LETTER XXXII.. Treatment of After-Pains.

TREATMENT OF AFTER-PAINS.

The Nature of After-Pains—The different Kinds—Their Causes—Treatment—The great Value of Water-Cure.

Usually after delivery, the woman experiences more or less pain in or about the abdomen, generally in the womb or the back, constituting what is termed “after-pains;” these are called after-pains, because they occur after delivery.

It is an important fact, one well worth considering, that as a rule, no after-pains worth mentioning are experienced during the first confinement. Do women become weakened necessarily by giving birth to children? Are their cares and duties too many as they become mothers, in the present state of society? Are the plans of medical treatment, such as are usually adopted in childbirth, calculated more and more to undermine the constitution? Are people almost universally in the habit of debilitating themselves by connubial excesses in the married state? These are questions of vital importance to all who expect to be mothers.

After-pains proceed from the contraction of the uterus, caused by the presence of bloody clots, the blood having oozed from the orifices of the torn vessels, and becoming coagulated in its cavity. The pains come on usually very soon after the expulsion of the after-birth, and may last a few hours, or for a number of days, according to the nature of the case and the treatment employed. Each severe pain usually expels a clot; they are often increased when the child attempts to suck, a fact showing the great sympathy existing between the uterus and the mammary glands.

After-pains may also be caused by costiveness, or, rather, by the presence of hardened fecal matter in the colon. They may also proceed from flatulency.

Dr. Dewees mentions one kind of after-pains of very distressing character, which he had not seen noticed by other writers. He met with a few cases, and I have myself seen one or two instances of the same kind. It is a most severe and constant pain at the very extremity of the sacrum and coccyx (the extreme lower portion of the spinal column). It begins, Dr. Dewees says, the instant the child is born, and continues, with the most agonizing severity, until overcome by the rapid and liberal use of camphor and opium. The sedative effect of cold water is, I hold, altogether better than these so-called remedies. This pain, it is declared by the patient, is vastly more insupportable than the pains of labor, for it is as intense in character, and holds on almost without intermission, which the pains of labor do not.

After-pains are, no doubt, sometimes rendered much worse than they otherwise would be, by improper management at the time of confinement; if the labor is hurried in an unnatural way, the probability of more severe pains is evidently increased; especially if the after-birth is hurried away before the uterus has sufficient time to contract itself they are rendered more protracted and severe; the better the womb contracts, the less the blood will flow into its cavity.

We should be careful always to distinguish these pains from inflammation of the uterus, peritoneum, or other parts within the abdomen. After-pains are remittent; the abdomen is not particularly painful to the touch; the lochial discharge is not obstructed; the patient has no shivering; milk is secreted in due time; there is no general feverishness worth mentioning; and the pulse is not affected. But in case of inflammation, the opposite of these symptoms obtains. There may be, it is true, and sometimes is, more or less increase of heat when there is simply after-pain, but this heat does not at all amount to inflammation.

There is still another kind of after-pains, different somewhat from any I have yet mentioned. They are called spasmodic. The uterus, like all other parts of the human system, and especially those which are highly endowed with nervous sensibility, is liable to take on spasmodic action. These spasmodic pains are sometimes very violent; the patient writhes in agony, tossing herself from side to side upon the bed, and sometimes it is necessary for a number of persons to hold her. These symptoms sometimes become so violent as to end in convulsions, it is said. Spasmodic after-pains appear to happen, for the most part, with those who are excessively nervous, and particularly with such as have been in the habit of using strong tea and coffee, opium, and other narcotic substances. The fashionable tea and coffee drinking, and the use of morphine and other preparations of opium, which have been so much resorted to in this country these later years, depend upon it, have a great deal to do in these things.

Treatment.—How are we best to manage these formidable difficulties in midwifery practice? Shall we stupefy the patient with camphor, opium, or prussic acid, as many have done? Shall we do better than this, and tell our patients, as many do, that these pains are natural, and should not therefore be interfered with, and are to be borne with as much patience as the sufferer can put forth? Or shall we adopt a process which is, on the one hand, more potent, more effective, and more powerful than any other known to quell pain and spasm, from whatever cause they may arise; while, on the other, it does not at all injure the constitution, or leave after it any bad effects?

Dr. Dewees tells us it must be admitted that neither camphor nor opium 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.