Aneurism also gives rise to a soft tumor when it reaches the surface, but this commonly pulsates ; a collection of pus can only do so under peculiar cir cumstances. The pus generally tends to the lower part of the chest; aneurism more frequently shows itself at the upper. In both cases, the lungs and heart must each be examined ; and some trace of disease in the one or the other will serve to determine us whenever there is any obscurity about the symptoms.
A firm elastic tumor, protruding above the ribs, is generally an advanced stage of malignant growth in the chest. It is associated with general dulness on percussion either on one or both sides, and with indications of pressure on the bronchi, the vessels, and the nerves; with local pains in the arms, local oedema, venous tortuosity, occlusion of arteries, &c. These symptoms will be taken in detail hereafter. It is to be remembered that the sallow hue of malignant disease is generally obscured by the obstruction to the circulation.
Fungoid tumor, attached to the interior of the ribs, and pressing out between them, is not very easily distinguished from superficial swelling. It very often happens that the patient has first noticed it after unusual muscular effort, and its progress has caused such infiltration and even protrusion of the parietes, that it is liable to be regarded as having been caused by the strain, and to consist merely of an effimion of blood under the muscles. When close to the sternum, its characters are more palpable, as a rounded, firm, and elastic swelling; it has not the softness of a collection of fluid, but it may pulsate, from its proximity to the heart. After a time the cachexia of cancer, or the appearance of a second tumor, may remove all doubts.
In thoracic tumors recourse may sometimes be had to the introduction of a grooved needle. It must be admitted that this is only a refuge for iporance ; but ignorance is somethnes unavoidable in such obscure cases.
In the abdomen, a tumor may be simulated by mere muscular resistance. Knotted contraction of the rectus, or even of some portions of the transverse muscles, may give rise to doubt ; some patients cannot be brought, by any inducement, perfectly to relax the muscles, partly perhaps from unwillingness, but partly also from abdominal irritation. This feeling of hardness is less
local than tumor ; it is also perceived to move with the parietee, and cannot be pushed aside. A jerking movement with the tips of the fingers in making pressure over different parts, will often serve to determine whether there be any hardness behind the abdominal walls ; or by slow, firm pressure, we may overcome the parietal resistance. It is also important to ascertain whether there be dulness, on percussion, over the part, where the existence of a tumor is suspected.
When a tumor is made out, its relation to the abdominal viscera must next be considered ; if small, its present position ; if' of some size, its point of origin. But patients very often give the most extraordinarily inconsistent accounts of the origin of these growths.
In the right hypochondrium it is probably connected with the liver, and the symptoms of disease of this viscue must be studied. It may be simply enlarged, from congestion or inflammation, or from chronic disease ; or it may be die. placed from the pressure of a belt in men or of tightly-laced stays in women. Under such circumstances, the edp of the liver of nearly ita natural form may be felt, some way below the margins of the ribs, with firm resistance above and dulness on percussion. Sometimes on the surface of this enlarged mass a rounded fulness is observed, giving a sense of obscure fluctuation. It is important to distinguish that it is on the surface, and not at the edp, where a distended gall-bladder may be felt in the same way. If the history and symptoms are those of acute disease, this will indicate suppuration ; if they are chronic, it is more probably due to the presence of hydatid cysts. In place of the regular form of an enlarged liver, several rounded masses may be felt in this region, extending more or less across the epigastrium. This undoubtedly malipant, and the diagnosis of its connection with the liver de pends both on the general symptoms of disease ef that organ, and on the circumstance that, by percussion and pitipation, it is ascertained that they are continuous with it. This point must always be thoroughly investigated, because of necessity, when enlarged, it extends into the epigsetrium, as it is limited by the ribs in the opposite direction.