A little girl, aged seven years, of healthy parentage, was a patient in the East London Children's Hospital. The child had passed through mea sles and whooping-cough, and between two and three years previously had had an attack -of scarlatina which was followed by dropsy ; but this had been completely recovered from. There was no rheumatic tendency in the family, and the girl herself had never suffered from rheumatic pains, but she was said to be subject to bilious attacks.
Six weeks before her admission she had begun to complain occasionally of feeling cold, and used to come back from school saying she had a head ache. She also occasionally complained of pains in the right side of the abdomen, and sometimes vomited. After these symptoms had continued for a fortnight, the pains became more severe and paroxysmal, and the belly began to swell. From that time she lost flesh. Her appetite had been pretty good, and the bowels usually regular ; but she had had two or attacks of diarrhcea, lasting on each occasion twenty-four hours. For two or three days before admission she had had attacks of shivering.
When first seen, the girl was in fair condition, and, although pale, had no distressed expression of face. Her lips were pink. There was no yel lowness of the sclerotics. The skin was a little dry, but not harsh or rough. The belly was very full and tense-looking. Its girth was 278 inches. It fluctuated freely, and the veins of the parietes were unusually visible. The lower edge of the liver could not be felt ; its upper border was in the fourth interspace. The spleen was estimated by percussion (the child lying on her right side) to reach from the seventh to the ninth rib. There was no tenderness of the belly. The heart's apex was be tween the fifth and sixth ribs, and the precordial dulness reached upwards to the second rib. On auscultation, a distinct rub was heard with the sys tole and between the two sounds at the mid-sternal base. The lungs were healthy, except for a little sub-crepitant rhonchus at the bases, which dis appeared in a great measure after a cough. The child was thirsty, but had little appetite ; her tongue was clean and rather red. Pulse, 128 ; very intermittent, weak and soft. Her bowels acted regularly every day, and the motions had a natural appearance. The urine was very clear and pale. It was acid ; had a density of 1.015, and contained no albumen or
bile pigment. The temperature on the morning after admission was 103°.
During the next three weeks the temperature continued to be febrile ; the physical signs in the chest became more developed, and the child passed through a well-marked attack of pericarditis with effusion. As the pericardial fluid became absorbed, the ascitic effusion began also to dis appear and the abdomen to diminish in size. In four weeks from the time of admission, the child was convalescent and was discharged. About a month afterwards she was readmitted with an attack of well-marked enteric fever. It is curious that during this illness the ascites and peri carditis both returned ; but they subsided again, as before, during con valescence from the fever. Eventually, the girl recovered her health com pletely.
The cause of the ascites in this case is not very clear ; but the absence of all symptoms pointing to the liver, combined with the natural size of the spleen, seemed to exclude cirrhosis. The history suggested peritonitis, and although the characteristic features of this disease were absent, such absence is occasionally observed. Taking into account the previous symptoms, the high temperature, the occurrence of pericarditis as if from extension of the inflammation, and the completeness of recovery, this view would seem to furnish the most probable explanation of the child's illness.
In some cases, fluid may be present in the abdomen from other causes than ascites. Thus, a large hydronephrosis which almost completely fills up the cavity of the belly, may be accompanied by free fluctuation, evidently due to fluid ; and it may not be easy to distinguish this condition from a copious peritoneal effusion. On careful examination, however, it will be usually found that in hydronephrosis the swelling of the abdomen is not quite syMmetrical, but that the flank on one side shows a greater promi nence than on the other. The resistance is also greater over the site of the greatest bulging ; and although, as the child lies on his back, the umbilicus is absolutely dull, a spot can often be discovered in the less prominent flank where a clear percussion-note is obtained. Lastly, tapping the swelling will withdraw a fluid containing urea.