Tokology

Proper bathing and diet are as essential after as before confinement. At least once a day the patient requires a bath. Ordinarily use tepid water. Sponge and dry a portion of the body at a time, keeping the balance protected. If there is heat in the back, bathe it several times a day. Should the patient be nervous and uneasy, try dry hand friction. A compress, too, is often serviceable, worn across the back for two or three hours, followed by bathing and rubbing. The breasts should be bathed frequently, and the colder the water the better. This prevents sensitiveness to cold, and may consequently prevent gathered breasts. Three to five days after confinement the patient can be put into a sitz-bath with benefit. Let the temperature of the water be from 85° to 95°. This bath is restful, cleansing and restorative, and is really as beneficial after as before parturition. A woman can often sit in a bath for a few moments when the same time spent in a chair would prove injurious.

Change the linen of bed and person daily, and the napkins every three or four hours. Keep the room light and well ventilated. The temperature of the room should never exceed 70°. A few years since not a ray of light or a breath of fresh air was allowed in the parturient room, and if the woman was to touch cold water, it was deemed sure death. In some parts of this country, within twenty years, the bed even was not changed for nine days after confinement. With frequent bathing and a constant supply of fresh air the patient will not be sensitive to cold, and inflammation and other post partum diseases will in consequence be rare.

The vagina must be syringed at least twice a day with water in which there are a few drops of carbolic acid. Use a fountain syringe, and have the patient recline over a bed pan. Thus the parts will be kept cleansed, and carbolic acid prevents septic poisoning. If the bowels do not move naturally by the third or fourth day, give an enema, one quart of tepid water. The regimen advised in this book having been followed, one will rarely be troubled with constipation. Beware of cathartics. Most of them have a specific action upon the uterus as well as upon the bowels, and will do harm. This is notably the case with aloes and podophyllum.

The food must be simple in character and easy of digestion, especially until after the milk is established. Bran or graham gruel is the very best food the first day or two. Having been withheld from the diet during pregnancy, on account of containing the phosphates which have a tendency to harden the bones, it should now be taken for that very purpose.

Many are prejudiced against graham gruel, yet it has been proven that most women relish it better than anything else after labor. In the Home of the Friendless, Leavenworth, Kan., are many cases of confinement every year. Almost universally the inmates are prejudiced against graham in any form, and rarely taste it before confinement. A former matron had been a nurse in a Water Cure. Invariably she brought a bowl of graham gruel to the mother a few hours after delivery. She never had one express any repugnance to it. On the contrary, they would say, “That tastes good;” “That goes right to the spot;” “Can any one eat too much of anything that is so good?” and similar expressions, showing that there was an actual relish for the dish. The gruel should be made thin at first, and without cream or milk. After a few days it can be made thick like mush, and eaten with fruit or cream and sugar. New milk, wheatlet, cracked wheat, barley, oatmeal, graham gems, fruit, etc., can be added to the diet as desired.

There is no need of milk fever. Women have been led to expect more or less constitutional disturbance accompanying the advent of the milk. With the bathing and diet recommended above, even if she has not had the best conditions during pregnancy, one hardly realizes any change in the system at that time. When patients were fed on brandy panada, wine whey, strong tea, and beef broth, were kept in unventilated rooms, deprived of water externally and internally, and besides were poisoned with drugs, it is no wonder they had milk fever, and were liable to other post partum diseases.

The child should be placed to the breast several times a day, even if there seems to be no milk. The act of nursing stimulates secretion, prevents engorgement, and from sympathetic relation causes uterine contractions. When the breasts become filled and are knotty and tender, bathe them in hot water and have them drawn. If the child does not empty them sufficiently, the nurse or some member of the family should do it. This is better than a breast pump, and can be easily done by remembering to lap the tongue around the nipple until it meets the upper lip.

The old tradition used to be that a woman, on no account, must leave her bed before the ninth day. No matter how well she felt, the nine days must be spent in bed. There is no positive rule. One must be guided by her strength. Probably few women can expect to be about before four or five days. The cases where they can leave their beds earlier than that are exceptional.

Mammary abscess, or inflammation of the breast, often called “gathered” or “bealed” breast, is usually ushered in with a chill, succeeded by feverish symptoms. Darting pains are felt in the breast, which, as the disease progresses, extend to the arm-pits. The breasts swell, become hard and tender to the touch—even nursing is painful. If pus forms, the skin becomes dark red, the enlarged breast softens, accompanied by a throbbing pain. The patient is feverish, nervous, irritable, has irregular chills, night sweats, debility, etc.

Hot fomentations should be used promptly and thoroughly at the first threatening symptoms. Wring a cloth out of an infusion of phytolacca, and keep hot by applying the water bottle containing a small quantity of very hot water. If too much water is put into the bottle it is made uncomfortably heavy. If the fresh root cannot be obtained, use the fluid extract, ten drops to a pint of water. Keep the breast well drawn and persevere in the hot applications; suppuration can usually be prevented. Farmers know the value of phytolacca, and use it with their new milch cows in case of caked bag.

Aconite should be taken internally if there is alternate chill and fever, with thirst and throbbing pulse, one drop of tincture in ten tablespoons of water, a spoonful every half hour.

Bryonia, 2d.—Constant aching in the bones and soreness of the flesh. Dose, six pellets every hour.

Use only liquid food until the disease is surely arrested. Keep quiet and have plenty of fresh air. Unless the suppuration is very deep the breast should never be lanced.

For excoriated nipples, bathe in a warm borax lotion, two grains to one cup of soft water; after which apply carbolated cosmoline or calenduline. If the base of the nipple is deeply cracked, before using the cosmoline, wash with a solution of nitrate of silver, one grain to two ounces of water. Protect with a shield while the child is nursing. None of the above preparations are harmful to the child, except the nitrate of silver, and the cases where this is needed are rare.

For insufficient milk, drink freely of new warm milk. Have it brought to the bed, and drink at least a pint. Take it one or two hours before breakfast. If milk cannot be obtained possessing animal warmth, take new milk, add one-tenth water, and heat over a water bath to a temperature of 120 degrees. Cheese makers testify that the addition of water prevents rennet from coagulating the casein. In the stomach also, warm water prevents the pepsin from curdling the milk. If it is as warm as the stomach, and does not coagulate, it will be taken up by the absorbents and conveyed directly to the blood, without going through the process of digestion. Mothers who have a great aversion to milk, learn to cultivate a decided relish for it for the sake of the child.

Dr. R. P. Harris, in speaking of milk as a diet for delicate mothers, says: “Those who with ordinary food invariably fail to nurse longer than a few weeks, are capable by this diet of becoming not only good nurses, but also of gaining flesh while secreting the milk in abundance. When a delicate mother of eighty-six pounds’ weight, who had failed after a month with each of three infants, is enabled by it to nurse a child eighteen months, and gain at the same time nineteen pounds, the diet must be an effective one.” The article next best for promoting the secretion of milk is cocoa or chocolate, prepared with plenty of milk.

Every form of malt and spirituous liquors should by all means be avoided. They derange the nervous and digestive systems of both mother and babe. Custom, happily, has to a large extent done away with the idea that “nursing women must have ale or beer.” To those who still maintain this view, I would recommend the study of the question, whether the help expected is at all commensurate with the danger incurred of a pernicious appetite being cultivated in both mother and child.

Good digestion is usually all that is essential for an abundant flow of milk. The food should be simple but nutritious. Depend upon grains and fruits mainly, and by no means exclude the bran from the wheat flour. The saline elements in the bran not only stimulate digestion, but excite the secretion of milk as well. Try the experiment of feeding an Alderney cow upon fine flour, excluding the bran. By the lack of milk you will prove that the bran contains elements pre-eminently stimulating to lacteal secretions.

Oysters eaten raw or slightly cooked are said to increase the flow of milk. Honey, too, often proves invaluable. With bread and gems, instead of the carbonaceous butter, eat honey. It stimulates all the secretions. It is evident that foods rich in phosphates are the best to increase lactiferous flow. Therefore, study well the food table in Chapter IX, and partake of foods which were avoided in pregnancy.

In the first days after confinement, if the milk is slow to secrete, apply bruised castor bean leaves.

For excessive flow of milk, once or twice a day use hot fomentations upon the breast, and apply cosmoline, in which there is a trace of camphor. Avoid salt and liquid food. Wear folds of cotton batting over the breast. In either insufficient or excessive flow of milk, guard against pressure of clothing. It is absolutely essential that the blood should circulate freely to and from the breasts.

(No one thing more frequently causes atrophied breasts in any woman than the pressure of corsets and padding ordinarily worn. It is not unusual for a fine development of the breast to result from the removal of all pressure, accompanied by bathing daily with cold water, and following the bath by friction. Should this fail, an apparatus on the principle of dry-cupping is used. This seldom fails of giving the desired results.)

After pains often accompany the contraction of the uterus. It is not true that women never have them with the first child and always have them subsequently. Like most of the sufferings of maternity, they are the effect of abnormal conditions. Women, who, in two or three confinements have suffered days with after pains, threatened with spasms and not relieved except by chloroform, have by previous preparation recovered without a twinge of pain.

After pains usually occur periodically every ten or fifteen minutes. They are cramp-like pains accompanied by a feeling as if pricked by many needles. They make one very impatient and nervous, depriving her of needed rest. They are often the result of poisonous doses of ergot taken during labor. The hot water bag or hot fomentations will usually give relief. Must be very hot and kept hot, consequently dry heat is to be preferred. Administering a hot sitz-bath is also excellent treatment. If relief is not obtained, and the physician is not within call, inhale ether moderately. Do not take it internally.

The lochia is the flow from the vagina which occurs after confinement. At first it has the appearance of fresh blood, then becomes lighter in color, and finally is only a glairy mucus. This varies greatly in amount and duration. As a rule the healthier the woman, and more natural the labor, the less the flow. Cases have come to my knowledge where there was no sanguineous flow, and the patient made a rapid recovery. It is said that healthy squaws have no flow of blood with menstruation, or after delivery. If there is no constitutional disturbance, there need be no anxiety about a scanty flow. If caused by a chill, fever or inflammation, etc., prompt attention will be required, according to accompanying symptoms.

Metrorrhagia, or profuse flow, often requires treatment before medical aid can be secured. Hot fomentations, hot sitz-bath and hot vaginal injections are the very best applications. Recently the medical profession recognize that heat is better than cold, to arrest hemorrhage. In surgery, hot water is applied to exposed bleeding vessels. Cases are known where hot vaginal injections have instantly arrested bleeding that had resisted applications of ice, styptics and the tampon.

A lady in Michigan, during the menopause, was taken suddenly with violent hemorrhage. For seven days and nights everything was tried in vain to arrest the bleeding. She became cold and clammy, had frequent fainting spells, and death seemed imminent. An old nurse came to take care of her over night. She set aside the physician’s potions and applications. She filled the big wood stove with bricks, and as fast as they were heated wrapped them in wet cloths and put them about the patient, who thus obtained her first sleep for days. The hot bricks were kept to her four days and nights. There was no return of hemorrhage. She made a rapid recovery.

If there are clots, retained placenta or membranes, or any foreign growth present in the uterus, they must be removed by surgical interference, before uterine contractions can be effected and maintained.

Pelvic peritonitis, puerperal or child-bed fever. “There is a word of fear that I shall pronounce when I utter the name of Puerperal Fever; for there is almost no acute disease that is more terrible than this. The small pox itself, which reduces the fairest form of humanity to a mass of breathing corruption, can not be looked upon with greater dread. Child-bed fever, like an inexorable Atropos, cuts the thread of life for those to whom Clotho and Lachesis would give the longest span.

“There is something so touching in the death of a woman who has recently given birth to a child; something so mournful in the disappointment of cherished hopes; something so pitiful in the deserted condition of the new-born, helpless creature, forever deprived of those tender cares and caresses necessary to it, that the hardest heart is not found insensible to the catastrophe. It is a sort of desecration for an accouchee to die.”

Thus feelingly writes Prof. Meigs, of Philadelphia, of this disease, the very thoughts of which strike terror to the stoutest heart. This disease is an inflammation of the uterus and its peritoneal covering, and often extends to the entire membrane lining the abdominal cavity, and possibly involves all the pelvic viscera.

The attack ordinarily commences from the third to the ninth day after delivery. Previous to this, the patient has seemed all right, when suddenly, often apparently without cause, she is taken with a chill. Rigors more or less severe extend up and down the spinal column. Clothing does not seem to impart any warmth. Almost simultaneously with the chill, periodical pains will be felt in the womb, and if there is not much constitutional disturbance, may be taken for after pains. Usually, however, they are accompanied by great soreness and tenderness in the pelvis; the abdomen soon bloats and becomes tympanitic; the legs are flexed to relieve the tension; the weight of the clothes, even, cannot be borne. The milk dries up, the lochia cease, there is headache, great thirst, increase of temperature, a quick, wiry or bounding pulse.

All of these appalling symptoms are accompanied by great anxiety of mind and distressed expression of countenance. A dark circle forms about the eyes, which are sunken, the nose pinched, and the lips drawn, and the face is flushed or very pale. The course of this dread disease is extremely rapid. “It will not unfrequently happen that she shall die within thirty-six or forty-eight hours from the onset of the malady, and some cases terminate fatally even in eight hours. They are to be cured promptly or not at all. Such a malady as this hurries with hot and furious haste to a turn, beyond which there is not and cannot be any useful therapia.”

Perhaps I shall be condemned for picturing to the sensitive imagination of the pregnant woman the possible dangers of this dread disease. Her attendants will look out for it, and she should not be led to anticipate it. For two reasons, however, she should be forewarned:

First, that she may at once summon her medical attendant.

Second, that the causes of this disease being known, she may avoid them.

Do not delay one moment in calling your physician. Having the symptoms indicated, procrastination is suicidal. The doctor would better come ten times for a nervous chill or after-pains, if by chance the mistake should be made, than that you should fail once to notify him of an attack of puerperal fever.

Under improved methods of treatment this disease does not terminate fatally as frequently as formerly.

The causes of this disease are:

First. The inflammatory condition of the system before delivery. If the fruit diet has obviated this, there is nothing to fear.

Second. The use of ergot in confinement. Puerperal fever following poisoning by ergot is very rapid in its course, and soon terminates in gangrene. If this drug were banished from practice, child-bed fever would be rare.

Third. Contusions and bruises from instruments not handled dextrously cause inflammation.

Fourth. The use of cathartics, tonics, stimulants and other drugs after delivery.

It is within the power of every woman that she shall not be subject to these causes of puerperal fever.

Some late teachers claim that all child-bed fever is pyæemia, blood-poisoning, and can not be avoided. Why is it, then, that it is notably absent in those who have led a hygienic life? Why is it that those physicians who insist on preparatory treatment seldom meet with it in their practice? Others claim that the disease is contagious, and that the poison can be conveyed by physician and nurse.

Dr. W. S. Playfair, of London, who gives to this disease the name of Puerperal Septicæmia, says: “The whole tendency of recent investigations is daily rendering it more and more certain that obstetricians have been led into error by the special violence and intensity of the disease, and that they have erroneously considered it to be something special to the puerperal state, instead of recognizing in it a form of septic disease, practically identical with that which is familiar to surgeons under the name of pyæmia or septicæmia.

“If this view be correct, the term ‘puerperal fever,’ conveying the idea of a fever such as typhus or typhoid, must be acknowledged to be misleading, and one that should be discarded as only tending to confusion.

“According to this theory, the so-called puerperal fever is produced by the absorption of septic matter into the system. It is not essential that the poison should be peculiar or specific; for, just as in surgical pyæmia, any decomposing organic matter either originating within the generative organs of the patient herself, or coming from without, may set up this morbid action.”

The treatment of peritonitis should be prompt and thorough. Sweat the patient as soon as possible. Place several steaming bricks or ears of boiled corn about her. Frequent hot enemas by rectum and vagina are beneficial. If gangrene threatens, it is often arrested by the application of a yeast and charcoal poultice. Take any good lively yeast, make a sponge of corn meal and graham flour, equal parts. When light, add two tablespoons of charcoal to one pint, put on to a large cloth covered with thin gauze and lay over the entire abdomen. Must be changed frequently, not allowing it to get dry. An injection should be given per rectum every three hours, of weak carbolic soapsuds.

The nutriment should be diluted hot milk, or oatmeal gruel. Small pieces of ice will be grateful.

When these directions are followed faithfully, accompanied by appropriate remedies, most cases can be saved.

Even if it should be proven that this disease is septic poisoning, a healthy tone of the organs resists the absorption of the foreign agent,which proves a poison. In twenty years of general practice I never had a fatal case outside of the hospital. My experience emphasizes what I have stated, that the hygienic life and habits, and the avoidance of drugs and instruments go far toward preventing child-bed fever.