Hints relative to Intra-Uterine 
Medication. / 
BY 
JAMES P. WHITE, M. D. 
BUFFALO, N. Y. " 
* 
REPRINT FROM VOLUME IV. 
(Sniwcaloatcal EraiisacttanS 
1880 HINTS RELATIVE TO INTRA-UTERINE MEDI- 
CATION. 
BY JAMES P. WHITE, M. D., 
Buffalo, N. Y 
It is not the purpose of this paper to consider the pa- 
thology or therapeutics of intra-uterine diseases, but to 
point out, simply, some of the means which have, in the 
writer's experience, been found valuable and important in 
the proper application of remedies to the surfaces within 
the neck and body of the uterus in diseased conditions al- 
ready recognized. It is believed that a somewhat detailed 
description of these measures will be found acceptable to 
all practitioners in this important department of medicine. 
In making applications of fluid substances to the uterine 
cavity, the most simple method would appear to be by injec- 
tion, and this method is still advised in the treatises and 
and periodicals of the day. On page 159 of the " Obstet- 
rical Journal of Great Britain and Ireland" for June, 1879, 
the injection of carbolic acid and water, pure nitric acid, 
and other liquids is advised in various diseases of the cav- 
ity of the uterus. While the most potent caustics, as fum- 
ing nitric acid, may be applied in full strength to the mu- 
cous membrane of the neck or body of the uterus, modify- 
ing the condition of the diseased surfaces without exciting 
grave symptoms, no liquid, however bland, can be injected 
into- the uterine cavity without the liability of exciting ter- 
rific uterine colic, if nothing more serious. The experi- 
enced practitioner seldom or never injects medicinal agents 
into the cavity of the uterus. It becomes, therefore, impor- 
tant often to- enlarge the canal of the neck, even when of 
normal size, in order that medicaments may be applied to 2 
INTRA-UTERINE MEDICATION. 
the lining membrane of the body when in a morbid condi- 
tion, and in stenosis or contraction of this canal the dilata- 
tion becomes absolutely necessary. 
The means most commonly resorted to for the purpose 
of dilatation is the employment of tents, made so as to be 
introduced when dry and compressed, the absorption of 
moisture producing expansion and dilating the canal. Be- 
lieving the tents made of sponge preferable, all things con- 
sidered, to those made of any of the various substitutes, at- 
tention will be directed to that variety only. 
The tent, as ordinarily made, is exceedingly imperfect, 
and is frequently constructed from coarse sponge which 
has scarcely tenacity enough to hold together. Good soft 
sponge, of uniform consistence, should always be selected 
for this purpose. They should be nearly cylindrical in shape, 
so as to dilate the canal of the neck uniformly, slightly con- 
ical at the point to facilitate introduction, and about one and 
three fourths inches in length. Each tent should have a lon- 
gitudinal perforation at its base to receive the instrument, 
to be described hereafter, for introducing it. More impor- 
tant than all they should contain in the centre, running quite 
to the small and internal end and securely fastened thereto, 
a small twine or wire, preferably the latter, the end of which 
should pass out of the base of the tent to sufficient length 
to be easily grasped in removing it. Securing the cord or 
wire quite at the extremity is of the highest importance. It 
has frequently occurred to the writer to have the tent part 
in the middle when making an attempt to remove it, by the 
twine fastened, in the usual way, only at or near its base. 
Few things are more embarrassing to the operator than to 
find himself called upon to remove the upper half of a tent 
thus retained at the os internum. Forceps introduced, how- 
ever carefully can scarcely be opened and fixed upon the 
fragment, or, if it be seized, owing to its friable nature, the 
operator is obliged to bring away a small portion at a time. 
Failing to seize the retained portion it is pushed in front of 
the forceps into the uterine cavity, necessitating complete 
dilatation of the os and neck before it can be secured and 
removed. JAMES P. WHITE. 
3 
A single case will be sufficient to illustrate an annoyance 
which can easily be avoided by proper arrangement of the 
string or wire, but which was the result of using a sponge 
tent as at present constructed. 
Miss B., aged 18, with severe dysmenorrhea accompanied with 
profuse catarrhal discharge from the os, had a moderate-sized 
sponge tent introduced in the evening which was found fully ex- 
panded the following morning. A cylindrical speculum was intro- 
duced and moderate traction made on the string attached to the 
base of the tent, but only about three fifths of the tent was drawn 
out. In an effort to extricate the retained fragment it was pushed 
forward into the cavity and could not be removed without further 
expansion of the canal. The forceps could be introduced into 
the os and passed up to the retained sponge, but could not be 
opened so as to grasp it. Menstruation being near at hand, it 
was deemed wise to omit further efforts towards its extraction 
until after that period had passed. The flow came on a day or 
two subsequently, was free and without any of the terrible suffer- 
ing to which the patient had been accustomed. Her general 
health rapidly improved arid the patient persistently refused to 
permit any further efforts to be made for the removal of the re- 
tained sponge, and, after a full explanation of the annoyance and 
danger which it would be certain to occasion, returned to her 
home in Canada, some hundred miles distant. 
In about six months she returned for its removal, assuring me 
that, notwithstanding all her efforts at cleanliness with the free 
use of deodorizing vaginal injections and washes, the discharge 
had become so offensive and profuse that she was obliged to se- 
clude herself, and her own family would not tolerate her pres- 
ence. 
A large tent was introduced in the afternoon, and the follow- 
ing morning the canal was so fully dilated that I was enabled to 
seize the specimen, which I here show you, and remove it without 
pain or difficulty. 
The piece of sponge here exhibited is useful in illus- 
trating the little change that had taken place during its re- 
tention of more than six months in the uterine cavity, and 
how futile would be any delay in expectation of its disinte- 
gration or expulsion by uterine contraction. 4 
INTRA-UTERINE MEDICATION. 
Other similar cases could be cited, but this is quite suffi- 
cient to show how important it is that the wire or twine for 
the extraction of sponge tents pass entirely through them, 
and be secured at their apex so as to command the entire 
mass of expanded sponge. 
The tent may be bent to accommodate its form to the 
flexions which may be present. It may be covered with 
gold-beater's skin, with tin foil, or with some gelatinous ma- 
terial, to facilitate introduction and to prevent irritation of 
the mucous membrane, but not with tallow or rancid cerate. 
By constructing the tent of sponge as here described, in ac- 
cordance with the specimen exhibited, it becomes a safe 
means of overcoming stenosis, and the operator will not be 
liable to meet with the accident just described. 
It has already been stated that the tent should have a 
perforation at its base, into which the point of the tent 
holder could be inserted. It will readily be seen that the 
operator has much better control of the tent by this holder 
than when held by forceps, as often recommended. The 
movable coil of wire around the stylet enables the operator 
to dislodge the tent, when in position, without in the least 
disturbing its relation to the parts. The instrument should 
be bent to conform somewhat to the pelvic curve. The 
whole procedure may be made through a cylindrical or 
Sims's speculum, or upon the finger without either. Sims's 
hook, with a long handle, is often very useful in holding 
the uterus forward and straightening the canal during in- 
troduction. The hook, if properly used, seems also to help 
the operator to pull on, as it were, the glove. 
It will often be found that time will be saved in the pro- 
cess by incising the lining membrane of the neck before 
any attempt is made to dilate. It is not necessary to JAMES P. WHITE. 
5 
make deep incisions, nor should they be as superficial as 
recommended by the lamented Peaslee in an article on 
stenosis, written shortly previous to his death. These in- 
cisions are best made with the long slender blades here 
shown, and their depth is to be governed by the skill and 
judgment of the operator, and not by a mechanical hystero- 
tome. 
By resorting to these incisions the canal is rendered much 
more dilatable, the endo-metritis of the neck lessened, and, 
if prudently made, there is no danger of hemorrhage or 
pelvic abscess. 
Whether the process of dilatation be preceded by tents, 
or by the knife, or both, sometimes without either, the di- 
lator here exhibited may be frequently used to dilate the 
canal or to keep it patulous. 
No matter by what process the dilatation is primarily ac- 
complished the canal is almost certain to contract, and 
even to become narrower than prior to treatment, unless 
regularly dilated for a considerable period subsequent to 
the first operation. The instrument here shown pos- 
sesses many advantages over any other with which I am 
familiar. It is as easily introduced as Simpson's sound. 
The dilating force can be applied as gently as desired, it is 
elastic and continuous, and may ordinarily be continued and 
increased for any length of time without pain. This instru- 
ment, which I have now used for more than thirty years, is 
very simple in construction and inexpensive. The amount 
of pressure is regulated with a screw and is entirely under 
the control of the operator. Having dilated the canal and 
the passage of instruments of moderate size now being 6 
INTRA-UTERINE MEDICATION. 
practicable, we shall find the long probe of hard rubber or 
whale-bone, first used, I believe, by Professor Miller of 
Louisville, Ky., and by him called an applicator, very use- 
ful. The point is easily coated with cotton or old muslin, 
which can be saturated with any desirable medicament, and 
applied to the uterine membrane. The cotton or muslin is 
then easily removed and fresh material substituted. Thus 
armed this probe is very convenient for removing from the 
membrane the catarrhal coating which absolutely prevents 
the application of substances to the surface until removed. 
The rag or cotton may be saturated with vinegar which 
will coagulate the albuminous secretion and facilitate its 
removal. It maybe here remarked, also, that acetic acid or 
common vinegar should always be at hand for removing 
sanguinolent or other matters which interfere with inspec- 
tion or treatment of the os or canal. Vinegar is a good 
astringent, coagulates, as already remarked, the albumen, 
removes muco-purulent discharges, and does not discolor 
the surface to which it is applied. Hence, in an examina- 
tion with cancer or epithelioma in a hemorrhagic condition, 
dossils of cotton saturated with vinegar, applied to the sur- 
faces on a probe or in forceps, will be found exceedingly 
convenient. The applicator or probe above described is 
not only useful in applying various remedies to the uterine 
mucous membrane by means of cotton or muslin saturated 
with these and wrapped about its point, but it may be coated 
for a short distance with nitrate of silver, deposited upon 
its surface by crystallization. 
For many years I have been accustomed to use nitrate 
of silver, either in substance in the ordinary crayon, or the 
still milder crayon used by oculists, or the points of Squibb, 
secured in rubber tubing. Notwithstanding that I have 
caustic holders of gold, platinum, hard rubber, and various 
other materials, for many years I have used exclusively the 
rubber tubing of various sizes. It holds the crayon firmly, 
is so flexible that, bending at the point of junction between 
the forceps or staff and the pencil, it adapts itself to the 
flexions of the canal without fracture of the crayon, as JAMES P. WHITE. 
7 
would be apt to occur in a rigid holder. This form of 
holder affords no opportunity for the instrument maker to 
display his taste or fill his exchequer, being almost without 
cost and readily made by any novice. The crayon and rub- 
ber holder may be slipped into a larger tube, taking the 
precaution to insert a stick alongside to prevent bending 
and fracture, and in this way it may be conveniently carried 
in the pocket and be always ready for use. This arrange- 
ment is unexceptionally safe and convenient, but lacks the 
attractiveness of more expensive paraphernalia, and will 
never be introduced to professional notice by the instru- 
ment makers. 
Glass tubes or rods drawn to a point, similar to the ex- 
tremity of the uterine probe, may be roughened and made 
a useful vehicle for carrying caustic fluids into the neck of 
the uterus, and there applying them. Sufficient nitric acid 
or saturated solution of chromic acid, or similar caustics, 
will adhere to this ground glass applicator for an ordinary 
application to the mucous membrane. Glass is for many 
reasons superior to all other materials for the handling and 
transmission of caustics, when it can be used, and it is in- 
expensive. But the cavity of the uterus cannot be reached 
with fluid on these glass or rubber probes. The narrow 
canal of the neck wipes off or removes any medicament on 
the surface of the probe, and it reaches the body of the 
uterus after parting with its surface coating in its passage. 
As has already been stated, injections, properly so-called, 
are inadmissible. Many instruments, uterine specula, can- 
ulae, etc., have been devised for carrying caustics and other 
remedies up to the cavity of the uterus without in their 
passage unnecessarily coming in contact with the mem- 
brane lining the canal of the neck. 
After much reflection, and many unsatisfactory trials of 
various metnods of overcoming the difficulty, I made a trial 8 
INTRA-UTERINE MEDICATION. 
of a small glass tube, drawn out at one extremity and 
curved in the form of the uterine sound. In this tube I 
could carry any desired number of drops of fluid by simply 
dipping its extremity to the proper depth in the liquid. 
By placing my finger or thumb over the opposite end the 
fluid was easily retained as long as the air was excluded. 
The tube thus charged was carried up thropgh the neck, 
and by careful manipulation its contents deposited upon 
the membrane lining the cavity. This procedure was some- 
what difficult, and required the exercise of great care not 
to allow the finger to be prematurely removed from the end 
of the tube and thus deposit the fluid upon surfaces where 
it was not desired. Some years since I placed the small 
rubber air-bulb which was found on the end of a pipet drop 
glass over the end of my long tube and secured it there by 
means of twine. This arrangement proved eminently satis- 
factory. By means of the bulb I could easily draw up any 
desired number of drops which were retained until made to 
exude by gently compressing the bulb. The point of this 
glass tube may, by a little gentle movement, be carried to 
different parts of the membrane, and the fluid deposited or 
spread over the surface. This method of applying sub- 
stances cannot properly be called an injection any more than 
when applied by a sponge or dossil of cotton. The inner 
surfaces of the neck are not touched by the fluid as in car- 
rying up the armed probe; more than that, you can deposit 
a definite number of drops with almost perfect accuracy in 
any desired locality. Again and again have I carried up a 
definite number of drops, from three or four to thirty, of 
fuming nitric acid and deposited them gradually upon the 
inner surface of the uterine cavity. It is proper here to 
remark that, while I am not an advocate of the frequent 
resort to this heroic treatment, when used as here described, 
I have never known it productive of serious consequences. 
It is astonishing with what impunity the most powerful 
may be thus applied to the inner surface of the 
uterus, while the most bland and anodyne solutions cannot 
be injected into the cavity without, in a certain proportion JAMES P. WHITE. 
9 
of cases, producing the most alarming symptoms. All gyn- 
ecologists are aware that the potential cautery can be ap- 
plied to the os and neck with but little pain, and is rarely 
followed by grave symptoms, although by no means always 
producing the desired result. The same rule will hold true 
with the application of caustics in fluid form providing they 
are used in the manner indicated. After several years of 
trial of this simple glass instrument I am prepared to say 
that I believe it indispensable in the treatment of intra- 
uterine disease, and commend it to the favorable consider- 
ation of members of this Society. Many friends have been 
induced to make trial of it during the last few years, and 
with but one have lauded its utility. It may be used 
to carry up any liquid substances deemed desirable for intro- 
duction into the uterine cavity. It need scarcely be again 
remarked that its contents must invariably be dropped and 
not expelled or injected. This is easily regulated by grad- 
uating the pressure on the rubber bulb. 
It remains to call attention to another method of intra- 
uterine treatment which is often found of incalculable ser- 
vice in arresting hemorrhage or serous discharges in gran- 
ular or polypoid developments on the uterine mucous mem- 
brane. 
The curette of Recamier is, in the writer's opinion, far 
superior to the " modern improvements " or substitutes. 
The instrument recommended by Dr. Sims is too small and 
is utterly inefficient. Peaslee's may answer in some in- 
stances, but I fail to perceive that it is in any respect su- 
perior to the one originally recommended by Recamier, 
and the same may be said of all the modifications intro- 
duced by various operators. The instrument can be much 
more conveniently used if made, as here shown, longer 
than originally designed. The edges, while they should 10 
INTRA-UTERINE MEDIC A TION. 
have sufficient sharpness to remove the bead-like growths 
studding the membrane, should not be so sharp as to endan- 
ger the deeper structures. 
The danger of deep wounds is guarded against by curving 
well the inner or cutting edge of the spoon-like margins. 
In these desultory remarks it has been my object to call 
attention to methods and means which in my hands have 
proved of value in the treatment of intra-uterine disease. 
They are not hastily recommended to the Society, but are 
the result of long and careful observation. 
Indeed this article, calling attention to the instruments 
and appliances herein described, is written in compliance 
with a request of some of the oldest and most successful 
practitioners among the Fellows of this Society, and with- 
out claiming that all the measures here recommended are 
new to the profession.