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the number of internal examinations during labor and the disinfection of the vagina, on account of the accompanying danger of infection.
That systematic external examinations in many instances give as trustworthy indications, and in many instances far more reliable information than internal ones, the author holds is incontrovertible. On the other hand, he argues that external observations often give very deceptive indications, especially when the observer has not had great experience in this line of work. Besides, this would furnish a very frequent excuse for incompetent midwives who had not forseen serious complications. They would simply say: "We were not allowed to make internal examinations."
These examinations cannot be dispensed with in institutions of instruction. Since puerperal fever has been recognized as an infectious malady, greatest care should be exercised in these institutions, to prevent the women from receiving injury from examinations.
That both purposes can be combined, namely, that the women may be used for purposes of instruction, and still be preserved from infection, the following figures from the Würzburger Klinik, will show: From the 1st Jany., 1890, to 21st Sept., 1891, 1,000 cases came under observation. Among them there
One died of hemorrhage in Placenta Praevia; two died after the thirteenth day, from pulmonary and circulatory troubles in pronounced Kyphoskoliosis; one from Peritonitis; one after Caesarian section from exhaustion.
While the entire mortality was 5 per cent., that from puerperal infection was but 1 per cent. The total morbidity was equally favorable.
Only 85 cases occurred where the temperature rose above 100%.
These figures are very conclusive evidence-the more so when we remember that the Clinic was visited by 1,263 practitioners, 1,100 of whom attended the labors. Besides these, 650 candidates for examina
tion, and 117 midwives attended the same women, and during the summer courses 510 students used the same material.
From the above figures the author argues that thorough internal examinations for instruction may be made without danger to the woman.
As in other institutions, the greatest aseptic precautions were taken. The examinations were not permitted if anything infectious had been handled during the preceding 24 hours. Before each examination the hands were washed and flushed with warm water and soap, and then in a 1-100 sublimate solution; the nails were then most carefully cleansed, and the examination made without drying the hands. The external genitals were carefully cleansed and disinfected with 1-2000 sublimate solution, and a disinfection of the vagina and cervix accompanied by a gentle manipulation with one or two fingers. This disinfection was repeated every two or three hours after each examination. No injections of any kind were used after labor.
Only the external genitals were disinfected. It follows therefore that there is no objection to frequent examinations, provided care be exercised.
The supposition that the mucous membrane was uselessly irritated by the disinfection, and that rupture of the peritoneum are more frequent and it seems to be more hypothetical than real; at least none of these objections have been observed in the Würzburger Clinic.
3.-TREATMENT OF NORMAL LABOR.
PROF. SCHAUTA, OF PRAGUE.
The chief elements in the treatment of normal labor may be summed up concisely in the two words, "cleanliness and rest."
With regard to cleanliness, this should be insisted on before the confinement. The woman must, therefore, make her genitals aseptic before labor and keep them so afterwards.
The abdomen, hips, thighs, inguinal folds, etc., should be washed with soap and sublimate 1-1000. Then the vagina should be rinsed with 2% carbolic solution, while the fingers distend the vagina. The physician's hands must be most scrupulously aseptic; as also the instruments and bandages which may be used made so by hot air or boiling.
Immediately after the delivery, the genitals are to be carefully wiped off with warm carbolic solution. Ordinarily, the vagina is not washed. Indications for the same are birth of a foul foetus, discolored amniotic fluid and operative cases.
The cleansing after labor is therefore confined to the external genitals. It consists of cleansing with carbolic solution 2 or 3 times a day. Wounds, be they ever so small, must be closed by suture immediately
after birth and covered with aseptic cotton, which is to be renewed at least three times a day.
Further treatment must consist in attention to the abdomen, breasts, bladder and the rectum. If ischuria is present, it is treated by laying cotton, which has been dipped in hot water, upon the external genitals. If this does not help, the catheter is to be carefully introduced. The vicinity of the meatus should be carefully cleansed, and the instrument is only to be used after having been boiled for at least ten minutes, and catheterization should not be done under the bedclothes.
If, after three days there has been no passage, then rectal irrigation (1-2 quarts) must be practiced. With women who wish to nurse their own children, the treatment of the nipples must commence before confinement, by drawing them forward and bathing them with alcohol. If the breasts of non-nursing women are swollen, then a light compression by means of bandages over breast and shoulders, in the form of the spica, recommends itself.
leave the bed. It may be supposed that it were best for the patient to recline until the genitals are entirely restored, that is, from 4 to 6 weeks. Against this it may be urged, that this prolonged rest may interfere with tissue change, the appetite may suffer and the woman may be much reduced.
After a normal labor a woman need not be confined longer than 14 days. She should in the latter days sit upright in bed, to accustom herself to this position.
3. How shall the patient lie? During the first days on the back, to consolidate the thrombi of the placenta and to heal the wounds. It is not necessary to continue this position during the whole period. The fundus of the uterus sinks back in this position, and there is danger of a retroversion. Therefore it is necessary to change positions as follows: During the first five or six days on the back, and then from the back to either side alternately.
The bed itself must be clean and dry. Fresh air is to be plentifully supplied at all seasons of the year, the temperature being kept at about 68° F., by open
As an internal means of suppressing the flow of ing a window in the sick chamber in summer, and in milk, belladonna and iodide of potash are used.
To strengthen the lax abdominal walls, bandages are put about the abdomen; however, they must not be too tense. Bandages such as are used after operations for laparotomy could also be advantageously used.
The second consideration is "rest." Soon after the delivery the recessity for sleep is felt, and this should be indulged. The woman should be carefully watched for fear of hemorrhages. The question of the best position, can be discussed under the following three divisions:
1. Why must a woman in confinement recline? The ligaments of the enormously hypertrophied and heavy uterus are flabby and cannot stand the pressure from above. The pelvic floor is enormously stretched and often even damaged. In consequence of a premature rising, displacement and pro-lapse could readily occur. The blood stagnation in the abdominal veins will be more easily overcome in the horizontal position. Rest will enhance the loosening of thrombi in the placental region and diminish the danger of emboli, and also act favorably towards the cure of the wounds.
2. How long must the patient lie? In general, we should say that the patient should recline until the ligaments and pelvic floor are sufficiently restored to give proper support to the pelvic organs. This is in general accomplished in from 10 to 14 days. It is necessary to individualize, and in extreme injuries the bed must be kept longer. Besides, the state of the uterus may serve as a good criterion. If its fundus has sunk into the small pelvis, and its position is otherwise normal, the patient may be permitted to
an adjoining one in winter.
Fortunately, the old starving method has been abandoned. Experiment has proven that an egg diet is best adapted to these cases-there are no disturbances of the digestion, the bowels are regular and the milk secretion commences early. On a pure meat diet the bowels become easily disturbed, the lochiæ be-come copious, involution is backward. Still meat must be taken if the woman is suffering from weakness, due to loss of blood. Wine is indicated in these cases. Generally speaking, an albuminous diet, mostly in fluid form, is to be adopted during the first days. When the need of nutriment becomes more urgent, some solid food-lean meat, white bread, etc., may be allowed; in each case the desire for food is the best indication.
4. THE CHOICE OF A WET NURSE. AD. OLIVIER, CHEF OF THE OBSTETRICAL INSTITUTE, PARIS.
As nothing exact is given on this subject in the books, it is necessary to give the practising physician some information concerning it. The important points are the age of the nurse, the date of her confinement, the number and manner of previous confinements, of previous illnesses.
1. No nurse under 20 years is to be accepted, because she is probably lacking in experience and may not be strong enough to fill the position. Besides the milk of a nurse from 16 to 20 years contains 20 grammes less water than the average, 16 more casein, 10 less butter and very little sugar, circumstances which render the milk more difficult of digestion. This milk resembles the milk of cows. On the other
hand, the nurse must not be older than 35 years; because then the milk is too watery and weak in solid constituents. The best age is from 20 to 30 years.
2. The date of her confinement. In general it is best to choose a nurse whose confinement has taken place from three to six months past, or so to choose that the date is not too far distant from the day of birth of the child she is to nurse. It has been found that when a child is given to a nurse who has had a recent confinement it often suffers from colic and green stools and takes too little nourishment. If the milk is three months old the stools of the child become at once yellow and the child thrives. There are also other unpleasantnesses. In three months the nurse has soft and red discharges, which is harmful to the child, especially when the return of the nurse's menses is taking place. Lastly one is not secure against the possibility of syphillis, as the first signs thereof become evident in the child of the nurse only after the first ten weeks. It is known that the milk of a wet nurse six months after her confinement is not suitable for a new born babe, because it is too weak-the entire breast is too empty, so the child drinks only the first portion of the milk which is found in the milk glands. This first portion contains only 30 per cent. of butter, while the second contains 50 per cent. As in this case, the breast is not emptied, the supply diminishes, and after a while disappears altogether, and this is the best cause for the change. The only method of preventing this is to allow the nurse to keep her child during the first four days, so that it can empty the breast from which the nurseling has drunk.
Primapara or multipara.-According to Archambault, multipara is to be preferred, inasmuch as they supply their milk more regularly and lose it less easily.
Pathological antecedents.-Aside from the question concerning tuberculosis and syphillis one must examine he teeth and see if they are good, ascertain if the digestion be good, the stools regular, heart sound, etc. Especially should one examine for symptoms of hysteria.
Examination of the nurse.-Local examination. The larger the breasts the richer will be the milk. The aggregations of fat are not to be confused with the knots which indicate the acini of the breast glands. A small mamma, which consists solely of glands, will furnish more milk than a large one which consists of fat. Among primapara the breasts are often as though glued upon the chest, while with multipara these are almost always hanging, indicating a scarcity of milk, but these must not be confused with those hanging breasts which are firm and full of knots; these commonly give rich milk. Blue veins, a sign of good circulation, traverse the breast of the
good wet nurse. The nipples, which should not be umbilicated, must have many openings from the milk spouts so that the suckling can easily get the milk. Both breasts should be examined.
Examination of the milk.-The mother's child should be given the breast, and after three or four minutes a teaspoonful of the milk collected. Take a drop upon the nail, and also upon a slip of glass and examine its transparency, and thus judge of its solid contents. In this test, the first portion of milk is not to be taken, as it is generally weak and watery; nor is the last portion to be taken, since it, on the other hand, is richer than the rest, and hence neither the first or last specimens can be taken as true criteria. The taste of mother's milk should be, according to Archambault, sweet, perhaps a trifle insipid, very different from other milk. It should not taste like sugar water. The child should be allowed to finish drinking to see if both breasts are necessary to satisfy it. The child should be weighed before and after, and the milk should be tested with a lactometer.
Examination of the nurse from a pathological standpoint.--Many physicians are prejudiced against blonde nurses, because they are predisposed to scrofula; many object to those having red hair, because they often have an ill-smelling sweat, which may be communicated to the child. Blepharitis Ciliaris is looked for, as also crusts upon the nipples as signs of scrofula. The sub-maxilliary gland and nuchae are examined for scrofulous signs. A most minute examination is made to guard against possibility of syphillis or tuberculosis.
Examination of the nurse's child.-A well nourished child leads to the conclusion that healthy, plentiful milk may be expected. The ano-genital region is examined for syphillitic signs, also the corners of the mouth and wings of the nose. Also assure yourself that you have the right child. Many nurses fatten their children artificially. These children are pale, their flesh is soft and weak.-Annales de la Policlin.
THE INDICATIONS FOR COLD BATHS IN THE TREATMENT OF BRONCHO-PNEUMONIAS.
BY DR. HUTINEL, PARIS, FRANCE.
ABSTRACT OF A CLINICAL LECTURE AT THE HOPITAL DES ENFANTS MALADES.
GENTLEMEN :-It would be difficult to find in France, within the last twenty-five years, a physician that would dare to prescribe a cold bath to a young or an old individual suffering from a serious attack of pneumonia. Cold being the principal cause of inflammation of the lungs, it would seem absurd to apply as a remedy that which is precisely the cause of the disease.
The method under consideration is not, nevertheless, a new one, going as far back as the time of Hippocrates.
Treatment: What must we do in broncho pneumonias? We cannot do much against the local lesion. I do not condemn revulsion; on the contrary, I consider such a measure useful, and I employ it; but I believe that it is not sufficient; often it acts slowly; and it does not appear wise, therefore, to depend on it entirely, especially in serious cases. I will not speak of innoculations with the serum of vaccinated animals; it does not seem to me that this method has given the results we were made to hope for by recent works upon the subject. Especially against the different manifestations of the general infection that we must act; and it is precisely in those cases in which the general phenomena are quite marked, that cold baths are particularly useful. Let us examine how these baths modify these various symptoms.
A cold bath, in cases of hyperthermia, diminishes, undoubtedly, the heat of the body; but there are chemical antipyretics which act as quickly, and, in general, more powerfully-such as antipyrine, for example. If to lower the bodily heat were our only object, and the only effect produced by the cold bath, there would be no use of resorting to it in those cases that exhibited marked hyperthermia; but the cold bath not only diminishes the temperature of the body, it at the same time exercises other beneficial influences it enhances the various secretions, increases the arterial pressure, and sustains the heart; while, on the other hand, most of the antithermic remedies produce, in similar conditions, untoward effects. Antipyrine, which I have cited as an example, depresses the patient, slows oxidation, and promotes in the economy the accumulation of toxic products. Quinine is preferable, but even in large doses this drug does not act with sufficient activity. This remedy is, nevertheless, an excellent adjuvant of the cold bath, and to which you must resort almost constantly.
The diminution of the temperature produced by the cold bath varies, the thermometer descending one, two or three degrees; in some cases the fall is only several tenths of a degree. The more marked and persistent the diminution of the temperature, the more favorable the results. In fatal cases, the fall of the temperature is insignificant.
The cold bath acts energetically upon the nervous system. It gives, as Professor Peter has remarked, speaking of typhoid fever, a lashing to the economy. It diminishes the depression so marked in certain cases of broncho-pneumonias, and especially suppresses all symptoms of excitement. It is indicated in the period of convulsions. After the bath, the child becomes calm and goes to sleep as soon as the temperature begins to rise again. Cold water acts
upon the circulation in a most favorable manner. The first effect, easy to understand, is a constriction of the peripheral blood-vessels, and a sudden increase of pressure in the left side of the heart. At such a time syncope is apt to occur, but this is not, nevertheless, so much to be feared in children as it is in case of adults, since in the former patients the cardiac muscle is generally healthy.
We must, however, be on our guard in case this accident should occur. If the syncope comes on, the child must instantly be flagellated, and given a hypodermatic injection of ether. The constriction of the peripheral blood-vessels determines an increase of the arterial pressure, steadies and notably slows the pulse. Following the constriction, there is dilatation of the peripheral vessels; the skin becomes reddened, this being due to a secondary derivative effect, a revulsion analogous to that produced by a sinapism, but more extensive. The changes which we have been able to observe in the greater circulation are the same as those produced in the lesser one.
The congestive foci in the lung become diminished, a diminution which, according to Jürgensen, may be detected by ausculting the little patients after the bath. The cough and the dyspnoea also diminish, and sometimes to an astonishing degree. In my experience the cold bath has never produced evil effects upon the lung, and, like many others; I am convinced that the measure has been wrongly accused of being the cause of pulmonary complications.
Upon the secretions the cold bath exercises a most beneficial influence; it increases the amount of urine, and facilitates the elimination of soluble poisons. It does not cause albuminuria, as has been supposed, and we can easily understand how it diminishes, instead of increases, passive congestions; it similarly promotes the salivary and the digestive secretions; under its influence the tongue becomes moist, the children accept voluntarily articles of food. Patients. who have been bathed return to life, to use the happy expression of Juhel-Renoy.
You see, then, that cold bathing acts energetically upon the circulation, the secretions, the nervous symptoms, and upon the dyspnoea when this is out of proportion with the pulmonary lesions. Is the measure under consideration indicated in all cases? Certainly not. Its application in all cases of broncho-pneumonias would be a very bad practice, indeed. We must always proceed in such a way as not to sink into disrepute the best methods. The bath is useful in these cases in which the general symptoms are marked, and in which the local lesions are not very extensive. I will detail the following case, which occurred in a little daughter of one of our most distinguished colleagues: B., a child, 5 years of age, enjoying the best of health, suffered an attack of influenza on the 24th of
November, 1891. The disease did not exhibit any peculiarities until the 26th, when, together with a marked elevation of the temperature there came on symptoms of great excitement, followed by those of depression.
Auscultation only revealed numerous disseminated rales in both lungs. The patient became worse on the following day and, in spite of her having been placed under hydrochlorate of quinine in doses of 0.40 grammes a day, with the frequent application of mustard plasters, there appeared on the 27th a marked rise of the temperature, 40° C.; there was also found over the angle of the right shoulder blade a zone of dullness in which subcrepitant rales, without any blowing sound, were detected.
She became still worse on the following night; on 28th the temperature was 41° C.; auscultation and percussion both revealed a double broncho-pneumonia; that is, over the base of the left lung, and also a little above the angle of the right shoulder blade. In two hours the temperature went up to 41.6° C., the condition of the little patient became very alarm. ing; her face was reddened, swollen; when made to speak, the muscles of the face would exhibit convulsive movements, giving rise to a grinning expression and one of terrible anxiety; she complained, besides, of a violent pain over the left side, and her excitement became exceedingly marked, this being a true jactitation. The number of respirations was 56 per
In the presence of such distressing symptoms, which appeared to augur an early fatal termination, I decided to plunge the moribund child in a bath at 30° C. (86 F.). The duration of this bath was 16 minutes.
When the little patient was taken out and placed in her bed, the scene had absolutely changed. The pain in her side, the excitement, the convulsive movements of the muscles of the face, all had disappeared, and there came on a condition of perfect calm. The little child slept profoundly for about a quarter of an hour; the respirations were reduced to 40, and the pulse from 142 came down to 120 per minute.
This amelioration did not last long; on the following morning, the 29th, the temperature rose to 41° C., that is, in the course of 11 hours; the excitement and the cough re-appeared. I gave her a second bath of 12 minutes' duration. Improvement occurred, but very soon afterwards, the temperature went up again, and I then ordered a third bath at 25° C. (77° F.), also of 12 minutes' duration.
The third bath was the signal of a definite defervescence, and the little child entered into a true convalescence, which became more and more marked every day, and pari passu with the favorable changes in the local lesions, there was a marked improvement
of the general condition. The period of convalescence was, nevertheless, prolonged, but the child finally made a complete recovery.
Families will often oppose the application of a cold bath in these cases: under such circumstances we must employ a certain amount of artifice. Under the cover of revulsion you add to the water a little mustard, for, as a general rule, parents believe in the efficacy of this simple remedy, and it behooves us to wrestle, not so much against their reluctance, as against their over-zealousness.
In favorable cases the temperature is decidedly lowered after the bath, and often descends to the normal point; the pulse is slowed, and calm is insured. These happy results are only obtained in cases in which the fever is high and the excitement marked, and in which the local lesions are of little moment. Nothing similar is observed when the lung is in a condition of marked hepatization, without there existing any febrile re-action; in these cases the depression produced by the bath is a negative or only a moderate one, the relief obtained being slight. This measure here, then, is useless, and it may produce, on the other hand, untoward effects. The fever which in part only, it has caused to disappear, may serve to enhance phagocytosis; we, therefore, ought not to suppress it, lest we place a weakened system in a greater jeopardy.
When an extensive lesion of the lung is accompanied by serious general symptoms, the bath is often. indicated, as it produces a quiet condition of the patient, lowers the fever, diminishes the cough, and makes us, on the other hand, gain a certain amount of time. In children, the bath sustains the strength and diminishes pulmonary hyperæmia; but often this amelioration is of short duration, and there comes a time when cold water produces no effect at all. In such cases the prognosis is exceeding bad, and death may be expected at every moment.
I shall not burden you with statistics. At the Hospice des Enfants-Assistes, I have obtained most excellent results, but I have also observed may failures. Serious, complicated broncho-pneumonias occur in very young children who live amidst bad surroundings.
I have often seen patients, after a marked amelioration, succumb to a secondary infection such as choleriform diarrhea, at a time when I thought that convalescence had already set in. In city practice, I have treated 12 children suffering from bronchopneumonia, with cold baths. Five deaths occurred, and among the other seven cured, there were one 2 months, one 6 months, one 9 months, and two 1 year old each.
Can we, from the nature of the broncho-pneumonia, point out a sure indication? Not absolutely. It