CHAPTER XX DIAGNOSIS OF PULSATING SWELLINGS (Part 1)

CHAPTER XX DIAGNOSIS OF PULSATING SWELLINGS The most important point in the diagnosis of a pulsating tumour is to determine whether the tumour is an aneurysm or not ; and secondly, if an aneurysm, whether the whole tumour is aneu- rysmal. As a rule the diagnosis is easy, provided care is taken and reliance is not placed upon any single sign, but upon a due weighing of all the signs. The tumours which pulsate may be thus enumer- ated : -J r 1 Aneurysm — fusiform, sacculated, cirsoid, false, arterio-venous. Pulsating tumour. Tumour or abscess situated over an aneurysm. Tumour or abscess situated over an artery or over the heart. Empyema. Encephalocele. Traumatic cephalhydrocele. We shall first detail the examination that should be made, and then, putting together the facts thus obtained, mention the distinguishing features of each of these tumoars. . 1. Notice the position of the swelling in rela- tion to the arteries of the part. Aneurysms are only met with in or ne.ar tiie course of 'main arteries, tumours with communica ted pulsation nro onlv found over largo arteries. Otlier PULSATING SWELLINGS 275 pulsating tumours may occur in tlie course of, or quite away from, large arteries. 2. Exanoine tlie pulsation and determine the following points : i. Is the ijulsatiou expansile, i.e. is the tumour enlarged in all directions by each beat of the heart, or is the impulse heaving— a, mere lifting or displacement of the tumour ? This is best de- termined by observing whether two fingers placed on opposite sides of the tumoui- are separated by each beat or are merely raised. An expansile pulsation IS caused by blood being forced into the tumour, and shows that it is either an aneurysm or a very vascular tumour. A heaving pulsation indicates that the tumour is so close to an adjacent artery or the heart that it is lifted by it. Should an aneurysm become sobdified without obliteration of the artery, the impulse wiU be heaving and not expansile. _ u. Is the pulsation uniform throughout the swell- ing ? This IS usually the case in aneurysm. If the pulsation IS felt only along the course of the artery It is commmncated. If parts only of the tumour pulsa,te It IS probably a pulsating mabgnant growth. m. Can the pulsation be abolished by changes in the position of the tumom- which do not afiect the circulation through the part ? If so, the pulsation is a commmncated one. 3. Compress the main ai tery of the part above the swelling, and notice the effect upon rhe swelling of thus arrestmg the flow through the artery of the part. It will stop the pulsation, except m some cases of cirsoid aneurysm. If the swelliiie spontaneously shrinks, it is an aneurysm with free commmucation with the artery. While the main artery is still compressed, apply a qcntle pressure to the tumour and uotiee its eifed if gentle pressure on the swelling does not cause it u' 276 SURGICAL DIAGNOSIS [chap. diminish in size, it indicates a pulsating growth, or a swelling with communicated pulsation not open- ing into a cavity, or an aneurysm nearly or wholly solidified. If the swelling yields to gentle pressure, it shows that it is partly fluid, and that the fluid can be passed into an artery or into some cavity, such as a vein, a joint, or a serous cavity, or a deep pouch of an abscess. Such a tumour may be an aneujysm, an arterio-venous aneurysm, an abscess or cyst, or an encephalocele. The amount of re- ducibility indicates the amount of fluid contents. If when the compression of the artery is removed the timiour is fiUed out again by two or three heart- beats, it shows that arterial blood is distending a sac, and that the tumour is an aneurysm. If the pulsation at once returns uniformly over the whole swelling and without enlarging the tumour, it indi- cates either that the pulsation is commimicated or that the swelling is a pulsating growth. 4. Examine carefully to determine whether there is any mobility oJ the swelling apart ii'om the neighbouring ai'tery. Arteries admit of a limited amount of lateral movement but of none in their length, and therefore, having relaxed as far as possible all the fasciae and muscles of the region, the surgeon should try whether the swelling under consideration is movable in the line of the artery. When this mobility is present it is very strong evidence of the pulsation being communi- cated. As an example of the great diagnostic value of this sign may be mentioned the rise and fall of a thyroid swelling during deglutition, which absolutely distinguishes it from a carotid aneurysm. Some swellings with communicated impulse are quite im- movable, e.g. abscesses over arteries ; " pulsating tumours " are very often immovable because of their XX] PULSATING SWELLINGS 277 growth from bone. Some abdominal tumours may be moved from over an artery, and so lose their pulsation. 5. Attempt to reduce the swelling without compression of the main artery above. This mani- pulation, like all the others, must be carried out with great gentleness and care. If successful it shows that the reduced part of the swelling is fluid and that it is not an aneurysm, and further that it communicates with a cavity such as the cranium or a joint. By this sign, then, we can diagnose a synovial cyst communicating with the knee-joint and having commumcated pulsation from a popliteal aneurvsm! or an encephalocele from a "pulsating tumour" of the cranium Part of a pulsating swelling may be thus reducible m the case of two tumours of different nature blended mto one swelling 6. Examine for bruit and for thrill. If a bruit IS heard over the swelling, determine-(a) Its time: If systo ic, the sweUing may be an aneurysm, ov irnur '.rrrf an artery, or a very vascular tumour ; if both diastolic and systolic, it is an aneurysm. (6) Whether it is intensified by pres- sure; if It IS It IS due to partial compression of an artery, (c) Whether it is heard over the whole tumour, or only along the course of the artery the TlvuT^'''^:" '"""^T'T ^^'^m^i'^icated pulsation. id) Whe her it can be heard beyond the area of the swellmg ; if so, it follows that the tumour is an aneurysm. umuui is A thrill IS felt in some cases of aneurysm but particularly in cases of direct communication be ween an artery and a vein. In aneurysm it is limited to the tumour, and its presence^ depend upon the relative size and conformation o ^t mouth of the sac, and possibly, too, upon the con 278 SURGICAL DIAGNOSIS [chap. dition of the interior of the sac. In aneurysmal varix the thrill is often very intense, and _ is also characterized by its wide extent, being felt in some cases along the veins of a whole extremity. In certain conditions of the arterial wall, and possibly also of the circulating blood, a thrill can be pro- duced by compression of an artery against a firm tumour or a bone ; the thrill is then increased by gentle pressure. 7. Examine the pulse in the arteries beyond the swelling. If the pulse wave is delayed, smaller in size, and a sphygmogram shows loss of " percussion stroke," these signs would be strong evidence of an aneurysm. If the pulse is unaltered in any way, it shows either that the tumour is a very vascular pulsating growth, or that its pvdsation is com- municated only. Loss of pulse below a tumour may be caused by an aneurysm, by a ruptured aneurysm, by a ruptured artery, or by embolism ; it cannot be due to compression of the main artery by the tumour, so long as that tumour itself pulsates. 8. Examine the condition of the heart and arteries generally. Aneurysm is in many cases associated with arterio-sclerosis and hypertrophy of the heart. 9. Notice the outline of the tumour, whether well or ill defined ; also its shape and tension, and the state of the tissues over it, and of the parts distal to it. Tumoiu's and aneurysms are well defined and, as a rule, tense ; inflammatory swellings and leaking or ruptured arteries and aneurysms are always ill defined. Extravasated blood may reach and stain the skin ; superficial h}'perfeniia and redema are common over inflamed tissues ; cold- ness and wasting of a limb, even paratysis, may be found beyond an aneurysm, and oedema, lividity, XX] ANEURYSM 279 aud threatened or actual gangrene may supervene upon rupture of an artery or of an aneurysm. It is necessary to insist that all manipulations of a pulsating tumour should be conducted with the utmost gentleness aud care, and that when once the diagnosis of an aneurysm has been made 110 further manipulations of the part are justifiable; It IS not intended, therefore, that all the above pro- cedures are to be gone through in every case of pulsatmg swelling. The surgeon has to answer the question, Is the swelling an aneurysm ? and it is only when that question cannot be answered in the affirmative that such varied and prolonged manipu- lations are justifiable to clear up the diagnosis. It may be well to state here that an aneurysm may lose its fulsation—ia) from solidification of its contents, (h) from occlusion of the mouth of the sac by coagulum, (c) by compression of the artery above by the sac, or {d) by its rupture. The rupture of an aneurysm may take place slowly, the blood clotting in the tissues ; or rapidly and even suddenly the blood infiltrating the tissues far and wide or escaping into a cavity. 10. Pressure eiieets.-Examne the parts dis- tal to the tumour for signs of ojdema and dilated vein.s, of paralysis of sensory or motor nerves Ihese .signs are particularly associated with aneu- rysms because of the close proximity of veins and nerves to the arteries from which aneurysms spring and also because the pressure exerted by an aneu rysm is so very great. Another striking pressure ettect of aneurysm is rapid absorption of bone most commonly seen in the spine, sternum, or femur The wasting of muscle in a limb beyond an aneurysm' apart from paralysis of motor nerves, is due to lessened blood supply. 280 SUEGICAL DIAGNOSIS [chap. We will now briefly describe the diagnostic signs oi individual pulsating swellings. 1. If, in a person with signs of general arterial de- generation, an elongated pulsating swelling is found in the position of one of the large arteries, which tapers at each end into the artery, it is a fusiform aneurysm. Slow growth of the swelling and absence of pressure symptoms are more frequently met with in fusiform than in sacculated aneurysm. 2. A circumscribed globular or ovoid tumour over a large or medium-sized artery, immovable apart from this vessel, with expansile pulsation in every part, collapsing to some extent when the artery above is compressed, and then yielding to pressure, filling out again, when the compression is removed, with two or three strong -bounding pulsations, with a well-marked bruit conducted along the artery, the pdse in the artery beyond the sweUing bemg retarded, smaller and of less tension than in the corresponding vessel of the sound side, is a sacculated aneurysm. Should there be a history of an injury or of strain, of alcoholism, syphiUs, or gout, or of a sense of something giving way at the seat of the swelling, and should the heart show signs of hyper- trophy while the arteries give indications of general degenerative disease, this diagnosis will be confirmed. An aneurysm is not compressible if there is a great deposit of clot in its cavity, although even then there will be slight modification of tension produced by compression of the artery above. Bruit and thrill may occasionally both be absent. If an aneurysmal tumour becomes^more clearly defined, with a less superficial and a less clearly expansile pulsation, and it is less compressible and reducible, it indicates the gradual obliieralion of its cavity by clot. ANEURYSM • ' 281 _ When the tumour is firm, incompressible, and exmbits a heaving, non-espansile pulse, it shows that the aneurysm is entirely obliterated, but the artery on which it is placed is still pervious. Such a tumour, if seen for the first time in this condition, would be distmgmshable from an independent solid tumour over the vessel by its fixity to the artery. VVlien all pulsation ceases in the firm contracting tumour, It shows that the artery from which it springs IS also obliterated. If the tumour is noticed to enlarge, and at the same time the pulsation has become more superficial and more distinctly expansile, the aneurysm is en- largtng But if the tumour is growing rapidly, and Its outlme has become less defined and its pulsation less distmct, there is a small ruptm-e of the sac, and it IS a leaking aneurysm. But if, either spontaneously or after some injury or strain, the tumour rapidly be- comes greatly mcreased m size, with an eAtire loss of Its clearly marked outhne, with first great weak- enmg and soon total loss of its pulsation, and loss ,i 'V^^ it ias ruptured-it is a diffused aneurysm. X-rays may be of help in the diagnosis of an aneurysm. Under the screen, especiali; in cases of intrathoracic aneurysm, pulsation may be seen before It can be detected by the hand, and a skiagram wTll show the outlme of the whole tumour and so enable Its size and relations to be fully appreciated. ... An irregular compressible swellmg, obviouslv formed of tortuous and sacculated t^bes witb ia the scalp and the ^a^uIZ:'^^^^^ deeper situations, such as the orbit and iliac foss " bometimcs congenital, it is more common befS. than 282 SURGICAL DIAGNOSIS [chap. after 30 years of age, and it may follow an injury. As it grows it extends superficially, and does not exhibit a tendency to form a globular tumour. The skin covering the swelling is hotter than the surrounding skin ; it may be thickened, but is often thinned, inflamed or ulcerated. The arteries which lead to the swelling are often dilated and tortuous. 4. If the vein or veins of a part are found dilated, with expansile pulsation, well-marked thrill, and a loud rasping or hissing continuous murmur, the murmur being increased in intensity at each cardiac systole, and conducted along the veins for some distance, it is an aneurysmal varix. If, in addi- tion to these signs, there is a more or less distinct tumour at the spot where the murmur is most intense, fixed to, but distinct from, the artery and vein, compressible, with expansile pulsation, it is a varicose aneurysm. These diseases generally follow an injury, either a stab or a gunshot wound. As a rule an aneurysmal varix develops within a very short time, but a varicose aneurysm may not appear for months or even years. The bruit is not uncommonly so loud as to be audible to the patient, and some- times even to bystanders. The name arterio-venous aneurysm or aneurysm by anastomosis is apijlied to both of these conditions. 5. If after an injury or strain an ill-defincd swell- ing suddenly or rapidly develops over a large artery, with expansile pulsation, rough bruit, and thrill, gradually increasing tension and cutaneous ecchy- mosis, and there is aboUtion of the pulse and venous obstruction with (Edema below the swelling, it is a rup- tured artery. If the case is seen for the first time after rupture has occurred, the diagnosis between a rup- tured artery and a ruptured aneurysm will rest upon XX] "PULSATING TUMOUR" 283 the history. If the patient had a tumour or noticed a ' beating " sensation or neuralgic pain down the hmb, or venous distension, and if the vessels are found atheromatous and the heart hypertrophied, It would point to the presence of an aneurysm. As regards the aboHtion of the pulse in the arteries below an aneurysm, it must be remembered that while this, when taken with other signs, is a most characteristic sign of a ruptured artery or diffused aneurysm, it must not be depended upon alone, for It may be caused by the gradual growth of an aneurysmal tumour compressing and then obliterat- ing the mouth of an artery, or by plugging of the artery by a portion of clot displaced from the sac. When an artery is torn completely across, or an aneurysm ruptures by a large aperture, the tumour is devoid of pulsation. 6 If a tumour has an expansile pulsation which IS ielt all over the tumour, or is present in certain situations only, and if it neither coUapses nor is com- pressible when the artery above is controlled, and the pulsation returns at once when the pressure upon tje artery is removed, it is a "pulsating tumour." It the tumour has been first noticed away from the site of a mam vessel, or has shown pulsation only late in Its history if it be fixed to a bone and the bone can be traced over its base or surface for any dis- tance if there is expansion of the bone, egg-shell cracHing, or spontaneous fracture of the bone the diagnosis IS rendered more certain. These tumours are often of irregular outline and of varyin- con sistence at different places; a soft blowing mm-mui may be heard in them. A similar tumoiir attached to the skull occui's in a^cirm^ -alignancy," and i^a caicmoma. Ihe presence of a carcinoma in the 284 SURGECA.L DIAGNOSIS [chap. thyroid gland confirms the diagnosis, although in some cases the gland appears to be the seat of a simple enlargement only, or even quite normal. 7. The diagnosis of abscess or other tumour asso- ciated with aneurysm is fraught with great diflB- calties. The presence of an abscess will