An essential point for the carrying out of these manipulations, and also for the success of the local treatment, is that the introitus vaginre be not too narrow. In children and in virgins treatment is rendered very diffi cult by this narrowness, since it leads to retention of secretion. In obsti nate cases we must resort to dilatation or to discission of the hymen, even as in case of stenosis vagina3 it is necessary to overcome the condition before treating the e,atarrh.
When disinfecting agents are used they should be as dilute as possible, and yet be effective. The experiments in regard to the minimum amount of various agents which are of use in diminishing the signs of life in certain bacteria, give us approximate data as to what we should use in cases of known infection, such as sepsis, gonorrhcea. These results, how ever, are not purely applicable to practice in that the microbes are differ ently situated on•the mucous membrane than in culture solutions, and so the work of the antiseptic must finally depend on the therapeutic results which it yields. The possibility that disinfection, aside from direct action on the infection-carriers, may act indirectly on them by changes in the tissue in which they lodge, is not, as Oppenheimer rightly remarks, excluded.
The following table recapitulates the results obtained by Oppenheimer in his experiments in regard to the action of agents on gonococci. The best agents proved to be sublimate and creosote. The former was effect ive in solutions of 1:20,000, and the latter in the strength of one drop in 20 cm. of water. The cocci were killed: Copaiva balsam and cubebs, although detected in the urine, amt. of lead, bismuth subnitrate, chloride of potaes, chloride of c,alcium, resorcin, tannin, etc.,were worthless.
In regard to the strength of the disinfecting solution it is to be remem bered that the first copious irrigation must be relatively concentrated, and it will depend on the stage and quality of the infectious inflammation as to whether it must be repeated in similar strength. Experience proves that in many instances, where we are not dealing, with gonorrhcea, pro tracted irrigation with weak solutions accomplishes the aim by preventing the extension of the bacteria. In case of gonorrhcea, however, strong solutions must be used on account of the chronicity of the affection.
At the first irrigation we use sublimate solution of 1:1000 to 2000, or carbolic 5:100, and repeat in the strength of 1:5000 sublimate, I to 100 carbolic, in other instances using even weaker solutions. Only later do we use permanganate of potass, or astringents (copper, zinc, etc.).
Disinfectants may also be brushed over the vagina or poured through a speculum. A tubular speculum is inserted into the vagina, the vaginal walls being thus held apart, and they are bathed in the fluid. Here
strong slightly caustic solutions are useful, such as nitmte of silver (2 per cent.), wood-vinegar (Schroeder), tincture of iodine, etc. The canal should be irrigated and wiped out before pouring in these agents. In case superficial sloughs are thus caused, iodoform should be insuffiated after the excess of solution has run out.
We now pass to the use of agents in powder form and to the dry intra vaginal packing. We have already spoken of the advisability of inserting a disinfecting tampon into the vagina in the intervals of the irrigations, in order to keep its wall apart and to disinfect any stagnant secretion. Sanger has especially advocated the dry disinfecting tamponade of the vagina in the surgical treatment of the genital canal, and he prefers iodoform gauze. He advocates this method even in case of inflammatory affections of the vagina, since it has the advantage of preventing decomposition of the secretions, and of sparing the patient the painful manipulation with the irrigator. I do not know whether Sanger or anyone else has ever method ically followed this plan in the treatment of catarrh of the vagina; I have never tried it, although I have satisfied myself of the value of iodoform packing in other cases. My experience with the dry and aseptic treat ment of catarrhal disease of the vagina has as yet been entirely limited to tampons of absorbent cotton, formerly salicylated, but latterly largely sublimated, and occasionally iodoform cotton. Although by changing these tampons twice daily, good re,sults were obtained, the iodoform alone could remain in the vagina one to three days without causing odor. Only very exceptionally, however, have I left them in so long, since at the end of one day the cotton becomes coated with mucus and it loses, in a measure, its absorbability. Since gauze is more absorbable than cotton I believe that Sanger's suggestion is worthy of trial, and on account of its antiseptic principle (something else than iodoform might be used) it differs from the old methods of application of astringents which were recommended by Scanzoni, Gautier, and latterly, again, by Gougenheim. Aside from iodoform, other antiseptics have been tested but little in the dry protracted tamponing of the vagina, and I can only cite II. Schmid's practice of filling. the vagina with salicylic powder and letting it remain there one to four weeks. Schmid has not tested this method in case of vaginitis since it irritated the vagina. Dry salicyl powder has, however, been inserted into the vagina, during the puerperium, in particular, by Cred6, Fehling, Gusserow, Fritsch, and others.