As the disease advances it gradually encroaches more and more on the whole cavity of the abdomen, and then we have recoarse to other measures to ascertain that the fluid is cysted, and not free in the peritoneum.
The principles have been already laid down (p. 103) which ought t,o be present to the mind in every case that comes before us, and they are equally applicable to the most self-evident as to the most obscure. Rising out of the pelvis, as the diseased ovary does, it is very often possible to trace in the lumbar and iliae regions resonant bowel pushed aside, not floated upwards upon the surface of the fluid. Even when the greater part of the in testines have been forced into the thorax by the enlargement of the cyst the ribs do not spread out as when subjected to the pres sure of fluid lodged in the peritoneum, and the abdomen has a globular form; at the same time, the height to which the dulness extends is not equal, but at some point resonance descends far below the level to which the fluid rises at another; for the very same reasons the relative positions of dulness and resonance are but little altered by change of posture.
At the risk of repetition it must be remarked that the whole of the facts upon which our inductions are formed may be resolved into the simple effects of the laws of gravitation, as modified by the circumstance of the fluid being free in the peritoneum, or confined in a cyst, and the intestine, which is speci fically lighter, being at liberty to float on its surface or not. Hence, in apply ing the fact of resonance being observed below the fluid level, or even in the groin, we must remember that it may be produced by a portion of the intestine which is naturally limited in its movement, or one tied down by old adhesions. Mistakes are less likely to be made in observing the effects of change of pos ture, except when the whole of the viscera are pushed up under the ribs ; the relative position of the fluid and the intestine in such circumstances cannot be so readily altered.
In mere physical diagnosis those cases most resemble ovarian dropsy in which adhesions have been formed in consequence of an attack of peritonitis, by which the fluid effused is'as much limited in position as if it had been con tained in a true cyst. In snob, however, the general symptoms, which are those of chronic peritonitis, are much more severe than are ever observed in the smaller sized ovarian cysts, which alone they resemble ; and the history, if correct, is wholly different. The one commences with a severe attack, of
which pain in the abdomen is a prominent feature, and continued uneasiness, tenderness on pressure, quick pulse and emaciation mark its progress ; in the other, the commencement of the disease is not easily traced, pain is at no time severe, and the general health is not much disturbed until it has lasted for a long time.
When the cyst is not very large, and its position central, there are two conditions which may produce analogous phenomena—a bladder or a uterus distended with fluid. In the former our necessary inquiry into the amount of the urine will be answered by a report either of retention or incontinence : no water passed at all, or a constant overflow from the paralyzed viscus, and either circumstance is sufficient to suggest the employment of the catheter. Hydrometre is so rare a form of disease that it may almost be passed over, and would be best recognized by vaginal examination, which may always be bad recourse to when any doubt exists as to the nature of a local collection of fluid in the abdomen.
The remarks on this mode of investigation must be reserved till the diag nosis of solid ovarian tumors has been discussed.
§ 2. Tumara.—The term is only relative, as in most instances the diseased structure contains cysts with larger or smaller collec tions of fluid ; and in the earlier stages, those in which the fluid ultimately accumulates to the greatest extent are scarcely dis tinguishable from those in which none at all is found : were the distinction more easily made, the information gained is of no practical importance, except we have regard to the more rapid growth and speedily fatal termination of some of the forms of solid growth. It is chiefly in these that symptoms are to be met with such as have been already mentioned as the only facts in the history of ovarian disease which can call attention to its ex istence: pains in the groins, a sense of weight and bearing down among the pelvic viscera, constipation, hssmorrhoids, and painful defecation; occasionally, too, the functions of the bladder are in terfered with, but this chiefly occurs at a later period, when the tumor rises out of the pelvis: During its growth, occasional attacks of more severe pain may take the place of the constant dragging sensation, and as this may imply that the sensation is excited by local peritonitis, and is not the mere pain of abnormal growth, the observation would be of importance if the question of excision were ever entertained.