In this c,ase- premature labor often comes on, especially if the woman has passed the seventh month, but unforttmately it is not always so; and particularly in the case where ascites is large in amount after the fifth month, one is often obliged to interfere. At other times, at last, the spontaneous death of the child interrupts the course of the disease; the child becomes thus a foreign body, remaining more or less long in the uterine cavity before it is expelled. It is understood that the prognosis of ascites complicating pregnancy will be more serious as it makas its ap pearance at a period remote from full term, because its course is likely to be more rapid, and it will also be complicated with hydmmnion. We will return again to this subject.
Aside from ascites, serous effusions have a variable influence on preg nancy; most often pregnancy follows its regular course; the effusions may disappear some days before confinement, or they may persist to that time. Pregnancy may be interrupted prematurely, or more rarely the patient may die before labor comes on. As for the child, it may be born strong and well developed, but it may also be born prematurely, or, filially, it may. die during pregnancy. In general, delivery le,ads t,o a de cided improvement almost immediately, and, at the end of some days, everything returns to its normal condition, but this is not always the case.
Treatment. —When the dropsy is slight, rest and simple purgatives will suffice in general, associated perhaps with tonics and iron in small doses. But when the dropsy is more pronounced, we advise, as in case of dropsy with albuminuria, a milk diet. In one case we obtained excellent results. The cedema was general, but without effusion into the serous cavities. Cazeaux rejects absolutely the use of venesection and advises laxatives, vapor baths, friction and diuretics. Not only do we not believe venesection injurious, but, in the presence of congestion in such cases, we believe that it is, on the contmry, perfectly justifiable to a modemte degree, i.e. , to relieve the vascular system of 3000 to 4000 grains of blood.
We are more conservative in regard to punctures, which a great many authors advise us to make on the labia majora and the lower extremities, in cases in which the cedema is very marked. The vitality of the tissue is somewhat modified, and the punctures may become the point of origin of gangrene. We are inclined, in such cases, to make three or four on each extremity and far apart. With Cazeaux, we do not advise blistering and irritating the skin. It is especially in cases of pulmonary congestion and encephalitis that we would advise blood-letting.
Whenever the effusion has reached the visceral cavities, we advise, first and foremost, venesection, together with a milk diet, mid, if these means fail, we advise paracentesis. The operation of thoracentesis, followed by success, without the interruption of pregnancy, as shown by lluguet in cases of acute pleurisy, ought to encourage us to perform the opera tion in cases of non-inflammatory effusion as in the passive effusion, 8,o to speak, of serous eachexia, and we would not, for our part, hesitate to have recourse to it. But, as we have said, the serous effusion is most
commonly in the peritoneal cavity, and, in view of imminent asphyxia, paracentesis should be resorted to.
As Cazeaux has remarked, the enlarged uterus makes it impossible to insert the trocar in the place usually selected in uscites. Scarpa also, in his paper on pregnancy complicated with ascites, advises that the punc ture be made in the left hypochrondriac region, between the upper border of the external oblique muscles and the borders of the false ribs, in order to avoid the uterus, the puncturing of which he does not consider as serious as Chambon seems to think, and he quotes, in regard to this point, the cases of Camper, Langius, Reiscurd and de Nissi, in which abortion was simply produced.
Ina case of wiles, Langstaff, as cited by Cazeaux, made an incision two inches below the umbilicus, to expose the peritoneum,which he pierced with a medium-sized trocar, but forcing it very slightly so as not to wound the uterus. After drawing off about ten pints of fluid,the uterus'eame in contact with the trocar, which gave such pain that it had to be withdrawn. A flex ible sound or catheter, introduced between the uterus and the anterior sur face of the peritoneum, withdrew the rest of the fluid. Eight hours after the operation, peritonitis, three days later abortion, recovery. 011ivier d'Angers, in a case in which the umbilicus projected considerably, opened this with a scalpel, a watery fluid poured out, and be withdrew at once twenty pounds of fluid. The discharge continued for twelve days; On the thirteenth the wound closed; twenty-eight days after the first punc ture it had to be repeated, with the same result, and twelve days later riatural labor set in, with the birth of a living, though feeble child; re covery.
When pregnancy is not far advanced paracontesis is the only resort, but when it is advanced to the eighth month, or further, should not the in duction of premature labor be preferred ? Cazeaux does not believe in this, because he thought that paracentesis would offer sufficient relief, so that pregnancy would go to full term without difficulty.
We think Cazeaux too hopeful on this point. Parakentesis, itself, is not always harmless. It may (as the case of Langstaff proves) give rise to peritonitis, which, on the one hand, may induce premature labor, and, on the other, may seriously compromise the life of the mother and child. Why then should we not have recourse to the induction of premature labor ? Still more should we do so if ascites is complicated by dropsy of the uterus i.e., by hydramnion.