ASCITES.
The first symptoms of ascites manifest themselves sometimes during the first months of pregnancy, more often toward the fifth or sixth month, rarely later. It may be produced slowly, gradually, or, as we have seen in one case, rapidly. In this last case, moreover, the quantity of effusion into the abdominal cavity may be considerable, and if the effusion ap pears early, there may be a marked disproportion between the size of the abdomen and what it should be at that period of gestation; and as, on the other hand, ascites is generally complicated by general (edema, there results a period of pain and suffering, which only goes on increasing as the disease advances.
The effusion goes on increasing more and more until the infiltration becomes general; the patient presents a puffy appearance which gives the face a, pale, livid look. The abdominal walls are greatly stretched and cedematous, extremely painful, and preserve the impress of the finger. Cazeaux compares this appearance to that of elephantiasis. The um bilicus, enlarged at its base, forms a more or less prominent tumor, which can, according to Cazeaux, acquire the size of a hen's egg; but this tumor does not exist constantly, and, in one case, the umbilicus did not form such a tumor. All was limited to an enormous distension of the umbilical ring, and to a thinning of considerable of the skin in the neighborhood.
The lower extremities and the greatly swollen genital organs increase still more the woman's suffering, who can neither stand, sit nor keep the dorsal decubitus, on account of the dyspncea and pain accompanying respiration.
If we try to palpate the 'abdomen, the extreme sensibility and the enormous distension of the abdominal walls render this almost useless. We make out easily dullness, but this dullness, contrary to that which occurs in ordinary ascites, is not displaced by the change of position of the patient.
The presence of the uterus changes, indeed, the ordinary conditions, and as Scarpa has pointed out, the dullness, slight or null (in the hypo gastric and iliac region) is very pronounced and very superficial in the left hypocliondria,c region.
Fluctuation, very evident in certain cases, is difficult or even impossible to perceive in others, in consequence of the sensitiveness and distension of the abdominal wall. This is also the case even when ascites is com plicated with hydramnion. The uterus is with difficulty made out through the walls of the abdomen. Its size can only be made out with much difficulty, the fcetal parts are hard, if not impossible to feel, and, if the woman at this time perceives fcetal movements, these are dull and • _obscure; often auscultation gives no results.
Depaul has nevertheless given two signs which enable us to recognize the uterus: first its abnormal mobility; this seems to us difficult to prove, but there is another sign, which is of great importance. It is this fact, mentioned by Depaul, which has been to us in one case a great help in making our diagnosis. that when the abdomen is palpated for a certain time its form is seen to change, become more globular, more prominent, and at tho same time forms under the hand a hard, globular mass, and one can with difficulty, it is true, but more or less clearly, appreciate its size and form. This mass is no other than the uterus, which hardens by the fact of its contraction. [The intermittent uterine contractions of Braxton-Hicks.—Ed.] When the effusion is moderate, the woman only experiences a feeling of constmint, of general fatigue and of slight oppression, but when the effusion becomes great enough to greatly distend the abdomen, the pains become severe, depriving the woman of rest and sleep. And, moreover, as the effusion progresses rapidly, fever arises, but what is more promi nent is dyspncea, which may go on to complete orthopnoaa, threatening the woman with asphyxia, syncope and serious complication from the side of the pulmonary cavity.