COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 16620 RC74 .01 42 Pulse-gauging; a cli "^^^^m^xm' RECAP l^# K^-;*^ Columbia Wini\}tx^itv intl)eCitj»ofi^etoPorfe College of Pftpssicianig anb ^urgeonsJ Reference Hihxavv PULSE-GAUGING THE ARTERIOMETEK. PULSE-GAUGING A CLINICAL STUDY OF RADIAL MEASUREMENT AND PULSE-PRESSURE BY GEORGE OLIVER, M.D.Lond., F.R.C.P. AUTHOR OF "BED-SIDE URINE TESTING" "the HARROGATE WATERS," ETC. LONDON H. K. LEWIS, 136 GOWER STREET, W.C. 1895 PRINTED BY H. K. LEWIS, 136 GOWER STREET LONDON, W.C. TO J. RUSSELL REYNOLDS, M.D. LoND., F.R.S. PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, ETC., WHOSE TEACHING, FRIENDSHIP, AND VALUED COUNSEL HAVE LARGELY CONTRIBUTED TO MY SUCCESS AND HAPPINESS, I DEDICATE THIS LITTLE VOLUME WITH SINCERE REGARD. PREFACE. In the following pages I have endeavoured to present an outline of the principal re- sults obtained by the application of the methods of observation of the pulse, which I have followed during the past three or four years. The data thus yielded have afforded me such practical clinical guidance, that I am fain to think there are some who may care to put them on trial, and who may find this chart somewhat useful in their attempts to study the pulse on the lines which I have adopted. In the earlier years of my practice I patiently applied the sphygmograph ; but I eventually concluded that the clinical aid which it can provide is but limited, and by no means commensurate with the Vlll PREFACE. time and trouble which the apphcation of that instrument demands. As years went on I could not divest myself of the impression that some other instru- mental mode of observation of the pulse would eventually be discovered, which would amplify and render more definite all the practical aspects of pulse-feeling : and, when some few years ago, I secured the freedom and leisure of the winter months I ventured to attack this problem. Since then my practice at Harrogate, and the various opportunities for observation which my friends have afforded me in the London hospitals, have enabled me to test the practical capabilities of the methods of observation I had devised. Guided solely by observation, I have been led to follow a path which has yielded results of some promise ; and I confess I should now find myself at a considerable clinical disadvantage were I to lay aside my arteriometer and pulse-pressure gauge. Though these instruments have contri- PREFACE. IX buted considerably to the training of the finger (which must always retain the pri- mary place in pulse exploration), they still remain to me indispensable ; for they pro- vide a clear definition of the tactile im- pressions, which cannot otherwise be re- corded with any approach to exacti- tude. My field of work at Harrogate is pecu- liarly favourable to the application of the methods of observation I have adopted,* and this circumstance has largely incited me to the prosecution of this enquiry. A clinical study such as this has many ramifications and connections. I have merely touched on those that have fallen within the range of my own experience, and there necessarily remains much to be * A large proportion of my cases are chronic, and, inasmuch as many of them appear year by year, or at intervals of a year or two, I find the lecording of the facts gleaned by the pulse-instruments of considerable value, in enabling me, with other data, to note changes in the individual, which are of pathological and clinical interest. X PREFACE. settled and explained by more extended observation. I am under much indebtedness to many friends — too numerous to be mentioned individually — for their generous aid in affording me opportunities of making ob- servations, and in giving me valuable suggestions ; and my best thanks are due to the Editors of the Practitioner for their permission to use several blocks of figures which were employed to illustrate my paper on " Pulse-Pressure." The substance of Chapter II., Part I., was read as a paper at the Meeting of the Physiological Society, held at King's Col- lege in February last. Of late years medical literature has grown so extensive, that I think it is in- cumbent on writers to express themselves as tersely as possible. I have, therefore, endeavoured to follow this injunction. Harrogate : November, 1894. CONTENTS. Part I. RADIAL MEASUREMENT. CHAPTER I. The Mode of Observation. PAGE Section I. — The Principle of the writer's Arterio- meter ...... i ,, II. — The Arteriometer .... 2 ,, III. — How to apply the Arteriometer . 5 ,, IV. — Sources of Fallacy . • . . . 9 CHAPTER H. The Calibre of the Arteries in Health : Physiological Variations. Section I. — The Calibre of the Arteries in Health is always varying within certain limits ...... 12 ,, II. — The Calibre in the Postures (recum- bency, sitting and standing) . 13 Xll CONTENTS. PAGE Sect. III. — The Calibre in Movement and Exer- cise 15 ,, IV. — The Calibre during digestion . . 18 ,, V. — The effects of External Temperature on the Calibre ot the Arteries . 19 ,, VI. — The Calibre in relation to Mechani- cal Causes affecting the distribu- tion of the blood .... 22 „ VII. — The relation between the Calibre of the Arteries and the Surface Tem- perature ..... 23 „ VIII. — The probable causes of variation of the Calibre 25 CHAPTER III. The Calibre of the Arteries in Disease : Pathological Variations. Section I. — The Pathological Variations are de- termined by the Physiological . 31 ,, II. — The maximum Calibre in the Re- cumbent Posture .... 32 ,, III. — The Calibre uniform in the Postures 34 ,, IV. — Restricted and Amplified Postural Variation . . . . . . 40 „ v.— The Calibres of both Radial Arte- ries : Asymmetry .... 41 „ VI. — The effects of Irritation on the Cali- bre of the Arteries ... 42 ,, VII. — The Standard Calibre, and some of the leading Pathological Devia- tions 50 ,, VIII. — The relation between the Calibre and the Blood-pressure . . 52 CONTENTS. Xlll CHAPTER IV. Radial Measurement in Relation to Diagnosis, Treatment, and Thera- peutic Enquiry. PAGE Section I. — The Arteriometer in relation to Dia- gnosis 55 ,, II. — The Arteriometer in relation to Treatment ..... 64 ,, III. — The Arteriometer as an Aid to En- quiry ...... 81 Part II. PULSE-PRESSURE. CHAPTER I. The Mode of Observation. Section I. — The writer's Pulse-pressure Gauge . 93 ,, II. — The mode of applying the Pulse- pressure Gauge . . . • g8 ,, III. — How to determine the Minimum and Maximum Pulse-pressure . . loi CHAPTER II. The Clinical Indications furnished by THE Pulse-Pressure Gauge. Section I.— The General Clinical Significance of the Movements of the Indicator . ic6 „ II. — The Signs of Plus and Minus Arte- rial Tension furnished by the Pulse-gauge ..... 108 XIV CONTENTS. CHAPTER III. The Radial Pulse - Pressure : Normal AND Abnormal. PAGE Section I. — Difficulties and Fallacies. . . 123 ,, II. — The tactile appreciation of Pulse- pressures ..... 125 „ III. — The average Pulse-pressures. Nor- mal Pulse-pressures . . . 126 „ IV. — Abnormal Pulse-pressures . . 128 CHAPTER IV. The Pulse-Pressure Gauge and Arterio- METER AS Aids in determining THE effects of THE TREATMENT OF PLUS Arterial Tension. Sect ion I. — Treatment by Recumbency . . 132 ,, IT. — Treatment by Diet .... 140 ,, HI. — Treatment by Mineral Waters and Baths 141 ,, IV. — Treatment by Vaso-motor Relaxants 145 CHAPTER V. Conclusions : Resume of Observations 149 Addendum 156 Index 165 PART I. RADIAL MEASUREMENT. PULSE-GAUGING. PART I. RADIAL MEASUREMENT. CHAPTER I. The Mode of Observation. I. The Principle of the Writer's Arterionieter, The internal diameter of a rubber-tube, placed upon a resisting surface, may be determined from the outside by a suitable mechanical arrangement. For example, let (i) two foot-rests be planted by the sides of the tube ; and (2) let a pad, con- nected with an indicator on a dial, settle on it — when its position, as the starting point of the measurement, will be shown ; and (3) let the pad be pushed forward so B 2 RADIAL MEASUREMENT. as to close the bore — when the space thus traversed will be recorded by the indicator (fig. I)- . . . This principle is followed in determining the calibre of the radial or temporal artery by the arteriometer ; the reading being taken when the pulsation ceases beyond m Fia. I. — Diagram showing the principle of the writer's arteriometer. the pad — the bore of the artery then being closed. 2. The Arteriometer, The mechanism is enclosed in a small circular box ; faced by a dial, graduated in four millimetres (each mm. being di- vided into tenths) ; and presenting below three stems, carrying the foot-rests and Y Fio. 3.— Section of arteriometer. 4 RADIAL MEASUREMENT. the pad. The sectional drawing (fig. 2) shows the details of construction. The stem to which the pad is screwed, is free to settle over the site of the artery ; and attached to it is a silk thread, which is maintained in a state of uniform tension around the axle by a piece of hair-spring, and communicates to the hand on the dial the exact position of the pad. A rod comes down on this stem, when the for- ward movement is made to close the artery. The instrument is enclosed in an outer case ; and when it is applied, the latter — carrying the rod just referred to — is merely pressed over it through the in- tervention of springs placed between them. This arrangement secures uniformity of pressure on the foot-rests throughout every observation. It will be observed, that the force used to effect the closure of the artery is that of the hand exerted through the travelling rod ; this force being always in excess of the blood-pres- sure, otherwise the indicator would not travel on the dial.* * The instrument was made for me by Mr. Hawkesley, Surgical Instrument Maker, 357 Oxford Street, W. MODE OF OBSERVATION. 3. How to apply the Arteriometer. Gf the superficial arteries the radial is best adapted to the purpose in view ; for, the calibre of it is sufficiently large to provide an ample scale for the definite recording of variations ; and, moreover, the vessel occupies an accessible position on a bony floor, and is flanked by firm structures. The temporal artery is some- what too small for general selection ; though the measurement of its calibre may now and then prove useful, when the radial arteries are not available for trust- worthy observation. Two conditions must be observed in order to make the reading as reliable as possible :— (i) The wrist must always be extended at a uniform angle ; and (2) the same part of the artery must be observed on all occasions. The first condition is secured by placing the extended arm on a wrist-rest providing an angle of 45°* ; * This angle of extension generally secures a slight and uniform traction of the tissues, which favours de- P RADIAL MEASUREMENT. and the second, by marking with an aniHne pencil the site of that portion of the artery selected for measurement. A preliminary examination by the finger quickly enables the observer to decide, where the bed of the artery is most even and resistant, and therefore best adapted to the observation ; and, as a rule, this is found to be on a level with the prominent point of the styloid process. Figure 3 represents the most convenient way of applying the arteriometer. The instrument is held by the index finger and thumb of the right hand; the foot- rests are planted, one on the styloid pro- cess, and the other on the flexor tendons rendered firm by the extension just re- ferred to ; and the pad is made to occupy the exact site of the artery. The index finger of the left hand is placed over the artery beyond the pad ; and the outer case is drawn slowly downwards. At first the indicator travels until it reaches a certain finite observation ; for example, the tendon of the flexor carpi radialis thus becomes a resistant platform for one of the foot-rests. MODE OF OBSERVATION. 7 point, when it turns in the opposite direc- I. » • 1-4 Petrissage ,, 17 Effleurage „ . 17 »» »» • . 1-5 j» »> • . 1-8 Tapotement 3 min. . 1-8 4. The Calibre during Digestion. Repeated observation has shown, that during the digestion of a full meal {e.g., dinner in the evening), the measurement of the radial calibre shows — * The brain-clearing, and indeed the brain-nourishing, effects of the judicious use of exercise and out-of-door games has undoubtedly a firm physiological basis. IN HEALTH. 19 {a) Reduction in the sitting posture, which begins in from fifteen to thirty minutes after the conclusion of the meal, and at- tains its maximum fall from thirty to sixty minutes : and {h) expansion in recumbency . In about an hour and a half the calibres in both postures may exceed those ob- served before the meal began. Example : Radial Calibre IN MM. Sitting. Recumbent. Before dinner . . . 15 min. after dinner 30 „ 45 „ 60 „ ,, ,, 75 M 90 „ 105 „ 2-0 1-8 1-8 17 1-6 1-9 1-8 2-3 i'5 1-6 2-3 2-6 2-3 2-3 2*2 1-8 5. The effects of External Temperature on the Calibre of the Arteries. It is well known that the calibre of the arteries is very readily affected by varia- tions of external temperature. C2 20 RADIAL MEASUREMENT In order to determine the effect of tem- peratures, ranging from 40° to 120° F. on the radial cahbre, I immersed the fore- arm in water for the definite period of three minutes at each observation, and, on the removal of the arm, I immediately measured the calibre in a uniform atmos- pheric temperature of 60° F. The follow- ing table provides a summary of these observations. Immersion in Temp. F. r c \CP 50- 0) 60° s 70*^ s 80"' J3 (J 90^ 95^ (U 96° 97° 98- 100^ s IOI«' 102® N W io3» io4«> ^ 105^ "rt no" u 115 ti 120" unchanged unchanged R. Calibre Immediately AFTER Immersion. 1*3 mm. 1*4 1-5 17 2'0 22 2'2 2*2 2-3 2-4 2-6 2*5 2-4 2*2 2-1 2-0 17 1-6 1-5 It will be observed, that the immersions IN HEALTH. 21 in the temperatures from go° to 96° did not disturb the cahbre : those in 97° to 99° enlarged it — 99° and 100° inducing the maximum enlargement : those in 101° and 102° still enlarged it, but to a small extent : that in 103° did not produce a discoverable effect : and those in higher temperatures reduced the calibre in pro- portion to the rise of temperature. Below 90° the calibre also fell — -pari passu with the reduction of temperature. Hot baths (from 100° to 105°) quickly reduce the radial calibre : and warm baths (from 97° to 100°) enlarge it — though, when the temperature is maintained for a cer- tain time at 99° or 100°, reduction, as a rule, takes place. A reduction is likewise effected by the Turkish bath, for example : — Sitting, Recumbent. R. calibre before bath . . 2*5 mm. 2'i mm. After 20 min. 250° . . . 2-0 „ 1-5 ., >» 15 »» »> • • • 1-6 ,, 2-0 „ ,, cold shower . . . 2-0 „ 1-6 „ 22 RADIAL MEASUREMENT The radial calibre is also lessened by the application of heat to a distant part. For instance, I have observed, that im- mersion of the feet in hot water for twenty minutes, the high temperature being well maintained the while, may reduce a radial calibre of 2'2 mm. to 1*3 mm. ; and, on allowing the water to cool, it may gradu- ally rise to i*8 mm. or so. I have also found, that on immersing an arm in hot water (115° F.) the calibre of the radial artery on the opposite side may fall from 2*0 mm. to 1*6 mm. 6. The Calibre in relation to Mechanical Causes affecting the Distribution of Blood, Gravity affects the radial calibre slightly ; for, I find the measurement varies some- what when the wrist is placed at different levels in relation to the heart. For ex- ample, the subject being recumbent, a calibre of i*6 mm. at the level of the heart may become 1*7 mm. ten inches below, and 1*4 mm. 10 inches above that level. IN HEALTH. 23 Raising the legs passively increases the radial calibre. A measurement of 17 mm. in recumbency may, on putting both legs up and supporting them, advance in two minutes to 2'2 mm., and, on lowering them, may return in three minutes to 17 mm. I have observed, that on reducing the atmospheric pressure on one leg by the application of Junod's boot, the radial calibre of i*8 mm. may fall to i*2 mm., and, on allowing the air to re-enter the boot, the original measurement may be restored in ten minutes. It, therefore, seems possible to control the circulation of a certain quantity of blood by mere mechanical means. 7. The relation between the Calibre of the Arteries and the Surface Temperature. I HAVE observed, that the temperature (sublingual)* varies in direct proportion * Though axillary temperatures provide readings, which correspond, as a rule, with sublingual ones, they are u^^on the whole less trustworthy. 24 RADIAL MEASUREMENT to the diameter of the radial artery as determined by the arteriometer. Accord- ing to the observations I have hitherto made, the extreme variations of tempera- ture, recorded in the different physiologi- cal conditions of the same individual, are confined within comparatively narrow limits — from i*o° to 1*5° F. ; but, as a rule, they have maintained a pretty constant relation to the size of the radial — as when from any cause, the variations of the radial calibre, induced by posture, digestion, or exercise, became more restricted, or more ample than usual, the temperature followed suit pari passu. I am satisfied as to the correctness of this position in regard to posture;* I can- not, however, speak so assuredly of this * Since making out this fact, I find that Kernig (quoted by Wunderlich) and Liebermeister (quoted by Prof. Bouchard) had already demonstrated on healthy men, that the axillary temperature is a few tenths of a centigrade degree lower in recumbency than in the sit- ting and standing postures : and Prof. Bouchard con- firms this position — his observations having been made on the rectal temperature. British Medical jfournal, April 14th, 1894. IN HEALTH. 25 relationship in the other physiological con- ditions which affect the calibre, because my data are as yet insufficient. The fol- lowing average example illustrates this interesting connexion in posture. Recumbent Sitting . . Standing . Radial Calibre IN MM. 1*5 i'9 2'5 Sublingual Temp. 98-0° F. 98-5° F- 98-90 F. 8. The probable causes of Variation of the Calibre. I. Diminution of the radial calibre may arise from : — {a) Contraction of the arterial wall : as from cold and from high temperature. Possibly the artery is reduced by contrac- tion in the active postures during the second stage of exercise, during digestion (perhaps as a reflex effect), and whenever the maximum calibre appears in the pas- sive posture. {b) Passive reduction : as from lowering 26 RADIAL MEASUREMENT of the heart's action — hence, perhaps, the minimum caKbre in recumbency ; or from relaxation of the small arteries favouring the flow into and through the periphery — as from excessive or continued heat, or exercise. 2. Enlargement of the radial calibre may result from : — (a) Reduced arterial tone : as from mode- rate heat. (b) Distension : as from increase of the heart's action — e.g., in the active postures, and in the first stage of exercise ; or from peripheric obstruction, such as constric- tion of the small arteries — as when the calibre enlarges in the passive posture, as the result of effort, fatigue, digestion, &c. The cause of this enlargement does not at first sight seem very obvious ; but I think it is not improbable, that it may be ascribed to a limitation to the terminal arteries of the widely diffused contraction which reduces the radial calibre in the sit- ting posture. I have observed in experi- ments on animals, that, when the arteries distributed to the limbs and to the viscera IN HEALTH. 27 are thrown into energetic contraction by the intra-venous injection of supra-renal extract (see ch. iv., 3), the central arteries — such as the carotid — become greatly dis- tended and enlarged ; the contraction of all the arteries below a certain size raising the blood-pressure, which dilates the large vessels. It is but reasonable to suppose, that were the contraction to be limited to the small arteries only, the consequent rise of blood-pressure will expand all the arteries of larger size. It is, therefore, not improbable, that in the physiological conditions just referred to, the arteries (including those of moderate size like the radial) are in the sitting posture contracted, and thus reduced in calibre ; and, that in recumbency, the radial enlarges, because the constriction ceases to affect it, and becomes confined to the vessels of smaller size only, where by increasing the peri- pheral resistance it augments the blood- pressure, and thus distends the arteries between it and the heart.* * When the radial calibre falls on changing the pos- ture Irom sitting to recumbency, in all probability the 28 RADIAL MEASUREMENT This condition of the arterial wall in posture may be reflected from some dis- tant source of irritation or discomfort. Thus I have repeatedly observed, that it exists whenever there is a call to stool ; and the normal arrangement of the radial calibres is restored at once by the evacua- tion. This physiological fact of reflected arterial contraction has some pathological bearing (see pp. 32, 33, 42-49). What relation (if any) subsists between the calibre and the frequency of the heart's action and the blood-pressure ? Though I have made a large number of observations in which the pulse-rate* was carefully re- corded by the side of the measurements of the radial calibre, I have failed to dis- cover any definite relation (direct or in- direct) between the two. It may be said, surely as the frequency has a recognizable connexion with the postures, it may be similarly related to the calibre also. If arterial tonus diminishes pretty equably throughout — the peripheral on-flow being thus favoured. * This was invariably taken by counting for the whole minute. IN HEALTH. 29 that were so, the pulse-rate should rise in recumbency when the calibre is found to be the largest in that posture. But it does not do so ; for, on taking 50 consecu- tive observations in which the recumbent calibre exceeds that of sitting, and 50 con- secutive observations in which it follows the reverse order, I find the relative aver- age frequency between the two postures is the same in both classes. Recumbent Calibre. Pulse-Rate. Sitting, Recumbent. 50 observations . 50 observations . maximum minimum 69-8 697 63-5 63-5 Individual observations, made in quite different physiological conditions, might likewise be quoted to strikingly disprove any connexion between the pulse-rate and the calibre. I have made a pretty large number of observations with my pulse-pressure gauge (see Pt. II., ch. i.) with the view of ascer- 30 RADIAL MEASUREMENT taining if any relation subsists in health between the blood-pressure and the radial calibre ; but I find recorded a good many apparent exceptions to any general rule that may be formulated. I am, however, inclined to think, that under physiological conditions there is a general direct con- nexion between them, which in the patho- logical field is apt to be considerably dis- turbed (see p. 53), IN DISEASE. 31 CHAPTER III. The Calibre of the Arteries in Dis- ease : Pathological Variations. I. The Pathological Variations are Deter- mined by the Physiological. In the pathological field the physiological variations of the radial calibre are apt to become disturbed in a marked degree ; and they naturally form the standard, by which the clinically observed departures are to be gauged. I have found the effects of posture on the radial calibre to form the most convenient practical test, in order to determine the pathological devia- tions ; and for this purpose, it is in the majority of cases sufficient to apply the arteriometer merely in the sitting and re- cumbent postures. But in certain cases I have observed, that the calibration of the artery in the standing posture may likewise yield useful information (see p. 63). 32 RADIAL MEASUREMENT The application of this test has shown, that in cKnical observation the leading departures from the average physiological variation of the radial calibre consist of the much greater prevalence of: — (a) The maximum measurement in re- cumbency. (b) The absence of postural variation. (c) A restricted or more ample range of postural deviation. 2. The Maximum Calibre in the Recumbent Posture, I HAVE already pointed out the leading conditions in health, in which I have ob- served the radial calibre to be larger in recumbency than in the sitting posture ; and, that when this arrangement obtains, it quickly passes away, and is indeed al- ways temporary. But in the clinical field, I have often found it to be less or more permanent in certain cases : cases in which the promi- nent pathological features were due to asthenia, or to some form of irritation, or IN DISEASE. 33 more commonly to a combination of both of these conditions. In the asthenic group were included anaemia, cardiac asthenia, neurasthenia, phthisis, glycosuria, asthenic gouty dis- crasia, and loss of tone from various causes.* The irritations were such as arose from eczema, urticaria, pruritus, constipation, intestinal irritation, dyspepsia, ovarian neuralgia, chronic cystitis, and pain gene- rally — whether of a neuralgic, rheumatic, or gouty character. A condition of semi-tension of the ar- terial wall may be said to exist : namely, a pretty widely spread contraction in the sitting posture, and a constriction merely limited to the small arteries, with conse- quent expansion of the radial in recumb- ency (see p. 27). I have, moreover, fre- quently observed, that discomfort or pain may induce such a thorough tonic contrac- tion of the arterial wall in all the postures, * When asthenia was the predominent clinical con- dition, the radial calibre in the standing posture was often remarkably reduced. D 34 RADIAL MEASUREMENT as to render the radial calibre uniform ; and when on the wane, this complete ten- sion may give place to this less advanced form.* 3. The Calibre Uniform in the Postures. In health the calibre of the arteries is but rarely free from variation in the postures ; and when this condition is observed, it is, moreover, quite transitory. On the other hand in clinical observation, I have met with this uniformity comparatively often ; and not merely lasting for a short time only, but persisting for a while, or remaining apparently permanent. The radial calibre may preserve its form just as does the pupil of a damaged iris. I. Temporary uniformity is of frequent occurrence. It may vanish under treat- ment ; and may occasionally recur. The causes are obviously not organic. When * In many cases of apparent increase of the calibre in recumbency, the artery enlarges just as the patient assumes this posture, but in a minute or so settles down to a lower point — either uniform with or below that of the sitting posture. IN DISEASE. 35 variation becomes apparent, the measure- ment of the major cahbre almost invari- ably advances several points beyond that recorded when the bore of the artery re- mained uniform ; and when the uniformity relapses, the calibre as a rule diminishes. I, therefore, conclude that in such cases the uniform calibre is caused by vaso- motor constriction — persisting in the re- cumbent as well as in the other postures. As a rule, there is generally present some pathological condition of an irritative type : such as pain, gouty discrasia, eczema, lichen, constipation, &c. According to my observation, the most frequent cause of this form of unvarying calibre is an increase of arterial tension due to gout ; and when the tension is relieved by treatment, the postural varia- tions return (see ch. iv., 2, and Part II., ch. iv., 3).* 2. Persistent uniformity characterizes an * When plus tension is the cause of the uniformity of the calibre, the pulsations perceived by the finger placed over the artery beyond the pad are apparently increased while the calibration is being made (see Part II , ch. i., 3, and ch. ii., 2). D2 36 RADIAL MEASUREMENT important group of cases. Here, ac- cording to my observation, the predomin- ant cause does not appear to be tonic muscular constriction ; but is more pro- bably referable to organic changes in the arterial wall, which may cripple or may even annul vaso-motor action. It does not, however, follow, that the arte- rial tube in such a condition is necessarily rigid or fixed in calibre ; for, I have fre- quently observed, that, though remaining uniform in posture, it may vary somewhat in calibre at different times — the fluctua- tions having apparently become limited and slow. Nor does this observation necessitate the existence of such a thick- ening of the wall of the artery as to be always obvious to the finger ; for, in a large proportion of the cases there was no tactile evidence of arterial change. The cases, in which I have observed this per- sistent uniformity of the radial calibre, were the subjects of — (i) Chronic interstitial nephritis. (2) Arterio-sclerosis (including the phy- siological form — atheroma). IN DISEASE. 37 (3) Myx oedema (13 cases). (4) Acquired syphilis (120 cases)*. (5) Chronic gout. In the renal cases the high intra-arterial blood-pressure alone might suffice to in- duce the continuous uniformity of the calibre; for I have observed, that — apart from any suspicion of organic changes in the walls of the arteries— a very moderate rise of blood-pressure will abolish the pos- tural variations, which, moreover, reappear as it subsides (see Part II., ch. iv., 3). But I am persuaded, that this is not the sole cause in the majority of cases; as it is not improbable, that the uniformity of calibre is maintained by organic changes in the ar- terial wall as well as by the high tension ; once set up, I have not known it to pass away— even though at times the arterial tension greatly diminished. Of other forms of chronic disease of the kidneys * Of these cases over 53 were observed at the Lock Hospital, Harrow^ Road, W. When the infecting sore, or well marked secondaries, or tertiaries, were not pre- sent, there was a well defined history either of a hard chancre, or of undoubted secondaries. 38 RADIAL MEASUREMENT I have had but a Hmited experience since I began this mode of observation. In waxy kidney (two cases only) postural variation of calibre was pronounced. In arteriosclerosis and in myxoedema the cause of the postural uniformity is pretty obvious : namely, the thickening of the arte- rial coats. But the remarkable prevalence of the uniform calibre in the subjects of acquired syphilis was a surprise to me ; for according to my observation, the cause producing it must be of quite general operation, and not such as to set up or- ganic arterial changes in a case merely here and there — such as syphilitic oblitera- ting endarteritis well known to patholo- gists. According to several trustworthy observers, syphilis " may be regarded as one of the most frequent causes of arteritis and its effects."* The inner coat of the artery is the part chiefly affected :t so * Outlines of the Pathology and Treatment by Syphilis, by Hermann von Zeissl, M.D., 1887, p. 274. f A Treatise on the Ligation of the Great Arteries in Continuity, &>€., by Charles A. Ballance, M.B., M.S., &c., and Walter Edmunds, M.A., M.C., &c., iSgi, p. 82. IN DISEASE. 39 that, it is quite possible, that the intima of the whole arterial tract may, in the first instance, become so damaged by the syphilitic virus as to cripple the physiolo- gical play of the tube ; and it is conceiv- able, that the textural injury might be so slight as to readily elude detection by the finger. The after history may, hov^^ever, in certain cases, reveal the development of advanced and palpable changes — such as obvious arterio - sclerosis and aneu- rism.* My opportunities for observation in cases of congenital syphilis have been too limited to enable me to form a definite opinion as to v^hether the same impair- ment of the arterial variation is as pre- valent in this as in the self-acquired form of the disease: so far, however, I have observed a marked difference, the radial variation being quite normal in the cases of congenital syphilis I have examined. * It is, I think, possible, that syphilitic arteritis may dispose to aneurism in two ways : — (i) damaging the arterial wall involved, and (2) inducing defective accom- modation of the more peripheral arteries, so that effort and other similar causes may temporarily cause undue strain on the more central vessels. 40 RADIAL MEASUREMENT 4. Restricted and Amplified Postural Variation, (a) Restricted Variation. — The radial calibre in health may present every now and then narrower variations in posture than is usual with the individual, e.g.y from 0*1 to 0*3 mm. only. An isolated ob- servation of this kind may, therefore, have no pathological significance ; but, when it becomes less or more persistent, I should refer it to minor organic changes in the arterial wall, or to the less pronounced forms of arterial tension. This observa- tion I have frequently recorded in my elderly patients — in whom physiological arterio-sclerosis was doubtless developing, and now and then in those who presented a uniform radial calibre at other times. (h) Amplified Variation, — In subnormal arterial tension I have several times ob- served a remarkable increase of the pos- tural variation — the calibre varying even to the extent of 100 per cent. IN DISEASE. 41 5. The Calibres of both Radial Arteries : Asymmetry. When in healthy subjects both wrists are equally favourable to observation, and the radial arteries are normally distributed. I have, as a rule, found the two vessels of equal or nearly equal calibre : the dif- ference, when existing, not exceeding 0*2 mm. So that when there is observed a disparity of 0*5 to i*o mm., it may possess some clinical significance. I have mea- sured such a unilateral reduction as this, as the result of (a) mechanical pressure (aneu- rism): or {b) vaso-motor constriction (distal irritation). In hemiplegia I have found the radial calibre enlarged on the paralysed side (see Part II., ch. iv., 4). I have ob- served that a well trained finger may be at fault in detecting minor differences than 0*6 mm. between the two arteries, and it is by no means always easy to appreciate with the finger those due to vaso-motor influence. The arteriometer would seem to afford not only a definite and record- 42 RADIAL MEASUREMENT able reading in place of this undoubted uncertainty, but to favour the pathological study of the vascular reflexes, which may be confined to one side only. 6. The Ejfects of Irritation on the Calibre of the Arteries. Every experimentalist is familiar with the fact, that when a sensitive nerve is cut across, the arteries immediately con- tract, and in consequence the blood-pres- sure rises.* I have observed, that the steps of an operation on man may in like manner produce fugitive contractions of the arteries which may be measured by the arteriometer, especially when the operation is an abdominal one. Fig. 4 gives the results of a series of observations on the radial calibre, made in rapid suc- * The large fact of arterial constriction, the result of stimulation of various parts of the nervous system, is conclusively demonstrated in Sir Joseph Lister's paper On the Parts of the Nervous System Regulating the Contraction of the Arteries, Phil. Trans., vol. cxlviii. IN DISEASE. 43- Nils iiii! g vj M « M O Fig. 4.— Diagram showing the effects of traction of the omentum and spermatic cord on the radial calibre during an operation for the radical cure of hernia. Each square = 2 minutes. 44 RADIAL MEASUREMENT cession, throughout an operation for the radical cure of inguinal hernia, performed by Mr. Barker of University College Hos- pital. The calibre dipped sharply when traction was made on the impacted omentum, and on the spermatic cord, and when the cord was cut ; and in the intervals when all was slack, it promptly rose again, and when the operative pro- cedures ceased, it no longer fell. In clinical medicine the arteriometer has likewise enabled me to observe, that contraction of the arteries of some area or other, or of the whole body, is the prominent effect of pain or irritation on the vascular system, the duration of the constriction being in proportion to that of the cause. It has seemed to me that any source of discomfort in the abdomen, and therefore in proximity to, and in direct communication with the great sym- pathetic system, produced a much more powerful reflex effect on the arteries, than when located elsewhere, e.g., colon loaded, ovarian or uterine pain, inflammation, colic, &c. That contraction of the ar- IN DISEASE. 45 teries, arising in this way, is quite a com- mon fact, has not escaped the chnical acumen of one good observer. In a recent valuable monograph (The Physiology of Death from Traumatic Fever — a Study in Abdominal Surgery) Dr. John Malcolm has brought this view prominently for- ward with much force and clearness. I will merely quote one of his "Conclusions as to the causes of the various pulse condi- tions found in fevers," and refer the reader to the work itself. '' The evidence seems very strong, that in traumatic fever, in shock, and in abdominal distension fol- lowing a laparotomy, the small feeble pulse, whether slow or fast, is in no sense due to cardiac weakness, is not a condi- tion beginning at the heart, but is an immediate effect of the contraction of the vessels." In such cases a widespread constriction reduces the blood-pressure in the more peripheral arteries (includ- ing the radial), while it greatly increases it in the central ones : hence the vigor- ous throbbing of the carotids, which is not present when a feeble radial pulse 46 RADIAL MEASUREMENT is due to cardiac failure.* Every one is familiar with the general clonic ar- terial contraction of angina vaso-motoria, of the rigor df malaria, of the hysterical attack, of migraine, &c., and many are equally conversant with the general tonic contraction of the arteries, which is a prominent feature in certain diseases of the nervous system, such as hysteria and allied ailments. In all such morbid con- ditions the arteriometer has • afforded me a complete demonstration of the fact of general arterial contraction. But it has likewise repeatedly shown, that this vas- cular disturbance may be limited to one side only. Medical literature contains, so far as I know, but few references to this limited form of tonic arterial con- striction. Sir W. Broadbent refers to an interesting and marked case of this type. " In a case of severe neuralgic pain along * I have already referred to an experimental parallel of this clinical observation, namely, the great distension of the central vessels observed when the blood-pressure is raised in them by inducing contraction of the arteries {ch. iv., 3). IN DISEASE. 47 the sciatic, which was ultimately found to be due to a malignant growth in the spinal canal, which I once saw, there was unilateral arterial spasm, giving rise to a perceptible difference in the pulse of the two sides, which resisted the influence of nitrite of amyl. One side only of the face flushed."* Dr. Thomas Oliver, of Newcastle-on-Tyne, has likewise made some instructive observations on the uni- lateral efl"ect of lead colic on the radial pulse. '' Admitting that even in health there is a degree of difference in the fulness and tension of the two radial pulses, this difference in lead colic is so pronounced as to stand out prominently as something peculiar to the illness .... like the inequality of the pupils, it stands in some way related to primary disturb- ance of the abdominal sympathetic fibres, and through them of the vaso- motor centre. "t But the arteriometer ♦ The Pulse by Sir W. H. Broadbent, Bart., M.D., F.R.C.P., p. 154. f The Goulstonian Lectures on Lead Poisoning in its acute and chronic forms by Thomas Oliver, M.A., M.D., F.R.C.P., 1891. 48 RADIAL MEASUREMENT has enabled me to observe, that in- equahty of the two radial arteries, from contraction of one of them, set up by some distant source of irritation, is not a very uncommon clinical fact ; and when it does occur, the temperature, as a rule, falls on the side of arterial reduction. t The following are a few examples of reflected unilateral arterial constriction quoted from my notes :^ f See a paper by the writer in Practitioner, August, 1893. IN DISEASE. 49 ? s ,ps «3 5 °^ " 0°°'' lU co .£fb E ■a cS t4 u bz) V to , u • • CO • • • ca ^ 0. ^ V • • , ^ * > Qi 43 V CO C 10 at o . c » 1) "... « eij 43 "3 J Cft E CO Ui .0 "3 °° E ^ C £ *j "3 'S.^^E 1-1 c o 4> ij E-^ E^ CS P- 5 p :;» 5^ fO."2 t^ 5 aa CO U C« ciJ "o E CO .2 CO 43 c S" S"3 • • • "3 4= C • • • 3 .:<; — V U .-tJ ... c , c (0 c ?— • i-l1 > E-21 w in m reac iling : 1) QWH QWH 3 ^1 .Sf M E s >b Pi -3 °^ E 5 d E QW H 50 RADIAL MEASUREMENT 7. The Standard Calibre, and some of the leading Pathological Deviations. Though the mode of observation I follow mainly depends on the determining of variations (if any) of the calibre of the same artery, and not on a comparison with a standard or mean measurement, some clinical advantages do arise from acquiring a general notion of the average maximum measurement, which may be furnished by a large number -of ob- servations in different individuals: for, in certain morbid conditions, the radial calibre is apt to be considerably re- duced or increased; and then the data provided by the arteriometer may prove of some use in diagnosis and treatment. Still, it will be borne in mind, that a reference of the calibration of any parti- cular case to an average measurement should only be made in quite a general way : as size and build of the individual, idiosyncrasy in respect to the calibre of the arteries, and variations of the radial IN DISEASE. 51 itself and of its surroundings require to be kept in mind. According to my obser- vation the average maximum calibre of the radial artery in men varies from 2*0 to 2*5 mm., and in women from i'8 to 2*3 mm. The following have seemed to me to be the leading pathological causes of pro- nounced variation. I. Diminution. — I have observed that the radial calibre may be reduced by (a) vaso-motor constriction, (b) passive shrink- ing, and (c) organic contraction. (a) Vaso-motor constriction is best seen in neurasthenia, hysteria, hypochondriasis, asthenic gout, &c. — and especially in the active postures. It is often set up by a distal source of irritation (see p. 48). (b) Passive reduction from mere shrink- ing of the wall is observed in all diseases that impair the general health and the nutrition of the blood, or lower the heart's action. (c) Organic reduction is found in the obliterating forms of arterio-fibrosis and endarteritis met with in atheroma (some E2 52 RADIAL MEASUREMENT cases probably forming a variety) ; in the second and tertiary stages of syphilis ; and in chronic gout. 2. Enlargement. — An exceptional in- crease has seemed to me to be most fre- quently associated with (a) Augmented resistance limited to the vessels of smaller size than the radial, as in some cases of chronic interstitial nephritis, and in chronic gout ; (6) Loss of elasticity of the arterial wall favouring dilatation of the arteries as in one form of atheroma ; and (c) Relaxation of the arterial walls, not unfrequently observed in large obese and plethoric subjects. Any marked deviation observed in any particular case may be the product of the co-operation of two or more causes. 8. The relation between the Calibre and the blood-pressure. In a large number of cases — especially of chronic gout and renal disease — I have ob- served, that the radial calibre diminishes IN DISEASE. 53 as the blood-pressure rises and vice versa (see Part II., ch. iv., 3). But this relation is by no means invariably maintained. In elderly subjects more especially I have repeatedly found, that the radial cahbre may increase or diminish in direct propor- tion to the blood-pressure ; of this the following is a good example : — Mrs. N., set. 71 ; hable to sudden acces- sions of blood-pressure, when the bowels fail to be properly relieved. Postural variation nearly lost : — Radial Calibre. Obliterating Blood-Pressure*. 2-4 mm. 280 grammes 2-3 j» 260 M 2'0 )> 230 )> 1-8 )j 220 )» I "5 >> 200 >> In these cases of direct relationship, it is not I think improbable, that the blood- * Determined by the writer's pulse-pressure gauge (see Part II., ch. i.). 54 RADIAL MEASUREMENT pressure is incited to rise from increased resistance set up in the terminal arteries, and the vessels of larger size — like the radial — merely become dilated, because the muscular contractility is insufficient to resist the distensile force of the augmented blood-pressure. IN DIAGNOSIS. 55 CHAPTER IV. Radial Measurement in Relation to Diagnosis, Treatment and Thera- peutic Enquiry. I. The Arteriometer in relation to Diagnosis, It seems to me not improbable, that there may arise now and then occasions in which some doubt exists in respect to dia- gnosis, when the arteriometer may prove useful: as in Bright's disease; myxcedema; syphilis ; gout ; angina pectoris ; and athe- roma. {a) Bright' s disease. — The cases of acute, as well as of chronic Bright's disease, which I have examined with the arterio- meter, having afforded a uniform radial calibre in posture, it is possible, that this clinical fact may be made available in deciding on doubtful cases of albuminuria: for, should the postural variations be ample in any particular case, the other negative evidence in respect to renal disease 56 RADIAL MEASUREMENT may thus find corroboration ; or should they be absent, or greatly restricted, the observer may thus be put somewhat on his guard in expressing a favourable opinion, especially if other signs are some- what suspicious, and there is no history of acquired syphilis. In the convalescence from acute nephritis I have found, that calibration of the radial artery may like- wise afford a definite hint as to whether the disease is clearing up, or is gradually merging into chronic renal disease. (b) Myxcedema. — Uniformity of calibre may not improbably prove useful in con- tributing to decide on a doubtful case; perhaps doubtful, from being in an early stage of the disease. (c) Syphilis. — The absence of the normal postural variation of the radial calibre in the subjects of acquired syphilis has led me to take this observation into account when deciding on an obscure history: for in- stance, when there is merely an admission of there having been a sore or something venereal at some time or other — but no subsequent development of well marked IN DIAGNOSIS. 57 secondaries ; or when the history points somewhat obscurely to secondaries ; or when a patient is reticent of the past ; or when circumstances render the enquiry difficult or undesirable — as in the case of a woman who may be ignorant of the cause. Such a doubt not unfrequently hangs round a case of locomotor ataxy, or of an obscure condition of the nerve- centres, or of questionable skin disease, or of rebellious ulceration, &c. Under all these conditions of uncertainty with re- gard to acquired syphilis as an setiological factor, the arteriometer has seemed to me to offer some clinical service ; for, accord- ing to the evidence which I have collected so far, when it pointed to a positive con- clusion, this inference was certainly ren- dered probable by some collateral evidence, or was undoubtedly confirmed by the issue of treatment ; and when it failed to sup- port the probability of a specific condition, that view coincided with either the denial on the part of the patient of syphilis ever having been contracted, or the total ab- sence of any confirmatory indications past 58 RADIAL MEASUREMENT or present. Guided by the observations I have made, I certainly would be disposed to hesitate to entertain the specific nature of a doubtful case, if the postural varia- tions were observed to be normally ample : and if they could not be detected, or were found to be restricted, to o*i mm. or so, the observation would be of but little sug- gestive value, until other causes of uniform- ity or of great restriction were excluded, and until subsequent observations showed that the condition of the artery was a per- sistent one (see p. 36). If, however, the calibre were much below the standard size (p. 51), a suspicion in favour of syphilis might be entertained ; for, I have detected a great reduction, even amounting to from 25 to 50 per cent., in a large proportion of the cases of chronic syphilis which have come under my observation. But of course it is needful to keep in mind the other causes of a small unvarying calibre (see pp. 51, 52). A clinical reminder of this kind is o some practical value ; for it keeps the mind alert to look out for, and to direct IN DIAGNOSIS. 59 enquiry in search of this important fact in the personal history — important espe- cially from the therapeutic standpoint. By means of the arteriometer I have over and over again detected evidence of the foot-prints, as it were, of syphilis in the arteries, when no other clinical clew existed, and when the enquiry unearthed the fact of a chancre, which existed per- haps twenty or thirty years before, but which had been lost sight of, because the recollection of it had not been maintained or revived by the development of any sequelae. This mode of observation has enabled me many times to demonstrate to my own satisfaction, that an infecting chancre, though it may not have in- duced secondary and tertiary manifesta- tions, or congenital syphilis in the pro- geny, has, nevertheless, left its impress on the arterial wall, as shown by the per- manent uniformity of the radial calibre in posture ; and I have observed that so long as this remains without serious re- duction, the general health in such cases, as a rule, continues apparently unim- 60 RADIAL MEASUREMENT paired. I have met with several in- stances of this kind in medical men, in w^hom the diagnosis of the hard chancre v^as well attested. While these pages are passing through the press, I am observing two cases of rheumatic gout (rheumatoid arthritis), which illustrate this position. In both, the arteriometer not only suggested the enquiry which revealed the history of a chancre (in one dating 30, and in the other 20 years ago), but thus provided a probable explanation of the resistance of the cases to the well-devised treatment that had been previously followed, and furnished a new and promising turn to the application of remedies. {d) Gout. — My work at Harrogate brings me much in contact with gout — especially in its chronic forms. I have, therefore, had ample material for the application of this mode of observation to this disease. In undoubted chronic gout I have almost always found the radial calibre to be in- variable and reduced ; and in the excep- tional cases in which it varied at all in IN DIAGNOSIS. 6l posture, it did so but slightly, and became uniform whenever symptoms or signs of gout appeared. In the absence of ac- quired syphilis and of arterio-fibrosis, I have, therefore, been led by observation to regard a reduced and unvarying radial calibre as a useful diagnostic sign strongly suggestive of the gouty diathesis. All the cases in which it was present were either positively gouty, or were very suspiciously so ; and were regarded by their medical attendants as gouty ; and gout was cer- tainly a prominent feature in the family history. I have, however, observed, that when asthenia is a prominent feature in the gouty, or in the quasi gouty, especially in women, the radial calibre is apt to in- crease in recumbency, either for a few minutes only, or for a longer period. According to my observation, rheuma- tism and chronic rheumatoid arthritis dif- fer, as a rule, in this respect from gout ; for in both these ailments postural varia- tions of the radial calibre were apparent. Now and then, however, in rheumatoid 62 RADIAL MEASUREMENT arthritis they were absent, when sus- picious signs of true gout were presented by the patient, or a family history of that disease was eHcited ; and the same fact was observed in many cases of quasi rheu- matism — especially muscular rheumatism • — which was obviously of gouty origin. {e) Angina pectoris. — In the cases of un- doubted angina pectoris which I have examined, I have found the radial calibre uniform in the postures ; but in several instances of quasi and doubtful angina I have observed considerable postural varia- tion, and the favourable issue of treatment in such cases has gone far to disprove the existence of the grave disease. I am, therefore, disposed to regard the presence of radial variation in a case of this kind as a favourable sign. (/) Atheroma. — Advanced or fully deve- loped atheroma is of course easy to re- cognize. I have, however, found the arteriometer of service now and then in detecting the earlier and ill-defined stages of it. It has likewise seemed to me of clinical value in distinguishing two forms. IN TREATMENT. 63 which cannot be accurately defined with the finger : namely, one in which the calibre is much reduced — though the ar- tery and the pulse may not seem to the finger to be less than normal ; and the other in which it is increased. I have observed that the contractile form is sometimes associated with imperfect cere- bration in the aged : as when a sub- normal calibre becomes further lowered by any cause that may suddenly depress the general health, such as the shock of a surgical procedure. I have seen an elder- ly patient of this type continue for several weeks after an operation in a befogged mental condition, without fever or other obvious cause, with a radial calibre of from 0*5 to 07 mm. ; and gradually emerge with recovery of the mental faculties when the calibre had risen — with rest and good nourishment — to 1*5 mm.* Inasmuch as it is well known that or- ganic arterial changes are apt to develop inequally in different regions, this fact * Such a case as this I observed in Middlesex Hos- pital through the courtesy of Mr. Henry Morris. 64 RADIAL MEASUREMENT should, of course, always be borne in mind in drawing an inference from evi- dence derived from the radial arteries alone. It has, however, seemed to me, that with regard to atheroma, a very slight degree of textural change suffices to restrict, and even to annul the play of the radial wall, and I am disposed to think, that it is not likely to become advanced elsewhere without some implication of the radial arteries, which the arteriometer will reveal. 2. The A rteriometer in Relation to Treatment. I. There are one or two points in which I have found that calibration of the radial artery may in a general way prove sug- gestive in the management of cases, {a) When the maximum calibre is per- sistently or generally apparent in recum- bency, tonic medication and rest are specially indicated, though now and then these measures may be advantageously combined with correctives. (6) When, apart from syphilis and IN TREATMENT. 55 myxoedema, the normal postural varia- tions are abolished, or are greatly re- stricted, tonics (such as iron, strychnine, &c.), are, as a rule, badly borne, and may prove injurious. In this class of cases it not unfrequently happens, that corrective treatment is attended with the happiest results, and constipation — even though comparatively slight — is generally more pernicious than w^hen the postural varia- tions exist. (c) In prescribing rest, exercise, and massage, the arteriometer may afford use- ful hints. I have observed, that a great reduction of the radial calibre will take place in the standing posture, when the ventricular action is much below par ; it may even become fifty per cent, less than in the sitting or recumbent postures. Then I have found it to be a good working rule to limit the exercise, or to adopt some passive form of it, or to prohibit it entirely for a time. When in such cases the maxi- mum calibre is persistently present in re- cumbency, I have observed much benefit to arise from the adoption of recumbent rest, F 66 RADIAL MEASUREMENT either absolute, or systematically resorted to in the intervals of exercise. In pre- scribing massage the arteriometer may point to the form in which this mode of treatment may be most advantageously applied to a particular case : for instance, when the artery is small and contracted, effleurage and tapotement are more es- pecially indicated, and should either take a prominent place in the procedure, or should be the only methods adopted ; and when the vessel is full and tense, petrissage will probably yield most benefit (see p. i8). I fear that massage — which is undoubtedly a valuable therapeutic measure when pro- perly and judiciously prescribed — is being much discredited by the empirical and indiscriminate way in which it is practised. {d) There is no department of clinical observation in which I have found the ar- teriometer of more use than in prescrib- ing baths. Bathing undoubtedly exerts a powerful influence on the vascular sys- tem, and through it on the general health. It should, however, be adjusted to the conditions of the circulation present in IN TREATMENT. 67 each individual, if the benefits it can con- fer are to be obtained ; otherwise it may prove injurious. I have observed, that all warm forms of still bathing^such as the Turkish bath, vapour bath, warm and hot immersion baths — reduce the arteries for a time ; and in this they form a super- ficial resemblance to the effect of petris- sage on the arteries (see p. 18), only the reduction they produce is obtained by surcharging the periphery, and not from clearing it. In the Turkish bath the excess of blood congesting the peripheral vessels is got rid of by petrissage and by the spray-bath, or by the cold dip. When such procedures do not follow a hot bath, there is generally experienced some lan- guor and depression, which arise from the temporary reduction of the arteries and the clogging of the periphery with an excess of blood ; and horizontal rest favours the readjustment and restoration. I have frequently observed, that when there exists already some peripheral em- barrassment — as when in gouty subjects there is an absence of the postural vari- F2 68 RADIAL MEAST REMENT ations— this form of bathing is apt to prove very injurious ^^^^^ aggravating the depression and ^ngour that exist, or even inducing an a^^j^ ^f ^^^^-^^ ^^^^^ On the other hand, ndoubtedly the form of bathing whicl: secures the most thorough passage f ^i^^^ through the periphery is the^i^.igg.gaij^s douche; for, the douching ^j^j^^j^ j^ principle is effleurage, or t^Q^gj^g^t plus v^armth, greatly favours agj-ial dilatation, and the easy passage of -^^ ^Ioq^j ^q ^he periphery, and the manipulations assist the flov^ through it * /-^ath of this kind may, hov^- ever, reduce q arteries ; but the reduc- tion IS due t(^ clearing of the periphery, and differs ojn that of the ''still" hot bath, and ifely requires horizontal rest for restor^Qj^^ When about nine years ago I mtr^cgfj ^he Aix-les-Bains douche The n^Q^ q{ massage adopted in the douche bath IS qu different from that usually employed after a Turkis.^^jj . fQj. j^- jg light and vibratory, and re- sembles jurage and tapotement in its physiological effects, \q the manipulative procedure of the Turk- ish ba^ iggg Qj- more firm and squeezing, and par- takes c^Q nature of petrissage (see p. i8). IN TREATMENT. 69 treatment into Harrogate as an addition to the bathing procedures there adopted, there were no facihties for returning pati- ents in the horizontal posture to bed as at Aix-les-Bains ; and consequently that part of the treatment could not be observed. I soon found, that this omission was by no means immaterial ; and I became dis- satisfied with my early results. I then prescribed the Harrogate needle-bath — warm to cool or cold — as a routine conclu- sion to the procedure ; when my patients began to flourish to my satisfaction.* The explanation of this experience is not far to seek ; for, the needle-bath being but a delicate and effective way of securing the physiological effects of effleurage and * The Aix-les-Bains douche in this modified form has become so much in request, that the Corporation of Harrogate are now spending ;£"65,ooo in the erection of a new bathing estabh'shment, in which it may be most efficiently applied. The Harrogate massage-douche is undoubtedly a valuable formof masso-therapeutics with a great future before it. My observations have shown that no other form of bathing can approach it in its power to restore the physiological play of the arterial wall when impaired or lost, and that it is most useful in the treatment of all forms of chronic gout. 70 RADIAL MEASUREMENT tapotement on the arteries, at once re- stored the arterial fulness and provided the final touch for the readjustment of the circulation. I have found this form of bathing, modified to the individual re- quirements of the circulation, of great service when postural variations were re- stricted or abolished from the presence of some form or other of increased peripheral resistance. When the calibre increased in recumbency the various modifications of the Harrogate needle-bath have, as a rule, yielded the best results. It is, how- ever, difficult to particularize in a few lines the leading indications to be learnt from the readings of the arteriometer for the selection of baths ; I must, therefore, con- tent myself with these brief references, as mere illustrations of the physiological basis on which the judicious prescription of baths should rest. 2. In observing the effects of treatment , I have likewise found the arteriometer useful. ia) The recorded calibrations have shown that the maximum calibre observed IN TREATMENT. 7I in the sitting posture is, as a rule, directly proportionate to the state of the general health; a progressive rise, if accompanied by the normal postural variations, coinciding generally with well-being and improved nutrition ; and a persistent reduction, whether the normal postural variations be present or absent, accompanying other signs of retrogression, and perhaps loss of weight. This mode of observation, there- fore, appears to reveal a fundamental fact of vitality, being a general gauge of the amount of arterial blood supplied to the tissues. {h) Progress may even be traced by the arteriometer, when the postural variations are absent, or are greatly restricted ; for, when the arterial wall is not organically involved, they may return, or may develop in the course of treatment, in proportion as the arterial tension is reduced, or the causes of irritation, maintaining constric- tion of the vessels, are removed or modi- fied. I have found this position abundantly proved in regard to gout, and it would 72 RADIAL MEASUREMENT be an easy matter to illustrate it by a long series of cases. The few examples quoted on p. 141 -3 will probably, however, suf- fice. The agents which I have observed to be most effective in determining this bene- ficial change — and they are those with the use of which I am most familiar — are {a) massage, especially in the form of the Harrogate massage-douche; and {b) aperi- ent salines, such as a course of the Harro- gate sulphuretted and ferruginous salines. In many cases I found that the massage- douche alone sufficed to restore completely the postural variation of the arteries, and that this remedial effect was not merely immediate and temporary, but less or more continuous. Doubtless it will be observed that other modes of treatment will also prove effective in this direction. Postural variation, however, remains in abeyance under treatment, when it is due to organic changes in the arterial wall ; but even then calibration may afford evidence of improvement by recording an increasing diameter. I have repeatedly observed this fact in the treatment of IN TREATMENT. 73 atheroma obliterans, myxoedema, and sy- philis, the mere enlargement of the calibre being accompanied by other indications of improved health and vigour. In syphilis the radial calibre is fre- quently very much reduced, especially after the lapse of several years since the date of infection ; and especially too when the disease is producing its secondary and tertiary manifestations. It is I think not improbable, that in many cases there may be some causal connexion between the reduced calibre of the arteries and these more remote effects of syphilis. I have, however, observed several times a marked reduction of the radial calibre without the appearance of any of the ordinarily recog- nized developments of the disease ; but associated with a considerable reduction of elasticity and vigour, and other signs of lowered nutritive activity of the nerve- centres. Patients thus affected were said to be suffering from neurasthenia, and general debility : and though the fact of syphilitic infection in the past was well known, it was not suspected that it had 74 RADIAL MEASUREMENT any causal relation with the lowered gene- ral health. The arteriometer, however, demonstrated the presence of one condi- tion common to all the cases — those of obscure nervous debility, and those in which syphilis was obviously manifesting its presence ; namely, a greatly diminished radial calibre: and on submitting them to treatment by mercurial inunctions and sulphur baths,* or by the administration of small doses of mercury by the mouth, the calibre, as a rule, not only progressively increased, but the nervous system and the general health acquired an accession of tone and vigour, and the more obvious signs of the specific disease receded and even vanished. I have tabulated a few of the observed results recorded in my notes. In such cases I have, therefore, learnt to accept the evidence provided by arterio- metric observation, as affording an im- * At Harrogate the treatment of syphilis by sulphur baths and inunction of mercury, on lines similar to those adopted at Aix-la-Chapelle, has been efficiently carried out for some years past. So far I have been well satisfied with the results observed. IN TREATMENT. 75 CO CO c/; '^ CO CO ^ £ t^ J3 ■3 cu erf J3 -1; J3 J3 >> s T3 •a -a ■a JU ^2 H C C C (u c c CO C J3 > CO CO •::-G ° .« ;^ >» ?% >, >i erf -a OO cfl M 0) ^H 6 M erf t-i erf M CO c 3 a I! erf -a M erf -a erf •a M . -^ 2ai i-I erf erf ^ •^ o > < •sqjBg jnqd -[ng puB suoipunui itjiinojaj^ •u o -f u! •3jiBjp-^H 'lid 76 RADIAL MEASUREMENT portant guide in treatment ; in determining for example, the dose of the remedy, the progress of the cure, and the duration of it. My observations have satisfied me, that the minimum effective dose by the mouth needs to be but small — smaller in- deed than that ordinarily prescribed — and it would seem that the duration of the treatment should be very prolonged : in a word they amply confirm Mr. Jonathan Hutchinson's teaching on these points. If the foot-prints* of the disease in the arteries are to be effaced, or to be effici- ently counteracted, the mercurial treat- ment should be extended over years, either continuously or with intermissions ; for all the cases, which had been subjected to fairly prolonged, and what might be generally regarded as thorough treatment, nevertheless presented a uniform radial * The arterial changes are doubtless the product of a bygone result of syphilis ; and cannot be regarded as an indication of the presence of the disease itself. Shrinking of the calibre — leading to reduced nutrition of the blood and of the tissues and organs, and to lowered vitality generally — is the evil to which the artery seems to be most prone. IN TREATMENT. 77 calibre. But even in such cases the further use of mercury by inunction and sulphur baths enlarged the calibre. More extended experience is needed, in order to decide whether a sufficiently prolonged treatment can accomphsh the happy result of restor- ing the postural variations.* In the mean- time, however, guided by the facts I have observed with the arteriometer, I am satis- fied, that in syphihs (i) the arteries, after the cessation of mercurial treatment for some time, are extremely apt to shrink in calibre ; and are more especially prone to do so on the occurrence of causes, which impair the general health : and (2) mercury * I have occasionally detected a slight postural varia- tion, {e.ff., o'l or 0-2 mm.), when the radial calibre at- tained 2-0 mm., or more than 2-0 mm. I am, therefore, disposed to hope, that more extended treatment than has ordinarily been applied may eventuate in further improvement in this direction. There is, I think, good grounds for the belief, that it is frequently advantageous for those who have even undergone good and prolonged treatment, to submit occasionally to subsequent short courses of inunctions and sulphur baths ; for such after treatment may, in a timely way, counteract the slow contraction, to which the arteries of the syphilitic are liable for many years after the primary infection. 78 RADIAL MEASUREMENT is the surest and best remedy to counteract this pernicious effect of the disease. The HabiHty of the arterial wall to re- duction, which I have observed in syphi- litic subjects, when the health is disturbed or lowered by any cause- — such as worry or some passing ailment—may in some cases form a bar to recovery when the patient is treated by ordinary remedies ; but, on the application of antisyphilitic treatment, the arteries may enlarge, and in consequence the health may improve? and any intercurrent malady present may thus be thrown off more readily. These observations have greatly con- firmed my faith in mercury as a remedy in syphilis. I am persuaded, that when properly administered, it will effect a real cure ; and that in the syphilitic it follows the lines of a true tonic, enlarging the arteries and increasing the number of red corpuscles, thereby raising oxidation and improving nutrition generally. I cannot say as yet what is the general effect of the iodides on the syphilitic artery ; for my opportunities of observa- IN TREATMENT. 79 tion with them have not been sufficiently numerous to enable me to draw a reliable conclusion. (c) When the maximum calibre is habit- ually present in recumbency— as in anaemia and various forms of debility — I have found it most instructive to trace with the arteriometer the progress of restora- tion ; the radial calibre increasing until its maximum development was attained in the sitting posture, while it correspond- ingly diminished in recumbency. The great value of recumbent rest in the treat- ment of such cases was thus forcibly de- monstrated ; though, as a rule, the rest pre- scribed was not absolute, and was only such as alternated with exercise, which was not unduly restricted. The amount of benefit achieved by this simple means, suggested by the physiological truth brought to light by the arteriometer, seemed to me to be far greater than that sometimes derived from a long course of tonic medication. A few examples are quoted from my notes on subsequent pages (pp. 136-8). Among the cases of this type the arteriometer has not 8o RADIAL MEASUREMENT unfrequently afforded data that suggested the right hne of treatment to be adopted, when the ordinary chnical indications seemed inconclusive. A good example of this kind I lately observed in a gentleman aged 30, suffering from great drowsiness ; he would fall asleep at his desk, and had a great difficulty in keeping himself awake while going about. There was no appa- rent cause of this condition— though it was suspected by his medical attendant that it was due to derangement of the liver. The arteriometer, however, showed that it probably arose from a very greatly reduced supply of blood to the brain in the sitting posture ; for in that posture the radial calibre did not exceed I'o mm., whereas in recumbency it measured 2*0 mm. Treatment by recumbency, needle- baths and tonics in ig days completely reversed the measurements of the radial calibre in posture, and at the same time removed the unwonted drowsiness. IN THERAPEUTIC ENQUIRY. 8l 3. The Arteriometer as an Aid to Enquiry. A FIELD for arteriometric obseiA-ation is presented by the action of remedies on the arteries of man ; and I have found that it may supply useful hints bearing on therapeutics, and especially on the effective dose of certain remedies. I have observed too, that it may reflect some light on such unsettled questions as the effects of anaes- thetics on man ; and, on testing in a preliminary way, the action of new reme- dies and products, it may suggest the lines of experimental enquiry in animals. In illustration, I will quote the results of some observations I have miade on the effects of anaesthetics, and of some auto- genous products — the extracts of the grey matter of the brain, of the thyroid gland, and of the supra-renal capsules — on the radial calibre. I. AncBsthetics (ether, chloroform, nitrous oxide, A. C. E. mixture), either enlarge or diminish the calibre (see fig. 5). Ether invariably increases it, and chloroform G 82 RADIAL MEASUREMENT reduces it— the rise or fall lasting with but slight fluctuations throughout the ad- ministration. Nitrous oxide causes a -SThT ja V jfi _ _ T A_ J J:J ^ A Jif 7 X Ji5 L Ji4 _ .___M A L t .0 ._.J^^t___,^)__ .__,L_^«i|!^^:_ ^ iV^"^ 1 \ JIfl V "^^^^^^^ ^ : : \.a_.. j^3^^ T JZ ;^ii^i::_::__•: J6 ^v'^% _13 .:%;^s,:^i--j_ Ji ^'SU^. ja -fe ^s^ _12 ^' -IJ Fig. 5. — Diagram showing the average results of observations on the effects of ar.eesthetics on the radial calibre. slight expansion, followed by a reduction either to the normal calibre, or to a point IN THERAPEUTIC ENQUIRY. 83 or two below it ;* the latter, however, fails to take place when the gas is inhaled along with oxygen. t Oxygen enlarges the calibre. The A. C. E. mixture re- duces it, but to a less degree than chloro- form. Inasmuch as I have shown (pp. 42-44) that operative procedures are apt to throw an increased strain on the heart and great vessels by causing extensive contraction of the middle and smaller sized arteries, it would seem to follow that those anaes- thetics will be the safest that maintain * I have tested the radial calibre under nitrous oxide administered by different anaesthetists, and I have ob- served, that the drop below the normal calibre need not necessarily take place : as a rule, for example, it was not apparent in the cases under the administration of the gas by Dr. Dudley Buxton, at the Dental Hospital, Leicester Square. f The mixed gases were administered at the Dental Hospital, by Dr. Frederic Hewitt, who advocates with much clearness the advantages to be gained from this combination, and informs me that he has given it with much satisfaction in from 2000 to 3000 cases. See Ancesthetics and their Administration, 1893, and On the AncBsthetic Effects of Nitrons Oxide when Administered with Oxygen at Ordinary Atmospheric Pressures ; with remarks on 800 cases, 1892. G2 84 RADIAL MEASUREMENT the heart's action and the fulness of the arteries. I therefore conclude from these observations, that ether for ordinary sur- gical work/and nitrous oxide with oxygen for short operations, best fulfil this physio- logical requirement, and that as a general anaesthetic the A. C. E. mixture is prefer- able to chloroform. 2. The extracts of the grey matter of the brain, of the thyroid gland, and of the supra- renal bodies,"^ when administered to healthy subjects by the mouth, affect the radial calibre ; the brain and thyroid extracts enlarging, and the supra-renal extract di- minishing it. I have observed, that thyroid extract in small doses not only enlarges the radial calibre, but reduces for a time the fre- quency of the pulsef ; and I have likewise * I am indebted to Messrs. Willows, Francis and Butler, loi High Holborn, for their aid in preparing for me an excellent dry extract of the cortex of the brain of the sheep, which I am prescribing with pro- mising effect in conditions of malnutrition of the nerve- centres, and also for their liberal supply of supra-renal extract for the experimental work here referred to. f When thyroidism is induced the temperature rises and the pulse-rate increases. IN THERAPEUTIC ENQUIRY. 85 found, that in myxoedema it increases the radial diameter, without, however — so far as my observations have extended — re- storing the postural variations.* In syphilis the radial calibre also enlarges under thyroid extract, but it appears to me to do so more slowly than in myx- oedema ; and I have observed, that quite diminutive doses (ni i.-iij.) twice a day, may maintain a marked acceleration of the heart's action — e.g., 130 per minute — or may even set up a slight febrile move- ment ; but notwithstanding this abnormal stimulation of the heart, I have seen the general health improve, and the weight increase. From the few observations I have lately made, I am disposed to think, that small doses of thyroid extract may prove useful in the treatment of syphi- lis ; when, for instance, the calibre of the arteries does not increase, and pro- gress is not apparently made — notwith- standing the administration of mercury ; though this drug will always hold the * The cases I have observed had been under thyroid treatment for several months or a year. S6 RADIAL MEASUREMENT first place as an anti-syphilitic remedy. It is possible that thyroid extract — when the dose is duly adjusted — may raise the nutritive processes by increasing the sup- ply of arterial blood to the tissues, when the pathological conditions involve a re- duction of the calibre of the arteries, and it may thus counteract or annul certain morbid processes of diverse origin. Hence probably the promise of benefit which it affords in the treatment of such widely different diseases as syphilis (secon- dary and tertiary stages), cancer, psoriasis, lupus,* and senile cerebral ansemia (from atheroma obliterans). Having observed that the radial calibre is reduced by supra-renal extract {vfi xv. = gr. XV. of supra-renal capsule by the mouth) I was led to determine whether contraction of the arteries resulted from injection of the extract into the veins of animals; and Professor Schafer of Univer- sity College, London, and myself are now * See, A Clinical Lecture on two Cases of Lupus treated by Thyroid Extract, by Byron Bramwell, M.D., F.R.C.P., Brit. Med. Journal^ April 14th, 1894. IN THERAPEUTIC ENQUIRY. 87 engaged in an experimental enquiry ''On the Physiological Effects of Supra-renal Extract " in which we have conclusively proved this fact * It is but natural to * The following are some of the leading results of the enquiry : — The intra-venous injection of the extract equal to 3 grs. of the gland produced in the dog (i) a remarkably pronounced rise of blood pressure, doubling or even trebling that recorded prior to the injection ; {2) power- ful contraction of the arteries as shown by the plethis- mograph applied to the limbs, the oncograph enclosing the kidney, and the arteriometer applied to the bared femoral artery— this effect, taking place even though the cord and brachial plexus were cut, was apparently of peripheral origin ; (3) stimulation of the vagus ; (4) stimulation of the cardiac muscle. The characteristic properties of the extract are not impaired by boiHng ; and they are not due to the pro- teid elements, or to neurine (as has been conjectured), but probably arise from the presence of an alkaloidal body. Alcohol, whether absolute or rectified, extracts the active principle. See your, of Physiol., 1894. In his Presidential address to the Physiological Sec- tion of the meeting of the British Association, held at Oxford, this year. Professor Schafer thus refers to this enquiry. " The results which were obtained show that there is present in both alcoholic and watery extracts of the gland a most potent physiological substance, which when injected into the body of an animal pro- duces, even in minute doses, a remarkable effect upon 88 RADIAL MEASUREMENT turn first of all to Addison's disease, as affording a promising field for the thera- peutic application of a supra-renal pre- paration.* I have seen but two cases, certain parts of the nervous system, upon the muscular system, upon the heart, and upon the blood-vessels. If only as much as a grain by weight of supra-renal cap- sule be extracted with alcohol, and if this alcoholic extract be allowed to dry, and then be re-dissolved in a little water or salt solution and injected into the blood of a dog, the results which are obtained, considering the minute amount of substance added to the blood, are certainly most extraordinary. The nervous centre which regulates the action of the heart is powerfully affected. ***** This is accompanied by a strongly marked influence upon the blood-vessels, and especially on the arterioles. The walls of these are chiefly muscular, and the drug exerts so powerful an action upon this muscular tissue as to cause the calibre of the vessels to be almost obliterated. The heart be- ing thus increased in force and accelerated, and the calibre of the vessels almost obliterated, the result is to raise the pressure of the blood within the arterial sys- tem to an enormous extent, so that from a blood-pres- sure which would be sufficient to balance a column of some four inches of mercury the pressure may rise so high as to be equal to a column of mercury of twelve or more inches We have to do here with a sub- stance which is as potent, although in a different direc- tion, as strychnia." * Messrs. Willows, Francis and Btitler have prepared IN THERAPEUTIC ENQUIRY. 8g previously diagnosed as supra - renal, which I have treated for three months with encouraging results. In both I ob- served a gain in weight, an increase of the radial calibre,* the transference of the maximum calibre from the recumbent to the sitting posture, a lessening of the pigmentation, and the disappearance of nausea and anorexia. One of the patients was sent to me by Dr. Mackern of Black- heath, who thus reports her present con- dition : — "The pigmentation now is not very noticeable ; the cardiac murmur, and the venous murmurs in the neck have dis- appeared ;t the patient is able to walk for me a tincture of the supra-renal bodie?, which con- tains all the active properties, as proved by experi- ments on animals, nij. is equal to gr. j. of the gland. I now propose pilules containing i gr. of the dry extract = 15 grs. of the gland. * This observation shews that the effects of the supra-renal preparation on the calibre of the arteries in Addison's disease differ from those observed in health ; possibly because the cachexia and anorexia of that disease induce passive shrinking of the arteries (see p. 51) which will give place to enlargement as the health is improved (see p. 70, 71). f This patient was very ansemic, and was treated go RADIAL MEASUREMENT. about with comparative ease ; and is in fact in every respect a resurrection." The physiological effects of the extract suggest, however, a much wider therapeu- tic range. The experiments show that it possesses to a high degree the power of contracting the arterial walls.* This property may be curatively useful in vari- ous forms of vaso-motor relaxation and paresis — such as those which may be met with in the menopause, in exophthalmic goitre, in functional or ''cyclic" albumin- uria, in diabetes,t in passive congestions, and in toneless states of the arteries. with ferratin as well as with supra-renal tincture (iTixv. ter die post cib.). * The constriction of the arterial muscularis induced by the supra-renal extract was in all the experiments so pronounced and decisive, as even to suggest the possible use of it as a haemostatic agent ; as, for example, in purpura hasmorrhagica, haemophilia, hae- moptysis, hsematemesis, metrorrhagia, &c. f " A vaso-motor paralysis implicating only the ves- sels of the chylo-poietic viscera may stand at the foundation of the form of diabetes limited to defective assimilation of ingested carbo-hydrates.'' — The Physio- logy of the Carbo-hydrates, by F. W. Pavy, M.D., LL.D., F.R.S., &c., 1894, p. 263. PART II. PULSE-PRESSURE. PART II. PULSE-PRESSURE. CHAPTER I. The Mode of Observation. I. The Writer's Pulse-pressure Gauge. In order to render more definite and re- gistrable the tactile sense of pulse-pres- sure, and to provide, moreover, a visible amplification of the pulsatile movements of the arterial wall, so as to league the sense of sight with that of touch in esti- mating the qualities of the pulse, I have for the past few years employed a small instrument which I have called a "pulse- pressure gauge." It is of portable size ; namely, three inches in length (inclusive of the pad and support), two inches in width, and a little more than half an inch 94 PULSE-PRESSURE. in thickness (fig. 6). A scale, indicating pressures in grammes, extends twice round the two-inch dial. Projecting from the lower part of the box are two rods, of Fig. 6. — The pulse-pressure gauge.* which the one in front carries the pad to to be adjusted over the pulse ; and the * The foot-rest as now adopted is not correctly in- dicated by this figure. MODE OF OBSERVATION. 95 Fig. 7. — Section of pulse-pressure gauge. 96 . PULSE-PRESSURE. other terminates in a foot-rest. Fig. 7 shows the internal mechanism. It is ar- ranged on the same Hnes as those of the arteriometer ; only a circular spring re- ceives the impact of the pulsations, and ensures the registration of the varying de- grees of pressure brought to bear on the ar- tery, and the appearance of the amplified pulsatile motion of the indicator. The rod carrying the pad is attached to the cir- cular spring, which is free in the box, but fixed above. A very fine thread passes from the lower part of the spring round the cylinder of the axle, and is maintained — as in the arteriometer — in a state of tension by a piece of watch hair-spring ; so that, when the pad is pressed upwards, or is affected by the pulse, the axle with its attached indicator acquires a corre- sponding motion ; and when the pressure ceases the spring and the indicator re- sume their former position. The gradua- tion is effected by scoring off on the dial the successive positions of the indicator, determined by gramme weights brought to bear on the spring ; and the scale of MODE OF OBSERVATION. 97 pressure presents 120 gradations of five grammes each." * The following have been the principal contributors towards our knowledge of clinical pulse-pressure : von Basch {Zeitschrift f. klin. Med., vol. ii., Wien. med. Woclienschr., vol. xxiii., Berl. klin. Wochenschr., vol. xxiv., Abhandliing i'lber den Sphygmomanometer und seine Verwerthnng in der Praxis, Berlin, 1887), Zadek {Zeitsch.f. klin. Med., vol. ii.), Christeller [Zeitschrift f. klin. Med., vol. iii.), Robinowitz [Inatigiiral Disserta- tion, 1881), Roy and Adami {Practitioner, vol. xlv.), Potain [Archives de Physiol, normale et pathol., i8go), Haushalter and Prantois {Gaz. Hebd. de Med., i8gi). Sphygmometers and sphygmoscopes have been pro- posed by Herisson (1834), Busco (1853), Scott Alison (1856), Berti (1857), Poznanski (1868), Handfield Jones (1871), Keyt (1874), Pond (1875), Waldenburg (1877), Stevens (1880), von Basch (1883), Bloch and Verdin (i888)-, Boccolari (1888), Potain (i88g), Roy and Adami (i8go), and Batten (i8gi). All the instruments hitherto suggested, except those of Herisson and his followers (Scott Alison, Poznanski, Pond, Keyt, Stevens, and some others), of Waldenburg, and of Roy and Adami, recorded the maximum or obliterating pulse-pressure only ; while those of Herisson and his following regis- tered merely the pressure which induced the fullest development of the pulsations (the minimum pressure, see p. loi): Roy and Adami were the first to demon- strate the clinical importance of recording the minimum as well as the maximum pressure and all intermediate pressures. My pulse-pressure gauge is not constructed on the lines of any of the foregoing instruments. H g8 PULSE-PRESSURE. 2. The Mode of applying the Puhe-pressttre Gauge. The patient places the ulnar side " of the right forearm on the table. The observer with his left hand extends the hand to an angle of 45 degrees with the forearm, maintaining it in that position throughout the observation, while he keeps his thumb over the radial artery at the flexure of the wrist* ; and with the forefinger of the dis- engaged hand he carefully feels out the position of the artery, and, after testing with his finger-tip, or the blunt end of a pencil, for the best place at which to apply the obliterating pressure (the tip of the right thumb feeling the effects produced on the pulsations and guiding the observer in this preliminary enquiry), he marks the * When taking the pulse-pressures (minimum and maximum, see p. loi), I am in the habit of keeping the artery blocked by the ball of the thumb, while the tip still perceives the direct pulsations ; for, I have found this proceeding advantageous in excluding a reflux beat, in amplifying the movements of the indicator, and in making the reading of the maximum pressure more definite. MODE OF OBSERVATION. 99 selected spot with an aniline point. The pulse-gauge is then applied, held between the forefinger and thumb, or in the con- cavity between them (fig. 8), while the hand rests on the table to afford m- FiG. 8.-The mode of applying the pulse-pressure gauge. A simple wrist-rest (consisting of two rods fixed at suitable angles and positions in a board) is shosvn. creased steadiness while applying the required degree of pressure. In order to discover the correct position of the pad, which ought to be perfectly true with the H2 100 PULSE-PRESSURE. axis of the artery, the observer should first aim to secure the most ample re- sponse of the indicator, and for this pur- pose it is only necessary to move the pad little by little in the same track, across the axis of the limb, between the tendon of the flexor carpi radialis and the styloid process of the radius ; and when the desired position has been found, the left thumb will provide confirmatory evi- dence, for, after passing the acme of motion, the perception of pulsation will ^Yow progressively and rapidly smaller un- till it vanishes, and will not linger in a minimal degree under increasing pres- sure, as it will do when the pad occupies an untrue position. Therefore, the proper rule to follow, is to accept only the lowest obtainable reading for the obliterating pulse pressure.''*' In expert hands the procedure may ap- * While experimenting with radial arteries through which water was propelled under definite pressures, I observed direct confirmation of this dictum, for the lowest readings could only be obtained when the pad exactly coincided with the centre of the vessel. MODE OF OBSERVATION. lOI' pear very easy, but a certain degree of facility can be acquired only by practice — as is indeed the case before any scientific instrument can be employed with satis- faction. 3. How to determine the Minimum and Maximum Pulse-pressures.^ As is well known, the intra-arterial blood- pressure varies between two extremes ; the maximum, which is attained during the ventricular systole, and the minimum, which is present between the pulsations, or, in other words, during the arterial systole. From the clinical standpoint, it is important to determine the relations which these two pressures bear to each other ; for they approximate when the intra-arterial pressure rises, and the in- terval between them widens when it falls. The reading of the minimum — or what is sometimes called the mean — pulse-pressure * I follow the nomenclature adopted by Roy and Adami, Practitioner, vol. xlv. 102 PULSE-PRESSURE, is taken when the indicator attains its maximum oscillation/'' At this point the external pressure, having just sufficed to overcome the intra-arterial pressure that persists between the pulsations, the ex- tremity of the pad then completely tra- verses the internal diameter of the artery. ■> Fig. 9.— The position of the pad in the intervals between the pulsations, falling in the intervals between the pul- sations to the opposite side of the vessel, and being raised a variable distance by the pulsations (fig. 9). The development of motion following the application of pressure to the artery is in proportion to the reduction of the minimum intra- * A series of equidistant dots, two millimetres apart, on the dial (fig. 6), serves to g^uide the eye in deciding at what pressure the amplest swing of the indicator takes place, when the volume of the pulse may be measured, and the minimum blood-pressure read off. MODE OF OBSERVATION. IO3 arterial pressure, until this is completely overborne, when the pad will make its longest excursion, and in the interval between the beats of the pulse will ar- rest the flow. The thumb on the artery beyond the pad will generally perceive at the same time a gradual increase of volume in the pulsations, until the point of minimum blood-pressure is being ap- proached ; this impression being due to the increasing contrast between the pro- gressive emptying of the vessel with ulti- mate collapse in the diastolic intervals, and the continued expansion of it when the beats take place. This tactile effect, induced by eliminating the minimum from the maximum blood-pressure by aid of the pulse-gauge, is most pronounced in cases of phis tension, and is but slightly ap- parent in those of minus tension. In phis tension also the observer will find the widest oscillation of the indicator is main- tained over a larger space, and conse- quently it will require more care to decide exactly where the maximum movement takes place, than in minus tension, or even 104 PULSE-PRESSURE. in moderate tension, in which it is con- fined within narrow Kmits. In attempting to read the minimum pulse-pressure, it is best gradually to increase the pressure of the pad until this point is definitely over- stepped, and then to reduce it until the widest swing of the indicator is again somewhat lessened ; and finally to narrow the interval by more careful adaptation of pressure. Then the graduation opposite the mean of the interval is taken as the correct reading. The reading of the maximum pulse-pressure should be determined by the combined in- formation provided by the indicator and the tip of the left thumb — the ball of which completely blocks the artery be- yond the pad. In all cases the pulsation perceived by the tip of the thumb must of course cease before the reading of the maximum or obliterating pressure can be made. At that point the indicator either becomes quiescent, or still retains a very small degree of movement. In the former case the reading should be taken, but in the latter it should be deferred until the MODE OF OBSERVATION. IO5 effect of adding more pressure is ascer- tained. If then the remnant of motion is not further diminished, it is not necessary to read off a higher degree, but if it is reduced, whatever additional pressure it is found necessary to add to the point of securing an irreducible minimum of mo- tion, should be included in the reading.* In all observations the thumb placed on the artery is the best guide to the true position of the pad over the centre of the vessel, the pulsations becoming more and more ample until the minimum pressure is approached, and then quickly diminish- ing to the vanishing point. According to my observations with the pulse-gauge, the normal minimum pulse- pressure comes out, as a rule, on attaining two-thirds of the obliterating pressure : for example, it will be 120 grammes when the latter is found to be 180. * This small margin of motion which cannot be reduced by pressure probably arises generally from a more sudden impact of the pulsations than is present in the cases in wh'ch the motion quite definitely ceases. I06 PULSE-PRESSURE. CHAPTER II. The Clinical Indications Furnished BY the Pulse-Pressure Gauge. I. The General Clinical Significance of the Movements of the Indicator. The eye, with a little practice, quickly learns to glean from the movements of the indicator of the pulse-gauge the lead- ing facts in each case respecting the mode and duration of the ventricular contraction, the amount of out-put, the condition of the arterial wall as to contraction or re- laxation, the quantity of blood present in the arteries, and the degree of peripheral freedom or resistance ; concerning which the unaided finger can form but a com- paratively inadequate idea. artery beyond pad. CLINICAL INDICATIONS. IO7 The following table epitomises my ob- servations on these points : — I. — Length of Stroke : 1. 5mfl// = Small out-put, and small amount of blood in the arteries ; arterial constriction ; peripheral fulness and arterial reduction; e.g., atonic gout. 2. Lar^c=Large out-put, and plethoric arteries; relaxation of arterial wall ; peripheral ob- struction and moderate arterial fulness. ,3. Small, then Large=Fvee peripheral flow with I considerable out-put, as in fever. ,4. Small, then -not en/a)-^ecf= Arterial narrowing Before and (muscular or organic). . , ^ after blocking-^ j^ar v\ \ 2 '/ \ V ■>, 1 1 1 / > V / r ^ 4 I \ / 2 \ o O O <0 o CO o o o o o o (0 o 09 O o o Fig. 12. — Recumbent. Hot bath (temperature ioi° F.). (i) Before 6fl^/j— calibre, 2-5 mm.; reflux beat, 2 mm. (2) In hath ten minutes— calihre, 1*5; reflux beat, 2 mm. 6 r 5 A 4 J A \ 3 'j f > V*. ii A 2 '^ A \ ^ ^ 1 / ^ ^ \ • I ^ • 2 > CD CO 5 CO (0 00 2 Fig. 13. — Standing, (i) Temperature in shade, 6i-6° F. ; calibre, 2-5 mm. ; reflux beat, 2 mm. (2) Temperature in shade, 43° F. ; calibre, 2 mm. ; reflux beat absent. flow through the artery ; and the interrupted line shows the increased amplitude of them caused by intercept- ing the current beyond the pad of the instrument. Each diagram represents an actual observation, and is a fair example of the average of a number of observa- tions made on the same subject under the same phy- siological conditions. CLINICAL INDICATIONS. 115 In the clinical field I have observed that when the arterial tension is low, the 6 ■" 5 4 F^ I 3 .' f^ c** ^' ^': 2 ^ \ ?^ ^ \ yj, 1 / V / V / I N / 2 \ CD CO CO I CO CO § 2 FiGv 14.— Sitting, (i) Temperature in shade, 6i'5° F.; calibre, « mm, ; reflux beat, I mm. (2) Temperature in shade, 43° F. ; calibre, i'5 mm, ; reflux beat, trace. 6 ~^ 5 f ■■% A // L 1 ,^ 3 / \ \ / A 2 > k y Y 1 / y / V ^ I > • ^ 2 \ s (D £4 5 § CO g 8 d 2 Fig. 15. — Recumbent, (t) Temperature in shade, 61*6° F. ; calibre, I's mm. ; reflux beat, •5 mm. (2) Temperature in shade, 43° F, ; calibre, i mm. ; reflux beat absent. movements of the indicator are greatly .amplified by blocking the artery beyond 12 ii6 PULSE-PRESSURE. the pad — they may even be doubled ; but when the tension is high, the augmenta- tion is but sUght, or may fail to become 6 ^ % 1 5 1 ' 4 •■' -n / A;. 3 ¥ ,r -\ g A\ 2 , '/ N v'l (y > \. 1 / V ) y \ O • I s • 2 V o o o (0 o CO o o o o 3 o CO o o o CO o CO o o o o 2 o CO Fig. i6 — Exercise (ascending). Standing, (i) Before Wfl/ft— calibre, 3 mm. ; reflux beat, 3 mm. (2) (a) Immediately after climbing half an /jowr— calibre, 1*5 mm. ; reflux beat absent. (6) After resting five minutes— csiUhTe, 1-5 mm. ; reflux beat, i mm. 6 5 4 ^ ; 3 / A \ ,' \ 2 y s X ,' ^ s \ 1 / V •» '^ / N J I "i, ■>• *' 2 'S 01 CD CO 2 CO CD CO 2 cd Fig. 17. — Exercise (level). Sitting. (1) Before walk — calibre, 2 mm.; reflux beat, 3 mm. U) After one hour's t«/fl^^— calibre, I's ; reflux beat absent. manifest. It has seemed to me, that the leading causes which prevent the appear- ance of the. normal development of the CLINICAL INDICATIONS. 117 6 ,.1 5 f \ 4 p- ^ . 7 \ \ 3 ¥ r- ■\ / c* 2 / / \ C\ / \ 1 ^ ^ J ^^ > V / I V / 2 \ M 1 (0 00 (0 CO Fig. 18. — Two hours after breakfast, (i) Standing — calibre, 3 mm.; reflux beat, 3 mm. (3) Recumbent — calibre, 2 mm,; reflux beat, 2 mm. 6 ■ 5 r'' „»•.., 4 1 / 1 t 3 1 1 1 r A 1 s. • 2 1 ! 1 1 \ 1 1 . / / 7 \^ / i 20 40 60 80 100 120 Fig 19. — Recumbent. Sleep. Reflux beat absent. expansile reaction are (i) vaso-motor con- striction, and (2) distension attaining to or approaching the maximum stretching Hmit of the arterial wall ; while those that amplify it are (i) vaso-motor relaxation, Il8 PULSE- PRESSURE. and (2) reduction of intra-arterial pres- sure. (c) It has been taught by Dr. Douglas Powell, that in high arterial tension the pulsations persist beyond the point of arrest of the onward flow — ^there being, what has been termed, a reflux beat, de- rived from an abnormally patulous con- dition of the inosculations between the radial and ulnar arteries.* I have ob- served that this distal pulsation may be temporarily developed under strictly phy- siological conditions ; as in the absorptive stage of digestion an hour or two after meals (fig. 18), and as a result of warmth (figs. II, 12, 13, 14, 15) ; and when present in the sitting and standing postures (figs. 13, 14), it will in health disappear in re- cumbency (fig. 15), during exercise (figs. 16, 17), and on exposure to cold (figs. 11, 13, 14, 15). * The ramus superficialis voice (which, though not visibly or palpably enlarged, may be felt pulsating on the inner border of the ball of the thumb) is, as a rule, the channel of the reflux beat : for, when the flow- through this vessel is obliterated by pressure, the distal pulsation usually ceases. CLINICAL INDICATIONS. II9 To be of value as a clinical sign the reflux beat should not be transitory, as it is apt to be in health, but per- manent, and it should be present in all the postures, and especially in recumbency. I have observed that in asthenic cases, it is, as a rule, absent in the sitting and standing postures, but becomes apparent and even pronounced in recumbency, when at the same time the radial calibre attains its maximum measurement (see pp. 32, 33)- The clinical significance of the reflux beat in regard to plus tension mainly rests in the fact, that it is usually permanent and well developed in all the postures, when the arterial blood-pressure is raised from increased resistance confined to the peripheric vessels only, and is, as a rule, absent — at least in the sitting and stand- ing postures — in that form of high tension caused by constriction involving the small and medium-sized arteries (including the radial). In order to show the absence or the presence — and when present the ampli- 120 PULSE-PRESSURE. tude — of the reflux beat by means of the pulse-gauge, it is merely necessary to arrest the onward flow through the artery while the instrument is in situ. I will briefly epitomize the radial signs of plus and minus tension afforded by the pulse-pressure gauge and the arte- riometer. (a). Plus-tension. I. Late development of the maximum oscillations of the indicator, which are maintained over a wide area on the dial, and encroach on the final third of the obliterating pressure. 2. The rise, fall, and turn of the stroke are apt to lose their normal sharpness, and a halt may appear in the middle of the fall (see p. 107). 3. An increase of the pulsations felt by the examining finger beyond the pad of the pulse-gauge or the arteriometer, as the artery is being gradually compressed. 4. Expansile reaction reduced or abol- CLINICAL INDICATIONS. 121 ished, especially in asthenic or constrictive tension — in the less complete forms of which it generally reappears or develops in recumbency. 5. Reflux beat permanent and in all the postures. In asthenic tension it may de- velop in recumbency. 6. The calibre uniform in the postures, increased in peripherally induced tension, and reduced in the constrictive form. In asthenic tension the contracted calibre of the sitting and standing postures enlarges in recumbency. 7. High pressures (minimum and ob- literating) in peripherally induced tension (see p. 129). (b). Minus-tension. I. Early development of the maximum movements of the indicator, vv^hich are sharply attained and passed in the middle third of the obliterating pressure. 2. The rise, fall, and turn of the stroke are quick, and a halt is apt to appear at 122 PULSE-PRESSURE. the bottom of the fall — dichrotism (see p. 107). 3. Expansile reaction increased. 4. Postural variations of the calibre are well marked. NORMAL AND ABNORMAL. I23 CHAPTER III. The Radial Pulse-Pressure: Normal AND Abnormal. I. Difficulties and Fallacies. The determination of the blood-pressure in man must always be merely approxi- mate ; for it can only be taken through the intervention of tissues, that vary in resistance in different individuals. Any- thing like uniform and absolute accuracy cannot possibly be attained. Taking, however, the general run of patients, I do not think that that resistance is quite so variable as to impair the practical charac- ter of this mode of observation. The finger can pretty readily detect exception- ally high tissue-resistance — so that, when it is apparent, observation may be made under qualification, or it should not be 124 PULSE-PRESSURE. attempted.'^' Some experiments with ex- cised arteries show, that the resistance offered by the arterial wall, even when thickened by atheroma, is much less than anyone would prima facie suppose it to be. For example, on allowing water to run through two radials, one with soft walls scarcely 0*5 mm. in thickness derived from a woman aet. 22, and the other with walls 0'75 mm. in thickness derived from a man set. 72, occlusion was effected in both cases by the pressure of 2^ grammes. A radial artery distinctly hard and cal- careous, would, of course, offer increased resistance ; but that is a condition readily detected by the finger, and may in some * In using the pulse-pressure gauge an approximate estimate of the amount of resistance offered by the superposed tissues may be obtained by observmg when the indicator begins to pulsate. As a rule it does so at once, or before the pressure attains twenty grammes, while in cases of increased tissue-resistance, it fails to do so until the pressure has been advanced to fifty, sixty, or more grammes. A correction may, therefore, be made in these exceptional instances, by deducting from the readings the motionless interval beyond twenty grammes, which suffices to cover the tissue- resistance met with in the general run of patients. NORMAL AND ABNORMAL. I25 degree be allowed for. A palpable thick- ening of the arterial wall short of calcifi- cation, therefore, offers but a trifling re- sistance to closure of the artery. As I have previously pointed out (pp. 9, 10) a certain proportion of cases is rendered un- suitable for any instrumental observation of the pulse, in consequence of anatomical departures, &c. 2. The tactile appreciation of Pidse-pressures. Perhaps the best illustration of the some- what feeble discriminative power of even the educated tactile sense, in estimating the degrees of intra-arterial pressure, is afforded by propelling water intermittently through a piece of artery in communica- tion with a mercurial manometer, the observer placing his finger over it and closing his eyes, and declaring the tactile readings of the various pressures, while an assistant compares them with the true record of the manometer. The discrep- ancies which thus become manifest — 126 PULSE-PRESSURE. amounting to fifty or more mm", of mer- cury — tell their own tale. The finger, in- valuable though it be in clinical observa- tion of the qualities of the pulse, does not, therefore, possess a highly refined sense of resistance for the purpose of determin- ing the variations of the pulse-pressure. Each observer, moreover, acquires his own incommunicable idea of the limits of the standard of normal radial resistance ; and I think it is not improbable, that many observers are apt to pitch it some- what too high. Observations with the pulse-pressure gauge has shown that when other indications are favourable, the lower ranges of pressure are not only more salu- tary, but are very often compatible with the highest health. 3. The average Pulse-pressures. Normal Pulse-pressures. A PRETTY large experience with the pulse- pressure gauge enables me to conclude that the normal obliterating pulse-pres- NORMAL AND ABNORMAL. I27 sure, as a rule, falls within the following limits— in men from 140 to 200, and in women from 120 to 160 grammes. I have already pointed out, that the average minimum pressure is one-third less than the maximum (see p. 105). Unless the finger detects an abnormally high tissue- resistance, I should regard, as a rule, a higher maximum pressure than 200 grammes in women, or 250 in men of average build as within the range of ex- cessive pulse-pressure. Therefore, if it is found necessary to press the indicator into the second circle before the pulsa- tions are obliterated, the pulse-resistance should be regarded as decidedly high." * In order to decide whether any particular observa- tion indicates a fairly normal pulse-pressure, or one above the average — for this is the aspect which is of special clinical importance — it is necessary to take into consideration certain qualifying conditions, such as the age, sex, build and general nutritive condition of the individual. As a rule, the normal pressure is higher in big broad-built men and women, especially when sanguineous and obese, and lower in the small and thin ; and whenever it rises, even sHghtly, above the maximum physiological limit of the individual, the calibre becomes uniform. 128 PULSE-PRESSURE. 4. A hnormal Pulse-pressures. The radial artery, occupying an inter- mediate position between the centre and the periphery of the circulation, is a con- venient site for the study of the variations of the average pressure within the arterial system ; but it fails to furnish much, if any, direct evidence of increased blood- pressure in that form of plus tension, in which the radial and even the arteries of larger size are involved in vaso-motor con- traction ; for then the area of increased peripheral resistance includes the radial itself, and the pulse becomes small and" weak, and the pulse-pressure gauge affords low readings — even though there may be undoubted evidence of increased blood- pressure in the central arteries.*^ The radial is, however, an important avenue of direct observation of the blood-pressure * The asthenic form of arterial tension here referred to is of frequent occurrence in anaemia, neurasthenia, hysteria, hypochondriasis, atonic gout — especially in women — asthenia in many other forms, and especially associated with some source of irritation, &c. (see p. 33). NORMAL AND ABNORMAL. I2g in the other leading variety of plus tension, in which the increased resistance is limited to the terminal arteries, or to the capillaries, as in lithiasis, contracting kid- ney, &c. In my observation of cases of this type I have found my pulse-pressure gauge of service in enabling me to de- finitely recognize the less palpable incre- ments of phis pressure — especially v^hen the finger afforded somewhat equivocal evidence — and to determine the degrees of pressure with more precision than could be defined by the finger. These practical advantages will not be regarded as inconsiderable, when it is recognised, how amenable to treatment are the minor degrees of plus tension, and how these, when disregarded, are apt to gradually and imperceptibly lead on to very serious evils that shorten life — such as irretrievable arterial and cardiac disease.'" It is un- * The peripheral origin of heart disease, &c., is a matter of con'-iderable clinical interest. It is, however, beside the purpose of this little book to detail the cen- tric and other effects of phis tension. This aspect of the subject is well delineated in Sir William Broadbent's excellent book on The Pulse. K 130 PULSE-PRESSURE. doubtedly an advantage to be able to de- tect the earliest drifting in this direction. Moreover, I have found this mode of ob- servation useful in tracking and recording the effects of the treatment of high tension, which in these days has acquired an im- portant position in practical therapeutics (see p. 132) : and it has occasionally re- flected a suggestive influence on diagnosis ; for now and then a persistent record of an exceptionally high pulse-pressure has prompted me to the belief, that there was a granular kidney maintaining the otherwise unaccountable tension, and careful enquiry has at times established the fact. I have, however, observed simi- lar high readings — such as from 350 to 500 grammes — when no evidence of in- sidious renal disease could be ascertained; but, whether such disease existed or not, the persistence of excessive intra-arterial pressure made me alive to the not improb- able occurrence sooner or later of cerebral haemorrhage ; and in several such cases this event has unhappily supervened (see p. 148), while in others the comparative NORMAL AND ABNORMAL. 13I frequency of death from apoplexy in near relatives seemed to point to a hereditary disposition to high arterial tension of this type. K2 X32 PULSE-PRESSURE. CHAPTER IV. The Pulse-Pressure Gauge and Ar- teriometer as alds in determining THE Effects of the Treatment of Plus Arterial Tension. I WILL briefly illustrate how the pulse- gauge and the arteriometer may enable the observer to follow the results of the treat- ment oi plus tension ; and for this purpose I will select the modifying influence of re- cumbency, diet, mineral water and baths, and vaso-motor relaxants. I. Recumbency, The reduction of the muscular contractility of the arterial wall in recumbency (as shown by the pronounced increase of the expansile reaction in that posture) shows that a much deeper physiological significance should be attached to it, than it possesses in the conventional sense : for the rest TREATMENT OF TENSION. I33 extends in a great measure to the plain involuntary as well as to the voluntary muscles. Hence the particular value of recumbent rest whenever the walls of the arteries are in a state of tonic constriction, as in the asthenic forms of plus tension. A typical illustration of this position is afforded by anaemia. In this condition the arteries are reduced in calibre by con- traction in the sitting, and still more so in the standing posture, and they become en- larged in recumbency when the contraction subsides. Hence in the sitting and stand- ing postures a heartward strain is induced by the contraction, which passes away on the assumption of recumbent rest. In keeping with this fact is the frequency of ventricular dilatation in anaemic subjects,* and the freedom from this cardiac com- plication when they maintain the recum- bent posture.t There is, moreover, a * On the Condition of the Vascular System in Ancemic Debility, by Arthur Foxwell, M.D., " British Medical Journal," vol. i., 1892, p. 799. f AncEttiia as a Cause of Permanent Heart Lesion, by Henry Halford, M.D., " British Medical Journal," vol. j., 1892, p. 853. 134 PULSE-PRESSURE. satisfactory physiological explanation why the ventricle becomes dilated when the intra-aortic pressure rises. Professors Roy and Adami have shown, that "the ventricles normally do not become com- pletely emptied at the end of systole. If the pressure in the aorta fall without any change in the force of the contractions of the ventricular wall, the ventricle empties itself more completely at each beat, and there is less residual blood. If, on the other hand, the aortic pressure rise, let us say from 80 to 160 mm. of Hg, which is within the normal limits in man or the dog, the resistance offered to each con- traction will be doubled. The increased aortic pressure will necessarily produce the same effect on the ventricular wall, which would result from doubling the weight on a parallel-fibred voluntary mus- cle, which is being stimulated to a series of maximal contractions by single in- duction shocks, care being taken to pre- vent the muscle being stretched by the weight when in a relaxed condition. In both cases the shortening in full con- TREATMENT OF TENSION. 135 traction will be diminished With in- crease of aortic pressure there is, other things being equal, an increase in the amount of residual blood The increase of residual blood is, of course, always increased, also, whenever the aortic pressure remaining constant, the force of the ventricular con- tractions is reduced from mal-nutrition or other cause."* In view of these physiological facts it is not surprising to find that dilatation of the ventricles is ,not uncommon in anaemic subjects, and that it may be avoided by enjoining recumbent rest. In anaemia the advantages of recumbency as a therapeu- tic measure are further emphasized by the arteriometer having demonstrated, that from 25 to 100 per cent, more blood is discharged into the tissues in the recum- bent than obtains in the sitting posture. According to my observation the radial * Contributions to the Physiolocry and Pathology of the Mammalian Heart, by C. S. Roy, F.R.S., M.D., Professor of Pathology, Cambridge, and J. G. Adami, M.D., M.A., Fellow of Jesus College, Cambridge (from the Cambridge Pathological Laboratory), ' Phil. Trans. of R. S. of London," vol. 183 (1892), pp. 212 and 213. 136 PULSE-PRESSURE. calibres of the standing and sitting pos- tures increase in recumbency, as a rule, in proportion to the severity of the anaemia, and to the need of recumbent rest. At present I am disposed to adopt the fol- lowing as a good working rule : when the sitting radial calibre enlarges 100 per cent. e.g., 1*0 mm. becoming 2*0 mm. in re- cumbency, the rest should be absolute for a time ; but when the rise falls short of this decisive one, it may suffice merely to alternate recumbency with passive or active exercise. The following radial measurements illustrate the application of this rule, and the prescription of the chalybeate waters of Harrogate and of other suitable treatment. Radial Radial Calibre. Calibre. mm. mm. Mrs. C, set, 56. R. i-7\ ri-6 S. o"6hin 14 days -j 17 St. ... 0-5) 1-8 Miss L., set. 20. R. 17] n'5 S. I'o • in 23 days- 17 I 1/ Vl'2 St. ... TREATMENT OF TENSION. 137 Miss E., ast. 42. R. S. St. Miss D., £et. 24. R. S. Mrs. W., Eet. 32. R. S. St. Miss T., set. 23. R. S. St. Mrs. B., »t. 56. R. S. Miss C, set. 18. R. S. Mrs. C, set. 31. R. S. Miss S., set. 22. R. S. St. 2-Oj /I5 I '4 ^ in 21 days J i'8 o"9 1 \i'6 i6| (1-3 1- in 30 days J 1*2 ) I 17 19 i'4 I'l [- in 22 days J i li 2*3 2 17 1'5 V in 21 days - 2'o I '2 2-4 I in 1-8 (19 ... 9 days 1-3) (2'0 171 fi'5 J- in 24 days < i-ij (.1-9 2-1) (1-9 y in 16 days < r6J U-4 2'3 17 I-5 r in 19 days ■'^ 2'o 1-3) l. The adoption of recumbency is bene- ficial in other forms of asthenic arterial tension. Radial Radial Calibrk. Calibre, mm. mm. Mr. B., ffit. Co. R. i-«\ r Neurasthenia. S. 0-9 t in 31 days ^ I -g St. o-ei ix-8 138 PULSE-PRESSURE. Mrs. L., at. 53. R. Neurasthenia. S. St Miss E., aet. 36. R. Asthenic dyspep- sia. S. Mrs. S., set. 38 R. General asthenia. S. St Mrs. T., at. 48. R rg^ fiT )- in 13 days*! Asthenia. S. I'sJ Va*! Mrs. S., St. 70. R. i7"\ ri'5 y in 14 days^ Asthenia. S, roj Kro Mrs. K., aet. 62. R 2-0^ fv8 Neurasthenia. ^insadays-^' Insomnia. S. ... ... i"3j ^ 2'3 Mrs. E., aet. 53. R. 2-4 fvg Neurasthenia. J- in 38 days*! Insorr.nia. S. 1.6J l.2"4 Miss R., aet. 61. R. 17^ fi'S y in 30 days-^ Asthenia. S. I'oJ i.2*3 Though constriction of the arterial wall is the predominant condition in this form of plus tension — especially in the active postures — my observations have shown, that in a minor degree it is very fre- quently present when the radial blood- pressure is raised by increased resistance mainly confined to the capillaries and the TREATMENT OF TENSION. I39 terminal arteries ; for, when the blood- pressure falls as the result of treatment, the radial calibre not infrequently in- creases (see pp. 141-2) * Here again recum- bency is often of considerable therapeutic value as an auxiliary to other measures adopted to modify the excessive blood- pressure ; and it is particularly so in that modified form of plus tension, which is frequently met with in elderly subjects — especially when of gouty habit — in whom the radial pressures, though not much, if at all, in excess of the normal range, are relatively high in view of the asthenic condition. My radial observations have clearly demonstrated, that recumbent rest * It may be thought that the readings furnished by an instrument like the pulse-pressure gauge, provided with a solid pad, should be qualified by a correction for the diameter of the artery — a given intra-arterial pressure becoming greater or less as the calibre of the vessel increases or diminishes. I have not yet sub- mitted this matter to ihe test of experiment ; for so far, I have been satisfied with the d'rect readings of the instrument, which has proved itself capable of deter- mining a marked reduction as well as a pronounced lise (see p. 53) of the blood-pressure, when in the same individual the calibre increased or diminished. 140 PULSE-PRESSURE. is most useful in the management of all forms oi plus tension, especially when pre- scribed during the periods of accession which are apt to supervene every now and then. 2. Diet. It is now well recognised that plus tension of peripheric origin (gout, renal disease) may be considerably modified by dietetic directions. The following is a good illus- tration of what may be done in this way. In 1892 I saw a gentleman, set. 57, suffer- ing from granular kidney, and presenting the typical symptoms of that disease. The maximum radial pressure varied from 400 to 450 grammes. A diet of milk, farinacea, vegetables, and white meats (chicken and white fish) was prescribed. Last year I found the obliterating pulse- pressure reduced to from 170 to 230 grammes ; and the patient's weight had increased from 11 st. 5 lb. to 12 st. 2 lb.* * This autumn I observed the same favourable con- dition of the pulse-pressure and of the body-weight. TREATMENT OF TENSION. I4I This case clearly showed that the high arterial tension of granular kidney may be markedly reduced by diet alone, while the general health is well maintained — and certainly does not suffer deterioration in consequence of the reduction of the ex- cessive blood-pressure. 3. Mineral Waters and Baths, Hydro-therapeutics is of undoubted value in the treatment of plus tension, especially when caused by gout. As my experience in this direction is mainly based on observation of the effects of the Harrogate waters (sulphuretted and fer- ruginous salines) I will quote from my notes a few examples of gouty arterial tension treated by them. E2 S;3? E2 l^i mm. Grammes. mm. Grammes. Col. S., St. 54. R. ... 1-9 ••• \ (^'5 - S. ... i'9 ... 260 1 in 19 days -I 2-1 ... 160 St. ... rg - ^ ^2-2 ... 142 PULSE-PRESSURE. Adm. C ..set. 73 R. . S. . . 1-9 . . 19 . . 250 - in 21 days - ii-9 . Col. L., aet. 60. R. . . 1-9 .. 1 M7 • S. .. . 1-9 .. 300 *■ in 42 days- 2'i . J 2*3 . St. .. . 1.9 .. Mrs. S. aet. 48. R . S. . . 1-6 . . 1-6 . ) 1-5 . \ in 35 days - • 330J 1-9 • Miss N ,ffit.49. R. . .. 15 . • [1-5 . • in 21 days-i a'o . S. . .. 1-5 . . 300 St. . .. 1-5 • . vg . Mr. M., 8Et. 43. R. . S. . . 2*0 . .. 2*0 . ) (1-6 . in 23 days • .. 250) (2-0 . Mrs. M. , at. 70. R. . S. . • 17 • .. 17 . ^ ri-8 Vin 18 days-^ .. 300J U'l Mr. C, ffit. 50. R. . S. . .. 2*0 . .. 2*0 . )^ in 16 days-( .. 260J V2-5 Miss B. , aet. 32. R. . S. . .. I'2 . .. 1'2 . ^ ri-6 ;»in 6 weeks-^ .. 300J Kvg Mr. A., aet. 50. R. . S. . .. 2-3 . .. 2*3 . .. 300, J- in 13 days<( ) U-6 170 230 I go 180 250 I have observed, that bathing alone may effectually reduce plus tension ; and the form of it which I have found to exert the most potent influence in this direction is the Harrogate modification of the Aix- les-Bains douche. In illustration of this TREATMENT OF TENSION. 143 fact I will merely quote an example or two from a large number of similar re- cords; and I select the following, because the age of the subjects might have war- ranted the conclusion that the radial cali- bre had already become fixed from the de- velopment of physiological arterio-fibrosis. The massage-douche, however, was suf- ficiently effective in liberating the arterial wall and in reducing the arterial tension, that the physiological postural variations gradually appeared and were fully restored within three weeks. Mrs. M., get. 70. R. 8. Col. K., Kt. 68, R. S. Mr. Mo., aet. 71. R. S. < < mm. 17 17 2*0 ro i-g i'9 S2S X PL, Grammes. Q " k5 y in 18 daysK 300J U-i ^ fa-o y in 21 days^ 180J V2-4 ^ ri-8 y in 17 days«( J V2-2 ^ pL, mm. Grammes. fv8 210 150 V* * These radial observations were, as a rule, made on bath-free days. The records intervening between the first and the last present confirmatory transitional readings. 144 PULSE-PRESSURE. The following examples show, that when the purgative waters reduce the arterial tension but slightly, and induce only limited postural variations of the calibre, the massage-douche may develop these effects more fully. Mineral Waters ALONE. Massage-Douche in addition. Mr. K., ast. 54. Radial calibre ■< VS. 2-5 Maximum pulse- \ pressure J ' Mrs. P., aet. 46. in ID days Radial calibre -( fR. 1-5 VS. 1-5 2*1 2-3 300 {1-6 in 7 days 2'I 2-6 250 Maximum pulse- pressure Dulse- \ 170 in4 , days 171 1115 days 150 1-3 [ in 1-7 Ti J 2-3 160 days 150 In all the cases in which the postural variations of the radial calibre were re- stored the general health was manifestly improved ; as shown by gain in weight, or by increased vigour and power of re- sistance, or by the return of elasticity of mind and body.* * Inasmuch as increased peripheral resistance may determine dilatation of the cardiac chambers (see pp. 129, 133-5), ^ reduction of that resistance by means TREATMENT OF TENSION. I45 4. Vaso-motor Relaxants. From the physiological standpoint, it would seem that the interesting group of remedies, of which nitroglycerine and the nitrites of amyl and of sodium are the repre- sentative members, should prove of service in the treatment of certain forms of peri- pheral resistance that induce ph{s tension ; and in many cases that therapeutic forecast has been amply verified— especially in the amelioration of the accessions of tension, of baths, massage, &c., when the cardiac muscle is over-taxed by it, will doubtless favour the unloading of the ventricles, and will thus lessen the amount of residual blood and the dilatation. Dr. Theodor Schott (in IJad Nauheim) has demonstrated this effect of baths, and has illustrated it by diagrams, showing the extent to which he had observed the reduction of the cardiac dulness, and the forward advance of the apex beat (see " Deutsche Medizinal-Zeitung," 1888 and i8qo ; " Zur Pathologic und Therapie der Angina Pec- toris," and " Neurasthenic und Herzkrankheiten "). Harrogate affords every facility for the application of this mode of treatment of cardiac dilatation ; especially too, as Dr. Theodor Schott's method of passive re- sistive gymnastics, applied with much success at Nau- heim, is now available there. L 146 PULSE-PRESSURE. which are apt to supervene during" the course of the cases of this type. The re- laxant effects of these remedies on the arterial wall may be followed by the ar- teriometer and the pulse pressure -gauge. I have observed, when the radial presents an uniform calibre in posture — as in angina pectoris, &c. — that nitroglycerine may induce postural variation and reduce the blood-pressure. The following is a good illustration of this fact. 1893. Mr. G., ast. 61 Radial calibres S, 20 mm. Liver derangement ... ... ... ... ... R. i"5 ,, No angina pectoris Obliterating pulse-pressure ... 180 grammes. 1894. Angina pectoris Radial calibres ... S. 2"o mm. R. 20 „ ... 300 grammes. ... S. I'gmm. ... R, 2-2 „ ... 220 grammes. ... S. 2'o mm. ... R. r6 „ ... 220 grammes. I Obliterating pnlse-pressure T.,.^ , . C ... Radial calibres ... Nitro-giycerine ) Gr- T50 t^f ^^^ [obiiierating pulse-presstire The same dose [ ... Radial calibres ... every night for -^ 14 weeks I Obliterating pulse-pressure When twelve months ago the patient came under observation for liver derange- ment, there were no signs of angina pec- toris or of plus tension ; and the arteries TREATMENT OF TENSION. I47 responded normally to posture. Now he reappears with angina pectoris, plus ten- sion, and the absence of postural varia- tions ; and under small doses of nitro- glycerine the pulse-pressure falls, the calibre varies with posture, and the attacks of anginal pain diminish.'" * In connection with the relief of excessive blood- pressure, which arises from the widening of the peri- pheric arteries, it is I think clinically interesting to find, that when cerebral haemorrhage, producing hemiplegia, takes place in a subject presenting a high maximum pulse-pressure, the radial artery on the paralysed side becomes considerably increased in calibre, and the blood-pressure falls on both sides ; so that it would seem that the haemorrhage, inducing at once an en- largement of the calibre of the arteries over half the body, relieves the general blood-pressure, and thus limits the disposition to further extravasation. The following case is instructive from this point of view : — 1893. Miss. B., aet. 64 ... Radial calibres S., R., and St., 2'0 mm. Glycosuria ... Obliterating pulse-pressure ... 400 grammes. 1894. Left hsemiplegia ... Radial calibre S., R., and St. from cerebral hsemorrhage Right 2'5 mm. March, 1894 Le/t a'g mm. Obliterating pulse-pressure 280 grammes. The patient has been glycosuric with a high pulse- L2 148 PULSE-PRESSURE. CHAPTER V. Conclusions : Resume of Observa- tions. I WILL briefly recapitulate the leading conclusions which the observations I have made with my pulse instruments support. I. The principal shortcomings of this pressure for several years. Last year the obliterating pressure exceeded 400 grammes, and the radial calibre (2*0 mm.) was uniform in all the postures, and was equal on the two sides. When attempts were made to relax the restricted diet, the glucose in the urine immediately increased. To her physician I expressed a fear that cerebral haemorrhage might supervene. That event did occur last March, producing left hemi- plegia. Her physician then remarked the fall of the pulse-pressure, and the reduction of the sugar in the urine to mere traces. The paralysis has now nearly passed away. The pulse-pressure is reduced on both sides to 280 grammes. The radial measurements have increased : the calibre on the right (unaffected) side being 0*5 mm., and on the left o*g mm. in excess of last year's observation. CONCLUSIONS. 149 (or indeed of any other) instrumental mode of observation of the pulse are : — (a). The inapplicability of it to those cases in which structural irregularities of the radial artery and of the wrist are present. Observation is thereby excluded in a certain proportion of cases. (6). Some degree of deftness in the ob- server is necessary for trustworthy read- ing of the instruments. 2. In health the calibre of the systemic arteries never remains persistently uni- form, but is continually varying within pretty wide limits in reponse to change of physiological condition ; and the varia- tions follow a definite order (pp. 12-30). 3. In disease, pronounced departures from the physiological order of variation are met with — as revealed by change of posture ; such as the following : — (a). The measurement uniform in the postures. (b). The maximum measurement in re- cumbency. 150 PULSE-PRESSURE. (c). The postural variation greatly re- stricted or amplified. (d). The calibre — whether uniform or varying — much reduced or enlarged. (e). The two radial calibres asymme- trical. 4. Postural uniformity may be tempor- ary or persistent. When temporary, it may be due to goutiness, or to arterial constriction from some source of irrita- tion ; when persistent the cause may be arterio-iibrosis, myxoedema, syphilis, gout, or chronic interstitial nephritis (pp. 34-49). So far my observations have shown, that the detection of a uniform radial calibre may prove to be of considerable practical value ; for, though it may now and then merely indicate a transitory con- dition of little or no pathological signifi- cance, it will always keep the observer alive to the possible existence of one or other of the important diseases in which it has been found to be a common clinical feature. CONCLUSIONS. 151 5. The maximum measurement persist- ently present in the recumbent posture is, as a rule, cHnically significant of an asthenic and impoverished state — espe- cially of the nerve centres and the blood ; or of the existence of some source of irri- tation ; or of a combination of both these pathological conditions. When the predominant clinical feature present is asthenia, the radial calibre diminishes as much in the standing posture as it in- creases in the recumbent (pp. 32, 33). 6. Restricted variation indicates either an increase of arterial tension, or the existence of slight organic changes in the arterial wall (p. 40). 7. Amplified variation, as a rule, im- plies subnormal arterial tension (p. 40). 8. The radial calibre may be diminished in a marked degree from : — (a). Vaso-motor constriction, the result of operative procedures, or of pain, or of some source of irritation — especially when located within the abdomen. 152 PULSE-PRESSURE. (b). Passive reduction, as in states of cachexia and wasting. (c). Organic reduction, as in arterio- fibrosis, syphilis (secondary and tertiary stages), and chronic gout (p. 51). 9.. The radial calibre may be enlarged as a result of increased peripheral resist- ance, or loss of elasticity of the arterial wall or reduction of arterial tonus (p. 52). 10. Asymmetry of the radial calibres, when showing a disparity of at least 0*5 mm., is of clinical significance, and may arise from : — (a). Mechanical pressure. (6). Vaso-motor constriction (distal irri- tation) . (c). Hemiplegia (p. 41). It produces an inequality of the surface temperature of the two sides (pp. 48, 49).* * Bilateral thermometric observation has afforded me some interesting clinical data — not merely in the febrile, but in the non-febrile. It is of course greatly faciltated by using, as I do, two thermometers known to register alike throughout the scale. CONCLUSIONS. 153 11. The chief cHnical value of pulse- pressure readings rests with the detection of those which indicate an excess of the pressure normal to the individual. The slightest rise of the intra-arterial pressure above this point — which varies somewhat in different persons — abolishes the pos- tural variations ; so that the arteriometer becomes a useful corrective and supple- ment to the pulse-pressure gauge (p. 127). 12. The pulse-pressure gauge is useful in definitely determining the excessive degrees of pulse-pressure which are mis- chievous to the heart and the arteries ; and in revealing with much more pre- cision than can be acquired by the finger the less pronounced grades of it, which may perchance escape digital detection, and which may be advantageously met by timely treatment (pp. 129, 130). 13. When the radial blood-pressure is increased, the calibre may be diminished or enlarged; diminished by the predomin- ance of vaso-motor constriction, and en- 154 PULSE-PRESSURE. larged when the distensive power of the increased intra-arterial pressure fails to be balanced by muscular contraction (PP- 53. 54)- 14. Radial calibration may provide use- ful diagnostic hints in respect to gout, rheumatism, chronic rheumatoid arthritis, syphilis, myxoedema, chronic renal dis- ease, arterio-fibrosis, angina pectoris, anae- mia, and asthenia in its various forms (pp. 55-64). 15. Observation of the radial calibre and pulse-pressure are of practical utility in regard to treatment ; in selecting and adjusting the remedial measures — such as tonics, evacuants, recumbent rest, exer- cise, massage and baths — and in observ- ing the effects produced. The pulse in- struments have specially demonstrated the great restorative value of such phy- siological agencies as recumbent rest, exercise, diet, massage, baths, and mine- ral waters (pp. 64, 132-148). CONCLUSIONS. 155 16. Radial calibration may suggest and aid enquiry. It has, for example, thrown some light on the unsettled questions re- lating to the effects of anesthetics and of operative procedures on the circulation of man ; and it has opened up an interesting enquiry relating to the function of the supra-renal bodies (pp. "j"])^- * * The arteriometer may likewise contribute some evidence towards the solution of certain debated clini- cal questions, such as the relation which gout bears to eczema (or certain forms of eczema), asthma, &c. ; and it may prove useful in testing and demonstrating the efficacy or otherwise of new modes of treatment. So far my observations bearing on the connexion be- tween gout and eczema suggest a definite aetiological relation in certain cases, while in others it is not apparent ; but this matter, all important in regard to treatment, demands more extended observation. Just as these pages are passing through the press, illus- trations of the suggestive guidance of the arteriometer present themselves in several directions. For instance, observation is demonstrating the undoubted efficacy of the Harrogate massage-douche in the treatment of the reduced arteries of syphilis, and points to it as a valuable adjunct to the therapeutic measures hitherto employed in that disease ; and likewise in the treat- ment of gouty eczema. 156 PULSE-PRESSURE. ADDENDUM. The results obtained by the Arte- riometer confirmed by experi- MENTS ON Animals. I HAVE shown (pp. 86-89) that the read- ings of the Arteriometer in regard to the constrictive effects of supra-renal extract on the arteries have been conclusively proved by experiments on animals ; and I have lately observed, that the result of intra- venous injection of thyroid extract is confirmatory of the indications furnished by the instrument. It has now, there- fore, been demonstrated in the laboratory that the extracts of the supra-renal bodies and of the thyroid gland exert contrary effects on the arterial wall — the former contracting, and the latter dilating it ; the position which was in the first instance suggested by the Arteriometer (see p. 84). ADDENDUM. 157 Experimental evidence proving varia- tions in the radial calibre and blood- pressure as the result of posture and cf gravitation, by which I have attempted to test the vaso-motor mechanism in man, has not, however, been forthcom- ing ; and up to the present I have been left to my own unsupported observations in the human subject. All along, however, I have been per- suaded, that the faithful record of fact without reference to theory or explanation would some time or other be confirmed by the results of experiments on animals. On the eve of publication that belief has, I am happy to say, been realized ; and I now have the satisfaction of adducing ex- perimental proof of that which is the key- stone of this enquiry. Mr. Leonard Hill, Assistant Professor of Physiology, University College, Lon- don, has for some months past been in- vestigating the effects of gravity on the circulation in dogs, cats, and monkeys ; and the outcome of his important work provides the experimental counterpart of 158 PULSE-PRESSURE. the physiological portion of this volume — and of the pathological variations of the arterial calibre which are founded on it. Through Mr. Hill's courtesy I have had the pleasure of going over all the tracings which will illustrate his forthcoming paper — a paper which will not only be a most valuable contribution to our know- ledge of the forces concerned in the cir- culation, but will prove of much practical value. Mr. Hill's work not being published I cannot of course quote particular experi- ments or portions which prove the phy- siological facts I have adduced ; I am, however, greatly indebted to Mr. Hill for the following resume of some of his posi- tions bearing on my observations. "At the time when I was just com- pleting a paper on a long series of experi- ments on the effects of gravity on the circulation — a paper which will be shortly published — I was fortunate enough to find that Dr. Oliver had obtained inde- pendently, and by an absolutely different ADDENDUM. 159 method, many of the same results which I had obtained in monkeys. By means of the most ingenious instrument, the Ar- teriometer, Dr. Ohver has found, that in the normal man, the diameter of the radial artery is greater in the standing posture and less in the recumbent position. He has also observed, that the fall of the cali- bre in recumbency is often preceded by a temporary rise. In the abnormal man, in a state of asthenia or shock, Dr. Oliver has determined that the diameter is less in the standing posture and greater in re- cumbency ; the arterial changes in the postures being entirely reversed. " Now in normal monkeys I have found, that the blood pressure falls at first in the vertical feet-down position, owing to the hydrostatic effect ; and then rises, owing to the over-compensation of the hydro- static effect through vaso-constriction in the splanchnic area. If, on the other hand, the monkey be turned from the ver- tical feet-down posture to the horizontal position, the blood pressure at first rises, owing to the hydrostatic effect, and then l6o PULSE-PRESSURE. falls owing to over-compensation by vaso-^ dilatation and cardiac inhibition. " In monkeys, however, weakened by long anaesthesia, or operative procedures, the conditions are reversed ; the pressure falls in the feet-down posture, and rises in the horizontal position. "There is, therefore, an exact agreement between the results of the Arteriometer and the physiological results obtained by me on monkeys. " The accuracy of the arteriometer was shown to me in another and more striking way. Dr. Oliver informed me, that ether as an anaesthetic produced a different re- sult to chloroform on the diameter of the radial artery. By my investigation on chloroform I have found, that this drug when pushed produced a rapid paralysis of the splanchnic vaso-motor mechanism, and in consequence a most marked fall of blood pressure in the feet-down position. On testing the effect of ether on a dog. Dr. Oliver's observations were at once es- tablished. Ether produced at first no fall of pressure when pushed with the animal ADDENDUM. l6l in the feet-down position, and the fall, when it did occur, was extremely slow and gradual. ''Dr. Oliver ascribes the diminution of the radial diameter to three causes : — i. Organic change — arterio-fibrosis. 2. Vaso- constriction. 3. Passive shrinking. "It is in regard to changes produced by passive shrinking that my results will be found to agree exactly with those obtained by Dr. Oliver on man. From my inves- tigations I have found, that the influence of position on the circulation affords us a most delicate test of the condition of the vaso-motor mechanism ; and I believe that the Arteriometer will be an instru- ment of great clinical value, as it will enable us to apply this test to man." According to the teaching of these ex- periments, when the maximum radial calibre is found in recumbency, and the minimum in the active postures— as dur- ing digestion (see p. 19), in the second stage of exercise (see pp. 15, 16) » and in asthenia and loss of tone — the diminution in the sitting and standing positions is M l62 PULSE-PRESSURE. due to reduction of the radial fulness, in consequence of the transference of blood through the agency of gravity into the legs and the splanchnic area ; and the radial enlargement in recumbency arises from the return of the blood from these regions — it being no longer retained there by gravity. It would, therefore, seem that gravita- tion — which comes prominently into play in the conditions just specified — should be accepted as an important modifier of the distribution of the blood, which has not hitherto been sufficiently recognized by physiologists. Inasmuch as the reduced tonus of the vessels in the areas into which the blood gravitates is the disposing cause of this transference, this event should be much less liable to occur, were it possible to bring vaso-constriction into play, and thus to tone the arterial walls. Ex- periments on animals have shown that the supra-renal extract exerts a powerful influence in this direction ; and, on pre- scribing it in asthenia, I have frequently ADDENDUM. 163 remarked how quickly the postural cali- bration has been restored — the maximum measurement becoming apparent in the active postures, and the minimum in re- cumbency. This fact I have frequently observed.* On the other hand, the re- * The experimental and clinical evidence shows that supra-renal extract is a powerful cardio-vascular stimu- lant or tonic. The intra-venous injection of it in ani- mals produces very pronounced cardiac inhibition ; but notwithstanding this, the energetic contraction of the arteries and arterioles which it causes, suffices even to raise the intra-arterial blood-pressure. When the vagi are cut the ventricle contracts with great force and fre- quency, and the blood-pressure rises to an enormous extent. From the dose (rttxv. ter die) I have merely observed the tonic effects on the vascular system, and I have not met with slowing of the heart from inhibi- tion ; perhaps that result can only be induced by com- paratively large doses. It is, I think, probable that much larger doses may be safely administered than I have hitherto employed ; for the experiments on cats and dogs have shown that large quantities of the ex- tract — decidedly large in proportion to the weight of the animal — may be injected into a vein to produce a temporary but very pronounced effect, or may be allowed to gravitate into it so as to maintain a con- tinuous and profound action, without destroying life. Much experimental and clinical observation is of course required, in order to settle the necessary de- tails bearing on the therapeutic use of the remedy. M 2 164 PULSE-PRESSURE. laxant effects of thyroid extract on the arterial wall should favour the occurrence of the asthenic form of radial calibration in the postures ; and my observation of the radial calibre in thyroidism confirms this anticipation. My clinical experience of the supra- renal and thyroid extracts, therefore, ac- cord with the results obtained in the laboratory ; but I had no satisfactory ex- planation of it to offer, until I observed Mr. Hill's interesting experiments and studied his tracings. INDEX. A.C.E. mixture affecting the radial calibre, 81-84. Adami, Prof., cited, 97. quoted, 134, 135. Addison's disease, supra-renal tincture in, 88, 8g. Aix-la-Chapelle treatment of syphilis at Harrogate, 74. Aix-les-Bains douche at Harrogate, 68-70, 155. Albuminuria, radial calibration in, 55, 56. Anaemia, radial calibration in, 33, 79, 136, 137. cerebral, thyroid extract in, 86. Anaesthetics affecting radial calibre, 8r. Aneurism producing asymmetrical radial calibres, 41. Angina pectoris, 46. radial calibration in, 62. nitro-glycerine in, 145-147. Aperient salines in gout, 72. Arteiial tension (see Tension, arterial). Arteries, calibre in health, 12-30. in disease, 31-54. muscular changes in, 35, 36, 41-49. organic changes in, 36-39. Arteiio-sclerosis, physiological, 14, 36, 38-62. pathological, 36, 38. Arteriometer, 2-4. how to apply, 5-8. l66 INDEX. Arteriometer in diagnosis, 55-64. in therapeutic enquiry, 8r. in treatment, 64-80. principle of, i, 2. results of, confirmed by experiments on animals, 156-164. Arteritis, syphilitic, 38, 39. Asthenia, 14, 32, 33, 79, 132-139. cardiac, 33. splanchnic paresis in, i5i, 162. Asymmetry of the radial calibres, 41. Atheroma, 14, 36. radial calibration in, 62, 63. thyroid extract in, 85. BALT.ANCE, C. A., M.B., M.S., &c., cited, 38. Basch, von, cited, 97. Baths, 66-70. affecting the radial calibre, 21, 22. in the treatment o^ plus tension, 142-144. massage (Harrogate), 68-70, 142-144, 155. needle (Harrogate), 70. still, 67. Turkish, 67. vapour, 67. warm, 67. Blood-pressure, relation of, to radial calibre in disease, 52-54- in health, 29, 30. pulse-rate, 2S, 29. Bouchard, Prof., cited, 25. Brain-cortex, extract of, 81, 84. 167 INDEX. Bramwell, Byrom, M.D., cited, 86. Bright's disease, radial calibration in, 55. Broadbent, Sir W., Bart., cited, 46. Buxton, Dudley, M.D., cited, 85. Calibration, radial, i-QO. asymmetrical, 41. enlarged, 52. postural, 13, I4» 3I' 32- confirmed by experiments in animals, 156-164. reduced, 51, 52. uniform, 34-39- variation amplified, 40. restricted, 40. Calibre, radial, enlargement, 52. organic, 63. passive, 52. vaso-motor, 52. in disease, 52. in health, 26-28. maximum in the active postures, 14. in recumbency, 14, 32-34- minimum, in the active postures, 14, 32-34- in recumbency, 14. in relation to pulse-pressure, 29, 30, 52. pulse-rate, 28, 29. reduction, 25, 51. organic, 51. passive, 25, 26, 51. vaso motor, 25, 51. standard, 50. l68 INDEX. Calibre, radial, uniform in posture, 32, 34. pathological variations of, 31-34, 40, 41. physiological variations of, 12-30. Chloroform affecting the radial calibre, 81-84. producing splanchnic paralysis, 160. Christeller, M.D., &c., cited, 97. Colic, intestinal, 44, 47. Climbing affecting the radial calibre, 15, 16. Constipation, 33, 35, 65. specially pernicious, 65. Constriction, arterial, general, 42, 44-46. unilateral, 46-49. Contraction of the arterial wall, 25, 42-49, 51. Diabetes, visceral vaso-motor paresis of, go. supra-renal tincture in, go. Diagnosis, arteriometer in, 55. Diet in the treatment oi plus tension, 140, 141. Digestion affecting the radial calibre, 18, 19. Dyspepsia, 33. Eczema, 33, 35. gouty, 155. Edmunds, Walter, M.A., M.C.,. cited, 38. Effleurage affecting arterial calibre, 18, 66, 68. Effort affecting the radial calibre, 15, 16. Enlargement of arteries, 26, 27. passive, 26, 52. Enquiry, relation of arteriometer to, 55. Ether affecting arterial calibre, 81-84. does not cause splanchnic paresis like chloroform, 160, 161, INDEX. i6g Exercise affecting the radial calibre, 15-18, 65. tonic effects of, on the brain, 17. Esipansile reaction, 111-117. effects of digestion on, 113. exercise on, 112. posture on, 113. sleep on, 113. temperature on, 112. diminished by vaso-contraction and plus ten- sion, 117. — increased by vaso-relaxation and minus ten- sion, 117, 118. Fallacies in determining the calibre, g-ii. pulse-pressure, 123-125. Fever, traumatic, 45. FoxwELL, A., M.D., cited, 133. Glycosuria, 33, 90. Gout, asthenic, radial calibration in, 33, 37. diagnosis of, 60, 61. radial calibration in, 60, 61. treatment of, 141-144. Gravitation affecting the radial calibre, 22, 23. arterial blood-pressure in animals, 156-161. Halford, Henry, M.D., cited, 133. Harrogate massage douche, 68-70. in gout, 72. in syphilis, 155. needle-bath, 70. 170 INDEX. Heart, dilatation of, treatment by baths, &c., 145. disease, peripheral origin of, 129. Hemiplegia affecting the radial calibre, 41, 147, 148. Hewitt, Frederick, M.D., cited, 85. Hill, Leonard, M.B., &c., quoted, 158-161. Hutchinson, Jonathan, F.R.S., &c., cited, 76. Hypochondriasis and hysteria, 4G. Irritation, distal, affecting the radial calibre, 41-44. Junod's boot, affecting the radial calibre, 23. Kernig cited, 24. Kidney, amyloid, radial calibration in, 38. granular, radial calibration in, 37, 55. Liebermeister, cited, 24. Lister, Sir Joseph, Bart., cited, 42. Mackern, J., M.D., quoted, 89. Malarial rigor, 46. Malcolm, J. D., M.B., &c., quoted, 45. Massage affecting the radial calibre, 18, 66. douche, Harrogate, 65, 68-70. prescription of the forms of, 66. Mercury in syphilis, effects of, on the radial calibre, 73-78, 85. ^ Mineral waters in the treatment oiplus tension, 141-142. Migraine inducing general or unilateral arterial con- striction, 46. Movement affecting the radial calibre, 15. INDEX. 171 Myxcedema, 56. treatment by thyroid extract, 85. — — uniform radial calibration in, 37, 38, 56. Nephritis, acute, radial calibre in, 55, 56. chronic interstitial, radial calibre in, 36. Neuralgia affecting radial calibre, 33. Neurasthenia, radial calibration in, 33. treatment of, by recumbency, 137, 138. — by extract corticus cerebri, 84. Nitro-glycerine affecting the radial calibre, 145-147. Nitrous oxide affecting the radial calibre, 81-84. and oxygen, 82, 83. Oertel, Prof., cited, 16. Oliver, T., Prof., quoted, 47. Operation, steps of, affecting the radial calibre, 42. Oxygen affecting the radial calibre, 82, 83. Pain affecting the radial calibre, 33-35. Pavy, F. W., M.D., F.R.S., quoted, 60. Petrissage affecting the radial calibre, 18, 66-68. Posture affecting the radial calibre, 13, 14. the arterial blood-pressure and calibre in animals, 158-161. Powell, Douglas, cited, 118. Pulse-pressure, 93-155. clinical contributors, 97. difficulties and fallacies, 123-125. maximum and minimum, loi. normal and abnormal, 126-131. qualifying conditions of, 127. reduced by hemiplegia, 147, 148. tactile appreciation of, 125, 126. 172 INDEX. Pulse-pressure gauge, 93-97. how to apply, g8-ioi. significance of the movements of the indi- cator of, 106, 107. use of, in diagnosis, 130. treatment, 132-148. Pulse-rate in relation to the radial calibre, 28, 29. Radial calibre (see Calibre, radial). measurement, i-go. Recumbency, 64-66. conditions of, 13. therapeutic value of, 64-66, 79, 80, 132-140. maximum radial calibre in, 32. minimum radial calibre in, 13, 14. Recurrent beat, 118-120. pathological, 119. physiological, 118. Reduction passive of arteries, 25, 26, 51. Rest recumbent, therapeutic value of (see Recumbency). Rheumatism, radial calibration in, 33, 61. Rheumatoid arthritis, chronic, radial calibrat'on in, 61. Roy, Prof., F.R.S., &c., cited, 97, loi. quoted, 134, 135. ScHAFER, Prof., F.R.S., &c., quoted, 87, 88. ScHOTT, Theodor, M.D., cited, 145. Semi-tension, 33. Sitting posture, conditions of, 13. Shock, producing arterial constriction, 45. Somnolency from cerebral anaema, 80. Sphygmometers and sphygmoscopes, 97. INDEX. 173 Splanchnic paralysis in chloroform narcosis, 160. Standard radial calibre, 50 Standing posture affecting the radial calibre, 13, 31, 33. radial calibration in, a test of asthenia, 33. Supra-renal extract, 86-go, 163. in Addison's disease, 88, 8g. in asthenic radial calibration, 62. in haemorrhage, go. in pilular and tincture form, 89 in vaso-motor relaxation and paresis, go. physiological effects of, 87, 88, 163. Syphilis, acquired, 37, hereditary, 3g. radial calibration of, 55-60, 73-78. use in diagnosis, 56. treatment, 73-78. mercury in, 73-78. reduction of the radial calibre in, 73-78. thyroid extract in, 85. Tapotement affecting the radial calibre, 18, 66-68. Temperature affecting the radial calibre, ig. of body, asymmetrical distribution of, 48. distribution determined by the calibre of the arteries, 23. Tension, arterial, 108. asthenic, 128. mmus, 121, 122. normal, 111-118. plus, 108, 109, 120, 121. treatment of, 132-148. varieties of, 129. 174 INDEX. Thyroid, extract in senile cerebral ansemia, 86. in myxcedema, 85. in psoriasis, 86. in syphilis, 85. Tonics, contra-indicated, 65. indicated, 64. Treatment, radial calibration in relation to, 64-80. Turkish bath affecting the radial calibre, 21, 67. Uniformity of the radial calibre, 32, 34. temporary, 34. permanent, 35. Urticaria, 33. Variation of the radial calibre in health, 12-25. as age advances, 14. in disease, 31-34. causes of, 25-30. postural, 33. absence of, 33. restricted or amplified, 33, 40. — range of in health, 13. Vapour bath, 67. Vaso-motor contraction, 41. paresis, 41, 90, 147, 160. relaxants in the treatment of ^Zms tension, 145-147. WuNDERLicH, Prof., citcd, 24. Zeissl, Hermann, von, quoted, 38. SELECTED LIST OF NEW AND RECENT WORKS PUBLISHED BY H. K. LEWIS, 136 GOWER STREET, LONDON, W.C. (Established 1844) *, * Fo/ full list of works in Medicine and Surgery published by H. K. Lewis see complete Catalogue sent post free on application. LOUIS C. PARKES, M.D. LOND., D.P.H. Lecturer on Public Health at St. George's Hospital, &c. INFECTIOUS DISEASES, NOTIFICATION AND -»- PREVENTION. Fcap. 8vo, roan, 4s. 6d. SIDNEY COUPLAND, M.D., F.R.C.P. Physician to the Middlesex Hospital, and Lecturer on Practical Medicine in the Medical School, etc. NOTES ON THE CLINICAL EXAMINATION OF THE BLOOD AND EXCRETA. Third Edition, i2mo, IS. 6d. \_Now ready. JAMES F. GOODHART, M.D. ABERD., F.R.C.P. Physician to Guy's Hospital, and Consulting Physician to the Evelina Hospital for Sick Children. rvN COMMON NEUROSES; OR THE NEUROTIC ^ ELEMENT IN DISEASE AND ITS RATIONAL TREATMENT. Second edition, crown 8vo, 3s. 6d. A. C. ABBOTT, M.D. First Assistant, Laboratory of Hygiene, University of Pennsylvania. T-HE PRINCIPLES OF BACTERIOLOGY. A Practi- ^ cal Manual for Students and Physicians. With Illustra- tions, post 8vo, 7s. 6d, JAMES ANDERSON, M.D., F.R.C.P. Late Assistant Physician to the London Hospital, &c. EDICAL NURSING. Notes on Lectures given to the Probationers at the London Hospital. Edited by E. F. Lamport, Associate of the Sanitary Institute. With an Intro- ductory Biographical Notice by the late Sir Andrew Clark, Bart. Second edition, crown Svo, 2s. 6d. Vjfust ready. M 2 New and Recent Works published by H. ALDER-SMITH, M.B. LOND., F.R.C.S. Resident Medical Officer, Christ's Hospital, London. DINGWORM : ITS DIAGNOSIS AND TREATMENT. ■*■*• Third Edition, rewritten and enlarged, with Illustrations, fcap. 8vo, 5s. 6d. HARRISON ALLEN, M.D. Consulting Physician to Rush Hospital for Consumption. A HANDBOOK OF LOCAL THERAPEUTICS. Gene- ■^ ral Surgery by R. H. Harte, M.D., Surgeon to the Epis- copal and St. Mary's Hospitals ; Diseases of the Skin by A. Van Harlingen, M.D., Professor of Diseases of the Skin in the Phila- delphia Polyclinic ; Diseases of the Ear and Air Passages by H. Allen, M.D.; Diseases of the Eye by G. C. Harlan M.D., Sur- geon to Wills Eye Hospital. Edited by H. Allen, M.D. Large 8vo, 14s. nett. E. CRESSWELL BABER, M.B. LOND. Surgeon to the Brighton and Sussex Throat and Ear Hospital. A GUIDE TO THE EXAMINATION OF THE NOSE ^ WITH REMARKS ON THE DIAGNOSIS OF DIS- EASES OF THE NASAL CAVITIES. With Illustrations, small 8vo, 5s. 6d. FANCOURT BARNES, M.D., M.R.C.P. Physician to the Chelsea Hospital ; Obstetric Physician to the Greeit Northern Hospital, &c. A GERMAN-ENGLISH DICTIONARY OF WORDS ^ AND TERMS USED IN MEDICINE AND ITS COGNATE SCIENCES. Square i2mo, Roxburgh binding, gs. H. CHARLTON BASTIAN, M.A., M.D., F.R.S. Examiner in Medicine at the Royal College of Physicians ; Physician to University College Hospital, etc. PARALYSES: CEREBRAL, BULBAR, AND SPI- ■*■ NAL. A Manual of Diagnosis for Students and Practi- tioners. With numerous Illustrations, Svo, 12s. 6d. II. VARIOUS FORMS OF HYSTERICAL OR FUNC- ' TIONAL PARALYSIS. Demy Svo, 7s. 6d. H. K. Lewis, 136 Gower Street, London. 3 DRS. BOURNEVILLE AND BRICON. MANUAL OF HYPODERMIC MEDICATION. Trans- lated from the Second Edition, and Edited, with Thera- peutic Index of Diseases, by Andrew S. Currie, M.D. Edin., etc. Crown 8vo, 3s. 6d. RUBERT BOYCE, M.B., M.R.C.S. Assistant Professor of Pathology in University College, London. A TEXTBOOK OF MORBID HISTOLOGY FOR ^ STUDEiNTS AND PRACTITIONERS. Royal 8vo, with 130 coloured figures, 31s. 6d. CHARLES H. BURNETT, A.M., M.D. Clinical Professor of Otology in the Woman's Medical College of Pennsyl- vania ; Aural Surgeon to the Presbyterian Hospital, Philadelphia. CYSTEM OF DISEASES OF THE EAR, NOSE AND ^ THROAT. By 45 Eminent American, British, Canadian and Spanish Authors. Edited by Charles H. Burnett. With Illustrations, in two imperial 8vo vols., 48s. fiett. {Now ready. HARRY CAMPBELL, M.D., B.S. LOND., M.R.C.P. Physician to the North-West London Hospital. I. THE CAUSATION OF DISEASE. An exposition of the ■*■ ultimate factors which induce it. Demy 8vo, 12s. 6d. II. TLUSHING AND MORBID BLUSHING, THEIR ■*• PATHOLOGY AND TREATMENT. With plates and wood engravings, royal 8vo, los. 6d. III. niFFERENCES IN THE NERVOUS ORGANISA- ^ TION OF MAN AND WOMAN, PHYSIOLOGICAL AND PATHOLOGICAL. Royal 8vo, 15s. IV. HEADACHE AND OTHER MORBID CEPHALIC SENSATIONS. Royal 8vo, 12s. 6d. IJust Published. R. E. CARRINGTON, M.D., F.R.C.P. OTES ON PATHOLOGY. With an Introductory Chap- ter by J. F. Goodhart, M.D., F.R.C.P., Physician to Guy's Hospital. Edited by H. E. Crook, M.D. Lond., F.R.C.S. Eng., and G. Mackeson, L.R.C.P., M.R.C.S. Cr. 8vo, 3s. 6d. N 4 New and Recent Works published by ALFRED H. CARTER, M.D. LOND. Fellow of the Royal College of Physicians; Physician to the Queen's Hospital, Birmingham, &c. ULEMENTS OF PRACTICAL MEDICINE. Sixth Edition, crown 8vo, gs. FRANCIS HENRY CHAMPNEYS, M.A., M.B. OXON., F.R.C.P. Physician Accoucheur and Lecturer on Obstetric Medicine at St. Bartholo- mew's Hospital; Examiner in Obstetric Medicine in the University of London, &c. T ECTURES ON PAINFUL MENSTRUATION. -^ Royal 8vo, 7s. 6d. W. BRUCE CLARKE, M.A., M.B. OXON., F.R.C.S. Assistant Surgeon to, and Senior Demonstrator of Anatomy and Operative Surgery at St. Bartholomew's Hospital, &c. 'THE DIAGNOSIS AND TREATMENT OF DIS- ^ EASES OF THE KIDNEY AMENABLE TO DIRECT SURGICAL INTERFERENCE. DemySvo, with Illustrations, 7s. 6d. WALTER S. COLMAN, M.B. LOND. Pathologist and Registrar to the National Hospital for the Paralysed and Epileptic. CECTION CUTTING AND STAINING: A Practical ■^ Guide to the Preparation of Normal and Morbid Histologi- cal Specimens. Illustrations, crown 8vo, 3s. W. H. CORFIELD, M.A., M.D. OXON., F.R.C.P. LOND. Professor of Hygiene and Public Plealth in University College, London. nWELLING HOUSES: their Sanitary Construction and ^ /Arrangements. Third Edition, with Illustrations, crown 8vo., 3s. 6d. [Now ready. EDWARD COTTERELL, M.R.C.S. ENG., L.R.C.P. LOND. N SOME COMMON INJURIES TO LIMBS: their Treatment and After-Treatment including Bone-Setting (so- called). Imp. i6mo, with Illustrations, 3s. 6d. CHARLES CREIGHTON, M.D. ILLUSTRATIONS OF UNCONSCIOUS MEMORY ^ IN DISEASE, including a Theory of Alteratives. Post 8vo, 6s. H. K. Lewis, 133 Gower Street, London. H. RADOLIFFE CROCKER, M.D. LOND., B.S., F.R.C.P. Physician for Diseases of the Skin in University College Hospital. niSEASES OF THE SKIN: THEIR DESCRIPTION, ^ PATHOLOGY, DIAGNOSIS, AND TREATMENT. Second edition, with Illustrations, 8vo, 24s. EDGAR M. CROOKSHANK, M.B. LOND., F.R.M.S. Professor of Bacteriology, King's College, London. I. MANUAL OF BACTERIOLOGY. Third Edition, col- ^'■*- oured plates and wood engravings, 8vo, 21s. II. ISTORY AND PATHOLOGY OF VACCINATION. 2 vols., royal 8vo, coloured plates, 20s. jtett. H HERBERT DAV1E8, M.D., F.R.C.P. Late Consulting Physician to the London Hospital, and formerly Fellow of Queen's College, Cambridge. T^HE MECHANISM OF THE CIRCULATION OF ^ THE BLOOD THROUGH ORGANICALLY DIS- EASED HEARTS. Edited by Arthur Templer Davies, B. A., M.D. Cantab., M.R.C.P. Crown 8vo, 3s. 6d. HENRY DAVIS, M.R.C.S. ENG. Teacher and Administrator of Aneesthetics at St. Mary's Hospital, and As- sistant Anaesthetist at the Dental Hospital ol London. UIDE TO THE ADMINISTRATION OF ANES- THETICS. Second edition, fcap. Svo, 2S. 6d. G A ALEXANDER S. FAULKNER. Surgeon-Major, Indian Medical Service. GUIDE TO THE PUBLIC MEDICAL SERVICES. Compiled from Official Sources. Demy Svo, 2s. [jfust Published. W. SOLTAU FENWICK, M.D., B.S. LOND. Member of the Koyal College of Physicians ; Assistant Physician to the Evelina Hospital for Sick Children, &c. 'THE DYSPEPSIA OF PHTHISIS: Its Varieties and ■*■ Treatment, including a Description of Certain Forms ot Dyspepsia associated with the Tubercular Diathesis. Demy Svo, 6s. [Noiv ready. 6 !N"ew and Recent Works published by J. MILNEB FOTHERGILL, M.D. I. INDIGESTION AND BILIOUSNESS. Second Edition, post 8vo, 7s. 6d. II. rOUT IN ITS PROTEAN ASPECTS. ^ Post 8vo, 7s. 6d. III. T'HE TOWN DWELLER: HIS NEEDS AND HIS -*- WANTS. Post 8vo, 3s. 6d. ERNEST FUCHS. Professor of Ophthalmology in the University of Vienna. TEXTBOOK OF OPHTHALMOLOGY. Translated from the Second German Edition by A. Duane, M.D., Assis- tant Surgeon, Ophthalmic and Aural Institute, New York. Large Svo, with igo Illustrations, 21s. SIR DOUGLAS GALTON, K.C.B., HON. D.C.L, LLD., F.R.S., Formerly, Secretary Railway Department Board of Trade ; Assistant Inspector- General of Fortifications, &c. HEALTHY HOSPITALS. OBSERVATIONS ON SOME POINTS CONNECTED WITH HOSPITAL CONSTRUCTION. With Illustrations, Svo, los. 6d. [Now ready. JOHN HENRY GARRETT, M.D. Licentiate in Sanitary Science and Diplomate in Public Health, Universities of Durham and Cambridge, &c. THE ACTION OF WATER ON LEAD : being an in- -^ quiry into the cause and mode of the action and its pre- vention. Crown Svo, 4s. 6d. ALFRED W. GERRARD, F.C.S. Examiner to the Pharmaceutical Society ; Teacher of Pharmacy and Demon- strator of Materia Medica to University College Hospital, etc. ULEMENTS OF MATERIA MEDICA AND PHAR- *^ MACY. With the New Official Remedies, 1S90. Crown Svo, Ss. 6d. JOHN GORHAM, M.R.G.S. Fellow of the Physical Society of Guy's Hospital, etc. TOOTH EXTRACTION : A manual of the proper mode of extracting teeth. Fourth edition, fcap, Svo, is. 6d. H. K. Lewis, 136 Gower Street, London. 7 GEORGE M. GOULD, A.M., M.D. Ophthalmic Surgeon to the Philadelphia Hospital, etc. I. A NEW MEDICAL DICTIONARY. A compact concise •**■ Vocabulary, convenient for reference, based on recent medical literature. Small 8vo, 12s. 6d. II. A POCKET MEDICAL DICTIONARY, giving the Pro- nunciation and Definition of about 12,000 of the Principal Words used in Medicine and the Collateral Sciences. 32mo, 4s. nett. LANDON C. GRAY, M.D. Professor of Nervous and Mental Diseases in the New York Polyclinic ; Visit- ing Physician to St. Mary's Hospital, &c. A TREATISE OF NERVOUS AND MENTAL DIS- ^ EASES FOR STUDENTS AND PRACTITIONERS OF MEDICINE. With 168 Illustrations, Svo, 21s. DR. JOSEF GRUBER. Professor of Otology in the University of Vienna, &c. ATEXT-BOOK OF THE DISEASES OF THE EAR. "• Translated from the second German edition, and Edited with additions by Edward Law, M.D., CM. Edin., M.R.C.S. Eng., Surgeon to the London Throat Hospital for Diseases of the Throat, Nose and Ear ; and Coleman Jewell, M.B. Lond., M.R.C.S. Eng. Second edition, with 165 Illustrations, and 70 coloured figures on 2 lithographic plates, royal Svo, 28s. S BERKELEY HILL, M.B. LOND., F.R.C.S. Professor of Clinical Surgery in University College, ARTHUR COOPER, LR.G.P., M.R.C.S. Surgeon to the Westminster General Dispensary, &c. I. YPHILIS AND LOCAL CONTAGIOUS DISOR- DERS. Second Edition, entirely re-written, royal Svo, iSs. T II. HE STUDENT'S MANUAL OF VENEREAL DIS- EASES. Fourth Edition, post Svo, 2s. 6d. 8 New and Recent Works published by BERKELEY HILL, M.B. LOND., F.R.C.S. Professor of Clinical Surgery in University College; Surgeon to University College Hospital, and to the Lock Hospital. THE ESSENTIALS OF BANDAGING. For Managing Fractures and Dislocations ; for administering Ether and Chloroform ; and for using other Surgical Apparatus. Sixth Edition, with Illustrations, fcap. 8vo, 5s. NORMAN KERR, M.D., F.L.S. President of the Society for the Study of Inebriety ; Consulting Physician, Dalrymple Home for Inebriates, etc. INEBRIETY: ITS ETIOLOGY, PATHOLOGY, ^ TREATMENT, AND JURISPRUDENCE. Third Edi- tion, 8vo, 21S. [Now ready. F. CHARLES LARKIN, F.R.C.S. ENG. Surgeon to the Stanley Hospital, AND RANDLE LEIGH, M.B., B.SC. LOND. Senior Demonstrator of Physiology in University College, Liverpool. fjUTLINES OF PRACTICAL PHYSIOLOGICAL ^ CHEMISTRY. Second Edition, with Illustrations, crown 8vo, 2S. 6d. iiett. J. WICKHAM LEGG, F.R.C.P. Formerly Assistant Physician to Saint Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the Medical School. A GUIDE TO THE EXAMINATION OF THE -^ URINE. Seventh Edition, edited and revised by H. Lewis Jones, M.D., Medical Officer in charge of the Electrical Department in St. Bartholomews' Hospital. With Illustrations, fcap. Svo, 3s. 6d. [Now ready. TEWIS'S POCKET MEDICAL VOCABULARY. Second Edition, 32mo, limp roan, 3s. 6d. WILLIAM THOMPSON LUSK, A.M., M.D. Professor of Obstetrics and Diseases of Women in the Bellevue Hospital Medical College, &c. TTHE SCIENCE AND ART OF MIDWIFERY. Fourth Edition, rewritten, with numerous Illustrations, 8vo, i8s. [^ust published. H. K. Lewis, 136 G-ower Street, London. 9 LElfiTIS'S PRACTICAL SERIES. In Crown ?)Vo Volumes, with Illustrations. DISEASES OF THE NOSE AND THROAT. By F. de HAVILLAND HALL, M.D., F.R.C.P. Lond., Physician to Out-patients, and in Charge of the Throat Department at the Westminster Hospital, &c. IDS. 6d. [Now ready. PUBLIC HEALTH LABORATORY WORK. By H. R. KENWOOD, M.B., D.P.H., F.C.S., Instructor in the Hy- gienic Laboratory, University College, London, &c. los. 6d. MEDICAL MICROSCOPY. By FRANK J. WETHERED, M.D., M.R.C.P., Medical Registrar to the Middlesex Hospital, gs. MEDICAL ELECTRICITY. By W. E. STEAVENSON, M.D., and H. LEWIS JONES, M.A., M.D., M.R.C.P., Medical Officer in charge of the Electrical Department in St. Bartholomew's Hospital, gs. HYGIENE AND PUBLIC HEALTH. By LOUIS C. PARKES, M.D., D.P.H. Lond. Univ., Lecturer on Public Health at St. George's Hospital, etc. Third Edition, los. 6d. MANUAL OF OPHTHALMIC PRACTICE. By C. HIGGENS, F.R.C.S , Lecturer on Ophthalmology at Guy's Hos- pital Medical School, &c. Illustrations, crown 8vo, 6s, A PRACTICAL TEXTBOOK OF THE DISEASES OF WOMEN. By ARTHUR H. N. LEWERS, M.D. Lond., M.R.C.P. Lond., Obstetric Physician to the London Hospital ; etc. Fourth Edi- tion, los. 6d. ANESTHETICS, THEIR USES AND ADMINISTRATION. By DUDLEY W. BUXTON, M.D., B.S., M.R.C.P., Administrator of Anesthetics at University College Hospital, etc. Second Edition, 5s. TREATMENT OF DISEASE IN CHILDREN. By ANGEL MONEY, M.D., F.R.C.P., late Assistant Physician to the Hospital for Sick Children, Second Edition, los. 6d. ON FEVERS: THEIR HISTORY, ETIOLOGY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. By ALEXANDER COLLIE, M.D. (Aberdeen). 8s. 6d. HANDBOOK OF DISEASES OF THE EAR. By URBAN PRITCHARD, M.D. (Edin.), F.R.C.S , Professor of Aural Surgery at King's College, London, etc. Second Edition, 5s. A PRACTICAL TREATISE ON DISEASES OF THE KID- NEYS AND URINARY DERANGEMENTS. By C. H. RALFE, M.A., M.D.Cantab., F.R.C.P. Physician to the London Hospital. los. 6d. DENTAL SURGERY FOR GENERAL PRACTITIONERS AND STUDENTS OF MEDICINE. By ASHLEY W. BARRETT, M.B. Lond , M.R.C.S., L.D.S., Dental Surgeon to the London Hospital. Second Edition, 3s. 6d. BODILY DEFORMITIES AND THEIR TREATMENT. By H. A. REEVES, I'.R.C.S. Ed., Senior Assistant Surgeon and Teacher of Practical Surgery at the London Hospital. Ss. 6d. 10 New and Becent Works published by JEFFERY A. MARSTON, M.D., C.B., F.R.C.S., M.R.C.P. LOND. Surgeon General Medical Staff (Retired). MOTES ON TYPHOID FEVER: Tropical Life and ■*■' its Sequelae. Crown 8vo, 3s. 6d. WILLIAM MARTINDALE, F.C.S. AND W. WYNN WESTCOTT, M.B. LOND. 'THE EXTRA PHARMACOPCEIA with the additions ■'• introduced into the British Pharmacopoeia 1885 and i8go ; and Medical References, and a Therapeutic Index of Diseases and Symptoms. Seventh Edition, limp roan, med. 24mo, 7s. 6d. A. STANFORD MORTON, M.B., F.R.C.S. ENG. Assistant Surgeon to the Moorfields Ophthalmic Hospital, &c. DEFRACTION OF THE EYE: Its Diagnosis, and the *^ Correction of its Errors, with Chapter on Keratoscopy. Fifth Edition, small 8vo, 3s. 6d. C. W. MANSELL MOULLIN, M.A., M.D. OXON., F.R.C.S. ENG. Surgeon and Lecturer on Physiology at the London Hospital, &c. I. CPRAINS; THEIR CONSEQUENCES AND TREAT- '^ ME NT. Second Edition, crown 8vo, 4s. 6d. 11. ENLARGEMENT OF THE PROSTATE: its Treat- ment and Radical Cure. With plates, 8vo, 6s. [Now ready. I WILLIAM MURRAY, M.D., F.R.C.P. LOND. Consulting Physician to the Children's Hospital, Newcastle-on-Tyne, &c. LLUSTRATIONS OF THE INDUCTIVE METHOD IN MEDICINE. Crown 8vo, 3s. 6d. WILLIAM MURRELL, M.D., F.R.C.P. Lecturer on Materia Medica and Therapeutics at Westminster Hospital. MASSOTHERAPEUTICS'; OR MASSAGE AS A MODE OF TREATMENT. Fifth Edition, crown 8vo, 4s. 6d. II. WHAT TO DO IN CASES OF POISONING. Seventh Edition, royal 32mo, 3s. 6d. [Now ready. H. K. Lewis, 136 Gower Street, London. 11 G. OLIVER, M.D., F.R.C.P. I. pULSE-GAUGING : A Clinical Study of Radial Measure- * ment and Pulse Pressure. With Illustrations, fcap. 8vo. [Nearly ready. II. QN BEDSIDE URINE TESTING : a Clinical Guide to the Observation of Urine in the course of Work. Fourth Edition, fcap. 8vo, 3s. 6d. in. THE HARROGATE WATERS : Data Chemical and ■* Therapeutical, with notes on the Climate of Harrogate. Crown 8vo, with Map of the Wells, 3s. 6d. WILLIAM OSLER, M.D., F.R.C.P. LOND. President of the Association of American Physicians ; Professor of Medicine, Johns Hopkins University, and Physician-in-Chief Johns Hopkins Hospital, Baltimore. QN CHOREA AND COREIFORM AFFECTIONS. ^ Large 8vo, 5s. [Now ready. R. DOUGLAS POWELL, M.D., F.R.C.P., Physician Extra-ordinary to H.M. the Queen ; Physician to the Middlesex Hospital; Consulting Physician to the Hospital for Consumption and Diseases of the Chest at Brompton. rvISEASES OF THE LUNGS AND PLEURA IN- ^ CLUDING CONSUMPTION. Fourth Edition, with coloured plates and wood-engravings, 8vo, i8s. [Now ready. DR. THEODOR PUSCHMANN. Public Professor in Ordinary at the University of Vienna. HISTORY OF MEDICAL EDUCATION FROM THE MOST REMOTE TO THE MOST RECENT TIMES. Translated by Evan H. Hare, M.A. (Oxon.), F.R.C.S. (Eng.), F.S.A. Demy 8vo, 21s. FRANCIS H. RANKIN, M.D. President of the Newport Medical Society. UYGIENE OF CHILDHOOD: Suggestions for the care *^ of children after the period of infancy to the completion of puberty. Crown 8vo, 3s. 12 IsTew and Becent Works published by SAMUEL RIDEAL, D.SC. (LOND.), F.I.C., F.C.S., F.G.8. Fellow of University College, London. I. PRACTICAL ORGANIC CHEMISTRY. The detection ^ and properties of some of the more important organic com- pounds. i2mo, 2S. 6d. II. PRACTICAL CHEMISTRY FOR MEDICAL STU- DENTS, Required at the First Examination of the Conjoint Examining Board in England. Fcap. 8vo, 2S. J. JAMES RIDGE, M.D., B.S., B.A., B.SC. LOND. Medical Officer of Health, Enfield. A LCOHOL AND PUBLIC HEALTH. Second Edition, Crown 8vo, 25. \_Now ready. SYDNEY RINGER, M.D., F.R.S. Professor of the Principles and Practice of Medicine in University College, Physician to, and Professor of Clinical Medicine in. University College Hospital. A HANDBOOK OF THERAPEUTICS. Twelfth Edition, ""■ revised, 8vo, 15s. FREDERICK T. ROBERTS, M.D., B.SC, F.R.O.P. Professor of Therapeutics in University College ; Physician to University College Hospital, &c. I, A HANDBOOK OF THE THEORY AND PRACTICE ^ OF MEDICINE. Ninth Edition, with Illustrations, large 8vo, 21s. \Now ready. II. nPHE OFFICINAL MATERIA MEDICA. Second Edit., •*• entirely rewritten in accordance with the latest British Pharmacopoeia, with the Additions made in i8go, fcap. 8vo, 7s. 6d. ROBSON ROOSE, M.D., F.R.O.P. EDIN. I. GOUT, AND ITS RELATIONS TO DISEASES OF THE LIVER AND KIDNEYS. Seventh Edition, crown 8vo, 4s. 6d. II. NERVE PROSTRATION AND OTHER FUNC- TIONAL DISORDERS OF DAILY LIFE. Second Edition, demy 8vo, i8s. H. K. Lewis, 136 Gower Street, London. 13 WILLIAM ROSE, B.8., M.B. LOND., F.R.C.S. Professor of Surgery in King's College, London, and Surgeon to King's College Hospital, &c. QN HARELIP AND CLEFT PALATE. Demy 8vo, with Illustrations, 6s. BERNARD ROTH, F.R.C.S. Fellow of the Medical Society of London. HE TREATMENT OF LATERAL CURVATURE OF THE SPINE. Demy 8vo, with Photographic and other Illustrations, 5s. T DR. C. SCHIMMELBUSCH. Privat-docent and Assistant Surgeon in Prof. v. Bergmann's University Clinic at Berlin. nPHE ASEPTIC TREATMENT OF WOUNDS. ^ With a Preface by Professor Dr. E. von Bergmann. Trans- lated from the Second German Edition by A. T. Rake, M.B., B.S. LoND., F.R.C.S. Eng., Registrar and Pathologist to the East London Hospital for Children. With Illustrations, crown 8vo. [Nearly ready. ALEXANDER J. C. SKENE, M.D. Professor of Gynaecology in the Long Island College Hospital, Brooklyn TiREATISE ON THE DISEASES OF WOMEN. Second Edition, with 251 engravings and g chromo-litho- graphs, medium Bvo, 28s. JOHN KENT SPENDER, M.D. LOND. Physician to the Royal Mineral Water Hospital, Bath. THE EARLY SYMPTOMS AND THE EARLY ■*■ TREATMENT OF OSTEO-ARTHRITIS, commonly called Rheumatoid Arthritis. With special reference to the Bath Thermal Waters. Small 8vo, 2S. 6d. LEWIS A. STIMSON, B.A., M.D. Professor of Clinical Surgery in the Medical Faculty of the University of the City of New York, etc. A MANUAL OF OPERATIVE SURGERY. With ■"• three hundred and forty-two Illustrations. Second Edition, post 8vo, los. 6d. ADOLF STRUMPELL. Professor and Director of the Medical Clinique at Erlangen. A TEXT-BOOK OF MEDICINE FOR STUDENTS '^ AND PRACTITIONERS. Second edition translated from the German by Dr. H. F. Vickery and Dr. P. C. Knapp, with Editorial Notes by Dr. F. C. Shattuck, Visiting Physician to the Massachusetts General Hospital, &c. Complete in one large vol., with 119 Illustrations, imp. 8vo, 28s. 14 New and Recent Works published by JUKES DE STYRAP, M.K.Q.C.P. Physician-Extraordinary, late Physician in Ordinary to the Salop Infirmary Consulting Physician to the vSouth Salop and Montgomeryshire Infirmaries, etc. I. nPHE YOUNG PRACTITIONER: With practical hints "*■ and instructive suggestions, as subsidiary aids, for his guid- ance on entering into private practice. Demy 8vo, 7s. 6d. nett, II. A CODE OF MEDICAL ETHICS: With general and •"■ special rules for the guidance of the faculty and the public in the complex relations of professional life. Third edition, demy 8vo, 3s. nett. III. lyTEDICO-CHIRURGICAL TARIFFS. Fourth edition, revised and enlarged, fcap. 4to, 2s. nett. IV. npHE YOUNG PRACTITIONER: HIS CODE AND -*■ TARIFF. Being the above three works in one volume. Demy 8vo, los. 6d. nett. C. W. SUCKLING, M.D. LOND., M.R.C.P. Professor of Materia Medicaand Therapeutics at the Queen's College, Physician to the Queen's Hospital, Birmingham, etc. I. ON THE DIAGNOSIS OF DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES. With Illus- trations, crown 8vo, 8s. 6d. II. ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. Crown 8vo, 7s. 6d. JOHN BLAND SUTTON, F.R.C.S. Lecturer on Comparative Anatomy, and Assistant Surgeon to the Middlesex Hospital. TIGAMENTS: THEIR NATURE AND MORPHO- "'"' LOGY. Wood engravings, post 8vo, 4s. 6d. HENRY R. SWANZY, A.M., M.B., F.R.C.S.I. Examiner in Ophthalmic Surgery in the Royal University of Ireland Surgeon to the National Eye and Ear Infirmary, Dublin, etc. HANDBOOK OF DISEASES OF THE EYE AND THEIR TREATMENT. Fifth Edition, Illustrated with Wood Engravings, Colour Tests, etc., large post 8vo. [jfust ready. A H. K. Lewis, 136 Gower Street, London. 15 ALBERT TAYLOR. Associate Sanitary Institute ; Chief Sanitary Inspector to the Vestry ot St. George, Hanover Square, etc. 'THE SANITARY INSPECTOR'S HANDBOOK. -*• Cr. 8vo, with Illustrations, 5s. [_Just published. A. J. WALL, M.D. LOND., F.R.C.S. ENG. Medical Staff of H.M. Indian Army (Retired List). A STATIC CHOLERA : ITS HISTORY, PATHOLOGY ^ AND MODERN TREATMENT. Demy 8vo, 6s. [Now ready. E. G. WHITTLE, M.D. LOND., F.R.C.S. ENG. Senior Surgeon to the Royal Alexandra Hospital, for Sick Children, Brighton. ONGESTIVE NEURASTHENIA, OR INSOMNIA AND NERVE DEPRESSION. Crown 8vo, 3s. 6d. C JOHN WILLIAMS, M.D., F.R.C.P. Professor of Midwifery in University College, London, &c. PANCER OF THE UTERUS: BEING THE HAR- ^ VEIAN LECTURES FOR 1886. Illustrated with Litho- graphic Plates, royal 8vo, los. 6d. E. T. WILSON, M.B. OXON., F.R.C.P. LOND. Physician to the Cheltenham General Hospital, &c, niSINFECTANTS AND ANTISEPTICS: HOW TO ^ USE THEM. In Packets of one doz. price is., by post IS. id. IS^ust tlioroiighly revised. BERTRAM 0. A. WINDLE, M.A., M.D. DUBL Professor of Anatomy in the Queen's College, Birmingham ; Examiner in Anatomy in the Universities of Cambridge and Durham. A HANDBOOK OF SURFACE ANATOMY AND "■ LANDMARKS. Illustrations, post 8vo, 3s. 5d. DAVID YOUNG, M.C., M.B., M.D. Fellow of, and late Examiner in Midwifery to, the University of Bombay, etc. DOME IN WINTER AND THE TUSCAN HILLS ^ IN SUMMER. A Contribution to the Climate of Italy. Small 8vo, 6s. OSWALD ZIEMSSEN, M.D. Knight of the Iron Cross, and of the Prussian Order of the Crown. THE TREATMENT OF CONSTITUTIONAL SYPHI- ■*■ LIS. Post 8vo, 3s. 6d. 16 H. K. Lewis's Pubiieations. ] EWIS'S DIET CHARTS. A Suggestive set of Diet Tables for '-^ the use of Physicians, for handing to Patients after Con- sultation, modified to suit Individual Requirements ; for Albuminuria, Alcoholism, Anaemia and Debility, Constipa- tion, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout, Nervous Diseases, Obesity, Phthisis, Rheumatism (chronic) ; with Blank Chart for other diseases. 6s. 6d. per packet of loo charts, by post, 6s. lojd. T EWIS'S FOUR-HOUR TEMPERATURE CHART. This form has been drawn up to meet the requirements of a chart on which the temperature and other observations can be re- corded at intervals of four hours. They will be found most convenient in hospital and private practice. Each chart will last a week. Prices, 20, is.; 50, 2s.; 100, 3s. 6d. ; 500, 14s. ; 1000, 25s. fHART FOR RECORDING THE EXAMINATION OF URINE. These Charts are designed for the use of medical men, ana- lysts and others making examinations of the urine of pa- tients, and afford a very ready and convenient method of recording the results of the examination. Prices, 10, is. ; 100, 7s. 6d.; 250, 15s.; 500, 25s. ; 1000, 40s. PLINICAL CHARTS FOR TEMPERATURE OBSERVATIONS, ETC ^ Arranged by W. Rigden, M.R.C.S. Price is. per doz., 7s. per 100, 15s. per 250, 28s. per 500, 50s. per icoo. Each Chart is arranged for four weeks, and is ruled at the back for making notes of cases ; they are convenient in size, and are suitable both for hospital and private cases. T EWIS'S CLINICAL CHART, SPECIALLY DESIGNED FOR USE -^ WITH THE VISITING LIST. This Temperature Chart is arranged for four weeks, and measures 6X3 inches. 30s. per 1000, i6s. 6d. per 500, 3s. 6d. per 100, IS. per 25, 6d per 12. [ EWIS'S NURSING CHART. 25s. per 1000, 14s. per 500, 3s. 6d. . per 100, 2s. per 50, or is. per 20. *^* Mr. Lewis is in constant communication with the leading publishing firms in America and has transactions with them for the sale of his publications in that country. Advantageous arrangements are made in the interests of Authors for the publishing of their works in the United States. Mr. Lewis's publications can be procured of any Bookseller in any part of the world. Complete Catalogue of Publications post free on application. Printed by H K. Lewis, Gower Street, London, W.C. ..-.^.fmtt^K'iei. ^mmm'rm-^m^:'' ivi •^^v^r