CLINICAL LECTURES ON SURGERY

1846 The Lancet  
caustic. CAUTERIZATION of the urethra is a very ancient operation. It has been employed sometimes as a general method, sometimes when other means have failed, and the occasions of using it have not been rare, since one of the principal characters of strictures is to resist all efforts to combat them. Adopted, abandoned, and again resumed, this practice would seem at present to be in entire discredit. Nevertheless, it appears to me to be useful to indicate the principal modes of practising it,
more » ... d again to draw attention to the value of this means, whether of cauterizing strictures of the urethra from before backwards, from within outwards, or from behind forwards. In the first of these procedures, adopted by the ancients, and which numbers Hunter and Horne amongst its partisans, the caustic acts from before backwards on the part of the urethra which precedes the contraction, and it attacks no less the circumference of the contracted point than the coarctation itself. It also is attended often by accidents which some moderns have endeavoured to obviate, but without much success. Those who adopt it proceed without guide and without precision. However, if so many efforts have not succeeded in effacing the inherent defects of the method, they have at least contributed to moderate the enthusiasm which it had at first inspired. The dangers and want of success could not be concealed, and cauterization gradually fell into disrepute. By some ancient proceeding strictures were attacked from within outwards, but it is only of late that Mr. Arnott in England, and Ducamp in France, have regulated this procedure, and have bestowed on it all the precision desirable, at least in theory. The method of Ducamp is known; the author has given a very lucid exposition of it; everything, so to speak, appears mathematical; but it is not so by the bed-side of the patient. Convinced of the defects of the porte-caustique of Ducamp, I endeavoured to remedy them by giving greater length to the part of the instrument which goes beyond the cuvette, provided that I was well assured of having entirely traversed the obstacle, before causing the nitrate of silver to project from the conductor. I employed, at first, a metallic instrument, but afterwards I knew that the flexible sound was preferable. My porte-caustique (see plate 1) occupies, so to speak, the middle of it. That part of the sound which projects beyond it is at least an inch in length. The length of the opposite end is not so constant ; it extends, generally, to eight inches. The smallest porte-caustiques have a diameter of three-fourths of a line. Their flexibility admits of their yielding to all the necessary movements. The conductors which I employ are very simple, and formed of elastic gum ; sometimes straight, and sometimes curved, according to the situation of the stricture ; they are seven inches in length, and from two to three lines in diameter, and, like most instruments of this description, they have a graduated scale, which serves as a guide to the manipulations. The anterior opening is always proportioned to the volume of the porte-caustique, which fills it without being tight. These instruments, the most simple in construction that have been proposed, are equally so in application. The only difficulty consists in contriving that the extremity of the portecaustique is completely introduced into the constricted point at the moment when it protrudes from the conductor. This is effected sometimes by proceeding with great gentleness, and by very gentle pressure, accompanied by a slight traction of the penis. There is no fear of the caustic dissolving and acting on the urethra before the stricture, for it is ascertained with certainty that the obstacle has been passed, before even that the nitrate of silver approaches the extremity of the conductor accurately filled by the porte-caustique. But very few attempts suffice to produce the desired effect. Sometimes we cannot succeed in engaging the smallest porte-caustique into the contracted point, notwithstanding our repeated efforts, whether by modifying the manœuvres, or by employing different conductors, with central or lateral openings. The porte-caustique only protrudes from the conductor to the extent of two or three lines. This slight protrusion, which is sufficient to lead into error when the instrument of Ducamp is used, or the cauterizing sound, cannot, with the instrument I employ, lead to any mistake. It is to this happy circumstance that I attribute my never having made a false passage, nor observed those severe accidents which the application of the caustic in other hands, and by other methods, has produced. The ancients cauterized with the view of destroying excrescences, to which they attributed most contractions. With other views, the moderns have recourse to the same means to remove the obstacle to the flow of urine. This obstacle varies according to its nature, its extent, its consistence, the place which it occupies, the period of its existence, and the texture of the region of the urethra where it is situated. This consideration alone suffices to cause distrust of the opinions which we daily see given in so precipitate a manner. If we isolate the action of the caustic from all foreign influence, whether of the proceeding itself, or of the manner of its application, the following are the phenomena which it presents:-1st. A patient has an incipient coarctation, consisting of a. simple bridle, occupying one side of the urethra, concerning which the explorative sound, and especially the bougie, have furnished the precise information. A slight application of the caustic is made. The pain is slight, and of short duration, and no immediate accident occurs; the patient passes his urine better than before the first time that he presents himself, and complains only of slight smarting. A mild form of urethritis is manifest. The contraction has disappeared, to a great extent, at least, and a tolerably large bougie can be passed, the introduction of which was before impossible. A multitude of facts attest this result. . 2nd. If the coarctation is more considerable, and the tissues are more indurated, provided the exploration furnishes an equally positive diagnosis, the action of the caustic will be equally favourable after a first, a second, or, perhaps, a third application, provided the applications are made gently, and are not continued, and that the new application is made many days after the falling of the eschar. 3rd. When the contraction is still greater, the action of the caustic is different, although we may have obtained the most exact impressions, and been enabled to give the same degree of precision to the procedure. There is not often much amelioration after the first application, still less after the second, and none after the third. If we persist, the amelioration obtained at first soon disappears, and the condition of the patient becomes more serious than ever. Sometimes there is an abundant mucous discharge from the urethra; the emission of urine is accomplished with pain; there is general uneasiness, sometimes fever, and a distressing state of nervous derangement, and the patient sinks. Sometimes, even, the immediate accidents are more serious, such as haemorrhage, strangury, severe pain, &c. The frequency, nay, almost constancy, with which these phenomena occur in each of these three cases, have appeared to warrant the conclusion, that the caustic destroys, without return, those strictures which consist only in a simple bridle; and if the destruction were less complete in the more severe cases, it would still be sufficient to account for the amelioration observed. It has appeared also quite natural to attribute the absence or the manifestation of accidents to the greater or less precision adopted in the use of the caustic. But a fourth case, which is also by no means of rare occurrence, has convinced me that this explanation is of no value. 4th. When many strictures exist at the same time, one of which, situated at the navicular fossa, or at the spongy portion of the urethra, is sufficiently great to prevent our arriving at the others, if we cauterize the first obstacle, a marked amelioration follows, and the flow of urine becomes easier than before, although the next stricture has not been attacked, which, nevertheless, is almost always the more considerable. I confess I was never able to explain this circumstance, which I have often witnessed; but it is not only after the destruction of the constricted point by prudent and methodic measures that it is observed, but also after a mode of procedure, generally condemned, of cauterization from before backwards, after which there is speedily observed an improvement, such as to induce the belief that a single application has destroyed the obstacle, although it has not. In connecting
doi:10.1016/s0140-6736(01)44422-9 fatcat:bqcwsw3kkfgifezovckp2bg53i