OVARIAN CYSTS. 119 



distended, and lying closely in contact with a large part of the ab- 

 dominal wall, may be so difficult to feel, and its fluctuation is some- 

 times so marked, that it may be mistaken for an ascites ; of course, 

 only with that extreme grade of ascites in which the tympanitic 

 sound of percussion is extinguished even in the very highest part of 

 the belly, and in which therefore the patient cannot by sudden 

 changes of attitude cause dull and tympanitic sounds to be heard 

 alternately upon percussion, a very characteristic mark of ascites of 

 moderate degree. The distinctive signs usually given that when 

 the patient lies upon the back the abdomen is rounded when there 

 is a cyst and flattened in ascites ; and that when there is a cyst, 

 the percussion in the lumbar region will be tympanitic because the 

 bowels are displaced downward and backward, -but that in ascites 

 the percussion-sound is dull deserve attention, but may cause error. 

 The vaginal portion of the cervix often gives no positive informa- 

 tion, since the tumor cannot always be touched from below through 

 the vagina. The womb, although at times grown fast to the tumor 

 and dragged up with it into the belly, and at others pushed down, 

 displaced, or bent, now and then presents no change of position. 



The state of the lower extremities deserves great attention in 

 the diagnosis. If but little swollen, then the fluctuating abdominal 

 tumor is probably a cyst. In obscure cases exploratory puncture 

 and aspiration, although not quite free from risk, give valuable aid, 

 both by rendering an exact palpation of the tumor practicable, and 

 by furnishing the material for chemical and microscopic tests. 



. The diagnosis of a dermoid cyst is based chiefly upon its small 

 size and slow growth. Not unfrequently it remains undiscovered 

 during the life of the patient. If, however, it continues to grow, it 

 may lead to perforation into the bladder, intestine, or vagina, or 

 else through the abdominal wall. The discharge of its peculiar 

 contents will then reveal its character. In one or two instances a 

 complete recovery has followed such an evacuation of a dermoid 

 cyst. Malignant degeneration sometimes occurs.] 



If the tumor grows, it usually approaches the median line. Very 

 large ovarian cysts, which rise to the costal cartilages on both sides, 

 and fill both sides of the abdomen, can no longer be distinctly 

 bounded and distinguished as separate tumors. The abdomen, which 

 is enormously distended and very tense, is usually more prominent 

 than broad, and changes its shape very little with change of the 

 position of the body. At the same time both inspection and palpa- 

 tion show the irregular shape of the distended abdomen, which is 

 due to the fact that these large tumors do not consist of one tumor, 

 but of a union of several cysts. Wherever the tumor comes in con- 

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