From these considerations in regard to the etiological factors, the rules for and the contra-indications to injections into the uterus may be formulated as follows: I. The cavity of the uterus must be wide enough that the walls be not distended by the injected fluid, and at times, hence, only a small quantity of fluid should be used, and its ready outflow must be assured. The capacity of the uterine cavity should be determined by means of the sound, and thus we may estimate the'amount of fluid which should be injected. In order to assure the outflow, Freund, Hennig, Gallard, Avrard, who are accustomed to use quarts of water, have devised double canula?. By employing these the danger of stasis in the uterus is lessened, but not entirely done away with, since the openings in the canula may become occluded by clots. The safest plan, according to Spiegelberg, is to dilate the cervical canal before injection, except where it is large enough already to allow the exit of even large clots by the side of the canula. Hildebrandt claims that this precedent dilatation is unnecessary in case after the injection the entire quantity of fluid can pass out of the uterine cavity. We must be specially careful in injecting in cases where uterine flexions exist or new growths in the wall of the organ.
The fluid should only be injected slowly, drop by drop. The temper ature of the fluid should be that of the body, certainly at the outset, when we have not ascertained the irritability of the uterus.
Injections' should not be administered in the presence of recent in flammatory processes in the uterus and its surroundings. Remnants of exudation are not absolute contra-indications, although they call for extra care.
In case there are new growths of the uterine mucous membrane, owing to the possibility of there being present as well patent blood-vessels, these growths (vegetations) should be removed before resorting to injections. We must always take care not to inject air, and it goes without saying that pregnancy must be excluded; many indeed do not administer injec tions shortly before or after the menstrual period, although solutions of iron have been injected during menstruation without bad effect.
Since, in regard to the occurrence of uterine colic, it is important to know what agents produce large and hard coagula, J. C. Nott and I ex perimented with various astringents and caustics. The persulphate and chloride of iron, alum, carbolic, tincture of iodine, permanganate of potass, zinc solutions, were tested on solutions of albumin, and it can be stated that iodine, zinc•oxide, permanganate of potass, and alum, produce scarcely any firm coagula, and that carbolic precipitates the albumin in powder form. The addition of glycerin produced no coagulum, and the mixture of glycerin and liquor ferri, and with nitrate of silver solution, diminished greatly the formation of coagula, while a tannin-glycerin mixture caused large coagula.
For the purpose of injecting fluids into the uterine cavity, various and frequently objectionable instruments have been used. C. Braun, Sims, Freund, Hoffmann, Vorstiidter, and others, have invented, however, very serviceable instruments, of which number the Braun-Madurowicz's instrument is most in favor. The cylinder of the instrument holds twenty drops of water, and the extremity is Curved like the uterine sound, being constructed of hard rubber. extremity of the instrument is fitted with a movable cap which may be rotated so that the stream may be directed in ally desired direction. It is of advantage to have the glass cylinder near the outer extremity of the instrument, for thus the working of the pis ton, may be noted by the eye. The Hoff mann syringe is constructed like the Braun's, except that the fluid, instead of being injected directly into the uterus, is deposited on a piece of absorbent cotton, which is wrapped the extremity of the canula, and thus the agent is brought indirectly in contact with the uterine mu cous membrane.
To inject the uterus the patient should occupy the dorsal or elevated dorsal posi tion; the lateral may be used, although care should be taken that the intra-abdominal pressure be positive; the cervix is exposed by a speculum and fixed by a tenaculum. The discharges are wiped off with cotton, the cervix is surrounded by it to receive the discharged fluid, the syringe, filled with the warmed fluid is inserted, care being taken that it contain no air. The cervical canal, where necessary, should first have been di lated, and the uterine cavity have been thoroughly irrigated after the manner to be mentioned further on. The piston is very slowly pushed home, the fluid being discharged drop by drop into the uterine cavity. During the pro cedure there should be a free outlet by the side of the syringe, otherwise the injection should at once be checked. Where the fluid remains in the uterine cavity, it is to be sucked out by reversing the action of the syringe. It goes without saying that the point of the canula must be inserted above the internal os.
The injection may be administered through a cylindrical speculum, or without using any instrument whatsoever, the canula being guided into the uterus along the finger. But thus, aside from the danger of infection bywervical or vaginal discharge, it is impossible to watch the outflow of the fluid, and we are unable to guard against its action on the vagina. In case it is impossible to insert a speculum, or in case we are unable to expose the cervix, as may happen where the uterus is much displaced by a fibroid, then the vaginal walls may be protected by irrigating the canal during the administration of the injection.