1895 The Lancet  
621 ',alculi. It also provided for efficient drainage of the bladder subsequently, which no other plan of treatment did. Mr. Brown said that he always varied Mr. Wheelhouae's method of prooeduie by the insertion of a perineal tube into the bladder, allowing it to remain there for four or five days ; and in bad cases he washed the bladder out with solution of quinine. With regard to the risk of serious haemorrhage, which had been alleged as an objection to this operation, he said he had only
more » ... aid he had only once met with any trouble from this cause, and he had never known suppression of urine to follow eternal urethrotomy, as had been the case after dilatation several times in his experience. In conclusion, he strongly deprecated undertaking such an operation as external urethrotomy without at least three assistants-in fact, with as many assistants as would be present if the operation were performed in a hospital.-The Vice-President, wished to speak of the relief of cardiac pain, which was a subject of the highest importance, espe-. cially in the senile heart. He could draw no hard line between the different forms of cardiac pain. The pain was a central discharging lesion. It was usually connected with some area of hypei3Sthesia. The pain of " impending sense of dissolution" was not specially cardiac, but seen in ovarian and other abdominal lesions. He agreed with Dr. Balfour when he said there was no angina without cardiac failure of some sort. The vaso-motor form would not hold water. To relieve the pain the nutrition of the circulation and primarily that of the heart must be improved. As drugs we must give the first place to the iodides, especially iodide of potassium. Iodide of ethyl was considerably more active, less evanescent in its action, and more certain than nitrite of amyl. The nitrites were more useful in asthmatic than -cardiac conditions. Of other drugs, opium was a sheetanchor in painful conditions in old people, and if used with ordinary precautions there was really no risk. The diathesis of the patient must be considered. In gouty people alkalies and colchicum were of use. Cardiac pain signified cardiac failure. He doubted if ansemia of the cardiac muscle could produce them, or neuralgia, or neuritis. Probably they were due to ,local irritation of sensory nerves. He dwelt on the usefulness of distilled water as a drink in senile cases. Dr. ALEXANDER JAMES expressed some doubts which he had in the treatment of cardiac cases. Were we really husbanding the strength of the heart when we reduced its rate and increased the blood pressure with drugs ? 7 Did we not give the heart more work to do ? Y Did our fathers not rather husband the strength of the heart in the early stages of the disease by lowering the blood pressure by means of antimony, venesection, &c. Again, could we not do more good by getting the patient to sleep instead of giving tonics ? 7 During sleep the heart got slower. Dr. GEORGE BALFOUR desired to make some supplementary remarks on the present question, rather than discuss the merits of certain drugs. Exercise he thought only applicable in the early stage of gouty heart. Excessive exertion tended to promote irremediable failure of the heart. In young people especially the nutrition of the skeletal muscles could be promoted by massage. He next glanced at the diet of a cardiac case, which he regarded as of very great importance. Of the drugs employed in cardiac cases nux vomica was of value in all cases where the cardiac energy was defective, and could be continued for a long time. Five minims of the liquor strychaias every twelve hours were a I dose which did not produce cumulative effects, but marked I and steady improvement due to the energising of the heart muscle, the cardiac ganglia, as well as the vaso-motor centre. Arsenic was also a valuable tonic ; though it was difficult to understand how it acted there could be no doubt as to the benefit resulting. Of all cardiac tonics, digitalis was paramount. It was an indigenous drug of the highest value, which J gave its name to a whole group of remedies of similar action, of which only one came within measurable distance in the possession of valuable qualities-namely, strophanthus. The active principle of strophanthus was soluble, it acted with great rapidity, and so might occasionally be used with advantage in cases of cardiac collapse. The defect of strophanthus was that though it forced the heart to contract it had no tonic action on it, and did not promote the nutrition, which digitalis did. This was a special disadvantage in cases of senile heart. Digitalis produced the desired action on the heart with certainty and without risk. Digitalis might be given-(1) to improve the nutrition of the myocardium and so augment the force of its contractions ; (2) to contract dilated ventricles ; and (3) to remove dropsy. In using it as a tonic saturation must be avoided ; thus a grain of powdered leaves or the equivalent might be given in twenty-four hours. This might be continued for months or years. In flabby or dilated heart larger doses might be used to contract the organ. In aortic disease where the ventricle was beginning to fail large doses at considerable intervals were required. For removal of dropsy a degree of saturation was required. When blood pressure was high purgatives were of the greatest use. In lowering blood pressure for a lengthened period without bad effect iodide of potassium was best, and was most useful in combination with digitalis. Referring to the statement that there was not always high blood pressure in angina, Dr. Balfour said he had at one time held that view, but he was now satisfied that there was always an initial rise, though it rapidly fell from the failure of the heart to keep the pressure up. In conclusion he glanced at the use of narcotics in cardiac cases. ' Professor FRASER, replying, said that it had not been his intention in the remarks with which he opened the discussion to specially emphasise the merits of any one remedy, but to demonstrate the remarkable therapeutic value of a pharmaco. logical group, which he illustrated in connexion with one member because his experience with it had been greater than with any other member. This group of remedies had a direct action on the muscle of the heart, increasing the strength and efficiency of the contractions with a power unequalled by any other remedies. Time alone had prevented him making more than incidental mention of secondary remedies, such as rest, diet, arsenic, nitrites, morphia, strychnine, measures for removing fluids and increasing elimination, &c. In conclusion, Professor Fraser, after ably and impartially reviewing the expressions of opinion of those who had joined in the debate, expressed his great gratification at the amount of interest the discussion of this important question had raised.
doi:10.1016/s0140-6736(02)02145-1 fatcat:oqijtldijbgknh3sqxi7s4mgze