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On the morning of April 25, 1882, I was telephoned for to attend Mrs. Simon Lewis, the wife of a B. & M. R. engineer, in her seventh confinement.

Presentation occiput to right S. J. S., sixth position.
Duration of labor :
First stage, six hours.
Second stage, one hour and thirty-five minutes.
Third stage, eighteen minutes.

Hemorrhage, profuse; pulse, 93 and irregular; cord around the neck; male child, weighing 171 pounds; mother medium height, weighing 120 pounds ordinarily; father five feet nine inches, weight, 190 pounds; recovery slow; labor difficult.

During the last three months patient was confined to her bed most of the time in consequence of excessive development.

The secretary of the Section, Dr. C. V. Mottram, reported a case in his practice where the child at delivery weighed 173 pounds; mother a healthy young woman of 23 years of age, then the mother of three living children, wife of a teamster, Mrs. - of Lawrence, Kansas. The labor was severe, but not unusually protracted. The only difficulty occurring was in the passage of the shoulders through the inferior strait. This was readily overcome by manipulation and gentle traction. She was a small woman of good figure. Had a rapid recovery, being up in a short time.






As early as 1843, Sir James Simpson called the attention of the profession to this condition of the uterus under the

“ Morbid Permanence of the State of Puerperal Hypertrophy.” But it was not till 1852, in a paper entitled, “Morbid Deficiency and Morbid Excess in the Involution of the Uterus after Delivery,” that he uses the term “Subinvolution " to indicate a deficiency in the normal involution after delivery, and superinvolution to designate an excess of the same process. Since this last paper by Professor Simpson, subinvolution has been recognized as a form of uterine disease.

The object of this paper will be to insist upon the importance of subinvolution, by describing its causes, effects and treatment.

Every physician, surely, has been astonished by the enormous hypertrophy of the uterus and other genital organs during the nine months of pregnancy, the uterus increasing from two ounces in weight to twenty-five or thirty ounces; and the cavity from less than a cubic inch before impregnation to over four hundred cubic inches at full term; and the vagina, vulva, and perineum before pregnancy with difficulty dilated beyond an inch or so in diameter, but at parturition distended till both the head and body of a ten or twelve pound fætus can pass. But remarkable as is this hypertrophy during pregnancy, the normal involution is still more wonderful, for during the two or three months following parturition these organs should return to about their dimensions before pregnancy. But while this is the normal process in the involution of the uterus and the other organs concerned in parturition, there are, unfortunately, very many cases in which they do not pursue this natural course, but, from a variety of causes, remain permanently enlarged, in a state of subinvolution, often following miscarriage, and not infrequently after labor at full term.

What, then, are the causes of subinvolution ?
In regard to time, they may be arranged in three groups :
First.—Those operating previous to the pregnancy.
Second.—Those occurring at the date of the confinement.
Third.Those subsequent to delivery.
1. Those operating previous to the pregnancy.

(a.) Constitutional diseases impairing the muscular strength and nervous power, such as tuberculosis, scrofula, syphilis, and the like; pernicious habits, as the alcohol and opium habit, depressing emotions, like severe grief or disappointment; insufficient exercise, improper food, and bad hygiene.

(6.) Local diseases interfering with the normal functions of the pelvic organs, such as pelvic peritonitis and cellulitis with their subsequent adhesions.

(c.) Tumors in or near the uterus, such as fibroid and fibrocystic with extra-uterine fætation.

(d.) Enlargement of the uterus, the result of previous miscarriages or frequent labors.

(e.) Inflammation of the uterus previous to the pregnancychronic metritis and endometritis—especially of gonorrheal origin.

2. Those occurring at the time of the confinement.

(a.) Overdistension of the uterine walls, by a large fætus, unusual quantity of liquor amnii, twins and the like.

(6.) Delay in delivery from the numerous causes of tedious labor, producing inertia of the uterus.

(c.) Parturient injuries of the uterus and its appendages, such as partial rupture of the walls of the uterus, inducing metritis and peritonitis ; injury of the broad ligaments and other ligamentous tissues about the uterus by the descent of the fætus, producing cellulitis; laceration of the cervix, vagina, and perineum ; also injuries of the uterus or its appendages in the production of a miscarriage, adherent placenta at full term, or premature delivery with pieces of the placenta retained; flooding, producing clots to distend the uterus.

3. Those occurring subsequent to delivery: (a.) Puerperal fever, in its various forms of septicæmia, peritonitis, metritis, and, possibly, something more than a combination of these in the epidemic form.

(6.) And then the milder types of fever, such as intermittent fever, rheumatism, the fever attending the disorders of the breasts, phlegmasia alba dolens, and the various forms of "slight cold.”

(c.) The absence of nursing, and its consequent reflex stimulation of the uterus.

(d.) Improper exercise before involution is complete, displacing the uterus, and so interfering with its circulation, and producing a passive congestion. .

(e.) And, at times, insufficient exercise, with bad hygienic influences, producing deficient vital activity, without, at first, well-marked disease.

(f.) Constipation of the bowels, with the accompanying hemorrhoids, fissures, and ulcers of the rectum.

(9.) Too frequent sexual intercourse; the physiological congestion of erection passing into the pathological congestion which accompanies inflammation.

Unfortunately, many of these causes may be combined in the same patient, and thus mutually aid in the certainty of the result,—subinvolution.

Effects of subinvolution :

It is the most frequent cause of the malpositions of the uterus, such as prolapsus, version, and flexion, in those who have borne children. The uterus being enlarged, and consequently heavier, its natural supports are not capable of holding it in its normal place in the pelvis, and hence the varieties of prolapsus and version, for the fætus has gone from the uterus, and this was the normal excitant in giving tone to the nervous, vascular, and especially the muscular structures of the organs of generation. During pregnancy these organs are very like those in a state of erection, and from their tonic firmness are not as easily displaced, and, if displaced, readily return to their normal position; but after miscarriage or delivery at full term, if the uterus remains enlarged, this normal tonicity is gone, and displacements easily follow.

The cavity of the uterus, too, is large, and the walls, including the cervix, soft and flexible, offering favorable conditions for flexions, if the cervix is held firmly while forces from above press downward upon the fundus.

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