(J52 DISEASES OF THE PERITONAEUM. 



DIAGNOSIS. To distinguish free dropsy from ovarian dropsy, it is 

 imperatively necessary to obtain a perfect history of the case by a 

 careful examination of the patient, and to pay particular attention to 

 any possible causes of dropsy that may be discovered. The circum- 

 stances under which ovarian dropsy occurs are little known ; we only 

 know that it is often found in apparently healthy women without be- 

 ing complicated with any other disease. It is quite different with 

 ascites. If we can determine that none of the anomalies of composi- 

 tion or distribution of the blood, described under etiology, have pre- 

 ceded the collection of fluid in the abdomen, and if degeneration of 

 the peritonaeum can also be excluded, in doubtful cases, the chances 

 will be most in favor of ovarian dropsy. There are cases where the 

 differential diagnosis depends entirely on the above factors, as the 

 physical examination gives no decided evidence. In small ovarian cysts, 

 it is true, the characteristic form and position of the sac, the lateral 

 deviation of the os uteri, the similar results of percussion while the 

 patient is in different positions, readily distinguish ovarian dropsy 

 from ascites. But, when the cyst is very large, the peculiar form of 

 the sac is lost ; it lies in the middle of the belly, the uterus is pressed 

 downward by the weight of the sac, but is not laterally displaced ; as 

 in extensive ascites, the percussion is dull over the entire anterior ab- 

 dominal wall. Bamberger advises us to pay particular attention to 

 the spot between the crest of the ilium and the twelfth rib, for, in 

 ovarian tumors at that point, we generally find the full sound of the 

 large intestine, in ascites we do not. Still he acknowledges that this 

 sign occasionally fails. 



After ascites has been recognized, the most important question is, 

 what is its cause ? We have already mentioned that ascites, occurring 

 as one symptom of general dropsy, is never its first symptom. Hence, 

 if ascites occurs in a person who has no oedema, it either depends on 

 obstruction of the portal circulation or on degeneration of the perito- 

 naeum ; it is often difficult to decide which of the two is the case. In 

 general we may say that the coincident occurrence of symptoms of 

 congestion in other branches of the portal vein, or the signs of dis- 

 turbed action of the liver, indicate the first form ; while cachexia, sigms 

 of cancer, or tuberculosis in other organs, but, above all, the presence 

 of tumors in the abdomen, indicate the latter form. The color of the 

 urine is very important in the differential diagnosis. For, in those 

 diseases of the liver that lead to ascites, the urine, as a rule, contains 

 either traces of the coloring matter of the bile or abnormal pigment; 

 in degeneration of the peritonaeum, on the contrary, it is almost always 

 of normal color. 



TREATMENT. When the ascites is a partial symptom of general 



