When, on the other hand, the woman is naturally irregular, the diag nosis is far more difficult. The suppression of the menses loses its value in diagnosis. It is not exceptional, indeed, to meet women who men struate only every two t,o three months, in whom the breasts swell, the abdomen enlarges, and who present the signs of pregnancy in its begin ning, and yet are not so.
• According to Madame Lachapelle, the hemorrhage precedes and accom panies the pains, and increases with the intensity of the pains, and is al ways attended by clots, in case of miscarriage. In case of dysmenorrhoea, on the other hand, uterine contractions always precede the hemorrhage, and diminish as the hemorrhage increases. Further, clots are always less abundant than in case of miscarriage. In miscarriage the os is open, and the cervix modified in consistency, while it remaina closed and is not softened in dysmenorrhces,. Clots coming from the empty uterus are tri angular, while in miscarriage they have no special shape. All these signs are more than hypothetical, and hence are of little value.
Still further, there are certain women who, during the first three months of pregnancy, suffer from slight hemorrhages which do not seem to have a tendency to provoke miscarriage. Such women may not know that they are pregnant, believing themselves to be menstruating. These slight hemorrhages differ, however, from the menses, in that they do not cor respond to the menstrual epoch, either in time, quantity, or duration.
We see, then, that there are many sources of error, and it is only by obt,aining all possible information, and by examining the discharges and the clots that we can reach a nearly certain diagnosis.
[The decision as to whether the woman is pregnant or not, it seems to us, may almost infallibly be reached by a sign not mentioned by the author, and this is Ilegar's sign of early pregnancy, which we have de scribed in the first volume, under the Diagnosis of Pregnancy.—Ed.] The woman is pregnant, then, but are the symptoms purely those of simple uterine congestion, or is miscarriage imminent? In the majority of instances, as Cazeaux justly eays, " We cannot tell whether, even when pains have ceased, if the congestion has been relieved before vascular rupture, and hemorrhage between the placenta and the uterus have killed the fcetus. Even though the fcetus be still alive, we know nothing about the extent of placental separation. Often, indeed, the fcetus, deprived of a greater part of its respiratory means, is placed in the same condition as an adult in whom a greater part of the lungs has been destroyed; there remains only insufficient respiration and nutrition, it dies little by little, and it is only after the lapse of eight t,o fifteen days, often at the next menstrual epoch, that it filially succumbs." jacquemier, further, has insisted that the first pla,cental apoplexy pre disposes to others, since it interferes with the development of the placenta.
Miscarriage has Commenced.—le it inevitable, or can it be caused to ce,ase? Generally it may be said that as long as the fcetus is not dead, miscarriage may be prevented. But, if at the fourth month, we possess certain signs of the.life or the death of the foetus, the same doeis not hold' true before this period, and, as we have seen, it is during the first three months that miscarriage most frequently occim. The foetus once dead,
the miscarriage will necessarily occur sooner or later. One sign alone, may be of value, and this is the cessation of all the rational aigns of pregnancy; but there are many women in whom these signs are so little marked as not to be noticed.
However intense the pains, however in character like uterine contrac tions, however much the profuseness of the hemorrhage, or however marked the changes in the cervix, we are yet not justified in considering the miscarriage inevitable if the ovum be intact, and the membranes not ruptured. In certain exceptional cases all these signs have disappeared, and the pregnancy has continued.
There are other instances again where the diagnosis is still more diffi cult. For instance: The woman had been certainly pregnant, she has passed through, apparently, a miscarriage, having lost much blood, and suffered greatly from the contractions of the uterus. Clots have been passed and with them a body, which a midwife or a physician has ex amined, and pronounced an ovum, and furthermore it is stated that the miscarriage is complete. This body has been thrown away, and the ac coucheur, hence, cannot examine it. The bloody discharge continues, the woman does not regain her strength. Now has she really miscar ried, and did the body really constitute the ovum? Is the miscarriage, if one has occurred, complete or incomplete? Here the diagrnosis is diffi cult, and often cannot at once be made. If the ovum has really been expelled, the hemorrhage will shortly cease, the cervix and the body of the uterus will return to the normal. If the miscarriage be incomplete, at the end of a certain interval the hemorrhage and the uterine contrac tions will recur, and the remnant be expelled, or else some pathological factor will supervene pointing to the retention of ovular remnants in the cavity of the uterus. Not infrequently a portion of the placenta remains behind, the woman will bleed irregularly, and have occasional contrac tions until it has been shed. Sometimes this placental remnant under goes complete changes in the uterus, and these are two in number: either this remnant becomes converted into a fibrinous polyp, (Fig. 28), as has been noted by Kiwisch, Virchow, Scanzoni, Sallinger, Frankel, Dun can, etc.; or else, more frequently, the remnant empties itself of the blood which it contained, becomes hard, takes the shape of the uterine cavity, and is transformed into what has been called placental polyp. (Braun, Schroeder, Valenta, Frankenhauser, Martin, etc.) In other instances the diagnosis is still more difficult; where a placen tal tuft, or remnant of membrane or of decidua, remains in the uterus, and undergoes change. Here, instead of abruptly ceasing, the discharge persists, being black in color, and composed of detritus, and further—a very characteristic phenomenon—is intensely fetid. At the same time the woman's health is compromised. She suffers from chilly sensations, and haEt fever, effects which we will study when we speak of puerperal complications.