When the requisite precautions have been taken, I have never wit nessed any marked reaction; occasionally there is slight colic, or slight hemorrhage, but I have never seen the untoward sequels which we have spoken of as possible following the injection of medicinal agents. Still it is necessary to resort to such disinfecting irrigation with great care, and with attention to the essential rules.
c. Permanent irrigation.
Although repeated irrigation of the uterine cavity is an excellent an tiseptic measure, still by means of it we cannot obtain lasting disinfec tion. It is further inconvenient to irrigate frequently, since it must be done by the physician, and the patient's rest is further disturbed. In all cases where the nature of the secretion, the temperature curve, etc., point to the fact that asepticism has not been obtained, notwithstand ing repeated irrigation, permanent irrigation should be resorted to. Although the indications for this procedure will usually be met with in obstetrical practice, cases are often enough seen in gynecological practice, such as septic wounds after operations, in particular partial enucleations of tumors from the uterus and vagina, and here as well constant dis infection is desirable.
For the prevention of septic infection, Billroth, Mikulicz, and others, after total extirpation of the carcinomatous uterus, have resorted to per manent irrigation, as also Holzer, and others, in case of chronic catarrh; but ordinarily the protracted hot douche is used to cause absorption of parametric exudations.
For the purpose of permanent irrigation, the patient should lie on a self-discharging bed-pan, and those parts of her body which come in contact with the fluid should be smeared with vaseline or glycerine. Many useful apparatuses have been devised in order to enable us to irri gate permanently with the least possible annoyance to the patient.
Irrigation of the vagina with the least possible wetting of the patient is possible by the use of a IIolzer or Mikulicz's speculum, which is very similar to the Bodenhamer. The Holzer speculum consists of a hard rubber cylinder fitted with two tubes, the one for inlet and the other for outlet. I have used a rubber bladder for closing the vulva. It is like the Trendelenburg only it is fitted with a third tube for the pur pose of inflating the bladder. My apparatus (Fig. S3) is self-retaining, while Holzer's must be kept in place by a T-bandage. By means of such apparatuses the patients are able to move somewhat without becoming wet through, but being difficult to cleanse they are themselves likely to be causes of infection.
It is preferable to resort to irrigation after Kfistner'a method. His apparatus consists in a reservoir from which extends a rubber tube, at the extremity of which is the glass vaginal canula. This canula has a number of openings in the portion which is inserted into the vagina. The patient occupies the dorsal position, with negative or diminished intra-abdominal pressure, the nates being elevated, the vulvar cleft look ing upwards, and thus the entire vagina may be filled with water. Under these conditions a very weak stream, drop by drop even, suffices for the irrigation. It is often unnecessary to have a constant stream. Accord ing to Schultze, with the patient in the above position, it is sufficient to renew the fluid in the vagina every few hours.
Permanent irrigation of the uterine cavity may be secured by means of Fritsch's hydrostatic disinfection apparatus. Schiicking has favored permanent irrigation, and with certain modifications his apparatus is a good one. It consists of a reservoir, rubber tube, and a canula
through which the fluid may discharge drop by drop. For purposes of irrigation, the disinfecting agents which we have mentioned may be used, the fluid being kept at the temperature of the body. The tube may be left in situ for days, being occasionally removed for cleansing. Only where there exists flexion is it advisable to use a rigid tube, and then a short, thick-walled, rounded glass tube is to be preferred.
Permanent irrigation, although based on correct principles, is not generally used, and the impression should not exist that it is always an agent for good. Aside from the disadvantage of the protracted stay of a foreign body in the uterine cavity, whence uterine contractions may be excited; aside further from the possibility of absorption of the fluid (car bolic acid poisoning, etc.), and the untoward sequehe of entrance of fluid into the veins and tubes, we should further remember that the disinfect ing fluid may not come in contact with every portion of the uterine cavity, for a similar condition exists as in case of irrigation of the bladder by the double current catheter. A tound the opening in the tube a cavity forms, and large portions of the mucous membrane lie close together and will not be reached by the fluid, and such is the case during irrigation of the cavity of any muscular organ. In case of irrigation of the vagina, it is possible, by utilizing the negative intra-abdominal pressure, for the fluid to bathe the entire canal even when the stream is weak. In the uterus, however, the conditions are far less favorable. Of this any one may convince himself by placing carmine, for instance, in the uterus or the vagina. Even after repeated profuse irrigation the fluid will return colored. I have often thus experimented with the normal uterus, and it is apparent that the conditions for disinfection are far greater in the cases where it is called for, owing to the many folds, creases, and angles which exist in the mucous membrane.
In case we take measures to lessen the intra-abdominal pressure, then the further difficulty arises that shreds and portions of tissue sink to the most dependent parts, and it is hence necessary to increase the force of the stream occasionally in order to thoroughly wash out the residual fluid and its contents.
Notwithstanding these considerations it is nevertheless true that per manent irrigation is a most valuable measure for obtaining the stringent disinfection of the genitals which is to-day deemed requisite.
In case we aim at simple drainage of the uterus, then we may use the rubber tubing with retention cross-bars, or preferably still glass tubes provided with numerous openings. In order to retain the drain in the uterus and to disinfect the discharges, the vaginal portion of the drain tube should be surrounded by carbolized, thymolized or iodoformized gauze.
Good results have been obtained by Ahlfeld and Schwarz from drain age of the uterus in case of chronic catarrh, mechanical dysmenorrhea, and amenorrhea. Ahlfeld uses for this purpose the perforated intra uterine stem which he devised, and Schwarz used rubber drains, and later, at Olshausen's suggestion, small glass tubes, in thin bundles, about two and a half inches long, and tied together at their uterine extremity, to guard against slipping. The bundle is powdered thoroughly with iodoform and carried into the uterus on the sound, or by means of a slender forceps. The outer extremity carries a string for the purpose of facilitating removal.