But it is the epidemic form of icterus that exercises the most marked influence upon pregnancy. Among 68 women thus affected 42 miscarried, 30 of whom died. Abortion usually takes place from three to five days after the beginning of the disease, and not only does this fail to bring relief, but, on the contrary, the most serious accidents generally occur subsequently; and the reported epidemics of icterus, which have never been confined exclusively to pregnant women, assume with them, as a rule, an exceptional severity.
The grave variety of icterus presents the phenomena so well described by Lavoix. The coloration is more or less intense, the urine contains bile or the products of albuminoid decomposition, such as leucin and tyrosin, :tnd finally albumin and blood. There are multiple hemorrhages (espe cially gastro-intestinal), petechia, and nervous symptoms, characterized particularly by coma or stupor. Its onset is nearly always insidious, being often preceded, as in the cases observed by David and Frerichs, by an acute gastric catarrh; the yellow tinge developes slowly and constantly, accompanied with vomiting of mucus, anorexia, constipation, cephalalgia, a general feeling of weariness and depression, but without fever; at other times the disease begins with a rigor, followed by intense febrile reaction, which quickly subsides when the jaundice appears, with or without fever, but attended with severe gastric symptoms, constipation, marked aordes, nausea and vomiting, which, although occasional at first, may become incessant, the vomited matter consisting at first of food, then of glairy mucus, liquid fmces, and bile. There is excessive thirst, great pain in the epigastrium, the liver and spleen become enlarged and very tender. This condition continues for several days, then follows the ataxic stage, during which abortion takes place, although this, according to Lavoix, does not affect the progress of the disease. He accordingly disagrees with most authors, who claim that abortion occurs first, the ataxic symptoms appear ing subsequently. However that may be, this period of ataxia, convul sions, or delirium, is characterized by extrems agitation, associated with disorderly, involuntary, and spasmodic movements. There is intense cephalalgia, delirium with subsultus tendinum, disturbances of vision, dilated pupils, while at the same time there may be high fever or almost none. The urine is scanty, reddish or bloody, often containing albumin,
and depositing from four to nine per cent. of solid residue, consisting principally of leucin, tyrosin and gelatinous extractions, with traces of uric acid (not urea), and slight traces only of ammonium. Then comes the stage of coma, sometimes interrupted by convulsive phenomena, but generally very brief, and soon ending in death. Hemorrhages, although they occur, are comparatively rare, being generally confined to those which accompany abortion and delivery. The pulse in simple or benign icterus remains below the normal, while in the grave form it ranges from 80 to 120 several times during the same day. Grave icterus in the pregn4nt female generally terminat,es fatally within five or six days, sometimes sooner. In some cases the disease progresses so rapidly that there is no time for abortion to take place (Woillez); but death is not the inevitable consequence of grave icterus, and there are a certain number of awes in which a cure took place in spite of the extreme severity of the disease. When the patient die, we find, on autopsy, fatty degeneration of the hepa tic cells, the kidneys, heart, muscular system, but the liver is rather in creased in size than diminished (Lavoix), and it is generally softened. The mucous membrane of the bile ducts is necrosed. The abdominal c,avity contains a yellowish or reddish, semi-purulent exudation, some times in large amount; the spleen is normal or softened, the peritoneum is covered with ecchymotic spots, the lungs are congested, cedematous, and filled with yellowish fluid. The pericardium contains a certain amount of yellowish serum, and there are numerous sub-pericardial moses. The heart is small, flabby, soft, fatty, and pale, containing with in the right ventricle adhesive blood, or a few soft, spongy, blackish clots. The meninges present a slight, often insignificant congestion. The autopsy in the case of the fcetus shows nothing striking.
We should then, it is evident, always be very reserved in our prog nosis, even when the icterus appears in a mild form, and we consider Miner altogether too positive in his opinion that icterus, occurring dur ing the last days of pregnancy, is of a benign character, and that, with out being quite neglected, it is to be considered as of merely secondary importance.