CHAPTER III.

CONVALESCENCE.

VARIATIONS FROM ORDINARY CONVALESCENCE will, under ordinary circumstances, receive necessary attention from the physician, but the skilled nurse should know as much about them as possible, and I here make a brief reference to some of them.

The NERVOUS SHOCK, caused by the last pains of labor, in some cases is very severe. This is indicated not only by the exhaustion, but by the countenance which is expressive of suffering, anxiety and oppression. The pulse may be very slow or unusually rapid, the breathing may be panting. Opium is the best remedy, and this may be given in small doses repeated, or a teaspoonful of paragoric may be given, also aromatic ammonia, and 3 or 4 drops of spirits of camphor.

The STATE OF THE PULSE after a natural labor soon comes down to near the ordinary standard; if it remains above a hundred it is because there is some special cause. It will be quick if there are very hard afterpains, a tendency to flooding, diarrhœa or disturbance of the stomach, and it is quickened also when lactation commences.

The LOCHIAL DISCHARGE ordinarily continues about three weeks, at first of pure blood mixed with coagula, and if good uterine contraction has not been secured, coagula may be expelled for several days after the delivery. Sometimes there is a SUDDEN DECREASE OF THE LOCHIA, perhaps on the fifth and sixth day, and at the same time an increased bulk of the womb, and increased frequency of the pulse. Apply hot fomentations to the abdomen, and probably some clots will be expelled, but at the same time give purgative enemata; and if there is abdominal tenderness give an aromatic purgative and laudanum. (F. 108, 122). There are remarkable differences in the QUANTITY, QUALITY AND ODOR OF THE LOCHIA without any morbid affection of the uterus or vagina. But when the lochia are acrid, the vagina, labia and external parts become excoriated, and smarting or itching is caused. Try extreme cleanliness, frequent bathing, lead lotions, black wash, vaginal injections of warm water, and F. 153, 154.

If the discharge ceases a few hours after birth, or if it continues the usual time, but in very small quantity, or if it is prolonged beyond the usual period, or if it is excessive at first, and if at the same time all the other symptoms are favorable, there is not occasion for much medicine, though it may be necessary to give the patient a better diet, possibly some tonics. (F. 174, 175). It sometimes occurs that the lochia is suddenly discharged in double quantity after the patient is permitted to sit up or walk about. In such cases enjoin extra rest.

If the red discharge continues longer than usual, or if it return after yellow or greenish discharges, you should be on your guard against HEMORRHAGE. Enjoin rest in a horizontal position under light clothing.

Occasionally the LOCHIA HAVE A VERY FETID ODOR. It is not very rare to observe a very disagreeable odor in the lochia without any bad results, but this often indicates the retention and putrefaction of coagula or a small portion of the placenta or membranes. Syringe out the vagina freely night and morning with Labaraques solution or some other antiseptic wash, (F. 153) and once or twice a day with warm milk and water. A weak solution of carbolic acid 1 in 50 may be used, and it may be proper to throw it into the uterus.

The SECRETION OF MILK generally becomes established in about forty-eight hours, and very often on the third day the breasts become turgid, hot and painful. There may, or may not, be some general disturbance, fever, chills, &c., but if there is it will usually be relieved after the milk is drawn out. It is customary on the morning of the third day to secure an action of the bowels, and this generally allays the vascular action if it is excessive. But very trivial causes may set up INFLAMMATION OF THE BREAST, and this is always liable to end in suppuration, which may be long continued and distressing.

The MAMMARY INFLAMMATION may follow exposure to cold, a blow or other injury on the breast, some temporary engorgement of the lacteal tubes, or sudden and depressing mental emotions, and it often follows from fissures and erosions of the nipples. To prevent the formation of an abscess, endeavor to remove the engorgement of the lacteal ducts by gentle hand friction with oil or F. 209, 202. Moderate the inflammation by giving five drops of the extract Phytolacca decandra (Poke root) every two hours—give saline cathartics, minute doses of aconite, and perhaps a large dose of quinine. Keep the patient in bed and have the affected breast supported by a suspensory bandage. Apply hot fomentations containing a solution of carbolic acid, or poultices containing it, and the breasts may be smeared with belladonna extract rubbed down with glycerine; or belladonna liniment or ointment may be applied (F. 201). Belladonna plasters or diachylon plasters may be useful. Give 15 grains bromide potassa.

WHEN PUS HAS FORMED notwithstanding efforts made to cure the inflammation, as soon as it is near the surface so that it can be detected by the fluctuation, the abscess should be opened. During the last few years careful surgeons have been unwilling to make any incision or lance even an ordinary abscess without employing some antiseptic method, such perhaps as the following:

The patient’s skin where the incision is to be made, is first to be washed in 1 to 1000 bichloride of mercury solution—hands and instruments employed in the work must touch nothing that is not sterilized; hands must be washed in the same solution before operating—sponges that are used must be cleaned and stored in a 1 to 20 carbolic acid solution, and instruments must be soaked in the same for 15 minutes before being used, and some apply a large wad of bichloride of cotton or gauze to catch the exuded pus.

The following is Lister’s antiseptic method which he first directed, to prevent the introduction of air containing living germs:

“A solution of one part of crystalized carbolic acid in four parts of boiled linseed oil having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised a scalpel or bistoury dipped in the oil is plunged into the abscess and an opening about three-quarters of an inch in length is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it, and all the pus should be pressed out as near as may be. For a dressing afterward Playfair recommends the following: About six teaspoonfuls of the above mentioned solution of carbolic acid in linseed oil is mixed up with common whiting to the consistence of firm paste; this is spread upon a piece of tin foil about six inches square, so as to form a layer about a quarter of an inch thick; the tin-foil thus spread with putty is placed upon the skin, so that the middle of it corresponds to the position of the incision, the antiseptic rag used in making the incision being removed the instant before. The tin-foil is then fixed securely by adhesive straps, the lower edge being left free for the escape of the discharge into a folded towel placed over it, and secured by a bandage. The dressing is changed once in twenty-four hours, as a general rule, and must be methodically done. A second similar piece of tin-foil having been spread with the putty, a piece of rag is dipped in the oily solution and placed on the incision the moment the first tin is removed. This prevents mischief during the cleaning of the skin with a dry cloth, and pressing out the discharge from the cavity.”

The same author directs methodical strapping of the breast with adhesive plaster, in cases of long continued suppuration, and he adds that “much attention must be paid to general treatment, and abundance of nourishing food, appropriate stimulants and such medicine as iron and quinine will be indicated.”

I give on the authority of another the following as good treatment for SORE NIPPLES:

“1. Keep everything that will irritate, whether clothing or medicine, away from the nipple, and have the excess of milk drawn from the breast in the easiest way possible. 2. Keep the excoriated nipple thickly covered with sub-nitrate of bismuth. 3. When the nipples are cracked at the base keep the cracks filled with bismuth, and put on a round piece of adhesive plaster starred in the centre, and just large enough to slip over the nipple and extend around its base an inch or more every way. When this is loosened it must be reapplied.” (F. 231, 243).

There are certain accidents of parturition so grave in their nature, and attended by symptoms so alarming and urgent that no nurse would attempt to treat the patient except under the direction of a physician. I only refer to them because it is believed that some of these serious cases might have been prevented by early proper action on the part of the midwife or other attendant.

INVERSION OF THE UTERUS sometimes occurs, though but rarely. If it is in the practice of a midwife, and if she be at the time pulling on the cord, that will be assigned as the cause of the accident. Inversion consists essentially in the enlarged and empty uterus being either partially or entirely turned inside out. The immediate symptoms are those of shock or collapse—fainting, small, rapid and feeble pulse, possibly convulsions, or vomiting, and a cold, clammy skin. The countenance becomes deadly pale, the voice weak, and other symptoms indicates sudden exhaustion or sinking. In cases of partial inversion the symptoms are not so striking. Hemorrhage to a large amount, frequently but not always occurs. In more than half the cases no mechanical cause can be traced, but as it is sometimes attributed to pulling on the cord, to pressure with the hand on the fundus, and also to the patient straining forcibly, these combined causes should be avoided. When the symptoms named are present, you can give the patient some aromatic ammonia or other stimulant; always obtain a physician as soon as possible.

PUERPERAL MANIA is nearly always preceded by restlessness, want of sleep, and other premonitory symptoms. When the mania first comes on there is usually causeless dislike to those around her, and as the child may be the object of suspicion, the nurse must be extremely careful that the patient does not have an opportunity to seriously injure it. The course of treatment must be mainly directed to the maintenance of the strength of the patient, and the two things most needful are a sufficient quantity of suitable food and sleep. Possibly your efforts in this direction before the disease is fully developed, may ward off the disease.

PUERPERAL SEPTICEMIA was formerly called puerperal fever; as its nature is now better understood than formerly, we hope to do more than was formerly done to prevent it. This fever is now very generally believed to be produced by the absorption of septic matter into the system, through some tear or laceration in the generative tract such as exists after labor.

This septic matter may be from within the patient such as coagula, or membrane, or placenta partly decomposed; or from without as might be on the hands of physician and nurse, or in the air from cases of erysipelas, &c., or in some way from puerperal patients.

The notion that puerperal fever and septicemia is produced by BACTERIA has now become an established doctrine, and has given rise to a rational treatment based thereon, especially for their prevention.

As prophylactic means may be mentioned, the use of a carbolic solution 1 in 30 which the practitioner or nurse applies before touching any case, the use of carbolized oil 1 in 8 for lubricating the fingers, catheter, forceps, &c.; syringing out the vagina with diluted Condy’s fluid, rigid attention to cleanliness in napkins, &c. The nurse should use antiseptics to only a very limited extent without the advice of a physician.