1712. In the most ordinary case, that of abdominal dropsy, the swelling at first is in some measure over the whole belly, but generally appears most considerable in the epigastrium. As the disease, however, advances, the swelling becomes more uniform over the whole. The distention and sense of weight, though considerable, vary a little, according as the posture of the body is changed; the weight being felt the most upon the side on which the patient lies, while at the same time on the opposite side the distention becomes somewhat less. In almost all the instances of ascites, the fluctuation of the water within, may be perceived by the practitioner's feeling, and sometimes by his hearing. This perception of fluctuation does not certainly distinguish the different states of dropsy; but serves very well to distinguish dropsy from tympanites, from cases of physconia, and from the state of pregnancy in

women.

1713. An ascites frequently occurs when no other species of dropsy does at the same time appear; but sometimes the ascites is a part only of universal drospy. In this case, it usually comes on in consequence of an anasarca, gradually increasing; but its being joined with anasarca, does not always denote any general diathesis, as for the most part an ascites sooner or later occasions œdematous swellings of the lower extremities. When

the collection of water in the abdomen, from whatever cause, becomes considerable, it is always attended with a difficulty of breathing: but this symptom occurs often when, at the same time, there is no water in the thorax. The ascites is sometimes unaccompanied with any fever; but frequently there is more or less of fever present with it. The disease is never considerable without being attended with thirst and a scarcity of urine.

1714. In the diagnosis of ascites, the greatest difficulty that occurs, is in discerning when the water is in the cavity of the abdomen, or when it is in the different states of encysted dropsy above mentioned. There is, perhaps, no certain means of ascertaining this in all cases; but in many we may attempt to form some judgment with regard to it.

When the antecedent circumstances give suspiçion of a general hydropic diathesis; when at the same time some degree of dropsy appears in other parts of the body; and when, from its first appearance, the swelling has been equally over the whole belly, we may generally presume that the water is in the cavity of the abdomen. But when an ascites has not been preceded by any remarkable cachectic state of the system, and when at its beginning the tumour and tension had appeared in one part of the belly more than another, there is

reason to suspect an encysted dropsy. Even when the tension and tumour of the belly have become general and uniform over the whole; yet if the system of the body in general appear to be little affected; if the patient's strength be little impaired; if the appetite continue pretty entire, and the natural sleep be little interrupted; if the menses in females continue to flow as usual; if there be yet no anasarca; or, though it may have already taken place, if it be still confined to the lower extremities, and there be no leucophlegmatic paleness or sallow colour in the countenance; if there be no fever, nor so much thirst, or scarcity of urine, as occur in a more general affection; then, according as more of these different circumstances take place, there will be the stronger ground for supposing the ascites to be of the encysted kind.

The chief exception to be made from this as a general rule, will, in my opinion, be when the ascites may, with much probability, be presumed to have come on in consequence of a scirrhous liver; which, I apprehend, may occasion a collection of water in the cavity of the abdomen, while the general system of the body may not be otherwise much affected.

1715. With respect to the cure of ascites when of the encysted kind, it does not, so far as I know, admit of any. When the collection of water is in the abdominal cavity alone, without any other

species of dropsy present at the same time, I apprehend the ascites will always be of difficult cure; for it may be presumed to depend upon a scirrhosity of the liver, or other considerable affection of the abdominal viscera, which I conceive to be of very difficult cure, and therefore the ascites depending upon them. At the same time, such cases may often admit of a temporary relief by the paracentesis.

1716. When the ascites is a part of universal dropsy, it may, as far as other cases of that kind can, admit of a cure; and it will be obvious, that such a cure must be obtained by the same means as above proposed for the cure of general ana

sarca.

It frequently happens, that the ascites is attended with a diarrhoea; and, in that case, does not admit of the use of purgatives so freely as cases of anasarca commonly do. It is therefore often to be treated by diuretics almost alone.

The diuretics that may be employed, are chiefly those above mentioned; but in ascites, a peculiar one has been found out. It is a long continued gentle friction of the skin over the whole of the abdomen, by the fingers dipped in oil. This has sometimes been useful in exciting an increased flow of urine; but in most of the trials of it which I have known made, it has failed in producing that effect.

1717. The ascites admits of a particular means for immediately drawing off the collected waters; and that is the well-known operation of the paracentesis of the abdomen. In what circumstances of ascites this operation can most properly be proposed, it is difficult to determine; but, so far as I can judge, it must be regulated by very much the same considerations as those above mentioned with regard to the paracentesis of the thorax.

The manner of performing the paracentesis of the abdomen, and the precautions to be taken with respect to it, are now so commonly known, and delivered in so many books, that it is altogether unnecessary for me to offer any directions upon that subject here; especially after the full and judicious information and directions given by Mr. Bell, in the second volume of his System of Surgery.

CHAP. IV.

OF GENERAL SWELLINGS ARISING FROM AN INCREASED BULK OF THE WHOLE SUBSTANCE OF PARTICU LAR PARTS.

1718. UPON the subjects of this chapter, several nosological difficulties occur, and particularly with