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

FIG. 142.

Bozeman's Double-current Uterine Tube.

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 nonpoisonous reliable disinfectant and an excellent hemostatic. I have never seen any untoward symptoms follow this kind of injections.

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. 156). 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 tympanitis 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.1

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. 143.

NO I

Keyes's Irrigator for Bladder.

irrigator (Fig. 143) may be used. It is essentially a fountain-syringe with a two-way stop-cock, which allows alternately to fill and empty 1 J. R. Chadwick, Trans. Amer. Gyn. Soc., 1880, vol. v. p. 282.

the bladder simply by turning the stopcock. It may be used with any hard or soft catheter. Where shreds are to be washed out, Nott's double-current catheter (Fig. 144) with its large eyes will be found to

FIG. 144.

Nott's Double-current Catheter.

answer a good purpose. For smaller injections, Thompson's rubber bag with stopcock (Fig. 145), inserted into a soft catheter with hard

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 hot water (110 to 115° F.) 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. 151). The

patient is placed on a table arranged for intra-uterine injection (p. 168). As the procedure is often protracted and painful, she ought to be anesthetized.1 The vagina and uterus are disinfected with creolin (p. 169). The cervix is dilated (p. 152). The condition of the inside of the uterus is ascertained by sound (p. 150) or finger. The index-finger is preferable if the cervix admits it. In introducing it counter-pressure is made on the fundus with the other hand. The nail of the finger is often used itself as curette. It is safer than, but not so efficient as, instruments. In gynecological cases I use the dorsal position, introduce the curette through Cusco's speculum (p. 142), and move it up and down along the surfaces and edges and from side to side along the fundus. In cases of incomplete abortion I turn the patient on her left side and work with the left index-finger and the large dull wire curette simultaneously. The scraping should be continued until everything is removed and the inside of the uterus is smooth. Then the patient is turned back into the dorsal position. Finally, the uterus and vagina are again disinfected, and a tampon is put in the latter until the following day. The hemorrhage is not very considerable. It is very rarely necessary to renew the tampon. On changing it a vaginal injection with creolin or carbolic acid is given, and after its final removal twice a day as long as there is any discharge. The patient is kept in bed for four days. If there is any pain, which is an exception, an ice-bag is applied over the symphysis and the patient is given an opiate..

Thomas's dull-wire curette being rather short to be used through Cusco's speculum (he uses himself Sims's position and speculum), I have had one made that is eleven inches long. The instrument should only be used for scraping in the direction from the fundus to the os and along the fundus. In moving the curette up toward the fundus great gentleness should be used, as otherwise the instrument may perforate the uterus. If this should happen, the beginner need not be particularly alarmed. It has happened twice to me, and no bad consequences were observed, but in such a case it is necessary to desist from washing out the uterus, an omission which, of course, in other respects is undesirable. The smaller the loop of the curette, the greater is the danger of perforation. We should, therefore, always use as large an instrument as will enter the cervix and is in reasonable proportion to the mass to be removed. In cases of incomplete abortion before the end of the second month, when the large dull-wire curette does not enter, Récamier's curette (Fig. 146) is sometimes useful.

D. Tamponade.-The word tampon is French, and means a small mass of cotton or other soft material which is carried into a wound or cavity for the purpose of filling it, so as to prevent hemorrhage, or

1 This applies to strictly gynecological cases; in cases of hemorrhage due to recent abortion, anesthesia can be dispensed with except in very nervous women.

applying drugs to it, or exercising pressure on it. A tampon being used for so very different purposes, becomes a very different thing, and we will, therefore, consider separately the application of medi

FIG. 146.

Récamier's Curette.

cated pledgets in the vagina, the packing of the vagina, the hemostatic vaginal plug, and the tamponade of the uterus.

Pledgets in the Vagina.-Small rolls of absorbent cotton, about 2 inches long and 1 inch thick, with a string of strong crochetyarn fastened round the middle and made long enough to hang an inch or two outside the vulva, are impregnated with some medicinal substance and pushed up to the posterior vault of the vagina. They are, as a rule, withdrawn morning and evening, when an injection is made and a new pledget put in. The cotton may be impregnated with different substances. The most generally useful and least objectionable is pure glycerin, which produces a watery discharge, relieves pain, and scatters swelling. I have used iodine-glycerin (5 per cent.) and an iodoform ointment,

but have always come back to the plain glycerin. Of late years I use much ichthyol-glycerin (5 per cent.), which has a special resolving power and some anodyne effect. As an astringent, for instance, for a spongy cervix, tannin-glycerin (10 per cent.) is very efficient, but, as it stains the clothes, it is necessary to wear a napkin with it. Others prefer boroglyceride, or sulphate or acetate of alumina, in the proportion of 3j to glycerin Oj.1

Packing of the vagina differs from the application of a pledget, as heretofore considered, by the combined action of drugs and pressure in the treatment of diseases of the uterus, ovaries, and periuterine structures. The patient is placed in the knee-chest position, Sims's speculum is introduced, and the upper third or fourth of the vagina is packed tightly with pledgets of cotton (Fig. 147). The uppermost, which covers the cervical portion and part of the vaginal roof, should be saturated with pure glycerin and spread with the abovementioned iodoform ointment. The others are rolled into balls and

1 Wiley, Med. Record, October 8, 1887, vol. xxxii. p. 483.