Chapter LIV: Introduction (24)

We venture to assert that less than one per cent. of those who imagine they have "Bright's," have this disease at all. We find that most of those who, as one of our Faculty puts it, _insist upon having_ Bright's disease, base their "diagnosis" upon the ever-changing condition of the urinary secretion, and especially upon the copiousness of the deposit; whereas, in true Bright's, deposits of any kind are rarely met with. Perhaps the form of deposit most commonly mistaken for Bright's disease, is that known to medical men as the _urates_. When the urates are in excess they form a heavy pinkish deposit of a flocculent nature within from five to thirty minutes after the urine has been passed--that is, after it has been passed sufficiently long to cool. To prove that the deposit is urates, heat the specimen to the temperature of the blood, when the deposit in question will disappear. Excess of urates has now been definitely traced, in the majority of instances, to functional torpidity of the liver.

Another common form of deposit is that in which the reaction of the urine, instead of being acid, as in health, is either neutral or alkaline, and in which the earthy phosphates are precipitated for this reason. The earthy phosphates, when thrown down by a neutral or an alkaline condition of the urine, appear as a heavy white deposit, which, though usually devoid of clinical significance, is certainly calculated to frighten timid patients who read of the "terrible ravages of Bright's" in the advertisements of various popular "kidney cures." To prove that the precipitate is phosphatic in its nature, add a few drops of vinegar and it will disappear; whilst, if, after the vinegar has been added, the specimen be brought to the boiling point, not only both the urates and phosphates remain in solution, but there is only one single substance known to pathological chemistry that can form a deposit under these conditions--and that substance is albumen, which, if present in quantity, is always indicative of serious disease.

The papers are filled with the plausible but unwarranted statements of the manufacturers of various "kidney cures," who anxiously desire that every one should be impressed with the idea that all their troubles arise from kidney disease in order to sell large quantities of their medicines. In many cases the unfortunate patient is rendered much worse by the use of remedies that are not suited to his condition, and which will not cure the real trouble with which he is affected.

Daily we are consulted by persons in whose cases these errors have been made. In reality, true Bright's disease is not a common affection, and nine out often individuals who think that they suffer from it, or the early stages of the trouble, in fact have something more curable. In some cases it is an affection of the liver, which forces an excretion of unnatural salts by the kidneys, and thus renders the urine acrid and irritating, or they may be suffering from some other disease, such as a deformity or enlargement of certain glands, as the prostate; unnatural position of the organs, as with women who suffer from weakness, the uterus pressing forward on the bladder and urethra, and thus showing every evidence of disease in the urinary canal. It is as common for persons to suffer from deformity of the urinary canal as from misshapen limbs, or from noses and ears not of proper size and proportion.

The urinary canal, from the bladder outward, is narrow and delicate. Any disease or injury therein is liable to result in gradual contraction, which may be manifested long years after the cause has been forgotten, or has disappeared. These affections, to the inexperienced, or the physician who is not particularly alert and cautious in his diagnosis, are liable to cause error, and he will pronounce a given case Bright's disease, when in reality there is some simple cause for the irritation of the urinary canal, and the pains in the kidneys, etc., all of which frequently result from a slight damming up of the flow of water, and the prevention of free expulsion from the system of the salts of which the body is relieved by the kidneys. They cannot work under pressure. When, from any cause, the flow of water is checked, and, as it were, dammed up so that a slight pressure is put upon the kidneys below, their secretion is most materially interfered with, and the many trains of symptoms that usher in disease of the kidneys, appear.

The true, and only sure way to relieve these conditions, as can be understood by any one, is to remove the real cause. The use of any medicine that stimulates the kidneys to an irritable action, under such pressure, is to be avoided, as it only makes the trouble worse, increases the amount of water that is dammed up, and results in more serious manifestations of constitutional disease; whereas, by merely relieving the choked outlet, the flow of water becomes free, and the kidneys are speedily restored to their natural condition. This is well illustrated by the following:

Case 113,396.

As recorded at the Invalids' Hotel. L.C.K., farmer, age 41,
married. For a period of nearly ten years, as a result of
slight injury, he had suffered from cloudy and
unhealthy-looking water, with some burning on passing it;
frequent calls to urinate; swelling of the limbs, loss of
energy and strength; headache, etc.; gradually there appeared
severe pain in the back, at times recurring with a sense of
fullness in the abdomen. For a period of nearly eight years he
had been constantly treated by physicians at his home, all of
whom had investigated his case. He had made several long
journeys to consult the manufacturers of a much-advertised
"kidney cure," who, after pretending to examine his urine,
scientifically (none of the proprietors are physicians),
assured him that, without the shadow of a doubt, his disease
was Bright's, and that he might be cured by their "kidney
cure," which was for sale at all drug stores. For a period of
eighteen months he steadily took this "cure," which, he states,
he is sure aggravated his disease, as, although his sufferings
at times were less, he felt that he was not improving in the
least, and that his disorder was not being properly controlled.
His home physician went with him on several occasions,
consulted with the owner of the proprietary medicine, and was
equally mistaken in his diagnosis. After consulting many
doctors, all of whom assured him they could give him treatment
that would prolong his life somewhat, and make his condition
comfortable, but that no treatment would affect his cure, he
was induced, by reading our article, heretofore referred to, to
consult us. A very thorough examination of the case was made,
which resulted in finding two contractions of the urethra,
which admitted only the smallest sized probe, and which,
necessarily, prevented the free flow of the urine. These were
speedily removed, when, much to the surprise of his family
physician, who accompanied him, over thirty-seven ounces of
fluid were drawn from the bladder. This gave him immediate and
perfect relief. The pains and aches in the region of the
kidneys, the weakness and tenderness, and the many other
uncomfortable symptoms with which he was troubled, all
disappeared. From a feeble and irritable invalid, in a few
weeks he was converted into a happy and cheerful man. The
symptoms of congestion and irritability of the kidneys
gradually disappeared, and in thirty days after visiting us he
writes that he feels himself entirely sound and well. This
gentleman states that he will be pleased to correspond with any
one who wishes to learn the particulars of his case, and his
full name and address will be furnished to any inquirer.

Bright's disease when fully established is characterized by degeneration of the kidneys. Submitted to examination, after death by this disease, these organs present various appearances. Hence, the degeneration that characterizes the disease has been designated as waxy degeneration. Some pathologists contend that the disease consists of several different renal maladies, all of which, however, agree in the one ever-present symptom of a more or less albuminous condition of the urine.

As to the causes of kidney disease, it may be said that any thing which will give rise to a greater or less degree of congestion of the kidney will induce either a temporary albuminous condition of the urine, or a true Bright's disease of the kidneys. Suppression of perspiration, by exposure to cold and wet, want of cleanliness, deficiency of nutritious diet, liver disease, certain poisons in the system, as of scarlet fever, measles, erysipelas or diphtheria, taken in conjunction with sedentary habits, bad air, excessive mental labor or worry, may each occasion an albuminous urine, and finally result in Bright's disease, but of all causes that appear to produce this disease, none are so prolific as intemperance. A scrofulous diathesis, or habit of body, may strongly predispose to the disease, and chronic kidney disease frequently follows acute rheumatism and the practice of masturbation. In some instances the chronic form of Bright's disease follows an acute attack, but is more often developed slowly and insidiously without any known cause.

THE SYMPTOMS of this fatal malady generally appear so gradually that they excite but little or no concern until it has reached its more advanced and dangerous stages. Frequently, a puffy, watery or flabby condition of the face, particularly under the eyes, is the first symptom noticed, and the patient may observe that his urine is diminished in quantity. The urine is sometimes abundant, but generally more scanty than in health, is acid in its reaction, and generally of a low specific gravity. The countenance is generally somewhat pale and bloodless, which, taken with the dropsical condition of the system, and the constant albuminous condition of the urine, points the expert specialist to Bright's disease of the kidneys. Various circumstances and conditions may give rise to the temporary presence of albumen in the urine, and, although albumen may be temporarily absent from the urine even when Bright's disease exists, yet this is not common. There are certain indirect symptoms which point clearly and almost unmistakably to the presence of this disease. These are deep-seated pain or weakness in the back, gradual loss of flesh, red, brown, or dingy urine, more or less drowsiness, and as the disease advances, a smothering sensation, or difficulty in breathing, with dropsical puffiness or swelling. Occasional attacks of nausea and vomiting are common; pains in the limbs and loins, which are often mistaken for rheumatism. Irregularity of the bowels is also common. The skin becomes harsh and dry, not perspiring even under active exercise. Sometimes these symptoms are years in their development, being very obscure at first, and in some cases the disease has been known to prove fatal without the patient having experienced any extraordinary symptoms. With those whose systems are enfeebled by want, intemperance, exposures or disease, as scrofula or syphilis, the first symptoms usually observed will be a frequent desire to urinate, occasional attacks of diarrhea, flatulency, dropsical swelling of the face, especially under the eyes, and afterwards of the extremities, paleness and increasing debility. Stupor, apoplexy and convulsions are the forerunners of a fatal termination.

Microscopical and chemical examinations of the urine are the only reliable means of diagnosis, and should be often repeated. (See Urinary Signs, in Appendix.) As albumen is often present in the urine without the existence of Bright's disease, it is impossible, except by the aid of the microscope, to distinguish true Bright's from other affections of the kidneys. In both purulent urine, and that containing blood, albumen will be found by the usual tests, but in smaller quantity than in Bright's disease. Albumen, with disintegrated epithelia, hyaline, and large granular casts, as well as waxy casts, are peculiar to, and characteristic of, this disease.

In the treatment of this malady, our specialist's experience has been very great, and attended with marvelous success. Of course, after the substance of the kidney has degenerated and broken down, and become destroyed to any great extent, a cure is impossible. But that we now possess remedies of great value, and specific power over this terrible disease, we have the most positive evidence in the remarkable success attended in its treatment. Most cases that are curable can be managed successfully at a distance, the necessary medicines being sent either by mail or express. Our specialists have cured many in this way who were so bloated from dropsical effusion as to weigh twenty-five to forty pounds more than usual. In our Sanitarium, where we have had the advantage of our Turkish baths and other appliances, we have cured some cases in which the removal of the dropsical effusion reduced the patient's weight sixty pounds.

We cannot, In conclusion, too strongly condemn the general resort to strong diuretics so often prescribed by physicians for all forms of renal maladies, but which, by over-stimulating the already weak and delicate kidneys, only aggravate and render incurable thousands of cases annually. Not less harmful are the many advertised "kidney cures," "kidney remedies," "buchus," and kindred preparations. They all contain powerful, stimulating diuretics, and, while they may appear for a short time to do good, invariably render the case worse and far more difficult to cure. The cases of Bright's disease reported cured by these preparations are cases of far less dangerous maladies, made to appear, by exaggerated accounts of them, as true Bright's disease. The use of these general, ready-made or proprietary remedies in any case of true Bright's disease is hazardous in the extreme. In no disease is there greater necessity for treatment nicely adapted to the exact condition of the patient (which should always be carefully ascertained by microscopical and chemical examinations of the urine) than in this. As it is a disease that runs a slow course, there is always time to send samples of the urine for examination by expert specialists, and no other physician than a specialist of large experience should be entrusted with the treatment of a malady so dangerous in its character, and in the diagnosis and treatment of which general practitioners commit such frequent, and often fatal, errors. (SEE TESTIMONIALS.)

DIABETES. (POLYURIA AND GLYCOSURIA.)

There are two essentially different varieties of this disease, one of which is called _Diabetes Insipidus_, or _Polyuria_, and the other _Diabetes Mellitus_, or _Glycosuria_. The first is characterized by an increase in the amount of urine excreted, and yields readily to proper treatment. The second is characterized by the presence of sugar in the urine, and under ordinary treatment often proves fatal.

The _causes_ are obscure, and are therefore not very well understood by the profession.

SYMPTOMS. A notable increase of the quantity of urine excreted is the first symptom which attracts the patient's attention. Frequently, several quarts, or even gallons, of urine are daily excreted, and it is paler than natural. The patient experiences extraordinary thirst, and has an almost insatiable appetite, though at the same time he loses flesh and strength. The tongue may be either clammy and furred or unnaturally clean and red. The bowels become constipated, and a peculiar odor is observed in the patient's breath and exhales from his body. The skin becomes harsh, dry, and scurfy. There are dizziness, headache, dejection, lassitude, and not unfrequently blindness, caused by cataract, is developed in one or both eyes. The intellect is blunted, and, as the disease progresses, the emaciation and debility increase, and pulmonary diseases develop; or, perhaps, an uncontrollable diarrhea sets in, and the patient dies from exhaustion.

In this disease, as in Bright's, we have many medicines that produce specific curative effects, enabling our specialists to treat it with greatly increased success. The disease is readily diagnosticated, or determined, by chemical examination of the urine, so that we have been enabled to treat this class of cases very successfully at a distance, and without personal examinations. Great attention should be paid to the diet in these cases. It should be highly nutritious, but anything of a sweet or starchy nature must be avoided.

The following articles are wholesome and afford sufficient variety, viz.: of animal food--beefsteak, game, poultry, fish, eggs, cheese, cream, butter; of vegetables--spinach, dandelion greens, turnip tops, watercresses, lettuce, celery, and radishes; of drinks--tea, coffee, claret, water, brandy and water, beef-tea, mutton-broth, or water acidulated with tartaric, nitric, citric, muriatic, or phosphoric acid. The _forbidden_ articles are oysters, crabs, lobsters, sugar, wheat, rye, corn or oatmeal cakes, rice, potatoes, carrots, bests, peas, beans, pastry, puddings, sweetened custards, apples, pears, peaches, strawberries, currants, etc., also beer, sweet wines, port, rum, gin, and cider. (SEE TESTIMONIALS.)

CHRONIC INFLAMMATION OF THE BLADDER. (CHRONIC CYSTITIS.)

This affection, also called _catarrh of the bladder_, is an inflammation of the mucous lining of this organ. It may occur at any period of life, but it oftenest appears in the aged, and is usually associated with some obstruction to the flow of urine.

CAUSES. It may be due to colds, injuries, irritating diuretics, injections, extension of disease from the kidneys or adjacent organs, intemperance, severe horseback riding, recession of cutaneous affections, gout, rheumatism, etc.; but it more frequently results from stricture of the urethra, enlarged prostate gland, gravel, and gonorrhea. It is also caused by an habitual retention of the urine, and sometimes results from masturbation or self-abuse.

SYMPTOMS. There is an uneasy sensation in the bladder, and heaviness and sometimes pain and weakness in the back and loins. The urine is scanty, and, although there is a desire to void it frequently, it is passed with difficulty. If allowed to stand, it deposits more or less mucus, which is sometimes mistaken for semen. As the disease progresses, the quantity of the mucus increases. It is very viscid, and adheres to the sides of the vessels, so that if an attempt be made to pour it out, it forms long, tenacious, ropy threads. Sometimes the quantity of mucus is so great that on exposure to cold the whole mass becomes semi-solid, and resembles the white of an egg. The excreted urine is alkaline, acrid, exhales a strong odor of ammonia, and soon becomes exceedingly fetid. Sometimes the urine becomes so thick that great difficulty is experienced in expelling it from the bladder. Nocturnal emissions, impotency, and loss of sexual desire are apt to ensue. Occasionally there will be a spasmodic contraction of the bladder, with straining and a sensation of scalding in the urethra, and sometimes the patient is unable to urinate.

When ulceration occurs in the progress of the disease, as it is apt to in its advanced stages, blood will occasionally be seen in the urine. In the advanced stages of the disease the system becomes greatly debilitated, emaciation supervenes, with hectic fever, nervous irritability and, finally, death.

TREATMENT. A strict observance of the rules of hygiene is essential to a cure. We must ascertain the cause if possible, remove it, and thus prevent it from perpetuating the disease. The various causes and conditions involved in different cases demand corresponding modifications of treatment; hence, it is useless for us to attempt to teach the non-professional how to treat this complex disease. We have succeeded in curing many severe cases without seeing the patient, being guided in prescribing by indications furnished by microscopical and chemical examinations of the urine. (See Urinary Signs in Appendix.) In fact, nearly all cases can be cured at their homes, and without a personal examination being made. In the worst cases, we have found it best to have our patients at our institution, where we can wash out the bladder with soothing, healing lotions, and thus make direct applications to the diseased parts. (SEE TESTIMONIALS.)

GRAVEL.

When the solid constituents of the urine are increased to such an extent that they cannot be held in solution, or when abnormal substances are secreted, they are precipitated in small crystals, which, if minute, are called _gravel_. Another cause of the precipitation of these salts is a stricture of the urinary canal which, by interfering with the free expulsion of all the fluid from the bladder, results in the retention of a portion, which gradually undergoes decomposition. Salts from the urine are thus precipitated in the same way that they are thrown down in urine which is allowed to stand in a vessel. Any one can illustrate this, by allowing a small quantity of the urinary secretion to stand for a few days either in an open or a closed bottle. Soon a white, flaky deposit will be observed, which will become more and more dense, and finally fine grains will be seen precipitated at the bottom of the bottle. Similar grains, lodging in the folds of the bladder, gradually increase in size, by the precipitation of more salts around them, and ultimately become a source of much irritation. When of large size, they are termed _calculi_ or stones. When these formations occur in the kidneys they are termed _renal calculi_; when in the bladder, _vesical calculi_. There are several varieties of gravel, each depending upon different conditions of the system for its formation. The two prominent varieties are the red, containing uric acid, and the white, or phosphatic, gravel.

SYMPTOMS. When the deposits are in the kidneys, there is pain in the back and loins, occasionally cutting and severe; sometimes it darts down the course of the ureter to the bladder, and extends even to the thighs. When the deposits are in the bladder, there is a frequent desire to urinate, with a bearing-down, straining pain; also a cutting or scratching sensation in the urethra during micturition. In the male, intense pain is often experienced at the end of the penis. When the urine is voided in a vessel and allowed to settle, a gravelly deposit is seen, generally of a red or a white color, and the particles varying in size.

TREATMENT. These urinary deposits indicate a general derangement of the system, as well as a local disease. Nutrition is imperfect and some of the excretory organs are not properly performing their functions, or, perhaps, some portion of the body is being too rapidly wasted. Very frequently we find these gravelly formations as the result of a rheumatic or a gouty diathesis. It is also a well-known fact that torpidity of the liver throws an excessive amount of work on the kidneys. These organs then, in part, perform the function of the liver, and hence unnatural activity is required of them, and the secreting of such substances as uric acid, which precipitates readily and gives rise to severe irritation of the urinary canal.

In order to treat these cases rationally and successfully, it is first necessary to ascertain by microscopical and perhaps chemical examinations, the character of the deposit. By such an examination, the exact condition of the system which gives rise to these abnormal products may be definitely determined, and the remedies to be employed indicated. As the non-professional are not qualified to make such examinations, it would be useless for us to suggest specific treatment for the various forms of this affection.

Samples of the urine may be sent to us with a brief description of the symptoms experienced, and the proper medicines to cure can be returned by mail or express. Our specialists are treating, with uniform success, large numbers of cases in this way. (SEE TESTIMONIALS.)

STONE IN THE BLADDER.

Few affections to which the human flesh is heir are more painful than this terrible affliction. The cutting operation heretofore required to remove it, is considered one of the most dangerous operations that the surgeon is ever called upon to perform.

The death of the Emperor Louis Napoleon, of France, from an operation for the removal of a stone, at the hands of surgeons renowned for their skill, gave new impetus to the efforts of surgeons to invent some method that would be less dangerous than that which has been heretofore commonly employed. The cutting operations have been the rule. Of these the operation by median-section is the safest, and is most commonly employed for the removal of stones that are not too large, while the lateral operation is used where the stone is more than about one inch in its smallest diameter.

As will be seen by the consultation of any hospital record, the deaths in these various operations have been, in adults, from one in three to one in every four cases--a very large percentage, and sufficient to deter any sufferer from undergoing an operation except for the relief of a condition which is in itself worse than death. Even when this alarming death-rate is explained to sufferers, they willingly undergo the operation, feeling that they would rather die than longer continue in their pain and anguish.

Our specialists, not satisfied with the results of these operative measures, in their studies of the disease endeavored to perfect some other means by which these foreign bodies could be removed from the bladder without such great danger and pain. The operation by crushing, and removal without cutting, appeared to them to present the most practicable advantages, and they therefore devote their entire time to the improvement of this method for the removal of stone.

The method of crushing was first invented by a French surgeon many years ago; but, owing to his crude instruments, and the difficulty that was experienced in expelling the pieces of stone, the operation was seldom employed by surgeons. The improvements in these methods at the hands of Bigelow and Sir Henry Thompson, with those that have been made by our specialists, have resulted in our being able to present to sufferers with this disease, a means of cure which is, we are assured, the most successful known to modern medical science.

There have been so far in the history of the treatment of this malady by the new method of cure, one hundred and twenty-odd cases operated upon at the hands of prominent surgeons, all of which were with less perfect methods than that of our specialists, and there were but four deaths in this large number. By the advantages which are the result of further improvements by our specialists, we can assure you that this mortality is even less in our hands; in fact, approaches, as near as possible, to a perfect method of cure.

We think that in a moderately healthy subject, one in which the kidneys are not badly diseased as the result of irritation from the calculus, the operation is almost absolutely safe. The method consists in the crushing of the stone, and its removal from the bladder by means of small silver catheters attached to an apparatus which gently and perfectly removes, by suction, all the pieces which are thrown to the bottom of the bladder. This operation has now been performed in our institution in a very large number of cases with uniform success, and the cures have been effected in from six to eight weeks without a single unpleasant symptom arising during their progress. By this method it is not necessary to remove the entire calculus at one operation, if it is a large one. By the old cutting operation this was required, as the bleeding was great, and what was to be done had to be done immediately, or the patient would die from the _hemorrhage_. With the new method a part of the large calculus, or when several exist, one or two of them, may be removed at a time, after which the patient can rest and gain strength for the second; or, if necessary, for the third operation.

The largest stone removed by us in this way was one weighing between seven and eight hundred grains, for which three operations were required. It is necessarily performed under a mild anæsthetic, which prevents suffering and secures the perfect relaxation of the patient. In the case in which this large amount of stone was removed we feel certain that a cure could not possibly have resulted from a cutting operation, as the heart was seriously affected, and the physical condition of the patient so low, as the result of years of suffering, that death would have occurred while undergoing the operation. By carefully pursuing the new method, and not prolonging the sittings more than a few minutes each time, the entire stone was evacuated. The health of the patient constantly improved during the interval of three operations, which covered a space of seven weeks. This stone was as large as a hen's egg.

Small calculi or gravel are readily removed in a few moments' time by the new method. In no case is there any bleeding. Instead of a large, gaping wound being left after the operation, from which secondary hemorrhage may take place, or poisoning result from the irritation of decomposing urine, the parts are left in a healthy state with the surface unbroken. The stone, a constant source of irritation, is removed, and the health is speedily restored.

When it is impossible for the patient to visit us, a careful examination of the urine is made, and if gravel have been passed, these are carefully examined also. An idea of the composition of the stone is arrived at by this means, and treatment is directed to dissolve it. Success has commonly followed this method of treatment, when the stone has not been very large. With the gradual reduction of the size of the stone the irritation subsides, and the general health of the patient improves. (SEE TESTIMONIALS.)

CHRONIC ENLARGEMENT OF THE PROSTATE GLAND. (HYPERTROPHY.)

The prostate gland lies just in front of the base of the bladder, and surrounding the urethra, or urinary canal. Enlargement, therefore, of this body, if it be of considerable extent, causes it to encroach and press upon the base of the bladder, and to more or less constrict the urinary canal near the base or outlet of the bladder. The enlargement may be only slight, or the dimensions of the gland may be increased from the size of a large chestnut, its normal dimension, to the volume of a pullet's egg, or even to the size of an orange.

Hypertrophy of the prostate generally arises from causes which operate in a slow and permanent manner. Whatever has a tendency to produce a determination of blood to, and an engorgement of, this organ, is capable of producing the affection, an augmented flow of blood to the the part having the effect to increase the nutrition. Among the most frequent causes of this affection, are excessive venery, masturbation, disease of the bladder, stricture of the urethra, horseback exercise, gonorrhea, and the employment of strong, stimulating diuretics. Some of the worst cases that we have had to deal with have occurred in old men, and, in fact, the malady is more common to those advanced in life; but it is frequently produced in those of middle age by the causes enumerated.

Among the earliest symptoms of the disease is an uneasy feeling in the region of the base of the bladder. There is a more frequent desire to urinate than usual, and, in the course of time, this frequency becomes more urgent; still no particular notice may be taken of it, it being considered as "only a slight inconvenience." After several months, or it may be years, the discomfort increases, and nightly calls to empty the bladder become habitual. By and by the patient begins to find the discomfort of getting out of his warm bed very troublesome; still no notice to taken of it. He does not consider it worth his while to consult a doctor for "such a trifle." In the course of time the patient is obliged to get out of bed twice during the night instead of once. Afterwards, the calls become still more frequent and urgent; the inconvenience more evident; finally, pain is substituted for inconvenience, and then the doctor is consulted. Unless a specialist of experience be consulted, the bladder will most probably be examined, and medicine will be prescribed only to excite the kidneys to secrete more urine, which does harm instead of good; the disease slowly, but surely progressing. Patients often write us that they have had something wrong with the bladder for a number of years, having to urinate more frequently than they ought; sometimes having to do so three and four times during the night; in extreme cases even every half hour or so, and that they are not able to pass it freely, but only in small quantities, and attended with much pain. These symptoms are not always constant, but let up for a few weeks and then appear again. Things go on in this way for a year or two, perhaps, when the passage of the urine is completely shut off for several hours, and the patient is in great agony until the bladder is relieved by the use of the catheter. After such instrumental relief, for a day or two the urine may be natural again, coming at first, perhaps, in very small quantities, but by and by more freely. Then, after a week or two intervening, there may be another complete stoppage, attended, as before, with intense suffering, which will have to be again relieved by the use of an instrument.

The foregoing is a fair account of the usual progress of the disease and its symptoms. As the prostate gland becomes more irritated and inflamed from the natural progress of the disease, or from the irritation caused by the passage of instruments, or the employment of strong, harsh, stimulating diuretics, the urine becomes cloudy, and still later is found to have deposited during the night in the chamber utensil a quantity of thick, tenacious, and usually offensive mucus. There is apt to be more or less discomfort in the rectum, or lower bowel, produced by the pressure of the enlarged prostate upon it. Rarely, the first intimation of a large prostate occurs through a sudden retention of the urine, and the patient being under the impression that there was nothing wrong with the organ previously. Closely questioned, however, the information is elicited that there has been a long train of mild symptoms, similar to those that we have described, preceding the attack of retention of the urine. This shows the importance of early attention and proper treatment when such symptoms are manifested. However slight the inconvenience experienced, it should not be neglected. The disease should be brought under control at the outset by skillful and nicely-adapted treatment. Usually before a person suffers from toothache, the decay occasioning it has been gradually progressing without pain for from five to eight years. Just as the decay of the tooth may be arrested by the early attention of the dentist, so may prostatic disease by early attention be not only promptly relieved, but permanently cured.

Disease of the prostate being slow in its inception and progress, is also slow to yield even to the most skillful treatment. Being slow to develop, patients rarely seek assistance until the organ has become so large as to be seldom restorable to a size where mechanical means can be wholly dispensed with for relieving the bladder. Most surgeons are too much in the habit of depending on the catheter for the relief of the patient, and usually instruct the sufferer how to use it, telling them that this, the catheter, is to be their only doctor for life. Great as is the relief afforded by the catheter, which has often saved life, yet it is a fact that its frequent and prolonged use often renders disease of the prostate very intractable and often wholly incurable. Frequent use of the catheter, without any treatment to prevent the further enlargement of the diseased gland, or to reduce its size, permits the part to go on enlarging, and, besides, the constant use of the catheter irritates the prostatic portion of the urethra, causing thickening of the lining membrane, and sooner or later a more or less complete organic stricture of this canal, depending upon thickening of the lining mucous membrane, as well as upon the encroachment of the gland itself upon this canal. Besides, when the use of the catheter is once commenced, even when the enlargement is not very great, it is with the utmost difficulty that we have been able to induce patients to leave off its use. The bladder, becoming accustomed to its use, refuses to obey the will without this help. The irritation set up in the parts by the friction of the catheter causes inflammation and exudation in the lining membrane. This extends to the structure of the prostate itself and increases the hypertrophy or enlargement. It will, therefore, be seen how important it is to early resort to treatment to relieve the first manifestations of this affection. A disease of so delicate a nature, and one so often confounded with other maladies by inexperienced physicians, should only be intrusted for treatment to expert specialists of large experience in the management of this and kindred maladies.

* * * * *

STRICTURE OF THE URETHRA.

Stricture of the urethra generally results from some specific disease of the urethra, but may be caused by sexual excesses, exposure, or strain, or by the practice of masturbation or self-abuse. It runs a course varying in time from a few days to many weeks or months, during which time the patient is often unaware of the real cause of his sufferings.

Commonly, the attention is first called to a stricture by a slight discharge, or smarting sensation, or the appearance of an undue amount of mucous deposit in the urine. Occasionally, some difficulty in starting the water, or a diminution in the size and force, or a twisting of the stream as it flows, is the first symptom. This passive stage is of variable duration. When skillful treatment is instituted at this stage of the disease, a speedy cure is easily effected without pain or danger. Any exposure, improper use of instruments, or irritating cause, may speedily give rise to the alarming symptoms due to closure of the urethra, from which fatal consequences may suddenly ensue.

This condition is illustrated in Fig. 2, which shows the hard and tough stricture which surrounds the soft mucous membrane that lines the urinary canal. When irritated or inflamed, as the result of a cold or other cause, the mucous membrane becomes swollen and thickened, and, as the stricture will not yield and enlarge, the result is that the urethra is almost completely closed, and it becomes impossible to pass the urine. Great pain is experienced, and the surgeon has to be called to draw off the urine with a catheter, which, at best, is a very difficult and painful operation, when the urethra is so irritable and constricted.

TREATMENT. In the earlier stages of the malady, relief is given by the skillful use of instruments for dilating the canal, or, where this fails by the operation of urethrotomy, for which we employ an improved and ingenious instrument, by which the stricture is readily and almost painlessly divided.

IMPROVED METHODS. Our surgeons have operated upon many hundreds of bad cases by a very ingenious and almost painless method, that requires no use of bougies in the after-treatment. This saves the patient an immense amount of pain and annoyance, and enables him to go home almost immediately after the operation.

The ordinary after-treatment, by dilatation with bougies, is very tedious, and often more painful than the operation itself, so that our peculiar method of treatment has been hailed with joy by those familiar with the old and unnecessarily-painful systems of treatment. Besides, our more improved method has been followed by far more perfect cures in every case operated upon.

In many of the cases coming under our observation and treatment, there have been several strictures, as illustrated in Fig. 3, which shows the urethra constricted at three different points, besides a congenital contraction at its mouth or meatus.

SPERMATORRHEA not infrequently results from stricture of the urethra, even when the affection is quite slight. Our attention was first called to this subject by the consideration of the numerous cases in which epileptic convulsions or "fits," and other serious diseases of the nervous system in children, have resulted from an unnatural contraction of the prepuce or foreskin, constituting what is termed _phimosis_.

Every surgeon of experience has met with many of these cases of reflex irritation. It occurred to us, that, inasmuch as these contractions of the foreskin give rise to nervous diseases of an alarming nature, may not an unnatural narrowing of the urethral canal, which must have exactly the same effect in retarding the flow of the urine, give rise to irritable nervous affections in adults. May not unnatural irritation and excitement of the sexual organs, so set up, cause loss of semen to occur during sleep, and consequent nervous and general debility?

It is a well recognized fact that the urethral canal should bear a certain definite and proportionate size to that of the penis, just as the length of the arm should naturally bear a certain proportion to the length of the body. In the case of some parts of the body, disproportionate development of the part may not give rise to anything further than unsightliness; but when we find the small size of the urethra retarding the free passage of the urine, then we may expect, if this condition is long continued, to find more or less irritation of the urethra and, perhaps, of the bladder, also. When there is a contraction of the urethra at its external orifice, or at any point along its course, unnatural pressure is put upon the urinary canal behind the constricted portion, and these parts must bear an undue strain during the passage of the urine.

It is a well established fact that improper diet, cold, exposure, and over-work exert a very powerful modifying influence upon the urinary secretion, frequently causing an acrid and irritating condition of this fluid. This condition, when associated with a contracted urethra, must result in irritation of the mucous membrane lining this canal back of the stricture, if long continued or frequently repeated. As an illustration, we have a hose pipe from which, by means of a small nozzle, water is expelled a considerable distance, but a great tension is put upon the hose behind the nozzle. If the pressure is increased greatly the hose will burst; but, if the small nozzle be replaced with a larger one, the projection of the stream will be quite as great, but all undue tension of the pipe is overcome and the danger of bursting is done away with. We have, in an unnaturally contracted urethra, a favorable condition for the development of disease in the urinary canal and adjacent parts of the generative organs. Irritation is set up in the urethra behind the stricture by undue strain in passing water, and the frequent reoccurrence of acrid urine, as the result of any of the causes we have already mentioned, this irritation keeps gradually increasing. It will be felt more during the periods when the urine is acrid, but may pass unnoticed even at such times. The seminal sacs and the prostate and Cowper's glands communicate with the deeper portions of the urethra by means of canals or ducts, lined with mucous membrane which is continuous with the urethral mucous membrane. Hence we can readily see that not only by reflex nervous irritation are those parts debilitated, through the contraction of the urethra, but the affection is apt to extend by continuity of the mucous membrane, and thus become more and more manifest, through symptoms of disease of the testicles, prostate gland and seminal vesicles, and these disorders become more and more seated the longer the morbid condition of the urethra is allowed to run on, until there may be an entire loss of the sexual functions, occurring at an age when there should be present the most vigorous manhood. From no other cause can we explain the common prevalence of disease of the deeper portions of the urethral canal and bladder, many times confounded with other diseases of the urinary and generative organs.

The following is the history of a case that fully illustrates the foregoing statements:

CASE 112,289. MR. O.C.E., SINGLE, 32 YEARS OF AGE.

He applied to us suffering from entire loss of the sexual
function, with great nervous debility, and there was a thin
slimy discharge from the urethra, and the usual symptoms of
melancholia and weakness. He had lost all taste for business,
and was extremely nervous, from the fact that he was engaged
to be married, and felt that his condition would not permit
it. On examination a contraction of the urethra was found at
the point shown in Fig. 4, which had probably been present
for years. He stated that he never had been just right in
those parts, but had lived a virtuous life, had never had any
venereal disease, and, hence, the true nature of his trouble
had not been suspected. With the removal of the stricture
there was an immediate improvement in his condition, which
became more and more rapid, as his system gained strength and
reaction became manifest. At the end of two months he wrote
that he felt sound and well, and that he had experienced the
most wonderful improvement in every way. His vital strength
was fully restored, and he was most profoundly grateful.

Chronic inflammation of the bladder, sometimes called catarrh of the bladder, an affection that is elsewhere herein fully treated of, and chronic inflammation of the kidneys, and true Bright's disease, as well as prostatic disease, are all liable to result from strictures of the urethra. Hence, it behooves one suffering from this malady to have it promptly and skillfully treated.

FALSE PASSAGES. In very rare cases of impassable stricture, or in which fistulous openings, or false passages, have formed, through which the urine flows or dribbles away, we have resorted to the operation of perineal section with the most gratifying results. The cases requiring this operation are rare ones, in which death must generally result but for the relief afforded by the operation.

DANGEROUS USE OF INSTRUMENTS. The worst and most dangerous cases of stricture with which we have met, in a long and extensive experience, were rendered thus by the careless or unskillful use of bougies, catheters, or sounds. Many surgeons and physicians are most recklessly careless or unskilled in the use of these most dangerous instruments, as the many cases of false passage or stricture of the most painful and dangerous kind, caused or aggravated by their ignorant or improper use, sorrowfully testify.

DELAY DANGEROUS. By proper treatment of stricture in its early stages, all danger and pain are avoided, and a cure is effected in a very short time. In an extensive practice, in which we yearly treat hundreds of cases, we have never yet failed to give perfect and permanent relief from stricture, or diseased prostate or urethra, without the necessity of cutting instruments of any kind, when we have been consulted before injury of the urethra has been produced by improper use of instruments. Having specialists who devote their entire time to the study and cure of these diseases, we are thereby enabled to attain the highest degree of skill in the management of these cases.

GREAT SKILL REQUIRED. The urethra is a sensitive and delicate canal, and is surrounded by tissues the most delicate, and lined with mucous membrane which is highly vascular and filled with sensitive nerves. The introduction of any instrument is to be undertaken only when absolutely required, and, when necessary, it should be so skillfully and carefully effected that no pain or irritation can result. The slightest awkwardness is liable to cause an unnoticeable injury, which results in false passage or an effusion of plastic lymph around the canal, and as it organizes, the formation of the most troublesome organic stricture. The attention not only of sufferers, but also of the profession, is called to the remarkable success of our operation, perineal section, by which a cure of extremely bad cases of impassable stricture and false passages, or urinary fistulas, is effected in from thirty to forty days, and with very little suffering. That we have been successful in such cases must be considered as conclusive evidence that no case of stricture, false passage, or urinary fistula, is beyond the reach of our skill.

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TESTIMONIALS.

In a practice embracing the treatment of a vast number of cases of diseases of the Urinary Organs, it has been our good fortune to effect many remarkable cures. The experience gained in this field of practice has made our specialists skilled experts, and hence hundreds consult them as a last resort. In fact we seldom get a case, in this line, that has not been the rounds of the home physicians before applying to us for relief and cure. The cures, therefore, which we shall introduce here are the more remarkable because of the failure, in nearly every case, of other medical men to benefit or cure. They are not the every-day, ordinary cases met with in the general practitioner's rounds, but complicated, obstinate ones, which had generally been given up as hopeless before coming to us.

CASE 4A-3431. "WASTED TO A SHADOW." BLEEDING FROM KIDNEYS. A SEVERE CASE.

WORLD'S DISPENSARY MEDICAL ASSOCIATION, Buffalo, N.Y.:

_Gentlemen_--I think it my duty to write to you concerning my case. In the year 1886 I was seized with inflammation of the bladder and passed nothing but thick blood, owing to heavy work, and I consulted a doctor and he said there was no cure for such a bad case; but he gave me medicine and it relieved me at the time I used it; and I took 16 bottles and I got worse and wasted to a shadow. I quit taking the medicine, and other complaints came, as rupture in the spermatic cord, for which I applied to you and soon got relief. And in 1891 the bladder disease made its appearance, and I wrote to the Invalids' Hotel and Surgical Institute and got no reply as our mails were stopped on account of snow drifts. I sent for the best doctor in Listowell and I still got worse, and he said I might live three or four weeks, but there was no stoppage of the disease. And I got so weak that I had to support myself by the furniture in my room; and I wasted down to 100 lbs. in two weeks; and I applied to your Institute and I received my medicine in a few days, and in two weeks I began to gather strength and now I am hearty and well and my weight is 145 lbs. I feel so thankful to the Medical Association and its Staff of skilled men. It is 15 months since I quit taking your medicines and no signs of the disease returning.

Yours gratefully,
THOMAS S. BAILEY,
Dorking, Wellington Co., Ont.

CASE 23A-877. INFLAMMATION OF THE BLADDER, WITH OTHER COMPLICATIONS. SUFFERED EXCRUCIATING PAIN IN URINATING.

For many years I suffered with inflammation of the Prostrate Gland and Bladder. It became gradually worse and I endured extreme pain, so much so that I was laid up for weeks at a time, and almost gave up in despair. I was persuaded to go to the Invalids' Hotel and Surgical Institute. I have never regretted following this advice. While there I submitted to an operation by their specialist. This was entirely painless and the result perfectly satisfactory. I left in a short time delighted, and have since been strong and well. I cannot speak in too high praise of this famous Institution; the rooms are large and pleasant, the food the very best, the attendants kind and attentive and the staff of physicians skillful and of large experience. I highly recommend all invalids to the World's Dispensary Medical Association. I feel confident that all the benefit to be derived from medical treatment is to be received at this Institution.

Yours truly,
GEO. W. HEFFNER,
Chicago, Ills.

CASE 2A-103. INFLAMMATION OF BLADDER, COMPLICATED WITH KIDNEY DISEASE.

WORLD'S DISPENSARY MEDICAL ASSOCIATION, Buffalo, N.Y.:

_Gentlemen_--Having been a patient in your Invalids' Hotel for several weeks, I take great pleasure in telling other sufferers of my treatment which I received under your efficient staff of physicians, surgeons and nurses, and I will say with clear conscience that every care and comfort was given me that could be wished for. I am sure that your Institution is far in advance of the age, and would wish that every invalid could avail himself of the treatment that I received in your most excellently kept Invalids' Hotel. I cheerfully give this as my testimonial to individuals, friends and sufferers. My health is so fully restored that I look upon life with pleasure and comfort, whereas before I was a suffering, nervous invalid, unable to sleep and much of the time in torment. Wishing you success,

I am your friend and well wisher,
M. MANHEIM,
Georgetown, S.C.

CASE 859,143. BLADDER, RECTAL, KIDNEY AND LIVER DISEASE. "ENTIRE URINARY ORGANS ONE MASS OF SORES." "DESPAIRED OF CURE."