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tripital massage reduces it quickly almost to flatness with slight clear urethral discharge. The initial rise is well marked and sustained for two minutes, followed by a distinct fall at 5 minutes, back to the lying pressure in seven minutes. There was a corresponding rise in the pulse following the manipulation.

The immediate effect of prostatic massage is to cause first a rise in pressure followed by a fall which in some instances is quite remarkable, with a return to normal not later than ten minutes after the manipulations. Stimulation of the schneiderian membrane with the Faradic current, and the vagina, and rectum by manual stimulation have been shown to induce marked lowering of pressure. creases blood pressure.

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The impression has gained ground that arteriosclerosis is always associated with high blood pressure. As a matter of fact arteriosclerosis may be about equally divided between the state of hypertonia and hypotonia. I have three cases of advanced arteriosclerosis at the present time with blood pressures varying from 90 to 120. The disease is marked in the peripheral arteries. The radials are round, and full, tortuous and palpable after compression. There is apparently no discoverable cardiac enlargement and no accentuation of the second aortic sound. These are usually cases of peripheral arteriosclerosis with little if any involvement of the capillaries or splanchnic vessels. On the other hand we may have high pressure with soft radials due to splanchnic involve

ment alone.

Should one picture a case of typical arteriosclerosis with hypertension he would group the following phenomena: high tension pulse, beaded hard arteries, palpable after compression, hypertrophy of the left

ventricle, accentuated second aortic sound, signs of interstitial nephritis.

Treatment. In the treatment of high blood pressure I have made use of the nitrites-nitroglycerine, sodium and potassium nitrite. It has been proven that sodium and potassium nitrite and erythrol tetranitrite have a more prolonged action than nitroglycerine. The fall in pressure is slower and the subsequent rise delayed. For permanent lowering of pressure theoretically sodium and potassium nitrite are to be chosen. The method of treatment aims at repeated periods of pressure lowering with the hope that sooner or later the 1904 4 5 7 8 1 M.M. 25 7 31 28 2

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CHART 6. CASE IV. time will come when the continuous administration will cause a greater delay, in the pressure reaching its height. I am in the habit of giving three and four doses daily and continuing the remedy over considerable lengths of time, always controling my dose by blood pressure records. When the pressure reaches what may be considered the low point sought the remedy is gradually withdrawn.

The nitrites should never be continued for long periods without systematic control. Some individuals are quite sus

, 1910

Series, Vol. V.,

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2. Complained of extremities being too hot, advised continue with glonoin. Continued to complain of hot extremities, allowed to discontinue glonoin. 4. Returned to glonoin.

with Dr. Darling. He died after operation for impacted gallstone in ilium with ulceration. Autopsy was permitted on the abdomen and heart. The coronaries were calcareous and brittle, the heart was slightly enlarged. Urine and blood negative.

ticularly noticeable in the morning, confusion of ideas. His pressure was 190, pulse regular, arteries palpable after compression, tortuous. He made steady improvement from his symptoms on spirits of nitroglycerine from 2 to 4 minims of the 1% solution, from May 11, 1904 to

July 29. I did not see him again professionally until November 11, the pressure was 170, he was feeling well so I did not advise continuing the remedy. He returned the following June with a similar group of symptoms. Pressure 165, symptoms relieved by nitroglycerine. He took a lake trip the latter part of June, returned home feeling better, but was found dead in bed one morning. No autopsy.

CASE 6. Charts 8 and 9. D. P. Aet. 55. Achylia Gastrica. This patient had typical attacks of achylia gastrica with diarrhoeal stools. During the period from September 12, 1905, to January 5, 1906, the symptoms required constant watching. The attack subsided and he remained to all intents and purposes perfectly well until September, 1907, when he had another attack but of short duration. A third attack occurred in September of the following year. The patient had been abroad and had had a miserable summer. When I saw him in October the pressure was again high but gradually subsided with the abatement of his symptoms. There was no attempt to reduce blood pressure in this case. He did not seem to be suffering from high pressure symptoms and his pressure was never excessively high. The records were kept as a routine measure and may illustrate how bodily states of various kinds may influence blood pressure. This patient now at 59 is a remarkably well preserved man with excellent arteries but with a well marked gastrointestinal neurosis.

CASE 7. Chart 10. Miss H. A. Aet. 57. Arteriosclerosis mild. Interstitial nephritis mild. Complained of sleeplessness, palpitation, gas in stomach, cold hands and feet, throbbing in the left temple, dizziness. The radials were slightly tortuous, easily compressed. She had a distinct hyperchlorhydria. During the first portion of the chart the urine was negative. I am unable to say that her hypertension was entirely due to her arteries. There was no accentuation of the aortic second sound. She did not sleep largely because she felt her heart beating. I put her on spirits of nitroglycerine. She returned two days later to tell me she must stop the medicine

because her feet and hands were now "so hot." I discontinued the remedy for two days, then encouraged her to begin again. She made steady and seemingly permannent improvement from now on. January, 1907, she returned with the same group of symptoms and in addition distinct urinary changes, albumin and large numbers of hyaline casts. The effect of the nitrite is shown in the chart. February 7 was the last time casts appeared in her urine. have examined the case several times since. There has been no return of albumin or casts. With these findings the diagnosis of interstitial nephritis can be made.

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