CHAPTER II

Genito-Urinary Diseases

Contagious Disorders—Common Troubles of Children—Inflammation of the Bladder—Stoppage and Suppression of Urine—Causes and Treatment of Bright's Disease.

GONORRHEA.—Gonorrhea is a contagious inflammation of the urethra, accompanied by a white or yellowish discharge. It is caused by a specific germ, the gonococcus, and is acquired through sexual intercourse with a person suffering from this disease. Exceptionally the disease may be conveyed by objects soiled with the discharge, as basins, towels, and, in children, diapers, so that in institutions for infants it may be thus transferred from one to the other, causing an epidemic. The mucous membrane of the lower part of the bowel and the eyes are also subject to the disease through contamination with the discharge. The disease begins usually three to seven days after sexual intercourse, with symptoms of burning, smarting, and pain on urination, and a watery discharge from the passage, soon followed by a yellowish or white secretion. Swelling of the penis, frequent urination, and painful erections are also common symptoms. The disease, if uncomplicated and running a favorable course, may end in recovery within six weeks or earlier, with proper treatment. On the other hand, complications are exceedingly frequent, and the disorder often terminates in a chronic inflammation which may persist for years—even without the knowledge of the patient—and may result in the infection of others after all visible signs have ceased to appear.

Treatment.—Rest is the most important requisite; at first, best in bed; if not, the patient should keep as quiet as possible for several days. The diet should consist of large quantities of water or milk, or milk and vichy, with bread, cereals, potatoes, and vegetables—absolutely avoiding alcohol in any form. Sexual intercourse is harmful at any stage in the disease and will communicate the infection. Aperient salts should be taken to keep the bowels loose. The penis should be soaked in hot water three times daily to reduce the inflammation and cleanse the organ. A small wad of absorbent cotton may be held in place by drawing the foreskin over it to absorb the discharge, or may be held in place by means of a bag fitting over the penis. All cloths, cotton, etc., which have become soiled with the discharge, should be burned, and the hands should be washed after contact with the discharge; otherwise the contagion may be conveyed to the eyes, producing blindness. It is advisable for the patient to take one-half teaspoonful of baking soda in water three times daily between meals for the first four or five days, or, better, fifteen grains of potassium citrate and fifteen drops of sweet spirit of nitre in the same way. Painful erections may be relieved by bathing the penis in cold water, urinating every three hours, and taking twenty grains of sodium bromide at night in water. After all swelling and pain have subsided, local treatment may be begun.

Injections or irrigations with various medicated fluids constitute the best and most efficient measures of local treatment. They should be used only under the advice and management of the physician. No greater mistake can be made than to resort to the advertising quack, the druggist's clerk, or the prescription furnished by an obliging friend. Skillful treatment, resulting in a complete radical cure, may save him much suffering from avoidable complications and months or years of chronic trouble.

At the same time the first medicines advised are stopped and oleoresin of cubebs, five grains, or copaiba balsam, ten grains—or both together—are to be taken three times daily after meals, in capsules, for several weeks, unless they disturb the digestion too much. A suspensory bandage should be worn throughout the continuance of the disease. The approach of the cure of the disease is marked by a diminution in the quantity and a change in the character of the discharge, which becomes thinner and less purulent and reduced to merely a drop in the passage in the early morning, but this may continue for a great while. Chronic discharge of this kind and the complications cannot be treated properly by the patient, but require skilled medical care.

In this connection it may be said that most patients have an idea that the subsidence or disappearance of the discharge is an evidence of the cure of the disease. Experience shows that the disease may lapse into a latent or chronic form and remain quiescent, without visible symptoms, during a prolonged period, while susceptible of being revived under the influence of alcoholic drinks or sexual intercourse. It is important that treatment should be continued until all disease germs are destroyed, which can only be determined by an examination of the secretions from the urethra under the microscope.

The more common complications of gonorrhea are inflammation of the glands in the groin (bubo), acute inflammation of the prostate glands and bladder, of the seminal vesicles, or of the testicles. The latter complication is a most common cause of sterility in men. Formerly it was thought that gonorrhea was a local inflammation confined to the urinary canal and neighboring parts, but advances in our knowledge have shown that the germs may be taken up into the general circulation and affect any part of the body, such as the muscles, joints, heart, lungs, liver, spleen, kidneys, etc., with results always serious and often fatal to life. One of the most common complications is gonorrheal arthritis, which may affect one or several joints and result in stiffness or complete loss of movement of the affected joint, with more or less deformity and permanent disability. Another complication is gonorrheal inflammation of the eye, from direct transference of the pus by the fingers or otherwise, and resulting in partial or complete blindness.

GONORRHEA IN WOMEN.—Gonorrhea in women is a much more frequent and serious disease than was formerly supposed. The general impression among the laity is that gonorrhea in women is limited to the prostitute and vicious classes who indulge in licentious relations. Unfortunately, this is not the case. There is perhaps more gonorrhea, in the aggregate, among virtuous and respectable wives than among professional prostitutes, and the explanation is the following: A large proportion of men contract the disease at or before the marrying age. The great majority are not cured, and the disease simply lapses into a latent form. Many of them marry, believing themselves cured, and ignorant of the fact that they are bearers of contagion. They transmit the disease to the women they marry, many of whom, from motives of modesty and an unwillingness to undergo an examination do not consult a physician, and they remain ignorant of the existence of the disease until the health is seriously involved. In women, gonorrhea is not usually so acute and painful as in men, unless it involves the urethra. It usually begins with smarting and painful urination, with frequent desire to urinate and with a more or less abundant discharge from the front passage. In the majority of cases the infection takes place in the deeper parts, that is, in the neck or body of the womb. In this location it may not give rise at first to painful symptoms, and the patient often attributes the increased discharge to an aggravation of leucorrhea from which she may have suffered. The special danger to women from gonorrhea is that the inflammation is apt to be aggravated during the menstrual period and the germs of the disease ascend to the cavity of the womb, the tubes, and ovaries, and invade the peritoneal covering, causing peritonitis. Pregnancy and childbirth afford favorable opportunities for the upward ascension of the germs to the peritoneal cavity. The changes caused by gonorrheal inflammation in the maternal organs are the most common cause of sterility in women. It is estimated that about fifty per cent of all sterility in women proceeds from this cause. In addition to its effects upon the child-bearing function, the danger to the health of such women is always serious. In the large proportion of cases they are made permanent invalids, no longer able to walk freely, but compelled to pass their lives in a reclining position until worn out by suffering, which can only be relieved by the surgical removal of their maternal organs. It is estimated that from fifty to sixty per cent of all operations performed on the maternal organs of women are due to disease caused by gonorrheal inflammation.

Treatment.—Rest in bed, the use of injections of hot water, medicated with various astringents, by means of a fountain syringe in the front passage three times daily, and the same remedies and bath recommended above, with hot sitz baths, will usually relieve the distress. In view of the serious character of this affection in women and its unfortunate results when not properly treated, it is important that they should have the benefit of prompt and skillful treatment by a physician. Otherwise, the health and life of the patient may be seriously compromised.

The social danger of gonorrhea introduced after marriage is not limited to the risks to the health of the woman. When a woman thus infected bears a child the contagion of the disease may be conveyed to the eyes of the child in the process of birth. Gonorrheal pus is the most virulent of all poisons. A single drop of the pus transferred to the eye may destroy this organ in from twenty-four to forty-eight hours. It is estimated that from seventy-five to eighty per cent of all babies blinded at birth have suffered from this cause, while from twenty to thirty per cent of blindness from all causes is due to gonorrhea. While the horrors of this disease in the newborn have been mitigated by what is called the CrÉdÉ method (instillation of nitrate of silver solution in the eye immediately after birth), it still remains one of the most common factors in the causation of blindness. Another social danger is caused by the pus being conveyed to the genital parts of female children, either at birth or by some object upon which it has been accidentally deposited, such as clothes, sponges, diapers, etc. These cases are very common in babies' hospitals and institutions for the care of children. Quite a number of epidemics have been traced to this cause. The disease occurring in children is exceedingly difficult of cure and is often followed by impairment in the development of their maternal organs. Much of the ill health of young girls from disordered menstruation and other uterine diseases may be traced to this cause. Another serious infection in babies and young children is gonorrheal inflammation of the joints, with more or less permanent crippling.

SYPHILIS; THE POX; LUES.—Syphilis is a contagious germ disease affecting the entire system. While commonly acquired through sexual intercourse with a person affected with the disorder, it may be inherited from the parents, one or both. It is often acquired through accidental contact with sources of contagion. Syphilis and tuberculosis are the two great destroyers of health and happiness, but syphilis is the more common.

Symptoms.—Acquired syphilis may be divided into three stages: the primary, secondary, and tertiary. The first stage is characterized by the appearance of a pimple or sore on the surface of the sexual organ not usually earlier than two, nor later than five to seven, weeks after sexual intercourse. The appearance of this first sore is subject to such variations that it is not always possible for even the most skillful physician to determine positively the presence of syphilis in any individual until the symptoms characteristic of the second stage develop. Following the pimple on the surface of the penis comes a raw sore with hard deposit beneath, as of a coin under the skin. It may be so slight as to pass unnoticed or become a large ulcer, and may last from a few weeks to several months. There are several other kinds of sores which have no connection with syphilis and yet may resemble the syphilitic sore so closely that it becomes impossible to distinguish between them except by the later symptoms to be described. Along with this sore, lumps usually occur in one or both groins, due to enlarged glands.

The second stage appears in six to seven weeks after the initial sore, and is characterized by the occurrence of a copper-colored rash over the body, but not often on the face, which resembles measles considerably. Sometimes a pimply or scaly eruption is seen following this or in place of the red rash. At about, or preceding, this period other symptoms may develop, as fever, headache, nausea, loss of appetite, and sleeplessness, but these may not be prominent. Moist patches may appear on the skin, in the armpits, between the toes, and about the rectum; or warty outgrowths in the latter region. There is sore throat, with frequently grayish patches on the inside of the cheeks, lips, and tongue. The hair falls out in patches or, less often, is all lost. Inflammation of the eye is sometimes a symptom. These symptoms do not always occur at the same time, and some may be absent or less noticeable than others.

The third stage comes on after months or years, or in those subjected to treatment may not occur at all. This stage is characterized by sores and ulcerations on the skin and deeper tissues, and the occurrence of disease of different organs of the body, including the muscles, bones, nervous system, and blood vessels; every internal organ is susceptible to syphilitic change.

A great many affections of the internal organs—the heart, lungs, liver, kidneys, brain, and cord—which were formerly attributed to other causes, are now recognized as the product of syphilis. The central nervous system is peculiarly susceptible to the action of the syphilitic poison, and when affected may show the fact through paralysis, crippling, disabling, and disfiguring disorders.

Years after cure has apparently resulted, patients are more liable to certain nervous disorders, as locomotor ataxia, which attacks practically only syphilitics; and general paresis, of which seventy-five per cent of the cases occur in those who have had syphilis.

Inherited Syphilis.—Children born with syphilis of syphilitic parents show the disease at birth or usually within one or two months. They present a gaunt, wasted appearance, suffer continually from snuffles or nasal catarrh, have sores and cracks about the lips, loss of hair, and troublesome skin eruptions. The syphilitic child has been described as a "little old man with a cold in his head." The internal organs are almost invariably diseased, and sixty to eighty per cent of the cases fortunately die. Those who live to grow up are puny and poorly developed, so that at twenty they look not older than twelve, and are always delicate.

It is to be noted that syphilis is not necessarily a venereal disease, that is, acquired through sexual relations. It may be communicated by kissing, by accidental contact with a sore on a patient's body, by the use of pipes, cups, spoons, or other eating or drinking utensils, or contact with any object upon which the virus of the disease has been deposited.

Any part of the surface of the body or mucous membrane is susceptible of being inoculated with the virus of syphilis, followed by a sore similar to what has been described as occurring upon the genital parts and later the development of constitutional symptoms. The contagiousness of the disease is supposed to last during the first three years of its existence, but there are many authentic cases of contagion occurring after four or five years of syphilis.

Diagnosis.—The positive determination of the existence of syphilis at the earliest moment is of the utmost importance in order to set at rest doubt and that treatment may be begun. It is necessary to wait, however, until the appearance of the eruption, sore throat, enlargement of glands, falling out of hair, etc., before it is safe to be positive.Treatment.—The treatment should be begun as soon as the diagnosis is made, and must be continuously and conscientiously pursued for three years or longer. If treatment is instituted before the secondary symptoms, it may prevent their appearance so that the patient may remain in doubt whether he had the disease or not, for it is impossible for the most skilled specialist absolutely to distinguish the disease before the eruption, no matter how probable its existence may seem. This happens because there are several kinds of sores which attack the sexual organs and which may closely simulate syphilis. The treatment is chiefly carried out with various forms of mercury and iodides, but so much knowledge and experience are required in adapting these to the individual needs and peculiarities of the patient that it is impossible to describe their use. Patients should not marry until four or five years have elapsed since the appearance of syphilis in their persons, and at least twelve months after all manifestations of the disease have ceased. If these conditions have been complied with, there is little danger of communicating the disease to their wives or transmitting it to their offspring. They must moreover, have been under the treatment during all this period. Abstinence from alcohol, tobacco, dissipation, and especial care of the teeth are necessary during treatment.

Results.—The majority of syphilitics recover wholly under treatment and neither have a return of the disease nor communicate it to their wives or children. It is, however, possible for a man, who has apparently wholly recovered for five or six years or more, to impart the disease. Without proper treatment or without treatment for the proper time, recurrence of the disease is frequent with the occurrence of the destructive and often serious symptoms characteristic of the third stage of the disease. While syphilis is not so fatal to life as tuberculosis, it is capable of causing more suffering and unhappiness, and is directly transmitted from father to child, which is not the case with consumption. Syphilis is also wholly preventable, which is not true of tuberculosis at present. It is not probable that syphilis is ever transmitted to the third generation directly, but deformities, general debility, small and poor teeth, thin, scanty growth of hair, nervous disorders, and a general miserable physique are seen in children whose parents were the victims of inherited syphilis. In married life syphilis may be communicated to the wife directly from the primary sore on the penis of the husband during sexual intercourse, but contamination of the wife more often happens from the later manifestations of the disease in the husband, as from secretion from open sores on the body or from the mouth, when the moist patches exist there.

It is possible for a child to inherit syphilis from the father—when the germs of syphilis are transmitted through the semen of the father at the time of conception—and yet the mother escape the disease. On the other hand, it is not uncommon for the child to become thus infected and infect its mother while in her womb; or the mother may receive syphilis from the husband after conception, and the child become infected in the womb.

The chief social danger of syphilis comes from its introduction into marriage and its morbid radiations through family and social life. Probably one in every five cases of syphilis in women is communicated by the husband in the marriage relation. There are so many sources and modes of its contagion that it is spread from one person to another in the ordinary relations of family and social life—from husband to wife and child, from child to nurse, and to other members of the family, so that small epidemics of syphilis may be traced to its introduction into a family. Syphilis is the only disease which is transmitted in full virulence to the offspring, and its effect is simply murderous. As seen above, from sixty to eighty per cent of all children die before or soon after birth. One-third of those born alive die within the next six months, and those that finally survive are blighted in their development, both physical and mental, and affected with various organic defects and deformities which unfit them for the battle of life. Syphilis has come to be recognized as one of the most powerful factors in the depopulation and degeneration of the race.

INVOLUNTARY PASSAGE OF URINE—BED-WETTING IN CHILDREN.—(Incontinence of Urine).—This refers to an escape of urine from the bladder uncontrolled by the will. It naturally occurs in infants under thirty months, or thereabouts, and in the very old, and in connection with various diseases. It may be due to disease of the brain, as in idiocy or insanity, apoplexy, or unconscious states. Injuries or disorders of the spinal cord, which controls the action of the bladder (subject to the brain), also cause incontinence. Local disorders of the urinary organs are more frequent causes of the trouble, as inflammation of any part of the urinary tract, diabetes, nephritis, stone in the bladder, tumors, and malformations. The involuntary passage of urine may arise from irritability of bladder—the most frequent cause—or from weakness of the muscles which restrain the escape of urine, or from obstruction to flow of urine from the bladder, with overflow when it becomes distended.

It is a very common disorder of children and young persons, and in some cases no cause can be found; but in many instances it is due to masturbation (p. 193), to a narrow foreskin and small aperture at the exit of the urinary passage, to worms in the bowels or disease of the lower end of the bowels, such as fissure or eczema, to digestive disorders, to retaining the urine overlong, to fright, to dream impressions (dreaming of the act of urination), and to great weakness brought on by fevers or other diseases. In old men it is often due to an enlargement of a gland at the neck of the bladder which prevents the bladder from closing properly. A concentrated and irritating urine, from excessive acidity or alkalinity, may induce incontinence.

Children may recover from it as they approach adult life, but they should not be punished, as it is a disease and not a fault. Exception should be made in case children wet their clothing during play, through failure to take the time and trouble to pass water naturally. It is more common among children at night, leading to wetting of the bed, but may occur in the day, and often improves in the spring and summer, only to return with the cold weather. Children who sleep very soundly are more apt to be subject to this disorder.

Treatment.—In the case of a disorder depending upon one of so many conditions it will be realized that it would be folly for the layman to attempt to treat it. Children who are weak need building up in every possible way, as by an outdoor life, cold sponging daily, etc. If there is in boys a long foreskin, or tight foreskin, hindering the escape of urine and natural secretions of this part, circumcision may be performed to advantage by the surgeon, even in the infant a few months old. Sometimes a simpler operation, consisting of stretching or overdistending the foreskin, can be done.

A somewhat corresponding condition in girls occasionally causes bed-wetting and other troubles. It can be discovered by a physician. Children who wet their beds, or clothes, should not drink liquid after five in the afternoon, and should be taken up frequently during the night to pass water. The bed covering must be light, and they should be prevented from lying on the back while asleep by wearing a towel knotted in the small part of the back. Elevation of the foot of the bed a few inches is recommended as having a corrective influence. Masturbation, if present, must be corrected.

It is a very difficult disorder to treat, and physicians must be excused for failures even after every attempt has been made to discover and remove the cause. Even when cure seems assured, the disorder may recur.

INFLAMMATION OF THE BLADDER (Cystitis).—The condition which we describe under this head commonly causes frequent painful urination. Primarily there is usually some agency which mechanically or chemically irritates the bladder, and if the irritation does not subside, inflammation follows owing to the entrance of germs in some manner. The introduction into the bladder of unboiled, and therefore unclean, instruments is a cause; another cause is failure to pass urine for a long period, from a feeling of delicacy in some persons when in unfavorable surroundings. Nervous spasm of the urinary passage from pain, injuries, and surgical operations constitutes another cause. Inflammation may extend from neighboring parts and attack the bladder, as in gonorrhea, and in various inflammations of the sexual organs of women, as in childbed infection. Certain foods, waters, and drinks, as alcohol in large amounts, and drugs, as turpentine or cantharides applied externally or given internally, may lead to irritation of the bladder. Exposure to cold in susceptible persons is frequently a source of cystitis, as well as external blows and injuries. The foregoing causes are apt to bring on sudden or acute attacks of bladder trouble, but often the disease comes on slowly and is continuous or chronic.

Among the causes of chronic cystitis, in men over fifty, is obstruction to the outflow of urine from enlargement of the prostate gland, which blocks the exit from the bladder. In young men, narrowing of the urethra, a sequel to gonorrhea, may also cause cystitis; also stone in the bladder or foreign bodies, tumors growing in the bladder, tuberculosis of the organ. Paralysis of the bladder, which renders the organ incapable of emptying itself, thus retaining some fermenting urine, is another cause of bladder inflammation.

Symptoms.—The combination of frequency of and pain during urination, with the appearance of blood or white cloudiness and sediment in the urine, are evidences of the existence of inflammation of the bladder. The trouble is aggravated by standing, jolting, or active exercise. The pain may be felt either at the beginning or end of urination. There is also generally a feeling of weight and heaviness low down in the belly, or about the lower part of the bowel. Blood is not frequently present, but the urine is not clear, if there is much inflammation, but deposits a white and often slimy sediment on standing. In chronic inflammation of the bladder the urine often has a foul odor and smells of ammonia.

Treatment.—The treatment of acute cystitis consists in rest—preferably on the back, with the legs drawn up, in bed. The diet should be chiefly fluid, as milk and pure water, flaxseed tea, or mineral waters. Potassium citrate, fifteen grains, and sweet spirit of nitre, fifteen drops, may be given in water to advantage three times daily. Hot full baths or sitz baths two or three times a day, and in women hot vaginal douches (that is, injections into the front passage), with hot poultices or the hot-water bag over the lower part of the abdomen, will serve to relieve the suffering. If, however, the pain and frequency attending urination is considerable, nothing is so efficient as a suppository containing one-quarter grain each of morphine sulphate and belladonna extract, which should be introduced into the bowel and repeated once in three hours if necessary. This treatment should be employed only under the advice of a physician. In chronic cystitis, urotropin in five-grain doses dissolved in a glass of water and taken four times daily often affords great relief, but these cases demand careful study by a physician to determine their cause, and often local treatment. Avoidance of all source of irritation is also essential in these cases, as sexual excitement and the use of alcohol and spices. The diet should consist chiefly of cereals and vegetables, with an abundance of milk and water. The bowels should be kept loose by means of hot rectal injections in acute cystitis.

RETENTION, STOPPAGE, OR SUPPRESSION OF URINE.—Retention refers to that condition where the urine has been accumulating in the bladder for a considerable time—over twelve hours—and cannot be passed. It may follow an obstruction from disease, to which is added temporary swelling and nervous contraction of some part of the urinary passage; or it may be due to spasm and closure of the outlet from nervous irritation, as in the cases of injuries and surgical operations in the vicinity of the sexual organs, the rectum, or in other parts of the body. Overdistention of the bladder from failure to pass water for a long time may lead to a condition where urination becomes an impossibility. Various general diseases, as severe fevers, and conditions of unconsciousness, and other disorders of the nervous system, are frequently accompanied by retention of urine. In retention of urine there is often an escape of a little urine from time to time, and not necessarily entire absence of outflow.

Treatment.—Retention of urine is a serious condition. If not relieved, it may end in death from toxÆmia, caused by back pressure on the kidneys, or from rupture of the bladder. Therefore surgical assistance is demanded as soon as it can be obtained. Failing this, begin with the simpler methods. A hot sitz bath, or, if the patient cannot move, hot applications, as a hot poultice or hot cloths applied over the lower part of the belly, may afford relief. Injections of hot water into the bowel are often more efficient still. A single full dose of opium in some form, as fifteen drops of laudanum[10] or two teaspoonfuls of paregoric[10] or one-quarter grain of morphine,[10] will frequently allow of a free passage of urine. The introduction of a suppository into the bowel, containing one-quarter grain each of morphine sulphate,[10] and belladonna extract, is often preferable to giving the drug by the mouth. These measures proving of no avail, the next endeavor should be to pass a catheter. If a soft rubber or elastic catheter is used with reasonable care, little damage can be done, even by a novice. The catheter should be boiled in water for ten minutes, and after washing his hands thoroughly the attendant should anoint the catheter with sweet oil (which has been boiled) or clean vaseline and proceed to introduce the catheter slowly into the urinary passage until the urine begins to flow out through the instrument.

A medium-sized catheter is most generally suitable, as a No. 16 of the French scale, or a No. 81/2 of the English scale.

BRIGHTS DISEASE OF THE KIDNEYS.—Bright's disease of the kidneys is acute or chronic, and its presence can be definitely determined only by chemical and microscopical examination of the urine. Acute Bright's disease coming on in persons previously well may often, however, present certain symptoms by which its existence may be suspected even by the layman.

ACUTE BRIGHT'S DISEASE; ACUTE INFLAMMATION OF THE KIDNEYS.—Acute Bright's disease is often the result of exposure to cold and wet. Inflammation of the kidneys may be produced by swallowing turpentine, many of the cheap flavoring extracts in large amounts, carbolic acid, and Spanish flies; the external use of large quantities of turpentine, carbolic acid, or Spanish flies may also lead to acute inflammation of the kidneys. It occurs occasionally in pregnant women. The contagious germ diseases are very frequently the source of acute Bright's disease either as a complication or sequel. Thus scarlet fever is the most frequent cause, but measles, smallpox, chickenpox, yellow fever, typhoid fever, erysipelas, diphtheria, cholera, and malaria are also causative factors.

Symptoms.—Acute Bright's disease may develop suddenly with pallor and puffiness of the face owing to dropsy. The eyelids, ankles, legs, and lower part of the belly are apt to show the dropsy most. There may be nausea, vomiting, pain and lameness in the small part of the back, chills and fever, loss of appetite, and often constipation. In children convulsions sometimes appear. The urine is small in amount, perhaps not more than a cupful in twenty-four hours, instead of the normal daily excretion of three pints. Occasionally complete suppression of urine occurs. It is high-colored, either smoky or of a porter color, or sometimes a dark or even bright red, from the pressure of blood. Stupor and unconsciousness may supervene in severe cases. Recovery usually occurs, in favorable cases, within a few weeks, with gradually diminishing dropsy and increasing secretion of urine, or the disease may end in a chronic disorder of the kidneys. If acute Bright's disease is caused by, or complicated with, other diseases, the probable result becomes much more difficult to predict.

Treatment.—The failure of the kidneys to perform their usual function of eliminating waste matter from the blood makes it necessary for the skin and bowels to do double duty. The patient should remain in bed and be kept very warm with flannel night clothes and blankets next the body. The diet should consist wholly of milk, a glass every two hours, in those with whom it agrees, and in others gruels may be substituted to some extent. The addition to milk of mineral waters, limewater, small amounts of tea, coffee, or salt often makes it more palatable to those otherwise disliking it. As the patient improves, bread and butter, green and juicy vegetables, and fruits may be permitted. An abundance of pure water is always desirable. The bowels should be kept loose from the outset by salts given in as little water as possible and immediately followed by a glass of pure water. A teaspoonful may be given hourly till the bowels move. Epsom or Glauber's salts are efficient, but the compound jalap powder is the best purgative. Children, or those to whom these remedies are repugnant, may take the solution of citrate of magnesia, of which the dose is one-half to a whole bottle for adults. The skin is stimulated by the patient's lying in a hot bath for twenty minutes each day or, if this is not possible, by wrapping the patient in a blanket wrung out of hot water and covered by a dry blanket, and then by a rubber or waterproof sheet, and he is allowed to remain in it for an hour with a cold cloth to the head. If the patient takes the hot bath he should be immediately wrapped in warmed blankets on leaving it, and receive a hot drink of lemonade to stimulate sweating.

For treatment of convulsions, see Vol. I, p. 188.

Vomiting is allayed by swallowing cracked ice, single doses of bismuth subnitrate (one-quarter teaspoonful) once in three hours, and by heat applied externally over the stomach. Recovery is hastened by avoiding cold and damp, and persisting with a liquid diet for a considerable period. A course of iron is usually desirable after a few weeks have elapsed to improve the quality of the blood; ten drops of the tincture of the chloride of iron taken in water through a glass tube by adults; for children five to ten drops of the syrup of the iodide of iron. In either case the medicine should be taken three times daily after meals.

CHRONIC BRIGHT'S DISEASE.—This includes several forms of kidney disease. The symptoms are often very obscure, and the condition may not be discovered or suspected by the physician until an examination of the urine is made, which should always be done in any case of serious or obscure disorder. Accidental discovery of Bright's disease during examination for life insurance is not rare. The disease may exist for years without serious impairment resulting.

Causes.—Chronic Bright's disease often follows and is the result of fevers and acute inflammation of the kidneys. It is more common in adults. Overeating, more especially of meat, and overdrinking of alcohol are frequent causes. Gout is a frequent factor in its causation. The disease has in the past been regarded as a local disease of the kidneys, but recent research makes it probable that there is a general disorder of the system due to some faulty assimilation of food—especially when the diet itself is faulty—with the production of chemical products which damage various organs in the body as well as the kidneys, notably the heart and blood vessels.

Symptoms.—The symptoms are most diverse and varied and it is not possible to be sure of the existence of the disease without a careful physical examination, together with a complete examination of the urine, both made by a competent physician. Patients may be afflicted with the disease for long periods without any symptoms until some sudden complication calls attention to the underlying trouble. Symptoms suggesting chronic Bright's disease are among the following: indigestion, diarrhea and vomiting, frequent headache, shortness of breath, weakness, paleness, puffiness of the eyelids, swelling of the feet in the morning, dropsy, failure of eyesight, and nosebleed, and sometimes apoplexy. As the disease comes on slowly the patient has usually time to apply for medical aid, and attention is called to the foregoing symptoms merely to emphasize the importance of attending to such in due season.

Outcome.—While the outlook as to complete recovery is very discouraging, yet persons may live and be able to work for years in comparative comfort in many cases. When a physician pronounces the verdict of chronic Bright's disease, it is not by any means equivalent to a death warrant, but the condition is often compatible with many years of usefulness and freedom from serious suffering.

Treatment.—Medicines will no more cure Bright's disease than old age. Out-of-door life in a dry, warm, and equable climate has the most favorable influence upon the cause of chronic Bright's disease, and should always be recommended as a remedial agent when available. Proper diet is of great importance. Cereals, vegetables, an abundance of fat in the form of butter and cream—to the amount of a pint or so a day of the latter, and the avoidance of alcohol and meat, fish and eggs constitute the ideal regimen when this can be carried out. Tea and coffee in much moderation are usually allowable and water in abundance. The underclothing should be of wool the year round, and especial care is essential to avoid chilling of the surface. Medicines have their usefulness to relieve special conditions, but should only be taken at the advice of a physician, whose services should always be secured when available.