In case the ovum is dead, a number of days may pass without the woman suffering at all to speak of, and then appears a gentle flow of dark ish blood, which may last six or eight days, in the absence of uterine con tractions. At length these supervene, a digital examination is made, the cervix is found more or less dilated, the internal os open, and the finger may pass in and touch the ovum. Finally, the ovum engages in the cer vix, which opens still further, and it falls into the vagina. where it may remain some time before expulsion. The amount of hemorrhage accom panying the process may be slight, there may be none at all. The ovum, indeed, having died some time before, the uterine and utero-placental circulation have become deeply modified through the cessation of preg nancy. Uterine congestion is, thence, relatively slight, and therefore the amount of blood lost is also slight.
If the death of the ovum be recent, and the result of accident or trau matism, if miscarriage follow soon on the death, the hemorrhage precedes by but a few hours the onset of contractions; frequently even they ap pear together, and the hemorrhage, if the act of miscarriage be a trifle prolonged, may be excessive and dangerous.
If, finally, the ovum has been dead a long time, it rests quietly in the uterus for a considerable interval, and then, of a sudden, the woman loses blood, violent contractions supervene, and in a few hours, at times almost at once, the uterus expels this foreign body, with scarcely any premoni tory symptoms. This variety of miscarriage is of unusual occurrence where the fcetus is dead, and still more so where it is alive, and it is only as the result of violent traumatism, and during the first five to six weeks of pregnancy that we see it. It has occurred twice in our experience.
When the ovum is living, and the process of miscarriage is prolonged, it may be expelled in two different ways: either entire, as is claimed by Gallard and Leblond, or else in two pieces, so to speak, as ordinarily hap pens at the second and the third month. Then the ovum is not a for eign body with nothing binding it to the uterus. It is no longer hemor rhage which causes it to separate, but it is the contraction of the uterus, and the ovum, still partially attached t,o the uterus, is incompletely pushed towards the cervix by these contractions. Pushed by the uterus at the time of contraction, it tends, during relaxation, to resume its normal place; but the contraction augments, the cervical canal opens, the ovum engages within it; the contraction now ceases, and the ovam lies between two forces, the cervix, on the one hand, which tends to retain it, the body of the uterus, on the other, which tends to pull it back on the cessation of contraction. Whence traction, which, if the adhesions resist, tends to inevitably rupture the ovum, a rupture all the more likely the greater the vitality of the ovum, and the stronger its adhesions. The miscarriage will,
therefore, occur at divided periods; the fcetus will issue first, the remain der of the ovum later, and this remainder will sometimes be expelled only after the lapse of a number of days. It is in these instances that hemor rhage may be profuse and serious. For apart from its intensity, the woman is exposed to a renewal as long as the placenta remains in the uterus. The uterine contractions are irregular, intermittent, appearing for a while, and then disappearing, and this very prolongation of labor is of grave import for the welfare of the woman. We will see further on that there is another danger, depending on retention of the placenta, and on the alterations it may suffer.
The prolongation of labor, in these cases, depends, on the one hand, on the weakness of the uterine contractions, and, on the other, on the resistance of the cervix and the adhesions of the decidua.
Weakness of contraction is to be expected at this period. The uterus has by no means attained the muscular development it will later; the muscular layer is only in process of formation, and contractility, hence, can be present only incompletely. Again, the cervix, at two months, has changed simply through a little softening at the tip. It has still its nor mal length. At labor at term, the cervix, which has been softening throughout pregnancy, first disappears, then dilates, being represented simply by a ring, the result of the disappearance of the external os, and the opening of the internal. In case of miscarriage, however, the cervix neither softens, nor dilates, but only opens sufficiently to allow of the pas sage of the ovum. It retains its entire length; the two orifices remain at the same distance, one from another; the ovum is obliged to pass through a canal, the more rigid the less advanced the pregnancy. Whence, there fore, an additional resisting force it has to overcome, and whence, also, the likelihood of rupture, the greater the more intense the uterine con tractions, the rigidity of the cervix, and the length of the labor. Miscar riage may last for days, and even for weeks. The process is started by the uterine contractions, the ovum tends to become detached, but un equally; pushed against the cervix, it engages in the canal, and it tears. What happens then ? The fcetus, which is so small and weak, passes out first, and easily. 'The cord, scarcely formed, breaks, and the ovum may be lost in the discharges. The true miscarriage, however, has not occurred; the membranes and the placenta must still detach themselves, and it is only at the end of a few days that these are shed, and the mis carriage is ended. These, then, are the two stages at this period of ges tation. The cervix closes after the escape of the fcetus. A second labor is needed for the expulsion of the remainder of the ovum.