THE LOCAL BATH.
When a woman sits in a sitz-bath or tub, the water only cleanses the external genitals or penetrates a trifle into the introitus vaginae. In order to keep the water for some time in contact with the vaginal walls and the cervix, a number of so-called bath speculums (Fig. 85) have been devised by Mier, Raciborsky, Spengler, Tiemann and others, on the principle of keeping the vaginal walls apart. The multivalve specula with slender blades or the wire speculum which we have described also suffices for this purpose, as also the speculum "grillage " (grated) of Gallard. The bath speculum generally used is conical in shape, its walls being perfo rated at many points. Tiemann's speculum is preferable in. that it does not cover much of the vaginal walls, although it is not as readily inserted and removed.
The use of such specula is very limited. They are used particularly in many "cure" establishments for the purpose of keeping medicaments in long contact with the vagina in the hope of absorption. In case of many fluids the speculum does not suffice, and furthermore, as Cohnstein says, the propriety is questionable of placing in the hands of women in struments which are very capable of exciting the sexual appetite.
Strong applications, which on this account cannot be administered by bath or injections, are best applied through a tubular speculum. By this means, first advocated by C. Mayer, we are able to use the stronger astringents and caustics, and we are able further to limit their action as may be desired. The patient should occupy the dorsal position, with elevated nates, a cylindrical speculum is inserted into the vagina, the cervix exposed and pressed well within the lumen of the instrument. After cleansing the canal, iodine, nitrate of silver solution, liquor ferri, etc., are poured in, in sufficient amount to cover the cervix, which organ is exposed to the action of the agent for a few minutes. This process may be repeated as often as may seem necessary. In case the cervical canal is patulous, the solution may also be applied to it by means of an applicator. In order to allow the solution to flow out, it is simply neces
airy to depress the speculum without withdrawing it, and to receive it in a pus basin. The vagina may then be injected with warm water, or, in case a strong solution has been used, with a neutralizing solution, as common salt, in case of silver solutions. A tampon is then inserted into the vagina. In case it is desired to bring the solution in contact with the vaginal walls, then the speculum may be gently rotated outwards, as far as the introitus, when, as the vaginal walls close together, they are bathed in the solution. In making such applications it should be re membered that while the cervix generally is not sensitive, the vagina is, and that hence it is advisable to remove by injections any excess of the fluid which has been applied.
Bandl has described an excellent way of administering the local bath, in order to render many intra-uterine procedures aseptic. The patient should lie in the dorsal position, with the nates elevated so that the vulva is directed upwards. A short Bandl speculum is inserted, the cervix exposed, and enough carbolic or other medicated fluid poured in to cover the organ. While the speculum is held with one hand, the sound, the curette, etc., may be used with the other, and similarly the cervix may be scarified. (Fig. 86.) In the same way the Cusco speculum may be used, and it has the advantage of being self-retaining, hut since the instru ment does not protect all of the vagina, strong fluids should not be used.
TIlE USE OF TILE APPLICATOR.
Applications to the cervix have been often recommended. Aran and Johns used tincture of cantharides and gutta-percha dissolved in chloro form, Mikschik and Andrceff tincture of iodine, Losacla chloroform. Generally, formerly, astringents were applied by a camel's-hair brush, a sponge, or cotton, to the vagina and to the uterus, as far as possible. The cotton-wrapped applicator, as recommended by Playfair, Fritsch, Braun, and others, has in my hands displaced all other means.