Pg. 343

¶ 1 Leave a comment on paragraph 1 0 THE LONDON PRACTICE OF MEDICINE AND SURGERY.

¶ 2 Leave a comment on paragraph 2 0 343

¶ 3 Leave a comment on paragraph 3 0 is not noted; and in two, the urethra is stated to have been much contracted. The seventh is not easily explicable, as, although the kidney contained two pints of pus, which had free communication with its pelvis, yet the notes state that “ the ureter was slightly enlarged.” It can scarcely be meant that the calibre of the ureter was enlarged, since, as the disease depended on a renal calculus, and there was no obstruction in the bladder or urethra, the non-escape of pus under such circumstances would be very difficult of explanation.

¶ 4 Leave a comment on paragraph 4 1 On the question of the diagnosis of tumours of the kidney we shall not enter until we have recorded several examples of solid growths from that viscus which will find their place in a future part of the seines. It may be remarked here, however, that when inflammation has been the cause of the tumour, the organ will generally have become more closely fixed in its position than under other circumstances; the prominence in the loin will be greater, and the bulging forwards and into the abdomen less. The rule is, however, by no means uniform. The differential diagnosis will generally be between abscess and malignant growths or hydatid cysts. The history of rigors having occurred, and of the disease haying been attended by pain and symptoms of irritation before the discovery of a tumour, will strongly favour the supposition of the  existence of abscess. The existence of stricture of the Urethra, the history of the passage of a calculus, or of an injury to the loins, are also indications which point in the same direction, though much less trustworthy. It is of course supposed, that the question is rendered difficult by the absence of pus from the urine; for if there be a flow of purulent secretion, unmixed with fragments of malignant structures, (to be detected by the microscope,) there can be but little doubt as to the nature of the disease. One of Dr. Bright’s cases is an example of the co-existence of a large abscess in the kidney, dependent upon an impacted calculus, with malignant disease both of that organ and of the liver.(a) Such a conjunction must, however, be very rare.

¶ 5 Leave a comment on paragraph 5 1 Case 14.—Abscess in the Kidney—Puncture in the Loin.-Death.—Some years ago a very interesting case of abscess in the kidney was under the care of Mr. Stanley in St. Bartholomew’s Hospital. The subject of it was a middle-aged man who had previously had fair health. The pus did not escape freely by the urethra, and there was such manifest bulging in the lumbar region, that it was thought advisable to make an external opening. The soft parts were divided by a scalpel, and a large trocar and canula were then thrust into the most prominent part of the tumour. A copious discharge of pus followed, and was kept up during the rest of the time that the man lived. The patient improved much in health during the first week or two, but subsequently he relapsed, and death, with symptoms of extreme constitutional irritation ultimately followed. At the post-mortem, several Oxalate of lime calculi, of moderate size, were found in the pelvis of the kidney, surrounded by a large abscess. The ureter was obstructed. It could only have been by the freest incisions and extended exploration that the calculi could have been removed during life. The supposition that they existed had often occurred to Mr. Stanley, and been the subject of discussion; but, as they could not be discovered by the probe, it was not thought justifiable to adopt at hazard the measures necessary for their discovery.

¶ 6 Leave a comment on paragraph 6 0 GUY’S HOSPITAL.

¶ 7 Leave a comment on paragraph 7 0 SIMULATED OR “PHANTOM” TUMOURS.

¶ 8 Leave a comment on paragraph 8 0 [Cases under the care of Dr. ADDISON and Dr. GULL.]

¶ 9 Leave a comment on paragraph 9 0 Among the circumstances which combine to make the investigation and diagnosis of abdominal tumours difficulty is the existence of a class in which the symptoms are so changeable that it becomes almost impossible to decide whether or not any tumour does exist. The signs are present one day, entirely absent on another, then present again, in a most perplexing manner.  Every practitioner of experience must have met with such puzzling cases; but to those who have not, it would be impossible to convey any idea of the degree to which they sometimes simulate real tumours. Dr. Bright, in his papers on Abdominal Tumours, in the Guy’s Hospital Reports,(b) mentions a case in which, in an hysterical woman, the Surgeon had been induced to attempt ovariotomy, believing that an ovarian cyst was present. The incision having been made, no tumour whatever could be found, and the operator was obliged to desist. The woman fortunately

¶ 10 Leave a comment on paragraph 10 0 recovered, and the tumour at a subsequent period again made its appearance.

¶ 11 Leave a comment on paragraph 11 1 One of the earliest allusions to this deceptive class of cases was, we believe, by Dr. Bright ;(a) and in the wards of Guy’s Hospital they have since been the subject of much investigation. Our own knowledge of them has been chiefly derived from the clinical observations of Drs. Addison and Gull, under whose care several very instructive cases have occurred during the last few years. To the latter gentleman it is, we believe, that the affection is indebted for its very appropriate name of “phantom tumour.” We shall attempt in the following sentences a, short summary of such facts as have been made out respecting them, but shall not occupy space with the details of cases, as the disease is one in which the prominent symptoms, from being essentially unreal, are interesting rather to the manipulator at the bed-side than to the reader of notes. Dr. Bright’s allusion to the subject, to which we have referred, is as follows. In speaking of reported cases of disappearance of ovarian cysts, that experienced Physician states :—“ It is even possible that a certain number of these cases may be set down as instances  of erroneous  diagnosis; for there is no question that the diagnosis is not always obvious. There is one class of cases more particularly liable to lead the unwary and inexperienced into error respecting the disappearance of an abdominal tumour;—I mean cases of hysterical distention of the bowels; for, although the swelling in these cases is essentially tympanitic, yet occasionally, from the singular way in which the intestines are partially distended, and remain so for days and weeks at a time, they sometimes give completely the forms of tumours; and sometimes even indistinct fluctuation may arise from fluid faeces, or even from the co-existence of a distended bladder; and sometimes the large accumulation of hardened faeces has led to a belief of a more solid tumour.” To state them seriatim, we have then the following, as the chief conditions on which these variable tumours may depend. 1. Distension of the bladder. 2. Solid faecal accumulations. 3. Irregular contractions’ of the intestine at two points, and distension of the intervening portion, with flatus or with fluid faeces, 4. Spasmodic rigidity of a part of the abdominal parietes. It may, perhaps, seem almost superfluous to add the last, but practically, it is one of the most frequent sources of deception. An hysterical patient is quite capable of making a circumscribed portion of the abdominal wall rigid and hard, while the rest remains  comparatively flaccid; and even in a person of calm nervous system the same condition may be produced by an instinctive reflex act, for the protection of a part of the belly which is tender on pressure. The recti muscles are peculiarly apt to the seat of these contractions, which may, however, also occur in the lateral regions of the abdomen. It is rare, perhaps, for any one of the above mentioned causes to exist singly and uncomplicated by any of the others. Neither of the first two, indeed, unless exaggerated by one or other of the latter could properly rank as a “phantom” tumour. Hardened masses of faeces are probably, however, the most frequent of the exciting causes of the affection. By the irritation produced by their lodgment, the intestines are made to contract irregularly, and local tenderness is, also induced, which latter, in its turn, acts as an excitant, in producing reflex rigidity of a part of the abdominal parietes. It has been observed of phantom tumours, that they are by much more frequent on the right than the left side, and that not rarely there are present in connexion with them indications of renal irritation. Both of these circumstances are probably to be explained by reference to the facilities afforded by the coecum and ascending colon for the delay and accumulation of scybalous faeces. The period pf early adult life would appear to be the one most liable to the development of this chain of symptoms. The simulated tumour in question is by no means met with only in the female sex, some of the most marked examples of it that we have seen having been in young men As it regards treatment, that

¶ 12 Leave a comment on paragraph 12 1 should of course be modified according to the peculiar circum- stances of the case. A brisk purgative will probably be a remedy almost always useful, and afterwards a course of nervine tonics, or perhaps of anti-spasmodics, may be exhibited with benefit. The chief importance of the cases is in the lesson they convey as to the necessity for great caution before pronounring positively as to the existence of an abdominal tumour. The Surgeon should always be content, in doubtful cases, to examine his patient, on several separate occasions, before venturing an opinion. In most cases, probably, the careful employment of percussion and palpation will be competent to decide the question correctly; but if there be the least doubt remaining, the diagnosis

0. ¶ 13 Leave a comment on paragraph 13 0
1. (a) Case 5, page 228, Guy’s Hospital Reports, Vol, IV., 1839.
2. (b) Guy’s Hospital Reports, NO. VI., p. 257.

¶ 14 Leave a comment on paragraph 14 0 (a) Loc. cit.