A system of practical medicine. By American authors. Vol. 4

by Unknown

Ergot stands at the head of the list from its well-known effect in causing uterine contraction, and although reliable in proportion to the increased size of the uterus and the distension of its cavity, it is indicated in almost all cases for its hæmostatic action on the capillaries, as well as for its specific action on the uterus. Digitalis slows the action of the heart and excites the contractility of the arterioles, while experience has proved it to be an efficient remedy for menorrhagia. Bromide of potassium moderates vascular and nervous excitement of the pelvic organs, and is especially indicated in cases having an ovarian origin. Several of the French writers give very strong testimony in favor of the efficacy of cinnamon as a remedy, having tested it in a large number of cases without other medicines. It may always be used as an adjuvant.

All these medicines may be combined in various proportions, and they should be given in full doses. Infusion is the best form for the administration of digitalis. Sulphate of quinia in doses of gr. vj-x is often an efficient remedy, and especially in cases where there have been malarial influences. Cannabis indica is stated, by very high authority, to be one of the best remedies, although its mode of action is not clear. Iron should be administered as an hæmostatic tonic, and not merely because there is some uterine disease or derangement.

The action of medicines may be supplemented by local applications. Cloths wrung out of cold water or vinegar and water may be applied to the hypogastric region or to the vulva. A bladder or rubber bag filled with pounded ice may be laid on the abdomen above the pubes, or applied to the lumbar region for its effect upon the spinal cord. One of the most efficient means of applying cold is by an enema of cold water, or, this failing, of ice-water. The rectum and uterus being contiguous, the cold is applied almost directly. Siredey speaks highly of the cold douche to the soles of the feet, the water being projected in jets from a sprinkler. During the application uterine contractions are felt and the flow stops. This is more especially adapted to debilitated and anæmic patients with loss of vascular tone. Patients will often object to the application of cold to check a flow of blood from the uterus, knowing well the bad effects of suppression of menstruation which often results from exposure to this agent. It is believed that evil results never follow the application of cold when the flow is excessive; perhaps because the system and the organs concerned have been relieved.

The application of heat is also an efficient remedy—hot-water bags to the spine on Chapman's plan, or hot vaginal injections may be administered, as recommended by Trousseau and Emmet, the water being at a temperature as high as the patient can bear. To be properly administered the aid of a nurse is required, as the flow should be kept up for some time, at least a gallon of water being used.

There is only apparent contradiction in the use of both cold and heat to check uterine hemorrhage. Various explanations of the action of both have been given, and much argument presented why one should act better than, or be preferred to, the other. The truth is, that both are efficacious, and the value of both is based upon clinical experience.

The flow in menorrhagia is sometimes, if rarely, so excessive as to demand mechanical means of restraint. A well-applied tampon gives absolute control, and should never be omitted when the hemorrhage is severe and the practitioner is not within easy reach of the patient. Plugging the cervix with a sponge tent, supported by a vaginal tampon, is to be preferred as most reliable, and also because upon its removal the uterus can be explored for diagnosis or is prepared for direct applications. Should a vaginal tampon alone be trusted, it must be thoroughly applied to be reliable. This can only be done through a speculum, preferably with Sims's duckbill. Pledgets or discs of cotton, the first provided with strings to facilitate removal, squeezed out of a carbolized saturated solution of alum, should be packed carefully and firmly around and over the cervix, and the vagina filled. A folded napkin to the vulva, supported by the usual T bandage, sustains the whole. Such a tampon may remain, if necessary, thirty-six hours, the catheter being used to relieve the bladder.

Direct applications to the interior of the uterus are sometimes necessary both to check the flow and, in some cases, especially those dependent upon fungous growths of the endometrium, as a means of cure. They may be either fluid by application or injection, or solid. The former may be by swabbing the interior of the uterus by means of an applicator armed with cotton dipped in the liquid, or by injection. The drugs used for application are carbolic acid diluted with glycerin or pure tincture of iodine, or the stronger tincture known as Churchill's, Monsell's solution, or the liquor ferri perchloridi diluted or of full strength. The preparations of iron are objectionable from the hard, gritty, and disagreeable coagula formed, and the tincture of iodine is generally quite as efficient as a hæmostatic and more active as an alterative.

For efficient application the cervix should be dilated if not sufficiently patulous, and a cervical speculum should be used, or the solution will be squeezed out of the cotton before it reaches the seat of the disease. For injection the same articles are used, beginning with weaker solutions and gradually increasing the strength. They should never be resorted to without the utmost caution. The os should be patulous as a sine quâ non, and the injection carefully administered. In case the os is open the instrument may be the common extra long-pipe rubber syringe bent to a suitable curve by heating. This having been charged with a drachm or so of the liquid, the end is served with cotton like an applicator; over this several clove-hitch turns with a string are taken, so that the cotton may be withdrawn if pulled off in the uterus. The pipe is then carried to the fundus and the piston very slowly depressed. Buttle's syringe is a more elegant and a safer instrument in cases where the os is not thoroughly opened. The terminal pipe of this instrument is very slender and perforated with minute openings, and the piston is forced in by screw-action of the handle, so that the fluid is expelled drop by drop.

Nitrate of silver is sometimes applied in solid form to the interior of the uterus, both as a means of checking excessive hemorrhage and to effect a cure by modifying the condition of the endometrium. It may be done with a probe, the end of which has been coated with the substance, passed in detail over the inner surface of the organ. A piece of the solid caustic is also sometimes carried into the uterus and left there, the application à demeure of the French, some of whom claim that in their hands this measure has never failed to check the hemorrhage.

In those cases where positive evidence has been gained that the disease depends upon fungous growths of the endometrium there is yet another and a more reliable remedy. It is the curette. By this instrument the growths which are the origin of the menorrhagia can be certainly and safely removed, their return prevented by a thorough application of iodine to the surface from which they spring, and a cure often effected when all other means have failed.