More or less engorgement with blood must necessarily accompany subinvolution; for, while pregnancy existed, all the tissues of the uterus were increased in quantity, the vascular, together with the muscular and nervous, and even the peritoneur; and this physiological congestion offers a favorable nidus for influences capable of exciting inflammation, to produce their legitimate results.

The tissues, from their imperfect circulation, are in much the same condition as the leg with varicose veins, readily taking on inflammation, but not easily resolving.

And the development of the nervous tissue in and about the uterus renders easy the transmission of the influences that will produce inflammation.

Again, the muscular fibres are undergoing, imperfectly, it is true, a retrograde metamorphosis, offering favorable conditions for inflammation, depressed vitality, with active nutritive changes.

The vascular structures, too, including both the lymphatic and blood-vessels, are in the best possible condition, enlarged and active, to absorb morbid products and assist inflammatory processes. A moment's attention to the size of the placental wound immediately after delivery at full term, when the uterus measures ten or even twelve inches in depth, as compared with its size when firmly contracted, and but four or five inches in depth, will convince any one that the opportunities for septic absorption are greatly increased by imperfect contraction of the uterus, the beginning of subinvolution.

After miscarriage, though the placental wound is not as large and the lymphatic and blood-vessels not as highly developed, the remains of placental tissue and blood clots are quite as likely to be present and induce septicæmia; and the muscular structure not being as much developed, does not contract as thoroughly.

The unusual development of the nervous structures in the uterus in subinvolution, explains the reflex symptoms of pelvic disease so constantly complained of by such patients and dated back by them, in their origin, to a miscarriage, or the birth of a child.

The excessive development of the nervous structures in and about the uterus, connecting with both the sympathetic and spinal systems of nerves, renders reflex transmission easy to any

part of the body-whence the headaches and dizziness, the backaches and pains in the side, the palpitation of the heart and dysuria, the stomach disturbances and diarrhoeas, so characteristic of these cases. And hence the gynecologist is not surprised to find the symptoms of pelvic disease, especially in subinvolution, reflected to any part of the body.

Treatment. Here, as in other diseases, prevention is the best. plan of treatment, and the recognition of the possible causes, and the removal of these, is the best cure; and the earlier the disease is recognized the more satisfactory will be the treatment.

After delivery at full term, and especially after miscarriage, the uterus should be frequently examined-daily at first-to determine whether involution is progressing normally, and if it is not such means should be adopted as will assist it.

All cases of confinement, whether premature or at full term, should be under the care of a competent physician during the whole period of involution, and this is normally from one to two months, and not one to two weeks, the usual time of attendance.

At delivery, if the uterus does not contract, but remains large and soft, or if there is a free flow of bright blood, the cause should be investigated at once. If due to clots or portions of the placenta retained, they should be removed immediately, before the accoucheur leaves the bedside. If there are clots in the uterus, they may be readily pressed out by compressing the uterus through the abdominal walls, or extracted by the fingers in the vagina, after which the uterus should be kept firmly contracted by kneading, and the use of ergot if necessary. If there are portions of the placenta retained, the hand or fingers should be introduced into the uterus, under ether if needed, and every particle of the placenta removed by the fingers, used as a curette, after which the uterus should be thoroughly washed out with hot water to remove all placental débris and clots, and to produce firm uterine contraction. If the fingers cannot be introduced, as after miscarriage, the cervix should be dilated with Laminaria or Tupelo tents, or the rapid dilator, as Hunter's or Nelson's, until the fingers can be introduced so as to sweep the entire cavity of the uterus, including the cornua-for the placenta extends at times into the entrance of the fallopian tubes even, and as the uterus contracts, portions of the placental tissue will be retained unless great care

is exercised. After the uterus has been completely emptied of its contents, if there is not firm contraction, it should be induced by some of the means for exciting uterine contraction, as the administration of ergot from the corn or rye, the use of electricity and the large hot-water douche. In this way, by preventing the formation of clots in the uterus, we will in great measure prevent afterpains in multipara, and as there will be no clots to decompose, this source of septicemia will be avoided. Firm uterine contraction is the best preventive of septicemia and subinvolution. If the bleeding after confinement is arterial, it is likely to be from a lacerated cervix, and the uterus should be brought down and the laceration closed at once by silver wire suture.

After delivery at term, in the relaxed condition of the parts, it is an easy matter to pull down the uterus, so that we may carefully examine the cervix at the vulva, and introduce stitches if necessary.

If the vaginal discharges are offensive, the hot-water douche should be used-water of the temperature of 100°, 110°, or even 120°-from two to four or six quarts, in quantity, containing common salt, carbolic acid, or some other antiseptic, and used three, four, or more, times a day.

The douche is likely to both correct the odor and contract firmly the uterus, so that absorption of the putrid discharges cannot take place.

If the putrid discharges come from the interior of the uterus, the intra-uterine douche, of the same temperature, but containing less of the antiseptic agent, is to be used two or three times a day, until the bad odors are removed, and the uterus is firmly contracted. I ordinarily use a half to one per cent. solution of carbolic acid, or a similar quantity of other antiseptics, for the intra-uterine douche.

The use of quinine, or some other anti-periodic, immediately after delivery, in doses up to, or just short of, cinchonism, is likely to prevent the onset of the milder types of fever, and by circulating in the blood to act as an antiseptic to prevent the severer forms, and so indirectly, if not directly, facilitate involution.

I will mention but two other remedies-strychnia and the mineral acids as likely to aid digestion and promote the nor

mal contraction of the uterus by their action upon the nervous system.

Local treatment.-If, at the end of a month, six weeks, or, at the most, two months, the depth of the uterus is not less than four inches, local treatment should be commenced and continued, with appropriate internal remedies, until involution is complete.

The mildest remedies should be used first, and continued until found insufficient-such as the hot-water douche, the glycerine tampon (cotton saturated with pure glycerine), and the diluted preparations and iodine of carbolic acid, by the applicator to the interior of the uterus. As, for example, one part of tr. iodine, or ninety-five per cent. carbolic acid, in eight or ten parts of glycerine. Later stronger solutions of these remedies may be used if the milder are not found sufficient; such as one hundred and ninety-five per cent carbolic acid; the tr. of iodine, or a stronger solution of iodine in glycerine, made of one part iodine crysts. three parts iod. potassium and three parts of glycerine; or a saturated solution of iodine crysts. in ninety-five per cent. carbolic acid; the crysts. of iodoform, and even the pure nitric acid, if necessary.

No parturient woman should be allowed to resume her full duties, or be discharged, and taught to consider herself fully recovered, until involution is known to be complete. If she does, she risks her future health, and perhaps even her life, and no physician performs his duty who does not instruct his patients in these things.