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CURATIVE MEDICINE.

PART XVII.

CARE DURING CONVALESCENCE.

Definition.—The word convalescence is derived from the Latin convalescere, meaning, "to grow strong." It is the period of recovery after disease, the state midway between the final cessation of the disease and complete restoration to health. Although it is applicable to the periods of improvement in the course of chronic ailments, yet it is generally used in connection with the acute or self-limited diseases.

Importance of Obedience.—Since convalescence is the termination to which proper treatment, nursing and strict obedience to all the instructions contained thus far in this volume would naturally lead, except in cases of chronic, incurable diseases and old age, for which no cure has as yet been discovered, it may appropriately conclude the sections on preventive and curative medicine—substantiating the prognosis, or the predictions as previously set forth.

CAUSE.

Overbalancing Disease.—When disease fastens itself upon the human organism the outcome or result depends entirely upon the resisting power of the different tissues and organs. If tolerance is maintained and the several functions are not arrested, the disease will be overbalanced by the vitality and resisting power of the body.

Failure of Response.—But if the different tissues and organs do not respond to the increased tax made upon them; if they grow progressively weaker, the disease will constantly find additional means of spreading and ultimately the forces of the body are arrested and death ensues.

The Causation.—The causation of convalescence is, therefore, the response of living tissue to injury, the rallying of the vital forces, which overpower the disease and its primary cause, whether it be due to the countless microorganisms, to neglect, exposure, or the many unknown factors.

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Sign of Convalescence.—Just how convalescence is established we do not know, just how or when the resistance first exerts itself is a mystery, yet that it is a fact is evident, for in some diseases convalescence can be noticed almost from the moment it begins.

Termination by Lysis.—In certain diseases there is resolution by gradual subsidence, the fever growing less and less each day, until normal temperature is reached; while the strength increases and the faculties brighten. After the fever has entirely subsided the improvement is much faster and convalescence is rapid, although very often a long time is required to bring the patient back to his usual health. This is called termination by lysis.

Termination by Crisis.—In other affections, as pneumonia, the turning point to health is pronounced and plainly evident. Very often the change can be noticed inside of a very few moments, and within twenty-four hours convalescence is established; recovery following rapidly. This is styled termination by crisis.

Recuperative Force.—But in both cases the termination is due to the recuperative power being stronger and more vigorous than the cause of the disease—and it is therefore simply a question of the stronger overcoming the weaker.

Recovery in Certain Diseases.—As will be seen further on, under the paragraphs dealing with the convalescence of the special affections, there are many diseases which run a certain, definite course, both as to length, severity and convalescence. In these diseases, one familiar with the science of medicine can form a very accurate opinion as to the initiation of recovery, and foretell with a fair degree of accuracy the duration of the convalescence. This information is gained by comparing the records and statistics of many thousands of cases, using the average as a basis and applying the particular patient's symptoms and conditions with it.

SYMPTOMS OF CONVALESCENCE.

Convalescence presents some very different characters according as it succeeds to acute or chronic affections—in the former case it is clearly defined and noticeable, even to a superficial observer.

Its Commencement.—This is often marked by critical phenomena, and always by the cessation of local pain or general symptoms of the disease. To the patient himself it announces its welcome advent by a feeling of ease and comfort previously longed for in vain; whilst to the physician it makes itself known by reliable characteristics—such as a natural and peaceful expression of the countenance, vivacity and clearness of the glance, susceptibility, and, as it were, curiosity of the senses, an agreeable change in the disposition, and a tendency to gayety, a prolonged and refreshing sleep and a greater mobility of the circulation.

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The Encouraging Signs.—These do not all make their appearance simultaneously, but generally follow each other in groups at short intervals, often merging together.

Almost always the first phenomena of returning health develop themselves amidst the fading evidences of illness, but occasionally we observe in individuals of vigorous constitution transitions from disease to convalescence occur with marvelous rapidity.

Recovery in Chronic Cases.—In recovery from chronic maladies the physician is not often called upon to assist at such kaleidoscopic changes from disease to health. The functions of the organism do not reëstablish themselves with the same promptitude, nor in the same almost simultaneous manner. They become regulated, as it were, one by one, in consequence of careful and individual attention, and even when restored to their physiological type they are wanting for a long time in force and endurance.

After Chronic Illness.—The loss of adipose is often not repaired until after months or even years of convalescence, and the countenance frequently retains for a great while the imprint of the sufferings which have been endured, while after the acute diseases, such as the fevers, the acquirement of flesh is usually rapid, often increasing the weight above the normal limit.

Hunger.—If we consider the symptoms of convalescence a little more closely we will find that hunger is one of the first and most important manifestations of returning health after an acute disease. The appetite for food is sharp, and renews itself after a very brief period; sometimes it is even voracious.

Eating becomes in many cases the great, perhaps the sole, aim of the convalescent; and when he happens to be of an age when growth is not yet terminated, and when, consequently, assimilation is normally active, he is apt to seek the gratification of this voracity with arguments and supplications which render it very difficult for the physician or nurse to enforce a proper regulation of the diet.

In military hospitals it is often necessary to resist the tears and most vehement prayers of convalescents in order to preserve them from dangerous and fatal consequences of their own excesses.

Heart and Circulation.—As hunger is the demand on the part of the attenuated tissues for more nourishment, so is the strengthened circulation due to the need of the body for more oxygen and less carbonic acid gas.

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Circulation in Convalescence.—During convalescence the circulation presents a singular impressionability—the pulse is often slower than in health, falling sometimes as low as forty, or even thirty-five beats per minute; but it is very excitable and is accelerated by the slightest cause. The simple act of changing the position or attitude will increase its rate greatly, while the approach of a stranger, especially the physician, the slightest worry or mental excitement, will at once increase the pulse rate.

Pallor and Flushing.—The increased mobility of the circulation gives rise to ultimate pallor and flushing of the face upon the slightest cause. A delicate softening of the skin and transient perspiration are also due to the easily-influenced circulation and the low muscular power.

The Pallor.—The pallor of convalescence arises, not by the emptiness of the blood-vessels, as was formerly believed, but from the diminution in the quantity of red blood corpuscles; in consequence of the prolonged abstinence from the proper amount of food or its malassimilation.

Blood Corpuscles.—This diminution is determined by the ingenious haematimeter of Hayem and Nachet, by which the number of corpuscles in a given amount of blood are counted—from which it is easy to compute the percentage in the entire arterial system. A cubic millimeter of normal blood contains about five million red blood corpuscles, yet in convalescence we often find as low as two million corpuscles in the same quantity.

Red Blood Corpuscles.—These are the carriers of oxygen to the different organs and tissues of the body; consequently when we find the carrying power so greatly diminished we can readily understand the many symptoms of an impoverished circulation. One of the best examples seen of this is in the excessive sensitiveness to cold due to lessened oxidation. Again we find vertigo and dizziness due to anemia or imperfect blood supply of the brain, and palpitation of the heart.

Respiration is not affected during repose and quietude, but slight muscular effort causes fatigue and shortness of breath; this is especially noticeable after ascending a short staircase, and is caused by impoverished blood, together with some slight febrile action.

Need of Oxygen.—For as muscular activity is destructive to the body it is necessary that carbonic acid gas (C O₂), the product of such destruction, be carried away, and that oxygen be returned to the tissues in order that they may recover from the loss. The convalescent's blood is not as able to perfectly carry out this function as the blood of a healthy individual, hence the lungs are required to put forth extra respiratory efforts, and shortness of breath results.

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Digestion.—Constipation is the rule rather than the exception in convalescence, and is due to the enforced quietude, the diminished secretions from fever, the febrile reaction and the lessened food supply. The tongue which has been coated, or hard and baked, as the case may be, gradually clears off, becoming soft and moist as the bowels are regulated. And disturbance of the stomach, as nausea and vomiting, discomfort after eating, and so forth, ceases under proper diet, and the extreme thirst disappears. The digestive symptoms will be mentioned more fully further on, under the special diseases.

Urine.—The urine during convalescence becomes more abundant (usually from forty to fifty ounces in twenty-four hours) and less fully charged with uric acid than in health. It ceases to present the dense, high-colored and strongly odorous character met with in disease, and if it has contained albumen or sugar this will disappear, unless the acute disease has developed into a chronic one.

If, during the course of the disease, there has been an involuntary voidance of the urine, the desire to urinate frequently and the inability to perfectly control the urine will be felt for some time during convalescence. This, however, will return to normal as the patient regains health and strength.

Sexual Powers.—In females the menstrual discharges are reëstablished during convalescence, and in many cases the genital organs show marked activity—married women becoming pregnant soon after convalescence. In the male convalescing from acute diseases, there is generally an energetic stimulation of the sexual functions. After convalescence from chronic diseases, middle-aged patients frequently suffer a loss of sexual appetite and emations. Cases of sexual weakness, discharges, and so forth, following acute diseases, are generally transient and leave no untoward effects.

Skin and Hair.—The outer layer of the skin, or the epidermis, the hair and the eyebrows, are frequently shed during convalescence; but this loss is as a rule only temporary.

Muscles.—The muscles after sickness are more or less emaciated and flabby; this varies greatly after different diseases; some acute diseases causing a very rapid loss of flesh, while others are more like chronic ailments, in that the emaciation is slow and progressive. The muscles of the abdomen are usually soft and flabby, while the long muscles of the legs and arms lose their firmness and are easily separated one from another. The muscular tissue of the several organs are also affected, being unfiltrated with fat, decidedly inactive and subject to tissue change.

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Muscular Movement.—Muscular movement, for a long time, fails in that energy and precision which marks a state of complete health, and all the organs display an inability to react against, or to withstand, any of the innumerable outside influences with which mankind is surrounded, as they would normally do.

Sleep.—The sleep of convalescence is sound and refreshing, losing the disturbed character which it had during illness and becoming calm and tranquil. As there is perfect rest, both physically and mentally, during normal slumber, the convalescent should be allowed a large portion of the day in which to sleep undisturbed.

Mental Powers.—The mental powers, both of perception and reasoning, gradually return during convalescence, but for a long time patients have little endurance, becoming easily fatigued and exhausted after mental exercise. After a severe, acute malady, such as typhoid fever, the intellectual faculties are often very slow in returning to their original integrity, and months or even years may elapse before the patient enjoys his full mental vigor.

Mental Disturbance in Childhood.—In certain acute diseases peculiar to childhood, such as scarlet fever, meningitis and diptheria, there is often mental disturbance, and while it takes a long time before the mind recovers its normal state, yet in such cases the outlook is generally favorable.

Loss of Mental Power in Adults.—In adult patients who are convalescing from nervous disorders, the loss of mental power is serious, and the full vigor of the mind is seldom acquired.

Convalescence of Old People.—In elderly people, a convalescence often hastens the physiological loss of mental power—the loss being especially appreciable to themselves and their associates, inasmuch, as it is sudden, instead of coming on gradually with each succeeding year.

COMPLICATIONS OF CONVALESCENCE.

How frequently we hear that a certain patient has "had a relapse." Yet in the majority of cases, such a relapse is due to some neglect or carelessness; and to impress upon the reader the danger of complication during convalescence, we take up a few of the most common points in connection with it. First, we will consider the causes which can be averted in most instances. They are improper feeding, exposure, over-exertion.

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Improper Feeding.—If the desire for food returns slowly and is capricious in its choice for articles for diet; if the patient is quickly disgusted and wishes to change his bill of fare daily; if, in eating, he does not experience the pleasure which accompanies the satisfaction of a real want of the organism, and if, during digestion, acid eructations, flatulence, flushing of the face and distinct febrile movement cocur[sic], convalescence is not yet sufficiently advanced to permit gratification of the appetite and diarrhoea is apt to supervene on such indulgence. Should it do so, whatever progress toward health has been made by the organism is often more than obliterated.

The Complications which must be watched for in connection with the diet are, diarrhoea, vomiting or nausea, acid eructations, belching of wind, flushing of the face and fever. When any one of these symptoms are noticed, look to the food and see if a reason cannot be found.

Exposure due to cold draughts, cold moist air, an over-heated or ill-ventilated room, poor sanitary conditions, may complicate the disease. A patient convalescing from typhoid fever may contract bronchitis or pneumonia from atmospheric exposure, and in his weakened condition the result is to be feared. A pneumonia may be complicated by typhoid fever due to defective sanitation, filthy bed-linen or sick-room vessels. These are most important details which must not be overlooked, as proper attendance to hygiene and dietetics is the sheet-anchor during convalescence.

Over-Exertion.—A heart weakened by disease is not calculated to withstand the sudden demands made upon it by severe exercise. An intestine just healing after ulceration is not prepared to undergo the straining efforts made at stools while in the erect posture.

Gradual Exercise.—Consequently in allowing a convalescent to exercise it must always be remembered just how weak all the organs are, especially the one which has been the main seat of disease. It is better to keep a patient quiet in bed, in spite of his protestations, than to allow him to over-exert. Moderate exercise, gradually increased, will be just as acceptable, and the termination is certainly more certain by success. The length of time that a patient must be kept in bed after sickness varies with the disease, its length and intensity. But generally speaking, a patient should not be allowed to get up until the fever and all other symptoms have been absent for at least ten days, and then the periods of exercise should be gradually increased as strength is regained.

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Complications in Convalescence.—Certain diseases have a particular disposition toward complication during the convalescent period—while such conditions cannot always be prevented, they can at least be expected and preparation made to combat them. In the convalescence of diphtheria, for instance, one must constantly be watchful of any nervous symptoms which may arise; paralysis of different portions of the body, especially of the heart, is a very common complication and should be treated energetically. Scarlet fever is often complicated by acute Bright's disease, heart affections and disease of the middle ear. Pneumonia or influenza may insidiously lead into consumption, unnoticed, except for constant watchfulness. In fact, during convalescence, the patient should be kept under the closest supervision; the smallest details must be noticed and acted upon immediately. By so doing many secondary diseases, both chronic and acute, may be aborted in their infancy.

TREATMENT OF CONVALESCENCE.

When a malady is terminated, sanitary science, which had previously labored in conjunction with therapeutics to extinguish the morbid tendency, resumes sole charge of the patient and directs the convalescence, during which the individual, although no longer sick, is not yet in a state of perfect health. In convalescence the functions, although brought to an equilibrium, are still wanting in energy and in stability; the entire organism, more or less shaken by the attacks to which it has been subjected, reëstablishes slowly, and, as it were, step by step, in its connections and its reactions with the external world.

Hygiene being the preëminently powerful agent in the management of convalescence the following sanitary rules are worthy of particular attention:

Protective Treatment.—The convalescent should be protected with special care against variations in temperature, from the baneful influence of cold air, of currents of air and from the effects of moisture. In the condition of his system he is particularly apt to be affected by these agents, which may readily bring on a relapse, or some more or less serious complication.

Ventilation.—What has just been said does not mean that the patient is to be denied plenty of pure air; for as we have shown in preceding paragraphs, oxygen is as much a necessity to the human economy as is food. A patient should be allowed at least 1,500 cubic feet of air space and the air should be changed once in every two hours. To do this requires some ingenuity if the sick room is not supplied with special ventilating apparatus—for the first air should be warm and dry.

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A Simple and Effective Method.—This is to admit the fresh, outside air into an adjoining hallway or room which can be heated. From this room the warm, fresh air may pass into the sick-chamber through an open door or window; the patient's bed being so placed as to be out of any direct draught or current of air.

Clothing.—In order to secure immunity from atmospheric exposure it is necessary that warm clothing should be worn—thicker and warmer than the clothing usually worn at the corresponding season of the year. Wool or silk under-garments are by far the best as they radiate the body heat and moisture gradually and are less apt to cause a feeling of chilliness after perspiration. If the weather is very warm, light-weight wool garments can be procured, which will be but little warmer than cotton or linen and at the same time preserve uniform body temperature.

Baths should be indulged in only near the end of convalescence, when health appears to be almost fully established. They should be very short and taken at least a half an hour before and two hours after a meal. It is well to employ those of a stimulating character, such as salt baths, bran baths, baths containing alcohol or whiskey, and so forth. Great precautions should be observed against the slightest exposure to draughts of air for some time after coming out of the water. After bathing the body should be well dried with rough bath-towels, rubbing the skin vigorously enough to bring a healthy glow to the surface. During convalescence from diseases of the respiratory apparatus baths should be strictly forbidden. (The previous remarks do not apply to baths administered during the active period of the disease, for the purpose of reducing fever, cleanliness, and so forth.)

Massage is beneficial in most cases of convalescence after they become strong enough to withstand the somewhat vigorous manipulations. The motions of massage differ in character; beginning with firm stroking with the palms of both hands they gradually change to a kneading motion, and end with percussion or a rapid tapping of the muscles.

Massage is generally practiced upon the bared skin, using enough fresh cocoanut oil to enable the operators hand to glide easily over it and render the skin soft and pliable. The object is to bring fresh blood to the muscles and stimulate the tissues to greater activity, and consequently is of great value in convalescing cases in which the muscles are soft and flabby and the circulation sluggish.

Food of Convalescence.—The diet must be carefully regulated and the following rules rigidly adhered to: In the first place, proportion the amount and character of the nourishment, not to the hunger of the patient, but to the digestive power of his stomach. Instruct him to eat often and but little at a time, to chew the food very thoroughly, not only to secure its reduction to small particles, but also its complete admixture with the salivary fluids. And lastly, to choose those articles of diet which are adapted to the comparative feebleness and sensitiveness of the digestive organs and as far as possible, also, those which gratify the taste of the individual.

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Generous Nourishment.—We must guard, however, against a disposition to restrain the patient too much in regard to nourishment, through an exaggerated fear of the effects which it may produce. It is essential to take into consideration the degree of appetite and the sensations which the convalescent experiences during the process of digestion. Also to consider how his illness has effected the several digestive organs, for, of course, the kind and quantity of nourishment must vary with the nature and duration of the illness from which recovery is taking place.

Examples.—For instance, a patient who is convalescing from typhoid fever, which has its seat in the intestine, should not be allowed to eat plentifully of foods which receive a large part of their digestion in that organ, as fats, starches, and so forth. Nor should a patient who has had a congested liver partake of fatty food to any great extent—simply because bile is required to digest fats and the disease has to do with a lessened supply of bile.

The Patient Must Diet.—Stimulating food given to an intensely nervous patient would only aggravate the condition, while a routine diet, without change or character, would be torture to one recovering from a long, chronic illness.

In other words the diet most suit the patient, not the patient the diet. There are many cases in which physicians and nurses gain more credit with a patient and his friends by a very minute attention to the diet during convalescence than by the most skillful treatment of the disease throughout its course.

Diet.—As a general rule a patient may begin with weak chicken or mutton broth, free from fat, and boiled rice, which probably represent the two great classes of nitrogenied[sic] and amylaceous articles of food in their most easily assimilated form. Experiments have shown that rice is digested in less time than any other substance of the kind, only requiring one hour. The rice may be substituted by tapioca, sago or cornstarch, made with milk, if these are more palatable, according to the directions on a previous page.

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Progressive Diet.—After from two to four days, if improvement continues, administer stronger soups, eggs very slightly boiled, calf's-foot jelly, rice-pudding and toasted bread, or stale bread with very little butter, In the course of a week the patient may proceed to a mealy roasted white potato, a tender mutton chop, or tender loin of beef, and light bread not less than twelve hours old, with sweet butter in moderate quantity.

It is much better and saves time for the invalid to go up the inclined plane of diet (never to ascend this hill of difficulty by jumps) a little slower than is absolutely necessary, than to advance too rapidly and bring on a relapse.

A Correct Guide.—The surest guide is the condition of the tongue; should that unruly member have cleaned off, as it usually does when full, frank convalescence sets in, go on carefully and cautiously up the list given above to stronger and more nutritious articles of diet. But should the tongue put on a coat of fur again, remember it is a sign of repugnance to such rich food as it has to help to swallow, and quickly taking the hint, put the patient back on liquid diet for a few days longer.

Medical Treatment.—During convalescence the secretions and excretions must be carefully watched over and any excess or insufficiency be corrected as soon as practicable. The patient should be encouraged to drink a great deal of water (between meals, and not at meals—this also, applies to the healthy individual) for water is an absolute necessity to the secretions, which if right will bring health much closer to hand.

Copious Perspirations, which are very apt to occur from simple relaxation of the tissues and integument, may be checked by six or eight grains of quinine, or by one-hundredth of a grain of atropia, or by sponging with a solution of alum and whiskey before retiring.

The Urine.—If the urine is rather scanty the patient should drink freely of water, or of some bland fluid, such as flaxseed tea, toast-water or gum-arabic water.

Constipation.—Constipation should be overcome by injections, or by tonic laxatives, such as rhubarb, in doses of five or ten grains daily. If convalescence is protracted and the patient does not regain strength as fast as should be expected a tonic containing iron and strychnia is indicated.

Surroundings of the Patient.—Those who have suffered from a protracted illness will remember how monotonous it became to lie in bed with your vision limited to one side of the room, or to a narrow strip of sky or landscape which could be seen through some particular window. You soon learned every detail of the room and its furniture; even the figures on the wall-paper took on grotesque forms and seemed perfectly hateful to you.

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Chamber Arrangement.—Consequently the furnishing of the sick-chamber, the arrangement of the bed gives us another topic in connection with the treatment of convalescence. While the sick-room should have as little furniture in it as possible (especially if the disease be contagious or infectious), yet what there is should be arranged with a view to cheerfulness and brightness.

Flowers.—Flowers or potted plants, brought in from time to time, give the patient a change and brightens him up. If possible the position of the bed should be changed from one part of the room to another so as to give the enforced occupant a new field of vision, especially if it be so that he can look out of a window. All these little details make sickness more bearable; taking away the gloomy thought goes a very long way toward establishing a speedy convalescence.

Visiting.—During the tedious convalescence which we often watch so anxiously after prolonged chronic diseases, or after relapses from more acute attacks, visits are capable of accomplishing great good if properly managed. Every care should be taken not to depress a patient who is slowly recovering, by allusions to unfavorable terminations in cases similar to his own. A sick person does so enjoy hearing good news; for instance, of a love and courtship which has a happy ending. Sick persons also intensely enjoy hearing of any material good, such as a positive or practical success of the right in their own neighborhood or country, or, indeed, in any part of the world.

Books.—They have generally a surfeit of books, principles, precepts and theories; so, instead of advising them about their convalescence, with advice which they have heard at least fifty times before, tell them of one benevolent act which has really succeeded practically—it will be like a day's health to them. It is hard for people to understand how intense is the craving of invalids, who, with reanimated powers of thinking, are still cut off from active participation in the world's work and progress, to hear of good, practical action even when they cannot yet partake of it.

Society.—In many instances there is no better society for a convalescent than that of babies, or of other invalids who are also convalescent; but, of course, this association must be carefully managed so that neither party will suffer from it, which is perfectly feasible as a rule. If you think the air of a sick-room is bad for an infant, of course it is injurious to the invalid also; and efforts should be made to remedy the aerial impurity without a moment's delay. It enlivens a sick person's whole mental atmosphere to see "the baby," and a very young child, if unspoiled, will generally adapt itself wonderfully to the ways of a sick person if the time they spend together is not too long. A small pet animal is often an excellent companion for a convalescent patient, especially if confinement to the house in consequence of unfavorable weather or complications of the original disease setting in, is unusually prolonged. A pet bird in a cage has sometimes proved the only pleasure, or, indeed, solace of an invalid shut up in the same room for weeks, or even months. If such a pet can be fed, cleaned and taken care of in every way, and perhaps taught some of the little tricks which birds, squirrels and even mice are capable of learning, and which prove such a source of pride to the trainer and entertainment to visitors, the patient should by all means be encouraged to undertake the task. By such devices many a weary hour has been whiled away, and the sick-chamber of lingering convalescence shorn of half its almost intolerable weariness.

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First Walks.—The first walks or rides should receive special attention, the convalescent being warmly clothed, a warm sunshiny day being selected, in accordance with the rules given under meteorology, and the exposure being at first for only fifteen minutes, or half an hour at the furthest.

Change of Air and Scene.—After the invalid is strong enough to leave the house complete change of air and scene is one of the most potent contributors to an entire restoration to health. The patient, who has remained for three weeks in nearly the same state, growing neither better nor worse, will often wonderfully improve after a few days spent in the country or at the seashore. If the period of sickness has been passed in a room where the only view was of the backs of houses or the fronts of those forming the opposite side of the street, how grateful and invigorating is the sight of green fields, shady groves and sparkling streams at some sylvan retreat. By the ocean, too, vitalizing sea breezes frequently exert an almost magical power over a frame enfeebled by disease and restore to the languid convalescent his wonted vigor with astonishing rapidity.

Avoid Excitement.—Lastly, try to secure the patient against any intense mental emotion or intellectual excitement, which will be almost sure to react with unfavorable effect upon his enfeebled physical powers.

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