The details of many of these subjects belong to surgery; the remainder, so far as diagnosis is concerned, must be considered with reference to the organs or regions in which they exist.
§ 2. Of the Locality of Tumor8.—In the diagnosis of tumors, properly so called, there are two very distinct sets of symptoms, which are derived, the one from their local action as they inter fere with function by mere size and pressure, the other from their general influence upon health; the former common to all, the latter belonging especially to malignant tumors. It is therefore necessary first to inquire into the localities in which they are found, and the evidence of their presence there, although this cannot be wholly separated from a consideration of their nature. A tumor lying superficially with reference to any of the gre,at cavities, or on any of the extremities, leaves no doubt as to its existence; one that is deep-seated in the abdomen, when its mar can be felt, or its resistance detected by firm pressure with El:points of the fingers, may be recognized with equal certainty ; on the other hand, if contained within the cranium, or deep in the thoracic cavity, and, in some instane,es, when situated close to the lumbar vertebra3, its existence can only be inferred from symptoms derived from the organs contained in the ca,vities, and must remain more or less uncertain. The indications are most indefinite in regard to the cranium; they are in' ore easily made out when the tumor is in the chest, and are seldom wholly UMW compa.nied by more direct evidence when situated in the abdo minal cavity. They must each be discussed in considering the phenomena peculiar to various organs at a later period; and for the present we must assume that the tumor is palpable.
It is of importance to study carefully the history of all such cases. In some it will be found that the symptoms detailed cor respond with the commencement and development of the tumor ; in others, they are only those of its later stages; while, again, the history sometimes points to a totally different disease, and it is only while pursuing this investigation that a tumor is accidentally discovered. This division corresponds in some measure to real differences of character, and roughly points out those having an inflammatory origin, those whose character has more or less of malig:nancy, and those which are slow in their growth, and com paratively harmless, except in their secon.dary results. To this, however, there are numerous exceptions.
When the patient has already become conscious of its exist ence, we seek to ascertain its specific history so far as it is known to him, the progress of its development, and the symptoms which have been associated in his own mind with its presence ; as well as those bearing upon the general state of health and the affec tions of other and more distant organs which have been observed since it was first recognized.
In a class so extensive as tumors, it is vain to look for general symptoms which shall characterize the whole of them, but there are many which are of much value in discriminating the nature of the disease, and the special locality where it is situate,d. It is, therefore, our next business to observe each of those circumstances carefully which have been mentioned as in, dications of the general state of the patient. Thus, as we know that the history is very often faulty, it is important to consider whether there be febrile symptoms, either such as usually accom pany inflammatory action, or those more distinctly pointing to suppuration; or whether there be only the quick pulse of de bility or tubercular deposit. Again, we have to consider the appearance of the patient, calculating how much of the change reported is due to the presence of the tumor, and how much may be accounted for in other ways ; and to note whatever strikes the eye as a deviation from the normal ideal standard.
This part of the inquiry has, perhaps, to do more with the nature of the tumor than its locality. Rapidity of growth is a very decided indication in favor of malignant disease ; such are also the evidence of general derangement of health and affections of distant organs other than can be accounted for by nervous sympathy and intercommunication ; they show the existence of a taint of the blood different from what accompanies non-malignant growths. The local signs of greater or less derangement of function in contiguous structures have also an important bearing on the question. The aspect of the patient may be of service in so far as the physiognomy of disease enables us to discriminate between the tubercular and cancerous diathesis for example. Changes of color, again, rather point to the organ in which the disease is located. These general considerations are also of value, as they afford evi dence of obstruction to the nutrition, or the circulation, in different parts of the body. Not less important, sometimes, are the indications derived from position, as the patient is obliged by pain, or other uneasy sensations, to main tain a fixed posture, or to prefer one to another.