THE POTENTIAL CAUSTIC AGENTS.
Lunar caustic is the most frequently used agent. It is one of the weakest caustics, and is still more frequently used in fluid or ointment than in solid form. Concentrated solutions are applied by long cotton sticks to the diseased parts, or else they are poured into the vagina and thus brought in contact with the cervix. After each application the parts should be irrigated with water until it returns clear. In case of cauterization of sensitive parts the immediate application of an ice com press will check the pain. This caustic is used in substance on a caustic holder or held in dressing forceps. In order to weaken the action of the stick it may be ordered made with one to two parts of nitre; and to ren der it less fragile, Ellis and Chassaignac have caused it to be perforated with platinum wire. Still, the breaking off of the stick in the cervix is not a dangerous thing, although severe colic and painful cauterization may result.
This caustic causes a greyish white slough which limits the deep action of the agent; after two to three days the slough separates with slight hemorrhage, and four to five days after the first cauterization it may be repeated.
Nitrate of silver in solid and in solution is used, in particular, in case of superficial catarrhal erosions, in ulcers with fungous granulations, in follicular and herpetic affections of the cervix, in chronic catarrh, in pruritus, in follicular vulvitis, in case it is desired to cause adhesion between the walls of cysts iu the vagina or on the external genitals. Often in case of masturbation it is a good plan to cauterize the entire surface of the external genitals, and at times cure may thus be attained. Aside from the pain caused by this procedure, it may cause cicatrization, and I have seen a case where there resulted contraction of the preputium clitoridis, so that there was retention of smegma and the formation of a cherry-size tumor, which stimulated hypertrophy of the glans.
Many writers, in particular Tyler Smith, use no other caustic agent, and claim that with lunar caustic they can attain any desired action.
In case of readily bleeding growths, papillary ulcerations, epithelial cancer, etc., lunar caustic does not answer. Its action is too weak to cause destruction, and it rather leads to increased growth and greater malignancy of the tumor.
In order to place the solid stick in the uterine cavity many instru ments have been devised, for instance those of Scanzoni, Lallemand, Chiari, Siixinger, Bandl, etc. Pencils of lunar caustic may be inserted by means of the so-called " uterine pistol," or we may use Chiari's porte caustique modified (Fig. 89, a) , or Bandl's instrument (Fig. 89, b.) The patient should preferably occupy the lateral position, the cervix being exposed by a duck-bill speculum and steadied by a tenaculum, the stick of caustic is inserted even as is the sound. In case the os is not sufficiently patent, dilatation is requisite. Before the insertion of the caustic we should test with the 'sound the length and direction of the uterine canal, the porte-caustique should be given the requisite curve, and pushed quickly, although not too forcibly, into the uterine cavity. The caustic stick may also be inserted without the speculum, although then the neighboring parts must be all the more carefully protected by cotton, or else during the insertion the vagina should be irrigated with lukewarm water or a weak saline solution.
When the caustic is in the uterine cavity, a portion dissolves in the fluid in the cavity, and a portion forms an insoluble albuminate of silver. By moving the instrument around we endeavor to break up this albuminate, and further to bring the caustic in contact with the entire endometrium. After the lapse of about one minute, the instrument is withdrawn, and this is often difficult, owing to energetic contraction of the internal os. The mucous membrane at this site sinks into the fenestre3 of the porte-caustique, and it may be torn off, by over energetic traction, and this is a frequent cause of metritis and of parametritis. It is well to desist from traction until the spasm at the internal os has relaxed.