The pain often becomes throbbing in character. The influence of tension is exemplified by the acute pain when the pedicle of an ovarian tumour becomes twisted, by the pain attending the growth of a tumour or an abscess within bone, and its relief when the disease has extended through the bone, and by the pain in a thrombosed pile. <Callout type="important" title="Important">The slow displacement of parts is as a rule painless, as evidenced in the case of large lipomata, cysts, and uterine fibroids.</Callout> While nerve terminals are seen in the pain attending many cases of malignant disease, muscular spasm and paralysis are rare. Absorption of tissues—By the growth of various swellings connective and other soft tissues are stretched, thinned, and absorbed, and even bone may be affected. The complete subcutaneous absorption of a large artery may cause great deformity as facial bones are spared corresponding arteries. The pressure of a tumour upon an artery and occasionally compresses it sufficiently to occlude its lumen. Venous engorgement, as indicated by the dilated veins coursing over the part or by its general lividity, is an important indication of an intimate connexion of a swelling with the vascular system. It is well, however, to remember that the association may be entirely accidental, as in the case of a fatty tumour of the thigh associated with varicose veins of the leg; inquiry as to the time of appearance of the swelling and of the venous distension will generally be sufficient to eliminate this error. The direct connexion of venous distension and swellings is fourfold: 1 Venous distension may be the cause of the entire swelling. In this case, the swelling will have the outline of dilated, convoluted, and sacculated tubes and is entirely reducible unless the contained blood has coagulated. <Callout type="tip" title="Tip">2 The venous distension and the swelling may be produced by one common cause, e.g., obstructive or regurgitant heart disease.</Callout> In this case, the swelling is cedematous. 3 The venous distension may be produced by the swelling obstructing the return of blood, either by compression or obliteration of a vein or veins by the growth, or by a communication between an artery and a vein, the flow of the arterial blood into the vein impeding the venous return: examples of the former are seen in popliteal and other aneurysms and in mediastinal and other growths. In these cases, the venous distension is on the distal side of the swelling, and may be accompanied by more or less oedema. Cases it is due to increased blood supply necessitating enlargement of the efferent veins, this is observed in very vascular growths, where the original calibre of the veins is not sufficient to carry off the great amount of blood conveyed to the part. 4 On the cardiac side of the swelling, deep veins some of which may be dilated and tortuous, may be noticed over and on the cardiac side of the swelling. As these deep veins some of which may be dilated and tortuous, may be noticed over and on the cardiac side of the swelling. These very vascular new growths are often malignant, and the blue veins coursing over a tumour are of some diagnostic value. <Callout type="warning" title="Warning">Uterine cysts and cystic hydatid, mammary cysts, and cystic hydatid, may be benign, and the enormous veins seen running from them are the result of this vascularity.</Callout> Enlarged lymphatics of chronic abscesses cedema, and infiltration of the tissues by malignant disease, may be firm and pits with difficulty or not at all. The character of a tumour can thus be distinguished. <Callout type="risk" title="Risk">Aggressive V. The patient genital tumours, cystic hydatid, mammary cysts, and cystic hydatid, may be benign, and the enormous veins seen running from them are the result of this vascularity.</Callout> Aggressive V. The patient genital tumours, cystic hydatid, mammary cysts, and cystic hydatid, may be benign, and the enormous veins seen running from them are the result of this vascularity. <Callout type="beginner" title="Beginner">Aneurysms, with the exception of those of the carotid artery, and cancer of the lips and tongue, are much more frequent in men than in women, but this is not due primarily to sexual difference.</Callout> The occupation of the patient has occasionally some bearing upon the diagnosis of a tumour or swelling: those who handle hides are liable to malignant pustule; workers in stables are more prone than others to glanders and to actinomycosis; workers in tar, paraffin, aniline, and X-rays are prone to develop cutaneous epithelioma. The previous history of the patient may aid in the diagnosis of tumours. The history of tuberculosis, of syphilis, of haemophilia, or of leukaemia may throw great light upon the nature of a solid tumour or an effusion of blood. In the malignant diseases, such as sarcoma and carcinoma, light may be thrown upon the nature of a secondary tumour arising after the removal of the primary focus of disease; thus, when a cancerous tongue has been excised, a progressively enlarging gland in the neck will not be mistaken for a tuberculous gland or some other simple tumour. In the diagnosis of pregnancy, whether intra-uterine or extra-uterine, the history may be important. Concomitant affections are frequently of special value in the diagnosis of tumours. This association may be twofold. Tumours may accompany other lesions produced by the same disease, both resulting from some common cause; the best examples of this are found in syphilis, where the existence or the characteristic ulcerations of the skin or mucous membranes, of nodes, of necrosis of the bones of the nose or of the skull-cap, etc., greatly aid the diagnosis of a gumma. The association of exophthalmos with goitre, and the coincident enlargement of many groups of glands, aid in the diagnosis of Graves's disease or of lymphadenoma; the presence of tuberculous disease of the lungs may simply the diagnosis of a tuberculous testicle. As examples of this may be mentioned glandular swellings, such as those with chancroid, urethritis soot-wart or epithelioma of the penis, those in the axilla from inflammation or carcinoma of the mamma, those in the neck from pericarditis otorrhcea, tonsillitis, facial chancre, sebaceous cysts, and so forth. Other examples are furnished by the association of chronic epididymitis or orchitis with stricture of the urethra, of a hydatid liver with old sinuses, or of cancer of the liver with cancer of the rectum, of bone with scirrhous breast, of the skull with a bronchocele. Cachexia is rarely of importance in the diagnosis of the nature of a swelling if it be the result and not the cause, and usually develops at a time when an external growth is quite evident from its local characters. There are, however, cases of internal cancer in which the cachectic condition of the patient may aid the diagnosis. VI. Exploration of a Tumour It is often necessary to explore a swelling before such an accurate diagnosis can be made as will form a basis for treatment. 1. In its simplest form exploration consists in puncturing the swelling with a sterilized syringe armed with a suitable needle. By this means we can determine in doubtful cases whether the swelling is solid or fluid, and, if fluid, what proportion of the swelling is fluid; and any fluid obtained can be submitted to examination. Such exploration is of value, e.g., in diagnosing a small deep-seated cyst in the mamma from a solid tumour, or a very soft sarcoma from a fluid swelling; it enables us to recognize a hydro-sarcocele and to feel the enlarged testicle after the tunica vaginalis has been emptied. 2. The second form of exploration is by an incision down to, and in some cases into, the swelling. When this is done a portion of the periphery of the swelling or a separate nodule can be removed for further examination. By this means we can learn the exact seat of the swelling, its relations, its mode of growth— encapsulated or infiltrating— the presence or absence and the extent of adhesions; and by subsequent examination of parts removed we can determine the actual structure of a growth, and in some cases the presence of specific micro-organisms. This method is employed chiefly in cases of abdominal swellings, but is sometimes necessary in tumours of the limbs, jaws, bladder, brain, and spinal cord. Whenever it is desired to examine microscopically the structure of a solid 'growth' a piece of its growing edge should be cut out; the examination of such a fragment as can be obtained by the use of the harpoon, or by scraping a surface, rarely affords a satisfactory result; if a portion of apparently healthy tissue around the growth is removed with it, the pathological examination can be carried out with more success. It must be borne in mind that diagnosis by microscopic examination is not always easy, and may be quite impossible unless a sufficient and well-chosen portion of the tissue to be examined is removed. Examination of parts removed This may be chemical, microscopical, or bacteriological. By these means we are enabled to distinguish the contents of various fluid and cystic swellings—serum, mucus, urine, cerebro-spinal fluid, saliva, pancreatic fluid, hydatid, ovarian, sebaceous, dermoid fluid, pus mulk, blood, altered blood, tuberculous fluid, etc. The various forms of solid tumours—inflammatory, sarcomatous, cancerous, and others—are to be identified; the presence of pathogenic organisms—septic, tuberculous, mycotic, and the rest—can be recognized. By these examinations a precision of diagnosis can be obtained which is often impossible by other methods. For particulars of the conduct of these examinations the student is referred to manuals of Clinical Chemistry, Pathology, and bacteriology.
Key Takeaways
- Swelling diagnosis involves examining venous engorgement, arterial occlusion, and the nature of fluid or solid swellings.
- Exploration methods include puncturing with a syringe and incision to remove tissue for examination.
- Microscopic examination is crucial for identifying specific micro-organisms and distinguishing between different types of tumors.
Practical Tips
- Use venous engorgement as an indicator of vascular involvement in swellings, which can help differentiate benign from malignant conditions.
- Always consider the patient's occupation and medical history when diagnosing tumors to identify potential risk factors.
- For internal cancers, look for signs of cachexia that may indicate the presence of a tumor.
Warnings & Risks
- Be cautious with exploration methods as they can cause further damage or infection if not performed correctly.
- Avoid making assumptions about benign vs. malignant tumors based solely on vascularity; always perform thorough examinations.
- Do not rely solely on external signs for diagnosis; internal swellings may require invasive procedures to confirm.
Modern Application
While the techniques described in this chapter are rooted in historical practices, many of the principles of swelling and tumor diagnosis remain relevant today. Modern imaging technologies like MRI and CT scans have largely replaced manual exploration methods but still rely on similar diagnostic criteria. Understanding these foundational concepts can aid in recognizing early signs of disease and guiding further medical interventions.
Frequently Asked Questions
Q: How does venous engorgement help diagnose swellings?
Venous engorgement, indicated by dilated veins or general lividity, is an important sign that a swelling has a connection to the vascular system. This can be particularly useful in distinguishing between benign and malignant conditions.
Q: What are some common tumors found in different parts of the body mentioned in this chapter?
The chapter mentions various types of tumors such as ovarian, uterine, mammary cysts, aneurysms, and genital tumors. Each type can present differently and may require specific diagnostic methods.
Q: How does a patient's occupation play a role in diagnosing tumors?
The chapter notes that certain occupations expose workers to risks of specific types of tumors. For example, handling hides increases the risk of malignant pustule, while working with tar and aniline can lead to cutaneous epithelioma.