As for the intrauterine douche, there exists absolutely the same indica tions in maternity hospitals and in private practice. The difficulty is not so much to decide when to administer it, as how often to repeat it. As Muncie has rightly insisted, there comes a time when repetition of the douche apparently does harm.
The foremost indications for the intrauterine douche are fcetor of the lochia, in the presence ordinarily, therefore, of putrid infection, and, as we have already stated, whenever the hand or instrument has been intro duced into the cavity of the uterus. None of the accidents which are said to be possible as the result of administering such a douche, are at all likely to occur if a proper tube be used, if it be inserted carefully and full of the solution, and if we remember that our aim is to wash out the uterus and not to inject it—that is to say, it is better to use the continuous stream from a fountain syringe, and not the intermittent from a David son.
The injection tube which we prefer is the Chamberlain, although a double current catheter, or in an emergency a gum-elastic catheter will answer very well. It is not after all the kind of tube, but the manner of inserting and the manner of injecting, which are of the greatest impor tance. The solution used, whether carbolic, or sublimate, does not we think make any special difference in the result. Our object is to wash out from the uterus the products of decomposition, and to disinfect the cavity. A point to be remembered is that certain patients are very sus ceptible to mercury, and that, therefore, a solution of the strength of 1 to 4000 is strong enough. The solution should be hot, at least 110° F., in order to avoid possible chill, and iu order to obtain the styptic, con tractile, effect of heat. At least one quart of water should be used at each injection. On several occasions we have used a mixture of iodine and water in equal parts, in case of endometritis with good results. A vaginal injection should be given before the intra-uterine, and it goes without saying that, in any case where the uterus is supposed to contain portions of placenta or secundine, which from their decomposition are causing the septic symptoms, careful exploration of the uterine cavity with the finger or curette under, if need be, an anaesthetic, should precede the intra-uterine douche.
As to the frequency of administration, it is difficult to speak with posi tiveness. In our hands the douche is used mainly for the purpose of cleansing the uterus, and not so much for its undoubted effect on the temperature. It has seemed to us, therefore, not advisable to repeat the douche more than twice, as long as fcetor is absent. For the reduction of the temperature we depend rather on means to be mentioned shortly. In case of septic endometritis of high degree, the use of iodoform pencils in the uterus, to be inserted between the douches, has been strongly re commended, but this seems to us inadvisable, because of the fact that we thus run the risk of disguising the danger signal, the call for another douche, that is to say, the fcetor. We believe that in mild cases of endo metritis one thorough douche will often be the only one requisite. In se verer instances the douche may be given every two hours even, without fear of injuring the patient, but, on the contrary, to her positive benefit.
There is one point in regard to the intra-uterine douche on which sufficient stress cannot be laid, and this is that it is useless and is not indicated except where the source of infection lies in the cavity of the uterus. Exudations around the uterus, whether of septic or traumatic origin, are not benefitted, but may be, on the contrary, intensified by manipulation of the uterus. The point to be decided is whether the endometrium is at fault, whether the cavity of the uterus contains a putrescent body, and this can only be settled by careful bi-manual palpa tion under, if necessary, anesthesia. Fcetor, rise of temperature, chill, may depend on a lesion of the vagina or cervix, as well as on infection from the uterus. We must first differentiate the source of the infection, as nearly as may be, and where in doubt, in the absence of evidence of cellulitis or of peritonitis, it is a good and a safe plan to give with care one thorough intra-uterine douche.