Abdominal Dropsy 317 



small, there is dulness in each flank, and resonance over the whole 

 antero-lateral aspect of the abdomen as the patient lies on his back 

 the resonance being due to the inflated intestines floating on the fluid. 

 But on turning the patient upon the side the area of dulness changes. 

 Were the fluid enclosed in a cyst, as in ovarian disease, percussion 

 would be but little affected by change of position. If the patient sit up 

 or stand the area of dulness extends across the inguinal and hypo- 

 gastric zone, the higher regions becoming resonant. When the effusion 

 is excessive, resonance may be discoverable only behind the recti, as 

 the patient lies supine. The diaphragm is then pushed far up, and 

 respiration is short and thoracic. The patient may breathe more 

 easily in the sitting posture, for in that way the compressible intestine, 

 and not serum, lies against the diaphragm. (See figs, on p. 316.) 



Tapping- the abdomen. An enormously distended bladder has 

 sometimes been mistaken for ascites ; the rule, therefore, is to empty 

 the bladder before thrusting in the trocar. The puncture should be 

 made in the median or semilunar line (p. 296) ; as the fluid escapes 

 pressure is removed from the caval and other deep abdominal veins, 

 which now become distended, so that the heart is robbed of its accus- 

 tomed supply, and faintness comes on ; the descent of the diaphragm 

 also embarrasses the heart's action. Puncture through the semilunar 

 line of the recumbent patient is a satisfactory operation ; the patient 

 should be rolled a little on to the side selected. But if there be so 

 much distension that the rectus is flattened out and displaced, and 

 the situation of the semilunar line cannot be determined, it were 

 better to follow the usual English custom, and to operate in the exact 

 median line. There, for certain, no vessel will be injured or muscular 

 plane traversed. The patient sits over the edge of the bed, and the 

 puncture is made a few inches below the umbilicus ; as the fluid 

 escapes, a jack-towel, which was previously arranged round the trunk, 

 is tightened up, so that the risk of faintness may be lessened. Some- 

 times, when the serum is only partially drawn off, the flow is checked 

 by the omentum or a piece of intestine being carried against the end 

 of the tube ; the obstruction is to be overcome by passing a probe 

 down the cannula. 



Development of intestines. The early intestinal canal is a 

 straight cylindrical tube in the internal blastodermic layer ; it runs 

 in the long axis of the germ, and its ends are closed. As the growth 

 of the tube proceeds with great rapidity, it escapes in abundant coils 

 through the front of the abdomen, which is as yet not closed in. But 

 after the end of the second month energetic growth of the abdominal 

 walls takes place, so that the truant viscera are soon surrounded and 

 swept within the cavity. I have seen a new-born infant in whom 

 there had not been this subsequent growth of the parietes, so that not 

 only were the bowels protruding from sternum to pubes, but the 

 liver and the urinary bladder were also prolapsed. These viscera 



