In dropsy of the amnion, 011 the contrary, the shape of the abdomen is globular and more regular. The uterus is uniformly distended, and its vertical diameter is almost always greater than is its transverse measure ment.
Of course, twin pregnancies are frequent in dropsy of the amnion, and it must be recollected that these signs are by no means absolute.
In twin pregnancies, fcetal mobility is always more or less interfered with; the parts that are appreciable by palpation are difficult to displace, whereas all authors agree that the size of abdominal ballottement is ob tained with great ease in hydramnion. The same holds true for vaginal ballottemeut. Baudelocque and Levret had already called attention to the fact that, while in twin pregnancy, ballottement is incomplete or ab sent, both it and the ehoc en retour are obtained in dropsy of the am nion with great facility. Depaul mentions another sign, which he has been the first and only one to recognize: " On examining by the touch the membranes that project from the os, he has twice encountered a de pression or furrow upon them, which divides the amniotic cyst into two parts; he was thus enabled to recognize the two eggs placed side by side." The supra-pubic oedema, regarded by some as of value in the diagnosis of twin pregnancy, may exist in cases of single pregnancy complicated with dropsy of the amnion; nevertheless, it should be regarded with attention, for a number of cases of hydramnion in which it occurred were also cases of twins. One extremely important sign for the diagnosis of dropsy of the amnion is fluctuation, since it is never met with in simple twin preg nancies. It is an absolute sign, but unfortunately it is not always pres ent, and when it is, it may be due to a dropsy other than that of the am nion, such as ascites.
Auscultation usually enables us to establish the diagnosis of twin preg nancy, while the fcetal heart-beats are obscure, fugacious, mobile, or even undetectable in cases of hydramnion.
Auscultation enables us in twin pregnancies to determine the existence at two different points on the abdomen of two hearts of different rhythms, and between which a point can be found where the two hearts are henx-d with a minimum of intensity, which increases as you proceed in either direction towards the points of maximum intensity, before ascertained.
The diagnosis is far more difficult when the fmtus is dead; for we are forced to rely upon palpation alone, and the modifications of the uterus are such that the very existence of pregnancy may be a matter of doubt.
When dropsy of the amnion has complicated twin pregnancy, as has been often the case, the latter diagnosis has usually not been made. The dropsy has been diagnosticated early, but the presence of a second foetus has only been known after the expulsion of the first.
We think that, in these cases, very gre,at importance is to be attached to the supra-pubic (edema; it does indeed exist in almost every case of twin pregnancy, and its presence should always awaken a suspicion of it when dropsy of the amnion is present.
In our case. where there was both twin pregnancy and acute hydram nion, this cedema was very marked; but it was accompanied by a general cedema of the abdominal wall, and of the genital organs. We must con fess that we recognized the complication without thinking of the existence of twin pregnancy, which was noticed by Dr. Savornin, whom we had called in to see the patient.
There remains for us to consider the differential diagnosis between hydramnion and the diseases which may be mistaken for it, hydrorrhceas, ascites, ovarian cysts, and vesicular moles.
It would seemingly be difficult to confound hydrorrhcea with hydram nion. llydrorrhcea is characterized by a flow of watery fluid, occurring during pregnancy, and usually first coming on during the night. There is generally, after the first outburst of fluid, a slower and continuous loss. The material that escapes is clear, has a spermatic odor, and stains the linen. The flow may be intermittent, or continuous, or come drop by drop. As a rule, there is no pain, though Naegell!, Belfinger, and Ches ton have recorded cases in which there was. Rare before the fourth, it is usually at the end of the fifth or sixth month that hydrorrhcea occurs. Recurring generally three or four times during the pregnancy, hydror rhcea may persist after delivery, and replace the lochia plauriceau, Nae gele, Dubois). The os remains closed, and if there are uterine contrac tions, they are regular and general. If nature be allowed to take its course, whatever pain may be present generally ceases, and the pregnancy advances normally. The flow of false water does not diminish the amount of normal liquor amnii present at birth, nor does it ever contain particles of sebadbous matter. The diagnosis from ascites may be more difficult, especially if the ascites complicates pregnancy.