lessened as to project not more than one and a half or two inches above the pelvic brim, while by the eleventh day it is no longer to be made out by abdominal palpation. Its increased size is, however, still apparent per vaginam, and should occasion arise for making internal examination, the mass of the lower segment of the uterus, with its flabby and patulous cervix, can be felt for some weeks after delivery. This may sometimes be of practical value in cases in which it is necessary to ascertain the fact of recent delivery, and under these circumstances, as pointed out by Simpson, the uterine sound would also enable us to prove that the cavity of the uterus is considerably elongated. Indeed, the normal condition of the uterus and cervix is not regained until six weeks or two months after labor. These observations are corroborated by investigations on the weight of the organ at different periods after labor. Thus Heschl1 has shown that the uterus, immediately after delivery, weighs about twenty-two to twenty-four ounces; within a week, it weighs nineteen to twenty-one ounces; and at the end of the second week, ten to eleven ounces only. At the end of the third week, it weighs five to seven ounces; but it is not until the end of the second month that it reaches its normal weight. Hence it appears that the most rapid diminution occurs during the second week after delivery.

Fatty Transformation of the Muscular Fibres.-The mode in which this diminution in size is effected is by the transformation of the muscular fibres into molecular fat, which is absorbed into the maternal vascular system, which, therefore, becomes loaded with a large amount of effete material. Heschl believed that the entire mass of the enlarged uterine muscles is removed, and replaced by newlyformed fibres, which commence to be developed about the fourth week after delivery, the change being complete about the end of the second month. Luschka and Robin' contend that this entire change in the structure of the fibres does not occur, but that their diminution in size is effected by granular degeneration and subsequent absorption of the existing muscle cells, by means of which they become gradually reduced to their natural size. This view has been more recently maintained by Sänger. Generally speaking, involution goes on without interruption. It is, however, apt to be interfered with by a variety of causes, such as premature exertion, intercurrent disease, and very probably by neglect of lactation. Hence the uterus often remains large and bulky, and the foundation for many subsequent uterine ailments is laid.

Changes in the Uterine Vessels.-Williams3 has drawn attention to changes occurring in the vessels of the uterus, some of which seem to be permanent, and may, should further observations corroborate his investigations, prove of value in enabling us to ascertain whether a uterus is nulliparous or the reverse; a question which may be of medico-legal importance. After pregnancy he found all the vessels enlarged in calibre. The coats of the arteries are thickened and

Researches on the Conduct of the Human Uterus after Delivery.

2The Involution of the Muscular Tissue of the Puerperal Uterus," Annals of Gynecology, Boston, July, 1888.

Changes in the Uterus resulting from Gestation," Obst. Trans., vol. xx.

hypertrophied, and this he has observed even in the uteri of aged women who have not borne children for many years. The venous sinuses, especially at the placental site, have their walls greatly thickened and convoluted, and contain in their centre a small clot of blood (Fig. 206). This thickening attains its greatest dimensions in the third month after gestation, but traces of it may be detected as late as ten or twelve weeks after labor.

Changes in the Uterine Mucous Membrane.-The changes going on in the lining membrane of the uterus immediately after delivery are of great importance in leading to a knowledge of the puerperal state, and have already been discussed when describing the decidua (p. 106).

Its cavity is covered with a reddish-gray film, formed of blood and fibrin. The open mouths of the uterine sinuses are still visible, more especially over the site of the placenta, and thrombi may be seen projecting from them. The placental site can be distinctly made out in the form of an irregularly oval patch, where the lining membrane is thicker than elsewhere. (See Plate V.)

Contraction of the Vagina, etc.-The vagina soon contracts, and by the time the puerperal month is over it has returned to its normal dimensions, but after childbearing it always remains more lax and less rugose than in nulliparæ. The vulva, at first very lax and much distended, soon regains its former state. The abdominal parietes remain loose and flabby for a considerable time, and the white streaks, produced by the distention of the cutis very generally become permanent. In some women, especially when proper support by band

aging has not been given, the abdomen remains permanently loose and pendulous.

The Lochial Discharge.-From the time of delivery up to about three weeks afterward a discharge escapes from the interior of the uterus, known as the lochia. At first this consists almost entirely of pure blood, mixed with a variable amount of coagula. If efficient uterine contraction has not been secured after the expulsion of the placenta, coagula of considerable size are frequently expelled with the lochia for one or two days after delivery. In three or four days the distinctly bloody character of the lochia is altered. They have a reddish watery appearance, and are known as the lochia rubra or cruenta. According to the researches of Wertheimer, they are at this time. composed chiefly of blood corpuscles, mixed with epithelium scales, mucous corpuscles, and the débris of the decidua. The change in the appearance of the discharge progresses gradually, and about the seventh or eighth day it has no longer a red color, but is a pale greenish fluid, with a peculiar sickening and disagreeable odor, and is familiarly described as the "green waters." It now contains a small quantity of blood corpuscles, which lessen in amount from day to day, but a considerable number of pus corpuscles, which remain the principal constituent of the discharge until it ceases. Besides these, epithelial scales, fatty granules, and crystals of cholesterin are observed. Various micro-organisms are found in the discharge, especially in the lower part of the vagina, such as the trichomonas vaginalis, streptococci, rod bacteria, and others, and they increase in numbers toward the end of the week after delivery. The conditions existing in the vagina greatly favor their growth, and hence the special importance of strict attention to cleanliness and antiseptic precautions during convalescence.

The amount of the lochia varies much, and in some women it is habitually more abundant than in others. Under ordinary circumstances it is very scanty after the first fortnight, but occasionally it continues somewhat abundant for a month or more, without any bad results. It is apt again to become of a red color, and to increase in quantity, in consequence of any slight excitement or disturbance. If this red discharge continues for any undue length of time, there is reason to suspect some abnormality, and it may not unfrequently be traced to slight lacerations about the cervix, which have not healed properly. This result may also follow premature exertion, interfering with the proper involution of the uterus; and the patient should certainly not be allowed to move about as long as much colored discharge is going on.

Occasionally the lochia have an intensely fetid odor. This must always give rise to some anxiety, since it often indicates the retention. and putrefaction of coagula, and involves the risk of septic absorption. It is not very rare, however, to observe a most disagreeable odor persist in the lochia without any bad results. The fetor always deserves careful attention, and an endeavor should be made to obviate it by directing the nurse to syringe out the vagina freely night and morning with creolin and water; while, if it be associated with quickened

1 Virchow's Arch., 1861.

pulse and elevated temperature, other measures, to be subsequently described, will be necessary.

The after-pains, which many childbearing women dread even more than the labor pains, are irregular contractions occurring for a varying time after delivery, and resulting from the efforts of the uterus to expel coagula which have formed in its interior. If, therefore, special care be taken to secure complete and permanent contraction after labor, they rarely occur, or to a very slight extent. Their dependence on uterine inertia is evidenced by the common observation that they are seldom met with in primiparæ, in whom uterine contraction may be supposed to be more efficient, and are more frequent in women who have borne many children. They are a preventable complication, and one which need not give rise to any anxiety; they are, indeed, rather salutary than the reverse; for, if coagula be retained in utero, the sooner they are expelled the better. The after-pains generally begin a few hours after delivery, and continue in bad cases for three or four days, but seldom longer. They are generally increased when the mammæ are irritated by suction. When at their height they are often relieved by the expulsion of the coagula. In some severe cases they are apparently neuralgic in character, and do not seem to depend on the retention of coagula. They may be readily distinguished from pains due to more serious causes, by feeling the enlarged uterus harden under their influence, by the uterus not being tender on pressure, and by the absence of any constitutional symptoms.

The management of women after childbirth has varied much at different times, according to fashion or theory. The dread of inflammation long influenced the professional mind and caused the adoption of a strictly antiphlogistic diet, which led to a tardy convalescence. The recognition of the essentially physiological character of labor has resulted in more sound views, with manifest advantage to our patients. The main facts to bear in mind with regard to the puerperal woman are her nervous susceptibility, which necessitates quiet and absence of all excitement; the importance of favoring involution by prolonged rest; and the risk of septicemia, which calls for perfect cleanliness and attention to hygienic precautions.

As soon as we are satisfied that the uterus is perfectly contracted and that all risk of hemorrhage is over, the patient should be left to sleep. Many practitioners administer an opiate; but as a matter of routine this is certainly not good practice, since it checks the contractions of the uterus and often produces unpleasant effects. Still, if the labor have been long and tedious, and the patient be much exhausted, fifteen or twenty drops of Battley's solution may be administered with advantage.

Within a few hours the patient should be seen, and at the first visit particular attention should be paid to the state of the pulse, the uterus, and the bladder. The pulse during the whole period of convalescence should be carefully watched, and, if it be at all elevated, the temperature should at once be taken. If the pulse and temperature remain normal, we may be satisfied that things are going on well; but if the one be quickened and the other elevated, some disturbance or compli

cation may be apprehended. The abdomen should be felt, to see that the uterus is not unduly distended and that there is no tenderness. After the first day or two this is no longer necessary.

Treatment of Retention of Urine.-Sometimes the patient cannot at first void the urine, and the application of a hot sponge over the pubes may enable her to do so. If the retention of urine be due to temporary paralysis of the bladder, three or four 20-minim doses of the liquid extract of ergot, at intervals of half an hour, may prove successful. Many hours should not be allowed to elapse without relieving the patient by the catheter, since prolonged retention is only likely to make matters worse. In many cases the use of the catheter may be avoided by propping up the patient in the sitting posture, in which she is often able to micturate when she cannot do so lying, and this plan has the further advantage of allowing the lochia to drain away from the vagina. It may be necessary, subsequently, to empty the bladder night and morning, until the patient regain her power over it, or until the swelling of the urethra subsides, and this will generally be the case in a few days. The utmost care should be taken to keep the catheter aseptic, and it should lie in a basin of 1: 1000 sublimate solution, otherwise its frequent use might lead to cystitis. Occasionally the bladder becomes largely distended, and is relieved to some degree by dribbling of urine from the urethra. Such a state of things may deceive the patient and nurse, and may produce serious consequences. Attention to the condition of the abdomen will prevent the practitioner from being deceived, for in addition to some constitutional disturbance, a large, tender, and fluctuating swelling will be found in the hypogastric region distinct from the uterus, which it displaces to one or other side. The catheter will at once prove that this is produced by distention of the bladder.

Treatment of Severe After-pains.-If the after-pains be very severe, an opiate may be administered, or, if the lochia be not overabundant, a linseed-meal poultice, sprinkled with laudanum, or with the chloroform and belladonna liniment, may be applied. If proper care have been taken to induce uterine contraction, they will seldom be sufficiently severe to require treatment. In America quinine, in doses of 10 grains twice daily, has been strongly recommended, especially when opiates fail and when the pains are neuralgic in character, and I have found this remedy answer extremely well. The quinine is best given in solution with 10 or 15 minims of hydrobromic acid, which materially lessens the unpleasant head symptoms often accompanying the administration of such large doses. The inhalation of the nitrite of amyl in severe cases is said to be very efficacious.1

Diet and Regimen.-The diet of the puerperal patient claims careful attention, the more so as old prejudices in this respect are as yet far from exploded, and it is by no means rare to find mothers and nurses who still cling tenaciously to the idea that it is essential to prescribe a low regimen for many days after labor. The erroneousness of this plan is now so thoroughly recognized that it is hardly

1 Mr. F. W. Kendle: Lancet, 1887, vol. i. p. 606,