THE MANAGEMENT OF THE NORMAL PUERPERIUM.
the physician should not leave his patient until he was satisfied that there was no danger of hemor rhage, syncope, etc. She should then be left in perfect quiet, and will soon sleep, and this sleep should not be disturbed, since she is exhausted by the efforts of labor. It is often a good plan to administer a little stimulant before she goes to sleep. The physician should make his next visit within six or eight hours after labor, and if delivery has occurred during the night, the first morning visit should be made to the last woman delivered. It is customary with many physicians to give a dose of ergot to the patient before leaving. We do not believe this at all necessary, and we do not give ergot except where the uterus seems in clined to relax. [The object of the administration of ergot being to guard against such relaxation, and the physician never knowing in what special case such relaxation may occur, it seems the better plan to administer the drug immediately after the delivery of the placenta, not before, as a rou tine measure. Ergot, so far as is determined, can do no harm, and it may do good. At any rate we feel more satisfied with the future of our patient if we leave her protected by ergot. In those cases where there is a tendency to relax, and where in consequence we may have hemorrhage, we would give a double dose by the mouth, or, better still, one drachm subcutaneously, deep into the abdominal muscles always, never super ficially for fear of causing abscess.—Ed.] We apply over the abdomen a sheet, folded a number of times, or else a moderately tightened binder. The patient should lie on her back for a number of hours after delivery, and the toilette of the vulva should be attended to at least four times in the twenty-four hours, and carbolized water, one part to 100, should be used. [On account of its unpleasant odor, carbolic may be dispensed with, and corrosive sublimate, 1 to 4000, substituted. In private practice we question if pure boiled water be not amply sufficient. As for the dressing for the reception of the lochia, to which no reference is made in the text, the old-fashioned napkin should be rejected, and absorbent cot ton substituted. A pad of this cotton, antiseptized or not, according to individual taste, should be laid against the vulva, and retained in place by an ordinary T bandage, which is pinned in front and behind to the abdominal binder. This makes a clean and comfortable dressing, and the cotton should be changed as soon as saturated, and this will vary with each patient according to the amount of the lochia.—Ed.] At the first visit we should assure ourselves of the height of the fundus of the uterus. Not uncommonly it is inclined towards one or the other side, usually the right, and reaching to the umbilicus. This elevation of the organ is due entirely to the distension of the bladder. If the woman cannot pass her urine, it must be drawn by the catheter. This retention of the urine usually disappears at the end of twenty-four hours, although it may last much longer; we have seen it last to the fourteenth day. The woman should be catheterized at least every twelve hours. [This we do not believe is often enough. At the end of six hours, at least, vesical dis tension is great enough to call for artificial aid, if the patient cannot pass her own urine. As a practical point in regard to the catheter, and one not insisted upon sufficiently, we would state that the catheter should always be passed by sight, never by touch, and that prior to its introduc tion the vestibule should be carefully cleansed. Thus the introduction of lochia into the bladder on the point of the catheter is avoided, and there fore a possible cause of cystitis.—Ed.
The toilette of the newly delivered woman should be made with the greatest possible care, and every cause of infection kept away from her, and from the lying-in room. Soiled linen, napkins, should be frequently changed, and taken from the room. The air in the room should be often changed; in summer the window may be left open from nine in the morn ing to seven in the evening. If the genitals are abraded, they should be covered by a compress wet in a solution of phenic acid, 1 to 100. For our part, this external toilette is not sufficient, and, in accord with the ma jority of foreign and French accoucheurs, we cause to be given to all our patients, from the day after delivery, vaginal injections of some antiseptic fluid. We are so convinced not only of the innocuousness, but of the
advantage as well, of these injections, that if the labor has been longer than usual, or we have been obliged to interfere, or the woman has given birth to a dead, petrified or macerated child, we begin with them imme diately after labor. One injection, night and morning, is enough for or dinary cases, but we give them every two to three hours, if the lochia be come foetid. We use phenic acid solutions, 1 to 100, and the injections are administered from Eguisier's irrigator, with a tube with lateral open ings. The irrigator should first be filled as well as the tube, and the fluid should be allowed to flow gently. In other words we simply aim at washing out the vagina. The water should be of a temperature of 90 to 95° F. In general, we resort simply to vaginal injections, reserving intra uterine for special cases. (See subject of Puerperal Fever.) [While we would not be understood as condemning the above practice, our belief is exactly the reverse. In the normal puerperium we are satis fied that vaginal injections are useless, and that women will pass through exactly as normal a puerperium without them. This applies with all the greater force to private practice, when we state that at the New York Ma ternity Hospital, vaginal injections, in normal cases, have been entirely dispensed with, and that it is the exception at this institution to see the temperature rise more than one to one and a half degrees above the nor mal, and this rise, during the puerperal period, is of no moment. Our only objection to vaginal injections, as a routine measure, is that they may readily be the source of infection, especially if our nurs9 be careless. The better plan, is never to touch the vagina, during the puerperium, with finger or with syringe nozzle, unless symptoms call for it, and the chief symptom is foetid lochia, when vaginal injections should be at once resorted to, followed, if need be, by intrauterine. In case of instrumen tal interference, or the birth of a foetid child, we would go further than Charpentier, and wash out, not alone the vagina, but the uterus once, thoroughly, immediately after the expression of the placenta. We would further prefer sublimate, 1 to 4000, to carbolic, except where frequent irrigation is called for, and then, remembering the possibility of poisoning from this substance, would substitute carbolic, or clean boiled water. —Ed.] The woman's stay in bed should be prolonged as long as possible—it should be absolute for the first six days. It is only at the end of this time that we allow the .bed to be re-made. The woman should be carried to another bed, or where she is too heavy, we can place the second bed by the side of the first, and she may roll herself into it. Thereafter the bed should be changed every two to three days. She should remain in bed at least three weeks, oftener longer, than less; all depends on the process of involution. At the end of this time, she may be allowed to change to a sofa or a reclining chair. Only at the end of the thirtieth day will we allow her to walk, and only at the end of the fifth week should she resume her household duties. She should not venture out before the sixth week. We would like to wait for the return of the menses, which is usual about this time, but this is impossible with women who feel well. When the menses return, we make our patients return to bed, or at least to a reclining position, for two to three days. The first outing should be on foot, and it is only after some days that we allow the use of the car riage. Convinced as we are of the slowness with which involution occurs, and of the influence of involution on the production of uterine disease, we believe it right to insist on prolonged rest after delivery, and the more women retard the resumption of their customary duties, the more they assist perfect involution, and consequently the more likely they are to pos sess perfect health. It goes without saying that if, before labor, the woman has had uterine disease, (metritis, displacement, etc.), her sojourn in bed should be further protracted, and that we cannot indicate the exact limit.