In connection with such sequelte we must take into account the fact as to whether the aim of the injection is to leave one or another drug in contact with the endometrium, in which event but little fluid should be used, or where the object is to cleanse the uterine cavity, in which case a quart or more of fluid should be used. The first aim may be better ful filled, and without risk, by methods we will shortly refer to; the second cannot be attained in any other way.
Various agents have been used for medicating the uterine cavity. Bennet, G. Braun, Breslau, Boissarie, Gantillon, Menne], Routh, Sigmund, advocate iron salts; Hildebrandt, Murray, Noeggerath, Ricord, Routh, Savage, Spiegelberg, Steinberger, Tilt, the tincture of iodine; Vidal, Sigmund, a solution of iodide of potass; Freund, iodide of lead and of potass; Martin, Sigmund, sulphate of copper and alum; Furst, Recamier, Retzius, Steinberger, Sigmund, solutions of nitrate of silver; Guillemin, sulphate of zinc; Evory Kennedy, nitrate of mercury; Furst, Sims, glycerin; Filhos, M. Duncan, plain water; others, salts of lead, alum, tannin, carbolic acid, etc. One or another of these agents may be used, and the risk does not depend on the kind of agent, but on the strength and the manner of insertion.
The chief risk from intrauterine injections is peritonitis. In Hamel berg's and Kern's cases, and in one of Heger and Kaltenbach's, it was determined post-mortem that the iron solution had been forced through the tube; Astros found the injected fluid in a vein of the broad ligament; Bessems found air in the vena cave, although this case, like Barnes's, was that of a puerpera. In Hase'berg's and in Kormann's case, as Gold schmidt has pointed out, it is probable that the fatal result was rather due to accumulation of pus or purulent fluid in the tubes than to the passage of the fluid through them.
Vidal de Oasis, Hennig, Olioli, Klemm, Rokitansky, and others, have made experiments on cadavers to determine the possibility of the passage of fluid through the tubes, and they reached the same conclusion that by taking the necessary precautions no fluid enters the tubes unless the cervix closes around the canula, and much fluid is injected (over 5 j. Vidal) and with considerable force. The results, however, are not en tirely applicable to the living, seeing that in them the contraction of the circular muscular fibres around the ostia tubarum guards against entrance of fluid, this contraction being caused by the stimulation of the uterine mucous membrane; but then, on the other hand, there are instances where the opening of the tubes are patent and here the entrance of fluid is favored (Bischoff). It sho•ild be noted, however, as is emphasized by
Heger and Kaltenbach, that there has been no fatal case recorded where all the requisite precautions, to be noted further on, were attended to.
Aside from the affections which result from the entrance of fluid into the tubes, and which are now of infrequent occurrence, we often see more or less severe inflammatory affections of the uterus, the cellular tissue and the peritoneum, uterine colic, nervous disturbances, collapse, fainting, spasms, and the like. These occurrences are to be laid to the irritation caused by the injection, and very frequently, as Schwiirtz has surmised, to infection from the cervical or the vaginal secretion. Although in general it may be stated that an hyperesthetic hysterical woman will react far more from a given irritation than a woman of the opposite constitu tion, this rule has many exceptions, and we may witness in phlegmatic women uterine colic, and not at all in anemic, hysterical women. It is wise to determine beforehand the tolerance of the genital canal to irritant causes. The bimanual examination will suffice to determine this irrita bility, and it is not necessary, as is recommended by Rehme and others, to test it by means of the sound. The presence of recent and old inflam matory affections in the uterus or its surroundings, will generally cause reaction against uterine injections.
The irritation caused by injections is either chemical, thermic or mechanical, and depends on the caustic or astringent effect of the fluid used, or on the degree of temperature, the force of the current, the amount of fluid which distends the uterine cavity.
The presence of large or small coagula in the cavity will cause the uterus to contract energetically, in order to free itself from its contents, and these contractions will be the more intense the greater the difficulty in expulsion; and, furthermore, large coagula prevent the outflow of the injected fluid, and the danger of its entrance into the tubes is heightened. Under mechanical irritation belongs, of course, damage to the endome trium by the point of the syringe.