Uterine Contractions.—Like those which occur at term, these are pain ful, although less intense, and they differ in regularity and in rhythm. Instead of pains progressively increasing in duration and in intensity, and which are separated by intervals less and less long, the contractions of miscarriage recur frequently at very long intervals only, during seve ral days, until they finally become established, and expel the fcetus.
Changes in tlu3 Cervix.—These are not at all comparable to those which have occurred at term. Jacquemier thus describes these changes: under the influence of the uterine contractions, there occur alterations in the cervix, which are the first indices of effective labor. These contractions are, for some time, obscure, irregular, as though continuous, with mo mentary exacerbations. The cervix is shortening and softening, the ors are opening, first the external, and then the internal, the vagina is re laxing, and is covered by a thick, abundant mucus. The body of the uterus sinks into the pelvis. Only after the above changes have occurred, do the contractions become regular, and truly intermittent. This period of labor may last a number of days. Once the cervix softened and re laxed, dilatation supervenes quickly enough, if the contractions are good. This dilatation is accomplished as follows. As the cervix softens it shortens—[Does it not rather seem to shorten, from the very fact of the softening? This matter is in dispute.—Ed.]—and the external and inter. nal os approach one another. The internal os insensibly opens more and more, and the contractions act on the external os, the border of which becomes thin, and cutting, as dilatation progresses. The ovum presents at this orifice, and is projected out by a pain. These expulsory pains not only dilate the cervix, and drive out the ovum, but they cause rupture of its adhesions to the uterus. Whence the premature hemorrhages which ordinarily accompany miscarriage, and which, in labor at term, or in ad vanced stages of pregmancy, are only seen after the expulsion of the fcetus. As soon as the entire ovum has been expelled into the vagina, the pains. and the hemorrhage cease.
The phenomena which follow the regular expulsion of the ovum are very similar to those of labor at term, but less accentuated the earlier the period of gestation.
The Lochial Discharge.—This is scarcely noticeable after very early mis carriage, and more and more marked thereafter, especially when the de cidual mucous membrane separates but slowly. The sero-sanguineous discharge then lasts a long time, and in the uterine and vaginal excretions are found blackish debris, often very fetid. Truly, as Garimond has well said, we are dealing not with the lochia, but with a discharge caused by the fact that the miscarriage is incomplete. It ceases with the expulsion
of the last shred.
The Lacteal Secretion.—This is present, as we have already stated, before miscarriage, in cases where the fcetus dies, but it ordinarily recurs after the expulsion of the ovum. Usually this is the case in multiparty, and after the third month. Joulin Itas related a ca,se where milk was secreted six weeks after impregnation.
Finally, involution takes place more rapidly than after labor at term, at least as regards the cervix, which closes much more quickly, and also re gains its length and consistency sooner. The same does not apply to the body, and it is not unusual, after mise,arriage, to find the body of the uterus remain larger than the normal; and in case of frequently repeated miscarriages, this incomplete involution merges into hyperplasia, the more so, indeed, because the precautions taken after miscarriage, parti cularly in the early months, are far less than after term.
After-pains do not follow miscarriages in the first months; usually they are not present till after the fifth in multiparty. When they do exist, it is usually proof that the miscarriage was incomplete, and that shreds of the decidua are still in the uterus.
the diagnosis of miscarriage there are included a num ber of questions: 1. Is the woman pregnant? 2. Pregnancy assured, are the symptoms those of pure uterine congestion or of beginning miscar riage? 3. Is miscarriage inevitable? 4. Is the miscarriage complete, or are there still in the uterus shreds of membrane, of placenta, or of deci dna ? Is the woman pregnant ? If the diagnosis of pregnancy is easy, after the fourth month, when the fcetal heart, and the active movements, of the ftetus are appreciable, it is far from being so in the earlier months when all we possess are the probable signs. There is nevertheless one sign which may be of the highest importance, and this is the suppression of the menses. If the woman was regular up to the time of suppression, if this latter has occurred without morbid cause, if the rational signs of pregnancy are present, if, in case of a nullipara, the mammary areola, and Montgomery's follicles are present, then the chances are great that we are dealing with pregnancy. If, under such circumstances, persistent lumbo hypogastric pains appear, with momentary exacerbations; if, at the same time, there appear an abundant bloody discharge, persisting, and mixed with clots; if at the same time, the cervix is scrftened, and the external os is open, we are nearly certain that we are in the presence of a miscar riage. One point only is in doubt, if we have not been present from the start, and have not seen the discharge and clots,—this is if the miscar riage is complete or not.