The use of the warm and of the hot douche, although its purpose was predicated and it was strongly endorsed by Kiwisch, was earlier still advocated by &dillot, and later by Trousseau, Scanzoni, and others. Its present wide popularity, however, must be traced to American influence. Kiwisch formulated the indications as being atonic amenorrhea, vicarious menstruation, chronic " induration " of the uterus, neuralgic dysinen orrhea, and in the writings of Benicke, Bertraun, G. Braun, Chadwick, Emmet, Kurz, Landau, Noeggerath, Peter, Richter, Rokitansky, Runge, Schenck, Simpson, Windelband, and others, it is endorsed in case of extra- and Sntra-peritoneal exudations, hemorrhages, in particular the puerperal and those associated with fibromas of the uterus. In case of inflammatory affections of the ovaries, hot injections ordinarily increase the pain.
At the outset we must carefully utilize the douche at a temperature which is pleasant to the patient, remembering that phlegmatic women bear higher temperatures than those of the reverse constitution. Where our aim is to cause absorption and softening of indurations, I know of no agent which will yield such good results. Higher temperatures (116°) have been advocated by Emmet in case of hemorrhage, and the uterine cavity itself may be similarly douched.
The hemostatic effect of hot water has, however, been exaggerated, and it has been claimed as valuable under all circumstances. This is erro neous, for it seems that after the use of hot water relaxation of the tissues surrounding the uterus, and of the organ itself, is more likely to occur than after the use of cold water. Nevertheless, hot injections, aside from the puerperal state, have often rendered me good service in case of hemorrhage, and it is particularly noticeable that they are less objection .able to anemic and nervous patients than are cold.
To administer these injections, a receiver holding from two to four quarts is needed, which yields a steady stream, 'and the patient must assume the dorsal position with the pelvis slightly elevated. We may add carbolic, or permanganate of potass, or, in case of hemorrhage, iron, to the solution which is to be injected. After the injection has been administered the patient should remain on her back for a while.
In the use of vaginal injections it is to be noted that the effects are variable according to the force of the stream, the elevation of the temper ature, the concentration of the solution, and the quality and quantity of the agent which is added to the injected fluid. Aside from the untoward
effects of entrance of the solution into the uterus, injections should be used with great care in acute inflammatory processes in the genitals, particularly of the ovaries, bladder and rectum. Intense pain in the pelvis, uterine colic, a feeling of oppression, increase in the inflammatory process, hemorrhages, general congestion, loss of consciousness, meteorism, profuse perspiration, such are often noted sequeke. Many women insert the tube too far into the vagina and do damage, particularly where readily bleeding neoplasms are present. It is therefore advisable to order injec tions only in the face of strict indications, and to give patients such apparatuses with which they are not likely to injure themselves. In stances where the sequelte have been untoward were not those in which an irrigator or similar apparatus was used. Even fatal cases have been recorded by Ebell, Spaeth, Thomas, and others, the result, likely enough, of the entrance of air and of different solutions into the uterine veins.
b. Int ra-Uterine Injections.
Lisfranc and Vidal de Casis are the first who resorted, in a routine way, to the injection of fluids into the uterus. From Cohnstein's histori cal sketch it is apparent that injections of this nature were used long before the time of these authorities, and Lisfranc states that Vignerie first used them at the end of the 17th century. It would appear, how ever, that the solution was not injected into the uterus. It is only in the last forty years that the procedure has gained ground, although still there are many gynecologists who refuse to resort to it, in view of the possible untoward sequelie.
Just at the time when intrauterine injections were beginning to be generally administered, Hourmann recorded a case where they were fol lowed by intense peritonitis; Bretonneau two deaths. Since then the like cases are frequent enough, Astros, Barnes, Bessems, Gubian, Haselberg, Heywood Smith, Kern, Kormann, Fanchon, Weber, and others, having recorded each one fatal case, and Becquerel, IIegar and Kaltenbach, each two instances, and the cases where the injections have been followed by alarming symptoms—generally peritonitis—are numerous. In many of these cases it is evident that faulty instruments were used, or else that there was neglect of the necessary precautions, and the vast majority of gynecologists are of the opinion that the injections are not danger ous, if they are resorted to under strict indication and with sufficient care.