Elements of Surgery

by Robert Liston

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.