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CURATIVE MEDICINE.

PART VIII.

DISEASES OF THE URINARY SYSTEM.

The Urinary Organs.—The important group of organs which, makes up this system comprises the kidneys, two glandular bodies about four inches long, and of the peculiar shape of a kidney-bean, with their outlet pipes communicating with the bladder, and its exit tube the urethra, opening in both sexes in conjunction with the organs of generation.

Office of the Kidneys.—The office of the kidneys in the animal economy is to secrete the urine which passes from each gland down its separate ureter into the bladder, where it may be stored to the amount of half a pint or a pint, and from which it ought, at suitable intervals of from four to six hours, to be evacuated. The ingredients of the urine being waste material, poisonous to the organism if retained in the blood, it will readily be understood why the suppression of the renal secretion, in certain morbid conditions, or its retention in consequence of any obstruction to its outflow, in the narrow ureters or urethra, may give rise to some of the most horribly painful and fatal diseases which mankind is ever called upon to endure.

Function of the Kidneys.—The function of the kidneys is purely an eliminative one, and a full understanding of its performance could only be gained by a study of the intricate structure of the organs, too complex to be considered here. It is sufficient for the present purpose to state, that the blood entering each kidney by its large renal artery is purified by having removed from it the elements of a poisonous substance, urea, with uric or lithic acid, phosphoric acid, and sulphuric acid, variously combined with potash, soda, lime, magnesia, and probably other refuse matters in smaller amounts. These solid ingredients of the urine are dissolved in the forty or fifty ounces of water which is also during health taken out of the blood by the kidneys, and in this way the urine is manufactured. The purified blood, after giving up these deleterious matters in the renal organs, is returned to the general circulation, by the renal veins.

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Passage of Urine.—In perfect health a man of average size would pass in the forty-eight ounces of urine, which he should daily evacuate from his bladder, an ounce and one-third of urea, nearly an ounce of chlorides, sulphates and phosphates, and from eight to twelve grains of uric acid. If, for any reason, the amount of water filtered out of the blood is less than this, there is danger that some solid constituents of the urine may crystallize within the urine or bladder, and being, perhaps, washed into the ureters in the one case, or into the urethra in the other, block up these outlets and give rise to the horrible agony of nephritic colic, gravel, or stone in the bladder; or, again, even slight inflammation in these small tubes may result in a contraction or stricture, which hinders the passage of the urine, and also causes great suffering to the unfortunate patient.

Guide to Kidney Disease.—The chief guide to diseases of the kidneys is, necessarily, therefore, a chemical and microscopical examination of the urine, with the sediments which fall from it, in each individual case, and this should never be neglected in any but the most temporary and insignificant derangements of the urinary apparatus.

ACUTE NEPHRITIS OR ACUTE BRIGHT'S DISEASE.

Nature of the Disease.—Acute Bright's disease, called also acute nephritis, is a malady in which the kidney becomes greatly. enlarged and vascular, with its minute convoluted tubes, in which the urine is primarily manufactured, plugged up with epithelial cells. These epithelial cells in the form of casts of the renal tubules are voided in the urine together with albumen, and sometimes with blood. The obstruction to the outflow of the urine and the interference with the function of the kidney give rise to the most serious general symptoms.

Causes.—Acute Bright's disease is a rather common complication of scarlet fever, and is one of the dangers most to be dreaded in that malady. It also occurs in cholera, yellow fever, erysipelas and diphtheria, and may be produced by alcoholic intemperance, or by exposure to cold and wet, particularly by sitting on a wet or cold object, such as a stone step. Certain poisons which are eliminated through the kidneys, as cantharides and turpentine. Pregnancy is also a potent factor in the cause of the disease.

Symptoms.—The symptoms are, first, in many cases, chilliness, followed by fever, some pain in the loins and across the lower part of the spine, scanty high colored and albuminous urine, and in a day or two dropsy, or watery effusion under the skin, beginning beneath the lower eyelids or in the organs of generation, but soon becoming general over the whole body. Uremic coma may develop at any time.

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The Urine.—Scanty always, and at times entirely suppressed. Smoky in appearance, high specific gravity, rich in albumen and throws down a heavy sediment, which, when examined microscopically, will be found to contain hyaline, blood and epithelial casts, and free blood and epithelium.

Treatment.—The treatment which is successful in a majority of the cases, consists in keeping the patient in bed in a room with a warm, moist and equable temperature, purging gently with those laxatives which cause watery discharges from the bowels, such as small doses of five grains of jalap and thirty grains of cream of tartar, promoting free perspiration by the use of sweat baths, which are given by placing the patient in a tub of water at the temperature of 106 degrees Fahrenheit for twenty minutes. Give a thorough rub and place in bed between blankets with hot water bottles, or hot cans around, but not touching the patient. A blanket should be interposed between the skin and the hot cans. Allow free perspiration for an hour to an hour and a half. Sweating may be aided by giving from one-twelfth grain to one-eighth grain of pilocarpine. Guard against collapse by giving strychnine sulph., one-twentieth grain. Dry cups followed by hot fomentations over loins. In bad cases, with robust patients, cut-cups or leeches may be used in place of the dry-cups, and acetate or citrate of potash in twenty-grain doses, with ten drops of tincture of digitalis or squills, and half a teaspoonful of sweet spirits of nitre are often given with benefit. Citrate of caffeine in one to two grain doses may be tried. Infusion of digitalis in one drachm doses is especially beneficial in children. Diuretin in from ten to twenty grains three times a day for adults, and two to five grains for children will often give good results. Bosham's mixture, one drachm thrice daily. Niemeyer recommends a pill if edema is present, composed of blue mass, powdered digitalis, powdered squill, each of one grain. Take one of these thrice daily. The following combination may prove efficient in troublesome dropsy: 

      Spartine sulph ..................................... 4 grains
      Caffeine citrate .................................. 20 grains
      Lithia benzoate ................................... 40 grains
          Divide into ten powders, and take one every three hours.

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CHRONIC BRIGHT'S DISEASE OR CHRONIC NEPHRITIS.

Causes.—It may follow the acute, or may be chronic from the beginning. Males are most frequently attacked. Adult life, frequent exposure to wet and cold, alcoholism and congestion from heart disease and syphilis are the chief predisposing causes.

Symptoms.—The symptoms of well-defined chronic Bright's disease are albuminous urine, containing renal epithelial cells and tube-casts, more or less dropsical effusion, especially noticeable about the face and ankles, anemia, shortness of breath, a peculiar dryness of the skin, dyspepsia headache and giddiness, together with a tendency to dimness of sight and inflammation of the retina of the eye, uremia or blood-poisoning from the retention of the urea, which ought to be removed by the kidneys in the circulating fluid, secondary inflammations, such as pneumonia and pericarditis, and hypertrophy of the heart. Its presence can only be positively ascertained by thorough microscopical examination of the urine, and such examinations repeated from time to time are the best guides as to the necessary treatment. The variety is essentially chronic, running a course of months or years, with a tendency to temporary improvement under treatment, on the one hand, and to subacute exacerbations in consequence of unhygienic imprudences on the other. It almost always proves fatal in the end, however, by uremia with or without convulsions, by secondary inflammations, or perhaps by general debility. It is estimated that uremia causes death in about one-third the cases.

Treatment.—The treatment for chronic albuminuria is in the main hygienic. Residence in a warm and equable climate. A quiet life without mental worry, with gentle but not excessive exercise, is recommended. In addition the bowels should be kept regular, skin active by daily tepid bath with friction. Abundant pure water or some pleasant mineral water should be drunk. The underclothing should be wool or silk, and the diet non-nitrogenous, and in severe cases absolute diet of skimmed milk will prove beneficial, unless dropsy or symptoms of uremia require active remedies.

Further Treatment.—Should the former be very troublesome, and diuretics, as suggested when speaking of the acute form, fail to act, as frequently happens, recourse must be had to the hydrogogue cathartics, such as a quarter of a grain of elaterium, already spoken of, with hot-air or vapor baths to promote elimination by the skin, as a partial substitute for the inefficient work of the crippled kidneys. If marked symptoms of uremia appear, such as headache, drowsiness, involuntary muscular twitchings, sudden and violent vomiting and diarrhoea, recourse to the active cathartics should be had at once, without any preliminary trial of a diuretic, and if uremic convulsions or coma come on, full doses of elaterium or a drop of croton oil will probably be required immediately to avert death. During the convulsion chloroform may be given by inhalation to restrain the violence, and perhaps shorten the paroxysm.

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Many cases of uremia are benefited and life prolonged by blood letting of from six to twelve ounces, depending upon the pulse, and followed by an injection of saline solution from one to two pints beneath the breasts, or in subcutaneous structures of the axilla, strength of solution about one teaspoonful of salt to a pint of distilled water, to be injected at about the temperature of 100 degrees Fahrenheit. Care must be taken to thoroughly cleanse the skin at the point at which the needle is to be inserted.

HEMATURIA OR BLOODY URINE.

This is more a symptom of other diseases than a disease in itself.

Causes.—Stevens gives as the causes thus:

1. Vicarious menstruation.

2. Traumatism applied to any part of the genito-urinary tract.

3. General blood dyscrasia as in specific fevers, purpura, malaria, scurvy, etc.

4. Congestion of the kidney from chronic heart, lung or liver disease.

5. Acute inflammation of any part of the genito-urinary tract.

6. Stone in any part of the genito-urinary tract.

7. Varicose veins in neck of bladder.

8. It may occur without obvious cause.

9. Parasites in genito-urinary tract.

10. Tumors and tubercle of the kidney.

The presence of blood may be suspected from the red, smoky or brownish color of the urine, and positively determined by a microscopical examination. If the blood is clotted it generally comes from the bladder, and if coagulated in long round strings, like earth-worms, it may have been effused in the urethra, from a rupture or ulcer in that membranous tube.

Treatment.—The most important thing is to discover the cause and treat that. If this cannot be done tincture of chloride of iron, which is especially useful in debilitated patients in twenty-drop doses every three hours, gallic acid in quantities of five grains, and ergot, or two grains of acetate of lead and half a grain of opium every four hours. The effect of the general remedies may be aided by the injection of a weak solution of alum in cold water, thrown into the bladder by means of a catheter if the case is urgent. Where a large mass of coagulated blood is formed in the bladder it may sometimes be gotten rid of by the injection of a solution of pepsin, which, if the ingenious plan succeeds, dissolves the clot of blood.

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PYURIA OR PUS IN THE URINE.

Causes.—1. Suppurative inflammation of the kidney.

2. Calculus (stone) or tuberculosis of kidney.

3. Cystitis or suppurative inflammation of the bladder.

4. Urethritis. Inflammation of urethra.

Symptoms.—Urine is alkaline and has a cloudy sediment. There is usually frequent and urgent desire to urinate, especially if the pus is from the bladder or posterior urethra.

Diagnosis.—Diagnosis can only positively be made from microscopical examination. If from abscess of kidney flow of pus is intermittent. If from calculus or tuberculosis of kidney the flow is constant, as it is in cystitis or urethritis.

Treatment.—The treatment consists in removing the cause.

SUPPRESSION OF THE URINE.

Description.—This is an affection in which the work of the kidneys in secreting the urine is very defective or altogether abolished. There may be some pain in the back or irritability of the bladder, the patient becomes anxious and restless, then dull and drowsy, and finally after an interval of from three to eight days usually dies comatose. In other instances there is nausea and vomiting, hiccough, and the whole body exhales a urinous odor. Where the suppression is less complete, and depends upon some obstruction to its outflow in the ureters, bladder, or urethra, the mind remains clear for a long time, perhaps, and the unfortunate patient is fully conscious of the intense local suffering and general distress produced. The time during which the urine may be suppressed and yet the patient recover varies considerably.

Hysteria.—In hysteria, cases where no urine has been passed for ten days are reported, but such instances are not free from suspicion of possible deception on the part of the patient. Children when teething will sometimes for days together void only a few drops of urine at once, and that at several hours interval. The urine passed at such times is extremely high colored, stains the linen, and is passed with great pain, the child crying bitterly, as it scalds the sensitive surface over which it flows. This disease probably arises, at least in some instances, from over-congestion of the kidney.

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Treatment.—The treatment recommended is to place the patient in a warm bath, and give a saline diuretic, such as a teaspoonful of cream of tartar, or twenty grains of acetate of potash dissolved in half a pint of water, combined with a moderate laxative. The sweet spirits of nitre, in half teaspoonful doses, is also frequently useful. Digitalis leaves made into a poultice, or the tincture of digitalis added to a flaxseed poultice; have often proved beneficial, and the digitalis may also be used internally with advantage in the form of a teaspoonful of infusion every four hours.

FLOATING OR MOVABLE KIDNEY.

The mobility of the kidney depends upon the relaxation of the surrounding structures.

Causes.—Females are most usually affected, probably due to the difference in dress between them and the males. Middle life. Any disease-producing rapid marked emaciation predisposes to it. A congenital relaxation of surrounding tissues. Muscular exertion. Repeated pregnancies.

Diagnosis is made by feeling kidney in abnormal position.

Symptoms.—There is a dragging sensation in back. Kidney may become swollen and painful to the touch. There is a sense of uneasiness and attacks of neuralgic pains. Emotional disturbances are often excited by this condition.

Treatment.—Use abdominal binder or pad. Regulate diet. Avoid exertion. If the condition persists the only treatment is surgical.

RENAL OR NEPHRITIC COLIC.

Causes.—Since the ureters commence inside the kidneys as funnel-shaped tubes, it is obvious that any solid substance capable of entering the upper part and yet a little too large to pass the lower portion, will stick fast, and can only progress as the pressure of the constantly secreted urine behind it drives it along with sufficient force to dilate the pipe and allow it to move onward. This process of dilatation is horribly painful, and with that of passing a gall-stone, and of certain forms of neuralgia, makes up the worst physical suffering of humanity since the Spanish Inquisition was abolished. The little stones which cause such agony in this way are generally composed of uric acid, or less commonly of oxalate of lime, deposited from the urine inside the kidneys, and washed down from the seat of their formation by the outflow of that fluid. It is not positively determined whether they crystallize out of the urine because they are produced in too large quantity in the system, or because a deficient amount of water to hold them in solution is filtered out of the blood; but in neither[sic] case, increasing the bulk of the renal secretion by drinking a larger quantity of water daily, is a most rational method for diminishing the tendency to their production.

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Symptoms.—The first symptom of an attack of renal or nephritic colic is usually pain in the region of the loin on the affected side. This rapidly increases in severity until it becomes excruciating, and radiates downward toward the groin, the testicle on that side being drawn up, a symptom constituting in males—who are chiefly the subjects of this malady—an important diagnostic sign. With the pain, nausea and vomiting are apt to occur, and the body is covered with a cold sweat.

Treatment.—The treatment of nephritic colic is to relieve the pain, if only moderately severe, by hypodermic injections of morphia and atropia, or laudanum enemas, as advised in the article upon gall-stones; but if the suffering is intense, by the inhalation of ether or chloroform. In order to mitigate the pain sufficiently by these anesthetics, it is not usually needful to administer them to complete unconsciousness. A few whiffs will lull the distress so as to make it endurable for the time, and as this blessed influence passes off, it can be renewed by a repetition of the inhalation. Persons whose hearts and lungs are healthy, can thus be kept in comparative comfort with comparative safety, for several hours, or until the passage of the stone out of the lower end of the ureter into the bladder renders the anesthetic no longer necessary.

Passage of Stone.—It is probable that both morphia and ether tend, besides, to hasten the exit of the stone by relaxing the spasm, which no doubt is caused by the irritation of the angular corners of the cruel little calculus as it makes its way through the slender and sensitive tube of the ureter. After the passage of a stone of this kind into the bladder, it usually is voided with the urine, in the course of the next day or two, and in order to make sure that the enemy has been completely gotten rid of, it is best to carefully examine all the urine which comes away in the next few days after an attack. The character of the stone, when found, will afford some information as to the best mode of treatment to be adopted for the purpose of avoiding the formation of others of like structure.

Prophylactic Treatment.—Those who are subject to attacks of nephritic colic should live a quiet life, avoiding exertion as far as possible. The diet should be regulated as in gout. Diuretics should be taken and water in large quantities.

Sir William Roberts recommends what is known as the solvent treatment. Citrate of potash in doses of half to one drachm every three hours. Osler has not found this satisfactory. Piperazine in doses of five grains three times a day may prove useful as a solvent.

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CYSTITIS OR INFLAMMATION OF THE BLADDER.

Symptoms of Acute Cystitis.—There is great frequency and urgent desire to urinate. The passage of very little urine at each act, accompanied by great pain above the pubis, and in the perineum radiating to the end of the penis and in the loins and sacral region.

The Urine.—The urine, at first clear, loses its transparency, becomes full of thick mucus and contains blood and pus. A rectal examination is very painful.

Treatment.—In treatment of cystitis remove the cause if possible. Put patient to bed, apply hot applications to perineum, give suppositories containing opium, one grain, and belladonna, one-sixth of a grain. Hips should be elevated and bowels opened by salines and glycerine enemas. An exclusive milk diet is often beneficial.

For the pain give a powder containing— 

      Extract hyoscyamus ................................. 4 grains
      Extract cannabis indica ............................ 4 grains
      Sugar ............................................. 20 grains
          Divide into ten powders, and take one every three hours.

Suppositories of ichthyol, one grain, are often beneficial. All alcoholic stimulants must be avoided.

Symptoms of Chronic Cystitis.—In this condition there is frequent urination, but it is not so marked as in the acute form. The urine is ammoniacal, fetid and filled with tenacious mucus and pus; not infrequently blood. Constitutional symptoms rarely appear. Tuberculosis is a frequent cause of cystitis, and by careful straining and examination the bacillus tuberculosis can be found. This form is accompanied by pyuria (passage of urine) and pain.

Treatment 1.—If possible, the cause must be removed. Water is drunk in large quantities. Salol and boric acid, five grains each, every four hours, is very good.

2. Urotropin, five grains six times a day, catheterize twice a day, and irrigation of the bladder with solution of silver nitrate, one grain to a pint of water, or solution of permanganate of potassium (1-20,000). The bladder is washed out by attaching a glass nozzle to the catheter at one end, and to a funnel with rubber tube at the other. The funnel is raised to four or six feet above the patient, and bladder filled, and then fluid allowed to flow out. This is repeated several times until it returns clear.

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CALCULUS OR STONE IN THE BLADDER.

Causes.—It is supposed by some writers to be in part due to the lime and magnesium contained in the hard water used for drinking in certain districts. It is more common in men than in women.

Symptoms.—The suffering is sometimes very severe, and is nearly always felt more or less both night and day. There is a continual and distressing sensation, as if there were retained secretion in the bladder, and more or less subacute inflammation is usually set up. The flow of urine is often suddenly stopped, and continues upon change of position. This is due to the stone obstructing the passage of urine at the neck of the bladder.

Treatment.—The medical treatment is only palliative, and similar to that recommended in cystitis and solvent in nephritic colic. The surgical operations of opening the bladder and taking out the stone, called lithotomy, and of lithotrity or crushing the stone, if of suitable size and texture, within the bladder, by means of a very ingenious instrument, afford, when successful, as they are in a large proportion of cases, a complete cure.

Diet.—After getting rid of a stone, something can be done by the management of the diet, and above all by the avoidance of impure drinking-water, toward escaping the further formation of these dangerous and painful concretions in the bladder. It is important, however, to determine the nature of the calculus removed, and this can only be decided with certainty by a chemical and microscopical examination.

INCONTINENCE OF URINE IN CHILDREN.

Causes and Cure.—Paralysis, irritability and spasm of the muscular coat of the bladder are not infrequent. When the muscular layer is irritable the urine has to be voided too frequently, producing incontinence of urine. This is sometimes a very troublesome affection in young children, often, however, in great part a bad habit, which is cured as soon as it has been broken up, let us say, by an anodyne suppository of one-twentieth of a grain of extract of belladonna and one-quarter of a grain of opium, to a child six years old, for four or five nights in succession.

Adhesions of foreskin to prepuce is often a cause which must be remedied.

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DISEASES OF THE PROSTATE GLAND.

Causes and Cure.—Among the diseases of the prostate gland the most important are chronic enlargement and calculus. This gland is situated just in front of the neck of the bladder, and encircles its outlet, the urethra. Hence its enlargement is apt to interfere with the outflow of the urine from the bladder as soon as it increases beyond a certain point. The difficulty thus caused in passing water is especially apt to affect elderly men, and would be very serious had not surgical science supplied a peculiarly formed instrument, called the prostatic catheter, by which the impediment can usually be overcome temporarily.

Inflammation of Urethra.—The urethra, which constitutes the final channel through which the renal secretion flows in making its exit from the body, is likewise subject to inflammation, and to obstruction from calculus, and, most important, to narrowing in consequence of inflammatory action. This contraction of the canal is called, as most people are aware, stricture of the urethra, and notwithstanding the numerous tales of accident producing this trouble, which are poured into the credulous ears of physicians, its true cause is, at least nine times out of ten, gonorrhea, which will therefore be considered in this connection.

GONORRHEA.

Character.—Gonorrhea, or, as it is vulgarly called, the clap, is a specific inflammation of the urethra, the result of contagion and very seldom innocently acquired. In the female it affects chiefly the vagina, and is much less serious or painful than in the male sex.

Symptoms.—The first symptom in the male is a slight uneasy sensation or tickling at the mouth of the urethra, which is generally felt between the second and seventh day after exposure to infection. On examination the organ is found slightly reddened, and the natural discharge of mucus a little increased, and more viscid than usual. These signs of irritation soon pass into those of inflammation, in which the redness, heat, pain and swelling, characterizing that process, are all experienced in an exaggerated form. The discharge becomes thick, yellow or greenish, and the pain on passing water, which must be done frequently, is very severe. Erections are frequent and painful. The penis is bent downward. These erections are called chordee. Swelling and inflammation of the glands in the groins, commonly called a bubo, is common, but the irritation seldom goes so far as to result in suppuration and abscess. Orchitis or inflammation of the testicle is more frequently observed. The disease is apt to last under the best treatment for a period of from four to six weeks, and if neglected or badly managed may be months before it is cured.

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Treatment.—The most important part of the treatment is rest in bed, but as this can seldom be secured the inflamed parts should be supported by a suitable suspensory bandage. At first the treatment must be that of inflammation elsewhere, that is by saline purgatives, such as a tablespoonful of epsom salts, low diet, and half teaspoonful doses of sweet spirits of nitre or ten grains of Dover's powder to promote perspiration. Wrapping the affected parts in cloths soaked in a mixture of four ounces of lead-water and two grains of acetate of morphia, and covered with oiled-silk is useful, and the injection of dilute solutions of the same medicines, made by mixing an ounce of this liquid with three ounces of water may be cautiously tried, or a one per cent. solution of protargal. In the first few days irrigation with a one to five thousand solution of permanganate of potassium. The scalding on voiding urine may be mitigated by drinking freely of flaxseed tea containing two drachms of acetate or bicarbonate of potash to the pint, and a belladonna and opium suppository at night, repeated in two hours if needful, will generally prevent much trouble from chordee.

Diet.—The diet should be rice, bread with very little butter, milk, and, if necessary to keep up the strength, soft-boiled eggs. Meat, alcoholic and malt liquors, acids and condiments, are particularly objectionable.

Secondary Treatment.—After the first violence of the inflammation begins to subside the injections, such as silver nitrate, one grain to six ounces of water, or copper sulphate, one-half grain to the ounce, or acetate of lead and sulphate of zinc, each three grains to one ounce of water, may be made stronger gradually, allowing them to be of sufficient activity to produce a little smarting, lasting not longer than five minutes, each time they are used. They should be employed directly after each passage of urine, provided that does not occur oftener than once in two hours. At this period the administration of balsam of copaiba is usually commenced, And a good article of oil of sandal-wood appears to be even more efficient in checking the remaining discharge, two capsules of either remedy being taken four times daily.

Third Treatment.—In the course of another week injections of acetate of zinc, sulphate of copper or nitrate of silver, one or two grains to the ounce of water, may come into service with benefit, but great care must still be exercised in regard to errors in diet, a single glass of malt liquor being frequently sufficient to bring on a relapse. If neglected or badly treated the malady may run into the chronic form, which is called gleet, and often proves exceedingly rebellious to treatment. Five-grain doses of salol, ten drops each of tincture of chloride of iron with tincture of cantharides thrice daily often, however, succeed in bringing about a favorable change, and the introduction of a bougie smeared with belladonna ointment three times a week is apt to contribute to the cure.

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STRICTURE OF THE URETHRA.

Causes.—Usually the attention is attracted by the circumstance that the desire to urinate becomes more frequent, and the force of the stream diminishes, so that the renal secretion dribbles away in drops, or runs off in a very fine stream not larger than a knitting-needle. There is more or less pain in passing water, and a good deal of straining is required to accomplish the operation, which begins to be dreaded from day to day, and even from hour to hour.

Treatment.—The treatment of stricture is purely surgical, as, being a mechanical obstruction, medicines can accomplish nothing for its relief. The usual method is by gradual dilatation, using first a small steel rod bent at the suitable curve and highly polished. This is to be warmed and thoroughly oiled, and then carefully passed into the bladder through the urethra, scarcely any force being employed. The great danger is that some of the inflamed and softened tissues in the neighborhood of the obstruction may give way, and what is called a false passage being formed, the condition of the patient is rendered far worse than before.

Using the Steel Rod.—The largest size that can be used successfully having been introduced, it is allowed to remain a few minutes and then an instrument of a little greater diameter is employed, and so on until the urethra, not without considerable suffering, is stretched to the original magnitude. In most instances, however, this dilating process must be kept up for months, the patient himself learning how to use the proper instrument, and introducing it at longer and longer intervals for a year or two until completely cured. Various other methods for relieving the obstruction of stricture have been devised, such as external incision, cauterization, and so forth.

Emergency Treatment.—In the emergency of an attack of retention of urine in a man who is the subject of stricture coming on whilst far from medical assistance, the first thing to do is to get into a warm bath, since this will often procure sufficient relaxation of the spasm, which always makes up part of the narrowing of an irritated stricture, to allow a little urine to dribble away, perhaps whilst bathing, and so relieve the distress of the patient. If this fails a laudanum and belladonna injection or suppository, or a full dose of twenty drops of laudanum, will frequently have the desired relaxing effect.

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Self-Use of the Catheter.—Care should be taken to drink as little fluid as possible, so as to diminish the amount of the renal secretion to a minimum, until the avenue for its escape is again, partially unclosed. If a catheter can be procured, the patient should try to pass it himself, choosing the time when he is still partly under the influence of the opium, which dulls the excessive sensibility of the urethra.

Substitute for Catheter.—In the absence of a catheter it has been most ingeniously suggested by Dr. Levis, of Philadelphia, to use a piece of bell-wire, doubled and bent to the right curve, along the sides of which, if safely introduced, enough urine might flow to relieve the over-distended bladder.

SYPHILIS.

A Punishment for Immorality.—This other form of punishment for immorality, even more far-reaching in its effects, since it often affects the unborn children of the offender, may be conveniently discussed in the present chapter.

Cause.—It is a disease the result of a specific poison produced solely by direct implantation of the contagious material, usually the purulent discharge from a venereal sore in a previously diseased person.

Development.—About a month after it is in any mode implanted in the human system it appears to begin a development throughout the whole organism, and penetrating to every part of the body, affects especially the skin, glands and throat in the form of secondary symptoms, and still later the cartilages and bones as tertiary manifestations, until finally, if unchecked, it often proves fatal, after intense and prolonged suffering.

Local Symptoms.—The first symptom of this horrible disease is usually a primary sore or chancre, which appears as a small pimple or blister upon some part of the organs of generation, or point of contact, any time within two or three weeks after the infection is received. The great distinction between the syphilitic ulcer, or true chancre, and the chancroid, or nonsyphilitic sore, is that the former has a hardened base, but the most eminent surgeons admit that neither this nor any other criterion is infallible. The infecting pimple may dry up without ulcerating, but more commonly a cup-shaped sore from an eighth to three-eighths of an inch in diameter, and with raised edges, is formed, and unless modified by treatment lasts for a month or six weeks, when it heals up, leaving a hardened lump of a dark red coppery or bronze color, which is often several months in completely disappearing. The glands in the groins during the ulcerating stage of the primary chancre become swollen, hard and slightly painful, but seldom suppurate. After some weeks the other lymphatic glands partake of this enlargement, and gradually those in the armpit, in the neck and behind the ear give evidence of the general infection.

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The Chancroid Sore.—The chancroid, soft-chancre or non-syphilitic sore, generally develops in a few days from the date of infection, first as a minute vesicle, then a pustule, and later as an ulcer, round or oval in shape, with clean-cut edges, and without any hardening of the base. The floor of the ulcer is generally covered with a thick yellowish matter, which is virulent and contagious in the highest degree. The glands in the groins are often not swollen, but if affected are much more apt to suppurate, constituting a bubo, the discharge from which is also intensely contagious. It is therefore far more troublesome than the primary syphilitic sore, and yet infinitely to be preferred to the latter on account of the absence of any constitutional infection.

The following is a diagnosis between chancre and chancroid:

 

CHANCRE.


1. Appears two to twenty days after exposure.
2. Is usually single.
3. Inflammatory phenomena comparatively slight.
4. Discharge is serous or bloody and readily inoculable.
5. Margins of preputial orifice are not markedly inflamed.
6. Marked induration.
7. Buboes are invariably present, and in both groins; they rarely suppurate.

CHANCROID.


1. The interval between exposure and appearance is much shorter.
2. May be multiple.
3. Inflammatory phenomena, heat, pain, redness and swelling very marked.
4. Discharge, profuse, purulent, very irritating and readily inoculable.
5. Induration, if present, is not marked.
6. Buboes, if present, are usually on one side, and suppurative.

 

Constitutional Symptoms; Secondary.—After a true or hard chancre has developed, and no matter whether it has healed promptly or is still open, there appears in about four weeks, on an average, from the first infection the first of the train of general or constitutional symptoms. These consist of the tumefaction of the lymphatic glands, followed after a few weeks more by fever, headache, rheumatic pains and soreness of the throat. About the tenth week after the dearly-bought pleasure its unfortunate purchaser usually finds a crop of eruption appearing upon his skin, sometimes slight and easily concealed, but oftener well defined and in a tell-tale abundance, which instantly reveals his guilty secret.

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The Eruptions.—This eruption may be of pimples, pustules, or scales, the former being the most common and having a new copper-colored red or brownish-red tint, which, when well marked, is to the experienced eye very characteristic. It is apt to be especially abundant round the sides of the nose and angles of the mouth and eyes, the roots of the hair on the forehead and back of the neck, the centre of the breast, the inner side of the limbs, and around the armpits and groins.

Hand and Feet Eruptions.—An important diagnostic mark of the scaly, syphilitic eruption is its appearance on the palms of the hands and the soles of the feet. These manifestations are also particularly liable to appear as pustules among the hair of the scalp. In some cases the whole body is thickly covered. After persisting for periods varying from two or three weeks to as many months, these spots usually fade, leaving behind them brownish stains which are very persistent, but ultimately may give place to pale scars, somewhat like the pitting of small-pox in a very mild form.

Other Appalling Symptoms.—In a minority of instances the patient escapes any well defined symptoms, but suffers instead from one of the following manifestations of secondary syphilis, which often accompany the eruptions also: Alopecia or falling of the hair, which in bad cases may include not only that of the head, but also the eyelashes and eyebrows; flat whitish sores in the mouth and anus, called mucous patches, the discharge from which in the former situation may easily convey, by kissing, the whole vile disease to a perfectly innocent person; inflammation of the iris injuring or even destroying the sight; and local diseases of the generative organs.

Tertiary Symptoms.—The late or tertiary symptoms of venereal disease are disease of the cartilages and small bones of the nose and throat, producing the shocking disfigurement of the countenance sometimes seen, especially among sailors; disease of the bones of the skull leading to persistent and excruciating headache, and sometimes actually perforating the cranium; disease of the tibia or large bone of the leg between the knee and ankle; disease of the nails which may entirely ulcerate out; disease of arteries which, of course, is most apt to prove fatal, and peculiar new growths called gummy tumors, which may appear in all parts of the system.

Congenital (Birth) Syphilis.—Congenital syphilis generally shows itself between the third and sixth week after birth, by cutaneous eruptions, similar to those seen in the secondary period of acquired syphilis, and of most frequent occurrence upon the buttocks, abdomen, palms and soles.

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Symptoms.—Congestion and subacute inflammation of the mucous membrane of the nose, with increased discharge, vulgarly called the snuffles, also appear, and the infant has usually a peculiarly shriveled, weazened aspect, like that of a prematurely old man. Mucous patches from about the baby's mouth may infect the mother or nurse, and keratitis or inflammation of the cornea of the eye is lamentably common. Early and active administration of mercury is very important, lest the syphilitic cachexia prove fatal.

Local Treatment of Chancre.—The treatment of the primary sore, or chancre, is much disputed. Cauterization with nitric or chromic acid, or the acid nitrate of mercury, and subsequent dressing with black-wash—a mixture of a drachm of calomel, and a pint of lime-water—is much employed; but the application of iodoform is highly recommended. Complete excision of the sore, with its hardened base, in the hope of preventing secondary symptoms, has been tried without success, even when performed early. If the enlarged glands in the groins give rise to much discomfort, they should be painted over with the tincture of iodine or twenty per cent. ichthyol ointment.

Treatment by Caustic.—The prompt destruction of the chancroid ulcer by caustic, and the dressing with black-wash or yellow-wash, is advisable, and hope may be entertained of thus putting an end to the whole malady. If the glands in the groins go on to suppuration, however, very serious trouble may be anticipated before a cure is effected.

Constitutional Treatment.—The treatment of the secondary symptoms is by the use of mercury, which, although decried by some physicians, is considered by our best authorities as the only effectual remedy for syphilis. It may be administered by inunction[sic] of mercurial ointment, by fumigation, or in the form of half a grain of calomel, or blue pill, or one-third of a grain of the iodide of mercury thrice daily, or protiodide of mercury one-fourth grain three times a day. It is also given by hypodermic injections of the bichloride, one-third grain, once a week. The injection must be made deep into the muscles. Proper precautions must be taken to cleanse the needle and syringe before using, also the skin at point at which the needle must be inserted. This treatment should be kept up at intervals for a year or two after an apparent cure has been effected. To obtain its beneficial effects, which are often very marked and satisfactory, it is not necessary to induce severe salivation, which, probably, in former times, often aggravated the ultimate effects of the syphilitic poison.

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Treatment of Third (Tertiary) Stage.—In the tertiary stage, iodine and iodide of potassium, in the form of the compound iodine solution, or the iodide occasionally in very large doses of fifteen or twenty grains, thrice daily, are the great remedies; but they may sometimes be associated with mercurials to much advantage. In a majority of instances, the development of well-marked tertiary symptoms may be prevented by judicious treatment in the second stage of the complaint, and even when a slight tendency to disease of the bones and cartilages is displayed, a combination of the iodides with mercury will often avert disastrous consequences.

Use of Tonics.—Throughout the whole management of the case the administration of tonics, such as iron, quinine and strychnia is very important, and strict attention to hygiene by promoting the best general health is an almost indispensable condition to securing a favorable result.

Should Syphilitics Marry?—Professor Alfred Fournier, in a late instructive work on syphilis and marriage, formulates some valuable conclusions in regard to the very difficult problem, from a hygienic point of view, whether a syphilitic person ought to marry or not. He asserts that a man who enters upon marriage, with syphilitic antecedents, may become dangerous: first, to his wife; second, to his children; third, to the interests of his family. In the first place the wife is apt to be infected directly by contact with the pus of secondary lesions; and Dr. F. says: "I know from long experience that it is rare to see a young wife live with a syphilitic man, or conversely, without the health of the former being effected by the diseased one." It was this which caused a witty French observer to say: "The pox is partaken of by a married couple equally, just like the daily bread."

Syphilis Conveyed by Conception.—Secondly, a man may convey syphilis to his wife by causing conception, as when a young girl, pure and healthy, is married to a man whose venereal disease has not been thoroughly cured. The physician calls a few months later and finds her diseased with, for example, distinct secondary symptoms, such as cutaneous syphilides, mucous patches in the mouth, scabs on the scalp, swelling of the glands in the neck, headache, vague pains, lassitude, febrile attacks, loss of hair, and so forth—all this without a trace of chancre, and even without that faithful companion of a chancre, a bubo, which M. Ricord calls so aptly the posthumous witness of a chancre. In these lamentable instances, the wife-mother, infected without having had any primary symptoms, and whose husband has long been freed from all external indications, is diseased, not from that husband, except indirectly, but from her child still within her womb.

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Danger to Children.—As respects the danger to children: Although offspring may be begotten by a syphilitic father who enjoys good health, yet the hereditary influence of paternal syphilis is very far from being as innocent, minute or negative as has been maintained.

Development of the Inherited Tendency.—This inherited tendency may be developed in the three following modes: Either that, which is an exceptional case, by the transmission of syphilis to the foetus; or that, which is sufficiently common, by the death of the child; or lastly, by the inherent degeneration of the germ, which ultimately reveals itself under a great variety of morbid conditions.

Worst Form of Danger.—But the worst form of danger to the family of a syphilitic father is that communicating the disease to the wife, the paternal and maternal influences will act upon the same side, and most disastrously conspire in unison against the fruit of any pregnancies which may result. In such sad cases we can predict that, with a few rare exceptions, either, first, the child will die before birth; or, second, it will be born with syphilis, and with all the possible and serious consequences of infantile syphilis, which in many cases are equivalent to death itself; or finally, third, it may be born without syphilis, but with uncertain health, with a weak nature and a feeble constitution, which will probably expose it to a rapid death; with menacing morbid tendencies; with a predisposition to certain organic diseases—in a word, to a relatively speedy decay; this terrible fate being visited again and again upon successive innocent babes.

Transmission of Syphilis.—At the New Orleans meeting of the Public Health Association, Dr. Gihon of the Navy, as chairman of a committee on the subject, presented a valuable report, in which he remarked: "Every one instinctively shrinks from the touch of the sufferer with small-pox, but how few realize that a syphilitic is a leper also to be most scrupulously shunned? How few mothers are aware of the danger, to themselves and their children, from nurses and housemaids drawn from a part of the population in which every fifteenth person is thus diseased? How few parents suspect the peril to their daughter from her accepted lover's kiss, since he may be that one in about every five young men among the better classes who has a venereal disease, which there is one chance in two is syphilis."

Transmission of Syphilis by Kissing.—These are not mere speculations, for Professor Gross reports that he has seen many cases communicated by kissing; and he tells of fifteen women, nine children, and ten men diseased by a single midwife, who had a chancre on her finger, contracted in the exercise of her profession, and who had thus carried the disease from house to house.

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Transmission by Cooks and Nurses.—Dr. J. Marion Sims says: "I have seen a cook and a chambermaid with syphilitic ulcers on their fingers; I have seen nurses infected by the children they had nursed, who were born of syphilitic parents, in turn infecting sucking babes, born of healthy parents; and I have known a drunken vagabond husband to contract syphilis and communicate it to his wife, who in turn gave it unwittingly to her four children, simply by using the same towels and washbowl."

Transmission by Towels.—One of this very committee adds the case of an estimable and venerable lady, who lost her eyesight that year, from a venereal affection arising from using a towel in her son's room, carelessly left by him upon the rack; and of another, the wife of a clergyman, who the preceding summer sought relief at a Virginia spring for a horrible affection contracted in domestic contact with her servant.

Transmission by Pipes and Cigars.—The present Surgeon-General of the Navy saw a number of cases of chancre of the lips among the smokers of one set of cheroots, of which the wrappers had been moistened by the saliva of a Manilla[sic] cigar girl; and at Beyroot he learned that it was not unusual for syphilis to be contraced[sic] by using a narghileh that had been pressed by the lips of a diseased smoker. How many people would venture to eat Smyrna figs if they had seen the top layer of the choicest box pressed flat with the saliva-wetted thumb of the packer, who, there was one chance in ten, was a syphilitic?

Transmission by Exhalation.—A certain lady was terribly alarmed when told by her husband, a physician, that she had invited to her table a young man who, in the course of a physical examination that morning, he had found to have his mouth and tongue covered with mucous patches; and that her daughter was dancing in a public ball room with another whose body was repulsive with syphilitic eczema.

Transmission by Instruments.—An editorial in one of our Philadelphia medical journals not long since stated: "It has happened to the writer to be recently called to see a man of most respectable surroundings, who bore an unmistakable venereal sore upon his lip, and subsequently manifested all the features of secondary syphilis. It was said that this sore had followed a trifling surgical operation upon the part affected for the removal of a slight deformity, during which the instruments or the hands of the surgeon had inoculated him with syphilis.

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Ever Present Dangers.—This energetic committee urged that it should be promulgated everywhere throughout the community, that so long as syphilitics are allowed to go unrestrained the spotless woman and the innocent child share the danger of this horrible contamination with the libertine and the courtesan.

The Various Ways of Transmitting Syphilis.—Let it be known by everyone, they exclaim, that this fearful pest may be communicated:

1. By the blankets of the sleeping car, the sheets, towels and napkins of the steamship, hotel and restaurant.

2. By the hired bathing dresses at a seaside resort, and the costumes rented for the fancy ball.

3. By the chipped edges of cups and plates, as seen at any hotel or eating house, and by the half-cleansed knives, forks and spoons of the same.

4. By public drinking vessels in a railway car or station, as well as the public urinal or water-closet.

5. By the barber's utensils, the comb and brush in the guest chamber, the hatter's measure, or the borrowed hat.

6. By the surgeon's and dentist's instruments, or the vaccinator's lancet.

7. By the broom or dust-brush handled by a parlor maid, or by the spoon or cup touched by the mouth of a cook or nurse.

8. By whistles and other toys sold to children in the streets by vendors with poisoned lips or fingers.

9. By playing or visiting cards which have been used, and especially by car tickets and paper money circulating in a city like Philadelphia, where 50,000 syphilitics are at large.

10. By the grasp of a friend's hand or the kiss of a betrothed lover, by the son to his mother and sister, the husband to his wife and unborn child, and by the latter to its mother.

SPERMATORRHEA OR INVOLUNTARY EMISSIONS.

Mental Anxiety.—As an appendix to the unsavory subjects discussed in this chapter a few remarks upon spermatorrhea and its usual cause are appropriate here. It would be impossible to estimate, with any approach to accuracy, the vast amount of anxiety and mental suffering needlessly endured in our community in regard to this disease. The lying advertisements of unprincipled charlatans are less openly displayed than formerly, and yet means are found with satanic ingenuity to reach their victims, and cruelly arouse, from mere mercenary motives, their liveliest apprehensions.

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The Disease and Results.—That the disease called spermatorrhea exists, and in rare cases does result in the utter wreck of mind and body, which is painted by these designing quacks in such sombre colors, cannot be denied, but that nineteen out of every twenty young men who have become alarmed by the occasional or even frequent occurrence during sleep of what they have learned to control whilst awake, have no real ground for their agonizing fears is equally indisputable.

Causes.—The usual cause of spermatorrhea, of course, cannot be freely discussed in a popular work like this, and yet enough may be expressed in veiled language, the meaning of which will be only or chiefly comprehended by those who need the lessons inculcated, to accomplish, it is hoped, much good. Many young persons of both sexes, after being made aware of the danger in which they were becoming involved through evil examples, perhaps, of school associates, have earnestly tried to escape the thraldom of bad habits.

Treatment by Will Power.—Some of those who have succeeded, by the exercise of a resolution and strength of will, for which they deserve great credit, have overcome their enemy, but are yet haunted with the fear that they have been irreparably injured in the struggle. This fear is entirely unfounded, as time will infallibly prove.

Treatment by Exercise and Nutrition.—A second and larger class are still discouraged by frequently recurring evidence that they are not in a natural and healthy condition, and some may even be so disheartened as to feel almost hopeless. For such plenty of exercise in the open air, good nutritious food, chiefly vegetable, occupation of the mind in some study or suitable recreation, and the medical treatment of full doses of bromide of potassium every evening for a week, with or without a one-grain opium suppository at bedtime, can with a continued exercise of the will power during the waking hours speedily accomplish a cure.

Treatment by Hygiene and Medicine.—To a third class, who find themselves still unable to overcome temptation, much aid will be afforded by adopting the plan of hygienic and medical treatment above mapped out, and by diminishing, as the drugs mentioned can do, the force of the impulse itself, they may so reduce its power that a little additional resolution will suffice to achieve a victory. In this struggle they may find some support in the grand old maxim, "He that ruleth his own spirit is greater than he who taketh a city."

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