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Dr.J.B.WALKE
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SURGICAL DIAGNOSIS
SURGICAL DIAGNOSIS
BY
ALEXANDER BRYAN JOHNSON, Ph.B., M.D.
PBOFESBOB OF CLINICAL Bl BGEB1 IN I III. COLUMBIA ONIVERSm MEDICAL COLLEG1
ATTENDING SI BGEON TO THE NEW YOBK HOSPITAL; VISITING -ri:..|.,\ fO nil.
MOUNT MOBIAH HOSPITAL; CONS1 LTING 81 BGEON TO ST. JOSEPH'S HOSPITAL,
FAB BOCKAWAY; FELLOW <>r THE 1MEBK W Bl BGK W. ASSOCIA-
TION; MEMBEB OF THE NEW YOBK SI BGICAL BO< 1 1.1 V
VOLUME II
INJURIES AND DISEASES <>E THE ABDOMEN AND OF II > CONTAINED
VISCERA â– THE RECTUM â– INJURIES AND DISEASES OF THE
KIDNEY, THE BLADDER, THE PROSTATE, THE URETHRA,
PENIS, SEMINAL VESICLES, SCROTUM, TESTIS,
AND SPERMATIC CORD
11777/ THREE COLORED PLATES AND TWO HUNDRED AND FIFTY-THREE
ILLUSTRATIONS IN TEXT
NEW YORK AND LONDON
D . APPLETON AND COMPANY
19 9
Copyright, 1909, by
D. APPLETON AND COMPANY
PRINTED AT THE APPLETON PRESS
NEW YORK, U. S. A.
CONTENTS
CHAPTER I
DISEASES OK THE ABDOMEN
PAGE
Diagnosis of the Diseases of the Abdomen 1
Methods of Examination I
Diagnosis of Ti mors of the Abdomen 17
Local Signs and Symptoms of Abdominal Tumors 19
CHAPTER II
SURGICAL DISEASES OF THE STOMACH
\'\ [iORic Stenosis
Acute Obstruction of the Pylorus and Duodenum
Congenital Stenosis of the Pylorus
Ulcer of the Skim w h
Perforating Ulceh of the Duodenum
\> i pe Suppurative Gastritis- Abscess of the Stom
tion of Tin: Stom \< ir
Diffuse Phlegmon of the Stomach ....
1 1 ustric Tetany
I'' mors of the Stomach
Phlegmonoi - Inflamma
29
37
•
39
50
55
55
55
.-,7
CHAPTKP, III
kuroicae diskasks of the intestine
Congenital Abnormalities of the Intestine
Intestinal Obstruction
Chronic Obstruction of the Large Intestine
\iMitr Intestinal Obstruction; Ileus
Ulcerative Processes of the [ntestine
Perforation of Typhoid Ulcer of the Intestines
Tuberculosis of tin- Intestine ....
Actinomycosis of the Intestine
l'i mors ok nil': Intestine
Benign Tumors ol" the Intestine
Cystic Tumors of the Intestine
Malignanl Tumors of the Intestine .
Thrombosis of the Mesenteric Veins
Tumors of the Peritoneum. Omentum, and Mesenteri
71
7"'
79
81
OS
98
104
107
110
110
111
111
11."
115
VI
CONTENTS
CHAPTER IV
APPENDICITIS
Anatomy ...
Causes of Appendicitis
Occurrence
Symptoms and Diagnosis of Appendicitis
Differential Diagnosis of Appendicitis
PAGE
118
119
122
122
134
CHAPTER V
THE INJURIES AND SURGICAL DISEASES OF THE LIVER
AND OF THE BILIARY PASSAGES
Injuries of the Liver 136
Injuries of the Biliary Passages 143
Abscess of the Liver 144
Echixococcus Cyst of the Liver 150
Cystic Tumors of the Liver Other than Echtnococ< as 154
Solid Tumors of the Liver 155
Floating Liver, Hepatoptosis — Dislocation of the Liver — Deformities of the
Liver 158
Diseases of the Billary Passages 159
Tumors of the Gall-bladder and of the Blllary Passages . . . . . .179
CHAPTER VI
INJURIES AND DISEASES OF THE SPLEEN
The Spleen — Topographical and Anatomical Remarks 183
Injuries of the Spleen 185
Abscess of the Spleen 189
Cystic Tumors of the Spleen ' 191
Solid Tumors of the Spleen 192
Movable Spleen. Floating Spleen. Wandering Spleen 193
CHAPTER VII
INJURIES AND DISEASES OF THE PANCREAS
Anatomical Relations .
Injuries of the Pancreas
The Diseases of the Pancreas
195
198
200
CHAPTER VIII
THE RECTUM
General Remarks
Methods of Examining the Anus and Rectum
Congenital Abnormalities and Defects of the Rectum and Anus
Foreign Bodies in the Rectum
Injuries of the Rectum
Inflammations of the Rectum and Surrounding Structures
Stricture of the Rectum and Anus ....
Hemorrhoids (Piles)
Prolapse of the Anus and Prolapse of the Rectum
The Tumors of the Anus and of the Rectum .
212
217
219
221
223
225
239
243
247
249
CONTENTS vii
OHAPTEB IX
HERNIA
I I i ii \ i . I .1 NERAL . 258
Special Forms of Hernia _'77
CHAPTEB \
THE KIDNEY \\l> URETER, TOPOGRAPHICAL ANATOMY
\.\ D \ll.l HODS OF i:\.\MI\ \'I [ON
A.NATOMICAL REMARKS 304
Methods of Examining the Kidney :;] 1
CHAPTER XI
congenital anomalies o] the kidney and ureter
History and Development of the Kidney and Ureter . . 350
Bmbryological Variations in the Kidney and Ureter 355
Varieties \m> Pathological Results <>f Congenital Anomalies <>f the Ureter 382
I »l IGNOSIS 384
Variations in the Blood Supply of the Kidney 385
CHAPTER XII
INJURIES OF THE KIDNEY
Subcutaneous Injuries of the Kidney 389
Open Wounds of the Kidney 395
Incised and Stab Wounds <>f the Kidney 395
Gunshot Wounds of the Kidney 398
CHAPTER XIII
movable kidney
Movable Kidney 401
CHAPTER XIV
hydronephrosis
Hydronephrosis 405
CHAPTER XV
suppurative lesions of the kidney
Suppi rative Lesions of the Kidney in Generai 414
Pyonephrosis .424
CHAPTEB XVI
tuberculosis of the kidney
Tuberculosis of the Kidney 435
CHAPTEB XVII
PERIRENAL INFLAMMATIONS
Etiolooy 156
Varieties of Perinephritis 457
viii CONTENTS
CHAPTER XVIII
NEPHROLITHIASIS. RENAL CALCULUS, KIDNEY STONE
PAGE
Nephrolithiasis, Renal Calculus, Kidney Stone 464
CHAPTER XIX
TUMORS OF THE KIDNEY
Tumors of the Kidney 472
CHAPTER XX
ANEURISM OF THE RENAL ARTERY— DISEASES OF THE ADRENALS-
SYPHILIS OF THE KIDNEY
Aneurisms of the Renal Artery 497
Surgical Diseases of the Adrenal Bodies 499
Syphilis of the Kidney 500
CHAPTER XXI
INJURIES AND DISEASES OF THE URETER
Injuries of the Ureter 501
The Diseases of the Ureter . . . . . . . . . . . . . 506
CHAPTER XXII
RENAL HEMATURIA
Renal Hematuria in General 512
Parasitic Diseases Causing Hematuria 514
CHAPTER XXIII
THE URINARY BLADDER— ANATOMY, METHODS OF EXAMINATION,
AND CONGENITAL DEFECTS
Topographical Anatomy of the Bladder 520
Methods of Examining the Bladder . 529
The Congenital Defects of the Bladder 541
CHAPTER XXIV
INJURIES OF THE BLADDER
Rupture of the Bladder 543
Open Wounds of the Bladder 548
Foreign Bodies in the Bladder 550
CHAPTER XXV
THE URINE
Examination of the Urine with Especial Reference to Diseases of the Bladder . 553
Microscopic Examination of the Urine, Especially in Diseases of the Bladder . 56(1
The Absorption Test for Raw and Ulcerated Surfaces in the Bladder . . . 564
CHAPTER XXVI
CYSTITIS
Cystitis 566
CON I ENTS
IX
CHAPTER X.WII
THE M.i ROSES OB I ill. BLADDER
I'm. N i i ROBES OF THE BlADDEB
PAOI
CHAPTER XXVIII
\ esical calculus
Vesi< \i. Calculus 580
CHAPTER XXIX
TUBERCULOSIS <Ji THE BLADDER
Tuberculosis of the Bladder
592
Tumors of the Bladdi r
CHAPTER XXX
TUMORS <>]â– THE BLADDER
General. ....
Injuries of the Prostate
Diseases of the Prostate
en a I'll :k XXXI
THE PROSTATE
608
614
(314
(II UThTt XXXII
THE URETHRA
Anatomy of the Urethra
Congenital Defects of the Urethra
Injuries of the Urethra
Foreign Bodies in the Male Urethra
632
638
642
645
CHAPTER XXXIII
DISEASES OE THE URETHRA
Gonorrhea and its Com plications
Stricture of the Urethra
C.47
661
( lONOENITAL ANOM ILIES
Injuries of the Penis
Diseases of the Penis
Tumors of the Penis
Benign Tumors
Malignanl Tumors of the Penis
CHAPTER XXXIV
THE PENIS
679
681
683
687
ox;
CHAPTER XXXV
THE seminal VESICLES AND THE SI MEN
The Seminal Vesicles and the Semen
x CONTENTS
CHAPTER XXXVI
THE SCROTUM, TESTIS, AND SPERMATIC CORD
PAGE
Anatomical Remarks 702
The Scrotum 702
The Testis and Spermatic Cord 704
Injuries of the Scrotum 710
Diseases of the Scrotum 710
Injuries and Diseases of the Coverings of the Testis 714
Hydrocele Testis, Chronic Serous Periorchitis 716
Periorchitis Hemorrhagica 721
Tumors of the Spermatic Cord and of the Coverings of the Testis . . . 722
Varicocele 722
Diagnosis of the Congenital Anomalies of the Testis 725
Inversion of the Testis and Torsion of the Cord with Strangulation of the Testis 725
Injuries of the Testis and Epididymis 727
Diseases of the Testis and Epididymis ........... 729
LIST OF COLORED PLATES
i u i -. . .
PLATE 1 136
Fio. I Tuberculosis of the Kidney; Cul Surface of the Organ, Showing Shape and
Arrangement of tin- Tuberculous Areas in the Cortex. Caseation has occurred,
hut as yel no softening. (Alter Israel.)
Fig. '_' Acute Pyelonephritis, Showing Numerous Miliary Abscesses in the Cortex of
the Kidney. (Alter Israel.)
PLATE II I Ki
Fig. I. Bxternal Surface of a Kidney, the Seat of Early Tuberculosis. The same
kidney as that shown in Fig. 1. Plate I. (After Israel I
Fig. 2. — Papillary Cancer of the Renal Pelvis. (Alter Israel.)
PLATE III 180
Fig. 1. Sarcoma of the Kidney Removed from the Child whose Photograph is Shown
in Fig. 129.
Fig. 2. — Cut Surface of Tumor Shown in Fig. 1. The remains of the kidney are
shown on the right. The organ was displaced downward and occupied tin-
lower and posterior portion of the tumor. Fig. 1 is a view of the tumor
Been from the front. In Fig. 2 the ragged border of the tumor to the left of
the kidney represents the position of the pedicle. Tumor tissue surrounded
the renal vein and extended upward a considerable distance upon the aorta
and vena cava. A clean dissection and removal of all the tumor tissue was
impossible.
LIST OF ILLUSTRATIONS
no.
1-
2,
3.
4.-
5.-
6-
7.-
8.-
9.
10.-
11.-
12.-
13.-
14.-
15.-
16.-
17.-
18.-
19-
20.-
21.-
22 —
2:;.
24.-
25.-
26.-
27.-
28.-
29.-
30-
31-
32.-
:;:;.
34.
:;.").
36-
:'>7.
38.
39.
40.-
41.-
42-
43.-
-Umbilical hernia
Ascites from malignant disease of ovary
Ascites from cancer of the uterus
-( â–ºvarian cyst
1 terine fibro-myoma
Acute dilatation of the stomach
I distended gall-bladder
-Echinococcus cyst of the liver
Acute dilatation of the stomach
Infected hydronephrosis
-Enlarged spleen
-Distended bladder .
-Sarcoma of the pelvis
-Fibro-myoma of the uterus .
-Dilated stomach from cancer
-Relations of the abdominal viscera
Relations of the abdominal viscera
Contracted stomach
-Contracted stomach
Stomach moderately dilated .
Misplaced abdominal viscera of a child
-Vermiform appendix
-Vermiform appendix, opened
lOchinococcus cyst of the liver
-( lummata of the liver
-Call-stones in gall-bladder
-Relations of spleen to the ribs
-Stab wound of the spleen
-Gunshot wound of the spleen
-Tuberculosis of the spleen
-Sigmoidoscope ....
Syphilitic papules of the anus
-Ischiorectal abscess
The relations of the rectum to adjacent par
-( iangrenous hemorrhoids
-Prolapse of the rectum .
-Prolapse of the rectum and exstrophy of tl
-< >blique inguinal hernia .
Irreducible scrotal hernia
-Reducible inguinal hernia
-Hydrocele
-Inguinal hernia and hydrocele
-Hydrocele of the hernial sac .
ts
1.1
ld<
6
7
i
s
9
9
in
in
30
32
33
:;i
35
:;.-,
73
129
129
l.'.l
I. Mi
164
Is:;
Is,;
Iss
189
218
229
234
236
246
_'!s
249
•J 7'.'
280
281
281
281
283
XIV
LIST OF ILLUSTRATIONS
FIG.
44. — Congenital hernia with hydrocele of the sac
45. — Hydrocele of the cord with inguinal hernia
46. — Inguinal hernia with hydrocele of the cord
47. — Hernia with hydrocele of the cord
48. — Hernia with hydrocele .
49. — Hydrocele with hernia .
50. — Hernia and tuberculosis of the testis
51. — Femoral hernia ....
52. — Incarcerated femoral hernia .
53. — Recurrent femoral hernia
54. — Large hydrocele
55. — Umbilical hernia
56. — Ventral hernia .
57. — Ventral hernia .
58. — Ventral hernia .
59. — Prolapse of the uterus, etc
60a. — Relations of the kidney
606. — Relations of the kidney
61. — Relations of the ureter, renal artery and vein
62. — Relations of the abdominal viscera
63. — Catheter in ureter, X-ray
64. — Catheters in ureters, X-ray .
65. — Corrosion preparation of the kidney
66. — Otis cystoscope ....
67. — Beak of Albarran's cystoscope
68. — Schlagintweit's retrograde cystoscope
69. — Brown's composite cystoscope
70. — Brown's composite cystoscopo
71. — Beak of Brown's cystoscope .
72. — Brown-Buerger cystoscope
73. — Leiter's bladder phantom
74. — Valentine's box phantom
75. — Ultzmann's hand syringe
76. — Ultzmann's drop syringe
77. — Cystoscope (after Luys)
78. — Cystoscope (after Luys)
79. — Catherization of the ureter through a s
80.— Urethral calibrator (Kelly) .
81. — Long mouse-toothed forceps (Kelly)
82.— Kelly's tube (Kelly)
83. — Ureteral probe (Kelly) .
84. — Examining the bladder through Kelly'
85. — Harris's urinary segregator .
86. — Luys's urinary segregator
87. — Luys's segregator in the bladder
88. — Urinary segregator of Cathelin
89. — Development of cloaca .
90. — Formation of the renal bud .
91. — Sprouting of the renal bud
92. — Relations of the ureter and Wolffian duct
93. — Terminal sprouting of renal bud
94. — Reconstruction of a cat embryo
95. — Reduplication of the ureter bilateral in the adult human
96. — Posterior view of Fig. 95
traight tube (after Luys)
tube
PAGE
283
285
285
286
286
287
287
287
288
289
292
293
294
295
300
305
306
306
308
309
310
311
313
325
326
326
327
328
329
330
330
331
335
336
338
338
339
340
341
341
342
343
346
347
348
349
351
351
352
352
352
353
355
356
LIST OF ILLUSTRATIONS
xv
97. -Relations of ureter and Wolffian duel
Relations of ureters and Wolffian duct
99. I 'orrosioii of ureter
100. — Corrosion of ureters
MM. Diagram of degrees <>f ureteric reduplication
101a. Diagram of complete ureteric reduplication
102. — Diagram of development of an additional renal elei
103.— The kidney of the otter ....
104. — Corrosion of the kidney of the otter
105. Corrosion <>f tlie ureters ....
106. — Bladder and prostate of a human adult showing abi
107. — Posterior view of Fig. 106 ....
108. — The genitourinary tract of Iguana tuberculata
109. — Diagram of complete ureteric reduplication
110. — Diagram of complete ureteric reduplication
111. — Human bladder with only one ureter .
112. — Discoid kidney
113. — Horseshoe kidney
114. — Horseshoe kidney
11"). — Complete unilateral fusion of the kidney
110. — The kidney of Fig. 11") .
117. — Tandem fusion of the kidney
118. — Horseshoe fusion of the kidneys .
110. — Caudal pole fusion of the kidneys
120. — Diagram of tandem fusion of the kidneys
121.— Bladder of Fig. 115 ....
122. — Dorsal view of the same bladder as Fig. 121
123. — Stab wound of the kidney
124a. — Pyonephrotic kidney containing stones
1245. — X-ray picture of calculi in the kidney of 124a
125. — Tuberculosis of a kidney
126a. — X-ray picture of a renal calculus
1266. — Photograph of the calculus shown in 126a
127. — Fibroma of the kidney ....
128. — Fibroma of the kidney ....
129. — Child with sarcoma of the kidney.
130. — Urinary sediment in Bilharz's disease
MM. — Ovum of distoma hematobia
132. — Shell of ovum of distoma hematobia
133. — Embryo of distoma hematobia
134.— The floor of the bladder
135. — Empty bladder in profile
136. — Section of body showing shape of the bladder win
137. — Section of body showing distended bladder
Mis. — Section of body showing bladder partly distended
139. — Section of body showing bladder greatly distended
140. — The relations of the bladder .
141. — Keyes syringe
142. — Thompson's searcher ....
14:'.. — Guyon's searcher
144. — \Y. K. Otis 's searcher ....
14"). — First stage in the passage of a sound .
146. — Second stage in the passage of a sound
147. — Third stage in the passage of a sound .
n ni
rinal development ol the ureters
ghtlj
elide
XVI
LIST OF ILLUSTRATIONS
FIG.
148. — Fourth stage in the passage of a sound
149. — The photographic cystoscope ....
150. — Perforated metal plate in photographic cystoscope
151. — Ocular portion of photographic cystoscope
152. — Cystoscopic photograph of a stone in the bladder
153. — Cystoscopic photograph of a dilated ureteral orifice
154. — Exstrophy of the bladder
155. — Gauze pad removed from the bladder .
156. — Bladder stone containing a safety-pin as a nucleus
157. — Cystoscopic picture of a hairpin in the bladder
158. — Hemin crystals
159. — Esbach's albuminometer
160. — Uric-acid crystals
161. — Sodium urate crystals
162. — Ammonium urate .
163. — Cholesterin crystals
164. — Oxalate of lime
165. — Triple phosphate
166. — Calcium phosphate .
167. — Pus cells in urine
168. — Blood corpuscles in urine
169. — Epithelia from the genito-urinary tract
170. — Urinary sediment in acute cystitis
171. — Urinary sediment in chronic cystitis
172. — Urinary sediment in putrid cystitis
173.— Cystin
174. — Cicatricial bladder . .
175. — Concentric hypertrophy of the bladder
176. — Eccentric hypertrophy of the bladder .
177. — Epithelia from the female urethra above, from the vagina below
178. — Epithelia from the male urethra above, from Littre's glands below
179. — Epithelia from the prostate
180. — Epithelia from the bladder
181. — Epithelia from the pelvis of the kidney and ureter
182. — Kidney epithelium .
183. — Hyaline casts .
184. — Finely granular casts
185. — Waxy casts
186. — Epithelial casts
187. — Bladder stones
188. — Faceted vesical calculi
189. — Tobacco-pipe calculus and calculi from diverticula of the bladder
190. — Normal curve of sound for male children
191. — Cystoscopic picture of a uric-acid calculus
192. — Cystoscopic picture of a congenital diverticulum of the bladder containing
193. — Villous epithelioma of the bladder
194.— Small tumor of bladder
195. — Villous tumor of the bladder
196. — Villous tumor of the bladder
197. — Multiple villous papilloma of the bladder
198. — Myxosarcoma in the bladder of young girl
199. — -Lobulated epithelioma of the bladder .
200. — Alveolar carcinoma of the bladder
201. — Carcinoma of the bladder
a stone
\A>\ OJ I l.l.i SI i:\ I ions
xvn
no.
202. Tran verse section through middle of human prostate
203. ( Outline <>i catheter
•_'o I. ( !atheter coudd "t Mercier
•jo."). Catheter bicoud£ of Mercier ......
206. Sagittal section of generalized hypertrophy <>f 1 1 1 « - prostate
â– _'u7 Generalized irregular hypertrophy >>t the prostate
208. Hi > - method of introducing a catheter in cases ><( prostatic hypertrophy
209. Bougie catheters
210. — Hypertrophy <>l" both lateral and median lobes <>f the prostate
211, 'I'lii- male urethra
•_ , r_'. Median section through urethra
213. Median section of tin 1 anterior extremity "!' penis
•j I I. Transverse section of the shafl of the penis
215. Outline diagram of the curved portion of urethra
216. Epispadias
217. Klotz endoscopic tube
218. The Chetwood urethroscope
219. !• . T. Brown's urethral Bpeculum
220. The Otis electric urethroscope
221. Se1 of endoscopic tubes
2 - . < lonical steel sound ,
223. Double tapered sound
224. Sound with benique curve
225. -Bougies i boule for detection of Btricture of urethra
226. Olivary bougies
227. Whalebone filiforma
•J'JS. The ( )tis urethrometer
229. Scale plate for determining the ^ix<- of urethral instruments
230. Soft-rubber catheter, scaled
231.- Lipoma <>i" the penis
•_':'._'. Lipoma of the penis
233. Sofl papillomata of penis
234. Epitheli a of the penis
235. The scrotum
236. — Transverse section of the right spermatic cord .
j:'.7. The testis seen from the side
238. — The testis and adjacent structures viewed from in front
239. Congenital cavernous angioma of the scrotum .
210. Recurrent varicocele
241. Double tuberculous epididymitis
_' 12. < lumma of the testis
243. Sarcoma of the righl testis
PAKE
.,11/
624
624
627
640
657
671
672
673
674
675
« • 7 "<
677
688
688
-
691
704
Tot
7i 15
713
724
: :
711
SURGICAL DIAGNOSIS
\ol.l Ml. II
CHAPTER I
DISEASES OF THE ABDOMEN
DIAGNOSIS OF THE DISEASES OF THE ABDOMEN
Methods of Examination
Assuming that all possible information has been obtained relating to the
previous history and present illness of the patient, the examination may be
conducted on the following lines :
Inspection. — By viewing the abdomen from various directions and with the
patient in various positions, much information may be obtained, sometimes of
a very definite character, sometimes only suggestive, furnishing a hint as to
the lines upon which the further examination should be conducted. The color
and general appearance of the skin of the abdomen should be noted, and the
presence of eruptions, sears, tumors, hernia 1 , sinuses, infiltrations. Linea? albi-
cantes (stria') may be present, pink or raw-ham colored when recent, sometimes
pigmented in brunettes. They indicate a previous distention of the belly, in
women usually due to pregnancy; sometimes to obesity, ascites, a tumor, or
other cause. Extreme degrees of distention from ascites or large tumors cause
a peculiar smooth, glistening appearance of the skin, sometimes combined with
edema, never present from mere obesity and usually associated with some
cachexia. Emaciation of the face, thorax, and upper extremities may be pre-
cut in such cases, and the legs may he swollen from edema. When the patient
stands erect and is viewed from the front, we may see enlarged varicose sub-
cutaneous veins radiating from the umbilicus (Caput Medusa?). They indicate
interference with the portal circulation, as from cirrhosis of the liver and
certain tumors of the liver (carcinoma). Large pelvic tumors which compress
the iliac veins or the inferior vena cava, and extreme degrees of ascites, may
pro. luce visible enlargements of the epigastric veins, both inferior and superior,
the blood finding its way into the internal mammary veins and veins of the
diaphragm. An unusual dilatation of the veins of the spermatic cord, often
greatly in excess in size and number of the veins found in varicocele, is strongly
suggestive of a malignant tumor of the kidney, especially if it be upon the
left side.
53 l
DISEASES OF THE ABDOMEN
Hernia 3 , whether umbilical, ventral, inguinal, or femoral, are often visible
by inspection in the erect posture. Diastasis of the recti muscles as the result
of repeated pregnancies is readily visible ; a large tumor, covered by little more
than integument and containing intestine, etc., may project through the gap,
and the edges of the recti are easily seen forming its boundaries. In these
cases, and in large reducible umbilical hernia? with a dilated ring, palpation of
the abdominal viscera may
be extraordinarily easy. The
thinned-out abdominal wall
may be inverted into the
belly by the examining hand
and the viscera readily pal-
pated. The size and shape
of the abdomen are to be
noted, whether normal, in-
creased, or diminished in
size, and, if increased,
whether the enlargement is
symmetrical or localized.
Further, whether the ab-
domen bears a normal rela-
tive size to the thorax. Ab-
dominal enlargement due to
obesity is accompanied by a
generalized thick panniculus
adiposus over the thorax,
buttocks, and extremities.
Distention due to mere flat-
ulence from intestinal fer-
mentation, constipation, etc.,
is moderate in adults ; in
children it may be more
marked, owing to the rela-
tively greater size of the
abdomen in infants. The
appearance of the umbilicus
should be noted. In ascites
and tuberculous peritonitis the umbilicus protrudes; the same is true of the fluid
accumulations in the belly accompanying malignant disease of the abdomen
(cancerous peritonitis). Ascites from malignant disease is accompanied by
emaciation, a cachectic appearance and a drawn, anxious facial expression;