COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD «^,. « HX641 27761 RC74.B781890 The pulse RECAP t . . ■■■■• ....;IVW. ■ V . • i^, Tt >!-'- • ''.AT' .-■/ - .,»'\- ■' .Aj-.-:." ^rj:^'. '. 5" u' CLINICAL :SIANUALS FOi: Pkactitioners and Stulent8 OF Medicine. THE PITTSE. BY W. H. BEOADBENT, M.D., I'-nLLOW OF THE ROYAL COLLKGE OF PHYSICIANS ; SENIOR THYSUIAX TO, AND LECTURER ON CLINICAL MEDICINE IN THE MEDICAL SCHOOL OF ST. MARY's HOSPITAL; CONSULTING PHVSICLVN TO THE LONDON FEVER HOSPITAL; LATE PRESIDENT OF THE CLINICAL, MEDICAL AND HARVEIAN SOCIETIES. ILLUSTllATKI) ll'lTII 59 SFHYGMOCrRAPHIC TRACIXOS. Cassell A: Company, limited LONDON, PARIS, NEW YORK & MELBOUIiNE. 1890. [all i:Iv1:its i:eseuvei>.] VI 'BIZ P E E r A C E . This little hook is, for tlie most part, a reproduction of the Croonian Lectures on tlie Pulse delivered before the College of Physicians in 1887, with some anipli- tications and additions — with the addition, in par- ticular, of a chapter on the Sounds of the Heart, which must always be taken into consideration if the full significance of variations in the character of the p\dse is to be estimated. More, probably, will be expected than is here found with regard to the pulse and its indications in different forms and at various stages of acute disease. But such indications cannot be laid down in words with the precision which would be required to make them useful. The aid furnished in the following pages towards an appreciation of the variations of the pulse in the course of acute disease will consist in directing separate attention to other points than mere frequency and force — the size of the artery and the character and duration of the individual beats and intervals by which the experience and observation, which are absolutely essential, will be guided and rendered more fruitful. An apology is necessary for the absence of reference to and due acknowledgment of the work of others who have contributed to our knowledge of vi The Pulse. the pulse. Had this l)eeii attempted, the production ot' this book, small and imperfect as it is, would have heeu impossible ; and it may be said that while no opportunity of gaining knowledge or insight Ijy reading has been neglected, the subject has been worked out by personal research and observation. I should be wanting in gratitude if I did not take this opportunity of acknowledging my indebted- ness to my late teacher and colleague. Dr. Francis 8ibson, under whom, more than thirty years ago, I entered upon the serious study of the problems of the circulation. His patient investigation and I'e- investigation of every point, experimental or clinical, his unwearied efforts for the attainment of minute accuracy, his complete subordination of theory and preconceived opinion to observation, were a lesson to me then, and have remained impressed on my mind ever since as an example which has had a determining influence on my thought and work. W. H. Bkoadbext. CONTENTS. I.— HiSTOKV 1 IG 39 53. 75 107 12i II.— The Pllsk, its Pkodcctiox and Sigxiucance III.— Mode ok Feeling the Pui.se .... IV,— The HExVRT-sounds in relation to the Pllse v.— Increased Frequency ok the Pulsk Vf.— Infrequent Pulse VII.— Intermittent and Irregular Pulse. VIIL— The Pulse as influenced by Variations in Arterio-Carillary Kesistance~-Lo\v AR'JE- rial Tension 132 IX.— High Arterial Tension 117 X.— The Pulse in Acute Disease . . . . . 187 XI.— The Pulse in Valvular Disease of the Heart . 199 XII.— The Pulse in Structural Disease ok the Heart 220 XIII.— The Pulse in Aneurism ....... 227 XIV.— The Pulse in Kidney Disease ..... 236 XV.— Intermittent Albuminuria 265 XVL— The Pulse in Affections of the Nervous System 272 Index . , 310 The Pulse. CHAPTER I. HISTORY. There can have been no true comprehension of the significance of the pulse, or intelligent appreciation of the relation between its A^ariations and the physio- logical or pathological conditions associated therewith, until the discovery of the circulation of the blood by Harvey, which, it will be remembered, was only announced in 1628. It was long after this, indeed, before the physiology of the circulation began to influence the ideas of physicians and to enter into the consideration of disease ; and anything like an adequate knowledge of the physics of the circulation, of the rate of movement of the blood, or of the varying degree of pressure within the vessels, and of the effects of such pressure, is of quite modern acquisition Many of the indications to be obtained from the pulse, however, are matters of simple observation, and are in a great measure independent of a knowledge of the physiology of the circulation ; the frequency and force of the pulse in fever, for exauiple, Avere perfectly well knoAvn, and their indications as to the actual condition of the sufferer and as to the probable course and issue of the disease Avere Avell understood, Avhen the most erroneous notions of the cause of the arterial beat Avere entertained. It may be doubted, indeed, Avhether OA'en noAv the medical man consciously refers to the movement of the blood Avhile estimating the B— 27 2 The Pulse. [Chap. i. significance of varying states of the pulse, and does not rather infer directly from the pulse the severity of the fever, or the degree of general weakness, or what not. For this reason, therefore, and because it is always interesting to trace the course of ideas and the progress of knowledge in any subject, the history of the pulse will be briefly followed ; and it may be stated at once that, although I had devoted much time to this many years since, I here take advantage of the complete and admirable account given by Dr. Cli. Ozanam in his recent work."* The earliest idea of the pulse appears to have been that the arteries were filled, not with blood, but with a vital air or spirit, the movements of which, independent in every part of the body and inde- pendent of the heart, gave rise to the pulsations. The pulse in the temples, for example, was supposed to be independent of, and to have a difi'erent signification from, that at the wrist. The veins were believed to carry the blood into every part of the body, and to have their origin in the liver, which was the great formative source of the blood. It was then discovered that the pulse was every- Avliere synchronous, and later that it coincided with the beat of the heart, and was dependent upon it. Now, also, it was the dilatation of the heart and arteries which drew the vital air into all parts of the body, and no longer the throbbing of the vital spirit in the vessels which gave rise to the jailsations. The Iieart was not supposed to contain blood any more than the arteries, and the septum between the ven- tricles was believed to 1)e perforated. Galen's great discovery was that the heart and arteries contained blood. He did not remove the errors with regaid to the perforation of the inter- ventricular septum, or with regard to the office of * " La Circulation et le Pouls" (Baillierc et Fils, 188G). Chap. I.] History. 3 the liver as the manufactory of blood, and of the veins as its distributors. Both in veins and arteries there was supposed to be a flux and reflux, and the dilata- tion of the heart and of the vessels was still supposed to be the active phase of their function, causing the pulsations and drawing the blood into them. This view prevailed from the time of Galen, a.d. 164, to 1628, when Harvey showed not only that the blood circulated, but that the ventricular systole supplied the force which drov^e the blood through the arteries and caused the pulsation felt in them. The distinction between the arteries and veins was made before the time of Hippocrates by Diogenes of Apollonia and Euryphon, but it is only in the writings of Hippocrates (400 B.C.) and of his school of successors that reference to the pulse under the names of G!^vy\ioc, and TraXfiog becomes frequent and definite. It appears to have been noted in the arteries generally, but it is most frequently mentioned as observed in the temples, where ib was considered to be an important indication of fever. Hippocrates was the originator of the idea that the arteries did not contain blood during life, since they were always found empty after death in animals killed for sacrifice, and that they were in communication with the trachea. His observations, however, with regard to the pulse are entirely clinical and practical, and various features of the pulse are recognised and named. Aristotle (384 B.C.) gave its name to the aorta, and ascertained that the pulse was due to the move- ment of the blood, and was synchronous throughout the body. Praxagoras and his disciple Herophilus (-344 B.C.), the latter of whom gave his name to the occipital confluence of the cerebral sinuses (torcularHerophili), treated more fully of the pulse, recognising the syn- chronism of the pulse and cardiac impulse. 4 The Pulse. [Chap. i. Heropliilus named the jDulmonary artery the arterial ^•ein, and the puhnonary veins venous arteries. The pulse he considered to be communicated from the heart to the arteries, but he believed that there was an active dilatation of these vessels which drew in vital air. He described four qualities in the pulse, size_, frequency, force, and rhythm, and gave special at- tention to the rhythm of the arterial pulsation, by which was meant the relative duration of the wave and the interval, not the regularity or frequency of the beats. This he compared to musical time and to the measures of verse. It is interesting to note this early attention to the character of the pulse as dis- tinguished from its force and frequency. Erasistratus, who lived about 280 B.C., discovered the valves of the heart and described their action ; he founded at Smyrna a school of followers, which flourished till the time of Galen. In the flrst century of the Christian era Archi- genes wrote a treatise on the pulse, which is often referred to by Galen in a controversial spirit, with the efiect of exciting regret that tlie book has been lost. Rufus of Ephesus, who lived a little later, also wrote a treatise on the pulse, which, after being lost, was discovered and translated l>y Daremberg in 1845. His description of the different characters of the jDulse leaves little to be added at the present day. It is frequent or infrequent, as regards time or rate ; quick or slow, as regards the individual pulsations ; strong or weak, as regards intensity of beat ; hard or soft, as regards the body of the artery. The intermittent, dicrotous, vibratory (foiinicans), and vermicular pulses are described and named, and, under the term P caprizans — which was already adopted by Heropliilus, but apparently applied dif- ferently by different writers — is described a pulse with a secondary beat, different from that of dicrotism, Chap. I.] History. 5 which it is not easy to identif j ; while the Pulsus myouros appears to be one in which the respiratory variations of pressure are recognisable by the finger. Galen, whose writings dominated the entire art of medicine for fourteen centuries, was born in A.D. 131 at Pergamos, and went to Home in 164. His in- dustry was extraordinary, and besides remarkable intellectual faculties, he must have possessed great force of character and much enthusiasm. He estab- lished the facts that the arteries did not contain air, but blood, and that there was no communication between them and the trachea, as had been taken for granted. He showed also that there must be some communication between the arteries and veins at their ultimate distribution, since, on bleeding an animal to death from an artery, the veins as well as the arteries were found to have been drained of blood. He sup- posed, however, that l)lood traversed the intra- ventricular septum from the right to the left side of the heart, and he considered the diastole of the heart and the pulsatile distension of the arteries to be corresponding phenomena, and to constitute the active phase of their action. The left ventricle, according to Galen,- attracted the blood vitalised by the pneuma, which had entered it in the lungs, as a magnet attracts iron, and then distributed it by the aorta, the arteries again drawing it in by dilating. He wrote voluminously on the pulse, as will be seen by an enumeration of his works on this subject : 1. '' LiLollus do Pulsihns ad Tirones." 2. " Libri Qnatuor do Pulsuura Differentiis." ?). " Libri Quatuor do J^ulsibiTS Dignoscendis." 4. " Libri Quatuor do Causis Pulsuum." 5. "Libri Quatuor do Prresagitione ex Pulsibus.'' 6. " Synopsis Soxdeeim Librorum do Pulsibus." 7. " Pulsuum Compendium." The general effect of his writings, however, is to 6 The Pulse. [Chap. i. confuse the essential features of the important varia- tions of the pulse by overwhelming them in minute distinctions of no practical significance. Indeed, his point of departure is not observation, but theory, and the varieties are not described from nature, but de- duced from axioms. It is not necessary to follow Galen in the enume- ration of the varieties of pulse which he names. His account of them is characterised by extreme verbal subtlety, and one cannot wonder that his terms furnished matter for inexhaustible discussions by his followers in successive generations. It is interesting, however, to find Galen noting carefully the relative duration of the periods of dis- tension and relaxation of the arteries, which he does under the head of Pauses. It will not be without interest, or indeed instruc- tion, even in the present day, to reproduce an example of Galen's writing on the pulse, and a translation of a part of his treatise for beginners is here given. GALEN ON THE PULSE. ELEMENTARY FACTS. Chapter 1. — I shall here sj^eak nierely of the elementary facts concerning- the pulse, as I have treated of the whole suhject elsewhere. The heart and all the arteries pulsate with the same rhythm, so that from one you can Judge of all ; not that it is possible to feel the pulsations of all to the same extent, for those in the fleshy i)ortions are much less distinct than those in the more superficial areas. For yoii could not perceive the pulsations of arteries which are thickly enveloped in flc^sh, or which lie within bones, or which have other bodies in front of them in an animal in natural health. But when the bodj' is wasted away, the pulsations felt in the artery that lies along the vertebral column frequently indicate the throbbing of the abdomen, and arteries in the limbs previously indistinguishable have been felt. But in all cases the pulsations of the arteries in the soles of Chap. I.] Galen on the Fulsk. , 7 the feet and the wrist arc easily felt. Not so distinct, yet Ity no means indistino-uishable, are the pulsations of the arteries behind the ears and in the arms, and others that do not lie deep in the flesh. But you could not find any arteries more convenient or better or more suitable for the pulse than those in the wrists, for they are easily visible, as there is little flesh over them, and it is not necessary to strij) any part of the body of clothing for them, as is necessary with miny others, and they run in a straight course ; and this is of no small help to the accuracy of diagnosis. Chai'Tek 2. — The artery will seem to the touch to be dis- tended in every dimension. There are three dimensions to every body — length, depth, and breadth.* In an animal in a normal state of health you will find the ai'tery quite moderately distended ; but in abnonnal conditions sometimes the tension is too low, sometimes too great in every dimension. Now you must remcMuber what a normal pulse is like, and if you find an abnormal j)ulse of excessive breadth, you should term it " broad," and if of excessive length " long," and if of excessive depth " deep," and in like manner the opposite of these " narrow," " short," and "shallow." And a pulse that is in all these dimensions abnormally diminished is termed "small," and one that is abnormally augmented "kn^ge." Such, then, are the varieties of pulse as far as dimension goes. Chapter 3. — As regards special characteristics, there is swiftness and slowness. In the former case the movement is free and unrestrained, in the latter case enfeebled. These con- ditions you must judge by comparison with the normal. The strength of the jiulse or the revei'se is determined by the force with which it repels the touch ; if it re})els violently it is strong, if weakly the reverse. And there are variations in the softness or hardness of the arterial coat ; it is soft when the ai'tery appears, so to speak, flesh-like to the touch ; hard when it seems dry and hard, like leather. So then you notice differences in pulses such as this at once, as you observe the movement of the artery,- though they * In his larger treatise Galen enumerates all the possible per- mutations and combinations of these dimensions in the three degrees of large, moderate, and small, to the number of twenty- seven, as varieties of the pulse — an over-refinement on purely theoretical or transcendental grounds which led to extreme con- fusion. Deserting the i)ath of observation, he did not see that a cylindrical tube would expand equally in all directions, and that there could not be any difference between its breadth and depth. 8 The Pulse. [Chap. i. are not, however, specially characteristic of it, as were the three before mentioned. For the speed or slowness of the pulse depends, we said, on the rate of movement, and the strength or feebleness on the character of the pulsation, and the largeness or smallness on the length of the diastole. . But the diastole is not devoid of movement, and there is no need of movement in a soft or hard body for it to be such. These four variations in pulses you will find according to the beat. Chapter 4. — Besides, there is a fifth variety depending on the pauses between the beats. For such is the term usually given by medical men to the space of time between the Ijeats, within which the artery expands and contracts. Moreover, I think that l)eginners should practise themselves as though the systole could not be felt. The two terms I shall use are the pulsation and the pause. By the pulsation I mean the feeling the artery strike against the finger as it is expanded ; by the pause I mean the period of quiescence between the pulsations, according to the length of which normal pulses are rapid, slow, or medium. These you will determine by the length of the pause. For a pulse is rapid when the interval of quiescence is short, slow when the interval is long. You may call it indifl:'erently quiescence or pause between the pulsations or systole.* Chapteh 5. — Regularity and irregularity occur in the above- mentioned variations. By regularity is meant an even and unbroken series. For example, when the dimension of a series of pulsations continues the same, the pulse would be termed regular in size ; and if the rate were unaltered, regular in rate. The same holds good in speaking of violence, feebleness, and frequency of pulse. Irregularity means the destruction of even rhythm in whatever varieties of pulse it occurs. For one may be irregular in size, another in rate, another in violence, feebleness, and frequency, and so on. Chapteh G. — Sometimes, too, when a number of beats are definite and regular, an uneven pulsation occurs in the midst of the even ones ; and tliis may ha])pen in various ways. For there may be three regular beats, then the fourth irregular, * It is the individual pulsation which is here spoken of, not the ])ulse rate or freipioncy. In his larger treatise ({alen describes two pauses — one after the diastole of the vessel, the other in systole ; and it must l)e borne in mind that the diastole or pul- sation was believed to be a more or less sudden exjiansion of the artery, and not, as we know it to be, a distension of the vessel by blood. Chap. I.] Galen on the Pulse. 9 and so on continuously ; or there may be four regular and the fifth irregular. The same thing may occur with any other number, for frequently the sixth is irregular after five regular beats, or the seventh after six. So, then, in these cases, a noi'mal rhj-thm is not preserved, and so the pulse is not normal ; and yet, as a certain fixed order of beat is maintained, it is regular. For though the number is always constant, yet an irregular beat occurring in the midst of regular beats destroys the normal rhythm ; but the recurring cycle insures a certain regularity. But if no period recurs, such a pulse is termed ii-regular. Chapter 7. — And abnormality may occur even in a single pulsation, owing to the different relations which the parts of the artery bear to one another in rest and in movement, and owing to the special movement of each separate pulsation. When the parts are at rest the abnormality consists in the artery seeming to have been drawn out of position upwards and downwards, and forwards and backwards, and to the right and to the left ; but when in movement from the movement of the parts being too quick or too slow, or too soon or too late, too violent or too feeble, too long in diu'ation or too short, being in perpetual movement or not moving at all. But in cases of irregular flow, when it is at first too swift and afterwards too slow, and again when it is first too slow and then too swift, and in the same wa}^ with regard to violence and feebleness, and diminutiveness and excessive size, when the flow is not diWded into two periods only, but into more, as far as can be discerned by the touch. Such, then, are the irregularities occurring in each separate pulsation. Chapter 8. — The pulses are arranged, as far as it is possible for one to be taken with another, one with many, many with many, and some of them have a name ; for instance, the worm- like (vermiform), the ant-like (formicans), and the hectic pulses. The worm-like pulse is a condition in which it seems as though a worm were creeping along the artery which is in waves of pulsation, the whole of the artery not being distended at the same time. If this takes place, accompanied by a short relaxa- tion, it is called worm-like ; but if with a long interval merely wave-like. The worm-like pulse, too, is readily seen to be feeble and beating quickly. But the pulse that has sunk to the extreme limits of feebleness, frequency, and smalluess is called ant -like, and this, though it appears to be swift, is not really so. So, too, the pulse is termed hectic, just as we apply the term to a fever, when it does not vary greatly, but remains much the same continuously, being entangled and never lo The Pulse. [Chap. i. getting free, as the whole condition is one of disease in fevers and pulses of this sort. I think I have said enough for beginners on the subject of varieties of pulses. For if any one wishes for more accurate knowledge, there is the entire book on Differences of Pulses written by me. So I need not here speak of a full and empty pulse or of rhythms ; for in my book I have given an acciu'ate account of them, and the subject is rather difficult for beginners. Let me then now sum up shortly what I have been speaking of, and then proceed to the subject next in order. An excessive pulse is that which occurs when the artery is greatly distended in length, depth, and breadth ; a pulse is long when the artery is distended only in length, broad when distended in breadth, deep when in depth. A violent pulse is One that strikes strongly against the finger ; a soft gentle pulse occurs when the coat of the ai-tery is soft. The pulse is rapid when the arterj' is distended in a short space of time ; frequent when there is little interval ; regular when each suc- cessive beat is the same ; constant when each recun-ing cycle of beats is the same ; a pulse that is uneven in one beat is termed irregular in one beat. Clearly the opposites of these would be the small, short, narrow, low, feeble, hard, slow, infrequent, iiTegular, incon- stant. Clearly, too, there is a mean between each of the other opposites ; but there is no mean between a regular and irregular, a constant and inconstant pulse ; and the means between all the others are the normal pulses, but in the latter cases the regular pulse alone is normal ; the others — namely, the irregular and inconstant pulses— are abnonnal. Chapter 9. — Since pulses are readily altei'ed in vaiious ways — in fact, I might say there is no cause that does r:ot change them — I have determined to take a thieefold and very general difference in their change, and to speak specially about each in turn. The first change I shall speak of is that occurring in a normal pulse : the second is one which is not natural, but is not abnormal ; the third is tbe abnormal. All these changes take place as well as the natural varia- tions, for there are many normal varieties of motion in arteries ; and he who would fain determine the cause of the change in motion of a pulse and its magnitude must first be familiar with these. But the special peculiarities of each must be learnt by accurate tiials and observations. And the artery should fre- quently be fingered, especially in a state of health and in the absence of all violent movement, and also, of course, in otber states. But, since it is not in the power of all to attain this knowledge by experience — for many have often felt the need Chap. I.] History. ii of doctors at one time with whom when in sound health they had no intercourse — it is certainly best, even in this case, for the professional to excel the amateur ; and he would do so if he has a knowledge of things which occur similarly in many cases. Men, in short, possess different natures from women ; those of a warm temperament from those of a cool. And each of these have a common nature, just as thin and fat people have. And there is rarely a trait in these common properties taken singly that is not similar to many. So the man who has an accurate knowledge of general common features will rarely make a mistake. The knowledge of the circulation and of the pulse remained at the point at wliicli Galen left it for many centuries. Then, early in the sixteentli century, tlie function of the valves of tlie heart was made clear by Berengario di Carpi; the valves of the veins were described and their uses explained by Fabricius D'Aquapendente in 1625 ; and the mitral valve was described and named, and the perforation of the intra- ventricular septum disproved, by the great Vesalius in 1555. Kealdo Columbo now also clearly described the pulmonary circulation in his work on " Anatomy," published in 1558, having already propounded the discovery in his " Lectures,'^ through which, perhaps, Servetus, who first published it, had obtained the idea. Finally comes Cesalpinus, who, writing in 1543, seems first to have conceived the notion of the sys- temic circulation, but without appreciating its im- portance, and without any recognition of the heart as the agent in the propulsion of the blood, and who, moreover, instead of devoting his energies to the demonstration and establishment of so great a dis- covery, buried his idea in a mass of other speculations ("Questiones Peripateticre ''), so that it was unknown to his contemporaries and to the professors who imme- diately followed him in his own country, leaving to 1 2 The Pulse. [Chap. i. Harvey the incontestable glory of the real discovery and proof of the circulation. This is not the place to explain once more the steps of Harvey's complete and lucid experimental demonstration of the circulation, but it is worth while mentioning that in his treatise " Exercitationes Anato- micae de Motu Cordis et Sanguinis Circulatione," the contraction of the ventricles was, for the first time, shown to be the agent in the propulsion of the blood along the arteries throughout the body. Harvey began to teach the circulation in 1610, but did not publish his book till 1G28. The porosities in the tissues by which Harvey concluded that the blood made its way from the arte- ries to the venous radicles, were shown by Malpighi to be a network of capillary vessels — a discovery which completed the demonstration of the circulation. Nothing is to be gained by attempting to obtain an idea of the critical pulses of Solano and Nihell, by which the occurrence of epistaxis, purgation, etc., was foreseen, or of the organic pulses of Bordeu and Fouquet, a special variety of pulse for disease in each oi'gan. These fantastic descriptions had no reference to the physiology of the circulation, and might more easily have Ijeen written before its discovery. It is, however, interesting to note that it was Kepler who originated the idea of counting the pulse by the minute. Before this there was no standard of frequenc)'^ to which reference could be made. With the complete overthrow of the theory which had obtained from the time of Galen as to the move- ment of the l)lood, his teachings with regard to the pulse foil into discredit, and the minute and exact observation which had established distinctions between tlie different varieties of pulse, scarcely surpassed in accuracy and completeness by the teachings of the sphygmogra])h, and which furnished ready-made almost Chap. I.] History. 13 all the terms required by the records of this instru- ment, was neglected. For the most clear and true terminology we must, indeed, go farther back than Galen, since he overlaid it with trivial and tran- scendental retinements, and confused the results of simple and accurate observation by verbal and theo- retical considerations. To-day the study of the pulse cannot be better begun, or a better description of its variations be more clearly given than by considering separately — (1) the rate or frequency of the beats ; (2) the character of the individual pulsations ; (3) the intensity of the beats ; (4) the size of the vessel and its hardness or softness, as given by Rufus, and probably by Archi- genes. No doubt physicians have continued to esti- mate with care and accuracy the diagnostic and prognostic significance of the indications furnished by the pulse, but it was a great loss to medical science when vague descriptions, such as quick, or rapid, and slow, full and bounding, firm, and the like, capable of various interpretations, took the place of the definite terms employed by the early writers named. It thus became impossible to transmit by writing the know- ledge gained by experience. A new era, however, set in when the circulation began to be studied as a physical problem. The early attempts to estimate the work done by the heart were, it is true, mere random guesses ; but when Hales in 1748 and Poiseuille in 1S28 applied the first rude apparatus for measuring the fluid pressure in the arteries, and setting it down as equivalent to a column of so many inches of blood or water, or so many millimetres of mercury, a real step was taken, and the way was opened for the complete and more exact investigations of Volkmann, Yierordt, Ludwig, Tick, Chauveau, Marey, and others. The fluid pressure has been measured not only in 14 The Pulse. [Chap. i. the arteries, but in the different chambers of the heart itself by means of instruments devised by Marey ; the rate of movement of the blood along the vessels has also been approximately determined. In another direction the action of the nerves upon the heart, accelerating or slowing its beats, and ren- dering them more or less energetic, and upon the arteries, narrowing or dilating their channels, was gradually ascertained by successive experimenters. From the fact that the heart continues to beat after its removal from the body, it was believed by early experimenters to be altogether independent of the nervous system, and there can be no doubt as to the independence of the property of rhythmic con- traction which it possesses. But the Brothers Weber in 1845, and Budge in 1846, discovered the controlling influence of the pneumogastric ; the excitant influence of the sympathetic and of the spinal cord, by means of communicating branches to the sympathetic, in which Prochaska and Brachet appear to have led the way, was also established. The most recent investigations, while they have contributed details and refinements, and have shown that the action of the heart is indi- rectly affected through variations in the blood pressure, as well as directly by the pneumogastric and sympa- thetic nerves, have only established these discoveries, which were the earliest rjsults of physiological ex- perimentation. Perhaps even more im])ortant was the discovery of the contraction and dilatation of the arterioles under nervous stimulation. The knowledge of the vaso- motor mechanism to which it led, while explaining the old maxim " Ubi stimulus ibi fluxus," is essential to any true comprehension of the varieties of pulse. The influence of the nerves upon the diameter of the arteries had been asserted by Henle and Stilling, and the latter had introduced the term vaso motor, but it Chap. I.] History. 15 is to Claude Bernard, whose discoveries were quickly- extended by Brown-Sequard, that science owes the complete demonstration of the vaso-motor function of the sympathetic. This was only in 1851. While in this way the physiology of the circulation was elucidated, the application of the graphic method by means of the admirable sphygmograph invented by Marey led to a scientific study of the pulse and to a comprehension of its indications never before possible. The object of this little book is to set forth these indications, and to bring to pass their application to the everyday practice of medicine. i6 CHAPTER II. THE PULSE, ITS PRODUCTIOX AND SIGNIFICANCE. Introductory remarks — The blood is the source from which the tissues draw their supply of nutrient material, and of oxygen which is consumed in the oxidation necessary for the evolution of energy, heat, motion, or nerve-force, and the object of the circulation is to renew this supply according to the needs of the structures and the demands for force. The renewal is effected by the propulsion into the aorta of a certain amount of blood by each systole of the ventricle, and this is distributed by the arteries to the network of capillaries which are in intimate relations with the tissue elements. The amount of blood delivered by the ventricular systole is variously estimated. Professor Foster accepts six ounces (180 grammes) as approximately correct. The velocity of its movement in the caiotid is estimated from experiments on animals at about 12 inches per second (300 millimetres), or at the outside 18 to 20 inches ; but in the carotid and vessels of tliis size the movement is rapid during tlie systole of the heart, almost suspended during the diastole. The average motion of the blood will therefore be less than this, even in the large arteries ; and since, with few exceptions pointed out by Mr. Nunn, the sectional area of the branches at each division of the arterial tree is together greater than that of the dividing trunk, the blood will move more and more slowly as it gets nearer the periphery ; in the radial tlie rate is probably three or four inches per second. In the capillaries the motion of the blood is very slow, in the Chap. II.] Capillary Circulation: 17 human retina it is estimated by Vierordt at "75 mm. (about y^ijths of an inch in the second). This gi^eat fall in the rapidity of the blood is due partly to the much larger collective capacity of the capillary channels, which may be said to form a lake in the course of the stream, partly to the friction in the tortuous and inter-communicating channels, but pro- bably also, in part, to cohesion between the blood elements and the capillary walls, which will intensify the friction. There is, then, in the capillary network considerable obstruction to the flow of blood, requiring considerable pressure to force it through. Now this pressure is an indispensable element in the adaptation of the circulation to the purposes of nutrition. While the blood is within the capillaries, it is out of reach of the tissues, and its albuminoid constituents are not available for their nutrition. These blood albumi- noids are not in a dilfasible form, and we have no right to suppose that they will diffuse through the capillary walls just because they are wanted outside. Here the pressure comes in ; it forces a certain amount of albuminoid matter to exude out of the capillaries into the interstices of the tissues where it is in imme- diate relation with their nutritional elements, and forms the " milieu " in which they live. Of course these albuminoids cannot get back into the blood against pressure, but the interstices of the tissues are continuous with the lym})hatics, and the oflice of the lymphatics is to afford a channel by which nutrient material, which has escaped from the capillaries in excess of the demands of the tissues, may be restored to the circulation. With regard to the diffusible con- stituents of the blood, its oxygen, its salines, its sugar, and the diffusible products of tissue waste, the carbonic acid and urea, the case is different. For them the intertextural fluid and the blood in the cajDillaries are in free communication, since the capillary membrane c— 27 1 8 The Pulse. [Chap. ii. offers little or no obstacle to their interchange, and the time occupied by the blood in filtering through the capillary network of blood-vessels, estimated to be a full second, is sufficient to allow of the mutual diftusion. We examine habitually the pulse at the wrist, and at first sight it seems strange that the radial artery, which supplies merely the structures of a part of the hand — a few small bones with their articula- tions, a few muscles and tendons, the skin and nerves distributed to it — should afford the varied and far- reaching knowledge we look for in the pulse. The hand is not essential to life, it contains no organ of any importance, and d. j)riori it might have been sup- posed that the variations in the circulation of the blood in so small a member could have no significance. We know as a matter of observation, however, that the pulse of the wrist indicates the condition of the circulation generally, and on reflection it is seen that, as a branch of the great arterial system, it receives every impulse starting from the heart, and reveals the frequency and force of its beats ; and not only this, but as fluid pressure is equal, or tends to become equal, in all parts of a freely communicating system of tubes, it shows the degree of freedom of the general outflow of the blood through the capillaries as well as the energy of its propulsion by the heart. The very fact that the hand has no special circulation of its own liable to extreme variations for functional pur- poses — such as, for example, those which occur in the salivary glands — ^makes the radial pulse a more trust- worthy index of the general circulation. ^liat file pulse really is — A preliminary question upon which a distinct understanding must be arrived at is the following : The pulse, what is it ? and what is the exact information which it furnishes % Chap. II.] True Nature of Pulsation. 19 Now it is not, as is commoulj understood, an expansion of the artery. This, at any rate, is not what we feel or what is recorded by the sphygmograph. A moment's reflection as to the volume of blood dis- charged by the left ventricle into the aorta, and a comparison of this with the capacity of the entire arterial system, will convince us that it is altogether inadequate to produce any such expansion of the smaller arteries as will be appreciable to the touch. The aorta and its primary branches are, it is true, dilated somewhat by the injected blood ; but even in a vessel of the size of the carotid it is diflicult to measure the increase of diameter, so minute is it ; whereas in the radial, in which it must be much less, the sphygmo- graph, if its trace were taken to indicate actual enlargement of the artery, would show the expansion to be considerable. Nor is the pulse a sinuous move- ment of the artery in its bed from elongation which throws it into curves. To feel the pulsation in an artery, or to take a sphygmographic trace, a certain degree of pressure must be applied to the vessel, and, as is well known, there must be a bone behind it against which it can be compressed. What happens, then, is as follows : — In the intervals between the pulsations, when the resistance by the contained blood is at its lowest, the tube of the artery is more or less flattened by the pressure of the finger upon it ; then comes the so-called wave of blood propelled by the systole of the left ventricle, or, to speak more accurately, the fluid pres- sure in the vessel is increased, and this forces the artery back into the circular form (Fig. 1). It is this change of shape ^^^ 2. from the flattened condition impressed upon the vessel by the finger, or by the sphygmographic lever, to the round cylindrical shape, which it as- sumes under the distending force of the blood wdthiu 20 The Pulse. [Chap. ii. it Avliicli constitutes for us the 2)ulse. Such a pul- sation can be felt on a large scale by placing the foot on the inelastic leather hose of a fire-engine in action, in which there can be no expansion, or shown in a schema of the circulation with inelastic vessels. It is not, then, an increase in the diameter of the vessel, but an increase of the bloodrpressure witliin it, created by the systole of the ventricle of the heart, which constitutes the pulse. Another connnon misconception must be cleared up — namely, that tlie pulse necessarily signifies on- ward movement of the blood in the artery. Since a certain amount of blood is normally injected into the aorta at each systole, it w^ould seem, at first sight, that there must be a corresponding propulsion of blood along the vessel which is under the finger, and misapi)rehension has been carried so far that the pulse- wave has been understood to mean the actual transport of the blood, and even to indicate the rapidity of such motion. Short of this, it is more commonly taken for granted that the rate of movement of the blood in the vessels is directly proportionate to the strength of the pulse, that a good strong pulse implies a vigorous rush through the capillaries, and a weak pulse a languid flow. The stream which issues from a divided artery and the pulsatile jet seem to countenance this conclusion. It is, however, an erroneous idea. If the radial is compressed close to the hand, the pulsa- tion above is not extinguished, but exaggerated ; and when an artery is tied, the pulsation up to the liga- tured point is more vehement than before. Pulsation is thus no evidence of onward movement of the blood. Now, resistance in the arteries and capillaries will ])ave jiro tanto the effect of a ligature, hindering or e\en arresting the onward current. And there can be no doubt that perij)heral obstruction does at times reach a point which almost stops the flow Chap. II.] Pr ess URE Va R I A TION NO T Mo I'EMENT. 2 1 from the arteries to tlie veins, tlie pulse appearing to be all the stronger on this account. The heart acts with increasing energy in order to combat the obstruc- tion, but may fail so far to overcome it as to propel an average amount of blood into the aorta, although it raises the pressure throughout the arterial system. This is a consideration which, it seems to me, is not adequately borne in mind. I think it entei's into the explanation of dropsy, and especially of the varying amount of dropsical effusion under apparently similar conditions, and that it also helps to clear up obscuri- ties in the relation between circulatoiy conditions n.nd head symptoms. The pulse, then, indicates simply the degree and duration of increased pressure in the arterial system caused by the ventricular systole. There is a certain mean blood-pressure maintained by the elasticity of the large arteries, varying greatly in ditferent in- dividuals, which keeps up the flow through the capillaries, and the level of which is determined by the resistance in the capillaries and the amount of force received from the heart, and stored up by the elastic walls of the large arteries. This pressure is lowered during the diastole of the heart by the out- flow through the capillaries into the veins, and is reinforced by the successive contractions of the left ventricle, and the pulse marks and indicates the mini- mum and the maximum pressures, with the gradation from one to the other. The term " tension," as applied to the pulse, means simply the degree of fluid pressure within the artery, putting its walls on the stretch. Arterial tension and blood-pressure mean exactly the same thing. Distension might perhaps be more expressive than tension if less exact and technical. Factors of the pulse. — With these prelimi- nary observations we may proceed to consider the factors of the pulse. ±2 The Pulse. [Chap. ii. There are three factors in the production of the pulse, and the influence of each on the variations observed in it must be understood. The three factors are : — 1. The action of tlie heart. 2. The ehisticity of the great vessels. 3. The resistance in the arterioles and capillaries. The heart determines unconditionally the frequency and regularity or irregularity of the pulse, and, with certain qualifications, its force or strength. The great vessels, acting as an elastic reservoir, convert the intermittent jet issuing from the ventricle into a more or less continuous stream, impressing at the same time certain characters upon the pulse according as the elasticity of their walls is perfect or impaired, and according as they are kept fully distended, or only slightly on the stretch. The capillaries and arterioles, by the varying resistance which they offer to the passage of blood through them, determine the mean pressure maintained in the arterial system and the character of the pulse, and influence materially the action of the heart. Each of these must be considered in some detail. I. — The Action of the Heart. 1. Frequency. — It has just been said that the heart determines absolutely the frequency of the pulse ; and this is true in so far that the nimiber of beats of the pulse corresponds with the number of heart beats, except when a certain proportion of the latter are too weak to reach the wrist, or when very little blood enters the ventricle during its diastole ; with the exception again of that curious modification of the heart's action in which there are two heart beats coupled together for every beat of the pulse. It must not be lost sight of, however, that resistance in the peripheral circulation re-acts upon the heart's Chap. II.] Heart axd Pulse, 23 action, as well as upon its cliaracter, the frequency being increased as resistance is lessened, and vice versd ; subject, however, in both cases to the intervention of the nervous system. 2. Rhytliiu. — The rhythm, as well as the rate, of the pulse is determined by tlie heart, and the pulse, generally speaking, is regular or irregular according as the action of the heart is re^jular or irreo-ular. The pulse, however, may be made irregular when the heart is acting regularly by beats failing to reach the wrist, and irregularity of the heart's action may be greatly exaggerated in the pulse. 3. Force. — With regard to the strength or force of the pulse, again, this must be directly dependent upon the strength of the ventricular systole. The pulse cannot be strong or forcible when the heart's action is weak, and it will not, as a rule, be weak wdien the heart's action is vigorous. But the volume of blood discharged by the ventricle into the aorta is another element in the production of the pulse. If from any cause the ventricle is not properly filled, as may be the case when the total volume of the blood has been reduced by haemorrhage or other cause_, or when there is obstruction in the pulmonary circula- tion, from disease of the lungs or extreme constriction of the mitral orifice, or when the ventricle has not time to dilate, as may happen in palpitation, the systole, however forcible, will have little effect in increasing the pressure in the arterial system ; and there may, under such circumstances, be powerful action of the heart, with a feeble pulse. It will also be seen, when the influence of peripheral resistance is discussed, that the apparent strength of the pulse may not correspond with the energy of the ventricular contraction, even when the amount of blood pro- pelled is normal ; and the blood-pressure or arterial tension — i.e. the degree of distension of the arteries — 24 The Pulse. [Chap. u. while it is maintained by the heart, and is dependent upon the degree of pressure supplied by the ventri- cular systole, is by no means necessarily propor- tionate to its vigour. II. — Elasticity of the Great Vessels. The principal effect of the large arteries is to act as an elastic reservoir, which converts the intermittent jet of blood which issues from the ventricle into a continuous stre<\m. They are kept by the resistance to the outflow through the capillaries in a state of continual distension, which is increased momentarily by each ventiicular systole, and runs down to some extent in the intervals, but never during life to a point at which the elastic coats of the vessel cease to exercise some compression on its contained blood. The force of the heart is thus stored up and delivered out gradually in the form of a steady pressure, which keeps up an almost uniform flow through the vessels of the ])eriphery. The regular current of blood sus- tained in this way is essential to the functional activity of the central nervous system. A collateral result of the elasticity of the large arteries is an economy of the force of tlie heart, since the outflow from elastic tubes under an intermittent supply is greater than if the tubes, being of the same size, were rigid ; but this effect is not appreciable in the pulse. Another effect, however, is a certain delay of the pulse wave. In a rigid system of tubes increase of pressure from the injection of fluid would be simul- taneous at every point, and, were the arteries in- elastic, there would be no loss of time between the heart and the pulse. The result of the elasticity of the great vessels is that the increase of pressure from the systole of the ventricle is partly expended in dilating them, and, in proportion as this obtains, there Chap. 11.] Great Vessels and Pulse. 25 is delay in the transmission of the pressure onwards. The pulse wave, as the increase of pressure is called, travels, according to Dr. A. Waller, at about the rate of thirty feet a second. The want of synchronism between the heart and the pulse is quite perceptible, and the pulse cannot therefore be taken as a point of reference by which to determine the position of a murmur or sound in the cardiac revolution, as has often been recommended. This is all the more liable to give rise to confusion, as the loss of time is variable, being greatest when the mean blood-pressure in the arteries is low, less when the tension is high, least when the great vessels have lost their elasticity from degeneration. Further, the elasticity of the great vessels is con- cerned in the production of the dicrotism of the pulse. Dicrotism — i.e. a double or re-duplicated beat — is, in a small or great degree, a constant feature of the normal pulse. As felt by the fingers, it may be Fig. 2.— Dicrotism. 'described as a sort of echo of the main beat follow- ing it at a very brief interval, and it is represented in the sphygmographic trace by a secondary rise of varying height occurring in the coui-se of the down stroke at a fairly constant point. (Fig. 2.) Dicrotism 2 6 The Pulse. [Chap, ii lias been the subject of much discussion. It lias been considered to be produced by a wave reflected by the periphery. But this view is now quite aban- doned ; had it been true, the reflected wave would have followed the primary wave more quickly near the jieriphery than near the heart, and the contrary is the case. The dicrotic wave is a secondary wave of pressure, due to the elastic recoil of the aorta from its expansion by the blood injected during the systole of the left ventricle. The conditions favourable to its manifestation are dilatation of the arterioles and sharp contraction of the heart, which commonly go together. When the outflow by the capillaries is rapid, the pressure in the aorta and great vessels will run down speedily during the cardiac diastole, and there will be a great and sudden rise with the systole. There being, moreover, comparatively little resistance to the blood entering the aorta from the ventricle, its systole takes place rapidly. The force of the systole is divided. There is at the same time a launching forwards of the column of blood and an expansion of the great vessels laterally, their elastic coats not being on the stretch, and so yielding easily. A contractile rebound follows, which starts the dicrotic wave along the arteries, the closed semilunar valves acting as a fulcrum. Another variety of double beat, the pulsus bis- feriens — which may easily be mistaken for dicrotism, but which must be distinguished from it — is met with under totally different conditions. This second beat is really a reinforcement of a prolonged systole near its close, and is represented by a sphygmogram, such as those here given. (Fig. 3.) It is most common as a result of aortic stenosis, but is met with in senile degeneration of the arteries. The artery is usually rather small, always full between the beats, and generally resisting compression; the Chap, ir.] Great Vessels and Pulse. 27 pulse wave is gradual in onset and long, and just before it begins to subside a second beat is felt. Fig. 3. — Pulsus Bisferieus. Wlien tlie arterioles are contracted and the onward movement of the blood in the periphery is ob- structed, the pressure in the great vessels cannot reduce itself by rapid outflow through the capillaries. The aorta is distended, and its coats are on the stretch, so that it cannot be quickly dilated to accommodate the contents of the ventricle : the force of the systole rig. 4. — Normal Higli Tension, will thus be expended mainly in pushing forwards the column of blood, and the exact converse of the eflfects above enumerated as giving rise to dicrotism will 2 8 The Pulse. ' [Chap. ir. hold. The systole will Vje slowed, there will be no great expansion and contraction of the aorta. There will in particular be little or no dicrotic wave. (Fig. 4.) When from atheromatous or other senile changces the aorta and its primary branches have lost their elasticity, the resemblance to a system of inelastic tubes is more complete, and the pulse curve not being inoditied resembles that of the ventricle. (Fig. 5.) Fig. 5. — Senile Pulse. IJI. — Arterio Capillary Resistance. Not less important than the action of the heart in its influence on the circulation of the blood, and even more important in the modifications it produces in the character of the pulse, is the resistance in the arteri- oles and capillaries. It is by their resistance in front and the force of the heart's action behind that the mean pressure in the arterial system is determined. If the outflow through the capillaries is free, then no amount of blood wliich the heart in a normal con- dition can pour into the arteries, and no degree of energy with which this is projected into the aorta, will maintain the general arterial pressure at a high point. It is possible that great frequency of the heart's action with the discharge of a full volume of blood by each systole may pour blood into the arteries more quickly than it can run ofF by the capillaries even when relaxed, in which case the pressure would rise ; but this is a rare occurrence, except for brief Chap, ir.] Arterio-Capillary Resistance. 29 periods in excitement or the early stage of eflfovt. On the other hand, when the passage through the capillary network is obstructed, the blood is dammed back in the arteries, and the pressure within them is raised, it being understood always that the heart is capable of supplying the requisite force, which must of course be sufficient to overcome the peripheral obstruction and keep up some onward movement of the blood, or life would cease. The average blood-pressure or mean tension present in a given case is a most im- portant part of the knowledge to be obtained from the pulse ; it is measured by the degree of fulness and resistance in the artery between the beats ; the varia- tions in the character of the pulse contributing to an accui-ate estimate of it. It follows from theoretical considerations, whicli need not be here discussed, and it is proved both by observation and experiment, that the higher the con- stant or mean pressure in the arteries, the less is the difference between the maximum and minimum ; or, in other words, the more full and firm the artery is between the beat, the less marked will be the pulsa- tion, and vice versd; the lower the tension and the more conspicuous the pulsation. The significance, again, of the constant or mean, and the variable or pulsatile, pressure is different. The mean pressure tells most with regard to the circula- tion and the circulatory system. The variable pressure or pulse tells most with regard to the general state of the individual. When the peripheral vessels oppose little resistance to the 2)assage of the blood through them, tlie pressure in the arteries will not only be low, but it will also be variable. The blood 'flowing off quickly, the pres- sure will rapidly run down in the intervals of the ventricular systole, and will rise suddenly with each systole. This would be the case even were the 30 The Pulse. [Chap. II, celerity of the individual contractions constant and nninfliienced by the amount of force to be overcome ; such, however, is not the ease, for when it meets witli diminished resistance the ventricle expels its contents more rapidly. The pulse, then, will be more sudden or sharp, and will seem to be more vehement. The artery at the wrist and elsewhere will allow itself to be flattened more easily and completely, as there is little pressure of blood ^vithin it to resist the external pressure ; it is then suddenly distended, and resumes its cylindrical form, repelling the finger and jerking up the sphygmographic lever. The effect is all the more marked from the fact that the walls of the artery will be relaxed and its diameter increased. It is shown in the following diagrams, the first of which (Fig. 6) Fig. 6. Fig. 7. is sui)posed to re})resent an artery of normal size, with its pulse-trace, the second (Fig. 7) the same artery when relaxed, with its pulse trace. Chap. II.] ArTERIO-CaPILLARY RESISTANCE. 3I But another consequence flows from tlie varying resistance in the peripheral arterioles and capillaries. A given volume of liquid will pass more rapidly through a large channel than through a smaller under the same pressure. When, then, the resistance in the periphery is weak — which is equivalent to the channel being large — the pulse will be short : that is, the wave is sudden and soon over. The converse effect will be produced by peripheral resistance. With a higher mean pressure the varia- tions will be less, and the rise of pressure which constitutes the pulse more gradual, this difference being accentuated w^hen the artery is contracted. The wave again will be long (Fig. 8). rig. 8. It is easy to confound the fulness of the artery between the beats with a prolonged beat; but al- though these two conditions are often met with to- gether, they are distinct, and must be kept so in our minds. The spliygniog:rapEi. — In recent teachings with regard to the circulation and the pulse, the constant reference to the sphygmograph has been an obstacle to the application of the newly-obtained knowledge to clinical work, and especially to everyday practice. It is not every student who can thoroughly familiarise himself with this instrument and acquire the requisite skill for bringing out its indications, and the busy practitioner has still less chance of doing this ; nor has he the time to employ it constantly, while without constant use the results are untrustworthy. 32 The Pulse. [Chap. it. It will, therefore, be an object in this little book to describe the v^ariations in the character of the pulse as they are felt by the finger, and the sphygnio- graph will be relegated to a position of secondary importance. It has been objected that the distinc- tions are too refined to be appreciated by the touch. But the answer to this is that every important variety of pulse revealed by the sphygmograph was recog- nised, described, and named before the Christian era, and it may be added that resident physicians and clinical clerks of the present day learn to do this without difficulty. The sphygmograph has been invaluable in research ; it has given precision to our ideas, and in the hands of Marey and others has made clear and compre- hensible many intricate and doubtful problems of the circulation. It is capable, too, of rendering important aid in clinical investigation, especially where demon- stration and records of changes in the circulation are required. To me i)ersonally the sphygmograph has been of innnense service. I worked with it under the eye of Sibson, and shared Anstie's enthusiasm Avith regard to it when he and Professor Burdon Sanderson took up the instrument with which Marey endowed medical science. It is not, therefore, from ignorance of or want of familiarity with the sphygmo- graph that I have come to the conclusion that it is not specially useful in practice — that in any form known to me it is not a clinical instrument for every- day work. It is rarely necessary for diagnosis, and scarcely ever to be trusted in prognosis. The indica- tions obtained from it are not, like those of tlie ther- mometer, independent of the observer. Skill and practice are required in applying it ; judgment is called for in determining the position and pressure which give tlie best trace, and indeed in deciding which of the traces obtainable is the best representative Chap. II.] The SPHYGMOGRArH. 33 of the particular pulse ; the personal equation of the observer, therefore, comes in, and if any special result is expected or wished for, an enthusiastic in- vestigator can obtain it, and may, without the least conscious intention, twist facts in the desired direction. It is necessary also before a trace can be interpreted with any degree of confidence to know what form of sphygmograph has been employed. Marey's is still, in my opinion, the best, and his traces appear to me to correspond most closely with traces taken without instrumental multiplication, and magnified by the lens. English modifications of Marey's sphygmograph often magnify the pulsation too much, and in doing so introduce exaggerations due to the rapid movement of the writing lever. Pond's and Dudgeon's instru- ments are extremely handy and convenient, but a gratuitous provision for exaggerations and for ex- traneous jerks and vibrations exists in the loose and unmechanical way in which the motion of the inter- mediate lever is communicated to the writing lever, and in the weight which acts as counterpoise in the last-named lever. The pretence, again, to measure the exact i)ressure employed in taking the trace, and thereby to obtain corresponding knowledge of the intra-arterial pressure, is illusory. To say nothing of the varying thickness and resistance of the skin, which would of itself vitiate all conclusions of this kind in at least three ways — by difference of flexibility, by affecting the position of tlie spring, and by varying the area of the button or pad actually in contact with the skin — the size of the artery would introduce an element of uncertainty. Hydraulic pressure is equal at every point of the containing surface, and its force is multi- plied Vjy increase of area ; the greater surface, therefore, of a large vessel would exercise greater lifting power, so that the same blood pressure would appear to be D— 27 34 The Pulse. Chap. ii. higher or lower accordinsj to the diameter of the artery. For the same reason buttons or pads of different size resting on the vessel would affect the degree of force required in order to compress it, as would slight differences of adjustment. A knife-edge resting transversely across the vessel eliminates some of these uncertainties, and gives a more accurate trace, but requires delicate adjustment of the strength of the spring. Tlie above would be true even if the pressure exercised by the spring were accurately graduated ; but this is far from being the case in any spbygmograpli known to me, and gra'l nation by the eccentric commonly employed is ridiculously inexact. While, then, I think that every student ought to be familiar witli the sphygmograph, and will gain from a study of its indications a comprehension of the pulse in its different forms, obtainable in no other way, I am of opinion that we learn by means of the educated finger all that the sphygmograph can teach, and more. This instrument is invalual)le as a means of educating the sense of touch and of cultivating the faculty of observation ; it is most useful in resolving doubts as to the difference between the pulse of the two sides in some cases of aneurism, and in recording pulses in the graphic form ; but it is not an infallible court of appeal, and there are niceties of information which are out of its reach. I need only point to the groups of pulse tracings exhibited, which are by experts, to show that a sphygmogram does not speak for itself, but requires interpretation. One set is a series of normal traces, made for me l^y the late Dr. Mahomed to illustrate my lectures at St. Mary's ; the others are copies — one from Marey, the other from Hayden, of traces from cases of aortic regurgitation or insuthciency. (Figs. 9, 10, 11.) Unless it were so stated it would be difficult to believe that tlie latter were all taken from the same form of disease. Chap. II.] N'ORMA L SpIIVGMOGRAMS. 35 Fig. 9. — Normal Forms of Pulse (Mahomed). 36 The Pulse. fChap. ir. Fig. 10.— Aortic Eegurgitation (Marey). Chap. II.] Sphvgmograms. 37 Aortic IiisiOiiiid. — The pulmonary second sound is still more sensitive to increase of pressure in the pulmonary cir- culation than the right ventricle first sound, and no examination of the heart can be considered complete unless the relative intensity of this sound has been carefully estimated. Accentuation of the pulmonary second sound, it is true, is produced by slight causes, and may be simulated by uncovering of the conus and artery from retraction of the lung ; but these sources of fallacy are easily eliminated by the exercise of a little thought and care, and then the pulmonary second sound becomes a means of recognising increased pressure in the pulmonary circulation at its earliest stage, long before this tells on the right ventricle, and Chap. IV.] Heart-Souxds axd Pulse. 6i of estimating tlie extent of valvular or other disease of the left side of the heart by its effects on the passage of the blood through the lungs. All the causes of intensification of the rio-ht ventricle first sound Avill give rise to accentuation of the pulmonary second sound, and need not again be enumerated. Heart- soiiuds : variation in cliaracter.— The first sound of the left ventricle may be pro- longed and dull as compared with the normal ; or, on the other hand, short and sharp. The former modi- fication is usually associated with hypertrophy, the latter with dilatation ; but the first sound is short whene\'er the heart is acting frequently, especially when the arterial tension is low, and there is little resistance to the contraction of the ventricle ; it is often specially short and sharj) in the early stage of pericarditis. But the most remarkable modification of the first sound as heard at the apex, and presum- ably therefore that of the left ventricle, is that met with in the late stao-es of narrowiuo' of the mitral orifice, when it is loud, short and sharp, and high- pitched, and so completely resembles the second sound as often to be taken for it. The principal modification in the character of the aortic second sound, which requires notice so as to mark the distinction between it and accentuation, is a change in the pitch and its having a musical tone or In order that the sio-nificance of this chansfe mav be fully understood it will be well to explain exactly the jDroduction of the second sound. The idea, not altogether extinct, that it is the click of the semilunar valves as they meet and are forcibly driven together by recoil of the blood in the aorta is mentioned only to be dismissed ; the sound is one of sudden tension and vibration, not of sharp contact. The vibration and tension, however, which give rise to the second 62 The Pulse. ichap. iv. sound, whether at the aortic or pulmonary orifice, are not limited to the valvular cusps, but affect the arterial walls for some distance from the valves. The second sound thus gives information as to the state of the aorta as well as of the valves. Were it not that the entire root of the aorta forms part of the vibrating membrane, dilatation of this part of the vessel and thinning of its walls would have no great effect upon the second sound ; whereas, modifications of the second sound are diagnostic of such changes, and in this way are of extreme importance. Just as a cord of longer length, when suddenly stretched, yields a lower pitch, so does the larger diameter of a dilated aorta lower the pitch of the second sound ; jnst, again, as the note becomes clearer and more musical as the cord is thin and homogeneous, so does the second sound acquire a musical tone when the coats are attenuated, and the three tunics are fused into one membrane in disease. Dilatation of the aorta rarely takes place except when there has been protracted arterial tension ; when, therefore, there has long been accentuation of the aortic second sound — and with accentuation the pitch of the sound is lower — it may be inferred that dilatation, simple or aneurismal, has supervened. When the second sound has a distinct musical tone or ring it may be inferred that the dilatation is associated with thinning of the coats of the vessel, probably uniform, and therefore, not aneurismal, except indeed, in case of aneurism of one of the sinuses of Valsalva, which may be attended with a ringing second sound. Another point to be noted in connection with the lowered pitch and sonorous tone-like character of the aortic second sound when the aorta is dilated is that it is audible over a very large area. This is not merely because the enlargement of the aorta brings it into more extensive relations with the wall of the Chap. IV.] Heart-Sounds and I^ulse. 63 chest ; but because the area of contact with the lung is increased, and from the larger conducting surface the sound is transmitted in all directions. As it is the right lung which lies in contact with the ascending aorta, it is over the right side of the chest that the sound is most extensively heard, but very commonly it is again caught on listening over the upper part of the left thorax just beyond the pulmonary artery. The modifications, independent of the intensifica- tion already described, of the first and second sounds of the right side of the heart are less noteworthy and have no particular significance ; they need not, conse- quently, occupy our attention. Mention may be made of a peculiar click which sometimes accompanies the first sound just to the left of the ensiform cartilage when the right ventricle is acting forcibly, and of a kind of scratching sound sometimes heard at the same spot. The latter occasionally gives rise to a suspicion of peri- carditis, and it may perhaps be due to the friction which is supposed to contribute to the formation of a white patch often seen on the corresponding part of the heart. The click appears to be endocardial, but it means nothing. Modilicatioiis of the rhythm of the lieart- sounds. — The term rhytlim is here employed in its strict sense, as denoting the time-relations of the first and second sounds of individual beats, and not the regularity of the succession of heart-beats. The two sounds of the heart so follow each other as to correspond normally with the first two beats of triple time in music, "one, two, three" — i.e. if in counting "one, two, three; one, two, three," the "three" were silent, the "one, two, — , one, two, — ; one, two, — ; " would represent the first and second sounds, the silent "three" the long silence. The accent would be on the " one " or the " two : " " one', two, — ," or "one, tWO', — ," according to the way 64 The Pulse. [Chap, iv- in which the heart was acting, or according to the point at which the stethoscope was applied. The relative length of the two intervals between the first and second, and between the second and the next first, giving the triple musical time, is maintained with remarkable constancy, whatever may be the rate at which the heart is beating— whether, that is, the pulse is 60, 90 or 120 in the minute, and this whether the increased frequency is from exercise, excitement, warmth, stimulants, or fever. Under certain con- ditions, however, the triple time is departed from in contrary directions. The cardiac systole may be pro- lonojed, and thus the interval between the first and second sounds increased, and this may be carried so far that the sounds become equidistant. The musical time would then be double instead of triple, and we should count " one, two ; one, two ; " instead of " one, two (three) ; one, two (three) ; " and the sounds may be compared to the ''tick-tack" of a pendulum, or of a watch, according as the heart's action is slow or rapid. The same result might come about by a shortening of the diastole, and an abbreviation of the interval between the second sound and the first. The spacing of the first and second sounds by the prolongation of the interval between them indicates, of course, that the systole is longer than usual in com- pleting itself, and this occurs, as might be inferred, when there is resistance in the peri2)heral circulation. But physiological resistance, while rendering the sys- tole more deliberate, is accompanied by a correspond- in*; increase in the duration of the diastole, so that the eff'ect is to diminish the frequency of the heart's ac- tion, the rhythmic succession of the sounds in triple time not being disturbed. It is when the peripheral re sistance is such as to affect the heart injuriously, and dilatation of the ventricle has set in, or is impending, Chap. IV.] Heart Sounds and Pulse. , 65 that the systole is prolonged at the expense of tl;e diastole, and the sounds tend to become equidistant. This occurs as a result of protracted high arterial tension, especially in kidney disease, and the effect on the ventricle is induced all the more readily when the heart is weakened, together with the muscular tissues generally, by pyrexia. In acute renal dropsy, there- fore, when there is at the same time the debilitating influence of acute disease upon the heart, and sudden increase of the resistance in the circulation, spacing of the sounds is often observed. Equidistance of the sounds, from shortening of the diastole, occurs in palpitation with extreme frequency of the heart's action. The sounds then resemble the ticking of a watch under the pillow, or the sounds of the foetal heart in utero. On the other hand, the systolic interval may be shortened or the diastolic interval lengthened till the rhythm is that of common time — "one, two, (three, four) ; one, two, — , — ; " or even " one, two, (three, four, five, six)." In extreme cases the second may follow the first quite precipitately. The approximation of the first and second sounds may be due to the rapid completion of the systole, when the ventricle contracts energetically and meets with little resistance, as may occur sometimes, in pyrexia, and in states of excitement ; but this is not common without a corresponding abbreviation of the diastole, which maintains the rhythm. More fre- quently, when the second sound follows the first too rapidly, it is that the systole is not completed at all, from weakness of the ventricular muscle or from re- sistance in the arterial system which it is unable to overcome. The ventricle discharges only a portion of the contained blood, sometimes a very small propor- tion of its contents, when the contraction is brought up short, so to speak, and ends unfinished ; then, as F — 27 66 The Pulse. [Chap. iv. soon as the pressure in the aorta exceeds that in the ventricle, which may be the case before the effort on the part of the ventricle ceases, the second sound occurs. Associated with the approximation of the sounds is a corresponding shortness of the pulse, but this is not so striking or so significant as the rapid succes- sion of the sounds, the latter being an extremely serious prognostic sign. In diphtheria it is often the first recognisable indication of the fatal cardiac asthe- nia which attends this disease, preceding sometimes by forty-eight hours or more other symptoms of heart- failure, and under various circumstances it may for a time stand almost alone as a warning of impending peril. Occasionally the hurried succession of the two sounds succeeds to an exactly opposite departure from the cardiac rhythm in high arterial tension, the sounds, from being equidistant, going to the other extreme, the second coming close upon the first. In a case recently seen with Dr. Habershon and Mr. Pedler the serious prognostic significance of this sign was verified by rapidly fatal failure of the heart three weeks after apparent recovery from an attack in which it was present for some time. The patient, aged fifty-four, a tall and powerful man, of remarkable mental vigour, was seized with cardiac symptoms after an indiscretion in diet and copious draughts of iced water on a hot day. There was at first severe pain in the epigastrium and in the region of the colon, apparently from flatulence, but without much distension, and with this a sense of oppression in the chest and extreme prostration ; frequent deep sighs and great restlessness. It was observed also that when he spoke, which was usually in rather a loud voice, the abdominal muscles contracted forcibly to reinforce the thorax in producing the requisite pres- sure of air, and that he could say only a few words Chap. IV.] Heart Sounds and Pulse. 67 at a time without tiking breath. There was not, however, paralysis of the diaphragm giving rise to reversed abdominal movements in respiration. The mental condition was peculiar and extremely variable ; he would be excited and almost violent at one time, at another quite himself ; the memory was greatly impaired. The pulse, which in healtli was 60 or under, ranged between 70 and 80. It was large for the most part, regular, and did not seem to be specially weak, but it was extremely short ; and on examining the heart the second sound was found to follow the first very hurriedly, the first being itself short and for a time weak. The shortness of the pulse was the more remarkable from the fact that the history of the patient and his appearance were suggestive of high tension. Stimulants had to be given freely at times to avert threatened syncope, but the average daily amount was moderate. The remedies employed wei-e chiefly digitalis with ammonia and strophanthus with bark or nux vomica. After a fortnight of serious danger the patient gradually recovered, and was able to leave town after an illness of about a month. Three weeks later anotlier attack came on, which proved fatal in a few days. The patient was gouty, and had had several attacks of thrombosis of veins ; this led to a suspicion of the formation of a coagulum in the heart, but no evidence, direct or indirect, of any such occurrence was present. The cerebral symi)toms were no doubt the result of antemia of the cortex caused by the inefficient con- traction of tlie left ventricle. Reduplication of the heart sounds. — There remains to be noticed the reduplication of the heart sounds which is so frequently met with. Either the first or the second sound may be re- duplicated ; occasionally, but rarely, botli at the same time. 68 The Pulse. [Chap. iv. Reduplication of the second sound may be taken first, since there is no great difference of opinion as to its causation, and it is generally recognised as being due to a want of synchronism between the aortic and pulmonary second sounds ; this asynchronism, again, being the effect of increased resistance in the pulmonic or systemic circulation (usually the pulmonic), which retards the completion of the systole of the corre- sponding ventricle, and therefore the closure of the semilunar valves. Instead of" lub-dup " we have " lub- dullup," or "one, two-two," instead of "one, two." Sometimes the two second sounds are so far apart as to give rise to a resemblance to the foot-fall of a horse at the canter ; and we have the hriiit cle galop or cantering heart-sounds, and different varieties of the canter are imitated according to the relative intensity of the sounds and the fall of the accent on one or other. We may have " one', two-two ; one', two-two ; " or "one, two'-two ; one, two'-two;" or "one,two-two'; one, two-two'." At other times they succeed each other with the utmost rapidity, and are only dis- tinguished by the practised ear. The reduplication of the second sound is usually most distinct at the base of the heart, and best heard over the left edge of the sternum at the level of the third space ; but it may be audible to the right of the sternum in the second space and across the sternum between these two sj^ots, or at the fourth left space, rarely upwards along the course of the pulmonary artery. Occasionally the reduplication is more distinct near the apex than elsewhere. Sometimes it is the aortic second sound which is first, sometimes the pulmonary, and it is not at all an easy task to determine which of them leads. Fortunately, though it is interesting to make this out, it is not important, and it is almost always the pul- monary second sound which is displaced, whether forwards or backwards, as regards the aortic sound Chap. IV.] Reduplication OF IiEART-SouNDS. 69 That such is the case is seen fiom the fact tliat re- duplication of the second sound can be induced by merely holding the breath ; this fact shows also that it is producible by comparatively slight causes. The causes of reduplication of the second sound are mostly such as tell upon the pulmonary circulation. Bronchitis and emphysema or fluid in the pleural cavity may give rise to it. Far more commonly it is produced by disease, valvular or structural, of the left side of the heart, and par- ticularly by mitral stenosis, which it may attend at almost all stages, but especially early. Reduplication of the second sound, indeed, is probably heard as frequently in association with obstruction at the mitral orifice as with all other causes })ut together. It is often heard, again, in pericarditis, which may be accounted for by the inflammation of the serous covering which paralyses subjacent muscular fibres, affecting more seriously the thin Avails of the right ventricle than the thick walls of the left. Occasion- ally reduplication of the second sound is present in renal disease, and is apparently due to the high systemic arterial tension to which this gives rise. , Occasionally, again, reduplication of the most marked character is heard in cases of cerebral tumour and of cerebral disease of other kinds, and is one of the many effects on the circulatory system produced by affec- tions of the nervous system. It is probable, however, that it is indirect, and that the intermediate agency is high arterial tension. Reduplication of the first sound is generally con- sidered to be strictly analogous to reduplication of the second, and to be due to a want of synchronism between the first sounds of the two ventricles, and therefore between the first moment of their contrac- tion, since tension of the auriculo-ventricular valves, which is the most important element in the first 70 The Pulse. [Chap. iv. sound, must occur as soon as tlie ventricular walls begin to exercise pressure on the contents. This seemed to be conclusively demonstrated by my late teacher and colleague Dr. Sibson; but Dr. Geo. Johnson does not accept the explanation, and considers that the reduplication is caused by the auricular systole giving rise under certain circumstances to an audible sound. The question must be discussed, but before entering upon the arguments adduced in favour of one or other of the two views, it will be well to state the facts of observation with regard to the re- duplication. The first is as to the point at which the double sound is best heard. This is near the apex of ^the heart, and especially about an inch to the inner side of the ajDex beat. The spot indicated corresponds very nearly with the interventricular septum, and the stethoscope applied here would be over both ventricles. Yery commonly to the right or left of a given spot the first sound seems to be prolonged or confused, and is sometimes described as impure, but at the point itself the prolongation is distinctly resolved into the two elements which constitute reduplication. Sometimes the reduplication is quite distinct along the lower border of the light ventricle from near the apex-beat to the edge of the sternum ; more rarely it is recognisable in an upward direction as high as the third space. Reduplication of the first sound is not, as a rule, so striking as reduplication of the second, and in most cases must be sought for, but it may be so well marked as to produce a cantering rhythm " one-one', two ; one-one', two ; one-one', two." Occasionally it is difficult to say at the first moment whether can- tering sounds are due to reduplication of the first or second ; whether they are represented by " one, Chap. IV.] Reduplication of First Sound. 71 two-two ; one, two-two ; " or by ^' one one, two ; one-one, two ; " and some care may be required to es- tablish the distinction. The most common cause of reduplication of the first sound is high pressure in the systemic circula- tion or high arterial tension, and it is met with most frequently in renal disease. It may also be produced by obstruction in the pulmonary circulation, such as attends bronchitis and emphysema ; but this is not frequent, and it does not occur when the obsti'uction is due to valvular or other disease of the left side of the heart. On the hypothesis that the reduplication is due to loss of synchronism between the first sounds of the two ventricles, one explanation is that the resistance in the systemic or pulmonary circulation delays the action of the corresponding ventricle. Dr. Barr in a very interesting paper in the Liverpool Meclico- Chirurgical Journal ai-gues very forcibly that, on the contrary, the ventricle which is working against undue pressure is the first to contract; "relatively greater blood supply," he says, " to one or other ventricle does not retard the closure of the auriculo- ventricular valve, but more quickly overcomes the inhibitory action of the vagus, stimulates that ven- tricle to initiate contraction, and fii'st apply tension to its auriculo-ventricular valve, which perhaps may be the more readily effected on account of the hyper- distension of the ventricle, and thus produce the tirst element of a duplex sound." I am more disposed to accept Dr. Barr's conclusion than his reasons ; I do not see that the left ventricle has any relatively ex- cessive blood-supply, or that it undergoes hyper- distension during diastole in Bright's disease ; and I distrust explanations which turn upon the influence of the pneumogastric or sympathetic nerves. But it is not tjie raere existence of abnormal 72 TllK FfLSE. [Chap. IV. rssistance which has to be overcome which gives rise to reduplication. Tlie occurrence of reduplication shows that the resistance is overtaxing the heart, and that the hypertrophy, which for a time meets the increa.sed resistance, is no longer equal to the task, and is beginning to give place to dilatation. It has been already said that Dr. Geo. Johnson considers one of the two elements of the reduplicated lirst sound to be auricular and the other ventricular The starting-point and basis of his hypothesis is that in pericarditis the auricular friction gives rise at the base of the heart to a triple instead of a to and fro rub, and that the auricular systole, preceding as it does the systole of the ventricle, were it audible would, with the second sound, give exactly the triple sound produced by the reduplication in question. It may be said in passing that l)asic friction sounds are often still more complex, and that they are suggestive rather of the sound of a distant loom than of a cantering horse. Dr. Johnson then endeavours to show that the contraction of the auricle may under certain circumstances give rise to a sound, and that the reduplication is most marked at the point where this would be heard. Here I am at issue with Dr. Johnson on a matter of observation : his hypothesis requires that the reduplication should be heard at the base of the heart near the left or right auricle re- spectively, and he states that it is frequently, if not constantly, audible here. This is certainly not in accordance with my experience. For some years — ever since, in fact, the j)ublication of Dr. Johnson's views — I have rarely omitted, on hearing the first sound reduplicated, to ascertain its seat of maximum distinctness and intensity, and to compare the sounds as heard at the base and near the apex ; and the result of repeated careful and conscientious exami- nation has been to confirm the original observation of Chap. IV. j RkDU PLICATION OF FiRST SoUND. 73 Dr. Sibson that the seat far excellence, of the re- duplication of the first sound is along the line of the interventricular septum where the stethoscope is over both ventricles. The duplicated sound is often heard along a horizontal line from the apex towards the sternum as far as the edge of this bone, less frequently upwards to the third intercostal space. When thus audible over the right ventricle the explanation is that the first sound of the left ventricle is audible through the shallow right ventricle Avhich overlies it ; and when it is heard in an upward direction it is that, in consequence of hypertrophy and dilatation of the left ventricle, the sejitum comes to run nearly along the left border of the heart instead of going- round to its posterior surface. As regards theoretical considerations, again, the conditions under which reduplication of the first sound arises are not such as to put stress upon the auricle, or to render its contraction audible, were this liable to occur. The high arterial tension and resistance in the peripheral circulation affect the ventricle, not the auricle ; the extra effort required to expel the blood from the ventricle in systole does not imply hindrance to its influx from the auricle during diastole and, until the mitral valve gives way and becomes incompetent, there is nothing to give rise to dilatation or hypertrophy of this cavity. Having frequently seen and felt and applied the stethoscope to the naked auricle, when assisting Dr. Sibson in his investigation of the changes of form which the heart undergoes in systole and diastole, I cannot understand how its contraction could under any circumstances give rise to an audible sound. That the reduplication of the first sound is due to asynchronism of the initial systolic contraction of the ventricles appears to me to be placed beyond the reach of doubt by two facts, The first is one which wa;5 74 The Pulse. [Chap. iv. originally adduced by Dr. Sibson — namely, that if the two cusps of a double stethoscope are placed one over the right and the other over the left ventricle; at points where on separate examination only a single sound, that of the subjacent ventricle, is audible, the two sounds are found not to coincide and the reduplication is heard. The second is that the asyn- chronism can often actually be felt, as well as heard, by pressing the fingers or the ball of the hand well into the intercostal space just to the inner side of the apex beat. When the impulse is distinct and the reduplication well marked, in a thin subject, two beats, clearly recognisable as belonging, one to the left, the other to the right ventricle, are felt quite distinctly. This I have habitually pointed out in the wards of St. Mary's Hospital for many years, and the obser- vation has been corroborated by a long series of resident physicians and clerks. 75 CHAPTER Y. INCREASED FKEQUEXCY OF THE PULSE. As lias been already said, many of the indications obtained from the pulse do not depend upon a com- prehension of the circulatory conditions which the varieties of tlie pulse denote, or, indeed, ujDon a know- ledge of the circulation at all. The ordinary diag- nostic and prognostic indications of the pulse are learnt only by experience. Observant physicians before the time of Harvey could gauge thoroughly the state of the patient in fever from the pulse, and it is not for the purpose of estimating the movement of the blood that we ourselves, in a case of fever, count the beats and note their force and volume. We calculate from the data thus obtained the strength of the sufferer and the effect upon him ot" the disease ; and we might or might not do this more accurately than our predecessors. On the other hand, it is only through a knowledge of the conditions which govern the circulation that such facts as the connection be- tween kidney disease and cerebral haemorrhage can be utiderstood, and that the prognostic significance of the hard pulse, which betrays this connection, can be appreciated. I propose, then, to consider first deviations from normal frequency, and abnormalities of the rhythm ; next variations of tension, their causes and conse- quences, and the indications for treatment which they furnish. The average frequency of the pulse in the adult male is 72 beats per minute ; in the female about 80 ; in the child it is much more frequent, and it gradually loses in frequency from infancy onwards. There are 76 The Pulse. [Chap v. slight diurnal variations, traceable perhaps to meals and exercise, but, independently of any such influences, the pulse is more frequent in the evening than in the morning, and it would appear from various considera- tions, but principally from what is observed in certain forms of disease, that daring a long night's sleep the circulation runs down in vigour as well, and not only in frequency. It is in the early morning that depres- sion of spirits is liable to be at its worst in nervous debility, so called ; or there is the morning headache which is relieved by the bath and breakfast, or wears off as the day advances; or the subject of this affection is more tired on waking up than on going to bed. In heart disease, again, the sufferer wil wake up gasping for breath after sleep, and paroxysms of asthma and the fits in epilepsy choose this time for coming on. The rate of the heart's action, with which the frequency of the pulse corres2:>onds, is governed by various influences. Resistance to the onward current of blood in the arteries, or, in other words, increase of pressure in the arterial system, whether produced by compression of large vessels, such as the femorals and brachials, or by obstruction in the arterioles and capillaries, tends to slow the action of the heart and render the pulse less frequent, and, conversely, dimin- ished resistance, or lowered tension, accelerates the heart and pulse rate. But more direct and powerful than these variations of the arterial pressure and entirely overruling their tendency, are nervous in- fluences, of which the channels are the pneumogastric and sympathetic nerves, the former inhibitory, the latter exciting. It is not my intention to enter at all upon a discussion or explanation of the respective action of these nerves ; this would help us very little clinically and knowledge with regard to them has not yet reached a perfectly stable condition. The ques- tion, too, is rendered complex by the fact that nervous Chap, v.] FrEQUEXCE OF PULSE. 77 influences reach the arterioles and capillaries as well as the heart, and modify the outflow of blood and the arterial tension ; and an efl'ect upon the heart, apparently dii'ect, may be brought about indirectly through variations in the degree of resistance in the circulation. Exertion of any kind at once sends up the pulse rate, and the action of the heart is more forcible as well as more frequent. At iirst the tension in the arteries is raised and the pulse is vehement ; but in a short time the artery is no longer full between the beats, and these, while still sudden, lose their force, becoming short and unsu stained. The regulating nervous apparatus no doubt plays an important part in the acceleration of the heart's action produced by exercise, but there is a physical necessity and cause for it which would explain it. The first eflfect of powerful general muscular action is to drive the blood along the veins towards the heart, and the right auricle and ventricle are at once dis- tended. To pass on the blood through the lungs as fast as it arrives, the right heart must act more frequently and pow^erfully and the stimulus to this exists in the increased pressure on its inner surface. For a time there is accumulation in the pulmonary circulation and while this is the case there is dyspnoea and shortness of breath and panting ; but when the indi^ddual is vigorous, the circulation in the lungs and system becomes equalised and he gets his second wind, as the term is. Position influences frequency, there being, on an average, a difference of eight beats per minute between the standing and the recumbent posture. The greater frequency in the upright position is not due to the muscular exertion required to assume and maintain it. The general blood pressure in the arteries has been found to be greater in the horizontal position of the 78 The Pulse. [Chap.V. body, and this probably is the influence which slows the action of the lieart. Excitement of any kind accelerates the pulse, as do all powerful emotions. For the most part they also cause contraction of the arterioles and so give rise to an increase of tension. There is, however, great diversity in this respect between emotions of different classes and also in respect of the force of the heart's action. Fear, for example, while increasing the frequency of the heart's action will render it feeble, while anger will make it violent. The effect of excitement must always be taken into account when examining the pulse, and it must be borne in mind that the tension as well as the frequency may be increased ; the sudden acceleration of the heart's action may of itself give rise to a temporary fulness of the arterial system and increased blood pressure, by the greater number of times per minute which the ventricle discharges its contents into the aorta. Food accelerates slightly the heart's action, re- laxing also the peripheral vessels. Stimulants do the same in a more marked degree. External warmth, again, increases slightly the frequency of the pulse and relaxes the arteries. There are certain drugs which increase the frequency of the heart's action, and therefore of the pulse ; these belong mostly to the class of stimulants. Some produce this effect through the central nervous system, such as the alcoholic and ethereal stimulants ; but, as most of them also dilate the peripheral vessels, the lowered tension and diminished resistance so brought about may contribute to the result. It may also be maintained that there is direct stimulation of the heart itself. Such agents as nitrite of amyl, nitro-glyceiine and the nitrites, while causing accelera- tion of the i^ulse, act primarily and chiefly upon the arterioles and capillaries. Chap, v.] Respiration and Pulse. 79 Other stimulants excite the heart to more rapid action mainly by excitation of peripheral nerves. They are characterised by pungency and comprise the essential oils; ammonia also belongs to this group, for, although its salts relax the arterioles and ac- celerate the pulse slightly, their action in this respect is not to be compared with that of free ammonia, which possesses pungency. Ammonia applied to the nostrils, when only the most minute quantity can be absorbed, excites the heart's action. In another class of cardiac excitants will come belladonna and its alkaloid, atropine. The influence of the respiratory movements and of variations of intrathoracic pressure upon the pulse is a question of considerable interest. In disease it often becomes manifest, as in emphysema, when the intra- thoracic pressure is very diflerent in inspiration and expiration ; it is seen again in the pulsus j^aradoxus, and it probably plays an important part in producing the irregularity of the heart's action in mitral disease. Neither the results of the respiratory variations of pres- sure nor the way in which these results are brought about, are set forth very clearly in the works on phy- siology which I have consulted. Such effects must be due entirely to the influence of pressure-variations on the veins and auricles, and on the movement of blood through the pulmonary capillaries; perhaps in some small degree to influence on the ventricles in dias- tole. The normal difference of pressure between in- spiration and expiration can have scarcely more direct effect on the aorta or on the pulmonary artery, than if their walls were made of metal, the pres- sure within these vessels being so great ; and the same may be said of the ventricles during systole : the principal effect on the pulse will be due to the influence of the respiratory movements on the filling of the left ventricle, and this will depend on their So The Pulse. [Chap. v. influence on the auricles. If a deep inspiration be taken and the breath be then held, the glottis being closed and pressure exerted on air contained in the chest, the pulse rapidly becomes small and weak ; the pressure on the thin- walled auricles interferes with their action and with the supply of blood to the ventricles. The pulse rate may be increased or dimi- nished. Similar effects are produced by holding the breath after a deep expiration. During an ordinary inspiration, venous blood is drawn into the chest along the great systemic veins and the right auricle is well filled, and the right ventricle well supplied, since the slight general negative pressure will scarcely affect the auricular contraction. The converse will take place in expiration. The effect on the left auricle is not so simple, as the pulmonary veins which supply it are exjiosed to the same negative pressure ; the greater surface of the auricle as com- pared with the veins will, however, promote influx into its cavity and a larger charge will be delivered to the ventricle. In investigating the effect of varying respiratory pressure, however, no account has been taken of the degree of tension in the arterial system of the subjects of the observation, and as this appeared to me likely to influence the result, I requested Mr. Eustace M. Cullender, while my house physician, to take sphyg- mographic tracings from two young men of good physique, both notable football players, one of whom had physiological high tension, the other low tension. The observations were taken first during ordinary tranquil breathing and afterwards when the intra- thoracic pressure was varied in a positive and nega- tive direction and in different degrees. It will be seen that the high tension pulse takes little or no notice of variations, which produce extraordinary perturbations in the low tension pulse. (Figs. 18 — 26.) Chap, v.] Respiration and Pulse 8i High Tension, Lo'u- Tension. Fig. IS. — Wliile sitting at ease and breatliiBg normally. Higli Tension Lq-w Tension. Fig. 19. — While holding the Breath, at the end of ordinary Inspiration. G— 27 The Pulse. [Chap. V Higti Teusion. Low Tension. Fig. 20.— ^hile holding the Breath at the end of ordinary Expiration. High Tension. Low Tension. Fi . 21.— Breath held at the end of dcej) Inspii-ation. Chap, v.] Respiration and Pulse. High Tension. Low Tension. Fig. 22.— Breath held, at the end of deep Expiration. High Tension. Fig. 23.— WMle sitting quietly, but taking'very deep Breaths at about the rate of Twenty per Minute. 84 The Pulse. [Chap. V Low Tension. Fig 23.— While sitting quietly, but taking very deep Breaths at ahout the rate of Twenty per Minute. High Tension. Low Tension. Fig. 24.— "While Breathing naturally after taking Forty such deep Breaths. Chap, v.] I^ESPIRATION AA'D Pl'LSE. High Tension. Low Tension. Fig. 25.— Breath held at the end of deep Inspiration after Forty deep Breaths. High Tension. Fig. 26.— Breath held at the end of Expiration after Forty deep Breaths. 86 The Pulse. [Chap. V. Low Tension. Fjg. 26. — Breath held at the end of Expiration after Forty deep Breaths. Increased frequency ol pulse in disease.— Almost all departures from a normal state of health are attended with increased frequency of the pulse. Even debility and anaemia have an average pulse-rate above the normal, but more marked than the frequency in these conditions is the increased mobility of the pulse under exertion or emotion, the least muscular effort or change of position sending up the frequency inordinately. Pyi-exia, as such, gives rise to marked and continu- ous acceleration of the pulse and to great relaxation of the peripheral vessels. The force of the heart's action may be increased or diminished, and the vehemence of the beats will vary accordingly. In sthenic pyrexia, such as attends acute inflanmiation, and generally in the early stages of fever, the force of the cardiac systole will be augmented and the pulse w^ill be frequent, sudden, vehement, large, short and dicrotous,giving a corresponding trace when the sphygmograph is applied. When the action of the heart is weak the jDulse loses in vehemence, and, when Chap V] FkEQUEXCY OF FULSE. 87 the weakness goes beyond a certain point, in sudden- ness and size, dicrotism being still well marked. Tlie frequency of the pulse bears some sort of relation to the pyrexial temperature, being usually greater as the temperature is higher in fever of the same character, and the pulse and temperature taken together mark the severity of the attack and the im- pression made upon the system. It might, perhaps, almost be said that^ while the temperature shows the degree of fever, the pulse indicates its effects on the system, and the efficiency of the constitutional reaction. The frequency of the pulse, then, is often of great prognostic importance. At all stages of the specitic fevers it is noted carefully ; at the outset it denotes the severity of the attack ; towards the end it tells whether the strength is sustained or is failing ; the increase of a few beats per minute daily at this period will be a source of grave anxiety, even independently of the vigour of the heart's action. The degree of frequency of the pulse, again, is one of the points by which septic fever is distinguished in surgical cases, and extreme frequency is often the first indication of deadly puerperal septicaemia. This ex- treme frequency may be regarded as a sign of shock, or as denoting the serious impression made upon the vital powers by the poison. Shock from other causes may be marked by a racing pulse, and, when such is the case, there is always danger. Among the causes of unusual frequency of pulse, scarlet fever must not be forgotten. At the onset of this disease a pulse of 120 to 140 is not uncommon in adults, and in children it may reach 160 or 200 beats per minute. So far, increased pulse frequency has been one among many other symptoms and has been a conse- quence and not in any sense a cause of the disease. But there are many affections in which the unduly &S The Pulse. [Chap. v. frequent pulse is, so to speak, of the essence of the disease, the disorder of the circulation of which it is the index constituting indeed sometimes its most im- portant factor, and not being a mere sign of its exist- ence. These must now be considered. Persistent frequency of pulse.— Persistent frequency of pulse is one of the signs or consequences of overstrain of the heart by exertion. It is met with in young men who have overtaxed their powers in row- ing, training for races, or by heavy gun drill, and was observed on a large scale in the American war, among men taken from sedentary or other occupations not attended with great exertion, and called upon to under- go protracted drilling or to make long and trying marches. The name "irritable heart" employed as a descriptive term may very w^ell be accepted. Besides the beating of the heart of which the patient is con- scious, there are breathlessness on exertion, nervous- ness, depression of spirits and anxiety, sensations of faintness, sleeplessness, and incapacity for sustained exertion. In all cases of this kind which I have seen the pulse-tension has been high. The great remedy for this condition is rest, and from one to three weeks may be well spent in bed, however irksome and wearisome it may be at this period of life, in allowing the heart to settle down. During and after middle age persistent frequency of pulse may be induced by a single act of excessive exertion, such as running to catch a train. The effects upon the heart of such an imprudence vary ; there may be dilatation of one or other ventricle or of both, with or without insufhciency of the mitral valve ; or a ^ alve may be actually damaged, or the action of the lieart may become irregular ; but the heart's action may become, as the result of strain, hurried, without irregularity and without obvious lesion, and the fre- quency may persist till the strength of the patient is Ciiap.V.] Frequency of Pulse. 89 worn out. Here, again, the arterial tension is, accord- ing to my experience, high, resistance in the periplieral vessels contributing to the effect, so that the distension of the arteries is not simply the result of blood being driven into tlie arterial system in consequence of the increased frequency of the heart's contractions. No satisfactory explanation has been given of these cases, and I have none to offer. Perhaps the most plausible is that the plexus of minute nerve-ganglia and network of fibres so copiously distributed beneath the endo- cardium may have been stretched and rendered unduly irritable. Oraves's or Base«low's disease, Ex«ph- thalmie Ooitre. — Inordinate frequency of tlie pulse is one of the tripod of symptoms which con- stitute Graves's disease or exophthalmic goitre. The three are — enlargement of the thyroid glynd, proptosis, and excitement of the heart's action. Together with the protrusion of the eye, there is retraction of the eyelids, and also a want of readiness in the upper lid to follow the eye downwards, so that the white sclerotic shows above the cornea, adding to the oddity of the patient's appearance. The protrusion of the eyes, however, may be absent, and occasionally the goitre may be small. The frequent and A'iolent action of the heart is, perhaps, the most constant and the most characteristic of the symptoms. The pulse is seldom under 100 per minute, often 120 or over, sometimes 160 to 200. In a case recently under obser- vation the pulse was never under 160 for many weeks, and in paroxysms of palpitation it sometimes num- bered 240 for seA'eral days, reaching at times 300. The beat is sudden, sharp^ and vehement ; and its very frequency renders it short. The artery has not time to subside ; but, though it is full between tlie beats, there is no peripheral resistance and no real pulse-tension. 90 The Pulse. tchap. v. Tills affection is evidently a neurosis, and a very jjlausible theory with regard to it is that it is due to disease of one or more of the cervical a:ano;lia of the sympathetic. This, however, cannot be looked upon as established. Further evidence of the neurotic origin of ex- ophthalmic goitre is found In the extraordinary pig- mentation of the skin, which is sometimes present. It may simulate in tint the bronze skin of disease of the suprarenal capsules, but has not the same distribution. The heart-sounds are loud and short, the first especially, the second being relatively weak. The relative length of the Intervals is little disturbed. This disease is most commonly met with in young women, but may come on in middle life and may affect men. Its causes are mostly such as are attended with excessive wear and tear of the nervous system : long hours, over- work, confinement to close rooms, unnourishlng food — conditions to which semp- stresses, shop-girls, and other women following similar occupations in towns are subjected, aided very often by uterine derangements. Other causes are frequent child-bearing and over-suckling, anxiety, and distress of mind. It usually comes on slowly, but may develop rapidly, and has been known to do so after mental shock. Its duration is long, and may be reckoned by months and years. Two years is, perhaps, a low av(jrage, but not uncommonly it resists all treatment and is incurable. It is mostly attended with considerable wasting, and indeed usually comes on in thin subjects. The sufferers are anaemic, breathless, liable to palpitation, dysj)eptic, and subject to constipation ; they are nervous, and sleep badly. Chap. \'. J FkEQUEXCV OF FuLSE. 9 1 One of the painful effects sometimes met with is destructive inflammation of the eye from exposure, the lids not being able to meet and cover it. Con- junctivitis and ulceration of the cornea from this cause are often troublesome. The treatment required consists of rest, which is of the first importance, so" that in bad cases the patient should be kept in the recumbent posture for the greater part of the day ; good food, iron, and arsenic, aloetic and tonic aperients, and other means Avhich may be required for the improvement of the general health. The special remedies suggested by the cir- culatoiy and other characteristic symptoms are digitalis, strophanthus, cafieine, and medicines belong- ing to the same class. These are, perhaps, the most generally useful, and sometimes seem to have an immediate palliative effect. Sedation of the heart and pulse by aconite has been tried, but tins drug is dangerously depressing. A line of treatment which has sometimes been attended with marked success is the administration of belladonna or atropine in gradually increasing and ultimately very large doses. Galvanisation of the sympathetic in the neck has been suggested, and has been reported to do good. For the most part, however, it is time and the gradual re-establishment of the general health and nervous tone by rest, food and tonics, and the removal of functional derangements, gastro-intestinal and uterine, which eftect a cure. Aortic piilsatiou. — Cases are met with, so far as is known to me, only among women, and usually at or after middle life, in which, with remarkable rapidity and violence of the heart's action^ and, of course, a corresponding frequency of the pulse, there is an extraordinary vehemence in the pulsation of the abdominal aorta. The beatino- is a source of constant discomfort, sometimes of actual pain, to the 92 The Pulse. [Cbap. v. patient, and is cohsjnciious both to the eye aiid hand of the observer. I have known it to be so violent as to be seen and felt through the dress, stays included. It is not to be wondered at that this condition is often taken for aneurism, but on reflection it will occur to the mind that aneurism is not attended with the constant excitement of the circulation, the violent action of the heart, and the frequent pulse, wliich are present ; and on examination, although the pulsation seems to extend laterally Vjeyond the normal limits, the pulsation is not localised in any particular part of the aorta, but can be followed along its whole length, and is found to extend beyond its division into the common iliac arteries. Where the pancreas lies across the vessel the thickness of the gland causes the pulsation to be felt over a larger area, especially laterally to the left, which may simulate a local dilatation of the aorta, and the pulse of the splenic arter}'- may contribute to this. The explanation of the violent throbbing of the aorta is not clear. Of course, the action of the heart is the primary cause, but there may l)e powerful and abrupt cardiac contraction without this effect. In some respects the aortic pulsation resembles the exaggerated beat in a ligatured artery, but the con- dition of the arterioles is not such as to coiToborate this comparison. It might, again, be an effect of extreme low tension in the visceral arteries and in the arteries of the lower extremities, allowing of extreme alternations of distension and relaxation of the abdominal aorta. The easiest hypothesis would be to suppose that the coats of the aorta itself were relaxed, from deranged vaso-motor influence or loss of vaso-motor control ; but the muscular element in the arterial walls suljject to such control is at a minimum in the large arteries. The general condition of the patient is very similar Chap, v.] Palpitation OF the Heart. 93 to that of the sufferer from exophthalmic goitre, and the two att'ections belong probably to the same class. The causes are much the same, and the ti'eatment would be conducted on the same princi])les. Palpitation of the heart. — Palpitation of the heart has not a very dehiiite signification. It may mean a beating of the heart of which the subject is conscious, whether this is unduly frequent or not, and whether it is unduly forcible or not, as felt or heard by the observer. Again, it may mean undue rapidity and violence of the heart's action, whether attended or not with conscious discomfort to the patient. We are here, however, concerned only with such forms as are attended with frequency of the pulse. Palpitation, so understood, varies extremely in its. significance ; it may be a mere passing disturbance set up by flatulence or indigestion ; it may be a severe recurrent affection easily provoked by emotion or excitement, symptomatic of a weak and disordered state of the nervous system, or of anreniia and de- bility, or attendant on a gouty state of system ; and is often a cause of extreme discomfort and of un- controllable nervous dread, sometimes renderinir the sufferer incapable of all business and enjoyment ; it may, again, be a symptom of complete and irreme- diable cardiac or nervous breakdown, and will be one of the effects of such breakdown which will help to wear out the strength. In the minor form of palpitation the attacks may come on at different times — soon after a meal, or at an interval of some hours ; very often in the night. There may or may not be antecedent discomfort of one kind or another — a feeling of fulness and dis- tension in the epigastrium, or a sense of oppression in the chest. In the night there may have been dreams, usually, but not necessarily, of an unpleasant 94 The Pulse. [Chap. v. character, or actual niglit-mare, out of which the patient wakes with the heart beating violently, some- times as if from fright or other powerful emotion arising out of the dream. Usually some discomfort lias lasted for a time, when the heart suddenly goes off with a kind of leap into ra[)id action, sometimes appearing to the subject to roll or turn over. There is more or less of a feeling of breathlessness and oppression, sometimes of anxiety, in severe cases of faintness and giddiness, so that the patient must lie down. On these symptoms we need not dwell. The pulse is frequent, short, variable in fulness and strength, rarely at all vehement, sometimes irregular. The attacks may be over in a few seconds or minutes, and pass off spontaneously, or may last an indefinite time, unless some remedy is applied. A teaspoonful or two of brandy taken neat, half a drachm or so of sal volatile with a little carbonate of soda ; or, in more severe cases, the well-known haustus stimulans, compounded of ammonia, ether, chloroform, spirit of lavender, with camphor water, will generally put an end to the attacks, usually with more or less eructation. At times an emetic will be required, especially when the stomach has been over- laden, or food of a particularly indigestible kind has been taken. The more serious kind of palpitation may also be, started by gastric derangement, flatulence, an ill- digested meal, or the like ; but when the predisposi- tion has been generated, no care in diet will entirely prevent the attacks, and there is danger lest the fear of taking food should increase the debility on which they depend. A more common exciting cause is emotion or excitement, which may be extremely slight, the mere apprehension of an impending attack being sufficient to bring it on, or the expectation of an interview, or the mere idea of seeing a friend will Chap, v.] Palpitation OF the Heart. 95 have this effect. A sudden noise, again, such as a banging door, or a step, or the rustle of a leaf may start a paroxysm. Where the predisposing condition is gout, slight exertion, or a particular position, or a tit of temper will perhaps induce an attack ; but acid and flatulent dys2oepsia is common as a cause. Hysterical palpitation might either be classed with the severe forms on account of the violence and duration of the paroxysms, or with the slight forms, as leaving the patient little the worse when the attacks are over. It is late in life that paroxysmal palpitation with frequency of pulse is most commonly a cause of suffering and danger, shortening life and rendering it miserable. It may complicate heart disease of any kind^ and may possibly sometimes be one of the con- sequences of the disease ; but it may occur inde- pendently of valvular affection or of any structural change sufficiently advanced for recognition, and it has seemed to me that when disease of the heart is present, the palpitation is often rather a complication than a consequence. The exciting cause may be indigestion and flatulence or the mere act of taking food, lying down, emotion, apprehension of an attack at a particular hour, or under given circumstances associated with former attacks ; but whatever this may be, the onset of the paroxysm is frequently accompanied by a sudden relaxation of the arteries, and the palpitation seems to resemble the excited action of the heart set up by nitrite of amyl or nitro- glycerine. Resistance to which it is habituated is suddenly removed and the heart starts oft" like the engine of a locomotive when the wheels fail to bite the rails. In the course of a prolonged attendance upon a medical man advanced in years and long subject to gout, who suffered greatly from palpitation, this occurred more than once when my hand was actually 96 The Pulse. [Chap, v. on the pulse ; the artery became large and soft, and there was a flatter of the heart, which then bounded ofll A remarkable complication occurred in this case which is worthy of being related. Early one morning the patient began to bring up bloody fluid from the lungs, and in the course of twenty-four hours expec- torated several pints of it. A pink froth covered the bright red liquid to the de[)th of half an inch, and the Avhole looked very much like the boiling red currant juice in the process of making jelly. There was no rise of temperature, the flux of blood-stained serum gradually ceased and the palpitation did not recur for several months, when after imprudent fatigue and exposure it returned, and ultimately wore out the patient. It should be added that there was no valvular disease and only moderate dilatation and hypertrophy with old-standing high arterial tension. In the severe palpitation now under consideration, the action of the heart is generally irregular, sometimes extremely so, and this irregularity is exaggerated in the pulse by the beats being very unequal in strength and by many of them failing to reach the wrist. The heai't sounds are short and confused, defying descrip- tion and often analysis, so that it is impossible to say which is most distinct, the first sound of the right or left ventricle, or whether the pulmonary or aortic second sound is the more accentuated. A short, smooth, high-pitched systolic whifi* is often audible near the ai:)ex, or in the tricuspid area on careful listening. The paroxysms are attended with extreme distress and suflTering, and tliere are not only greater oppression, more vertigo, worse faintness, with pallor and cold perspiration, but the attacks last longer, and when they have passed ofl* leave the patient pale, weak and depressed, perhai)S for the rest of the day or till after sleep. In the worst cases the attacks of palpitation become Chap. v.] Palpitation of the Heart. 97 so frequent that they ahiiost run into each other and become continuous. This condition may be reached gradually, the paroxysms, which at first seemed to be at- tributable to some exciting cause or other, coming on without provocation ; or it may be established abruptly with or without apparent cause. No descrij)tion can convey an idea of the suffering and misery of the patient. Awake he is breathless, or rather, has a besoin de resjnrer, which it is impossible to satisfy, and which makes him take deep voluntary inspira- tions ; he has an abiding sense of oppression and anxiety and faintness j he feels painfully in need of support, yet dare scarcely eat or drink ; not un- commonly, however, the conscious sense of palpitation is absent, or is present only at intervals. Asleep in his chair, which happens from time to time from utter exhaustion, the face twitches and the limbs jerk, and he wakes up with a start and is not only unrefreshed, but feels as if the nap had started the palpitation. He is usually able to lie down in bed at night, but tosses restlessly and cannot sleep, or, if he does so, will often wake with a sense of impending death, feeling as if the heart had stopped and could only be started again by an effort of the will. Death may be sudden in the sleep or during some slight exertion, or it mav come as the result of crvadual exhaustion of the most distressing character. I have more than once in a gouty condition of the system known a severe attack of palpitation to es- tablish mitral regurgitation, the usual effects of which have been speedily developed : a systolic apex murmur, never before heard, has appeared and persisted, the result, no doubt, of dilatation of the left ventricle. In the treatment of the attacks, the remedies already enumerated will be tried, with, in some cases, bromides, in others, valerian ; or oil of cajuput may be given, three to five drops on a piece of sugar. 11—27 98 The Pulse. [Chap. v. Digitalis and ammonia, stropliantlius_, or convallaria may be given and sometimes afford relief, as may- ether or chloroform. Ether hypodermically may pro- duce striking alleviation, but it is generally fugitive. A. sinapism or turpentine stupe, or chloroform and belladonna liniment sprinkled on spongio-piline wrung out of hot water as an application over the heart and epigastrium will often quiet the palpitation for some time and afford an opportunity for sleep ; a belladonna plaster may be employed as a preventive, and it often seems to keep off the attacks ; it is decidedly more efficacious when so applied as to give support. A dozen very deej) breaths may stop an attack at the outset ; this is especially the case in hysteria. The most important point in the treatment is, however, to i-emove the constitutional condition which j>redisposes to the attacks by such measures as are adapted to the purpose. A careful mode of life, with attention to the diet, and to the regular action of the bowels, none but very gentle exercise being taken — this, however, not being neglected — may enable the heart to recover itself, and small doses of digitalis or strophanthus will contri- bute to this. Convallaria may in such cases do better than either. Differing from ordinary palpitation in many respects is an extraordinary rapid action of the heart lasting for days or weeks, or even months, with or without severe distress, to which Dr. Bristowe called attention in Brain for July, 1887. A case of the kind has recently been under my care at St. Mary's hospital. The patient, a married woman from the country, a fruit-gatherer, aged 40, was well-nourished, and had a good colour ; she had had rheumatic fever fifteen years before, but, with this exception, liad never had a day's illness till nine weeks before admission, when she began to suffer every three Chap, v.] Persistent Frequency OF Pulse. 99 or four days from attacks of pain under tlie right shoulder-blade, with sickness, and then for a few days she had felt weak and trembling. The pulse was found to be extremely frequent, and on this account she was sent into the hospital. After admission, the heart beats were 152 in the minute ; the pulse could not be accurately counted on account of inequality and slight irregularity. She was not conscious of any heart trouble, and after a few days looked and felt well. There were no cardiac murmurs. She was made to remain in bed and strophanthus was given. The progress of the case will be best shown by a series of sphygmographic traces. (Fig. 27.) Before Strophanthus, May 4tb. After Strophanthus, May 5th. May Gth. Fig, 27.— To illustrate Case of rapid Action of the Heart. June isc. Fig. 27.— To illvxstrate Case of rapid Action of the Heart. There was great improvement, but the lieart was in a very unstable condition when she left the hospital. Other examples have come under my notice from time to time. One is related in a lecture published in the Lancet for 1875 (vol. ii. p. 442). The patient, a lady's maid, was supposed to be suffering from some sudden affection of the lungs; when first seen she was sitting up in bed with a pale and anxieen known to exist for forty years. Dr. B. W. Richardson, however, states that acute disease is not well borne wlien the pulse is inter- mittent. Chap. VII.] Irregular Pulse. 127 A practical question not unconimonly arises as to whether it is safe to administer chloroform when the pulse is intermittent. I do not hesitate to authorise it when consulted on the subject, on condition that the pulse be carefully watched. The rule is that the chloroform suspends the intermission ; should it have a contrary effect from the first, the pulse becoming weak and irregular, fatty degeneration of the heart may be suspected, and the administration should be at once stopped. It is unnecessary to say that no treatment of intermittent pulse, as such, should be attempted. When it is traceable to tobacco, tea, or coffee, these should be relinquished ; and when it is symptomatic of indigestion, or other cause of reflex disturbance of the heart, appropriate remedies should be applied. If the nervous system is depressed, influences tending to this should be removed, and such tonics as strych- nine and arsenic or zinc may be given, or occasional bromides. Irreg'iilar pulse.— This term conveys its own meanino- ; the beats follow each other at irreijular intervals, and are unequal in force. In degree, ir- regularity of the pulse varies greatly, and it is not impossible that different varieties may have a dif- ferent significance. Slight irregularity needs no further notice ; but when it is extreme there may be a rapid succession of small, weak beats, and then a few large and distinct: or there may be no method whatever in the irregularity, no two beats being alike, either in time or force. Irregularity, like intermission, may be either habitual or occasional. When occasional, it may be induced by reflex disturbance of the cardiac rhythm, by gastric derangement, with or without flatulence, by flatulent distension of the colon, or by other functional affections. A\nien there is distension, either of the 128 The Pulse. [Chap.vii stomach or colon, it may be mechanical embarrassment of the heart by upward displacement of the diaphragm which sets up the irregular action. Tobacco is a very common cause of irregular and weak pulse, especially the stronger forms and such as are rich in nicotine. In one case in my experience, irregular action of the heart, attended with unusual discomfort, was traced to a particular and very fine brand of cigars. Tea in this respect is to women as tobacco to men. Irregularity of pulse and palpitation mostly go together as symp- toms of reflex disturbances. The regularity of the pulse may be disturbed either temporarily or permanently by affections of the respi- ratory organs. The pressure in the large arteries near the chest rises and falls with each respiration, and the influence on the circulation thus manifested as a normal phenomenon, is sufiicient to afiect the regularity of the action of the heart when exaggerated in any way. A deep inspiration, and still more, to hold the breath either at the end of inspiration or expiration, will aflect the pulse, as has been shown in a previous chapter. The respiratory variations in the blood-pressure are variously explained. Professor Burdon Sanderson attributes them, in his " Croonian Lectures," to the effect on the respiratory centre of varying aeration of the blood ; Marey, to the varying pressure upon the aorta. But it seems to me that the respiratory varia- tions of pressure will tell most on the thin-walled auricles ; and that while in the right inspiration helps to draw blood from the vena cava, in the left it will influence the amount of blood passed on into the ventricle. Respiratory effort when the air-passages are obstructed will intensify such effects, and these will be still greater when the lungs themselves are affected, as in bronchitis, and obstruction in the pulmonary circu- lation is added to obstruction in the minute bronchial tubes. The frequency of the pulse and other changes Chap. VI I J Irregular Pulse. 129 ill the circulation due to pyrexia, disguise, more oi' less, the irregularity of the pulse in acute bronchitis, but this is often distinct in chronic bronchitis and emphysema; and it may be noted on careful observa- tion tliat tlie effect on the pulse is most marked at the end of inspiration and (ixjiiration, and is thus coincident with the changes of pressure in the chest. Habitual irregularity of pulse is a common result of mitral insufhciency, and among valvular affections of the heart is the characteristic pulse of tliis form of disease. It is so frequent in mitral regurgitation, and so rare in other forms of valvular disease, that it can scarcely be put down to any secondary alterations of the cavities or w^alls of the heart ; still less can it be attributed to nervous influence. It appears to me that it is explained l^y mechanical or hydrostatic con- ditions, peculiar to insufficiency of the mitral valve, which intensify the effect of the varying pressure upon the heart in respiration. The heart lying in the mediastinum between the lungs is habitually exposed to negative pressure ; the lungs, were the pleural cavities opened, would collapse, and this tendency to collapse, which is only prevented by their being lodged in closed cavities, will exercise traction on all the walls, the costal parietes, diaphragm and mediastinum ; the lungs, therefore, do not press upon the pericardium, but drag upon it and upsm the great vessels, and the suction - action thus caused io a recognised aid in promoting the flow of blood in the vena cava into the right auricle. When from damage to the valve there is reflux of blood from the left ventricle into the auricle, the auricle is dilated and, although there is some hypertrophy of its muscular walls, these are still so thin and flexible that they are incapable of resisting variations of ext(3rnal pres- sure^ Uie influence of which will be all the greater in consequence of the dilatation, Now, in mitral J— 27 T30 The Pulse. ichap. vii. regurgitation, the blood is driven partly onwards into the aorta, partly back again into the auricle, and the proportion which passes onwards or backwards will depend on the degree of resistance met with in one or other direction : if the pressure in the arterial system is low, and that in the pulmonary veins and left auricle great, there will be little reflux into the auricle, however slight the obstacle presented by the damaged valve ; if, on the other hand, the systemic arterial tension is high, while the pressure in the auricle is low, the regurgitation will be consider- able. Whatever, then, increases or diminishes the blood pressure in the auricle, will have a correspond- ing effect on the amount of regurgitation. Now, the dilated left auricle Avill be supported by a certain amount of pressure during expiration which will tend to resist distension by the regurgitant blood ; but at the end of expiration the conditions are suddenly re- versed, and it will be exposed to the negative pressure or suction-action which fills the chest with air, so that the reflux is favoured. The sum total of the resistance to the ventricular systole is thus diminished at this moment, and the systole is con- sequently very rapid, at the same time that less of the blood goes forward into the aorta. At the end of inspiration opposite forces come into play, and the repetition every two or three beats of these disturbing influences quite accounts for the irregularity of the heart's action. In an early stage the irregularity can be seen to occur coincidentally with the end of in- spiration and expiration. It is the incompetence of the mitral valve which exposes the ventricles to the respiratory pressure variations. In mitral stenosis, although the auricle is dilated and subjected to the varying pressure of the respiratory movements, the narrowed orifice prevents this from taking effect on the ventricle, Chap. VI 1.] Irregular Pulse, 131 Dilatation of the heart is frequently but not con- stantly attended with irregularity of the pulse ; when it is present its influence and significance arc not very clear, and the prognosis is determined by other con- siderations. Extreme and habitual irregularity of the pulse may be present which cannot be traced to any other cause, and must, therefore, be attributed to the nervous system. Irregularity of pulse of nervous origin is illustrated by the disturbance of the cardiac rhythm in dyspepsia and by tobacco, already mentioned ; but it may be present in an extreme degree independently of any recognisable influence, and may be habitual. There need be no affection of the general health, or impairment of vigour or endurance. In one of the worst cases I have ever seen, the patient, who was for some time under my observation, was, long after the age of sixty, in the habit of addressing public meet- ings. The trace exhibited was taken recently upon a gentleman, now aged seventy, who consulted me twenty years ago on account of irregular action of the heart, and has had it ever since. (Fig- 36.) I Fig. 36. — Irregular Pulse. am unable to fix any prognostic value on irregularity of the pulse as such. Speaking generally, however, irregularity is much more serious than intermission. 132 CHAPTER YIII. THE PULSE AS INFLUENCED BY VARIATIONS IN ARTERIO- CAPILLARY RESISTANCE — LOW ARTERIAL TENSION. The effects on the pulse of variations in the force of the heart's action do not require separate discussion, and we now proceed to the consideration of those characters of the pulse which are due to changes in the vessels. Of these, the most important are those produced by contraction and relaxation of the arterioles and capillaries, which, as has been already said, give rise to the variations in the arterial tension, or pressure within the vessels, by hindering or facilitating the passage of the blood through the capillaries. Seat of arterio - capillary resistance. — A preliminary discussion must be undertaken here : namely, whether the freedom of flow through the peripheral vessels is determined entirely by changes in the size of the arterioles, or is influenced primarily by the degree of obstruction in the capillaries : whether, in fact, the stop-cock action of the arterioles — as the contraction and relaxation of the arteries was happily named by Dr. Geo. Johnson — is the sole or main agency in raising and lowering the arterial tension, or is secondary to changes in the flow of blood through the capillary network. Arteriole contraction and relaxation.— It must be admitted at once that the muscular walls of the minute arteries respond more promptly and energetically to nervous stimuli than the capil- laries ; and in emotional and reflex influence upon the peripheral circulation there can be little doul)t that spasm or relaxation of the arterioles is the Chap. VIII.] ArTERIO-CAPILLARY RESISTANCE. I 33 meclianism employed. When, for example, there is from nervousness sudden and fugitive high arterial tension, it is in part due to tightening up of the minute arteries, and. not solely to the hurried and forcible action of the heart ; and in blushing, it is re- laxation of the arterioles of the atfected region which allows the skin of the face and neck to be flooded with blood. Such relaxation may be partial, as is fre- quently seen on exposing the chest in young women for the purpose of stethoscopic examination, when it is found to be covered with large bright red blotches. Chief resistance in capillaries. — But while the arterioles are competent to influence the supply of blood to different parts and organs of the body, and undoubtedly play an important part in regulating ■ this, in doing which they will produce corresponding effects on the arterial tension by op- posing or facilitating the flow into the capillaries, it is probable that the capillaries themselves are the seat of the principal obstruction to the onward move- ment of the blood, and of those variations in the degree of obstruction which are most influential in modifying the blood pressure. It is indeed certain that it is in the capillary network that the normal physiological resistance in the peripheral circulation takes place, and it is only here that the resulting pressure could have the effect which it subserves, of promoting the transudation through the capillary walls of nutrient material for the use of the tissues. Up to the very edge of this network the blood pressure in the arteries and arterioles is maintained ; beyond it there is only just sufiicient to carry the blood back to the heart in the veins. We might reasonably expect, then, that where the resistance which gives rise to the pressure in the arterial system is originally situated, there would arise those differences in the degree of 134 The Pulse. [Chap.viii resistance which affect arterial tension. Evidences in favour of this view are not wanting:. The relaxation and contraction of the arterioles are reflex, or, at any rate, take place in response to stimulation of their muscular walls by the vaso-motor sympathetic nerves, but experiments with a variety of drugs have shown that variations in the rate of flow through the capillaries and in the arterial tension can be induced when the spinal cord and sympathetic ganglia and nerves are destroyed — i.e. when the vasomotor nervous apparatus is abolished. Drs. Ringer and Sainsbury have described such ex- periments made with the digitalis gi'oup of remedies (Med. Chir. Trans., vol. Ixvii.), and corresponding re- sults have been obtained with aniyl nitrite and other relaxants of the peripheral vessels by Dr. Lauder Brunton. Important evidences, again, are derived from an examination of the minute arterioles in the brain after death, resulting from contracted granular disease of the kidney. When there have been ursemic convulsions, capillary haemorrhages are almost always present in various parts of the cortex, so much so that the late Dr. Mahomed attributed the convulsion to capillary rupture. If the capillaries were protected by contraction of the arterioles, such rupture could scarcely occur. Again, these arterioles are them- selves at certain points dilated into miliary aneurisms and liable to rupture : not where they are given oft' from larger branches, but just where they break up into the capillary network, which shows the obstruc- tion to have been beyond, and not in, the arterioles ; while not only are the perivascular spaces round them large, as if from distension, but a ring of the sur- rounding brain substance is pale, as if from pressure. Another reason is that although the medium-sized arteries (such as the radial) and the small arteries (such as the digital) are usually contracted and small Chap, vm.j Capillary Resistance. 135 in higli tension, this is not always the case, and it seems improbable that in vessels anatomically con- tinuous and physiologically correlated there should be contraction in the minute arterioles without a cor- responding condition of the arteries leading to them. We find, indeed, in cases of old standing high tension, the worn-out arteries large, as well as thick and de- generated, as if they had been unable to resist the distending pressure of the blood within them. Capillary contraction. — Taking it as estab- lished that the capillary network is the seat of the varying resistance which affects the blood pressure in the arteries, a further question arises whether such variations are the result of relaxation and contraction of the capillaries, or of varying cohesion between the blood and capillary walls. Much is to be said for this latter view. Capillary attraction is capable of facilitating or opposing the transit of liquids according to the affinity between them and the walls of the channels ; and capillary force is of itself the agent of the circulation of the sap in vegetables, carrying it to the summit of trees, and back again. There is apparently also ocular demonstration of in- creased cohesion of the white corpuscles to the capillary walls in inflammation. While, however, the affinity between the blood and tissues probably has a share, and sometimes an important one, in modifying the rate of the capillary circulation, the contractility of the capillary walls, which has been demonstrated by Roy and Graham Brown, is no doubt the great agent in the production of the varying resistance which in- fluences the arterial tension. Changes in the blood, which are too slight to affect the cohesion between the blood and the capillary walls, affect powerfully the ai-terial tension, and the variations in the volume of a member, as demonstrated by the apparatus of Mosso and Francois Franck, indicate variations in the 136 The Pulse. [Chap.viii. capacity of the capillaries, best explained by their contraction and dilatation. Although it appears from the preceding considera- tions that the starting-point of the physiological resistance in the peripheral circulation and of the variations in this resistance is the capillary network, tlie arterioles are not without an important share in the process. The contraction of the capillaries is continued backwards along the arterioles to arteries of the size of the radial, and the narrowing of the afferent channels thus produced, at the same time contributes to the production of the arterial tension, and protects ths capillaries from the afflux and pressure of blood ; in like manner when the capillaries are relaxed, the arterioles and arteries are large. The arteries and capillaries, in fact, form part of one system, and the expression arterio-capillary resistance is more exact than when an obstruction is qualified as either arterial or capillary alone. LiOW arterial tension. — The capacity of the arterial system, as has already been stated, increases with the subdivision of the arteries, and the capillary channels are collectively much larger than the arteri- oles which supply them ; it is conceivable, then, that the outflow might be so free, in spite of the friction lebween the blood and the walls of the containing vessels, that it would pass onward into the veins as fast as it was injected by the heart into the aorta. Of course the same amount of blood does f>ass through the capillary network generally at each pulsation as is propelled by the corresponding ventricular systole, but the systole is effected in one-third of the time occupied by the entire cardiac revolution, so that the blood is three times as long in escaping by the capillaries, and there are accumulated in the arteries, distending them and bringing into play the elasticity of their coats, a considerable number of charges of the ventricle. In Chap. VIII. ] Loiv Tension. 137 proportion as the flow through the capillaries is free, the number of heart-beats stored up in the arteries will be diminished, the mean of continual blood pres- sure within them and the degree of tension of their coats will be lowered, and, most important of all, the smaller will be the amount of nutrient material passing through the capillary wall for the use of the structures. Low arterial tension, which is now to be considered, then, implies a diminished arterial reserve and a les- sened supply of nourishment to the tissues. Venous pulsa,tioii. — It has just been re- marked that it is conceivably possible for the blood to pass so readily through the capillaries that it would issue into the veins as fast as it was propelled into the arteries, but the actual reali- sation of this possibility is incompatible with life, as the functional activity of the nerve centres is dependent upon a continuous flow of blood through them, and under the circumstances supposed it would be intermittent. The resistance, however, in the arterioles and capillaries may be so slight that the blood has still a pulsatile movement when it reaches the veins. This is best seen in the veins of the dorsum of the hand, the fore-arm being held horizontally and the wrist dropped ; a long film of sealing-wax resting on the vein will render the gentle rise and fall more visible. Such venous pulsation in the veins of the back of the hand can often be demonstrated in aortic regurgitation, but here it is not so much the diminished resistance in the capillaries as the exaggeration of the pulsatile variations of pressure in the arteries which brings it about. In order to see pulsation in the veins, however, the capillaries must be relaxed by putting the hand in hot water, or there must be pyrexial relaxation of the peripheral vessels, as, for example, in acute rheumatism, especially when attended with pericarditis, which often renders it very 138 The Pulse. [Chap. viii. evident. Occasionally venous pulsation is met with when there is no heart disease, or any other cause than abolition of the normal resistance in the capil- laries. I witnessed it in a gentleman who was gradually sinking from the effects of alcohol, without any of the usual alcoholic disease of the liver and kidneys. He took less and less food, and came to live on alcohol, and finally had slight pyrexia and oc- casional attacks of haemoptysis. The arteries were large, thin, and soft, and for some weeks pulsation in the veins of the dorsum of the hand could be rendered visible at any time by droj^ping the wrist so as to allow the veins to till. Characters* ol low - tension pnlse.— The essential characters of the low-tension pulse are, that the artery is so readily effaced by moderate pressure that it cannot be felt at all between the beats. It seems to start into existence with each Fig. 37. — Normal low-tension Pulse. pulsation, and to disappear as the wave passes. The pulse is sudden in its ictus, is brief in its duration, seeming to pass quickly under the tingers (celer), and its subsidence is rapid, and is broken by a dicrotic rebound, easily recognisable when sought for in the way described in an earlier part of this book. The sphygmographic trace will have a perpen- dicular upstroke, a sharp top, and a steep fall, with a deep notch and dicrotic rise. (Fig. 37.) Chap. VIII.] Loiv Tension. 139 Varieties of low-tension pulse.— There are many varieties of low-tension pulse, according to the frequency and force of the heart beat. When the heart is acting forcibly the pulse is large, sudden, and vehement (full and bounding), the size of the dilated artery and the shortness of the wave intensifying the impression of force conveyed to the fingers. The force and frequency of the systolic discharge of blood into the aorta may be such as to maintain a degree of fulness of the arterial system in spite of the free outflow by the capillaries, and the radial can then be felt between the beats when only Fig. 38. — Low Teusion, with, forcible Action of the Heart. moderate pressure is employed. It can, however, be flattened without difficulty. Dicrotism is, of course, distinct. The sphygmogram will have an amplitude corre- sponding to the increased size of the artery, and will require a certain degree of pressure for the develop- ment of the trace. (Fig. 38.) When the heart acts feebly, or sends out a diminished amount of blood at each systole, the diminished amount of blood in the arterial system allows the arteries to contract, and the pulse will be small and very easily suppressed ; the ictus^ again, will lose in sharpness, so that the fingers must be 140 The Pulse. [Chap. VIII. applied very lightly. Carried to an extreme, this association of weak heart and relaxed arterioles and capillaries gives the running pulse. (Fig. 39.) Fig. 39.— Low Teusiou, with feeble Actiou of the Heart. Names have been given to pulses of low tension according to the position of the dicrotic notch and wave. The dicrotic notch may descend below the base line of the trace, when the pulse is said to be " hyper- dicrotic." This, however, is merely a question of the Fig. 40. — Hyperdicrotic Piilse. degree of pressure on the artery by the spring of the sphygmograph. (Fig. 40.) The name " anacrotic " pulse is given when the dicrotic wave seems to come in the upstroke of the next beat. This is simply a question of frequency ; the dicrotic wave occurs at a definite interval after Chap. VIII.] Low TeXSIOX C A USES. 141 the primary wave, and when the pulse is extremely frequent the lever has not time to fall after the dicrotic rise before the next rise is due. Causes of low tension. — As with the time of the heart so with the tone of the arteries : there are variations on each side of the normal averao'e without apparent effect on the health and vigour, and a low- tension pulse may be congenital, or it may run in a family. It is sometimes important to bear this in mind ; absence of a proper degree of tension is one of the signs of fatty degeneration of the heart, and when present after middle age, together with symp- toms of cardiac debility, it might lead to an erroneous diagnosis of this disease. A medical man who knew the family pulse to be soft would be in no danger of making this mistake. Obesity is usually associated with low-pulse tension, the arteries also being small and the action of the heart weak. It is not unlikely that the languid movement of the blood indicated by these conditions may favour the deposition of fat. Warmth, especially combined with moisture, re- laxes the arterioles and capillaries, and lowers the arte- rial tension ; a hot bath will do this very effectually. Food, particularly when taken warm ; hot drinks, sustained exertion, fatigue, and exhaustion, bodily or mental, are other physiological causes of relaxation of the peripheral vessels. As regards the effect of a meal in lowering the pulse tension at the wrist, it might be attributed to the large diversion of blood to the abdominal viscera during digestion, but this will be compensated in some degree by the increased volume of the blood by rapid absorption from the gastro-intestinal mucous surfaces. It is, moreover, evident from the character of the pulse that the arteries are relaxed and large, and not simply unfilled. We see, too, in the flushed T42 The Pulse, [Chap.viii. face and red nose of certain forms of dyspepsia, especially in women and young girls, a local exagge- ration of tlie general arterial relaxation. Anxiety, worry, and the depressing emotions ; in- adequate food or deficiency in the nitrogenised con- stituents of food, occasionally excessive indulgence in alcohol, and various unfavourable hygienic influences, may give rise to low arterial tension. Debility of certain kinds is attended with low blood pressure, 1)ut an?emia, especially when associated with chlorosis, often has a high-tension pulse. Certain states of the nervous system are associated with low-pulse tension. Sometimes it is the affection of the nervous system which causes the low tension, sometimes it is absence of due intra-arterial pressure, which gives rise to the morbid condition of the nerve centres. This subject will ])e discussed later. The most common cause of relaxation of the arterioles and capillaries and of low tension in the pulse, however, is pyrexia. Effects of low arterial tension. — Deficient resistance in the peripheral circulation, and con- sequent abnormally low pressure, are not likely to affect injuriously the heart or arteries directly, and no morbid change in either has been traced to low- pulse tension. The nutrition of the tissues generally will not, however, be maintained at a high point, and the heart will share in the imperfect renewal of structures, especially as the blood pressure in the coronary arteries will be low, and the movement of blood in the walls of the heart languid. More- over, the heart is not called upon to exercise full normal energy ; and just as over-work in consequence of high arterial tension gives rise to hypertrophy, under- work will tend to atrophy. It is possible, then, that low-pulse tension may predispose to cardiac degeneration. Chap, ^•l 1 1 .] Lo w Tension S\ 'Mptoms. 143 f^yiiiptoms. — The symptoms associated with a pulse of low tension are extremely varied, and they are, for the most part, not the result of the weak pulse, but concomitant effects of an underlying cause. Many of them are equally common when the pulse tension is high, and the question is not what symp- toms arise out of low or high pressure in the arteries, but, given certain symptoms, what is the state of arterial tension, since this is an impoitant guide in the treatment. It has appeared to me that undue relaxation of the small arteries is sometimes a cause of weakness and depression by permitting undue loss of heat. It is the duty, so to speak, of the arterioles to shut off the blood from the surface of the body on exposure to cold, and thus to protect it from being cooled down. When this function is imperfectly performed the skin and the extremities may be warm in spite of very low external temperature, but the body must lose heat rapidly from exposure to cold of successive portions of blood distributed freely to the skin, and either the temperature of the body generally will fall, or increased oxidation and tissue change will be required in order to keep it at the normal level. In either case the tax on the system will be heavy, and only a vigorous constitution can support it with im- punity. A sufferer from the depression produced in the way just described will often exhibit his warm hands and boast of his warm feet as proofs of his excellent circulation. Some years ago I had under my care for several successive winters a melancholy giant, one of the tallest men I ever saw, proportion- ately stout and well built. During the summer he was well, and was capable of considerable and sus- tained exertion ; but in cold weather he was de- pressed, miserable, incapable of giving his attention to his official duties, and continually under the 144- The Pulse. LChap.vui. fancied necessity of resorting to stimulants. At the same time, he was unconscious of the external cold, and did not take cold ; he never wore an overcoat, and his hands were always comfortably warm. He could not understand that the very warmth was a cause and a mark of weakness, and refused to seek protection from cold which he did not feel to need. Under the influence of depression and want of energy he resigned a valuable appointment, and incurred the evil consequences of entire want of occupation, and is now, a confirmed hypochondriac and the subject of the curious dread of open spaces which has been called agoraphobia. Cases of this kind are by no means uncommon. Abnormally low pulse-tension may be associated with a great variety of functional derangements, as well as of symptoms ; dyspepsia, constipation, sleeplessness, headache, and a multiplicity of pains and sensations in the head, or about the heart, or in the back ; and when flatulent dyspepsia and constipation are present it is sometimes a defensible hypothesis that the de- pression and other nervous symptoms may be due to the gastro-hepatic or intestinal derangement, and the rectification of all recognised departures from func- tional efficiency and regularity would be one of the first objects of treatment. It is worthy of note, however, that when the pulse tension is low the patient often feels better while the bowels are con- fined, and depressed and faint for some time after any action, either spontaneous or however induced. Such patients bear purg-itives of all kinds badly, especially when mercury in any form enters into their composition. Low arterial tension in diseases usually attended with high tension is prognostic of evil. This is especially the case in kidney disease, as will be seen by examples related when the subject of Bright's Chap. VIII.] Zc/K Tension. 145 Disease and associated circulatory conditions are con- sidered later. Treatment. — In speaking of treatment, it is scarcely necessary to say that it is not treatment of low tension as such, but of cases in which low arterial tension is a prominent symptom. The first point to be considered will be whether the imperfect resistance in the arterio-capillary system of vessels is due to the state of the blood and tissues, or to deranged nervous influence. It is not easy to establish such a distinction, for, under the influence of mental shock, or grief, or anxiety, anaemia may supervene with extraordinary rapidity; and, on the other hand, deterioration of the blood and tissues may re-act upon the nervous system. Iron, the mineral acids, arsenic, phosphorus, nux vomica, or strychnine, quinine, bark, are among the medicaments most generally useful ; digitalis, again, the special tonic of the heart and arterioles, may be of service. The food will, of course, be simple, nourishing, and digestible. Alcohol will be given with caution at meal-times only, and in the form of red wine or l^eer. Change is often of the greatest service, the most powerful climatic influence being sea or mountain air, one or other being selected, according to the previous experience of the patient. While absence of resistance in the peripheral vessels is the normal cause of low tension in the arteries, it is obvious that, since the blood pressure is ultimately due to and dependent upon the ventricular systole, the tension must be low when the propulsion of blood into the arterial system is feeble or deficient in amount. In the latter case, however, the arteries con- tract upon their contents, still remaining full between the beats, and the pulse becomes small without necessarily being short. Usually, relaxed arteries K— 27 146 The Pulse. [Chap. viji. and capillaries and weak action of the heart go together, or the circulation would come to a standstill. There are, however, circumstances in which a low tension pulse, due to the heart, is worthy of special note. This is in association with approximation of the first and second heart sounds already considered in chapter iv., to which attention was originally called in a paper in the Practitioner. 147 CHAPTER IX. HIGH ARTERIAL TENSION. Unduly high pressure in the arterial system or high tension of the pulse is a condition worthy of careful attention and study. It explains many of the forms of failing health at and after middle age, and is often the means of shortening life through lesions of the brain and heart. It points out tendencies which later result in serious illness or fatal disease, and its recognition often directs us to measures by which ailments may be relieved, and enables us to foresee and sometimes to avert premature death. Cbaracteristicis of liig^ti tension pulse. — High arterial tension is not to be measured by a certain number of grammes or ounces of pressure employed to elicit a characteristic sphygmographic trace ; it is a relative, not an absolute term. Ulti- mately, the measure of the tension in the arteries is the force of the systole or the heart, but modifying in- fluences of extreme importance are introduced by the peripheral circulation. Under normal conditions the relation between the force of the heart and the out- flow by the capillaries is such that the artery gradually subsides under the pressure of the fingers in the intervals between the pulse-waves ; and the chief char- acteristic of unduly high tension is that the vessel remains full between the beats. For our present pur- pose, then, it may be taken that high tension exists whenever the artery is full between the beats, so that it can be rolled under the fingers like a tendon in the wrist. To appreciate this condition, three fingers should be placed on the vessel, when it will be found to. stand out not only during the wave of the pulse, but in the intervals; and, as has just been said; it can be 148 The Pulse. [Cbap. ix. rolled transversely under the fingers, and can often be followed for some distance up the fore-arm, feeling almost like the vas deferens. This having been recognised, other points must then be ascertained. The force of the pulse beat and the degree of actual pressure in the blood column may vary. This will be approximately estimated by the pressure of the lingers required to flatten the artery and arrest the wave — one, two, and all three fingers being employed, and the pressure being varied several times. Yery frequently the force needed is unexpectedly great, and a pulse which at first seems to be weak may really be extremely powerful. Not unfrequently, especially when the skin is thin, the artery can be seen to form a distinct cord- like projection along the line of its course, but no pulsa- tion will be visible in it, unless it is thrown into a curve, when this will be seen to be accentuated at each beat. The artery may be either large or small ; some- times it is distended and dilated to its full capacity, Imt so long as its coats are sound and not worn out, it will usually be contracted and small. The pulsa- tion is not very marked, and to the fingers lightly applied seems weak, since, as has already been stated, when the mean blood pressure is high, the fluctua- tions are comparatively small. The onset of the wave is gradual ; it is felt for an appreciable and relatively long period under the fingers, and it subsides slowly. The sphygmographic trace will have an upstroke with a faint inclination forwards, a round or flat summit, and a gradual decline without dicrotic notch or wave. (Fig. 41.) While there is no apparent vehemence of the beat, when the strength of the pulsation comes to be tested by an attempt to arrest the wave it is found to have an unexpected degree of force, and very often the greater the pressure of the fingers the Chap. IX.] High Tensiojw 149 stronger it seems to become. This is especially the case when the artery is much contracted and the pulse Fig. 41. — High Tension Pulses. therefore small, the pulse under these conditions often being supposed to be weak from the inconspicuous character of the pulsatile movement. Virtiifil tension. — An important deviation from the form of pulse just described may, however, be met with when the essential cause of hioh arterial tension — obstruction in the peripheral circulation — exists. This is usually at a late stage in the history of the case, when the arteries are worn out and dilated by old-standing high pressure of the blood within them ; when, also, the heart has yielded to the resistance by which it has been opposed and dilatation of the left ventricle has taken place. The artery then is large and full between the beats, but when moderate pressure is employed it allows itself to be flattened, and the pulse is sudden in onset and as sudden in its ending, the pressure in the vessel is abruptly raised, remains high for a brief period^ and then falls abruptly. The ventricle, in fact, cannot 2:0 throuo;h with its svstole in the face of the resist- ance in front. This may be called the pulse of virtual as distinguished from actual tension ; the peripheral ISO The Pulse. [Chap. IX, condition for the production of tension exists, but the sustained central force required for " actual " tension is wanting. (Fig. 42.) Causes of liig^ti arterial tension. — The causes of high arterial tension are many and various. Fig. 42.— Pulses of Virtual Tension. 1. Increase in the volume of blood. — It is easily understood that when the amount of blood in the body is increased, the vessels generally must be fuller and the fluid pressure in them greater. There is a temporary increase in the volume of the blood after each meal, as tlie products of digestion are absorbed, but the effect of this on the tension in the arteries is neutralised by the relaxation of their muscular walls, and the freedom of the outflow through the capillaries which attends digestion. The tension of the pulse is thus usually lowered after meals. After a very heavy meal, however, the amount of matter taken up into the blood may be so large as to give rise to a general vascular turgescence, and, the predisposition existing, this may determine the occurrence of cerebral hfemorrhage. AjDoplectic attacks do not come on after a copious repast so frequently as is popularly supposed, Chap. IX.] High Tension. 151 hut instances are met with, especially where stimu- lants have been taken freely. A constant repletion of the entire vascular system is present in the condition called plethora. This, of itself, would give rise to high pressure in the arteries ; but in plethora elimination is rarely efficient, and the blood is charged with waste products, which provoke resistance in the capillaries, so that an additional cause of arterial tension is present. Another instance in which an increase in the volume of the blood contributes to the production of high tension is afforded by the early stage of acute desquamative nephritis, where the retained urinary water at the same time dilutes the blood and aug- ments its volume. 2. Frequent and poioerfid action of the heart. — Whenever, from any cause, the heart begins to beat more rapidly and to pump more blood into the aorta in a given time, the outflow by the capillaries remain- ing the same, there must be a rise of pressure in the arteries. This occurs in excitement and on exertion ; but high tension produced in this way is usually fugitive. The first effect is to transfer blood from the veins and abdominal venous reservoirs to the arterial system ; but when the surplus in the veins is exhausted, the ventricle does not receive a full supply, and, although it may act frequently and vigorously, the total amount of blood propelled into the arterial system will not be increased. The increase of pres- sure may, however, last long enough to do mischief. 3. Arteriole contraction. — The most simple ex- ample of this is the increased arterial tension which is produced by external cold. This is the result of the physiological contraction of the cutaneous vessels, which excludes the Vjlood from the surface, and so prevents undue loss of heat. But, although a normal process, the increase of intra-arterial pressure is often 152 The Pulse. [Chap. ix. the excitinjj cause of cerebral lifemorrliaf'e when the predisposition exists in atheroma of the cerebral arteries. Every winter the first spell of cold weather is attended with a number of cases of apoplexy, as is each succeeding one. The cramp which proves fatal to swimmers is almost certainly a general arterial spasm provoked by the chill of immersion, the resistance to the circu- lation being aided by the pressure of the water, while the heart is usually also -sveakened by exertion. It is not only after prolonged exertion in swimming that the so-called cramp occurs. I have known one in- stance in which a vigorous young man plunged into a poo], and was seen by his companion to go straight to the bottom and lie there dead. One of the factors in the causation of angina pectoris, or, at any rate, in one form of this affection, appears to be general arteriole spasm. ^Vhy such spasm should be associated w4th a fatty condition of the heart walls and atheroma of tlie coronary arteries — the most common morbid change found after death from angina — is not clear ; and it may be that a merely physiological contraction of the arteries, such as is constantly taking place in health wdthout appre- ciable effect, is sufficient to arrest the systole of the ventricle. This will lie effected all the more readily when the aorta has lost its elasticity from disease, so that it cannot dilate to receive the blood. The term "angina vaso-motoria " has been employed to designate angina in which the arterial spasm is a prominent feature. It is, however, possible that in some cases of angina the initial phenomenon is failure of the cardiac systole, and that the small size of the arteries is the result of their contracting down upon their diminishing contents when blood is no longer pro- pelled into the aorta, as they do after death for Avant of distending force within them. Chap. I X.] High Tension. 153 It would be interesting to know whether the pseudo-angina of young adults is entirely of vaso- motor origin. The prominent phenomenon of rigor is general arterial spasm ; and in the cold stage of malarial fevers this may be carried to such a degree as to bring the heart to a standstill by the resistance pro- duced. It is from this cause that the cold stage of malignant intermittent or remittent fevers is attended with danger of fatal syncope or serious nervous complications. Cases are sometimes met with, independently of malarial poisoning, in which general arterial spasm becomes a source of danger, as in some forms of angina pectoris ; and I may relate an illustration of another kind. . A lady still living, aged seventy-five or upwards, the subject of chronic arterial tension, caught a chill, and the arteries, which were usually large, were found to be tightened up, small, and incompressible, while there were severe occipital headache and a sense of oppression in the chest. The urine, previously normal, became, temporarily, extremely copious and pale, had a specific gravity of only 1*006 or 1*008, and contained a small proportion of albumen. On another occasion a similar attack was accompanied by slight left hemiplegia, with marked impairment of articulation ; and, in my absence, two distinguislied colleagues, not aware of the previous history, came to a diagnosis of advanced Bright's Disease, and 'gave a most unfavourable prognosis. On both occasions a dose of calomel put an end to the serious symptoms almost at once — the hemiplegia, of course, excepted, which only disappeared very gradually. In hysteria, arteriole spasm is a highly character- istic feature, especially during a hysterical fit. The copious limpid, watery urine is, no doubt, an effect of the high arterial tension so induced. Nervous 154 The Pulse. [Chap. ix. excitement of certain kinds is attended with contrac- tion of the arteries ; and this is the exphmation of the diuresis of nervousness. In migraine, again, there is general arteriole spasm, and the attack itself has been attributed to contrac- tion of the cerebral arteries. The early stage of meningitis is attended with arterial tension from contraction of the arterial walls, and in some cases of cerebral tumour there is per- sistent contraction of the arteries with reduplication of the second sound of the heart. In a case of severe neuralgic pain along the sciatic, which was ultimately found to be due to a malignant growth in the spinal canal, which I once sasv, there was unilateral arterial spasm, giving rise to a per- ceptible difference in the pulse of the two sides, which resisted the influence of nitrite of amyl. One side only of the face flushed. 4. Resistance in the capillaries. — This is the most frequent and important of the causes of arterial tension. The grounds on which the resistance is localised in the capillary network, as distinguished from the arterioles, have already been discussed, and the cause only of this resistance has now to be con- sidered. This can scarcely be other than some sub- stance present in the blood which acts directly upon the capillary walls, eitlier provoking contraction or affecting the cohesion of the blood and the capillary membrane. The former is the more probable mode in which the obstruction is produced, but in inflammation there is marked cohesiveness between the capillary walls and the blood elements. That certain substances, present in the blood in very minute proportions, give rise to obstruction in the capillaries is clearly demon- strated by Drs. Ringer's and Sainsbury's experiments with digitalin, ergotin, etc., which show also that the effect is independent of reflex jiervous influence. Chap. IX.] High Tension. 155 since it occurs wlion all the nerves are divided. The special material which plays this part is almost certainly nitrogenised waste which has not undergone the complete oxidation necessary for elimination. This is difficult to prove ; but carbonic acid retained in the blood gives rise to resistance in the systemic capillaries and to extremely high blood-pressure. The first effect of suffocation is not obstruction to the transmission of blood through the lungs, but resistance to the passage of the blood charged with cai-bonic acid through the capillaries. And it is not unreasonable to conclude that retained excretory matters of another kind will have a similar effect. The diseases, gout and renal disease, in which high arterial tension is most marked, are exactly those in which there is the greatest certainty of the existence in the blood of the products of imperfect metabolism. The effects of treatment, again, almost amount to a demonstration, eliminants being the great means of removing the resistance in the capillaries and lowering the tension. High arterial tension produced by arterio-capillary obstruction occurs under the following conditions : 1. Age. — There is a tendency to the development, of resistance in the peripheral circulation and of arterial tension with advancing years ; it is one of the ways in which the tissues show that they are growing old. This is most marked when high tension exists from other causes. 2. Heredity. — Inherited tendency must in many cases be assumed as the only explanation of undue ten- sion in the arterial system. I have frequently found it in young students and school-boys, and sometimes in young children, quite independent of gout or gouty family history, and not traceable to habits or mode of life. No condition, indeed, runs more strongly in families than high arterial tension, and it is the explanation of a family liability to apoplexy and 156 The Pulse. [Chap. ix. paralysis, or to death from heart disease. It is not an nncommon thing for all the males of a family to die off about or before the age of sixty or sixty-five from consequences of arterial tension of one kind or another, while the female members, although pre- senting signs of extreme pressure within the arterial system, survive to a greater age — women not being exposed in the same degree as men to the influences, dietetic and other, which intensify arterial tension and precipitate its fatal effect. In my own ex- perience I have had a school-boy suffering from head- ache and loss of the power of application to work, with a high-tension pulse, whose brother had hae- morrhoids at a very early age, and his father dilated heart and degenerate tortuous arteries ; while uncles had died of apoplexy and heart disease. There was no gout, as such, in the family ; the boys were active and athletic, the adults strictly temperate. 3. Renal disease. — Renal disease of whatever kind, except acute suppurative pyelitis and nephritis and perhaps tuberculosis and amyloid degeneration, is attended with high arterial tension, due to the im- perfect elimination of urinary constituents. So characteristic of disease of the kidney is the pulse of high tension, that it has been named the "renal pulse ; " but the term is extremely objectionable, for, although such a pulse is often at once suggestive of disease of the kidneys, and may facilitate the diagnosis, it is very common when there is no renal change ; and, on the other hand, it may be absent, temporarily or per- manently, when advanced disease of tlie kidneys exists. If tension be permanently wanting, however, when the kidneys are diseased, it may be a prognostic sign of the worst augury. 4. Gout. — Gout, again, is soconstantly accompanied by high pulse tension tliat the term " gouty pulse " has passed into currency. It is, of course, open to the Chap. IX.] High TENsioy. 157 same objections as the name "renal pulse." Arterial tension is present in both acute and in chronic gout ; and the name " suppressed gout," conveniently vague and open as it is to abuse, might perhaps serve some useful purpose if it were employed to designate such states of impaired health in middle and advanced life as are characterised by the presence of unduly hioh arterial tension. The class would correspond very closely with the conditions described by the late Dr. Murchison in his work on functional derangement of the liver, the symptoms being attributed to lithcemia. In gout the form of nitrogenised waste is uric acid ; in some of the states comprehended under the head of suppressed gout the oxidation of nitrogenised matter has probably stopped short of the stage at which uric acid is formed, and the compounds are even more injurious in their effects on the system. 5. Diahetes.^ln connection with gout may be mentioned diabetes, one form of which is accompanied by high pulse tension, and is closely associated with It is well known that diabetes is in early life a deadly disease very rarely yielding to treatment, and is from its onset attended with progressive loss of strength and flesh, while after middle age, especially in stout people, it may exist for years without making any obvious impression on the general health and vigour. In a patient recently under observation, sugar had been known to be present in the urine for twenty years. The sugar, again, may, under treat- ment, completely and permanently disappear from tlie urine. So marked is the difference between the symptoms and effects associated with the presence of sugar in the urine before and after middle age, that many observers refuse to the glycosuria of elderly persons the name diabetes. Sugar, however, may 158 The Pulse. [Chap. ix. be excreted in large amount and without intermission, and tlie condition is quite distinct from the temporary glycosuria of over- feeding, or indigestion, or of nervous attacks. For the present, therefore, it will be suffi- cient if we speak of two forms of diabetes. Between these two forms there is, speaking gener- ally, a remarkable difference as regards the pulse. In the diabetes of the young the pulse is small and of low tension ; in the diabetes of advanced life it is large and of high tension. As has already been said, late diabetes is closely associated wdth the gouty diathesis. It may super- vene in an individual who has had repeated attacks of gout, or who suffers from chronic gout, and when this takes place the patient often feels relieved, and has not only less gouty pain, but is less depressed, and has less indigestion and flatulence. There may, however, have been no overt gout. The state of the arteries, w^hether gout has been manifest or not, gives evidence of protracted arterial tension ; they are large, full between the beats, not very easily compressible, and their walls are thick and dense. Until the heart has begun to suffer from the effects of the peripheral resistance, the pulse wave is forcible and sustained. As the heart becomes worn out the beat becomes sudden and short. In this condition of the circula- tion it appears to me to be dangerous to insist on a strictly nitrogenous diet, and I have not found it necessary. Taking the high tension as an indication for treatment, a pill containing calomel or other form of mercury with one of the vegetable aperients, is given every night or every second night for a time, and salicylate and carbonate of soda with quinine or gentian three times a day, or the alkaline carbonates without the salicylates will often be sufficient. Usually the sugar disappears from the urine, sometimes very quickly, and the urine may be kept free from it almost Ciiap. ix.i High Tension. 159 indefinitely l>y measures which prevent the recurrence of high tension. When the heart is worn out and the pulse tension is virtual and not real, the good effects are more difficult of realisation. These high tension diabetics are the cases which are cured at Carlsbad, Marienbad, and Vichy. It is interesting to note that the sugar often, entirely disappears from the urine during an acute febrile attack of any kind, such as pneumonia or bronchitis, to which patients of this class are very liable. In the more serious diabetes of the young, the pulse, as has been said, is small and short — that is, the tension is low. Exceptions, however, occur in which the artery is full between the beats, and can be rolled under the fingers, but no case has come under my observation in which the artery has been large as well as tense. When tension has been at all note- worthy, the loss of strength has, in my experience, been much less marked, and the disease has remained apparently stationary for a long time. Conversely, diabetes may be met with in elderly people associated with low arterial tension, and when this is the case the prognosis is serious. 6. Lead-2>oisonin(j . — Lead-poisoning is another cause of high arterial tension, and it is noteworthy that it frequently gives rise to gout and kidney disease, the conditions already spoken of attended with excessive intra-arterial pressure. Probably the formation of compounds of organic matter with lead salts, albumi- nates of lead too stable to undergo readily dissociation and oxidation, is the cause of accumulation of imper- fectly oxidised products in the blood. 7. Pr6«/n«nc2/.— Pregnancy is invariably accom- panied by increase of tension in the arteries. Whether this arises from a general augmentation of the volume of the blood, or from the presence in the blood of effete matters derived from the foetus, is perhaps not i6o The Pulse. [Chap. ix. altogether settled. Drs. Galabin and Mahomed have carefully investigated the rise of the pulse-tension in pregnancy. It is worthy of note that Bright's Disease may be established by pregnancy as well as by lead-poisoning. 8. Anoimia. — It is not easy to understand how anaemia can give rise to high tension in the pulse. One would have expected the watery blood to pass readily through the capillaries and the vis a tergo supplied by the heart to be deficient ; but it is a matter of daily observation that the artery is full be- tween the beats, and that the pulse, if more abrupt than in renal disease, is long. The occurrence of dilatation of the left ventricle and mitral regurgita- tion, which is very common as an effect of anaemia, is at once understood when the resistance in the peri- pheral circulation is taken into account ; it is not merely the innutrition of the walls of the heart, due to anaemia, which causes them to give way, but the increased work thrown ui)on the left ventricle by this resistance. It has been conjectured that the defective oxygen-carrying power of the corpuscles may cause oxidation to be imperfect, and so lead to the formation of substances which are not readily eliminated, and which provoke resistance in the arterioles and capil- laries ; but the instability of the tension is suggestive of the intervention of nervous influences, and there are other peculiarities which lend support to the hypo- thesis that the arterial contraction and powerful heart- action may be vaso-motor phenomena. While high tension is the rule among anaemic patients seen in the consulting-room and in the London practice generally, exceptions are met with, and in agricultural districts, where little animal food is consumed, low vascular tension is very common. It has been an object of attention with me to make Chap. IX.] High Texsiox. i6i out whether any constant cliflference of another kind attends this difference in the state of the circuhition. In particular it seemed probable that there might be some influence on the production of hsemic murmurs which might throw light on their causation, especially from the point of view of Marey's theory, which refers all cardiac murmurs to low pressure beyond the point at which sonorous vibration is excited. Up to the present-, however, I have been unable to recognise any distinction between anaemia with high tension and anaemia with low tension, except the difference in the circulatory conditions. 9. Emidliysema. — In cases of emphysema and chronic bronchitis, and sometimes even in phthisis, the systemic arteries present the signs of increased tension; in emphysema they are specially marked. This may be attributed to general fibrotic change in the tissues as well as in the lungs ; but this is not the whole explanation : imperfect aeration of the blood has a share in provoking the resistance, as is shown by its varying degree in the early stages of the affection of the lungs. Mitral stenosis may here be mentioned as associated with arterial tension, without discussing the relation between the two. With scarcely an exception the radial artery is full between the beats in mitral stenosis. The etiology of high arterial tension will require very few words. The remote causes are just those which conduce to the imperfect oxidation and elimina- tion of nitrogenised waste. 1. Food. — A high proportion of animal food, and especially of the butcher's meat, stands first on the list. There is no such great ditlerence between fowls of all kinds or game and red meat as is popularly supposed, but perhaps meats contain more extractive matters. Soups, beef-tea, and animal juices, meat extracts, and the like, however valuablej contain a maximum of 1 62 The Pulse, [Chap. ix. potential waste in comparison with matters available for tissue nutrition. I have been greatly struck with tlie frequency and decree of hiijh arterial tension met with in Eno[lishmen returning from India and other hot climates, but es- |)ecially from the West Indies. My preconceived idea was that the external heat and free perspiration would produce general vascular relaxation ; l^ut observation has shown the exact contrary of this to be the usual result. The explanation, apparently, is that the Englishman carries his meat-eating habits with him to hot climates, and there being here comparatively little need for combustion in order to maintain the temperature of the body, the nitrogenised food is im- j^erfectly burnt off and eliminated. 2. Alcoholic drinks. — Any form of alcoholic fluid in excess, spirits, wine, or beer, will interfere with the normal metabolic processes and lead to the reten- tion of impurities within the system. The stronger wines such as port and sherry, in the preparation of which the fermentation has been prematurely arrested by the addition of spirits, and beer, which contains glucoid matters, have this effect even in moderate quantities. 3. Sedentary habits. — An inadequate amount of exercise in the open air, especially when a great part of the day is }>assed in offices lighted by gas and im- perfectly ventilated, intensifies greatly the effects of excessive food and alcoholic drink, and will of itself conduce to imperfect oxidation. A walk through the streets to and from business is a very inadequate means of counteracting the effects of confinement in an' impure atmosphere all day, and the same may be said of oc- casional violent exercise, which, indeed, may indirectly promote the accumulation of nitrogenised matter in the system by creating an appetite. 4. Constipation. — This is a very important cause Chap. IX. 1 HlCff TliXSIOX. 1 63 of higli arterial tension, and it acts in at least two ways. The undue retention of f?ecal matters in the large intestine leads to resorption of the fluid parts, and these constitute impurities in the blood likely of themselves to provoke resistance in the capillaries and calculated also to interfere with digestion and with metabolism in the liver and tissues generally, which would add to the impurities. The fo\d tongue and offensive breath and sallow complexion attending habitual constipation are sufficiently suggestive. But constipation has a direct influence on arterial tension, probably through the efffect on the abdominal circula- tion, and on the amount of blood in the large abdominal veins. This is patent to everyday observation if the pulse is examined before and after defalcation. Many weakly persons are greatly depressed after even an ordinary evacuation, and come to dread it, and syncope is not uncommon after an unusually large motion. It is easily understood, then, how constipation becomes a source of danger and injury. It promotes high arterial tension both directly and indirectly, and a further danger arises from straining at stool, which not unfrequently determines the rupture of a cerebral vessel, or breaks down the modus vivendi of a weak heart. Constipation is the special danger of old age, and the indirect cause of death to numberless old people. It is not inconsistent with a daily action of the bowels, the relief being incomplete ; so that gradual accumulation of ffccal matters takes place, and so- called diarrh(]ea in old people is very often a symptom of such accumulation. The presence of scybala gives rise to frequent calls to the stool, and all that escapes is a little liquid consisting of secretion from the mucous membrane of the rectum stained by debris washed from the surface of the hard masses. Patholog^ieal effects of hig^li tension. — The pathological changes resulting from unduly high 164 , The Pulse. [Chap. ix. tension must no^y be traced in the arterioles, arteries, and heart. llypertropli]) of muscular coat of arteries and fibroid change. — The capillaries being the seat of the obstruction, the minute arterioles, either because they contract under the same influence as the capil- laries, or contracting to resist the distending influence of the high lilood-pressure within them, are in a con- stant state of excessive functional muscular activit}^ and the result is hypertrophy of their muscular tunic. In course of time change of a tibroid character super- venes. The same process goes on in arteries of a larger size. Whenever the middle coat contains any considerable proportion of muscular fibres, these will undergo hypertrophy in the first place and fibrosis later. Rufture of vessels. — The most common and serious effect on arterioles of the smallest size is cerebral haemorrhage from rupture of terminal branches of cerebral arteries. This takes place almost invariably in vessels distributed to the white substance, which are extremely few in comparison to those of the grey material ; to speak more exactly, the vessels ruptured are usually small arteries traversing white substance on their ^vay to the central grey masses, and miliary aneurisms have been described by Charcot and Bouchard as preceding the rupture. Eui3ture of minute vessels may occur elsewhere than in the brain. Retinal haemorrhages, for example, are not' uncommon, attended with more or less injury to vision ; sometimes with complete loss of sight. Epistaxis, again, is frequent and is usually salutary, givincj the relief which venesection would aflbrd. In rare instances there is coj^ious haemorrhage from the lunfjs or bowels. In the arterioles generally the gradual substitution of fibroid for muscular tissue will prevent these vessels Chap. IX.] High Tension and Atheroma. 165 from taking the part in the reguhition of the supply of blood to dijfferent organs and structures which belongs to them. The consequences of this are not immediately conspicuous, especially in apparent health, but the loss of this function must impair very seriously the adjustment of the circulation to varying conditions, and must exert an unfavourable influence on the course of disease, and on the processes which lead to recovery. Any marked degeneration in the vessels is recognised as an unfavourable element in prognosis either in acute or chronic disease, and it has been well said that a man's age is that of his arteries. Atheroma and degeneration of small arteries. — But fibroid change is not the only form of arterial degeneration to which high tension contributes. Pres- sure within the vessels takes effect on the vasa vasorum in their walls, and tends to interfere with the flow of blood along them, and thus to cut off the supply of nutriment from the coats of the arteries themselves. This will give rise to a change of a strictly degenera- tive character. Fatty and cretaceous deposits are formed in their walls, and the vessels accessible to the fingers in advanced cases become converted into inelastic tubes, presenting bulgings and tortuosities and often calcareous indurations. Atheroma of aorta and its co7iseqnences. — In the large arteries high blood-pressure is one of the chief causes of atheroma. The constant stress on their walls sets up a chronic inflammatory process, at- tended with exudation into or beneath the intima, which gives rise to the opaque raised patches of the early stage of atheroma. Degenerative changes follow ; the lining membrane of the vessel gives way, and the exuded matter is gradually carried off by the blood ; or a calcareous plate is formed in the patch, or other changes take place. At the same time the nutrition of the middle coat suffers from the stretching and 1 66 The Pulse. ichap. ix pressure to which it is subjected, and the general result is that the elasticity of the great vessels is lost, the inner surface is uneven and opaque, the walls are thinned, and general or, more rarely, aneurismal dila- tation is produced. The loss of elasticity in the aorta necessarily abolishes the characteristic effect of this elasticity on the pulse wave. In proportion as it becomes a rigid, undistensible tube it ceases to convert the inter- mittent propulsion of blood by the heart into a con- tinuous stream, and the pulse becomes sudden in its Fig. 43. onset, and full, the trace resembling more or less tljat of the left ventricle. This is the well-known senile pulse. (Fig. 43.) A secondary result of degeneration in the aorta not uncommonly met with is an extension of the dilatation to the ostium, which becomes so stretched that the valves are not large enough to meet and close it. In this way arises one form of aortic incompetence or regurgitation, which comes on for the most part at or after middle age, and is distinguished from regur- gitation due to actual valvular disease Ijy the imperfect development of the collapsing pulse and of the carotid delay, and by the persistence of the accentuated aortic second sound, which had preceded the appearance of the muruiur. Any hypertrophy of the heart which may exist will have been produced by the protracted arterial tension, and not by the regurgitation, which supervenes at a time of life when the heart is no longer Chap. IX.] High Tensiox. 167 capable of compensatory increase of muscular fibres and contractile powers. Another secondary effect of aortic atheroma is narrowing of the orifices of the coronary arteries. This, wdth extension of atheromatous disease into these arteries from the aorta, is the most common cause of fatty degeneration of the heart, which must thus be set down as one of the consequences of high arterial tension. Disease of valves of heart. — Valvular dis- ease, properly speaking, is also set up by high arterial tension. The greater the difficulty of driving the blood through the arterioles and capillaries, the greater the pressure in the arterial system and the greater the strain upon the aortic valves in sustaining the column of blood in the aorta. This persistent strain gives rise to chronic valvulitis, which results in thick- ening and contraction of the cusps with incompetence or stenosis. A systolic murmur is frequently caused by roughening and rigidity or irregularity of the valves without actual obstruction, and the loudest cardiac murmurs ever heard are those so produced. As there is no interference with the mechanism of the heart, such murmurs have no importance, except that they show that changes have set in of a progressive character, which, moreover, may possibly implicate the orifices of the coronary arteries. The mitral valve sutlers in like manner, for, though it has not to sustain the column of blood in the aorta during the diastole, it has to act as the fulcrum during systole, and the greater the pressure in the arterial system the greater the strain upon the mitral valve, while the contents of the ventricle are propelled into the aorta, overcoming this resistance. The conse- quence of mitral valvulitis thus induced is usually insufficiency — never, so far as my experience goes, stenosis, except, perhaps, to a slight degree, w^hen 1 68 The Pulse. [Chap. ix. calcareous deposit has rendered the valves rigid and unyielding. Regurgitation through the mitral orifice may also result from dilatation of the ventricle, which may implicate the auriculo-ventricular opening, and make it so large that the flaps fail to occlude it. Hypertrophy of lieart-Avalls.^On the heart- walls the first and most constant effect is the pro- duction of hypertrojthy. When the blocd no longer passes with normal freedom through the arterioles and capillaries, increased propulsive force is required of the ventricle, and this results in a true increase of the muscular fibres in its walls. Some fibroid tissue is associated with this, and, sooner or later, as the vigour of the nutritive processes declines with ad- vancing years, fibroid or fatty degeneration affects the enlarged heart, and there is a gradual diminution in its efficiency, with or without dilatation. Dilatation of the heart. — Dilatation is an- other common result, either preceding hypertrophy, or associated with it from the beginning, or supervening at a later period. It is usually gradual in its develop- ment, but acute dilatation of the heart is a more com- mon occurrence than is generally supposed, and, when it is induced by effort, antecedent high arterial ten- sion is, according to my experience,- a constant pre- disposing factor. The left ventricle is unable to over- come the obstruction in the peripheral circulation, and gives way under the strain. The effects on the heart and vascular system are direct and easily understood. Other conditions which in my experience have usually been associated with liigh arterial tension, and which I have therefore come to regard as consequences, may be mentioned, although the mode of causation is not clear. Olaiicoma. — One of these is glaucoma, the cha- racteristic feature of which is intra-ocular tension, under Chap. IX.] Cheyne-Stokes' Breathing. 169 which the globe of the eye becomes bullet-hard and the optic disc cupped. The circulatory conditions in the eye are peculiar. The retinal artery and vein occupy the axis of the optic nerve, but the arteries which supply the vascular tunic and structures — the choroid, the ciliary processes and iris — and the veins which carry off the blood perforate the sclerotic at various points, and there is a remarkable convergence of the venous twigs in a whorl to the emissory veins, which is suggestive of an arrangement for maintaining Avithin the eyeball the tension which enables it to keep its globular form by obstruction in some degree to the outflow of blood. Such an effect is indeed mechanically inevitable ; and it is clear that undue interna] pressure compressing and flattening, so to speak, tlie choroid against the sclerotic would have the effect of greatly obstructing the current in the venous whorls, and the exit by the axial veins. The penetration of blood along the various ciliary arteries will not be obstructed in the same degree : high arterial tension, then, must tend to raise the pressure in the vitreous chamber, and may carry it to a point at which it effectually obstructs the liltration angle between the iris and cornea by carrying forwards the lens and ciliary processes, thus realising the conditions which Mr. Priestley Smith has shown in his lucid and instructive lectures before the College of Surgeons to be the immediate cause of glaucoma. Clicyiic-Stokes' respiration. — The remark- able modification of the respiratory rhythm, first noticed and recorded by the two eminent Dublin physicians, whose names Trousseau linked to give a designation to the phenomenon, has, in my experience, been so constantly associated with high arterial tension, that I feel justified in looking upon it ns an effect of this condition of the circulation, not indeed, perhaps, simple and direct, but in the sense that high pressure 170 The Pulse. [Chap. ix. in the arterial system is, if not a necessary, yet the most constant recognisable factor. By Cheyne-Stokes' breathing is meant a cycle re- peated with remarkable regularity, consisting of an absolute pause and cessation of the respiratory move- ments, averaging, according to my observation, about twenty seconds in duration, followed by a resumption of breathing at first so slight as scarcely to be per- ceptible, but gradually increasing in depth till the inspiration and expiration far exceed the normal, after which is a diminution, equally gradual with the rise, down to an absolute cessation. The number of respirations is usually twenty to thirty, and the time occupied by an entire cycle sixty to eighty seconds, during forty to sixty of which there is breathing, and for twenty a pause. Cheyne-Stokes' respiration proper must not be con- founded with the irregular suspension of breathing, seen in the later stages of meningitis and other affec- tions of the brain, in which there is neither the uniformity of the cycle nor the gradual rise and fall, but sudden or gradual arrest, and sudden return of the respiratory movements. This may be called cerebral Cheyne-Stokes' breathing, but only for the purpose of marking its total difference from the true Cheyne-Stokes' rhythm. On the other hand, in the sleep of infants, some- thing like Cheyne-Stokes' breathing is often observable, and in the snore of an old man there is sometimes a gradual diminution of intensity to a full stop and pause of surprising duration, but the breathing is resumed with a snort, and is compensatingly vigorous for a time ; this sort of cycle, however, recurs again and again. A fact of great interest is that there is no evidence of imperfect aeration of the blood, such as lividity of tlie lips, and, indeed, the respiratory movements Chap. IX.] C HE YNE- Stokes'' Breathing. 171 are about equal to normal, though distributed in cycles. Usually, again, the heart takes no notice of the alternations between breathing and pause, but some- times the beats slacken in frequency and force towards the end of the pause, and the respiratory curve will be distinct in the sphygmographic trace at the maximum of the period of breathing. The patient may be conscious or unconscious, waking or sleeping. When sleeping or unconscious there are often twitchings of the face and jerking of the limbs towards the end of the pause, as a sort of preliminary to the resumption of breathing. Kot un- frequently the Cheyne-Stokes' rhythm will be present during sleep and absent in the waking state. 1 have been told by an intelligent nurse, in one case in which it was marked and constant while the patient was awake, that the breathing was regular and natural during sleep. When the patient is conscious, there is no respiratory distress, no complaint of shortness of breath. He will be unable to talk during the height of the breathing period, but he employs the interval for the purpose, and will thus seem to talk himself out of breath. The grounds upon which I have been led to refer Cheyne-Stokes' breathing to high arterial tension are as follows : — In the first place, Cheyne-Stokes' breathing is most frequently met with in association Avith ur^emic symptoms, especially ur^emic coma, and it is in kidney disease that the injurious effects of high tension are most common and most marked. The occurrence of ursemic phenomena and Cheyne-Stokes' respiration under like conditions is a reason for attributing both to the same cause. It is common, again, when dilatation of the left ventricle is giving rise to the symptoms which lead 172 The Pulse. [Chap. ix. Tip to a fatal termination, and it need scarcely be repeated that this condition of the heart is for the most part due to resistance in the peripheral cir- culation. Dilatation of the aorta has been assigned as the special cause of Clieyne-Stokes' respii-ation, and, in effect, it is a very common antecedent. But were it invariably present, it is itself, like dilatation of the left ventricle, an effect of protracted high pres- sure in the arterial system, and is open to the representation of being simply concurrent with the respiratory cycle, and not causative of it. When the aorta or ventricle is dilated, Cheyne- 8tokes' respiration is often pre.sent during sleep long before other symptoms become urgent, or when the only other symptoms are anginoid attacks and breath- lessness on exertion. But it is not the case that the aorta is always dilated. The fact, however, that such a view has been propounded with any degree of evidence in sup]:>ort corroborates my experience of the association of the Cheyne-Stokes' phenomenon and high tension. When the aorta is dilated the ostium may partake in the overstretching so that the valves fail to close it, and regurgitation may take place. I cannot find a note of the occurrence of Cheyne-Stokes' breathing in either aortic regurgitation or aortic obstruction due to primary disease of the valves, but I have an im- pression that I Jiave met with it in aortic obstruction. When high tension is habitually present the supervention of Cheyne-Stokes' breathing may be deter- mined by some complication. In one very interesting case it followed an attack of left hemiplegia due to cerebral haemorrhage. This was one of the cases in which the patient employed tlie ])ause for the purpose of talking, and had to stop while the breathing was going on. In eating, also, he took advantage of the Chap. IX.] Chevne-Stokes^ Breathixg. 173 pause to masticate and swallow. He was unconscious of any distress or even inconvenience, and did nob notice that he had to wait till the deep breathing had subsided to speak or ssvallow. He lived for many years, remaining badly paralysed. The breathing very gradually returned to its normal regularity, t'he Cheyne-Stokes' cycle lasting altogether several weeks. In two other instances the exciting cause was con- stipation. One patient was a vigorous old gentleman, over eighty years of age, who had habitually a large tense pulse and thickened arteries and powerful heart. When I was called to see him he had slight pyrexia, with a foul tongue and loss of appetite, accompanied by great prostration, confusion of the mental faculties, and a degree of stupor approaching unconsciousness. The Cheyne-Stokes' breathing was perfectly character- istic. Under the use of aperients, which dislodged an extraordinary amount of fsecal matters, all the symptoms disappeared. In another case the cause of the obstruction was malignant disease of the sigmoid flexure ; the patient was all but luiconscious, and was supposed to be dying, but the obstruction was overcome for the time being, and he lived for many months. The significance of the association of Cheyne- Stokes' respiration with the conditions enumerated is accentuated by its absence when there is mental confusion and loss of consciousness or respiratory dis- tress from other causes not attended with high arterial tension. I have only once seen even an approach to the characteristic cycle in fe^er, and this was in a case of enteric fever of altogether exceptional character attended with extraordinary excitement from the first and a high tension pulse throughout, notwithstanding temperature of lOS"^ F. For a short time there was the characteristic rise and fall, but the pause was very brief. In the case related on pages 174 The Pulse. [Chap. tx. 1 74-5, in which Clieyne-Stokes' breathing was suspended on the supervention of pulmonary apoplexy, it cannot be said with confidence whether it was the respiratory embarrassment or the pyrexia which produced the effect Again, we do not see Cheyne-Stokes' breathing in mitral disease. Two observ^ations which appear to me to have crucial importance with respect to any hypothesis as to the causation of the Cheyne-Stokes' rhythm have come in my way. One Avas in a case of severe cerebral hsemorrhage with left hemiplegia. When T was called to the patient, some hours after the attack, I found him lying on his back, with flushed, almost purple, face, full and bounding pulse, and stertorous breathing. The congested countenance was obviously due to imperfect aeration of the blood, and this, again, to the falling back of the tongue and to paralysis of the soft palate and parts about the pharynx, which interfered with respiration and gave rise to the loud stertor. The stertor and obstruction to breathing were instantly relieved by turning the patient well on to the paralysed side, as suggested by Dr. Bowles ; the face became natural in appearance, and the pulse quiet. But, as the respiratory distress was removed, Cheyne-Stokes' breathing set in, and continued till the patient's death. In the other case the patient, who was suffering from atheromatous degeneration of the aorta impli- cating the valves, exhibited the Cheyne-Stokes' respiratory cycle for some months while still going to the City for a short time daily. I saw him under a variety of circumstances and at different periods of the day, sometimes after he had walked a mile and a half to my consulting-room, sometimes in his own house, and this kind of breathing was always present. After a time thrombosis in the veins of the leor took Chap. IX. J CffFA-NE-SrOKEs' BrEATHINC. T75 place, and wliile in l)ed on account of this the breathing was still of tlie same type. It may be inferred, therefore, that it was constant during the waking hours. A portion of clot became detached, and was carried into the pulmonary artery ; tlie infarct was large, and gave rise to hpemoptysis and to consolidation of a considerable portion of lung attended with pyrexia. As was to be expected, the respirations became more frequent ; but they also became perfectly regular, and, during the stress of the disturbance caused by the pulmonary embolism, the Cheyne-Stokes' rhythm entirely ceased. As the dis- turbance subsided and the acute symptoms dis- appeared, however, it returned, and was re-established in its typical character. The night nurse, however, stated that the breathing was regular duiing sleep. Another pulmonary embolism occurred, and again the Cheyne-Stokes' cycle Avas exchanged for accelerated regular respiration. These observations appear to me to be adverse to any hypothesis with regard to the respiratory centre, whetlier of exalted or diminished sensibility, and to point to a loss of the normal adjustment between the systemic and pulmonary circulations. Prognosis. — The prognostic significance of Cheyne-Stokes' breathing is always grave, since it marks a serious want of accord between the systemic and pulmonary circulation, and the cause of such interference must be attended with danger. It must not, however, be looked upon as of necessarily fatal import. In many cases in which it is associated with uremia, there is not only recovery from the ursemic condition, but cure of the kidney disease, or, at any rate, such alleviation as allows the patient to live for years. The same may be said when it is an incident of high arterial tension from other causes than renal disease, if the heart or aorta is not irreparably 176 The Pulse. [Chap. ix. clamafred. Cases have been mentioned in which the patient recovered from attacks of various kinds, attended with well-marked Cheyne-Stokes' breathing, and li\'ed for some time. The case may also be again referred to of the patient who attended to his busi- ness in the City for some time while exhibiting this phenomenon, and ultimately died from thrombosis of the femoral veins and pulmonary embolism {see pages 174-5). AVhile the immunity from other symptoms of a serious character was more complete than in any other case, he is not the only patient who has come to my consulting-room breathing in the same way. ^yiiiptoins atteiidiiig: liig^li arterial ten- sion. — Numerous symptoms are associated with high arterial tension, but it is not easy to say with regard to all of them whether they are due to the state of the circulation, or to the impurity present in the blood, which is the cause of the resistance in the arterio- capillary network and high pressure in the arteries. Doubtless the primary cause is the blood-contamination ; and certain substances, the result of incomplete Ijlood and tissue metabolism, or of imperfect digestion and assimilation of food, are capable of giving rise to head- ache, of depressing the spirits, and clouding the mind. But it seems clear that circulatory conditions are not unfrequently an intermediate cause, and it is certain that the pulse affords a clue to treatment. Among the more frequent and important of these symptoms are headache, sleeplessness, breathlessness, depression ; loss of energy, resolution, memory, and nerve ; giddiness, a sense of fulness in the head, pain and oppression in the chest, and neuralgia. Headache may vary in seat, character, and dura- tion. It may be frontal, occipital, or vertical. It is sometimes a morning headache, which disappears after the bath and breakfast ; at others it comes on after mental work or towards the end of the day. Chap. IX.] High Tension. 177 Headache is very common in the subject of high arterial tension ; but high tension has no specific form of headache. Migraine, or sick-headache, again, is, according to my experience, almost always associated with high tension, not only during the attacks, but as an habitual condition ; and the liability runs in high- tension families. Dr. Haio- has endeavoured to show that the paroxysms are associated with the elimination of a large amount of uric acid ; and in many cases there is habitual precipitation of uric acid in excess of the normal quantity. Sick-headaches, howevei", often cease as old age comes on, while the liability to tlie formation of uric acid continues ; and I have seen cases in which migraine lapsed with age, when the formation and excretions of uric acid continued to Ije extremely great. Neuralgia, not of migraine character, is one of the less common etfects of high tension, and it is only mentioned because we should not under ordinary circumstances think of resortino- to the treatment suggested. I have, however, seen neuralgia cured by a dose of calomel when all other remedies, in- cluding change of air, had failed to give relief. The patients were pale and weakly ladies, and were not suflering from constipation. Calomel, therefore, ap- peared to be contra-indicated, and was only at leng-th given because of the high arterial tension which had been noted throughout. Depression of spirits, loss of the power of con- centrating the attention, impairment of the memory, painful irresolution, irritability of temper, and loss ot nerve^ are other symptoms commonly met with in association with high arterial tension. A member of the profession, aged about 54, who had retired to a country life, came to me complaining M— 27 1 78 The Pulse. [Chap. ix. of these symptoms. He was a man of active habits, sjDending much time in the saddle, temperate in eating and drinking, and had the look of perfect health and. vigour; but he wept before me when relating his trouble, and said that when out riding he was sometimes taken with sudden nervousness and timidity, and was compelled to make some excuse for returning home. His tongue was clean, his bowels regular, his urine normal, and his sleep good. No- thing wrong could be discovered about him, except very high arterial tension, and he was gradually re- stored to cheerfulness and energy as the tension was reduced. In another case the patient would be seized in the street with sudden faintness and deadly appre- hension. The attacks ceased with the disappearance of high tension from the pulse. Breathlessness on exertion, as severe as in ad- vanced heart disease, may be simply the result of high tension ; the resistance in the peripheral vessels may have an effect on the circulation equivalent to that of valvular disease or dilatation of the heart. I have seen several cases in which the patient has been com- pelled to stop and sit down or support himself by railings, gasping for breath, two or three times in the course of a few hundred yards of level walking at a slow pace, no cause for this being recognisable in the heart, and complete and permanent relief being afforded when extremely high tension was reduced. In one case, complicated by pulmonary emphy- sema, there was not only extreme shortness of breath, but lividity of countenance, considerable cedema of the legs, and a large amount of albumen in the urine. Under treatment suggested by the high arterial tension, which was present in a marked degree, the dropsy and albuminuria disappeared at once. This patient was seen three times at intervals of two or Chap. IX.] High Tension. 179 three years with the same train of symptoms. The emphysema no doubt played an important part in tbe production of the dropsy and albuminuria, but these conditions were relieved too rapidly to be due to it alone. Sleeplessness, as a result of high arterial tension, will be considered later in a chapter on the pulse and the nervous system^ as will also sudden loss of con- sciousness and convulsions, which may ulso be due to this condition. Treatnieiit. — We need occupy ourselves only with the treatment of persistent hit^li tension, the injurious effects of which have just been set forth. The main cause beinj^ the presence in the blood of imperfectly oxidised nitrogenised wastes, the object to be aimed at must obviously be to keep the blood free from such impurities. Exercise and fresh air are of primary importance for this purpose, and a persistent neglect of these essentials to health will defeat any attempt to rectify permanently a tendency to high pressure in the arterial system. From this point of view, a morning gallop is invaluable to men whose occupations are sedentary. Diet. — One great source of nitrogenised waste is the consumption of an undue amount of nitrogenised food, and in all cases of abnormal tension in the arteries, the amount of highly nitrogenised articles of diet should be limited to a minimum compatible with the health and vigour of the individual. It is usually sufficient if animal food is taken once a day ; fowl and game being included under this head as well as beef and mutton and the like. In the estimation of the public there is a broad line of demarcation between butcher's meat and poultry, and a patient will often suppose that he is limiting his animal food if he takes mutton or beef i8o The Pulse. [Chap. ix. in the middle of the day and chicken at breakfast and game at dinner ; but chemically there is no great difference. In Germany gout has actually been called the chicken disease, on the absurd hypothesis that since the urinary excretion of birds is uric acid their flesh will yield it when eaten. Fish, milk, and cheese are, of course, also animal food, and it would not be impossible to take an excess of nitrogenised matter in this form. The most important chemical difference between butcher's meats and other animal food consists in the presence of a greater amount of extractive matters so called, to w^hicli they owe their flavour, and since soups contain these matters in large proportion, they are an article of diet which must be very sparingly employed when the tendency to high tension exists. A more important difference than the chemical one is the difference of digestibility and assimilability, and this will in one case tell in one direction, in another direction in another case. In many instances the reduction in the amount of nitrogenised food has little effect on the presence of imperfectly oxidised matters in the blood. The meta- bolic processes are imperfectly carried out, and be the amount of nitrogenous foods assimilated little or much the oxidation is incomplete. Alcoholic drinks, if consumed at all, should be taken in very moderate quantity. It must be borne in mind that in some cases high- pressure in the arteries may be simply one result of a general superaV^undance of fluid in the blood and tissues, and it may be necessary to reduce tlie volume of blood by restricting the amount of liquid drunk. Few people are aware how much they drink in the course of the day, and when told to measure it, patients are often astonished at the quantity. When the drink is limited the restriction should apply especially to meal times. Between meals the effect of Chap. IX.] High Tension. i8i drinking water is A^ery different from when it is taken with food. Water in considerable quantity taken on an empty stomach, flushes the secreting glands and washes out the tissues and is thus a valuable means of eliminating impurities. A good time for taking it is night and morning, and the effects are greater when the water is hot. At night hot water stimulates the stomach to contract, gases are expelled and undigested contents swept on into the duodenum and usually there is a general relaxation of the arterioles ; in this way it often conduces to sleep ; in the morning it is rapidly absorbed and has a greater effect on the glands and tissues. It is quite as much by the amount of water taken and the conditions under which it is taken, as by any special constituents of the various mineral waters, that most of the summer and autumn resorts in Germany and France for baths and drinking waters prove beneficial. A course of treatment, however, at one or other of these places is a most valuable resource in reducing high arterial tension. Early rising is enforced, and repeated doses of a weak saline solution taken hot on an emj)ty stomach with intervening walks of ten or fifteen minutes, are admirably cal- culated to promote blood and tissue metabolism, and to carry off the waste products. The diet, moreover, is regulated, and although some of the restrictions in fashion at different baths are irrational and absurd, the establishment of a sort of superstition on the subject of food and drink has its uses. While it is to the complete reversing of habits and the action of copious draughts of water that the chief benefit is to be attributed, there is no doubt that some of the saline constituents are of greater service in particular cases than others, and judgment is to be exercised in sending patients to different baths. 1 82 The Pulse. [Chap. ix. Tlie lesson obtained from the good effect of baths and watering-places may be utilised for patients who cannot resort to them, and who are the immense majority, by ordering a three weeks' course of Carls- bad salts, or sulphate of soda, or phosphate of soda in small doses, 5i to ^ii, taken in a copious draught of hot water every morning on rising and while dressing. There is sometimes an advantage in employing a weak infusion of taraxacum as the vehicle, or in adding the succus taraxaci to the saline. In many cases the Turkish bath is of great service, but if made to take the place of exercise it will in the long run be injurious. The greatest possible service may be rendered by medicinal remedies at all stages of high tension. An attack of apoplexy may be staved off by a timely dose of calomel, and by the same means a labouring heart, unable to cope with the lesistance in the arterioles and capillaries, may be at once relieved. The great remedy for mischief of any kind impending as a result of high blood-pressure is a mercurial purge. The effect of mercury employed as an aperient upon abnormal tension in the arteries is matter of observation. The method by which the effect is produced is a question of hypothesis, but there can be no doubt that it is by elimination, and there need be little hesitation in concluding that the seat of the accelerated metabolism — of which the elimination is a resultant — is the liv^er. Such, at any rate, is the working hypothesis by which 1 am guided. It may be added, perhaps, that I entered npon the independent study of medicine fully impressed with the view of teachers held in high respect and confidence, who considered that the action of mercury on the liver had been entirely disproved, and that mercury, indeed, had practically no useful place in medicine, and that it has been from my experience of its effects on blood-pressure that I have come to value it Chap. IX. J High Tension. 183 as one of our most important remedies. Full closes of calomel being reserved for emergencies, the less serious symptoms may be met by the administration of a single grain of pil. hydrarg. with ipecac, and rhubarb or colocynth twice or three times a week, with which may ]je combined from time to time a three weeks' course of mild salines. To intermediate degrees of urgency may be adapted suitable doses and com- binations. Next to mercury as eliminants will come potash and its salts, liquor potassse having a greater metabolic influence than the salts ; the carbonate a greater effect of this kind probably than the citrate, and the citrate and acetate, which undergo decomposition into car- bonate, a greater effect than the phosphate, or nitrate, or sulphate. As diuretics these different salts are much on the same footing, except in so far as this action is influenced by varying degrees of solubility. The effect of phosphate of potash in preventing the splitting-up of the quadrurates, which constitute the common urinary deposit, with separation of uric acid in the crystalline form is, however, worthy of special note. The demonstration of this by Sir William Koberts is one of the neatest and most interesting- bits of recent work with which I am acquainted. The soda salts have some elirninant influence, Vjut it is not to be compared with that of potash. The idea that potash and soda compounds can be em- ployed indifferently is as erroneous as it is prevalent. The two bases have totally different relations with the organic substances entering into the structure of the body, and have, indeed, nothing in common except their alkalinity. Prognosis. — At the very outset of the employ- ment of the sphygmograph for clinical purposes, Dr. Burdon Sanderson pointed out the prognostic signifi- cance of high arterial tension, and the importance of 184 The Pulse. [Chap. ix. this can scarcely be exaggerated. Years beforehand it can be foreseen that certain persons will at a given age be in danger of an attack of apoplexy or will suffer from dilatation or other disease of the heart. These events are simply the developments of the effects of unduly high pressure in the arterial system, and are foretold by the tense radials and tortuous tem- porals. It must not be at once concluded that everyone who presents these marks of high tension will neces- saril}^ be cut off prematurely by cerebral haemorrhage, or heart disease, or crippled by paralysis. There are individuals of so tough a fibre and of such vital tenacity that the teachings of average experience do not apply to them, and the heart and vessels do not suffer appreciaVjly from over-strain, which would be destructive of more cheaply organised structures. Again, degeneration in the arteries and failing energy in the heart may proceed with such even steps that the heart does not rupture the vessels nor the vessels ruin the heart. More than once I have seen patients in Avhom the tension was dangerously high, and in whom it seemed that somethins: must give way, outlive the dangers to which they were exposed from high blood-pressure in the arteries, and, after slow and gradual failure of mental and bodily vigour extending over many years, ultimately die of senile gangrene or thrombosis of cerebral vessels. Allow- ance, again, must be made for the effects of change of regime and mode of life adopted voluntarily, as \vhen a man retires from business, or enforced by illness. How often does an attack of hemiplegia lead to a prolongation of life ] While, therefore, abnormally high arterial tension is a sufficient ground for apprehension, it is only one factor in the prognosis, and must serve as a starting- point for investigation. Chap. IX. 1 High Tension. 185 The lirst point to be ascertained will obviously be the amount of injury already sustained by the heart and vessels. The radial artery will be carefully explored, by the methods already described, as to its diameter and capacity of contraction, as to the thick- ness and elasticity of its coats, as to the existence of indurations, bulgings, tortuosities in its course, and as to the character of the pulse wave. The aorta will be examined as to any dilatation indicated by exten- sion of dullness l)eyond the right border of the sternum or by pulsation perceptible on pressing the finger into the intercostal spaces here ; the aortic second sound will be the subject of very careful scrutiny with regard to the degree of accentuation it may present and to its audibility at and l^eyond the apex of the heart, especially with regard to its being heard lower down along the right edge of the sternum than normal, and to the left of the manubrium. The character as well as the loudness of this sound will be noted, a low-pitched and ringing second sound indicating- dilatation and degeneration of the root of the aorta. One of the most important inquiries will be as to the family longevity and the modes of death which have prevailed. In one family apoplexy will pre- dominate, in another heart disease ; the latter reveals the more serious tendency. If brothers or sisters have died at a comparatively early age from cardio-vascular disea.se this will be much more signihcant than the age at death of parents or grandparents, and may entirely neutralise inferences from their longevity. It is not at all un-. common in high ten.sion families for successive generations to become shorter-lived, with or without the development of tendencies to diabetes or kidney disease. The medical history of the individual will have to be taken into account, e.g. attacks of acute and 1 86 The Pulse. [Chap. ix. subacute gout from which he may have suffered, lia- bility to functional derangements of the kind ascribed to supj)ressed gout, the character and quantity of the nrine, especially its specific gravity. An estimate also must be formed of his vital tenacity, of the integrity of his structures, and the quality of his blood, from his general appearance and complexion and from the condition of his skin. Conclusions from a healthy and hearty look must be subject to the results of the examination of the heart and vessels ; when the vessels are degenerated and the heart is sound, rude health becomes a source of danger. The habits, dietetic and other, and the mode of life generally must also be taken into consideration. They may be responsible for the high tension in a greater or less degree, and the prognosis may turn on the power or willingness of the patient to modify his mode of life. These will be the principal elements in a forecast of the probable length of life and cause of death in the subjects of high arterial tension, which, applied with judgment at different ages and in the two sexes, will be of great service. i87 CHAPTER X. THE PULSE IN ACUTE DISEASE. It has already been said that almost all deviations from a normal state of health are attended by in- creased frequency of the pulse, and this increase of frequency is especially marked in febrile disease. Elevation of the temperature is, indeed, almost as common a result of disease as increased frequency in the action of the heart ; and it might be supposed, on a superficial review, that the one depended on the other. This, however, would l>e very far from the truth ; and even in diseases in which pyrexia is the most prominent and characteristic phenomenon, there is no constant relation between the temperature and the pulse. A degree of frequency, which in one kind of fever would have no particular importance, would in another be prognostic of a fatal result. With increased frequency in the action of the heart, there is in most febrile conditions relaxation of the arterial walls, and arterial relaxation is the condition of the vessels characteristic of pyrexia. The pulse of fever, as such, then, is frequent, large and short ; usually, also, markedly dicrotic, since the cardiac systole is mostly sharp. The vehemence of the beats will vary greatly, according to the kind of fever and at different stages, as the action of the heart becomes weaker from the exhaustion due to continued pyrexia. The sounds of the heart are louder, and tlie first is somewhat shorter; but there is no modification, and it is interesting to note, as has already been pointed out, that the systolic and diastolic intervals 1 88 The Pulse. [Chap. x. retain veiy nearly the relation of health, both being shortened. The pulse in iiiterniitteiit fever. — TJie pulse in intermittent fever is of great interest, first because in twenty-four hours we have almost all the varieties producible by varying states of contrac- tion and relaxation of the arterioles ; and, again, because it was in malarial fevers of different types that the pulse was studied by the ancients. It was out of this study and observation that the doctrine of crisis arose, critical epistaxis or diarrhoea being common in case of recovery, and hebetude a common precursor of a fatal termination. Paludal diseases were infinitely more common in early times than they are now in civilised countries and temperate climates, and the forms which they assumed were more varied and malignant on the shores of the Mediterranean than were ever known in Great Britain. It will be remembered that the Asiatic and African shores, which still furnish illustrations of malignant intermittent fevers, were the seat of early civilisation, and were very thickly populated. In the first or cold stage of a paroxysm of inter- mittent fever with rigor, when the internal tempera- ture is high — 104'' or 105°, or even higher — while the surface is cold and pale, with intense subjective feeling of chill and violent shivering, the pulse is frequent, but small and long, the cutaneous arterioles being tightened up so as almost to exclude the blood from the surface of the body. If the same amount of blood were discharged from the left ventricle with each systole as in health, it would follow that there must be an enormous increase in tlie movement of blood through the muscles and internal organs. But althougli the pulse has the characters of high ten- sion, the actual pressure within the vessel is not very great, and the wave can be extinguished witliout Chap. X.] In Intermittent Fever. 189 much difficulty. The heart is affected as well as the arteries ; it is not simply overpowered by the in- creased peripheral resistance ; its action is not that of violent effort to overcome the obstruction, but Fig. -W. — Pulse iu luteruiitteut Fever. (From Marey.) is often irregular, sometimes intermittent, with ap- parently an imperfect diastole, so that the ventricle has little blood to drive on into the arteries. That the heart suffers from the direct depressing and almost paralysing influence of the poison is still more evident when the algid stage of pernicious fever is considered. The pulse is infrequent, small, and 190 The Pulse. TChap. x. scarcely perceptible ; the lips and tongue are pale ; the extremities, the face, and even the breath, are cold, as in the collapse of cholera. In the second stage, in which the skin is flushed, hot, and dry, the pulse is that of sthenic fever. The heart's action is more frequent and powerful, the arterioles and capillaries are relaxed, but not to an extreme degree. The pulse is frequent, large, vehe- ment, not very short, the trace being round-topped ; the artery full between the beats and not very compressible ; dicrotism is not very marked. It is the typical full and bounding pulse. In the sweatinu" stage the relaxation of the arterioles is more complete, but the action of the heart is also languid. The pulse remains frequent and large, but is soft and weak, the artery being less full between the beats and more compressible. There is little dicrotism — rarely any perceptible to the linger for lack of vigour in the cardiac systole. (Fig. 44.) The piil^e iu the eruptive and continued fevers. — In small-pox there is nothing characteristic in the pulse. Its frequency is such as might accom- pany the high tempei'ature, and there is nothing in the early stage of even a severe attack of confluent small-pox either in the rate or character of the pulse to foretell the danger which will arise in the course of the disease. It has appeared to me that before and during the coming cut of the eruption the arteries are not so much relaxed as in other febrile conditions, but that there is a degi'ee of fulness between the beats and an absence of dicrotism. Later the congestion and in- filtration of the skin and the presence of vesicles interfere with a proper appreciation of the characters of the pulse, but it feels short. In the malignant h?emorrhagic form of small-pox the pulse is frequent, small, and weak from avery early stage. Chap. X.] In Fevers. 191 In the fatal convulsions which occasionally attend the onset of variola I have found the pulse frequent, large, and short, as in sharp sthenic pyrexia. The pulse of measles calls for little remark. In frequency it has the average relation with the tempe- rature ; the relaxation of the arteries is only moderate, so that the vessel is distinctly felt between the beats, and there is little or no dicrotism. Scarlet-fever has a very remarkable pulse. To begin with, the frequency is very great, and is altogether disproportionate to the degree of fever as indicated by the thermometer. In children a pulse of 160, 180^ or even 200 is not micommon, and in adults it may be 120 to 140, and this when the tempe- rature is not higher than 102° F, ; although with an extremely frequent pulse it will more frequently be 104° F. or upwards. When the frequency is in- ordinate it is indeed much better that the temperature should be high. The woi'st cases of scarlet- fever are those which set in with extreme frequency of pulse and low temperature. The pulse, again, is extremely small, instead of large, as is the rule in febrile conditions, the arterioles being contracted instead of relaxed, and this is more remarkable even than the frequency. It may be compressible easily, or with difficulty, but usually the vessel can be felt between the beats ; the individual pulsations are necessarily short when they follow each other with such rapidity. In typhus fever the pulse is not frequent, being usually below 100; it is large and peculiarly soft, as if the muscular coat of the vessel were paralysed, there being also a want of ictus or sharpness of stroke, evincing a languid action of the heart which helps to give the pulse its soft feel ; it is, however, also very compressible. Dicrotism is present, but is not so easily recognised by the finger as in enteric fever or pneumonia. Towards the end of a fatal case, although 192 The Pulse. [Chap. x. the pulse becomes more compressible, it retains the character described, and is not so profoundly modified as in enteric fever. It is worthy of remark that while the nervous and muscular prostration and the dry brown tongue of the later stage of typhus seem to demand stimulants, it has l)een found that they can be withheld with safety — perhaps even with advantage. The tendency to death is, in fact, by coma, and not by asthenia ; by oppression of the nervous system, and not by wearing-out of the power of the heart ; and when the crisis of the disease is past, recovery of strength and return to a normal state of the pulse are veiy rapid. In enteric fever the pulse undergoes considerable modilications in the course of the disease, by reason of the diminution in the volume of the blood which takes place, and of the exhaustion of the heart and the granular degeneration of its walls produced by the protracted high temperature. In the early part of the disease the characters are simply those of the degree of pyrexia. The pulse gradually increases in fre- quency, during the hrst four or six days rising to 100, or in severe cases to 120; the arterial walls are relaxed, but uot to an extreme degree, so that the vessel is only moderately large ; the beat is sharp and short, and dicrotism is usually well marked and easily distinguished by the finger. During the second week there is not much change, except that usually dicrotism becomes less distinctly perceptible to the finger. After this, from failing power in the heart and by diminution in the amount of blood, the pulse becomes more frequent, smaller, weaker, and more compressible. When at any period of the disease, but especially later, the degree of cardiac asthenia becomes extreme, the beats of the pulse become indistinct, the pulsa- tions with their dicrotic waves run one into another, Chap. X."] In Tvphoid Fever. 193 and the line of a .spbygmogra})hic trace is a mere undulation. This is called a running pulse, and is attended with enfeeblement and ultimately extinction of the first sound of the heart, the only audible evidence of the action of the heart being a weak second sound. Stimulants are necessary as the heart runs down, and Fig. 45.— The Pulse m Typhoid Fever. (From Marey.) the pulse is steadied and the temperature lowered by alcohol. Digitalis has sometimes seemed to be of real service. (Fig. 45.) Relapsing fever in most of its features corresponds with the description of synochus by older writers. The pulse is frequent, forcible, and large, without being very short up to the time of the crisis ; after which it is infrequent, soft, and short. The pulse in pneumonia, ete. -Pneumonia has a frequent, large, vehement pulse witii well marked N— 27 194 T^^ Pulse. [Chap. x. dicrotism. It is not very compressible, nor is tlie wave strikingly short, the dicrotism Ijeing the re- sult rather of the sharp propulsion of blood by the heart, than of the diminished resistance in the peripheral vessels. Not unfrequently, when the radial is com]:»letely closed by the pressure of the linger, pulsation can be felt on its distal side, which has been propagated round through the palmar arch from the ulnar artery in consequence of the re- laxation of the arterial walls. This is the pulse characteristic of the early stage, and it often persists up to the crisis ; but at times, local conditions affect the circulation, and bring about profound and signiti- cant modifications. The obstruction to the pulmonary circulation, either from the extent of lung implicated, or more frequently from attendant engorgement of parts of the lung not distinctly implicated in the inflammatory process, is such as to embarrass the right ventricle. It is unable to propel tlie blood through the lungs as fast as it arrives by the venai cavfe, and there result distension of the right auricle and veins and dilatation of the ventricle. The ventricle, indeed, becomes in some degree paralysed by the over- distension. Under these conditions, the amount of blood reaching the left side of the heart is inadequate, the ventricle is imperfectly filled during the diastole, and, having little blood to propel into the aorta, how- ever forcible the contraction may be, there can be little increase of pressure in the arterial system, and little effect on the pulse. AVe have, then, instead of the large, vehement pulse, a small artery and weak beat, and this while the action of the heart is found on examination to be unusually forcible. The contrast between the violent action of the heart and the weak pulse which results is very significant. The face, again, instead of being flushed, is pale and haggard and often livid. It is in these ciicumstances that Chap. X.] /iV Acute Diseases. 195 venesection is of such remarkable service, relieving the over-distended heart, and the engorged lungs, and enabling the right ventricle again to get control over the pulmonary circulation. In acute bronchitis the pulse varies greatly. It is essentially that of catarrhal fever — i.e. in which the relaxation of the arteries is more marked than the increased action of the heart, — modified more or less by the interference with the transit of blood through the lungs. Sometimes no effect of obstruction in the pulmonary circulation is perceptible ; at others, the in- terference with the supply of blood to the left ventri- cle is such as to render the pulse small, and unequal in force and irregular in time. When the aeration of the blood is imperfect, contraction of the arterioles is induced, and contributes, with the defective filling of the ventricle, to render the pulse small. In erysipelas the pulse is large and soft, markedly dicrotous, rather from diminished resistance than from sharpness of propulsion. Any vehemence which it may have at first is soon lost, and it tends to become undulating. Diphtheria may begin insidiously, or with sharp fever. There is nothing remarkable in the pulse in the early stages, except that it is weak and, for pyrexia, small. The weakness of the pulse is not marked at first in cases in which the fever runs high, but becomes so in a few days, and is observed throughout. In the insidious form of the attack at an advanced period of the disease — sometimes after the membrane has cleared away from the fauces and the local affec- tion seems to be cured, — a peculiar shortness, in- dicative of cardiac asthenia, is often the precursor of a fatal termination. The beat is, perhaps, rendered more distinct from being so extremely brief and un- sustained, so that its essential weakness is disguised. The modification of the heart- sounds accompanying 196 The Pulse. [Chap. x. this pulse is even more noteworthy : the systole is extremely short, and the second sound follows the first at so brief an interval as to seem almost to come on the top of it, the rhythm being altered from the normal triple time, which is maintained, or nearly so, in pyrexia, to common time "^ ONE, TWO, three, four," or even to "ONE, TWO, three, four, five, six," in which " ONE " and '' TWO " represent the sounds, and the small letters the counted intervals. In septicaemia there is the greatest possible range of diversity in the pulse. Speaking generally, the characteristic tendency is to frequency and sharpness of beat with a small artery. In severe puerperal septicaemia the frequency may be extreme — 140 to 160 or even 200 per minute — the artery being small and full between the beats but compressible, the heart- sounds short and equidistant, and reminding one of the " tick-tack " of the foetal heart. This is indicative of shock which may be fatal without rally, or may usher in other effects of blood-poisoning. From this extreme, gradations may be met with to a pulse differing little from that of ordinary pyrexia. In pya3mia, which is a particular kind of septic- aemia, evidences of shock are present at the onset, and throughout the pulse has a frequency and sharpness which do not belong to pyrexia as such. The vehe- mence of the beat and the feel of the artery will vary according to the phase of fever (rigor, heat, or sweating) which may be present, and it will be re- membered that the irregular recurrence of paroxysms and remissions of fever is a distinguishing feature of pyaemia. Inflammation of serous membranes, while raising the temperature, appears to give rise to contraction of the arterioles, instead of to the dilatation which accompanies pyrexia due to most other causes. This is most conspicuous in peritonitis, in which the pulse Chap. X.] In Acute Diseases. 197 is frequent, small, long and hard, the artery being full between the beats and not easily compressible. There may, however, be evidence of shock from the very first in severe peritonitis, so that the tempera- ture is little, if at all, raised ; or it may even be de- pressed, and when such is the case the pulse is not only extremely small, but weak and compressible, the heart is afiected as well as the vessels, and it is either tightened up, like the arteries, so that its diastole is imperfect and the ventricles admit only an inadequate charge of blood, or its systole is feeble. Sometimes the terms '• wiry " and " thready " have been applied to the pulse of peritonitis and abdominal shock, according as pressure within the arteries is pre- sent or absent. This thready character of the pulse is common, as peritonitis tends to a fatal termination, and all observers are familiar with the pallor of the face, the pinched features and sunken eyes, and the cold extremities of abdominal collapse, which are effects of imperfect filling of the arterioles and ca- pillaries, intelligence remaining perfect to the last. It has been supposed that the mesenteric and other veins of the abdomen are paralysed and dilated in such cir- cumstances, and, as is well known, these "S'eins will hold the blood of the entire body, so that, stagnating and accumulating here, very little is carried to the heart, which is thus deprived of blood. It has been said that the sufferer is bled into his abdominal veins. In acute pleurisy, again, there is a degree of tightening up of the arteries, but it is much less marked than in peritonitis ; the pulse is full between the beats and longer than in fever of the same height from other causes. Possibly the arterial contraction is less marked in purulent pleuritis. Gout, as has been already said, is one of the causes of high tension in the pulse. This statement applies strictly only to the intervals between the acute attacks. 198 The Pulse. [Chap. x. for during a paroxysm the pyrexia relaxes in some degree the peripheral vessels and diminishes the ten- sion. The pulse, however, has a certain vehemence, and, though sudden and comparatively short, is not readily compressible, nor does the artery eflface itself altoojether between the beats. At the onset of a paroxysm before redness and swelling of the affected part have set in, when the pain is at its worst and is of a shooting neuralgic character, the arteries are more than ever tightened up. In acute and subacute rheumatism the pulse presents great differences in different cases, and in the same case at different times. The tension is never really high and the beats are mostly short, but some- times the artery remains full between the beats and can be rolled under the fingers, and at others allows itself to be flattened by very slight pressure. The degree of acuteness of the articular inflammation will influence the frequency and vehemence of the pulse, and the copious perspirations which are characteristic of rheumatic fever will both relax the peripheral vessels and diminish the vigour of the heart's action ; but it is not always easy to connect the pulse found at a given moment with the symptoms then present^ or to explain all its variations by the conflicting tendencies which may be traceable in the course of the attack. 199 CHAPTER XI. TJIE PUL.SE IX VALVULAR DLSEASE OF TFTE HEART. Heart disease produces the multifarious distressing symptoms which attend it. hy its effects upon the circulation, and these effects ought to be more or less manifest in the pulse. Such is, in fact, the case, and especially in valvular disease, which will first be con- sidered ; but the compensatory changes in the heart, which tend to neutralise the derangement of the circulation produced by the damage to the valves, will tend also to modify the influence of the valvular lesion on the pulse. This, however, does not impair the diagnostic and prognostic importance of the pulse, but, on the contrary, heightens it, since tlie pulse comes to represent a resultant of opposing influences and forces. The pulse in aortic stenosis.— The frequency of the pulse is little affected by this condition, and while the muscular walls of the heart remain sound it is quite regular ; but narrowing of the aortic orifice must have the effect of intercepting the sudden pressure brought to bear on the column of blood in the aorta at the beginning of the ventricular systole and of increasing the time required for the discharge of the contents of the ventricle. The corresponding modification of the pulse will be a loss of suddenness in the ictus and a longer duration of the beat ; the dicrotic wave also will be annulled, since the conditions of its production — rapid action of the ventricle and great fluctuations of the blood pressure — are absent. The ordinary characters of high tension in the pulse are thus reproduced as a result of obstruction and delay in the delivery of the blood by the heart. The 200 The Pulse. [Chap. XI. obstruction at the orifice is met and compensated by hypertrophy of the left ventricle ; but this does not neutralise altogether the influence upon the character of the pulse. Another element of similarity to the pulse of high tension also comes in, namely, the small size of the artery. It is not very clear why, with normal resistance in front, the arteries generally should not be kept at their usual size by the pressure from the heart, Avhich will be maintained at a normal >^t^ Fig. 46. — Pulse in Aortic Stenosis. point by the compensatory hypertrophy, merely because the pressure takes effect more gradually ; but the entire arterial system seems to contract down upon the diminished blood-stream, and the small diameter of the radial and other arteries is a constant phenomenon. The pulse, then, of aortic stenosis has the following characters : — The artery is small and full Ijetwecn the beats, but not, as a rule, really tense ; the wave has no ictus, properly speaking, but lifts the finger gi-adually — it is persistent and subsides slowly ; the trace has a sloping upstroke, little altitude, a rounded or flat top and a gradual descent. (Fig. 4G.) Sometimes the wave is reinforced towards its end and the finger is conscious of a second beat : this constitutes the pulsus bisferiens, traces of which are Chap. XI. In Aortic Stenosis. 201 here given, from which the difference between the double beat thns produced and that of dicrotisni will be recognised at once. (Fig. 47.) A further differ- ence is that the pulsus bisferiens is brought out by firm pressure while dicrotism is best felt when the fingers are very lightly placed on the artery and is FiH'. 47. — Pulsus Bisferiens. extinguished by pressure. The pulsus bisferiens is interesting in connection with the view propounded by Professor d'Espine, of (ieneva, that the ventri- cular systole is a 'deux temps, i.e. is compounded of two distinct efforts fused together, which are not separately recognisable in normal action, but become distinct in certain forms of disease. The tracing was taken from a case under observa- tion since March, 1884 — that of a lady, aged 41, who for nearly three years had been subject to attacks of faintness coming on about one a.m., in which slie was cold and absolutely powerless, without, however, losing consciousness ; the faintness was followed by 202 The Pulse. [Chap. xi. l^alpitatio]!. Tlie left pulse was very small and long ; the right, from an abnormal superficial distribution, was visible and gave a higher trace than would other- wise have been obtainable. She was subject also to menorrhagia and neuralgia. A very loud, coarse, low- pitched systolic murmur was heard over the aorta and its branches and again at the apex by conduction ; a faint, short, diastolic murmur was also heard to the left of the sternum, but there was no visible carotid pulsation or other evidence of aortic regurgitation suf- ficient to affect the pulse or circulation, and the aortic second sound was audible in the neck. There was a moderate degree of hypertrophy of the left ventricle carrying the apex one inch to the left of the nipple line. The pulse is of special importance in aortic stenosis, since upon it the diagnosis may almost be said to turn. A systolic aortic murmur is one of the most common of physical signs ; actual obstruction at the aortic orifice comparatively rare. A slight roughness or rigidity of the valves, a tag of fibrin, or other deposit, not affecting their functional efl&ciency or interfering at all with the blood-current, a fenestrum in the thin crescent near the free edge of a valve, will cause loud murmurs, and a murmur may be produced at the aortic as well as at the pulmonary orifice in ansemia. There is nothing in the character of a systolic aortic murmur to tell us whether it is indica- tive of serious obstruction, or is produced by a mere roughness, or some other of the conditions just enumerated, and it is only by symptoms, when present, or, in their absence, by the changes in the heart, and by the character of the pulse taken together, that the distinction is made between dangerous disease and insignificant derangement. The pulse may be made to throw further light on the degree of obstruction attendinoj an aortic murmur by causing the patient to make some slight but Chap. XI. 1 In Aortic Disease. 203 sudden exertion. Compensatory hypertrophy makes the heart perfectly equal to all ordinary calls upon it, and to the increased demands of exertion, provided this is not begun suddenly ; but it does not accom- modate itself quickly to the increasing rapidity of arrival of blood in the right side of the heart, caused by the compression of the veins in muscular exercise. The pulse then becomes unequal, short and irregular, and, excluding other causes of cardiac weakness, ansemia, sedentary habits, etc., a faltering pulse, say on going up a single flight of stairs, will indicate mechanical interference with the transit of blood through the heart, while if the pulse responds simply by increased frequency and force, the obstruction cannot be great. It does not come within the scope of this book to describe the murmur of aortic stenosis, or the physical signs, either of compensatory hypertrophy, or of the changes which attend the later effects, which lead to a fatal termination ; but there is one modifica- tion of the heart-sounds which should be noted, since it belongs, like the characteristic pulse, to the stenosis as such. This is the muffling of the aortic second sound. The propulsion of the blood into the aorta is gradual, the pressure in the arterial system is not high, the recoil, therefore, of the valves, even were they not thickened, as is probably the case, will not be violent. The piilse of aortic reg^irg^itatioii. — This is the well-known "collapsing pulse" of Corrigan, called also sometimes the " water-hammer pulse," which is visible in all the superficial arteries, and is especially conspicuous in the carotids. A diagnosis of aortic insufficiency may indeed be made from a glance at the neck, or from a moment's examination of the radial pulse, or by watching the movements of the foot when one leg is crossed over the other knee. The throb of 2 04 The Pulse. [Chap. xi. the carotids is visible up to the ear, and the beating of the temporal, facial and subclavian arteries at once attracts attention, while, if the elbow is bent, the sinuous brachial artery becomes extremely con- spicuous. Insufficiency of the aortic valves, however, is pro- duced in two quite different ways — by damage to the valvular cusps themselves, which renders them incom- petent to close the orifice, and by stretching of the orifice, so that it is too large to be closed even by valves of normal size. In the latter case the enlarge- ment of the orifice is part of a general dilatation of the root of the aorta, due to atheroma or arteritis de- formans ; the valves may be little changed and will then stretch across the mouth of the aorta, leaving a small central aperture where they fail to meet, or they may be implicated in the degenerative process, when they will be rigid, more or less contracted, and perhaps calcareous. Valvular lesions, properly speaking, thick- ening:, adhesion and contraction, and occasionallv ulceration or destruction, tire, for the most part, the re- sult of rheumatic, more rarely of gouty, inflammation, and it is as a result of such lesions that the true collapsing pulse is, met with. The description to be given in the first instance of the pulse of aortic in- competence will apply only to this form of disease ; the modifications presented when the incompetence is produced by aortitis deformans or atheroma will be reserved for separate consideration. As in aortic stenosis, the pulse remains regular until the heart begins to fail, and then the first de- parture from the normal rhythm consists in an occa- sional falter, a hurried, ineliectual contraction of the heart with a weak beat at the wrist, or an inter- mission due to the wave not reaching the radial artery. The most striking features of this pulse are the Chap. XI.] Lv Aortic Regurgitation. 205 sudden and complete collapse, or emptying of the artery between the beats, and the extremely sudden, vehement, and shoi't pulsation. This comes from the fact that the aortic valves being insufficient, the fulcrum which sustains the column of blood in the aorta, and therefore the blood pressure in the arteries, is, pro ianto., wanting, and the blood drops back out of the radial and other arteries. It must be remembered that for the colhipsing character of the pulse to be fully developed the hand must be raised ; if the patient is in bed this will be done in the mere act of feelincj the pulse, but if the patient is sitting or standing, the wrist will be below the level of the shoulder, and gravity v/ill keep the vessel more or less continuously full, disguising the collapse. But in a well-marked case even in the dependent position, the sudden and collapsing character of the pulse will be recognisable ; the column of blood from the shoulder to the wrist has not weiglit enougli to simulate the normal blood- pressure in the intervals, but the collapse becomes much more conspicuous when the hand is raised, so that the blood, no longer sustained by the aortic valves, drops back out of the artery. When, there- fore, the prognostic import of the pulse is sought in aortic regurgitation, it should be carefully examined in all positions of the hand and arm. There is one other important feature of the pulse of aortic regurgitation — the size of the artery. The compensation of aortic regurgitation consists in dilata- tion and hypertrophy of the left ventricle, and the dilatation — which in other forms of heart-disease is at once a sign, a cause, and a consequence of heart- weakness and failure — is here an essential factor in the compensation. If a certain i^rojDortion of the blood propelled into the aorta regurgitates into the ventricle, there must — if the circulation is to be maintained at the normal rate of flow — be a larafer 2o6 The Pulse. [Chap. xi. amount than normal injected at each systole : that is, the capacity of the left ventricle must be increased — or, in other words, it must be dilated. A consequence of this will be that a larger amount of blood is launched at each systole into the aorta ; and, although a certain l)roportion of it immediately flows back into the ven- tricle, room must be made for it in the arterial system for the moment, and so the arteries generally are large. Still another effect is loss of time between the heart and the wrist. It has already been said that when the general arterial tension is low the wave takes a longer time to reach the periphery, and when the aortic valves are incompetent, this delay reaches its maximum. Accordingly, the loss of time is such that very often, when one hand is placed over the apex of the heart and the other on the pulse, the two beats are felt to alternate at equal intervals, and the loss of time may be carried so far that the pulse at the wrist seems to come before the cardiac impulse. The loss of time is manifest even in the carotids, and the apex beat, the carotid pulse, and the radial pulse follow each other in triple time — " one, two, three ; one, two, three." This delay has not reaeived adequate attention, and the only observer who has fully brought out its significance and importance is Prof. Eaymond Tripier, of Lyons, whose papers on the " Ketard Carotidien " are of great interest and value. We can now give a complete technical description of the pulse of aortic regurgitation. The artery is large, but between the beats quite empty ; the pulsa- tion is extremely sudden and vehement, and often communicates a vibi-atory sensation to the fingers ; its duration is very brief, and its cessation peculiarly abrupt, giving it the collapsing feel. Dicrotism is not altogether absent, but for want of the fulcrum formed by the valves, it is much less marked than might be Chap, xi.j In Aortic Regurgitation. 207 expected from, the violence of the fluctuations of pres- sure and the rapidity of the systole. It has already been said that this is the visible pulse '[tar excdlence, and it is not only visible but also audible. If the wrist is placed against the ear, the blood can be heard to conie into the radial with a rush, or with a sound like the cut of a whip. Mention may also be made of the capillary pulsa- tion, the pulsatile reddening of a patch of congestion induced by rubbing the skin. Several traces are here shown ; they vary con- siderably in appearance, but there will be seen to be common to all of them a sharp and long upstroke, usually ending in a hook at the summit, due to jerking up of the lever, a great altitude, and a very abrupt descent, with a slight dicrotic rebound, usually from the base line. In the last, good compensation has been established. (Figs. 48, 49.) Here, as in aortic obstruction, the pulse enters into the diagnosis and has very great weight in the prognosis. A diastolic, or a double aortic murmur, will be present whenever there is incompetence of the semilunar valves, whether the leakage is slight or considerable, and we cannot depend on the murmur to tell us whether it is merely a thin vein of blood or a large stream which pours back into the ventricle. For this information, upon which the prognosis largely turns, we must look to the effects upon the heart, the amount of dilatation and hypertrophy, but especially to the character of the pulse. However loud the diastolic murmur, or wherever heard, unless there is a visible carotid and radial pulse, the regurgitation will not be large, it being understood, of course, that we are spcjaking of a period of the disease in which the patient is in apparent health, and not of a late stage when the heart is failing. But we do not rely on a single first -sight indication ^ all the characters of 2o8 The Pulse, _rchap. xl the pulse must be separately considered, the size of the artery, the suddenness and vehemence with which the pulsation strikes the finger, the suddenness and Fis- 48.— Aortic Regurgitation. Fig. -19. — Aortic Rcgurgitatiou in which Conipeusatiou has been established. completeness of the collapse. Especially must the state of the artery l>etween the beats be ascertained when the hand is held up above the level of the shoulder or head. If the valves are seriously damaged, so that the regurgitation is free, the blood Chap. XI. j liY Aortic Regurgitation. 209 drops out of tlie artery immediately the systole is completed, and we have, fully developed, those characters which have given to the collapsing pulse the names "water-hammer" and "whipping;" and when the wrist is applied to the ear the rush of blood, or rather the sudden stretching of the artery, is distinctly heard. If, on the other hand, the reflux is inconsiderable, the valves may sustain the column of blood for an appreciable period ; and, although the pulse may be sudden, the artery is emptied gradually only, and can be felt to contain blood for a time after the beat, or even throughout the interval between the beats. Nothing can be more simple and easy than the appreciation of the differences here pointed out, or more trustworthy than the indications they furnish, when taken together with other indications obtained from the state of the heart and the general condition of the patient. Here, as when treating of aortic stenosis, while the physical signs of hypertrophy and dilatation cannot be described, nor their significance discussed, the modification of the aortic second sound comes within the scope of this book. The valves enter into the causation of this sound by their sudden tension under the pressure of the blood in the aorta. If, therefore, they are practically non-existent, there can be no aortic second sound ; and, in proportion as they are incapable of op]:)Osing the reflux of blood into the ventricle, they will be unable to give rise to the tension-vibration of the valvular cusps and aortic wall, which produce this sound. The aortic second sound thus becomes an important criterion of the amount of regurgitation. Its absence is among the indications of serious incompetence ; and, on the other hand, when it is distinct the regurgitation cannot be considerable. In order that the pulmonary second sound may not be taken for the aortic, the stethoscope must be applied over the carotids. 0—27 2IO The Pulse. rchap. xi. In cases of extreme aortic insufficiency the murmur is often short, smooth, and almost noiseless, so that it might escape the ear unless the attention has been awakened by the pulse ; and when the patient is in bed suflfering from some acute disease, such as rheu- matic fever, or congestion of the lungs, the diastolic murmur may be inaudible. It has several times occurred to me in such circumstances to predict the appearance of a murmur as the patient recovered, the pulse indicating regurgitation, of which the most careful examination failed to detect the usual auscul- tatory evidence. It must be borne in mind that pyrexia will exaggerate to an extraordinary degree the collapsing character of the pulse by relaxing the peri- pheral vessels ; and other causes of arterio- capillary relaxation will have the same effect. It must, again, especially be borne in mind that stenosis of the aortic orifice will modify and disguise the effects on the pulse of incompetence of the valves. The pulse of aortic incompeteiice from aortitif^ tleforinaiis, — In considering the depar- tures from the collapsing type of pulse as fully deve- loped in valvular disease proper, it has first to be borne in mind that regurgitation through the aortic valves resulting from dilatation of the orifice in aortitis deformans is usually a late event in the course of the disease. There will be associated with the regurgita- tion loss of the elasticity of the coats of the aorta ; this will, indeed, have preceded it in most cases by some considerable time. The pulse then will have the character produced by rigidity of the great vessels those, namely, already described under the head of senile pulse. The artery will be large, its walls pro- bably thickened and hard, and it will be full between the beats ; it will, however, be compressible, and the pulse- wave will arrive and depart suddenly. These features belong to the pulse independently of the regurgitation, Chap. XI. 1 I.v Aortic Regurgitation. 211 and almost the only modification which this introduces will be that the artery will be more easily flattened between the beats, which will give the beats a sharper feel. (Fig. 50.) The most striking departure from the type of pulse of incompetence from valve disease is that there is no real collapse or emptying of the artery between the beats, even when the hand is raised ; the regurgi- tation through the valve is, in fact, comparatively small, as has been already pointed out. Any consi- derable insufficiency of the valves produced by Fig. 50. — Aortic Regurgitation from Atheroma. atheromatous disease of the aorta would be incom- patible with life ; the heart would be incapable of responding to the need for compensatory increase of vigour and hypertrophy. This would be rendered impossible by the loss of elasticity in the aorta, and consequent imperfect blood-pressure in the coronary arteries, the orifices of these vessels also being liable to be implicated in the disease and more or less obstructed, were it not also the case that the degenerative change under consideration usually occurs at a time of life when there is not sufficient energy in the nutritive processes for the production of hypertrophy. Another point of difference between the pulse of aortitis deformans with regurgitation and that of regurgitation from valvular disease is that the loss of time between the heart and the vessels is much less. This is specially noteworthy in the carotids^, and the 212 The Pulse. [chap. xi. absence of retard carotidien has been pointed out by Professor Tripier as a clinical distinction between the two forms of incompetence. In the cardiac physical signs there is also an im- ])ortant difference which must be pointed out. It is that, whereas in valvular disease the aortic second sound is impaired or lost, in aortitis this sound, often accentuated and ringing, is distinctly heard heading, so to speak, the diastolic murmur. The prognosis in aortic insufficiency due to dilata- tion of the orifice is not dependent simply upon the amount of regurgitation. It is always serious because of the probability that the coronary arteries may be implicated in the thickening and degeneration. The pulse in eombined aortie stenosis and incompetence. — As has just been said, narrowing of the aortic oritice will neutralise some of the effects of incompetence of the valves ; it will inter- cept the sudden and violent discharge of blood into the arterial system by the ventricular systole, and it will diminish the freedom of the regurgitation during diastole. It will thus tend to destroy all the special characters of the pulse, its sharp and powerful ictus, its instant collapse on the passing of the wave, and to interfere with the large size of the radial artery ; as regards the indications of the pulse, therefore, it may completely disguise the serious character of the valvular lesion. Since stenosis and insufficiency may be combined in various degrees, no general description of the pulse Avould be applicable to all cases : it will be regular, will have more or less of the collajjsing character, and will be more or less visible ; the appreciation of its diagnostic and progncstic significance must be left to the individual observer. Obstruction and regurgitation are together more sei'ious than obstruction; stenosis may add to or take Chap. XI.] In Mitral Stenosis. 213- from tlio clang(;r attending incompetence. On tlie whole, ])ro}>ahly, combined obstruction and regurgita- tion will have a greater tendency to shorten life than regurgitation alone ; l>ut I have more than once seen the supervention of stenosis stave off the fatal effects of extreme regurgitation, and even lead to apparent recovery. The pulse of mitral steiiosis.— Great differ- ence of ojxinion has existed as to the pulse in constric- tion of the mitral orifice. It has often been described as irregular, sometimes, as by Dr. George Balfour, as exhibiting the extreme of irregularity. This is altogether contrary to my experience, according to which, in simple uncomplicated mitral stenosis, the pulse remains regular up to an advanced stage of the disease, frequently even when the effects on the cir- culation have reached a serious point. It is true that when the pulmonary circulation is almost brought to a standstill, the right heart distended, and the tricuspid valve no longer prevents regurgitation into the systemic veins, the pulse may be extremely irregular ; but even in these circumstances the Pieart will usually be found to be beating regularly, and the irregularity of the pulse is the result of beats not reaching the wrists. The pulse, then, of mitral stenosis is regular ; its other characters are that it is small, long, and extin- guishable by moderate pressure ; it could not justly be termed a weak pulse. A constant feature is that the artery is full between the beats, and the pulse is exactly such as would be described as essentially one of tension, in which the arterioles are contracted, Vjut the vis a tergo from the heart necessary to the produc- tion of high pressure in the arteries is only moderate. The explanation of this condition of the arterial side of the circulation is not very apparent ; it may be that the vessels adapt themselves to an inadequate supply of blood by contracting down upon their contents ; or 214 The Pulse. [Chap. xi. that a tendency to backward pressure in the veins makes itself felt in the capillaries and arterioles. This last supposition, however, is scarcely tenable, and Mitral Constriction (Pulse 60). Mitral Constriction. Mitral Obstruction and partial Aortic Regurgitation. Fig. 51.— Pulse of Mitral Stenosis. (From Haydeu.) there is possibly some intervention of the nervous sys- tem, the arterial walls being stimulated to contraction by a reflex action through the sympathetic vaso-motor. The tracings in Fig. 51 are taken from Hayden's work on heart disease rather than from cases of my own, and they correspond with the description just jriven. All are seen to be regular. Chap. XI.] Tn Mitral Stenosis. 215 In the final stages of mitral stenosis, when stasis of the venous circulation is setting in and severe symptoms are being developed, the pulse, as has been said, may become irregular. The irregularity first shows itself as inequality in the force of different beats due to imperfect tilling of the ventricle ; the weaker beats also travel less rapidly, and thus the time as well as the strength of the pulse becomes irregular. Then a certain number of the beats fail to reach the wrist at all, and in this way extreme iiTegu- larity is produced, and there is an entire loss of corre- spondence between the heart and the pulse, so that it seems difficult to believe, when listening to the heart and feeling the pulse at the same time, that the one is at all dependent on the other. The effects here described are not difficult to understand. When narrowing of the mitral orifice is carried to any considerable degree, the filling of the ventricle in its diastole, which in a normal state is almost instantaneous, must be greatly retarded, and it is only by high pressure in the pulmonary veins that anything like an adequate charge of blood is forced through the constricted communication between the auricle and ventricle in the time during which the diastole lasts. The auricle helps in this for a time, especially when hypertrophied; but, sooner or later, it becomes dilated, and is often distended into a large passive sac or reservoir ; and even while it retains contractile energy, the fulcrum — which, in the ab- sence of valves, causes the blood to pass onwards into the ventricle — is the resistance opposed by the pres- sure in the pulmonary veins. The pressure in the pulmonary circulation is, of course, kept up by the hypertrophied right ventricle, and the right ventricle thus virtually comes to the aid of the left by driving the blood with greater velocity through the narrow mitral orifice. When, therefore, any obstacle is 2i6 The Pulse, rch.ip. xi. interposed to the free passage of blood through the lungs, as by bronchitis, or pneumonia, or congestion, or pleural effusion, and still more when the propulsive efficiency of the right ventricle is impaired by weak- ness of its muscular walls or by over-distension, and especially when the tricuspid valve becomes insuffi- cient, either from dilatation of the cavity and orifice or from damage to its flaps or tendinous cords, and the right ventricle loses its fulcrum, the blood is no longer forced through the narrow mitral orifice quickly enough to till the left ventricle. This being so, although the ventricle may act regularly and forcibly, when it con- tracts upon an inadequate charge no beat will reach the wrist, and its contraction, not encountering a normal decree of resistance, will be short and hurried. All this being considered, the wonder is, not that the pulse should be irregular, but that it should continue for so long to be regular. When mitral regurgitation co-exists with obstruc- tion, it is an independent source of irregularity of the pulse ; and the same may probably be said of tricuspid regurgitation when it is established in the course of the disease. A few words may be said with regard to another variety of pulse sometimes met with in mitral stenosis, especially when under treatment by digitalis. This is when there are two beats of the heart to one of the pulse. It has already been descril^ed and discussed in an earlier part of this work (chap, vi., page 108), but is of sufficient interest and importance to merit further reference. It does not occur in connection with any other form of valvular disease, nor, so far as I know, in mitral stenosis, except when digitalis is being administered, and then only in a small minority of cases ; but in certain cases it can be produced at will by giving this drug. The pulse is usually quite regular, both as to time Chap. XI.] In Mitral Disease. 217 and force, but is infrequent, the number of beats being, perhaps, forty per minute. Wlien the heart is examined, it is found to be beating at exactly twice this rate. The beats, however, are not alike, but run in couples — a strong beat followed at a brief interval by a weaker one, while a longer pause separates the coupled beats, from each other. The first only of the couple gives a pulse at the wrist, as a rule. Not only do the two heart-beats differ in strength, but the im- pulse is felt at a different spot — at the a})ex with the first, over the right ventricle with the second ; and on auscultation the sounds of the first are heard to belong to the left ventricle, those of the second to the right. It is obvious that the two ventricles are acting alter- nately ; not that one is absolutely quiescent during the systole of the other, but the first beat is predomi- nantly that of the left, the second that of the right. On careful (examination, however, both sounds of the right ventricle are audible with each systole, but with the second there is only a short, weak, left ventricle first sound and no aortic second sound, the aortic valves not being raised. A more exact statement of the facts than that the ventricles contracted alter- nately would be that there were two effectual beats of the right heart to one of the left. And it seems clear that an extra systole of the right ventricle may be useful, and indeed necessary, in order to drive an, adequate supply of blood into the left ventricle. The piil«!»c of mitral insiifliciency. — This may almost be said to be the one irregular pulse of valvular disease. It cannot be stated with confidence that the regurgitation throucfh the mitral orifice gives rise in all cases to irregularity of the pulse, but it is rare that it goes on to the production of sym])- toms without this eflJect. It is an eflTect which is easily understood, and which might have been anticipated. When there is free refiux into the 2i8 The Pulse. [Chap. xi. auricle, since the Ijlood will move in the direction of least resistance, the proportion of the contents of the ventricle propelled into the aorta will depend on the fluid-pressure maintained in the auricle and pulmonary veins. Now this will vary in inspiration and expiration ; and accordingly at one moment more, at another less blood will be injected into the arterial system, and this inequality will be felt in the Fig. 52.— Mitral Be^argitatioii. pulse. The resistance experienced by the ventricle in its contraction, again, will vary : in inspiration there will be negative pressure in the auricle and diminished resistance to the reflux of blood from the ventricle, in exi)iration, positive pressure and increased resistance to reflux ; and the systole will be short and sharji, or prolonged, accordingly : this is another obvious source of irregularity. Tlie final result is that no two beats of the pulse are alike, either in strength, or duration, or interval. The pulse, besides being irregular, is easily com- pressible, short, and unsustained ; that is, the tension is low. (Fig. r)2.) As in the case of other valvular diseases, the pulse Chap. XI. J In Mjtral Incompetence. 219 enters into the diagnosis and j)rognosis of mitral insufficiency, but not in the same degree as in aortic insufficiency. A systolic apex murmur conducted to tlie left and audible in the back may attend either slight or free regurgitation, and of itself gives no information as to the amount of blood which escapes back into the auricle. This, which is a part of the diagnosis and a very important element in the pro- gnosis, is determined upon other considerations, among which is the character of the pulse, together with the hypertrophy and dilatation of the different chambers of the heart and the accentuation of the pulmonary second sound. 220 CHAPTER XIT. THE PULSE IX STRUCTURAL DISEASE OF THE HEART. In liypei'tropliy. — There is no form of pulse wliicli can be said to be characteristic of hypertrophy of the heart. This condition has its oricjin in some kind of over-work of the heart, occasionally in ex- cessive muscular exercise or sustained effort, but usually in some ol stacle in the systemic or pulmonary circulation which demands additional contractile energy on the part of the corresponding ventricle. In the pulmonary circulation the chief causes of obstruction are bronchitis and emphysema and disease in the left side of the heart. In the systemic circulation, with wdiich we are concerned when speaking of the pulse, the obstruction may be at the aortic orifice, very rarely in the course of great vessels — most commonly at the ]ieriphery in the capillaries and arterioles. ^^'hen, therefore, the heart is hypertrophied the pulse will be that of the condition which has given rise to the hypertrophy, modified by the increased contractile energy of the heart. If the hypertrophy is caused by aortic stenosis, the pulse will be regular, small, long, and firm under compression ; if by aortic insufficiency, large and shoi-t, and more or less collapsing. If, as sometimes, though rarely, happens, there is no assignable cause for gi-eat hypertrophy, except adhesion of the pericardium, the pulse will present nothing characteristic. "When the case is one of peripheral obstruction and high arterial tension the artery may be small or large, its coats normal or more commonly thickened ; but it will be full between the beats, and can be rolled Chap. Xn.] /.V D/LA7 AVION OF THE 11/: ART. 22 1 under the finger, and, until the heart and vessels have suffered serious damage and degeneration, the pulse- wave will be deliberate, sustained, and not easily arrested by pressure. When the arteries have lost their elasticity, are thick, leathery to the feel, presenting bulgings and irregularities in their walls and tortuosity in their course, while the heart, if not dilated, has become fibroid, the pjulse, while the vessel is full between the beats and capaVjle of being traced up the fore-arm nearly to the elbow, will be abrupt both in its onset and cessation. The pulse of clJIatHttioii of the heart.— Dilatation of the loft ventricle, which will alone be here considered, may, like hypertrophy, have various causes. Among them are aortic and mitral insuffi- ciency, but these have been sufficiently dealt with elsewhere. Dilatation, being at the same time an effiEict and evidence of cardiac weakness, the pulse will generally be weak, but it may strike the finger sharply and give a deceptive impression of vigour ; there is, again, a general tendency to irregularity in the pulse of dilatation. One cause of this condition is premature exertion after acute disease. In acute rheumatism the mus- cular substance of the heart rapidly loses tone, and probably in many cases there is more or less myocar- ditis ; if the patient is allowed to sit up and walk about too soon dilatation may easily be established, This is particularly liable to occur after pericarditis, when a certain thickness of the muscular fibres is paralysed by the inflammation of the serous covering and infiltrated with the inflammatory products. In enteric fever the heart is not only exhausted and its nutrition impaired by the protracted pyrexia, but granular degeneration takes place, and many 2 22 The Pulse, [Chap. xii. instances of sudden death during convalescence have occurred simply fi'om the patient sitting up in bed. It will easily be understood that dilatation may follow premature exertion under such circumstances. Acute rheumatism and typhoid fever are the diseases which are most frequentl}^ followed by this form of heart damage, but it may be induced after any acute febrile affection in poor constitutions or badly-nourished subj ects. The pulse of dilatation produced in the way de- scribed is usually weak, short and irregular, un- less in the course of time compensatory hypertrophy has been brought about by care and an improved state of health : the artery may be small or large. The pulse is perhaps most likely to be irregular after rheu- matic fever. When dilatation of the heart takes place under other circumstances, antecedent high arterial tension usually plays a part in its production. This is the case, for example, in the dilatation which sometimes occurs at the beginning of acute renal dropsy. Slight dilatation is not uncommon in the first few^ days of this affection, and when sufferers go about their work for some days before seeking admission into hospital it may reach a considerable degree. Here the factors in the causation are resistance in the capillaries and arterioles, due, as has been before stated, to retained nitrogenised matters, increase of the volume of the Ijlood by water which ought to have escaped in the urine, and impaired nutrition of the walls of the heart. In acute dilatation, again, from violent exertion or from exertion which, without being excessive in point of violence, is unduly protracted, and, perhaps, repeated, as in training for races or other athletics, in all the cases which have come under my observa- tion there has been undue resistance in the peripheral Chap. XT I. J Tn Dilatation of the Heart. 223 circulation whether the patient has been old or young. After middle age a single imprudence, such as hurry- ing to catch a train, climbing too steep and too long a hill, even running upstairs may break down and dilate the left ventricle ; this is much more likely to occur when a weight of some kind, such as a bag, is carried, and in my experience the factor of high tension has very rarely been absent. In the young, brief exertion, however violent, does not produce a joermanent dilatation, as the heart speedily recovers itself after being over-distended j but this effect may follow effort carried to the point of exhaustion and especially when renewed day after day. In ansemia, which, as has already been stated, is often attended with high pulse-tension, dilatation of the heart is not uncommon, and it may take place suddenly or gradually. The breathlessness attending this state of the blood may be due not merely to the defective carriers of oxygen to the nerve-centres, but also to this state of the heart. It may be worth mentioning that I have twice seen acute dilatation of the left ventricle after mumps in young men, without apparent cause, except that there was marked arterial tension ; in one it was renewed and kept up by comparatively slight exertion, and threatened to be very serious. Dilatation of the heart is produced suddenly more frequently than is generally supposed, but it usually comes on gradually in the subjects of chronic arterial tension. Yery often there is antecedent hypertrophy, which after a time fails to cope with the resistance in the arterio-capillary network, as fibroid change or fatty degeneration invades the muscular fibres of the cardiac walls. In other cases the heart is from the first incapable of developing compensatory hypertrophy as obstruction in the peripheral circu- lation increases, and primary dilatation is the result. 2 24 The Pulse. [Chap. xii. Occasionally, when dilatation lias been thus established in the first instance, improvement in the healtli and changed conditions of life, aided perhaps by treatment, may bring about secondary hypertrophy. It will be seen from these considerations that the pulse of dilatation will vary greatly, not only accord- ing as the dilatation is slight or great, but according as it is the simple, direct effect of weakness or de- generation in the muscular walls of the heart, or is superinduced upon antecedent hypertrophy, or is more or less neutralised by subsequent compensatory hypertrophy. Since high arterial tension plays so large a part in the production of the cardiac change, the artery will almost always be full between the beats ; but, in proportion as the dilatation has impaired the propulsive power of the heart, it will yield to the pressure of the finger, and that feature of genuine liigh tension — the feeling that the greater the com- pression, the stronger the pulse — will be absent. Other effects of the dilatation will be that the systolic pressure in the arteries is not sustained, tbe pulse-wave begins and ends more or less abruptly — the tension is virtual not actual. Added to these characters may be some degree of inequality in the force of individual beats, and in many cases irregu- larity as regards time. Another feature will be, that while the pulse may be regular, strong, and sustained, and apparently in all respects a good pulse in repose, slight exertion will develop in a marked degree the characteristic evidences in the pulse of the cardiac weakness^ — frequency, irregularity, shortness, and compressibility both during and between the beats. Fig. 53 is a trace from a case in which acute dilatation with haemoptysis had occurred from over- exertion ; a mitral systolic murmur remained ; the artery was not large. In the case from which the trace in Fig. 54 was Chap. xiL] In Dilatation OF the Heart. 225 taken here were breathlessness, difficulty of lying down, and enlargement of the liver, all of which were Fig. 56.— Same Case (Fig. 55) after Treatment. Pulse of Dilatation of the Heart. relieved by treatment. The patient whose pulse is represented by the trace in Fig. 55 was liable to stagger and even fall on ri.sing from a seini-recumbent p— 27 2 26 The Pulse. [Chap. xii. position_, with momentary loss of consciousness, and on slight exertion he would suddenly lose all power. The artery was always full between the beats, notwithstanding the appearance of the trace. He improved under treatment, could walk eight miles, was more cheerful, and could lie on his side ; the pulse then gave the second trace. (Fig. 56.) Later, over-exertion aggravated the dilatation, and throm- bosis of the left middle cerebral artery occurred, the case ending fatally. Ill fatty degeneration of the heart. — A very infrequent pulse has been said to be highly characteiistic of fatty change in the muscular sub- stance of the heart. There is, of course, foundation for this statement, and some justification for the ex- pression, " the slow pulse of fatty degeneration " ; but in my experience there may be advanced fatty change without marked slowing of the heart's action, and on the other hand extreme infrequency of the pulse with- out disease of this character in the heart. The pulse- rate varies in fatty heart, and the rhythm may be regular or irregular, the arteries may be soft and apparently healthy, or they may be in a state of ad- vanced degeneration. A fatty heart is incapable of giving either a distinct genuine apex push or a sustained pulse, except in the rare case of degenera- tion affecting the right ventricle only. The pulse, therefore, which would tend to confirm a suspicion of fatty degeneration of the heart would be weak, short, and compressible, and the significance of such a pulse would be greater were it infrequent. The great cri- terion, however, is the eflect of slight exertion ; if the heart is only functionally weak it will respond, and the pulse will improve ; if, on the other hand, it is in an advanced stage of fatty change, it cannot accom- modate itself to the least increase of work, and its action becomes irregular and faltering. - 227 CHAPTER XIII. THE PULSE IN ANEURISM. Difference between the radial pulse of the two sides has long been recognised as one of the most important signs of thoracic aneurism, and here it must be stated that the sphygmograph is of very great service in bringing out and defining the specific difference pro- duced by aneurism Vjetween the right and left pulses, and that its indications precede in point of time, and are more delicate and, perhaps, more trustworthy than, those recognisable by the educated finger, although they are very rarely belied. Inequality in the pulse of the carotids and of their branches will often corroborate and supplement, and occasionally correct the inferences derived from differences between the radial pulse. The femoral pulse, again, may afford valuable information with regard to aneurism of the abdominal artery and its branches. The radial pulse may be different on the two sides from other causes than aneurism, and these must be specified. Difference in the size of the two arteries at the point where the pulse is examined is the most common. Sometimes it is that the radial artery of one fore-arm is smaller than the other in its whole length and the ulnar larger Ijy way of compensation ; at others the radial artery turns round prematurely to the dorsal aspect of the limb, and is represented at the wrist by a branch, the superficialis volae. An apparent difference may result in another way from the artery being more super- ficial on one side than on the other, or from the presence of a curve in the vessel in one wrist and not in the other. 2 28 The Pulse, [Chap. xiii. A real difference in the pulse of the two sides, simu- lating more closely than any of the above the effect of aneurism, may be produced by the pressure of a tumour upon any part of the arterial channel, of which the radial is a branch — subclavian, axillary, or brachial. The modification of the pulse caused by aneurism is not merely a change in the diameter of the vessel or in the strength of the beat — there is an alteration in the character of the pulse-wave, as will be described shortly ; but, when the issue is so grave as that in- volved in a diagnosis of aneurism, all possible sources of error must be considered and excluded. When, therefore, a suspicion is excited by difference of the pulse on the two sides, the causes of such difference above enumerated must be borne in mind, as must also the possibility of pressure upon one or other artery due to the position of the limb. Such a position, for example, as will stretch the subclavian over the first rib or will compress the axillary against the body or across the arm of a chair or partially obliterate the brachial by flexion of the elbow. A passing remark may here be permitted. It ought to be a routine practice to examine the pulse at both wrists, not only because a careful investigation may be suggested by which an aneurism of the aorta or intrathoracic tumour may now and then be de- tected, but for the purpose of acquiring familiarity with sucli differences between the two sides as are common and devoid of significance. Not unfrequently it is the pulse of one side only which can be depended upon as indicating the state of the patient, and if, in the course of acute illness, one of the two different pulses is felt one day and the other on another, without knowledge of the difference between them, the most erroneous conclusions may be drawn. Coming back now to the pulse of aneurism, it must first be observed that, in order to give rise to Chap, xiii.j In Aneurism, 229 difference in the two radial pulses, a thoracic aneurism must be so situate as to affect differently the two subclavians. An aneurism at the root of the aorta, or in the ascending aorta, or even in the first part of the arch, need not cause any difference between the pulse on the tw^o sides. Aneurism of the first part of the arch will have this effect when the innominate is directly or indirectly implicated, as will aneurism of the innominate artery itself, and in such cases the chief modification w^ill be in the right pulse. It is, however, in aneurism of the transverse and descending arch that a difference is most frequently felt between the two pulses, that of the left side being affected, and it often constitutes an important, sometimes almost a determining element in the diagnosis. There is a great difference between aneurism of the ascending aorta and of the arch, both as to the effects whicli they produce and as to the indications by means of which they are recognised. I have long been in the habit of calling the former the " aneurism of physical signs," the latter the "aneurism of symptoms." The ascending aorta is freely movable, and does, in fact, move up and down — or, to speak more exactly, down and up — with each beat of the heart ; it probably expands and contracts also more than any other part of the vessel. Accordingly, provision exists for its free play ; it is not closely attached to surrounding parts, and is not in close relation with the nearest important structures, the root of the lung and the vena cava superior and the pneumogastric nerve. In this way it comes to pass that an aneurism of the ascending aorta may attain a considerable size before pressure-effects, or, in other words, symptoms, are produced. On the other hand, this part of the aorta is near the surface of the chest, an expansion of the vessel here very often takes a superficial direction upwards and outwards, and in whatever direction it 230 The Pulse. [Chap. xiii. takes place can scarcely fail to produce actual contact with the chest- wall ; the aneurism, therefore, reveals itself by dullness, pulsation and characteristic auscul- tation signs. The aortic arch^ especially the transverse and descending part, presents a complete contrast of anatomical conditions to those just enumerated. It has little freedom of movement, is closely related with important parts — the trachea and oesophagus, the root of the left lung, the innominate veins — while the cardiac plexus of nerves, and the branches of the pneumogastric and sympathetic, which form it, may almost be said to ramify upon it, and the left re- current laryngeal nerve actually winds round it. Again, crossing as it does almost directly backwards, it recedes from the surface of the chest. Pressure- effects or symptoms — pain, paralysis of the laryngeal muscles, dyspnoea, blocking of the great veins, etc. — thus appear at an early period of the disease, before the aneurism has attained a size which is appreciable by percussion, or has reached the surface so as to com- municate pulsatile movement. It will be evident that a characteristic modification of the left radial or carotid pulse will be a critical indication in doubtful cases when symptoms are present which may or may not be due to aneurism. An aneurism may interfere with the flow of blood throucrh one of the main branches given ofT from the aortic arch in four ways : — 1. By \\\^ interposition of a sac which expands under the systolic increase of pressure and receives part of the blood injected by the heart, diverting it for the moment from the current in the aorta, and delivering it gradually aftersvards so as to render the stream more continuous. 2. By the branch or branches being given off from the aneurismal sac itself. Chap. XIII.] In Aneurism. 231 3. By i3ressure upon the vessel by the sac ; not unfrequently one of the branches of the aorta will run for a longer or shorter distance in the wall of the aneurism, 4. By simple narrowing of the mouth of the branch at its orifice. The general tendency is the same in all : namely, to intercept the systolic ictus and to retard and smooth down the pulse-wave. The degree of modifi- cation varies greatly ; in some cases this is carried so far that the flow of blood in the radial and other small branches becomes almost equably continuous, the variations of pressure which give the pulse being obliterated, and the beat being scarcely perceptible, while the artery is continually full. The interposition of the aneurismal sac, acting the part or imitating the efifect of a blacksmith's bellows, by receiving a considerable jDroportion of the blood propelled into the aorta by the ventricular systole, and thus annulling or diverting the pressure-wave normally transmitted onwards to the remotest branches, the special and characteristic effect of which is supposed to be the modification of the pulse just described, is, according to my experience, less frequently its cause than one or other of the remaining conditions enumerated, the origin of a branch from the sac, and obstruction by pressure or narrowing of the orifice. When the artery comes off* from the aneurism itself or is implicated in the wall of the sac it may be completely obliterated, so that the circulation in the parts which it supplies is entirely collateral. Sometimes an effect upon the pulse is attributed directly to the aneurism as an elastic reservoir, which is produced indirectly by interference with the full and free flow of blood through a branch. A remark- able case came under my notice some years since, in which, without aneurism, a simple narrowing of the 232 The Pulse. [Chap. xiii. mouth of the innominate and subclavian arteries, with enlargement of these vessels near their origin from the aorta, almost completely annulled pulsation in both radials. The patient was admitted into St. Mary's Hospital suffering from cirrhosis of the liver, and it was at once observed that he had no pulse in either wrist, except under excitement or on exertion, when it could just be detected, and scarcely per- ceptil)le pulsation in the bracliials or carotids. At tlie same time, the arteries were full and the circula- tion in the hands good. There was forcible pulsation in all the arteries of both lower extremities. To add to the difficulties of the case, the absence of the pulse had been fiist observed after a railway accident many years previously, and had been taken into account in the compensation awarded. No signs or symptoms of aneurism existed, and it turned out, on post- mortem examination, that the cause was simply a constriction at the mouth of each of the branches given off from the arch of the aorta with a small ampulla just above. ' In comparing the pulse of the two sides with a view to the diagnosis of aneurism, the most important point to which attention must be given is whether they are absolutely synchronous or not ; the most significant indication of aneurismal interference with the pulse is delay of the beat. To appreciate this the two pulses must, of course, be felt simultaneously ; and it is well to test the first impressions by varying the position of the patient's hands, raising and lowering them, and by examining each pulse with both hands, i.e. after feeling the right pulse with the left fingers and the left pulse with the right, sitting in front of the patient, to cross the hands either of the patient or of the observer so as to feel each pulse with the corresponding hand, or to stand behind the patient for the same purpose. With the delay on Chap. XIII.] Ly Aneurism. 233 the affected side there will usually be a smaller artery and a more compressible pulse, and the vessel will be more continuously full between the beats. Case 1. Left Side. Right iSide Case 2. Left Side. Eight Side. Fig. 57. — Pulse in Aneui-ism. As has been already said, the sphygmograph is here more definite and delicate in its indications than the pulse as felt in the usual way. (Fig. 57.) The upstroke of the trace is more sloping, the height less, the summit more rounded, and the fall more oradual ; 234 The Pulse. [Chap. xiii. and the trace shows minute changes in the character of the pulse which are not appreciable by the finger. It shows, moreover, as pointed out by Marey, that the delay of the beat is not any retardation of the begin- ning of the wave, but of the period of maximum pressure. Applying these conclusions to the effects on the pulse of aneurisms of different parts of the aorta. 1. Aneurism of the ascending aorta will affect all the pulses equally, unless it is large enough or so situate as to implicate directly or indirectly the inno- minate artery. Occasionally, the right pulse seems to be stronger and better than the left. There being no difference between the pulse of the two sides, and thus no comparison between a normal and a modified pulse, the modification of the pulse pro- duced by aneurism may be scarcely appreciable, even when it is very large, especially if much laminated clot has been deposited. In some cases the wave is more or less smoothed down, as already described. When aneurism of the ascending aorta involves the innominate, or when the aneurism springs from the tiist part of the arch, the right radial pulse will be modified, and, as compared with the left, it will probably seem to be slightly retarded and longer, but smaller and more compressible, while the artery will be more continuously full between the beats. An examination of the carotids ought to show a corre- sponding modification of the right carotid pulse, since the carotid and subclavian arteries would be equally affected by interference with the innominata. 2. Aoienrism of the innominate artery^ whether by extension from the aorta, which is a frequent event, or of independent origin, Avill usually affect the pulse of the carotid and of the radial, and in much the same degree ; but one of the two divisions may be implicated more than the other, and such a Ch pp. XIII.] Ix Aneurism. 235 difference might have diagnostic importance as be- tween innominate aneurism and a sac projecting into the neck from the aorta. Occasionally aneurism of the arteria innominata is simulated by an abnormal origin and course of this artery, which, arising from the aorta farther along the arch, crosses over the root of the neck in front of the trachea ; or it may be the subclavian (rarely the carotid) which, springing independently from the arch of the aorta, takes this course. Sometimes the diagnosis between such an abnormality and aneurism is really difficult, and the pulse may afford valuable aid in establishing the distinction. It will not be affected when there is no aneurism. 3. Aneurism of tJie transverse 'part of tlie arch. — This may involve the innominate artery, on the one hand, or the left carotid, with or without the sub- clavian, on the other. Occasionally, though rarely, aneurism of the arch may be large enough to impli- cate all the three great branches. Either right or left pulse, therefore, may be affected to a greater or less degree, or both. It is when a small aneurism of the third part of the arch or of the descending aorta implicates the left subclavian artery and gives rise to distinct delay in the left pulse, with other of the cha- racteristic modifications enumerated, that inequality of the two radial pulses has its maximum diagnostic importance. There may be no other physical sign of any kind, and the pulse may be the only indication which gives a definite interpretation to a group of symptoms which might otherwise be uncertain and perplexing in their indications. 236 CHAPTER XIY. THE PULSE IN KIDNEY DISEASE. So constant is the association of a pulse of high ten- sion with renal disease, that it has sometimes been called the " renal pnlse." This, however, is extremely oltjectionable, for although almost every form of disease of the kidneys, except suppurative inflam- mation, is attended with high arterial tension, and although the cord-like artery and persistent wave, when well marked, are extremely suggestive of renal disease, these characters of the pulse are common enough when no aflfection of the kidneys is present. The Pulse in Contracted Granular Kidney. It is in the contracted granular condition of the kidney — the disease to which the name " chronic Bright's" is usually applied— that high arterial ten- sion is most common and best marked : the artery con- tracted and cord -like, full between the beats, and capable of being rolled under the finger and followed up the fore-arm, while the pulsatile movement is deliberate and inconspicuous, but arrested only by great pressure. It is with regard to this state of the pulse that so much controversy has arisen. The hard pulse and tliickened ai-teries had been early noted when Dr. George Johnson advanced his well-known theory to explain these facts. This, put l)riefly, is that impurities, which ought to have been eliminated by the kidneys, being retained in the blood, act as an irritant to the tissues, and provoke a reflex contrac- tion of the minute arterioles, which is protective of the tissues by shutting off*, in some measure, the con- taminated blood. At the same time, the narrowing Chap. XIV.] In Contracted Kidney. ^t,! of the arterioles gives rise to obstruction, which dams back the blood in the arterial system and causes the blood pressure to be high. But the distending in- fluence of the increased Ijlood pressure in the arterioles will necessitate increased contraction of the muscular walls of the vessels, and the persistent exercise of contractile energy demanded by the persistence of the cause leads to hypertrophy of the muscular coat of the arteries. Nothing could be more clear than the demonstration of the increase of muscular fibre-cells in the thickened arterioles of chronic Bright's Disease • and except that, in my opinion, the obstruction is primarily in the capillaries, and the arteriole contrac- tion secondary to this. Dr. Johnson's theory . com- mands my entire adhesion. The opposing theory is that of Sir William Gull and Dr. Sutton, according to which the increased thickness of the walls of the vessels is a fibroid sub- stitution and not true hypertrophy of the muscular structure, and the arterial tension is due, not to arteriole contraction but to arterio-capillary fibrosis or hyaline fibroid change in the capillaries and arterioles. It is based partly on microscopical, partly on clinical evidence ; but the former was completely overthrown by Dr. Johnson, who showed that the hyaline fibroid appearance was producible by the method of jitrepar- ation employed. A certain degree of fibroid change is, no doubt, present together with the hypeiiirojDhy of the muscular fibres, and late in the disease the muscu- lar fibres undergo more or less degeneration, allowing the fibrosis to predominate ; but this, in my judgment, is all that subsequent investigations have established. The clinical evidence adduced is to the efiect that the renal changes in Bright's Disease are not primary, but are led up to by a long train of symptoms due to general degenerative change in the arterioles and capillaries. It is, no doubt, true that before albumen 23S The Pulse. [Chap. XIV. appears in the urine, and before the change in the kidneys has reached a point which could affect the health, almost before the morbid condition of these organs is recognisable on examination after death, there may be loss of flesh and strength, headache and depression, impairment of appetite and digestion, and other indications of failino- liealth. But evidence of Tracing taken just before Inhalation of Nitrite of Amyl. Patient had chron Bright's Disease. Tracing taken about two minutes after Inhalation of Nitrite of Amyl. Fig. 68.— Effects of Nitrite of Amyl in Briglit's Disease. this kind is capable of another interpretation, namely, that these symptoms are due, if not to the high arterial tension itself, yet to disturbance of the normal relation between the blood and tissues which provokes resis- tance to the circulation in the capillaries, and con- stitutes the real antecedent of the renal disease. When it is considered how minute a proportion of various drugs may aflect in one direction or another the freedom of the peripheral flow of blood, it can scarcely be denied that impurities due to imperfect metamorphosis or insuflicient elimination may give rise Chap, xiv.] In Contracted Kidney. 239 to obstruction in the capillaries and arterioles. There is, further, the simple experiment to which appeal was made when the question was under discussion before the Medico-Chirurgical Society. If the change which gives rise to resistance in the arterioles and capillaries is degenerative or hyaline fibroid, it must interfere with the contraction and relaxation of which these Morb. Br. Anasarca, albuminuria. No cardiac murmur, and firm ; radial tortuous. Pulse A'ery small Took calomel gr. v. ; lias had some diarrlicea since. contains less albumen. Feels much better. Urine Fig. 59.— Effects of Calomel. vessels are normally capable. Relaxation, especially, should be slow and imperfect. Let, then, nitrite of amyl be administered to the subject of this supposed fibrosis ; if the physiological effects are produced, the muscular fibres of the arterioles and the contractile element in the capillary wall cannot well have under- gone structural change or degeneration. This test has been applied and always with the same result : the full efi'ects of the nitrite are manifested. (Fig. .58.) 240 The Pulse. [Chap. xiv. Other physiological relaxants of the peripheral vessels also have their normal influence ; nitro-glycerine is, indeed, employed therapeutically in kidney disease. A mercurial aperient will lower the arterial tension, as may be seen by the accompanying traces before and after a dose of calomel, sent to me by Dr. Handfield Jones many years ago, when my senior at St. Mary's Hospital. (Fig. 59.) Pyrexia also relaxes the arterioles and capillaries, and it is a common experience that a patient suffering from contracted granular disease of the kidneys, whose pulse exhibits habitually all the characters of high tension, will on the supervention of pyrexia at once have a large, soft, and dicrotous pulse. We have thus every proof of full physiological activity in the muscular coats of the arterioles, and they cannot, therefore, have undergone fibroid change. The hypothesis of a general hyaline fibroid degen- eration, of which the cirrhosis of the kidney is only a part or a consequence, appears to me to have no foundation in fact, and to survive only in virtue of the great and merited reputation of its authors, and of the euphonious terms which they introduced. It will, then, be taken as proved that the high arterial tension of contracted granular kidney is due to arterio-capillary contraction and not to arterio- capillary fibrosis or degeneration, the contraction being l^rovoked by the presence in the blood of some matter which acts as an irritant. The fact that increased blood pressure often precedes the kidney mischief shows that it is not due purely and simply to deficient renal elimination, but it cannot be doubted that, when disease of the kidneys is established, the retention in the l)lood of waste products which ought to have passed out of the system by these organs adds to opposition in the capillaries, and becomes an impor- tant factor, perha})s the most considerable factor, in Chap. XIV.] In Contracted Kidney. 241 the production of the high arterial tension. Additional certainty is given to this conclusion by the fact that other affections of the kidneys at once give rise to in- creased blood pressure, and that it is in chronic Bright's Disease that arterial tension reaches its maximum. Co-operating with the arterio-capillary resistance to produce the renal pulse, so-called, is an increased, pro- pulsive power of the heart. The gradual advance of the renal changes and of the peripheral obstruction to the circulation in chronic Bright's Disease affords time for the heart to accommodate itself to the increased work thrown upon it, and to meet the resistance in the arterio- capillary network by hypertrophy. That the hyper- trophy is a real increase of the cardiac muscular fibres and not merely an addition of adventitious fibrous tissue there can be no manner of doubt ; it is demonstrated by the microscope and proved by the increase of functional energy. In the late stages of the disease, when the heart is worn out, an excess of fibroid material is present and the proportion at all periods will vary according to individual tendencies and mode of life — it may be larger, for example, in cases of alcoholism — but the characteristic change in the heart is true muscular hypertrophy, the result of excessive functional exercise. The apex beat is displaced downwards to the sixth or even to the seventh space and carried somewhat outwards ; it is a genuine thrust and not a mere shock, and the cardiac impulse generally is powerful. The first sound, as heard at the apex, is dull and pro- longed, while over the aortic area it is scarcely, if at all, audible. At an advanced period of the disease, when the heart has begun to suffer from the effects of protracted over-work, and in some cases throughout, the first sound is reduplicated over a larger or smaller area near the apex, The aortic second sound is loud Q— 27 242 The Pulse.. [Chap. xiv. and accentuated both in the right second space and at and to the left of the apex. It would almost appear from the considerations stated that the heart and vessels were engaged in a work of mutual destruction, and such is indeed the fact, as is testified by cerebral haemorrhage and valvular and structural disease of the heart. It is, however, probable that other evils are averted which would prove fatal sooner, and that high arterial tension is really the result of a defensive reaction. Cases will be related later in which kidney disease with low arterial tension has run a raj)id course, but for the present we may try to discover in what ways arterial tension may •be conservative. The general condition of the circulation will at any rate have the effect of keeping np a ra})id flow of blood through the kidneys ; this must result from the increased driving power of the heart and from the contraction of the minute arterioles and the resistance in the general systemic capillaries. Now, the trans- mission of an increased amount of blood through the kidneys gives rise to an increased flow of urine which will in some degree comj)ensate for the diminished eliminative action of these organs ; and, in effect, the low specific gravity and diminished urea of the urine in contracted kidney are more or less neutralised by the polyuria. Another conservative effect of the rapid passage of blood through the kidneys resulting from the high arterial tension and hypertrophied heart will Ije the diminished tendency to albuminuria. It would seem a fTiori that the increased blood pressure would tend to promote transudation of albumen from the malpighian glomeruli ; but all clinical evidence is against this, and experiment has shown that the condition which determines the passage of albumen from the tufts of capillaries into the tubes is not high or low pressure, Chap. XIV J Jx COXTRACTED KlDXEV, 243 but stasis or slow movement of the blood in. them. Variations of pressure influence it only as they tend to produce stasis. Now, it is obvious that the morbid change in the kidney which causes the contraction, -whether it is denudation of the tubes or cirrhosis of the intertubular cement, will tend to obstruct the "capillaries ramifying between the tubes and to give rise to stasis of blood in the glomeruli. This the hiorh -pressure and rapid circulation will tend to obviate, and thus to prevent albuminuria. The conservative eflfect of sustained blood pressure in the prevention of albuminuria in chronic Bright's Disease is illustrated when from any cause the propul- sive power of the heart is impaired, or when the peripheral resistance is diminished, as by pyrexia. As the heart gets worn out and dilatation or des^eneration supervenes upon hypertrophy, in proportion as it fails to maintain the arterial tension at a high point, the amount of albumen increases in the urine, and it is slackening of the circulation and not aggravation of the kidney disease which gives rise to this increase. Again, it is not uncommon for acute dilatation of the heart to occur in course of Bright's Disease in con- sequence of eft'ort or sustained exertion ; or without recognisable event of this kind, the heart may become weak from insufficient food, alcoholic excess, anxiety, or impaired health. The diminished vigour of the circulation is at once attended with increase of albumen in the urine. Pyrexia, again, from whatever cause, will give rise to an aggravation of this album- inuria ; the relaxation of the arterioles and capillaries lowers the general arterial tension and thus slackens the current of blood in the renal vessels. The sudden increase of albumen in the urine due to cardiac weak- ness or to pyrexia is often attributed to intercurrent tubular nephritis. More.. striking still is the effect of bronchitis in 2^4 ^^'''^-' P^^I^^F'- [Ch.ip XIV. increasing the amount of albumen in the urine when the kidneys are diseased, and in precipitating the ap- pearance of dropsy. In addition to the pyrexial influence on the general circulation there is obstruction to the passage of blood through the pulmonary capil- laries, which at the same time tends to dam back the blood in the systemic veins and diminishes the supply of blood to the left ventricle. The characteristic pulse and heart sounds of con- tracted granular kidney have been fully described, and the modifications of these which attend the downward progress and attest the injurious effects of the disease may now be traced. Beginning with the pulse, the walls of the arteries become thickened, and when the blood is excluded from the radial by pressure, and the fingers are made to carry the skin to and fro along it, the vessel has a leathery, inelastic feel, and may present indurations, inequalities, and bulgings. It is large, also, as if it had yielded to the distending force of the protracted blood })ressure within it. The muscular coat is worn out, and is more or less replaced by fibroid structure. In proportion as the muscular coat of the small arteries has lost its contractile power there will be loss of control over the blood supply to different parts, and in proportion as the arteries generally have lost their elasticity there will be a change in the clipracter of the pulse- wave, which will become more sudden. In the heart, reduplication of the first sound will become more distinct, and the interval between the first and second sound prolonged. The apex-beat loses in vigour and precision, and becomes diffuse and sla})ping. As these changes in the pulse and heart take place, symptoms referable to weakness and disorder of the circulation supervene : — Sleeplessness from loss of Chap. x[v. 1 In Contracted Kidney. 245 tone and power in the cerebral vessels, which are unable to co-operate in the production of the anaemia of the cortex, essential to sleep, by contracting and shutting off the blood from the brain ; breathlessness on exertion and palpitation of the heart ; paroxysmal dyspncea, often extremely severe, occurring chiefly in the night ; a form of cardiac asthma; fugitive amaur- osis in some very rare instances ; oedema of the lower extremities. It is when the heart is no longer competent to cope with the resistance in the periphery that ursemic phenomena are liable to set in, and it appears to me that disorder in the cerebral circu- lation, associated with, and in some way resulting from, high arterial tension, constitutes the connecting link between the contamination of the blood and the convulsions, which are the most striking and char- acteristic effects of uraemia. When the connection between renal disease and convulsions was ascertained, it was a most natural and plausible idea to attribute the convulsions to the direct action upon the brain of the urinary con- stituents retained in the blood, and expression was given to this theory in the term " ursemic " applied to the entire group of symptoms. From the first, how- ever, a difficulty was recognised in the capricious incidence of the convulsive attacks. It was seen that they occurred early in some cases when comparatively little poison could have been accumulated, late or not at all in others when the blood must be charged with it : the convulsions appeared, in effect, to have no rela- tion with the amount of urinous impurities present in the system, or, with the general deterioration of the blood and tissues. The difficulty was only shifted, not removed, by supposing that the iioison which gave rise to convulsions was not urea or uric acid, or any of the normal constituents of urine, but 246 The Pulse. [chap. xiv. ammonia, derived from the decomposition of urea or some nitrogenised waste of a lower degree of oxida- tion than urea or uric acid which was imperfectly oxidised and broken up, because the blood was already charged with products of combustion. Experimental investigation rendered the idea that urseraic symptoms were due to urea altogether untenable. Urea injected into the blood, in what- ever quantity, did not give rise to convulsions, and when convulsions resulted from some experimental interference with the renal excretion there was no abnormal amount of urea in the blood. The same conclusion was reached when the hypothesis that the symptoms were due not to urea, but to the products of its amnioniacal decomposition in the blood or tissues was experimentally tested. First one substance, then another obtained from the urine, has been considered by different experimenters .to be the toxic agent to which the convulsions and other ura?mic symptoms were attributable. It seemed, indeed, to be almost a reductio ad absurdum when the potash salts were found, after most careful and skilful and apparently exhaustive investigation by Feltz and Hitter, to be the most powerfully toxic of the constituents of urine. If the theory of Traube, which refers the con- vulsions and other ursemic symptoms to cerebral ansemia, the result of oedema, be slightly modi- fied, it seems to me that all the phenomena fall within the range of its explanation. For the pro- duction of the cerebral an?emia, Traube considered a watery state of the blood and hypertrophy of the heart to be necessary, and these conditions are not always present : there may be no hypertrophy of the heart, for example, when convulsions come on early in acute renal dropsy, and there may not be a watery state of the blood in contracted granular kidney with ciiai>. XIV. J In Kidney Disease. 247 ursemic symptoms. The oedema of the brain, more- over, has not been demonstrated. If blood-stasis in the brain, local or general, com- plete or partial, be the condition to which the symptoms are attriVjuted, we find ourselves on more solid ground. It has been demonstrated experimentally that convulsions are excited b}' stasis in the cerebral circu- lation, in whatever way the stasis is induced : whether by rapid loss of blood, when the vessels will be empty, or by suffocation, when they will be engorged ; by liga- ture of the arteries, or by compression of the veins. The question, then, is, are there conditions in renal disease capable of so influencing the intracranial circulation as to produce local or general, partial or complete, stagnation of the blood in the capillaries, especially of the cerebral cortex % In other words, can high arterial tension have any such effect % The question as thus stated, and the way in which the effect may ]>e produced, will be discussed more fully later ; >)ut it may be said here that cases are met with in which convulsions are associated with high arterial tension, no other cause for them being assignable but this state of the circulation. Further, the good effects of venesection in unemic convulsions, to which all observers bear witness, are scarcely explicable except through its direct influence on the circulation, which is to lower the blood-})ressure. Assuming that the above considerations lend a priwA facie support to the hypothesis that ursemic convulsions are produced by blood-stasis in the cerebral convolutions, and that the high arterial tension attending renal disease may give rise to such stasis, it may be pointed out in how many instances the varieties of urjjemic phenomena, and their occur- rence under various conditions, are capable of ex- planation. 248 The Pulse. rchap. xiv. As has already been said, it is when the arterial tension or resistance to the onward movement of the blood is over-mastering the heart that symptoms* super- vene. This being so, a local aggravation of the general obstruction, which the heart overcomes with difficulty, Avill easily give rise to local stagnation of blood. Bearing this in mind, we may go back to the fact that ursemic convulsions may occur without ante- cedent hypertrophy of the heart, which has been made an objection to Traube's theory. Instead of being a difficulty, the absence of hypertrophy enters into the explanation of the attack. Convulsions, for example, sometimes come on early in acute desqua- mative nephritis when there is no cardiac hypertrophy. Now, in this disease, the obstruction in the arterio- capillary circulation conies on so suddenly that the heart, which is enfeebled by the pyrexia and general interference with nutrition, is for a time unable to cope with it efficiently. If time is given hypertroj)hy will gradually be established ; but, the tissues being waterlogged, the blood increased in volume and diluted by water which has not been proi:)erly carried off in the scanty urine, the weak and dilated heart is so far overpowered that the stagnation in the cere- bral circulation which gives rise to convulsions occurs. In proportion as efficient hypertrophy is established the danger is warded off*. The occurrence, which is not very uncommon, of unilateral ur^emic convulsions followed by temporary paralysis is almost inexplicable on the hypothesis that they are due to the action of a poison on the brain, which would have equal access to the two sides. The late ]Mr. Callender, it is true, found that injuries to the right hemisphere were more fre- quently followed by convulsions than injuries of the left, but unilateral uraemic convulsions are not con- fined to the left side. It is not at all difficult, on the Chap. XIV. I In Kidney Disease. 249 other hand, to miderstaiid that stasis might be pro- duced more easily in the cortex of one hemisphere than in the other, Wlien the circulation is being- carried on with difficulty, a very slight anatomical difference between the two sides — a smaller jugular foramen, a different disiDOsition of the veins on the surface of the hemisphere, a different curve of the internal carotid — might determine an arrest of the blood-current on one side sooner than on the other. Experimental evidence in favour of the possibility of such an occurrence is not wanting. It has been found by Raymond and G. E. Bernard that if the inferior cervical ganglion of the sympathetic on one side be cut through and the ureters be then tied, the resulting convulsions, instead of being bilateral, affect only the side opposite to that on which the ganglion was injured. That is, the loss of vaso-motor control on one side of the brain determined the production of unilateral convulsions on the side governed by it. But much smaller areas than an entire hemisphere are often affected in uraemia, and this would increase the difficulty of attributing the symptoms to the action of a poison. There may, for example, be fugitive aphasia, or amblyopia, or hemiopia, which are easily explained by stasis or ischtemia in certain vascular areas, but incomprehensible as results of a poison circulating everywhere through the brain. The great diversity of the symptoms met with in uraemia, again, is best explained by varying degrees of interference with the intracranial circulation. If a given set of symptoms were present in one case throughout, and another set in another, it would be permissible to suppose that different kinds of urinary^ impurity predominated in different cases, excitant, convulsant, or narcotic respectively ; but the various symptoms may all succeed each other in the same case, and it is not difficult to trace some kind of 250 The Pulse. [Chap. xi\'. parallelism between the effects of progressive degrees of pressure as observed in meningitis and successive urtemic phenomena. It has seemed to me, from obser- vation of cases of disease of the brain, attended with convulsions and maniacal excitement, that the latter represented a minor degree of the same irritation, which, carried further, gave rise to convulsions. For irritation may be read blood-stagnation, or stasis, or congestion, or anjemia ; and just as I have seen maniacal excitement supervene on the cessation of violent convulsions in a case of interpeduncular tumour, so have I seen maniacal excitement come on when severe ursemic convulsions had been arrested by venesection. The piil^e in acute tubular nephritis. — In acute renal dropsy the tension of the jDulse is raised, but the conditions are not such as to favour the production of the extreme blood-pressure found in contracted granular kidney. At the onset of the disease the resistance in the arterioles and capillaries is developed too rapidly for hypertrophy of the heart to keep pace with it, especially as there are the anorexia, the tissue- relaxation, and the impaired nutrition of all the structures attending acute disease with pyrexia. The artery, while full between the beats, is at first, though small, compressible, and the pulse-wave is not sus- tained. At this period, again, the apex-beat is more or less displaced to the left, diffused, and wanting in push ; while the first sound at the apex is either short or reduplicated, the aortic second sound being only slightly accentuated. Sometimes there is reduplication of the second sound. There is, in fact,in a large proportion of cases, a temporary acute dilatation of the left ventricle. Under favourable circumstances and proper treatment the heart rapidly gains strength, as is testified by the increasing vigour and definition of the apex-push, the prolongation of the first and the accentuation of the Chap. XIV.] In Acutjc Tubular N/cpi/ritis. 251 second sound, the pulse becoming, pari passu,, longer and stronger, and the fulness and firmness of the artery between the beats more marked. Reduplication of the first sound often persists for a long time, and this is not an unfavourable sign ; persistent redupli- cation of the second sound is, according to my ex- perience, unfavourable. The prognosis in acute tubular nephritis turns very much upon the way in which the heart responds to the demand for increased contractile energy, and the pulse develops actual tension. In proportion to the rapidity of the passage of blood through the malpighian tufts will the transudation of albu- men be lessened and the excretion of water in- creased ; and, other things being equal, this will depend on the vigour of the propulsion by the heart. When, therefore, the pulse becomes firm and long, and hyper- ti'ophy of tlie left ventricle is developed, the increased vigour of the circulation is not only a sign, but also a cause, of improvement and a direct agent in diminish- ing both the albuminuria and the dropsy. When, on the other hand, the pulse remains unsustained and compressible, and the signs of cardiac M^eakness or dilatation persist, the state of the circulation favours the stasis in the obstructed renal capillaries, which diminishes the outflow of water and permits of the transudation of albumen. The sudden increase of urine, which usually marks the beginning of conva- lescence from the disease under consideration, is often entirely attributable to increased arterial tension, and not \nicommonly an increase or reappearance of albumen in the urine on getting out of bed and walking about is thought to indicate a relapse of the renal affection, when it is really due to weakness of the heart, which has been unequal to the increase of work thrown upon it by the exposure and exertion, and has been unable to maintain the arterial pressure 252 The Pulse. [chap. xiV. at the point required for keeping the circulation through the kidneys at the proper rate of speed. The Pulse in Chronic Desquamative Nephritis AND Fatty Kidney. The large white kidney, whether it comes on as a primary disease or represents the effects of acute tubular nephritis, is attended with resistance in the capillaries and arterioles ; but the actual degree of tension in the pulse is dejjendent upon the strength and vigour of the heart, which is Very different in different cases. It is very rarely indeed that the artery has the incompressible cord-like feel character- istic of contracted granular kidney, or that the hypertrophy of the heart is carried to the same degree. The pulse is usually small, long, full between the beats, and moderately tense ; the left ventricle first sound is short and weak, reduplication of the first sound not being marked, even if present. Here, again, the state of the circulation is a prog- nostic factor of enormous import. While the vigour of the heart and the tension of the pulse are well sustained, there may be no dropsy even when the urine is loaded with albumen. When, on the other hand, the heart is weak and the pulse, though full between the beats, is short and compressible, dropsy, if not present, is imminent. In this form of disease, as in contracted kidney, extreme high tension when present will tend to dilate the heart and damage the arteries ; but its immediate effects are protective. Much has been already said as to the apparent usefulness of arterial tension in the various forms of renal disease, and some degree of comprehension of the way in which it operates has perhaps been at- tained ; but the evidence would not be complete without the relation of cases which have come under Chap. XIV] Ix KiDXEV DISEASE. 253 my notice, in which absence of tension has coincided with an unfavourable course and issue. It is clear enough why, when the resistance in the capillaries is increased, inadequate propulsive power on the part of the heart is of unfavourable prognostic import ; but it is not so clear why absence of peripheral obstruction should be a bad sign : but so it appears to be. Absence of resistance in the arterioles and capil- laries is most uncommon in contracted granular kidney^ but a few cases have come under my observation. One was a patient seen in November, 1885, with Dr. Ranking at Tunbridge Wells. His age was 66, and he first consulted Dr. Ranking in July of that year on account of tightness across the chest experi- enced on walking uphill. He was ansemic, and had no appetite ; the bowels were regular. His sleep was broken three or four times every night for micturition, the daily quantity of urine, measured on three suc- cessive days, seventy-six, fifty- six, and sixty-six ounces; it was pale, had a specific gravity of 1008, and contained neither albumen nor sugar. The pulse was frequent, 120, soft, short, and compressible; the cardiac apex was in the nipple line, the impulse weak and excited, the first sound short, the aortic second slightly accentuated. The patient improved under treatment, but again came under Dr. Ranking's care in October with in- creasing weakness and ana}mia, and the urine now contained albumen with hyaline and granular casts, being still copious, pale, and of low s})ecific gravity. When seen by me on November 17th the urine was of the same character, and was considered to indicate definitely the existence of contracted granular disease of the kidneys. The pulse, however, Avas frequent, short and weak, and had none of the features of high tension, but was, on the contrary, a characteristic low-tension pulse, and the heart-sounds were short 254 The Ptlse. [Chap. xiv. and feeble. The ])atient sank raiDidly, and died in December from asthenia. In another case the evidence of granular kidney was not so decided, but the patient suffered from gout, and after a time had albuminuria. He always had a large, shorty soft pulse, the arteries being free from any evidence of thickening or degeneration, and never full between the beats ; the low tension was due to absence of resistance in the capillaries, and not to any weakness of the heart. This patient drank a good deal of whisky, which may have influenced the tension, and contributed to the final result, which was rapid succession of violent, one-sided convulsions, which came on suddenly, and persisted to a fatal ter- mination. An imperfect development of arterio-capillary resistance and arterial tension is much more common in acute tubular nephritis. It is met with at all ages, but with greater relative frequency in patients of middle age. One of the most striking examples came under observation many years since. The patient was a man of forty-five or thereabouts, stout, fresh- coloured, and healthy-looking, perfectly temperate in his habits, and not very sedentary in his mode of life : he was a foreman at a large place of business. He was admitted into St. Mary's Hospital on account of acute albuminuria, attributed to a chilL At first sight it seemed that the patient had vigour sufficient to en- able him to throw oft" any form of acute illness, but the pulse was found to be singularly deficient in ten- sion, not because of any weakness of the heart, but from absence of resistance in the capillaries. Dropsy was developed rapidly, and the patient died after a Jong, lingering illness. In younger patients there is usually recovery from the acute attack, but large white kidney remains. Brief notes may be given of a case recently under Chap. XIV.] In Kidnev Disease. 255 observation. The patient, a carman, aged t^yenty- seven, of sober habits, and previous good health, was admitted into St. Mary's Hospital on October 29th, 1887, suffering from acute general oedema affecting the scrotum specially, and the hands and arms more than the legs. The urine had a specific gravity of 1030, and was almost entirely converted into a coagu- luni of albumen by heat and acid. It was straw- coloured, and not smoky, but gave slight evidences of blood-reaction with guaiacum and ozonic ether. The pulse was 60, short and very compressible ; the heart's impulse weak, and the sounds short and indistinct. The opinion formed on these grounds was that the case would be tedious ; but that the large amount of albumen did not necessarily indicate a specially severe affection of the kidneys, being probably due to the lan- guid movement of blood in the renal capillaries result- ing from the slight development of resistance in the arterioles and capillaries generally, and the weak action of the heart. For a fortnight the dropsy increased, and much fluid accumulated in both pleural cavities, and at the end of this time the pulse was still short and compressible. The urine, however, had a specific gravity of 1008, and the coagulated albumen only occupied half its volume. At the end of three weeks a marked improvement had taken j)lace in the pulse ; the artery could be felt between the beats and rolled under the finger and w^as not so compressible. Simultaneously the amount of albumen had fallen so that it was described by the clinical clerk as rather more than a trace, and the dropsy and pleural effusion were much less. The rapid diminution in the pro- portion of albumen justified the opinion that the ex- cessive amount present at first was attributable rather to the languor of the circulation than to the severity of the local disease. A week later the patient appeared to be so. nearly 256 The Pulse. [Chap. xiv. well, that he was allowed by the resident to get Tip for a short time ; but there was at once some return of swelling in the legs, the pulse became more compressible, the apex-beat and heart- sounds weaker, and the proportion of albumen rose from one-eighth to one-third. The heart was not equal to the main- tenance of the circulation in the erect position, and with the languid movement of the blood, which re- sulted, came the increased amount of albumen. On the patient's return to complete rest in bed, the albumen promptly diminished. He was now kept in bed, took his food, slept well, remained free from any dropsy, and had only a varying trace of albumen in the urine. Before it was considered safe to let him get up again — six weeks from the previous attempt — he had ton- silitis, with a temperature of 103° F., and, accom- jmnying this, severe ha3moglobinuria, the urine having a dark lilood-plirple colour, and containing albumen to four- fifths of its bulk, but presenting no blood-corpuscles under the microscope. The blood and albumen disappeared rapidly, and were succeeded by uric acid crystals in large quantity. Or the attack might be described as one of hfiemoglobinuria com- plicated with tonsilitis. It seemed to me, however, that the tonsilitis was primary, and that under the stress of high temjjerature hsematolysis occurred. Like the defective reaction of the capillaries and heart, it showed that the patient was made of poor stuff. He remained in hospital some months longer, and, when discharged, was still suffering from albumi- nuria. Similar examples might be given in quite young children. Usually the prognosis from this condition of the circulation becomes fairly definite at the end of a fortnight. In primary large white kidney, the imperfect development of cardio-vascular reaction is almost the Chap. XIV.] Ix KiDXEV DISEASE. 257 rule, the weakness, however, being more commonly on the side of the heart than of the vessels. It may be pointed out, in conclusion, that cases of fatal disease of the kidneys without thickened arteries and hypertrophied heart {which are cited for the pur- pose of proving that, when such changes are found associated with renal disease, they are concurrent with, or antecedent to, and are not consequent upon it) are simply cases of the kind just exemplitied, in which the kidney disease has proved fatal early from want of the cardio-vascular changes. Arterial tension a!S n griide to treatment In renal disease. — Perhaps the most striking illustration of this is the resort to venesection in urtemic convulsions. Here, no doubt, practical ex- j)erience was in advance of scientific teaching, de- monstrating the good effects of bleeding before the modus operandi was understood. It is, indeed, the rule, as yet, in therapeutics that facts are first estab- lished by observation, and the explanation is learnt afterwards. This has always been the safest basis for treatment, and the advance of medicine has been retarded and countless lives have been sacrificed through the premature adoption of theories of thera- peutic action. The time will come, however, when the processes of disease and the mode of action of remedies will be understood, so that treatment will be guided by knowledge of methods, and not only by observation of results. It is not necessary to give cases illustrating the good effects of bleeding in urfenna. I have employed it in all forms of renal disease. In acute albumi- nuria, not only are the immediate effects good as regards the convulsions, but sometimes the kidney affection is at once relieved, and recovery takes place with extraordinary rapidity. In chronic disease of the kidney, curative effects are not to be expected, R— 27 8 The Pulse. [Chap.xiv but a condition of great danger is often promptly ended for the time being ; and in the last extremity, although a fatal issue cannot be prevented, life may be prolonged, and the mode of dying may be changed, a quiet and peaceful asthenia being substituted for excitement, convulsions, and coma. In chronic Bright's Disease it has already been seen that a fatal result is reached in a large pro- portion of cases through the injurious effects of high arterial tension on the arteries or upon the heart. It is a cardinal principle of treatment to obviate the tendency to death, and we ought not to wait till a fatal termination is imminent before acting upon it. The tendency being foreseen, and the danger being in some sort measurable by the degree of tension present . in a given case, one of the main problems of treatment will be how to keep down the tension at a point which will not work mischief in the circulatory system without doing injury or incurring danger in other ways ; and this must be done by removing, as far as this is practicable, the resistance in the capil- laries, which is the cause of the tension. If, for example, the tension is lowered simply by reducing the power of the heart, the result will be the disas- trous one of opening the door to albuminuria and dropsy. Injury, again, would be produced by any course of treatment which impoverifshed the blood or imjjaired the nutrition of the tissues. All the hygienic measures in common use in the treatment of Bright's Disease comply with the indi- cation laid down, the diminution of obstruction in the capillary circulation. The amount of nitrogenised food is restricted, care being taken that the general nutrition does not suffer, and the simplest forms of such food are recommended. The object of this is not merely to throw less work upon the kidneys, but, since the great cause of resistance in the capillaries is Chap, xiv.j In Kidnkv Diseasi:. 259 the presence of nitrogeiiised waste of some kind in the blood, the limitation of nitrogenous food cuts off the supply of the irritant. On the same ground milk, eggs, and fish are better than flesh, since they con- tain little of the so-called "extractives," which, while giving flavour to meat and soups, yield a minimum of nutrient material, and probably a maximum of waste products. The various meat extracts consist of little more than the extractive matters. All the fuel for the generation of heat and mechanical energy should be applieil, as far as possible, in the form of fats, starches, and sugars. Alcoholic drinks are forbidden, or strictly limited, for reasons which need not l)e here si)ecified. Fresh air and exercise are ordered as promoting complete oxidation of all forms of food and all pro- ducts of tissue metamorphosis. Elimination through the skin is also encouraged. Warm clothing is enjoined, with a pure woollen material of some kind next the skin, for the double purpose of promoting perspiration and reducing to a minimum the physiological arteriole contraction set up by external cold. A warm, dry, equable climate is recommended on the same grounds. Turkish baths, again, when well borne, niay be of the greatest service by promoting free cutaneous elimination, but they must ])e taken with caution and in moderation. All these hygienic measures may be faitlifully carried out, and yet the arterial tension may remain at too high a point. The question then arises whether medicinal treatment may not find an opportunity. The mind naturally turns to the physiological relaxants of the arterioles — nitro-glycerine, amyl nitrite, and the nitrites ; and great results have been attributed to their employment. In my experience, 2 6o The Pulse. [Chap. xiv. they have not been of any real service. A patient will look better, and sometimes feel better, while taking nitro-glycerine ; the pallor is lessened by the free admission of blood to the surface, but the effect is fugitive ; it ceases witli the withdrawal of the drug, and often wears off while it is being taken. This line of treatment, moreover, has the defect of dealing only with an effect, the arteriole contraction, without removing the cause, the blood contamination. Nitro-glycerine and the other remedies belonging to the same class may, however, render great service in an emergency — averting, perhaps, convulsions, or relieving the heart when overpowered by the resist- ance in the peripheral vessels. In ursemic asthma they are often of signal service, relaxing the spasm in the systemic, and probably also in the pulmonary arterioles. Great caution must be exercised in first admin- istering nitro-glycerine for the relief of extreme tension, whether due to renal disease or to other causes. Sometimes the effect of tlie first dose of a single minim of a one per cent, solution is as if a violent blow had been received at the back of the head, and the patient feels stunned and giddy. This is, no doabt, the impact of the blood driven by the hypertrophied heart along the suddenly relaxed arteries. In all cases of chronic renal disease the influence of constipation in increasing the blood pressure must be borne in mind, and the bowels must be kept not merely regular but open. Very impoi'tant service may be rendered in this respect. Both the liver and the bowels may be made use of for the purpose of elimination. Some aperient mineral water may be taken from time to time for a week or two in sufH- cient quantity every morning to j^roduce a single copious loose motion ; or Carlsbad or Glauber's salts Chap. XIV.] Ix Kidney Disease. 261 may Le employed in the same way ; or sulphate of magnesia, or of soda, or the two sulphates combined, may be given. Better than salines, according to my experience, is a mild mercurial pill — a single grain of calomel or blue pill with rhubarb or colocynth and hyoscyamus taken at night, either regularly once or twice a week, or occasionally more frequently for one, two, or three weeks. The pill may or may not be followed by a mild saline draught in the morning. It is often useful to give blue pill and colocynth once or twice a week in connection with the fortnight's course of mineral water or salines spoken of above. Mercury in all forms has been forbidden in renal disease, but this is to forego a most valuable remedial agency. A so-called " course of mercury " would, no doubt, be injurious, aggravating the angemia and rapidly producing specific effects on the gums and tissues ; but an occasional aperient dose is attended with no such results, and, with comparatively slight effects on the bowels, it makes a more decided im- pression on the arterial tension than free purgation by other means. In some way or other — probably by an action upon the liver — mercury, as an aperient, has an extraordinary eliminant influence. The best remedy for ursemic vomiting or diarrhcea known to me is calomel in doses of two or three grains or up- wards. With these measures for keeping the blood free from the impurities which provoke resistance in the capillaries and tension in the arteries, will be com- bined the administration of iron and tonics to prevent anaemia, and it will be found that these are all the better tolerated and assimilated in consequence of the employment of eliminants. When in contracted granular kidney the heart has at length given out under the stress of protracted 262 The Pulse. rchap. xiv. arterial tension and the left ventricle lias begun to dilate, a careful study of the dilJierent influences co- operating in the production of this result, and an estimate of their relative share in it, will greatly con- duce to successful treatment. In one case the main factor will be the peripheral resistance, and the pulse will not only be full between the beats, but firm and incompressible, and the impulse and apex beat of the heart will be powerful ; here free j)urgation by calomel or blue pill and colocynth, or with salines, will be the most important part of the treatment. In another, over-work or anxiety has impaired the vigour of the heart, and it has yielded under moderate strain ; or anaemia may have been allowed to gain ground ; or the heart, together with the structures generally, maybe lowered in tone by intercurrent illness of one kind or another. In proj)ortion as the strength and vigour of the heart are impaired, its impulse will be diffuse and deficient in push, and the pulse, while full be- tween the beats, will be sudden and short, and in the same proportion iron, strychnine, digitalis, and the like will be required. Eliminants, however, and especially aperients, must still be employed boldly, the eff'ects being carefully watched ; greater service is often rendered to an overweighted heart by relieving it of work than by endeavouring to improve its strength. In large white kidney disease the same principles are applicable. It is when severe cardiac symptoms have arisen which place life in jeopardy that a clear realisation of the circulatory conditions existing at the moment, and of the relative force of the influences which are in conflict, is more necessary than in any other circumstances. The heart does not fail from intrinsic weakness, but is overmatched by the ob- struction in the circulation. The fact that it has for a long time coped with the high arterial tension shows that it has been abnormally strong, and unless Chap. XIV.! Ix Kidney Disease. 26 o it is completely worn out there is a possiV)ility that a diminution in the resistance may enable it to resume its command over the circulation. The great object, then, as in connection with contracted kidney, will be to atibrd this relief. It is true that the arterial tension does not reach so high a point, and that the strain upon the heart is not so great, but the yjeripheral re- sistance is present and plays an important part in pro- ducing the symptoms and in determining the course of the disease. The nutrition of the heart is injuriously affected by the watery condition of the blood, which is diluted by the water being retained instead of being given off by the kidneys; the increased volume of this diluted blood also adds to the difficulties of the heart ; the resistance in the arterio-capillary network then may easily so far add to the embarrassment of the heart as to retard very seriously the movement of the blood, and with slow movement of the blood exudation of albumen into the renal tubes and of serum into the connective tissue will be promoted ; ursemic symptoms, again, are liable to supervene from stasis in the cerebral capillaries. The pulse, then, is a valu- able guide in the treatment. Whatever may be the other indications and the other remedial measures, it must be an object to diminish the peripheral resistance and to increase the driving power of the heart, so that the heart may have full control over the circulation and may maintain a steady flow of blood through the capillaries. It is by means of the pulse and heart sounds that the degree in which this object is attained is ascertained, and it adds greatly to the interest of this struggle against the fatal tendency of severe dis- ease of the kidneys to know this guide. It would simply be a repetition of what has been already said were the treatment of acute renal dropsy to be discussed from the same point of view. But it is worth while pointing out that here treatment will 264 The Pulse. [Chap. xiv. not merely relieve suffering and prolong life, but will definitively restore health and soundness. Anything, therefore, which gives a more definite aim and direc- tion to our endeavours is of special value, and this is claimed for the indications derived from the pulse and heart. It has been pointed out that at the onset of acute renal dropsy the heart is embarrassed by the sudden increase of resistance in the peripheral circula- tion, and, being itself enfeebled by the pyrexia and general derangeuient of the system, is unable to cope with it, so that a degree of dilatation takes place. Botli experience and theory (experience especially) show that the recovery of the heart from this condition and the establishment of a certain desfree of arterial ten- sion are necessary to the cure of the disease ; this appears to be a link in the chain of reaction by which a return to the normal state is brought about. It becomes an object, therefore, to aid in the production of this condition in the circulation. Ursemic symptoms of the most violent character may occasionally supervene at quite an early period of acute desquamative nephritis. The peripheral resist- ance so far overcomes the propulsive power of the heart as to give rise to stasis in the cerebral circula- tion. Venesection is of such striking service in these circumstances, not merely in arresting the convul- sions but in its beneficial influence on the disease itseJf, tliat it has become a question in my mind whether it ouglit not to be commonly resorted to as part of the treatment of acute renal dropsy at an early stage. 265 CHAPTER XV. INTERMITTENT ALBUMINURIA. The intermittejit alljumiiiuria of young people may not seem to come within the scope of a book on the pulse ; but it is, according to my judgment, entirely dependent on the condition of the circulation. The term intermittent albuminuria seems to me to be pre- ferable to the other names which have been employed to designate this affection. To call it " cyclic " is to misstate facts ; to speak of it as " functional " raises a controversy as to its character ; while to name it the "albuminuria of adolescence" ignores its occurrence at other periods of life. Dr. George Johnson has, as was to be expected, in- vestigated this interesting subject, and it had attracted the attention of the late Dr. Moxon. Professor Grainger Stewart also has discussed the questions which suggest themselves in connection with the appearance of albu- men in the urine of children and adolescents otherwise apparently healthy ; while Dr. Clement Dukes has taken advantage of the opportunities afforded by his position as physician to the great school of Rugby for obtaining experience as to the conditions under which the albuminuria occurs, and as to the symp- toms and effects on the health and vigour which attend it. The most strijs:in2; feature of this form of albu- minuria is the extraordinary fluctuation in the amount of albumen present. One day the coagulum may occupy one-third or even half the volume of urine, on the next there may not be a trace ; the albumen may Ije abundant at one period of the 266 The Pulse. [Chap. xv. twenty-four hours, and entirely absent at another. The conditions under which these variations occur are of great interest. The morning urine is usually free from albumen, while that passed after breakfast not un- commonly presents the maximum for the day. Later, the amount varies in a manner which appears to be capricious, until the causes are traced in the incidents of the day ; albumen, for example, is often absent after the midday dinner of a boy when it has been abundant after breakfast. Except for the presence of albumen the urine appears to be normal. It is usually clear, and has a good colour, varying in tint and in the presence or absence of lithates, as in health ; and there is nothing in its appearance or specific gravity or reaction which enables us to say that a given specimen contains albumen. From the fact that the albumen often appears after breakfast it has naturally been attributed to malassimilation of the food taken ; but this idea is not supported by any peculiarities in the character of the albumen, which, according to the researches of Dr. R. Maguire, consists mainly of globulin and serum- albumen, and not of peptones ; and it is rendered un- tenable by the fact that after a larger meal richer in albuminoids later in the day there may be no albumen in the urine at all ; and still more clearly by the fact that the albumen will be absent, or greatly diminished in amount, after breakfast taken in bed. I have found, again, that a cup of hot milk taken before dressing has a marked effect in diminishing the amount of albumen found after breakfast, especially in cold weather. External cold has naturally a considei'able in- fluence on the albuminuria, and Dr. George Johnson has found that albumen is often present in the urine after cold bathing, and probably it is very common after swimming for any length of time ; but good Chap. XV. J In Inter Mir tent Albuminuria, 267 swimmers are rarely under the necessity of consulting a medical man. The influence of greatest power is undoubtedly exertion, but from this it is difficult to disentangle altogether the influence of position. The difference observed between one day and another and between different times of the same day can usually be traced to the kind and amount of exertion. In one young lady of twelve or thirteen albumen appeared in the urine whenever she was allowed to go up and down stairs, whereas it was absent so long as she was kept on one floor. In some cases, however, violent exer- tion will be followed by little or no albumen, when an ordinary walk gives rise to a considerable amount. In my opinion it is the combined influence of the erect position, of the exertion of dressing, and of ex- ])0sure of the surface to the lower temperature of the room after the warmth of bed, which determines the after-breakfast albuminuria^ aided probably by the lowered tone and energy of the heart and vascular system after sleep, and perhaps by the rapid repletion after a long fast. When a patient, subject to inter- mittent albuminuria, and actually suffering from it, is kept in bed, the albumen usually ceases to appear ; but when he again gets up it reappears copiously for a time, unless a purgative has been taken. Pyrexia appears to dismiss the albumen, but as the patient is usually put to bed it is not easy to determine how far pyrexial relaxation of the vessels and activity of circulation of themselves produce the result. Constipation is another influence under which the albumen is extremely liable to appear. This and the effect of an aperient in dismissing the albumen have been well brought out by the experience of Dr. Dukes of Rugby. The special feature of intermittent albuminuria is the readiness with which albumen appears in the urine, 268 The Pulse. rchap.xv. and the comparative sliglitness of the cause which is sufficient to induce it. A temporary albuminuria is not uncommon as a result of over-study, with the attendant late hours and privation of fresh-air exer- cises. Attention has been called to it by Sir Andrew Clark in connection with the laborious and protracted preparation for Civil Service and other examinations, and with the over-strain of the examinations them- selves. This is no doubt allied to intermittent albu- minuria, but it cannot properly be included under it. Intermittent albuminuria, while most common in growing boys and adolescents^ is met with at all ages and in both sexes, except in infancy and early child- hood and old age ; I have seen it in a boy of eight, in girls of twelve and thirteen, and in a man of forty- five. It cannot, therefore, be put down to mastur- bation, and in very few of the cases Mdiich have come under my observation has there been any reason to suspect that this vice was practised. In every case which I have seen there has been a neurotic family history, usually of a marked type. In one case, however, the only neurosis traceable w^as spasmodic asthma. The subjects of the affection are not by any means necessarily ant^mic, or weak, or languid. On the contrary, they have often a good colour, and are well developed and muscular, and only too full of energy and impetuosity. Very commonly, however, they are easily exhausted, and especially are incapable of sustained mental effort. At school they are subject to headaches when the lessons demand close ai^plica- tion, and at college, or when preparing for the ex- aminations which form the portal to the military or civil service, they are liable to break down, or to- find that they are unable to concentrate their attention on their work. In many of them there is a great prone- ne.ss to catarrh, which is often very severe and attended Chap. XV.] In Tntermittext Albumixuria, 269 with great prostration. Dr. Dukes has made the interestino* observation that when a bov faints in the class-room or chapel, he is certain to be the subject of intermittent albuminu ria. If we exclude malassimilation, this irregular oc- currence of albumen in the urine can only be ex- plained by variations in the blood pressure or circula- tion ; it is, indeed, closely analogous to the fluctuating albuminuria of some forms of heart disease. It is cer- tainly not due to any organic disease of the kidneys, though it may possibly lead to the establishment of organic changes in these organs if it persists for long periods. The continued blood stasis in the malpighian tufts, and filtration of albumen through the walls of these capillaries must in time impair their nutrition and structural integrity. I have not known disease of the kidneys, either acute or chronic, follow upon this intermittent albuminuria ; but Dr. Dukes, Avho sees large numbers of boys at school, and has the op- portunity of watching their careers in after life, has met with examples. But to return to the question of the relation of in- termittent albuminuria with varying conditions of the circulation. Malassimilation may be excluded as a cause on tlie grounds already stated, namely : that albumen is found in the urine most frequently and abundantly after breakfast, a comparatively light meal, and not after dinner, when more nitrogenous and less digestible food is taken ; that it does not appear, or is comparatively slight in amount, when breakfast is taken in bed, and is often lessened after breakfast when hot milk is taken before the patient rises. The influence of position and exertion, which is marked and undoubted, is also against malassimilation, and perfectly consistent with variations of circulation, as causing the albuminuria. The great characteristic of the circulation met 21 o The PVlse. [Chap. xv. with in association with intermittent albuminuria is its extreme instability. The pulse will be small and weak one day, and large and firm another, or such diversities will be exhibited at different hours on the same day ; this, indeed, I should expect would be found to be the rule were the pulse examined at short intervals throughout the day. Sometimes the pulse appears to be destitute of tension, but I have met with no case yet in which the pulse does not possess from time to time, or^ indeed, habitually, a certain degree of tension — i.e. the peripheral resist- ance, which is the ultimate cause of tension, is present, keeping the arteries full between the beats ; but the energy of the cardiac systole, the vis a tergo, which determines the actual degree of blood pressure within the vessels, is deficient, and varies extremely. In all the cases which I have examined, the heart has presented an interesting peculiarity. The apex beat has been feeble and inconspicuous, and the left ventricle sounds have been short and weak ; while the beat of the right ventricle has been powerful, lifting the costal cartilages, and its sounds have been loud. This I have found, not only in boys and girls in whom the apex beat is often undefined, but in young men. The significance of such a disproportion between the action of the two sides of the heart in relation to the albuminuria is not clear ; it would seem to indicate some obstruction in the pulmonary circulation and, if this went so far as to interfere with the supply of blood to the left auricle, it might greatly influence the systemic circulation. Pro tanto the effects of mitral disease would be imitated, and it is in mitral regurgita- tion that fluctuating albuminuria is most common. Treatiiieiit. — From the point of view here set forth the main object of treatment is to improve the tone and vigour of the circulation. The patient should live an active outdoor life. I have not often Chap. XV.] In Intermittent Albuminuria. 271 considered it necessary to advise that a boy should not be sent to a public school, or that while there lie should be forbidden to engage in games ; I have sometimes permitted even football, if the boy has been otherwise physically qualified for it. Girls should be encouraged to take exercise, such as skipping and lawn-tennis, besides walking, and should be allowed to ride. Tlie effects of confinement to the house, and of such care as would be required for kidney disease, have been in my experience most injurious. When a long voyage has been ordered I have known the al- buminuria to persist while at sea and cease with active exercise on shore. Flannel, or some other material made entirely of wool, should be worn next the skin, summe^ as well as winter. The diet should be simply that suit- able for a growing boy or youth. It is very important that the bowels should act regularly and efficiently, and an occasional or even regular small dose of liydrarg. cum cret, with rhubarb and soda, or of pil. hydrarg. with pil. rh?ei co., or colocynth and hyoscya- mus is most useful. The prognosis is good. Most youths grow out of the liability, and when it is perpetuated, or induced by coaching or cramming for an examination, it usually disappears after a time. Young men subject to it, who have to go up for a medical examination previous to admission into one of the public services, should always take an aperient beforehand. The presence of albumen in the urine would probably disqualify a candidate, and a purge prevents its appearance for twenty- four hours or longer. 272 CHAPTER XYI. THE PULSE TN AFFECTIONS OF THE NERVOUS SYSTEM. The pulse is under the direct and immediate control of tlie nervous system. The centres for the cardiac and vaso-motor reflexes are situate in the medulla, and receive, on the one hand, impressions from the viscera, the cutaneous surface, and the body generally, which reach them in an upward direction through the spinal cord and sympathetic system, and on the other, im- pulses which travel downwards from the brain. The heart thus responds to every emotion and sensation, and even thought, as well as to the demands created by muscular exercise, or by the organic processes, such as digestion. In excitement the action of the heart becomes more frequent and violent, producing a corresponding frequency and force in the pulse. This, however, is not all, for the arterioles are almost as susceptible as the heart to nervous influence and there may be local dilatation of these vessels, such as is seen in blushing and in the flushed face of excitement, or a general contraction. Since, then, the nervous system is the intermediary through which all modifications of the pulse are pro- duced from whatever cause, and whether due to the action of the heart or of the arterioles ; since, again, all states of the nervous system are reflected upon tlie circulation, each emotion beins: attended with its own reaction upon the lieart and arteries, and even sensa- tions producing recognisable effects, it is to be expected that diseases of the nei'vous centres will be attended with special symptoms manifested through the circula- tion and by the pulse, and such is the case. It is, however, very difficult to give any such account of the Chap. XVI.] In MENiNGiris. 273 modifications of the pulse in affections of the nervous system as shall be useful ; for, while the slow hesitating pulse is almost as significant as the purposeless vomiting in meningitis, and the contracted arteries almost as characteristic as the retracted abdomen, in respect of these, as of other symptoms, different and even' opposite effects may be produced by the same disease, and different diseases may give rise to like effects. Although, therefore, the pulse may form a most important item in the diagnosis of disease of the brain, it is not by any individual symptom, but by the concurrence of symptoms derived from various sources, that a trustworthy opinion is formed. JYleiiiii^itis and the pulse.— Perhaps the most remarkable effect upon the pulse produced by cerebral affections is the slow and hesitating pulse of the early stage of meningitis ; it is scarcely met with except as a result of serious brain mischief, and is therefore of very great diagnostic importance. The temperature is above the normal point, but instead of increased frequency in the pulse and relaxation of the arterioles, the i)ulse is less frequent than normal, and the arteries are contracted ; the individual beats are long and not quite equal in force or regular in time, and the general effect is to give the pulse a peculiar, deliberate and slightly hesitating character. The second sound of the heart is not unfrequently reduplicated with this kind of pulse. At this period of the disease, in which the pulst has the character just described, the inflammation has reached the stas^e at which stasis of the blood is takin" place in the capillaries. With the effusion which occurs later and the compression of the brain produced by it, an uncontrolled frequency of the pulse super- venes varying from minute to minute under the influence of slight causes, and it is at the same time devoid of tension. s— 27 2 74 The Pulse. [Chap. xvi. €erebritis and tumour.— Cerebritis and cere- bral tumour may also slow the pulse, and, without affecting the frequency, a local cerebritis going on to the formation of an abscess may be attended with so much spasm of the peripheral vessels that the surface of the body may be cool and the ex- tremities cold, while the internal temperature is as high as 103° or 104° F. In some cases of tumour of the brain there may be very remarkable reduplication of the second sound of the heart in association with high pulse-tension. In late stages of tumour of the brain the pulse often becomes extremely weak, short, and small, exemplifying an extreme degree of low tension from a combination of relaxed arteries and weak action of the heart. Tlie pulse in coma.— Coma has no character- istic pulse. The causes of this condition are varied^ and the pulse will be that of the particular cause. As regards the circulation, the cerebral hemispheres have in coma ceased to act as controlling or disturbing agents, and it is abandoned to the influence of lower centres or of external impressions. The pulse may be frequent or infrequent, of high or low tension. Convulsions.— Convulsions react ujDon the circu- lation like any other form of violent muscular exertion, increasing the frequency and force of the heart's action and lowering the arterial tension. Convulsions and the pulse, however, will be considered fully from another point of view. Mania. — In acute mania the pulse is singularly little affected, and it is astonishing to find how little it is accelerated or otherwise influenced by the mental excitement and bodily agitation present in this disease. Whatever the local vascular conditions of the cerebral hemispheres may be in mania, the symp- toms are not due to any excitement of the general circulation. Chap. XVI.] /.v JVj-:j^rous Disorders. 275 Melancliolia.— IMelancliolia may be associated with difterent kinds of pulse as regards tension — usually, however, the frequency is diminished ; but the relation of melancholia with states of the circula- tion is reser^'ed for special consideration. General paralysis in its early stage usually has the arteries contracted and a pulse of tension ; later the pulse becomes weak and toneless. Hysteria. — In hysteria the pulse may have differ- ent characters, but it will be mobile and liable to disturb- ance in sympathy with the emotional mobility of the subject. The hysterical paroxysm is usually attended with frequent and violent action of the heart and throbbing of the vessels in the neck, of Avhich the patient is conscious ; but even more constant and characteristic is the arterial spasm, which makes the pulse small and hard, and gives rise to high arterial tension — probably the most important factor in the secretion of the pale and watery urine which accom- panies an hysterical attack. Mig^raiiie. — Migraine or sick-headache, again, is attended with contraction of the arterioles, sometimes, if not unilateral, yet predominant on one side ; and it has been questioned whether the essential condition and cause of the attack is not spasm of the cerebral arteries. Lesions in the pons and medulla oblongata, im- plicating, directly or indirectly by proximity, the great cardiac and vasomotor centres, will produce very important effects. It is by pressure or other form of disturbance of the cardiac or respiratory centre that tumour or abscess of the middle lobe of the cerebellum so often causes sudden death. There are not many diseases of the spinal cord which are attended with modifications of the pulse in any degree characteristic or entering prominently into their symptomatology. 276 The Pulse. [Chap. xvi. In spinal meningitis the pulse is small and tense ; and in locomotor ataxy the arterioles are habitually contracted, and are specially tightened up during parox3'Sms of the lightning pains — perhaps as a reflex eftect of the pain. In cervical pachymeningitis Avith compression of the cord the pulse becomes infrequent, and, according to Charcot, sudden death from arrest of the heart is not uncommon. Neuralgia is attended with contraction of the peripheral vessels ; and it is not without interest to lemark that many of the agents by which attacks are warded oflf or arrested are such as relax the arterioles. More important for the purposes of this book are the eflects produced on the brain and cord by abnormal conditions of the circulation, since, if these can be identified, it may often happen that the pulse will aflford a clue to remedial measures. The nutrition of the brain, as of all j^arts of the body, is dependent upon the suj^ply of an adequate amount of healthy blood ; but the functional activity and efficiency of the brain are even more dependent upon the blood-supply than its nutrition, and are influenced by it to an extraordinary degree ; so that blood which would maintain the structural integrity of the brain might be altogether unfit to minister to its functions. The foetal brain, for example, grows and develops with the greatest rapidity when sup- l)lied only wdth placental blood, which is very imperfectly aerated. The presence of alcohol, or chloroform, or morphia in the blood, again, does not interfere with the nutrition of the nerve-centres, but it deranges their action ; and it cannot be doubted -that poisons generated in the system or retained excretory matters have a similar eflTect. The most striking illustration of disturbance of the cerebral functions by interference with the supply of blood is Chap XVI.] Tn Sleeplessness. 277 the occurrence of convulsions as a late, if not final, symptom attending rapidly fatal litemorrhago. The liberation of nerve-force has heen represented as an explosive action, and tliis implies the presence in the nerve-cells of a substance of a high degree of chemical tension, ready, on the application of the j)roper stimulus, to combine instantly with the oxygen brought by the blood. The formation of such material, its maintenance at a given state of chemical tension, so to speak, which differs in the different centres — in the cortex, in tlie central ganglia, and in the medulla and cord — -is not paralleled by any other nutritive operation. It is only, moreover, by the free access and renewal of aerated blood that the oxygen required for the proper and orderly evolution of nerve-force is supplied. Sleeplessness aiiecome irregular, and she has occasional attacks of threatened convulsions. The above account was supplied to me by Dr. Kane in April, 1887. 1 first saw the case on October 9th, when the pyrexia had been overcome and the convulsions had set in, Chap. XVI.] Zv COM'ULSIOAS. 2y5 and had no hesitation in referring them to the ex- hausted state of the heart, which could not be felt, and could scarcely be heard, while the pulse was all but imperceptible. The fact that the patient could scarcely be raised in bed without bringing on an attack of convulsions was of decisive significance. There had no doubt been an embolism of some vessel in the right hemisphere which rendered the cerebral circulation more liable to disturbance. This patient has been lost sight of, but at a recent period was still subject to fits. A gentleman, aged lifty-two, consulted me on account of shortness of breath on going upstairs, and especially on going up the steps from the railway- station. He had become so nervous on the subject, that his heart began to palpitate and his breath to go before he came to the foot of the stairs. He had palpitation also occasionally at night. He looked the picture of health and younger than his years, was stout and of rather high colour, ate and slept well, and had a regular action of the bowels. He rode a tricycle, and had much fresh air and exercise. The pulse was frequent — 90 to 108 — small, short, and extremely compressible. The heart was partially covered hy lung, did not appear to be enlai'ged, and gave no impulse or apex-beat ; the sounds were short and approximated, the second following the first too quickly. The first sound was audible not only at the apex and right second-space, but also in the neck, where both sounds were remarkably distinct. He spoke of having had a fainting attack ; and, when this was inquired into, it was described as having occurred as follows. It was in August, and he had had a tricycle ride, had washed and changed, when he thought he would like a glass of beer, which he had not tasted for years. Shortly afterwards he felt a peculiar tingling in his feet, and had just time to 296 The Pulse, [Chap. xvi. lie down when he lost consciousness, and did not come to himself for forty minutes or more. This could not have been a syncopal attack, and, whether convulsions occurred or not, was epileptoid. It was further learnt, on inquiry, that he had had several similar attacks within the last few years, always beginning with tingling in the feet, and attended with complete loss of consciousness lasting, on an average, twenty minutes. He had had no fits as a boy, or until the occurrence of those referred to. The pulse and epilepisy. — I am not without hope that a careful study of the pulse, and of con- ditions of the circulation made known through it, may be of service in furnishing indications for the treat- ment of epilepsy. It is attended with interest, throws light on different forms of epilepsy, and serves as a guide in |)rognosis. Epilepsy is apparently the result of instability in the highest nerve-centres, the cells of the cereliral cortex permitting of an indiscriminate general or partial discharge upon lower centres of nerve-force, which normally ought to be set free only in definite degree and in well-defined direction, in response to given stimuli. Such instability is ob- viously a nutritional defect, which may be due to the inherent want of constructive energy in the nerve- cells themselves, or may l)e the result of blood which cannot furnish the proper pabulum, or of an inade- quate supply of blood. Even in the case first. sup- posed, a regular and ample supply of blood, under sufficient pressure to cause a due exudation of nu- trient material and of proper composition, will be important, while in the other conditions supposed it will be lemedial. But, given more or less of in- stability, this does not of itself start the convulsive explosion ; some exciting cause must be applied. At one time this was supposed to be arterial spasm in certain convolutional areas; but this hypothesis, which Chap. XVI.] Ix Epilepsy. 297 never seemed to me to be tenable, has gone out of fashion. There are, however, facts which seem to show that circiihitory conditions have much influence in determining the occurrence of attack. For ex- ample, the great frequency with which fits come on in the night, sometimes on first going otf to sleep, when the horizontal position and the anaemia of the cortex attending sleep produce great changes in the intracranial circulation ; or more frequently towards morning, when the general circulation has slackened down, as it does during sleep. Another favourite time for attacks is soon after rising in the morning, when the erect posture, the exertion of dressing, and exposure of the surface to a lower temperature make great demands on the circulatory mechanisQi for ad- justment to altered conditions. It is not my intention to discuss the questions which might be raised on the subject here alluded to, ■ but I desire to call attention to a provisional con- clusion to which I have been led by my own limited obserN'ation. This is, that in essential epilepsy — the epilepsy which comes on al)0ut the period of puberty or during adolescence, the epilepsy met with in neurotic families, and in which the nerve-cells may fairly be assumed to be inherently unstable — the arterial tension is low and variable or fluctuatino-. I am unable to afiirm that Avhen the attacks are sus- pended, as they may be for months, the pulse-tension is improved ; but it is worthy of remark that preg- nancy is not unfrequently attended with immunity from fits; and, as is w^ell known, one effect of this condition is high tension in the pulse. A low-tension pulse, therefore, has become with me a mark of " unfavourable import in epilepsy. On the other hand, when the pulse-tension is de- cidedly and constantly above the average, it has seemed to me that the epilepsy has been amenable to 298 Tjie Ihn.si:. [Chap. xvi. treatment. Epilepsy svitli high arterial tension ofteji comes on at a later period than the epilepsy which has its source in a radical weakness of the nervous system; and in most of the cases I have met with the first fit has occurred after the age of twenty ; and not uncommonly there have been peculiarities, such as a number of attacks close together, with long but irregular intervals, or some well-marked exciting cause. The fits may, however, date from the usual age at which epilepsy sets in. Many years since a surgeon- major in the army brought his son to me on account of epileptic attacks, which had compelled him to leave the navy. He was a fine, strong, healthy- looking lad, and had a large pulse, not easily com- jiressed. Under treatment directed to the reduction of arterial tension which was extremely high for his age, the fits, which had been frequent, ceased to come on. He studied for and got into Sandhurst, obtained a commission in an infantry regiment, and has since served through the Afghan campaign. So far as I know — and I have seen him quite recently — he has only had two attacks since he entered the army 1 one in Afghanistan, when, together with trying work, he had bad food and water ; and another in Ireland, after great fatigue and a bout of dissipation. Senile epilepsy is, according to my experience, associated with high tension and scarcely ever fails to yield to a regulated diet with a restricted amount of animal food and little stimulant, aperients and other eliminants being given according to the requirements of the particular case. The introduction of bromides in the treatment of epilepsy has not in my opinion been an unmixed advantage. It is true that in many instances there lias been an apparent cure of cases Avliich seemed hopeless, and that in many more the number of fits has been so far reduced as to restore the suflierer to Chap. XVI.] Ix Epilepsy. 299 comparative happiness and to a useful place in society, but on the other hand we have been too easily content with this result of diminishing the number of attacks ; the administration of bromides has become a matter of routine, and under the idea of diminishing reflex excitability we have come to neglect the higher aim of increasing the stability of the nerve-cells by improving their nutrition. The epileptic who enjoys a certain degree of immunity from attacks in virtue of large doses of bromide is on a lower platform than one who obtains such immunity by means w^hich raise tJie tone of liis nervous system, and the immunity may be purchased too dearly. Xot to speak of the disfigure- ment produced by the bromide rash, or of the derangement of the digestion, or of the anaemia, which are common results, I have seen patients reduced to a condition scarcely distinguishable from general paralysis by bromides, and all minor degrees of intellectual and nervous debasement, from which condition they have been rescued by discontinuing the drag and adopting a different treatment, the fits in several instances also ceasing. The legitimate use of bromides I conceive to be for the purpose of palliation, of staving off attacks which have become too frequent, and so of gaining time for a study of the peculiarities of the case, its true causation and ultimate pathology, and for the ap])lication of remedial measures which shall go to the root of the disease. When the fits are separated by intervals of months, I can see nothing but harm in giving bromides regularly. If, in such a case, an ex- citing cause can be identified, bromides can be usefully employed to parry its influence and avert the attack ; but no such identification is possible if the bromides are being taken constantly. Only by careful inquiry into the antecedent circumstances of each fit can this be done, and attention to the administration of the drug takes the place of attention to other matters. A very 300 The Pulse. [Chap. xvi. common history is that the absence of attacks begets carelessness in taking the remedy, and to this, or some omission of a dose, is attributed the next attack, upon which it is taken for a time with renewed diligence, only to be again neglected. It is not pretended that the pulse furnishes the only clue to the rational treatment of epilepsy or that its teachings are applicable to all cases. Other indications are to be sought in deviations from normal functional action of whatever kind. Closely allied to epilepsy, and occurring under the same conditions as senile epilepsy, is sudden loss of consciousness, in which the patient falls as if shot without any trace of convulsion, recovering again instantly. All that he knows of the attack is that he finds himself on the ground, and he is usually able to get up and walk at once. This I have met with in elderl}^ or old men, the subjects of old-standing tension with dilated, thickened, and degenerate arteries. The patient may look hale and strong and may exhibit both mental and bodily vigour. The attacks can scarcely be due to anything else than a momentary cessation of the circulation in some jDart of the brain, either in an area where blood-stasis does not give rise to convulsions, or lasting for too short a time for their occurrence. In one case of the kind the patient s\il)ject to these attacks suffered from acute dilatation of the heart after imprudent over-exertion, and at a later period, after complete recovery from this, from ])araplegia, due to innutrition of the lower end of the spinal cord. In other cases also I have seen para- plegia supervene.- Maniacal delii'iiiiii* — I have several times seen violent maniacal delirium associated in such a way witli convulsions as to suggest the conclusion that a minor degree of the disturbing influence which caused convulsions had given rise to the maniacal excitement ; Chap. XVI.] In Maniacal Excitement. 301 after bleeding, for exami:)le, for ui-*mic convulsions ; Ijefore and after, or apparently instead of, urieniic con- vulsions ; in syphilitic disease of the brain. In the following case the connection between the state of tension of the pulse and ungovernable excitement was recognised Ijy several observers over a long I'jeriod. The patient was under the care of Dr. Ranking, at Tunbridge Wells, and Dr. Marcus Allen, at Brighton, and in town under Dr. Seton an-d Dr. Coates, with whom I saw her weekly from March to July, 1884, and again in March, 1885. Dr. Ranking, who has kindly supplied me with the particulars, was called to her in May, 1882, when she was convalescing from a third attack of slight left hemiplegia. She was very nervous and apprehensive, and had dilata- tion of the heart, with an unstable pulse of virtual tension. Durinj; the summer she had several anginoid attacks, which were relieved at once by nitro- glycerine, and in the winter attacks of congestion of the lungs, with partial suppression of urine and albu- minuria. One day in July, 1883, she became suddenly excited, with delusions, which lasted some time, but went off after the administration of one-hundredth of a grain of nitro-glycerine. Later in the summer she got into an excited, unsettled, suspicious and violent state^ which persisted, together with high tension of the pulse. Once she was comatose for twenty-four hours, but recovered after nitro-glycerine, and at once became maniacal. In the winter of 1883-84 she was under the care of Dr. Marcus Allen at Brighton. It was found by observation that her mental condition was always worst when the pulse -tension was high, and that the only way of keeping it down was to cut off all meat and feed the patient chiefly on milk. This was confirmed by our experience when she was Ijrought to town. When the tension was high she was suspicious, abusive, violent and unmanageable. When 302 The Pulse. [cbap. x\i. it was normal she was cheerful and tractable. Mercu- rial aperients were constantly needed in order to keep down the tension and regulate the bowels. Ultimately she died with symptoms of meningeal haemorrhage. With advancing years there comes a liability to many forms of cerebral affection. 8ome are examples of structural change which are clearly traceable to in- terference Avith the normal blood-supply. Among such chano^es are local or oreneral softening; from thrombosis of individual arteries or veins, or general obstruction to the blood -supply from atheroaia, affecting all the cerebral arteries. Yery commonly the existence of atheromatous change in the cerebral arteries can be inferred from the evidence of advanced degeneration in the radials. When the fingers are made to carry the skin to and fro along the vessel with ^'arying pressure, it is found to present irregularities, bulgings, and tortuosities, and in its coats can be felt calcareous patches or rings ; or the artery may be converted into a calcareous tube. Such a condition of the arteries at the wrists seldom exists without corresponding alterations in the arteries of the brain. The local arterial change is not, however, the sole factor in the production of the lesions. A state of blood which renders it prone to coagulate or deposit fibrin will predispose to the formation of a thrombus at any point where the walls of the artery are diseased ; and want of propulsive power in the heart, giving rise to languid movement in the blood, may antedate the occuri'euce of tle^jenerative chaufjes in the nerve-centres attributable to widely distributed disease in the ves- sels. Over-fatigue, or a slight indisposition, such as an attack of diarihcea, is thus sometimes the immediate occasion of hemiplegia or aphasia, or other form of paralysis, by so far weakening the action of the heart that an opportunity is given for thrombosis to take place. But an impeded cerebral circulation niay, Chap. XVI.] Ix Senile Cerebral Disease. 303 in course of time, so far modify the nutrition of the brain as to give rise to functional affections without structural lesions ; and this, in my opinion, is the mode of causation of some forms of insanity which come on late in life, — such, for example, as senile melancholia. The term "senile" may have two meanings : it may designate an age or be descriptive of a kind of change. The term "senile" is un- objectionable if it is meant to apply simply to the period of life at which this affection is met with ; but it is often understood to imply a certain character of change, and its frequent employment to designate degeneration has led to the common idea that "senile" and " degenerative " are convertible terms. This does harm in two ways. Senile changes, if degenerative, are irreversible ; and, if this view is taken of dementia or melancholia, there will be no object in careful investigation of associated conditions. No other cause than senile decay will be looked for, and no individual treatment will be adopted, based upon the peculiarities of different cases. Furthermore, the reproach of insanity or of neurotic tendencies may be attached to families, when the derangement of the cerebral functions may be as much a result of vascular disease as cerebral li?emorrhage. A family liability to melancholia may consist in hereditary high tension of the pulse, just as a liability to apoplexy may be due to family gout. Now, the complete recovery witnessed in many cases of melan- cholia is proof that there cannot have been any structural degeneration, and- an example like the following may be worth relating. 8ome four years since I Avas asked to see periodi- cally a gentleman aged about sixty-five, who for four or five years had been under the Connnissioners in Lunacy on account of melancholia. He had had de- lusions as to conspiracies against his life, but such 304 The Pulse. [chap. x^•I. delusions as remained related chiefly to wilful and malicious injury inflicted upon him and attempts to destroy him in an asylum. He spent nearly all his time in bed, scarcely ever left his room, and never went out of doors. He was well nourished, and, excepting that he was etiolated by his long confinement to the house, looked well ; but the pulse was extremely small, soft, and short, and the action of the heart extremely Aveak. He had eczema, and suffered from constipation and want of appetite, and treatment was prescribed for the relief of these symptoms. His general health ini- l^roved, but his mental condition remained much the same, and in particular the death of a son made little impression on him. In June, 188G, he suddenly shook oft' his delusions and became perfectly sane and cheerful. Simultaneously, whether as a cause or as an effect, the pulse improved, but never reached an average volume or tension. In October he remained well, and after examination by Dr. Maudsley was discharged from his lunacy. He transacted business, arranged his affairs, and was himself in every way, exhibiting no irritability or depression, and free from eccentricities or delusions till in February, 1887, after excitement and over-exei'tion, he unfortunately became aphasic from thrombosis of the vessels supplying the cortical s}X!ech centre, which was followed by a relapse into melancholia and speedy death. Pulse au€l iiielaiicliolia.^ — The connection be- tween melancholia and its allied mental states and conditions of the circulation is more direct and decided than can be traced in epilepsy. An unbroken series of gradations can be traced from the irritability and depression of spirits attending functional disorder of the li\er and other ailments up to complete melancholia with delusions. In the case of temporary hepatic de- rangement, the state of the temper and spirits might be attributable to the retention in the blood of the Chap. XVI. 1 /.V Mia.AXCIIOIJA. 305 impurities which tinge the eyes and complexion, these acting as a poison ; or to some reHex influence in- hiVjiting cerebral functions, or deranging the cerebral circulation by setting up contraction of some of the arteries. When, however, the mental depression is more pronounced and persistent, these explanations are found not to apply ; there may be, in the first instance, constipation, a furred tongue, sallow com- plexion, large liver, etc. But when these evidences of deranged function are removed the mental condition does not clear up. If the symptoms, therefore, are due to any somatic cause and are not the outcome of a primary cerebral affection, this cause is something more persistent than tlie functional derangement or reflex disturbance mentioned. This has appeared to me to he protracted arterial tension, or, if this is not itself the cause, it is at least the index of the state of system on wliich tlie mental condition depends. The method by which high arterial tension may influence the cerebral functions may he conceived to be as follows. The resistance in the peripheral vessels calls for increased contractile force on the part of the left ventricle, and there is a response by a certain degree of hypertrophy. In the course of years, how- ever, the resistance increases, degeneration of the capillaries and thickening of the arterioles being superadded to the original loss of due relation between the blood and tissues, while the heart no longer gains in strength. With, then, the same, or somewhat dimin- ished, driving power, and increased resistance in the peripliery, there will be a slower onward move- ment of the blood. The pulse may be equally strong, may even seem to Vje more incompressible, but the capillary circulation will be sluggish. This Avill l)e the case throughout the sj'stem, but it will not give lise to appreciable efl'ects in most of the structures and organs; in the brain, however, as has already been u— 27 3o6 The Pulse. r.ciiap. xvi. said, functional activity and eflSciency are absolutely dependent upon a due supply, not only of nutrient material but also of oxygen, and this fails when the How through the capillaries is sluggish. In a very large proportion of the cases of melan- cholia coming on late in life, the evidence of per- sistent high tension of the pulse has been most marked; and, when this has been the case, it has seemed to me that persevering endeavours to diminish the peripheral resistance, and at the same time to strengthen the action of the heart, have been more successful tlian any other line of treatment. The object is so to relieve the heart that it may no longer be mastered by the obstruction in the general capillary circulation ; there will then be a general acceleration of the flow of blood through the tissues, and by the increased supply of blood to the brain, its nutrition and functional efficiency may gradually be restored. The possibility of this result and the time required for its attainment will depend on Aarious conditions. There must Ije a capability on the part of the heart to resume its control over the circulation ; it must not be degenerate or worn out. The state of the cerebral arteries, again, will have an important in- fluence. If they are extensively diseased, the access of blood to the convolutions may be barred, even when the circulation elsewhere is good. Further, the change in the nervous elements must not have gone coo far; the longer they have been subjected to the deteriorating influence of imperfect blood-supply, the longer will be the time required for the reversal of these eflfects. Of these three sets of conditions we can only estimate the first by examination ; with regard to the others, the basis of our judgment must be the history. Speaking generally, the more acute the attack and the shorter its duration, the better will be the chances of recovery. cii.-tp. xvi.j Jx Mel.\.\ciioli.\, ^^07 Cases of this kind, many of which have conio under my notice, do not lend themselves to narra- tion, especially when seen in consultation only once or twice, and I shall not, therefore, attempt to give examples. I may, however, relate an occurrence with regard to one such — a most distressing case of religious melancholia in a lady of about sixty — with extreme high tension in the pulse. I had explained my views to Dr. Baines, with whom I saw the patient, and had recommended, among other measures, a series of mild calomel purges, when the sister of the patient joined us in order to learn our opinion. Before hearing this, however, she said there was one more fact which she ouiijht to have told us, namely, that their mother, at very nearly the same age, had suffered in exactly the same way. It seemed as if my hypothesis of the relation of the melancholia to the state of the circulation was at once overthrown, and with it my favourable prognosis. "But," she continued, "in those days they gave calomel for everything, and it was prescribed for her, and she got quite well." Our patient also recovered, only, however, to relapse some time later. Melancholia, associated with low — extremely low — pulse-tension, has, in my experience, usually proved incurable, and has in several instances gone steadily from bad to worse to a fatal termination. The case; related a few pages back is the only instance of re- covery I have met with. The pul^e and coiiiiuoii parapleg^ia. — The subject may be brought to a conclusion by a brief notice of an affection of the lower end of the spinal cord, especially as it furnishes a sort of parallel to the pro- duction of melancholia by derangement of the circula- tion. The late Dr. Moxon, whose loss those who knew him well will never cease to deplore, pointed out in hi^ brilliant and original " Croonian Lectures " that J 08 TjII: Pri.SE. [Chap. XVI. coiumoii paraplegia, as he called it, was explained by anatomical facts. The spinal cord receives its blood- supply by means of the arteries which reach it along the nerve-roots. These, in consequence of the down- Avard elongation of the spinal canal beyond tlie cord, get the more oblique and longer from above down- wards, and at the cauda equina are many inches in length, so that the arteries of the lumbar enlargement which occui)ies the lower part of the dorsal division of the spine liave to tiavel npwards for this distance from the foi-amina in the lumbar and sacral regions. When, then, the circulation becomes languid, the mechanical disadvantages of this arrangement make themselves felt. The blood is not propelled with sufficient force to travel up the long narrow vessels against gravity from the lumbo-sacral foramina to the cord, stagnation occurs, and the nutrition of the cord suffers. The symptoms attending the early stage of para- nleoia, duo to failino- circulation in the lumbar enlargement of the cord, are very interesting. As the nutrition of the lower end of the cord begins to suffer, there is at first muscular weakness and loss of con- trol over the legs only after a night's rest. The patient has some difficulty in standing and walking steadily when he first gets out of bed, Init after he has moved about a little the legs regain })Ower and he can walk perfectly. A similar state of things is observed with regard to the bladder. He cannot j^ass urine on rising, but when he has had a little walking he empties the bladder easily. AVhenever he sits down for any lengtli of time during the day there is more or less imjiairment of mobility and strength in the lower extremities, Avhich quickly passes off with movement. Sensation is not affected at first, but tliere may be feelings of numbness. The coming on of the weakness during the night is due to the slackening down of the Chap. XVI.] In FAKArLEGIA. 309 circulation, which takes place during sleep, and is paialleled by the morning depression in melancholia and debility. I have met with this train cf symptoms at the two extremes of high and low pn^ssure. "When there is high pressure it is that the general re- sistance in the periphery has overtaxed the powers of the heart, so that the w^iole circulation is sluggish, and the languid flow is most easily brought to a stand- still where the difficulties are greatest. Usually the symptoms come on very gradually, but I have known their onset to be determined by the occurrence of acute dilatation of the heart, and have seen cases in com- paiatively young men suffering from high arterial tension in which paraplegia came on almost suddenly after prolonged over-^^"ork. The patient may have previously suffered from other ill effects of high arterial tension. When the tension is low and the heart weak, no explanation of the impeded circulation is needed. INDEX. Acute disease, Pulse iu, 187 Albumiuuria, Intermittent, 265 Anacrotic pulse, 140 Anaemia, Pulse in, 160 Aneurism, 2.11 Angina pectoris, 152 Aortic pulsation, 91 regurgitation or insufficieiicv, Pulse ofi 203 from aortitis deformans, 210 ; , Venous pulsation in, \'\1 , Visible pulse in, 51 stenosis, Pul.-e of, 199 stenosis and regurgitation, Pulse of, 212 Arterio-capillary resistance, 28,13"? Arteriole contraction, a cause of increased tension, 151 Atheroma, 165 Basedow's disease, 89 Bigeminal pulse, 108, 118, 120 Blood, Eate of movement of, 16, 20 jjressure, 29, 40 Bright's disease. Pulse in, 236 Bronchitis, Pulse in, 195 Caijillary resistance, 135, 154 Cerebritis and cerebral tumour, 274 Cheyne-Stokes' respiration, 109 Coma, Pulse and, k:74 Constipation, 162 Convulsions, Pulse and, 274, 2S1 in connection with hitrh ten- sion, 287 low tension, 291 uraemic symptoms, 245 venesection, 290 Cramp, 152 Diabetes, 157 Dicrotism, Description of, 25 , Production of, 26 , Kecogtiition of, 44 Dilatation of the heart, 168 , Pulse in, 221 and irregularity of the pulse, 131 Diphtheria, Pulse in, 195 , Modification of heart-sounds in, 66, l95 Elasticity of great vessels and pulse, 24 Eiuphyspnia, 161 Enteric fever, Pulse of, 192 Epilepsy, 296 in connection with high ten- sion, 297 low tension, 297 two beats of heart to one of the pulse, 110 , senile, 298 Erysipelas, Pulse of, 195 Exophthalmic goitre, 89 Fatty degeneration of the heart, 108, 226 Glaucoma, 168 Gaut, 156 , Pulse in, 197 Graves' disease, 89 Heart, Connection of, with the pulse, 49 , Dilatation of, 163, 221 , Fatty degeneration of,108,226 , Hypertrophy of, 168, 220 , Kapid action of, or recurrent palpitation, 98 ., Two beats of, to one of the pulse, 108, 120, 216 Hear: -sounds iu relation to the pulse, 53, 61 , Modifications of, in diph- theria, ^, 195 , Modifications of rhythm, 6;i , Reduplication of, 67 Index. 311 High arterial tension, 147 , Causes of, 150 , Effects of, 163 • ■ , Pro^nosis in, 18$ , Eecoguitiou of, 40 symptoms, 176 treatmeut, 179 in connection witli anaemia, 160 ■ convulsions, 287 • diabetes, 157 emphysenia,161 glaucoma, l(j8 gout, 156 melancholia,3'J6 renal disease, 156, 236 History, 2 Hyperdicrotic pulse, 1 10 Hypertrophy, 168 , Pulse in, 220 Hysteria, 153 , Pulse ill, 275 Infrequent pulse, 107 associated with epilepsj' 121 Intermittent fever, Pulse in, 188 pulse, 124 Irregularity of the pulse, 127 of dilatation, 131 of mitral regurgitation, 129 in connection with the nervous system, 131 atfections of the re- spiratory organs, 128 Irritable heart, 88 Kidney disease, Pulse in, 236 and convulsions, 245 , Contracted granular, 236 , Fatty white, 252 Lead poisoning, 159 Low arterial tension, 136 ■ , causes, '41 , effects, 142 , Pulse of, 138 symptoms, 143 treatment, 145 in connection with convulsions, 291 epilepsy, 297 Mania, Pulse in, 274 Maniacal delirium, 300 Measles, 191 Melancholia, Pulse in, 275, 304 Meningitis, Pulse in, 273 Migraine, 177, 275 -Mitral insufficiency, 217 , Irregularity of pulse in, 129 stenosis, 213 , Bigeminal pulse in, 109 Nephritis, acute tubular, Pulse in, 250 , Chronic desquamative, 252 Nervous system. Pulse in affec- tions of, 272 , Action of, on circula- tion, 76, 142 Neuralgia, 177, 276 Palpitation, 93 Paraplegia, 307 Peritonitis, Pulse of, I9.j Pleurisy, 197 Pneumonia, 193 Pregnancy, 159 Pulse, Factors of, 21, 49 , History of, 2 ■, Production of, 19, VI , Terminology of, 45 , Force of, 23 , Frequency of, 22 , average, 75 , diminished, 107 . , with epileptic seizures, 121 , increased, 75, 86 , ,Influence.s governing, 76 , , persistent, 88 , Rhythm of, 23 , Mode of feeling, 39 , character of the Vjeat, 41 , Normal, 42, 46 , Effects of respiratory move- ments on, 79, 12s , tension, 46 of low tension, 40, 138 of high tension, 40, 147 of virtual tension, 149 , Bigeminal, 108, 118, 120 , Collapsing, or "watei- himmer," 203 , Eecurrent, 52 , Intermittent, 124 , Irregular, 127 , lienal, 51, 236 , Running, 140 , Senile, 27, 166 , Trigeminal, 119 12 The Pulse. Pulse, Visible, 51 , Anacrotic, 140 , Dicrotic, 25 , Hvperdicrotic, 140 Pulsus ibisferiens 26, 200 caprizans, 4 uiyoiiros, 5 Pyaemia, 196 Pyrexia, Pulse in, 86 Eedui^licatiou of sounds oi" the heart, 67 Relapsing fever. Pulse in, 193 Renal disease, Pulse in, 236 , cause of high tension, 156 ■ , Arterial tension as a guide to treatment in, 2i7 Resistance in capillaries, 154 Rheumatism, 198 Rigor, Pulse cf, 51 Rupture of vessels, 164 Scarlet fever, Pulse in, 87, 191 Senile changes in the brain, 302 Septicaemia, 87, 196 Sleeplessness, 277 in connection with high ten- sion, 278 low tension, 280 Small-pox, Pul-e in, 190 Spbygmograph, 31 Structural disease of the heart. Pulse in, 220 Typhoid fever, Pulse in, 192 Typhus fever, Pulse in, 191 Uraemia, 245 Valvular disease, Pulse in, 199 - — produced by high tension. 166 Venesection in uraemia, 257, 290 Venous j)ulsation, 137 Virtual tension, 149 Pm.NTEU UV C.V.SSBLL &OOM1>AKV, LlMlTKU, L.\ BKI.hK SAUVAUK, LoNUOX, K.C. 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