phenomena always accompany miscarriage: hemor rhage, and uterine contraction. These symptoms are variable, according to the stage of preg-nancy, and according to the life or death of the fcetus. When the miscarriage occurs during the early weeks of pregnancy, whether the fcetus be dead or alive, makes no difference. The uterine tissue is denser than the normal, but the muscular fibres have only be gun to develop. It is not the contractions of the uterus which are going to c,ause the shedding of the ovum, but it is uterine congestion and the resultant hemorrhage which produce this phenomenon, and dilatation of the cervix occurs but imperfectly. As at the time of menstruation, the cervical canal opens, and becomes patulous, but without true dilatation, and clots and ovum are so soft that they readily pass through this canal. The resistance offered is lessened by the softening of the uterine tissue, and it is not the ovum which gives rise to trouble, but the clots which surround it. The ovum is lost within these clots, and the miscarriage is, usually, soon accomplished. The hemorrhage, often no more than is lost at the menstrual periods, is accompanied, or at once followed, by a few colic-like pains, or uterine contractions, and these suffice to expel the ovum. If the process lasts over long, occasionally, it is because the uter ine mucous membrane is detached with difficulty, often in shreds, as is seen in pseudo-membranous dysmenorrhcea, which has often been mis taken for miscarriage. At times, shreds are passed for a few days, ac companied each time by hemorrhage and contraction; then the discharge becomes sero-sanguinolent and serous, and the miscarriage is ended. The cervix remains patulous for a few days, but it retains it,s length, and the uterus quickly regains it,s form, consistency, and normal dimensions. In such cases, the ovum is passed entire, and, if it seem torn, this i,s because the scarcely formed cavity, between the decidua reflexa and parietalis, is mistaken for the cavity of the ovum. The shreds, which are seen, do not belong to the ovum, but to the decidua which the uterus furnishes to the ovum as an outer covering.
Miscarriage from the first to the second month, differs notably from that of the early weeks. The uterus, indeed, has developed with the ovum, has become proportionately hypertrophied, especially in its mus cular tissue, since the mucous coat is intended to be shed with the ovum, and replaced by another. Miscarriage here, then, consists in: 1st. Sep aration of the ovum. 2d. Separation of the mucous membrane. 3d. Expulsion of the ovum.
At this period still, spontaneous miscarriage frequently occurs, because the bands which unite the ovum to the uterus are very fragile, and it is, in particular, at the menstrual epoch that the accident occurs. The mis carriage. may occur entire—that is to say, the ovum may be expelled eat inasse, intact, or with ruptured membranes. If the catamenial or other congestive factor be strong, hemorrhage results, and the blood, escaping into the uterine cavity, tears these fragile bands, oft,en even tears the chorion, penetrates this membrane, reaches the amnion, ruptures it, and gains the interior of the ovum, as is proved by the cases of Breschet, Dance, Blot, Dolull, Hegar, Henning, etc. The ovum, therefore, is ex
pelled with ruptured membranes, and not entire. If the hemorrhage be less abundant the ovum is simply detached, and this, being a foreign body, is expelled by the uterus, either entire, or with ruptured mem branes, but ruptured here from another cause. We insist on this point, because we are opposed to the opinion of Gallard and of Leblond, who state that the expelled ovum is, in the early months, always entire, with membranes intact, and who believe that when the membranes are rup tured, it is a sign of criminal abortion. Miscarriage, it is undoubted, has greater chances of resulting in an intact ovum, the younger this is. But, even as early as the fifth week, the ovum may be expelled with torn mem branes, and to call such rupture proof of criminal attempts is in opposi tion alike to the experience of scientific and practical observation.
That which characterizes, in particular, mise,arriage at this period, is the initial hemorrhage, contractions of the uterus only supervening sec ondarily. At the outset there exists congestion, then hemorrhage, and it is only when the ovum is entirely detached, or nearly so, that contrac tions appear to expel it. Now, it is precisely because of this tardy ap pearance of contractions that we often obtain an. intact ovum. Since the hemorrhage affects almost complete separation of the ovum, only a few uterine contractions are necessary to complete the detachment, and the ovum falls on the cervix. Then it only has to overcome the resistance of this portion of the uterus. That which delays the completion of the miscarriage is not the ovum, but the decidua. As for the ovum, it slowly insinuates itself in the cervix, which dilates enough for its passage, but surrounded as it is by clots, it passes without rupture.
In other rare instances, the contractions of the uterus are the initial phenomenon. At first faint, irregular, these contractions approach nearer one another, and become intense enough to detach the ovum. Here, the hemorrhage is secondary.
The ovum detaches itself slowly, progressively, little by little, each act being preceded by contraction, and accompanied by hemorrhage, which has not the same characters as at first. It is now intermittent, coincid ing with the contractions, and the more intense these latter, the more abundant. This hemorrhage only ceases with the expulsion of the deci dua. In this instance the ovum is living, and resists destruction as far as in it lies. It is no longer a foreign body, of which the uterus tries to rid itself as soon as possible; it is a living being, which, engrafted on the maternal organism, requires, for its separation, heroic and persistent efforts. Whenc,e the longer duration of the miscarriage, whence the alter nation of rest and pain, the intermittent character of the contractions which is typical of uterine action, in particular during miscarriage. It is apparent, therefore, that for us the vitality of the ketus plays an impor tant part in the symptoms of miscarriage, and it is this vitality which en tails on miscaniage a portion of its gravity.