side openings lower down or the nozzle is not introduced to the proper depth, an opening may face the os and some fluid be injected into the uterus, which gives rise to a very painful and alarming uterine colic.

If the chief aim of the injection is to combat inflammation and cause absorption of inflammatory exudations, plain hot water is the best. The amount should not be less than two quarts. The temperature should be as high as the patient can stand it-i. e. so that she just can hold her hand in it (110° to 115° F.). In exceptional cases hot water increases instead of relieving pain, and is then advantageously replaced by lukewarm water. Cold injections are injurious.

For merely cleansing the vagina-for instance, when a pessary is worn-a pint of tepid water suffices, and its effect may be increased by adding a heaping teaspoonful of common salt or bicarbonate of sodium.

If an astringent is called for, alum, borax, or equal parts of sulphate of copper and alum are dissolved in the water. Of alum or borax, a teaspoonful is added; of the mixture of copper and alum, only half a teaspoonful.

If there is a spongy os uteri giving rise to hemorrhage, I use half a teaspoonful of the liquor ferri chloridi to a pint of water.

For antiseptic injections carbolic acid (1 to 2 per cent.) or creolin (to 1 per cent.) are used. The latter is also an excellent hemostatic, but in some patients it produces a smarting sensation. Bichloride of mercury should be avoided, except for gonorrhea, on account of its poisonous properties, and the solution should not be stronger than 1 to 3000 or even 5000.

As an emollient injection a decoction of flaxseed tea or slippery-elm bark, a heaping teaspoonful to each quart of water, is good.

Vaginal douches are, in chronic cases, as a rule, used morning and evening, and in acute three times a day, or even every three hours. Intra-uterine injections are much more dangerous than vaginal injections, and should always be administered by the physician himself. We distinguish between small and large intra-uterine injections. The former are really only applications of drugs made on a larger scale. The injection is made by means of a small glass syringe with a long nozzle, with one or more fine openings near the end (Fig. 147). Having seen several cases of alarming collapse follow the use of this method, and knowing that it has been fatal in the hands of others, I have entirely discarded it.

Large uterine injections are used for cleaning and disinfecting the uterus and for checking hemorrhage. If the cervix has been thoroughly dilated before injecting, a single-current tube is preferable, as it leaves more room for evacuation of large débris. For this purpose 1 Garrigues, "Corrosive Sublimate and Creolin in Obstetric Practice," Amer. Jour. Med. Sci., Aug., 1889, vol. xcviii. pp. 109-128.

I find the so-called soft-metal male catheters sold in the stores of the instrument-makers very convenient, as they are easily bent so as to adapt themselves to any shape of the uterine canal. By adding a flange at the open end, connection is easily established with a fountain

FIG. 147.

Braun's Uterine Syringe.

syringe (Fig. 148). If the cervical canal is not so wide, a double-current uterine tube (Fig. 149) should be used. When it is of importance to bathe the whole inside, cervix and body, it is best to use two

FIG. 148.

Garrigues' Single-current Intra-uterine Tube.

single-current catheters, a thinner afferent and a thicker efferent. The fluid then comes out partly through the thick tube and partly between and around both.

The patient is placed on a table, unless she is so weak that it is deemed better to leave her in her bed, and only move her sufficiently beyond one edge to have a free back-flow from the vagina. The outer leg is placed on a chair. Whether she remains in bed or is placed on a table, a rubber sheet or oil-cloth is pushed in under her buttocks, and pinned with two pins so as to form a funnel, the lower end of which opens into a slop-pail. Intra-uterine injections ought only to be given in the dorsal position in order to avoid the entrance of the fluid through a possibly dilated tube into the peritoneal cavity. The vagina is first disinfected by injecting some of the fluid and by swabbing the wall thoroughly with large pieces of absorbent cotton dipped in the same. Cusco's speculum is introduced. The intra-uterine tube is attached to the tubing of the fountain syringe, and, all air having been expelled, is pushed up to the fundus of the uterus while the fluid is turned on. The physician watches the flow all the time to make sure that there is no obstruction. I use about a quart for the vagina and from a pint to a quart for the uterus. When the uterus is deemed to be sufficiently washed out, it is squeezed in order to remove all fluid from its cavity. Finally, the vagina is again douched, and the perineum depressed so as to allow all fluid to flow off.

For these injections I prefer creolin (1 per cent.), as it is a non

poisonous reliable disinfectant and an excellent hemostatic. Lysol is also good, and has the advantage of forming a nearly clear mixture

FIG. 149.

Goelet's Double-current Intra-uterine Tube.

with water. I have never seen any untoward symptoms follow this kind of injections.

If the patient is anesthetized, it is better to dilate the cervix, introduce a cervical speculum (p. 150), and introduce an intra-uterine tube through the speculum all the way up to the fundus.

Rectal injections, enemas, or clysters are used for emptying the lower part of the bowels, or as a vehicle for medicinal substances to be applied to the diseased mucous membrane, or in order to exercise an influence on the pelvic organs, or to overcome an obstruction in the intestine, or to mark the course of the intestine (p. 158). If the object is only to cause a movement of the bowels, plain lukewarm water may be used, or a teaspoonful of salt may be added, or soapsuds or an infusion of linseed-meal (a tablespoonful to a quart) may be injected. In cases of constipation with impaction of hard feces the following is an excellent enema: a teaspoonful of inspissated ox-gall, a tablespoonful of glycerin, a tablespoonful of castor-oil, and a heaping teaspoonful of salt, to a quart of linseed-meal infusion. The ox-gall is stirred with the warmed glycerin, the oil is added, then the flaxseed tea, and finally the salt.

For tympanites an enema with a teaspoonful of oil of turpentine, a tablespoonful of castor-oil, and a quart of soap-suds or flaxseed tea is good. All these enemas are given lukewarm.

In diseases of the rectum often astringents or sedatives are used in injections. As the fluid in these cases is meant to be retained for some time, the amount should be small ( 3j to 3iv).

Large injections (1 to 2 quarts) of hot water (110° F.) into the rectum have been recommended instead of vaginal injections in uterine and other pelvic disease.' They offer the advantage that the hot water reaches a larger area in the pelvis, but the aperient and weakening effect is in most cases a drawback.

1 J. R. Chadwick, Trans. Amer. Gyn. Soc., 1880, vol. v. p. 282.

After operations rectal injections of a pint of tepid water may be used to relieve thirst. Similar injections of very hot water may be used to combat collapse caused by loss of blood.

All rectal injections are best given with the patient lying on her left side. Evacuant enemas are preferably administered by means of a bulb-and-valve-syringe (Davidson's), but where it is desirable that as much water as possible should enter the bowel, the fountain-syringe used with very little pressure is by far better.

Vesical injections are used very much in diseases of the bladder. The patient occupies the dorsal position. For large injections Keyes's

FIG. 150.

NO I

Keyes's Irrigator for Bladder.

irrigator (Fig. 150) may be used. It is essentially a fountain-syringe with a two-way stop-cock, which allows alternately to fill and empty the bladder simply by turning the stopcock. It may be used with any hard or soft catheter. Another good and simple apparatus for washing out the bladder consists of a catheter, an intermediate piece of rubber tubing about two feet long, and a funnel. The funnel is held up during injection, and is brought down below the level of the bladder when we want to empty it, thus establishing a siphonage. Care should be taken to let as little air as possible enter the bladder. Where shreds are to be washed out, Nott's double-current catheter (Fig. 151) with its large eyes will be found

to answer a good purpose. For smaller injections, Thompson's rubber bag with stopcock (Fig. 152), inserted into a soft catheter with hard

FIG. 151.

Nott's Double-current Catheter.

rubber mouth-piece is handy. For the injections is used plain water, or solutions of chloride of sodium (1 per cent.), salicylic acid (1 per thousand), boracic acid (3 per cent.), tannin (to 1 per cent.),

carbolic acid (per cent.), creolin (per cent.), permanganate of potassium (to 2 per thousand), nitrate of silver (2 to 5 per thousand), etc. The amount of fluid used varies from half a pint to a quart; for small injections one to four ounces are used. Generally the fluid should be pleasantly lukewarm (95° F.), but as hemostatic hot or icewater is used. The irrigation of the bladder is repeated once, twice, or three times a day.

Intravenous, subcutaneous, or intraperitoneal injection of a hot solution of 6 parts of chloride of sodium in 1000 parts of hot water (110° to 115° F.), or about a flat teaspoonful to a quart, is used with great benefit to counterbalance loss of blood in operations. (See Uterine Fibroids.)

C. Curetting. The instruments used for scraping the inside of the uterus have been described in the preceding chapter (p. 153). The patient is placed on a table arranged for intra-uterine injection (p. 173). As the procedure is often protracted and painful, she ought to be