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 anaesthetic, 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.
[Illustration: Fig. 2.
A Single Stricture of the Urethra.]
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.
[Illustration: Fig. 3.
Condition of the Urethra with three Strictures and a congenital contraction at the meatus or outlet.]
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.
[Illustration: Fig. 4.
Condition of the urethra in Case 112,289; permanently cured at the Invalids' Hotel and Surgical Institute.]
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.
TESTIMONIALS.