color, and watery.
Bowels have been constipated. The feet have swollen some-
times. She has never vomited blood.

Condition on Admission.—Medium-sized, greatly emaciated,
lips and mucous membranes pale, tongue presents a whitish fur.
Pulse 92, regular, of fair volume. With the exception of a soft
systolic murmur at the heart apex, there are no abnormal phys-
ical signs in the thoracic organs. The abdomen is symmetrical,
not specially distended. Tn the right hypochondrium, just be-
low the costal margin and opposite to the cartilage of the eighth
rib, there is a small nodule, apparently the size of a horse-
chestnut, which descends with inspiration and gives the im-
pression of being at the pyloric orifice. It varies somewhat
in position and in firmness; thus the day on which I examined
her (September 1st) it could by no means be satisfactorily de-
termined, although the day before Dr. Thayer had been able to
feel it with the greatest distinctness. On inflating the stomach,
the area of gastric tympany was found to be greatly increased,
extending from the fifth rib above fully three fingers’ breadth
below the umbilicus. During great distention of the stomach
the nodular mass could not be felt. The material obtained
after a test breakfast was mixed with fragments of undigested
bread and curds of milk which had been taken the day before.
Tt has a strong sour smell, suggesting butyric acid. The reac-
tion was acid. The congo and tropwolin tests were negative.
Uffelman’s test gave sharply positive results.

After treatment for some time with washing out the stom-
ach no special benefit followed, and, as the lesion seemed most
probably stenosis from ulcer, it was thought advisable to at-
teropt dilatation. Accordingly, Dr. Finney made an exploratory
examination and found externally much thickening about the
pylorus. He opened the stomach on the anterior wall, and,
exploring digitally, found the orifice much narrowed, partly by
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 85

contraction, partly by polypoid excrescences, several of which
were removed. As it was doubtful whether this would be
sufficient, a communication was made between the stomach and
the jejunum. The patient did very well for ten days, but then
vomiting and diarrhoea set in and the latter became severe and
she died in the third week after the operation.

The post-mortem showed chronic adhesive peritonitis about
the pylorus and over the surface of the liver. The jejunum
was very firmly adherent to the anterior wall of the stomach.
The tumor mass which had been felt during life was the thick-
ened pylorus. When laid open, a large ulcer was found in the
pyloric region with much puckering of the mucosa about it and
cicatricial contraction.

Tubular and Small Nodular Tumors at the Pylorus.—
Next let me call your attention to four cases which have
presented a good deal of difficulty in diagnosis, not as to
the existense of the tumors, but as to their nature. In
three there was a cylindrical, somewhat tubular-shaped
tumor to be felt. In two of them there was evidence of
some dilatation of the organ after inflation, but the symp-
toms in each case were those of chronic dyspepsia, not of
extreme dilatation of the stomach. I will first read you the
report of the cases,

Case XIII. Chronic Dyspepsia ; Cylindrical Tumor of the
Pylorus.—Mr. 8., aged seventy years, was admitted to Ward OC
October 6th, complainiug of dyspepsia.

The patient has been a dyspeptic ever since 1848, and un-
less very careful with his diet had fullness and tenderness in the
epigastrium. He frequently had very disagreeable feelings
after eating, and would vomit or regurgitate the food. In
spite of the dyspepsia, he has always been robust and has never
been laid up in bed. For the past two years the dyspepsia has
been more troublesome and he has frequently had pain after
eating. The gastric trouble increased so much that four
months ago he had to take peptonized milk. There has been
no vomiting, though at any time he could regurgitate the food.
For the past ten months he has lost in weight (as much as
twenty pounds) and in strength, and has been in very low
spirits.

The patient is a well-preserved man for his years, of spare
habit, but neither emaciated nor cachectic. The general physi-
cal examination is negative. The heart, arteries, and lungs are
normal. :

Abdomen flat, on palpation soft, no pain. Four centi-
36 THE DIAGNOSIS OF ABDOMINAL TUMORS,

metres above the navel there is to be felt a ridgelike tumor,
which can be rolled beneath the fingers, and which extends six
centimetres in the transverse direction. On inspiration it de-
scends slightly. It can be moved up and down; the surface 1s
smooth, and firm presenre is not painful, The point of greatest
interest is the remarkable variability in consistence within a
few minutes. At times it ig firm, hard, and ridgelike, and
within a minute it becomes very much softer. Gas can be felt
to bubble through it.

There is no glandular enlargement. After a test breakfast
sixty cubic centimetres of a light greenish fluid, rather slimy
and mucoid, were removed, which gave none of the reactions
for free hydrochloric acid.

Patient left hospital on October 22d, somewhat better, but 1
hear from Dr. H. M. Thomas that he died before Christmas.

Case XIV. Dyspepsia of a Year's Duration ; Cylindrical
Tumor of Pylorus.—Bertha N., aged forty-four, admitted to
ward G, October 28th, complaining of pain in the epigastric re-
gion and loss of appetite.

Father died of tuberculosis ; mother, of hemorrhage from
the uterus. She has had two healthy children.

Her present illness ig of more than a year’s duration. She
has had weakness, loss of flesh, and for several months the
appetite has been very poor. She gives an account of what she
calls spasms, which would appear to be fainting fits at the men-
straal period. After eating she has pain and has to lie down,
and finds relief by pressare on the abdomen. There has been
no vomiting. Lately she has lived principally on milk.

Present Condition.—There is uniform pigmentation of the
face except in one or two spots on the cheeks and chin. The
general pigment over the surface of the body seems to be some-
what increased, particularly on the abdomen and the arms.
She is decidedly emaciated, but the lips are of a red color, and
she has not a cachectic look. The tongue is furred. The ex-
amination of the thoracic organs is negative. The heart sounds
are clear. The superficial arteries are slightly thickened.

The abdomen is flat, somewhat sunken, walls relaxed. In
the epigastrium, alittle below the ensiform cartilage and ex-
tending into the right hypochondriac region, a cylindrical tu-
mor can be felt and rolled beneath the fingers; at intervals gas
can be felt to bubble through it. The inflation of the stomach
shows the organ to be depressed and somewhat dilated.

An hour after a test preakfast there was very little material
obtained. It was acid to litmus paper; no yeaction to congo
paper. On washing out the stomach, two or three lumps of
bread, not digested, were obtained, There was no free hydro-
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 87

chloric acid. Subsequent examinations showed persistence of
this ridgelike mass in the epigastrium, but it varied considera-
bly in position; thus on November 4th it could be felt distinct-
ly to the left of the middle line, and even a ridge beneath the
skin could be seen in this position to descend on deep inspira-
tion.

The patient left the hospital December 22d, and has not
since reported for examination.

Case XV. Dyspepsia for Several Years ; Cylindrical Tumor
of the Pylorus.—M. 9., aged fifty-four years, admitted March
10, 1893, complaining of pain in the stomach. Father died at
sixty-two of pulmonary tuberculosis, of which disease also one
brother died. Mother died at sixty-five of dropsy.

She has always been healthy; married; has three children.
Has been subject to dyspepsia for several years.

Last winter she had a great deal of pain in the epigastrium,
diarrhea, and vomiting of a greenish fluid. She was in hospi-
tal for eleven weeks, but improved, and from July of last year
until January she was perfectly well and could eat any-
thing, but she has been paler and more sallow and has lost in
weight.

The present trouble began about four weeks ago with pain
in the epigastrium and great tenderness. She has had nausea,
but no vomiting. The patient is a small woman, looks ill, com-
plexion very sallow, lips and mucous membranes pale. Tongue
is flabby but clean. With the exception of a soft murmur at
the apex of the heart, examination of the thoracic organs is
negative,

The abdomen is a little full, everywhere tympanitic. There
isa marked depression just below the costal margin on both
tides; no peristalsis visible. Palpation at first caused so much
senderness that the examination was unsatisfactory ; but ag she
drew a deep breath a small nodular mass could be felt descend-
ing beneath the ribs in the parasternal line. In a few days she
was somewhat better, and a more thorough examination could
be made. In the parasternal line, midway between the costa
margin and the navel, there is a cylindrical mass, transversely
placed, which can be rolled beneath the fingers. It is ex-
tremely sensitive; no flatus is felt passing through it, On deep
inspiration, it descends and the fingers can be placed above it
so as to hold it down. On percussion, itis resonant. After
inflation of the stomach there is no marked dilatation of the
organ ; no peristalsis is seen, but the tumor is then not so easily
palpable.

Ewald’s test breakfast, withdrawn fifty minutes afterward,
showed about fifty cubic centimetres of grayish, slimy fluid,
88 THE DIAGNOSIS OF ABDOMINAL .TUMORS.

containing portions of undigested food, and, on testing, no free
hydrochloric acid.

Patient was under observation until May 11th. The tumor
did not change in any way. The pain lessened and she gained
in weight from a hundred and seventeen pounds on admission
to a hundred and twenty-five pounds on discharge.

Case XVI. Nodular Tumor in the Pyloric Region ; Dilata-
tion of Stomach.—J. A. R., Talbot County, Md., seen October 19,
1892, with Dr. Chamberlaine. The patient had been admitted
to Ward ©, November 17, 1891, with the following history :

For ten months he had had occasional paroxysms of boring
pain in the abdomen, coming on usually at night. Six months
previous to admission he had noted a small nodular tumor in
the abdomen, which he says has gradually become larger. He
has had no symptoms of indigestion or special distention of
the stomach after eating; has vomited only twice, on both oc-
casions, he thinks, caused by a severe paroxysm of pain. He
has lost about fourteen pounds in the past month. He was a
man of spare habit, but was not anwmic. A test breakfast,
withdrawn an hour after the meal, showed about two ounces
of fluid containing small lumps of partly digested food. Free |
hydrochloric acid was present.

In the abdomen, just above and to the right of the umbili-
cus, there was felt a rounded tu-
mor about the size of an Eng-
lish walnut, freely movable. On
inflation, the stomach tympany
extends two fingers’ breadth be-
low the umbilicus.

The patient remained in hos-
pital for a couple of weeks; had
no special ‘gastric symptoms,
gained in weight, and returned
to his home November 27th.
The case was regarded as one of
tumor of the pylorus, and he
was told if the trouble increased
an operation might be advisa-
ble.

October 19, 1892.—Patient
examined to-day ; has been very
Fie. 18.—Positions into which the much better; entirely free from

can could be moved in Case pain; bas had no vomiting; has

been taking an ordinary diet;
no nausea; no sense of distress after eating. He looks and
feels well.

 
NODULAR AND MASSIVE TUMORS OF THE STOMACI!. 89

The abdomen is a little full in the umbilical region, flat in
the epigastric. It is everywhere soft and painless; nothing
can be felt in the epigastric region. Midway between the
navel and right costal margin there is the same well-defined,
firm, hard nodule to be felt, which is now painless. It descends
with inspiration and can be moved about in the positions noted
in the diagrams, The patient says that it is not nearly so evi-
dent when the stomach is empty. It is prominent enough to
be seen when the skin is pressed over it. It can be pushed far
up under the right costal margin and at first could not be felt,
as it was high in this position and only made to descend by
deep inspiration. To the left it can be pushed beyond the
middle line to a point midway between the navel and the left
costal margin. It is very mobile. On inflation of the stomach
the lower border was found to descend some distance below
the umbilicus—three or four fingers’ breadth—while the lesser
curvature was almost as low as the umbilicus. When the
stomach was inflated the mass could not at first be felt, but
afterward was found a trifle more to the right and not ap-
parently quite so superficial as it was before the distention.
Nearly a year has elapsed since this patient left the hospital ;
in that time the nodular tumor has increased but little in size,
and the patient’s general condition is remarkably good.

In Cases XIII, XIV, and XV the tumor had a definitely
cylindrical shape, and in Case XIII there seemed to be no
question that the tumor wasa thickened pylorus, as marked
variations occurred in its consistence and gas could be felt
bubbling through it. So also in Case XIV similar fea-
tures seemed to indicate clearly that the tubular structure,
so readily felt, represented in reality the thickened pyloric
ring and adjacent part of the stomach. In Case XVI the
tumor was rounded, nodular, and very movable. It did
not vary in consistence and no gas was felt to bubble
through it. It felt very hard and firm. While its local
features seemed to indicate definitely that it was a new
growth, the general condition of the patient after its exist-
ence for eighteen months seemed to be very much against
the view that it was cancer. Scirrhus, however, may de-
velop very slowly indeed at the pylorus, and make very
slight progress within six months. Thus in Case XVII,
on the first admission in September, after an illness of fif-
teen months’ duration, the pyloric tumor constituted a tubu-
lar, sausage-like tumor, which could be rolled beneath the
av THE DIAGNOSIS OF ABDOMINAL TUMORS.

finger. I frequently discussed with Dr. Thayer the ques-
tion whether it was an instance of hypertrophic thickening
of the pylorus or a scirrhus growth, and the time element
seemed to be in favor of the former; but when the patient
returned in April of this year the tumor, which meantime
had increased in size, was found to be a scirrhus. The
hypertrophic stenosis, with which the annular scirrhus of
the pylorus could alone be confounded, occurs in connec-
tion with chronic gastritis, with scars of old ulcers, in con-
nection with a cirrhosis in other parts of the stomach or
intestines, and sometimes with a general sclerosis of the
tissues of the mesentery and peritoneum. It may be im-
possible, for a time, to give a positive opinion, In either
case, however, the condition is serious.

Cases of Large Nodular Growths at the Pylorus.—These
constitute a large majority of pyloric tumors. Most of
the cases have already been described in the first lecture in
connection with the dilatation of the stomach. In some
the tumor itself was visible beneath the skin. The follow-
ing cases are good illustrations of this type of growth. In
one the tumor was an annular cancer, which was removed
by operation :

Cass XVIL Annular Carcinoma of the Pylorus ; Excision
of Growth ; Death ; Autopsy.—Henry M., aged sixty-one years,
laborer, admitted September 30th, complaining of ‘sour stom-
ach” and vomiting.

No history of hereditary disease. Patient has been healthy
and strong, and has bad only a few illnesses. He has used alco-
hol freely, but has not been a heavy drinker.

Present illness began fifteen months ago with an uneasy
feeling in the abdomen and churning sensations, which contin-
ued until he vomited a watery, very bitter fluid, which some-
times had a greenish-yellow color. At first his appetite and
digestion remained good. The uncomfortable feeling after eat-
ing gradually increased, and during the past five months, al-
though his appetite has been good aud he took his regular
meals, vomiting came on about an hour and a half afterward.
He has never brought up very large quantities, and pain has
never been a prominent featare. He has Jost weight rapidly,
and within six months has fallen from a hundred and fifty to
a hundred and fourteen pounds. The bowels have been very
irregular, and he sometimes has had no movements for a week
or ten days, and recently has gone as long as sixteen days.
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 4]

Present Oondition.—Large-framed man; much emaciated,
particularly in the face. The cheek bones are prominent and
the eyes sunken. The mucous membranes are not specially
anemic, and the facies can scarcely be termed cachectic. The
emaciation is marked about the thorax; the skin is smooth and
clean; superficial lymph glands are not involved. The tongue
is a little swollen, indented, and furred.

The abdomen is flat, very much below the level of the cos-
tal margin. There is aslight prominence just to the right of
the navel, and on deep inspiration a ridgelike mass descends
below the point.

On palpation, there can be felt just above and extending to
the right of the navel a firm mass which descends on inspiration
and can be rolled beneath the
fingers, giving one the impres-
sion of a tubular, sausage-like
tumor. On deep inspiration, it
moves down nearly three inches
and can be readily held at the
navel, and then slips away from
beneath the fingers.

The patient was placed upon
a careful diet of milk and egg
albumin, upon which the nausea
disappeared and he became very
much more comfortable. The
examination on the 17th showed
that the elongated mass above
referred to had changed in posi-
tion and lay to the left of and

 

just above the navel. ]

The liver is not enlarged ; Fic. 14.—a, position of the tumor in
the edge of the spleen is not pal- expiration ; 5, in inspiration.
pable.

The patient got dissatisfied with the diet, and left the hos-
pital October 17th, thongh he seemed to be considerably im-
proved.

April 6, 1893.—Patient returned to the hospital, having
had, in the space of nearly six months which has elapsed since
the last note, very marked gastric symptoms and occasional at-
tacks of vomiting of large quantities of fluid. He has lost in
weight, though he does not look much more emaciated than
when he left.

Examination.—Abdomen is scaphoid and the walls held
rather rigidly. Between the ensiform cartilage and the navel
the solid rounded tumor present in September can be felt in the
42 . THE DIAGNOSIS OF ABDOMINAL. TUMORS.

same position, but it appears definitely to have increased in
size. It can be rolled beneath the fingers, and part of it at
least varies somewhat in consistence, becoming. harder and
firmer. The stomach is moderately dilated, and when inflated
with gas shows distinct peristalsis, and then the tumor is not
nearly so evident.

. The advisability of an operation was suggested to the pa-
tient in the autumn, but he refused; now he is anxious that one
should be performed.

The age, the profound emaciation, and the very evident
increase in the size of the tumor suggested cancer rath-
er than cicatricial contraction, with thickening at the py-
lorus; and as the case was a desperate one, and the man’s
condition hopeless, the election of operation was left to the
patient.

On the 11th Dr. Halsted operated and found a solid annular
growth in the pylorus, extending for about seven centimetres,
reaching to the orifice, but not extending into the duodenum.
As there were no special adhesions and no nodules, he pro-
ceeded to resect the growth, which was done successfully. The
operation lasted about two hours, and the patient was very
much exhausted; he rallied well through the night and seemed
very comfortable, but failed rapidly on the 12th and died on
the 13th.

Case XVIII. Cancer of the Stomach; Large Tumor in the
Pylorie Region.—Patrick K., aged twenty-eight years, admitted
to Ward E, January 3, 1893, complaining of pain in the abdomen.
Patient had been an orderly in the hospital in 1889-91, during
which time he was laid up on several occasions—once in Decem-
ber, 1889, with vomiting and diarrhea; again in April, 1890,
with acute gastritis, an attack associated with much pain; and
in April, 1891, he had a sharp attack of amygdalitis. A very
noticeable feature was the persistent anemia, and on severak
occasions in 1889 and 1890 I had examined his blood, which
presented all the characters of a secondary anemia of moder-
ate grade. From his earliest boyhood he has been subject to
nose-bleeding, and has always, he says, been pale.

In October, 1891, be returned to his home in Ireland, and
remained fairly well, but was troubled on several occasions
with epistaxis. He returned to this country last year. Four
months ago he had an attack of pain in the abdomen with
vomiting, and these symptoms have persisted ever since. The
vomiting is chiefly after taking food, and the pain is also most
severe at this time. He has never vomited blood. Bowels.
have been constipated. He has lost in weight, he thinks, as
much as fourteen pounds. He is short of breath on exertion,
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 43.

and when he walks about for any length of time the feet and
ankles swell.

Present Condition.—We is very ansmic, but not emaciated;
his face is full; blood count, 8,000,000; hemoglobin, thirty
per cent.; eyelids a little puffy ;
hands very pale; pulse, 87, soft,
compressible; radials a little
thickened; vessels of neck
throb; the heart sounds are
loud and clear at the apex, the
second very ringing and accen-
tuated at the base; no murmur.
The examination of the lungs
was negative.

Abdomen full and a little
prominent ; on palpation, every-
where soft and painless until
the right epigastric region is
reached. Tere, under the cos-
tal border in the perasternal
line, there is a resistant mass
which extends to the right al- \
most as far as the middle line and Fie. 15.—Situation of the tumor in
to the left as far as the nipple Case XVII.
line, and below at least six cen-
timetres from the costal border. During a deep inspiration the
mass descends and the fingers can then be placed between it
and the costal margin. In the middle line in the epigastric
region nothing is palpable. There is resonance over the above-
described tamor mass. There is no peristalsis apparent; no
gurgling to be felt inthe mass. After dilatation of the stomach
the tympany in the parasternal line was at the seventh rib, and
extended two fingers’ breadth below the navel. The tumor was
pushed far over nearly beyond the nipple line.

A test breakfast withdrawn an bour after gave a hundred
and twenty cubic centimetres of thick, dark-brown fluid, con-
taining undigested food and a few shreds of clotted blood. The
reaction was acid; there was no reaction with congo paper, nor
with the other tests for free hydrochloric acid. Uffelman’s test
for lactic acid was positive; starch test negative. The spleen
was not enlarged; the liver not enlarged. The urine presented
no changes.

The patient failed rapidly, became very anemic, and lost
sixteen pounds in weight within a month. The vomiting was
very troublesome and intractable. No special change took
place in the character of the tumor mass, though as he became

 
44 THE DIAGNOSIS OF ABDOMINAL TUMORS.

thinner it was rather more evident. He died on February 23,
1893. There was no autopsy.

Practically, then, the tumors at the pyloric orifice which
we have been studying consisted of cicatricial thickening
caused by ulcer, possibly hypertrophic stenosis, annular
carcinoma, and large nodular masses. There are one or
two points of general interest to which I will here refer.
In the first place, the tumor is always larger than you ex-
pect from the examination through the abdominal wall.
This has to be borne in mind in a discussion on the advisa-
bility of operation. It is frequently very variable—well and

. plainly to be felt to-day, and perhaps scarcely palpable to-
morrow—variations which depend a great deal upon the
degree of dilatation of the organ, particularly of the por-
tion known as the pyloric pouch, which may cover over
and mask even a large pyloric tumor. Examination in the
knee-elbow position often gives valuable information as to
the relations and positions of a tumor, and should never be
omitted in doubtful cases. The value of careful palpation
with a view of determining whether gas bubbles through
the tumor is of the very greatest importance. The masses
are usually firm, hard, and often of a stony consistence ;
sometimes the nodular masses formed. by the glands in the
neighborhood of the pylorus can be very plainly felt. A
feature in the pyloric tumor which merits special attention
is the mobility. I have already referred to it in Case V,
in which the solid rounded tumor mass could be pushed
beneath the ribs on the right side, far down into the iliac
regions, and far over to the left costal border. So also the
nodular tumor in Case XVI, which I have just read to you,
was extremely movable. I reported a case a few years ago
(University Medical Magazine, vol. i, p. 368) which is of
great interest in this connection :

The patient, aged sixty-five years, was admitted to the
Philadelphia Hospital, October 14, 1888, with chills and fever.
The blood, however, was negative, and it was ascertained that
he had had for some weeks distress after eating, and our atten-
tion was then directed to a more careful examination of the
abdomen. On November 11th the following note was made:
Patient is anzemic and emaciated ; the abdomen flattened ; there
is a prominent projection below the left costal border in the para-
NODULAR AND MASSIVE TUMORS OF TILE STOMACH. 45.

sternal line, reaching nearly to the navel and descending with
inspiration. Palpation reveals a firm, hard mass, occupying the
left hypochondriae region and the left half of the epigastric
region. It is smooth and not painful, and can be moved from
side to side to an extent of two or three inches. Percussion
over it gives a flat tympanitic note; liver dullness not in-
creased; glands in the groin are double the normal size; vom-
ited matters are brownish in color, acid, but contain no sarcine.
The tumor changed curiously in position from day to day; at
one time it was far over in the right hypochondriac region, en-
tirely beyond the middle line, but more commonly a greater
portion of its extent was in the left hypochondriac region. On
several occasions it seemed to have disappeared altogether, and
only a hard, small mass could be felt far over in the left hypo-
chondrium. Patient sank gradually and died November 20th.
When the abdomen was opened no trace of tumor was visible
until the stomach was pulled down and to the right. It was
then seen that the mass hed fallen back into the left hypochon-
driac region below the ribs, where it was completely covered
by the splenic flexure of the colon. The duodenum was curi-
ously elongated and straightened; from the pyloric ring it
measured over two inches as a straight tube. The pancreas.
was also drawn over to the left. The tumor could readily be
pushed to occupy the positions in which it was felt during life.
It involved the anterior wall of the stomach, which, when
opened, presented a large hemispherical mass, involving three
fourths of the circumference of the pyloric region and extend-
ing to within an inch and a half of the ring. The surface of the
mass was ulcerated, and at the base near the greater curvature
suppuration had taken place.

(2) Tumors oF THE Bopy oF THE Stomacu.—Tumors.
of the pyloric region often encroach extensively on the an-
terior wall of the stomach, but I have placed in this category
three cases in which the tumor mass appeared to be more.
in the central part of the organ. In Case XIX the left epi-
gastric region was occupied by a rounded, irregular tumor,
and the patient had had marked gastric symptoms and had
vomited blood. Though there was no question as to the
nature of the growth, it is interesting to note that during
his stay in hospital he gained six pounds in weight. In
Case XX the tumor mass was more extensive and seemed
to involve a Jarge section of the anterior wall of the stom-
ach, forming a very prominent and readily palpable tumor.
46 THE DIAGNOSIS OF ABDOMINAL TUMORS.

In Case XXI a large nodular mass could be felt between
the left costal margin and the navel. It was unusually firm,
and post mortem showed that it occupied more than ten
centimetres of the anterior wall of the stomach.

Cask XIX. Large Tumor of the Body of the Stomach.—
Gustave P., a shoemaker, aged fifty-three years, admitted De-
ember 28, 1892, complaining of pain in the abdomen and back.

Parents died over eighty years of age; one sister died of
cancer of the womb. :

Patient was born in Germany; has been very healthy; has
not been a heavy drinker; and denies lues.

The present illness he dates as far back as eight years ago,
at which time he had dyspeptic symptoms, which persisted for
two or three years; then he remained quite free from them for
about three years, but early in
1890 they recurred. He has
had uneasy sensations after
meals, and belching, sometimes
bringing up acid fluid. During
the past summer he had a good
deal of vomiting, and once in
June brought up dark-brown
fluid, which was said to be blood,
and the next day the same ma-
terial was noticed in the stools.
His appetite is fair, but he is
afraid to eat, and lately has on-
ly been taking liquids. He has
not lost very much in weight—
only about five pounds in the
last six months.

; Present Condition.—Patient

Fig. 16.—Outline of the tumor mass 18 emaciated, pale, and a little

in Case XIX. sallow ; mucous membranes dis-

tinctly anemic. Tongue has a

patchy coating and indented edges, Examination of the tho-
racic organs is negative.

The abdomen is symmetrical, a little depressed below the
costal border ; no peristalsis visible. On palpation, the left epi-
gastric region is occupied by a superficial mass with a rounded,
irregular, nodular surface. It extends sometimes almost to the
middle. line, and below crosses the transverse costal line. To
the left it extends to the nipple line. It isalittle painful on firm
pressure; descends with inspiration. The pulsation of the aor-
ta is transmitted through it. Percussion gives a flat tympany

 
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 47

over the mass. Ewald’s test breakfast, withdrawn fifty-five
minutes after, yielded about seven hundred cubic centimetres of
brownish fluid with a heavy sediment of undigested food; odor
acid. The filtrate turned blue litmus red, congo red to blue, and
yielded a rose-red color with phloroglucin vanillin. Uffelman’s
test negative. The urine was normal, The patient remained up
and about the ward, and with a careful diet was made much
more comfortable. The condition of the gastric juice was
frequently tested; thus on January 4th Ewald’s test break-
fast, withdrawn an hour later, yielded about five hundred cubic
centimetres of sour, yellowish food matter, which gave the
reactions previously noted.

The patient continued to improve, gained in weight from a
hundred and fourteen to a hundred and twenty pounds, and
was in every way more comfortable. He had almost constant-
ly, while in hospital, a little fever, temperature rising to 100°,
sometimes to 101°, every day. No special change occurred in
the position or condition of the tamor mass. He was discharged
February 27th, and has not since been heard from.

Case XX. Tumor of the Body of the Stomach.—_N. R., aged
sixty-nine, shoemaker, German,
came to this country in 1872.
Admitted March 13th, com-
plaining of loss of appetite,
nausea, and vomiting.

Patient was sickly asa child.
Six years ago he had a fever
which kept him in bed for three
weeks. He had been a moderate
drinker; denies syphilis. Has
not been a dyspeptic. ,

Present illness began before
Christmas with pain after eat-
ing, nausea, and vomiting, the
latter usually a short time after
taking food. The appetite has
failed: and he has lost rapidly in
weight. He has had much full-
ness and distress in the epigas- Fie. 17.—-Area of the tumor mass in
tric region, but no very sharp Case XX.
pain. Of late all these symp-
toms have become aggravated. He has never had vomiting of
large quantities of food. . :

Present Condition—Patient is a large man, still fairly
well nourished. The lips and mucous membranes are pale;
tongue has a thick white coat. Pulse is regular, .64, ten-

 
48 THE DIAGNOSIS OF ABDOMINAL TUMORS.

sion slightly increased the vessel wall sclerosed. Tempera-
ture is normal. Examination of the thoracic organs is nega-
tive.

The abdomen is symmetrical, except that there isa slight.
prominence at the end of the tenth rib on the left side; on
palpation, soft, and nothing is felt until the epigastric region is
reached. In the region indicated in the figure is a mass which
moves freely in inspiration. The lower border is sharp like
that of the liver or spleen; the surface is irregular and some-
what nodular. On percussion, there is a distinct tymmpany over
the mass. On inflation, at there is no abnormal dilatation of the
stomach.

Ewald’s test breakfast given at 8 a.m.; at 9.80 a tube was
inserted. There seemed to be some slight obstruction about
the cardiac orifice, and about fifty enbic centimetres of coffee-
colored fluid removed, together with a very little fresh blood.
There was no'free hydrochloric acid. Microscopically, it pre-
sented fresh blood-cells, blood pigment, and remnants of food.
No enlargement of the lympb glands.

No material change took place within two weeks in the pa-
tient’s condition; he was evidently failing, and he decided to
go home.

Oase XXI. Tumor of the Pyloric Region and Anterior Wall ;
Perforation ; Peritonitis.—August B., aged fifty-eight years,
farm laborer, German, admitted complaining of pain in the ab-
domen, loss of appetite, vomiting, and insomnia. Father died
aged fifty-six, cause unknown ; mother, of drepsy at sixty; one
sister died of cancer of the stomach; no history of tuberculosis
in the family.

Has always been a healthy man; the father of seven chil-
dren, Has been a moderate drinker; denies venereal disease.
Has always had good digestion; never suffered from dyspepsia.

His present illness began four weeks ago with pain in the
abdomen and vomiting, which comes on very shortly after eat-
ing. He has never vomited any great quantities. Though he
does not appear to have had any wuarked stomach symptoms,
during the past six months he has lost in weight from a hun-
dred and sixty-five to a hundred and thirty-five pounds. Pa-,
tient is a medium-sized man, pale, thin, lips and mucous mem-
branes pale, and he looks somewhat cachectic. Thorax is
symmetrical; above the left clavicle one of the lymph glands

‘jg enlarged and hard. Examination of the lungs and heart
negative..

The abdomen is full, particularly in the right epigastric re-
gion. Here, on palpation, a nodular mass can be felt midway
between the costal margin and the navel. It is flat and extends
NODULAR AND MASSIVE TUMORS OF TIE STOMACH. 49

transversely as far es two cubic centimetres beyond the median
line. It is hard, a little painful, and descends with each inspira-
tion. It is resonant on percussion. No peristalsis was felt, no
changes in consistence, and no gas was felt to pass. The stom-
ach tympany begins at the seventh rib in the left parasternal
line and does not quite reach the navel. After inflation of the
organ no peristalsis is seen.

Test breakfast was given and a tube inserted an hour after-
ward. The fluid obtained was dark-brownish, with a sour
odor ; contained organic acids, but no free hydrochloric. The
blood count showed hemoglobin forty-five per cent., and the red
blood-corpuscles about four million.

The patient left the hospital and was readmitted April 12th,
and the following notes were made: He is very emaciated and
looks cachectic. There isa marked prominence in the epigastric
region, just below the ensiform cartilage, and here very slight
irregular movements may be seen. The indurated mass noted
above appears to have increased in size. It lies at the junction
of the umbilical and epigastric regions, and, on inspiration, de-
scends almost to the navel. It is firm and resistant. There is
no peristalsis visible after inflation of the stomach, and no
change in the position of the tumor. Just above the navel in
the linea alba there is to be seen a flattened prominence, which
feels soft and like a little fatty tumor beneath the skin. Patient
became progressively weaker and died June 4th.

Autopsy.—Peritoneal cavity contains nine hundred cubic
centimetres of turbid fluid; fibrinous exudate covers the intes-
tines. There is a large tumor mass to the left of the pylorus,
involving the anterior wall of the stomach nearly to the cardiac
end. Midway between the greater and lesser curves is an oval
perforation, measuring seven by three millimetres, through
which the contents of the stomach can be squeezed. On
opening the stomach, there is a large ulcerated cancer extend-
ing laterally for ten centimetres. The stomach walls in the
neighborhood of the ulcer are much infiltrated and are raised
and in places overhang the ulcer. In the anterior wall there
is the perforation already mentioned. The ulcer does not
extend to the pyloric ring. The glands about the stomach and
pancreas are enlarged. The head of the pancreas is also in-
volved. There are small white tumor nodules on the surface
of the omentum and mesentery.

Death from perforative peritonitis is a not very uncom-
mon complication of cancer. Perforation may also take
place externally. A more common communication is with
50 THE DIAGNOSIS OF ABDOMJNAL TUMORS.

the colon, which in all probability took place in Case XXIV.
A rare perforation in cancer, which I do not see men-
tioned even in the exhaustive article of Professor Welch, is
into the pericardium, which I found at autopsy in a case of
the late Palmer Howard’s, of Montreal. There was, of
course, the most intense pericarditis, and the group of
physical signs of pneumopericardium.

(c) Massive Tumors o¥ THE Stomacn.—No cases are
more difficult to recognize than those in which the walls of
the stomach are extensively infiltrated. You might think
that under these circumstances the diagnosis would be
made with the greatest ease, but in reality they are cases
which require no little care and study. Of the three cases
which I shall narrate to you, in one the diagnosis was easy
and definite ; in one the tumor was so extensive, occupy-
ing such a large area in the left side of the abdomen, that
some doubt existed as to whether it was not associated
with the spleen or the kidney, while in the third there re-
mains a doubt as to the exact nature of the growth.

Case XXII. Cancer of the Stomach ; Prominent Tumor m
the Epigastric Region —H. P. C., aged fifty-seven years, ad-
mitted September 1, 1892, complaining of loss of appetite, pro-
gressive weakness, and irregular pains in the abdomen. Fam-
ily history is good; parents lived to old age.

Patient since childhood bas been healthy; appetite always
good until about six years ago, when he began to have dyspep-
sia, occasional attacks of nausea and eructations, and some-
times vomiting. He appears at this time to have had consider-
able gastro-intestinal disturbance, as he had also diarrhoea, and
became very weak and emaciated—quite as much so, he says, as
he is at present—and the ankles were also swollen. The vomit-
ing and nausea and diarrhoea stopped and he gained in weight,
but his digestion for the past five years has not been as strong
as before the illness six years ago. In June of this year he be-
gan to have feelings of oppression in the stomach, as though he
had eaten a very full meal, but he had no vomiting; once or
twice the food has been regurgitated. A marked symptom at
first was inability to swallow after the second or third mouth-
ful. With these local symptoms there has been loss of appetite
and progressive emaciation. He has lost forty pounds since
June. He has never had any severe pain; only a feeling of
heaviness and distention after eating.

Condition on Admission.—Patient is a large, well-built
man; face pale, and he looks depressed. There is marked
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 51

emaciation. The pulse is of fair volume and the heart’s action
is strong. The temperature during the sixteen days le was
under observation was always a little elevated toward evening,
rising on several occasions to 102°. He had no cough ; respira-
tions quiet.

Abdomen flat, except in the epigastric region, in which it is
alittle prominent. On palpation, it is soft, painless, and just
below the ensiform cartilage, extending across the whole upper
zone, is a firm, resistant mass. Above, it extends to within two
inches of the ensiform cartilage, and the lower margin was
rather more than this distance from the navel. To the left it
passed under the costal margin opposite the seventh and eighth
cartilages. To the right it reached nearly, but not quite, to the
costal margin. There was a distinct concavity above anda
convexity below, and at no time was the mass below the level
of a line joining the tips of the eleventh ribs. It was at times
much more prominent than at others. On palpation, it was
firm, gave an impression of solidity, was quite painless, of uniform
resistance in all parts, and to-
ward the left passed beneath
the costal margin. To the right
it terminated at a much higher
position than is usual for the
pyloric orifice. No movements
were noticed in it, but the hand
placed upon it occasionally felt
distinct gurgling. Everywhere
over it there was, on percus-
sion, modified resonance. There
were no nodules.

At no time during the pa-
tient’s stay in the hospital was
there vomiting, nor could it be
said there was marked distaste
for food. At first he took an or-
dinary diet, but, finding that it
gave a good deal of distress, ye. 18—Area of the tumor in Case
it was replaced by a liquid XXII.
diet of egg albumin and milk,
which agreed very well. Mentally he was very despondent.

Bismuth and soda were at first given an hour or so after
eating, and they relieved promptly the sense of oppression. It
was not thought worth while to distress him with attempts at
lavage or test breakfasts. Patient left the hospital unimproved
on the 19th,

Patient died September 28, 1892. .

 

 

 

 

 

 
52, TIE DIAGNOSIS OF ABDOMINAL TUMORS.

i

Case XXIIL— Unusudlly Large Cancer of the Stomach.—
Mrs. L., aged about fifty years, seen September 12, 1892. The
patient has been a high strung, nervous woman, and has not
been in her usual health for the past two years, complaining
chietly of weakness and ill-defined nervous symptoms. I saw
her a year ago for these symptoms, and at that time made an
examination of the abdomen, which was negative. In June she
was seen by a physician, who tells me that there was a lump on
the left side which be thought was a floating kidney.

During the early summer she was under the care of a New
York quack, who put her upon meat diet and hot water, under
which treatment she appeared to improve. She went north to
a watering place, and, though growing weaker and losing rapidly
in weight, she kept up until August, when, on account of the
swelling of the feet, she consented to go to bed. All this time
she was chiefly on the meat diet, and apparently digested it
very well, as she had no eructations and no vomiting. Subse-
quently she had a more varied diet and complained a good deal
of distention and uneasiness after eating, and on several occa-
sions had regurgitation of food. The lump in the left side had
apparently increased in size, but caused her very little pain, ex-
cept when it was rubbed by the masseuse.

The condition when I saw her was as follows: Profound
emaciation, particularly marked in the face. The mind quite
clear; the voice strong, and the grasp of the hand firm and
good. In spite of great wasting, she did not look cacheetic, and
the color of the lips was good. Pulse 84, of fair volume; tem-
perature normal. Tongue was red with a light furry coat.
Her chief complaint was of uneasy feelings of distention after
food, and of the weakness and prostration. The sleep was not,
as a rule, disturbed, though she had been taking opium supposi-
tories to allay the irregular pains in the side. She lad no
cough; no diarrhea.

The abdomen was a little distended, contrasting with the
extreme emaciation of the thorax. The upper zone was full and
the skin over the left hypochondriac and umbilical regions red-
dened with applications, and these parts looked the most promi-
nent. No peristaltic movements were noticed on inspection.
On palpation, there was felt a large mass occupying the area
shown in the annexed diagram, extending to the right 2°5 centi-
metres beyond the navel and the same distance below. The
edge passed transversely to the left to a point four centimetres
above the anterior superior spine; the edge could then be
followed readily in the line of this spine to the point of the
last rib. Above, it passed beneath the costal margin, and the
upper line reached to within five centimetres of the ensiform
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 53

cartilage. It felt superficial, firm, not tender; below and to
the right the edge was unusually distinct, and just at the navel
there was a slight depression. The hinder edge could be dis-
tinctly felt, and it did not pass
deep into the renal region.

On bimanual palpation, the
mass could be moved slightly.
At the first examination there
was no gurgling to be felt On
percussion, it was flat in the
greater portion of its extent, but
in the right fourth of the mass
it was distinctly resonant.

There were no glandular en-
largements. The blood exami-
nation was negative, with the
exception of a very great in-
crease in the blood plates.

I was not a little puzzled at
first as to the nature of this
tumor. The situation, the flat-
ness, its superficial character, te. 19—The tnmor area in Case
excluded definitely, it seemed, XXIL.

a movable kidney, which would

not fora moment have been considered had I not been in-
formed that a physician in whose judgment I have great confi-
dence had in June pronounced this to be the condition present.
The situation was suggestive, naturally, of an enlarged spleen;
the right edge seemed thin and there was an indistinct feeling
of a notch, but the very superficial, character, the absence of
a definite notch or notches, and, above all, the resonance over
one half of the tumor, seemed inconsistent with this view. A
phantom tumor in a hysterical woman had also been sug-
gested. The large size, the unusual situation, and the slight
character of the gastric symptoms did not favor gastric carci-
noma, suggested, of course, by the profound emaciation and
the existence of a resonant tumor in the left hypochondrium,

The next few days, however, developed additional symp-
toms which made this view very much more likely. On the
12th she had taken six oysters and one on the 18th. On the
15th she had eructations of dark, very offensive material, and
regurgitated one of the oysters in a condition of decomposition,
but undigested. On the 16th she regurgitated the chopped
mneat in a similar condition of decomposition, and a second
oyster which had been very slightly acted upon. The odor of
the materials brought up was intensely offensive. She had also

 
54 THE DIAGNOSIS OF ABDOMINAL TUMORS.

at this time slight diarrhea. The tumor did not show any
material changes, but the area of resonance seemed to vary
somewhat, and, on drinking, gurgling could be distinctly heard
over the mass, and sometimes with the hand upon the tumor
the flatus could be felt.

September 19th.—For the first time the patient to-day had
attacks of actual vomiting, the first at about six in the morning
and the second at noon. On both occasions she brought up
about half a pint of dark, bloody fluid of a most horribly offen-
sive character, having a distinctly fecal odor, as well as an odor
of decomposition. In the material last vomited there were sev-
eral grayish, sloughy masses the size of peas, which under the
microscope did not show any definite structure. The patient
after these attacks was much exhansted.

For a week after this there was vomiting and at intervals
entire inability to take food, and occasionally vomiting of the
same offensive material.

Died gradually of asthenia. There was no autopsy.

The extent of the tumor was due to infiltration of a
very large area of the anterior wall and fundus of the organ.
In all probability there was also extension to the omentum
and to the colon. Evidently sloughing took place in the
tumor mass, and, judging from the fecal odor of the vomi-
tus, perforation into the colon had occurred.

Case XXIV. Large, Massive Tumor in the Epigastrie and
Upper Umbilical Regions.—Patrick C., harness maker, aged
fifty-six years, admitted April 15th, complaining of weakness
and a lump in the left side.

Family history is negative ; father died of accident; mother,
cause unknown, aged fifty-five years.

Patient has never been a very strong man; was hurt when
alad by falling off a load of hay; rheumatism in 1876. Has
always been rather pale; lived a sedentary life; has not been a
heavy drinker; never had venereal disease. Within the past
year he has lost between twenty and thirty pounds in weight.

Present illness began about a year ago with diarrhea, which
persisted for between eight and nine months. Sometimes he
would have four or five stools in an hour, and often as many as
twenty in a day. Never passed any blood; sometimes would
have none for two days. Was always better when he rested in
bed. Thirteen weeks ago he left off work on account of the
weakness, and during this time he has been rather inclined to
constipation. He thinks he has become paler. One day about
three months ago he felt a Jump under the left ribs, and this he
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 55

thinks has increased in size. His appetite has been variable;
lately it has improved somewhat. He has had no nausea and
no vomiting; no trouble in digesting his food. Once or twice
has had slight nausea after taking milk. Tas had no pain;
only a slight heavy feeling in the left side.

Present Condition.—Patient is pale, but not specially emaci-
ated; hair and beard gray; conjunctive pearly white. Tongue
lightly furred. Pulse, 98; vessel wall not sclerosed.

Abdomen a little prominent to left of navel; throbbing of
abdominal aorta marked. Subcutaneous veins not enlarged.
On palpation, occupying the left hypochondriac, the left half of
the epigastric, and the upper and left part of the umbilical re-
gions, is a large flat mass. To the right it extends a little be-
yond the navel, and here the edge can be felt, and at the lower
part the suspicion of a notch. The upper limit is ill-defined.
At the costal margin it is felt to extend a short distance under
the ribs. On deep inspiration the hand can be placed between
the costal border and the tumor, which in this region has a dis-
tinctly rounded globular surface. Above and to the right it
can be separated distinctly from the liver. During inspiration
and on deep palpation no splenic margin can be detected in the
normal position. On prolonged palpation of the tumor, no
changes in consistence can be
felt; no gasis noticed to bubble
through it.

Percussion.—In the middle
line there is no dullness. There
is resonance over the whole tu-
mor. <A modified, flat tympany
is elicited in the left half of the
epigastric region. The stomach
tympany begins in the paraster-
nal line at the upper margin of
the seventh, and extends to two
fingers’ breadth above the navel.
The artificial inflation of the
stomach did not show any
marked changes, and no gas
was felt bubbling in the mass.
The distention of colon with air :
made no change in it. Fig. 20.—Outline of the tumor in

The mass is distinetly, though Case XXIV.
not very freely, movable. It can
not be pushed back under the costal margin, and in fact can
not be moved to the left so that its right margin is beyond the
middle line. It does not extend deep into the renal region, pal-

 
56 THE DIAGNOSIS OF ABDOMINAL TUMORS.

pation in which is normal. The tumor mass is not at all
sensitive. The liver dullness is reduced; in the nipple line not
more than a finger’s breadth; in the axillary line no actual
duliness. Though there is this extreme diminution in the area
of liver dullness, the edge of the organ can be distinctly felt just
below the costal margin. Although the edge of the spleen could
not be felt under the left costal margin, there was at the first
examination definite splenic dullness over the ninth and tenth
ribs in the mid-axillary line. The blood condition shows a pro-
found secondary anemia and is net specially suggestive of a
splenic form. The examination shows only thirty per cent.
of hemoglobin, a little over three million red blood-corpuscles
to the cubic millimetre, and a little over nine thousand white
corpuscles.

The urine is negative, pale, no abnormal deposits, no casts.
He is constipated. Stools formed, and presented no special
features.

A test breakfast showed no free hydrochloric acid.

Comments.—April 19, 1893. It has been suggested that this
mass might possibly be a dislocated and fixed spleen, but the
solidity and firmness, the rounded character of the mass, and
the indefiniteness of the notches (supposed to be felt) were
against this. Moreover, dislocated enlarged spleens are usually
very mobile, and, most important of all, the splenic dullness
was quite marked in the mid-axillary line, and the mass was
every where resonant.

One of the most suggestive features of the case is the onset
of the disease with diarrhea. The situation of the mass, its
fixity, and its size are against tumor of the colon, There are,
on the other hand, instances of malignant disease of the small
bowel in which the tumor mass has attained a very large size,
and in which progressive emaciation, anemia, and diarrhea
have been the main symptoms. The most remarkable case of
this which I call to mind is one which I saw at the General
Hospital, Montreal, with Dr. Molson, for whom T made the dis-
section. A man, aged forty-one years, was admitted on March
4, 1882, with swelling of the feet, vomiting, and constipation.
For six months he had had pains and vomiting and more or less
constipation, with loss of flesh. The patient had general ana-
sarca and shortness of breath. The abdomen was full and large,
and the examination was very difficult on account of the infil-
tration of the abdominal walls, and there was ascites.

The post-mortem showed a large mass occupying the left.
half of the abdomen, from the ribs to the crest of the illum. It
was firmly attached to the left kidney behind, and the colon
and sigmoid flexure were at its left border. It was removed
NODULAR AND MASSIVE TUMORS OF THE STOMACH. 5Y

with the small intestine, and the tumor was found to involve
eighteen inches of the jejunum, which tunneled the mass in a
curved direction. The walls were in places from six to eight
inches in thickness. The lumen was expanded, the mucosa still
evident, presenting blunt valvule conniventes.

In Case XXIV the main portion of this tumor is in the epi-
gastric region in the situation of the stomach. Though firm and
solid, it was resonant, and, in the absence of definite features,
the probabilities seemed to me that it was a large, massive tu-
mor of the anterior wall and fundus. He died in October, with
what symptoms we could not learn, There was no autopsy.

Finally, let me sum up a few leading points for your
guidance, based on the study of the cases we have had un-
der consideration :

1. Though only a small section of stomach is available
for palpation, a very large proportion of all tumors of the
organ may be felt, owing in part to their greater frequency
at the pyloric portion, and in part owing to the frequent
depression of the organ. In every one of the twenty-four
cases a tumor or induration was detected, and it is interest-
ing to note that in the same period of time during which
these cases were observed no instance came to autopsy with
a tumor at the cardia or posterior wall.

2. In a considerable number of cases the dilated stom-
ach itself forms a tumor in the abdomen, characterized by
undulatory peristalsis, sometimes by a definite stomach
contour. In ten cases of the series these features were dis-
tinct enough to render the diagnosis clear on inspection alone -

3. Ina majority of cases no serious trouble is experi-
enced in determining whether or not a tumor is in the
stomach. Excessive mobility of a pyloric growth and ex-
tensive infiltrating masses in the epigastric region were the
only conditions causing trouble in any of the cases of this
series. The more systematic and thorough the examination,
the less is the liability to error.

4, The character of the tumor is rarely in doubt. Large,
nodular, and massive growths are invariably cancerous. At
the pylorus it may be difficult to distinguish between cica-
tricial thickening about an ulcer, hypertrophic stenosis, and
annular scirrhus. It may, in fact, be impossible to decide
the question. The age, previous history, the general and
local conditions—all have to be carefully taken into account,
58 THE DIAGNOSIS OF ABDOMINAL TUMORS.

but, as in Cases XIII, XIV, and XV, it may not be possi-
ble to reach a definite conclusion.

And, lastly, the very serious nature of tumors of the
stomach may be gathered from the fact that, of the twenty-
four patients, eight have already died.

 

Leorore Ii.
Tumors oF THE LIVER.

Ler me remind you of two anatomical points : First,
that the liver extends entirely across the upper portion of
the abdominal cavity, so that tumors may project to either
side of the middle line in front, more rarely into the left
pleura behind ; and secondly, that in women the organ is
frequently so dislocated that a large part of the convexity
is in contact with the anterior abdominal wall; moreover,
the anterior margin may be irregular from the projection,
of tonguelike portions, to which special attention will be
directed in considering tumors of the gall-bladder.

Tumors of the liver are common, and, as a rule, their
nature is not difficult to recognize. 1 shall not here refer
to the simple enlargements of the organ in hypertrophic
cirrhosis, in amyloid and fatty degenerations, or to the
cases of uniform increase in volume met with in cancer
and abscess. I shall call your attention only to those in
which a prominent nodular mass or swelling—a tumor—
was detected, and the nature of which had to be decided.

The usual causes are cancer, abscess, syphilis, hydatids,
and occasionally tuberculosis. The tumors in connection
with the gall-bladder I shall consider separately. Under
certain circumstances the liver itself may form a tumor-
like structure. The cases which have come before me for
diagnosis in the past twelve months are distributed as fol-
lows: The liver itself, one; abscess, four; syphilis, two ;
cancer, four.

I. Tumor FORMED BY THE LivER ITSELF.—L show
you here a little patient (Case XXV) in the upper part
of whose abdomen you can see, even from a distance,
TUMORS OF THE LIVER. 59

a prominent tumor, which pulsates actively at the rate
of ninety per minute, lifting the skin in the epigastric
region. This case has been under our care on and off for
the past two years. She is thirteen years of age, and has
an old mitral-valve lesion from rheumatism, with enormous
enlargement of the heart. The apex beat is, as you see,

Fig, 21.—Pulsating tumor in the epigastric region consisting of the rounded and contracted liver.

 

far out in the sixth and seventh interspaces. The precordia
is very prominent, and there are signs indicating that the
pericardium is adherent. During the past eighteen months
ascites has constantly recurred, so that she is now tapped
60 THE DIAGNOSIS OF ABDOMINAL TUMORS.

once a week, yesterday for the seventy-first time. When
the abdomen is distended nothing is noticed, but after the
fluid is withdrawn this remarkable tumorlike mass appears
in the epigastrium (Fig. 21). On palpation, it is smooth
with a rounded edge, descends with inspiration, and ex-
pands visibly; and under the fingers, during the cardiac
systole, it can be traced to the right, where at about the
nipple line it passes beneath the costal margin. As it pul-
sates there can be felt, particularly at these periods, a to-
and-fro peritoneal friction rub. The pulsation is expansile,
and with the fingers of the left hand beneath the costal
margin in the nipple line, and the right hand over the
prominent mass, the whole structure can be felt to expand
with each contraction of the heart. The situation, the
shape, and the character of the pulsation leave no doubt
whatever that this is a pulsating liver, anot very uncommon
condition in chronic mitral disease, when the tricuspid be-
comes insufficient and allows each systole of the right ven-
tricle to be communicated through the right auricle directly
to the column of blood in the hepatic veins. The deform-
ity of the liver, its cakelike shape, and rounded edge are
caused, I believe, by a perihepatitis, possibly a direct ex-
tension from the pericardium, associated with which there
is a chronic proliferative peritonitis. The recurring ascites
is due partly to the contraction of the liver by the peri-
hepatitis, partly to the chronic peritonitis. A case with
almost identical features was for a long time under my ob-
servation at the University Hospital, Philadelphia.

In two other conditions—neither of which, however,
has been before us this year—the liver itself may form a
tumor and cause no little difficulty in diagnosis: first, the
so-called floating liver, which is most commonly met with
in women (though sometimes met with in men, as in a re-
cent case reported by Kreider, of Springfield, IIl.), and is a
feature of enteroptosis; and, second, the cases of great
shrinkage and deformity of the liver in syphilis, in which
the whole organ may be converted into a cluster of irregu-
lar nodular masses, held together by fibrous tissue, a con-
dition to which the term botryoid has been given from its
resemblance to a bunch of grapes.

II. Asscess or tHe Liver.—Unfortunately for the
TUMORS OF THE LIVER. 61

victims of this serious disease, a prominent tumor mass is
only oceasionally present. Of nine cases of abscess of the
liver seen since the first of September of last year, of which
seven were in the hospital (hospital numbers 5876, 6109,
6745, 7679, 7687, 7738, and 8001), four presented a promi-
nent tumor, the nature of which came up for discussion.

Case XXVI. Abscess of the Liver ; Prominent Tumor ; In-
cision; Recovery.—Dr. X., aged sixty years, admitted Septem-
ber 6, 1892, complaining of weakness and of a painful tumor in
the side. Family history good. The. patient bas been a
healthy man and has had very few illnesses, the only severe one
being typhoid fever, in 1863. The present trouble dates from
April of this year, when he began to have pain in the right
side, fever, and chilly sensations. The temperature sometimes
rose to 103°, and he had a sense of distention and fnlilness in
the right side, but there was no bulging, as at present. No
history can be obtained of any local disease in the gastro-
intestinal tract. He is positive that there had been no diar-
rhea. After a month, during the greater part of which time
he was in bed, the fever disappeared, but the pain and full-
ness in the right side persisted. Toward the end of June he
noticed that there was a prominence below the right costal
margin which has steadily increased. He has lost much in
weight—from 250 to 185 pounds. Since June he has hac at
times slight fever, bat no chills, and only occasional sweating.
The bowels have been irregular, and he has had to take purga-
tives. There has never at any time been jaundice.

Present Condition.—Fairly well nourished, a little pale, but
neither emaciated nor cachectic. Temperature last evening
101°; pulse 104, occasionally intermits. The radials are scle-
rotic. The tongue is red, not dry.

Abdomen.—A large tumor mass fills up the right half, and
is strikingly prominent, as indicated in the figure from a pho-
tograph (Fig. 22). Below, it reaches the transverse umbilical
line; above, it passes beneath the costal margin. To the left
the swelling begins at the middle line. The skin over it is
glossy and a little reddened. The respiratory movements of
the abdomen are slight. On palpation, the entire right side
above the transverse iliac line is occupied by a solid mass which
is resistant except at the most prominent point, where it is soft
and fluctuating. It is nowhere painful on pressure. Below, no
definite sharp edge can be felt. Above, it is continuous with
and not to be separated from the liver. Behind, it occupies the
entire tlank and can be felt on deep pressure below the eleventh
rib. On bimanual palpation it is fixed, not mobile. Percussion
62 THE DIAGNOSIS OF ABDOMINAL TUMORS.

gives a flat note everywhere over the tumor. Liver dullness
begins at the seventh rib and is continuous with that of the
tumor mass. In the parasternal line there is a slight reso-
nance between the margin of the ribs and the tamor. The
spleen is not palpable; area of dullness not increased.

The cervical and inguinal glands are not enlarged. There

 

is a soft systolic murmur at the apex; otherwise the examina-
tion of the thoracic organs is negative, .

As doubt had been expressed by several physicians who
had examined Dr. X. as to the nature of the tumor, an explora-
tory aspiration was made in the most prominent portion and

Fa. 22.—Abscess of the right lobe of the liver forming a prominent tumor (Case XXVI).
TUMORS OF THE LIVER. 63

a grayish-red pus withdrawn, which on examination con-
tained mach molecular débris, pus cells, fatty crystals, but no
amcebee.

On the 10th, under chloroform, Dr. Finney made an oblique
incision over the tumor and opened a large abscess cavity in
the liver, removing more than a litre of foul-smelling pus, darkish
in color; on examination, no amoeba were found. The walls of
the abscess cavity, as felt by the finger, extended beyond the
middie line and upward out of reach beneath the ribs. They
were everywhere hard and firm. The patient reacted well after
the operation ; the temperature fell, and on the sixth day he
was wheeling himself about the ward in a.chair.

Patient left the hospital September 28th, and when
last heard from, six months after the operation, remained
well.

Case XXVII. Adscess of the Liver ; Prominent Tumor in the
Epigastrium.—Mr. W., merchant, aged fifty-four years, seen
September 16, 1893, with Dr. Opie. Patient was a healthy man
until July, 1892. Has had the ordinary diseases, and syphilis
when a young man. Twenty or more years ago he had diar-
rhea for some time.

He dates his present illness from July, 1892, when without
any vomiting or diarrhea he began to have pains in the abdo-
men, which persisted with great severity for about two weeks.
At this time he could not straighten himself without very great
pain, The abdomen was swollen; he had no jaundice. He im-
proved somewhat and went away for about six weeks and
gained a great deal in weight. In September, on his return, he
again had the severe pain and oppression in breathing. He
was at this time under the care of Dr. Opie and Dr. Chambers,
who state that the liver was greatly enlarged. Abscess was
suspected, and an operation was suggested but declined. The
swelling was not so marked as it is at present. He does not
appear to have had any chills, sweats, or indeed much fever.
There never has been jaundice, and it was subsequently sug-
gested that the enlargement of the liver was due to syphilitic
disease. He lost a great deal of flesh during this illness—as
much, he thinks, as fifty pounds. Throughout the early part of
this year he was very much better and gained about twenty-
five pounds in weight. He went away in March, but was not
at all benefited by the change. He lost strength and flesh, and
lately has had a great deal of dragging pain in the side, par-
ticularly if he attempts to lie on the left side. He has had no
diarrhoea and no vomiting.

The patient is a large-framed man, with sallow complexion,
looks ill, and is decidedly emaciated. He was sitting up; no
64 THE DIAGNOSIS OF ABDOMINAL TUMORS.

swelling of the feet; conjunctive pale but not jaundiced. The
pulse is 96, tension not increased ; he has no fever.

The abdomen is enlarged and a prominent tumor fills the
epigastric region and extends toward the left hypochondrium.
The skin over it is glistening, dry, and abraded from counter-
irritation. The superficial veins are not specially enlarged, ex-
cept the left mammary, which is prominent. No enlargement
ef the superficial glands. On palpation, the abdomen is soft
and natural until just at the level of ‘he navel. Here the edge
of the liver can be distinctly felt. To the left the edge passes
obliquely and can be felt to pass
under the costal margin at the
ninth cartilage. To the right the
edge passes obliquely upward and
can be felt at the costal margin
at about the tenth rib. Occupy-
ing the right epigastric region
there is a prominent flat pro-
jection which causes a distinct
asymmetry in this region. It is
not painful on pressure. It is
soft and boggy, but there is no
definite fluctuation. Percussion
shows the liver dullness to be
greatly increased. Above, it ex-
tends nearly to the lower margin
of the fourth rib, crosses the
sternum opposite the cartilage
Fie. 23.—Outline of the liver and of the fifth rib, and is continu-

ae of the tumor in Case ous with the cardiac dullness.

There is a vertical liver dall-
ness from the fourth interspace to the level of the navel in the
parasternal line. Behind, the dullness reaches very high, almost
to the angle of the scapula.

The spleen is not enlarged. The heart is a little pushed up ;
the sounds are clear. The examination of the lungs is negative.

The diagnosis of the condition was not at all easy. The
progressive emaciation and the enormously enlarged liver and
somewhat irregular outline suggested, of course, cancer, against
which, however, was the notable fact that he had improved so
much after a very severe attack last year, in which the liver
was enlarged. The prominent hemispherical mass in the right
epigastric region was suggestive of abscess. Though he had
had no chills and no fever, and although in the history not one
of the usual etiological factors preceding abscess of the liver
was present, the sallow cachexia, the dragging pains on at-

 
TUMORS OF THE LIVER. G5

tempting to lie on the left side, and the prominent doughy
tumor of the liver, made an exploratory examination advisable.
An aspirator needle was thrust deeply into the most prominent
part of the tumor and immediately a grayish and subsequently
a reddish-brown pus flowed out freely.

The patient was removed to the City Hospital, where on
September 21st Dr. Chambers opened the abscess and removed
a gallon and a half of reddish, thin pus, which microscopically
was made up of a granular débris, very few pus cells retaining
their contour; no amcebe. The patient rallied from the opera-
tion, but sank and died in about ten days.

Case XXVIII. Abscess of the Liver; Tumor in the Right
Epigastric Region; Rupture into the Lung.—Simon G., aged
twenty-seven years, admitted July 11, 1893, complaining of
hiccough and pain below the ribs on the right side. He has
always been healthy until five years ago, when he was laid up
in the Hebrew Hospital for six weeks with a severe cough.
His habits are good and he has not had venereal disease.

Three weeks ago his present illness began with irregular
cramps in the hepatic region. He had hiccough for nearly a
week, day and night, and this was in reality his most distress-
ing symptom. He has vomited several times; lost his appetite
and has only been able to take milk and whisky. The bowels
have been constipated and he had never had any severe diar-
rhea. No cough; no expectoration. On July 1st he bad a
very severe chill in which he shook for an hour, followed by
fever and sweating. The following day, July 2d, he felt better.
On the 3d he had a second chill at eight o’clock in the morning,
and shook for an hour. On the 4th he had another chill. He
then went into the Norfolk Hospital, where he was given a
great deal of quinine. He has sweated a good deal; has not
noticed that he has become at all yellow. He has lost soire-
what in weight. At present he complains of the incessant hic-
cough and of pain in the region of the liver.

Present Condition.—Patient is fairly well nourished; face a
little emaciated ; conjunctive slightly tinged. The skin is not
jaundiced. Tongue has a light white fur. Temperature has
not been above 99°5° since his admission; pulse, 84; tension
normal.

On inspection, the thorax on the right side looks a little
fuller than the left, particularly behind in the infrascapular
region. The left intercostal grooves are faintly visible; the right
not at all. The apex beat of the heart is not visible; the per-
cussion is clear on the left side; on the right side in front it is
clear to the upper border of the sixth in the nipple line, and to
the upper border of the fifth in the midaxillary line. Behind

5

o
66 THE DIAGNOSIS OF ABDOMINAL TUMORS

there is defective resonance at the angle of the scapula, shading
quickly into dullness. The respiratory murmur is heard well
on both sides, It is feeble in the infrascapular region on the
right side; no rales; no friction. The abdomen looks natural,
but there is a marked fullness on the right side in the hypo-
chondriae region, and the groove below the costal margin is
completely obliterated. In this region, occupying a space thir-
teen centimetres in diameter, there is a very definite promi-
nence. On palpation, this is resistant and tender, and the skin
at the costal edge seems a little infiltrated. The liver margin
can be felt reaching nearly to the level of the navel and the edge
is rounded. To the right it passes under the costal margin at
the tip of the tenth rib. The left lobe can be felt filling the
upper epigastric region. The liver dullness extends high in the
axillary region, reaches the upper border of the fifth, and there
is here eighteen centimetres of vertical dullness.

The edge of the spleen is
distinctly palpable. The super-
ficial lymph glands are not en-
larged and the examination of
the stomach and intestines is
negative. A rectal tube was
passed, but no amosbe were
found in the mucus obtained.
The blood examination was
negative.

TI aspirated in the paraster-
nal line at the most prominent
point of the tumor, but obtained
no pus.

I did not see this patient
again, but abstract the follow-
ing from Dr. Thayer’s notes:
Although no pus was obtained
Fie. 24.—Outline of the liver and on the first aspiration, there

situation of the tumor in Case :

XXVIIL. seemed to be no question as

to the correctness of the diag-
nosis. Chills occurred on July 14th, 17th, 19th, and 284d,
andjon August 1st, 8d, and 4th. The patient was urged to
have an operation, but declined. The tamor mass remained
prominent, ‘but no definite fluctuation developed. On August
20th the patient suddenly began to cough, calling for the
nurse and saying that he felt something had burst inside him.
He expectorated several spiteupfuls within a short time of
a dirty, yellowish-green pus. The odor was not offensive;
microscopically, it showed degenerated pus cells; no ame-

 
TUMORS OF THE LIVER. 67

be. An interesting feature is that on the following day the
prominence in the right epigastric region had almost disap-
peared. The physical signs at the right back had not changed.
Over the area of dullness the respiratory murmur was simply
enfeebled, and there were a few fine rales on coughing. The
temperature range was from subnormal to 102°; once only,
after a chill, 103-3°. He was repeatedly advised to have an
operation, but declined, saying that he would sooner take his
chances. The expectoration of purulent matter continued, but
in diminishing quantities; thus on the 28d it was one hundred
and twenty cubic centimetres; by the 26th, thirty cubic centi-
metres; and on the 28th, forty cubic centimetres. On August
ist it had fallen to only ten cubic centimetres; on the 3d he had
none, and on the 6th only ten cubic centimetres. No amebs
were found, only pus cells, most of them in a condition of dis-
integration. On August 8th he was taken home by his brother,
the condition not having materially improved, and the tempera-
ture still ranging from 98° to 102°, occasionally to 103°. The
prominent mass on the right side never reappeared. On dis-
charge, the liver flatness began in the fifth interspaze in the
nipple line; the border could be felt five centimetres below the
costal margin. In the midaxilla there were thirteen and a half
centimetres of vertical dullness. In the median line from the
upper limit of flatness to the lower border, determined by pal-
pation, was fourteen centimetres.

Case XXIX, Acute Dysentery ; Abscess of the Left Lobe of
the Liver ; Tumors in the Left Epigastric Region; Incision ;
Death.—Raphael F., tailor, aged twenty-seven years, admitted
August 22, 1893. His family history is good. Patient is a
Russian, and has been in this country only nine years. Has
been always healthy and strong.

Present illness began abruptly about a month ago with an
attack of vomiting and purging; had six or eight stools the
first day. The next day he was rather better and was pretty
well for two or three days. Then he again had vomiting and
much purging. Evidently the attack was one of acute dysen-
tery, as he had numerous stools containing slime and blood,
passed with much straining and tenesmus. He does not think
he had at this time any fever. He has lived almost entirely on
milk, The diarrhoea has continued ever since. On admission,
he was thin ; lips and mucous membranes of good color; tongue
covered with a thick, white coating. The temperature was
97°. The examination of the thoracic organs was negative.
The abdomen was retracted ; patient complained of pain on pal-
pation over the cxcal region. The liver dullness began in the
sixth interspace in the nipple line and extended to the costal
68 THE DIAGNOSIS OF ABDOMINAL TUMORS.

border. The edge was not palpable. We had three stools
within the first twenty-four hours, brownish in color, fluid, and
containing small strings of mucus. In the mucus obtained by
passing the rectal tube numbers of actively moving amoeba
were found. He was ordered large, high injections of sulphate
of quinine—-one to two thousand—and a milk diet. During
the tirst week in hospital there was no special change. The
passages were from four to seven in twenty-four hours. The
temperature was never above 99°, and he seemed to be doing
well. For the next two weeks also he seemed to be very com-
fortable. The temperature between August 29th and Septem-
ber llth was not above normal. The dysenteric symptoms
had improved very much, and from September 9th to the 13th
he had only had one or two movements a day. On September
14th he made, for the first time, complaint of a pain in the epi-
gastric region, and there had been for two days slight fever, the
temperature rising to 100°. There was a little sensiliveness
over the liver in the middle line, but the organ did not appear
to be enlarged. On September 17th there was noticed for the
first time a rounded prominence occupying the left half of the
epigastric region, which moved up and down with respiration
and which pulsated with each heart beat. It extended from
the costal margin in the parasternal line to a little beyond the
middle line. It was rounded,
smooth, firm, but elastic, and
did not appear to fluctuate.
The pulsation was very marked
and seemed almost expansile.
On placing the patient, how-
ever, in the knee-elbow position
the pulsation entirely ceased;
no bruit was heard over it. The
situation of the tumor is indi-
cated in the annexed diagram.
The liver dullness began at the
sixth rib and extended just be-
low the costal margin in the nip-
ple line. In the parasternal line
it did not begin until the sev-
enth rib, and in the middle line
the dullness was about the mid-

Fig. 25.—Outline of the liver and aie of the ensiform cartilage and

situation of the tumor in Case .

XXIX. was then continuous with the
tumor mass on the left side.

In the midaxillary line the dullness began at the seventh rib
and extended to the costal border. The splenic dullness

 
TUMORS OF THE LIVER. 69

could not be obtained, nor could the margin be felt. There was
no increase in the hepatic dullness behind.

On the 18th the temperatare rose to 101-2°, the highest
point reached, and the patient had no chills, but was sweating
profusely. The tumor was more prominent; was very tender,
but there were nosigns of fluctuation. The diagnosis of abscess
of the liver was made and the case was transferred to the sur-
gical wards. Dr. Finney operated, found the peritoneum ad-
herent to the liver, and opened a superficial abscess in the left
lobe. About seventy-five cubic centimetres of thick, yellowish-
green pus were evacuated, in which amcebe were present.
The patient stood the operation very well, but he became pro-
gressively weaker. The temperature never rose above 101°5°.
He died on the 24th.

The situation of the palpable tumor in liver abscess is
well illustrated by these four patients. In Case XXVI it
was in the right lumbar and right side of the umbilical re-
gions, entirely below the costal margin. In Case XXVIII
it was in the right hypochondriac region. In Case XX VII
it was median, projecting prominently midway between the
navel and ensiform cartilage; and in Case XXIX it was
entirely to the left of the middle line in the upper quad-
rant of the epigastric region.

In the diagnosis of liver abscess you must take into
consideration the following points:

Antecedent Conditions.—Dysentery is in this latitude by
far the most common, though it was only present in one of
the four cases I have narrated. Of the nine cases, however,
under observation during the past year, dysentery occurred
in six cases. There may, however, be no recognizable
cause, as in Cases XXVI, XXVII, and XXVIII. Bear in
mind that when the patient comes before you with chills and
fever, a sallow cachexia, and an enlarged, tender liver, the
dysenteric symptoms may have entirely disappeared, or
there may be only at intervals slight recurrences. Under
these circumstances a catheter or the long rectal tube
passed into the bowel may bring away portions of mucus
containing the amcebs, associated with the severer form of
dysentery.

Toxie Features.—lrregular fever, chills, and sweats are
rarely absent. The sallow tint of the skin, the progressive
70 THE DIAGNOSIS OF ABDOMINAL TUMORS.

anemia, and the paroxysms of intermittent fever lead very
frequently to a diagnosis of malaria.

Local Symptoms.—Increase in the size of the liver and
tenderness on pressure are the most important. The en-
largement is most frequently of the right lobe, but the
whole organ may be greatly increased in size and extend
below the navel. When the abscess is in the right
lobe the enlargement may be chiefly behind, ascending
high into the right pleura. Prominent bulging of the
lower portion of the right side of the thorax is extremely
common.

And lastly, and what interests us here especially, a tu-
mor mass may develop beneath the right costal margin or in
the epigastric region. The tumor is usually (always when
recent) tender; often develops with rapidity. The rapid
increase in size with tenderness, however, is not to be re-
lied on as characteristic, as I will mention to you in the
fourth of the cases in the cancer series this was a very
marked feature. Fluctuation may be obtained readily
when the tumor mass becomes superficial. The tumor
may persist, as in Case X XVI, for months without very
much change. With or without the presence of tumor,
when liver abscess is suspected, the long aspirator needle
should be freely used.

III. Sypuiuis or tHe Liver.—Of four cases diagnosti-
cated during life as syphilis of the liver, two presented defi-
nite tumors. Diffuse syphilitic hepatitis does not produce
a tumor, but gummata, either in the inherited or acquired
disease, may form tumors in two stages: first, when fresh
and developing, constituting nodular masses of large size,
which may persist for months; and, second, gummata which
have undergone cicatricial contraction and healing may so
fissure and divide the liver by bands of connective tissue that
an extremely nodular, irregular mass may occupy the right
hypochondrium. Of the four patients this year, two died,
but in neither of them were tumors felt. I show you here
a photograph of the liver of one of them (Fig. 26), which
will give you an idea of the extraordinary subdivision of
the organ, an extreme grade of which forms the so-called
“ botryoid ” liver, in which globular masses of normal tissue
are held together by fibrous bands. The other case also,
TUMORS OF THE LIVER. 71

which came to autopsy, had an extremely irregular fliver,
and was of exceptional interest, inasmuch as the recurring
ascites, for which she had been tapped repeatedly, disap-
peared entirely under iodide of potassium, as did Falso
nodes on her shins, In the following cases definite tumor
masses were present and the correctness of the diagnosis in

 

Fig. 26.—Showing the extreme irregularity of a syphilitic liver.

both instances was in a measure borne out by the therapeu-
tic test. In anomalous tumors of the liver it is well to
bear in mind that gummata may form flat or nodular
masses in the epigastric region * which may persist for a

* A case illustrating an error in diagnosis is that of hospital number
5234, Joshua M., aged fifty-four, admitted May 16, 1892, with swelling
of the abdomen and an illness of nearly a year’s duration. The patient
was a large, powerfully built man; had always enjoyed good health,
and denied venereal disease. For nearly a year he had had trouble in
the abdomen, and had twice been slightly jaundiced. The legs had
been swollen, and he had had shortness of breath. The examination
q2 THE DIAGNOSIS OF ABDOMINAL TUMORS.

long time, and which may, under treatment, disappear as
satisfactorily as gummata of the long bones or of the testes.
One of the first private patients who applied at the hos-
pital was a young man aged about twenty-eight years, who
presented just below the ensiform a flat tamor mass evi
dently attached to the liver, the nature of which had been
very much discussed. He was sent to me for an opinion
as to the advisability of a laparotomy. A positive history of
syphilis was obtained and he was urged to have a thorough
course of treatment. I did not see him again for nearly a
year, when, to my astonishment, the tumor had practically
disappeared.

Case XXX. Prominent Tumor Mass in the Epigastrium ;
Disappearance in Four Months under the Use of Iodide of Potas-
sium.—John C., aged thirteen years, seen November 11th with
Dr. Thayer. He bad been in hospital during my absence in the
summer with a tumor connected with theliver. The notes made
at the time are as follows: Admitted July 13, 1892, complaining
of pain in the right hypochondrium.

The father is living and is paralyzed; mother is living and
well; two sisters and one brother died young; has three broth-
ers and four sisters living.

As a child he was well, with the exception of enlarged
glands, which, at about his fourth year, appeared on the right
side of the neck and discharged for nearly three years.

His present illness began about three months ago with pain

showed an cnormously enlarged liver. The whole of the upper part of
the abdomen was filled with a hard, irregular, nodular mass, correspond-
ing to the greatly enlarged liver. The lower border was felt. midway
between the umbilicus and the pubes, There were prominent bosses
on the surface of the liver, and from its great size and irregularity there
seemed to be no question as to the correctness of the diagnosis of sec-
ondary cancer of the organ. No primary disease could be determined,
and there was decided hyperacidity of the gastric juice. The patient
remained in the hospital for a month and gained slightly in weight,
but the liver developed stil] further, and the irregularity on the surface
was more marked. An aspirator needle was thrust in, but nothing but
blood obtained Naturally enough the diagnosis was entered as cancer
of the liver. Dr. E. T. King, of Washington, under date of February
10, 1894, writes that he has Joshua M. under his care at present. He
has a well-marked syphilitic skin eruption, and the liver, still enlarged,
extends nearly to the pelvis. The time element in this case, I should
think, definitely excludes cancer, while the syphilitic rash on the skin
is suggestive in the highest degree that the whole trouble is specific.
TUMORS OF THE LIVER. 73

in the right side, which has continued, and two weeks ago be-
came much worse; the abdomen became swollen, particularly
in the upper zone and to the right side. The feet have never
been swollen nor has he had any swelling of the face. Since
his illness began there has been progressive loss of weight, and
he frequently sweats profusely at night.

Present Condition.—Poorly nourished and not very well
developed lad. Lips and mucous membranes of a good coior.
Skin clear, not jaundiced. Scars on the neck just below the
right ear and one on the episternal notch. The cervical glands
are not enlarged; the inguinal glands are only just palpable.
The epitrochlear glands are enlarged ; there are no nodes, though
about the middle of the right tibia there is a slight roughening.
There are rhagades at the angles of the mouth; the cornes are
clear; the upper central incisors are well formed. Examina-
tion of the blood is negative.

The thorax is somewhat expanded in the lower part, par-
ticularly on the right side. Examination of the lungs and of
the heart is negative.

The abdomen is prominent in epigastric and right hypochon-
driac regions. The hepatic flatness begins in the sixth interspace
in the nipple line and extends two fingers’ breadth below the
costal margin. The epigastrium is filled with a firm, hard mass,
which appears to be the left lobe of the liver or a mass con-
tinuous with it. It extends in the median line within two
centimetres of the umbilicus, and a slight notch can be felt.
The surface is somewhat irregular and a distinct rounded nodule
can be felt a little above and to the right of the navel. In the
nipple line the edge of the liver is difficult to feel, as the ab-
dowinal walls are rigid. The splenic flatness begins at the sev-
enth rib and is continuous with that of the mass in the epigas-
trium, The edge of the spleen is not palpable.

The urine was clear, Jemon-colored; no albumin; no tube
casts. He had slight fever; temperature on admission 100'5° F.,
and every day for a week it rose to 100° F. The patient was
placed upon iodide of potassium, five grain doses three times a
day, increasing rapidly until he took a drachm three times
a day. He improved in weight and gained seven pounds
within a month. The mass in the epigustrium gradually dis-
appeared.

The condition to-day, November 11th, is as follows:

The boy has grown somewhat, though he looks thin. The
tongue is clean; the lips and mucous membranes are of good
color. He has no cough.

He certainly has not a luetic facies, though the scars at the
angle of the mouth are suggestive. The edge of the liver does
74 THE DIAGNOSIS OF ABDOMINAL TUMORS.

not appear to be below the costal border in the nipple line; flat-
ness begins at the sixth rib in the nipple line. Palpation in the
epigastric region is negative un-
til the extremity of the angle is
reached, and here, just below
the tip of the ensiform cartilage,
can be felt a hard, firm ridge
with, in the right xiphoid angle,
a little prominent projection the
size of a walnut. Just to the
left of the tip of the ensiform
cartilage a second prominent but
smaller elevation ean be felt.
The one to the left, when he
draws a deep breath, can be
seen distinctly in the descent of
the liver as a slight prominence
beneath the skin. The edge of
the liver comes about a finger’s
breadth below the tip of the
Fic. 27.—The situation of the tumor ensiform cartilage and fills up

nodules in Case XXX. the entire left costo-xiphoid

angle.

This case is similar in some respects to one reported from
my clinic at the University Hospital by Dr. A. C. Wood,* the
history of which is so interesting that I abstract it here: ‘‘ He
had an eruption on the skin when six months old. Did not
have snuffles. Has always been robust. For several months
back his mother has noticed his abdomen becoming more and
more prominent. The patient has lost flesh of late. Has had
no jaundice. The boy, aged thirteen, is fairly well grown, well
nourished, looks a little pale; abdomen prominent, and on the
right side between the navel and the costal margin there is a
distinct hemispherical swelling about two inches in diameter.
The tumor descends slightly on inspiration. The superficial ab-
dominal veins are not especially dilated. The upper teeth are
not good, but are not notched. He has not a syphilitic facies.

“On palpation, the lower zone of the abdomen is soft. In
the left hypochondriae region the edge of the spleen is dis-
tinetly felt, with its notch at least two fingers’ breadth below
the costal margin. Toward the right bypochondrium a firm,
solid mass is felt, the edge of which is ill-defined below and to
the right. Above, it seems to pass directly beneath the costal
margin in the position of the liver. The tumor is painless.

 

* University Medical Magazine, vol. ii.
TUMORS OF THE LIVER. QS

The liver dullness begins in the midsternal line at the level of
the sixth costal cartilage, in the nipple line at the upper border
of the fifth rib, and is directly continuous with that of the tumor
and reaches to within a tinger’s breadth of the navel. In the
axillary line there is dullness from the upper border of the
eighth to the lower border of the tenth rib. The left lobe of
the liver does not appear to be enlarged. The splenic dullness
begins at the upper border of the eighth rib and extends two
fingers’ breadth below the costal border.

“ Fowler’s solution was prescribed, four minims three times
daily, to be increased by one drop each week. This was taken
at intervals until the middle of January, about five months,
when it became necessary to discontinue it on account of nau-
sea and vomiting. During this time the color of the face had
improved, the tumor had enlarged, and, on deep inspiration,
the margin now reached the navel, and it was rough on the
surface.

“Tn October, 1888, the patient complained of pain in both
tibiee. The pain was thought to be periosteal, and tive grains
of iodide of potassium were ordered to be taken three times a
day. When seen again, two months later, the tumor was more
nodular, the spleen had increased in size, extending three
inches below the costal margin. The general condition of the
patient remained good. He was now given one grain of calo-
mel three times daily, and instructed at the end of three weeks
to intermit for a week. This was continued with similar inter-
missions for about six months, with gradual improvement in
appetite, color, and general health.”

After leaving Philadelphia the boy came under the care of
Dr. A. C. Wood, who reported that he returned to the hospi-
tal in February, 1890, and the mother thought there had been
a slow improvement. There was, however, on the forehead a
small region of necrosis of the frontal bone about the size of a
ten cent piece, which had followed a definite node. The inter-
esting thing is that the hemispherical swelling in the hepatic
region, which was so striking in this case, had practically disap-
peared. I demonstrated this case on several occasions before
my class in the session of 1887-88 and of 1888~-’89, and on
each occasion the hemispherical swelling on the right side, be-
tween the nave) and the costal margin, was unusually distinct—
so much so that it could readily be seen by the students from
the most distant benches of the amphitheater. I confess that
until October, 1888, when there were pains of the tibie, I did
not think the case syphilitic, but regarded it as an anomalous
tumor of the organ. In October, 1888, however, he was given
iodide of potassium and subsequently calomel. Its syphilitic
76 THE DIAGNOSIS OF ABDOMINAL TUMORS.

nature seems to be definitely established by the development of
the gummatous tumor on the forehead, which subsequently
broke down and left a patch of necrosis.

Case XXXL. Syphilis of the Liver ; Convulsions ; Right Hemi-
plegia ; Irregular Tumor over the Left Lobe.—On May 3d J. M.,
aged forty-seven years, returned by appointment to report on his
condition. I had not seen him since the 25th of September of
last year. The case is one of a good deal of interest with refer-
ence to the diagnosis and treatment of syphilis of the liver. I
saw him first in March, 1892.

The patient is a stout man, well built, but looks ten years
older than the age he gives. He isa traveling salesman, and, in
response to an inquiry as to his habits, gave the characteristic
reply that “he took his luck on the road.” He had syphilis in
1866, and was treated for some time. For eighteen months or
more he had been complaining of dyspepsia and irregular pains
in the abdomen, In December, 1890, he had vomiting, and last
March, just a year ago, the pains were very severe—so much so
that be had to have a hypodermie injection of morphine. He
had no jaundice after this attack. He went to the country,
stayed until June, and improved a great deal, but he had there
another severe attack of pain in the abdomen. Through the
summer he lost thirty-five pounds in weight. Jn the autumn
he had an attack of jaundice which lasted for nearly two months
and gradually disappeared. This jaundice set in with pains,
which were very severe. Two months ago, while sitting in his
office, he fell, lost consciousness, had a convulsive seizure, fol-
lowed by left hemiplegia. Gradually the power returned. He
had another convulsive seizure, with loss of consciousness, a
week ago, not followed by paralysis,

When seen, March 24th, he was well nourished, not jaun-
diced. The point of special note was the examination of the
abdomen. The panniculus was thick; the liver was enlarged.
The right lobe felt’ somewhat irregular, but there were no
definite nodules. The gall-bladder was not palpable. In the
left hypochondriac region, emerging beneath the costal border,
was a flat tumor mass, which extended in the parasternal line
nearly to the level of the navel. It was sensitive, firm, felt
about the size of the palm of the hand, and descended with
inspiration. It was superficial, no definite edge could be felt,
and to the right it could be separated clearly from the edge of
the liver (right lobe) in the right ‘parasternal line. On per-
cussion, its dullness could be separated definitely from that of
the spleen.

Of course, the attacks of pain, one of which was followed
by jaundice, were very suggestive of gallstones. On the other
TUMORS OF THE LIVER. TT

hand, the anomalous character of the tumor mass attached to
the left lobe of the liver, the fact that he-had had syphilis, and
that he had had, without obvious cause, two convulsive seizures,
made me suspect that possibly the mass on the liver was syphi-
litic in character. He was ordered thirty grains of iodide of
potassium three times a day.

On the 16th of April I saw him again, after he had had for
a week or more a very severe attack of nausea and vomiting.
The mass referred to was very evident. A feature of interest
was the development, about a month after beginning to take
iodide of potassium, of an acute parotiditis on the right side,
probably secondary to the abdominal disease, such as Stephen
Paget has so well described.

I saw the patient again on September 25th. Ie had had no
attacks, no jaundice, no pains, and had not had a convulsion for
five months. He has taken the iodide at intervals. Lately he
has had an ulcer on one tendo Achillis, which was very trouble-
some, but is now healing. He has gained in weight, has been
able to attend to his work, and looks very well. The tumor
mass which was so perceptible in the left hypochondriace region
has almost disappeared. The edge of the left lobe of the liver
can be distinctly felt.

May 8d.—He reports that he has kept well all through the
winter. He has had no attacks of abdominal pain, no convul-
sions. He has gained in weight; looks well. The condition of
the liver is practically negative. Nothing definite to be felt in
the left lobe, only slight irregularity as it descends in deep in-
spiration.

IV. Cancer or tHe Lrver.—With the exception of
the fibromyoma of the uterus, cancer of the liver may
constitute the largest tumor met with in the abdomen. In
extreme cases, as in the photographs I here show you, the
entire cavity is occupied by the enormously enlarged liver.
The diagnosis is not difficult, particularly in the secondary
cancer with great enlargement of the organ. Cases of pri-
mary cancer, and especially the peculiar form of “ cancer
with cirrhosis,” may be extremely difficult to recognize
A very large proportion of all cases are secondary, and char-
acterized by a very rapid growth, profound cachexia, and
often jaundice. The new growth may be so diffusely scat-
tered throughout the organ that the enlargement is uniform
and the surface is smooth; but more commonly there are
large outgrowths on the surface or at the edge of the liver,
48 THE DIAGNOSIS OF ABDOMINAL TUMORS.

which form prominent tumors of the greatest value in diag-
nosis, Not infrequently, indeed, they project beyond the
surface of the liver far enough to be seen through the thin
abdominal walls, as in this photograph from a case in the
hospital last year (Fig. 28). In a patient with cancer of

 

Fie. 28.—Cancer of the liver, showing the enormous increase in the area of dullness. The shaded
areas show the situation of the visible tumor masses,

the liver (secondary to disease of the cxcum), who recently
died on the surgical side, these masses were of great promi-
nence, as this photograph shows (Fig. 29). These nodules
are known in the older literature as Farre’s tubercles of the
liver, They vary in size from a walnut to an orange; they
“IOA{] OY} JO BDU Jo SaRgVUI IB[UpoU 9q} SULMOTS— 6s “OL

 

 
80 THE DIAGNOSIS OF ABDOMINAL TUMORS.

are usually firm and hard, the edges rounded, and the cen-
ers cupped—a sort of umbilication caused by the fibroid
and degenerative changes goirg on in the central portion
of the mass. Frequently these characters can be deter-
mined on palpation, and are of special importance in diag-
nosis. In the following cases tumor masses were present:

Case XXXII. Cancer of the Liver; Chills, Fever, and
Sweats.—Mrs. S., aged sixty-nine years, seen with Dr. Amanda
Norris on April 380th. Family history good; husband died in
1879 of cancer of the stomach.

The patient bas been a strong, healthy woman. During the
past winter has not been in good health, has been losing in
weight, and has had indigestion. She has kept about, and the
condition was not thought tg be serious until March 4th, when
she had a severe chill with pain in the right side. There was
no cough, no signs of any pleoral or pulmonary trouble, nor had
she any jaundice. The chills recurred very frequently, some-
times every day; she was in bed for three weeks. The fever
rose, and she had heavy sweats. She had also marked gastric
symptoms, and vomited almost every day; never brought up
any blood, and never very large quantities. “She got somewhat
better, and for a couple of weeks was up and about and seemed
improving, and she had no chills. During the past three weeks
the chills and fever have beeu again present, and she has had
vomiting and inability to take much food. The temperature
goes up to 102° and 103°, and the chills are sometimes severe.
The bowels have been constipated; she has never had any jaun-
dice.

Present Condition.—Patient is not cachectic-looking; face
has a grayish, rather anemic aspect. Tongue is slightly furred.
Examination of the thoracic organs is negative.

The abdomen is somewhat full; panniculus moderately
thick ; the upper zone of the abdomen a little prominent. On
palpation, it is everywhere soft on the left side and below. Oc-
cupying the upper umbilical and all of the epigastric regions
and extending to the right in an oblique line toward the ante-
rior superior spine there is a solid resistant mass, which de-
scends on inspiration. It is evidently a greatly enlarged liver.
In the anterior axillary line the edge descends unusually low,
and here, at a short distance from the anterior superior spine,
there is a prominent nodular mass as large as the top of a lemon,
firm, hard, attached to the liver. It gives one the impression
of a secondary nodule. A second mass, not so large, can be
felt just above the border of the liver in the nipple line, and a
TUMORS OF THE LIVER. 81

third at the edge of the liver, a little beyond the left upper
sternal line. The upper limit of the liver dullness is greatly
extended, particularly in the nipple and anterior axillary lines,
The stomach does not appear to be dilated. No tumor mass to
be felt on deep pressure in the left hypochondriae and umbilical
regions; the spleen is not enlarged.

As usual, the chills in this latitude had been taken to indi-
cate malaria, and she had been saturated with quinine for weeks
without any influence. Chills with enlarged liver mean in the
great majority of cases suppuration, either abscess or pylephle-
bitis. Here in a woman the onset with pains and the early
chills suggest, even in the absence of jaundice, that the whole
trouble may depend upon gallstones, and that the chills may
be associated with suppurative cholangeitis.

Chills and fever may, however, occur in cancer of the liver,
and in this case the emaciation, the enlargement of the organ,
and particularly the nodular masses, suggest the presence of a
neoplasm. The chills and fever may be associated with the
rapid growth of cancer, but in the liver the suppuration may
be in some of the large bile ducts, blocked with the neoplasm.
Dr. Norris wrote that subsequently jaundice developed. The
fever persisted, and before her death the emaciation was ex-
treme,

Case XXXII. Large Nodular Tumors at the Edge and
Surface of the Liver.—Mvs. S., aged about fifty years, consulted
me January 24th, complaining of cough, loss of flesh, fever,
and shortness of breath on exertion. There was slightly defi-
cient expansion at the left apex, and a few rales in the supra-
scapular region. An exatination of the sputum showed tuber-
cle bacilli. I did not see the patient again until October 18th
in consultation with Dr. Aaronsohn. She had had pleurisy on
the left side, with some effusion, which had almost completely
disappeared. She had become progressively weaker; had had
some loss of appetite, but no marked gastric symptoms. On
examination of the abdomen, however, there was felt a remark-
able ridgelike tumor extending just below the level of the
navel, with a very hard, everted, and irregular edge, above
which was a sort of shallow groove. The abdomen was much
relaxed and the intestines lay between the abdominal wall and
this ridgelike mass. At first I thought it possibly might be
the omentum curled up and indurated, but ou more careful pal-
pation it was evident that the indurated, irregular edge was
continuous with the liver. The extreme hardness and irregu-
lurity were, of course, very suggestive of cancer, in favor of
which also were the enlargement and the pain on pressure.

I saw this patient again in consultation on the 30th and 31st,

6
82 THE DIAGNOSIS OF ABDOMINAL TUMORS.

and the two weeks which had elapsed had made a very striking
change in the condition of the liver. It was considerably be-
low the level of the navel. The irregularity was very much
more pronounced, and definite nodular masses could be felt.
both at the edge and on the surface. One of these, a little to
the left of the middle line, was at least six centimetres in
diameter, with a rounded edge and a depressed center. The
condition was still a little peculiar and unusual from the fact
that the abdominal walls were extremely relaxed and the intes-
tines lay in front of the liver, so that there was resonance as
high as the costal margin. The growths in the liver were, from
their local character, evidently secondary, and though the pa-
tient had profound anorexia, there was no evidence as to the
seat of the primary disease. She died a few days after my last
visit.

Case XXXIV.—Enlargement of the Liver ; Prominent Mass
in the Upper Umbilical Region; Latent Cancer of the Stom-
ach.—Henry T., aged fifty-nine years, admitted October 4th,
complaining of pain in the abdomen and back. Family history
is good.

Has been a temperate man and has had no serious illnesses.
Three months ago he says he was quite well. About eight
weeks ago noticed that he had occasional pain in the abdomen,
which for the past four weeks has been constant and of a dull
aching character. He only stopped work three weeks ago ; has
lest, he says, thirty pounds in weight in two months. His
appetite is poor; has never had any vomiting; has no nausea.
Food makes no difference in the pain. Two days ago his feet
began to swell.

Patient is a tall man, much emaciated. The skin has every-
where a sallow tint, and the conjunctive are slightly tinged.
Tongue moist, covered with a white fur. Condition of tho-
racic organs is negative. Abdomen much distended in epigas-
tric and hypochondriac regions, especially on the right side.
In the upper part of the umbilical region there is a prominent
mass which is to be seen readily, and which moves up and
down with respiration. On palpation, it is felt to be separated
by a distinct groove from the swelling in the right hypochor-
driac and epigastric regions. The surface is smooth, painless ;
no nodules are to be felt, but on the lower margin which ex-
tends to the navel it is distinctly irregular. The percussion
dullness does not correspond to the edge of the mass, but is
fully a hand’s breadth above it. The upper limit of duliness is
at the fifth rib in the nipple line, and at the seventh in the
midaxillary. The splenic dullness is not increased; the edge
is not palpable.
TUMORS OF TITE LIVER. 83

The urine was dark brownish-yellow and contained a faint
trace of albumin.

There seemed no question at all that this was a liver en-
larged by cancer, but at first the prominent mass in the umbili-
cal region, which seemed separated from the upper part by a
distinct groove, raised a slight doubt; but the profound ca-
chexia, the rapid growth, and the irregular, nodular edge
seemed conclusive. The primary trouble was not evident. The
examination of the rectum was negative. A test breakfast,
withdrawn fifty minutes after, gave fifty cubic centimetres of a
dirty reddish-brown fluid consisting of undigested food, and
showed a great many blood-cells. Free hydrochloric acid was
not present. On the 10th he had been suffering a great deal ot
pain, and following three injections of a sixth of a grain of
morphine at 9 a.m., 3 p.m, and 10 p. m., he became profoundly
comatose, and died at 2 a. m. on the 11th.

The autopsy showed the primary carcinoma to be in the
stomach, at the greater curvature, just eight centimetres from
the cardiac orifice. The liver was enormously enlarged and
weighed five kilogrammes and a half. The prominent tumor in
the upper umbilical region felt during life corresponded to a
new growth in the left lobe of the liver, which formed a pro-
jecting knob ten by ten centimetres in extent. The entire
organ was occupied with small and large secondary nodules,
very little liver substance remaining. The bile ducts were not
affected. There were secondary nodules of cancer in the
pancreas.

The following case is of great interest from the local
character of the tumor masses, which in the epigastric re-
gion were so prominent, soft, and fluctuating that the con-
dition of abscess of the liver was suspected. It illustrates,
too, the importance of obtaining a thorough history.

Case XXXV. Sarcoma of the Liver ; Two Prominent Tumor
Masses in the Epigastrie Region ; Diagnosis of Abscess ; Explora-
tory Laparotomy.—E. K., aged nineteen years, seen September
6, 1892, with Dr. McGill. Condition on visit was as follows:
The most extreme grade of emaciation, particularly of the face.
The skin was bathed in perspiration; pulse, 104, of fair vol-
ume and good tension; respirations quiet; no fever,

On exposing the abdomen, the upper zone is distinctly full,
and two tamor masses are visible in the middle line, the smaller
and less prominent just below the ensiform, and the other, a
larger hemispherical mass, bulges the thin, tense skin between
the ensiform cartilage and the navel. Both rose and fell with
84 THE DIAGNOSIS OF ABDOMINAL TUMORS

the respiratory movements. No glandular enlargements were
visible.

On palpation, the superficial tumor masses were not tender,
nor were there any spots of special sensitiveness anywhere over
the liver. The Jower and larger mass was soft and appeared to
be distinctly fluctuating. The upper tumor was not quite so
soft, and fluctuation could not be obtained between the two.
The apparent fluctuation was also recognized by Dr. Tiffany,
who had seen the patient some days before. A distinct ridge,
like the edge of the liver, could be felt two fingers’ breadth
above the navel and extended to the right, passing at the ante-
rior axillary line beneath the costal margin, at which point
there was a somewhat indistinct irregularity.

The liver dullness began on the midsternum opposite the sixth
costal cartilage, and extended within two fingers’ breadth of
the navel. In the midaxillary line it was at the eighth rib and
the dullness was not increased at the right infrascapular re-
gion.

The condition of the heart and lungs was negative. The di-
gestion was good and he had been taking plenty of nourish-
ment. Lately he had had occasional attacks of diarrhaa.

The history of the case was not very satisfactory. He had
been a fairly healthy lad, but had some indefinite illness this
summer, and had gone out to Colorado with a friend. He was
there on a ranch, and seemed to be fairly well until about six
weeks ago, though he had apparently been losing in weight.
He became much worse after a long ride, and about three
weeks ago his father was summoned and immediately went
to Colorado and brought him home. Since his return the chief
symptoms have been progressive weakness and loss of flesh.
The liver was found to be enlarged, and the tumor masses
above referred to have within the past ten days become very
prominent. There have been no definite chills, though he has
occasional chilly feelings. The temperature has on no occasion
been elevated and not infrequently been subnormal. He has
had heavy sweats, particularly during sleep. No history
could be obtained of any attack like dysentery, though he has
had looseness of the bowels from time to time.

The first glance at the emaciated form of the patient at once
suggested a new growth, but the age, the quick onset, and
more particularly the examination of the superficial tumor
masses and their rapid increase in size, seemed to favor the ex-
istence of abscess. Suppurating hydatid tumor could not be
definitely excluded, though the rapid course was against this
idea; also the profound emaciation which, though rare, is oc-
casionally present, as in the case of an Italian who came under
TUMORS OF THE LIVER. 85

my observation in Montreal.* I suggested the propriety of
aspiration or of an exploratory incision, and this the next day
Dr. Tiffany proceeded to do. I then learned for the first time
that in May, 1891, more than eighteen months ago, the lad had had
disease of one testis, which had been removed, and Dr. McGill
states that on section it seemed to be in a sloughing condition.
He had, however, bruised himself on his bieycle. This fact was
of very special importance in the history of the case, as it
seemed most likely that the liver condition was associated with
the disease of the testis, and from the length of time which had
elapsed since the removal of the organ it rather favored the
idea that the condition was neoplasm. I must say, however,
that the physical examination of the two tumor masses in the
epigastrium led us all to expect fluid, and I should unhesitating-
ly have put in an aspirating needle with the expectation of
withdrawing either pus or a clear fluid.

Dr. Tiffany made an incision four inches in length over the
lower tumor and exposed a large hemispherical swelling in the
left lobe of the liver. There were no adhesions; the superfi-
cial substance had a natural reddish-brown color, and punc-
ture with the hypodermic needle withdrew nothing but blood.
Dr. Tiffany inserted his fingers and examined the upper mass,
which was a second soft enlargement, and on the under surface
of the liver there were several others, leaving no question that
there was a multiple new growth in the organ. The patient
was extremely weak after the operation, but rallied for a few
days.

In this case, as in one or two others which I can call to
mind, I have been led astray by the deceptive, semi-fluctu-
ating character of liver tumors.

Primary new growths in the liver in young men are, of
course, extremely rare, and, taking all the circumstances of
the case into account, it is more rational to suppose that the
lad had a new growth in the testis, which was bruised by
the bicycle, and it was this in an inflamed condition which
Dr. McGill removed in May, 1891.

The presence of tumor masses on the liver is, then, one
of the most distinctive features of cancer of the organ,
more particularly of the secondary form, which constitutes
so large a proportion of all cases. The primary lesion is
to be looked for in the stomach, intestines, urogenital
organs, or the breast. The new growths are scattered dif-

* American Journal of the Medical Sciences, October, 1882.
86 THE DIAGNOSIS OF ABDOMINAL TUMORS.

fusely with large nodular masses on the surface or at the
edge. The rounded margin and cup-shaped depression are
pathognomonic of these secondary cancerous nodules.
The irregular syphilitic liver could alone be confounded
with it, but in this condition there is rarely progressive
enlargement of the organ, and the general features of the
case are those of cirrhosis of the liver.

Tumor masses, as a rule, are absent in the primary
cancer of the organ and in the form known as cancer with
cirrhosis, in both of which conditions the organ may be of
normal size, or even somewhat reduced. Lastly, large,
rapidly growing encephaloid or sarcomatous growths may,
as in Case XXXV, produce prominent tumors evident be-
neath the skin in the epigastric region, and which may ap-
parently fluctuate, due either to the very soft nature of the
neoplasm, or in some instances to hemorrhage.

Leotore TV.
Tumors oF THE GALL BrLappnER.*

Tue gall bladder may be dilated or its walls infiltrated
with a new growth. In a large proportion of all cases
these conditions are associated with gallstones. Of six
cases in which the gall bladder presented either tumor or
enlargement, three were due to gallstones, one to compres-
sion of the common duct by malignant disease, and in two
the walls were infiltrated with cancer.

(2) Ditarep Gatti Brapper.—The organ may form a
small, firm, rounded projection beneath the edge of the liver,
a pyriform tumor of varying size and freely movable, in ex-
ceptional cases a very large tumor reaching to the pelvis, or,
indeed, as in a case reported by Tait, a huge cyst occupying
the greater part of the abdominal cavity. The usual causes
of dilatation are blocking the ducts with caleuli and com-
pression of them by new growths. The greatest dilatation
is associated with obstruction of the cystic duct. Perma-
nent blocking of the common duct does not necessarily lead

* Delivered December 6th.
TUMORS OF THE GALL BLADDER. 87

to very great distention of the gall bladder. The contents
of the dilated organ may be a clear mucoid fluid when the
obstruction is in the cystic duct and very prolonged ;
bile most frequently when the obstruction is in the com-
mon duct; pus or a puriform bile-stained fluid when sup-
puration has occurred, and an albuminous or bloody fluid
in cancer of the walls. I will first read to you the cases in
which the gall bladder formed a prominent tumor. Two
of these were associated with gallstones and one with ob-
struction of the common duct by cancer. The diagnosis,
which seemed perfectly clear, was confirmed in one case by
operation and in another by autopsy. But before I do so
let me call your attention to two monographs, the most im-
portant contributions to the literature of cholelithiasis
which have been made for some years. Professor Naunyn’s
work, Alinik der Cholelithiasis, deals particularly with
etiology and symptomatology, while that of Professor Rie-
del, Hrfahrungen iiber die Gallensteinkrankheit, mit und
ohne Icterus, is of very special value to workers in clinical
medicine, and illustrates in an interesting way the close
interdependence of medicine and surgery. His careful
study of an extensive series of cases upon which he had
operated enlarges in certain directions our knowledge of
the symptomatology of gallstones, more particularly of the
cases without jaundice.

Case XXXVI. Gall Bladder forming a Visible Tumor ;
Operation ; Recovery.—Elizabeth D., Lonaconing, Alleghany
County, Md., aged sixty-two years, seen with Dr. Kelly. She
had been married thirty-eight years; had six children; three
miscarriages; labors non-instrumental, but tedious.

Family history good. Has always been well until the pres-
ent trouble. In December, 1891, she fell against the curbstone
and struck the right side. At the time she felt very little pain,
but remarked that she had had a great ‘“‘shaking up.” Some
time in January, she does not know exactly when, she noticed
a lump in the abdomen which changed in position as she
moved in bed. It has not, she says, got any larger since Janu-
ary. Five weeks ago she one night became jaundiced. She is
positive that the skin was clear one day and the next morning
pretty deeply jaundiced. The stools were clay-colored, and re-
main so. Since then the bowels have been at times loose,
sometimes three or four in a day. The urine became high-
88 THE DIAGNOSIS OF ABDOMINAL TUMORS.

colored; the skin has been itchy, and the pulse rate very slow.
She has lost somewhat in weight; she has had no chills, no
Sever, and no sweating.

Present Condition.— Large, well-nourished woman; the skin
of an orange-green color; tongue clean; pulse, 32; tempera-
tare normal. The abdomen is enlarged and flabby. On the
right side, midway between the costal margin and Poupart’s
ligament, there is to be seen a hemispherical prominence,
which moves up and down with respiration. On palpation the
abdomen is everywhere soft, not painful. The liver can be
felt in the epigastric, right umbilical, and right hypochondriae
regions, firm and resistant, and in the middle line the margin
can be felt about two fingers’ breadth above the navel. In the
right parasternal line a distinct notch can be felt, the separa-
tion probably between the right and left lobes. In the nipple
line the edge reaches to the level of the navel and in the ante-
rior axillary line nearly to the level of the anterior superior
spine. The prominent mass which is seen with such distinct-
ness can be felt a hand’s breadth
below the liver margin; it is
smooth, rounded, resistant, and
as the fingers are pushed be-
neath it there is the impression
of a globular body. It can be
freely moved from side to side,
and changes in position as she
turns to the left. The dotted
line in the diagram indicates the
position when she rolled over on
the left side; the fundus of the
gall bladder then almost reaches
the middle line.

The surface of the liver is
smooth. There are no nodules.
On deep inspiration the spleen
can not be felt; there are no
Fic. 30.-Showing the position of glandular enlargements. There

the gall bladder in Case XXXVI. is a systolic murmur at the apex

of the heart, but the sounds are

clear at the base. The stools are clay-colored; the urine con-
tains much bile pigment.

November 7th—This morning Dr. Kelly made an incision
fifteen centimetres long over the tumor. On opening the
peritoneal cavity the liver looked of a dark greenish-brown
color. Projecting beneath the edge of the right lobe for a dis-
tance of about five centimetres was the rounded end of a dilated

 
TUMORS OF THE GALL BLADDER. 89

gall bladder. The liver substance above it was considerably
atrophied. There were no adhesions. The chief bulk of the
dilatation was beneath the liver, and the dilatation was much
greater than indicated by the portion which could be felt pro-
jecting beyond the edge. One handred and fifty cubic centimetres
of turbid, grayish pus were removed with the aspirator. Cal-
culi could be felt in the cystic duct and at the first portion of
the common duct. After aspiration the gall bladder was care-
fully stitched to the external wound and incised and a large
gall stone removed weighing thirty-eight grammes. The stone
occupied the cystic duct and projected into the common duct.

The points of interest in connection with this case are,
in the first place, the easy diagnosis of dilated gall bladder
on account of the position and character of the tumor. It
seemed most likely, too, that the dilatation and the jaundice
were due to gallstones, though she had never had attacks
of biliary colic. In all probability the cystic duct was
blocked by the large stone as early as December, when she
fell against the curbstone; she is positive that the lump on
the right side has been present ever since that time. The
sudden onset of the jaundice five weeks ago was connected
doubtless either with the moving of the stone into the
common duct or the extension of inflammation from the
cystic duct to it; most probably the former.

A second point of great interest in the case is the ex-
istence of an empyema of the gall bladder without chills or
fever. In all probability the suppurative process was con-
fined to the gall bladder and had not extended to the general
bile passages, associated with which, so far as I know,
there is invariably fever of a septic type.

The patient did very well. Much bile-stained material
escaped from the wound, the jaundice became distinctly
lighter, and bile appeared in the feces. By the 14th of
November the skin was much less yellow, the urine lighter
in color, and the itching of the skin had entirely ceased.
She improved rapidly, sat up by November 21st, and was
discharged on December 14, 1892.

Case XXXVII. Attacks of Gallstone Colic; Tumor of Gall
Bladder.—Miss S8., aged about forty-eight years, seen with Dr.
Ames, June 16, 1893, complaining of swelling and pain in the
abdomen. Patient has been delicate from childhood, and has
been for years a chronic invalid.
90 THE DIAGNOSIS OF ABDOMINAL TUMORS.

When about ten years of age she had a severe illness and
for some time could take no nourishment without severe ab-
dominal pain. Dr. Buckler thought that it was possibly ulcera-
tion of the stomach. When twenty years of age she had a
similar illness—evidently protracted, painful dyspepsia. When
thirty-five years old she had a severe attack of liver colic, in
which she changed color and was slightly jaundiced. She has
had since that time many attacks of pain, particularly at
night, after a very trying or exhausting day. At forty three
the menopause began, following which she had a nervous
breakdown and went to Italy, and for a-couple of years she
had a great deal of intestinal trouble. After returning, on Sep-
teinber 6th of last year, she had a very severe attack of colic
and was extremely weak. These attacks of colic have occurred
throughout the winter and the last one she had was only a
few weeks ago.

Present Condition.—Small-framed woman, looks ill, very
anemic and sallow; no definite jaundice; no special emacia-
tion. Pulse 92; tension a little increased.

Abdomen flat, natural-looking. Palpation is everywhere
negative until one reaches the liver region. Here inside the
nipple line there is a definite
rounded projection, the outlines
of which can be readily deter-
mined, particularly below and
to the left. It projects as a
somewhat conical mass and is
rounded at the right border. It
is a little painful on deep press-
ure. The fingers can not be in-
serted definitely beneath it, but
on either side the edge of the
liver is distinct; as she draws a
deep breath the fingers seem to
pass over a prominence into a
depression on the surface of the
liver just at the level of the
costal margin. During the at-

| tacks the projection, as she calls
as it, forms a prominent tumor
Fig. 31.—Showing the position of the .

gall bladder and outline of the Which can be seen beneath the

right kidney. skin and is then exquisitely sen-

sitive. The liver dullness ex-
tends to the upper border of the sixth rib. The right kidney is
distinctly palpable and descends below the edge of the liver,
from which it can be readily separated.

 

 
TUMORS OF THE GALL BLADDER. 91

At a subsequent examination the tumor was not nearly
so large, and she insists that it is extremely variable in size.
Whenever the colic is severe the tumor becomes very much
more prominent, a point confirmed repeatedly by Dr. Ames.
She is excessively anwmic, and though anxious for an opera-
tion, it was thought best to postpone it until the condition of
her blood was more satisfactory.

Additional Note —The tumor mass in the epigastrium de-
veloped considerably and became very much firmer, reaching
almost to the level of the navel. The patient herself said that
it had undergone a change, and she had a good deal of pain at
intervals. She was very urgent that an operation should be
performed, and, as her general condition seemed fairly good,
Dr. Tiffany, on January 9th, made an exploratory incision.
The gall bladder projected between two and three inches below
the margin of the liver. A coil of the small intestine, and also
the transverse colon, were firmly adherent to it, and over its
surface there was a definite vascular membrane. There were
numerous adhesions between the upper surface of the liver and
the diaphragm. The gall bladder felt firm, and at its fundus
there was a nodular mass. When it was opened a bile-stained
mucus exuded and the whole organ appeared filled with a semi-
solid, friable, grayish-yellow mass. Fragments removed with a
curette, particularly the scrapings of the wall, had a grayish-
white appearance, and looked like a new growth. On micro-
scopical examination they consisted of large, irregular cells,
many of which were in a state of fatty degeneration.

After doing well for three or four days the patient began to
complain very much of pain in the lower part of the abdomen.
There was no swelling, and until the evening of the 14th there
was no fever. On the 15th the pulse was more rapid, and she
seemed very much weaker. She was worried about not having
had an action of the bowels, and was a good deal exhausted in
an attempt to get them relieved. About one o’clock she became
feebler, gradually sank into a condition of unconsciousness, and
died about 5.30 in the afternoon.

Autopsy, Jan. 16.—The wound of the skin and the incision
in the gall bladder had both united well. After turning back
the skin flaps, the intestines were found to cover the gall blad-
der everywhere, except at a small area just below the liver
margin in the nipple line. The portion of the right lobe of the
liver adjacent to it was considerably elongated, and consisted of
a grayish-white atrophic tissue. The stomach was distended
and the duodenum was pushed forward and much dilated with
gas. It was opened in sitw, and its posterior wall found to be
in close contact with the gall bladder. The bile papilla, which
92 THE DIAGNOSIS OF ABDOMINAL TUMORS.

was in the transverse portion of the duodenum, was not oc-
cluded. After dissecting off the duodenum the tumor beneath
it was seen to be the greatly distended gall bladder, somewhat
larger than a closed fist. It was deeply placed, lifted the head
of the pancreas and the duodenum, as already mentioned, and
was in contact with the right side of the vertebral column. It
was readily and freely lifted from its bed, and then was seen to
project about eight centimetres below the liver margin. The
transverse colon was adherent to it, and just at the point of
their union there was a nodule of new growth of the size of an
English walnut. On incising the gall bladder, a swall quantity
of turbid bile exuded, but the entire viscus was occupied by a
globular new growth, which was everywhere free, except at the
upper wall, where it was densely adherent and had grown into:
the substance of the right lobe. It did not extend to the neck
of the gall bladder, and the orifice of the cystic duct was free.

On section, the mass consisted of a fresh, grayish neoplasm,
on its surface much bile-stained. There were six or eight small
black, irregular gallstones. There were no secondary nodules
in the liver. The common duct was free. The stomach and
intestines looked normal. There was a small cyst of the left
parovarium, which was united to the rectum by old, firm ad-
hesions.

Case XXXVUI. Enlarged Gall Bladder ; Jaundice ; Cancer
of the Head of the Pancreas.—Mr. M., aged fifty-one years,
seen April 26, 1893, with Dr. W. W. Johnston. The patient
isa large man, very active in business, and with an excellent
family and personal history. Ie hada slight attack of jaundice
during the civil war. Has not been a heavy drinker. Was
well and strong until toward the end of last year. Ie had a men-
tal shock and worry in October which distressed and disturbed
him a good deal, and he had dyspepsia on one or two occasions
before Christmas. Early in January he had a very severe attack
with vomiting, and then began to lose in weight and had uneasy
sensations in the epigastric region, but no sharp, acute pain.
About the middle of January he noticed that he was yellow in
color, and the jaundice, increasing in intensity, has been perma-
nent. The stools have been clay-colored ; the urine very mach
bile-tinged. He has had no itching, nor has the pulse ever
been slow. He has lost progressively in weight, thinks as
much as forty or fifty pounds, and has become very weak,
though he has kept up and about and until two weeks ago has
attended to his business.

Present Condition.—Intense olive-green jaundice; moder-
ate emaciation; pulse, 82; fair volume; moderate tension ;
vessel not sclerosed.
TUMORS OF THE GALL BLADDER. 93

Abdomen prominent, and percussion and palpation demon-
strate the existence of moderate ascites, which, Dr. Johnston
says, has not materially changed for several weeks. On palpa-
tion, no pain, nothing abnormal to be felt until toward the
right costal margin, below which the liver extends for about an
inch and a half in the parasternal line. In the anterior axil-
lary line, about two inches in front of the cartilage of the tenth
rib, there is a firm, rounded, nodular body the size of the top of
a lemon, which is attached to the liver and projects definitely be-
yond its edge. It feels like a distended gall bladder, but it is
unusually hard, firm, and inelastic, and it is not movable from
side to side. On deep inspiration, the surface of the liver
above it can be felt to be distinctly depressed. In the para-
‘sternal line the edge of the liver is irregular, and there appear
to be one or two nodules. In the middle Jine, on deep inspira-
tion, the surface of the left lobe also appears rough and irregu-
lar. The spleen is not palpable. The stomach does not appear
to he dilated. Examination of the thoracic organs is negative.

Patient died May 7, 1898. The autopsy showed cancer of
the pancreas, with secondary nodules in the liver. The gall
bladder was greatly distended and projected beyond the edge
of the liver, and formed the tumor which had been so plainly to
be felt during life, measured about six inches in length and about
three inches in diameter, and was full of a light-greenish fluid.
The walls were not indurated,

In the diagnosis of the tumor caused by dilatation of
the gall bladder there are details to which I may here
refer, The patient should be recumbent, in a perfectly
easy posture, with the abdominal walls as much relaxed as
possible. Sometimes, as in Case XXXVI, a prominent
tumor is at once visible, descending with inspiration, or
there may be a swelling of considerable size in the right
half of the abdomen. More frequently, however, inspec-
tion is negative, and the facts must be elicited by careful
palpation. The facility with which this procedure can be
carried out depends upon the degree of rigidity of the ab-
dominal walls, and a thorough examination may be impos-
sible without anzsthetizing the patient. Bimanual palpa-
tion is the most satisfactory. Sitting by the side of the
patient, the left hand beneath the lower ribs, with the right
upon the abdomen, a little below the costal margin in the
nipple line, gentle palpation with the pads of the fingers
is first made during quiet breathing. The patient is then
OL THE DIAGNOSIS OF ABDOMINAL TUMORS.

asked to draw a deep breath, and gentle but firm palpation
is repeated, the fingers of the right hand following the re-
ceding abdominal walls. The anterior edge of a normal
liver can in this way be readily felt, and any marked pro-
jection of the gall bladder detected. On the whole, I
think you will find it more satisfactory to use the fingers of
the right hand for palpation, but it is possible also to use
the thumb of the left hand in the method described by
Glénard, his procédé du pouce. The left hand grasps the
right flank with the fingers behind. With the thumb,
which is then free, the edge and surface of the anterior
part of the right lobe of the liver can be readily felt, as the
organ descends during inspiration. The facility with which
this procedure can be carried out depends somewhat upon
the length and mobility of the thumb.

Situation and General Charocters.—The position va-
ries with the size of the tumor and the existence of en-
largement of the liver. Moderately distended in a liver of
normal size, the gall bladder may be felt projecting be-
neath the costal margin opposite the end of the tenth cos-
tal cartilage. It is superficial, appearing to lie immediately
beneath the abdominal wall. The long axis may be parallel
with the nipple line. More frequently, however, the direc-
tion is somewhat to the left, as indicated by Fig. 31. The
tumor is usually to the right of the parasternal line, but it
may be directly in or even to the right of the nipple line,
while in other instances it may be chiefly to the left of the
parasternal line. The fingers may be placed directly be-
neath it, and the sensation given is that of a smooth, rounded
body, larger at the lower end than above—that is, pear-
shaped. While the outlines below are usually readily de-
fined, toward the liver they are obscure, and no definite edge
can be felt above the tumor. This is a point of importance
in the differentiation of floating kidney. Sometimes the tu-
mor appears to be turned forward on its axis, like a gourd,
and a groove may be felt separating it from the liver. As
a rule, palpation is not accompanied with much pain. The
sensation conveyed to the finger is usually that of a tense,
firm, elastic body. This is not always the case, for an en-
larged gall bladder may be extremely flabby and soft, and
is then difficult to feel. On the other hand, it is to be re-
TUMORS OF THE GALL BLADDER. 95

membered that in long-standing cases of cholelithiasis
there may be complete calcification of the walls of the gall
bladder, forming a tumor of stony consistence. The size
of the tumor projecting beyond the liver margin is some
measure of the degree of distention of the gall bladder, par-
ticularly when the dilatation is due to plugging of the cystic
duct. When the common duct is obstructed there may be
great dilatation of the gall bladder and ducts with only a
slight tumor projecting beyond the costal margin. I have re-
ported a case, operated upon by the late Dr. Agnew, in which
the fundus of the gall bladder projected only 2°5 centimetres,
but on lifting up the liver it was seen that the distention
was chiefly beneath the margin, and eighteen ounces of
bile were removed by aspiration. While these statements
hold for moderate dilatation of the gall bladder, you must
remember that there are instances on record in which the
tumor is exceptionally large, extending to the pelvis, occu-
pying the entire right side, or even filling the abdominal
cavity like a large ovarian cyst.

You will have noticed in the reading of the report of Case
XXXVI that the tumor was extremely mobile and that
the patient herself noticed its variability, and, projecting
as it did so plainly, the alterations in position could be
seen. The mobility during respiration is also well marked
and it may be seen to descend with inspiration. On palpa-
tion the tumor may be moved freely from side to side. On
the deepest inspiration, however, it can not be grasped and
held in position as is possible with an extremely mobile
kidney.

Nature of the Contents—In a doubtful case of tu-
mor projecting below the right costal border aspiration
may be practiced, using a fine needle and exercising cau-
tion that the bowel does not lie between the tumor and
the abdominal wall. The contents of a dilated gall bladder
are either clear mucus, which is most common in prolonged
obstruction of the cystic duct; bile, when the common duct
is blocked, though when occluded for a prolonged period
the entire bile passages, including the gall bladder, may be
filled with a thin mucus. Pus is met with frequently, usu-
ally general symptoms indicating that suppuration has
occurred ; and, lastly, blood may be present in cases of neo-
96 THE DIAGNOSIS OF ABDOMINAL TUMORS

plasm of the gall bladder. In acute phlegmonous inflam-
mation due to calculus, the gall bladder may contain a
dirty, brownish-red, ill-smelling fluid.

From growths at the pylorus and in the colon, which
may occupy a similar position, the gall-bladder tumor is, as
a rule, readily distinguished, both by the differences in the
symptoms, and particularly by the systematic local exam-
ination, using also the inflation of the stomach and intes-
tine. To two conditions I would, however, call your atten-
tion. In stout persons, and when the abdominal walls are
unusually tense, movable kidney on the right side may
be mistaken for an enlarged gall bladder. Only, how-
ever, when the kidney is very movable does it descend
so low and so far to the left that this mistake could
occur. It does sometimes, however, emerge beneath the
liver margin as a rounded tumor in a most deceptive
manner. With the patient recumbent and the kidney in
its natural position, no tumor is evident; but on change of
position (turning to left) or on deep inspiration it then ap-
pears. A movable kidney on the deepest inspiration, with
the fingers placed above it, can be held down and prevent-
ed from returning during the expiratory movement. A
gall bladder tumor rises and falls with the respiratory
movements, and can not be held down during expiration.
Again, above the rounded surface of the kidney, the sharp
margin of the liver may be felt with great distinctness,
whereas in gall bladder tumor the upper limit is not to be
defined, and there is no sharp edge above it.

An interesting anatomical condition of the liver which
you must learn to recognize has been referred to—par-
ticularly by Professor Riedel—namely, a tongue-shaped
process of the anterior margin. A knowledge of its ex-
istence may save you from error. I show you here the
outline as given by him in one of his cases (Fig. 38).
He believes that this extension is seen particularly in
women whose livers have suffered from the effects of lac-
ing, but it is directly caused by traction, the gradually dis-
tending gall bladder elongating the anterior margin. In
twelve of the cases upon which Riedel operated this tongue-
like process was present; in nine instances the gall blad-
der was palpable either at the median or under margin of the
TUMORS OF THE GALL BLADDER. 97%

process. In Case XXXVIIII believe this process is pres-
ent. It is not always, however, associated with dilated
gall bladder, and I have seen
very curious elongations of
the anterior margin of the
right lobe in perfectly nor-
mal livers, and in several in-
stances of the posterior mar-
gin of the left lobe. It is im-
portant to recognize the exist-
ence of this process as it may
form a very definite mass in
the right flank, A very in-
teresting instance of it was re-
ferred to me by Dr. Weir
Mitchell two years ago. An
extremely nervous woman,
aged about fifty-six years, had
had for several years Ssymp- Fig. 32.--The tongue-shaped exten-

 

toms of neurasthenia, pains in sion of the anterior margin of the
¢ 2 P i, right lobe, with the gall bladder
the abdomen, and ill-defined projecting below it. (Riedel.)

manifestations, for which she

had sought relief in many quarters. In his note to me Dr.
Mitchell stated that there was a tumor of doubtful nature
in the right flank. [ saw the patient with her relative, Dr.
Tilghman. The only interest in the case is in the examina-
tion of the abdomen, Just beneath the right costal mar-
gin, extending toward the anterior superior spine, was an
elongated mass with very ill-defined borders. The fingers
could not be inserted beneath it, nor was there a definite
edge palpable. It was tender on pressure, not movable in
a lateral direction, but with the fingers deep in the flank
behind it could be tilted forward. It did not seem to be
continuous with the liver, the dullness of which terminated
just below the costal margin. It descended somewhat with
the respiratory movements. The right kidney was not
palpable. Altogether I was puzzled by the condition, and
could not give a positive opinion as to the nature of the
trouble. She had a good deal of abdominal pain and dis-
tress, most of which I thought was associated with nervous
dyspepsia. As there had been some uterine trouble I sug-

7
98 THE DIAGNOSIS OF ABDOMINAL TUMORS.

gested that the pelvic organs should be examined. Subse-
quently, she came under the care of my colleague, Dr.
Kelly, who at once discovered the tumor in the abdomen
and, with the advantage pertaining to surgery, he very
quickly determined by laparotomy the nature of the
tumor—namely, an elongation from the right lobe of the
liver. He writes: “There was no visceral trouble, except-
ing the enormously elongated thinned-out lobe of the liver,
which extended down on the right side at least four
inches below the normal position, and seemed to be an
elongation of the anterior margin. The gall bladder was
not enlarged.” *

(6) Cases wits ILL-pertnep Nopvutar Tumor at Liver
Epes, supposed To BE Gait Buappsr.—While the pres-
ence of a well-defined tumor is of the utmost importance
in the diagnosis of gall. bladder disease, there are cases in
which we have to be content with less positive evidence.
A special value of Professor Riedel’s work in relation to
the diagnosis of gallstones lies in a somewhat startling re
vision of accepted data regarding the cardinal symptoms of
this disease. Thus, ten of the fifty cases upon which he
operated had never had colic; only fourteen presented a
definite tumor, and a majority had never had jaundice.

The following cases are of interest from the fact that a
small nodular tumor was felt in both, not very clearly de-
fined ; in one the history of severe and protracted attacks
of colic seemed clearly to indicate the presence of gall-

stones, while in the other case the condition was more
doubtful.

Case XXXIX. Severe Attacks of Colic for Five Years;
Nodular Tumor at Edge of Liver ; Operation with Removal of
Three Hundred Gallstones.—August W., aged forty-two years,
seen April 28, 1898. Sent by Dr. Salzer.

Patient is a large-framed, well-built man; has always en-
joyed excellent health, with the exception of malaria twelve or
thirteen years ago. Has always had a very good appetite and
has been a heavy eater. He has not been a dyspeptic, but has
been troubled at times with constipation, but until the onset of

* Those interested in the subject may consult with advantage
Hertz’s recent work, Abnormititen in der Lage und Form der Bauchor-
gane bet dem erwachsenen Weibe, eine Folge des Schniiren und Hénge-
bauches,
TUMORS OF THE GALL BLADDER. 99

his present illness he always regarded himself as a very healthy
man.

He comes complaining of attacks of severe and protracted
pain in the abdomen, which began five years ago. While walk-
ing in the garden one evening he had severe colicky pains, like
cramps, which lasted throughout the greater part of the night;
he was not jaundiced and the attack was regarded as one of
simple colic. Six months afterward he had a second and more
severe attack, which came on suddenly in the same way. Sub-
sequently the attacks became more frequent, and he had at
least six or seven in the second year, and they have gradually
increased until be has been rarely a month or six weeks with-
out pain. He has only once had vomiting with the pains, and
never brought up any blood; has never had diarrhcea, most
frequently has been constipated. The pain begins as a rule in
the upper abdomen, radiates to the back, and sometimes is very
diffuse throughout the back and sides. Its duration varies ex-
tremely ; thus, the day before yesterday he had a severe attack ;
yesterday he was free from pain. Ina bad attack he is quite
incapacitated, and can not straighten himself to walk. He
never has had bloody urine after the attacks, and never has
passed gravel. The early part of this winter the colic was very
severe and he lost considerably in weight. I could get no his-
tory of jaundice from the patient or from his wife, but Dr.
Salzer informs me that at least twice icterus followed the at-
tacks of severe pain.

Present Condition.—Face is flushed; color good; venules
of cheeks a little dilated; conjunctive not stamed.

Abdomen is full; panniculus well preserved; on palpation
everywhere soft. In nipple line, three fingers’ breadth below
costal margin, he winces on pressure, and here is to be felt an
irregularity at the edge of the liver. In middle line the edge
is indefinite; in parasternal line the liver can be felt about
two fingers’ breadth below margin, and there is an ill-defined,
rounded, somewhat nodular mass in this situation, which moves
with respiration. It is sensitive on deep pressure. Liver dull-
ness begins at the seventh rib and extends to the costal margin
in parasternal, and a finger’s breadth below in nipple line.

The edge of the spleen is not palpable, but dullness extends
from the eighth to the eleventh ribs in midaxillary line.

The stomach is not dilated; thoracic organs negative.

The diagnosis of gallstones was made and he was advised to
have an operation.

May 4th.—Dr. Halsted opened the abdomen and explored
the gall bladder. It was found that the irregular mass at the
edge of the liver was due to a marked projection of the an-
luv THE DIAGNOSIS OF ABDOMINAL TUMORS.

terior border, It was not to the left of the notch of the gall
bladder and did not form a definite tonguelike extension, but
was rather an irregular projection of the border. There were
numerous adhesions between the under surface of the liver and
the colon. The gall bladder did not look enlarged. It was laid
open and found to contain a clear mucoid fluid and about three
hundred gallstones of various sizes, chiefly very small, but one
at the orifice of the cystic duct was the size of a small cherry.
The patient reacted well from the operation, had no fever, and
made a satisfactory recovery.

In the following case, led astray. by a nodular promi-
nence at the edge of the liver, I thought the condition was
possibly gallstones in the common duet; but unfortunately
the exploratory laparotomy did not give us any definite in-
formation.

Case XL. Enlarged Liver; Nodular Tumor at Margin ;
thought to be the Fundus of Gall Bladder.—Henry L., aged
thirty-three years, traveler for a spirit house, was admitted
November 1, 1892, complaining of jaundice.

Father died at sixty years of paralysis; mother and seven
brothers and sisters living and well.

Patient has always been well and strong. The only serious
disease was diphtheria at his fifteenth year. Patient has been
a pretty steady drinker, chiefly of beer; has had gonorrhea,
and was under treatment many years ago for syphilis, the con-
stitutional symptoms of which were very slight. He has never
had hemorrhoids.

He has not been feeling very well for a year or more, and
has been depressed in spirits owing to domestic troubles, He
has been at work until a month ago. The present illness began
two months ago, when he noticed that he was gradually getting
yellow. There were no pains at the outset; no colic; nor had
he nausea or vomiting. The appetite was good; the bowels
were regular, and he did not feel badly enough to stop work for
more than a month after the jaundice appeared. He had at
times a sense of weight and dragging in the liver region, but
never any pain. He has lost gradually about twenty pounds
in weight within the past few months.

Present Condition.—Patient is a well-built, spare man; not
specially emaciated; skin and conjunctive of a tolerably intense
yellow color. The temperature is normal; pulse 64, full, regu-
lar; tension a little increased and the vessel wall slightly
thickened. Thorax is barrel-shaped; resonance everywhere
clear; no adventitious sounds. The heart beat is in the normal
TUMORS OF THE GALL BLADDER. 101

position; the sounds are clear, and the second, at the aortic
cartilage, is decidedly accentuated.

Abdomen is enlarged, particularly in the upper zone, and is
prominent in the right hypochondriac region. On palpation
the whole of the right hypochondriac and epigastric, and part
of the umbilical regions are occupied by a firm, resistant mass,
corresponding to an enlarged liver. The lower border extends
to within about three centimetres of the umbilicus and passes
under the right costal margin at the junction of the eighth and
ninth costal cartilages. The flatness begins at the sixth rib in
the nipple line. The surface is, as a rule, smooth, though
toward the navel slight irregularities are felt, The edge is not
very well defined. A little within the nipple line, at about five
centimetres to the right of the navel, there is felt on deep pal-
pation a little projection, rounded, somewhat nodular, and
which appears to be attached to the liver border. It is not
movable, and is in the position and extremely suggestive of the
tip of the gall bladder projecting beneath the liver margin. The
edge of the spleen was just palpable on deep inspiration. The
splenic flatness began in the eighth interspace. The stomach was
not dilated and the gastric juice contained free hydrochloric acid.

The urine was bile-stained, clear, acid, 1 025, contained a
trace of albumin and a few hyaline and granular casts.

The patient remained in hospital three weeks. The jaun-
dice varied considerably in intensity, and the complexion got at
times very much clearer. The stools were clay-colored, and at
no time were of such tint as to indicate that at any rate much
bile passed into the intestine.

During his stay in the hospital the patient gained a couple
of pounds in weight, his appetite was good, and he was always
able to be up and about.

The nature of the trouble did not seem at all clear. The
patient’s habits, the length of time the liver had been enlarged,
the size of the organ, without ascites, favored the view that he
had a form of hypertrophic cirrhosis, to which even the inten-
sity of the jaundice was not opposed. The question of syphilis
was also discussed. The stools, however, had rather the char-
acter of a definitely obstructive jaundice, and at times he was
intensely yellow. There seemed a possibility that the common
duct was obstructed, and, though he had not the intermittent
fever and chills so common in the impaction of a gallstone in
this part, yet the jaundice was variable, and the nodular mass at
the edge of the liver was suggestive, to say the least, of en-
largement of the gall bladder. He wished for an operation to
determine the nature of the trouble, and agreed to return for
an exploratory laparotomy.
102 THE DIAGNOSIS OF ABDOMINAL TUMORS.

January 2, 1893.—Patient came back to-day in practically
the same condition; but he has gained a couple of pounds in
weight. There is no change in the liver, and the nodular en-
largement can still be felt. The skin is deeply jaundiced, the
stools clay-colored, avd the urine very dark.

6th.—This morning Dr. Halsted did an exploratory laparoto-
my. An incision was made about three inches below the cos-
tal margin, just above the border of the liver and following its
curve. When the peritonaum was opened there appeared to
view, covering the entire surface of the liver, a smooth
structure, covered by peritoneum, looking like omental tissue,
containing vessels and fatty tissue. Jt was adherent to, but
could be moved like a skin upon the surface of the organ.
The nature of it was doubtful. There were numerous adhe-
sions between the edge of the liver and the transverse colon,
which had to be separated, and the lower surface of the liver
was united by adbesions to the adjacent parts. In the separa-
tion of the adhesions there was a good deal of bleeding, and
the vessels had to be tied. The gall bladder was not found,
and it was impossible under the circumstances to make a satis-
factory dissection of the gastro-hepatic omentum. Nothing ab-
normal was felt about the head of the pancreas, and no stone
could be felt in the duct. The edge of the liver itself was irregu-
lar, and at a little distance from the margin there was a distinct
indentation or groove. The nodular mass which we felt so re-
peatedly was, inall probability, a projecting portion of this ledge-
like edge. The membranous fold already mentioned was loosely
adherent to the surface of the liver, and, when lifted up, there
were numerous bleeding points which had to be touched with
the Paquelin cautery. The surface was somewhat irregular,
roughened, of an intensely bluish, almost plum color, and looked
like an organ in a state of hypertrophic cirrhosis.

It did not seem possible to be able to determine precisely
the nature of the remarkable fold of membrane covering the
liver. It covered the left lobe and extended up as far as could
be felt. It seemed more like a large properitoneal membrane
covering the liver. It was outside of the liver capsule, which
was not itself thickened.

I heard "from this patient last on November 6, 1898. His
jaundice had all disappeared, and the stools and urine are natu-
ral. He had improved a good deal, but the dropsy had been
very much worse, and he had been tapped twelve times.

(c) Cancer or tHE Gatti Biapper.—New growths of
the gall bladder, which are not very uncommon, have of late
attracted much attention, particularly in their relation to
TUMORS OF THE GALL BLADDER. 108

gallstones, The diagnosis ig in some cases easy, in others.
extremely difficult, and if the patient has had attacks of
gallstone colic, and presents a rounded tumor mass below
the edge of the liver, the condition is very naturally re-
garded as simple dilatation of the gall bladder. The fol-
lowing cases, which have been under observation, illustrate
certain points in the diagnosis :

Case XLL—Persistent Jaundice with Emaciation and As-
cites; Nodular Tumor at Edge of Right Lobe-—Magdalen H.,
aged fifty-two years, admitted to Ward G on October 18, 1892,
complaining of swelling of the abdomen and legs.

Her father died of tuberculosis. No history of cancerous
disease in the family.

The patient has always been very healthy, was married at
twenty-two; had one child. She has been troubled for many
years with constipation, She has never had attacks of colic.

The present illness, dating from about the middle of June,
began with vomiting, after which she became yellow and had
itching of the skin. The jaundice has never entirely disap-
peared. The legs became swollen about the end of August, and
the abdomen six weeks ago. There has been pain in the back,
so that she always has to lie on the side; otherwise she has not
had much distress. The stools have been yellow. She has had
but little vomiting. There has been progressive loss of weight,
and she has become very weak.

Present Condition.—Patient is much emaciated, and has an
intense olive-green jaundice. There is general anasarca. The
abdomen is extremely distended, and the lower zone of the
thorax is expanded. Without going into details foreign to the
main point, it may be said that she had all the signs of ob-
structive jaundice, and an ascites which required frequent tap-
ping. The immediate interest of the case was in the condition
of the liver. After tapping, the liver was distinctly palpable,
and in the parasternal line the rounded edge could be felt about
two fingerbreadths from the costal margin. Passing toward
the flank, in the anterior axillary line, a prominent nodular mass
was reached, and here the liver margin was nearly seven centi-
metres below the costal margin. The mass felt about the size
of a walnut, was prominent, not umbilicated. No other masses
could be felt, but the edge of the liver in the parasternal line
was somewhat irregular.

Remarks.—This illustrates a group of cases of obstructive
jaundice the precise cause of which is often difficult to deter-
mine. The persistent icterus and the loss of weight suggest a
104 THE DIAGNOSIS OF ABDOMINAL TUMORS.

new growth, but whether in the stomach, the pancreas, or the
liver itself is almost impossible to say. A test breakfast shows
free hydrochloric acid, and she has not hud much vomiting
since admission to hospital. The stools are grayish yellow,
not fatty and not suggestive of pancreatic disease. The nodu-
lar body at the right border is the main objective point in the
local examination, and the question discussed between Dr.
Thayer and myself before the class has been whether this is a
secondary nodular growth or the projecting end of a firm, hard,
cancerous gall bladder. To my touch it rather resembles the
former, feeling as though the finger could be passed all around
the liver tissue at its base. Supposing it to be secondary can-
cer of the liver, the organ is not nearly so large as is common
in this condition in the space of five or six months. On the
other hand, in primary cancer of the gall passages the liver is
often not much enlarged, and the jaundice, as in this case, is
intense from the outset. A point in favor of this view is the
absence of evident signs of disease of the stomach, pancreas, or
intestines,

Patient died November 16, 1892. The above comments
were written before the patient’s death. The autopsy showed
a primary carcinoma of the gall bladder, the end of which was
the nodular body which we had been able to feel so definitely
on palpation. The walls of the organ were greatly thickened,
and it contained vearly one hundred small gallstones. There
was great induration and thickening about the common bile duct,
the head of the pancreas, and in the gastro-hepatic omentum.
The common duct passed through this indurated tissue and
was almost occluded. The liver weighed only fifteen hundred
grammes and presented numerous medium-sized cancerous
nodules throughout its substance.

Case XLIL Cancer of the Gall Bladder ; Jaundice; Pro-
gressive Emaciation.—E. 8., aged fifty-four years, admitted to
Ward G on January 25, 1893, complaining of pain in the abdo-
men and soreness in the back. There is nothing of any moment
in the family history. She has been married; has had six chil-
dren; four miscarriages. She has never had uterine trouble; no
serions illness until the present attack.

More than a year ago she had pains in the back, sometimes
quite severe, and accompanied with high-colored urine. After
several of these attacks she had passed small calculi in the
urine. She has had none of these attacks and has not passed a
stone for about a year. She has been failing in health for the
past few months, has had indigestion, belching, and occasional
attacks of vomiting, and has lost a good deal in weight. About
five weeks ago she noticed change of color in the skin and that
TUMORS OF THE GALL BLADDER. 105

she was getting yellow, and for about the same time she has
had a dull aching pain on the right side of the abdomen. The
urine has been high-colored, and the stools, which formerly
were very dark, were light-gray in color.

The patient is a medium-sized woman; face thin, but the
body and limbs still well nourished. There is moderate jaun-
dice.

Abdomen full; panniculus well retained. On palpation, it
is soft, nowhere painful except at a point about five centime-
tres below the costal margin in the nipple line. Here thereis a
firm mass which extends to the left te within six centimetres of
the umbilicus, and at this border the fingers can be placed di-
rectly beneath it. Below it reaches to the transverse navel
line, and is here rounded, and the fingers can not be placed so
well beneath it as to the left. To the right the margins are not
very clearly defined, but it extends nearly to the tip of the
tenth rib. Above, it can not be separated from the liver mar-
gin. It feels like a rounded mass, larger than a lemon, is ex-
tremely resistant, hard, and, though it has the situation of the
gall bladder, it scarcely conveys the impression of the rounded,
pear shaped outline of that organ. The right kidney can not be
felt. The liver dullness is not present in the midsternal line,
jast three centimetres and a half in the parasternal and five
centimetres in the nipple line. The mass above described,
though directly continuous with the liver, presents a flat tym-
pany on percussion. Deep pressure from behind in the right
flank presses the tumor mass forward.

The spleen is not enlarged, stomach not dilated, and the pel-
vis is clear. The urine is very dark in color, 1°016, pale; bile
pigments present; no sugar; a few granular casts. The stools
are clay-colored and very offensive. Repeated examinations
showed no essential change in the condition of the tumor mass.
The jaundice became very much more intense, though the gen-
eral symptoms were somewhat ameliorated. She took her
food better, and had much less pain.

The case was regarded as tumor of the gall bladder asso-
ciated with gallstones, and probably malignant disease. The
patient’s condition was so satisfactory that it was thought ad-
visable to have an exploratory operation to determine if any-
thing could be done.

February 8th.—This morning Dr. Halsted made an explora-
tory operation. The mass above described was in the situation
lready referred to—between the transverse colon and the under
surface of the liver, to which it was firmly attached. The ad-
hesions to the colon were so tight that it was not thought ad-
visable to attempt to separate them. The tumor mass was firm,
106 THE DIAGNOSIS OF ABDOMINAL TUMORS.

solid, and grayish white in color, passed beneath the surface of
the liver, and occupied the position of the gall bladder. The
liver itself was not enlarged, but the edge could readily be felt
about six centimetres above the lower border of the tumor
mass.

The jaundice persisted; she got progressively emaciated ;
the wound healed. Her friends took her home on March 2d,
where she subsequently died.

Carcinoma of the gall bladder is not very easy to
recognize, but there are certain suggestive features in sus-
pected cases. The disease is most common in women—two
thirds of the cases collected by Musser. In seven eighths
of the cases the cancer has been associated with gallstones,
so that a history of colic or of previous jaundice should
be sought for. Rapid emaciation, with or without jaundice,
and the development of a cachexia within three or four
months, speak for cancer; simple hydrops vesice may per-
sist for months without impairment of the general health.
Chills and fever are, as a rule, against neoplasm. So long
as the disease is confined to the gall bladder jaundice is
not present, but when it extends to the common duct the
icterus is intense and persistent. Ascites may be caused
by the propagation of the disease to the peritoneum
by pressure of secondary masses on the vena porte, by
extension to the gastro-hepatic omentum, as in Case
XLI, and occasionally is due to thrombosis of the portal
veins.

The local features are variable and uncertain. In the
cases I have narrated the walls of the gall bladder were in-
filtrated, but the cancer may be at the outlet, causing ob-
struction with great dilatation and a tumor resembling in
all respects that produced by any other occlusion of the
cystic duct. When the fundus is involved the tumor is
harder, more resistant, not so movable as in simple hy-
drops, and the growth may be very rapid. The liver is
not usually much enlarged, even when secondary nodules
are present. Aspiration of the tumor gives most impor-
tant indications. A clear mucoid fluid favors gallstones ;
turbid, albuminous contents suggest neoplasm, as does also
blood or a blood-stained fluid. Fragments of the new
growth may be found in the material aspirated. Pure
TUMORS OF THE GALL BLADDER. 107

bile is rather in favor of gallstones, and indicates that the
cystic duct is not involved.

But taking all the circumstances, general and local, into
consideration, you may not be able to reach a conclusion,
in which case remember that the hazard of an exploratory
operation is slight, and that by far the most frequent cause
of tumor in the region of the gall bladder is cholelithiasis.

Lecture V.

Tumors or tHe InrestiIns, OMENTUM, AND PANCREAS;
MiscetLangous Tumors.

I. Tumors of the Intestine—Cancer, the common cause
of tumor, occurs most frequently (apart from the rectum)
in the cecum and the sigmoid, hepatic, and splenic flexures
of the colon. Not one of the three cases which have been
under observation presented a typical group of symptoms,
but singly and together they illustrate many interesting
features of the disease. In the first place, the affection may
be latent, revealed at autopsy alone, or the early and indeed
the chief symptoms may be due to the secondary tumors,
The first case illustrates very well the latency of the disease.
Without intestinal symptoms, for some months after he
came under observation the sole objective feature was the
progressive enlargement of the liver. Only six weeks be-
fore his death, after he had become greatly emaciated, we
discovered a tumor in the right iliac region, and subse-
quently he had hemorrhage from the bowel.

Case XLII. Cancer of the Caecum and Colon; Latent
Course; Enormous Secondary Enlargement of Liver.—Johbn R.,
aged twenty-nine years, admitted February 6, 1892; under ob-
servation until September 25th. The family history is good.
The patient was healthy and strong until four years ago, when
he had severe malaria. For eight months prior to his admis-
sion he had not been very well, and had had irregular pains
in the abdomen. Daring the past eight months he has been
pale, has felt weak, has not been able to work, and on several
occasions he has been slightly jaundiced. His appetite has been
good; bowels regular; has had no diarrhea. For several
months past he has noticed that the upper part of the abdomen
108 THE DIAGNOSIS OF ABDOMINAL TUMORS.

was swollen and tender to the touch. On admission, the pa-
tient was pale, but looked well nourished; no fever; pulse, 86.
The lower thoracic zone is much expanded, particularly on the
right side. The epigastric and hypochondriac regions bulge in
a very prominent manner, and there is a rounded mass, nine
centimetres in transverse extent, which extends from under the
ribs on the right side. In the median line the edge is clearly
defined, and reaches to within four centimetres of the navel.
To the left it extends far over beyond the parasternal line, and
to the right deep into the lumbar region. The percussion over
this large mass is flat and continuous with the liver dullness,
which begins in the median line at the base of the xiphoid, in the
nipple line at the sixth cartilage, and in the axilla at the seventh.
Although there was no fever and no definite history of any in-
testinal trouble, the patient’s age and good condition seemed
against the diagnosis of cancer of the liver. Accordingly, an
aspirator needle was thrust in at the prominent part, but only
blood obtained. Under observation the liver evidently in-
creased in size, and there seemed to be no question that it was
anew growth. The question then arose as to the primary seat
of the disease. The stomach symptoms were insignificant, he
had no vomiting, the appetite was good, and a test breakfast
was readily disposed of, Subsequently, in August, very carefal
examination of the abdomen revealed a hard mass low down
in the flank. It was usually ill-defined, but on several occa-
sions Dr. Thayer thought that it was quite distinct. There was
no diarrhea; no special change in the feces, which were al-
ways well formed. He remained under observation outside the
hospital during the summer. The liver tumor did not increase
very much in size. He became progressively weaker and very
much emaciated. Two weeks before death he passed two large
stools containing clots of blood. He became extremely ema-
ciated. before his death.

Autopsy.—The liver weighed seven thousand two hundred
grammes; the right lobe was much disfigured, and presented
numerous nodular tumors with elevated margins and depressed
centers. A distinct groove marked off the anterior margin of
the right lobe from the rest of the organ. On section, second-
ary cancerous nodules were found scattered through the entire
organ. The primary growth was found to be at the head of
the cweum and the beginning of the colon, which presented an
extensive fungating mass, softened and necrotic on the surface.
The mesocolon was thickened and the glands much involved.
Microscopically the tumor proved to be a eylindrical-celled epi-
thelioma, Extensive secondary nodules were scattered through
the langs.
TUMORS OF THE INTESTINE. 109

In the following, by far the most interesting and in-
structive case of the series, intestinal symptoms were ab-
sent throughout, and the presence of a solid, firm mass
deep in the right side Jed us to think at first that there was
arenal tumor. I give you the notes just as I dictated them
from day to day, as they illustrate the erroneous diagnosis,
and the gradual development of features which led to its
revision,

Case XLIV. Tumor in Right Flank; Suspected to be a Re-
nal Sarcoma; Subsequent Development of Dilatation of the
Stomach and Signs of Tumor in the Bowel.—Thomas B., aged
thirty-two years, admitted August 3, 1892, complaining of pains
in the abdomen. There was nothing of special moment in his
family history. Present illness began about eighteen months ago
with griping pains in the abdomen, attacks of which occurred
from time to time and were attributed to indiscretions in diet-
On the voyage to this country, ten months ago, he was very
seasick, and had a great deal of pain in the abdomen; and then
for the first time he noticed a hardness or Jump on the right
side. The bowels were, as a rule, constipated. He has never
passed blood in the stools or in the urine. For some months he
has been gradually losing in weight, and has been getting pale
and weak. When in good condition he weighs one hundred
and seventy-seven pounds; he now weighs one hundred and
twelve pounds.

Present Condition.—Patient is a tall, well-built man, pale,
scarcely cachectic. The tongue is moist, slightly coated; pnise
104, of fair volume. The examination of the thoracic organs is
negative. The abdomen is symmetrical, but looks a little
fuller in the right flank. The right hypochondriac and lumbar
regions are filled with a firm, somewhat irregularly rounded
mass, which on bimanual palpation can be readily moved up
and down. On making firm pressure with the left hand in the
right renal region the mass becomes apparent beneath the skin
just to the right of the navel. To the left it extends almost to
the middle line; the lower border is three centimetres below
the transverse navel line. Both the lower and the left borders
are rounded, but toward the right, just beneath the tip of the
eleventh rib, there isa distinct nodule to be felt. In its ante-
rior part it can be separated distinctly from the liver both by
palpation and percussion, but in the anterior axillary line the
tumor passes beneath the ribs, and the dullness is here cuntinau-
ous with that of the liver. On percussion there is resonance
over the tumor mass to the left of the nipple line. The general
110 THE DIAGNOSIS OF ABDOMINAL TUMORS.

situation of the tumor is indicated in the annexed chart. There
are no glandular enlargements. The spleen is not palpable and
the dullness is almost obliterated.

The patient has no sweats, no cough. There is a leucocy-
tosis, the white corpuscles numbering over twenty thousand to
the cubic millimetre; hamoglo-
bin, forty-one per cent.; red
blood corpuscles slightly over
four million to the cubic milli-
metre. The urine (many exami-
nations) has usually been clear,
acid; specific gravity, 1:012; at
first no albumin, but subse-
quently slight traces. No su-
gar; microscopically, a few
blood-cells, but as a rule, even
after centrifugalizing, neither
casts nor blood-cells were found.
The sediment obtained was also
examined for tubercle bacilli,
with negative result. The tem-
perature was at times a little
above normal, and on the even-
Fig. 33.—Outline of the tumor mass ing of the 20th of August he had

in Case XLIV. a chill, the temperature rising

to 108°5°. On the 6th of Sep-

tember a medium-sized aspirator needle was thrust upward

and backward beneath the twelfth rib, and a little blood-stained

fluid removed, which contained round cells twice the size of

leucocytes. The needle seemed imbedded in the firm substance.
The patient objected to an exploratory operation.

 

The situation and shape of the tumor, the mobility, and
the readiness with which it could be pushed forward by
pressure from behind pointed to a renal origin. ‘The na-
‘ture of the growth was less certain. If he is correct, in dat-
ing the first symptoms as far back as eighteen months the
tumor has not attained the size usually reached by new
growths of the kidney within this time. There has also
been no blood in the urine. The single chill does not
speak specially against new growth. Can it be tuberculous
nephritis? The family history is good; the urine is and
has been clear; there is no involvement of the epididymis,
and fever has not been a marked feature. If the tumor
were due to saccular dilatation following occlusion by tuber-
TUMORS OF THE INTESTINE. 111

culous or calenlous disease, certainly the aspirator would
have withdrawn purulent fluid, and there would have been
at some time pus in the urine. The rapid loss in weight
points strongly in favor of new growth.

October 12th.—The patient was shown in clinic this morn-
ing. The emaciation has progressed; he has had for ten days
much more fever, and a chill on the sixth in which the tem-
perature rose to nearly 104°; on the seventh, eighth, and
ninth it remained between 102° and 108°. There are no special
changes in the urine. He has been at times constipated, but
the stools show nothing peculiar. The tumor mass has: not in-
creased materially in size, though perhaps it reaches a little
further toward the navel.

The patient says that he notices flatus bubbling in the
vicinity of the tumor, and that it divides into, as he expresses
it, two or three portions. The hand placed on the tumor ex-
periences occasionally a feeling as if gas was escaping through
it, and the left half is resonant; but this might be due to the
presence of the colon over the mass.

This morning, with the students, the various probabilities of
renal sarcoma, or tuberculosis, or calculous pyelitis were dis-
cussed. The state of the urine and the failure of aspiration to
draw fluid seem opposed to the latter conditions. The chills
and fever were not thought to be inconsistent with sarcoma.

The question was also discussed as to whether it really was
a renal tumor, and whether it might not be associated with the
liver or with the hepatic flexure of the colon. It did not
seem possible, with the evidence at our disposal, to reach a
definite diagnosis.

Since the above note of October 12th there have been sev-
eral developments in this case.

15th.—For the past two days the patient has had a great
deal of vomiting, often bringing up large quantities. Last night
he vomited eight hundred cubic centimetres of brownish fluid
containing half-digested food. The reaction was acid, the odor
rancid, and tests for free hydrochloric acid were negative.

16th.—Ewald’s test breakfast given this morning, and with-
drawn fifty minutes later, gave nearly three hundred cubic
centimetres of a slightly grayish, muddy fiuid, containing com-
paratively little food matter. It was acid in reaction, odor
rancid and sour, turned congo paper blue, and gave a very dis-
tinct rosy-red color with the phJoroglucin-vanillin solution.
Microscopically, there were fat crystals, undigested food stuffs,
numerous bacilli, and yeast cells.

17th.—The vomiting has continued during the past twenty-
112 THE DIAGNOSIS OF ABDOMINAL TUMORS.

four hours, and he does not look so well to-day. The tumor mass
occupies the right hypochondriac region, extends into the right
lumbar and umbilical regions, but not into the epigastric,
reaching apparently to within about two centimetres of the
navel. Below, it extends exactly eight centimetres from the
costal margin in the nipple line. The greatest prominence is
just below the point of the tenth rib. On first palpating it this
morning there was at the lower margin a prominent rounded,
yidge-like mass, firm and hard, which gradually disappeared,
feeling as if it were a tubular, muscular structure in contrac-
tion. Again this morning gas was felt bubbling through the
mass. Percussion over it gave flat tympany; slight change
noted in rolling the patient over on the left side. Ata second
visit to-day there were noticed for the first time waves of peristul-
sis crossing the upper abdomen from left to right, and the out-
lines of the stomach could be distinctly seen, the lower border
reaching to the navel. At the time of the passing of the waves
the walls of the stomach became firm, and bubbles of gas could
be felt passing through the tumor.

20th.—-The signs of dilatation of the stomach have been for
the past few days unusually distinct. He has had vomiting of
large quantities of liquid. The amount of urinary secretion is
very scanty. He sank gradually and died on the 20th.

Autopsy.—By Dr. Flexner. On opening the abdomen the
stomach was seen to be greatly dilated, reaching considerably
below the level of the navel (Fig. 35). In the right hypochon-
driac region a tumor mass was adherent in part to the anterior
abdominal wall, just between the costal margin and the crest of
the ilium. Just below the hepatic flexure of the colon there was
a tumor the size of an orange completely encircling the bowel. It
was seven centimetres in length and eight centimetresin circum-
ference. The coats were uniformly infiltrated and the tissue
looked infiltrated with colloid. Theinner surface was ulcerated
and the lumen of the bowel not here narrow. The ew#cum and
ascending colon were opened im situ. At the hepatic flexure the
tumor mass was adherent to the right lobe of the liver and be-
hind was attached to the kidney. The finger, introduced into
the colon at this region, entered a number of pockets, one of
which directly led into the liver substance. On its posterior
surface and to the right the tumor was closely united to the
curve of the duodenum, into which it had grown in such a
way as to cause a distinct narrowing. The mucous membrane
of the duodenum was ulcerated from the central part of the
tumor, but was intact elsewhere. The stomach was greatly
dilated ; the mucous membrane smooth. The pylorus itself
and first part of the duodenum were greatly stretched; the
TUMORS OF THE INTESTINE. 113

groove between them is well seen in the figure. The finger
could be passed into the duodenum, but the narrowed lumen
would not more than admit the tip of the little finger. The liver

Fie. 34—Cancer of the colon: dilatation of the duodenum and stomach in Case XLTY.

 

showed'numerous secondary nodules of cancer. The mesenteric
glands were enlarged and contained metastatic nodules.

The third case presented a very prominent movable
tumor which, from its general characters and situation,
seemed to be connected with the bowel, though the intes-
tinal symptoms were here also quite in the background.

Cask XLV. Tumor in Right Flank; Removal of Growth in
Caecum and Ascending Colon.—Sylvester H., aged sixty years,
8
114 THE DIAGNOSIS OF ABDOMINAL TUMORS.

admitted October 15th, complaining of a Jump in the abdomen.
He has been a very healtly man. For two years past has had
slight pain after eating, with nausea and constipation.

His present illness began about three months ago with
troublesome constipation, and three or four days would pass.
without a movement from the bowels, and the feces would be
hard and lumpy. He took medicine for it, since which time
the bowels have been rather loose, the stools yellow and con-
taining slime, but never blood. No tenesmns, no cramps. Five:
weeks ago he had an attack of vomiting, followed by a second
attack a week later; brought up sour material; no blood. In
the past three montlis he has lost a great deal in weight, and
has become, he thinks, a little pale. He has been short of
breath on exertion, and lately the feet have been swollen.

Present Condition.—Patient looks a little pale, but is fairly
well nourished; no fever; tongue slightly furred. Abdomen is-
fall, and about six centimetres to the right of the navel there is
a projection beneath the skin, unintluenced in position by the
respiratory movements. On palpation this is felt to corre-
spond to a rounded nodular
mass, feeling of about the size
of a cricket ball, situated mid-
way between the navel and the
anterior superior spine of the
iliam. It feels very superticial ;
is not tender; is very hard; and
one or two ridges can be felt
upon it. There are no changes.
in its consistence. On deep in-
spiration it descends slightly.
It is freely movable and can be
pushed over as far as the navel.
No gas is to be felt to bubble
through it. On light percussion
there is a flat tympany over it.

As the patient had had very
few intestinal symptoms and
Fig. 35.—Situation of the tumor in had had dyspepsia for several

Case XLV. years, with recently two at-

tacks of vomiting, the attention

was naturally directed, in the first place, to the condition of
the stomach. Palpation was negative in the region of the
pylorus. There was no clapétage. The organ did not appear
to be dilated. The upper limit of resonance was at the fifth
rib in the nipple line, and the Jower limit above the navel.
On October 17th the tests for free hydrochloric acid were:

 
TUMORS OF THE INTESTINE. 115

negative. On the 21st it seemed that the stomach tympany
was somewhat more extensive than before. There were no
peristaltic waves. On several occasions a test breakfast was
given, and on October 26th the mucus withdrawn was blood-
stained; no free hydrochloric acid. The tumor could be readily
separated from the liver and could be moved far down into the
right iliac fossa. While the symptoms in this case pointed
rather to disease of the stomach, the situation and general
character of the tumor were those of an intestinal growth.
The stomach, too, seemed somewhat relaxed, and the absence
of free hydrochloric acid was suggestive,

On November 7th Dr. Halsted operated and found that
the tumor occupied the cweum and the commencement of the
ascending colon. It was readily removed. The patient seemed
to do very well, taking his nourishment and gaining in strength
until the 18th, when, after an attack of nausea and coughing,
the stitches gave way and about two feet and a half of the
smal] intestine protruded. He became very restless, gradually
sank, and died the same day. The tumor was a eylindrical-
celled epithelioma, involving the entire circumference of the gut,
but excavated and not narrowing in any way the lumen of the
gut. The autopsy showed an interesting feature—namely, the
presence also of a cancer on the posterior wall of the stomach
and of a second small tumor mass in the jejunum.

In the diagnosis of cancer of the intestine the follow-
ing points may be taken into consideration, In comparison
with the subjects of malignant disease of the stomach very
many of the patients are young; thus you have noticed
that Case XLIII was only twenty-nine years of age, and
Case XLIV was only thirty-two. Intestinal features are
present in a majority of cases, though they were by no
means suggestive in the patients who have been under our
observation. Griping, colicky pains are common, even
without the signs of obstruction. With narrowing of
the lumen of the gut very characteristic features occur—
attacks of severe griping pain, abdominal distention, the
presence of active, sometimes visible peristalsis in the dis-
tended coils of bowel, and, if the condition persists, vomit-
ing and all the signs of intestinal obstruction. In the case
of Sylvester H., I called your attention repeatedly to the
fact that the intestinal symptoms depended largely upon
the state of the lumen of the bowel at the seat of the tu-
mor. If fungous masses project and cause more or less
116 THE DIAGNOSIS OF ABDOMINAL TUMORS.

narrowing, colicky pains and constipation are inevitable ;
but, on the other hand, as the tumor grows, if there is
necrosis of its surface, with excavation, neither pain nor
constipation may be present. Diarrhoea and the passage of
much slime with the faces are not infrequent symptoms.
Hemorrhage is also common. The blood is not often in
large quantities; when the tumor is in the sigmoid flexure
it may be bright and very little changed, but in growths
about the cxwxcum it is often much altered before it appears
in the stools. There are cases in which constant loss of
small quantities of blood is a very special feature, and
the patient becomes profoundly anemic. Sloughy frag-
ments of the tumor may sometimes be passed in the
feeces.

A cachexia develops progressively but with very vari-
able rapidity. It may, however, be well marked before any
features have arisen suggestive of intestinal trouble. The
loss in weight may, too, be slight, even after the tumor has
persisted for many months. There is at present a patient
in Ward C with a tumor in the right iliac region, which. has
persisted for nine or ten months, and upon the nature of
which very many opinions have been expressed. She is
well nourished, but profoundly anemic. It did not seem
possible from the symptoms, general or local, to make a
definite diagnosis, but an exploratory operation showed an
extensive new growth in the cecum. Another patient,
who had repeated smail hemorthages, developed an extreme
anemia, with retention of the general fatty panniculus.
When extensive secondary growths develop, as in Case
XLIII, the cachexia may be profound. The tumor in can-
cer of the intestines may be readily and easily discovered—
indeed, evident on inspection, as in Case XLV, On the
other hand, as in Case XLIII, it may not be until the ter-
minal stage of the disease that the growth is found. A
small tumor of the hepatic or splenic flexure of the colon
may escape repeated examinations. Mobility is a special
feature of growths in the large bowel. Large tumors,
however, of the cewcum may be quite fixed. The most
movable growths are those connected with the sigmoid
flexure. Variability in size is also a marked character,
and at one examination the mass may appear as large as
OMENTAL TUMORS. 117

the closed fist or even two fists, and the next day it ap-
pears not larger than a small apple. These variations are
due largely to the presence of faecal masses in the vicinity.
Two very important features in the intestinal tumor may
sometimes be detected on careful palpation—namely, the
hardening during contraction of the hypertrophied wall in
the vicinity of the growth, and the bubbling of gas through
the tumor, which may be heard as well as felt. This latter
feature drew our attention to the possibility of the tumor
in Case XLIV being associated with the colon, The in-
testinal symptoms above referred to and a progressive
cachexia are generally sufficient to warrant a diagnosis.

Il. Omznrat Tumors.—In two cases a rolled, thickened
omentum formed a definite tumor in the upper portion of
the abdomen. I will not enter into full details, but just
mention the cases in abstract.

Case XLVI. Pleuro-peritoneat Tuberculosis ; Ridge-like
Tumor in the Epigastric Region.—A man, aged thirty years,
admitted May 9, 1893, with ascites. In October he had had
shortness of breath with swelling of the legs and abdomen.
He improved gradually, but the ascites has persisted and on
admission there were signs also of effusion in the right pleura.
In the abdomen there was an ill-defined resistance, a hand’s
breadth in width, at the junction of the umbilical and epigastric
regions ; below it terminated in a well defined, hard border,
which could be very easily felt, and was indeed at first thought
to be the edge of the liver. On percussion there was a flat tym-
pany above the hard transverse ridge. There was in this re-
gion also a very well marked peritoneal friction rub. The his-
tory of the case, the involvement of pleura and peritoneum,
and the existence of this transversely placed tumor mass in the
upper abdominal zone led to the diagnosis of tuberculosis. Dr.
Finney made an exploratory operation and drained the perito
neum, The omentum was rolled up, thickened, and attached
to the transverse colon. The patient did well and was dis-
charged from the hospital greatly improved.

Case XLVI. Chronic Proliferative Peritonitis ; Thiekened
Omentum.—In this patient the tumor was more interesting and
unusual, though I must say no diagnosis was made. I refer to it
especially because I have been talking to you so much in the
ward class about chronic proliferative peritonitis in connection
with the case of the little girl with a visibly pulsating liver.
Without going into unnecessary details, the patient, aged about
118 THE DIAGNOSIS OF ABDOMINAL TUMORS.

fifty-five years, was admitted with suppurative cellulitis of the
left leg which had come on in connection with an ascites of
some weeks’ duration. His condition was very serious, and one
for which we could not do very much. He gradually sank, and
died ten days after admission. The abdomen was persistently
distended, and we never arrived at a definite opinion as to the
cause of the dropsy. The parietal peritoneum was adherent
to the anterior surface of the colon and to the omentum for a
distance of 3°5 centimetres. The omentum was represented by
a thick fold, seven centimetres in vertical by nineteen centi-
metres in transverse extent, the upper part of which was con-
verted into a white, shining, leathery-like structure, not, how-
ever, rolled or curled upon itself. Similar thickenings were
present over the anterior surface of the colon. The intestines,
particularly the loops of small bowel, were bound together by
dense adhesions, separated with the greatest difficnlty, and
there were patches of thickening on the mesentery. There was
a condition of chronic perisplenitis and perihepatitis. There
was a thrombus in the portal vein.

As in the chronic tuberculous peritonitis, this simple
proliferative form may pucker the omentum into a definite
tumor, lying athwart the upper zone of the abdomen. En-
capsulated exudate may also form tumor-like masses.
More frequently, however, the recurring ascites simulates
cirrhosis of the liver. In one way the proliferative perito-
nitis may produce a very extraordinary tumor, of which I
have reported an example.* So great may be the thicken-
ing of the mesentery that the whole bowel is shortened, and
the coils of intestine matted together may form a mass the
size of a cocoanut firmly bound to the spine.

Ill. Tumors or tHE PancrEeas.—Two cases of dis-
ease of this organ came before me for diagnosis—one a
cancer, the other possibly a cyst.

The cancer case you will remember, as I demonstrated
the specimens after a ward class early in the session. A
reasonable probability may sometimes be reached in the
diagnosis. The following may be mentioned as suggestive
points: Rapid emaciation with early, intense, and persist-
ent jaundice; dilatation of the gall bladder, fatty stools,
glycosuria, salivation, and the presence of a tumor between
the umbilicus and ensiform cartilage. Nausea and vomit-—

* Tuberculous Peritonitis, Johns Hopkins Hospital Reports, vol. ii.
TUMORS OF THE PANCREAS. 119

ing, though often present, are variable features. Begin-
ning usually in the head of the pancreas, the growth early
compresses the common duct and causes obstructive jaun-
dice. <A persistent, intense icterus may also result from
compression of the duct in the gastro-hepatic omentum by
infiltrated glands, secondary to cancer of the stomach, to
invasion of the ducts themselves by cancer, and by stenosis
of the common duct, rarely by gallstones without any com-
plication. The emaciation is rapid, and stress is laid by
some writers upon an excessive cachexia. There may be
very little pain throughout the illness; in some cases, how-
ever, attacks of colic oceur. A dilated soft gall bladder,
while not in itself of special import, is often suggestive,
taken in connection with other features. In the primary
cancer of the bile passages, which also causes an early and
intense icterus, the gall bladder, if enlarged, is more often
hard and firm. Disturbance of the function of the organ
may be manifest by (1) the presence of fat in the stools
(even a definite stearrhea), which is not a constant symp-
tom, but of value when present; (2) by glycosuria, which
is also not constant. Salivation is sometimes present, and
Dr. Lainé, of Media, has called my attention to several
cases in which this symptom was present, and in which the
diagnosis of cancer was confirmed by autopsy.

The tumor in cancer of the pancreas is not always to be
felt, and, as in Case XLVIII, there may be ascites, which
renders it difficult. The mass may be between the navel
and the margin of the right lobe of the liver, as in our case.
It is deep seated, not mobile, variable with the degree of
distention of the stomach and intestines. The involvement
of the adjacent parts may give to it the characters of a
deep-seated, dense, massive tumor. Bear in mind that in
very thin-walled persons, particularly in women with en-
teroptosis, the pancreas can be felt with distinctness, but
the conditions are very exceptional in which it could be
mistaken for a tumor.

Case XLVITI. Intense Jaundice; Progressive Cachexia ;
Ascites ; Tumor in Epigastric Region.—E. V., aged thirty-four
years, admitted to Ward C, October 24th, complaining of dys-
pepsia and jaundice. Family history is good.

With the exception of chills and fever fifteen years ago, he
120 THE DIAGNOSIS OF ABDOMINAL TUMORS.

has been a very healthy man. For a year he does not think he
has been in his usual health, feeling tired and ont of sorts; but
has had no nausea and no vomiting. For about two months he
has been losing rapidly in weight, and has had uncomfortable
sensations in the abdomen after eating. A month ago jaundice
developed, and has gradually become very intense. He has had
no severe pain. The upper part of the abdomen has been a
good deal swollen. He came to hospital on account of the
jaundice, weakness, and progressive emaciation. Patient pre-
seuted all the characters of severe obstructive jaundice. He is
much emaciated ; skin everywhere of a deep yellow color; no
fever; pulse, 76. The abdomen is distended, particularly in
the apper zone. It is tympanitic in front and dull in the flanks,
with well-marked movable dullness. No peristalsis seen in epi-
gastric region. The prominent tympanitic zone extends as low
as the umbilicus. On deep pressure in the right epigastric re-
gion, between the navel and the costal margin there is a hard
nodular mass, difficult to outline, owing to the distention.
There is enlargement of the lymph glands. The test breakfast
showed the presence of free hydrochloric acid, and the stomach
did not appear to be dilated. Examination of the heart and
lungs was negative. On Octuber 28th and on November Ist he
had some stomach distress, for which lavage was practiced, and
a quantity of dark, coffee-ground-looking material was washed
out. On November 2d it was noted that the distention in this
case was unusual; no coils were to be seen; no peristalsis.
The tympany extended to the fifth rib on the left side, and a
little above the costal margin on the right side. The stools
were clay-colored, rather firm, and he constantly had to take
purgative mineral waters. Microscopically there was some-
times a good deal of fat. There was never any sugar in the
urine, which had the usual characters of this secretion in ob-
structive jaundice.

The intensity of the jaundice, the rapid emaciation, without
enlargement of the liver or recognizable disease of the stomach,
and the presence of a deep-seated tumor mass led to the sug-
gestion of pancreatic disease. The tumor was diffichit to feel
satisfactorily owing to the very great distention of the epigas-
trie region, and as the patient’s physician had suggested that it
was possibly due to gallstones, and as he was himself very anx-
ious that something should be done, Dr, Halsted performed an
exploratory operation. More fluid was found in the perito-
neum than we had expected. The remarkable distention in
the epigastrium was due to the floating up on the top of the
fluid of the colon and small bowel. The gall bladder was found
to be dilated; but the mass which had been felt was a deep-
TUMORS OF THE PANCREAS. 421

seated growth in the situation of the head of the pancreas. The
patient was a good deal relieved by the operation, but no essen-
tial change took place, and he gradually sank, becoming very
intensely emaciated, and died November 18th.

The post-mortem by Dr. Flexner showed the head and body
of the pancreas to be the seat of a tumor mass. The growth
had infiltrated the wall of the duodenum, and the posterior wall
of the stomach was involved directly from the tumor in an area
eight centimetres in extent. The gall bladder and ducts were
much dilated with dark, thick bile.

To the case of possible cyst of the pancreas I shall only
just refer, and show you the chart, as Dr. Halsted, in whose
practice it occurred, will publish it with full details.

The man (Case XLIX), aged about thirty years, was ad-
mitted April 14, 1893, with a greatly swollen abdomen, measur-
ing over forty inches in circumference. His illness dated from
January, 1890, when, without any fall or injury, be had for
three days severe colic, not associated with vomiting or with
jaundice. A month Jater he had a second attack, also lasting
three days; in this one he vomited, and noticed for the first
time swelling of the abdomen.
Then the attacks recurred fre-
quently, two or three a month,
each time with nausea, vomit-
ing, and colic, and the abdo-
men progressively enlarged un-
til July, 1890, after which he
had no further attacks of colic.
The abdomen remained large,
but his general condition was
good and he was able to do
light work. In July, 1892,
he fell out of a wagon, jumped
up, got into it again, but im-
mediately ‘had a severe attack
of colic, and had to go to bed
in a hotel near by for two days.
He had nausea, vomiting, and |
great pain. The swelling gradu- ue ee pancreas (Case
ally disappeared, and in ten XLIX).
days the girth of the abdomen
decreased from forty-three to thirty-one inches. He had pro-
fuse diarrhoea, but he does not think there was pus or blood
in the stools. He gained in weight rapidly, and went to

   
122 THE DIAGNOSIS OF ABDOMINAL TUMORS.

work. He was married in October, and remained well until
January of this year, when he felt his trousers were tight at the
waist; and during the past three months, without colic, vomit-
ing, or jaundice, the abdomen has gradually increased in size.

A truly remarkable history! The man was unusually intel-
ligent, and insisted that his statement about the complete disap-
pearance of the tumor after the fall from a wagon was correct.
When he came under observation the entire abdomen was dis-
tended, particularly in the upper zone; the ensiform cartilage
and the lower ribs were everted. The distance from the tip of
the ensiform cartilage to the navel was 21°5 centimetres; from
the navel to the pubes, 16°5 centimetres. The wall was tense
and elastic; fluctuation was readily obtained. The percussion
outlines are given in the chart. There was resonance only in
the epigastric angle, in the hypochondriac regions, and in the
flanks, Inthe right inguinal region there was an elevated ridge.
Dr. Halsted incised and drained the cyst, which was found ad-
herent to the abdominal wall. Eighteen litres of a dark, cof-
fee-colored fluid were removed, which was alkaline in reaction,
contained granular débris and much altered blood, fresh red
blood-corpuscles, and a few large cells deeply stained with
blood pigment.

The patient had a tardy convalescence, but ultimately
left the hospital in good condition. The diagnosis of pan-
creatic cyst in this case rests rather on general than special
grounds. The gradual development with attacks of colic,
the persistence without serious damage to the health, the
disappearance once after a fall, the gradual reaccumulation
—all point to a retention cyst. There were no features
pointing to loss of the function of the pancreas—neither
fatty stools nor glycosuria. Large pancreatic cysts may fill,
as did this one, the entire abdomen; in long-standing cases
the contents consist, as a rule, of altered blood, and while
an amylolytic ferment, which is not in any way distinctive,
may exist, the trypsin, which would be definite and conclu-
sive, is usually not present.

Many of the cases described as cysts of the pancreas
are really instances of hemorrhage into the lesser perito-
neum. Let me refer you to Mr. Jordan Lloyd’s suggestive
and timely contribution.* From four of his conclusions
you may gather the gist of the whole matter :

* British Medical Journal, November 12, 1892.
MISCELLANEOUS TUMORS. 123

1. “That contusions of the upper part of the abdomen
may be followed by the development of a tumor in the epi-
gastric, umbilical, and left hypochondriac regions.”

2. “That such tumors may be due to fluid accumula-
tions in the lesser peritoneal cavity.”

3. “That, when the contents of such tumors are found
to have the property of rapidly converting starch into sugar,
we may assume that the pancreas has been injured.”

4. “That many such tumors have been regarded as true
retention ‘cysts of the pancreas,’ and that this opinion has
been formed upon insufficient evidence.”

IV. Miscettangous Tomors.—In this group I shall
place seven cases, in two of which the diagnosis was doubt-
ful or could not be definitely made.

(a) A Cyst of the Abdomen of Unknown Origin (Mesen-
teric).—The following case presents many remarkable fea-
tures. For more than two years he has had recurring disten-
tion of the abdomen, which reaches such a size that he has
to be tapped. With the exception of the period of onset,
from October to December, 1891, during which he lost about
fifty pounds in weight, he has remained in excellent condi-
tion, and is inconvenienced only by the bulk of the fluid as
it accumulates. He has usually gone to work the day after
the tapping. The physical signs are those of a cyst. The
dullness is in the front of the abdomen, with resonance in
the flanks. He was tapped eight times in 1892, and five
times up to date this year. The quantity removed has
varied from one gallon to five gallons and a half. At the last
two tappings the amount has been only a gallon and a gal-
lon and a half. At first the fluid was dark and bloody, but
since the second aspiration it has been a turbid, muddy-
looking fluid, alkaline in reaction, containing leucocytes in
a condition of disintegration, much granular and molecular
débris, and very many cholesterin crystals. I regret that
no chemical examination was made of the digestive proper-
ties of the sample of the fluid which was sent to me. Dr.
Miller has reported recently that the patient is in the best
of health, and the amount of fluid is gradually diminishing.

Case L. Cyst of Doubtful Origin.—November 29, 1892. I
saw to-day the following very unusual and remarkable case:
X. F., aged forty-four years. Referred to me by Dr. G. B.
124 THE DIAGNOSIS OF ABDOMINAL TUMORS.

Miller, of Philadelphia. Patient is a large-framed, stout man,
looking the pictare of health.

Family history is good. His personal history is also excel-
lent. He had the usual diseases of childhood; scarlet fever,
bat not a very severe attack. He Las had two attacks of gon-
orrhwa; has never had syphilis. He has been married ten
years; no children. He uses alcohol moderately; has never
been a heavy drinker. At times during the past six or eight
years he has had “ gouty” pains about the joints. In October,
1891, he noticed that he was getting uncomfortably large in the
abdomen, and for this he tvok three bottles of some “reduction
remedy,” and lost in weight everywhere except in the abdo-
men, which became progressively enlarged. He then consulted
Dr. Loeling, who told him he had fluid in the abdomen. He
kept at work, however, until December, feeling weak and hav-
ing occasional attacks of nausea and vomiting. The distention
of the abdomen became so extreme, in spite of active catharsis
and diuretics, that, on December 26th, he was tapped and five
gallons and a half of a dark, bloody fluid withdrawn. An ex-
amination of the abdomen after removal of the fluid failed to
reveal any hardness, tenderness, or tumor. The urine at this
time was negative. He lost in weight from two bundred and
fifty pounds to two hundred and two pounds. After the first
tapping he gained in strength, and very quickly went to his
business. Gradually, however, throughout January the fluid
reaccumulated, and on February 14, 1892, he was again tapped,
and three gallons of dark, bloody fluid removed. Witbvut any
aggravation of his general condition, and without any special
interference with his business, the fluid continued to reaceu-
mulate at intervals, and he was tapped on the following dates:
March 25th, five gallons and a quarter; May 5th, five gallons
and a half of dark serum ; June 12th, one gallon; June 22d, dry
tapping, no fluid was obtained; July 9th, twenty-eight pounds;
August 12th, three gallons and a half of muddy, turbid fluid;
October 4th, twenty-six pounds of turbid, muddy fluid; No-
vember 22d, last tapping, three gallons removed. He has felt
no inconvenience from the tappings, and has usually resumed
work on the following day. The only trouble has been the
gradual increase in the size of the abdomen, which causes short-
ness of breath on exertion and a feeling of tension. He has
never at any time had swelling of the feet; the bowels have
been regular; the appetite has been lately very good, and, as a
rule, with the exception of a short period this summer when he
got pale and thin, he has been in very good health and has
been able to attend to his work systematically.

Present Condition —As stated, the patient is a large-framed,
MISCELLANEOUS TUMORS. 195

powerfully built man, looking the picture of health. The color
is good; the venules on the cheeks are somewhat marked; the
tongue is clean; the pulse is quiet, 78 a minute; tension moder-
ate; no sclerosis of the arteries.

The abdomen is moderately full, but not larger than is fre-
quently seen in a man of his build. It is symmetrical, not spe-
cially prominent in any region. The pulsation of the abdominal
aorta is not transmitted to the surface; respiratory movements
of the abdomen are natural. There is no special enlargement
of the superficial veins. The inguinal glands are not enlarged.
On palpation it is everywhere soft and painless. No tumor
masses or areas of specially increased resistance are to be felt.
On deep palpation below the right costal margin, and during
inspiration, the edge of the liver can be touched. Fluctuation
can not be obtained.

On percussion the entire front of the abdomen is flat, and
only on the deepest percussion in the region of the navel is
there flat tympany. The dulloess continues into the left flank,
but there is a flat tympany high up beneath the tenth and
eleventh ribs, and this is continuous in the left hypochondriac
and left epigastric areas with the stomach tympany. In the
right flank, between the costal margin and the ileum, there is
resonance. On turning from side to side, resonance on the left
side becomes more extensive, that on the right side not much
changed. In the nipple line the liver dullness begins at the
lower margin of the sixth rib, and there is no tympanitic note
below the costal margin. The flat note extends to the pubes.
In the erect posture there is tympany in the epigastric and lett
hypochondriac regions, and on the left side beneath the lower
ribs.

The material removed at the last tapping was turbid, some-
what creamy looking. On microscopical examination it con-
tains numerous leucocytes in a condition of disintegration,
larger cells in a state of advanced fatty degeneration, and very
numerous cholesterin crystals.

Of course the first thought in this case that suggested
itself was that the condition was an anomalous form of
ascites, due either to chronic peritonitis or to liver disease.
The patient’s history, the absence of any trace of jaundice,
the retention of general nutrition, and the absence of any
evidences on examination of enlargement or contraction of
the liver seems definitely to rule out hepatic disease—cir-
rhosis, perihepatitis, or tumor. Nor did it seem likely
that any of the known forms of disease of the peritoneum
196 THE DIAGNOSIS OF ABDOMINAL TUMORS.

itself could cause recurring ascites without serious deterio-
ration in the health, tuberculosis, cancer, or those remark-
able forms of epithelial papillomata involving chiefly the
omentum to which Lawson Tait refers.

On the other hand, the existence at first of a bloody
fluid, the filling of the abdomen repeatedly without serious
damage to the health, the readiness with which the patient
gets up and goes about immediately after the tapping, the
physical examination, the presence of cholesterin in the
fluid, suggest strongly the existence of cystic disease, either
of the omentum or of the pancreas, most probably of the
former.

January 26, 1898.—Patient looks in robust health. Abdo-
men full, but not so much as at former visit. Everywhere soft,
but more resistant on the right side; and on deep pressure to
the right of and a little above the navel there is an ill defined
mass. No definite fluctuation obtained. Percussion is clear in
epigastric and upper umbilical region and to the left side shading
off toward the middle of Poupart’s ligament. Dull in hypo-
gastric, right iliac, right lumbar, and right half of umbilical,
and when he turns on the deft side the dullness persists and the
bowel tympany on the left side is exaggerated.

Tapped again April 8, 1893, and only fifteen pounds of fluid
removed. He was tapped June 17th, three fourths of a gallon
removed; October 1st, a gallon and a half; and November 26th,
one gallon removed.

Additional Note, February, 1894 —He had been doing very
well, and had been tapped only once since last date. One Fri-
day, during a business trip, he felt very ill on the train, and had
a great deal of abdominal! pain and vomiting that night. There
was no very special distention of the abdomen, but there was a
great deal of sensitiveness on palpation. Attempts were made
in various ways to move the bowels without any effect. On
Saturday he was very much worse, and seemed collapsed and
feeble. There were a few small discharges from the bowels,
chiefly of blood. There was not very great abdominal disten-
tion. He had vomiting and great depression, which increased,
and he died on the Sunday evening.

Through the kindness of Dr. Loeling and Dr. Miller I was
notified of the post-mortem and was present. The body was
that of a large-framed, well-nourished man. The panniculus
over the abdomen was at least two inches and a half in thick-
ness. There was no special distention of the abdomen.
MISCELLANEOUS TUMORS. 127

Peritoneum: No exudation, serous or fibrinous. In the
right iliac and lumbar regions there was a large cyst, the ante-
rior wall of which was adherent in several places to the abdomi-
nal wall, and in addition there were several strong bridles of
adhesions, one, the longest, from the left side of the cyst to the
peritoneum in the neighborhood of the left crest of the lium.
Two groups of fibrous bands passed from the left cornu of the
eyst to the abdominal wall, just to the left of the navel. There
were also one or two smaller bands of adhesions, and at one
point the upper part of the jejunum was closely adherent to the
top of the cyst. After freely exposing the peritonwum by a
crucial incision the cyst was seen occupying the position already
mentioned. In the lumbar region there were several coils of
the small intestine which had passed beneath the bands of ad-
hesion, uniting the left cornu of the cyst with the abdominal
wall near the navel. There were two different loops through
which the coils of intestine had passed; one anterior, through
which about eight inches of the jejunum had passed and the
intestine was only slightly reddened, whereas through the pos-
terior loop about eighteen inches of the upper part of the ileum
had passed and had become strangulated. The coils were of a
deep maroon color, swollen and infiltrated, and the attached
portion of the mesentery was enormously thickened and also
plum-colored. The peritonzum over these strangulated coils
was smooth, there was no fibrinous exudate, and they could be
withdrawn without any difficulty through the snare.

The intestines were then removed as far as a foot above the
ileo-cecal valve. They presented nothing of note except in the
strangulated portion just described. After their removal the
position of the cyst could be clearly determined. It was of
about the size of a man’s head, occupied the right iliac and right.
lumbar regions, and extended to the left beyond the middle line.
It lay directly upon the spine and on the lumbar and iliac mus-
eles on the right side. The hand could be placed beneath it,
and it could be lifted readily from its bed. The lower foot of
the ileum was closely attached to its left and lower margin ;
below was the cecum, and the appendix formed a long, flat-
tened, cord-like structure passing up its posterior wall. The
ascending colon lay along its right side. The tumor lay in the
mesentery of the last foot or eighteen inches of the ileum, and
it was removed very readily by stripping the ascending colon
and cecum from its attachment to the peritonaum. The sac
had a grayish-white appearance, except at its left side, where it
was stained of a greenish color. There were no other adhesions.
except those mentioned to the parietal peritonzum and to the
jejunum. It was a little roughened and puckered in places,
128 THE DIAGNOSIS OF ABDOMINAL TUMORS.

When it was laid open, the fluid was a little turbid and slightly
blood-stained.

(b) Multiple Tumor Masses in Abdomen ; Phantom Tumor
Casz LI.—Mrs. E., aged fifty-two years, admitted June 8,
1898, complaining of a swelling below the right jaw, pain in
the abdomen, and of having vomited blood. There is nothing
of note in her family history.

She has had eight children; four are living. She has never
been a very strong woman. Fourteen years ago she had a sub-
mucous uterine fibroid, which wasremoved. Twenty-eight years
ago she had a severe attack of typhoid fever. In October of
1891 she had diphtheria, which was followed, she says, by a
lump at the angle of the right jaw. Shortly after this, too, she
began to have occasional pains in the abdomen. In October,
1892, after a period of a good deal of excitement and worry,
she had what was called brain fever, and was unconscious for
two weeks. She was in bed at this time for nearly three
months, partly in consequence of a carbuncle on the back.

She dates her present illness from about February of this
year, when she had a great deal of oppression atter eating,
sometimes nausea, which were unusual symptoms. She also
had at times straining at stool and a desire to go very frequent-
ly. The dyspeptic symptoms increased, though she never had
severe pain. Four weeks ago, after a day or two of much dys-
peptic trouble, she had an attack of vomiting after breakfast,
and brought up a large amount of black, clotted blood. Her
appetite has been poor, and she has had a great deal of erncta-
tion and pain after eating, relieved sometimes by the use of
soda. For a week before her admission the right foot began to
swell. Within the past six months a tumor mass has developed
below the right jaw. Her condition on admission was as fol-
lows: Much emaciated; sallow complexion. Attached in
front of the angle of the right lower maxilla is a group of en-
larged glands, which extend over the jawbone on the cheek.
The whole mass can be readily moved; the skin is a little red-
dened; the individual glands can be felt. The supraclavicular
glands are not enlarged. The abdomen looks a little full. The
right epigastric vein is much distended with blood; the left
vein not quite so large. The current in both is from below up-
ward. In the epigastric region to the left of the navel several
nodular masses can be seen beneath the skin. There is no
peristalsis visible. On palpation to the left of the navel, there
is a solid, somewhat cord-like mass, about six centimetres in
length, which extends in an oblique direction toward the axilla.
It is very firm and hard, superficial, and feels as if attached to
something beneath, as it is only partially movable. No gas is
MISCELLANEOUS TUMORS. 129

felt bubbling in it. Just above and to the right of the navel is
a firm mass which is more difticult to imit and define. Midway
between the navel and the ensiform cartilage is a soft, button-
like mass which at intervals projects beneath the skin, and then
suddenly relaxes with a sizzling sound. In a few moments it
appears. bardens into an ovoid, resistant body about three
centiinetres in lateral extent, and then relaxes again with a
sound of gas bubbling in it. The right inguinal region is oecu-
pied by a large nodulated mass feeling like a collection of
lymph glands. The left inguinal glands are somewhat enlarged.
She had no diarrhoea; the stools were liquid, grayish-brown in
color. The rectal examination was negative.

The patient remained under observation for two wecks, and
no essential change took place in the condition. There was no
dilatation of the stomach. The tumor masses above described
were very evident.

She left the hospital on June 30th, unimproved.

In many respects no case in the series was more inter-
esting than this one, but a definite conclusion as to the seat
of the primary disease did not scem possible. Naturally,
with dyspepsia, belching, loss of appetite, and progressive
emaciation, one suspected the stomach to be the seat of the
malady, the more so with an account of an attack of vomit-
ing in which she brought up a large amount of clotted
blood. While under observation in hospital, the condition
was not such as to justify putting her to the worry of a
test breakfast. Not one of the tumors in the abdomen was
apparently connected with the stomach itself, nor were
there signs of dilatation. The tumors were rather like
masses of enlarged lymph glands. The enlargement of the
glands in the right side of the neck dated, she insists, from
the diphtheria in October, 1891, but they had enlarged
very much since February. The supraclavicular glands
were not especially enlarged. Altogether we inclined to the
opinion that there was a new growth in the stomach with
extensive secondary lymphatic infection. By far the most
striking feature in the case was the phantom tumor appear-
ing and disappearing midway between the navel and the
ensiform cartilage. Every minute or two it would emerge
beneath the skin like a button, get firm and hard, assume
an ovoid shape, and then, as one watched it, relax and dis-
appear with a sizzling noise, which could be heard as well

9
130 THE DIAGNOSIS OF ABDOMINAL TUMORS.

as felt. Of course such a tumor is only felt in connection
with the tubular muscle of the gastro-intestinal canal, and
in this case it was in all probability a limited portion of
the coat hypertrophied on the proximal side of a constric-
tion, caused either by a new growth at the attachment of
the mesentery, or by some narrowing neoplasm in the wall
itself. There was admitted yesterday to the ward a case in
which you can study another remarkable phantom muscle
tumor. The young man has a well-marked history of ulcer,
with vomiting of blood and hyperacidity of the gastric
juice. The stomach is somewhat dilated, and in the epi-
gastric region there appears at intervals, readily seen be-
neath the skin, an ovoid tumor, four to five centimetres in
length, which lifts the abdominal wall definitely, and then
in a few moments relaxes and disappears. When visible it
is very firm and hard, and when relaxed it can only just be
felt.

(c) Uterine Fibroids.—It speaks well for the differentia-
tion of the cases in the hospital that, so far as I know, the
following is the only instance of tumor associated with the
female pelvic organs which came before me for examina-
tion. This, too, was rather by accident. As she had tu-
berculosis of the lip and tongue, the question was raised
whether the abdominal condition was not due also to tuber-
culosis :

Case LII. Tuberculosis of the Lip and Cheek ; Multiple Tu-
mors in the Abdomen.—The patient, aged about forty years, was
admitted for tuberculosis of the lip, tongue, and cheek. The abdo-
" men was distended, and I was asked to see her to determine the
nature of the masses which could be felt. She stated that they
had been present for many years, and had never given her any
trouble. The characters were very definite. The lumbar, iliac,
the greater part of the umbilical, and the entire hypogastric
regions were occupied by solid masses, which in the iliac re-
gions presented several rounded movable prominences. The
uterus was firmly fixed, and the whole pelvis appeared blocked
with the masses. One point only was of interest in connection
with the differential diagnosis of tuberculous peritonitis. In
the iliac regions palpation was much softer, and the areas of
resistance were separated by distinct intervals, and only on
deep pressure could solid, uniform masses be felt. On percus-
sion, there was a flat tympany, such as one finds not infre-
MISCELLANEOUS TUMORS. 131

quently when tuberculous tumors are scattered about among
the coils of intestines. Here the history, the character of the
masses, and the persistence for more than a duzen years were
quite sufficient for the diagnosis.

(d) Sarcoma of the Abdominal Wall.—The following case
is uncommon in my experience and is worth placing on
record. Not only was there a large, massive, subcutaneous
tumor in the lower umbilical and upper hypogastric regions,
but there were secondary nodules beneath the skin of the
other parts of the body.

Case LIT. Sarcoma of the Abdominal Wall; Numerous
Subcutaneous Metastases—Mrs. A., aged fifty-two years. The
patient had been a healthy woman, had worked hard, and
brought up a large family. For two months previous to my
consultation with Dr. Atherton, of Toronto, August 24th, she
had suffered with diarrhoea and attacks of dyspepsia. The fre-
quent movements have persisted. There was considerable nau-
sea during last month, and vomiting occurred frequently after
eating or drinking. She said she felt full, and could not hold
much in the stomach. Within the past two months she had
lost flesh rapidly and had become very weak. When first seen
by Dr. Atherton, August 9th, the tumor about to be described
was present. The examination by him of the pelvic viscera was
negative. There was no cancer of the breast.

The patient was a medium-sized woman; looked emaciated,
searcely cachectic; was somewhat pale; tongue furred. Noth-
ing of special moment about the circulatory or respiratory sys-
tems. The pulse was a little rapid, but of fair volume, some-
what irregular. Slight cough and some bloody expectoration,
which continued until her death.

On exposing the abdomen there was seen a remarkable con-
dition of the abdominal walls. While the portion above the
navel looked normal, below this point there was a large mass
occupying the lower umbilical, the whoie of the hypogastric
region, and extending into the inguinal regions. The skin was
not discolored and showed the lineg albicantes.

On superficial inspection it might have been taken for a some-
what unusual localized development of the fatty panniculus. On
palpation the mass was felt to be firm, hard, involving the skin
(which could not be moved separately), and presented a curious
nodular feel, suggestive rather of bunches of lymph glands, or
of the sensation given by touching the lobulated kidney of a
sheep. With this there was also a feeling of massiveness and
solidity, as if the tumor extended through the subcutaneous tis
1382 THE DIAGNOSIS OF ABDOMINAL TUMORS.

sues. The mass sloped, as it were, gradually toward the pe-
riphery, and here the nodules were more isolated, and in lines
running obliquely toward the false ribs. There were chains of -
these little nodules, like lymph knots. The whole surface of
the body seemed tender and painful on palpation. She com-
plained bitterly of pain after much handling of the mass. There
were nodules also beneath the skin of the right breast, one or
two in the right thigh, and several in other parts.

Dr, Atherton writes that he saw her for the last time on
September 3d, and that she died on September 17th. The
daughter states that diarrhcea and vomiting continued, but no
blood was passed at any time. For a few days before death
“blue lumps,” of about the size of a small bean, appeared in
various parts of the trunk and extremities, which were tender
and painful, like those seen by us.

Whether or not this growth was primary in the abdomi-
nal walls is impossible to say in the absence of details
which could be furnished by the autopsy alone. She had
had gastro-intestinal trouble, but not such as pointed to
malignant disease of stomach or bowel.

(e) Tumors of Doubtful Nature.—In none of the follow-
ing cases did it seem possible to arrive at a satisfactory
diagnosis. The salient points are as follows:

Case LIV. Dysentery; Two Tumor Masses in Abdomen.—
Samuel T., aged about forty years, seen with Dr. F. R. Smith,
November 17, 1892, complaining of a Jump in the abdomen and
diarrhoea. His general health has been excellent, and his fam-
ily history is good. He had typhoid fever when nine years of
age. Ten years ago he was caught between two cars and in-
jured about the hips and legs. He was laid up at this time for
four months and had a dull pain in the right side, which has
recurred at intervals, but never prevented him from working.
Two months ago he appears to have had an attack of acute
dysentery, frequent passages, and swelling of the legs. Ie was —
in bed for six weeks. As late as October 17th of this year he
passed blood in the stools. He now has no swelling in the
legs; appetite is good; bowels regular; and he has gained in
weight and looks well, perhaps a little sallow. He has had no
fever; tongue is clean. No enlargement of the lymph glands.
In the right upper quadrant of the umbilical region, extending
into the adjacent hypochondriae and lumbar regions, there is a
firm, resistant mass, which reaches to about two centimetres
below the level of the navel, and to the right can be felt as far
MISCELLANEOUS TUMORS. 133

out as the tip of the tenth rib. To the left it does not quite
reach to the middle line. On bimanual palpation it is freely
movable, It is not well felt below the ribs behind, but on deep
pressure it can be pushed forward, and then is distinctly mov-
able. It can be readily separated above from the liver, the
edge of which is easily to be felt. In the hypogastric region,
just above the pubes, and to the right of the middle line, there
isa second tumor, feeling about the size of an orange, some-
what elongated. To the right it appears to have a definite
ridge-like edge. The percussion
is everywhere resonant, and a
clear note is elicited over both
tumors, except for a short space
to the right of the middle line -
over the one in the hypogastric
region. Neither spleen nor liver
dullness is increased. There is
no dilatation of the stomach.
The urine is clear and he has
passed no blood, and there is no
albumin; no tube casts.

The patient was seen again
January 10th. General condi-
tion has been excellent, and he
has been at work. There is no
eachexia. The tumor masses
previously noted were present
with great distinctness. The yg. 37,—gituation of the tumors in
lower one appeared to be scarce- Case LIV.
ly so large as on previous exami-
nation. In the left inguinal region, about three centimetres
from Poupart’s ligament, there is a freely movable, subcu-
taneous nodular body about the size of a bean. The inguinal
glands are not enlarged.

 

Tt did not seem possible to arrive at any conclusion as
to the nature of these tumors. The strongest possibility
seemed to be of their connection with the intestine, as he
had had tenesmus, diarrhea, and melena, but the patient’s
excellent general condition and rapid improvement would
seem to contraindicate new growth.

While preparing this lecture for the press this patient
was seen (December 20th), His condition remains excel-
lent and he has been steadily at work. The lower tumor
is no longer palpable; the upper is still quite distinct,
184 THE DIAGNOSIS OF ABDOMINAL TUMORS.

though smaller than at date of former note. Its position
is unchanged.

The following case I regarded at first as tumor of the
stomach, but on subsequent examination it seems to be ex-
tremely doubtful whether it is really in this organ:

Case LV. Tumor Mass in the Epigastrium of Doubtful Na-
ture.—Kate H., aged forty-one years, admitted August 29, 1893,
complaining of pain in the left side and swelling in the epigas-
trium. There is nothing of moment in the family history. She
has been healthy with the exception of typhoid fever at twenty-
one and pleurisy last winter. She has had at times irregular
cramps in the abdomen. For several years she has had dyspep-
sia, suffering with belching after eating and slight discomfort.
Ten months ago she had an attack of severe pain in the epigas-
trium, with nausea and vomiting, and was in bed for a week.
In the next two months she had four similar attacks, which
lasted about a week. Some of these attacks, the doctor said,
were due to gallstones. About two months ago she first
noticed the swelling in the abdomen which is now present.
She does not think it has increased in size. She never has
been jaundiced ; bowels are regular; passes a normal quantity
of urine. Iler chief complaint is of a dull pain below the left
costal margin. She is a fairly well-nourished woman ; lips and
mucous membranes are pale; tongue is coated. The abdomen
is distended, chiefly in the epigastrium and in the right hypo-
chondriae region, in which there is a smooth prominence. On
palpation this corresponds to a rounded, hardened, somewhat
nodular tumor, which in the middle line feels quite smooth and
on the right side is more irregular. In the nipple line there is a
marked ridge to be felt midway between the costal margin and
the transverse navel line. The liver dullness begins at the sixth
rib and continues directly into this prominent tumor mass. At
first it was thought that this represented an enlarged liver, bat
on September 2d, on palpation, gurgling sounds were noted “in
the prominent tumor in the epigastrium, and to-day it is every-
where resonant. The gurgling can be felt in this solid mass
with the greatest distinctness. The tympany reaches as high
as the base of the ensiform cartilage.” Ewald’s test breakfast
showed the presence of free hydrochloric acid. This case in-
terested us extremely from the remarkable simulation of the
outline of the tumor mass to that of an enlarged liver.

On September 5th the following note was made: ‘There
is a very distinct prominence below the costal margin in right
epigastric and right hypochondriac regions. On palpation, a
firm, resistant mass fills the upper zone of the abdomen, the
MISCELLANEOUS TUMORS. 135

outline of which resembles quite accurately that of an enlarged
liver. Beyond the left parasternal line no very distinct edge
is to be felt, but toward the right, as she draws a deep breath,
there is a distinct nodular edge. The entire mass descends with
inspiration. The resonance is not so extensive to-day; it does
not reach beyond the right parasternal line. After inflation the
stomach tympany extends two fingers’ breadth below the navel,
and there is in the left epigastric and the left upper quadrant
of the umbilical region the outline of a dilated stomach.”

When resonance was first noticed in the mass below the
ensiform cartilage we thought that possibly extensive infiltra-
tion of the stomach wall existed; but the patient has been un-
der observation on several occasions since, and she has gained
in weight, looks well, free hydrochloric acid is present in the
gastric juice, and after inflation the resonance is not more tym-
panitic, and the stomach outlines seem somewhat below the
mass. Altogether there was doubt enough to exclude the case
from the stomach list, and I place it here among the miscellane-
ous tumors of doubtful nature.

(f) Aneurysm of the Aorta.—And lastly, not the least
interesting of the miscellaneous tumors was a large saccu-
lated aneurysm of the abdominal aorta.

Case LVI.—Lee K., aged sixty-seven years, admitted July
5th, complaining of a ‘fluttering lump” in the abdomen. With
the exception of scurvy and rheumatism during the civil war
he has been a very healthy man. Ue is temperate and denies
venereal disease, bat there is a distinct cicatrix just beyond the
glans penis.

Present Itlness.—For three years he has noticed a lump in
the abdomen, which for the past two years has been painful,
and which he says has lately increased in size. He has a dull,
steady, gnawing pain in the tumor itselff and more or less pain
in the back. The pain and throbbing sometimes nauseate him,
particularly after eating, and he has vomited twice in the past
two weeks. Bowels are constipated; he has severe headaches,
and has had occasional bleeding from the nose. He is short of
breath on exertion. Patient is a very vigorous, healthy look-
ing man; well built; well nourished; musculature above the
average. The conjunctive are a little watery and yellow; pu-
pils are equal. Pulse regular, equal in both radials; the arter-
jes thickened; can be rolled under the finger; pulse wave can
not be obliterated. The brachial arteries are tortuous. The
examination of the lungs is negative. The apex beat of the.
teart is seen in the fifth interspace, just outside the nipple line
136 THE DIAGNOSIS OF ABDOMINAL TUMORS.

jt is forcible and well defined. The sounds are clear; the first
a little thudding, and both somewhat accentuated at the base.
Abdomen.—tin the epigastric and upper part of the umbilical
regions there is an irregularly rounded prominence, which pul-
‘sates forcibly and almost synchronously with the heart impulse.
Tt has a transverse diameter of 8°5 centimetres; vertical nearly
eight centimetres. It is perhaps a little more prominent to the
right than to the left of the middle line, and on the right side
almost obliterates the groove below the right costal margin. On
palpation it feels smooth, yields to firm pressure, expands forcibly
and in all directions. There is at times a distinct systolic thrill.
The borders are everywhere rounded and it seems to dip down
rather sharply just above the umbilicus. The tumor is not in-
fluenced by the knee elbow position, The whole mass can be
grasped in the hand and the expansion in that way very readily
felt. It is unusually mobile laterally. It can be moved to the
right, so that its left border is at the middle line. It can not be
moved to the left quite so far, but far enough so that it pulsates
under the left costal margin. The up and down movements are
very slight: it is not influenced by respiration. There is dull-
ness on light percussion over the top of the mass, and in a cir-
cle the diameter of which would
be five centimetres. Beyond
this there is tympany on all
sides. On auscultation there is
“sa lond systolic bruit heard every-
where over the tumor. There is
no definite diastolic shock. The
condition of the liver, spleen,
and other parts of the abdomen
is negative. The diagnosis of
aneurysm of the abdominal aor-
ta was made by Dr. Hewetson,
under whose care the patient
first came, and subsequently,
when I saw him, the doubt arose
in my mind, owing tu the ex-
treme mobility, whether it was
really in the aorta, or whether
Fig. 38.—Position of the aneurysm. it might not be connected with
The dotted outlines illustrate the one of the branches—the tumor
extreme mobility. Case LVI. seemed remarkably mobile, and
could be pushed so far from left
to right. Dr. Halsted, too, thought that the tumor might pos-
sibly be in one of the branches; and as the patient consented he
did an exploratory operation, The tumor was found to spring

 
TUMORS OF THE KIDNEY. 137

directly from the aorta just above the renal arteries. The
pedicle of the sae was short and almost as wide as the aneurysm
itself. It was thought better to leave the case to Nature than
to attempt any measnres to promote consolidation in the sac.
The patient recovered rapidly from the operation and left the
hospital in about ten days. :

Aneurysm of the abdominal aorta is rare. This is the
first one which has been under our observation since the
hospital was opened, during which time there have been
between forty and fifty aneurysms of the thoracic aorta in
the wards. The diagnosis here was readily made; the tu-
mor was so pronounced, so rotund, so expansile in all direc-
tions, and with a well-marked thrill and systolic bruit—no
single feature of aneurysm was absent. The mobility alone
was unusual; not one of the few aneurysms in this situa-
tion which I have seen presented such remarkable mobility.

A few weeks subsequently I saw in Montreal with Dr.
Shepherd a patient who had progressive ansmia and de-
bility with great abdominal distention and pain. An ab-
dominal tumor had been suspected, but the tympany and
distention of the stomach and bowels prevented any satis-
factory examination. She became more anemic and died
the day after I saw her. Through the kindness of Dr.
Wyatt Johnston, I saw the specimen, which proved to be a
large aneurysm of the abdominal aorta which had com-
pressed the duodenum, causing great dilatation of the stom-
ach, It had ruptured at one edge and haemorrhage had
taken place into the retroperitoneal tissues.

Leorore VI.
Tumors or THE Kipyey.*

Nowuegrz is the close interdependence of medicine and
surgery better illustrated than in the diagnosis and treat-
ment of tumors of the kidney. A very large proportion
of the cases come first under the care of the physician,
whose province it is to recognize the condition; but to do

* Concluding lecture of the course. Delivered Dee. 26, 1893,
188 THE DIAGNOSIS OF ABDOMINAL TUMORS.

justice to his patient he should be thoroughly familiar with
the advances which have been made in the department of
renal surgery. Let me first call your attention to the diag-
nosis of certain conditions associated with—

I. Movagste Kipyey. (a) Errors in the Diagnosis of
Movable Kidney.—I have no statistics to offer with refer-
ence to the frequency of movable kidney, but throughout
the session you have had many opportunities of noting its
commonness—so common, indeed, that we are never with-
out examples in the wards. A majority of the cases pre-
sent no symptoms whatever. Others complain much of
dragging pains in the back, with neuralgia, epigastric dis-
tress, and general nervousness; many of neurasthenia with
dyspepsia; and one often finds, particularly in women
who have borne children, the condition to which Glénard
has given the name enteroptosis. In a thin person, male
or female, who presents the general features of neurasthe-
nia, you will be almost certain to find, on examination, mo-
bility of one or other, or of both the kidneys. Inability to
lie comfortably on the left side, and paroxysmal attacks of
pain such as I shall describe in a few moments, are less
frequent symptoms. It is ditlizult really to determine how
far all these features are dependent on the renal condition
It is quite possible that the pains and uneasy feelings may
be due to stretching and tension of the tissues in the neigh-
borhood of the great abdominal nerve plexuses; but one
not infrequently meets with cases of the most extreme mo-
bility without any symptoms whatever. It may be that, in
persons with a debilitated and bankrupt nervous system, the
tension caused by the dragging of a movable kidney may
be at once felt, just as many persons find the first indica-
tion of physical fagging in subjective sensations of the
movement of the heart, of which in health we are not cog-
nizant. The text-books and monographs now contain a full
and satisfactory account of the condition, but I wish to call
your attention to some less widely recognized features in
connection with it.

While in the great majority of all cases movable kidney
is quite unmistakable, there are cases in which its recogni-
tion is by no means easy. You will remember that in Case
V we made a somewhat serious faue pas, and thought that
TUMORS OF THE KIDNEY. 139

an unusually mobile pyloric tumor was a movable kidney.
A more frequent error is the mistaking of it for a dilated
gall bladder. I have already alluded to this, and in Lec-
ture IV have spoken of the points to be attended to in the
diagnosis. Here I may mention a case of a good deal of
interest in which this error was made, and the operation
for dilated gall bladder performed by Mr. Tait.. The pa-
tient, a doctor from California, consulted me in 1888 about
a lump in the abdomen, the nature of which had puzzled a
large number of physicians. Jt had been present for ten
or eleven years, and had appeared first after a somewhat
severe attack of sea-sickness. He had suffered a great deal
with nervous troubles and dyspepsia, and when I saw him
there were signs of dilatation of the stomach. The posi-
tion, mobility, and general characters made me feel tolera
bly certain that the tumor was a movable right kidney, and
with this opinion the late Dr. Agnew coincided. The diag-
nosis relieved his mind very much, and he improved, so
far as nervous symptoms were concerned. Subsequently
he grew worse, and in the spring of 1890 he consulted Mr.
Tait, who diagnosticated dilated gall bladder, and made an
exploratory incision. The gall bladder was normal, and the
kidney, so he stated, was iz situ. Subsequently the patient
came under the care of Dr. C. O. Baker, of Auburn, N. Y.,
who found the tumor very evident, made a diagnosis of
floating kidney, and performed nephrorrhaphy, with great
relief to the patient. The case is reported in the Medical
Record for May 14, 1892. The patient died in September
of this year (1893) of empyema, and in the post-mortem
notes, which were very kindly sent to me, the statement
about the kidney is: “ Right organ in normal position, held
by firm union; nephrorrhaphy had been performed for
floating kidney.” There is no mention made of enlarge-
ment of the gall bladder.

With very pendulous and lax abdominal walls and an
unusually mobile right kidney there may be at first. dif_i-
culty in separating clearly the right lobe of the liver and the
kidney. In the following case I was at first in doubt:

Case LVI. Movable Kidney, simulating a Local Growth in
the Right Fiank; Right Lobe of Liver mistaken for Right
Kidney.—Jane E. G., aged fifty-two years, seen with Dr. IIew-
140 THE DIAGNOSIS OF ABDOMINAL TUMORS.

etson, in the Medical Dispensary, September 25, 1892, com-
plaining of cough and pains in the back and side and headache.
She is pale and somewhat emaciated, and looks ill. Lips and
mucous membranes are, however, of a good red color. She has
borne nine children. She has lost in weight during the past six
months. There are no abnormal physical signs in the thorax.
tn the examination of the abdomen there was detected a solid,
nobile tumor in the right side, which was not thought to be
‘he kidney, as it was believed that this organ could be also felt
atheflank. On the examination, I found a well-marked, readily
novable tumor, just at the right of the navel, and, on bimanual
salpation, the right kidney could, I thought, also be felt. The
eft kidney was readily palpable. As I was unable to satisfy
nyself as to the nature of the mass, I asked to see her again
on the 28th.
Examination.—Patient is thin; not cachectic. The abdomen
s pendulous, and the walls are very lax. On the right side, a
-ittle above the line drawn from the anterior superior spine to
the navel, a movable tumor can be felt, somewhat rounded in
shape, about the size of an orange, not distinctly reniform, but
with a slight depression on the right side. It can be pushed up,
but not entirely, beneath the ribs, and it does not slip into posi-
tion like a floating kidney. Below it can be pushed down so as
partially to pass the line joining the anterior superior spines.
To the left it can be pushed over to the middle line. It is not
painful. Examination of the right renal region showed a de-
pression below the ribs behind, but, on bimanual palpation, the
flank appeared to be filled with a solid mass. Careful examina-
tion, however, determined that this was not, as suspected on
the first examination, the kidney, but in reality part of the
right lobe of the liver, the ligaments of which were much re-
laxed. An edge could be distinctly felt; to the right the lobe
was ill-defined, and it could not be made to slip up in the way so
characteristic of movable kidney. On the left side the kidney
was readily palpable, and, on deep inspiration, depressed so
much that the fingers could almost be inserted above the upper
border.

I have no doubt that in this case the tumor in the right
side of the abdomen was the kidney, and that the mass felt
in the right flank represented in reality the right lobe of
the liver.

Among the scores of cases of movable kidney which
have come under my observation I do not remember one in
which the condition was exactly as presented in this patient.
TUMORS OF THE KIDNEY. 141

At the first examination I felt sure that a kidney was pal-
pable in the renal region, but the more careful subsequent
examination convinced me that I had been in error.

I have already called your attention to the elongation
of the edge of the right lobe of the liver as a cause of an
anomalous tumor mass in the right flank, and mentioned
the case in which laparotomy was performed by Dr. Kelly
for an obscure tumor, which proved to be the thinned-out
edge of the right lobe.

In the following case I erred in thinking that a tumor
in the right side of the abdomen was a dislocated and fixed
kidney:

Case LVI. Tumor in Right Side supposed to be a Dislocated
and Fixed Kidney ; Gradual Disappearance —Mrs. H, O., seen
December 9, 1892, with Dr. Arthur Williams, of Elkridge, Md.

J saw this patient first in October, 1891, when she consulted
me for pains in the abdomen. She had always been in good
health as a girl; had been married twelve years; had four chil-
dren, the youngest three years of age. Six months ago she be-
gan to have pain in the abdomen, chiefly in the epigastric re-
gion, and radiating to the back and to the chest. She has never
had any vomiting, nor is the pain connected with the taking of
food. Within this period of time she has lost about sixteen
pounds in weight. A few months ago she noticed a lump inthe
abdomen, which has caused her great uneasiness, and it was for
the purpose of determining the nature of this that Dr. Williams
advised a consultation.

Examination.—She was a thin, dark-complexioned woman,
neither anemic nor cachectic. The abdomen was distended,
uniform, with normal respiratory movements. On palpation not
tender, not sensitive, and nothing was felt except at the bound-
ary of the epigastric and umbilical regions on the right side,
where an elongated tumor occupied exactly the extension of
the parasternal line. The lower end was rounded and smooth,
and reached a little below the level of the navel. The upper
end was not palpable. To the left the mass did not extend be-
yond the middle line. The right margin was rounded and well-
defined ; the left a little depressed and irregular. It was not
very movable, but by using both hands it could be shifted slight-
ly from side to side. The surface was smooth; it was a little
sensitive to pressure, and felt very resistant and solid. The
fingers could be placed directly beneath the lower end, but it
did not appear to have an ovoid or globular outline. No gas
was felt to pass through it after repeated examinations. The
142 THE DIAGNOSIS OF ABDOMINAL TUMORS.

stomach was not dilated. The kidney could not be felt on
either side. The urine was normal and the bowels were regu-
lar. She had no attacks of colic, and the pains which she de-
scribed were not specially suggestive of biliary colic. I noted at
the time that the case was somewhat puzzling. The tumor had
the situation rather of a pyloric growth, though its long axis
was vertical, but there had been no dyspepsia, and there was
no dilatation of the stomach. The situation was somewhat
suggestive of the gall bladder, though it seemed to have more
resistance than a tumor caused by dilatation of this organ.
Jt had an outline very suggestive of renal tumor, and I was
rather inclined to regard it as a dislocated and fixed kid-
ney. I gave the patient every encouragement and assured
her that it was not a malignant growth. At my request
the patient returned on December 9, 1892. To my astonish-
ment the tumor had disappeared entirely; not a trace of it
could be felt. Examination of the abdomen was absolutely
negative. The right kidney was not palpable; the gall blad-
der could not be felt; the edge of the liver could be jast
touched during deep inspiration. The patient stated that she
had improved very much. The pains had diminished, and she
now had very little distress. She had gained in weight, and
was on the whole very much better. Here, in all probability,
Thad mistuken a dilated gall bladder for a movable kidney.
The tumor was scarcely large enough, and had not the situation
of intermittent hydronephrosis, the only other one which could
disappear in this way.

(b) Dieti’s Crises in Movable Kidney.—Remarkable
attacks of pain oceur in connection with movable kid-
ney, to which attention was first called by Diet A
knowledge of the existence of these renal. crises, as they
have been termed, is very important, and as they form a
very striking feature in certain cases of movable kidney, I
propose to call your attention to them at some length.
The text-books, with the exception of the last edition of
Flint’s, have been curiously silent regarding this symptom-
group. In Dietl’s paper, which appeared in the Wiener
medicinische Wochenschrift, 1864, nine cases of movable
kidney are reported, all of which had pains in the side and
back. In four there were also attacks of nausea and vom-
iting, with great pain, swelling, and tenderness of the
affected kidney. These were liable to recur, particularly on
exertion. Dietl was doubtful about the pathology of the
TUMORS OF THE KIDNEY. 143

condition, but from the title of the paper, Wandernde
Nieren und deren Einklemmung, it is evident that he re-
garded it as a strangulation caused probably by a twist in
the vessels.

The case which first called my attention to the condi-
tion was a patient of the late Dr. Palmer Howard’s, of
Montreal.

A lady, aged about forty years, stout and well nourished,
began some months after her third pregnancy to have violent
attacks of pain in the abdomen, in which she became nauseated,
often vomited, and suffered so intensely that hypodermies of
morphine alone gave relief. She was seen by the late Dr.
George W. Campbell, who discovered a lump in the right side
of the abdomen. The attacks recurred with great severity
throughout the winter of 1879-80. The patient lost in
weight and the diagnosis of a new growth was made. In the
spring of 1880 she consulted in New York the late Dr. Austin
Flint, who agreed with Dr. Howard and Dr. Campbell as to the
very serious nature of the case. Throughout the year the at-
tacks recurred, and she lost in weight from one hundred and
seventy to one hundred and twenty pounds. In the spring of
1881 she again went to New York and consulted Flint and Van
Buren. <As she was at this time very mueh thinner, a more
satisfactory examination of the abdomen could be made. Van
Buren at once suggested that the tumor was a movable kidney,
with which he stated that he had frequently met with parox-
ysmal attacks of severe pain, particularly in gouty persons. IIe
advised a very strict diet. The relief of mind was naturally
very great, and the patient began at once to improve, gaining
rapidly in weight. The paroxysms reduced in frequency, and
for years she remained well, having at intervals, particularly
if she committed any indiscretion in diet, recurrences of the se-
vere pain.

The following cases have been recently under observa-
tion:

Case LIX. Enteroptosis ; Movuble Right Kidney ; Severe
Renal Crises.—Susan 8., aged forty-six years, admitted Janu-
ary 13, 1893, complaining of agonizing pain in the abdomen
and back, and a lump in the right side. She was married at
twenty-three; has had nine children, no miscarztages ; meno-
pause two years ago. Of late years she has been very nervous
and is often irritable and depressed. At the time of the meno-
pause she had pains in the back, and once the head was drawn
44 TIE DIAGNOSIS OF ABDOMINAL TUMORS.

to one side for a few days. Until two years ago the pains
were of a dull aching character, but at this time she noticed a
lump in the right side, and the pains became much more in-
tense. The attacks now come on without warning and are so
severe that she becomes helpless. They last for several hours,
and though she never loses consciousness, they are so agonizing
that for a time she can not speak. On two or three occasions
she has fallen down. She gets cold, sweats a good deal, feels
nauseated, but has never vomited. The pain is chiefly in the
right side, and the lump becomes, she says, sensitive and larger.
The attacks have recurred every two or three months. The
last one was four weeks ago. On several occasions after very
severe attacks the urine has been dark-colored. She has never
had jaundice. The patient is a well-nourished woman ; lips and
mucous membranes of good color; temperature normal; exami-
nation of heart and lungs negative.

The abdominal walls are greatly relaxed, and the much-
scarred skin can be grasped in large folds. On the left side the
kidney can be felt readily on deep inspiration, On the right
side, extending outward to within 3°5 centimetres of the middle
line, and downward at least 85 centimetres frum the costal
margin, is a smooth, rounded mass, very freely movable to the
right. It is superficial and seems to emerge directly beneath
the ribs. It descends with inspiration, and when the patient
turns on the left side, falls far over beyond the middle line, and
can be lifted with the fingers beneath it. It is smooth on the
surface, and as stated seeins to emerge directly from beneath
the costal margin. To the left it can be felt beyond the middle
line. The lower edge is rounded, but the fingers can not
be placed beneath it. It is evident that this mass is a de-
pressed and somewhat freely movable liver, On bimanual pal-
pation, deep pressure opposite the point of the tenth rib, the
right kidney can be readily felt behind and separate from the
liver, and on deep inspiration it moves down and can be readily
grasped.

We had a good deal of discussion about the natore of this
large flat mass in the right flank. It felt very superficial,
smooth, and we thought at first it might be an enlarged and
movable kidney, but repeated examination seemed to indicate
that it was the liver, somewhat movable and tilted forward,
owing to the relaxed condition of the abdominal wall. The
following note was made on the 19th: When the patient lics
on the left side the hepatic flatness does not begin in the ante-
rior axillary line until the ninth rib; when on her back it be-
gins at the eighth. In the nipple line, when she is on her
back, the flatness begins at the seventh rib, and apparently
TUMORS OF THE KIDNEY. 145

falls an inch lower when she is on her left side. The border of
the mass can be felt more distinctly in the nipple line, and sug-
gests, taking into consideration the fact that one feels below it
the kidney sliding backward, while near the umbilicus there is
asharp border, the existence both of a movable kidney and a
movable liver.

The patient remained in hospital for nearly four weeks and
gained in weight. She was greatly relieved by our statement
as to the nature of her case. She had no attack of severe pain
while under observation. The character of the attacks sug-
gests the renal crises common in floating kidney.

The following case is, I believe, a very typical instance
of Dietl’s crises, and is interesting also from the protracted
course and the intensity of the recurrences:

Case LX. Movable Kidney ; Renal Crises at Intervals for
Seven Years.—Dr. X., aged forty-three years, seen October 18,
1893, complaining of attacks of agonizing pains in the abdomen,
which have recurred on and off for seven years. The patient
has been a very healthy man, of good habits, and has for
twenty years been engaged in a very laborious country prac-
tice. At the time of the onset there was a great deal of ty-
phoid fever in his district, the roads were very bad, and for
seven weeks he was in the saddle constantly. The first attack,
which was of a very agonizing character, came on when he was
very much fatigued, and wasso severe that he nearly fainted and
required morphine. He had no vomiting and did not pass any
blood in the urine. Since that time the attacks have recurred,
sometimes two or three in a week, sometimes only one in six
or eight weeks. He has never vomited in them, though some-
times the intensity of the pain makes*him nauseated. The
bowels are regular and he has never had jaundice. He never
ean tell exactly when the attack will come on. It usually be-
gins abruptly, and the intensity of the pain is such that he often
has to take chloroform. The attacks last from a few hours to
the greater part of a day, and, in passing away, leave him a
little exhausted and with a feeling of soreness and aching. The
pain is most intense in the right flank and extends toward the
navel and to the spine. He does not think that any tumor de-
yelops at the time, but the muscles of the abdomen are tightly
contracted and the right flank is sensitive. He has noticed in
very many of the attacks that he. micturates freely, and the
amount of urine is increased as the attacks pass off. There
never has been any change in the character of the urine.

The patient is a moderately well built man; looks healthy

10
146 THE DIAGNOSIS OF ABDOMINAL TUMORS.

and strong; tongue is clean. The abdomen is soft, flat; ne
sensitiveness over the stomach; the pylorus is not palpatle;
the edge of the liver can be felt just below the costal margin; it
is not sensitive. The spleen can not be felt.

The right kidney is readily palpable, and, when he draws a
deep breath, comes down so low that the fingers can easily be
slipped above it and fix it below the level of the tenth rib. it
is a little sensitive on pressure, but is not apparently enlarged.
When he turns on the left side the kidney falls forward and
can be also readily felt just below the margin of the liver. The
left kidney is not palpable.

These renal crises constitute perhaps the most distress-
ing symptoms of movable kidney, and they are, I think,
very much more common than we are led to suppose. The
knowledge of their existence is important, as the attack
may be so severe as to simulate peritonitis, The cause of
the symptoms is not at all clear. The terms which have
been used, Hinklemmung by the Germans, and étranglement
by the French, are based upon the view originally expressed
by Dietl, that it was a condition of strangulation or ex-
treme engorgement caused by a twist in the vessels of the
floating kidney. Dietl thought that about the moving
organ there was a local peritonitis. The explanation which
passes current at present is more reasonable, namely, that
the condition is due to a kink or twist in the upper part of
the ureter, with retention of the urine in the pelvis and
calices, and a production of a transient hydronephrosis, the
severe, agonizing pain being caused by the distention of
the tissues.

Il, Invermirrent Hypronepurosis.—With the excep-
tion of a remarkable case of the rare congenital form, upon
which my colleague Halsted operated in this hospital three
years ago, I had never seen—to recognize—a case of in-
termittent hydronephrosis. During the present session
three examples have come under my notice. Let me first
read to you the notes of the cases:

Case LXI. Intermittent Development of Large Tumor on
the Left Side.—Mrs. F., aged forty-three years, seen with Dr.
Finney, September 9, 1893, complaining of trouble in the left
side. She has been a healthy woman; has had four children;
never has had any trouble after her confinements, and she does
not think that she was unusually large during her pregnancies
TUMORS OF THE KIDNEY. 147

She has, on the whole, enjoyed very good health. In April
last she stumbled over a slop jar and wrenched her back, but
she did not feel it very much at the time. Early in May she
had the first severe attack of pain in the left side, which Dr.
Archer, who attended her, thought was renal colic. There were
three paroxysms—at 8,6, and 9 p. m. They were evidently
very severe, as she was bent over with the pain and had severe
vomiting. The urine was not bloody, and in a few days she
was herself again, but one evening she was surprised to feel a
“lump ”’in the left side, which has been present at intervals ever
since, Jt has not been especially painful, but is a little uncom-
fortable, and associated with a feeling of distention and uneasi-
ness, particularly when she is lying down. It is not more
painful after eating, nor has diet any special influence. She
has not lost in weight. She is quite positive that the lump in
the side appears and disappears; thas, she says, she could not
feel it on the Sth and 6th of this month, and she thinks that
throughont the greater part of July it was not present. Its on-
set is always ushered in with pain in the left side, but the
attacks have never been so severe as those which she had in
May. She bas noticed on sever-
al oceasions that she bas voided
large quantities of urine, as much
as five pints between 8 p. M. and
six o’clock the next morning,
usually of a very pale color.
She has not had her attention
drawn to any coincidence be-
tween the disappearance of the
tumor and the large amount of
urine.

Her bowels are regular, ap-
petite good, but she has been
sleeping badly of late, owing in
part to the worry about the
tumor.

Present Condition. — Well-
nourished, healthy- looking wom-
an of medium height. The ab-
domen looks natural; no special Fie. 39,—Ilustrating the position of
prominence. When she turns the tumor in Case LX.

a little on the right side there

can then be seen a projection in the left flank just above the
ilium, and between the tenth rib and the anterior spine there
is felt a prominent solid mass, which above lies close beneath
the ribs, while anteriorly it feels superficial. It can be readily

 
148 THE DIAGNOSIS OF ABDOMINAL TUMORS.

grasped between the hands and moved to and fro. When she
draws a deep breath it does not give one the impression of
coming out from beneath the ribs and is not much depressed.
No sharp edge can be felt, but it is everywhere rounded in
outline. :

Percussion in the splenic region is clear, and beneath the
level of the eighth rib there isa flat tympany in mnidaxillary
line. As she turns on the right side the mass comes forward
and produces a bulging beneath the skin. It is tolerably firm
and elastic, but fluctuation can not be obtained.

The edge of the spleen is not palpable; the liver dullness is
not increased; the edge can not be felt. The right kidney is
just palpable on deep inspiration. Examination of the thoracic
viscera is negative.

The patient was requested to make a careful estimation o
the urine each day, and note with reference to the presence or
absence of the tumor.

September 11th.—Dr. Finney reports that last night on ex-
amining the abdomen no trace of the tumor could be felt.

She was ordered a bandage with a carefully adapted pad,
and asked to estimate the amount of urine, which she only did,
however, for about a week. On the 11th the amount of urine
was five pints and a fifth; on the 19th, three pints and a half;
on the 18th, four pints and a half; on the 14th, four pints and
a half; on the 15th, three pints and a half; on the 16th, two
pints and a half. From 6 a.™. to 6 P.M. on the 16th she felt
tired and weak, and had uncomfortable sensations, and she
passed at this time not quite a pint. At 11 P.M. on the 16th
the tumor mass was quite evident, projecting prominently be-
tween the ribs and the hip. It was evident throughout the
17th, but she felt very much better toward the afternoon, but
was inclined to ery and fret, and was a good deal distressed at
the recurrence of the mass. On the 18th it had disappeared
entirely. The sample of urine examined was clear, specific
gravity 1:015, and contained neither albumin nor tube casts.

Additional Note—I saw this patient last on January 8th.
She had been very nervous and uneasy about herself. The
tumor was present, though not so large as when first seen. Its
appearance and disappearance have been repeatedly verified by
Dr. Finney.

Case LXII. Attacks of Colic; Tumor in the Left Renal Re-
gion which Appears and Disappears.—Mrs. A., aged twenty-
seven years, bipara, had consulted me on two or three occasions
for dyspepsia. On October 94 she came complaining of a lump
in the left side, which had been present on and off al] the sum-
mer, and which sometimes gave her a great deal of pain. She
TUMORS OF THE KIDNEY. 149

first noticed it in May, following an attack of colic of great in-
teusity. A few days subsequently she noticed that there was a
jump in the left side, which, however, gradually went away.
Since then it has appeared and disappeared five or six times, at
intervals of a week or two, usually developing with an attack
of pain, which gradually subsides as the tumor becomes ap-
parent. No special uneasiness attends its disappearance, and
she has not noticed any special increase in the amount of
urine.

Her general condition has kept very good; she has gained in
weight, and the old dyspeptic symptoms for which I saw her
last year have almost entirely disappeared.

She is a medium-sized, fairly well nourished woman; color
of lips good. Pulse 80; no fever.

The abdomen looks natural; skin not very mueh scarred ;
only a moderate amount of panniculus. A prominence can be
seen in the left flank. On quiet breathing, below the lett costal
border, ip the position of the edge of an enlarged spleen, there
is a rounded, superficial mass, which deseends with inspiration,
reaching fully three fingers’ breadth from the margin. It
passes deeply in the region of
the kidney, and the fingers can
be inserted between it and the
costal margin. Pressure from
behind in the left flank pushes
the mass forward so as to ele-
vate the skin to the left of the
navel. When very large she
says it reaches quite as far as
the middle line. The lower end
is rounded, but without any
marked prominence; it is mova-
ble when grasped between the
hands. The splenic dullness
can not be obtained, nor is an
edge to be felt. The percussion
over the tumor mass is flat.
When lying on the left side it

 

falls down somewhat, and the |
. < . Fic. 40.—Position of the tumor in
fingers can be passed freely be Case LXU.

neath it. There is no uterine
or ovarian trouble, and the tumor mass does not appear to pass
toward the pelvis. The liver is not enlarged; there is no dila-
tation of the stomach.

October Vth.—The mass ‘is stated to have been absent for
three days.
150 THE DIAGNOSIS OF ABDOMINAL TUMORS.

Examination.—Fingers can be passed deeply at the left cos-
tal margin without meeting anything. The kidney is readily
palpable and descends with inspiration. She passed three pints
and three quarters of urine during the three days after the last
examination; then on Thursday and Friday the lump had dis-
appeared, and there were three pints and a quarter, so that the
difference is not very great.

The attack in which I first saw the patient came on Sunday,
October ist, with moderately severe pain, and during the night
the “lump” was felt. She states that it was not so prominent
as it has frequently been. Twice the mass has extended as far
as the middle line.

The urine was examined repeatedly. It was light in color;
specific gravity never above 1:020, acid in reaction, and con-
tained no albumin or abnormal ingredients. There were no
differences between the urine when the tumor was present and
that passed during the time of disappearance of the mass.

Throughout November the patient was very well. A care-
fully adapted pad and bandage have given her great relief, and
she has noticed the tumor only once. She has been in Phila-
delphia staying with friends. Throughout the week ending
December 16th she had had a great deal of worry and trouble
with illness in the family, and had been on her feet a great
deal. On the 15th she was tired out and went to bed. Stayed
in bed all day and had some pain and distress on the left side
and noticed the reappearance of the tumor.

December 16th.—To-day, at 4.30 p.m, the tumor mass is
present, though not so prominent as on the former examination.
It dues not reach beyond the parasternal line; is not specially
sensitive; easily moved on bimanual palpation. On deep in-
spiration the fingers can be placed weil above it.

On questioning the patient with reference to the onset of
the attacks, she states that even when a young girl she remem-
bers to have had pain in the left side after running or after
dancing for a long time, but she never noticed the presence of
the lump until May of this year. She has given up measuring
the daily amount of urine, but she is certain that there is no
striking and sudden increase in the amount as the tumor disap-
pears.

Case LXIII. Pains in Left Side, with Development of Tumor,
which gradually Disappears.—Mrs, X., aged forty-six years, ad-
mitted to Ward C, October 23d, complaining of intermittent
attacks of pain in the left side, and a swelling or Jump which
occurs at the same time.

The family history is good. She was always very strong as
a girl; married at twenty-two; has had three children, the
TUMORS OF THE KIDNEY. 151

youngest now ten years old. Was never very large during her
pregnancies. “Has been always regular; has no uterine disease ;
still menstruates. Of late years she has had a good deal of
mental worry and trouble, and has had a very busy life, actively
engaged in housework.

The attacks of which she complains date as far back as eight
or nine years ago, and consisted then of pain in the left side
occurring once in one or two months, which was, however,
quite bearable. It sometimes followed imprudence in diet ;
sometimes after ajolting ride. The worst attack, shortly after
the trouble began, followed a day’s journey on the railroad.
The pains were never so severe as to require morphine, but
there was a sensation of uneasiness and of discomfort and ach-
ing in the left side. Nearly four years ago she first noticed a
swelling beneath the ribs on the left side. It was not large and
usually only lasted a day or two. She can always tell for
twenty-four hours before an attack comes on from curious
dull, heavy feelings all over her, and then the backache and
dragging sensation in the left flank begin. Within the past
year or so the attacks have been more frequent, and not a month
has passed without them. The lump, too, has become more
prominent during the attacks. Lately they have recurred as
often as every week, and for the past month they have begun
regularly on Sunday. She does not think that any special diet
brings them on, nor has she noticed lately that exercise or jolt-
ing has any influence. The urine has been clear; she has not
noticed any special difficulty, nor has she had any trouble in
micturition. The bowels are sometimes constipated, and more
particularly at the time of the attacks.

Patient-is thin, weighs only one hundred and five pounds,
and is pale. The following note was made at noon of October
24th: The abdomen is Hat —not specially scarred. On palpation
it is every where soft until toward the left costal margin, where
a large mass can be felt occupying the left side of the abdomen,
and projecting apparently from beneath the ribs. Anteriorly
it extends into the umbilical and epigastric regions as far as the
thiddle line. The lower margin, rounded and smooth, is nearly
at the level of the anterior superior spine. At first it was
thought possible from its situation to be an enlarged and some-
what irregular spleen. Tt descends with inspiration, and during
the deepest breath the hand can be passed over it, and the mass
in this way held down. It can readily-be felt from behind, and
on bimanual palpation can be grasped between the hands, and
on firmest pressure below the ribs behind the mass can be
pushed forward so as to lift distinctly the abdominal wall. The
Tower and posterior surfaces appear to be irregular. The sen-
152 THE DIAGNOSIS OF ABDOMINAL TUMORS.

sation given on deep pressure is of an clastic resistance. On
percussion there is tympany over the mass in front, a flat tym-
pany in the midaxillary line,
and dullness behind. The right
kidney is distinctly palpable and
descends far enough on inspira-
tion to be held down. For the
first twenty hours in hospital
patient passed only 880 ¢. c. of
urine, clear, straw-colored; spe-
cific gravity, 1:006; slight trace
of albumin; no sugar; a few
leucocytes and flakes of epithe-
lium.

Patient menstruated from the
25th to the 28th. The tamor
mass was present on the 25th;
no examination was made on
the 26th. On the 27th the tu-
mor had disappeared entirely.
The abdominal walls were so re-
Fig. 41.Position of the tumor mass laxed that palpation could be

in Case LXIII. freely and thoroughly miade.

The left kidney could be felt on

deep palpation. it did not appear to be in any way enlarged ;

it felt, in fact, rather small and round. A daily note was then

made on the patient and the urine carefully measured. The pa-

tient says she can always tell a day or so before the attack
comes on by feeling dull and the onset of backache.

From October 28th to November 6th the daily note with
reference to the left kidney was negative. It was felt every
day. She seemed to be doing very well; gained in weight, and
had not so much tenderness.

November 7th.—Last night patient had a heavy feeling in
the abdomen after eating, and a little distress in the back, as if
an attack might be coming on. This morning, however, she
felt well again, got up, went to town on a street car, walke
about a good deal. On her return after dinner the usual symp -
toms ushering in an attack appeared—slight headache and feel-
ing of sluggishness, and a dull, gnawing ache in the left side,
with a feeling of fullness, Patient expresses it that she is en-
tirely “taken possession of by the occurrence,” is listless, and if
it comes on while she is up and about, her knees tremble under
her and she feels that she must lie down. She never, however,
is nauseated or sick at the stomach.

An examination was made at 11.80 a. mM. on the 6th, and the

 
TUMORS OF THE KIDNEY. 133

following note dictated: “On drawing a Cezp breath the left
kidney feels a little larger and more prominent than previ-
ously, but is not tender.” To-day (7th) the examination was
made at 3 p.m. The abdomen is slightly distended; the left
side more prominent than the right. The tumor mass previ-
ously existing again occupies the entire left flank, extending
anteriorly almost to the level of the umbilicus. The anterior
border is hard, somewhat abruptly defined, and a depression
can be felt along the margin. On deep inspiration the mass de-
scends, the lower end almost reaching the anterior superior
spine. During the deepest inspiration the fingers can be passed
above its upper margin, and the tumor can be held entirely
below the level of the tenth rib. From behind, the postero-
lateral surface of the tumor is somewhat irregular. With the
right hand in the renal region behind it can be readily pushed
forward so as to cause a prominent bulging in the left half of
the umbilical region. The right kidney is readily palpable and
presents no change.

S8th.—The tumor mass is not nearly so large this morning.
It is firm, rounded, readily palpable between the two hands,
and is still large enough to be made to project beneath the skin
when lifted from behind. She says she has not nearly so much
uneasiness and distress in the side to-day.

9th.—The mass is smaller than yesterday. She has now no.
pain.

10th.—The tumor has disappeared. The left kidney is readi-
ly palpated ; feels smaller than the right. A careful estimate
was made of the quantity of the urine each day, and the total
solids, the reaction, and the specific gravity. From the 28th of
October to the 7th of November, daring which time there was
no tumor, the amount of urine ranged from 1,000 to 1,900 c.c.
For the twenty-four hours ending November 7th the amount
was 1,900 c.¢. On the 8th there was only 1,100 c.c¢.; on the
9th, 820 c. c.; on the 10th, 1,200 c.¢.; on the 11th, 1,210 ¢. ¢.5
on the 12th, 980 c.c. The urine has always been clear, is usu-
ally acid; the specific gravity ranges from 1:010 to 1:017; gen-
erally yellow, straw-colored, and contains a few leucocytes.
There was no special change in its appearance or microscopical
characters, either on the 7th, 8th, or 9th, when the tumor was
present, or the 10th, 11th, and 12th, after it had disappeared.
The patient went to her home on the 11th. She had subse-
quently kept account of the amount of urine, which has ranged
from two and a half to five pints daily. She had an attack
in which the tumor was present on the 17th and 18th, on
which days she passed two and a half and three pints of
urine, and on the 19th, 20th, and 21st there were only two,
154 THE DIAGNOSIS OF ABDOMINAL TUMORS.

three, and three pints. On December Ist and 2d there was
again an attack with the tumor present. The amount of urime
was three pints on both days, and on the 3d, 4th, and 5th it
was three, three, and five pints.

December 16th.—This patient was seen last to-day. She
has been better in many ways, but for the past week has not
been feeling at all strong, and has been very nervous. The
tumor has been present, she states, for about two days. On ex-
amination the tumor mass was distinct, thongh small in cotm-
parison with the previous notes. It extended as far forward as
the parasternal line, and could be readily moved on bimanual
palpation. On deep inspiration the fingers could be pressed
above it, and it can be held down, It was distinctly lobulated.
In the anterior axillary line it felt superficial, and it could be
made to bulge beneath the skin.

A carefully adapted pad and bandage have given much relief,
and the attacks have not recurred so frequently, She has also
gained in weight and is in every way better.

Additional Note, February 17, 1894—She has been very
much better since Just note, and has only had three attacks;
one severe, requiring opium. In all three the tumor mass,
however, was present. There has been no attack for four
weeks, the Jongest intermission which has had for months. Her
appetite is good, and she now weighs one hundred and twenty-
two pounds.

These cases have the following points in common: The
patients have borne children: there have been attacks of
colic-like pain in the left side, during which a tumor de-
velops, to disappear in the course of a few days, sometimes
with an increase in the amount of urine. The diagnosis
seems perfectly clear. There is no other condition in
which a tumor in the flank appears and disappears in this
way. Intermittent hydronephrosis, as is well known, con-
stitutes the most remarkable form of phantom tumor, to-
day you may find the side of the abdomen occupied by a
large, firm mass which you can grasp between the hands,
and which may be so prominent as, when pressed forward,
to lift the skin of the abdomen in the region of the navel,
and to-morrow you may be completely nonplussed to find
that the tumor has disappeared, leaving not a trace behind.
There are remarkable cases in which this history repeats
itself throughout a series of years, as in the case of con-
genital hydronephrosis to which I referred—a young man,
TUMORS OF THE KIDNEY. 155

aged twenty-one years, who had had from his second year
the intermittent. development of an enormous abdominal
tumor which disappeared with the passage of a large quan-
tity of urine.

The subject is one to which much attention has been
given of late, and you will find in the monograph of Landau,
and in the works of Morris and Newman, excellent descrip-
tions of intermittent hydronephrosis. The whole question
has been most thoroughly considered in the monograph
which I here show you,* in which the authors have col-
lected from the literature seventy cases. I see that there
has been published recently in London a brochure on the
subject by Knight, which has not yet reached me.

A large proportion of all the cases are in women, who
are the subject of it at least four times more frequently
than men, in about the same proportion as they are more
liable to movable kidney. The left side is more frequently
affected than the right. Of forty-nine cases in the list of
Terrier and Baudouin available for analysis on this point,
thirty were on the left side and nineteen on the right.

The general symptoms of intermittent hydronephrosis
you have gathered from the report of the cases. In the
intervals the patient may feel perfectly well, or may have
only the mental worry consequent upon the uncertainty of
the nature of the trouble. From this cause Case LXITI
lost rapidly in flesh. Case LXI suffers much with the
nervous features so often associated with enteroptosis. As
a rule, and this is an important point in the diagnosis, the
health is good, and the patients are very comfortable, ex-
periencing only, perhaps, a sense of weight or dragging in
the side, more rarely local or radiating pains. The exami-
nation of the side may be negative; more commonly there
is a movable kidney, sometimes feeling quite normal, but
it may feel small, as in Case LXIII, or swollen, large and
tender. There are instances also in which a sac may be
felt, presenting indurated areas, or it may be partly filled.
The urine is clear and presents usually no abnormal ingre-
dients; in some cases there is a slight turbidity from
pyelitis.

* De Vhydronephrose intermittente, par Félix Terrier et Marcel
Baudouin. Paris, 1891.
156 THE DIAGNOSIS OF ABDOMINAL TUMORS.

You will have noticed in the reports that the attacks re-
cur with variable frequency. Among the circumstances
liable to cause them are sudden and violent exercise, the
jarring and jolting of riding and driving, any fatigue, men-
tal emotions, and errors in diet. In Case LXUIT the pa-
tient assured us that she could at any time bring on an
attack by a ride in a jolting street car, It is important to
bear in mind that indiseretions in eating may cause them.
The patient of Dr. Palmer Howard’s could at any time
bring on a severe renal crisis by taking a heavy supper and
a bottle of Bass’s ale. The onset is usually manifest to
the patient by pain and uneasiness in the affected side and
general restlessness. In Case LXII the patient knew at
once when the tumor was developing by the gnawing ache
in the left side, the slight headache, and the feeling of
sluggishness. The attack may have the severity of ne-
phritic colic and require morphine for its relief. There is
rarely fever, nor do 1 see any cases reported with recurring
chills, the absence of which is somewhat remarkable, con-
sidering their frequency in affections of the pelvis of the
g, diarrhea, and distention of
the abdomen may be present. The attack may last from a
few hours to the greater part of a day; the pain gradually
passes away, and the patient feels only a soreness and
heaviness in the side. The tumor gradually develops dur-
ing the attack, and may increase in size for several days
after the intensity of the pain has subsided. The three
patients who have been under observation had learned to
recognize the tumor, and knew at once when it was pres-

kidney. Nausea, vomitin

ent. In the frequent examinations which I have made of
Cases LXII and LXIIT I never found them in error on this
point.

The tumor itself offers no characters which would call
attention to the existence of intermittent hydronephrosis.
Tt has the situation and relations of a kidney tumor, with
perhaps a greater mobility than usually met with in neo-
plasms or pyonephrosis. When small, it may be very
mobile, and some have detected a difference between the renal
and the pelvic portions of the sac, separated by a groove. It
is deeply placed, rounded, and from behind can be lifted for-
ward from its bed. The median and lower surfaces are
TUMORS OF THE KIDNEY. 157

smooth, sometimes irregular, but there is no sharp margin
or rounded edge. Pressure is often painful, and causes at
times an urgent desire to urinate. Fluctuation is rarely
obtained, but there is often a sense of elastic resistance.
The colon, small bowel, and part of the stomach usually
lie in front of the tumor and mask the percussion in the
outer half of the umbilical region or in part of the flank.

During the existence of the tumor the amount of urine
passed is, as a rule, greatly diminished. After persisting
for a variable time the tumor may disappear suddenly with
the greatest relief to the patient, and when the evacuation
is rapid there is always a notable increase in the quantity
of urine. In not one of the three cases which we have
considered was the discharge brusque, as in some instances
which are on record, but the disappearance of the tumor
was gradual, and the increase in the amount of urine,
though noted in two of them, was not striking.

With the disappearance of the tumor the patient again
becomes quite comfortable, and may remain so for weeks or
even months without a recurrence of the attack.

The recognition of the condition, when fully established,
is comparatively easy. The pains, the development of a
tumor in the flank, its disappearance, usually with an in-
erease in the amount of urine, form a symptom group
sufficiently characteristic. It is by no means so easy to de-
termine always the cause. Some of the cases, as already
mentioned, are congenital, and have persisted for years.
Terrier and Baudouin divide the cases of acquired inter-
mittent hydronephrosis into those in which the cause is
obscure or ill-determined, the cases due to lesion of the
bladder or of the parts in the vicinity of the lower end of
the ureter, and the casés associated with displaced or
movable kidney, and due to lesions in the upper extremity
of the ureter. In the first group there are a certain num-
ber of cases in which the intermittent hydronephrosis is
due to calculus. There are instances also caused by blood
clots, by tuberculous lesions, and by spasm of the ureter.
In the second group of cases the lesion of the bladder is
most commonly tumor, with infiltration of the wall near
the orifice of the ureter, and by lesions of the uterus and
vagina, particularly cancer.
158 THE DIAGNOSIS OF ABDOMINAL TUMORS.

The important réle in intermittent hydronephrosis is.
unquestionably movable kidney, the association with which
has been recognized since the publication of Landau's
monograph in 1881. You will find in the work of Terrier
and Baudouin the records of the autopsies which have been
made, and of the examinations of the kidneys which have
been removed by operation, and I show you here several of
the figures which illustrate the marked kinking at the up-
per part of the ureter. Tn other instances the ureter has
penetrated the pelvis at a very acute angle; and in other
cases, again, there appears to have been a positive flexion
or twist. It is not difficult to understand how, in the dis-
placement of the organ, such a flexion or kinking could
occur, and the wonder, indeed, is that it does not occur
more commonly.

You will naturally ask, What becomes of these cases ?
It is quite possible that the condition may be transient,
even when associated with movable kidney. The careful
adaptation of a bandage and pad may give great relief, as
in Case LXIII; also in Case LXTI to a less degree. When
the attacks are severe and the tumor recurs with frequency,
nephrorrhaphy should be urged. The chief dangers are
the conversion of an intermittent into a permanent hydro-
nephrosis, and the infection of the sac with pyogenic or-
ganisms—conditions which demand operative interference.
It is interesting to note, however, the prolonged period dur-
ing which the contents of the sac remain clear. In the
congenital case of twenty years’ duration, to which I have
so frequently referred, the secretion of the affected kidnev
—-dilated to a shell, but still containing renal tissue—was:
-only a little turbid.

Ul, Mauiewanr Diszase.—Of three cases which came
before me for diagnosis, two were in children under the age
of ten.

Case LXIV. Gradual Development of an Enormous Tumor
in Left Side of Abdomen.—. R., a boy of ten years, seen with
Dr. Hewetson, May 10, 1893. I had seen him about six or eight
months before for a few minutes in the dispensary. Unfortu-
nately, the notes made at that time have been mislaid. He has
had for nearly a year a progressively increasing tumor in the
left side of the abdomen. Untii two months ago he has been
TUMORS OF THE KIDNEY. 159

able to get about by himself, but he is now so weak and the
tumor is so large that he is scarcely able to walk. Ile has be-
come very much emaciated, and since I first saw him the tumor
has increased greatly insize. His chief complaint at present is of
pain down the left leg, and about the ankle and hip of the same
side. The abdomen is greatly distended, particularly on the left
side, and the superficial veins are very full. The lower part of
the thorax on the left side is much expanded, and the costal
margin everted. The entire left half of the abdomen is occu-
pied by a solid mass, which extends from the ribs to the pubes,
and is extremely firm and itn-
mobile. The surface is smooth,
except toward the lower and
right margins, where it is irregu-
lar. Percussion over it is every-
where flat. It extends upward
as far as the seventh rib, and be-
hind to the angle of the scapula.
Just above the anterior snpe-
rior spine of the ilium there is
a prominent bulging. The in-
guinal glands are enlarged and
hard, and the supraclavicular
glands on the left side are also
slightly enlarged. The left leg
is slightly swollen, and the veins
are enlarged and prominent, as
are also the veins over the flank
and buttocks. There have never Fie. 42.—Outline of the tumor in
been any urinary symptoms; he Case LXIV.

has not passed any blood, but

he has had pain lately owing to pressure upon the nerves and
veins in the left side of the pelvis.

Casz LXV. Large Tumor in Left Side of Abdomen ; Hama-
turia ; Removal of Sarcomatous Kidney ; Recovery.—Minnie H.,
aged five years, admitted to Ward G from the dispensary, Janu-
ary 18, 1893, with tumor in the abdomen, which the mother
said had been noticed for several months. She had been failing
in health, losing weight, and on several occasions had passed
blood in the urine.

Present Condition.—Not greatly emaciated; not particular-
ly anemic. Veins look blue and the blood a little watery. She
has had no fever; pulse quiet. Abdomen greatly distended,
unsymmetrical ; the greatest prominence is in the hypogastric,
umbilical, and left inguinal regions. The whole of the left side
is fuller and larger than the right, and does not display the re-

 
160 THE DIAGNOSIS OF ABDOMINAL TUMORS.

spiratory movements, The superficial epigastric and mammary
veins are much distended. There are two prominences to the
Jeft of the navel, and one, less prominent, seven centimetres

      

Fig. 43.—Outline of the tumor mase in Case LXIV.

below the costal margin in the left nipple line. There is a
fourth just at the tip of the eleventh rib in the left flank. On
TUMORS OF THE KIDNEY. 161

palpation, the greater portion of the abdomen is occupied by
a firm, solid growth, which fills completely the left half, extends
fully five centimetres beyond the middle line, and fills the greater
portion of the hypogastric region. In the left half of the epi-
gastric region it is covered with stomach or bowel and is not
so prominent, and can only be felt on deep pressure. It passes
under the costal margin of the seventh rib. It is extremely
firm, resistant, not very movable on bimanual palpation, and
not sensitive. It fills the entire flank, and behind is superficial,
and gives the impression of occupying closely the whole lum-
bar region, The surface is irreguiar, and on palpation the
prominences referred to are very distiner. In the right iliac
fossa a soft mass can be felt, which is probably the colon pushed
over, partly adherent, and can be felt on the tumor mass. Above,
as already mentioned, the tumor is covered in the left half of
the epigastric region by stomach and intestines, and there js a
soft, movable mass, which may represent the curled and thick-
ened omentum.

I will read to you the remarks which I made in ward
class after demonstrating this child, and which I find here
with the type-written report of the case:

“Tn children, massive tumors of the abdomen are not un-
common, and, as a rule, are either sarcomata of the kidney
or of the retro-peritoneal glands. The kidney tumors are
the most frequent. Both ultimately produce large, solid
growths, which may occupy the greater portion of the ab-
dominal cavity. In the differentiation of these two forms
we rarely have any difficulty. Both develop painlessly, and
the child may make no complaint whatever; the general
health may not be seriously affected, even when the mass
has attained a considerable size. Death, indeed, may occur,
as in a remarkable case which I have reported of embolism
of the heart (the transference of sarcomatous thrombi from
the renal vein), before there were any symptoms to attract
attention. Progressive emaciation, with enlargement of
the abdomen, usually painless, as in the case of this child,
are the prominent characters, which are common, however,
to both the renal and the retro-peritoneal growth. The two
important points of differentiation are, first, the retro-
peritoneal growth is more central in its origin, and, if seen
early, it is found to occupy the umbilical region, not ex-
tending to the flanks ; whereas, in the renal tumor, as in the

Il
162 THE DIAGNOSIS OF ABDOMINAL TUMORS.

case before us, the growth is lateral, and fills the entire flank,
extending deeply behind.

“The kidney tumor is, as a rule, associated with changes
in the condition of the urine. Blood is present, either as
free hematuria, or the constant presence of a small number
of red blood-corpuscles. There may be large clots, the
passage of which causes great pain. In some cases molds
in blood of the pelvis of the kidney and of the ureters are
passed, though this is not so common in children as in
adults. Other conditions which have to be differenti-
ated are ovarian tumors, pyonephrosis, and cysts, but in
cases of doubt the exploratory operation should be strongly
urged.”

The tumor in this case was removed by Dr. Halsted
and found to be an enormous sarcoma of the kidney. The
operation was not at all difficult, the child made an wnin-
terrupted recovery, and when last heard of, a month or

two ago, remained well.

Case LXVI. Large Tumor in the Left Side of the Abdomen ;
Recurring Hamaturia.—November 2, 1893. I saw to-day, with
Dr. Lillian Welch, Mrs. X., aged sixty-three years, who had for
many months a progressively enlarging tumor of the abdomen
with hematuria. Until within the present year she has always
been a very healthy woman. She has been gradually failing in
strength, and within the past six months has lost a great deal in
weight, and lately the emaciation has become very great. On
several occasions during the past four months she has passed
bloody urine, and only at these times has she had any pain.

The patient is a small-framed, much-emaciated woran.
The abdomen is distended. particularly on the left side, which
is occupied in its whole extent by a large, solid tamor. To the
right it extends beyond the middle line, and reaches below the
anterior superior spine. It is firm, but with bimanual palpa-
tion it can be moved slightly from side to side. The right sur-
face and lower border present large irregularities. It is every-
where flat on percussion, except at the right border. The
glands are not enlarged; the superficial veins are only slightly
prominent ; the examination of the other organs is negative.
The urine at the time of my examination was clear. At inter-
vals, however, she has passed considerable quantities of blood,
and on these occasions there has been a good deal of pain.
Considering the solid nature of the growth, the occurrence of
hematuria, and the rapid emaciation, the diagnosis of malig-
TUMORS OF THE KIDNEY. 163

nant disease of the kidney was thought to be quite clear, and it
was not deemed advisable to put her to the pain of an aspira-
tion; nor did her condition seem favorable for an exploratory
operation.

The patient died a few weeks after my visit, and Dr.
Welch tells me that the post-mortem showed an enormous
new growth in the kidney, with small secondary nodules in
t he liver.

There are two points which you must ever bear in mind
in the diagnosis of large tumors in the flank : first, the im-
portance of thorough and systematic examination of the
urine with a view of determining the presence of pus, tu-
berele bacilli, or blood ; and, secondly, the use of the aspi-
rator needle. The condition which is really most apt to
cause error is the progressively enlarging kidney of pyo-
nephrosis. Gynaxcological records indicate how frequently
this tumor leads to error, but the chances are reduced to a
minimum if attention be paid to the two points I have just
mentioned. Catheterization of the ureters may also give
information of the greatest value.

IV. Tupercutosis.—A large kidney tumor is rarely due
to tuberculosis of the substance of the organ, but tubercu-
lous pyelitis may lead to considerable enlargement of the
pelvis and calices, and a certain number of all cases of pyo-
nephrosis have this origin. The tuberculous kidney, how-
ever, rarely forms a large abdominal tumor. The follow-
ing case illustrates two important features in the diagnosis
of renal tuberculosis ; namely, the determination, by
catheterization of the ureters, that the pus came altogether
from one side, and the detection of tubercle bacilli in the
urinary sediment.

Case LXVI. Cough for Five Years; Pulmonary Tubercu-
losis ; Enlargement of the Right Kidney ; Pyuria; Tubercle
Baeilli in Urine —Susan §., aged sixty-three years, admitted
June 4, 1893, complaining of pain jn the abdomen. The pa-
tient was under observation for a few days in September, 1890,
when she had slight cough, and pus and albumin in the urine,
but no tubercle bacilli were found at that time.

The patient’s mother died of tuberculosis. She has had five
children, all living and well. She had pneumonia when thirty-
five years of age. For five years at least ghe has had cough,
16+ THE DIAGNOSIS OF ABDOMINAL TUMORS.

with slight expectoration, and she has had at times severe
chills, which have been supposed to be due to malaria.

Lately she has had a great deal of pain and uneasiness in the
abdomen, and has been under treatment for cystitis, though she
has had no special pain in passing water.

Present Condition. —Moderate emaciation ; marked patchy
pigmentation on the face; slight anwmia; no fever; pulse 92,
of fair volume. At the left apex the percussion is a little
higher in pitch, and there are piping and moist sounds in the
first and second spaces. The sputum is inuco-purulent, with
yellowish lumps, and in these a few tubercle bacilli are found ;
no elastic tissue.

The heart sounds are clear.

The abdomen is flat, soft, no pain on pressure. The right
kidney feels two or three times as large as a normal organ. On
deepest inspiration it does not come down far enongh for the
fingers to be placed above it. No cord-like mass to be felt in
the course of the right ureter. The left kidney is not palpable.
The urine is turbid, light yellow in color, specifie gravity from

1-007 to 1-010, and on settling deposits a creamy pus. There is
atrace of albumin, and one or two granular casts are found.
Many examinations were made for tubercle bacilli. At. first
none were found, but subsequently they were found after
ceatrifugalizing the urine, and once in considerable numbers.

On July 12th, under chloroform anmsthesia, Dr. Kelly
catheterized the ureters. From the left a perfectly clear urine
flowed; from the right, a yellow-brown pus, in which tubercle
bacilli were detected. The patient had very slight fever, no
chill while in hospital, and appetite and general condition im-
proved very much.

There are two points in the diagnosis of tuberculous
pyelonephritis which are well illustrated by this case.
The condition is very frequently mistaken for cystitis, and
in men more frequently than in women there is great fre-
quency in micturition and great irritability of the bladder,
for which on more than one occasion I have known peri-
neal section to be performed. The urine, however, is as a
rule acid in tuberculous pyelonephritis, as in this case, un-
less there is extensive co-existing tuberculous cystitis, The
other point is the association of recurring chills. You will
have noticed in the history that this patient was supposed
to have malarial disease on account of the severe chills
which occurred at intervals during the past five years.
They may form a very special feature in the disease, as
TUMORS OF THE KIDNEY. 165

was pointed out many years ago by Owen-Rees, and it is
to be remembered that the chills may occur with a very
slight amount of pus in the urine.

One of the most important advances in the diagnosis of
renal affections has been the facility with which of late
surgeons have practiced catheterism of the ureters. Such
a demonstration as we had in this case by Dr. Kelly
the catheters in position in both ureters at once, from the
right of which a turbid, purulent urine flowed out, from the
left a perfectly clear—illustrates the remarkable technique
which has been developed by specialists. The demonstra-
tions which many of you have seen in the genito-urinary
department by Dr. James Brown prove that catheterism
of the male ureters, though not so easy, may be performed
with readiness, and gives information of the greatest value
as to which kidney is involved. .

In the series of cases which we have studied together
you have had many illustrations of how far the reasonable
probability of Bishop Butler will carry the clinical physi-
cian in his endeavors to determine the nature of an ab-
dominal tumor. You will have noticed in how many cases
the surgeon made it a certainty, not, unhappily, in diag-
nosis only, but also in prognosis. But desperate cases
require desperate remedies, and in no single instance
were the chances of a patient damaged by the exploratory

 

incision.

Amid many pleasant memories of Berlin, just twenty
years ago this session, none recur more persistently than
those associated with that true Asclepiad, Ludwig Traube,
who, adding probety to learning, sagacity, and humanity,
‘reached the fall stature of the Hippocratean physician.
When acknowledging some error he would say—often in a
soft, meditative manner, as if gently reproaching himself—
Have we carefully observed all the facts of the case? Yes.
Did the art permit of a judgment on the facts under con
sideration? Yes. Did we reason correctly upon the data
before us? No. Wir haben nicht richtig gedacht. And
with these significant words—may they long echo in your
ears !—let us close the exercises of the session.