If the tampon be used for retention then a large roll is inserted, and this is held in place by smaller ones. It is generally unnecessary to fill the entire vagina; even in case of hemorrhage it is sufficient to fill the cul-de-sac, for thus the cervix is surrounded and compressed.
In case more tampons are inserted into the vagina, then its S-curve is destroyed, and the walls are incited to contract, and thus there is a ten dency to expel the tampons. Where it is essential to keep the vaginal walls apart or to bring some medicinal agent in contact with them, then the canal may be filled with thick and long cylindrical rolls of cotton.
Plain cotton tampons should not remain in the vagina longer than twelve hours,lince at the end of this period they have absorbed the secre tion as much as possible, and this degenerates, giving rise to foul odor, acting as an irritant, and even becoming the source of infection. Dry tampons are seldom used, but it is preferable to wet them and squeeze them dry, for thus they are more readily pressed together. Tampons which have remained in the vagina for a greater length of time through forgetfulness, have, on careless examination, been mistaken for broken down carcinoma. To prevent decomposition, it is advisable to use salicy lized cotton, or else cotton which has been impregnated with some disin fectant, such as glycerine, carbolic, chlorine water, alcohol, tliymol; iodo form gauze tampons may remain, as we have stated, for two to three days.
The tampons may be removed through a speculum by means of dress ing-forceps, or else by exerting traction in the axis of the canal on the strings which are attached to them. In case a number have been inserted they should be removed in the order the reverse of that in which they were inserted. The patients frequently remove the tampons themselves, and, they only find this difficult when they make traction in the wrong direction. They should be instructed, therefore, to squat or lie on the back and to pull the strings in a direction downwards and backwards.
If the tampon is intended to act as the carrier of some medicinal agent, then the latter should be used in watery solution or with glycerine. In this way the same astringents, narcotics and resolvents, are used as in case of injections. Agents in glycerine, and glycerine alone, not only tend to prevent decomposition, but they also cause a profuse transudation of serum from the mucous membrane. Sims and Fiirst used glycerine alone; Gosselin added iodide of potass to it, and Gustin, Demarquay and others, tannin, and these agents are now universally used. Five to ten parts of iodide of potass to fifty of glycerine, and five to twenty-five of tannin, alum, sulphate of zinc or copper, with glycerine, are used, the alum, zinc and copper having the advantage over tannin that they do not soil the clothing. The medicinal agent may also be applied on the tampon in the form of an ointment, as Rochard, and in particular Hildebrandt, have recommended. Either fat, simple ointment, benzoinated ointment, or the glycerine ointment (one part glycerine to four of starch) recom mended by Tilt, may be used. Vaseline, the petroleum ointment, is pre ferable to all of these, since it is absolutely without odor, does not become rancid, and I use it in every instance where a fatty base is required. The
ointments may contain half again as much of the agent as the glycerine solution, and the tampon coated with it is best inserted through a slender bladed valvular or a duck-bill speculum, care being taken that the oint ment does not rub off on the speculum.
Drugs in the form of powder may be used as well as ointments, the tampon being simply covered with them, and inserted as usual. Alum, as recommended by Scanzoni, is thus very frequently used, either the plain powder or else mixed with equal parts of powdered sugar or starch. ' The plain alum tampon is a most energetic astringent, frequently caus ing intense burning pain, contraction of the vagina, and loss of the epithelium in flakes or as a cast of the canal. For this reason the powder should be used weakened at the outset, and only in its full strength at the beginning of three to four days. Instead of sprinkling the powder over tampons, it may be placed in little bags for insertion into the vagina. Narcotics and vesicants may be used as well as astringents. The powder may further be insufflated into the vagina and a tampon inserted after wards.
' In order to obtain the effect of cold in the vagina, Aran recommended the insertion of pieces of ice; it is preferable, however, to order cold in jections or else to insert one of the previously described Heitzmann regu-. lators or a colpeurynter filled with ice water.
Before applying the tampon the canal should be cleansed of secretion by a lukewarm or a cold-water injection of soap suds, of a weak alkali solution or a disinfectant, etc. The same procedure should be repeated after removal of the tampon, and often it must be frequently repeated in /41.
order to wash away the flakes of epithelium or insoluble albuminates which result from the use of astringents, and which on the one hand irritate the vagina, and, on the other hand, interfere with the action of the second tampon.
For a number of years Schultze has recommended the tamponade of the vagina, in order to collect the secretion from the uterus for examina tion, a procedure which Kiwisch had previously favored. I have often resorted to this test-tampon, in order to differentiate a catarrh of the body of the uterus, in the absence of much secretion. For this purpose, after washing out the vagina and removing the secretion from the cervix, a flat cotton tampon, soaked in a 10 to 20 per cent. solution of the glycerole of tannin, is applied through the speculum against the external os, and over this are applied a number of similar tampons to hold the first in place. The vagina contracts around these tampons and holds them well in place. After a day's interval, the tampons are carefully removed in the reverse order in which they were inserted, preferably through a duckbill specu lum. On the last tampon the secretion has collected, and at the spot cor responding to the external os, there is a mass of mucus, pus, blood, etc., which may be submitted to a microscopic examination.