Supplement to Practical observations on the natural history and cure of lues venerea : containing remarks on the application of the lunar caustic to strictures of the urethra, on the use of sedatives in gonorrhaea, and their dangerous consequences in lues venerea : with a brief enumeration of those effects of mercury which are decisive in the cure of this disease / by John Howard.

  • Howard, John, -1808.
Date:
1801
    ( 18 ) A young Gentleman of 18 years had, in conse- quence of a gonorrbaea virulenta, an abscess in peri- naso, which was healed by internal'medicines and ex- ternal means only, without a bougie ever having been introduced or worn to promote the healing of the sore or remove the probable obstruction. In 1778 he was salivated for secondary venereal symp- toms, (eruptions,)and cured. In 1783, in consequence of the old diseased state of the urethra, which had never been treated with a bougie, he was seized with . a suppression of urine, lasting seven days and as many nights. It was impossible to pass either bou- gie or catheter. Bleeding, the warm bath, oil, opium, and tepid water, frequently injected into the rectum, were the principal means of relief. His urine after that length of time forced its way with violence, and he emptied his bladder at once.' Though re- lieved from imminent danger, he continued to neg- lect the trial of what a bougie might have done towards removing the stricture afterwards, until he was aged 57, (in 17Q5) when the difficulty of passing his urine became greater, voiding mucus, sometimes a small quantity of blood, and sometimes gravel and small stones. At this period, whenever his avocations in business would allow him to attend to these com- plaints, he submitted to have the bougie tried. At : different times it was introduced with great care, but after getting a short way into the stricture and towards the bladder, pain, heat of urine, a quick- ened pulse, even shiverings, would come on, attend- ed also with an evident disj)osition to suj)pression of urine. With these impediments occurring, the bougie was repeatedly used, and occasionally discon- tinued to quiet irritation, without making any con-
    ( ‘^9 ) siderable progress. Although he had sometimes frequent calls to discharge his urine, yet at times (more particularly when in a warm room, and even after drinking a quantity of wine or other fluids,) he would make it with perfect freedom ; this latter, cireumstanee seemed to depend on a copious secre- tion from the kidneys, filling the bladder and forcing a stream of urine from behind, through the ob- structed part. Thus, did he rub on for-a great number of years, the urine itself keeping the ob- struction passable, in the na'tural course of the canal, and in a direction contrary to our attempts by a' bougie. The latter is an artificial, but unnatural way, of keeping a greatly obstructed urethra open ; the other is a natural one, and if we could imitate this by large dilution, to increase the secretion from the kidneys, it would be a force applied from be- hind, propelling the urine by the united action and general consent, both of kidneys and bladder, and thus by the stream dilating the stricture. The mouths of the lacunas open outward and not inward. This fact explains why the bougie and caustic some- times hitch in the lacun*, and why a larger sized bougie will pass when a small one will not, and why a false route may sometimes be made by these as well as other instruments for drawing off the water. And lastly, why patients too often express pain, sensibility, and'spasm, by attempts against the natural ' course of the passage, sometimes injurious to its structure. So favourable are the lacunae to the progress of the stream of urine from the bladder forwards, that it is possible some obstinate strictures may be long -kept so far open as to suffer the functions of the
    several parts to be performed, though in an imper- fect state, without any hazardous symptoms coming on, by the mere force of the urine in sufficient quan- tity from the kidneys only ; and if, by means of an opening made behind a stricture into the urethra, we could pass a bougie in the same direction that the urine passes naturally, over the lacunas towards the penis and through the stricture, we might possibly relieve in some cases where we now fail. But to return; general and topical bleeding, relaxants both . externally and internally, opiates and laxatives, were at different times used : amongst the latter,- manna had frequently a good effect. The bougie he could not bear at the stricture ; and even touching gently the anterior part of the urethra by keeping in, for a short time, a few inches of a bougie, produced too much uneasiness, and had not the effect I have seen in many other cases. Once, when I had with great tenderness and caution passed the smallest bougie some little way into the stricture, he thought his symptoms relieved ; but as I proceeded, although with the greatest gentleness, shiverings and fever followed. This happened so often during the course of my attendance, which was not constant but occa- sionally only, for years, that I was convinced there must be not only permanent stricture, but disease of ! the prostate, kidneys, and bladder, probably con- nected with stone. The prostate I could feel per anum enlarged, hard, and pressing into the rectum, which occasioned a frequent forcing, not only of urine involuntarily, but of faeces. He had moreover a frequent disposition to piles, which never bled, but ■ there passed sometimes from the urethra a kind of bloody gleet, and blood itself in the urine. He had
    sometimes pains in his back ; some perhaps muscular, rheumatic, or gouty ; but at times he had a more de- cided pain in both kidneys, his urine would be fre- quently quite clear, and yet sometimes contain a quantity of mucus, and some small portion ofblood. These circumstances, when compared with the shi- verings, fever, &c. produced by a common bougie, convinced me, that the several parts were much too irritable to bear it; and having met with cases simi- lar to this, failing me Jn the same way, I wholly desisted. He would, I believe, have submitted to the caustic, had that been urged ; but knowing the state of the prostate gland, reflecting that he could not bear even a common bougie used in the most guard- ed manner, and believing his stricture was of that kind, that it would have done no good, but probably have hastened his end, it was not attempted. And indeed some instances of suppression of urine arising from the caustic, which he had heard of, had alarm- ed him so much, that the idea was given up. He was strongly predisposed to a suppression of urine, but without any absolute suppression taking place for some months before his death. At length, however, when verging towards Oo, whether it was from a few small doses of balsam capaivi producing inflammation, that had been recommended, from a gouty attack upon his kidneys, or from both, 1 can- not say ; but such a total suppression came on with violent pain, &c. in the region of both kidneys as baffled every effort for his relief. Upon examination after death both kidneys were found greatly diseased, but one much more enlarged than the other; the prostate very hard, and tho- roughly diseased also j a stricture of considerable ex« 1
    tent, callous and imper\^ious ; a thickened and con- tracted bladder, and a large quantity of matter in the pelvis and 'substance of the larger kidney, and ulcerations on the exterior surface of the other. The distension of the bladder in this suppression of urine was neither large nor equable, but more to one side than the other, and that side corresponded to the larger kidney. I suspect that there was but little secretion of urine from eitherof them. This was an instance of very great irritability of all the parts, in connexion with stricture, probably occasioned by that general consent which naturally pervades them, but which from disease long kept up was greatly heightened. The abscess in perinseo was at the age of 18; the first suppression of urine 25 years after. From that time, the prostate, the bladder and kidneys were getting gradually, partly from age, and partly from other causes (viz. gout, or disposition to thegravel and stone) into a morbid state; the stricture all this time remained without any thing having been donetowards its removal,from youth up- wards. And when at last the bougie was employed, the obstruction was so great, and the general tendency of other parts to irritation so firmly*established, that no progress could be made ; to this, I attribute in some measure the failure of the bougie, which, if applied at an early period, might have been attended with more success. It is very remarkable, with such permanent disease about him, that the mere daily secretion and evacuation of his urine should, for so many yeans have been sufficient by the force of its stream alone to keep the passage open, with but one single suppression of seven days and nights from the dale of the abscess in perinaeo at 18 'to the last