is always successful in calming these distressing contractions of the
uterus. They sometimes persevere with great obstinacy, even after the
faithful trial of both these remedies; while, in other cases, no form of
opium can be made to suit the peculiar idiosyncrasy of the patient, and
to some the camphor is absolutely disgusting.
_We_ have a remedy incomparably more effectual than either or both of
these, and which will act in the most friendly manner with every
patient—pure water, tepid, cool, or cold, judiciously applied, according
to the exigencies of the case, is a hundred-fold better than all other
remedies combined in subduing the pains in question.
What substance in nature that will at all compare with water in
arresting hemorrhage? There is nothing. So also in regard to securing a
proper contraction of the uterus, the same principle holds good. We
place wet cloths upon the abdomen, the generative parts, the thighs, and
a wet sheet about the trunk of the body, if need be, in order to secure
the desired effect. Even placing the hands in cold water will, by
sympathy, aid in the result.
In the slighter cases of after-pains, the frequent laying on the abdomen
cold wet compresses, the same upon the back, together with frequent
drinking of cold water, and the use of the accustomed baths—such as are
always taken, even when labor pains do not appear—will in general prove
sufficient. But in many cases a far more heroic treatment will be found
necessary. Many times in the twenty-four hours we may have to persevere
in the water appliances, particularly the shallow-bath; the common
wash-tub, or the sitting-bath tub, answer very well for this; the
patient sitting in the vessel, the feet, of course, being left outside,
she is rubbed all over smartly with the wet hand, there being one or
more assistants, herself aiding in the operation somewhat; in this way
she is rubbed until the desired effect is obtained. No matter if it
makes her chilly and shake, as it often does, for it is much better to
be shivering with cold, and suffering in this way, than to be writhing
and groaning under the effects of these terrible pains. I have myself,
with my own hands, aided in giving these baths by the half hour at the
time, and many in the course of a day, and in such cases we have
succeeded—usually in a few hours—in getting the mastery of the pains. I
cannot conceive of a case in which this treatment, if properly managed,
must not succeed. I know that in some cases, where persons have been
much injured by narcotic substances, and in which the agony amounts to
spasms and convulsions, perhaps, it will be found no boys’ play to cure
the case. But I have yet to see the first one in which these remedies
will not succeed, and I trust the time is not far distant when both
physicians and the people at large, all over this country, and the whole
civilized world, will understand and be able to apply, in a very good
degree of perfection, these simple and yet immensely valuable means for
relieving pain.
But to proceed; if a patient is too weak to sit up for a half-bath, we
must do the best we can with her in the recumbent position, and by
dexterous and persevering management, a great deal may be done in these
cases. The wet sheet, folded once each way, and then slipped under the
patient, so that it can be lapped over the whole trunk and pelvis, and
the frequent renewal of the wet compresses under the sheet, upon the
abdomen, genitals, and thighs, are invaluable means. The washings of the
surface may be repeated as often as is necessary, and the wet sheet
should be always changed before it becomes too clammy and warm.
But it is fortunately the order of nature, that where there is great
debility not much pain is experienced. If a patient experiences a great
deal of after-pain, we may know that she has a pretty good amount of
vitality in her organization, and that she can bear a large amount of
treatment, sufficient to bring about the desired result.
Water injections for the bowels are also valuable in these cases. I do
not think it best to use the water very cold. In one very obstinate
case, where the most agonizing after-pains had gone on for hours before
I saw the patient, we used, among other means, frequent clysters of
water, at about 70° Fah. with excellent effect. Nor would I be afraid to
use very cold clysters in such cases.
Some have recommended vaginal injections in strong terms as a remedy of
after-pains. It has indeed been affirmed that occasional cold injections
to the uterus prove a _sovereign_ remedy for them. But no one of much
experience has testified to this. It will be found, I think, by those
who have put forth these strong statements, that when they have gained a
sufficient amount of experience to enable them to form a good judgment
upon these matters, they will find, I am confident, that a much more
powerful and general treatment will be necessary in those severer cases.
No single application, however powerful, can of itself succeed. But if I
am myself in error on this subject, I shall be most happy to become
convinced of it, for I love the _truth_ better than every thing else;
better even than my own opinions, however strongly and confidently
expressed.
I would prefer the tepid vaginal injection—say at a temperature of from
70° to 80° Fah.—rather than the cold. If we have an aching tooth, its
nerves all sensitive and bare, we do not take _cold_ water into the
mouth, but that which is tepid. We repeat this pretty often, and at the
same time rub the face, neck, and other adjacent parts with the coldest
water we can get.
If we have a cut and bleeding finger, we do not immerse the wound in
cold water, or put cold water upon it, to arrest the bleeding, but we
immerse it in tepid water, and make our cold applications some little
distance from the wound, as upon the arm and elbow; thus we secure our
object in the better way. If we are to treat a felon, we may immerse the
hand and arm in cold water, leaving the extreme part, at which the agony
is felt, out of it; we may have a wet compress about the painful member,
but the greater and more effective applications must be made on other
parts, contiguous to the one affected. From these well established
principles I infer that the vaginal injections, whatever may be claimed
for them, are of minor importance, when compared with the external and
more general applications to which I have referred, as a remedy for
after-pains. It is to be remembered, likewise, that patients, from the
extreme sensitiveness and soreness of these parts after delivery, dread
very much applications of this kind. The external applications are
soothing, pleasant, and wonderfully effective in relieving soreness, but
not so with the internal applications.
Thus, then, it will be perceived, that I place great reliance upon the
shallow-bath, tepid, cool, or cold, with prolonged friction by the wet
hands, the sitting-bath, the cold wet compresses, often repeated, the
wet girdle, cold wet cloths upon the thighs and back, the folded packing
sheet, with covering sufficient to keep the patient comfortable, tepid
or cold clysters, and water-drinking, together with good nursing
throughout, as a remedy for the distressing affection of which I have
been treating.
LETTER XXXIII.
THE LOCHIAL DISCHARGE.
The Mosaic Law concerning Purification of Women—Nature of the
Lochia—Excessive and Offensive Discharge—Treatment of Suppression of the
Lochia.
We read in the New Testament, in reference to the birth of the Saviour
(Luke ii., 21, 22), that “when eight days were accomplished for the
circumcising of the child, His name was called Jesus, which was so named
by the angel before He was conceived in the womb;” that “when the days
of her purification, according to the law of Moses, were accomplished,
they brought Him to Jerusalem, to present Him to the Lord.”
These passages refer to the Mosaic law (Leviticus, chap. xii.), which is
as follows:
“And the Lord spake unto Moses, saying, Speak unto the children of
Israel, saying, If a woman hath conceived seed, and born a male child,
then she shall be unclean seven days; according to the days of the
separation for her infirmity, shall she be unclean.
“And in the eighth day the flesh of his foreskin shall be circumcised.
“And she shall then continue in the blood of her purifying
three-and-thirty days; she shall touch no hallowed thing, nor come into
the sanctuary, until the days of her purifying be fulfilled.
“But if she bear a maid child, then she shall be unclean two weeks, as
in her separation: and she shall continue in the blood of her purifying
threescore and six days.”
This law refers to what is called in medical science the _lochia_, or
_lochial discharge_, the term being derived from a Greek word signifying
“a woman in childbed.”
After the birth has taken place and the placenta has been removed, the
woman experiences a discharge from the womb, which is at first red in
color, consisting, probably, of little else than blood; afterward it
acquires a greenish hue, possessing a peculiar and disagreeable odor.
The lochia is considered purifying in its character. It is a natural
discharge which oozes from the orifices of blood-vessels, laid open by
the separation of the placenta from a portion of the internal surface of
the womb. In all cases wherein a wound is made in the living body, or
wherever the blood-vessels are by any cause laid open, there must be
necessarily more or less discharge before the healing can be fully
accomplished; and the same principle holds good in the womb as in other
parts of the body.
In quantity, the lochia varies much in different cases; it may be three
or four times as abundant, apparently, in one case as in another, both
patients recovering, however, with equal facility or difficulty.
The length of time varies also as much as the quantity of this
discharge. It may last for a few hours only, for days, but more commonly
for weeks; fourteen to twenty-one days may be stated as its usual
duration. Something, I think, depends upon the treatment; cleanliness
certainly has its effect in these cases. If a woman wash herself three
or four times daily, and keep herself at all times as strictly clean as
the circumstances will admit of, the process of healing must be
materially hastened, the discharge rendered smaller in quantity, and
less offensive in character.
_Excessive Discharge._—From various causes the lochia sometimes becomes
excessive in quantity. More anciently, when the humeral pathology was
much in vogue, this discharge was studied with more attention than in
modern times, and our forefathers in medicine may have gone to an
extreme in this matter; but certain it is, the importance of the lochia
should not be overlooked.
A piece of placenta retained may augment the flow of the discharge. If
the patient experience vomiting, very offensive and too great a quantity
of lochia, or if very severe after-pains come on, there is some reason
to suspect that such is the case; so, also, portions of the membranes
may have been retained, causing some degree of irritation. Any thing
which debilitates the system, such as too much lying in bed, overheated
rooms, too much sitting up, walking, or other exercise, and especially
too much excitement in the way of seeing company, gossiping friends,
etc., may likewise cause an excessive discharge. In those cases where a
portion of the placenta is retained, removing it is often considered the
best remedy; but according to one very able author and practitioner, Dr.
Blundell, “unless the symptoms are very urgent, it is better to refrain
from manual operations; left to its own efforts, the uterus will,
perhaps, more safely clear itself.”
_Treatment._—In all these cases the general principles of management are
plain and easily understood. We must, of course, as far as possible,
remove the causes of the difficulty; we must also treat the system
constitutionally in order to improve the general strength. Cooling wet
compresses upon the abdomen and genitals, frequent ablutions, the
sitting-bath, and in some cases the packing wet-sheet, will prove a
highly useful means; vaginal injections of water, tepid injections in
the bowels, and drinking of pure, soft water, are also to be
recommended.
_Offensive Discharge._—There is one condition of the lochia which is
very troublesome from its offensive smell and extremely loathsome
character. In such cases the red discharge ceases and is succeeded by a
profuse watery one of a greenish color, and which is sometimes called by
women “the green water;” it is frequently so acrid as to excoriate the
parts upon which it runs. It is often attended with a good deal of
general debility, causing, not unfrequently, a considerable degree of
hectic fever.
The water processes, practiced in a manner suited to the exigencies of
the case, cannot be too highly recommended or too much praised, as a
means of purification and cure in this offensive and troublesome malady.
_Suppression of the Discharge._—Women, in general, very much fear a
sudden cessation of the lochia, and for the reason that it is generally
well understood that this occurrence is attended with circumstances of
an unfavorable character. But while patients should, on the one hand,
always be careful and considerate in matters pertaining to health, they
should, on the other, not become at once frightened at every little
cessation of the discharge. As I have before said, it may cease of
itself spontaneously, and without harm to the system, within a few hours
after birth. Dr. Good, indeed, tells us “that in some women who have
healthy labors, there is no lochial discharge whatever, the
blood-vessels of the uterus contracting suddenly and closely as soon as
the red blood ceases to flow.” This celebrated author points out an
example of this kind that occurred to Professor Frank, even after a
third natural delivery; the patient, moreover, having been from a girl
as destitute of menstruation as afterward of lochia; yet her health was
in no respect interfered with.
_Diagnosis and Treatment._—If thus, on examination, we find that there
is no increase in the frequency of the pulse, or other unfavorable
symptoms, no fear whatever need be entertained. If the patient has taken
cold, causing an inflammation of the womb, an accident which may be
known by sensations of chilliness along the spine, accompanied, perhaps,
with general rigors, by the roundness, hardness, and tenderness of the
womb, which may be easily felt through the abdominal coverings; and, if
added to all these symptoms, there is great heat of the skin and
frequency of the pulse, rising to 110°, 120°, 130°, or even more; then
we may know that the suppression is a morbid one—one, too, which if not
promptly treated, may soon end in death.
Patients, under such circumstances, have great fears of cold; they
bundle themselves up, and heat their systems in all manner of ways, as
if their physical salvation depended wholly upon such a course. But the
truth is, the mischief has been already done; once there is a severe
inflammation or fever upon a patient, it is impossible for her to take
another cold until the previous one has been cured.
This fact, then, indicates clearly what the proper treatment of such
cases should be; we must treat them on the same general principles of
all other inflammations; and as soon as the fever and inflammation are
sufficiently removed by means of ablutions, wet compresses, injections,
water-drinking, and, if necessary, the packing wet-sheet, the
discharge—if any such be at all necessary—must follow as inevitably as a
stone falls to the ground. Thus it is, then, that under certain
circumstances, a cold may give fever and inflammation; while under other
circumstances, cold cures these symptoms. These operations of nature,
simple and beautiful as they are, must prove highly interesting to every
reflecting mind; and they show, moreover, the goodness, benevolence, and
design of the Creator, in furnishing us everywhere, so abundantly, a
remedy so powerful and safe as pure, cold water.
In all those diseases following delivery, the excellent Dr. Good
observes, “That cleanliness and purity of air are of the utmost
importance,” and “that, without these, no plan whatever can succeed; and
with them, no other plan is often wanted.” “They are, moreover,” he
continues, “of as much moment to the infant as to the mother. It is a
striking fact that, in the space of four years, ending in 1784, there
died in the lying-in-hospital of Dublin—at that time a badly-ventilated
house—2944 children out of 7650; though after the ventilation was
improved, the deaths within a like period, and from a like number
amounted to not more than 279.”
LETTER XXXIV.
OF CHILDBED FEVER.
Milk Fever as distinguished from Puerperal Fever—The great Danger of
Childbed Fever—Its Symptoms and Nature—Modes of Treatment—Is it a
Contagious Disease?
In the course of two or three days usually after the birth of the child,
the woman experiences more or less febrile excitement of the system.
This is what is termed _milk_ fever, it being connected with the coming
on of the lacteal secretion. The attack sometimes amounts to a “smart
febrile fit, preceded by shivering, and going off with a perspiration.”
It is not dangerous, seldom lasts over twenty-four hours, and during the
time of its appearance the breasts are full, hard, and painful, which
distinguishes this from more dangerous fevers.
Puerperal or childbed fever is a very different thing from the
foregoing, and is reckoned by physicians as being one of the most
fearful of maladies.
According to the celebrated Dr. Blundell, “women after their delivery in
general do pretty well, although no attentions are paid to them;” and it
is the testimony of the same distinguished author, that “when the
constitution is good, and the circumstances are not extraordinary, the
less they are interfered with the better;” and yet it must be admitted
by every candid and reflecting mind, that, do what we may in all the
known possible ways of fortifying and invigorating the general health,
woman must, ever in childbirth be subject to some of the most fearful
diseases and accidents to which the human frame is liable. Suppose it be
only one in fifty, one hundred, or one thousand, that is to be attacked
under such circumstances with a threatening and most dangerous malady,
who is there that wishes his wife, sister, or friend to be that one—and
that one, too, to be subjected to the treatment of an ignorant or
unprincipled quack, whether of the male or female stamp? It is for the
cases of exception, then, and not the rule, that physicians should toil
long and hard in their efforts to remedy the ills to which human nature
now is and ever must be subject.
I am led to these remarks, partly from the necessity of the case, but
more from the fact, that there are those in modern times who, through
ignorance, as we must charitably conclude, would mislead the public on
this most important subject. I will go as far as any one in encouraging
woman to pursue a rational course in the preparation for, and the
consummation of, childbirth. Those who have read my humble efforts at
authorship on this subject hitherto, must, I am confident, be aware of
this. At the same time, while I would encourage woman—encourage her even
more than any of us have yet done—I would have her to understand that
there are dangers, fearful and imminent dangers, always attending the
parturient state. Be these dangers only _one_ in a hundred or thousand
cases, they are yet dangers; and who among us, even of the most
experienced, can tell who is to be the subject of them, and who is not?
It behooves to be ever watchful in these important matters of the
healing art.
I propose, then, here to speak of that most formidable, most fearful of
all diseases to which the puerperal condition is liable, the puerperal
fever—the puerperal _plague_, as it has been called—so sudden in its
attack, so rapid in its progress, and so fatal in its effects—fatal,
that is, according to the old methods of treatment—sanctioned, as they
are, by the usage of ages.
_Time of Occurrence._—The puerperal or childbed fever comes on usually
within the fourth day, reckoning that of delivery the first. It happens
oftenest the second or third day. It may come on the first day, or it
may, though rarely, attack the patient eight, ten, or more days after
delivery. The later the day, the less the danger, as a general fact.
_Symptoms._—Childbed fever is more commonly ushered in by a chill, which
is not, however, long in duration. This is experienced most along the
back, and sometimes about the shoulders and neck. The chill varies in
degree of intensity in different cases; with some patients there is a
degree of chattering, such as occurs in a severe ague fit; with others
there is very little of the symptom; and in some cases no chill whatever
is experienced. These last, however, must be the exception to the rule.
In almost every conceivable case, a degree of chilliness, greater or
less, is experienced. As in other inflammations, this chill is followed
by fever. The intensity of the chill is considered no measure of the
vehemence of the subsequent fever; the most terrific fever may follow
very mild chills, and the contrary. Some regard that there is most
danger to be apprehended when the chills are of a mild character.
Here I ought to remark, that patients should not be frightened at every
little chill they may experience. The coming on of the milk—the milk
fever, as it is called—heat in the breast, and a variety of
circumstances other than those of childbed fever, may be preceded by or
attended with chills. Indeed, almost every mother with a new-born child
experiences more or less of chilly symptoms; and yet fortunately but few
are attacked with that terrible malady of which we are treating. So much
by way of encouragement in regard to the matter of chills.
In connection with the rigors before mentioned, the patient complains of
pains in the abdomen; these may be so slight as to be scarcely
perceptible to pressure on the part, or they may be so violent and
severe that the gentlest touch of the finger is regarded with
apprehension, and the weight of the bed-clothes proves a burden that
cannot be borne. “Sometimes the pain,” says Professor Meigs, “which is,
at the onset of puerperal fever, felt in the hypogastric region, is too
intense to be borne by any human patience; and no exhortation or
recommendation can prevent the woman from crying out aloud, or even
screaming with her agony. All over the abdomen these pains may be felt,
above, below, to the right, to the left, in the region of the diaphragm,
and in the lumbar region; this diffusion, however, is neither constant
nor frequent, and it is found, especially in the less malignant
varieties of the disease, that it is in the region of the navel, and
more especially below it, that the patient complains.” Severe
after-pains may be experienced in connection with the disease, or the
reverse. Little or no fever may occur in connection with severe pain,
and so the contrary. If the pain is circumscribed, as we say—confined
mostly to one spot—it is far more favorable; but if the pain and
tenderness are spread over a large surface, beware, lest there be
mischief at hand. If the pain be even slight, and yet diffused
extensively over the surface of the abdomen, we must take heed lest we
get into trouble that will imminently endanger the patient’s life.
The pulse always rises high in childbed fever. This is one of the most
distinctive features of the disease. It is seldom lower than 115 or 120
per minute, except when it is giving way before the power of remedial
means. More commonly it rises to from 130 to 140 beats per minute, and
it has been known to rise as high as 160 or 170. These last, however,
are extreme cases—exceptions to the general rule.
Besides the symptoms enumerated, there sometimes occurs headache,
sometimes vomiting, and at others purging, which last symptom is
probably in general a good omen.