In simple ascites, besides what can be ascertained by palpation, auscul tation, and the vaginal touch, and besides the absence of positive signs of pregnancy, the abdomen is peculiarly flattened and widened laterally, and fluctuation is very readily perceived. There is absolute flatness ever the lateral portions of the tumor, with an intestinal tympanitic percussion note over the superior, anterior, and median portions.
This flatness varies of course with the position of the patient, the in testines being always uppermost. There is no ballottement, nor can foetal parts be felt. (Edema of the lower portion of the abdomen is often present, and filially we find in the heart, liver, or kidneys, evidences of the lesion that has caused the ascites.
If the ascites complicate pregnancy, the diagnosis is more difficult. The fluctuation is more readily perceived in the upper than in the lower part of the abdomen, and the fluid is displaced according to the woman's position.
But when ascites exists with hydramnion, the diagnosis may be very difficult; and this explains the errors that have occurred.
Robert Lee says: " The diagnosis of hydramnion with ascites is very difficult Fluctuation is distinct, but it does not tell us whether the fluid is in the peritoneal cavity, or in the amniotic cavity, or in both places. The presence of fluctuation, therefore, is not a certain evidence of the existence of the affection, and the only way to arrive at a precise diagno sis is by means of the vaginal touch. This enables us to determine whether the uterus has undergone changes consecutive to impregnation, and also whether there is an excessive amount of liquid within the membmnes of the ovum. This will be shown by the almost entire effacement of the cervix, by the development of the body of the uterus, and by the sensation of vaginal fluctuation upon abdominal percussion." In ascites complicated with pregnancy, Scarpa has observed that the symptoms are different from those of hydramnion. " The large collection of fluid interferes with our recognition of the regular form of the fundus and body of the gravid uterus. The urine is diminished and lactescent, thirst is constant. There is obscure fluctuation in the hypogastric region, more distinctly percepti ble in the hypochondrium, between the edge of the rectus muscle, and the false ribs."
Scarps thereupon maintains that puncture of the pregnant uterus is not aa serious an operation as luts been maintained by Chambon, and cites the observations of Bohn (pregnancy mistaken for ascites), of Camper, Langius, and especially Nesse: (Dropsy of the amnion at the fifth month. Paraceutesis at the linea alba, midway between umbilicus and pubes. Twins born, that died soon after. A metrorrhagia, not followed by serious results, was all that ensued.) Ovarian Cpts.—Though usually easy to distinguish from dropsy of the amnion, it is not always so, as the cases of Boddy, Hiod. Hunt, and Kidd would show.
The recognition of the certain signs of pregnancy only can prevent error. The menses may be absent in both cases, and there are on record cases of inflammation of ovarian cysts in which the accumulation of liquid has taken place, almost as quickly as in dropsy of the amnion. In both cases great pain accompanies the abdominal enlargement. But the pro gressive growth of hydra,mnion is replaced in the case of the cyst by sud den enlargements at the menstrual epochs, with slower and more cont'n nous progress between them. Besides this the tumor in ovarian cyst begins on one side, and the uterus is displaced in the opposite direction. Finally, we may detect the modifications in the neck and lower part of the uterus, and the three certain signs of pregnancy, ballottement, the fcetal heart and ketal motion.
Sometimes, as in one of our cases, these signs fail us, and we must have recourse to other means of diagnosis. Fluctuation is said to be more manifest in hydramnion than in ovarian cyst; but in certain cases it may be wanting. But there is one sign which is pathognomonic, and which was present in our second case.
In this case all the certain signs of pregnancy were absent, and rectal and vaginal touch gave us no aid. Palpation was difficult from the ex treme sensibility, and the o3dema of the abdominal walls permitted only the perception of a false fluctuation. Only the suppression of the menses, and the results of an anterior examination made by a physician, c,aused UR to suspect pregnancy. But at the second examination I could feel in the abdomen intermittent contractions, and the uterus is the only organ which could give rise to any such sensation.