lst. Pregnancy checks the development of plithisis, or arrests its course after it has already begun. But after delivery tuberculosis resumes its cou-.-se, and the temporary amelioration established during pregnancy is followed by a relapse which often carries off the patient in a short time. This opinion, advanced by Cullen, Borden, Sims, and others, is based on the theory that the growing uterus diverts a part of the blood from the lungs to nourish the ftftus, hence the immunity during pregnancy. The hemorrhage accompanying delivery insures amelioration afterward; but this is only temporary, because, as this diversion ceases after delivery, the pulmonary congestion begins anew, and all the phthisical symptoms reap pear, and become rapidly aggravated. Gaulard calls attention, in connec tion with this theory, to the fact that pregnant females enjoy no immu nity from diseases, and that all authorities insist that pregnancy influences, more or less injuriously, every acute or chronic affection. There is, then, no reason why- pregnancy, which exerts such a particular disturbing effect upon a lung that is the seat of pneumonia, should, on the other band, affect favorably a lung strewn with gray nodules, or attacked with tubercular pneumonia. If, as the supporters of this idea believe, preg nancy produces a salutary derivation of blood from the lung of a tubercu lous woman, why should it produce such a result only in tuberculosis ? Now, this derivation does not exist, for the researches of Peter have shown conclusively that pregnancy unquestionably causes pulmonary congestion, and the antagonism between rickets and tuberculosis (admitted by Gubler, Beylard and Trousseau) is not certain. As regards the influence of deliv ery and the puerperium upon the progress of phthisis, Lebert thinks that it is even more fatal than that of pregnancy, while Gaulard, though ad mitting that phthisical females are generally delivered easily and rapidly, nevertheless attributes to these conditions considerable influence, be eause of the exertion demanded by the woman, exertion which increases her weakness and induces attacks of pulmonary congestion. Now, it is evident that these violent and repeated congestions act unfavorably upon tuberculosis, at any stage of its advance; they may even lead to the rup ture of vessels and consequent luemoptysis, and, a,s Fernet says, " even granting that lnemoptysis can not cause tubercle, can it not lead to the development of a chronic inflammation of the lung ? and, supposing this inflammatory process to become caseous, may it notpinvolve the destruc tion of the organ and all the phenomena of pulmonary consumption ?" The puerperal state also aggravates pulmonary tuberculosis, and Lebert attributes this injurious influence to traumatism, to the feebleness and exhaustion of the woman, to loss of blood, and to the lochial discharge. Every debilitating agent favors the production and development of tuber cles; the puerperium exerts such an influence, and this applies more par ticularly to lactation. On this point all authorities agree. But, in addi tion to this enfeebling influence of the puerperal condition, does it not act directly upon the respiratory apparatus? If during .pregnancy the lungs are relieved of a considerable amount of blood, which is diverted to the uterus, after delivery there is a sudden change in these relations, which leads to congestion, hemorrhage, and acute exacerbation of exist ing inflammations. According to Spiegelberg, the sudden lowering of the pressure in the aorta after delivery causes a corresponding elevation in the venous pressure, which is still further increased by the closure of the uterine sinuses. After labor, the diaphragm can sink lower and the blood flows into the lungs more freely.
2d. Pregmancy not only does offer no resistance to the development of phthisis, but, on the contrary, it hastens and aggravates the course of tuberculosis. This opinion is based on numerous observations, in the course of which tuberculosis existing before conception was sometimes' seen to advance more rapidly solely by reason of the pregnancy, while, again, a tuberculosis previously latent may develop during gestation and as a result of its influence. Thus .Gaulard reported thirty-two cases in which the disease existed before conception, in twenty-five of which the patient's condition was aggravated, and collected eighty-four in which it developed during pregnancy and was evidently aggravated by the same.
Caresme noted the appearance of tuberculosis in twelve patients after confinement, two of whom subsequently gave birth to other children.
3d. Mixed Opinion.—Pregnancy aggravates the course of the disease, but the latter undergoes a marked amelioration during the early months. This view is held by Gardien, Capuron, Pidoux and Peter.
4th. Finally, there exists a fourth view, still more eclectic in its charac ter, according to which pregnancy sometimes interrupts and seems to ar rest the progress of the disease, sometimes hastens it. This is supported by Portal, Andra], and others.
The ages of the patients have ranged from eighteen and a half to thirty-nine and a half years, and the interval elapsing between the initial symptoms, from the end of gestation, has varied from a few days to twenty one months.
Pregnancy, accordingly, exercises a marked influence upon phthisis, and this influence will be so much the more injurious if this afferent cause is combined with other predisposing ones, such as heredity, malnu trition, bad hygiene,,exposure to cold, hard labor, scrofula, pre-existing pleurisy, repeated pregnancies, etc. Lebert has presented the following statistics showing the duration of the disease. Death occurred in 12 per cent. within three months, in 20 per cent. within six months, in 44 per cent. between six months and a year, and in 24 per cent. between one and six years. According to the same writer the influence of pregnancy upon tuberculosis is most marked between the ages of twenty and thirty. He draws the following conclusions: lst. Latent tuberculosis in young girls most often appears after mar riage as a result of pregnancy, either the first or a subsequent one.
2d. In exceptional cases, the health in tuberculous women is not affected even by repeated pregnancies; in some instances the children are feeble. a certain proportion dying early.
3d. Advanced phthisis usually prevents conception; incipient phthisis does not prevent it, and the pregnancy goes on to full term.
4th. Abortion, pregnancy, and the puerperal state, determine the de velopment of phthisis in at least three-fourths of the cases.
5th. Children born of a phthisical mother are generally feeble; they oft,en become first scrofulous, then tuberculous.
The IVuenee of Phthisis on the Product of Coneeption.—This is much less pronounced, though in many instances it is undoubted. Bourgeois noted 96 living children among 124 tuberculous mothers; 36 infants con tinued in good health, 60 became scrofulous, and 22 died of tuberculosis before their seventh year. Ortega observed 95 women, in whom pulmonary phthisis developed before, during, or after gestation. The disease ad vanced steadily in every instance. Although there was sometimes an amelioration during gestation, it nearly always made rapid strides after delivery.
From these 95 women there were 185 pregnancies. 95 went to term; 28 premature labors; 9 miscarriages; 18 women did not cough before preg nancy. In 20, the disease appeared in the first half of pregnancy; in 11, at term; in 6, before the 9th month; in 2, during lactation; in 10, 4 weeks after delivery; in 2, 15 weeks after delivery.
Icterus.
Icterus may present itself in the pregnant woman under two forms, the sporadic and the epidemic, or the benign and the innocent, and it is evi dent that it . may, according to the conditions, exercise a more or less marked influence upon the product of conception. Icterus results from an exaggeration of the physiological hyperismia of the liver. But in ad dition to the simple form there is a malignant type peculiar to pregnant females, in which death is caused by an accumulation in the blood of the components of the bile which the diseased liver can not eliminate. Others say that the form of icterus observed in gravid women differs neither in its etiology nor in its development from that which attends other patho logical conditions. Authorities differ widely in their explanations. Pouchet attributes the icterus to compression of the hepatic vessels by the growing uterus, Meunier to a similar pressure by the distended colon. Schroeder and others regard the grave form as identical with Frerich's acute yellow atrophy. It is generally conceded that the toxic phenomena are due to the presence of bile salts in the blood, and especially to the noxious influence of tlie latter upon the nervous system.