The Treatment of Chronic Pelvic Pain, BY ELY VAN DE WAfiKEI^ M. D., SYRACUSE, NEW YORK., Fellow American Gynecological Society, Surgeon to the Central New York Hospital for Women, Surgeon to the Syracuse Woman and Children's Hospital, Consulting Surgeon to St. Ann's Maternity Hospital. REPRINTED FROM The American Gynecological Journal, Toledo, Ohio FEBRUARY, 1893. THE TREATMENT OF CHRONIC PELVIC PAIN. BY ELY VAN DE WARKER, M. D., SYRACUSE, N. Y., FELLOW AMERICAN GYNECOLOGICAL SOCIETY, SURGEON TO THE CENTRAL NEW YORK HOSPITAL FOR WOMEN, SURGEON TO THE SYRACUSE WOMAN AND CHILDREN'S HOSPITAL, CONSULT- ING SURGEON TO ST. ANN'S MATER- NITY HOSPITAL. There are among the diseases incident to the sex none that demands relief more urgently, or that makes more exactions upon the skill and knowledge of medical men, than the chronic pelvic pain of women. This is, or I believe I am anticipating the march of events but little if I say was, the age of laparotomy. Among the conditions which were regarded as ample justification for this operation was the purely subjective one of pain. I have some surgical friends who never hesitated to remove the ovaries for all painful pelvic diseases, and without regard to what appeared to be the secondary matter of organic disease. If pain were cured by this simple surgical operation but few would object. But, unfortunately, radical surgery does not always cure. Abdomino-pelvic surgery is practiced everywhere and by every- body to such an extent that I doubt if there are many of you who have not had the subjects of this operation, made for this subjective condition, come back upon your hands no better, if not made worse, than before the operation. For myself, I will make the assertion that there are many cases of pelvic pain for the relief of which it is not proper to remove the uterine appendages; and further, that there are many cases of pelvic pain in which these organs are perfectly healthy, and the conclusion is logical that their extirpation could furnish no relief. There is one other thing that is more harmful as a routine treat- ment than even an unnecessary laparotomy, and that is the use of morphia. One thing is absolutely true, that if you continue the use of 2 this subtle drug in the treatment of chronic pelvic ailments, you will probably wreck a human life and involve a soul in unspeakable gloom and sorrow. Understand me, I do not say that morphia ought not to be used; that it is not a beneficent drug; that it has not even life saving qualities, or that our therapeutic agencies would not lose one of its most potential factors if this drug should be obliterated; and, although it has inflicted untold miseries and disgrace upon weak humanity and will always continue to work its destructive charm, is there one among us who could conscientiously consent to forego its rightful use ? I do, however, state without any qualification, that if you begin and continue its employment in chronic pelvic pain, either constant or periodic, you will not only not cure your patient, but will build up around her a morbid therapeutic environment, as it were, that will effectually close all other avenues of relief and cure. She measures every drug you may employ thereafter by the spiritual and physical standard of morphia. It may be that you will be called into a case in which the morbid demand is established. You have before you, then, the thank- less task of readjusting the value of the actual pain to the morbid sensibility engendered by the resort to morphia on each recurring exacerbation. In order to get control of the patient, it is necessary to discontinue the use of morphia, which, if she has been accustomed to it for any great length of time, is used in a dose altogether out of pro- portion to its proper anodyne effect. In many cases it will be impossible to discontinue the drug with the patient in her family environment. Even in hospital work I have often been obliged to insist that the mother, sister or husband return home and leave that patient, under the penalty of declining to treat the patient if they refused. When at last the drug is discontinued and the craving for morphia is appeased, then other measures may be resorted to with some hope of success. Many of these cases are not morphia habitues; it is employed only during the periodical attacks, the period of the inter- crisis being free from the drug. In this condition, the difference from daily use is only one of degree. It will be nearly as difficult to get the patient to place faith in any other agency. Morphia holds another relation to these cases of pelvic pain, and as I have never seen it referred to, it is worth mentioning. Pelvic pain of a purely hysterical type is not unusual. These cases may often be traced to some prior instance, either in a relative or friend. Cases of this kind may deceive the most acute. As you observe the contortions of the woman in her agony, your sympathies are appealed to in a most active way. If you have any doubts of the character of the pain, it comes later, when you remember that her demonstrations were too histrionic and the circulation and temperature were not at all disturbed in proportion to the outward expression of suffering. Now, if you administer a hypodermic dose of morphia a 3 new train of symptoms develops that antagonizes all the accepted facts concerning the drug as an anodyne. The pain continues in full force, but the patient has acquired fresh energy in her expressions of suffering. Instead of an anodyne, the drug has become an intoxicant and has de- stroyed what little self-control the patient had left. I have seen morphine used far beyond the danger line with no other effect than to render the patient uncontrollable. [ regard the rule as absolute that in any instance of pain in which the intoxicant instead of the anodyne effect of the drug is evidenced, it is a case of simulated or hysterical pain. And this is only another way of saying that morphia and hys- teria are entirely incompatible at any and all times. In doubtful cases I have frequently resorted to morphia purely for diagnosis, as in hospital work strange cases will exhibit emergencies of pain before you have an opportunity to study their temperament, and I cannot recall an instance in which it has failed to give me a clue to the character of the pain. As this paper is devoted to the therapeutics of the condition, we will not stop to define either the cause or pathology of pelvic pain, but simply describe the treatment, other than operative, best calculated to give relief. The agent upon which I rely for the treatment of sudden and violent attacks is codeia, generally in the form of codeine sulphate. It cannot be used on parallel therapeutic lines with morphia, if the latter has been previously used any length of time. Administered hypodermically, its effect is nearly as rapid, but without the seductive cerebral effect of morphia, and also without the secondary gastric reaction that is oftentimes such a painful after effect of liberal doses of the latter. Given by the mouth, it may render the bowels constipated, but only in a moderate degree, and easily regulated by mild laxatives. In severe paroxysms its hypodermic use is advised and will rarely ever fail in repeated doses. I have now been using it for several years, and I have never yet seen the morbid craving so quickly excited by mor- phia follow its use. In severe pain not of an explosive character I always administer the drug by the mouth. I reserve codeine for what I may term severe pain. It is to be used in the emergency, just as morphia is used by many, designing to combat the more moderate forms of pain with less potent agencies later. Generally speaking, it is the minor ills that make up the sum of human misery, and the same may be said of pelvic pain. The mod- erate, constant grinding pain is what impairs vitality and moral fibre alike, and sends the woman, oftentimes helpless and discouraged, to bed. I think we all owe to Dr. Edward W. Jenks, of Detroit, a debt of grati- tude for bringing the value of viburnum prunifolium to the notice of the profession. It is essentially a uterine anodyne, and for pain of moderate intensity it may be relied upon to render good service. Especially is it valuable in the pain of dysmenorrhoea, either of an 4 obstructive or congestive origin. In its administration I employ the fluid extract and give small doses frequently repeated, and thereby gain a considerable advantage over large doses at long intervals. One of its drawbacks is its very disagreeable odor, which can be modified by being combined with aromatics. Pulsatilla is another drug which will give very satisfactory results, although it is given an officinal place coupled with a doubtful charac- ter. Yet I have often been greatly pleased with its action in pelvic pain of any character. A very useful combination is with viburnum, and is the way I generally prescribe it. While the viburnum expends its action upon the uterus, tending in a marked manner to control the circulation, pulsatilla selects the ovaries as the seat of its action, largely controlling pain of a throbbing, congestive character. Clinically, the difference in effect between the two drugs could be expressed by their therapeutic action. Pulsatilla would not relieve the pain of an obstruct- ive dysmenorrhoea, which, unless it was of a severe and explosive character, viburnum would do, demonstrating its quality of uterine selection. Viburnum would not relieve the pain of an irritable and congested ovary, for which pulsatilla could be given with marked effect. Aletris farinosa is another of the milder pelvic sedatives which has a good general reputation, but, from my experience, I doubt if it can be relied upon to overcome a painful state of any of the pelvic organs. Singly, its employment is indicated in passive congestions of the pelvic viscera, cases in which we can observe a highly reddened state of the vaginal portion, and when the finger detects with abnormal clearness the pulsations of the uterine or cervical artery. It serves a more useful purpose when given in combination. Belladonna is a very powerful pelvic sedative. It has to be used with caution when continued any length of time, and its dosage must always be limited to the comfort of the patient. In the form of suppo- sitories, either alone or combined with morphia, as it so frequently is, considerable caution is to be employed, as it tends to diminish intes- tinal contractility, allowing large quantities of gas to accumulate, which seriously disturbs the patient and is difficult to get rid of. The sitz bath and the hot water douche are valuable agents when properly employed, but in domestic nursing I have always found it difficult to have the details of the work carried out effectually. It re- quires a trained nurse to secure ideal results. From a long series of observations in the Central New York Hospital we found that a tem- perature of about 110° gave more certain sedative results than where used as " hot as it can be borne," as some direct. Some cases of pelvic pain are accompanied by a disagreeable sense of pulsation of the pelvic vessels. The combined douche, as we call it, will sometimes give marked relief. Cold is a more direct sedative than heat, but when we speak of a cold douche it is only relative cold, as the water itself is 5 really warm. The theory of it is to produce a marked shock upon the arterial circulation of congested organs, even if caused by inflammation or strangulation due to adhesions or distortion. With the patient lying, she is given a vaginal irrigation of about fifteen minutes with water at 110°. This current is shut off and one of 70° substituted. The shock is quite marked, but rarely painful. The arterio-capillary circulation is profoundly influenced by the sudden slap, as it were, that is given to the vaso-motor nerves, and an effect is produced that will last for hours. If a contrast of 40° is too great it may be lessened by giving the initial douche at 95° to 100°. The secondary douche is never used lower than 70°. As a method of controlling painful pelvic conditions, the effect of properly adjusted manipulation of the parts within the pelvis must not be overlooked. This is sometimes called massage, but if by this term is meant any of the indescribable manipulations known as Brandt's method the term is misapplied. If, to illustrate, it were the knee or ankle joint that was being manipulated to restore impaired mobility, we would describe it as passive motion. And that term conveys the very idea I wish to apply here. It does not require any special tech- nical training in massage as an art to apply what I call pelvic passive motion; it calls, however, for a definite idea of what you intend to ac- complish by your manipulations. Two objects must be in view; first, to break up, or to cause the absorption of adhesions between the intra- pelvic parts. Secondly, to relieve the venous engorgement that results from want of exercise or the immobility caused by adhesions. It is proper to say, that while it may require but little manual dexterity to make the simple manipulations necessary to do this, it requires a very practical expert knowledge to know when to do it, otherwise one might find himself patiently handling a distended tube, to the great danger of his patient and the sure defeat of his well meant efforts. With this contra-indication eliminated, the method is about as follows: With the finger of one hand-the left is the better hand-inserted into the poste- rior vaginal cul-de-sac, the part is gently raised up to resist the external manipulating hand. This consists of a gentle rubbing motion with sufficient force, if the parts are not too tender, to detect the impulse by the finger within the vagina. This may elicit a sharp sense of pain at first, which passes off as the treatment continues. As the manipulating hand is carried successively to the right and left ovarian region, the supporting finger follows it to the right and left cul-de-sac. As the tenderness is gradually overcome by the repeated treatments from day to day, the intra-vaginal finger may elevate the parts with carefully graduated force to meet the pressure of the hand. The finger, as it presses against the uterus, may give a lateral movement to the cervix, producing a corresponding movement in the fundus of the organ, and thus put a new strain upon adhesions. It is surprising in some cases 6 how quickly motion may be restored to the uterus. In cases of retro- version this is a peculiarly effective manipulation. Sometimes, drawing the uterus down with a volsella and throwing the fundus forward as the organ descends will expedite the treatment. The latter procedure is also effective in contraction of the utero-sacral ligaments. This method can never be carried out in the office safely, but is either home or hos- pital work, the patient confined to the bed for one or two hours after. In some cases of very sensitive pelvis it may take some time before free manipulation can be practiced, but patience is generally rewarded. In painful pelvic conditions it is very desirable oftentimes to diminish the blood supply of the lower uterine segment. To this end I have found elastic pressure in the vagina to give great relief, especially in those cases in which the uterine artery may be felt by the examin- ing finger to pulsate with morbid energy, the throb of which may even be appreciated by the patient. Lambs' wool forms an ideal tampon. That the patient may easily remove it, a string should be attached to each tampon, but the simple matter whether the string is tied by a knot has a practical bearing. If the string is tied it prevents the ex- pansion of the wool when in place; if, however, the string is doubled and the ends passed through the loop around the wool, the bulk can be greatly reduced while being introduced, to expand to its full size the moment the string is released. Generally, two tampons are required, but the number may be varied according to the degree of pressure required. A liberal application to the parts, before the introduction of the wool, of a 5 to 8 per cent, solution of ichthyol in glycerine or albo- lene has appeared to have a local anodyne effect. Churchill's tincture may be used for the same object, with a more pronounced alterative and absorbent action. In cases where the pelvic adhesions are very firm and extensive upon the left side, abdominal and pelvic pain is far more in evidence than where the trouble is mainly upon the right. This is due to flatu- lence caused by the implication of the upper rectum and sigmoid flexure. A careful regulation of the diet and the correction of flatulent indigestion will afford complete relief. Some practitioners resort very freely and continuously to the use of bromides in these cases. This practice is to be condemned. The pain controlling influence of the drug is very limited in active or chronic inflammatory conditions, such as are very generally present in the cases in view, but its power to impair muscle nutrition is by no means so limited. I have seen very disastrous results follow the use oi bromides in long standing cases, the muscle waste being almost beyond repair. So very general is the use of the salt that I doubt if this action is as well known as it ought to be. From my own experience I do not hesitate to say that the bromides have no place in the treatment of chronic pelvic pain. Hydrochlorate of ammonia, by its definite 7 quality of resolving inflammatory products, fills a well marked indica- tion. By its stimulating action upon gastric and hepatic functions it also contributes further aid to its specific action. The absorption of inflammatory products is a vital function which is active just in pro- portion to the vigor of nutrition and the consequent rapidity of tissue metabolism. This equation in the problem must be given its due value. It is not necessary to enumerate the agencies that tend to this end, as they must be familiar to every one. I cannot in a brief practical paper refer to all the remedies that may be used to relieve chronic pelvic pain. This is an age of constant advance in therapeutic agencies, and it forms an interesting index to the tendencies of the age to observe that the majority of these new drugs are either anodynes or hypnotics, and are the product of the chemical laboratory and not of the herbarium. From this numerous list each may select what seems good, with results, I doubt not, more or less beneficial. I will conclude with the advice not to treat tubal disease with any of the methods I have detailed here. As a rule, to which I am willing to admit there are many exceptions, a tube distended with pus, or any other fluid accumulation, has but one remedy, and that is its removal by laparotomy. It ought to be removed as early as possible, before the general health is broken down and before serious and extensive pelvic lesions are caused by repeated acute outbreaks. Especially are we not to make the mistake of employing electricity in any form of distended tube with the idea of curing it. Such a use has done more to bring into disrepute a valuable remedy in the opinion of surgeons than its failures in all other pelvic diseases combined. In many forms of func- tional pelvic pain it will be found that electricity in any of its forms, with due observance of tension and quantity, will give great satisfaction and often lasting results.