Organs._—It has been previously observed, that these membranes closely
sympathise with the skin and with the mucous linings of the digestive
organs. Stimulating substances introduced into the stomach frequently
produce irritation of the urinary organs; and if the stimulants be
employed in large quantities, and continued for some time, inflammation
of the mucous membrane, investing the bladder and urethra, will be
induced, with vitiated and increased secretion from the parts. In
children, dentition is a common cause of urinary irritation; and not
unfrequently discharge from the urethra comes on during the cutting of
the teeth. The application of acrid matters, as cantharides, to the
skin, will occasion unpleasant effects in the urinary organs; and these
unpleasant and distressing symptoms often supervene upon disappearance
of cutaneous diseases. In short, the practitioner, in attending to
affections of these parts, must ever bear in mind the close sympathy
which exists between them and the external surface, the stomach, and
the intestines, particularly the lower.
_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.
[Illustration]
_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.