It is true that small hemorrhages are not necessarily followed by miscarriage. One may even experience slight loss of blood repeatedly, and yet give birth to a healthy child at the natural end of pregnancy. None the less, bleeding, however moderate, should always excite suspicion, as we know it usually denotes the breaking to some degree of the connection between mother and child. The extent of the separation usually determines the degree of the hemorrhage, which in turn indicates the seriousness of the accident. The fate of the fetus will depend upon the area of placenta, which has been incapacitated. Flooding, however, always imperils the fetus, and generally warrants the inference that so much of the placenta has been separated as to render further development impossible. On the other hand, so long as the hemorrhage does not exceed the customary flow at the monthly periods, the life of the child is rarely endangered; while a chocolate-colored discharge, and even the loss of small clots, may continue indefinitely without doing serious harm. Under such circumstances, however, the patient should communicate with her medical adviser, and should save for his inspection whatever may be expelled.
Pain, the other conspicuous symptom of threatened miscarriage, has not a uniform significance. Since it frequently occurs during the course of pregnancy in association with a number of conditions, it is not a reliable sign of danger. Moreover, the susceptibility to pain varies; thus, of two patients in the same stage of threatened miscarriage one may suffer intensely, while the other remains comparatively comfortable.
Typically, the onset of miscarriage is attended by discomfort in the small of the back, which may be continuous, but more often is intermittent. If preventive measures are instituted at the outset, there is hope of relieving the discomfort and averting the miscarriage; but if the warning goes unheeded, the pain will gradually shift to the lower part of the abdomen and become more severe. It often happens that the cramp-like abdominal pain of threatened miscarriage is confused with that associated with intestinal indigestion. A simple test will sometimes decide the question. If due to the latter cause, the discomfort will usually yield to a teaspoonful of paregoric, whereas it will be without effect if miscarriage is imminent. Exceptions to this rule are not uncommon, yet a better one cannot be given; as a physician, even after considering the technical evidence, may find it impossible to decide at once whether or not miscarriage is threatened.
No confidence can be placed in many so-called signs of miscarriage, though implicitly trusted by the laity. Lassitude, depression of spirits, and general bodily ill-feeling may forecast the interruption of pregnancy; but more frequently they have no such significance. The same estimate holds true of other symptoms, including diarrhea and a persistent inclination to empty the bladder. Nor does fever always lead to the termination of pregnancy. A moderate rise of temperature is without significance; but high fever, persisting for several days, may result in the death of the fetus and subsequent miscarriage. Nevertheless, prolonged febrile affections, such as typhoid fever, frequently leave pregnancy unharmed.
So long as the symptoms are confined to slight bleeding and mild attacks of pain, physicians regard miscarriage merely as threatened. If the bleeding increases, the outlook becomes less favorable, and, as I have said, miscarriage is inevitable when it amounts to flooding. Likewise, rupture of the sack containing the fetus, with escape of the amniotic fluid, indicates that the culmination of events will not long be delayed.
The most favorable outcome is when the entire contents of the womb are spontaneously expelled, which unfortunately does not always occur. There is, to be sure, rarely any difficulty in the natural birth of the fetus, for its meager development prevents serious complications. The separation and extrusion of the placenta, on the contrary, are apt to be imperfect when pregnancy ends in the early months, and medical attention is necessary to determine whether the uterus has been emptied completely. This is particularly important, because the retention of placental tissue affords opportunity for several unpleasant complications; and neglect in this regard accounts in part for the belief that miscarriage is certain to leave women irreparably broken in health.
AFTER-EFFECTS.—No one will deny that invalidism follows the untimely interruption of pregnancy more often than the birth of children at full term. This is not due, as is sometimes said, to the fact that a miscarriage differs from a normal birth in that it is unnatural, for other reasons are apparent. One of them, the retention of placental tissue, has just been mentioned, but serious consequences resulting from it are almost inexcusable, for, although the placenta may separate less readily and be cast off less thoroughly after miscarriage, modern medical skill can successfully cope with such conditions. Another fruitful source of unfortunate after-effects is the imprudence of the patient. Women should remain in bed fully as long after a miscarriage as after the birth of a mature infant; if they would consent to do so, many ill-effects would be averted. But physicians frequently encounter strong opposition to precautionary measures such as this. Many patients argue, illogically, that less precaution is necessary since pregnancy failed to attain its natural conclusion, and infer that the earlier that it ends the more quickly one may leave the bed. In point of fact, even greater precaution is required than if all had gone normally. Still a third cause for ill- health may be found in physical ailments which antedated the miscarriage but were not recognized until after its occurrence.
Invalidism which follows pregnancy and which may be fairly regarded as chargeable to it depends, in most instances, upon an infection acquired at the time of delivery. Infection occurs more frequently when pregnancy ends during the early months, because in this category is included the great majority of criminal abortions, which are usually induced without regard for surgical cleanliness. Fatal complications, or serious consequences which narrowly escape a fatal ending, are common among women who attempt to rid themselves of an unwelcome pregnancy. As they are ignorant of aseptic precautions, their manipulations must necessarily contaminate the site of operation; for this reason and others as well women who attempt to perform an abortion upon themselves imperil their lives. The danger is scarcely less when abortion is induced unlawfully by incompetent operators; for lack of skill, the need of secrecy, and the desire of haste all interfere with necessary aseptic technique. Everyone knows that sad accidents befall those who submit to such operations; but it is not generally recognized that these cases are largely responsible for the ill-repute borne by miscarriage in general. On the other hand, properly supervised miscarriages are attended by no greater danger and probably less than delivery at full term.
CRIMINAL ABORTION.—The destruction of a pregnancy, except when its continuance threatens the life of the patient, is forbidden by law. The important ethical and religious aspects of the act which the law thus stigmatizes as criminal we may properly neglect. Although various religions present a diversity of teaching relative to its moral nature, all agree in regarding it as sinful. Equally important, however, is the fact that no matter what opinion anyone may hold as to the morality of the act he is bound to obey the law. This is apparently not clearly understood by the laity, for many persons think that a physician may terminate pregnancy whenever he is so inclined. If the liability to criminal prosecution which a physician would assume should he comply with a request for the means of destroying pregnancy were clearly realized, patients would not beseech him to incur the risk of heavy find and long imprisonment merely to gratify their own convenience or to save them from disgrace.
The Common Law, an inheritance from England, enriched with authoritative decisions by our own courts, is the groundwork of the law in all the States, and its principles are binding in the absence of express statutes. At Common Law, abortion is punishable as homicide when the woman dies or when the operation results fatally to the infant after it has been born alive. If performed for the purpose of killing the child, the crime is murder; in the absence of such intent, it is manslaughter. The woman who commits an abortion upon herself is likewise guilty of the crime.