ASCITES. — With uncomplicated ova rian cysts diagnosis from ascites is not difficult. They have in common en largement of the abdomen, fluctuation, and symptoms arising from pressure against the diaphragm. Both may be characterized by progressive loss of strength and flesh, more or less oedema of other parts of the body, and an en larged abdomen. In ascites, the ab domen is more or less flattened, its widest diameter transverse, while an ovarian cyst is most prominent in the vertical diameter, and narrow from side to side. Fluctuation over the abdomen is very distinct in ascites and in uniloc ular ovarian cyst, but its wave extends nearer to the vertebra= in ascites. In the well-filled cyst the projection of the ver tebrae prevents the approach of the fluid in the lumbar region. In multilocular cyst the wave is more broken and fre quently is only recognized as a sensation of elasticity. Loss of strength is fre quently greater in ascites, while emacia tion is more marked in ovarian cyst. In renal and cardiac disease there is a greater disposition to anasarca. In very ad vanced and large ovarian tumor pressure may exist, and considerable dropsy of the extremities, but the abdominal distension is in greater proportion. In palpation, ovarian tumor presents greater resist ance, and the outline of the surface is more distinctly determined. The abdom inal surface can be moved over it. Per cussion affords the most valuable infor mation, and ascites a distinct zone of resonance over the abdomen or part of greatest prominence, while the more de pendent portions are dull. The zone of resonance changes with the position of the patient; in ovarian cyst, on the con trary, there is dullness upon percussion over the whole surface of the tumor— resonance only after we have passed be yond its limits, and the line of resonance does not change with the position of the patient. In tubercular peritonitis and in hepatic dropsy, where the mesentery has undergone contraction and the peri toneum is very much thickened, diag nosis can be so obscure as to require ab dominal incision to determine it. As cites may complicate an ovarian cyst. By displacement of a layer of fluid the hand will come in contact with the cyst. The amount of resistance will afford in formation as to whether the tumor is solid or cystic. Complication of a cyst by ascites should awaken suspicion of malignancy or some degenerative process. The greater the amount of ascites, the more probably the growth is malignant. The uterus is freely movable in ascites and ovarian cyst, displaced either down ward and backward or upward and for ward. In ascites arising from rupture of papillary cyst the recognition of a dense, thickened mass upon either side the uterus should cause a suspicion of its true character.
Second, is the tumor under our ob servation an ovarian growth ? The phys ical signs vary with the size and situation of the tumor. In its early stage it is entirely within the pelvis, and its posi tion varies. When as large as a hen's egg it falls into the pelvis, where it remains until it attains a size which will no longer permit its accommodation in that situation. Its relation with the corre
sponding side of the uterus permits its determination by conjoined manipula tion. Where the condition has been complicated by peritonitis, the diag nosis may be difficult. Fluctuation or even elasticity does not characterize the smaller growths. It is absent entirely in proliferating cystoniata, in dermoids, and often even in single cysts. If we are unable to separate the tumor from the uterus and determine the existence of a pellicle, it can be accomplished by seiz ing the uterus with a vnlscllum while the patient lies upon her back, and with two fingers in the rectum differentiate the borders of the uterus and the relation of the latter to the growth. In small growths the hand over the abdomen and finger in the rectum will generally en able us to outline them. Fibroid tumors of the uterus and inflammatory growths of the tubes are likely to be confused with small ovarian cysts. Tubal growths are pyosalpinx, hydrosalpinx, and hfcm atosalpinx, the characteristics of which we have already discussed. In pyosalpinx the acute history, marked tenderness, ex istence of inflammatory exudation, and the matting together of the pelvic tis sues should distinguish it. A hydrosal pinx is generally movable, gives a sensa tion of elasticity or of fluctuation, but the tumor is oblong and gourd-like, rather than spherical. A hfematosalpinx is situated to one side of the uterus, is at first soft, but becomes harder from the coagulation of blood. In the large abdominal growths an ovarian cyst dis tends the abdomen, particularly at its lower part, rises abruptly from the pubes, and is sharply defined and symmetric ally developed. In large single cysts the surface will be smooth and regular, but, in the multilocular, projections and ir regularities are found. When made up of a large number of small cysts, it will be more resistant, although it will still present a sensation of elasticity.
Large growths are confounded with pregnancy, hydramnios, extra-uterine gestation, uterine myomata, retroperi toneal growths, and tumors of the vari ous viscera of the abdominal cavity.
PREGNANCY.—The enlargement of the abdomen is more rapid, is generally asso ciated with suppression of menses, and the presence of sympathetic nervous phe nomena, while in the more advanced stage the patient presents a florid, healthy appearance. Errors are more likely to occur in the unmarried during the early stage of pregnancy. The phy sician should not be hasty in expressing an opinion, so long as there is any reason for doubt. The examination a few weeks later will dispel uncertainty. As preg nancy advances, foetal movements, heart sounds, and parts of the foetus are recog nized. Foetal heart-sounds, when heard, are characteristic. Gestation in one horn of a bicornate uterus will make the diag nosis difficult, but a careful himanual examination will demonstrate the asso ciation of the enlargement with the uterus. Under no circumstances should the size of the uterus be determined with the probe when there is the least sus picion of pregnancy.