PREVENTION AND TREATMENT OF PELVIC IN-
FLAMMATORY DISEASES IN THE FEMALE
BY THE GENERAL PRACTITIONER.

By R. R. KIME, M.D., ATLANTA, GA.

As a basis for our remarks we make the following quotations:

"Pelvic inflammation arises almost without exception from septic or specific infection." Amer. Text-book Gynec., page 439.

"Whether or not the disease starts or exists elsewhere, an endometritis eventually develops in every case of gonorrheal or puerperal pelvic inflammation." Amer. Text-book Gynec., page 443.

"Of 116 cases of tubal disease twenty-seven were gonorrheal with peritonitis." Schmidt, Annual Universal Med. Science, page 23.

"Puerperal sepsis most frequent cause of tubal disease. Gonorrhea not cause of more than twenty-five per cent." Baldy--2 Annual Universal Med. Science, 1891, page 23.

"All cases of ovaritis are preceded by endometritis or salpingitis except rare cases of sclero-cystic ovaritis of funetional and diathetic origin." 3 Pozzi (p. 487, latest edition). "Lesions of the ovary as a rule coexist with those of the tube." Pozzi, page 486.

"Puerperal infection following labor and abortions, especially under septic conditions, should be placed among the chief causes of inflammation of the appendages." Pozzi, page 489.

"Sanger and A. v. Rosthorn find tubal disease in thirty

three per cent. of women affected with gonorrhea." Kelly, page 210, Vol. II.

"Gonococci have been found in ovarian abcesses by Wertheim, Sanger, Zweifel." Kelly, page 210.

"Gonococcus infection travels usually along the mucus membrane, may be arrested in tube or extend to peritoneum." Kelly, page 210.

Streptococcus infection usually follows badly conducted puerperium or after abortion, or introduced by use of dirty instruments." Kelly, page —.

"Wertheim found in 116 cases of pyosalpinx that seventy-two times there were no bacteria, thirty-two times there were gonococci, six times streptococci and once staphylococci." Kelly, page 211.

We may approximately estimate without statistics that fifty per cent. of pelvic inflammatory diseases are due to infection after labor or abortion, twenty-five per cent. to gonorrheal infection, the remainder to various causes including "rheumatic diathesis, chilling during menstruation, venereal excesses," the use of unclean instruments, dressings or hands in minor gynecological manipulation.

If these statements be true a great responsibility is forced upon us, and we must face the inevitable in the discharge of our duty to womankind.

The prevention of puerperal, gonorrheal and instrumental infection in the great majority of cases is the duty of the general practitioner. He should know how, and conduct labor and abortions antiseptically if not aseptically. See that the patient is properly prepared, that bedding, clothing and dressings are clean, that his own hands and instruments are properly cleaned and disinfected. In fact everything that comes in contact with genitalia during and after parturition should be clean--aseptic. After every labor be certain that uterus is thoroughly emptied and properly contracted. Never use post-partum vaginal douches except for special cause. Have genitals cleansed twice a day with some efficient antiseptic solution.

If there is a continuous slight elevation of pulse and temperature a week after labor when bowels have been properly moved, diet regulated and quinine given without effect, it is usually due to some mild form of infection and want of drainage. Such case can occasionally be relieved by giving strychnia with some bitter tonic and using ergot in sufficient doses to produce contractions of uterus, lessening its size and expelling contents. Copious hot antiseptic vaginal douches may be of benefit if properly used at this time.

If these means fail, then the uterine cavity should be irrigated, disinfected and drained. In all cases of active infection such a course should be instituted at once.

curette a uterus in acute active septic infection.

Never

As to treatment and technique of drainage see transactions for last year, page 185.

Here I again urge, after twelve or fifteen years of practical tests in all grades of infection, that drainage, uterine and alimentary, is the best method known to the profession of to-day for the treatment of these cases. That it will save more lives, conserve more tubes and ovaries, prevent more hysterectomies, and leave a woman's generative organs in a healthier condition than by all other means of treatment combined.

The prevention of infection after abortion and its treatment is much easier accomplished. Simply clean out, irrigate, disinfect and dress uterine cavity with iodoform gauze moistened with camphorated phenol, let remain twenty-four to forty-eight hours, then remove, using all the while copious hot vaginal douches twice a day. The expectant plan of treating these cases has sacrificed the health and life of many a woman, especially in the city. It is worse than meddlesome midwifery to undertake to treat these cases without proper disinfection of hands and instruments and everything that comes in contact with the field of operation. To fail to do so is not only wilful neglect, but may be murder of the innocent unsuspecting confiding patient.

As to gonorrhea, he who treats the male has the first duty to perform, which should never be neglected. Every physician that treats such a case and fails to warn his patient of the danger to the female of sexual intercourse before the male is completely cured is derelict of his duty and indirectly responsible for the suffering of many a poor innocent

woman.

Any man who conveys gonorrhea or syphilis to a woman should be subject to punishment by law.

Its treatment in the female, when recognized, should be prompt and energetic, especially if it is an acute active infection.

Always endeavor to prevent the virus entering uterine cavity. In gonorrheal vaginitis cleanse vagina, apply camphorated phenol pure on pledget cotton held in uterine dressing forceps, cover inflamed area with C. P. pulverized boric acid, then dress with a pledget of gauze lintine or absorbent cotton. Let dressing remain twenty-four hours, remove, irrigate vagina thoroughly with two to three gallons of hot antiseptic solution for repeated use, boric acid preferable. Redress the same, except use camphorated phenol and olive-oil mixed in proportion of one to two parts respectively to apply to infected area and moisten the dressing, using it freely, also as much as two to four drachms of boric acid at each dressing. When cervix is involved treat similarly.

When the uterine cavity is invaded, and not until then, dilate cervix, curette uterus, wash out with mercuric chloride 1:4000, dress with iodoform gauze moistened with camphorated phenol. Irrigate with mild antiseptics and redress uterine cavity every twenty-four hours, using the oil and camphorated phenol on gauze after first dressing.

If urethra or bladder is involved give pyrozone, three per cent. solution, one teaspoonful in teacup hot water three times a day on empty stomach; also a bitter tonic containing fluid hydrastis colored and an alkaline diuretic with plenty of water, preferably lithia water.

If much tenesmus one quart infusion of buchu and uvaursi leaves is drunk every twenty-four hours.

In sterile women with deficient uterine development, flexed uteri, dysmenorrhea, to prevent or correct tubal involvement, dilate cervix thoroughly, curette uterus, disinfect and dress antiseptically with iodoform gauze, intrauterine end wet with camphorated phenol.

Use copious hot antiseptic vaginal douches with dressing in uterine cavity, give salines, also equal parts Elix. Six Bromides and Liquor Sedans to relieve pain and for its sedative effect on generative organs.

Such cases should be followed with uterine drainage commencing a week or ten days after operation; never use a plug or stem cervix that does not drain, but a drainagetube with plenty of openings and large channel so as to secure free drainage. In placing and replacing tube always cleanse, disinfect and dip tube in pure camphorated phenol, cleanse cervix and introduce tube without touching anything except cervix with tube.

If drainage is obstructed in these cases, or you infect patient by dirty work either at operation or removing, cleansing and replacing tube afterwards, you will do more harm than good. Where work is done properly and aseptically the dysmenorrhea and abnormal condition of uterus is not only relieved, but tubal and ovarian involvement in many cases prevented or relieved and the sterility cured.