Reference to individual practice and methods is out of the question here, nor is it at all necessary. There is hardly an accoucheur of any note, who has not of late years expressed his views in regard to vaginal and uterine injections. The majority certainly grant the broad general principles on which the uterine douche in particular is based, even though they differ in minor details. Accurate diagnosis is above all necessary, and then, in the presence of strict indication, the uterus may and should be washed out, and thus frequently is a most forlorn hope saved.
In administering the intrauterine douche, there are certain details at tention to which will facilitate the procedure, and render it less irksome and disturbing to the patient. It is above all necessary to determine at the outset the exact position of the uterus in order to insert the tube with as little traumatism as possible. This position may be ascertained by means of the bi-manual palpation. The choice of the tube is, we believe, a matter of some importance. An inflexible tube is preferable to a rubber, for the reason that it cannot be compressed, and therefore a con tinuous flow is assured. We have already insisted on the necessity of closure of the central orifice of the tube, for the reason, to quote Mundt, " that, although not often likely to occur, it is still not impossible that the jet of injection fluid, thrown from the central terminal opening of a uterine tube, may dislodge a fresh thrombus at the placental site, and air enter the venous circulation, or a secondary hemorrhage be produced. . . . . In order that this may not occur with side openings, it is well to have the latter so arranged as to throw the jets slightly backward." It is not at all essential to use a double current tube, for the reason that in all cases where the uterine douche is called for, the uterine orifices and cervical canal are wide open, and there is no obstruction to the return flow by the widest outlet.
The patient should lie on a self-discharging bed-pan, since thus we are at liberty to use as much fluid as we desire continuously without disturbing the patient for the purpose of emptying the bed-pan, as is necessary when the ordinary china bed-pan is used. The external geni tals are first to be carefully washed, and the tube, filled with the hot fluid, is then inserted into the vagina and this canal thoroughly douched. Then, guided preferably by the index of one hand, the tube, still full of fluid, is gently inserted into the cervical canal to the internal os, and then the handle is depressed or elevated or rotated, according to the position of the uterus. When sufficient fluid has been allowed to flow into the uterus to acquire a clear return flow, the tube is withdrawn carefully and the manipulation is at an end. In case of a slight chill, this is of no im
port, and will soon subside of itself.
We would conclude this matter with two recent expressions from eminent authorities which, we think, summarize this question of intra uterine douching in a nut-shell.
Mundt says : " I desire to put myself on record in this matter of intra uterine injections, which have been recommended by eminent authors in every instance of rise of temperature in the puerperal state. I do not agree with this practice unconditionally, for if there be no fcetid lochia, no evidence of intra-uterine decomposition, I believe there is nothing to be gained by intra-uterine irrigation, even though there be a rise of temperature. On the other hand, the presence of offensive lochia without a rise of temperature does not necessarily call for intra-uterine irrigation, since many women have offensive lochia without the slightest constitu tional disturbance. In such cases I think vaginal irrigation all-sufficient. I wish to qualify these statements by saying that even in the absence of offensive lochia, if there be no obvious cause for the elevation of tempera ture, it may be a wise precaution to irrigate the uterus once or twice; but after such irrigation, there being no detritus removed from the uterus, I should consider further irrigation useless, and perhaps even injurious, and whether the temperature fell or not, I should then look elsewhere for the cause of the rise, and seek to reduce it by other means. Finally, I believe that intra-uterine irrigation should be discontinued as soon as it fails to remove decomposing matter from the uterine cavity, even though the temperature may not be reduced, for I think that I have seen the continuance of uterine irrigation under such circumstances cause hemorrhage, chills, abdominal tenderness, and be even followed by increase of temperature, which symptoms I am inclined to attribute to the traumatic irritation caused by the passage of the tube and the injec tion." Lusk says : " In the treatment of puerperal fever, the intra-uterine douche is warmly recommended, but it cannot be too strongly insisted upon that, in a rightly conducted confinement, infection does not begin in the uterine cavity, and that the need of such injections is a confession of faulty procedure. There are two forms of fever which cannot be reached by the uterine douche, one derived from sewer poisoning, and the other from peritonitis, starting from some of the recently studied forms of tubal disease."—Ed.]