When felt above the pubis, the surface of a solid tumor is seldom perfectly uniform, especially when it is one of rapid growth; the feeling of elasticity is sometimes closely allied to the sense of fluctuation when the latter is obscured by the depth at which the fluid is placed beneath the parietes and the thick ness of the walls or the multitude of the cysts. Before it can be reached in this situation it must already have acquired some size, and therefore it cannot very well be confounded with fibrous tumor of. the uterus: its mobility will distinguish it from chronic matting together of the tissues by local peritonitis: and its deep connections leave no room for the supposition that it is attached to the bones of the pelvis: at the same time, it is distinguished from omental growths, or malignant enlargement of abdominal glands, by our being able to trace it under favorable circum stances down into the pelvis. No certain conclusion can be arrived at if the abdominal walls be tense and resisting ; but when the patient is placed in a proper position, and the resistance can be overcome by gradual pressure, the practitioner can always place his hand between the brim of the pelvis and the growth, when not ovarian, and cannot do so when the seat of the disease is the ovary itself.
The position of the tumor generally determines that it is not due to preg nancy m its ordinary form : the exceptions are when the tumor is central, or the pregnancy is tuba]. The distinction in these cases must depend almost entirely on the absence or presence of other signs of pregnang and it is to be remembered that the two conditions may coexist, and no mg is lost by waiting for the termination of gestation before pronouncing a definite opinion. In place of giving an elaborate account of the signs of pregnancy, which does not come into our classification, I would refer my readers to the treatises especially devoted to this subject, only remarking that this question, perhaps more than any other, calls for the exercise of common sense. The history is full of instruction, if rightly read ; the time of the cessation or alleged irregu larity of menstruation, and its assigned causes, compared with the manner of the patient; her appearance with regard to size, aspect, carriage, Sm., give the practitioner hints that need not be quite disregarded, even when he is told of the casual recurrence of the menstrual flux; in exceptional cases, when men struation was irregular at the time of conception, or has persisted regularly since, the sum of the signs from the breast, from the abdomen, and from the Cactus eruditus per vaginam, are sufficient for his guidance if taken together.
Perhaps it is scarcely stated in general with sufficient distinctness that the color of the areols is of much less moment than the development within it of the glandular follicles ; it is asserted also that the fluid which so frequently oozes from the mamma presents under the microscope all the appearance of inilk in cases of pregnancy : and as the result of my own experience I may state that the undefined 'Illness of the abdomen, 8,nd the feeling of solidity perceived in pregnancy, is never exactly simulated by enlargement from any other cause. The sound of the fcetal bean is unquestionably the most con clusive evidence, but it is often difficult, and sometimes impossible to discover it. WItatever be the conclusion arrived at by the practitioner, he must exer cise great caution in communicating it to the patient, or her friends, except he have heard the sound of the fcetal heart or felt the movement of the living child. He may raise hopes which are never to be realized or excite appre hensions in the minds of friends which are wholly unfounded ; and in either case justly forfeit the confidence of his patient by grounding a positive opinion on insufficient data. I know no circumstance which can render an absolute diagnosis of early pregnancy a matter of real importance : the progress of the case will speedily solve all doubts.
Digital examination detects, in the early stages of ovarian dis ease, a tumor to one side and at the back of the vaginal wall— movable, but independent of the uterus, which at this period re tains ite normal position. As the ovary enlarges, the uterus may be somewhat pushed down : at a later period it is drawn up, and the neck is sometimes most remarkably elongated. The mobility of the mass and its regular form, as perceived in this examination, are the points which especially distinguisl it from the matting together of tissues which is produced by local peritonitis of a chronic form ; and the elongation of the neck of the uterus, when any change occurs in that organ, proves that the enlargement is not a consequence of pregnancy.