It is in the differential diagnosis of the various pelvic tumors that the bimanual palpation is of the greatest utility. In case these tumors can be reached by the vagina, then we are able, even as in case of the normal pelvic organs, to determine their size, relative position, surface, con sistency, movability, etc., but the question of attachment is still left un settled. The position of the tumor may suggest this, but its connection with the normal organs must be determined. Tumors which occupy the walls of the uterus project more or less beyond the surface of the organ, and appear to be entirely or partially imbedded in its tissues. Growths which are not very intimately connected with the uterus may still be de termined as attached to it by the finger pressed down between them and the organ, but they simulate and are to be differentiated from flexions. Motion imparted to the uterus and to the tumor may inform us in regard to the connection, although such information is fallible, the larger the tumor and the nearer and more intimate its connection with the uterus. We may utilize Schultze's method of causing an assistant to draw up the abdominal tumor, and then to study more carefully the relations existing between it and the pelvic organs; but frequently this method is not avail able, owing to the tension of the abdominal walls. In case it is possible by means of the fingers to separate the tumor from the uterus, then the pedicle may be felt, or else a simple projection of the parenchyma of the uterus. In case of large tumors which are not movable, we may not be able to press the fingers down between them and the uterus, but we may be able to feel a depression such as is formed by two fairly convex bodies close together. The consistency of the object, the condition of the uterine tissue, the position of the uterus relative to the tumor, are valuable points to be determined; still there are many sources of error, as where the bodies are close together, or where the interspace between them is filled in by adhesions or by exudation.
Tumors which spring from the uterine adnexa lie, at least in the be ginning, laterally. Those in the parametrium, in general due to exuda
tion, are so close to the uterine wall, that it is impossible to find a point of separation. The form, immovability, unequal consistency and sensi tiveness, enable us generally to differentiate small exudations, but the larger so frequently surround the uterus, that it seems to be completely merged in them. The bimanual examination is out of the question, and the most we can do is to feel the cervix surrounded by tense tissue. In case of collections of fluid in the neighborhood of the uterus, their con sistency and relation to the vagina, the bladder and the rectum are to be determined. Tumors of the ovary, the broad ligament, the tubes, may at the outset be differentiated from the uterus, but as they increase in size they approach it more closely behind or to one side, and perhaps become imbedded in exudation products, and the difficulty in examina tion is rendered much greater. In these instances the great point to decide is as to the separability of the parts. Changes in posture are of great assistance; frequently bodies apparently immovable in one posi tion may be found easily displaceable in another. We must always en deavor to differentiate the uterus and the ovaries from the tumor, since, for instance, the recognition of the ovaries apart from it certifies to the growth not being ovarian. We must always, furthermore, bear in mind the possibility of the presence in the pelvis of tumors or organs from the abdominal cavity, such as the spleen, the kidneys, or growths of the omentum or peritoneum, as also those originating from the walls of the pelvis, from the bladder, etc. The former may be differentiated by the means emphasized under the subject of abdominal palpation, and generally their independence from the genital apparatus may be recog nized. Tumors of the bony pelvis are characterized by their close union with the pelvis, and generally by their consistency, although certain ones, such as an echinococcus cyst of the pelvic wall, might give rise to error in diagnosis.