Part 61

_Of Gonorrhœa_, or Inflammation of the Urethra.—The morbid action is usually limited to the extremity of the canal, seldom extending more than two or three inches from the orifice. There is itching and heat at the orifice, with swelling and redness of the glans, and of the lips of the urethra, and generally the whole penis appears more full than natural. When making water, the patient experiences acute heat and pain, often most agonizing—chiefly referable to the extremity of the passage, and extending for two or three inches backwards. The urine is discharged in a small and scattered stream, the anterior part of the urethra being diminished in calibre by the swollen and turgid state of its lining membrane. The diminution may be in part caused by spasm of the muscles surrounding the canal, in consequence of the morbid excitement in it; or by fear, as the patient dreads making water, well knowing the excruciating pain which he must in consequence undergo. During erection, there is great increase of pain. The lips of the urethra, and the glans around, are often tender, and partially excoriated through neglect of ablution. There is seldom, if ever, any breach of structure in the canal; there is discharge of increased and vitiated secretion, without ulcerative absorption; the matter is poured out from the relaxed, but entire, mucous membrane.

In severe cases, the erections are abnormal, and attended with much pain, constituting chordee. This troublesome symptom usually occurs during the night; the inflamed membrane is stretched, and great pain is felt along the course of the urethra. From extension of the inflammation to the vascular tissue around the canal, and effusion of lymph into it, the penis is bent downwards during erection, the corpus spongiosum not admitting of so complete distension as the corpora cavernosa. Sometimes a portion of the spongy body is obliterated permanently by the effusion, causing deformity of the organ, and imperfect erection. I have also seen the penis bent to an inconvenient extent from a similar affection of the corpora cavernosa.

After the uneasy and painful sensations have continued for some time, puriform matter, of a greenish or yellow colour, is secreted by the inflamed membrane, and discharged in profusion. The discharge changes very much as to quantity and quality, according to the intensity of the action and duration of the disease, and is also modified by the constitution of the individual. When the discharge is suppressed, either from the imprudence of the patient, or from bad treatment, the inflammation is much increased; and when the secretion returns it is in general thin and bloody. As the disease abates, the matter becomes thick, ropy, and less abundant, is seen only in the morning, and in quantity little more than sufficient to glue together the lips of the orifice; ultimately it loses its whitish or streaked appearance, becoming clear and colourless. The first attack of the disease is generally the most severe.

In neglected cases, the prepuce swells, often to a great size During the progress of the gonorrhœa there is always a tendency to serous infiltration in the prepuce; and if the patient walks much without supporting the organ, or have the part exposed to friction, swelling will inevitably take place. From this cause Phymosis and Paraphymosis are apt to recur—affections that will be afterwards described. The inguinal glands often enlarge, but such swelling is generally small, and seldom suppurates.

Induration and enlargement sometimes occur along the urethra from effusion of lymph, or from obstruction and distention of the lacunæ. Suppuration may take place at these points, and the matter escape either into the urethra or externally. Swelling of the lymphatics of the penis is by no means uncommon in severe or neglected cases of gonorrhœa; a hard chord, tender, and extremely painful when pressed, is felt running along the dorsum penis, and terminates in the inguinal cluster of glands, which are in general also affected. Inflammation and abscess under the strong tendinous sheath that envelopes the penis occasionally follows the affection of the lymphatics. The whole penis swells greatly, with fever and much pain; the matter is confined, burrows under the unyielding sheath, and appears either at the junction of the glans and prepuce, or over the symphysis pubis.

Occasionally the inflammation is not confined to the extremity of the urethra, but pervades its whole extent, in consequence of maltreatment, neglect, or idiosyncrasy. On this account, abscess in the perineum, or over that part of the urethra which is covered by the scrotum, is no uncommon consequence of a badly managed clap; the inflammatory action extending from the urethra to the cellular texture exterior to it. The formation of matter is preceded by fever and great pain; the patient is unable to sit; and occasionally retention of urine takes place. The part affected feels hard, and extremely painful when pressed; it gradually softens, and at last fluctuates and points. But if the matter form deeply, behind the bulb and in the cellular texture beneath the perineal fascia, or in the situation of Cowper’s glands, it may be a long time of appearing externally. Fluctuation should never be waited for; and in most cases there are distinct enough signs of the presence of matter long before fluctuation can be felt.

Some people are much more liable to inflammation of the urethra than others, and many are exposed to the ordinary causes of gonorrhœa without suffering, whilst perhaps they are readily affected by such animal poisons as produce disease of the prepuce and glans. Patients often give very ridiculous accounts of the way in which their clap was contracted. They will say that the infection was received in a common necessary, that the disease was produced by a blow, by a strain of the back, by taking drugs that did not agree with them, by drinking out of the same cup or smoking the same pipe with an affected person, by wearing tight boots, falling into a dirty pond, &c. They will exert their ingenuity to the utmost, in order to deceive their surgeon, and attempt preserving their moral character untainted. Discharge from the urethra may be occasioned by dentition, &c., as already mentioned; or may take place from calculi passing along and getting fixed in the urethra, or from irritations about the anus. Inflammation of the passage not unfrequently arises, to a greater or less extent, from the acrimonious condition of the urine. The most common cause, however, is the application of irritating matter to the lining membrane; and this may take place during coition with females suffering from leucorrhœa, or during their menstrual discharge; but gonorrhœal matter is the specific virus, and the application of it to the orifice of the urethra is by far the most frequent cause of inflammation of the canal. Irritating substances injected into the passage may, and often do, produce or aggravate the inflammatory action. Besides all this, irritability of the urethra is common in gouty individuals.

Gonorrhœa has been termed virulent when caused by gonorrhœal infection—simple, when induced by irritations such as those previously enumerated; the distinction is seldom attended to, and is of no practical importance. It has been supposed that the poison which produces chancre is the same with that which gives rise to gonorrhœa, the action being modified by the texture in which the virus is lodged: such an opinion has been found to be wholly untenable.

Gonorrhœa supervenes at various periods after exposure to the infection, from twenty-four hours to six or eight weeks, but generally in from ten to twenty days; often the time cannot be correctly ascertained; much depends on the idiosyncratic susceptibility of the urethra, on the degree of acridity in the matter applied, and other contingent circumstances.

When the discharge becomes more clear and thin, and the inflammatory symptoms have disappeared, the disease is termed _Gleet_. The passage remains contracted in some degree, from relaxation of the mucous surface; there is a desire to make water more frequently than usual, and the urine is passed in a tortuous or scattered stream; in many cases the discharge continues profuse. There is now no pain nor scalding during the passage of urine, but these are readily reinduced by slight excess; perhaps there is a trifling chordee. After connexion, the discharge returns as if fresh infection had been caught, though such be not the case; both in simple gleet, and in that attending stricture, the seemingly virulent symptoms come on speedily, often appearing within a few hours after the coitus. In gleet the matter is no longer green or yellow, but whitish and flaky; the globules are contained in a mucous instead of a serous fluid. The disease is usually attendant on stricture, but occurs frequently without any organised contraction, the discharge being furnished by the vessels of the surface, which have become weak and relaxed in consequence of previous excited action. In feeble constitutions, inflammation of the urethra is almost always followed by long-continued and intractable discharge.

A practitioner is not unfrequently asked when the infection of gonorrhœa is not communicable, and if an individual in whom the discharge is very slight, or has just disappeared, is likely to contaminate a healthy female. The question is a difficult one to answer. In general it is prudent to err, if at all, on the safe side—by expressing doubts, and dissuading from intercourse until all discharge shall have entirely ceased for a considerable time. Discharge is often brought back, as already observed, by the excitement of sexual connexion.

In simple inflammation of the urethra, with discharge, little or no treatment is required; if the patient keep quiet, and avoid the causes which give rise to the affection, the symptoms will disappear in a short time. But virulent gonorrhœa is often very unmanageable, particularly if it has been allowed to follow its own course, and consequently to make head before it is attacked. It is no easy matter to arrest it after the parts have got into the habit of furnishing discharge, and particularly if it has been aggravated by thoughtlessness and imprudence of the patient. All violent exercise should be avoided, as also indulgence in venery and liquors. A great variety of remedies, both external and internal, have been employed. General bleeding has been recommended, but never can be required in simple clap. If the bladder, or other important organ, become affected, depletion will be indispensable. Abstraction of blood by leeches from the perineum may be required, when from any cause the inflammation extends beyond its usual seat; and great relief is afforded by afterwards employing hot fomentations, or the bidet, and by diaphoretics given internally. Mercury was used in clap by those who conscientiously believed that the disease was the same as what they called syphilis. But it had been better far for mankind had such a term, or the notions associated with it, never been broached; or at least had mercury never been considered as necessary for the cure of affections of the genital organs. In gonorrhœa mercury may do much harm; it never can do good, either in the way of cure or prevention. The disease has often been contracted, whilst the system was saturated with the mineral. Frequent and violent purgings with neutral salts—a common plan of treatment amongst the unprofessional and inexperienced—are hurtful; the extremity of the rectum is irritated, and may inflame, and the urethra, from intimate sympathy, will suffer accordingly. Turpentine, copaiba, cubebs, buchu, &c., have been long employed in all forms of the disease; of these, copaiba, administered from the first, and not after the inflammatory symptoms have subsided, is perhaps the one chiefly to be relied on. It maybe taken pure, with a little water or bitter tincture, or mixed with an equal part of honey; the copaiba may be given in gelatinous capsules, or made into pills with magnesia; it should be given at bedtime, and in a large dose, from a drachm to two drachms. The medicine may with prudence be continued after the disappearance of the discharge, though its beneficial effects are scarcely observable, excepting during the inflammatory stage. An unpleasant eruption, resembling urticaria, sometimes follows its employment; it appears on the inside of the lips, and on the glans penis, and if the drug is continued, the eruption spreads over the whole surface. Cubebs, though somewhat similar to copaiba in its virtues, often disappoints the practitioner. The two medicines may be given very advantageously together, made into a confection, and a bolus of it taken occasionally in wafer paper. This class of remedies, instead of stimulating, diminish greatly the irritability of the urethra or the other parts of the urinary organs. In severe cases it is of importance to increase the quantity of urine, and thereby diminish its acrimony, by the free employment of diluents, mucilaginous drinks, and alkalis; on this principle, infusion of linseed, containing more or less of nitrous æther, is very efficacious. The patient suffers much when the urine is scanty, and contains a large proportion of saline particles. Rest and moderate diet are of paramount importance as means of cure. Support of the penis, by a suspensory bandage, or otherwise, should always be attended to when the patient takes exercise, for many bad consequences will thereby be avoided; indeed it is a measure requisite in all affections of the organ, and particularly in gonorrhœa—when the prepuce, or even the whole penis, is liable to swell enormously. By low diet, and the frequent use of warm bathing of the part, or of the whole surface, the disease often disappears rapidly; but when the cure is supposed complete, a hearty meal and a few glasses of wine will suffice to bring it back with all the violent symptoms.

Cooling washes applied externally to the penis are of little use, and will seldom be long submitted to by the patient. Fluids injected into the urethra, so as to be applied to the affected part of the mucous membrane, are much more efficacious. When slightly stimulating, the relaxed membrane is constringed by them, the action in the part is changed, and a healthy secretion ensues; such are applicable after the inflammatory symptoms have subsided. But in many instances astringent injections are of much service from the very commencement; the morbid action seeming to be arrested, and the parts quickly brought into a healthy condition. Yet the use of such is not unaccompanied with risk, and the mildest are sometimes hurtful; the incited action is apt to extend along the passage; the discharge may be suddenly suppressed, and inflammation of the bladder or testicle will generally supervene; in short, the prominent symptom, discharge, may be arrested, but at the same time such violent inflammatory action may be induced as will be followed by change of structure in the canal, callosities, contractions, abscess, &c. The injections may contain nitrate of silver, sulphate of copper, sulphate of iron, sulphate of zinc, acetate of zinc, super-sulphate of alumina, or bichloride of mercury, in various proportions, or vegetable astringents may be used, as kino, galls, &c.: their strength may be gradually increased according to their effects. These solutions and infusions are injected by means of either a small syringe, or an elastic bottle fitted with an ivory tube, the point being smooth and rounded. This is carefully introduced into the orifice of the urethra, and the patient is recommended to press on the canal with his finger to prevent the fluid from passing farther than an inch or two. It may be thrown in two, three, or four times during the day, according to circumstances, and retained for a few minutes; at each time the patient should make water immediately before. The quantity injected at one time should not exceed a teaspoonful; more is unnecessary, and may do harm. By passing bougies or other instruments along the canal during active inflammation much mischief is done. When excitement has gone off, and discharge remains, advantage may be obtained by the internal administration of lytta or other stimulants. When contraction of the passage is suspected, or when, in spite of all means, no progress is made towards a cure, slight discharge continuing long without pain, and probably furnished by a relaxed portion of the membrane, recourse must be had to the occasional introduction of a full-sized bougie. Cold bathing, local or general, is sometimes useful.

If during the violent symptoms the discharge be from any cause suddenly suppressed, inflammation of the bladder, swelled testicle, or both, are to be dreaded; and endeavours should be made without delay to procure its return, as by leeching the perineum, fomentations, and the general warm bath.

The Consequences of Gonorrhœa occur in parts closely connected with the urethra by sympathy and function; or they are such as affect the constitution.

_Of Hernia Humoralis_, or swelled testicle. Pain and swelling occur in the epididymis, and soon affect the body of the testicle. The pain is most excruciating, the unyielding nature of the tunica albuginea preventing the vessels from relieving themselves fully, and inducing compression of the enlarging organ. Effusion takes place into the cavity of the tunica vaginalis, and thereby the tumescence is still more increased, this tunic from its great dilatibility readily accommodating itself to the accumulation of fluid within. Sometimes the effusion is bloody, more generally serous, and not unfrequently composed of serum more or less tinged with blood. The epididymis remains enlarged longer than any other part, often during the remainder of life. Sickness, vomiting, and violent fever, attend the progress of the swelling. Pain in the lower part of the abdomen is not infrequent, and may be mistaken and treated for enteritis. The spermatic chord becomes enlarged and tender. The pain is much increased when the patient assumes the erect posture, from the enlarged and pendulous gland stretching the inflamed chord. Uneasy feelings are complained of in the back, and pain there is sometimes so acute as to be compared by the patient to the sawing of his loins asunder. When the inflammation is violent, and effusion into the substance of the gland extensive, suppuration may occur; and in infirm constitutions this is not an infrequent, though remote, consequence of hernia humoralis. The testicle is said to be rendered useless by the supervention of this disease. Certainly it is in danger of having its functions destroyed when the incited action is intense and the effusion great, and particularly if suppuration follow. The disease may be induced by violent exercise during inflammation of the urethra, bruising of the organ, suppression of gonorrhœal discharge, the imprudent introduction of bougies, the use of strong urethral injections, or debauchery of any kind, during inflammatory gonorrhœa.

In the treatment, complete rest occupies a prominent station. The inflamed organ must be supported; and all means which may have been employed with the view of checking gonorrhœal discharge must be abandoned. General bleeding may be necessary when the system is much excited; and in all severe cases blood should be abstracted copiously from the part, by the application of leeches or the opening of the scrotal veins, and the organ is afterwards to be fomented for some time, and then enveloped in a warm poultice. The bowels must be kept open, the diet must be very low, and the value of antimonial medicines as a powerful remedy in all inflammatory affections must not be overlooked. Cold applications are of little or no service at any period of the disease, and frictions with mercury and camphor had better be dispensed with. When the violent symptoms have subsided, bathing the part with a tepid solution of the murias ammoniæ is often useful; or it may be rubbed gently with an ointment containing a small portion of iodine, or with a liniment of soap and camphor, with tincture of iodine. Much relief is experienced from interposing between the scrotum and suspensory bandage a soap plaster, or one composed of equal parts of the gum and mercurial plasters; thereby the organ is defended from irritating friction and motion, and slight stimulation is produced and kept up on the surface. Blisters promote discussion if the swelling become indolent, but are very annoying to the patient. They require repetition, but generally are in the end effectual; perhaps the rest necessary during their use is of as much benefit as the application.[54]

_Inflammation of the Bladder_ and posterior part of the Urethra may arise from other causes than suppressed or badly treated gonorrhœa; but, however induced, its symptoms and consequences are the same. The presence of calculi or other foreign bodies, over distention, &c., will be treated of hereafter, as causing irritation and inflammation of the viscus. Much vesical irritation is often produced and kept up by disease of the kidney.

When inflammation of the bladder is slight, it is attended by uneasy feelings referred to the perineum, pelvis, and glans penis; frequent desire to empty the organ; pain felt acutely before evacuation of the urine, and relieved immediately afterwards; scanty secretion of acrid and highly coloured urine; a discharge of slimy, tenacious mucus, either pure or voided along with the urine. In severe cases, most excruciating pain is experienced during the discharge of the contents of the bladder. The urine is often bloody; in general it is of a milky appearance, containing lymph or puriform matter, and vitiated secretion from the lining membrane. Micturition is almost constant, small quantities being voided at a time. Sometimes the inflammation extends to the ureters and pelves of the kidneys, causing violent pains in the loins, nausea, occasional vomiting, and colicky affections.

In very violent cases lymph is effused on the inner surface of the bladder, and may become organised; but such effusion is rare. I met with one remarkable instance of it in my own practice, and have seen several others. An old pensioner fell from a scaffolding, and sustained a severe contusion of the back. Retention of urine came on; it was drawn off regularly for some weeks, but then severe pelvic symptoms supervened, and at last nothing but a small quantity of purulent matter flowed through the catheter. The symptoms became urgent, the bladder was very much distended, and rose to the umbilicus; all endeavours to evacuate the urine per urethram failed, the instrument being always closed by the thick pus, and I was obliged to open the bladder pretty freely above the pubes. Much purulent matter mixed with fetid urine escaped from the wound, as also a false membrane which invested the mucous coat of the viscus. The membrane presented a flocculent appearance, in some places distinctly fibrous, in others was thin and transparent; its internal surface was irregular, as if from the deposition of minute granules of recent lymph. The patient died exhausted, after having survived about three weeks, voiding his urine partly by the wound, and partly per urethram. It should perhaps be mentioned, that those who saw him immediately after the accident supposed that blood was extensively effused into the bladder, and attempted to extract the suspected extravasation by means of an exhausting syringe through a catheter, probably not passed into the bladder.

Occasionally, though rarely, the inflammation extends to the peritoneal covering of the bladder, and thence to the external surface of the intestines.