CHAPTER XVII DIAGNOSIS OF SWELLINGS AND (Part 2)

tumoura.^Vamtion t their consistence, while a frequent feature of mali? nant tumours, especially sarcomata, is rarely sel m benign growths. Secondary epitheliomatous^iwtis The for ' '^"^^"'^^"^g swellings ' I he form of a tumour must be carefulfv oh ne'dSg:^r veryS:^;;^- unifort 'ymV7 ^ r^'^'^ "-^-^t- the pressureoTl frowth or^ '''^'/"""^ all tissues enuallv i,7r i. implication of we find thl /sts of a^l gJ-^-g tumour. Thus globular oiftlinT't also do^t/T'^ ' ^^'^""^ ' and diseased joints when the fib? '? ^^^^^T-sms softened and ^are nrionge/atJe '"'^^ normal outline of the part while snff carcinoma frequently as.n.l i , ? sarcoma and globular formTdeLioti^ ' ? '^"P^- ^he guishes these and hemispherical abscesses ^ A tumour may be lobulated and ihi. characteristic. Thus the fin^ I i T? ^ '^^^ be the distension of tl acin/ ^ '^""^^^ by congestion are qui e characte i.?' TT'' "^^^^ tension. The flltfeLd ovo ^^^^^^^^^ b. its -^uia?r-^z:^^^^^^ 228 SURGICAL DIAGNOSIS [chap; lobulation of tumoui-s may be due to yielding of the siirrounding tissue in certain directions only, as in some ganglia ; to cystic formation, as m cystic disease of the mamma and testicle ; to an inherent mode of growth of the tumour, as m enchondroma ; or to multiplicity of the tumours, as in uterine fibroids. Lobulation may also be explained by the ana- tomical relation of the swelling, as in psoas abscess. The retraction of a tumour is an important char- acter, indicating a contraction of the tissue; it is a special feature of scirrhous carcinoma. Other characteristic forms are the luarty or villous, the fedimculated or polypoid. Ti-ausluccney of a swelling shows that it con- sists of a collection of transparent fluid, serous or synovial ; and it is, therefore, a diagnostic sign oi .n-eat importance. To test for translucency, the tumour should be grasped so that it is made tense and the skin stretched tightly over it ; a good hght is then to be held close to it on one side while the observer's eye is on the opposite side, the rays ot lioht which pass over the surface of the sweilmg behig shut ofi by the hand or some smtable screen ; if it is translucent, the light is seen through the swelling more or less intensely. Some prefer to look through a stethoscope, a roll of paper, or some similar tube. Translucency may be missed by carelessness in carrying out this manoeuvre thus, a scrotal swelling may be so held that the patient s penis or the sound testicle, or the surgeon's hand co^es between it and the light, the rays of l^gl^^ being thus interrupted ; or one part only of a sweilmg which is partly solid and partly fluid, such as a hydrosarcocele, may be exammed. On the other hand, it may be wrongly detected if the observer is not careful to shut off from his eye all the rays xvii] TRANSLUCENCY OP TUMOURS 229 of light except those passing into the swelling; thus, if a stethoscope or other tube is used and the end is not placed quite firmly and uniformly on the swelling, light passing into the tube under its tilted end may be mistaken for that passing through the swelling. Tumours usually translucent may he opaque through great thickening of the covering as m some cases of old hydrocele ; or through a change m the fluid, as when hsBmorrhage occurs into a hydrocele, or a serous cyst becomes inflamed and suppurates. When testing for translucency it IS always well to examine the whole swelling, both because a translucent part may otherwise be over- looked, and also to localize exactly any opaque portions In this way the position and approximate size of the testicle m a hydrocele, or the presence and position of the spinal cord or nerves in a spina bifida, may be determined. Although translucency is positive evidence of the presence of a clear fluid in the sweUmg serous or synovial, the surgeon must member tha opacity is not by itself evidence of the absence of such fluid. a. f?L"''''"?^' ^ ^^'^^^^^ "^^y be so thinned as to become transparent and allow the colour and appearance of the swelling to be seen through them as e.g. a pomtmg abscess, a spina bifida with a veT; thm sac, a na^vus, a sebaceous cyst, dilated veins a melanoma, or a chloroma. ' Opacity of a tumour to X-rays.-A good deal may be learnt about the nature and^tje position of a tumour by a cirpfil . with X r;,va A { • ■ examination ..nifonn u„les,, ifs wall i, caKd^o^o fiStAi opaque dissepiments wliicli aWo a rlirl,™ .1 i Abscesses are more „pa,ue than'^l b^t"tte;:i 230 SURGICAL DIAGNOSIS [c'rap. give a uniform shadow. Solid tumours usually give a faintly striated shadow. Bony tumours give a deeper shadow, and the arrangement of the bone lamellae can be traced in a good skiagram. The relation of a tumour-shadow to the shadows of adjacent bones and viscera often gives great help in diagnosis, as for instance in cases of aneurysm, mediastinal tumour, psoas and other deep abscesses. In some cases the contrast between the shadows can be artificially increased with great advantage. Thus, the stomach or colon can be inflated with transparent gas, or rendered very opaque by a bismuth meal ; the urinary bladder may be made transparent by inflation, or opaque by being filled with a solution of protargol or sodium bromide ; the ureter may be made to stand out on a photographic plate by the passage into it of an opaque bougie ; and the pelvis and calyces of a kidney can be gently filled, like the bladder, with an opaque solution. Occasion- ally the relations of a tumour itself translucent may be revealed by the deformity it produces of the shadow of an opaque part, e.g. when a distended gall-bladder indents the outline of a barium-filled duodenum. Of even greater value is a good skiagram when it shows a tumour, or its exact extent and position, which cannot be recognized by any other means, as in growths in the s^unal column, in the mediastinum, in the antrum of Highmore, or in the interior of bones before any alteration in the outline of the bono is produced. Rcduciljilily of tumours.— Some tumours are reducible, either wholly or in part, really or appar ently, and the observation of this fact may tlirow great liglit upon their nature. A tumour is really reduced when its contents are emptied out of its capsule into one of the normal cavities of the body xvri] POSITION OF TUMOUES 231 or into the vessels of the part. Examples of this are seen in hernia, some forms of hydrocele, varix, aneurysm, and meningocele. A tumour is' appar- enthj veduced when it disappears from its original position, but is not emptied out, and still reniains of Its origmal size. We see examples of this in the reduction of hernia en bloc, in some cases of tumour of the spermatic cord, and of cryptorchism ; in psoas abscess, where the femoral pouch can be emptied into the abdominal; and in effusion into the bursa beneath the semimembranosus tendon, when this does not communicate with the knee-joint. In the i^™^^^?^ reducible contents of tumours are always tluid (blood, pus, synovia) ; in sweUings in connexion with the trunk the contents may be solid or fluid as in herma and varicocele. Reducible tumours are liable to temporary mcrease of their usual bulk, and the conditions under which they become overfull or emptied often aid materially m diagnosis. Position pressure and effort or strain are the means usually employed to cause these variations in tumours Position.-It IS only the most easily reducible . wellmgs, and particularly varices, that are affected by position. In the dependent position dilated veins whether m the limbs or scrotum, fill out, and when the part is raised they at once empty, either wholly or partially. Some herniee slip up and down with alterations m the position of the patient It must be observed that oBdema may be greatly modified by, or only appear in, the dependent pos^ tion. When this is the case the c^dema is certain y passive. A vaginal hydrocele, although enti ely irreducible, may be fuUer in the evenmg than J the morning owmg to increased exudation durin. the day. In both oedema and hydrocele, however he change takes place slowly. iowcvei, tlie 232 SURGICAL DIAGNOSIS [chap. Position has a further influence upon tumours, due to the altered tension of muscles and fascia3 accompanying changes in position of the limbs. A typical illustration of this is seen in the case of effusion into the bursa between the tendon of the semimembranosus and the inner head of the gastroc- nemius. When the knee is flexed these muscles are lax, and the swelling partially or wholly disappears, the fluid bulging the sac towards the space of the ham ; but when the Imee is extended these two muscles are tightly stretched and compressed one over the other, and the fluid is driven from between them and distends the superficial part of the bursal sac, causing a prominent swelling behind the inner side of the knee. Pressure. — When exerting pressure we are enabled to judge of the amount of resistance to reduction, to note the manner of reduction, whether sudden or gradual, and any special accompaniments of the process. Venous tumours are always very rapidly reduced by pressure ; other fluid tumours, such as hydrocele and abscess, are steadily reducible, and whether rapidly or slowly depends upon the size of the aperture for reduction and the amount cf resistance in the cavity into which they are reduced. If the contents of the tumour are fluid, containing numerous small solid particles in suspension, a flue thrill is detected by the finger during reduction. Solid tumours go back with a sudden motion recognized as a " slip " ; and the reduction of in- testine is often accompanied by a gurgle. By the use of pressure, too, we are able to judge of the completeness or incompleteness of the reduction, as in the case of partially reducible hernia, or reducible hernia conjoined with an irreducible hydrocele. By following up the reduced swelling wo may generally xviij EFFECTS OP STEAIN ON TUMOURS 233 ascertain with the finger the aperture through which reduction has taken place. The effect of pre^s^re i^pon individual blood-vessels above or bdow a swelhng may give valuable information. Thus pres- sure on an artery feeding an aneurysm causes a partial shnnkmg of the swelling, and "thl pressure Chap. XX.) Agam, m cases of varix of the lower limb been emptied pressure is made upon the upper end litllTf "PJ"^^ ^^"^ saphenaTagnat and when the patient stands up the swelling Dre v^ausly noticed does not reappea^mtil the pTess^^^^^^ on he vem is removed, it shows both the coSnexSn vLt i;lsSof of those which are influenced by obstruction S venous circnlatmr, ^n, ^^J' oubcrucmon to the a true impulse, or fihin- out nf . .r ^'"'^"^guish mere thrust fo vvards J. ?,n '""""/"S' ^ (-See Chap. XX j "^''Vlacement. P..'-.tion is of the utmost importance as a 234 SURGICAL DIAGNOSIS [chap. symptom ; in all cases it indicates a special comiexion of the tumour with the arterial system. It is neces- sary to bear in mind, however, that pulsation is only observed when the passage of blood mto a part meets with a certain amount of resistance: thus, when an aneurysm or an artery ruptures subcuta- neously and the blood is difiused in the loose tissue of the part there may be no pulsation m the sweUmg. Pulsation in a swelling may be due (a) to the direct comimmication of an artery with the sweUmg, as in aneurysm or aneurysmal varix ; (b) to the pres- ence of numerous pulsating arteries m the tumour, as in aneurysm by anastomosis, m pulsating bron- chocele, and in very vascular sarcoma ; (c) to the presence of an artery in close contact with the sweil- lug to which it transmits its pulsation, as m some cases of enlargement of popliteal glands and of tumours of the thyroid gland and some abdominal tumours. (For the diagnosis of pulsatmg tumours see Chap. XX.) e .1 „ The colour and vascular condition of tiie skin covering a swelling are often noteworthy. The skin may be reddened, and, if so, care must be taken to distinguish between certain varieties of this discoloration. If the colour is not altered by pressure, it is due to escape of blood from the vessels the result being spoken of as fdeclncu if m small isolated spots, or as a bruise or an ecchymosis if more difiused; such a condition aids m the diagnosis of purpura, scurvy, hc^matoma, contusion, or the rup- Lre' of an artery or vein. If. bowever the colour disappears on pressure it shows that it is due to blood circulating in the vessels and the i^P d 7 with wliich it returns corresponds with tl^^ ^^^^^^ f of the circulation in the part. When the red colour is uniform and individual dilated vessels cannot xvn] COLOUR OP SKIN IN TUMOURS 235 be detected, the couditiou is due to rnniU..^ motor dilatation, and is very often ,-nfl? I and .s certainly not inflammatory • if of a^ nnrnf ' tint It IS probably due to obstruction to fJ, ^ ^ circulation. Where hnta ° yenous vessels larger thin clZ ' dilatation of a bright-ref colom is containmg blood of it ofL mdicates the T 7'' the morbidTow h in 7 °^ ^^m in of treatment^Jy X-r'ays ^^^"1^ foJs^'Ld^^tl^f?"^"^^^'-^^-- above ance of whfc is ani l T T^'^'^'"' '^^^'^ ^PP^^^" vanes from hLu TLT'TT' ■ ^'^^^^ i« slightly raisef allay shaiSv "^''''^ ^^^^ presents an uneven anil ^ 7 often pouched. arrang:2.?KTl r of skm IS usually congenitnl n7 ' condition birth. Such a sfate of ? ^^"^ ^^^^ after subjacent swelhng ,s e tl er t.V''^''"''' of congenital tumour. fo^-m The skin may be pigmented. This is m.f • moles, and m the results nf .1 Pigmentation also fLnr^'T^'^" tion and from X-ra^tr atmen il 'T^ '''''Ses. 236 SURGICAL DIAGNOSIS [cHap. mole. The black colour of a melanotic sarcoma may be seen in the skin or mucous membrane. Hairy or pigmented moles frequently become the seat of epithelioma or melanoma. III. Vital Characters of Tumours The important features of the hfe-history of a tumour are the history of its first appearance, its progress, its mode of growth, the pathological changes occurring in it, and evidence of infectivity. 1. The history oi the Gist appearance of a ewelUng will often throw great light upon its nature. The following varieties may be distinguished : i. Congenital tumours.— These include malformations, such as meningocele, encephalocele, spina bifida, attached fostus, included fastus, congenital disloca- tion, hydrocele, and hernia ; cystic tumours, such as dermoid cyst and cystic hygroma ; solid tumoiu's, such as lipoma, fibrous tumour of gum, scalp, or »skin, sacral and coccygeal tumours; hypertrophies, seen particularly in the Hmbs ; vascular groivths,^ or the different varieties of na3vus and thiclcemngs around bones in cases of intra-uterine fracture. ii. Swellings arising suddenly.— Such a swelling can only be caused by (1) the displacement of parts, as m dislocations, hernia, and pneumatocele; (2) the rapid effusion of blood, as in traumatic aneurysm, hannato- cele, ha^matoma ; or (3) the escape of the contents of the hollow viscera, as in some cases of traumatic emphysema and in extravasation of urine. _ (1) Displacement of parts will be recognized by three signs : («) the absence of the part from its normal situation, as e.g. the head of the humerus immediatclv below the acromion, or the head oi tlie radius bcloV the cxtsrnal condyle of tlie luimcrus ; (b) the continuity of the swollmg with the part xv-ir] HISTOEY OF TUMOURS 237 supposejl to be displaced, as when the swelling pro- duced by a displaced bone moves when the other end of the bone is rotated, or its connexion is traced by the finger passed along it, or is shown by certain special signs, as the reducibility and impulse in a hernia, and the respiratory modifications of a pneu- matocele; and (c) the character of the swelling re- sembling that of the displaced organ, as the rounded head of the humerus, smooth tympanitic gurgling intestme, or granular omentum. (2) Rafid effusion of blood will be distinguished (a) by the absence of the above signs, and also of those associated with the escape of the contents of the hollow viscera ; (b) by the evidence of the fluid nature of the swelling, shown by its being dull on percussion and either by fluctuation or by its in- filtrating character (a rapid infiltration can only be by gas or by fldd— the percussion note at once dis- tmgmshes between these) ; (c) by signs of bruising or blood-staming ; {d) by the general signs of loss of blood (m some cases) ; (e) in some few cases by evidence of the disturbance of the circulation in the part; and (/) by increase in size of the swelling gomg on for a time at least— this is one of the most important signs of all. Where the escape of blood IS arrested and the effusion forms a distinct tumour It IS called a hcematoma ; in such cases the blood is usually poured out from smaller vessels. When how- ever, blood is poured out from a single large vessel and the opening in the vessel remains patent, so that blood continues to flow, it is spoken of as a ruptured artery or ruptured aneurijsvi. These mav be thus distinguished : ■' _ If the swelling is more or less well defined and circumscribed, at first fluctuating, without pulsa- tion, brnit, or thrill, and there is no interruption of 238 SURGICAL DIAGNOSIS [chap. tJie pulse in the