:Qj "FY 01 I* 8M' 1 JtuJL • PRIZE ESSAY. w ■= 3 § £ « a ^ - M n 6 1 s « til - 2 ^ «* -S * THE SPHYGMOGRAPH ITS PHYSIOLOGICAL AND PATHOLOGICAL INDICATIONS. The Essay to which was Awarded the Stevens Triennial Prize, by the College of Physicians and Surgeons, New York, April, 1873. Two hundred and ninety Illustrations. EDGAR HOLDEN, A.M., M.D PHILADELPHIA: A LINDSAY & BLAKISTON. 1874. Entered according to Act of Congress, in the year 1873, by EDGAR HOLDEN, In the office of the Librarian of Congress, at Washington. Jennings & Hardhaii, Printers, Newark, N. J. WM. MAXWELL WOOD, M. D., late surgeon general u. s. navy, In remembrance of acts of kindness, and of association in peril in the u. s. navy, and with the hope that the labor bestowed in preparation may justify so ceremonious an, act, this work is inscribed by THE AUTHOR. INTRODUCTORY NOTE. r-p he work as here presented lias been the resnlt of many months of labor, for the field has been path- less and virtually unexplored ; but it is hoped that it may prove at least a definite and tangible starting point for other observers. The author desires to state to those who may have read his Essay, published by the State Medical Society of New Jersey, or that delivered before the New York Journal Association, that the views there advanced have been found in some cases erroneous, because drawn from tracings made as with Marey' s Instrument, without the means since adopted for accurately deter- mining the compressibility of the artery. Since then, moreover, the facilities afforded as medical adviser of one of the largest Life Insurance Companies of the United States, and as clinical physician for diseases of the chest to St. Michael's Hospital, have been more liberally drawn upon, that previous opinions might be verified or corrected. 10 INTRODUCTORY NOTE. The Essay thus published differs somewhat in form from that presented in competition for the Stevens Prize, but only as regards a certain diffusedness both of tracing and subject matter ; and it is believed that as the tracings particularly have been culled with care, the work has been made only the more serviceable. It may thus be of the more assistance to any who desire to pursue the complex yet interesting study of Sphygmographic hieroglyphics. The reader is desired not to consider the tracings of cases as the universal and invariable exponents of individual diseases. Such could only be obtained after long and patient investigation into every variety and phase of disease, and is equivalent to making a new symptomatology, a task indeed for a generation of observers. They will, however, probably prove in all cases suggestive of the pathological condition involved. Edgar Holden. Newark, N. J., October, 1873. CONTENTS. PART I. CHAPTER I. GENERAL CONSIDERATIONS REGARDING MECHANISM. Vierordt — Professor Marey — Defects of Instruments hitherto — Description of Marey's Sphygmograph, and Illustrations of the Principle involved — Objections to Pressure upon the Artery — Improvements by Professor Sanderson— Advantages of a new Principle in Construction — The Pen and its Action — The Pressure Spring and its Index — Drs. Anstie and Sanderson on the amount of Pressure required — Possibility of Utilizing 17,000 grains — Dial described — Value of a Knowledge of the Minute Peculiarities of the Arterial Current, 17-29 CHAPTER II. INDICATIONS AFFORDED BY THE PULSE. Ideas of the Chinese — Physiological Variations — Quotation from Da Costa— and Description of Chief Varieties of Pulse, . 30-38 CHAPTER III. TRANSLATION OF TRACINGS. Shock Wave, or First Event — Indications afforded by this— Signifi- cance of Amplitude — Wave of Health — Axiom regarding Ampli- tude — Error of General Opinion — The Systolic Wave, or Second Event, 38-45 12 CONTENTS. CHAPTER IV. THE SECOND EVENT. Description of Chart — Explanation of Tracings given —Significance of this part of the Tracing— Corollaries — The Third .Event — Explanation of the Cause of this Event — Wave of Recoil — Refer- ence to Cases— Significance of this Event. . . . 45-54 CHAPTER V. THE FOURTH EVENT. Opinions of Namnann and Marey — Disproval by Sanderson — Cases and Tracings Illustrative— Deductions from a Study of the Trac- ings—Experiments with an Artificial Heart and Capillaries, pub- lished by New Jersey State Medical Society — New Theory, and Facts Substantiating the same — Is Dicrotism always due to Arterial Impletion ? — Cases quoted -Dicrotism in Typhous Fever — Dicro- tism of Epilepsy — Views of Voisin — Origin and Significance of the word Dicrotism — Tricrotism, ..... 54-64 CHAPTER VI. GENERAL PROPERTIES OBSERVABLE BY THE SPHYGMOGRAPH. Compressibility — Oscillation, Locomotion, Recoil — Opinion of Dr. Corrigan relative to Locomotion of Arteries —Value of a Means of Ascertaining Compressibility — Causes and Significance of Oscilla- tion — Singular Case in the Practice of Dr. Whittingham of New Jersey — Patient of the late Dr. Valentine Mott— Chart and Expla- nation of Cases — Summary of Points of Significance of Oscilla- tion, 64-74 CONTENTS. 13 CHAPTER VII. RECOIL. Tracings from the Carotid, by Dr. Anstie — Significance of the Wave of Recoil — When a purely Physiological and when a Pathological Phenomenon, 74-79 CHAPTER VIII. COMPRESSIBILITY OR TENSION. Importance of ascertaining the Exact Character and Extent of this — Experiments of Prof. Dalton on the Sympathetic Nerves — Investi- gations of M. Bernard — Summary-^-Experimental Observations with Tracings, 79-86 PART II. CHAPTER I. THE PRACTICAL APPLICATION OP THE SPHYGMOGRAFH. General Considerations — Reduction in the number of Tracings Given, and the Reason therefor — Practical Suggestions to Observers, 86-91 CHAPTER II. DESCRIPTIVE NOTES IN CONNECTION WITH TRACINGS. Cases of Apparent Health— Influence of minor Disturbing Causes — Wider Deviations, suggestive of existing Disease -Debility — Hys- teria—Tobacco Poisoning — Influence of Loss of a Limb on a Trac- ing, 91-101 14 CONTENTS. CHAPTER III. CASES CHIEFLY OF CARDIAC DISEASE. Irregularity due to mitral disease — Opinion of Prof. Sanderson— Ver- tigo — Description of the Cases and Tracings — Functional and Organic Disease, 101-113 CHAPTEE IV. AFFECTIONS OF THE NERVOUS SYSTEM. Mania-a-potu — Opinions of a Celebrated Observer, . . 113-114 CHAPTEE V. SAME CONTINUED. Asthma and its Varieties — Cardiac Dyspnoea— Bronchitis — Progresso- loco-moto-ataxia, 114-121 CHAPTEE VI. SINGULAR CASES OF DOUBTFUL DIAGNOSIS. Epilepsy— Rheumatic Arthritis, 121-128 CHAPTEE VII. PHTHISIS, ITS VARIETIES, WITH CASES AND TRACINGS OF SAME. Selection of Tracings from Several Hundred — Detail of Cases— Acute Phthisis — Latent Phthisis — Chronic Phthisis — Aneurism— Impos- ture Detected, 128-133 CONTENTS. 15 PART III. CHAPTER I. ACTION OF MEDICINES. Detection of Effect prior to any Sensible Manifestation— Drugs Se- lected — Time of Commencing Observations — Facility with which Examination can be Made by the Experimenter on Himself— Can- nabis Indica — Minuteness of Detail — Alcoholic Extract — Twelve grains taken. Second Experiment — Instrumental and Physiological Observations Compared— Tincture Cannabis Indica — One Hundred, and, Ten Drops Taken ! Third Experiment — New and Fresh Tincture— Comparison of Sensa- tions with Records — Four Hundrtd and Twenty Drops Taken! Fourth Experiment — Fresh Alcoholic Extract — Terrific Excitement from Poisoning — Twenty six Chains taken in Two Hours and Forty Minutes ! Synopsis of Effects— Tracings of the following Day — General Deduc- tions as to Effects of the Drug, 133-149 CHAPTER II. EXPERIMENTS WITH GELSEMINUM SEMPERVIRENS. Reason for Selecting the Drug — Difference of Opinion among Medical Authorities — Sensible Effects — Opinion of Dr. Da Costa — Amount Taken— Effects Observable only by the Sphygmograph — Deduc- tions, 149-153 16 CONTENTS. CHAPTER III. EXPERIMENTS WITH ACONITE. Fluid Extract Taken— First Case a Young Lady — Amount Taken — Interval before Circulation was Affected — Maximum and Minimum of Excitement — Arterial Tension — Deductions and Comparisons — Value to Pathology, 153-158 CHAPTER IV. EXPERIMENTS WITH QUININE. Small Doses — Single Small Dose and its Action on the Pulse — Re- peated Doses — Effect on the Nervous System— Deduction, 158-162 CHAPTER V . CONCLUDING REMARKS. What has been Attempted in this Essay — A Construction of the In- strument Justified — A Discussion of the Value of a Knowledge of hitherto Undeveloped Features — The Power of the Instrument to Develop these, 162-163 Index, 165-169 THE SPHYGMOGRAPH : ITS PHYSIOLOGICAL AND PATHOLOGICAL INDICATIONS. PAET I. CHAPTER I. GENERAL CONSIDERATIONS REGARDING MECHANISM. A Sphygmograph is an instrument which can automatically record the peculiarities of the arterial pulse. According to Vierordt, to whom we are pro- bably indebted for its suggestion, it was simply "an instrument which, when applied over an artery, indi- cated its character as to force and extent of undula- tions," and, as originally constructed, could accomplish this only with difficulty and uncertainty. More recently the ingenious device known as Professor Marey's, showed a wider significance in the sphyg- mographic tracing, and gave promise of great practical usefulness. It is no disparagement of the invention to say, that the sanguine hopes entertained with 18 THE SPHYGMOGEAPH. regard to it have not been fully gratified, and that to no inconsiderable extent the disappointment has been due to certain imperfections in the instrument itself. These, however, have arisen mainly from a want of ready applicability, and a tendency to fall out of repair, from the very perfection and refinement of its own mechanism. As the word Sphygmograph is, to most of those who know of the device, intimately connected with the name of Professor Marey, it is but proper, before presenting results obtained by other means, to allude to the principles, merits and defects of his invention. This may perhaps be more briefly done by present- ing a skeleton diagram of the instrument, or rather endeavoring by an outline drawing, to illustrate its action. A simple lever, attached at one extremity, rests at the other upon the artery to be examined, and com- presses it, therefore, in a vertical direction ; a second lever, bent at a right angle and lying directly above this, communicates its motion by a knife edge to a third, and this latter, which is at the same time the tracer, and has upon its free extremity a peculiar pen, amplifies or magnifies the motion communicated. This amplification is simply due to the fact that, as will be seen by the drawing, the motion is directed against the tracer very near its attached extremity. THE SPHYGMOGRAPH. 19 Artery. F— Points of attachment of levers. P— Pen. S— Screw. A screw, near the same point, traverses the tracer and regulates the pressure. The other parts of the instrument, being simply accessories, with perhaps the exception of a concealed watch movement, designed to move the paper to receive the writing, need not be described. This instrument is strapped to the wrist to insure immobility ;* and in the hand of its inventor has developed features in the arterial pulse never before discerned. Inasmuch, however, as disappointment has resulted from its subsequent use, and its delicacy and cost have limited the observations which should be manifold, within a narrow scope, it is a fair inquiry whether this disappointment may not after all be due, not to a meagre pathological or physiological value of the pulse-wave, but to some defects in the instrument employed. A glance at these may both answer inquiry and suggest a change. In the first place, the end of the lever, which may be called the pulse-spring, rests upon the artery and 20 THE SPHYGMOGRAPH. compresses it, as already remarked, in a vertical direc- tion. Tims, as may be seen in the following drawing, any increase of pressure flattens the vessel, and, as will be shown in speaking of amplitude of tracings and arterial tension, a deceptive result is obtained. The movements of the spring are, as observed by Sanderson, not therefore those of the arterial wall in the fullest sense, and extent of motion is inaccurately measured. As an artery is distended laterally as well as verti- cally, some of the peculiarities of the contained wave are of necessity lost ; especially when the current of blood is small, and the flaccidity of the vessel consid- erable. The second defect, as will be conceded by all observers, lies in the method necessary to secure the instrument to the wrist. This is done by straps, or rather a bandage, which hooks in alternate loops over wire pegs on the sides of the instrument, or may be a continuous and single band with straps and buckles. The difficulty. of adjustment to the artery, even under favorable circumstances, is considerable ; and when the patient is nervous and excited or frenzied by delir- ium, the tracing obtained after a prolonged trial cannot be accepted as the correct index of the pulsating wave. Indeed, so great is the liability to obtain an THE SPHYGMOGKAPH. 21 inadequate or erroneous tracing, that many observers have cast the instrument aside, as unworthy the expen- diture of time and patience. Much has, however, been accomplished in the way of remedying this defect by the patient efforts of one to whom much reference must be made in this essay — as having, more than any other, endeavored to render the Sphygmograph of Marey of practical benefit — Professor Burdon Sanderson. Yet, after all, his de- vices did not perfectly obviate the defect last referred to ; and only modified it in so far that the involuntary muscular movements in the wrist of the patient would not impair the tracing. He adjusted slips of brass to the instrument in such a way that the body of it rested more firmly upon a surface of bone ; but an elastic band was made neces- sary for the retention of this, and this added to what was a much underrated and additional defect, viz., obstruction to superficial venous circulation by the retaining straps. To be sure, this obstruction would of necessity be slight, but, in obtaining a record, the nicety of whose indications depends upon such minute particulars, even so slight an obstruction miglit vitiate our results. To what extent this is actually the case, will be seen by reference to the direct experiments made in this direction, and recorded in this essay. 22 THE SPHYGMOGRAPH. The third, and, as will be shown by a multitude of observations, vital defect, is the inability to accurately and quickly determine the compressibility of the artery. By the adjustment of the brass slips referred to, some improvement resulted, inasmuch as, after a series of experiments with various weights, an approximate relation could be arrived at between the distance from the surface of the lever to the spring, and the actual pressure at the time upon the artery. Other workers adopted various devices to remedy this defect, one only, however, seeming to be a real improvement, viz., that of graduating the screw ac- cording to a pre-arranged scale, and thus having at hand an index upon the screw itself. By reference to the drawing, it will, I think, be manifest, that the defect consists in the screw itself, since it bears like an inflexible brake upon the levers with which it is in contact, and when we shall consider this compressi- bility as one of the most important elements in the arterial current, it will be seen that its ready and accurate record are essential to any real practical use- fulness of the instrument. Recognizing, then, the importance of having as few defects as possible in the device we employ to record the peculiarities of the pulse, and feeling indeed that the question of real moment does not relate to the THE SPHYGMOGKAPH. 23 practical utility of any given Sphygmograph, nor yet of the Sphygmograph, in its best known signification, but to whether there is any deep meaning in the blood current of the accessible arteries, of value in Physi- ology, Pathology or Therapeutics, which can be accu- rately ascertained and recorded, I have endeavored to remedy the defects enumerated, as the best method of answering the question in hand. Despairing of any success in the direction taken by the eminent observers of England and the Continent, after their but partial success, it occurred to me that a new principle of construction might accomplish better results. In all instruments thus far adopted the attempt had been made to employ the lifting power of the current of blood to obtain a tracing, the diffi- culties of friction and amplification being the problems to be solved. The arrangement of the levers and the shape and position of the tracing point, already considered, are probably the most perfect adaptation of mechanism in this direction. (See first Frontispiece.) But instead of attempting to utilize the lifting, why not employ the displacing power of the artery % Instead of having the spring press doion upon the artery, let it partially surround it, J thus : Then with each pulsation ""\ ^W ^"^ a force is transmitted not only up- "€K 24 THE SPHYGMOGEAPH. ward, but in an oblique direction, as shown by the dotted lines, the preponderance being toward the side upon which the spring may be inclined. Prolong the pulse spring, and shorten the distance between the point of attachment (the fulcrum) and the point of pressure, and this upward and oblique movement is evident to the eye. To amplify this, allow the free and distal end to be bent as an inclined plane or the curve of a circle ; polish it to obviate friction ; magnetize it, if desired, to add a repellant power to the power already evident, and allow it to impinge against another lever quite near its attached extremity, (a lever of the third order) ; make this last flexible, and its distal end will move with regular, accurate sweep under the distensile power transmitted. The skeleton drawing below will illustrate more perfectly the principle involved. B Artery. B — Place for Pen. P — Pulse Spring. F — Attachment of Flexible Lever, i. e. Tracer. The movement obtained by this means is from side to side, and not, as in Marey' s instrument, in a vertical direction ; and in consequence the paper to receive the THE SPHYGMOGRAPH. 25 tracing may lie as in ordinary writing. (See design on second Frontispiece.) The accessories necessar}^ to the application of this principle need not be described in detail ; they are simply a framework of brass ; a sliding-post for the attachment of the tracing-lever by which it may be brought in apposition to the inclined plane described ; a watch movement for moving the paper to receive the writing ; and a means for holding the instrument in the thumb and finger over the artery. The drawing on the second page may render this description more intelligible. Two points, how- ever, of importance, are worthy a moment's notice, viz., the pen, and the means for determining and recording the compressibility of the artery. As already stated, the motion obtained is from side to side, and although ample, it is yet so delicate that a hair upon it stops it at once. After many disheartening attempts to utilize chemical re-agents, and the sugges- tions of various persons of ingenuity, the simple plan of pivoting the writing-point — in fact an ordinary pen — and thus making the paper and not the delicate lever carry the weight, solved the problem — thus : To ascertain with precision the pressure necessary 26 THE SPHYGMOGRAPH. to obtain an ample tracing, it was evident that no power should be brought to bear upon the pulse, except that of the pulse-spring itself, since relative compressibility could only be accurately determined by variations of the intensity of a common force. The increase or diminution of pressure should therefore be ratios of the ability of the spring itself; in other words, the spring should have within itself the power to press lightly or heavily upon the artery. Its attachment to the body of the instrument was there- fore made by a coil of watch-spring, whose tension could be controlled and measured on a dial, at will, an amount of pressure being possible beyond any requirement, and reaching four, five or six pounds. The drawing illustrates both the coil and the record- ing dial. It will be at once evident, that coiling the spring from its centre, A, will bring a pressure just in the very direction most desired, viz., downward and back- ward against and upon the vessel as indicated by the THE SPHYGMOGRAPH. 27 dotted line. A curved wire, B, acts both as a brake to prevent the uncoiling of the spring and maintaining it at any desired point, and also as an index for the dial. As the best and only test for the utility of any invention, is the amount and character of the work it will accomplish, more minute description may perhaps be dispensed with, and reference made to the charts presented in a subsequent part of this essay. A few words of comment on the extent of pressure sometimes necessary, appear, however, in place at this point. Most observers, especially Drs. Anstie and J. Bur- don Sanderson, have found that a pressure of 100 grammes is the average minimum, and that by the device of the latter a variation of 200 grammes is easily attainable ; this is equivalent to about 3,000 grains. It will be observed on the charts appended, that 700 grammes were often necessary ; and it may be added, that in some cases I have found it possible to obtain a tracing under a pressure of 1,100, or about 17,000 grains. The dial already described is, as will be seen in the drawing, marked in degrees, the equivalent of each in grains being easily determined by the equipoise of weights upon a balance. The following exhibits the amount of pressure exerted when the spring is coiled 28 THE SPHYGMOGKAPH. sufficiently to bring the index opposite each degree : ° — about 100 grammes, or 1,560 grains. 2i° " 186 " 2,880 5 ° " 690 " 10,620 Somewhat singularly, the application of this different principle gives results similar, and therefore readily comparable with those of Professor Marey, and al- though the celerity and certainty by which the com- pressibility can be ascertained has often developed features of a pulse-wave that would have been con- cealed without this, yet the tracings are so nearly akin that they may be explained and treated under the same rules as his own. Whether the defects that have so nearly wrecked the science of Sphygmography, ere it had well begun its career, have been fully corrected by the means described or not, the reader, who will patiently review- the results obtained, will be able to judge. Two elements, at least, toward the success of the instrument as an aid to science, will, I think, be conceded to the change in its construction, viz., a reduction in cost down to a reasonable and available point,* and a more ready applicability. Most of the tracings delineated on the charts were * Note. — The instrument used for this work has not become disarranged or out of order after several thousand tracings, and could be duplicated by the maker at a cost of about one-third that of the imported instrument. Otto & Keynders, Inst. Makers, New York. THE SPHYGMOGRAPH. 29 taken during an ordinary visit, and occupied only from thirty seconds to two minutes ; no fastenings were employed, and no preparation necessary, not even in most instances the preliminarjr rolling- up of the sleeve, save barely to uncover the radial pulse. The instru- ment was held by the linger and thumb of the left hand, the paper introduced, the ink applied, and the watch-work started by the other. To a great extent, therefore, nervous excitement due to the simple act of examination has not vitiated the tracing, and it is be- lieved that so far as Sphygmographic observations can be the true record of the pulse-waves, these are reliable. Of the many other devices for ascertaining and recording the peculiarities of the pulse, from the simple column of mercury and the. semaphoric regis- tration by the aid of photography, to the attempts to utilize the galvanometer, it is unnecessary to speak ; since their failure hitherto to develop better results than their predecessors, has not yet brought them a measureable success. The subj ect of chief interest is, after all, outside of any particular method; of observa- tion, and relates to the observations themselves. We may, perhaps, the better define the true physio- logical and pathological indications in these by dis- cussing, first, the actual value of a knowledge of the minute peculiarities of the circulatory current, and then, the power of an instrument to develop them. CHAPTER II. INDICATIONS AFFORDED BY THE PULSE. The pulse, from the earliest record of historic medi- cine, has been to the Physician a guide and instructor ; and, although the elaborate anatomical knowledge of the present day has divested it of the mysterious ele- ment so familiar to the student of ancient medicine, and we no longer profess to divine or prophesy by its aid, it is still, in many cases, the key to our patient' s condition, and in all a valuable assistant in diagnosis. Nor can this be due merely to the effect of education, or the example of our predecessors. Every skillful, ambitious physician realizes in daily life that the "tactus eruditus" is to-day as valuable an acquire- ment as in the days of Galen. We may no longer hide our ignorance under the look of deep and digni- fied wisdom, or with our fingers on the pulse shake our heads with complacence, while puzzling confusedly over the remedy it would be best to hazard on the case. It is our privilege to have within our reach ample means of information, and neither to over or under- rate the significance of the pulse we feel. To do this, however, it is not sufficient that we be versed in THE SPHYGMOGRAPH. 31 anatomy or physiology ; for, as we realize to-day that we can read a deeper meaning in its throbbings than a year ago, so each year' s experience shows new indica- tions to our more practiced touch, and we feel that without it we should be . often in doubt, when doubt might be fatal to our patient. We are wont to regard as absurdities many of the notions of the early physi- cians, simply because the better facilities of modern times have shown their deductions to have been un- tenable ; but we overlook the fact that, although shut out from our refinement of pathology, they were yet not devoid of wisdom, and, drawing largely from experience, often showed that the homage and respect bestowed upon them were well deserved. "We deride the assumption of mystery, although it is fast becom- ing evident in the present age, that its absence is far from beneficial. There is, perhaps, no better aid to the success of the charlatan of to-day, than the arrogance grown out of a little knowledge that presumes to weigh for itself questions of disease and treatment. The contempt of familiarity has taken the place of the faith that once helped to cure. We may be, however, and probably are right in regarding the diffuse nomenclature and labored at- tempts to make of pulses critical guides to treatment, as not particularly wise, yet in the days of Solano it 32 THE SPHYGMOGRAPH. is not improbable that they possessed value, crude and imperfect it may be, but value of which we with better information have no knowledge. This concession can hardly be made, however, to the Chinese of even our own day, by whom the pulse of one wrist is believed to indicate the disease of one organ, that of the axillary artery of another, and who pretend by the femoral pulse of a pregnant woman to determine the sex of her child ; yet even in this extreme tax upon credulity there is more of good sense than we are at first inclined to believe ; and the fact was strongly suggested during a series of exper- iments with an artificial heart and system of vessels to which allusion will again be made in this essay, e.g. Upon ligating one of the capillaries in a network of interlacing tubes, the quantity of fluid forced through them remaining the same, very little disturb- ance or change appeared to have been caused in the others, at least so far as the touch could decide ; and yet it was evident that a larger quantity of fluid was compelled to find its way through them than before. A Sphygmograph however, indicated a difference ; and when two or more were ligated, a perceptible difference was observed by the fingers. Apply this fact to the human body: suppose, for example, a mass of enlarged lymphatics obstructing the subcla- vian artery ; if this obstruction were slight, the differ- THE SPHYGMOGBAPH. 33 ence in the feeling of the axillary artery might be perceptible, while the radial, being smaller and more distant, wonld appear to be unchanged ; or, suppose an engorged liver, or spleen, or hepatized lung, it is by no means irrational to assume that some change would occur in even a remote artery. Our experience with the fact that ligating a limb will check an hemo- ptysis or other hemorrhage exhibits the same fact. Out of similar observations may possibly have grown the whimsical oddities of the Chinese. What the change in the arterial wave, remote from the source of disease, may be, we may not be able accurately to determine ; but in the artificial system referred to, it was a peculiar oscillating feel, sometimes a thrill, and more frequently an increase in the fullness, suggestive of the pulsus magnus et durus of old writers. The Sphygmograph, however, may yet be able to determine this with approximate certainty ; and, though we laugh at the Chinese, it is not impos- sible that it may reveal a difference between the right radial and the left, when an organ on the right side is the seat of disease. Laying aside Sphygmographic definition, the pulse may be briefly defined to be the perceptible distension of those arteries of the body which are accessible to touch or sight; and in a purely physiological sense the distending process may exhibit singular variations. 34 THE SPHYGMOGEAPH. There are some that are marked and familiar. The variation may be that of interval (increase or diminu- tion in frequency), as under emotion, fatigue or exer- tion. Rarely it may be that of rhythm, the beats being unequal or intermittent ; this, however, is more frequently other than a physiological variation. The most common form of it is probably that in which the period of rest is prolonged, due to a derangement of the sympathetic system. To say that it is, or may ever be, a purely physiological variation, assumes, I am aware, to decide a question concerning which differ- ence of opinion exists. It may be a variation of volume, as in the plethora of the young and robust, so long as this falls short of disease ; more strictly this is exemplified during the contraction of the capillaries from cold. The variation may be one of duration of impulse— that is to say, the distension may be soft and even, or have a sharp accentuation due to nervous excitement. The latter change is commonly accompanied by a sense of vibration when the ear is applied over the heart. The shades of variation are more clearly expressed in the Sphygmographic writings, on charts 1, 2, 3, 4 and 5. Pathologically, the variations of the pulse are of of greater significance ; thus changes in frequency THE SPHYGMOGRAPH. 35 may indicate the wide departure from health of cere- bral disease or excessive fever, or the steady sapping of vital energy in any constitutional disease, when, as expressed by Latham, it has engaged the nervous sys- tem perilously. Quickness , as distinct from frequency, assumes a new signification, as in phthisis or inflam- matory fever, or the impaired and irritable heart of dissipation, or excessive use of tobacco. Volume, in a pathological sense, becomes the index of cerebral compression, of blood poisoning, of hyper- trophy, or the loss of contractile tone of the artery itself. The variation of rhythm is still more important, whether as the precursor of a gouty paroxysm — of the action of certain poisons, as of digitalis or colchicum ; or as indicating mitral disease (Sanderson), or fatty degeneration (Dr. Todd). Strength, as indicative of increased tonicity ; and weakness, as of dilated left ventricle, or unhealthy blood ; of ebbing life in cancerous disease ; or the debility of innutrition, are qualities most familiar. Tension, or resistance of the pulse, finally offers to the touch a guide of considerable importance ; and when we shall come to consider its pathological value from a sphygmographic point of view, will be seen to deserve more than passing notice. The arteries, full to repletion, are incompressible, be- 36 THE SPHYGMOGKAPH. cause unable to free themselves from the accumulating blood with sufficient rapidity, and the fullnes may be due to either interference with avenues of escape in front (the capillaries), or exaggeration of quantity of fluid forced into them from behind (over-working heart). In the former case a deranged sympathetic system may be indicated, and in the latter an hyper- trophied left ventricle. Before proceeding to the consideration of these varia- tions from a sphygmographic stand-point, the cursory and brief manner in which they have been reviewed, suggests a summary, and probably no better could be given than by quotation from the work of Da Costa, on Medical Diagnosis, pp. 38 and 39 : " A hard, full, frequent pulse occurs in active inflam- mations, and in most of the acute diseases of robust persons. A hard pulse, full or small, bounding or not, if unconnected with acute symptoms, leads to the suspicion of cardiac disease, or of an affection of the artery itself. A tense, contracted and frequent pulse is met with in a large group of inflammations below the dia- phragm, as in enteritis, peritonitis and gastritis. A frequent pulse, full or small, but rarely tense, is the pulse of most idiopathic fevers. A very frequent pulse, but very feeble and compres- ' THE SPHYGMOGRAPH. 37 sible, is the pulse of marked debility, of prostra- tion, of collapse. A pulse frequent and changeable in its rhythm, is produced for the most part by disease of the heart or of the brain." More particular features of the pulse-wave developed by the instrument we are considering, such as are due to elasticity, contractility or locomotion of the vessel itself, the relative tension of the venous and arterial systems, the condition of the capillary structures, etc., may be better dwelt upon, after an endeavor to under- stand the hieroglyphics themselves. CHAPTER III TRANSLATION OF TRACINGS. The different portions of a sphygmographic tracing, which possess any appreciable meaning, are termed the events of the tracing. The first event, is the sudden, primary ascent, or shock-wave. The second event, is the true systolic wave, or wave of filling of the vessel with blood. The third event, is the diastolic collapse, or descending wave, the line permitted by the emptying of the artery. The fourth event, has generally been considered the diastolic expansion or recurrent wave — the wave of dicrotism. (In order to introduce no new element of confusion, into our subject, it will be so considered in this essay, although in some tracings there appears a wave evi- dently preceding this, viz., that of recoil. Instead of making it a new event, it will be introduced like com- pressibility as one of the general elements of a tracing.) THE SPHYGMOGRAPH. 39 The s7iocJc-ioave, or first event. Sphygmographically, the pulse-wave is found to indicate several distinct occurrences. If the artery be full when the heart contracts and discharges its blood into the aorta, the first occurrence is a swiftly trans- mitted impulse, similar, as pointed out by Professor Sanderson, to that conveyed through a series of balls suspended in a straight line. Upon striking the first of the series the last or outer one only is propelled. (As explained by him, when objected that this occurs only with elastic bodies, and that blood is not elastic, the elasticity of the arteries by a well-known law gives to their inelastic contents their own pro- perty). This transmission may, if the artery be full, be almost instantaneous, and is important to the pro- per understanding of all tracings. The writer quoted has ascertained that this transmission is at the rate of about ninety feet per second. It is at any rate frequently exhibited by a sudden ascent of the trac- ing just ahead of the filling of the artery ; and is consequently the cause of the first wave, under the circumstances named, and indicates either one of three things (see example A) : A A 40 THE SPHYGMOGBAPH. 1st. Increased vigor 'of contraction of the heart, as in hypertrophy of the left ventricle. 2d. Increased irritability, dne to disease of the sym- pathetic system. 3d. Increased irritability, due to simple nervous ex- citement. The amplitude of this initiative wave is in direct 2?roportion to tension. The distinction between tracings in which this fea- ture is due to pathological change and those in which it is a purely physiological event, may not always be easy, but even if it were supposable that ordinary means of auscultation and percussion were not avail- able, or, as in the case of a deaf examiner, such assistance to diagnosis were impossible, there are yet two points of difference of great value : one, the per- sistence in disease, of increased impulse, as communi- cated to the hand applied over the apex of the heart — tending rather to increase during the sitting, and. exhibiting a peculiar heaving motion (and suggestive, as observed by Walshe— p. 223, Dis. of Heart — of a pressure forwards, steadily against an obstacle) ; its increase, moreover, in extent, and quite frequently the lowering of the point of apex beat. The other point of difference lies in the amount of pressure required to bring out the peculiarity. THE SPHYGMOGEAPH. 41 Generally, unless when the disturbance of the sympa- thetic is sufficient to amount to disease, as in excessive use of tobacco, the increase of pressure tends to oblit- erate it in the simple form, while in hypertrophy a great pressure rather exaggerates it. (It is to be remarked, that simple hypertrophy of the left heart is now referred to, without dilatation or valvular disease ; these complications presenting changes in the tracing peculiar to themselves.) Should a diagnosis in any given case be of import- ance, the action of proper remedies and the disappear- ance of the wave under their use would be sufficient to establish it, for it may be here remarked that this wave of a tracing is by no means an essential one. The normal tracing of perfect health is generally a single symmetrical wave, of which the following is an example : And in this the transmitted impulse which we have described as causing a wave of shock, is merged into the next or true systolic wave, . the wave of distension or simple filling. This, which has usually been described as the second event, is most marked when the artery is a little less than full at the time of its occurrence ; and it is the prominence of this which is referred to in the axiom of 42 THE SPHYGMOGEAPH. Marey, that "amplitude of a tracing is in inverse ratio to the tension." With the instrument I have used, this axiom is cor- rect only in a very limited number of cases, and as only the power of an instrument to ascertain and record pressure with readiness could demonstrate this, it may here be the best opportunity to refer briefly to it. A moment' s reflection would seem to make it certain that if an artery be partly empty, a wave transmitted through it would lift its surface higher, and conse- quently give a wider tracing than if already full ; but supposing the amount transmitted be the same in both cases, the statement could be true only if the disten- sible quality of the vessels were within narrow limits, as is the case when their coats are diseased, and the quantity of the fluid therefore forced to pass more slowly ; and I have not been surprised to find that as the vis-a-tergo remains in both cases the same, and the distens%le quality of the artery is -very great, the am- plitude bears no determinate ratio to the fullness of the vessel, i. e. the tension. In many instances, as will be seen upon the charts appended, a tense artery which will bear the highest pressure, gives the greatest amplitude of tracing. The explanation of this apparent discrepancy of observation, probably lies in the fact already alluded THE SPHYGMOGKAPH. 43 to, viz., the adjustment of pressure in the instrument used, for if a uniform rate be employed in all cases the axiom would be universally true. With facilities for adjusting pressure, the axiom might be that " am- plitude of systolic wave appears in inverse ratio to tension when a uniform pressure is maintained upon the instrument used, Met often bears a direct ratio to it when a graduated pressure is employed" The reason for this distinction will be obvious when con- sidering the physiological and pathological signifi- cance of tension and its measure, compressibility. It may be more clearly explained by the observation, that when we press firmly upon or into the distended artery we obtain a measurement not so much of the distension of the vessel as of the force employed for its dilatation. The systolic toave, or second event. Theoretically, in a pulse we should have but two events, viz., the filling of the artery, which is more or less quick, owing to the character of the heart's action, and its emptying, which is more or' less slow ; and practically these are the essential elements to be con- sidered, for it is evident that by the former would be shown any increase or diminution in the filling force, i. e., any increase or decrease of vigor in the heart's action, or any interference with the current by pres- 44 THE SPHYGMOGBAPH. sure or otherwise between the heart and point of observation ; and in the latter, i. e., the emptying of the artery, would appear any distal obstruction, whether capillary or venous. With the first of these we have to do in considering the systolic wave, or second event. As already ob- served, it is sometimes merged into the shock-wave, which should precede it. It is sometimes not at all discernible as a wave of distension, because merged into a quickly succeeding wave of impulse, and is subject to greater variations than any other part of the tracing. It was formerly supposed to be most fully developed in the pulse of old age. In the following hypothetical tracing it is indicated by the letter B B B, and represents in the artery the systole of the heart. It is quite frequently almost impossible to determine whether it is postponed in the tracing, and so appa- rently hidden by a reflex wave yet to be considered, or really takes the place of that wave. The reader may in such cases be able, from the amount of material furnished, to form an independent opinion. CHAPTEE IV THE SECOND EVENT OP A TRACING. The tracings on the chart opposite this page are ex- amples of varieties in this wave, including some that may be subject to two interpretations. The first is the tracing of a healthy person whose pulse generally gave a plain smooth wave, but who in this case was under the slight influence of the fluid extract of gelseminum sempervirens, taken for exper- iment. It is peculiar in nothing save the smoothness with which the wave of systole is developed. The second is of the same person, under widely different circumstances. The systolic wave begins without marked ascent, apart from the shock -wave, and is indeed probably merged wholly in it, and were it not for the slight indication of the two events exhibited in the first apex of the writing, we might suppose the shock- wave to be absent. The fullness of the artery is prolonged almost to the beginning of the succeeding pulsation. This was due to the slow emp- tying of the capillaries, a condition arising purely from derangement of the sympathetic system from over-taxation and fatigue. 46 THE SPHYGMOGRAPH. The third is an example from a healthy woman, twenty-four hours after delivery, and after and during a profuse metrorrhagia. This rounded wave has usually been considered the evidence of slow empty- ing of the capillaries, and almost always as indi- cating impairment of the coats of the smaller arteries. Example number six, which follows, illustrates this condition ; but there is an abundant evidence to show that this is a far too limited signification. The case we are considering is an evidence of this, for since that observation was made, tracings have been perfectly normal. Other examples on the same chart show that no degeneration of arteries would be likely to exist, owing to the youth of the parties. In the present instance the explanation probably lies in the fact that the heart failed to fill completely during its diastole, and therefore lacked the customary stimulus of impletion, for no obstruction to circulation seems to be indicated in the tracing. The fourth is the record of a man subject to epi- lepsy, but in whom no organic affection of heart or other thoracic viscera could be detected. This variety is frequently met in organic disease of the heart, but generally only when cerebral symptoms have also given trouble. The fifth is that of an hysterical female, with no disease except uterine anteflexion— the only source of THE SPHYGMOGRAPH. 47 annoyance in the case arising from globus hys- tericus. The peculiar elevation of the systolic wave above the first is an unusual event where no disease exists, and in this case was probably due to the volume of blood discharged into the aorta with each pulsation, and a perfectly unobstructed capillary delivery. In such cases tracings may vary singu- larly, during a sitting, since any of the disturbances of the capillary circulation, so common in hysteria, may at any moment occur, and a state of arterial or venous tension change the whole character of the record. The sixtli exhibits the compressible artery with weak heart and degeneration of arteries of a patient eighty-one years old, suffering from chronic phthisis, and frequently from venous engorgement. This latter condition, which properly belongs for description under the subject of "tension," was in this instance always the precursor of an increase of cough and other troublesome symptoms, which compelled the patient to take to the bed. Singularly emaciated, the veins of the body at such times, where most superficial, were prominent, dark blue and distorted. It is impossible to conceive a nearer resemblance to an anatomical preparation de- signed to show the veins, than the hand of this patient, yet when relieved by proper nervous stimulants, or 48 THE SPHYGMOGBAPH. otherwise, they were not different from those of other emaciated people. The radial arteries gave no indication to the touch of calcareous degeneration, nor indeed is it likely that such existed. The seventh is the record of a young lady twenty- three years of age, suffering from aortic valvular dis- ease. The general flatness of the wave, which has already been alluded to as a subject of some difference of opinion, the distinction between the first and second event and the prominence of the latter, as in the case of Mrs. Y. (see above, example 5), are the only points of interest. The tension, as indicated by the degree of pressure requisite, is greater than in any of the preceding, and indicates a prolongation of effort of the heart to overcome some obstruction. The eighth is the tracing of a young man, suffering from serious valvular disease. The affection followed acute articular rheumatism, and in many of its circum- stances is a case of particular interest. So far as our present purpose is concerned, however, it is presented merely as an illustration of a peculiar form of systolic wave. The other features of the tracing will be ex- plained in their appropriate place. The ninth is a tracing taken over a subclavian aneurism, which subsequently burst, and in which a post mortem examination was made. The systolic THE SPHYGMOGRAPH. 49 wave is evident in each apex of the writing, varying in each to a remarkable degree. The abrupt termination of the wave, as shown by the sharp angle which deter- mines the commencement of the collapse, indicates the absolute want of elasticity of the vessel, and for the present is the point of chief interest. The tenth exhibits the marked preponderance of the first above the second event, in a young lady with aortic obstruction and regurgitation. The high pressure required upon the artery is a feature of interest. The eleventh gives probably the smallest systolic wave obtainable as a distinct event, and contrasts remarkably with the preceding. It is the record of a young man during slow convalescence from a pericar- ditis with endocardial complication and subsequent hypertrophy. The twelfth was taken from the same person on another occasion. This remarkable tracing may be open to more than one interpretation, and it is not improbable that I may be mistaken in translating it, simply as an exhibit of the two events we have been studying. If I am right, the systolic wave is deferred consider- ably beyond the usual time, and the artery once filled remains so till after the heart has again begun to con- tract. The only other cases in which I have observed 50 THE SPHYGMOGEAPH. this peculiarity have been two, a victim of senile gan- grene, and another, a case of advanced phthisis. This event may have the following variety of signi- fication : 1st. It shows the manner in which the chief function of the heart, that of supplying the blood to the arte- ries, is performed, whether as to force, duration of propulsive effort or method of cessation. 2d. The condition of the capillaries may by it be to a great extent determined, especially with reference to their contractility, as may be seen by reference to the changes grown out of sympathetic disorder or degene- ration of their tissues. 1st corollary. The condition of the nerve supply to the heart, and the possible influence of cerebral disor- ders upon its action, may be to some extent ascertained. 2d corollary. It will, in most instances, determine the volume of blood delivered at each cardiac systole. 3d corollary. It may enable us to decide upon the condition of the mitral or aortic valves. The next feature of a sphygmographic tracing is one that naturally follows the one just considered, for as that was a wave due to the filling of the vessel, this would show its emptying or collapse. As it is of course synchronous with the cessation of the filling force and the diastole of the heart, it has generally been termed the diastolic collapse or third event. THE SPHYGMOGBAPH. 51 The third event. This, as already said, is but the evidence of what occurs in the artery after the distending or filling power is removed. A moment' s reflection will show that as the arteries are for all practical purposes open only at one end, i. e. toward the capillaries, it is through them that the contained blood must find escape. If it does so, other things being equal, the wave of distension, i. e. the systolic wave or second event of the writing would subside suddenly or slowly, in direct ratio to the freedom of exit ; but, as one may easily imagine an artery only partly full and without any means of escape for its contained blood, in which a propelled influx would produce distension and subsequent col- lapse due to a retirement of the wave, it is evident that the collapse may not always be a simple or easily explained event. Such is the case, and the variations in this part of a tracing are therefore of considerable importance. It has been suggested that the period occupied by this collapse of the artery is significant, because the measure of duration of the contraction of the heart ; but that this can hardly be the case, would appear from several facts, viz. , that although when the heart' s contraction ceases, the propulsion in the aorta also ceases almost simultaneously, yet such cannot be true of the remote arteries, and at the instant of cessation 52 THE SPHYGMOGEAPH. of current at the sigmoid orifice, there is still an onward movement in them. It is true, that this condition must be of brief dura- tion, but as fractions of seconds would be of value in estimating the actual duration of contraction in an organ whose evolution often occurs twice in a second, this feature of the tracing could hardly be relied upon as an index of it. Further than this, there may and often will occur in a writing what I have elsewhere alluded to as between the third and fourth event, viz., a wave probably of recoil. This may be noticed in the tracing marked four, "on the chart illustrating the systolic wave or second event. Its significance will be weighed in con- nection with the fourth event, yet to be explained. For the present purpose, it is only necessary to say that as this occurs during and before the actual cessa- tion of the collapse of the artery, it must interfere with our deciding the instant of such cessation. For examples of this event in a tracing, reference may be had to the chart above alluded to, illustrative of the systolic wave. The slow and even emptying of the artery is seen in example No. 6. The sudden collapse in Nos. 8 and 11. The abrupt yet confused collapse in No. 9. The failure of the event in No. 12. THE SPHTGMOGRAPH. . 53 That of the first case was due to a weak heart, but pervious though probably inelastic capillaries. With an excited or hypertrophied heart, this impairment of capillaries would have effectually prevented so even a collapse. Those of the second cases (Nos. 8 and 11) were due to aortic regurgitation. Of the third (No. 9) to aneurism. Of the fourth (No. 12) to commencing hypertrophy with excitement. The chief significance to be attached to the third event is probably as follows : 1st. By it we may determine the manner of subsi- dence of the propelling power, such as would arise from dilated or weakened heart, or regurgitation of the blood back into the heart, whether from the aorta into the ventricle or from the ventricle into the auricle. Aside from the assistance to be obtained from other parts of the tracing, the existence of eccentric, as dis- tinct from concentric, hypertrophy might be proxi- mately determined. 2d. By it, also, information may be gained as to the manner of exit of the blood from the arteries into the capillaries, a matter the importance of which is closely allied to the condition of arterial or venous tension, and valuable from a physiological point of view, as of assistance in estimating the character of nerve supply and the action of remedies. CHAPTER V. The fourth event. This lias been variously styled the diastolic expan- sion, the dicrotous wave, the wave of recoil and the recurrent or reflex wave. In a hypothetical tracing it could be represented as follows, letter C. As this wave is a feature often of importance, and has been the subject of much discussion, any new facts elicited by a new instrument may serve to settle its trne significance. Naumann and Marey have supposed it a recoil of the blood current, due to a rebound against the closed aortic valves. Many experiments made by Sanderson have dis- proved this theory, and a reference to the fourth tracing on the chart, opposite page 45, affords confirmatory evidence. Experiments made by myself also with an artificial heart, and elsewhere published, seem to ren- der such an explanation untenable. As intimated on the preceding page, the tracing just alluded to shows that the wave of recoil correctly inferred to exist by Nanmann and Marey, comes when at all, before the THE SPHYGMOGKAPH. 55 collapse, and not after, and is probably almost syn- chronous with the closure of the valves. The true diastolic expansion occurs subsequently. Omitting further allusion to the opinion of others, I may be pardoned the attempt to explain the wave by reference to my own observations, but before offering such explanation would present examples of the event under varying circumstances. The first (see chart of 4th event) is the case of a man under treatment for persistent vertigo, of full habit, robust and broad-shouldered, but with the red vessels apparent on the cheeks, and the peculiar appearance suggestive of apoplexy without any other actual or well-marked signs of it. For the present purpose, it is sufficient to say, that the general capillary circula- tion, of the integument at least, had never been impaired. Critical examination of the heart indicated disease of the aortic valves. The tracing shows marked shock-wave, sudden collapse of the artery, and conse- quently either the rapid escape of the blood through the capillaries, as if by their dilatation, or a limited supply of blood at each pulsation. In this case the slip of paper was moving slower than usual. The influence of this variation in an instrument will be hereafter considered. The second is that of a young female suffering from hypertrophy and aortic obstruction, with possibly 56 THE SPHTGMOGEAPH. aneurism of the arch of the aorta. The most sug- gestive evidence of the latter seemed to be a marked thrill communicated to the hand when placed on any part of the thorax. The slow filling of the artery as indicated by the flat- tened apex of the systolic wave, the somewhat sudden diastolic collapse, and the irregularity of the tracing, suggest a failure of the heart to propel a great amount of blood, such as would be the case, for example, in mitral insufficiency, where a portion of the blood is forced back with each systole into the auricle. The tension is somewhat greater than the preceding, and the dicrotic wave not remarkably prominent. The case itself will be elsewhere considered. The third is the tracing of a young man, age twenty- six, with but one arm, amputation having occurred at puberty after an accident. The patient had generally been known as a healthy, hard-working man, but at the time of observation was somewhat debilitated from over- work and anxiety. A peculiar murmur could be heard over the pulmonary valves, but no distinct evidence of organic disease was discoverable. The indications of the tracing seem to be such as would arise from impaired action of the heart due to simple debility. The skin was moist and soft, the muscles flabby, and the integumentary circulation atonic. The patient has since recovered. THE SPHYGMOGKAPH. 57 The fourtli is the record of a man supposed to be sound, age forty, and accustomed to much travel and out door exercise. When thus engaged he is appa- rently vigorous, with exception of a chronic pharyn- gitis, but a few weeks confinement at office-work pro- duces languor, cough and debility. Eight or ten years since he raised considerable blood, probably from the lungs. A rigid examination gave no positive evidences of thoracic disease at the time of the observation. Dicrotism is not well marked, and might possibly be deemed absent but for the presence of the first and second event combined in the first wave. The collapse of the artery follows, and the next ascent is therefore truly dicrotous. Here also there appears atony, either of the heart or arteries. The fifth and sixth are both from patients weak- ened by disease ; the first a female with consolidation at the apex of one lung, occasional haemoptysis and progressive debility ; the other a man age sixty, much worn by the exhausting discharges and general irrita- tion produced by a sloughing foot, probably a case of senile gangrene. The seventh is a singular tracing for a person free, to all ordinary means of observation, from organic disease, but debilitated somewhat by excessive use of tobacco. The eighth is from a man of fifty, during the pros- 58 THE SPHYGMOGKAPH. tration of a low form of delirium tremens — healthy so far as known. The ninth is common in phthisis, and in this case was the record of a young man rapidly growing worse and with extensive cavities. The tenth exhibits very plainly the wave we are con- sidering. It is the tracing of a young lady, age twenty- eight, much debilitated by prolonged mental work, the entertainment of company, and the cares of a large household. This patient has phlebectasis laryngea and hypertrophy with aortic regurgitation. The eleventh is the case of a young gentleman with cardiac disease and^debility, similar to. the preceding. Other examples of the dicrotous wave, or fourth event, will be found in a subsequent part of this work. In summing up the examples given, one feature pre- dominates, namely, a condition of atony either of the capillaries or the heart. We may, therefore, enquire whether this be the cause, and to what extent the phe- nomenon is explainable in our experience. Two especial conditions are alluded to by Professor Sanderson in his work (p. 64), as giving rise to this wave, viz., a smaller quantity of blood than normal discharged by the heart into the aorta, and conse- quently a less quantity to be disposed of by the capil- laries ; and second, a dilatation of the capillaries by THE SPHYGMOGRAPH. 59 which a normal quantity may be just as readily passed through them. Experiments with the artificial heart, which need not be given in detail, show conclusively that freeness and not constriction of capillary circulation favors dicrotism. The explanation of this phenomenon, which at first seems at variance with what we should expect, may be seen if we analyse the method of trans- mission of blood from the heart through the tortuous capillaries to the veins. As already said, when the onward movement ceases in the aorta and large vessels it is still evident in the remote and smaller ; the cessa- tion, beginning at the heart, travels quickly toward the periphery. During the most violent portion of the propulsive effort of the heart, the onward move- ment may be almost uniform throughout the calibre of any given remote artery, as, for example, the radial ; but as this diminishes, the slowing of the current must appear in the part of it nearest the coats of the vessel, according to a well-known philosophical law ; the best exemplification of which is seen in a running stream. In this, the water nearest the shore moves perceptibly slower than in the center, owing to the friction. In a tube of small dimension another principle is intro- duced, viz., that known as capillary attraction. In both cases, however, the same thing is true ; the central part of the current is the last to fail and cease. 60 THE SPHYGMOGKAPH. These two philosophical facts seem to explain in every particular the phenomenon of diorotism. Under all circumstances, except those of such rigidity of arterial coats as to resist slight impressions, the con- dition might be educed. Careful adjustment of the instrument shows this to be true. If the arterial tissues were in a state of atonic relaxation, the wave would be increased. This also is true, for the condition has been heretofore best known in connection with adynamic fever. Were the amount of blood thrown into the aorta small, an event usually accompanied by relax- ation of the elastic and contractile tissues of the body, the wave would be quite prominent. This, also, is true. I am not aware that this explanation has ever been offered except, elsewhere, by myself ; but as it appears to be consonant with practical experience with the instrument, and in no ways at variance with the expe- rience of other observers, it has appeared to me the correct one. In this connection it may be interesting to ascertain whether the deduction of Prof. Sanderson, that ' ' dicro- tism is characteristic of that condition of the circulation in which the arterial pressure is diminished while the venous is increased," is generally a correct one. 1st, Tracing (No. 163) was taken from a person in whom the venous engorgement was excessive, and THE SPHYGMOGKAPH. 61 which was evidenced by exacerbation of weakness, and of all the unpleasant symptoms occasional during her previous illness ; so great, moreover, that the super- ficial veins were singularly prominent, even painfully so, and yet the chief feature in all the tracings taken was, as in the one given, the absence of dicrotism. Three days later the venous engorgement had subsided and the arterial pressure had increased, dicrotism being faintly evident. 2d, Case (No. 70 to 73 — see chart) shows a precisely opposite condition. The patient whenever exposed to cold has attacks of vertigo, dyspnoea and faintness. At such times the veins, wherever within reach of touch or sight, are found flaccid and almost empty. The arterial pressure is very great, as will be seen by the degrees marked upon the tracings, and dicrotism is well marked. On other occasions when the equilib- rium of pressure in the venous and arterial systems is more nearly maintained, the dicrotic wave is reduced or absent. These two examples have been taken at random, and show that the deduction quoted cannot be universally true. They do not, however, militate against the explanation of the wave as given above ; and one additional and important fact may be added to this explanation as corroborative, viz., that it explains the well-known connection between dicrotism and hemor- 62 THE SPHTGMOGEAPH. rhage, of which in typhous fever it is so often the precursor. The significance of the fourth event may therefore be set down as indicating chiefly — -1st, a condition of atony of the arterial tissues, particularly of the capil- laries, as evinced in the dicrotism of adynamic fevers ; of debility from impairment in vigor of the heart, and of reactionary debility, as after delirium tremens. In all of these it is not improbable that the deficient tonicity is due to the condition of the inhibitory nerves. The dicrotism of epilepsy, an example of which will be found in a later part of this Essay, and to which attention was probably first called by M. Voisin in the Biennial Retrospect of the Sydenham Society, 1867-8, p. 471, would form in this connection the subject of an interesting essay, so also that of asthma, vertigo, sun- stroke, etc. , as seen upon the charts appended. 2d, From the very nature of the above essential pe- culiarity, it may be of value as a ground for prognosis when occurring during the progress of any wasting disease. Before leaving the subject of the fourth event of a tracing — the dicrotous wave — it may be in place to observe that the term has given rise to some confusion, because not literally expressing its actual meaning. Derived from &v and Kuoriu, and meaning " I strike twice," it has conveyed to many casual readers the THE SPHYGMOGRAPH. 63 impression that any break in the smooth, even wave of robnst health is an evidence of dicrotism. From what has been said concerning it, this will be seen to fall wide of its proper meaning. Tracings are, in a literal sense, frequently tricrotous ; but for purposes of Sphygmographic interpretation, not so, correctly speak- ing. The words tricrotic and dicrotic, as similarly derived, should be held as having similar meaning, and this meaning was settled before the invention of the Sphygmograph. The double beat perceptible to the touch of the older physicians could arise only from the occurrence of a second impulse, late enough to fall just prior to a new systolic wave, and quite subsequent to the diastolic collapse. Whatever, therefore, may be the number of waves preceding the collapse of the artery, they cannot be termed dicrotic ; the meaning of the term, as established years ago, should and does retain its old significance. CHAPTER VI. GENERAL PROPERTIES OBSERVABLE BY THE SPHYGMOGRAFH. COMPRESSIBILITY, OSCILLATION, LOCOMOTION AND RECOIL. Many of the general properties of arteries and the circulation have been incidentally considered during the above remarks. There are, however, some of greater or less importance, deserving especial mention, viz: Compressibility (or tension), recoil, and oscilla- tion of the circulating fluid ; and of the arteries as purely mechanical contrivances, locomotion. Of the latter quality, which is properly but an ana- tomical peculiarity, little need be said, save that as it is sometimes excessive, it may communicate a vibra- tory character to a tracing, sufficient to be mistaken for true oscillation of the blood current itself, or cause vexatious delay in obtaining a proper record. The property of locomotion grows naturally out of the elastic character of the arterial tissues, and is simply that displacement of the vessel often observable in old persons, whose emaciation renders the arteries quite superficial, or in any one, when under sufficient excite- ment to cause an unusual volume of blood to be forced into the arteries by the heart. In the former case, the fact that all arteries elongate THE SPHYGM0GRAPH. 65 under the pressure of the blood, as well as expand laterally, is quite evident to the eye, and it is probable that the locomotion is much exaggerated by the im- pairment of natural elastic resistance due to age. In the latter case, it will be usually found accom- panying great arterial fullness. It is easy to perceive how any excess of this quality should exhibit itself in a tracing. Generally, however, the groove in the pulse- spring already described, by fixing the vessel against lateral motion, prevents the marring of the record, and the regulation of the pressure- spring utilizes the quality to increase the amplitude of the tracing. The chief pathological significance of locomotion is probably in connection with cases of aortic regurgita- tion, as remarked by Dr. Corrigan. Oscillation or Vibration. This quality of the circulatory blood is an important one in connection with the translation of a Sphygmo- graphic tracing. It is to be carefully distinguished from the waviness of line caused by muscular or ten- dinous tremor, which is of itself an interesting feature. It may be the best described by a simple illustration : When a rubber tube of small calibre is attached tc the ordinary house supply pipe, from the hydrant, the current produces to the touch no appreciable thrill; 66 THE SPHYGMOGRAPH. but when compressed slightly between the point of observation and supply, a peculiar vibration is com- - municated, often to such extent as to be accompanied by a low musical note. This vibration is most evident at the point of pressure, and diminishes as we recede toward the open extremity. Partially close the ex- tremity, as by the division into smaller and branching capillaries, and the thrill is still better transmitted. Now apply the pressure more remotely, and examine in the opposite direction, no thrill or vibration is com- municated in this direction, i. d «j =M Cu CD O o o m CD s o o bp O !> P! bfc 3 &JD ^_< r-l CD •3 (H fl CD CD W Ph CD cd CO cd CD Jo Ph' O r- 1 rd CG id o d T-H CD pi 0Q o -1-3 o ' i r6 CD o p ■+-3 0Q ^ 'g3 "oQ CD '3 ft -t-3 O o of rjH. oq '"d 1 W & OQ O CD O © CD ^ O o CD += ^3 a O O CD CD H i — i C3 o d p] c3 CD « pq o H O O Ph' Ph' CM d 03 Ph" "o oq O d CD m c3 CD Ph' iO o 0Q bJO .3 o oS -1-3 Ph' iO T-H rH CO o o" d i C5 cd T-H 1— 1 rH 136 THE SPHYGMOGKAPH. CO a o ^ CM fl DO r9 O +3 ft 9 l '§" -a o CO .e s bJD i o ►J o CO 0) fr £ CM <3 O Ph M o 9 D oi 15 CO ■^ d iO o r- 1 o S rH Eh «4 o O GO d ^ 5 He* JrH H bC .s o GN> o ~ CM -1-3 ft co "55 g 5 o < > « H en o +3 CO CO o3 CO ?H CO .9 O co CO O CO CO P3 ft O ft CO ft Pn H o o 1H GO 3 id CO co CO CD GO £ W P* « a .9 63 co "53 CO rH si CO bO .9 rH bfi • 9 1 H-3 S o H' £> "o c3 1 CO 'o C3 "o C3 £ H j§ EH, "53 CO > £ EH EH CO 00 'ft o3 .2 CO 'ft c3 pH o3 CO CO O Ph" bD o " O Ph' Ph CO -t-3 -(J CO CO CO ■+3 O io fl s o IQ r^ «H ^ CO tij c3 io o -t-3 O © rH rH rH rH rH rH rH THE SPHTGMOGRAPH. 137 a 15 es P «P X 03 ^ ^d o # p p r >* Q s H 1l +3 1 — 1 rd EH O ►J c CD O Xfl m P-i PC c3 02 N JC ! ft JO* T— 1 * "r-H O +2 -+i cd ^d o fH p « CD h-=> •4^> "co CO 1 OQ M o c3 rO CD B p < 02 £ o e O H-= 0) CO o a O o CD * «Pt rH 1— | i o i p O =H += o o OQ CD 'Si bC ft CO c3 P o p Q a 3 <1 — ■' O ^ 1=1 .s O o Ph 3 H Oh M W Q 30 M -1-3 .s CO ^ D o H «i « OQ o Hi H 1— I OS 1-1 bC • S 2 9 o CO CO CO o o 0) P3 CM OS rH .2 "co PI CD -t-= c3 CD fee o CD 0< CD fcJD .S' P to H-3 c3 CD CO CO CD rH .2 'co Pi CD o o c o o o CO Eh Ph CM © 1 CD o OS rH 'o o +3 1 CD CO c3 M CD C CD o co H-= 1 — +: ■J. 0) ^ N .1 ^ CD CO CD N r Cv CD aT rH o p e3 «t-H Ph' Ph" ~c3 CO s 0Q p p P^ CO CD 'o CO CD "e3 o CM s CM S) Ph 3 "0 9 f-4 & g d d d 1— 1 ^H rH i—i rH rH 1— 1 THE SPHYGMOGRAPH. J 31 co" H co O fl rd C+5 1 o CD O M § CD «1 "A ^ % CD Ph £ GO ^ M M CD o 03 K P H o .9 CD o Hi o 'a? CD O ^ GQ w fr ^ Ph N a O P Ph' Ph' o 1— 1 OS rH m i> ?3 o o 1— 1 CD <=H — 1 PI <3 id OS CO Pi CD -H-3 Pi .9 co -f3 CD !> » CO c3 CD CD co o cT CO OS ■4-3 CD i 3 ^ « "PH ■+3 co W i— i O < > Ph H cc n o g p P3 o bfl "o o3 .2 "~h2 .3 c5 co a E Ph s a ■5" ^ c3 EH Ph o 1—1 c CO -(-3 co O c3 M ft P3 io O n O .S ^ a IB 'co a CD CD b£ *i— | co "3 o r" i Ph O CD EH o o -1-3 co Ph' Ph O £ *i p- o H rH e3 +3 1=§ r-i H OS OS c r- 5 CD H rH d rH 140 THE SPHYGMOGRAPH. O 02 Ph CD > CD o P5 ■+3 O H o GN* 1 M O Eg CD ^3 CD M c3 <3 3 o o en +3 to ■+^ 1 D fe O s c3 id CO . O s © r-i H <1 r-i jz ID ^ o >» o 1 1-] "(X) 02 *5d PI +3 S 3 PI .2 o s CD +3 CD 1 O Pi CD 5 § £3 id 3 o 02 i-H "i CD o .9 1 s ■+3 3 ^ e3 c . rO Q 3 Eh o H a & m OS rH bJD .5 "o o3 *n a c P. Z f- z O j. o3 I CM C '+- c p" a C CM CO OS H &C EH P o "-+3 CD m a a CD N 4-: 05 P N m S N CD K B Ph* c fc 'oD P- Ph' Ph io P »G io § £ GO CO H ^ • r-i t rH rH o o C rH rH rH rH rH r-i rH THE SPHYGMOGRAPH. 141 i — i CO H ^ cd Q CTJ k. ^Zj o o CD H CD CD r— 1 o !» pi 44 co o o PP qP Hi C £P O c3 < 1-5 < p PI O K CO O 3 o Hi 'a; CD PR CO > o CD +3 ■ rH o be .3 M o o i — 1 r — 1 CD 1 CO 2 bD . <\ >* CD o hH Ph' '$ "bC id > CO d o o *S rH CO R d d OS rH ■M hH m CD CO bO £ 6 CD CD' += C^ PQ "B 1 ffi & 02 CD ■H-3 co HH > pi O CO CD H s CO M Z Ci EH Ph' IO d °2 CO O s 1 CD CO a o o d c3 S C3 bC ^ • 3 £ 1 ■S 9- CD 5 Ph' o CO of d co o CD .Pi i — 1 -M i— i o O d OS tH rH 142 THE SPHYGMOGKAPH. S(-H CD o CD b0 © i O CD cp! 6 rd p +3 -4-= Pi eft •i— i «« +3 CD CD CD «r-l s 03 en "d o3 CO O << CD +3 CS Si a ft B CD «.02 e*H Pi <3 EH CO a CD o 5JD .2 CO CO CO M o o ""cD o3 CD 1' •§ 6 5K o M o CO o PI -1-3 cd" P o &J0 CO CM tH CO bJO CO '3 O CO .a CO CO CD d o p CD CD CO c3 P o CD o tH ?H d CD p4 lO - 5 3 o CD £ c o ^ o o CD a-* CD O o rH tH tH 1—1 iH THE SPHYGMOGKAPH. 143 -+-3 cT CD c o CD ■ rH ~ "^ H ew p O "3 cc rd CO '■0 <3 ft CD o P co o c3 r~ &J0 bb CD -1-3 P P X CD °CO CD C70 •§ 6 Pi co ft CD a CD 1 o 0) P ■ a § CD CD -1-3 o Ph (X CD CD t> W ■d CO Pi CD P o 1 ■+= o o (X p q-i ' o Pi .2 "Eq P i—i Eh 03 ^ bJD c3 -4-3 (3 Pi 'op CD % £ '$■ O '<£ o bC CO b Jo £ ■+= c3 * O ^ -H r& co '& 03 "3 of c3 o PI 3 CO "o rH c3 'cS P co Pj CO bo CO H-3 o o fH o bb bO '3 CM be o 4-3 J -5 c3 M © 03 Eh £ r — 1 co 03 +J CD ^2 5H o a ■+- s3 o 03 o a o CO CO* rH O co 3 144 THE SPHYGMOGRAPH. V JO •1 •to o H ft 6h 5? •1 is CO p CO ^2 •1 g 5s Q> o CO >* 1 *to O 8 •Si o 52 0Q CD co CD 'to JO S i— 1 CO* O JO 5: — *?" 2 ^ f_l • <5 £ f_4 ■S *s 2 ^ "s o & M o^ ~ & 5^ fe> ^ =t-H , . CO CD C^- 3 "to o =H >, CD O O __i o (-H Cj | CD co CD CO •+3 .9 CD p .2 '-£> O CD CO CO CD CO co CO S 'co CD CD CO "^ CD 5 Ph g o fcD CD o H3 3 CD "' cl co ■S •S !-;-{ -1-3 CD ^ .2 'co m O to ~cl CD So 5d CD co CO co CD a 'd 'Pn co 6 -+■3 CD 5b co CD co -1-3 CO CD O CD co S O 2 <^ O O CD -+3 CO § CD 02 co CD o .9 CO .9 efl o °co CD •9 ,5 -1-3 CD s CE CD p O CD -1-3 .9 "^ CD CD O '1 o CO o CD*"' ~£ Ph CD co 0) ^ l d o CO o CD bJO O Id JO CO -1-3 CD O co CD -1-3 JO cl CD CO CO CD -(-3 'CD 3 +3 o fl ^ pi CD „ ^ £ J3 o 5 o CD O CO CD > c o CD CD O o co CO pj T— 1 co i— 1 pj t> tH q-H ^ £ £J C7 1 fl co rt OH <£ rn o O 1 — 1 M hH 1— 1 HH H £ En 1 CD 1 CD w O o g K o ^ £j a S" co CO co W p. Ph i~< Ph O o C id O JO o nc) — 1 ^ ^ o H ai ci T-H OQ o CO o o 10 146 THE SPHYGMOGRAPH. Eh H § * 9 ■+= d th CO S _^ d ° d jxj rr-T ° d !H d 1 JO CM Maximum of seda- tive effect in 12 minutes. ration in iment 45 1st dose. a a I'll O O O m g S d o S d •r-H CD 3 & 2 ®.2 d ^ .d 'd o 53 a W C H . - o •4 • ■+ 3 cd d "g s -4 . CD 1 w o m E- +3 C3 1 1 • "^ d © P . i— 1 ^ a CO « « o rtf H fi d O H Eh " & ^ 03 fa fa CO cp ^ d £ 03 « 'H "8* CD CO CO CD fa fa o O H O w 05 d ii d d d rd r ^ J d "to "§ CO r_l CO a o .1—1 d CO >j CD ^ o< PU O P co D 3 o o I ! I erf CD ■+3 of % 1 S3 d .3 d S d d H (5 • H i "s '1 "a 8 « S JO JO o CM Oi CO & d d p) d d d M •— • 1— 1 HI HI i— i 1 Eh • J. ^ 9 a H S o g a «w id rl as' rl d o • ad T— 1 p P JO < fA H 'I T— 1 w Sb QQ O 9 m OS P JO m o CO THE SPHYGMOGEAPH. 147 o r3 O q-L cS _5 © O QQ CD CO q-n O g r-i — K K o •4-i .-9 CD 'm O 02 pi g 02 02 ji © 02 o - — CD % CM rrt § e3 "qq © © CO £ ^ o 4§ o M cd | 1—1 „ o ac O n3 ^ ^> .2 50 02 m CD p) CO 02 *H '02 '•Th o CD •4-3 fc X "02 c5 O © £ to fd af p CD ■4-= of CD -^ ■4-3 £3 r-l °^H fl "a o -^ "i JQ r ~ 1 ©3 P o xH tH a CO fl S PJ r^ 1— 1 I— I M 1— 1 I c5 © fl o s co ft O 02 ft O id rrt IT CM Tt ""d © © cr © rH xH rj) 148 THE SPHYGMOGRAPH. Synopsis of the two later experiments with Canna- bis Indica need not be given. It may be briefly said of them, that the doses were large and repeated at nearly one hour intervals. The effect was in the first of these apparent in the tracing in ten minutes, and a steady diminution of frequency resulted, until in 45 minutes there occurred evidence of implication of the nervous system. In 35 minutes after the second dose there appeared evidence of some obstruction to circulation, either near the heart or in the capillaries, and after 420 drops had been taken the arterial tension was greatly reduced, with corresponding increase of the venous pressure, and marked sedation just two hours and fifteen minutes from the first dose, and thirty from the last and largest. Finally sudden cessation of effect. In the last experiment detailed, in which a fresh alcoholic extract was again used, the following facts were noticed : 1st. — Tracings abnormal from malaise at the begin- ning became normal in forty minutes, with marked sedation and diminished frequency. In fifty-five min- utes began the stage of exhilaration, at which time a larger dose was taken. After fifty-five minutes the heart's impulsive power was evidently weakened, and shortly after began a vacillation both of equilibrium of pressure and frequency. THE SPHYGMOGEAPH. 149 In one hour and forty-five minutes the nervous system was broken down by the excitement of re- action, a state ■ lasting for twelve hours. CHAPTER II EXPERIMENTS WITH GELSEMINUM. It would be tedious and unnecessary to give the minute details of the experiments made with the remaining remedies. In brief, these were Gelseminum Sempervirens, Aconitum Napellus, and Quinhe Sulphas. The first, the tracings illustrative of which are given (JSTos. 204 to 209 inclusive), were with reference to the action of Gelseminum Sempervirens : At 9.00 P. M. Six drops of Tilden' s fluid extract were taken. At 9.30 P. M. Being slightly drowsy, six drops more. At 10.00 P. M. Ten drops more, with the following re- sult : — 10.15. A heavy feeling in the ears, and sense of weight over the forehead. 10.20 P. M. A peculiar sense of constriction at the base of the tongue. 10.40 P. M. Drowsiness increasing. 10.55 P. M. Peculiar slowness of respiration— 7 to the minute. THE SPHYGMOGEAPH. 151 11.05 P. M. Disappearance of all effects. 11.25 P. M. Sense of giddiness. 11.35 P. M. Free from all sensible effects. This drag lias been selected for experiment for the two-fold reason that difference of opinion as to its action has existed among medical men, and that a somewhat large personal experience with it enables me to speak of it with some familiarity. This experi- ence has been favorable in puerperal eclampsia and the convulsive disorders of children, the neuralgic and congestive affections of the uterus or ovaries, and par- ticularly in cardiac and pulmonary' diseases, where sedation and reduction in frequency of pulse have been desired. With reference to its action in the latter respect, the tracings will be found instructive ; and in view of the unfavorable opinion expressed by Da Costa (Am. Jour. Med. Sc. 1871) as to its action in irritable heart, they will probably be also interesting. In his hands, reduction of impulse and frequency were so slight as to be unimportant. The tracings given may be compared profitably with those of Aconite, which succeed. It is a fact worthy of notice, although already referred to, that in this case, as in many others, the Sphygmograph shows the action of the remedy often long prior to the exhibition of any sensible or physio- logical effect. 152 THE SPHYGMOGRAPH. This, in the present instance, is made the more noticeable by the fact that at the beginning of the experiment the pulse was not perfectly normal, owing to fatigue, excitement, and loss of rest. With regard to the dose used, a word is necessary. Having frequently observed the toxic action of the drug, even to ptosis, roaring in the ears, &c, after giving three drops of the fluid extract at intervals of half an hour, this fact of personal experience has been in mind throughout the experiment ; — as with Can- nabis Indica I was myself the subject in the case. On the 12th of November, at 9 P. M., six drops were taken ; at 9.30, six drops more ; and at 10 o'clock, ten drops. The results, which were as follows, are also indicated on the chart. Not being perfectly well, there existed either a recoil or dicrotic wave in the preliminary tracing, which in 30 minutes seemed rather to become more prominent, and but for the records that follow, might be at once set down as a true dicrotous wave. As at this time there will also be seen diminution of compressibility, as shown by diminished amplitude under the same pressure, the prominence of the waves, whatever its explanation, must be ascribed to a morbid condition, viz : that produced by the influence of the poison administered. The pulse at this interval has reached a minimum as to frequency, and in ten THE SPHYGMOGKAPH. 153 minutes more shows slight impairment of rhythm. The new dose of ten drops exhibits its first influence in the tracing in 30 minutes, by increased arterial ten- sion and nervous stimulation, followed however in five minutes by diminution of both, and great decrease in frequency. From this time on to the end of an hour, the tension in the arterial system slowly increased, although the frequency remained nearly the same, and after one hour and a half the appearance of some obstruction as shown in the flattening of the conjoined apices of the first and second events was manifest, and irregularity of impulse and of rhythm exhibited the effect of the poison upon the heart. Neither of the effects tast named could have been perceived by any other means than the Sphygmo- graph ; and at this time the sensible action of the medicine had disappeared. The simple deduction from this investigation, apart from what is already known of the remedy, lies in this — that while reducing the frequency of the pulse, it does so with an increase of arterial tension, and after a while impairment of the heart's action, indicating a toxic influence upon the nervous system. It is therefore not surprising that singularly incom - patible experiences have been recorded by different physicians. CHAPTER III. EXPERIMENTS WITH ACONITE. The third experiment * was made November 14, 1872, with a fluid extract of Aconite root, npon a young lady perfectly well, as far as could be ascertained, and aged eighteen years. A pressure of 2° was found the most available, and was, as in all these later investigations, maintained throughout : tension being ascertained by amplitude, as already described in the preceding pages. The oscillation evident in the first tracing was simply the result of nervous tremor. This 3 r oung lady took four drops in all, 1 at 1.50 P. M., one at 2.20, and two at 2.45. In twenty-five min- utes from the first dose occurred the first effect in the tracing ; reduction of frequency and force, there being no physiological influence perceptible. In jive min- utes more occurred a sudden increase of both, without apparent cause, although from the fact that the tracing shows slowness of collapse of the artery, it may have Tracings 209 to 213 inclusive. THE SPHYGMOGEAPH. 155 arisen from capillary constriction due to the direct stimulus of the impelled current against them. In five minutes more this has disappeared, and in forty from the administration of the first dose, the force, frequency and arterial tension have reached a minimum without any perceptible physiological effect being experienced. The new dose shows itself in twenty minutes instead of twenty -five, as with the first, and two drops addi- tional were taken. In thirty minutes thereafter, the pulse-writing being almost a straight line, and having thus exhibited the maximum effect of the remedy in a minimum of ten- sion, force, frequency and complete disappearance of all evidences of nervous or other excitement, tlie first appearance of any sensible effect occurred in a simple dizziness upon exertion. Aconite continued — larger doses. The next experiment was made November 14, 1872, upon myself, with a fresh fluid extract of Aconite root, and its effects were briefly as follows (tracings 214 to 221 inclusive) : The first effect visible in the tracing occurred in fourteen minutes, viz., diminished frequency ; and in three minutes more, or seventeen from the taking of 156 THE SPHYGMOGEAPH. the remedy, a great increase of arterial tension, with prominence of the wave of recoil. After thirty minutes this was slightly less, and the first physiological or sensible effect occurred in a sen- sation of fullness of the carotids. The maximum of nervous excitement and increased tension is visible at 9.45, or 35 minutes after the dose, followed by reaction and minimum of frequency, and tension at 10. With the next dose the maximum, showing the stage of excitement due to the remedy, occurs in thirty min- utes. The reaction, or minimum of force, frequency and tension, and showing sedative influence, occurs ten minutes later. In fifty minutes a feeling of faint- ness occurred, not however indicated in the tracing, and therefore, probabty, a reflex phenomenon due to the condition of the stomach. In one hour and twenty minutes, when the true physiological effects of the remedy were shown, as stated on the chart, a great increase of frequency and arterial tension with cerebral excitement were manifest, followed however by reaction and variations in the pulse-wave, until at twelve o' clock the long even wave of health is given, even under a pressure of 5°, and all sensible effects had passed away. The deduction from these experiments is of special interest, and we may compare it with a degree of cer- THE SPHYGMOGRAPH. 157 tainty eminently satisfactory with that of Gelseminmn. Leaving out all other considerations, we have this one fact apparent, that Aconite unlike Gelseminum, while primarily showing a stage of excitement, yet reduces the heart's action as to frequency of beat without increasing arterial tension. The application of this fact to pathology will be evident. CHAPTER IV EXPERIMENTS WITH QUININE. Two experiments with this drug are presented, showing the effects of single large doses, and of fre- quently-repeated smaller ones. The deductions, in brief, are as follows : First. November 16th (tracings 222 to 225 inclusive). Being especially sensitive to the tonic action of qui- nine, and moreover very susceptible to the influence of substances having a bitter taste, when taken simply into the mouth, the first dose taken was but half a grain, dry, upon the tongue. Its action when thus administered cannot be mistaken as affecting the cir- culation ; a lessened frequency, increased tension, and developed vibratile character, were apparent in fifteen minutes, no sensible effects of course being manifest. At this time, the pulse being 64 per minute, ten grains were taken. The above-named features (tracing 226) were magni- fied, and reached a maximum in twenty-five minutes after the large dose, and in thirty minutes occurred the THE SPHYGMOGRAPH. 159 minimum of tension, with, however, increased fre- quency, and after that a variation of both within a very brief interval. The only inference from this experiment, relates to the stimulant and sedative properties of quinine upon the nervous and circulatory system. Quinine continued — small and repeated doses. November 18, 1872 (tracings 227 to 233 inclusive). On this occasion two grains of the sulphate were taken every ten minutes up to sixteen grains, with the effects perceived in the tracings, beginning at 10 o'clock P. M. On this evening, as shown by the pre- liminary tracing, there existed the fatigue and slight excitement due to the arduous work of the day just closed. At 10 P. M., first dose of two grains. In seven minutes occurred diminished frequency. In twenty-three this had reached a maximum, the tension being slightly increased, as shown by the transmission of the alternate waves. A sedative influence, both nervous and circulatory, became apparent at 11.30, and existed until 12 o'clock, when the influence upon the nervous system is shown by the peculiar shape of the primary wave and the delayed collapse of the artery (231). From this hour, when a feeling of tension in the back 160 THE SPHYGMOGRAPH. of the head was noticed, the excitement of the nervous system increased, and is thus described in my notes made the following day : "Unsound and troubled sleep; nervous jactitation and twitching ; stuffed sensation in the head, and fre- quent desire to micturate, with painful vesical spasm after each attempt — and heavy deposit of phosphates ; pain in the bowels ; and severe neuralgic or congestive pain under the left nipple, lasting all night. ' ' Awoke with all the sensations common to a man after a night of dissipation and excess. Feeling of twitching all over the body, with no apparent or actual trembling ; dull heaviness in the ears and back of the head, with pulse of 96." At 8.30 P. M. tracings were taken (232) which ex- hibited all the feelings above described as graphically as they were experienced. The oscillation here evident furnishes an interesting comment to the rules relative to this feature, given on page 73. The deductions from this experiment, aside from what is already familiar, in conjunction with the action of quinine, relate chiefly to the influence upon the frequency of the pulse and the state of the nervous system, the effect of large and small doses, and the moment at which their action begins. Reference need not be made in this connection to the THE SPHYGMOGRAPH. 161 experiments with ordinary means of observation by others — detailed in the many periodicals of the day — as it is presumed that its singularly diversified actions under different circumstances are familiar, but the facility with which observation may be stamped as accurate or otherwise by the Sphygmographic record, is suggested by the examples here given. CHAPTER V. REMARKS IN CONCLUSION. To attempt in any perfect manner to epitomize the indications afforded by the Sphygmograph in the numerous examples presented, would prove a serious task, especially as deeper meaning probably lies in the tracings than has yet been revealed ; but if the reader will bestow the requisite amount of patience upon their study the appearance of similarity will vanish, and assurance that both the pathological and physiological indications afforded by the instrument are of great importance, will seem well founded. What we have endeavored to show, by the some- what diffuse exposition of the subject, may, however, be thus briefly summed up. First. That the new principle in the construction of the instrument exhibits a new and wider field as within its scope. Second. The value of a knowledge of the minute peculiarities of the arterial current, in connection with the determination of the condition of both the vascular and nervous system. THE SPHYOM0GRAPH. 163 (Under this head have been considered the condition of the heart as to vigor or irritability, character of impulse, duration of systole, hypertrophy eccentric or concentric, condition of the valves, etc. ; the relative tension in arteries or veins ; the condition of the former as to contractility, passive dilatation, degeneration, etc. ; and also the physiological inferences educed under the action of medicines.) Third. The power of the Spliygmo graph to develope this knowledge, and correctly record it. (Under this have been considered the significance of each part of a tracing, so far as heretofore described, and also new features drawn from personal experience, substantiated by examples. Studies of tracings and numerous cases have been presented, that the student desirous of forming his own conclusions may do so.) INDEX. PAGE Aconite, ........... 154 Action of Medicines, 45, 71, 133, 150 Acute Enteritis, 122 Amputation, Influence of, 56, 70, 98 Aneurism, 48, 56, 70 Anger, Influence of, 93 Aortic Pulsation, 97 Arterial Tension, 79 Arterial Waves, 38 Artery, Artificial Obstruction of, ..... 84 Arthritis, Rheumatic, 123 Artificial Heart, . . 59 Asthma, with Bronchitis, 115, 116, 117 with Disease of Heart or Kidneys, . . . . 116 with Emphysema, . . . . . . . .115 without Complication, . . . . 115, 116, 117 Bronchitis. See "Asthma with. 1 ' Bright' s Disease, 124 Cancer, 122 Cannabis Indica, 135 Cardiac Waye, . . 39 Cardiac Disease. See "Heart." Carotid Tracings, 75 Cautions, • 90 166 INDEX. PAGE Chinese Views of the Pulse, 33 Chronic Ovaritis, 94, 123 Compressibility, * . . 64, 79, 84, 85 Congestive Chill, . ■ 121 Corrigan, Dr., 65 Da Costa's Diagnosis by the Pulse, 36 Debility, 99 Degree of Pressure required, 27, 28 Delirium Tremens, 58 Deranged Sympathetic, 97 Description of Instruments, 18 Dial, 26 Diarrhasa, Diagnosis, Cases for, 121 Diastolic Wave, 54 Dicrotism Explained, 58 Disease of Sympathetic System, 97 Lungs, 128 the Heart, . . . .48, 49, 55, 58, 101, 126, 127 Spinal Cord 117 Dissipation, 114 Duration of Impulse, 34 Effect of Artificial Obstruction of Circulation, .... 84 Emotion, Effect of, . . 93 Emphysema. See " Asthma -with." Enlargement of the Heart, lOietseq. Enteritis, 122 Epilepsy, Case and Tracing, . . 46, 122, and Chart opp. p. 44 Exciting News, Effects of, 93 Experiments with Medicines, .... . 133 INDEX. 167 PAGE Faintness, 92 Fatigue. See first Tracing in Final Experiment with Cannabis Indica. Fourth Event, 54 Frequency of Pulse, 85 Full Meal, 93 Functional Derangement of Nervous System, ... 92, 93 Functional Disease of the Heart. See Chap, on Dis. of the Heart, 101 Gangrena Senilis, . . . . . . . . .125 Gelseminum, Effects of, 150 Haemoptysis, Recent and Remote, .... 94, 95, 128 Health, Variations Compatible with, 91 Heart. See " Disease of the Heart." Hemorrhage after Confinement, 46, 70, 124 Hysteria, 46, 96, 99 Kidneys, Disease of, 124 Laryngeal Phthisis, 126, 127 Lifting Power of the Arteries, . . . . 23 Locomotion of Arteries, 64 Locomotor Ataxy, 117 Longevity, 86 Loss of Limbs, 56, 70, 93 Lungs, Disease of, 128 Mania-a-Potu, 113 Manufacturer of the New Sphygmograph, .... 28 Marey, Professor, 17 54 Medicines. See " Action of," 168 INDEX. PAGE Metrorrhagia, 46, 70, 124 Minor Disturbances of the Pulse, 93 Nervous Element in a Tracing, 113 Nervous System, Affections of, . . . . . .113 Oscillation, 64, 65, 72 Over-work, 91 Over-exertion, 93 Ovaritis, 94, 123 Pen Described, 25 Pericarditis. See " Disease of the Heart." Phthisis, 47, 57, 58, 126, 128 Pressure, Element of, 26, 64 Prognosis, 86 Progresso-loco moto-ataxia, 117 Pulmonary Diseases, 128 Pulse, Characteristic Tracings of, 86 Pulse, Indications afforded by, 30 Quinine, Action of, 158 Recoil, Wave of, . 64, 75 Regurgitation. See " Disease of the Heart." Rheumatism, 126, 127 Rhythm, 35 Sanderson, Professor, 21, 35 Second Event, Significance of, 50 Senile Gangrene, 125 INDEX. 169 PAGE Singular Cases, 121 Stomach, Empty or Full, 93 Sunstroke, 114 Tension of Arteries and Veins, ....... 35 Third Event, 51, 53 Tobacco, Influence of, 57, 71, 95, 96, 100 Translation of Tracings, 38 Value of Means of Registering Pressure, ..... 80 Valvular Disease. See " Disease of the Heart." Variations Compatible with Health, 91 Vertigo, 55, 103, 110, 113 Vibration, 65 Vierordt, 17 Volume of Pulse, ......... 34 Waves, Successive, explained, 39 Whittingham, Dr., of New Jersey, Singular Case by, . . 69 PHILADELPHIA, yanuary, 1 874. LINDSA Y & BLAKISTON call the attention of Booksellers and the Medical Profession to their extensive list of Medical Works as embraced in the enclosed Catalogue, to which they are constantly adding by the addition of New Books on every branch of Medical Science. Their assortment of books also embraces all other Medical Works published in the United States, which they will furnish to the Trade or Profession on the most liberal terms. Their own publications can be had from or through Booksellers in most of the principal cities of the Union. When for any reason they can- not be thus procured, they will forward them by mail prepaid, upon receipt of the Catalogue price. Having special arrangements with Messrs. J. & A. CHURCHILL, of London, they are prepared to supply all their publications in this country at greatly reduced prices. Many of their leading books, especially those of recent publication, they have either reprinted or keep in stock. Those not on hand they will supply promptly to order at the lowest rates to the shilling of the London retail price to the Profession, and to the Trade at their usual discount. MEDICAL WORKS or PERIODICALS, published by other Houses in Great Britain, will be imported to order on the most liberal terms. SYDENHAM SOCIETY'S PUBLICATIONS Having been ap- pointed agents in the United States for this Society, they are prepared to receive subscribers at the rate of TEN DOLLARS per annum, and to furnish any of the back years on the same terms, payable always in advance. Reports of the Society, with a list of the works already published by them, will be furnished upon application, LINDSA Y & BLAKISTON will furnish to Dealers in Medical Books, without charge, a descriptive Catalogue of their Medical Publications, with their imprint attached, for distribution amo?ig their Customers, upon application. Lindsay & Blakiston's PHYSICIAN'S VISITING LIST. NOW EEADT FOE 1874. ♦'The simplest of all the visiting lists published, it must continue to hold, what M now has, the preference over all other forms of this indispensable companion for the Physician." — New York Med. Journal. OOK"TElTTS. 1. Table of Signs, or Guide for Registering Visits, En- gagements, &c. 2. An Almanac 3. Marshall Hall's Ready Method in Asphyxia. 4. Poisons and their Antidotes. 6. Table for Calculating the Period of Utero-Gestation. 8. The Visiting List arranged for 25, 50, 75, or 100 Patients. 7. Memoranda pages for every month in the year. 8. Pages for Addresses of Patients, &c. 9. " . Bills and Accounts asked for and hatic Gravel and Calculi. 8. Oxalic Acid, Oxaluria, Mulberry Calculi. 9. Inosite in Urine, Creatin and Creatinine, Cholesterin, Cystin, Xanthin, Leucin, 1. What is Urine? 2. Changes in the Composition of the Urine, induced by Food, Drink, Medicine, and Disease. 3. Urea, Ammonsemia, Uraemia. 4. Uric Acid. 5. Hippuric Acid, Chloride of Sodium. 6. Urohsematin, Abnormal Pigments in Urine. Tyrosin. 10. Diabetes Mellitus. 11. Albuminuria. On the whole, we have here a valuable addition to the library of the practising physician ; not only for the information which it contains, but also for the suggestive way in which many of the subjects are treated, as well as for the fact that it contains the ideas of one who thoroughly believes in the future capabilities of Therapeutics based on Physiological facts, and in the important service to be rendered by Chemistry to Physiological investigation. American Journal of the Medical Science. HABERSHON (s. 0.), M. D., Physician to Guy's Hospital, &c. ON THE DISEASES OF THE LIVER. Their Pathology and Treatment. Being the Lettsonian Lectures, delivered at the Medical Society of London, 1872. Price $ I -5° These Lectures contain within a brief compass a large amount of information and many practical suggestions that cannot fail to be of great value to every practitioner. Dublin Medical Journal. HEWITT (graily), M. D., Physician to the British Lying-in Hospital, and Lecturer on Diseases of Women and Children, &c. THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF WOMEN, including the Diagnosis of Pregnancy. Founded on a Course of Lectures delivered at St. Mary's Hospital Medical School. The Third Edition, Revised and Enlarged, with new Illustrations. Octavo. Price in Cloth . . . $5. 00 " Leather . . . 6.00 This new edition of Dr. Hewitt's book has been so much modified, that it may be considered substantially a new book ; very much of the matter has been entirely rewritten, and the whole work has been rearranged in such a manner as to present a most decided improvement over previous editions. Dr. Hewitt is the leading clinical teacher on Diseases of Women in London, and the characteristic attention paid to Diagnosis by him has given his work great popularity there. It may unquestionably be considered the most valuable guide to correct Diagnosis to be found in the English language. 7 HEWSON (addinell,) M. D. Attending Surgeon Pennsylvania Hospital, &c. EARTH AS A TOPICAL APPLICATION IN SURGERY. Being a full Exposition of its use in all the Cases requiring Topical Applications admitted in the Surgical Wards of the Pennsylvania Hospi- tal during a period of Six Months. With Four full-page Illustrations. CONTENTS. Preface; Introduction; Histories of Cases ; Comments as to the Effects of tlie Contact of the Earth ; Its Effects on Pain ; Its Power as a Deodorizer ; Its Influence over Inflammation ; Its Influence over Putrefaction; Its Influence over the Healing Processes; Modus Operandi of the Earth ; As a Deodorizer and other Putrefaction ; In its Effects on Living Parts. Price, ........... $2.50 It presents the results of researches by the author into the action of Earth as a surgical dressing, and embraces the histories of over ninety cases which occurred in the wards of the Pennsylvania Hospital some three years since, but whose publication has been delayed, for the double purpose of weighing them by subsequent experience, and of interpreting their - '-y a careful study of the various subjects which they involve. HODGE (hugh l.), M. D. Emeritus Professor in the University of Pennsylvania. HODGE ON FOETICIDE, OR CRIMINAL ABORTION. Fourth Edition. Price, in paper covers, .... $0.30 " flexible cloth, . . . .0.50 This little book is intended to place in the hands of professional men and others the means of answering satisfactorily and intelligently any inquiries that may be made of them in con- nection with this important subject. HOLDEN (edgar), A. M., M. D., Of Newark, New Jersey. CONTAINING THREE HUNDRED ILLUSTRATIONS. THE SPHYGMOGRAPH. Its Physiological and Pathological In- dications. The Essay to which was aAvarded the Stevens Triennial Prize in the College of Physicians and Surgeons in New York, April, 1873. Illustrated by Three Hundred Engravings on Wood. One vol- ume octavo. Price. ........ $ LEBER & ROTTENSTEIN (drs.). DENTAL CARIES AND ITS CAUSES. An Investigation into the Influence of Fungi in the destruction of the Teeth, translated by Thomas H. Chandler, D.M.D., Professor of Mechanical Dentistry in the Dental School of Harvard University. With Illustrations. Octavo. Price $1-50 This work is now considered the best and most elaborate work on Dental Caries. It is everywhere quoted and relied upon as authority by the profession, who have seen it in the original, and by authors writing on the subject. LEGG (j. wickham), M. D. Member of the Royal College of Physicians, &c, A GUIDE TO THE EXAMINATION OF THE URINE. For the Practitioner and Student. Third Edition. i6mo. Cloth. Price, $0. 75 Dr. Legg's little manual has met with remarkable success; the speedy exhaustion of two editions has enabled the author to make certain emendations which add greatly to its value. It can confidently be commended to the student as a safe and reliable guide. LEWIN (dr. george). Professor at the Fr.-Wilh. University, and Surgeon-in-Chief of the Syphilitic Wards and Skin Diseases of the Charity Hospital, Berlin. THE TREATMENT OF SYPHILIS by Subcutaneous Sublimate Injections. With a Lithographic Plate illustrating the Mode and Proper Place of administering the Injections, and of the Syringe used for the purpose. Translated by Carl Prcegler, M.D., late Surgeon in the Prussian Service, and E. H. Gale, M.D., late Surgeon in the United States Army. Price $2.25 The great number of cases treated, some fourteen hundred, within a period of four years, in the wards of the Charity Hospital, Berlin, only twenty of which were returned on account of Syphilitic relapses, certainly entitles the method of treatment advocated by this distinguished syphilographer to the attention of all physicians under whose notice syphilitic cases come. LIZARS (john), M. D. Late Professor cf Surgery in the Royal College of Surgeons, Edinburgh, THE USE AND ABUSE OF TOBACCO. From the Eighth Edinburgh Edition. i2mo. Price, in flexible cloth, . $0.60 This little work contains a History of the introduction of Tobacco, its general characteris- tics ; practical observations upon its effects on the system ; the opinion of celebrated profes- sional men in regard to it, together with cases illustrating its deleterious influence, &c, &c. MACNAMARA (a). Surgeon to the Ophthalmic Hospital, and Professor of Ophthalmic Medicine in the Medical College, Calcutta, MANUAL OF THE DISEASES OF THE EYE. The Second Edition, carefully Revised; with Additions, and numerous Colored Plates, Diagrams of the Eye, many Illustrations on Wood, Snellen's Test Types, &c, &c. Price . . . . . $5-°° " This work when first published took its place in medical literature as the most complete, condensed, and well-arranged manual on ophthalmic surgery in the English language. Arranged especially for medical students, it became, however, the work of reference for the busy practitioner, who could obtain nearly all that was best worth knowing on this subject, tersely stated, and easily found by the aid of the excellent marginal notes on the contents of the paragraphs." — Philadelphia Medical Times. MACKENZIE (morell), M. D. Physician to the Hospital for Diseases of the Throat, London, &c. GROWTHS IN THE LARYNX. Their History, Causes, Symp- toms, Diagnosis, Pathology, Prognosis, and Treatment. With Reports and Analysis of One Hundred Consecutive Cases treated by the Author ; and a Tabular Statement of every published case treated since the in- vention of the Laryngoscope. With numerous Colored and other Illustrations. Octavo. Price ...... $3.00 Dr. Mackenzie's position has given him great advantages and a large experience in the treatment of Diseases of the Throat, and for many years he has been regarded as a leading authority in this department of Surgery. The Illustrations have been prepared with great care and expense. OTHER WORKS BY SAME AUTHOR. THE LARYNGOSCOPE IN DISEASES OF THE THROAT. With an Appendix on Rhinoscopy, and an Essay on Hoarseness and Loss of Voice. With Additions by J. Sous Cohen, and Numerous Illustrations on Wood and Stone. Price .... $3-oo PHARMACOPOEIA OF THE HOSPITAL for Diseases of the Throat; with One Hundred and Fifty Formulae for Gargles, &c, &c. Price 3S1.25 9 MAUNDER (c. f.), F. R. C. S. Surgeon to the London Hospital; formerly Demonstrator of Anatomy at Guy's Hospital. OPERATIVE SURGERY. Second Edition, with One Hundred and Sixty-four Engravings on Wood. CONTENTS. Chap. 1. Compress, Splint, Bandage Strap' ping. 2. Ligature. 3. Operations on the Vascular System 4. Operations on Arteries. 5. Ligature of special ditto. 6. Operations on the Bones. Price . . . . . . . . . .$2.50 Chap. 7. Operations on the Surfaee of tha Body. _ " 8. Amputation. " 9. Lower Extremity. " 10. Upper ditto. " 11. Special Operations. MARTIN (john h.). Author of Microscopic Objects, &c. A MANUAL OF MICROSCOPIC MOUNTING. With Notes on the Collection and Examination of Objects, and upwards of One Hun- dred Illustrations on Stone and Wood, drawn by the Author. Price $3-oo " This book is more than its title indicates. It gives a description of the apparatus neces- sary for microscopical research, as well as the methods of preparation and preserving the various objects. It is a complete and well-illustrated work on its subject, which is daily becoming more valuable to. the scientist and more cultivated as an elegant and interesting study." — Scientific American. • MEADOWS (alfred), M. D. Physician to the Hospital for Women, and to the General Lying-in Hospital, &c, MANUAL OF MIDWIFERY. A New Text-Book. Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal State, &c, &c. First American from the Second London Edition. With numerous Illustrations. Price . . . $3.00 This book is especially valuable to the Student as containing in a condensed form a lar.ee amount of valuable information on the subject which it treats. It is also clear and methodi- cal in its arrangement, and therefore useful as a work of reference for the practitioner. The Illustrations are numerous and well executed. MILLER (james), F. R. C. S. Professor of Surgery University of Edinburgh, ALCOHOL, ITS PLACE AND POWER. From the Nineteenth Glasgow Edition. i2ino. Cloth flexible. Price . . . $0.75 This work was prepared by Professor Miller at the special request of the Scottish Temper- ance League, who were anxious to have a work of high authority, presenting the medical view of the subject that could be freely disseminated among all classes. NORRIS (GEORGE w.), M.D. Late Surgeon to the Pennsylvania Hospital, &c, CONTRIBUTIONS TO PRACTICAL SURGERY, including numerous Clinical Histories, Drawn from a Hospital Service of Thirty Years. In one volume, Octavo. Price $4.00 10 RINDFLEISCH (dr. edward). Professor of Pathological Anatomy, University of Bonn, TEXT-BOOK OF PATHOLOGICAL HISTOLOGY. An Intro- duction to the Study of Pathological Anatomy. Translated from the German, by Wm. C. Kloman, M.D., assisted by F. T. Miles, M.D., Professor of Anatomy, University of Maryland, &c., &c. Containing Two Hundred and Eight elaborately executed Microscopical Illustra- tions. Octavo. Price, bound in Cloth, . . . . $6.00 " " Leather, .... 7.00 This is now confessedly the leading book, and the only complete one on the subject in the English language. The London Lancet says of it : " Rindneisch's work forms a mine which no pathological writer or student can afford to neglect, who desires to interpret aright pathological structural changes, and his book is consequently well kuown to readers of Ger- man medical literature. What makes it especially valuable is the fact that it was originated, as its author himself tells us, more at the microscope than at the writing-table. Altogether the book is the result of honest hard labor. It is admirably as well as profusely illustrated, furnished with a capital Index, and got up in a way that is worthy of what must continue to be the standard book of the kind." ROBERTS (FREDERICK T.)., M. D., B.Sc. Assistant Physician and Teacher of Clinical Medicine in the University College Hospital ; Assistant Physician Brompton Consumption Hospital, &c. A HAND-BOOK OF THE THEORY AND PRACTICE OF MEDICINE; One volume medium octavo, containing over 1000 pages. Price . . . $5.00. This work has been prepared mainly for the use of Students, and its object is to present in as condensed a form as the present extent of Medical Literature will permit, and in one volume, such information with regard to the Principles and Practice of Medicine, as shall be sufficient not only to enable them to prepare for the various examinations whicli they may have to undergo, but also to guide them in acquiring that Clinical Knowledge which can alone properly fit them for assuming the active duties of their profession. The work is also adapted to the wants of very many members of the profession who are already busily engaged in general Practice, and consequently have but little leisure and few opportunities for the perusal of the larger works on Practice or of the various special monographs. REYNOLDS (j. russell), M. D., F. R. S., Lecturer on the Principles and Practice of Medicine, University College, London. LECTURES ON THE CLINICAL USES OF ELECTRICITY. Delivered at University College Hospital. Second Edition, Revised and Enlarged. Price $ RYAN (MICHAEL), M. D. Member of the Royal College of Physicians. PHILOSOPHY OF MARRIAGE, in its Social, Moral, and Physi- cal Relations ; with an Account of the Diseases of the Genito-Urinary Organs, &c. Price ........ $1.00 This is a philosophical discussion of the whole subject of Marriage, its influences and results in all their varied aspects, together with a medical history of the reproductive func- tions of the vegetable and animal kingdoms, and of the abuses and disorders resulting from it in the latter. It is intended both for the professional and general reader. 11 SWERINGEN (hiram v.). Member American Pharmaceutical Association, &c. PHARMACEUTICAL LEXICON. A Dictionary of Pharmaceu- tical Science. Containing a concise explanation of the various subjects and terms of Pharmacy, with appropriate selections from the collateral sciences. Formulse for officinal, empirical, and dietetic preparations; selections from the prescriptions of the most eminent physicians of Europe and America; an alphabetical list of diseases and their defini- tions; an account of the various modes in use for the preservation of dead bodies for interment or dissection ; tables of signs and abbrevia- tions, weights and measures, doses, antidotes to poisons, &c, &c. Designed as a guide for the Pharmaceutist, Druggist, Physician, &c. Royal Octavo. Price in cloth $5-°o " leather ...... 6.00 " We have received from publishers so many English reprints ill adapted to the needs of this country, that it is with pleasure we welcome a thorough American book, written for the uses of the American pharmaceutist. Besides, the work is well written, creditably arranged, and neatly printed. It will be found very useful to the druggist as well as to the physician. Being in the form of a dictionary, its aim is to give immediate information in a concise man- ner, and not a complete treatise on each subject. So far as we have been able to see, the Pharmaceutical Lexicon is remarkably correct. " — Druggist's Circular. t SHEPPARD (edgar), M. D. Professor of Psychological Medicine in King's College, London. MADNESS, IN ITS MEDICAL, SOCIAL, AND LEGAL AS- PECTS. A series of Lectures delivered at King's College, London. Octavo. Price $2.50 SAVAGE (henry), M. D., F. R. C. S. Consulting Physician to the Samaritan Free Hospital, London. THE SURGERY, SURGICAL PATHOLOGY, and Surgical Anat- omy of the Female Pelvic Organs, in a Series of Colored Plates taken from Nature : with Commentaries, Notes, and Cases. Third Edition, greatly enlarged. A quarto volume. Price TANNER (thomas hawkes), M. D., F. R. C. S., &c. MEMORANDA OF POISONS. A New and much enlarged Edi- tion. Price . . . . . . . $°-75 This manual is intended to assist the practitioner in the diagnosis and treatment of poison- ing, and especially to prevent his attributing to natural disease symptoms due to the admin- istration of deadly drugs. OTHER WORKS BY SAME AUTHOR. THE PRACTICE OF MEDICINE. Fifth American Edition, $6.00. A PRACTICAL TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American Edition, . . . $3.50. AN INDEX OF DISEASES, AND THEIR TREATMENT, $3.00. " Dr. Tanner has always shown in his writings that he possesses a peculiar faculty of com- mitting to print just that kind of information which the practitioner most needs in every-day practice, and of rejecting useless theory." — Lancet. 12 THOROWGOOD (j. a), M. D. Physician to the City of London Hospital for Diseases of the Chest, and to the West London Hospital, &c. NOTES ON ASTHMA. Its various Forms, their Nature and Treatment, including Hay Asthma, with an Appendix of Formulae, &c. Second Edition. Price $!-75 TOMES (john), F.R.S. Late Dental Surgeon to the Middlesex and Dental Hospitals, &c, A SYSTEM OF DENTAL SURGERY. The Second Revised and Enlarged Edition, by Charles S. Tomes, M.A., Lecturer on Dental Anatomy and Physiology, and Assistant Dental Surgeon to the Dental Hospital of London. With 263 Illustrations. Price . . $5.00 This book has been for some time out of print in this country. The material progress made in the science of Dental Surgery since its first publication has rendered large additions and many revisions necessary to the New Edition : in order to bring it fully up to the time ; this has been done without increasing the size of the book more than possible. Many improve- ments, however, will be found added to the Text, and some Sixty new illustrations are in- corporated in the volume. TROUSSEAU (a.), M. D. Professor of Clinical Medicine to the Faculty of Medicine, Paris; Physician to the Hotel Dieu, &c, &c, LECTURES ON CLINICAL MEDICINE. Delivered at the Hotel Dieu, Paris. Vol. I. Translated with Notes and Appendices, by P. Victor Bazine, M.D., London and Paris. Vols. II., III., IV., and V., Translated from the Third Revised and Enlarged Edition, under the auspices of the Sydenham Society, by John Rose Cormack, M.D., Edinburgh; M.D., Paris, F.R.S.E., &c. Price of Vols. 1, 2, and 3, each, ...... $5.00 " " 4 and 5 " • • • • ■ • 4-oo A Complete Edition, in 2 vols, octavo, can also now be furnished. Price bound in Cloth $10.00 " " Leather 12.00 TUKE (DANIEL s.), M. D. Associate Author of "A Manual of Psychological Medicine," &c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY. Octavo. Price . . . . $4.00 The author shows very clearly in this book the curative influence of the mind, as well as its effect in causing disease, and the use of the imagination and emotions as therapeutic agents. His object is also to turn to the use of legitimate medicine the means so frequently employed successfully in many systems of quackery. TIBBITS (HERBERT), M. D. Medical Superintendent of the National Hospital for the Paralyzed and Epileptic, die. A HANDBOOK OF MEDICAL ELECTRICITY. With Sixty- four large Illustrations. Small octavo. Price . . . $2.00 The author of this volume is the translator of Duchenne's great work on " Localized Elec- trization." Avoiding contested points in electro-physiology and therapeutics, he has pre- pared this handbook as containing all that is essential for the busy practitioner to know, not only when, but in EXPLICIT AND FULL DETAIL, how to use Electricity in the treatment of disease, and to make the practitioner as much at home in the use of his electrical as his other medical instruments. 13 WILSON (george), M. A., M. D. Medical Officer to the Convict Prison at Portsmouth. A HANDBOOK OF HYGIENE AND SANITARY SCIENCE. With Engravings. Second Edition, carefully Revised. CONTENTS. Chap. 1. Introductory — Public Health and Preventable Disease. " 2. Food — Construction of Dietaries ; Examination ; Effects of Un- wholesome Food. " 3. Air : its Impurities ; Unwholesome Trades. " 4. "Ventilation and Warming. " 5. Examination of Air. " 6. Water, Waterworks, Water Analy- sis. " 7. Effects of Impure Water on Public Health. " 8. Dwellings, Structural Arrange- ments, Dwellings of the Poor. " 9. Hospitals; Plans of Pavilion, Cot- Price tage, and Contagious Diseases Hospitals. Chap. 10. Removal of Sewage and Refuse Matter. " 11. Purification and Utilization of Sewage. " 12. Effects of Improved Sewerage and Drainage on Public Health. " 13. Preventive Measures ; Disinfec- tion ; Management of Epidemics. " 14. Duties of Medical Officers of Health. Appendix I. Excerpts from the various Public Health and Sanitary Acts. II. List of Analytical Apparatus and Re- agents, with prices. $2.50 WARD (stephen h.), M.D., F. R. C. P. Physician to the Seaman's Hospital, &c.j &c. ON SOME AFFECTIONS OF THE LIVER and Intestinal Canal; with Remarks on Ague and its Sequelae, Scurvy, Purpura, &c. Price . . . . . . . . . . . $3.00 " Dr. Ward's book is of a purely practical character, embodying the author's experience, from his long connection as physician to the Seaman's Plospital. His accurate description of the diseases treated will amply repay the reader." — Dublin Medical Journal. WILSON (erasmus), F.R.C.S., &c. CONTAINING THREE HUNDRED AND SEVENTY-ONE ILLUSTRATIONS. THE ANATOMIST'S VADE MECUM. A Complete System of Human Anatomy. The Ninth Revised and Enlarged London Edition. Edited and fully brought to the Science of the day by Prof. George Buchanan, Lecturer on Anatomy in Anderson's University, Glasgow, with many New Illustrations, prepared expressly for this Edition. Price $5.50 WEDL (carl), M.D. Professor of Histology, &c, in the University of Vienna. DENTAL PATHOLOGY. The Pathology of the Teeth. With Special Reference to their Anatomy and Physiology. First American Edition, translated by W. E. Boardman, M.D., with Notes by Thos. B. Hitchcock, M.D., Professor of Dental Pathology and Therapeutics in the Dental School of Harvard University, Cambridge. With 105 Illustrations. . . . Price, in Cloth, $4. 50 ; Leather, $5.50 This work exhibits laborious research and medical culture of no ordinary character. It covers the entire field of Anatomy, Physiology, and Pathology of the Teeth. The author, Prof. Wedl. has thoroughly mastered the subiect, using with great benefit to the book the very valuable material left by the late Dr. Heider, Professor of Dental Pathology in the Uni- versity of Vienna, the result of the life-long work of this eminent man. 14 CONDENSED LIST OF ALL THE MEDICAL PUBLICATIONS OF LINDSAY & BLAKISTON, PHILADELPHIA. AITKEN'S SCIENCE AND PRACTICE OF MEDICINE. Third American, from the Sixth London Edition. In Two Volumes, Eoyal Octavo. Over 2000 pages. With a Colored Map, Lithographic Plate, and nearly Two Hundred Illustrations on Wood Cloth, $12 ; Leather, $14.00. ATTHILL'S CLINICAL LECTURES ON DISEASES PECULIAR TO WOMEN. Second Edition, Eevised and Enlarged, with Illustrations. . $2.25. AGNEW'S LACERATIONS OF THE FEMALE PERINEUM AND VESICO- VAGINAL FISTULA. Numerous Illustrations. 8vo. . . $2.00. ACTON ON THE FUNCTIONS AND DISORDERS OF THE REPRO- DUCTIVE OEGANS. Third American Edition. Octavo. . . . $3.00. ACTON ON PROSTITUTION, in its Moral, Social, and Sanitary Aspects. Second Edition. ......... $5.00. ALLINGHAM ON FISTULA, HiEMORRHOIDS, PAINFUL ULCER, STEICTUEE, PEOLAPSUS, and Diseases of the Eectum. Second Edition. $2.00. ADAMS ON CLUB-FOOT, its Causes, Pathology, and Treatment. Second Edition. With Numerous Lithographic and Wood-Cut Illustrations. . . . $6.00. ADAMS ON RHEUMATIC AND STRUMOUS DISEASES OF THE JOINTS. With a quarto Atlas of Plates and other Illustrations. 2 Vols. $8.50. ANSTIE ON STIMULANTS AND NARCOTICS, their Mutual Eelations, and on the Action of Alcohol, Ether, and Chloroform on the Vital Organism. $3.00. ALTHAUS' MEDICAL ELECTRICITY, its Use in the Treatment of Paralysis, Neuralgia, and other Diseases. Third Edition. Enlarged and Eevised. . $6.00. BYPORD'S PRACTICE OF MEDICINE AND SURGERY. Applied to the Diseases and Accidents Incident to Women. Second Edition. . . $5.00. BYFORD ON THE CHRONIC INFLAMMATION AND DISPLACE- MENT OF THE UNIMPEEGNATED UTEKUS. Second Edition. With Numerous Illustrations. ........ $3.00. BLACK ON THE FUNCTIONAL DISEASES OF THE RENAL, URI- NAEY, AND EEPEODUCTIVE OEGANS $2.50. BLOXAM'S CHEMISTRY, INORGANIC AND ORGANIC. With 276 Engravings on Wood. Second Edition, carefully revised. Octavo. . . $4.50. BLOXAM'S LABORATORY TEACHING; OR, PROGRESSIVE EX- ERCISES IN PEACTICAL CHEMISTEY. Second Edition. Illustrations. $2.25. BRUNTONS EXPERIMENTAL INVESTIGATION OP THE ACTION OF MEDICINES. In preparation. BEETON'S BOOK OP HOUSEHOLD MANAGEMENT. 672 Illustrations, 1,100 pages. ......... $3.25. BRANSTON'S HAND-BOOK OF PRACTICAL RECEIPTS, for the Chemist, Druggist, &c. With a Glossary of Chemical Terms. . . $1 .50. BRODHTJRST ON THE DEFORMITIES OF THE HUMAN BODY. A System of Orthopedic Surgery. Illustrated. .... $3.00. BEASLEY'S 3000 PRESCRIPTIONS, from the Practice of the most Eminent Physicians and Surgeons — English, French, and American. Fourth Edition. $2.50. BEASLEY'S DRUGGISTS' GENERAL RECEIPT-BOOK AND VETE- RINARY FORMULARY. Seventh Edition, Revised and Improved. . $3.50. BEASLEY'S POCKET FORMULARY. The Ninth London Edition, Revised and Enlarged. ......... $2.50. BARTH & ROGER'S MANUAL OF AUSCULTATION AND PERCUS- SION. From the Sixth French Edition. . ... . . $1.25. BOUCHARDAT'S ANNUAL ABSTRACT of Therapeutics, Materia Medica, Pharmacy, and Toxicology, for 1867. ...... $1.50. BEALE'S HOW TO WORK WITH THE MICROSCOPE. Fourth Edition. 400 Illustrations. ........ $7.50. BEALE ON KIDNEY DISEASES, URINARY DEPOSITS, AND CALCULOUS DISORDERS. Third Edition. 70 Plates, 415 Figures. . $10.00. BEALE'S USE OF THE MICROSCOPE IN PRACTICAL MEDICINE. Fifth Edition. 500 Illustrations. In preparation. BEALE'S BIOPLASM. A New Introduction to the Study of Physiology and Medicine, for Students. With Plates. ...... $3.00. BEALE'S LIFE, MATTER, AND MIND; OR PROTOPLASM. Third Edition, very much enlarged. Sixteen Colored Plates. . . . $5.00. BEALE'S DISEASE GERMS; AND ON THE TREATMENT OP DISEASES CAUSED BY THEM. Second Edition. Much Enlarged. . $5.00. BIDDLE'S MATERIA MEDICA. For the Use of Students. With Illustrations. Fifth Edition. Revised and Enlarged. ..... $4.00. BASHAM'S AIDS TO THE DIAGNOSIS OF DISEASES OF THE KIDNEYS. Ten Plates, 60 Figures. $2.00. BIRCH ON CONSTIPATED BOWELS. The Various Causes and Means of Cure. Third Edition. . . . . • . . . $1.00. BRAITHWAITE'S EPITOME OF THE RETROSPECT OF PRACTICAL MEDICINE AND SURGERY. 2 Vols $10.00. CHAMBERS ON THE RENEWAL OF LIFE. Lectures chiefly Clinical, illustrative of a Restorative System of Medicine. Fourth Edition. . . $5.00. CHEW ON MEDICAL EDUCATION. A Course of Lectures on the Proper Method of Studying Medicine. ....... $1.00. CARPENTER ON THE MICROSCOPE AND ITS REVELATIONS. Fifth Edition. Over 400 Plates. Revised and Enlarged. COOLEY'S CYCLOPiEDIA OF PRACTICAL RECEIPTS. The Fifth Eevised and Enlarged Edition. With Illustrations. .... $10.00. COBBOLD ON WORMS. Lectures on Practical Helminthology. Illustrating the Symptoms, Diagnosis, and Treatment. ...... $2.00. COLES ON DEFORMITIES OF THE MOUTH. With their Mechanical Treatment. Second Edition. 8 Colored Illustrations and 51 on Wood. . $2.50. COLES' MANUAL OF DENTAL MECHANICS. With Numerous Engrav- ings on Wood. $2.50 CAMPBELL'S MANUAL OF SCIENTIFIC AND PRACTICAL AGRI- CULTURE. With Illustrations CLYMER'S EPIDEMIC CEREBRO-SPINAL MENINGITIS. . $1.00. CAZEAUX'S GREAT WORK ON OBSTETRICS. The most complete Text- book now published. Greatly enlarged and improved. Containing 175 Illustrations. Fifth American, from the Seventh French Edition. Bound in Cloth, . . $6.50. " Leather, . 7.50. CLARK'S OUTLINES OF SURGERY AND SURGICAL PATHOLOGY. Second Edition, Eevised and Enlarged. ...... $3.00. CLEAVELAND'S PRONOUNCING MEDICAL LEXICON. Containing the Pronunciation and Definition of Terms. New and Improved Edition. . $1.25. COHEN ON INHALATION. Its Therapeutics and Practice. With Cases and Illustrations $2.50. CARSON'S HISTORY OF THE MEDICAL DEPARTMENT OF THE University of Pennsylvania, from its Foundation in 1765. . . . $2.00. CHAVASSE'S APHORISMS ON THE MENTAL CULTURE AND TRAINING OF A CHILD $1.50. DARLINGTON'S FLORA CESTRICA; or, HERBORIZING COMPANION. Third Edition . $2.25. DILLNBERGER'S HANDY-BOOK OF THE TREATMENT OF WOMEN AND CHILDREN'S DISEASES $1.75. DIXON'S GUIDE TO THE PRACTICAL STUDY OF DISEASES OF THE EYE. Third Edition. . . . . . . . $2.50. DOBELL ON WINTER COUGH ( C at aesh, Bronchitis, Emphysema, Asthma). New and Enlarged Edition, with Colored Plates. .... $3.50. DRUITT'S SURGEON'S VADE-MECUM. Tenth Revised London Edition. $5.00. DUCHENNE'S LOCALIZED ELECTRIZATION. Translated from the Third Edition, by Herbert Tibbits, M.D. 92 Illustrations. . . . $3.00. DUNGLISON'S HISTORY OF MEDICINE. From the Earliest Ages to the Nineteenth Century • • $2.50. ELLIS'S PRACTICAL MANUAL OF THE DISEASES OF CHILDREN. With Formulary, &c. Second Edition. ..... $2.75. DURKEE ON GONORRHOEA AND SYPHILIS. Fifth Edition, Eevised and Enlarged ; with Portraits and Colored Illustrations. . . . $5.00. ELAM ON CEREBRIAAND OTHER DISEASES OF THE BRAIN. $2.50. PULLER ON RHEUMATISM, RHEUMATIC GOUT, AND SCIATICA. Fourth Edition. Octavo. ....... $5.00. PULLER ON THE HEART AND GREAT VESSELS. Second Edition, Eevised and Enlarged. FLINT'S REPORTS ON CONTINUED FEVER. Octavo. . . $2.00. POTHERGILL ON THE HEART AND ITS DISEASES. With their Treatment, and Illustrations. Octavo. ...... $5.00. POTHERGILL ON DIGITALIS. Its Mode of Action and Use. . . $1.25. FOX ON THE HUMAN TEETH. Their Natural History, Structure, and Treat- ment. With 250 Illustrations. ....... $4.00. GANT'S SCIENCE AND PRACTICE OP SURGERY. With 470 Illus- trations. .......... $7.50. GANT'S IRRITABLE BLADDER. Its Causes and Treatment. Third Edition, Eevised. With Illustrations. ....... $2.50. GROSS' AMERICAN MEDICAL BIOGRAPHY OP THE NINE- TEENTH CENTUEY. Octavo $3.50. GREENOW ON BRONCHITIS. Especially as connected with Gout, Emphy- sema, and Diseases of the Heart. ...... $2.00. GODFREY'S DISEASES OP HAIR. Its Preservation and Management. $1.50. GARDNER ON STERILITY. Its Causes and Curative Treatment. With Illustrations. Octavo. ........ $3.00. HOLDEN'S MANUAL OF THE DISSECTION OP THE HUMAN BODY. Illustrated ' . . $5.00. HILLIER'S CLINICAL TREATISE ON THE DISEASES OP CHIL- DEEN $3.00. HARRIS' PRINCIPLES AND PRACTICE OF DENTISTRY. Tenth Eevised Edition. In great part Ee-written, Ee-arranged, and with many New and Important Illustrations. In Cloth, $6.50 ; In Leather, . . . $7.50. HARRIS' DICTIONARY OF MEDICAL TERMINOLOGY, DENTAL SUEGEEY, AND THE COLLATEBAL SCIENCES. Third Edition. Cloth, $6.50. Leather, 7.50. HANDY'S TEXT-BOOK OF ANATOMY, AND GUIDE TO DISSEC- TIONS. 312 Illustrations. Octavo $4.00. HARDWICH & DAWSON'S MANUAL OF PHOTOGRAPHY. With Engravings. Eighth Edition. ....... $2.00. HARLEY'S URINE AND ITS DERANGEMENTS. With the Applica- tion of Physiological Chemistry to the Diagnosis and Treatment of Constitutional as well as Local Disease. With Illustrations. ..... $2.75. HEWITT ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF WOMEN. Third Edition, Eevised and Enlarged, with new Illustrations. In Cloth, $5.00 ; In Leather, ..... $6.00. HABERSHON ON THE DISEASES OP THE LIVER. Their Pathology and Treatment. . . . . . . . . . $1.50. HEADLAND ON THE ACTION OF MEDICINES IN THE SYSTEM. Sixth American Edition. ....... $3.00. HILLE'S POCKET ANATOMIST. For the Use of Students. In Cloth, $1.00. In pocket-book form, 1.25. HEATH ON THE INJURIES AND DISEASES OP THE JAWS. Second Edition. With 150 Illustrations. ..... $5.00. HEATH'S MINOR SURGERY AND BANDAGING. With Numerous Illustrations. $2.25. HODGE ON FOETICIDE, OR CRIMINAL ABORTION. Fourth Edition. In Paper Covers, $0.30; In Flexible Cloth, . . . . $0.50. HOLMES' SURGICAL DISEASES OF INFANCY AND CHILDHOOD. Second Edition. . . . . . . . . $5.00. HUFELAND'S ART OP PROLONGING LIFE. Edited by Erasmus Wil- son, M. D., F. Pv. S $1.25. HEWSON'S EARTH AS A TOPICAL APPLICATION IN SURGERY. With Illustrations. ........ $2.50. JONES' DEFECTS OF SIGHT AND HEARING. Second Edition. $1.25. HOLDEN ON THE SPHYGMOGRAPH. Its Physiological and Pathological Indications. With 300 Illustrations. LAWSON'S DISEASES AND INJURIES OF THE EYE, THEIR MEDICAL AND SUKGICAL TKEATMENT. With Illustrations. . $2.50. LEBER & ROTTENSTEIN ON DENTAL CARIES. With Illus- trations. .......... $1.50. LEGG'S GUIDE TO THE EXAMINATION OF URINE. Third Edition ' $0.75. LEWIN ON THE TREATMENT OF SYPHILIS, WITH SUBCUTA- NEOUS SUBLIMATE INJECTIONS. With Illustrations. . . $2.25. LIZARS ON THE USE AND ABUSE OF TOBACCO. . . $0.60. MEIGS AND PEPPER'S PRACTICAL TREATISE ON THE DIS- EASES OF CHILDKEN. Fifth Edition, Enlarged and Improved. Cloth, $6.00. Leather, 7.00. MACKENZIE ON GROWTHS IN THE LARYNX. With Numerous Colored and other Illustrations. ... ... $3.00. MACKENZIE ON THE LARYNGOSCOPE IN DISEASES OF THE THKOAT, &c, &c. With Illustrations. $3.00. MACKENZIE'S PHARMACOPOEIA OF THE HOSPITAL FOR DIS- EASES OF THE THROAT $1.25. MACNAMARA'S MANUAL OF THE DISEASES OF THE EYE. With Colored Plates and other Illustrations. Second Edition. . . $5.00. MARSHALL'S DESCRIPTION OF THE HUMAN BODY". Its Struc- ture and Functions. With 193 Colored Illustrations. 2 vols. Cloth, . $10.00. MARSHALL'S PHYSIOLOGICAL DIAGRAMS. Life-Size, and Beauti- fully Colored. Price of the Set, eleven Maps, in sheets, . . . $50.00. Handsomely mounted on canvas, with Pollers, and varnished, . . $80.00. AN EXPLANATORY KEY TO THE ABOVE. . . . $0.50. MARTIN'S MANUAL OF MICROSCOPIC MOUNTING. With Illus- trations on Stone and Wood. 8vo. ...... $3.00. MAUNDERS OPERATIVE SURGERY ADAPTED TO THE LIVING AND DEAD SUBJECT. Second Edition. Illustrations. . . . $2.50. MAXSON'S PRACTICE OF MEDICINE. Octavo. Leather. . $4.00. MEADOWS' MANUAL OF MIDWIFERY. Including the Signs and Symp- toms of Pregnancy, Obstetric Operations, &c. With Illustrations. . . $3.00. MENDENHALL'S MEDICAL STUDENT'S VADE-MECUM. Tenth Edition, Pevised and Enlarged, with 224 Illustrations. .... $2.50. MILLER ON ALCOHOL, ITS USE AND ABUSE. . . . $0.75. MILLER ON ALCOHOL, AND LIZARS ON TOBACCO. The Two in One Volume. 12mo. ....... $1.00. MORFIT'S CHEMICAL AND PHARMACEUTICAL MANIPULA- TIONS. New Edition, with over 500 Illustrations. Preparing. MURPHY'S REVIEW OF CHEMISTRY FOR STUDENTS. . $1.25. NEW SYDENHAM SOCIETY PUBLICATIONS. Prospectuses furnished upon application. Per annum. ...... $10.00. OTT ON THE MANUFACTURE OF SOAPS AND CANDLES. With Illustrations. ......... $2.50. OVERMAN'S PRACTICAL MINERALOGY, ASSAYING AND MINING. With a Description of the Useful Minerals, &c. . . . $1.25. PAGET'S SURGICAL PATHOLOGY. Third London Edition. With Numer- ous Illustrations. ......... $7.50. PARKE'S MANUAL OF PRACTICAL HYGIENE. Fourth Edition. Enlarged & Improved Octavo. . ... . . . . $6.00. PARKER'S MODERN TREATMENT OF SYPHILITIC DISEASES. Fifth Edition $4.25. PENNSYLVANIA HOSPITAL REPORTS. Vols. 1 and 2, for 1868 and 1869. With Illustrations. Per volume, ..... $4.00. PEPPER'S CLINICAL TREATISE ON RELAPSING FEVER. Colored Plates. Preparing. PIESSE'S WHOLE ART OF PERFUMERY. The Methods of obtaining the Odors of Plants; Manufacture of Perfumes, &c, &c. From the Third London Edition. With Illustrations. '. . . . . • • $3.00. 50 PERBIRA'S PHYSICIAN'S PRESCRIPTION BOOK. From the Fifteenth London Edition. In Cloth, $1.25; In Leather, with Tucks and Pocket, . $1.50. PHYSICIAN'S VISITING LIST, PUBLISHED ANNUALLY. Sizes and Price. For 25 Patients weekly. Tucks, pockets, and pencil, . . . $1.00. 50 " " " " " • 1.25. 75 " " " " " • 1.50. 100 " " " " ".."... 2.00. , in , f Jan. to June, 1 « Cf . 2vols -\JulytoDec. } ' ' ' " 2 - 5(X -inn a a o i f Jan. to June, ) « A a 100 2vols -|j u lytoDec. } .... 3.00. Interleaved Edition. For 25 Patients weekly, interleaved, tucks, pockets, etc., . . . $1.50. 50 " " " " " . . 1.75. Kf\ « " o ™i a / J an - to June, \ « a o aa 50 2vols -ijulytoDec. 1 ' ' ' 3m PIGGOTT ON COPPER MINING AND COPPER ORE, &c. 12mo. $1.50. PRINCE'S PLASTIC AND ORTHOPEDIC SURGERY. With Numerous Illustrations. ......... $4.50. PROCTOR'S (BARNARD S.) PRACTICAL PHARMACY. RADCLIFFE'S LECTURES ON EPILEPSY, PAIN, PARALYSIS, and other Disorders OP the Nervous System. With Illustrations. . $2.00. REESE'S AMERICAN MEDICAL FORMULARY. . . $1.50. REESE'S ANALYSIS OF PHYSIOLOGY. . . . . $1.50. RENOUARD'S HISTORY OF MEDICINE, FROM ITS ORIGIN TO THE NINETEENTH CENTURY. Octavo $4.00. REPORTS ON THE PROGRESS OF MEDICINE, SURGERY, &c, &c. Prepared for the Sydenham Society of London. . . .- . $2.00. REYNOLDS' LECTURES ON THE CLINICAL USES OF ELEC- TRICITY. Second Edition RICHARDSON'S PRACTICAL TREATISE ON MECHANICAL DENTISTRY. Second Edition, Enlarged $4.50. RIGBY'S OBSTETRIC MEMORANDA. Fourth Edition. . . $0.50. RIHL & ©'CONNER'S PHYSICIAN'S DIARY. A Monthly, Semi-Annual, and Annual Journal and Cash-Book combined, &c. .... $7.50. RINDFLEISCH'S TEXT-BOOK OF PATHOLOGICAL HISTOLOGY. An Introduction to the Study of Pathological Anatomy. With 208 Illustrations. Bound in Cloth, $6.00 ; in Leather, ...... $7.00. ROBERT'S HAND-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. ROBERTSON'S MANUAL ON EXTRACTING TEETH. Second Edition, Revised and Improved. With Illustrations. ..... $1.50. ROSER'S SURGICAL ANATOMY. By Gaeton. With Illustrations. ROSS. THE GRAFT THEORY OF DISEASE. Demy Octavo. . $4.00. RYAN'S PHILOSOPHY OF MARRIAGE. In its Social, Moral, and Physi- cal Relations. 12mo. . . . . . . . . $1.00. SANDERSON'S PHYSIOLOGICAL HAND-BOOK FOR THE LABO- EATOKY. With over 350 Illustrations from Original Drawings. 2 volumes. $8.00. SANSOM ON CHLOROFORM. Its Action and Administration. 12mo. $2.00. SAVAGE'S SURGERY, SURGICAL PATHOLOGY, AND SURGICAL ANATOMY of the FEMALE PELVIC ORGANS. Colored Plates. Third Edition. Enlarged. Preparing. SCANZONI'S PRACTICAL TREATISE ON THE DISEASES OF THE SEXUAL ORGANS OF WOMEN. With Illustrations. . . $5.00. SCHULTZE'S LECTURE DIAGRAMS FOR INSTRUCTION IN PREGNANCY AND MIDWIFERY. 20 Large Maps or Diagrams, and a 4to vol. of Letter-press. In Sheets, $15.00 ; Mounted on Rollers, . . . $30.00. STILLE'S ELEMENTS OF GENERAL PATHOLOGY. Second Edition. STILLE'S EPIDEMIC MENINGITIS; OR, CEREBRO-SPINAL MEN- INGITIS. Octavo $2.00. STOKES ON THE DISEASES OF THE HEART AND AORTA. $3.00. SWERINGEN'S PHARMACEUTICAL DICTIONARY. A Lexicon of Pharmaceutical Science. Cloth, $5.00 ; Leather, .... $6.00. TAFT'S PRACTICAL TREATISE ON OPERATIVE DENTISTRY. Second Edition. Revised. Over 100 Illustrations. Octavo. . . . $4.50. TANNER'S PRACTICE OF MEDICINE. Fifth American, from the Sixth London Edition. Royal 8vo, over 1100 pages. In Cloth, $6.00; in Leather, $7.00. TANNER'S PRACTICAL TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Third Edition $3.50. TANNER'S INDEX OF DISEASES AND THEIR TREATMENT. With Formulae for Medicines, &c, &c. Octavo. .... $3.00. TANNER'S MEMORANDA OF POISONS. A New and much Enlarged Edition $0.75. TIBBITT'S HAND BOOK OF MEDICAL ELECTRICITY. Illustrated. $2.00. THOMPSON'S PREVENTIVE TREATMENT OF CALCULOUS DIS- EASES '. $1.00. THOMPSON'S PRACTICAL LITHOTOMY AND LITHOTRITY. Second Edition. ......... $4.50. THOROWGOOD ON ASTHMA. Its Nature, Forms, and Treatment. Second Edition $1.75. TILT'S CHANGE OF LIFE IN HEALTH AND DISEASE. From the Third London Edition. ........ $3.00. TOMES' DENTAL SURGERY. Second Edition, Revised and Enlarged. 263 Illustrations. ......... $5.00. TOYNBEE ON DISEASES OF THE EAR. A New Edition. By James Hinton. With Illustrations. Octavo. ...... $5.00. TROUSSEAU'S LECTURES ON CLINICAL MEDICINE, DELIV- ERED AT THE HOTEL-DIEU, PARIS. 2 volumes octavo. Complete. Price in Cloth, $10.00 ; in Leather $12.00. TUKE'S ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY. London Edition $4.00. TYLER SMITH'S OBSTETRICS. With Illustrations. Octavo. . $5.00. TYSON'S CELL DOCTRINE: ITS HISTORY, PRESENT STATE, &c. With a Colored Plate, and Numerous Illustrations. .... $2.00. VIRCHOW'S CELLULAR PATHOLOGY. With 144 Engravings. 8vo. $5.00. WALKER ON INTERMARRIAGE. With Illustrations. 12mo. . $1.50. WALTON'S PRACTICAL TREATISE ON DISEASES OF THE EYE. Third Edition. 300 Engravings, and 20 Chromo-Lithographs. Preparing. WARD ON SOME AFFECTIONS OF THE LIVER AND INTES- TINAL CANAL. Octavo $3.00. WARING'S PRACTICAL THERAPEUTICS. Considered chiefly with refer- ence to Articles of the Materia Medica. Third American, from the last London Edition. In Cloth, $5.00 ; Leather, ...... $6.00. WEDL'S PATHOLOGY OF THE TEETH. With Special Keference to their Anatomy and Physiology. 105 Illustrations. In Cloth, $4.50; in Leather, . $5.50. WELLS' TREATISE ON THE DISEASES OF THE EYE. Illustrated by Ophthalmoscopic Plates and Numerous Engravings on Wood. Third London Edition. Cloth, $5.00 ; Leather, ...... $6.00. WELLS ON LONG, SHORT, AND WEAK SIGHT. Third Edition. With Illustrations. Octavo. ....... $3.00. WILSON'S HAND-BOOK OF HYGIENE AND SANITARY SCIENCE. With Engravings, &c. Second Edition Kevised .... $2.50. WILSON'S MANAGEMENT OF THE SKIN AND HAIR. Seventh Edition $1.25. WOODMAN & TIDY'S HANDY-BOOK OF FORENSIC MEDICINE AND TOXICOLOGY. Preparing. WRIGHT ON HEADACHES. Their Causes and Cure. 12mo. . . $1.25. WYTHES' PHYSICIAN'S POCKET, DOSE, AND SYMPTOM-BOOK. The Tenth Edition. In Cloth, $1.25 ; in Leather, tucks, with pockets, . $1.50. NEW BOOKS, JUST HEADY. TROUSSEAU'S CLINICAL MEDICINE. Complete in Two Volumes, Oc- tavo. Price in Cloth, $10.00 ; in Leather, .... .$12.00. NORRIS'S CONTRIBUTIONS TO PRACTICAL SURGERY. Octavo. $4.00., BUCKNILL & TUKE'S MANUAL OF PSYCHOLOGICAL MEDI- CINE. The Third London Edition. Eevised and Enlarged. SHEPPARD'S LECTURES ON MADNESS. In its Medical, Legal, and Social Aspects. ........ $2.50. DALEY'S LECTURES ON DISEASES AND INJURIES OF THE EAE. With Illustrations. CLARKE ON DISEASES OF THE TONGUE. With Illustrations. . $5.00 THOMPSON ON THE PREVENTATIVE TREATMENT OF CAL- CULOUS DISEASE . . . $1.00. PHYSICIAN'S VISITING LIST FOR 1874. See Catalogue for Prices and Styles. WILSON'S ANATOMIST'S VADE MECUM. The Ninth Eevised and En- larged London Edition. ....... $5.50. TEXT-BOOKS AND MANUALS PUBLISHED BY LINDSAY & BLAKISTON, Philadelphia. TKOUSSEAU'S Clinical Medicine. Complete in 2 volumes octavo. Price only $10.00. ALTKEN'S Science and Practice of Medicine. The Third American, from the Sixth London Edition. 2 Volumes, Royal Octavo. SANDERSON'S Hand-Book for the Physiological Laboratory. Exercises for Students in Physiology and Histology. 353 Illustrations. 2 vols. CAZEAUX'S Text-Book of Obstetrics. Fifth American Edition. Illustrated. WARING'S Practical Therapeutics. From the Third London Edition. RINDFLEISCH'S Text-Book of Pathological Histology. Containing 208 Elaborately Executed Microscopical Illustrations. MEIGS & PEPPER'S Practical Treatise on the Diseases of Children. Fifth Edition. TANNER'S Practice of Medicine. Fifth American, from the Sixth London Edition. TANNER & MEADOW'S Diseases of Infancy and Childhood. Third American Edition. BIDDLE'S Materia Medica, for Students. Fifth Revised Edition. With Illustrations. HARRIS' Principles and Practice of Dentistry. The Tenth Revised Edition. PAGET'S Surgical Pathology. By Turner. Third London Edition. SOELBERG WELLS on Diseases of the Eye. Third London Edition. BYFORD'S Practice of Medicine and Surgery, applied to the Diseases of Women. Second Edition. Illustrated. HEWITT'S Diagnosis and Treatment of the Diseases of Women. Third Edition. HEADLAND on the Action of Medicines. Sixth American Edition. BEALE'S How to Work with the Microscope. Fourth Edition. HARLEY on the Urine and its Derangements. With Illustrations. MEADOW'S Manual of Midwifery. Second Edition. Illustrated. ATTHILL'S Manual of the Diseases of Women. With Illustrations. LAWSON'S Diseases and Injuries of the Eye, their Medical and Surgical Treatment. ROBERT'S Hand-Book of the Theory and Practice of Medicine. BLOXAM'S Chemistry, Inorganic and Organic. Second Edition. 276 Illustrations. MACNAMARA'S Manual of Diseases of the Eye. Second Edition. Numerous Colored and other Illustrations, with Test-Types. CARPENTER on the Microscope and its Revelations. 500 Illustrations. TIBBITT'S Hand-Book of Medical Electricity. 64 Illustrations. KIRKE'S Hand-Book of Physiology. Eighth London Edition. DILLNBERGER'S Hand-Book of the Treatment of Women and Children's Diseases. CHEW'S Lectures on Metlical Education. MENDENHALL'S Medical Student's Vade-Mecum. The Tenth Edition. 224 Illustrations. ROBERTSON'S Manual for Extracting Teeth. Second Edition. Revised. DIXON'S Practical Study of the Diseases of the Eye. Third Edition. PEREIRA'S Physician's Prescription Book. The Fifteenth Revised Edition. WYTHES' Pocket, Dose, and Symptom Book. Tenth Edition. With Additions. BARTH & ROGER'S Manual of Auscultation and Percussion. Sixth Edition. CLEAVELAND'S Pronouncing Medical Lexicon. Thirteenth Edition. LEGG'S Guide to the Examination of the Urine. Third London Edition. HILL'S Pocket Anatomist for the use of Students. TANNER'S Memoranda of Poisons. From the Third London Edition. RIGBY'S Obstetric Memoranda. Fourth Edition.