can be mapped out between the hands. Usually the uterus and tumour are not very movable, owing to the limited space of the pelvic cavity. When the tumour is tapped, ovarian fluid is got.

3. Differential diagnosis.-When lateral to the uterus they require to be differentiated from the following:

(1.) Pelvic cellulitis ;

(2.) Pelvic peritonitis (encysted serous effusions);
(3.) Parovarian cysts;

(4.) Hydrosalpinx, Pyosalpinx;

(5.) Fallopian tube gestation;

(6.) Fibroid and fibro-cystic tumours of uterus;
(7.) Blood effusion;

(8.) Solid ovarian tumours.

(1.) Pelvic cellulitis.-With this we have inflammatory history and probable cause, as abortion or labour, to guide us. When the cellulitis has gone on to suppuration, there will be rigors and other indications of suppuration. Cellulitic deposits are almost always fixed; are firm when not purulent, and even when purulent do not give very distinct fluctuation.

(2.) Pelvic peritonitis.-This will not cause the fornix to bulge downwards, and the history will help us. Tapping gives serum, and not ovarian fluid. When an ovarian tumour is fixed by peritonitic adhesions, it will be almost impossible to diagnose it from encysted pelvic peritonitic effusion except by examination of the fluid.

(3.) Parovarian cysts are not so rounded and have very distinct fluctuation; their secretion is simple salt and water, and when tapped they do not recur.

(4.) Hydrosalpinx and pyosalpinx are high in pelvis, tortuous, elongated from side to side.

(5.) Fallopian tube gestation (v. extra-uterine gestation under Section IX).

(6.) Fibroid and fibro-cystic tumours of uterus (v. Section V).

(7.) Blood effusion in the broad ligaments is difficult to diagnose during life, and is chiefly discovered on operation or post mortem. The same is true of Hæmatometra.

(8.) Solid ovarian tumours are rare. When malignant there are often nodules in the fornices and ascitic fluid which shows the cells shown at Plates VI. and VII.

b. Pelvic Ovarian Tumours posterior to Uterus.

1. Symptoms. The most striking one is associated with urination;

there is either retention or constant desire to micturate. menorrhagia.

There is no

2. Physical signs.-Palpation, auscultation, and percussion give the same result as when the tumour is lateral. On bimanual examination, the uterus is felt markedly displaced to the front but is not enlarged; and bulging downwards behind the cervix, the round globular cystic ovary can be grasped. Tapping gives ovarian fluid.

3. Differential diagnosis. When posterior to the uterus, they require to be differentiated from the following conditions.

(1.) Encysted serous peritonitic effusion,

(2.) Retro-uterine haematocele,

(3.) Fibroid and fibro-cystic tumours of the uterus,

(4.) Retroverted gravid uterus and extra-uterine fœtation, (5.) Parovarian cysts.

(1.) Peritonitic effusion has an inflammatory history; it is not so rounded nor so well defined above. The fluid is serous.

(2.) Retro-uterine hæmatocele has, after the blood has coagulated, a hard feeling and is more expanded transversely. There is a history of sudden onset, menorrhagia, and subsequent inflammatory symptoms.

(3.) Fibroid and fibro-cystic tumour of the uterus (v. Section V.). (4.) Retroverted gravid uterus and extra-uterine fatation (v. Section IX.). (5.) Parovarian cysts.-The character of the fluid is our only certain guide.

It should be specially noted that these pelvic ovarian tumours are apt to cause pelvic inflammation and thus render the exact diagnosis, unless aided by tapping, very difficult.

B. DIAGNOSIS OF OVARIAN TUMOURS WHEN LARGE, AND CHIEFLY

ABDOMINAL IN POSITION.

1. Symptoms. These are chiefly due to its bulk. The patient's notice is attracted to the fact that she is getting rapidly stout. Recently, Jastrebow has alleged that the sensibility of that part of the groin supplied by the genitocrural nerve is impaired on the same side as that on which the tumour is.

2. Physical signs.-When the patient lies on her back and the abdominal surface is bared, the following points can be noted.

On inspection the abdomen is seen to be greatly distended. The distention may be uniform, but is often more or less markedly lateral. The distance from the anterior superior spinous process to the umbilicus is greater on one side than the other. The superficial abdominal veins may be dilated, and lineæ albicantes are sometimes present.

On palpation, the distention is felt to be due to an encysted collection of fluid. A mass is felt in the abdominal cavity which is like a sac filled with fluid. Fluctuation is got by placing one hand at a special part and tapping at an opposite point with the fingers of the other hand. However long the tumour be manipulated, there is never felt any muscular contraction of the cyst wall.

On percussion when the patient lies dorsal, a dull note is obtained over the tumour (fig. 132); but at the flank, where the tumour does not

The shaded portion shows the dull area; left figure-ovarian tumour, right figure-ascites (Barnes). bulge, it is clear and tympanitic, since the intestines are there. When the patient turns on her side, with this flank uppermost, the dulness and tympanitic note do not change in position. This sign shows we have to deal with an encysted collection of fluid.

Auscultation gives entirely negative results. No sound is heard unless that of friction over a localised peritonitis.

On vaginal examination, the uterus is felt displaced to one or other side, or very much to the front. It is rarely retroverted, and-unless impregnated-is not enlarged. The tumour does not usually bulge down into the fornices, but may be made out bimanually.

In order to ascertain how the pedicle lies, we have to make the examination per rectum. The tumour is drawn upwards in the abdominal cavity by an assistant. We now lay hold of the cervix

with a volsella, pass the index finger of the right hand into the rectum, make traction on the cervix till the fundus is brought within reach of the rectal finger. We recognise a tense band passing from one angle of the fundus, and the enlarged ovarian artery may be felt pulsating in it. We now examine for the ovary of the opposite side; this is ascertained to be normal in size. The possibility of both ovaries being cystic (which would produce a pedicle on each side), should not be forgotten, though this is comparatively rare. The examination with the volsella is made easier by placing the patient in the genupectoral posture; the weight of the tumour makes it gravitate into the abdomen, and renders the pedicle tense; it is also easier to make the rectal examination in this position.

3. Differential Diagnosis of Abdominal Ovarian Tumours. They must be diagnosed from the following conditions :— (1.) Pregnancy and Hydramnios,

(2.) Fibroma uteri,

(3.) Ascitic fluid,

(4.) Fibrocystic tumours of the uterus,

(5.) Parovarian tumours,

(6.) Encysted dropsy,

(7.) Thickened omentum enclosing intestines by adhesions,

(8.) Omental tumours,

(9.) Renal tumours,

(10.) Hydatid of liver,
(11.) Pseudocyesis,

(12.) Distended bladder.

In observing a case of abdominal tumour, the student makes first his positive examination systematically; he makes in every case what is called the routine examination, noting what he observes. By this means he may get facts enough to warrant his drawing a distinct conclusion as to its nature. This, however, is not always the case; he has then to use diagnosis by exclusion; it must be one of a certain fixed number of things; the possibilities are excluded one by one till a definite diagnosis is reached.

We have stated above that ovarian tumours require to be diagnosed from twelve conditions. On each of these we make some brief remarks.

(1.) Pregnancy.—At the period of pregnancy when the uterus is so enlarged as to be above the pelvic brim, certain conditions are present. These are suppression of menstruation for a given period, and size of the

uterus corresponding to this; mammary signs; lineæ albicantes, and pigmentation. On palpation, we feel a tumour without distinct fluctuation and having intermittent contractions; the fœtus can be palpated out. The foetal heart (after the fourth month) and the uterine souffle are heard. The vagina is dark in colour, the mucous secretion increased, and the cervix soft.

We need hardly say that the palpation, the foetal heart-sounds, bruit and vaginal changes mark out the pregnancy unmistakeably. These points may seem too simple to require mention, but cases have been recorded where the pregnant uterus has been tapped for an ovarian cyst.

Hydramnios may simulate an ovarian cyst. The amenorrhoea will help and especially the occurrence of intermittent contractions as Braxton Hicks has specially pointed out. In one of his recorded cases,

the tumour was the size of a seven months' uterus with distinct fluctuation, and there was amenorrhoea for tive months. Palpation gave the uterine hardening. Previous to this it had been tapped as a cystic ovarian tumour.

(2.) Fibroma uteri (v. Section V.).

(3.) Ascitic fluid.-When the patient lies on her back, percussion gives a tympanitic note at the umbilicus and a dull one at the flanks (fig. 132); when on her left side, the note is dull on that side and clear over the right; when on her right, it is dull on that side and tympanitic on the left; when she sits up,. the upper limit of the dulness is curved with the convexity downwards.

The reason of this is evident. The intestines float on the fluid at its highest point and give the tympanitic note accordingly (fig. 132).

(4.) Fibrocystic tumours of the uterus are difficult to diagnose. The following points should be noted. Fluctuation is only partial, and the consistence is variable; the rate of growth is slower; and the fluid drawn off coagulates spontaneously. It is often difficult to separate these from ovarian tumours, and the best operators have sometimes failed to do so (v. Section V.).

(5.) Parovarian tumours have very well marked fluctuation, have their characteristic fluid, and when once tapped do not refill as they are mere retention cysts.

(6.), (7.), and (8.) In many cases we can make out that the tumour does not pass down into the pelvis and is not connected with the uterus. Sometimes the case is obscure, and abdominal incision alone clears matters up.