We have next to note the relations and connections of the tumor itself; with the skin, with muscles, with bone, with glands, or with internal organs; and it must be evident that very much will depend on the correctness of the antecedent knowledge of the observer. He must be familiar not only with the relations of deep-seated parts in health, but also with the changes of posi tion that they are subject to in disease, inasmuch as the direction of the displacement may serve to point out the true origin or starting-point of the tumor. Not less needful is a correct know ledge of structure and of function, in order that he may be able to distinguish alteration of form from change of position, and to recognize symptoms of disease in particular viscera.
The simplest form in which we can recognize the existence of tumor is when swelling is the result of inflammation, with effusion of lymph and serum, which terminates either in resolution or in suppuration. It can scarcely be mistaken for growth of any kind, because of the pain and superficial redness in its early stage ; it is very closely adherent to the skin and muscular structures, which cannot be made to move over it. In the iliac region, and over the surface of the chest, such swellings in their advanced stage are apt to be taken for growth from bone; the diagnosis, when the history fails to indicate the origin of the tumor, rests upon two points, viz., that inflammatory effusion is evenly spread out among the muscular structures, while morbid growth presents a more defined edge ; and that the one adhering more to the skin can be made to move over the bone, while the other, adhering directly to the bone, does not become attached to the skin till it has attained considerable magnitude. In the chest, we may be also guided by the circumstance that more than one in tercostal space is equally filled up by superficial inflammatory action, whereas the fulness is almost entirely limited to one, or at most two, when growth of any sort from the rib is its cause, until its size is such as to leave us in no doubt.
Enlarged synovial bursae, and lymphatic glands, give rise to tumors in vari ous regions. The former have a very elastic feeling, and are generally some what tender, or rather, one might say, a cause of aching than of pain ; the latter are hard, very constantly tender, and often inflamed •, they can only exist in the situations in which anatomy teaches us these structures are to be found in health. This forms the first ground for diagnosis ; and in regard to the glands, we have the further knowledge of the ordinary causes of their enlarge.
meat—the existence of some wound of skin or irritation at a distance, and the scrofulous diathesis.
Scrofulous enlargements are much more frequent in the neck than elsewhere. Difficulty is most likely to be experienced in deciding whether a swelling in the groin be an enlarged gland or a small hernia. The history will very gene rally serve to clear up any doubt, because the descent of a hernia is sudden, commonly after a strain or muscular effort, and if it continue to enlarge it soon exceeds the magnitude of a gland. In addition to this, a hernia may be almost always pushed back, and protrudes sensibly on forced expiration in coughing. Enlargement of the mammary gland is another form of superficial tumor; its consideration belongs entirely to the domain of surgery, as also does that of fatty tumors.
In reviewing the various regions, we find on the scalp eneyated tumors, periosteal thickening, and fungoid growth; the former distinguished by their not being adherent to the bone, the latter by their hardness and tenderness. The face is especially the seat of epithelial cancer. In the neck we encounter enlarged glands, both lymphatics already mentioned, and salivary glands, which will be noticed in speaking of affections of the mouth and throat. We also find occasionally a chronic enlargement of the thyroid gland, in the form of goitre. This is a tumor, soft and painless, and generally very movable, extending across the trachea below the larynx commonly more to one side than the other. There are no general symptoms connected with its presence ; it may indicate faulty nutrition, but the health is unimpaired, and it is more a matter of inconvenience than actual disease.
The region of the neck is closely connected with the thoracic cavity, and deep-seated tumors there may come within reach of the finger as they rise in the neck. We are not now to enter upon the consideration of such as can only be recognized by auscultation ; our present purpose is only to speak of those which are superficial. Mention has already been made of tumors upon the ribs, and inflammation and suppuration of the wall of the chest. Where matter has already formed, a soft tumor is found on the surface of the chest : this may have its origin in a local collection of pus in the pleura making its way out. The history of internal inflammation and superficial abscess is in general different, and if there be any doubt on the subject recourse must be had to the evidence which the stethoscope affords of the state of the lung and pleura.