The ovaria become enlarged by degeneration of their structure and the addition of solid matter in great abundance. The consistence and structure of such tumours are very various; they are sometimes, though rarely, medullary, often fibrous, with or without cysts, sometimes melanotic. In the majority there are cysts, varying in size, number, and contents; sometimes the bag contains hydatids, or it is filled with curdy matter, sometimes with glairy colourless fluid, sometimes with a turbid and flaky serum, sometimes with blood; and in them, as well as in the enlargement from accumulated fluid, though perhaps more rarely, are occasionally found teeth, hair, and membranous looking matter; some are intermixed with bone, cartilage, and fat. The situation and attachments of such tumours cannot be correctly ascertained by examination during life, far less can their internal structure and dispositions be arrived at. Indeed an accurate diagnosis is exceedingly difficult, if not impossible. Innumerable mistakes have been made, which have led to most unjustifiable proceedings. In one case, the abdomen was, after two or three dry tappings, opened by an incision from the ensiform cartilage to the pubes; the viscera were turned over and over, but no tumour could be discovered. The woman was sewed up, and did not die. The following was a still more complete failure in diagnosis. In a case of large tumour of the belly, many persons accustomed to manipulate abdominal swellings considered that extra-uterine conception had taken place; and that the child had come to maturity and perished. The history of the case countenanced the supposition; the symptoms had been such as indicate impregnation. The woman, to avoid exposure, went to a distance to be relieved of her burden, which was becoming more and more troublesome and bulky. The usual period passed over. It was thought that the head and thorax of an infant could then be felt readily through the parietes, and perhaps some one might have been found heroic enough to have divided them and explored the tumour. The young woman, however, was in the last stage of phthisis, and soon died. A wonderfully tuberculated omentum, a very small portion of which is here represented, filled the peritoneal cavity; the uterus and its appendages were quite healthy.
Operation has also been proposed, when, on dissection, the liver was found to compose the abdominal swelling. Such cases, a long list of which might be given, render the prudent surgeon very cautious in his diagnosis of abdominal tumours, and chary of operative interference with them. The abdomen has been opened, as already stated, and the result has been such as to render the perpetrator indictable for culpable homicide, and to qualify him for such punishment as his rash and reckless conduct richly deserved. A less severe censure might have sufficed, had not the example been followed by similar proceedings, and equally direful results; and these have been such as to render any condemnatory remarks not only justifiable but absolutely necessary. A great many unfortunate women have, I am afraid, been sacrificed to a desire for false reputation. The attempts to remove abdominal tumours by incision of the parietes were some time ago very numerous; and, as might have been expected, the issues were highly unsatisfactory to those concerned. Such doings, however, were recorded in print, represented in plates, and moreover puffed and placarded ad nauseam. The majority of those who were thus “dissected, to see what part was disaffected,” perished within forty-eight hours. One woman survived for some time, after having been subjected to this operation, improperly so termed. In her there was a tumour, but of such a size, and so connected, that it could not be removed. A second survived the extirpation of one ovarium; and the other, also diseased, was left for a further exhibition of daring intrepidity. It is not easy to conceive how the proposal could have been seriously entertained by any sane individual, far less put in practice and persevered in, when disaster after disaster crowned every attempt. It is my opinion, and I believe that I express the sentiments of a very large portion of the profession, that the repetition of any such incisions and gropings would be unpardonable.—1. On account of the difficulty, nay, impossibility, of forming a correct diagnosis; of ascertaining with certainty what organ is involved; of ascertaining the structure and disposition of the tumour, if any, and to what parts it is adherent. 2. Because the ovarian disease, in general, even though extensive, does not threaten imminently a fatal termination, being slow in its progress, and the greater number of the swellings being not of a malignant nature. The solid tumours are sometimes of a bad kind, as already stated; but enlargement by fluid is much more frequent in the ovaria than that by solid and new matter. 3. If the tumour be malignant, it will be impossible to ascertain to what extent the parts are involved by the diseased action, or whether the lymphatics are affected or not. There is a strong probability of the lymphatic system being involved, even at a very early period; and then the extirpation of the tumour—supposing the mass to be so situated as to admit of removal without difficulty or danger—cannot be attended with any advantage; in every point of view, therefore, interference is unadvisable. 4. The operative attempt is attended with imminent danger. There is almost a certainty of the patient being almost instantly destroyed by it, as shown by the sad experience of the past. “We are not the arbiters of life and death of those who apply to us for relief. If people die in consequence of disease, it cannot be helped. They submit to it because they know it is inevitable. But we had better refrain from making such experiments as may probably destroy them, and bring disgrace upon the profession.”
Bruises of the abdomen are apt to be followed by inflammation of the contained parts, particularly of the serous membrane. Occasionally lacerations of the viscera, both solid and floating, but more frequently of the former, are produced by bruising or squeezing of the abdomen, as by a blow, or by a heavy body passing over; they may also follow a violent concussion of the parts by falling from a height. The liver is the organ most frequently torn, and death is commonly the result, rapid, and principally from hemorrhage. The laceration is generally on the convex surface; extravasation takes place under the peritoneal covering; or this is torn, and the effusion is into the abdominal cavity. When the quantity of blood is not so great as to cause speedy dissolution, the patient may survive for some time, and even ultimately recover. Reaction is slow, the patient continuing a long time pale, exhausted, and almost pulseless; there is tenderness in the hypogastric region, with swelling. The spleen is liable to similar injury, and pours out a large quantity of blood.
The gall-bladder has sometimes been torn, as also portions of the small intestines, by a blow or kick, or by a heavy body passing over the abdomen, as the wheel of a loaded wagon. The escape of the contents is followed by sickness, rigour, quick, weak, and indistinct pulse, most excruciating pain, a sense of heat diffused all over the abdomen, and rapid sinking of the powers of life; a fatal termination generally occurs within twelve hours. The same train of symptoms supervene when the contents of the intestinal canal have been effused into the peritoneal cavity, through an opening in the stomach or bowel, caused either by slow destruction of the coats, the peritoneum giving way last, or by a rapid ulceration or sloughing process, as in hernia. The patient may live in agony for a day or two, but death generally takes place much within twenty-four hours. The same may be said of the rupture of the bladder, from external violence, with effusion of urine into the peritoneal sac. No treatment is of any avail; venesection hastens the sinking. Fomentation over the abdomen, and sedatives either by the mouth or by the anus, soothe the patient, and render his last moments more calm.
Penetrating wounds of the peritoneal cavity, if they reach the solid viscera and large vessels connected with them, are attended with effusion of blood externally and internally, in quantities proportioned to the size of the external aperture, the importance of the vessels concerned, and the vascularity of the part. The patient may perish from the bleeding, either instantly or after some time; or inflammation and its consequences supervene in the violent form, and destroy him at a more remote period. The mere opening of the peritoneal cavity, and to a very slight extent, without the slightest injury of the contained parts, is often attended with a great shock to the system, and is followed by inflammatory action, which may run on to a fatal issue, in spite of the most active and judicious management. The inflammatory symptoms are to be combated by free abstraction of blood; in short, the utmost endeavours must be made to keep the action within bounds. When the intestines are wounded, the injured part may protrude; or the relative size of the openings through the parietes and bowel may be such, that the intestinal contents do not escape into the peritoneal bag. A natural cure sometimes takes place by adhesion of the surface of the bowel to the lining of the parietes round the wound, feculent matter continuing to be discharged externally; after a time the opening may contract, and the discharge diminish and ultimately cease; or an artificial anus may be permanently established, and this is not so easily cured as that following upon hernia. Wounds of the intestines, whether transverse or longitudinal, attended with feculent escape into the peritoneal cavity, are not uniformly fatal. Effusion of lymph takes place around, gluing the wounded bowel to the peritoneal surface of a neighbouring fold, or forming a sort of pouch within which the extravasation is limited. The treatment consists in absolute rest, and most rigid antiphlogistic regimen; manual interference with the wounded part is not generally advisable.46
Lumbar Abscess is generally chronic; the collection of matter is gradual and slow. Sometimes it is acute, and rather rapid in its appearance. It may originate in the sheath either of the psoas or of the iliacus muscle; more frequently it seems to form behind these, and is connected with diseased bone. The precursory symptoms are often not particularly attended to; these are rigors and pain of the loins. As the disease advances, the patient feels great pain in the erect position, and in general the pain is aggravated by extending the thigh. Thickening and slight glandular enlargement takes place in the groin; there is an evident fulness there; and then swelling appears on the inner side of the femoral vessels, beneath the pubal portion of the fascia lata. This swelling is more prominent in the erect position, and is also increased by exertion of the abdominal muscles; an impulse is given to it on coughing. As it advances, and comes more to the surface, fluctuation is perceived. This is the most common site in which the abscess presents itself; but it is not unfrequently met with on the outside of the vessels, either lower or higher in the thigh, above Poupart’s ligament, in the loins over the crest of the ilium, and occasionally the matter is insinuated under the pelvic fascia and appears by the side of the anus. Large and neglected collections may work their way to the surface in two or three of these situations at the same time.
The disease is often attributable to a sprain or wrench of the loins, or to exposure to cold and over-fatigue. Occasionally the mischief is confined entirely to the soft parts; the vertebræ, a portion of the os innominatum, or the sacrum, may be denuded and of irregular surface, but this is evidently the result of the pressure of the abscess. A striking example of this, and of the extensive destruction of parts which this affection sometimes produces, may be shortly stated.—A very large lumbar abscess formed within a few weeks, in consequence of great and continued fatigue and exposure to bad weather. At first it had been trifled with. At last it was opened in the usual situation in the thigh, and a vast quantity of matter evacuated. Thirty-six hours afterwards, the patient was suddenly suffocated by a flow of purulent matter into and through the air passages. On dissection, the cavity of the abscess was found to be immense, opening through the diaphragm into the lung which was adherent, and communicating with the bronchi. The forepart of the lumbar vertebræ was exposed, and in some parts stripped of the theca; but there were no cavities in the bone, and no disease of the interposed cartilages. Such cases are now and then met with, of abscess in the loins not originating in any vice either of the bones or of any other part of the apparatus of the spinal column. Most frequently, however, the collections have their foundation in ulceration of the bodies of the vertebræ. The patient has had tenderness in the part, weakness of the back and of the lower limbs, and increase of pain on pressing or striking some particular spinous processes—perhaps slight excurvation. Then pain in extending the thigh supervenes, followed by swelling and other signs of abscess. This is preceded generally by deposit of tubercular matter in their cancellated texture. Sometimes the disease seems to originate in the ligaments and articulating surfaces; occasionally portions of the bone perish, and are found lying in the cavity of the abscess, as seen in this specimen, taken from a young subject. When the bodies of the vertebræ are attacked by ulcerative absorption, and sometimes the disease is very extensive, involving perhaps four, five, or six of the bones, there is more or less curvature of the spine outwardly—excurvation. If the disease affects one or two bones, and their bodies are almost destroyed, then the projection is sharp and angular. When the disease is more extensive the curve is greater, and more gradual ulceration sometimes exists to a considerable extent in one articulation, without change of form externally in the spinal column, and sometimes without any great collection of pus. When curvature commences there is very generally more or less weakness of the limbs, though curvature, whether from ulceration or interstitial absorption, is by no means of necessity attended by any degree of paralysis. The power of motion of parts supplied by nerves in the neighbourhood of disease is diminished earlier in general than the sensation, in consequence, possibly, of the mischief commencing in the anterior part of the bodies of the vertebræ. It is wonderful to what extent disease may extend in the vertebral column, without much impairment of the functions of the spinal chord, and how perfectly the functions are restored in cases where it has suffered. The lumbar vertebræ are those most frequently affected, but the ulceration may also be either in the dorsal region or in the pelvis. Disease of the last lumbar vertebra at its connection with the sacrum, or disease of the sacrum itself, is attended with abscess around, which descends into the pelvis, displacing the bowel, and appearing by the side of the buttock.
Such abscesses may have been allowed to come to the surface, and to discharge their contents spontaneously; or they may have been at a late period opened either at one point or at several. In these circumstances, the discharge is generally profuse, long-continued, and attended with exhaustion and hectic, gradually but surely destroying the patient. But, by good management, a perfect and permanent recovery may in many cases be obtained. When the vertebræ are affected, absolute rest must be enjoined and enforced; and a drain is to be established by the sides of the spinous processes, either by moxa, potass, or seton—it is immaterial which. The discharge is kept up by occasionally dressing the issue for a few hours with an acrid ointment, so as to reproduce a slough. When the abscess begins to present, it should be opened as early as possible, and a free exit allowed to the matter; the discharge should be at no time confined. The opening of the cavity, and again shutting it up, however carefully conducted, is in almost every instance followed by alarming and hazardous results. Rapid accumulation of putrid and bloody matter takes place, and air is extricated within the cavity; the vessels of the cyst, being unsupported, part with their contents; irritative fever is lighted up, with rapid pulse, anxious countenance, and delirium. These symptoms are relieved only by immediate evacuation of the fluid. Some slight constitutional disturbance follows the making of a free opening, but quickly subsides; then the discharge improves in quality, becomes more pure and unmixed, diminishes in quantity, and gradually ceases. During the discharge the strength requires support; and the attention to the original mischief must not be neglected or intermitted.
Spina Bifida is a congenital fluctuating tumour, with deficiency of the subjacent vertebræ. It is usually situated in the lumbar region, sometimes in the dorsal, and often over the sacrum. The size of the swelling varies according to the age of the child, and the extent of deficiency in the parietes of the spinal canal. The spinous processes are either imperfect or altogether wanting, and over the space so formed the tumour is situated. Its contents are usually of a serous character, thin and colourless; sometimes they are turbid and flaky. The parietes seem to be a continuation, or protrusion, of the membranes of the spinal chord, thickened and somewhat altered in structure, and usually in close contact with and adherent to the integuments. By pressure the size of the tumour is diminished; but, if firm or long continued, unpleasant effects are apt to result. There is often debility of the lower limbs, and the disease is not unfrequently coexistent with hydrocephalus. Children with this affection seldom live more than a few years.
The application of gentle, uniform, and continued pressure affords support to the parts, and prevents increase of the tumour; and, under this palliative treatment, life may be both rendered more comfortable and prolonged. It has been proposed to combine continued pressure with occasional puncturing of the cyst by means of a fine needle, with the view of diminishing the tumour and ultimately obtaining entire obliteration of the cyst. The practice has been made trial of, and the result may warrant repetition; caution, however, is necessary, for the too free opening of the tumour is often followed by a rapidly fatal issue. A case occurred to me not long since, in which the tumour, of large size, was situated over the sacrum. The fluid was evacuated by a small trocar and canula, the parietes shrank, and a very satisfactory cure resulted.
Of Hemorrhoids or Piles.—Piles are blind, furnishing no discharge, except a mucous or puriform fluid; or open, pouring out a greater or less quantity of blood from time to time. They are usually of small size, invested by the mucous membrane, thickened, congested, and consequently of a dark colour; and either within the sphincter or projecting externally. Internally, they may sometimes consist of blood, coagulated or not, effused between the mucous and muscular coats of the intestine; but in general their inner structure is venous, at least in the first instance. Branches of the hemorrhoidal veins, ramifying near the inner surface of the gut, become varicose, probably from their superior trunks being compressed by hardened feculent matter or other obstructions. The varix protrudes the superimposed mucous membrane; and at first the excrescence is composed of the dilated venous trunks containing fluid blood, and invested by the membrane, which inflames, thickens, loses its villous character, and discharges a vitiated secretion. In this stage the tumour is easily compressible, and by pressure may be made to disappear almost entirely, the communications between the varicose vessels and the trunks above being still unobstructed. But inflammatory action is soon kindled in the incommoded venous branches, as frequently happens in varix of the lower extremities; their coats become changed, are thickened, effuse lymph externally and internally, adhere to one another, and are ultimately matted into one confused and solid mass; the contained blood coagulates, becomes fibrinous, the whole tumour feels hard and firm, and often is exceedingly painful. At length all traces of venous structure disappear; the tumour seems to consist chiefly of effused lymph, condensed cellular tissue, and coagula.
In not a few instances, however, the contents of the veins remain partially fluid, and a communication exists between the vessels of the tumour and those of the surrounding parts.
That such is the usual structure of piles I am convinced, from repeated and careful dissection of the tumours.48
The neighbouring parts often swell and inflame. Sometimes one or two tumours only exist; or they occur in numbers, clustered together, and form a large irregular mass, inflamed, and often ulcerated. Acute pain is experienced in the part, when touched and after straining at stool; by straining too, such as are attached within the sphincter are pushed out, together with folds of the mucous membrane, and, if allowed to remain, are constricted by the sphincter, swell in consequence, ulcerate or slough, and discharge blood. The bleeding often is very violent in such cases, or when the tumour is punctured; the blood flowing in great quantity, and in a rapid stream. The hemorrhage is often periodical, both in males and females; in the latter, it would seem occasionally to take the place of the menstrual flux. The soft bluish tumours that are compressible, and fluctuate when large, furnish blood more readily and profusely than the hard and tuberculated.
Much irritation is produced by piles, and some of them are more irritable than others. There are often extensive excoriation of the nates around, and profuse discharge from the raw parts, particularly when the tumours are external. In such cases, flat, hard, warty excrescences often form in the cleft of the nates, and increase the irritation; and these are termed fici, mariscæ, and condylomata.
In internal piles, a frequent desire to go to stool is induced, and more or less of the mucous coat of the rectum is protruded and swollen. The tumour, along with the protruded portion of bowel, may become strangulated if not replaced. By such or other causes inflammation is excited, which often extends to the neighbouring parts, and terminates in abscess; but this is not so apt to occur from tumours seated high in the rectum as from those about the verge of the anus.
The usual cause of piles is obstruction to the return of blood in the hemorrhoidal veins; and this may be occasioned by advanced pregnancy, habitual distension of the colon and sigmoid flexure, with hardened feces, or tumours of the abdominal viscera.
Inflammation of the Rectum is attended with excruciating pain, burning heat, and a feeling of contraction, increased very much when the parts are thrown into action by evacuation of the contents of the bowel, or of the bladder. The heat may be felt on introducing the finger, with the view of examination; by doing so, dreadful torture is produced, and such manipulation should not be had recourse to unless there is a suspicion of foreign matter lodging in the part, by removal of which the action might be cut short. The bladder is often affected sympathetically; there may be frequent desire to empty it, or else retention of its contents: this latter occurrence not unfrequently follows operations on the bowel, as for the removal of hemorrhoids, by ligature or extensive incision, which is neither warrantable nor requisite. The inflammation extends to the cellular tissue round the rectum, with swelling and increased pain; the pain is aggravated by pressure, and the patient is unable to sit erect. As the painful symptoms abate, puriform discharge from the membrane of the gut takes place, and often is very profuse. The morbid action sometimes extends to the other intestines, attended after a time with mucous or even bloody evacuations. When the affection is confined to the rectum, the feces and vitiated secretion are distinct from each other, and the former are usually of their natural appearance; but when the other intestines participate, to a greater or less extent, the feces are fluid, and intimately mixed with the morbid secretion.
Ulceration of the mucous coat, with continued discharge, often supervenes. Sometimes the peritoneal coat of the bowel is affected secondarily, and then the pain is much more acute and more aggravated by pressure.
Patients affected with hemorrhoidal swellings,—the action of whose bowels is irregular, and in whom the vessels about the anus are congested,—are peculiarly liable to inflammation and abscess in the rectum or its neighbourhood, from the application of cold or wet to the surface, particularly that of the lower part of the body. Ascarides often produce violent irritation in the extremity of the rectum, both in children and in adults; and the morbid excitation is communicated to the bladder, as will afterwards be noticed. Not unfrequently the inflammation is induced by a foreign body, either lodging in the cavity of the bowel or imbedded in its coats—as hardened feculent matter, alvine and biliary concretions, bones of small animals, needles, pins.
Effusion often takes place into the loose cellular tissue round the bowel, with hard swelling, followed by unhealthy and extensive suppuration. Rigors generally precede the formation of matter, and violent fever almost always attends, abating, along with all the painful feelings, on evacuation of the fluid. Still the discharge continues, and the patient is kept uncomfortable and unhappy. Resolution can very rarely be produced; suppuration is the almost uniform termination of the action, and in persons of bad habit this sometimes occurs in these parts without any assignable cause, and without previous warning. The purulent collections are often very extensive, both externally and internally, the integuments are all undermined, and in some cases it is difficult to ascertain the depth of the abscess, even with the aid of a long probe.
Owing to the loose nature of the texture surrounding the gut, abscesses near the anus often attain a great size, and extend deeply before there is much external indication of their existence; a hardness is felt on pressing the fingers deeply by the side of the tuberosity of the ischium; this is at first obscure, but gradually becomes more developed; and at last a small dark red spot appears, indicating that the matter has approached the surface, and is most superficial at that part. But the surgeon should not wait for the pointing here, as the matter may burrow much previously, and abscess form in the substance of the sphincter, or exterior to it. If the matter does not cause ulceration of the coats of the intestine, and escape into its cavity, pointing takes place, and the pus is discharged externally, in general through a small opening. The matter is of a very offensive odour. The external aperture, and even the whole cavity of the abscess, may be at a distance from the gut, but in most cases the matter is close to it: its coats are denuded, and often ulcerated through. The surrounding degree of induration, the quantity of contained matter, the extent of the cavity, and the situation of the opening, vary almost in every instance.
Cases occur of induration, often very extensive, in the neighbourhood of the anus, on one or both sides, with dark discoloration of the integuments, and burning pain. The affection resembles carbuncle. The precursory symptoms are soon followed by partial suppuration, and extensive sloughing of the cellular tissue. At first there is excitement of the system, but symptoms of debility, and flagging of the vital powers, soon present themselves—irregular pulse, delirium, disordered stomach, hiccough, vomiting, and cold extremities. The disease is one of great danger, and the patient can be saved only by free and early incision, and the judicious employment of stimulants.
In some instances the inflammation is merely superficial, seated merely in the integuments, and followed by slow collection of matter.
It is indeed seldom that a cavity formed by abscess near the anus fills up entirely, however large and free the opening into it may have been. The parietes contract, but the hardness around is not entirely dissipated; the opening may close for a little while, but is soon found again discharging, and may continue to do so for months or years. A sinus is thus formed. Fresh collections and openings, either externally or internally, are apt to occur, with extensive induration of the cellular tissue, and disease of the gut. Instead of a single sinus, a number of collateral ones are formed, all running into the main canal, like branches to a common-sewer, or by-lanes opening into one spacious street. The disease is one of frequent occurrence amongst females; and often from a false sense of delicacy its existence is not declared till it has advanced to a state of truly horrible perfection.
Fistula is generally the consequence of abscess in the cellular substance near the anus. By the term is understood a sinus or track, with narrow orifice and hard parietes, discharging thin gleety matter. If the track extends from the cavity of the gut to the surface, flatus must often pass through the narrow and tortuous canal, and, from a peculiar noise being produced by its passage, the name of Fistula has probably been adopted. The term cannot be properly applied to recent cavities of abscesses, but only when their sacs have contracted, their lining has become callous, and their discharge thin and almost colourless.
The fistula may be one of three varieties—blind external, blind internal, complete. The first denoting that the sinus opens externally, but does not communicate, either at its origin or elsewhere, with the cavity of the bowel. The second, that it communicates with the bowel, but does not open externally. The last, that it both communicates with the bowel and opens externally. Some contend that fistulæ are always complete, that they commence from within, and that the internal opening is always at one particular point; but such, according to my experience, is far from being the case.
Fistulæ occur in children, though rarely; generally in people advanced in life. The cavity of the sinus, after long continuance, becomes coated with an expansion resembling mucous membrane, and secretes a discharge of mucous character.
In every case, it is necessary that the surgeon should ascertain, as accurately as possible, the extent and nature of the fistula; and, with this view, examination with the probe is requisite. The probe is introduced into the canal, when the fistula is an external one, and directed through its windings, so as to discover its direction, length, and divarications; the guidance of the instrument is facilitated, and the information augmented, by the forefinger being placed in the rectum. Sometimes all the by-paths cannot be detected, until the orifice of the canal is enlarged. When the fistula is complete, the probe, entered at the external extremity, can be passed into the bowel so as to be felt by the finger in the rectum; but it must be remembered that the internal opening is not always at the inner termination of the sinus, but often seated more externally—the cellular tissue being destroyed to a considerable extent above it, so as to form a large unhealthy abscess, communicating with the main track of the fistula. But the gut may not be opened into, though denuded to a large extent, and forming part of the walls of the sinus; and in some instances, the sinus may not come within a considerable distance of the bowel.
An internal fistula is more difficult of detection. The symptoms leading to a suspicion of its existence are—puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus; pressure on the side of the anus, causing pain, and sometimes an augmentation of discharge; and in many instances hardness, deeply seated, is felt. On introducing the finger into the rectum, the aperture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest; through this point a curved probe, introduced along the finger, may be passed into the sinus, and being then directed downwards, reaches the outer extremity of the canal, causes the integuments to project, or is readily felt from the surface. The internal opening is usually immediately within the sphincter, seldom higher.49 The discharge, in general, is rather profuse, the bowel is very irritable, desire to evacuate it is frequent, and the feces are often tinged with blood. There is a sensation of itching about the fundament, the heat of the parts is felt by the patient to be increased, he is unable to bear pressure there, and sits on one buttock: in most cases the bladder sympathises considerably. The giving way of the bowel may be produced by ulceration commencing in the mucous membrane, but is more frequently the result of inflammatory action in the surrounding cellular tissue. The aperture is the seat of acute pain when pressed upon, and during evacuation of the bowel. Great light is thrown on such cases by the use of a proper speculum. But its introduction can seldom be borne in cases of inflammation, abscess, or recent fistula. In ulceration of the coats within the sphincter it is useful. Considerable information can certainly be obtained by the finger; but to the sense of touch, however acute, it is better, when admissible, to add that of vision. The speculum, made of silver or steel, and having its internal surface highly polished, is introduced gently into the anus, and expanded fully; and by changing the situation of the instrument, and holding a light so as to illuminate the interior, the surface of the bowel for five or six inches above the anus can be examined accurately, as if it were an external part of the body.
Simple indurations and contractions of the lower part of the bowel follow long-continued irritation and inflammation of its parietes. The part is not an uncommon seat of stricture, and sometimes the bowel is constricted at two or more points near each other; frequently the stricture is extensive and firm, in other cases it is narrow, consisting merely of a thin band. It is often complicated with fistula; if so, the internal aperture is immediately above the stricture, and is caused by ulceration; abscess sometimes forms above the stricture, destroys the coats of the bowel at that point, burrows around, and not unfrequently points at a great distance from its origin; or sloughing and ulceration may take place in the coats of the bowel, and feculent matter be discharged through the opening of the abscess. In females, the vagina may be opened into in consequence of unhealthy suppuration in the cellular tissue, between that organ and the gut.
The existence of stricture is in general readily ascertained by examination with the finger; its most common situation is here shown; the medical practitioner must not suppose that every obstruction, however slight, to the passage of a bougie into the bowel is owing to organic disease; the top of the sacrum naturally projecting forwards on the commencement of the rectum, in some degree opposes the entrance of any large body, and this circumstance is laid hold of by the unprincipled or ignorant; the patient is very often declared to labour under stricture of the bowel, when none exists. Some practitioners discover stricture in almost every patient with disordered digestion; the whole digestive apparatus is certainly thrown into disorder by obstruction in the lower part, but this obstruction is fortunately rare. In cases of tight stricture, the bowels are distended with feces and flatus; and if evacuation is not procured vomiting ensues, followed by enteritic symptoms, as in strangulation of the higher bowels. The gut above the stricture is always more or less dilated.
The symptoms which lead the surgeon to suspect the existence of stricture, are—difficulty in voiding the excrements; a long time occupied in the evacuation, with pain and much straining; small thin portions of feculent matter coming away, when the matter is consistent; discharge of puriform fluid, mixed with a slimy mucus; itching and heat in the parts; and irritability of the urinary organs.
Strictures of the urethra and rectum often coexist, as exemplified by the following case:—A middle-aged man, when in Holland, laboured under a very deep and extensive fistula in ano. Sinuses were divided in all directions, and some healed; one, however, remained open, leading towards the gut from near the tuberosity of the ischium on the left side. He was desired to keep this open by means of bougies, which, as many were used, he manufactured himself out of cloth and plaster. On one occasion a portion passed deeply, and could not be extracted; but his alarm at this occurrence was appeased on being told that the foreign body would be absorbed. His condition at that time was very miserable; and inflammation was often excited in the parts, with fresh collections of matter. At the same time, he laboured under stricture of the rectum and urethra. He applied to me fifteen years after the commencement of the disease. Then the most troublesome symptom was a constant itching in the perineum, and round the anus, preventing sleep, and causing much excoriation from involuntary scratching; besides, he was annoyed by seminal emissions, and frequent desire to make water. I first divided a small internal fistula, and some time afterwards operated on a large complete one; in the latter instance, a foreign body was felt deep in the wound, the incision was extended, and a large portion of bougie, firmly impacted, was with some difficulty withdrawn. Some days after, other portions of bougie were extracted along with numerous hairs; and these continued to be discharged for many weeks. The symptoms were much relieved. An occasional itching remained, but disappeared after the cure of a very bad stricture in the urethra. He recovered perfectly from the complication of diseases.
Schirro-contracted Rectum, a malignant and truly horrible disease, may be the consequence of inflammatory action, or of neglected stricture. The neighbouring parts are involved in cartilaginous induration; the surface of the bowel is lobulated and ulcerated, its cavity is contracted, and the discharge is profuse, sanious, bloody, and putrid; there is frequent desire to void the contents of the gut, but in general nothing but flatus and puriform fluid is evacuated; when feces do pass, dreadful pain is excited, and continues for some time. The difficulty of voiding feculent matter becomes greater and greater, frequent attacks of ileus occur, and in one of them the patient expires. During the progress of the disease, the functions of the bladder become disturbed; change of structure in it and in the vagina takes place; and frequently the cavities of the rectum, bladder, and vagina are laid into one by inveterate and malignant ulceration. The affection is more common in females than in males, and rarely occurs in young persons. The countenance has the sallow hue peculiar to carcinoma, and in the advanced form of the disease becomes still more cadaverous from profuse discharge of matter and frequent hemorrhage.
The cellular tissue, anterior to the rectum, is liable to become the seat of tumour. Malignant medullary formations occasionally form here, causing most distressing symptoms; by displacing the bowel they may obstruct its canal, and simulate stricture or schirro-contraction.
Prolapsus Ani. Folds of the lining membrane of the lower portion of the rectum are apt to protrude during evacuation, as already mentioned, in those labouring under hemorrhoids. These are readily replaced, and the painful feelings relieved, if the attempt be made before swelling and engorgement of the vessels and cellular tissue take place. Protrusion, however, is sometimes to a great extent; the sphincter is relaxed, and the lower part of the bowel is retained within it with difficulty; indeed there is often more of the lining membrane of the gut without the sphincter than within it. The mucous lining becomes insensible, thickened, and white; and the patient is subject to attacks of inflammation, with additional swelling, excoriations, and ulcers of the parts. Slight protrusion is very common, and patients who have long laboured under it are in the habit of reducing the bowel after every stool, in the intervals wearing a supporting bandage. They are subject, however, to constant uneasiness, and more or less puriform discharge from the parts; often there is a flow of blood while at stool; the health is undermined, and comfort diminished; all exertions are gone through with difficulty, and undertaken with reluctance. During exertion protrusion is almost certain to occur, and apt to be increased. The part most commonly prolapsed in time becomes hard, thick, and in a measure insensible; and new folds appear on extraordinary straining at stool, in coughing, or any exertion of the abdominal muscles.
Tumours occasionally grow from the coats of the rectum, and are of various consistence. They may be either vascular, or deposited in consequence of increased vascular action, and afterwards increased by addition of solid matter. They are to be removed either by ligature or incision, according to their situation, nature, and attachments.
Foreign bodies may lodge in the rectum—as bones, portions of hard indigestible meat, &c., introduced by the mouth—or clyster-pipes, bougies, &c., which have been passed up per anum. From being the source of constant irritation, and obstructing the functions of the part, they demand removal. Alvine concretions are now rare; they are usually situated in the caput cæcum coli, sometimes in the sigmoid flexure, or in the arch of the colon; they may descend into the rectum, and lodge there.
Children are sometimes born with the anus imperforate, the extremity of the rectum being covered merely by integument, or the bowel terminating an inch or two above the usual site of the anus; or the rectum may be wholly deficient. In the last case, the colon may end in a blind sac at the fundus of the bladder, or it may open either into that viscus or into the vagina.
Treatment of Affections of the Rectum.—In the treatment of hemorrhoids, the cause should be removed if possible; and this may suffice for the cure. When the tumours are recent and small, they may be made to disappear by the use of astringent ointments or decoctions, as of galls, kino, oak-bark, and by sedulous attention to cleanliness of the part. In inflamed tumours, blood may be extracted by leeches or punctures, and hot fomentations afterwards used. Recent hemorrhoids are sometimes got rid of at once by the puncture of a lancet,50 by which a clot of grumous blood is discharged, with immediate subsidence of the swelling, and abatement of pain. When constriction of the internal tumours or folds of bowel by the sphincter has occurred, the tumour should be replaced if possible. In irritability of the sphincter, a bougie is sometimes used with advantage; and incision of the muscle, by which rest is afforded to the parts, will often effect a cure, after the failure of all other means: this is essential when rugged ulcers or fissures occupy the orifice; the division may be made on either side, certainly not in the mesial line. In most cases, the tumour must be got rid of by the knife or ligature. When the piles are internal, removal by ligature is to be preferred; the patient being made to strain, and thereby bring the tumours as low as possible, a ligature is placed round the base of the swelling, provided its form conveniently admits of it; otherwise the base is pierced by a fixed needle armed with a double ligature, the separate portions of which are applied tightly to the corresponding parts of the base. This operation is very inconsiderately and indiscriminately employed. It can only be warrantable when the tumours are so large as to obstruct the orifice so perfectly as to prevent evacuation, unless they are extruded. Before proceeding to this measure, the bowels should be emptied by mild and repeated purgatives, and afterwards all stimuli should be avoided. It is imprudent to apply ligature to several tumours at once, for serious consequences will most probably ensue, inflammation of the bowel, obstinate constipation, and general excitement.51 Excision of such piles is contraindicated by the risk of profuse hemorrhage. The bleeding is into the cavity of the bowel, a coagulum is there formed which encourages the flow; and from this cause, and the peculiar situation of the bleeding point, it is with difficulty arrested. When the tumours are external, ligature may certainly be adopted; but here there is no objection to the use of the knife, and excision is much less painful and more speedy. The tumours, along with protruded portions of the mucous lining of the rectum that cannot be reduced, and are changed in structure and function, are readily taken away by the rapid stroke of sharp curved scissors. Or they may be laid hold of and stretched, and their base divided by one or more sweeps of a bistoury. The removal of these tumours, or of a portion of the loose fold of skin or altered mucous membrane which occupies the sphincter in the direction of the bowel, is in general followed by a cure of the prolapsus. The sphincter now acts fully, and on the cicatrisation of the open surface contraction of the tissues occurs to such an extent as to produce a permanent cure without interference with the internal parts. Should hemorrhage follow upon the removal of external tumours or folds, the surgeon has it completely under command. Pressure by a large graduated compress is generally sufficient.
In inflammation of the rectum, the exciting cause often is not discovered; when detected it should be removed without delay. In simple inflammation of the part with violent fever, general bleeding may be required; and in all cases blood should be abstracted locally and freely. Leeches are to be applied to the verge of the anus, and the lower part of the perineum, and hot fomentations afterwards used. Internal antiphlogistics are at the same time not to be neglected. In retention of urine, or great irritability of the bladder, in consequence of the affection of the rectum, the perineum should be leeched and fomented, perhaps, also, the lower part of the abdomen; the use of the catheter should be avoided if possible. When induration takes place in the cellular tissue by the side of the anus, or in the perineum, suppuration must in all probability occur, and poultices, with occasional fomentation, are to be used, though only for a short time; for, as already mentioned, pointing of the matter is not to be waited for in this situation; incision must be had recourse to early, in order to prevent bad consequences. Leeching is sometimes used here, as in purulent formations in other parts, from gross ignorance of the real state of matters; and sometimes their use is continued after fluctuation is distinct, and until the pus begins to ooze through the leech-bites; such is very useless and very dangerous practice; in most cases the internal parts are extensively destroyed before the matter comes spontaneously to the surface.
In the carbunculous state of the cellular tissue, near the rectum, with extensive infiltration, dark integument, and a tendency to sloughing, an early and free opening must be made wherever matter is suspected to have formed, however deeply seated, and in whatever quantity, and whether the parts are indurated or not; nothing but mischief can result from delay. When the cellular substance is destroyed, the incision must be proportionally extensive, to afford a free exit for slough as well as matter. During the suppuration which follows, the system will require good support, and most probably a free administration of stimuli.
It has been recommended that, in abscess extending along the gut, the cavities of the bowel and abscess should be at once laid into one by incision. I have done so, but always found the cure to be tedious. It is better that the matter should first be evacuated through an external opening, that the painful symptoms and constitutional disturbance should be allowed to subside; and that after the cavity has contracted, and the extent of the sinus has been ascertained, the operation should be performed. In the operation the knife is now employed; but in former times the ligature and cautery were in constant use. The old surgeons supposed that there was something malignant in the hardness and callosity attending this disease, and were not contented with opening the cavities, but endeavoured to dissect out the whole parts; and, if foiled in this, they finished the work with a red-hot iron. Indeed the practice of excision was recently in vogue in the Parisian hospitals.
But the operation for fistula has been much simplified. The bowel is generally so much separated from its connexions as to be incapable of again adhering, or of furnishing granulations; and, though capable, healing is effectually prevented by the frequent motion of the parts caused by the action of the sphincter and levator of the anus. One side of the cavity is fixed, whilst the other is in motion. It becomes necessary to lay the cavities of the bowel and of the fistula into one. This can generally be effected with great ease; a salutary degree of excitement follows the use of the knife, rest to the parts is procured, the edges are allowed to retract and adhere to the opposite surface, and the wound heals quickly from the bottom. The surgeon, in his operative procedure on these parts, must use both hands equally well, otherwise he must vary his position, and often put his patient in a very awkward predicament, more particularly if a female. The patient is placed in a stooping posture, with the legs unbent, or kneeling on a chair, and resting his arms on its back, the fundament being turned towards the light. The surgeon inserts the finger, well soaped and oiled, into the rectum, and with the other hand insinuates a curved probe-pointed bistoury into the sinus, using the instrument merely as a probe. Having reached the extreme depth of the canal, the direction of the instrument’s point is changed so as to apply its cutting surface to the coats of the bowel, at that part. The instrument on being thus passed into the bowel is fixed by the finger, and by drawing both outwards, the coats of the bowel and the parts intervening between them and the sinus are divided. All collateral sinuses extending towards the perineum and buttock must be freely divided, for they cannot be expected to contract otherwise. Such is all that is necessary in the generality of cases; but it is evident that the steps of the operation, and the extent and number of incisions, must be varied according to circumstances. A great part of the affected bowel may be pulled down by a director before being cut, as is sometimes done; but the practice is useless and painful. Should hemorrhage take place, it may be restrained by stuffing the wound gently with lint; if this fail, the bleeding vessels are to be secured by ligature; but this is seldom necessary. The bowels should be well cleared out before the operation, so that two or more days may pass over without the parts being required to perform their functions; and, if the bowels are naturally loose, opiates may be administered. Afterwards copious evacuation is to be procured by enemata or gentle laxatives. It is necessary to prevent the external part of the wound from adhering, until the whole has contracted equally, and begun to be filled up by granulations from the bottom; and with this view a piece of lint is interposed between the margins. Stuffing the wound daily with large dossils of lint, smeared or not with irritating ointments, is attended with much pain, and certainly impedes the cure. The dressing should be simple and light, and introduced with gentleness and care. The first should be allowed to remain undisturbed till spontaneously discharged along with the feculent matter. In the greater number of cases, a second interposition of dressing is all that is required. In all cases, dressing should not be continued long; but as the cavity gradually contracts, discharging laudable pus, and becoming coated with healthy florid granulations, the interposed pledgets should be daily diminished, and soon omitted entirely. If the surgeon continue long to stuff the wound it cannot contract, will become callous as before, and a fistula will be reproduced. Injections into the wound, or the application of lint soaked in a gently stimulating lotion, are often beneficial in promoting contraction. But, as already stated, most fistulæ get well after proper incision, with but one or two dressings, and without any after application excepting abundance of soap and water. During the cure, the general health must be kept vigorous, and the state of the bowels strictly attended to.
In ulcer of the mucous lining, with irritability of action in the bowel, injections of tepid or cold water are useful, by removing irritating matters from the part. By means of a speculum ani the ulcer can be readily exposed; it maybe touched occasionally with the nitrate of silver, in substance or solution, or, if very indolent, with a solution of the bichloride of mercury. When the irritation is very great, and the lower part of the bowel frequently in a state of spasmodic action, the sphincter may be divided so as to allow the parts to remain quiet; and anodyne suppositories or soothing enemata will then be used with much greater advantage than previously. To obtain reparation of breach of structure in any part, rest is a principal part of the treatment; and in the case of the rectum and other mucous canals it is preëminently required.
Strictures of the rectum are treated by bougies of wood, plaster, or elastic gum, introduced at intervals, and gradually enlarged. The bougie should be smooth in the surface, and rounded at the point; also slightly curved, so as to suit the figure of the bowel; and with a narrow neck, so as to remain without the irritation caused by distention of the sphincter. At first it should be of such a size as can without much difficulty be pushed past the stricture, and, as this relaxes, the size of the instrument must be proportionally increased till it completely fills the bowel when dilated to the natural calibre. The bougie may at each time be retained from a quarter of an hour to an hour, according to the feelings of the patient. Suppositories and enemata are at the same time employed; the latter to clear out the lower bowels, the former to allay the irritation which accompanies the disease, and which may be increased temporarily by the bougies. When the stricture is callous, and will not yield by dilatation, it may be divided with the knife, and notched at various points of its circumference; and, when the parts have begun to granulate, recourse to the bougie will soon effect a cure. When fistula and stricture coexist, both are got rid of at once by the usual operation for the former, and by the after treatment peculiar to each.
In malignant contractions of the gut, all that can be done is to palliate the disease by anodynes, administered by the mouth, or applied topically. Injections, bland, and occasionally anodyne, tend to diminish irritation; bougies aggravate the disease. At the commencement, the diseased parts may be removed by the knife or by ligature, and relief and exemption follow, at least for a time; but no operation is warrantable in this or any other cancerous affection, when the morbid action has gained ground, and the disease is extensive. Female patients have by some been cruelly treated; the vagina and diseased bowel have been laid into one loathsome cavity, and though the patients have continued to pass excrement and discharge through this cloaca, with the symptoms undiminished, themselves miserable and obnoxious to others—still such cases have been reported as cures!
In prolapsus ani, the protruded parts are to be carefully reduced, and kept so by means of a compress supported by a T bandage; often a spring with a pad is used with advantage. In inflamed prolapsus, with ulceration of the mucous coat, the patient is confined to the recumbent posture, and soothing applications employed; and when thus the irritation has been removed reduction is performed; but the bowel seldom remains up till after the ulcerations have been healed. In chronic obstinate cases, the altered parts within the verge are removed by the knife or scissors with safety; contraction attends the cicatrisation, and so further protrusion, as already noticed, is prevented.52
By the speculum ani, assisting the eye and finger, the nature and position of foreign bodies in the rectum are ascertained, and their removal facilitated. They are to be extracted by the finger, by a scoop, or by forceps. It has been proposed by some to cut into the colon from behind, so as to open that part of the bowel which is unconnected with the peritoneum, when it is distinctly ascertained that alvine concretions lodge there. This might be put in practice when the case is clear and the symptoms urgent, but, as already observed, such foreign bodies are now very rarely met with.
In imperforate anus, when the bowel terminates high, it has been proposed to cut through the abdominal parietes, and open the sigmoid flexure, so as to establish an artificial anus. The proceeding is unwarrantable, both in congenital deficiency and in malignant disease of the bowel. There is no doubt a possibility of life being thus prolonged, but it is by no means probable, and scarcely desirable. In the more common cases, the bowel is opened, and the meconium evacuated, by a slight and safe incision in the site of the anus. Even through a considerable depth of soft parts, the impulse of the fluid in the bowel is distinctly felt during exertion of the abdominal muscles. If incision through the integuments and cellular tissue prove insufficient, a sharp-pointed bistoury is pushed onwards in the direction of the bowel, under the guidance of the forefinger of the left hand, carefully avoiding the bladder, vagina, and uterus, as also the vessels within the pelvis. To reach the bowel is an object of great consequence, yet the risk incurred in its accomplishment must be considered, and the incisions made within certain limits. The opening scarcely requires to be kept pervious by the use of bougies, the functions of the parts being sufficient for the establishment of the anus.
[Persons often suffer from pruritus or itching of the anus, or in the parts immediately around. The affection is most common in old people, and in such as are of a weakly constitution. Women who have recently ceased to menstruate are also prone to it. The exciting causes are generally ascarides, hemorrhoidal excrescences, and a morbid state of the alvine secretions. Sometimes the skin around the anus is covered with an eruption of papulæ, or even tubercles, the former of which are often attended with vesication and the discharge of a thin, watery, irritating humour. Patches of a similar description are occasionally seen on other parts of the cutaneous surface; as the scrotum, thighs, back, and even the face and neck.
The pruritus, which is often very troublesome on retiring at night, so much so, indeed, as to prevent the patient from sleeping for hours, usually subsides after a few months, but is certain to return from the slightest irregularity in the diet, from fatigue, loss of rest, or from exposure to heat. “From constant rubbing the skin about the anus becomes thick, dense, and furrowed, even when there are no hemorhoidal tumours. The furrows assume a radiated direction, and converge in the anus; they vary in number from six to ten, and are from a quarter of an inch to an inch in length.”53
In the treatment of this affection the first object should be to ascertain, and, if possible, to remove, the exciting cause. Proper attention should then be paid to the general health, which, as was before stated, is often much impaired. Under such circumstances tonics may be demanded, such as iron, bark, or quinine, either alone or combined with blue-mass, sarsaparilla, or Plummer’s pill. The latter articles are particularly serviceable when there is an eruption around the anus. The most useful topical remedies are, a solution of acetate of lead and laudanum, yellow-wash, the nitrate of silver, and the ointment of the proto-ioduret of mercury. Cold ablutions also afford great relief, and are indispensable to the patient’s comfort.
Neuralgia of the rectum, a disease first described, I believe, by Dr. Montegre, of Paris, in 1812, is occasionally met with. It is most common in persons of a nervous, irritable temperament, from the age of thirty to forty-five or fifty, and who are subject to similar attacks in other parts of the body, particularly the face, stomach, testicle, or mamma. It is characterised by paroxysms of pain, which is usually described as of a tearing, burning, or lancinating nature, situated at the extremity of the rectum, from which it frequently extends to the sacrum, the loins, pubes, and genito-urinary organs. Defecation is painful, and the urine is discharged in jets or drops, attended with a burning or scalding sensation. The attacks commonly subside in eight or ten hours, but recur with tolerable regularity about the same period the following morning or evening, though sometimes not until the second or third day. During the intermissions the patient is, in great measure, free from pain, and passes his feces and urine without difficulty. The affection often continues for years, and the paroxysms are then apt to be more frequent and irregular.
A remarkable instance of this disease is given by the late Professor Bushe. His patient was a middle-aged physician, of active habits, in tolerable health in other respects, but of a nervous temperament, and subject to occasional attacks of neuralgia of the face, stomach, and testicles. Several times a year he would be seized with pain at the extremity of the rectum and at the pubes, accompanied with frequent desire to void his urine; sometimes he suffered excruciating torments at the end of the penis, or posterior part of the urethra. The attacks generally subsided in twelve or twenty-four hours, and were almost always either preceded or followed by neuralgia in other situations. No remedies were of any avail. In another case—that of a nervous female, thirty-five years of age—the pain was seated over a spot about the size of a shilling, on the left side of the bowel, less than half an inch above the verge of the anus. For weeks the pain would almost wholly subside, when it recurred with extreme violence; her distress was generally greatest towards evening, and was always much increased during defecation. Mr. Mayo of London mentions the case of a man who laboured for several years under paroxysms of neuralgia of the rectum and the teeth. The attacks came on frequently during the day, without any assignable cause.
Neuralgia of the rectum, as other parts of the body, is almost invariably attended with a deranged condition of the digestive apparatus, and hence a mild but systematic course of purgation constitutes a primary object in the treatment. On no account should the rectum be allowed to become distended with fecal matter. After due attention has been paid to the secretions of the stomach, liver, and bowels, the best remedies will be quinine, iron, arsenic, strychnine or nux vomica, stramonium, the warm bath, and blisters to the sacrum. During the paroxysm, hot fomentations, anodyne injections, and opiate suppositories will be beneficial. In spite, however, of these and other means, the disease often continues for years with little mitigation, baffling the skill of the surgeon, and compelling the patient to spin out a miserable existence.—ED.]
Affections of the Mucous Membranes of the Urinary and Genital 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.