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In some cases also, as Hare1 very wisely writes: "We must endeavor not to bring pressure to the normal, but recognize that while the arterial pressure is too high, and must be lowered, it is nevertheless essential to bear in mind that a tension higher than normal is essential if the blood is to be driven through rigid and narrow bloodpaths." I beg to add that in reasonable doubt it is wiser and safer not to attempt to lower pressure, but regard it as evidence of a natural and conservative process, and especially is this true whenever the patient is free from unpleasant subjective symptoms.

After all is said, we are obliged to return to old time knowledge. When digitalis causes much slowness or irregularity of pulse, when in addition there is nausea and pallor, and no favorable reaction noticed in any way, we shall act most wisely in stopping it altogether for a while, or in giving it in small doses and it might be, at longer intervals.

The form of giving digitalis is not unimportant. To obtain its most powerful effect the fresh infusion from good English leaves is usually the best; when nausea is marked, or the stomach intolerant and we feel we must try it, no preparation tablet triturate, equals the tablet the best homaeopathic ones appearing to me the most reliable for cause. They are made from tinctures prepared with the fresh plant and most carefully compounded.

In a few cardiac cases, crystalized digitalis is most effective. And occasionally when every other combination of digitalis fails, Trousseau's diuretic wine is a very

"The Therapeutic Gazette, Oct. 15, 1909, p. 688.

saving help in time of greatest need.1 Now much of all the foregoing is the result of experience, empirical, and backed up with no recorded scientific notes or data. It is the outcome of watching and doing during a lifetime; it is invaluable to know, and should not be overthrown, in my judgment, by any researches of even the most careful and

judicious among the scientific workers. It is true, and must be admitted,—precisely why, there may be many theories, but which is the wholly true one, time alone shall ultimately decide, and perhaps never.

For many years we have had constant reminders of the great power and efficacy of strychnine as a most valuable and rapid heart stimulant. Occasionally the statement is true, but in many instances incorrect. To some patients strychnine proves of very little, if any, temporary value, and when taken continuously for a time and even in moderate doses, wakefulness, irritability, increased nervousness, are undoubtedly produced, and without any appreciable gain in general strength or vigor.

Both caffein citrate in tablet form and strophanthus in tincture are far superior in the majority of instances. But with the first of these we may get unpleasant effects in some persons and from moderate doses. I have known as little as one grain of caffein cause undue stimulation of the nervous system, and only half the amount could be given at a dose without evident

1While digalen is said by some to be a good substitute for digitalis, Müller reports that it (digalen) differs but little in its action from other preparations of digitalis and has no marked advantages over them. Am. J. Med. Sciences., Nov., 1909, p. 766. Squibb claims good effects at times from the combined use of digitalis and nux vomica in preference to giving digitalis alone. With both drugs he makes use of the tincture.-Personal Letter, Oct. 26, 1909.

Again, E. H.

injury to the patient of a temporary, but somewhat disquieting nature, since depression seemed to me to follow rapidly after undue exaltation.

A word also, in regard to the other drug. It must be known that we are using the best strophanthus by mouth or hypodermatically, if we may expect from and count upon it as a helpful cardiac stimulant or tonic. This important fact is frequently ignored in practice.

These observations might be readily added to, but I trust they will, even brief as they are, serve the purpose of bringing forth new thought and fresh discussion.

A word may be added usefully on the subject of exercise-of walking. While I approve of walking at the proper time and in almost all forms of heart disease, I insist upon its strict regulation according to the stage of the disease and the strength of the patient. Again, while I have remarked benefit to result from increasing the length and duration of the walk on the level, I am not so sure of its evident utility at times in making ascents, even carefully graded ones. I doubt very much the value of Oertel's theory and practice in this regard, and I have learned rather to dread even short ascents when at all rapid, and I am also convinced that longer ones where the graduation is more even and the ascent less pronounced for a short distance, are to be advised only with extreme care and prudence. The going up stairs, the rapid doing of some act which requires the output suddenly or rapidly, of an undue amount of effort gives a strain to the weak heart which it requires sometimes. days and even weeks to recover from.

In older people, and especially after long illness, we cannot be too solicitous

and careful in this regard. Heart strain

is then very readily caused and to undo its evil effects is difficult and occasionally very disheartening.

In this category I would particularly direct attention to instances of cardiac irritability, or cardiac neurasthenia, brought on by several factors no doubt, but among them should be especially emphasized, so as to be neutralized or avoided later, the disastrous results of continuous. overwork, bodily, or of undue continuous mental effort-or of both combined. Daily routine with many cares and anxieties, and few or no respites, finally breaks down the most vigorous health and the strongest will.

When this has unfortunately occurred, it requires much time, continuous care, appropriate doing and proper medicinal means to re-establish a healthful balance. For a long while undue exertion, emotional excitement or worry, will cause directly inappetence, indigestion, and in

somnia.

And the sum of all these will very soon make a very ill patient out of one who seemed to be on the fair road to recovery.

In these latter remarks I am having in view more particularly the nervous disorders of the heart without apparent organic changes. And yet with middle life. or advanced years, we cannot be always sure that myocardial changes in subtle, organic form are not present, and are not indeed the essential underlying factors of many disquieting, and for a while otherwise unexplained symptoms of impaired strength and nutrition.

Occasionally in such instances and when all the ordinary cardiac remedies and nerve tonics with change of scene, change of air and prolonged rest had failed to effect a complete cure, the addition of iron and

New Series, Vol. V., No. 6.

ORIGINAL ARTICLES

manganese in a soluble form to a quinine. tonic has apparently accomplished the greatly desired result.

Olla podrida if you will, and the rationale of it I deplore, yet the outcome of its taking was the end most hoped for, namely, health, and the basis of its utility some blood defect

defect possibly, although

anaemia was not invariably noted by an accurate blood count and differentiation or an estimation of the amount of haemoglobin proportionately.

How often do we read in the daily papers of an operation performed successfully, as stated during the first day or two, perhaps, and yet later bulletins speak of the very precarious condition of the patient. It may be that this unfortunate aftermath is the result of something unforeseen and possibly irremedial. Or it may be while the condition of the patient. was considered as carefully as possible prior to the operation and it was determined judiciously that the patient was in good shape to have the operation performed with good hopes of a rapid and complete recovery from it, yet despite the probabilities trouble and danger had suddenly become manifest. Apart from the foregoing instances which we all recognize, and although we deplore we would not change for the while and until knowledge is greater and more accurate, there are other examples of a far different order.

Not infrequently operations are undertaken which are not justified simply because there is no need of an operation, or, if there be in a sense need of them they are not permissible to the upright surgeon because the result to the patient, even if successful, is more than questionable as regards ultimate benefit.

Complete Series, Vol. XVI.

305 Admitted that the patient will almost surely recover from the operation and that the operation itself entails practically very little or no risk to life, yet the ultimate outcome so far as health or usefulness is concerned, would be doubtless, nil. Why then undertake them? Certainly not to gratify personal vanity or ambition, or worse still, to add to the amount of illgained lucre.

But there are examples, and we read of them almost daily, where no fault could be found with the skill of the surgeon in a technical way; with his probity and care and good intentions, primarily.

But to say the least, his judgment is faulty and his mental horizon limited, because of lack of instruction in most important by-paths of his work.

And here comes to the front above almost every other consideration, the role of the heart in the economy,-the first of all the organs in the vast number of cases involving life and death. If the heart be weak functionally; if it be unable to bear the strain of a formidable operation and all the necessary calls made upon its power during and immediately subsequent to the operation, in what way can the patient be benefited by any operation?

A heart may be enlarged, have perhaps one or more pronounced organic murmurs and yet be functionally able to withstand even a formidable operation.

On the other hand, given a patient who is evidently much below par,-run down in body and mind, from over-strain in one way or another, and perhaps during many previous weeks or months, and the heart of such a one may give way suddenly and death occur, and despite every known means being used intelligently to ward it

off at the time of the final "heart failure." Here indeed prevention is highest wisdom and not the so-called cure, and sometimes it means proper management of fever which is present and possibly due to existing toxaemia.

I know of no more difficult, uncertain problem at times in medicine than the correct estimate of what a patient can stand in the way of an operation, simply having the staying power of the heart in view. Here the personal equation is the one important thing and which must be estimated with keenest judgment. And here, too, the wisdom and horse-sense of the ex

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the wards of the Mt. Sinai Hospital suffering from hematuria-her haemoglobin was reduced to 18%, the haematuria having existed for three years,

perienced, all round practitioner triumphs with progressive loss of flesh and strength, immeasurably Over merely advanced science of the schools backed up with the very latest means of physical exploration.

Moreover, "the failure of circulation may be due to functional causes as much as to a condition represented by appreciable structural change. The teaching of modern science has been too much in the direction that phenomena can be wholly explained by structure. This is not true of the working mechanism of the human organism, nor indeed is it true even of mechanical things.1"

The Coaltar Derivatives.- Dr. Sajous says in The Monthly Cyclopoedia: “Summarizing these facts, it seems plain that far from being harmful, in the hands of the profession, the coaltar derivatives have furnished us the only means to avoid the use of the opiates which, notwithstanding the great service they have rendered humanity, have left in their train victims in numbers untold, and the shadows of which hover at once before the modern practitioner's mind when he is called upon to alleviate suffering."

'Heart Disease and Blood Pressure, Bishop, 3rd ed., 1909, pp. 78 and 79.

She had seen many doctors and yet had been going along year in and year out, no diagnosis being made until she was in an absolutely inoperable condition; inoperable not because of her age but because her intense anaemia absolutely forbade an operative procedure either palliative

or for radical cure. So

I think we are not doing our full duty toward many of those affected with neoplasms if the bladder; either we are not recognizing the condition, or, having recognized the condition, a great many of us are still of the opinion that the neoplasm of the bladder may as well be left untreated as treated, the results being so uniformly. bad.

First, let us briefly consider the pathology and the varieties of vesical neoplasms. There is not very much we can say about etiology so we proceed to the pathological aspects. Almost all varieties of tumor affect the urinary bladder. For purposes of discussion we may consider but two, the

'Read before the Eastern Med. Society, March 11, 1910.

malignant forms or carcinoma and the comparatively benign types or papilloma. Sarcoma occurs but very rarely, fibroma, cysts, echinococcus cysts, etc., all have been recorded but they are so rare that we need give them very little consideration. My remarks are about papillary tumors of the benign type and carcinoma of the malig

nant

Papillary tumors may be single or multiple. They are of benign character histologically. In clinical manifestations, they have some of the malignant characteristics, i. e., they tend to cause implantation tumors on other portions of the bladder and have a great tendency to recurrence after they are completely removed. As regards recurrence in what we consider benign tumors, we must not forget that pathologists frequently report a growth to be papillary when it is really a carcinomatous papilloma, the carcinomatous changes at the base of the tumor having been overlooked.

Regarding carcinoma, Klebs in 1870, said carcinoma of the bladder was always a secondary growth and therefore should never be treated in the surgical way by removal. He said it was secondary to carcinoma of the rectum, prostate, vagina or uterus. Motz and Monford thought carcinoma of the bladder was frequently primary. Dr. Mandelbaum found that adenoma-carcinoma and fibro-carcinoma were usually secondary to carcinoma of the rectum and uterus whereas squamous and papillary carcinomata are usually primary growths in the bladder. It has been claimed that surgery of malignant disease of the bladder is out of place as most cases recur within a short time. If we remember those conclusions of Dr. Mandelbaum, namely, that adenoma and fibro-carcinomata are usually

secondary secondary tumors and that papillary growths and squamous celled tumors are usually primary, we will have better results from operative interference in malignant disease. Because if the surgeon opens the bladder and on immediate frozen section of the tumor finds that it is adeno- or fibro-carcinoma, he can be sure that removal of the tumor of the bladder will not cure the patient; that there is a primary growth behind it which will invite recurrence and further spread of the disease. If on the other hand, he finds the tumor to be a papillary or squamous celled one, he can do a resection of the bladder with fair hope that if he cuts wide of the disease and removes the glands, the patient will have as good a chance for cure as though he were suffering from a malignant disease elsewhere. So it is necessary to have the pathologist present to give an immediate report on the specimen.

Tumors of the prostate, as Dr. Young of Baltimore, has shown, are carcinomatous in 17% of the cases and such carcinoma of the prostate we know extends into the trigona of the prostate very, very frequently.

So much for the pathology of carcinomata of the bladder and for the pathology of the benign papillary growths of the bladder. In the papillary growths of the bladder, the base of the tumor should always be subjected to very careful histological examination because there is the most frequent site of the carcinoma.

Symptoms. Practically the first symptom of tumor of the bladder is a haematuria. It is a painless haematuria. It is the haematuria which lasts for a day or several days, stops for several weeks and recurs, then again stops for a shorter

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