In ascites, although excess of fluid will excite discomfort and distress, there is seldom actual pain unless the peritoneUm be inflamed. Still grip ing pains may be sometimes complained of. These are due probably to the interference with digestion set up by the congested state of the gastric and intestinal mucous membrane. For the same reason, looseness of the bowels is a not uncommon symptom. The appetite is often good ; the tongue is usually clean • and, in non-inflammatory cases, the temperature is that of health. Often the skin is dry and the secretion of urine scanty, high coloured, and perhaps albuminous.
Other symptoms may be present, according to the disease of which the peritoneal effusion is the consequence. If there be peritonitis, the tempera ture is generally elevated, and, in ordinary cases, there is tenderness of the belly with abnormal tension of the wall. We must not, however, always expect such definite signs. As described elsewhere, peritonitis, like pleurisy and pericarditis, may be completely latent, accompanied by none of the characteristic phenomena by which its presence is usually revealed. In peritonitis the amount of fluid is small, as a rule ; and fluctuation is often far from being distinct. A scanty secretion may gravitate into the pelvis and thus escape detection on superficial examination ; or may be retained in the coils of intestine by adhesion of the coats of the bowel to one an other. Evidence of fluid may, however, be often obtained by placing the patient for some minutes on his side, according to the plan advocated by Duparcque. The effusion will then gravitate into the undermost flank. Afterwards, by turning the child quickly on to his back and examining the region lately depending, dulness and signs of fluctuation will be often dis covered before the fluid sinks away again from the surface. Another plan is to place the child upon his elbows and knees ; the fluid then gravitates to the umbilical region and gives the usual evidence of its presence.
In cases of hepatic cirrhosis, the peritoneal effusion is usually copious, and fluctuation very distinct. The spleen, in these cases, is often en larged ; signs of digestive disturbance are noted ; the skin, in advanced cases, has an earthy tint, or may even be jaundiced ; the veins of the ab dominal wall, especially in the umbilical region, are unnaturally prominent ; and signs of dilated haemorrhoidal veins, even in young subjects, may be sometimes detected.
When the ascites is due to cardiac disease, there is general anasarca ; the lips are bluish and the complexion livid ; the jugular veins are full and pulsating, and often fill from below ; the breathing is oppressed. The
urine is scanty and albuminous ; effusion into the pleural cavities may be perhaps discovered, and an examination of the heart at once reveals the cause of the obstructed circulation.
Diagnosis.—A large belly is no sign of ascites. The abdomen in a young child is always relatively large as compared with the rest of his body ; and if the child be•the subject of rickets, or be injudiciously fed, or suffer from looseness of the bowels, the disproportionate size of his belly is still further exaggerated. Flatulence is the commonest cause of abdom inal distention in the child, and the increase in size from this reason is sometimes so great as to excite serious alarm in the minds of the parents. It is very common in rickety children who habitually suffer from derange ment of the bowels and consequent fermentation of food. In this dis tress, the flatulent distention is rendered more conspicuous by the relaxed state of the abdominal muscles and the shallowness of the pelvis. Often, in these cases, on palpation of the belly, an indistinct sense of fluctuation may be felt between the hands, placed on either flank. This is conveyed through the distended bowels. It is distinguished from the impulse con veyed by a wave of fluid by the effect upon it of pressure made in the mid dle line of the abdomen. If fluid be absent, the tap of the finger will then at once cease to be felt by the hand placed on the opposite side of the belly.
Enlargement of the abdominal organs may also determine the disten tion of the belly. Congestion, amyloid and fatty degenerations, hydatid disease, and hypertrophie cirrhosis of the liver ; a spleen enlarged from amyloid disease, rickets, or ague ; a kidney the seat of sarcoma or hydro nephrosis ; cancerous or lymphomatous growths from the omentum or ab dominal glands—in all these eases the size of the belly may be increased.
The only test of ascites is the presence of fluctuation. This, if the amount of fluid is small, can often be obtained by placing the patient in such a position that the fluid may gravitate to the surface and thus be brought within reach of the fingers. It is not enough, however, to detect the presence of ascites. We have to ascertain, if possible, the cause to which this excess of fluid is owing. If the symptoms of the determin ing disease are well marked, the diagnosis may be easy. If, however, the symptoms are obscure, the case may present great difficulty, and often it is impossible to arrive at a positive conclusion.