DIRECTOR   Borivoj Kokinos


The mesentery seems to open for them, so to speak, and the enlarged glands lie close to the spine, and in front of them lie the intestines. ■ The big belly is the result of imperfect digestion, and of the weakening of the intestinal and of the abdominal walls, so that the child makes too much wind, and is unable to expel the flatus from its bowels. The disturbed digestion causes the generation of excess of flatus; the weakened intestinal walls and the weakened abdominal walls do not readily expel it. To detect enlarged mesenteric glands you have to feel for them carefully. The enlarged glands do not come near the surface like the spleen, which you cannot fail to find at once, though you may mistake the nature of the tumour. To feel a tumour formed by enlarged mesenteric glands, put the patient on the back in a proper position, and then suddenly depress the walls of the abdomen. You may thus come down, pushing the flatus away, upon a hard mass lying close to the spine. Enlarged glands may sometimes be detected by grasping the two sides of the abdomen between the hands, or between the fingers of one hand; and then by bringing the fingers slowly together, you may at last feel the glands between your finger, or, if greatly enlarged, as an unmoveable solid mass. By the manipulation I have described, you may feel very slightly enlarged mesenteric glands—e.g., those the seat of albuminoid infiltration. The great causes of chronic enlargement of the mesenteric glands are: albuminoid disease, tubercular disease, repeated inflammation of special sets of glands, malignant disease, and that hypertrophy which is accompanied by excess of white corpuscles in the blood—the glandular form of leukamiia. The albuminoid never attain any great size; you just feel them roll under your finger by manipulating in the way I have described. Distended tumours formed by enlarged lymphatic glands are nodular, the nodules being large and round. This drawing shows how impossible it maybe by palpation to distinguish an enlarged gland from a kidney, and how impossible it may be to distinguish enlarged glands from an enlarged pancreas. When the lymphatic glands are large enough from chronic disease to form a distinct tumour, they are fixed, and can be moved neither by respiration nor, to any extent, by palpation. We now and then find a small tumour in the right iliac fossa caused by enlarged and indurated glands. The most common cause of glandular tumour in this situation is one or more attacks of typhlitis. The healthy pancreas can now and then be just felt in very thin persons with small lax muscles, whose lower dorsal and lumbar vertebrae are somewhat curved forward. I may have satisfied myself that I have felt it half a dozen times in my life. The pancreas crosses the aorta and the spine, and when perceptible to touch, is felt on deeply depressing the abdominal walls about a hand's breadth above the umbilicus, bythen rolling the subjacent parts under the hand (the stomach and colon must both be empty). I have known the pancreas of normal size, in such persons as I have described, mistaken for disease; it has been taken for malignant disease of the transverse arch of the colon, and for an aneurism of the abdominal aorta. The head of the pancreas may be so large, when the seat of cancer or of tubercle (I have seen one case only of the latter), as to form a distinct abdominal tumour. The pancreas in health and in disease is fixed— i.e., is unchanged in position by the respiratory movements or by palpation.