Conservative Treatment of Pelvic Infections.
(From Transactions National Association.)
J. C. MITCHELL, M. D., LOUISVILLE, KY.
This paper will deal with those inflammatory troubles, due to an infection, following child-birth, abortion, or miscarriage. I will not mention the well known symptoms.
Treatment.—First be sure that the uterus is completely free from all decomposing material, such as remains of placenta or secundines. If any are present, remove them by a thorough curettage.
Next clean the bowels out very thoroughly. If the rectum is very full, use repeated enemata. Give small doses of calomel—1/10 grain hourly for ten or fifteen doses. If vomiting is present, add two to five grains of cerium oxalate to each dose. Or you may give any cathartic you wish, just so you get the desired effect. Then give small repeated doses of magnesium sulphate every hour or two until the bowel movements are very watery.
In giving epsom salts, if you will add 25 per cent of soda bicarbonate and thoroughly dissolve in a glass of water, your patient will not taste either. The nasty taste of the soda seems to neutralize the horrible taste of the salts.
Your patient may be suffering with sharp, stabbing, lancinating pains through the lower abdomen. She is so tender that she cannot bear the weight of the bed-clothes. The least movement of the body or even of the bed causes her to cry out in agony. Turpentine and heat, usually moist heat, will relieve until your remedies have a chance to act. You can put the turpentine in the hot water, out of which you wring the cloths, or you can mix up equal parts of lard and turpentine and rub over the bowels and then apply the hot, wet cloths. It is desirable to stimulate absorption of the turpentine with the heat. After the tenderness is relieved some, you may use a hot plate, stovelid, or hot water-bottle to continue the heat, so that the cloths will not have to be changed so frequently.
The sharp cutting pain in a serous membrane, aggravated by motion, calls unmistakably for bryonia. Veratrum is called for by a full, tense pulse with dry, hot skin. I usually combine these two unless marked asthenia is present, when I use aconite. If to these two drugs is added colocynth, for the stabbing pains that cause the patient to draw up the knees, or nux for the intermittent pains around the navel, we will usually relieve our patient rapidly and effectively. But some patients can stand so little pain that they insist on something being done quickly. But never accede to their almost universal demand for morphine or any other form of opiate. Take the sharp edge off the pain with atropine or hyoscine hydro-bromate or a combination of the two may be more effective.
Opium, while it will certainly relieve the pain, paralyzes the bowels, locks up the secretions, and worst of all, masks the symptoms. I have seen cases of peritonitis doing well until some idiot gave them morphine, when their abdomen would swell up like a drumhead, pulse run up, and death close the scene.
Hot frequent copious douching will aid materially in relieving pain and reducing the inflammation. Carbolic acid, lysol, or creoline may be added to the douche with much benefit. The douches should be hot and re-repeated every three or four hours, using a half or a gallon of water each time. After the acute stage has passed they may be used one to four times daily.
The use of depleting suppositories frequently produces profuse watery discharges, thereby reducing the inflammatory exulate. These may contain only boroglyceride or boroglyceride with iodine or ichthyol. They should be used just after the douche.
For the first twenty-four to thirty-six hours the patient should not receive any nourishment—never until the bowels are thoroughly cleaned out. It is senseless to fill a patient up with food when she cannot digest it, because it would lie in her stomach and ferment, causing more trouble. The patient appreciates plenty of water unless vomiting, when she should have all liquids in small amounts or none at all if vomiting persists.
A faithful observance of this treatment, modified to suit positive indications, will almost invariably result in marked improvement in the patient's condition. After the acute stage has passed keep your patient in bed on light diet and with loose bowels, giving the intestinal antiseptics—the sulpho-carbolates or salol—in sufficient quantities to keep the odor non-offensive. Continue the indicated remedies.
Veratrum is usually called for by the chronic inflammation. This remedy helps to absorb the exudate and acts as a general alterative. Bryonia will be called for if the pains, worse on motion, continue. Macrotys is indicated by the deep aching, with occasional twinges. Tiger Lily relieves the continuous hurting in one or both sides. Pulsatilla relieves nervousness, and fear of impending danger—(she is sure she will have to be operated upon). The pains that pulsatilla relieves are those that come and go, first in one place and then in another.
Echinacea is called for when symptoms of sepsis commence to develop or after the fever has continued for more than thirty-six hours, to assist in preventing or limiting the formation of pus. This can be combined with the other liquids. Calcium sulphide, chemically pure, is an excellent thing to help the action of the echinacea. Give it until the patient complains she tastes rotten eggs. If we have the white, dirty, pasty tongue, we would naturally think of sodium sulphite.
Tincture iodine, turpentine and lard aa, chloroform liniment, oil of wintergreen, mustard or any stimulating application applied to the skin over painful area two or three times a day, and the continued use of a hot water bottle to keep up the counter irritation, will be grateful to the patient.
The depleting suppositories can be used once or twice daily as long as they cause a watery discharge. Ichthyol, iodine, zinc sulphocarbolate, zinc sulphate and many other astringents may be incorporated in them.
The hot copious douches should be given two to four times daily. They may contain soda bicarbonate when the leucorrhea is thick and glairy, some astringent when it is profuse and watery, or a sedative lysol or carbolic acid, when there is a good deal of inflammation remaining.
In instructing a patient to take a douche explain that the vagina should be ballooned and to use a large quantity of water and allow it to run through very slowly. Tell her that the first effect of hot water is to cause a swelling of the tissues and the next to cause a shrinking. This is the effect that you want. Whenever a woman understands why you want her to do a certain thing nothing is too much trouble. Have them use a douche pan in the bed or bring the hips to the side of the bed with feet on two chairs and a pillow under the hips. Have a piece of oilcloth or rubber from under the hips to carry the water into the slop pail. A douche taken, squatting over a commode or jar, is absolutely useless.
A faithful observance of this line of treatment for from one to six or eight weeks will result in saving the sexual organs of many women that would otherwise be compelled to sacrifice them. If, in spite of our earnest work, pus forms in any appreciable quantity and it points in the cul-de-sac, give it free vent. If it localizes in one or both tubes, take them out. But just because a woman has an enlarged and tender tube or ovary it is no excuse for any surgeon to unsex her. Anybody can take out a tube and ovary, but it takes a physician, well acquainted with his materia medica, to cure a case of pelvic infection.
Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.