Читать книгу Porneiopathology - Robert James Culverwell - Страница 8

The Surgical Treatment of Gonorrhœa.—The principal symptoms indicative of the outbreak of a gonorrhœa are a scalding burning sensation along the urethra as the urine passes through it, and also the pouring forth of a profuse discharge of yellow matter from the same passage. The urethra is lined with a very sensitive membrane, fashioned, however, to be insensible to the urine in its natural state; but if the character of the urine or the membrane itself be altered, the most exquisite misery is produced. Now in gonorrhœa, when it is a first attack, the initiatory sensation is invariably heat, itching, or pain in the urethra; the seat of this suffering is in the mucous membrane. On separating the lips of the orifice of the urethra, the passage appears highly vascular, very red, and looks, according to the popular notion, very sore. On examining it with a powerful glass, little streaks or surfaces of a yellow and tenacious matter are perceived, which, upon being removed, are soon replaced by others. When the patient attempts to urinate, this purulent exudation becomes washed off. By this time, the system is somewhat excited, and the urine is consequently more deeply impregnated with uric acid, which renders it more acrid and pungent to the delicate and now tender outlet through which it flows: the sensation is faint at first, but is rendered very acute by the combined worry inflicted upon the urethra, by its muscular contraction to eject every drop of urine, the denuded state of the membrane itself, and the irritating quality of the water. Such, however, is the habit of action, that the urethra in course of time becomes indifferent to the annoyance of the flow of urine. The nervous sensibility is much diminished, and the urethra is further protected by an abundance of the venereal secretion. There are numerous contingencies that prevent the changes ensuing in such order, and, consequently, the scalding, and the amount of discharge, are seldom two days alike. Were there to be no interruption, the inflammation, for such is the whole process in obedience to the animal law, would fulfil its intention and retire; but molested as it is by diet, exercise, the varied states of health, and numerous other fortuitous circumstances, as we well know, it exists indefinitely. It would be next to an impossibility to explain the process whereby the character of a secretion becomes altered, or to describe the exact changes which the structure or vessels undergo when furnishing the discharge; but we well know that some such changes do take place, and that a cause must precede an effect. In like manner we can ascertain the result of certain experiments, although the modus operandi may baffle our penetration. Gonorrhœa is originally a local complaint, but if not arrested, it involves not only the neighboring parts, but it compromises the general health. Now if the same ends can be brought about by artificial means in a few days, that it takes weeks to effect in the ordinary routine, all the intermediate suffering may be avoided, and all the inconvenience of confinement and physic-taking spared.

To cure this disease I find that in many cases, if the parties apply at the very onset of the disease, before the discharge and scalding have set in with anything like severity, and they themselves be not of a very inflammatory temperament, that a sharp stimulating injection will at once subdue the sensitiveness of the urethra and alter the action, and, at the cost of very little, and that only temporary suffering, effect a speedy cure: the mode, except it be by stimulating the relaxed vessels, or owing to the specific action of the injection, is, like all other medical operations, a mystery. A favorite prescription is the nitrate of silver, say one scruple of the nitrate to the ounce of water, but the disease must be thus treated at the very first symptom: the patient must be otherwise in comparatively good health, and his occupation must not expose him to much bodily fatigue. He must not be given to intemperance, nor should those instances be selected where the sufferer is of a very inflammatory constitution. Experience begets confidence, and confidence begets experience. In cautious hands I am satisfied of its usefulness; but there are cases that turn out failures. I have used the injection when the disease itself was a week old, and with like success; but I am ready to confess I have known cases, the cure of which were retarded by its employment. The inflammation has been temporarily aggravated, but they were cases where the treatment was not appropriate; the disease was far advanced, there was much heat and swelling, and the patient’s health was in most instances considerably affected; but yet beyond the few hours’ of suffering merely, no extraordinary symptoms were produced. The cure was very shortly after effected by means which I shall presently allude to.

In all cases of suspicious connexion I recommend copious ablution as soon as possible.[1] The syringes I would advise to be used should have their points conically shelved off pear fashion; they fill up the urethra like a wedge, and prevent the immediate escape of the injection: all injections should be retained a few seconds, and then be allowed to flow out. It is seldom worth while to repeat the operation more than twice on an occasion; but that occasion may be resorted to two or three times a day.

When the nitrate of silver is used, the syringe had better be made of glass. The nitrate of silver discolors the skin, linen, &c.; therefore gloves should be worn, and care taken that the fluid be not spilt over the person or dress, but should the skin be stained, it can be removed by a strong solution of hydriodate of potash.

The plan of injection, I must remind the reader, is only applicable in early and old cases. The recent cases, as I have before stated, are less frequently before the medical man than what we may call a “ripe” gonorrhœa. The old cases present also some difference as to the cause of their continuance, and require also some difference in their treatment, and they will be introduced under the chapter headed “Gleet.”

The symptoms of a clap, fully developed, are severe scalding, voluminous discharge, painful erections, local inflammation, probably phymosis or paraphymosis, glandular swellings, and possibly swelled testicle.

But all cases of gonorrhœa are not ushered in with such severity; nor do many, if common cleanliness and quiet only be maintained, experience even the various accompaniments just described, and still fewer would if the following precautions and measures were used.

The plan just laid down, may be called the surgical treatment of gonorrhœa; the following may be designated the Medical. This is divided into two methods—the one denominated the Antiphlogistic, the other Specific. The Antiphlogistic is a term applied to medicines, plans of diet, and other circumstances, that tend to oppose inflammation by a diminution of the activity of the vital powers, whereby the inflammation is subdued, and nature rights herself again of her own accord. The Specific implies a reliance upon a particular remedy, which is supposed at once to set about curing the disease, as, for instance, by giving Bark in Ague—Colchicum in Rheumatism—Cubebs or Copaiba in Gonorrhœa.

Now, both these plans are successful in curing gonorrhœa; but the majority of medical men adopt the former method, inasmuch as although it but quietly conducts the case to a successful termination, still it does so, whereas the specific, in unskilful hands, is often productive of many annoyances, much delay, and not always a cure.

Our plan, however, is as follows: in the first place, I take into consideration the appearance of the patient; if he be strong, robust, sanguine, or of full habit, and youthful—if it be his first attack, and if the symptoms be ushered in with any degree of severity, I invariably and rigidly (where I choose not the surgical) pursue the antiphlogistic course of treatment; if the case be in a person of phlegmatic temperament, of mature age, and the disease be but a repetition of the past, and there be no evidence of physical excitement, I fearlessly adopt the specific. Where, in the third place, I encounter a patient with no very prominent peculiarity, nor with symptoms demanding extraordinarily active measures, experience has taught me the propriety of cautiously combining the two methods—a mild aperient had best always a precede a tonic or a stimulant, in cases where there is a doubt of inflammation lurking in the system; and, recollecting the tendency our complicated organization has, when assailed by a distemper, to become irritable, it is always as important to know when to withhold a remedy as when to prescribe one.

The three following imaginary cases will serve as no inapt illustration of the principles laid down:—

A. B. A man twenty-six years of age, five feet six inches in height, weighing eleven stone six pounds, of a full rounded form—florid complexion, of what is termed a sanguine temperament, and harassed with the following symptoms: profuse discharge in large yellow clotted lumps of gonorrhœal virus—intolerable scalding on passing water—great pain at the rectum at the close of micturition—redness and swelling of the orifice of the glans penis, puffiness of the prepuce, a vicious chordee—inclination to headache—a bounding pulse—hot skin, and an anxious mind. Treatment: say first bleeding, then purging; warm bath, saline powders or mixtures, cold lotions to the part, rest, abstinence; the following eve, symptoms will be less severe. Continue the powders, temperance and quiet. In a few days, the discharge will be lessened, the scalding mitigated, the chordee gone, and the fever exchanged for the cool skin of health. The resuscitative powers of nature await only the fillip of some gentle stimulant, and the sick man throws off his mantle for the coronal of health.

B. C. At twenty-three, dark countenance, marked features, well developed muscular form, pulse 66, bilious temperament, accustomed to late hours, hard drinking, and seldom still, and subject to clap. Symptoms: plenteous discharge with but little scalding, and no inconvenience beyond the suspension of ordinary sensualities. Treatment: cleanliness, cubebs or copaiba, injections, a black draught, and half a dozen days’ rest, release him from his quarantine.

C. D. At nineteen, a timid bashful youth, for the first time infected with gonorrhœa, which he had enduringly borne for the last fortnight, having neglected until now to seek professional aid, although cajoled into the purchase and imbibing of some popular “never-failing antidote” for a “certain disease.” Symptoms: discharge cured? right testicle swollen, and treble the size of the other, and excruciatingly painful; frequent desire to pass water, pain in the groin and back, general lassitude, and a feeling of illness all over. Treatment: leeches, warm bath, bed, purging, fever medicines, cold lotions, hot fomentations, low diet and patience, a month’s imprisonment, and a slow recovery. Had the treatment of the first two cases been reversed, the results would have been very different: and had the last sought timely and efficient aid, he would have been spared much that he endured.

However, to particularize the treatment for each symptom; to commence, I will request the reader to remember that on the first appearance of gonorrhœa, attended with an unusual inflammatory aspect, I practise, where permissible, venesection; if the case demand it not, at least there should be administered an aperient; let, therefore, a dose of opening medicine be taken immediately (Form 1). This is the first step toward reducing inflammatory action—the next should be directed toward allaying the local symptoms, by diminishing the nervous irritability of the urethric passage.

With this view, no plan surpasses that of bathing the penis in warm water, or immersing the entire body in a warm bath. The former should be repeated several times in the day; the latter daily, or certainly on alternate days, so long as the severity lasts.

By these means, the parts will be preserved clean, and will derive benefit from the soothing influence of warmth; and, in many cases, this will be the means of averting chordee or swelled testicle.

Where, however, from peculiar circumstances, warm water and warm baths are not to be had, the penis should be bathed in cold water, or encircled with pledgets of rags or lint, moistened with cold goulard or rose-water. Warm, however, is to be preferred, although cold water seldom fails of affording relief.

To lessen the acrimony of the urine, which keeps up the irritability, and somewhat to lower the system, all strong drinks, such as ale, beer, wine, and spirits, should be avoided, and milk, tea, barley-water, toast and water, linseed tea, gum arabic in solution, and other such mucilaginous diluting liquors taken instead. The diet should be lowered: in fact, a spare regimen should be adopted, not wholly abstaining from animal food, but partaking of it only once in the day, and carefully excluding all salted meats, rich dishes, soups, gravies, &c. The usual employment should be suspended, and rest should be taken as much as possible in a recumbent posture.

Of course the preceding remarks apply only to cases of severity; I mean such cases as first attacks ordinarily prove; and which remarks, if attended to, will greatly mitigate the violence of the disease.

To assist the foregoing treatment, the aperient medicine, which should be repeated, at least, on alternate days, until the inflammation is ameliorated, should be followed by some saline or demulcent medicine to allay the general disturbance. Several formulæ are suggested for that purpose, suitable to various temperaments and conditions—[See Forms 2, 3, 4, 5 in Formulæ annex.]

By these means, the disease, if not aggravated by intemperance of living, or otherwise, will gradually subside, and in the course of a fortnight or three weeks, cease entirely, without the aid of any other remedy whatever.

But we need not rest satisfied with merely “showing” the disease through its stages; we can expedite it, and many of its steps we can skip over, and here it is we may call to our aid the specific method of treatment alluded to. This specific method consists of the suspension of a vitiated secretion, and a restoration of a healthy one. Now how this is effected we know not; we only know that it can be done—and experience has taught us that it may be done safer at one time than another. During the existence of a fevered state of the circulation, it would be highly impolitic suddenly to check a discharge from any surface, much less one situated like the mucous membrane of the urethra, in the immediate connexion, as it is, of important nerves and glandular structures—a metastasis of the inflammation will almost invariably ensue; and hence we account for swollen testicles, buboes, painful affections of the bladder, &c. Whereas, on the subsidence of inflammation, the revulsion is borne; and to our satisfaction, the disease disappears. A constitution in a state of excitement is like a fretted child—it will have its “will” out, and the rod is not always the safest corrective.

On the subsidence, therefore, of the scalding, and a lessening of the general fever, the specific plan of treatment may be commenced. Upon the same principle that the surgical treatment is selected according to the symptoms, so also are the just-named preliminaries in many cases dispensable, and hence, as hereafter detailed, it will be found that the antiphlogistic and specific do not go always hand in hand. However, to explain the latter:—

By specifics are meant those remedies that exert a positive curative effect on a particular disease; and the most prominent of those, in gonorrhœa, are copaiba and cubebs. See Formulæ annex for some useful recipes of both—Forms 6, 7, 8, 9, 10.

For instance, cubebs may be taken alone, in water, in doses of a tablespoonful twice or thrice daily. If cubebs produce no good effect in four or five days, it had better be discontinued, and other means sought after.

These proceedings usually carry the disease to a close, and, if no adventitious circumstances occur, successfully and speedily. It is well to deserve success, but it can not be always commanded.

The business engagements of young men render it almost impossible for them to devote that care and attention so importantly requisite; and few, consequently, will be found who will be fortunate enough to escape the usual concomitants of a gonorrhœa.

Where, therefore, the scalding or passing the urine is very severe, the pain may be mitigated by carefully injecting, previously to making water, either of the formulæ No. 11 or No. 12 (see Formulæ annex) into the urethra.

The inflammation extends in general not more than two inches down that passage, so that much force is not required to inject the intended fluid, nor should an unnecessary quantity be used.

When the inflammation reaches the bladder—which is indicated by pain in that viscus and the perinœum, with a constant desire to pass water—the taking of a warm bath at a temperature of 100°, and remaining therein for a quarter of an hour, will afford essential relief.

When a chordee is attendant on a gonorrhœa, and the patient can not sleep, the draught (Form 13) may be taken on going to bed, or the powder (Form 14) in some gruel. The embrocation (Form 15) rubbed on the parts affected, however, will instantly remove both the pain and the spasmodic contraction, and not unfrequently prevent their recurrence. Care must be taken that the embrocation be only used for its specific purpose, and not swallowed by mistake, as it is poisonous.

In the event of the patient being obliged to follow his ordinary occupation, or to go about, the use of a suspensory bandage will be found of great benefit; indeed it is indispensable, and the neglect of it has often brought on swelled testicle, or most excruciating chordee.

By way of recapitulation, the treatment of gonorrhœa thus far consists: in severe cases, of bleeding; in ordinary ones, and in both, of warm bathing, local or general—where impracticable, cold—attention to diet, the taking of aperient, soothing and astringent medicines, rest as much as possible, and the use of the suspensory bandage. These remarks are equally applicable, then, through every stage of this complaint that is accompanied by inflammation, and may be relied upon as the most effectual to avert all the consequences I now proceed to detail.

The consideration of the symptoms here following is not in the order in which they always occur; for swelled testicle may ensue without phymosis or paraphymosis preceding, or even being present; and the converse holds equally good with regard to every other.

The successful treatment of phymosis (that condition of the foreskin in which it can not be drawn back over the glans) depends very much upon local management. Bathing the part frequently in warm water, the daily use of the warm bath, and the frequent injection, by means of a syringe, of warm milk and water, are generally all that is required to reduce phymosis; but where it is attended with much inflammation, where the glans is excoriated, probably by the discharge from the urethra accumulating between it and the prepuce, and thereby inducing irritation, bleeding is even sometimes necessary, the strictest antiphlogistic regimen should be preserved, and the treatment advised in the early stages of gonorrhœa scrupulously followed.

Sometimes the prepuce becomes so swollen as to assume an œdematous or dropsical appearance; in which case it may be scarified with a lancet, or several leeches applied. With the exception of concealing the state of the glans, phymosis is less dangerous than paraphymosis, and is most usually produced by the patient worrying the part, by frequently uncovering the glans to observe its condition. Where a discharge is perceived oozing from beneath the prepuce, which is not urethral, and the glans does not feel sore or tender, the injection (Form 16) syringed up five or six times a day, will prove very efficacious in healing the ulceration.

Where there is an unnatural elongation of the prepuce, it will be constantly subject to phymosis, not only from gonorrhœal inflammation, but from the accumulation of the natural secretions of the part. In that case, cleanliness is the only remedy the patient can employ of himself. Occasionally it is necessary to have recourse to the surgeon’s knife.

Paraphymosis is the opposite to phymosis, and usually arises in this way: the orifice of the prepuce, being contracted by the inflammation, is drawn back for the purpose of washing or examination, and is allowed to remain, or, as frequently happens, it can not be redrawn. When this continues some time, considerable inflammation, both of the glans and prepuce, arises. The contracted orifice pressing more tightly, it will often happen that a sloughing of both it and the glans will take place; but this occurs only in consequence of neglect, or in constitutions injured by intemperance.

If seen and attended to early, this state may be removed very easily. The penis should be immersed in a basin of cold water, or sponged, so as to cool it as much as possible; or it may be well oiled. In either case there will not be much difficulty in pressing up the glans and drawing up the prepuce over it; but where adhesion has taken place, or ulceration exists, it will be harder to accomplish: the adhesions must be separated, or the stricture divided with the scalpel.

I need scarcely observe, that such an operation is out of the province of the non-professional person, who should lose no time in consulting his surgeon.

I omitted to mention, in the description of the symptoms of gonorrhœa, that occasionally, in very severe cases, a tumor forms in the perinœum, which, if neglected, proceeds to suppuration, and establishes a fistulous communication with the urethra. On the instant of such a swelling appearing, leeches, fomentations, and poultices, should be applied with a view to disperse it; but the management of such a case had better be intrusted to the surgeon.

Excoriation of the membrane of the glans or prepuce requires for its treatment frequent ablution with warm water until the redness and discharge somewhat diminish, when Form 16 may be resorted to, and applied, if practicable, by a moistened layer of lint; but if accompanied by phymosis, the syringe must be used.

Warts, if not large, are easily removed, by brushing them with the muriated tincture of iron, or the application of a lotion of lunar caustic (Form 17).

Where they are numerous and large, and resist the remedies just recommended, the nitric acid is an excellent escharotic; it gives little or no pain, and is rarely productive of inflammation. The glans, if not naturally denuded (in which instance, by the way, warts seldom accrue), should be kept so for a time; and the nitric acid, after a few moments, washed off with cold water. Notwithstanding, excision is sometimes necessary to their complete removal.

When the organs of generation are infested by pediculi, or crab-lice, the most efficacious and agreeable remedy is the sulphur-bath; one bath generally effecting an extinction of every one of them, even though they be all over the body.

Some recommend shaving the hair off the pubis, the locality in which the vermin are most usually engendered, and applying blue ointment or the black wash. Such a practice is seldom ineffectual, but the irritation attendant upon the reproduction of hair is absolutely intolerable. The hair need not be removed, as the above remedies will be all-sufficient without it. Rubbing the parts well with strong mercurial (or blue) ointment, or the black wash (Form 18), or even powdering them with calomel, will at once destroy the insects, and thereby remove the itching.

Swelled testicle, or hernia humoralis, more especially that proceeding from gonorrhœal irritation, is ushered in and discovered in the following manner: The patient, on some sudden movement of the body, experiences a pain, darting from one of the testes (both being rarely affected at the same time) to the loins—the left testicle is the one generally attacked. On examination, he finds that the testicle is rather swollen and full, and very painful on being handled; the swelling quickly increases and becomes hard, which hardness extends to the spermatic chord, presenting the feel of a rope, passing from the scrotum to the groin.

It is remarkable that when swelled testicle occurs, the discharge from the urethra, which, from previously being very profuse, and the scalding on making water, which was very severe, both suddenly diminish, or cease entirely, until the inflammation of the testis declines; hence, it has been supposed by some, that the disease is translated from the urethra to the testicle.

It is more probably however, derived from the sympathy between the two; the irritation of the one affecting the other, and the preponderance of inflammation in the testicle acting on the principle of counter-irritation to the urethra, and, for a time, thereby lessening the disease in it: for it is observed that, as soon as one improves, the disease returns in the other. The treatment of hernia humoralis must be strictly antiphlogistic. In no form of gonorrhœal disease is bleeding more absolutely necessary.

The timely and prompt loss of twelve or sixteen ounces of blood from the arm will often cut short the complaint, and render other remedies almost unnecessary; while the temporising delay, under the vain hope of the inflammation subsiding, will allow the disease to make rapid progress, and impose a necessity of several weeks’ rest and absence from business, before a cure can be effected.

Immediately, then, on the occurrence of swelled testicle, I would recommend the patient to be bled—to take some aperient medicine, and, if the inflammation continues, to apply from twelve to eighteen leeches, and afterward suffer the wounds to bleed for twenty minutes in a warm bath; to retire to bed or to the sofa, and to maintain a horizontal posture. If he be strong, young, and robust, an emetic (Form 19) may be given previous to the aperient, which has been known to remove the swelling almost instantaneously.

Iodine (Form 20) also possesses a similar specific property in reducing swelled testicle, and may be taken during the inflammatory stage after bleeding and aperients, as may likewise the chlorate or hydriodate of potass (Form 21).

With regard to local applications, the repeated employment of leeches, fomentations, and poultices, with the frequent use of the warm bath, and, above all, keeping the testicle constantly supported by means of a bag, truss, or suspensory bandage, will subdue the disease in a very short time, without impairing the functions of the important organ concerned.

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A hardness, however, of the epididymis commonly remains and continues during life, but rarely gives rise to any inconvenience, although this may often be remedied by compressing the testicles with strips of adhesive plaster, as seen in the cut.

Almost every case of inflamed testicle will terminate favorably by strictly pursuing the plan proposed; but when, from any untoward circumstance, the inflammation proceeds to suppuration, the case must be treated like one of common abscess, in which event professional aid should be sought for without delay.

Other diseases of the testicle will be treated upon under a specific head.

To return to the treatment of Gonorrhœa:—On the abatement of all or any of the enumerated symptoms, such as the diminution of the scalding upon making water, the subsidence of chordee, the escape from, or cure of, swelled testicle, phymosis and paraphymosis, warts, crabs, excoriations, &c., the discharge may still continue, though thicker in consistence, and deeper in color: and it is at this period, which I will call chronic gonorrhœa, when all inflammatory symptoms have left, that stimulants may be judiciously given; but it must be borne in mind that relapses often occur from imprudence: and this chronic form requires as much attention as the acute or early stage. (See article Gleet.)

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