CHAPTER XVII DIAGNOSIS OF SWELLINGS AND (Part 3)

arteries beyond, and especially if it Las resulted from direct violence, it is a hcematonia. If the swelling is ill defined, very tense, of great size, not fluctuating, but more or less boggy at the edges, and the limb beyond is cold, oedematous, hvid, and numb, and the arteries pulseless, and if there is severe pain in the part, with perhaps fainting and other general signs of a severe loss of blood, it is a diffused aneurysm. A bruit may be heard in such a swelling, at times thrill may be felt, and if the parts around the flmd blood are much compressed and condensed into a spurious sac, faint pulsation may be detected ; if the artery is partially ruptured there may be a feeble pulse in the arteries beyond. Sometimes the patient experiences a sensation of something snapping or giving way, followed by a hot rushing feeling. If such a swelling has formed as the result of a severe twi^t or strain, and there is no previous history of any affection of the vessel, it must be diagnosed as a ruptured artery. But if the swelling has occurred spontaneously, or from only slight violence, and there is a history of aneurysm, or of a swelling, or of a sense of beating in the part, or of pain supposed to be " neuralgic," or of venous engorgement below, then it must be diagnosed as a ruptured aneurysm. If unrelieved, this condition speedily runs on to moist gangrene. (3) Traumatic emphysema is recognized by the softness of the swelling, the crackling sensation when it is compressed, and the resonance to very light percussion. Extravasation of urine is characterized by the position and limits of the swelling, by its oedematous nature, and by interference with the act of mic- turition. {See p. 633.) xviij HISTORY OP TUMOURS 239 lii. Swellings arising rapidly are izi all cases due to an accumulation of excess of the animal fluids or of gas in the part, for only these can thus rapidly collect. Acute inflammcdion, as it occurs in the cellular tissue, glands, periosteum, tonsil, tongue, larynx, tunica vaginalis, bursas, synovial membranes, etc.,' IS the most frequent cause of such rapid swelling.' It also occurs when a sudden or rapidly formed obstruction to the venous circulation leads to fassive fjedema of a part, as in thrombosis and compression of veins, and it may occur when some profound change m the character of the blood leads to in- creased transudation of serum, as in acute nephritis. A swelling is rapidly formed, too, when small blood- vessels are mfured and bleed, as in some briuses ; in cases of obstruction of the ducts of actively secreting glands, the secretion poured out in considerable- quantity may accumulate behind the obstruction and lead to a rapid .swelling. Examples of this are so-called ■ milk congestion," where a mammary lobe is_ distended with its own secretion, the distension ot a sabvary gland behind a calculus in its duct and acute retention of urine. Emphysema of the clie,st, neck, and face may cause rapid svvellmg in the Eascue of these parts. The coagulation of blood in a vein (thrombosis) may cause a swelling by the clot distending the vein. Acute inflammation will be readily distinguished by Its characteristic local signs : (a) redness^ when the inflamed part is superficial ; {b) heat ; (c) pain usually severe, and {d) tenderness ; as well as bv general fever. Qldema is recognized by the pitting of the swollen part ou pressure ; when a swelling is wholly ccdcma tons It can be entirely obliterated at any one s] ot 240 SURGICAL DIAGNOSIS [chap. by properly applied pressure. If due to venous obstruction, it is limited in area, and there is some- times more or less lividity of the surface and distension of the veins ; if due to altered blood condition, it is general in distribution, there is no lividity, but, on the contrary, marked pallor. Extravasation of blood is distinguished (a) by the discoloration of the part, which cannot be altered by pressure, and which undergoes the characteristic colour changes of a bruise ; (h) by the ill-defined character of the swelling ; and (c) by the history of an injury or strain. A distended gland or viscus is recognized (a) by the position of the swelling ; (6) by the outline of the swelling corresponding to that of the gland or viscus ; (c) by the influence of secretion in causing the swelling, e.g. the enlargement of a salivary gland at each meal when its duct is obstructed by a salivary calculus ; and {d) by the effect of removing the contents of a viscus, as by siphoning the stomach in dilatation of that organ, or by catheterism in retention of urine. A venous thromhus is characterized («) _ by its position in the course of a vein ; (6) by its cylindrical shape, with or without romided projections corre- sponding to pouchings of the vein ; and (c) by its firmness. The manipulation of a suspected throm- bus must be very gentle, lest part or all of it be detached. iv. Swellings slowly formed, or chronic swellings, may be caused by accumulation of tlie iiuids of the part, or by an increase of the formed elements, or by both. Thus, such swellings are caused by (1) chronic inflam- mation ; (2) GBdema due to gradually produced altera- tion in tl>e character of the blood or to obstruction to the venous circulation ; (3) yielding of vessels XVII] HISTOEY OP TUMOURS 241 to intravascular pressure, e.g. aneurysm, varix • U) accumulation of secretion in a closed sac, or behind ZZ l' "'1'' ^'^"^""'^ displacement of hefZ'- fm T '''T^^''' exophthalmos, many m Z:. ^ ^ ^^P^^™PJ^7. e.g. of mamma, tonsil; (7) tumours proper, or new growths. (a) is generally characterized by (a) gradual mcrease of the swelling ; (5) its infil tratmg character; (o) pain especially ehcS.d by issue e?M.; f^'l^^^'^^ ^ the consistence of the faction S t'hr ?'^^ ^-/^ "^^P^i-d unction of the part ; (g) m some cases, pyrexia To Sfa' n? r'.''^ T^^'^ chrom^'mflamma- as wffr'lSitf ^'^^ ^'--^ters Dilatation of a vein is known bv (n\ +i tjon of the swelJmg in the course nf I P""'" ;t is most common L th vet T^^! ' limbs, spermatic cord, and anus J V and often tortuous ^r sacculated^ J the elongated swelling- (r\ if '''peculated character of the 242 SURGICAL DIAGNOSIS [chap. largemeut. When tliere is a direct communica- tion between an artery and the dilated vein, the latter exhibits pulsation, bnut, and thrill. {See p. 282.) Accumulation of secretion is recognized (a) by the occurrence of the tumour in the position of, or actually in, a gland or closed sac; (&) by its more or less globular outline ; (c) in some cases by the fluidity of its contents as evidenced by fluctuation ; {d) by the absence of the usual signs of inflammation ; (e) by the nature of the contents of the swelling, obtained by an explora- tory puncture. Disflacement of organs. {See p. 236.) Hijpertrophy most often occurs congenitally, or m early life. Its general features are {a) uniform painless enlargement of the part or organ, which after attaining a certain size remains stationary ; {b) unaltered consistence ; (c) the function of the part is not interfered with, except in some cases from its mere bulk ; {d) absence of heat, of red- ness, and of degenerative changes. Neiu groivths vary very much in their features, but they are to be generally recognized by {a) their continuous growth, which may be slo^f or rapid : some tumours may become stationary ; {b) the abrupt limitation of their outline ; (c) absence of local heat, redness, pain, oedema, and fever: exceptions in all these particulars are met with ; {d) apparently spontaneous formation ; (e) resistance to treatment other than excision and " radiations." V. Traumatic swellings.— In many cases a swelling more or less directly follows an injury. Injury can cause swelling {a) by displacevieM of parts, as m liornias, fractures, and dislocations ; (fc) by rupture of vessels, as in fractures, bruises, hajmalouui, and xviij PROGRESS OF TUMOURS 243 aneurysm; (c) by exciting inflammation or leadmo to infection as in acute orchitis from a blow and m abscess following a puncture or woimd; li) by the 0f^,lasuc lymph in the process of repair^ as the callus aroimd a fracture ; and (.) by excftiii' the development of a neiv groivth ^ IS a'^not'mr.'"'"'rf"'''~^^'™"^" appearance IS a not mfrequent characteristic of swelUngs caused displaced v^scera structures, as hernifs, recta polypus prolapsus am, and prolapsus uteri • bv S in T ? "-^'^ ^"^^ anklefnoticecl e e varicl . by distens^ons, pSs PP''"^^ ""^'^ ^""^g pregnancy, and 2. The progress of a tumour is another fnct A tumour may diminish in size T]n« ■ usually a favourable sign. If nraZ'al i ' f absorption of the elements of ff >• "^^^^^t^^^ Huid, as blood, serunHnd pt^o 's^l' tion tissue, fibrm, bone • or a slm-nl ' / retrograde nutritive change ast ^'T '''''' calcification of tuberculous glaiVs and ''h 0^ swellll^^Vt « 244 SURGICAL DIAGNOSIS [chap. nephrosis and in rupture of an ovarian cyst ;^ or the replacement of a displaced viscus, as in the " re- duction " of a hernia. iii. A tumour may suddenly increase in size. This is caused by the onset of acute inflammation in or around it, e.g. an inflamed pile ; by effusion of blood or serum into it, as when a hydrocele becomes a hydro- hasmatocele, or a hernia becomes strangulated, or an ovarian cyst becomes congested by twisting of its pedicle ; or by increased displacement of organs, as in hernia. . iv A tumour may continuously Increase, and tliis increase may be slow or rapid. The rate of increase depends upon the relation between the intensity of the cause of the enlargement and the resistance to that enlargement. Where the swelling increases sloivly, it is due either to a. feeble tendency to enlarge- ment, as in chronic inflammation and m the more benign tumours, or to considerable resistance to enlarge- ment, as in aneurysm, varix, and intra-osseous tumours and inflammations. Wliere the swellmg mcreases rafidhj it indicates a great inherent poiver of growth in the tumour, as in acute inflammation, soft mahg- nant tumours, and some cysts, or a feeble resisiamce to enlargement, as in ojdema of cellular tissue A continuous enlargement of a solid tumour without alteration in consistence is an important character- istic of malignant disease. . . v A swelling may enlarge intermittently. 1 his is met with in (a) displacement of viscera : under the influence of strain further displacement occurs from time to time, as in hernia and prola])sus am ; (0) successive attacks of inflammation, as m some cases of adenitis and tonsiUitis ; (c) vasciila.r enlargements, either active or passive, as m exophthalmic goitie, where it is duo to intermittent arterial dilatation, or xvn] GROWTH OF TUMOURS 245 in varix, where it is the result of intermittent venous obstruction, e.g. successive pregnancies. vi. A tumour may change its position. This is ob- served in fatty tumours, which have been known to travel in the subcutaneous tissue of the back from the shoulders towards the buttock ; the movement IS never in a direction contrary to gravity. More often we see that as a tumour enlarges it appears to change its position, owing to the growth taking place in one special direction. Thus, an inguinal hernia may at first cause a swelling in the groin, but as it enlarges it passes into the scrotum, and so distends it that the small inguinal swelling is obscured. vii. The direction in whicli a tumour enlarges is often a matter of considerable diagnostic value. It is either an indication of the direction of least resistance to the growing tumour, and so shows its relation to some of the stronger and more resistant fascias of the part, as m psoas and ihac abscess, hernia, extravasa- tion of urine, synovitis, bursitis, and many other tumoui's ; or it indicates the affection of some par- ticular tissue, as in diffuse lipoma, where the fatty tissue alone is involved, in lymphadenoma, where lymphatic glands alone are enlarged, and in varicose veins. 3. The mode oi c/row(h.— A tumour may en- large in one of three ways : either by the continuous expansion of the primary swelling ; by the invasion of the tissue aroimd it ; or by the development of separate swellings, which become incorporated with the original growth. The first is exemplified in the growth of aneurysra.s, cysts, and lipomata. The second IS seen in cases of malignant tumom-the inhitratmg mode of growth is one of their most important features ; and tlic third form is seen in 246 SURGICAL DIAGNOSIS [chap. some cases of cancer, especially cancerous glands, also in lymphadenoma, gummata, lupus, and actino- mycosis. 4. The patholofjical changes occurring in a tumour may aid in the diagnosis. A tumour, as it enlarges, may ulcerate. Two varie- ties of this ulceration are to be distinguished. In some cases the skin over a large tumour ulcerates, either from distension or from constant friction. In such cases the skin is thinned, the swelling is always very large, and the ulceration of the mass is not deep. In cases of the other class the ulceration is caused by molecular disintegration of the tissue of the tumour itself, and is therefore independent of the size of the mass, and is an important indication of the vital condition of the tumour. Such ulcers are deep, or at any rate not limited to the skin, and involve the tumour itself ; the skin, or mucous membrane, is adherent to and involved in the mass, and often there is more or less fungous protrusion of the growth. We see illustrations of this in cases of epithelioma and other carcinomata, sarcomata, gummata, lupus, actinomycosis, etc. A swelling may alter in consistence, becoming firmer or softer, (i) Increased firmness ma,y be due [a] to increased tension, in which case it is always accom- panied by enlargement of the swelling, e.g. hydrocele, strangulated or obstructed hernia, ovarian cyst with twisting of its pedicle ; (6) to solidification of fluid contents, as the coagulation of the blood in a hajma- toma or an aneurysm, or thrombosis in a varix ; (c) to organization of a softer cellular exudation or growth, e.g. ossification of callus, of a node, or of an enchondroma ; {d) to absorption of the fluid parts of swellings, e.g. resolution of inflammation ; or (e) to calcification of a thrombus. In the last XVII] TUMOURS: MALIC4NANCY 247 three instances, except in the case of enchondroma, the induration is accompanied with shrinking of the swelling, (ii) Softening of a swelling is due [a) to liquefaction of its solid parts, as in the formation and progress of an abscess, and in the disintegration of tumours; (5) to destruction of firm, resisting structures, e.g. bone and fascia, as in the growth of central tumours of bone— in these the softening IS attended with increased size of the tumour; or (c) to lessened tension from absorption, as in serous and synovial effusions— this is associated with less- ened bulk of the swelling, and indicates resolution. Cysts may form as a tumour grows ; we see this in the progress of cystic adenoma or cystic sarcoma of the breast, and in cystic degeneration of uterine myoma. 5. Evidence of malignancy — Malignancy may be Local or remote. An infiltrating mode of growth shown by the incorporation of the surroundinc^ tissues with the circumference of a swelling, and the occurrence of small detached nodules of tumour around the mam mass, are the usual signs of local mahgnancy. Local recurrence of a tumour after apparently complete removal is also due to the same cause. The results of remote mahgnancy are seen m secondary swelHngs in the lymphatic glands m connexion with the part, and in the lungs, hver and other tissues and organs. Evidence of the in- fective nature of a swelHng is of the utmost import ance in the diagnosis of carcinoma, sarcoma, certain granulomata and papillomata, and some other con ditio.-Ls. _ It IS important to remember that carci" nomata infect pnmarily through the lymphatics while sarcomata as a rule infect through the blood-vosse s .Sarcoma of the tonsil and periosteal sarcoma of loi a bones form notable exceptions to this rule, infection in them being through lymijhatics. 248 SURGICAL DIAGNOSIS [chap. IV. Effects of Tumours upon the Surrounding Tissues Reference has been made to the locally infective influence of some swellings, and to the infiltration of surromiding tissues that is a distinguishing feature of all inflammatory, granulomatous, and malignant growths. The other local effects we have now to study are what are often spoken of as pressure effects. Pain. — The pain of tumours depends upon three chief factors : the seat of the swelling — whether it has formed in a sensitive part or near nerve-trunks ; the tension of the swelling, and whether this has been slowly or rapidly attained ; and the infiltrating character of the swelling. Where nerve-trunks are involved the pain is referred to the terminal dis- tribution of the nerves, often at some distance from the swelling, e.g. pain in the hand from a bulbous nerve in the arm, pain in the foot from a popliteal aneurysm, pain up the side of the head from malig- nant growth in the neck. Where the pain is caused by the involvement of nerve terminals it is local, and varies with the rapidity of the destruction of the nerves ; in acute inflammation it is always present, is intensified by posture or use or any condition that adds to the engorgement of the part — when acute suppuration occurs