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BLOOD -PRESSURE 
 PRIMER 
 
 THE 
 
 SPHYGMOMANOMETER 
 
 AND ITS PRACTICAL 
 APPLICATION 
 
 BY 
 FRANCIS ASHLEY FAUGHT, M.D. 
 
 LATE DIRECTOR OF THE LABORATORY OF CLINICAL MEDICINE, MEDICO- 
 
 CHIRURGICAL COLLEGE AND HOSPITAL. INSTRUCTOR IN MEDICINE, 
 
 MEDICO-CHIRURGICAL COLLEGE. AUTHOR OF ESSENTIALS OF 
 
 LABORATORY DIAGNOSIS. BLOOD PRESSURE FROM A 
 
 PRACTICAL STANDPOINT, ETC., ETC. 
 
 Containing One Full-page Plate and Numerous 
 Explanatory Diagrams in the Text 
 
 COPYRIGHT, 1914 
 B Y 
 
 FRANCIS Ashley Faught 
 
 PUBLISHED BY 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA 
 1914 
 

 Pilling-Faught Pocket Sphygmomanometer in Use. 
 
C O N T E N 1 S 
 
 CHAPTER I. 
 
 i'A(;k 
 The Value of the Sphygmomanometer . 3 
 
 The Diastolic Test. 
 
 CHAPTER H. 
 The Circulation 15 
 
 CHAPTER 111. 
 The Sphygmomanometer .... 21 
 
 CHAPTER IV. 
 Normal Blood-Pressure and its Variations 53 
 
 CHAPTER V. 
 Practical Application of Clinical Data . 65 
 
 CHAPTER VI. 
 Pregnancy, Toxemia and Eclampsia . . 91 
 
 CHAPTER VII. 
 Blood-Pressure in Surgery and Anesthesia 95 
 Dental Anesthesia. 
 
 CPIAPTER VIII. 
 Therapeutics Indicated by Blood-Pressure 
 
 Changes Ill 
 
 CHAPTER IX. 
 Blood-Pressure in Life Insurance . . 115 
 
CHAPTER I. 
 
 THE VALUE OF THE SPHYGMOMANOMETER, 
 
 The Importance of the Blood-Pressure Test . 4 
 
 In General Diagnosis . . . . 5 
 
 In Insurance Examinations . . . 6 
 
 Importance of Diastolic Reading .... 6 
 
 Accuracy of the Auscultatory Method . 7 
 
 The Pulse Pressure ..... 8 
 
 Normal Relations in Complete Blood-Pressure Tests 9 
 
 Graphic Formulas for : . . . . 9 
 Estimation of Heart Work . . .10 
 
 Estimation of Velocity .... 10 
 
 In Arterial Disease . . . . . 11 
 
 In Heart Disease 12 
 
 Example of Case . . . . . 12 
 
 Infectious Diseases ..... 13 
 
CHAPTER I. 
 
 THE VALUE OF THE SPHYGMOMANOMETER AND 
 THE IMPORTANCE OF THE BLOOD- 
 PRESSURE TEST. 
 
 "The value of the blood-pressure test is acknowl- 
 edged by every up-to-date physician. Like the 
 clinical thermometer, the stethoscope and other 
 instruments of precision, the sphygmomanometer 
 is an aid to accuracy in diagnosis, and any instru- 
 ment that will enable the physician or surgeon to 
 do better work is not to be set aside or passed by 
 without careful investigation." (J. F. Prendergast, 
 Chicago Medical Record, March, 1913.) 
 
 The best single guide to the practical value of 
 a new method is to determine whether it is receiv- 
 ing increasing endorsement from qualified authori- 
 ties. At the present time all well-equipped hospi- 
 tals have sphygmomanometers in daily use in the 
 wards. It is seen in Children's Wards as a guide 
 to prognosis and treatment ; in Obstetrical Wards 
 in diagnosis and treatment of toxemias. 
 
 The oculist and aurist are finding blood-pressure 
 measurement of increasing value, and tuberculosis 
 sanatoria are modifying their prognosis and treat- 
 ment according to the indications of this sign. 
 
 J. B. McAllister, in "The Medical Council" for 
 July, 1912, states that the Medical Director of a 
 
Importance of Test. 
 
 large insurance company published statistics which 
 show that in 1247 risks of all ages in which there 
 was a blood-pressure of 150 mm. Hg. or over, the 
 mortality was 2^ times greater than the general 
 average mortality of the company covering the 
 same period. 
 
 Richard C. Cabot says: "If I were allowed to 
 have only two instruments of precision for my aid 
 in physical diagnosis, they would be the stetho- 
 scope and sphygmomanometer. I have been saved 
 from wrong diagnosis and put on the track of right 
 ones more often by this machine than anything 
 else I know of except the stethoscope. I regard this 
 measurement of the blood-pressure as the most 
 important of all the resources that have been added 
 to our armamentarium as physicians in the last 15 
 years. I could talk all afternoon on the subject of 
 blood-pressure, but I will confine myself to saying 
 that it puts me right most often in relation to car- 
 diac and renal diseases. Patients, the examination 
 of whose hearts did not show anything certainly 
 characteristic of disease, have often been shown to 
 me to be diseased, or proved later to be diseased, 
 by the high blood-pressure registered by the ma- 
 chine, pressure which my fingers are not always 
 able to detect. In feeling the pulse I no longer 
 trust my fingers to be sure of a high tension pulse; 
 I used to, but I have convinced myself that I can- 
 not do it. On the other side there are many irregu- 
 lar hearts, which you finally conclude to be merely 
 functional in origin, having no immediate signifi- 
 cance; because the blood-pressure is normal. An 
 irregular heart plus a high blood-pressure is serious. 
 
Importance of Test. 
 
 The very same irregular heart, with low pressure, 
 may be of no great significance. 
 
 "Then call your attention to the early diagnosis 
 of kidney lesions. I see a good many cases of renal 
 disease entirely free from albumin or from casts, 
 but with high blood-pressure, which are shown, 
 post-mortem, to be renal disease. These cases could 
 not have been suspected to be renal diseases ex- 
 cept by blood-pressure. In other words, I regard 
 the blood-pressure measurement as of more im- 
 portance than the examination of the urine in 
 chronic kidney trouble. Examination of a specimen 
 has again and again led me astray; the measure- 
 ment of blood-pressure almost never." 
 
 Physicians who can practice successfully without 
 materials for a urinalysis or without a blood-pressure 
 instrument will find it difficult to hold insurance 
 appointments ; furthermore, patients are learning 
 that an examiner who is preferred by an old insur- 
 ance company is the safest man to trust as a physi- 
 cian. 
 
 A hundred examiners could give us a reliable 
 blood-pressure reading where only one could detect 
 cardiac hypertrophy or an accentuated aortic second 
 or a minute trace of albumin in chronic interstitial 
 nephritis. 
 
 The foregoing has all been said of the simple 
 estimation of the systolic blood-pressure, as made 
 by the modern sphygmomanometer, of which the 
 Faught instruments are typical. It must not be 
 forgotten, however, that recent developments in the 
 study of blood-pressure have emphasized the grow- 
 ing importance of the diastolic pressure. In this 
 
The Diastolic Test. 
 
 connection I quote again from the article of Dr. 
 Prendergast above referred to, in which he says : 
 "Some of our cHnicians place little value on dias- 
 tolic pressure for the simple reason that they can- 
 not interpret its findings. This is a great mistake, 
 as the systolic pressure is only one side of the 
 picture, and we cannot explain the pulse pressure 
 or judge of the systolic output or the work the 
 heart is doing without knowing the diastolic pres- 
 sure. Now I contend that it is of great importance 
 to know whether under certain conditions the pulse 
 pressure, if 20, 40, 60 or even 100. In the first 
 case it would mean a rather feeble drive to. the 
 heart, with a small systolic output. In the latter 
 the heart is working too hard in overcoming periph- 
 eral resistance, or loss of elasticity in the vessel 
 wall, and is calling on its reserve capacity; as long 
 as it is compensated we have a good case, but once 
 our reserve capacity is overcome and decompensa- 
 tion sets in, look out for trouble. The narrow pulse 
 pressure is found in wasting diseases, like tuber- 
 culosis, in shock, after profuse hemorrhage, in chlo- 
 rosis, etc., and always accompanies a failing heart." 
 
 Diastolic Test. 
 
 Until the practical demonstration of the accuracy 
 of the Auscultatory or Auditory method of reading 
 blood-pressure, little valuable work was recorded 
 in connection with this test, for the reason that so 
 much difficulty was experienced in making this 
 part of the test, that few routinely employed it, 
 and those who made this effort were not repaid 
 for their trouble, as the figures obtained were so 
 
The Diastolic Test. 
 
 uncertain and unreliable that no dependence could 
 be placed on them. 
 
 The studies of Warficld and others have shown 
 the accuracy of this method, which can be relied 
 upon to give an accurate reading under practically 
 all circumstances, irrespective of the age of the 
 patient, the size of the vessel, or the size of the arm to 
 which the cuff is attached. 
 
 In' order to analyze the results of a complete blood- 
 pressure observation, it is essential to review the fac- 
 tors controlling blood-pressure. From the clinical 
 standpoint at least, we may consider the blood-pressure 
 depending mainly upon the contractile powers of the 
 heart, which pumps the blood forward, on the one 
 hand, and the calibre of the blood-vessel walls, which 
 offer peripheral resistance to its flow, on the other. 
 And also that peripheral resistance itself depends 
 largely on the tonicity of the walls of the blood-vessels 
 which comprise the general capillary system. Patho- 
 logically, we must recognize that changes in blood- 
 pressure are largely due to departures from the normal 
 force of the heart and to alterations in the elasticity 
 and tonicity of the general arterial tree. It will thus be 
 seen that the systolic pressure will approximate closely 
 the actual pressure developed by the heart within the 
 heart itself at the moment of systole, while the mini- 
 mal or diastolic pressure wall be the measurement 
 of the peripheral resistance, w^hich is able to maintain 
 to a varying degree the arterial pressure, while the 
 heart is dilating, plus the factor of elasticity, wdiich also 
 aids in maintaining the continued pressure in the vessel 
 during diastole. 
 
 In the pulse pressure, then, we must have the 
 
The Pulse Pressure, 
 
 measurement of the amount of force exerted by the 
 heart in maintaining blood-pressure over and above 
 that normally maintained by peripheral resistance, i. 
 e., the pulse-pressure gives a figure which roughly 
 measures the pumping capacity of the heart. These 
 facts show clearly the importance of always making 
 a diastolic reading, so that the pulse pressure may be 
 computed. 
 
 Gibson, due to his ingenuity and experience, has de- 
 vised formulae whereby we are able to more or less 
 carefully estimate not only the capacity of the heart 
 for work, but also, in a rough way, its output. 
 
 Gibson has demonstrated that there exist certain 
 definite relations between these several factors and has 
 combined them into a working formula. Briefly, these 
 propositions are as follows: 
 
 Under normal conditions there is a definite relation- 
 ship between systolic and diastolic pressure and also a 
 relation between systolic and pulse-pressure. The re- 
 lation of the diastolic pressure to the systolic pressure 
 obtained by auscultation is about as two is to three and 
 that of pulse-pressure to the systolic pressure as one 
 is to three. For example, if the systolic pressure is 
 140, the normal diastolic will be approximately 95, 
 while the pulse-pressure should approximate 45 or 50. 
 
 If we bear in mind the fundamental fact that all 
 blood-pressure readings vary normally within certain 
 well-known limits, it will readily be seen that these 
 relations are at best only approximate, which, how- 
 ever, does not materially detract from their clinical 
 value. Actually employed, they have been found to be 
 most valuable guides in separating the normal from the 
 pathological and in estimating the degree of over-load 
 in cardio-renal cases. 
 
Gibson's Formula. 
 
 Following tlie same reasoning, if the pulse-pressure 
 roughly estimates the systolic output, it follows that 
 this is also an important factor in the velocity of the 
 blood-stream, which for i)hysical reasons must bear a 
 definite relation to the volume output of the heart and 
 to the caliber of the conduits — the arteries — so that, if 
 other factors remain the same, it is not a difficult mat- 
 ter to estimate both the velocity and also the work of 
 the heart while operating under either normal or ab- 
 normal conditions. 
 
 The above propositions can, according to Gibson, be 
 arranged graphically as follows : 
 
 For example, take a case presenting these figures : 
 S. P. 130, D. P. 85, P. P. 45, P. R. 70; then— 
 P. P. (45) X P. R. (70) = Velocity (3100), and 
 S. P. (130) X P. R. (70) = Work (9100). 
 We may carry our calculations further and state 
 that the velocity and the work, as estimated by the 
 above formula, also bear a definite normal relation 
 which is dependent entirely upon the normal relation 
 of pulse-pressure to systolic pressure (which can only 
 be determined by measuring the diastolic pressure). 
 This velocity-work relation is as one is to three, and 
 is not dependent upon the pulse rate. For as long as 
 the relation of systolic to diastolic pressures remain 
 normal (they may of course be different in every case, 
 without changing their normal relation), the velocity- 
 work ratio will be normal, no matter what the pulse 
 rate. If we have a more rapid pulse, with unchanged 
 pressure, we undoubtedly increase the total expendi- 
 ture of heart energy, both for velocity and work; on 
 the other hand, it is possible to conceive of a decreased 
 pulse rate with a rising general pressure, w-hich 
 
10 Gibson's Formula. 
 
 would not only allow the velocity-work ratio to remain 
 unchanged, but which need not necessarily add ma- 
 terially to the work of the heart. As a matter of fact, 
 this is precisely what does occur within certain limits 
 under normal conditions. To show this, it is only 
 necessary to note the effect of change in posture upon 
 blood-pressure and pulse rate, as discussed on page 00. 
 
 The normal arterial tree will withstand a continual 
 variation in pressure of from 35 to 50 mm. without 
 undergoing pathologic change. Under those condi- 
 tions in which we have a pulse-pressure of more than 
 this, it is evident that the blood-vessels are required 
 to withstand undue stress ; and so if we here subtract 
 the normal pulse-pressure from the pathologic, we 
 have relatively the measurement of the increased work- 
 ing of the heart. Now if this difference is multiplied 
 in turn by the pulse rate per minute, then by 60 and by 
 24, it is very easy to see the relatively tremendous ex- 
 cess of work and energy required of the heart in every 
 24 hours in order to maintain circulation and nourish 
 the tissues. This w^ould seem to be the true explana- 
 tion of heart hypertrophy, arterial change and ultimate 
 cardiac dilatation with failing circulation. 
 
 Lauder Brunton says "The diastolic pressure is a 
 factor of great importance, because by its amount 
 and by the dift'erence between it and the systolic pres- 
 sure we obtain valuable data in regard to the strength 
 of the heart and the condition of the arterioles." 
 
 V. Pachon w^as among the first to express the belief 
 that the normal systolic pressure was not only of un- 
 certain value in the study of many pathologic cases, 
 but that its variation within wide limits and at short 
 intervals for any individual, even slight physiologic 
 
TiiK Diastolic Pkkssuuk 
 
 causes, might be actually misleading, as under the fol- 
 lowing conditions: In decomi)ensaled cardio-renal 
 cases where the maximal pressure may be normal, it 
 is only by determining the abnormal elevation of the 
 diastolic pressure and consequent reduction in ])ulse- 
 pressure that we are able to clinically confirm the cir- 
 culatory fault. 
 
 The minimuni pressure represents the true constant 
 load borne by the arterial tree and the resistance which 
 the heart is obliged to overcome before its contents 
 can be expelled. Both data of fundamental importance 
 from the clinical pathologic standpoint. It has been 
 found also that the diastolic pressure is a far more 
 constant factor in normal individuals than the systolic, 
 that it is practically the same for all parts of the arterial 
 tree, while the maximal pressure drops progressively 
 from aorta to periphery. 
 
 W. R. Sheldon, Medical Record, December 31st, 
 1910, adds the following to our already rapidly in- 
 creasing information : 
 
 The lessened elasticity of the arteries which is 
 found in many conditions contributes to an abnormal 
 relation between the diastolic and systolic pressure, so 
 that in long-continued high blood-pressure, due to les- 
 sened elasticity in the artery, there is a failure of the 
 diastolic pressure to maintain its normal relation. The 
 pulse-pressure is increased and we can, by the formula 
 already described, estimate the amount of extra work 
 which is demanded by the high pressure incident to 
 arterial rigidity. From these we can draw the follow- 
 ing corollary, which is, that increased strain on the 
 heart is to a large degree measured by the amount of 
 diastolic failure, i. e., the larger the pulse-pressure in 
 
12 The Diastolic Pressure. 
 
 relation to the diastolic pressure, the greater will be 
 the cardiac strain, which finally fails to respond to 
 the increased demands and enters into a condition of 
 decompensation. So that we may look for signs of 
 poor circulation when there is a high systolic pressure 
 and a diastolic pressure that is relatively low; and 
 conversely, if measures directed toward removing the 
 cause of this abnormal relation are successful, we may 
 measure the amount of improvement by the elevation 
 of diastolic pressure and consequent reduction of 
 pulse-pressure, as is well shown in the case above de- 
 scribed. 
 
 These two formulas have been discussed at some 
 length because of their fundamental importance and 
 wide applicability. By means of these, it is a simple 
 matter to compute the excessive work required of the 
 normal heart under varying conditions of strain and 
 load, and also in those pathologic conditions of the 
 circulation accompanied by changes in the heart, blood- 
 vessels and kidneys. Anyone who appreciates the value 
 of the blood-pressure test will find these studies of 
 great assistance in diagnosis, prognosis and treatment. 
 
 The following case from actual practice shows the 
 method of its employment and the information de- 
 rived : 
 
 Case of Chronic Myocarditis and Arteriosclerosis. 
 
 Before treatment—S. P. 210, D. P. 100, P. P. 110, 
 P. R. 104. 
 
 S. P. (210) X P. R. (104)=\ 
 
 Work (21840) _ . 
 
 P. P. (110) X P. R. (104) —' ~ ^^^^^ ^ ^° ^• 
 
 Velocity (11440) ) 
 
Effect of Treatment. 13 
 
 After two weeks' treatment— S. P. 195, D. P. 140, 
 P. P. 55, P. R. 84. 
 S. P. (195) X P. R. (84) =\ 
 
 Work (14580) __ 
 
 P. P. (55) X P. R. (84) = - ""^^'^ ^ ^° ^• 
 
 Velocity (4620) ) 
 
 Here, under proper methods of treatment, the 
 work-velocity was greatly benefited, the actual work 
 reduced one-third, so that while the heart was at first 
 only able to maintain the needs of the case under 
 serious strain, and accompanied by evident signs of 
 cardiac distress. After two weeks the danger of acute 
 failure of the circulation was overcome and the whole 
 complexion of the case altered for the better. 
 
 In pneumonia and most infectious diseases a 
 falling blood-pressure with a narrowing pulse-pres- 
 sure means great danger. A wide pulse-pressure 
 is found in arteriosclerosis, with loss of elasticity 
 in the blood-pressure and with increased peripheral 
 resistance ; in chronic interstitial nephritis, and is 
 very wide in aortic insufficiency, in fact, it is often 
 pathognamonic of this condition. Dr. George Oliver 
 says that of the two he has come to consider the 
 diastolic pressure just as precise as the systolic and 
 more valuable. 
 
CHAPTER II. 
 
 THE CIRCULATION. 
 
 Instruments for Study of Blood-Pressure 
 
 Practical Sphygmomanometry 
 Physiology of the Circulation 
 Arterial Pressure 
 Causes of Normal Pressure 
 
 Terms and Definitions . 
 
 The Pulse 
 
 Blood-Pressure 
 
 Systolic Blood-Pressure 
 Diastolic Pressure 
 Pulse Pressure or Range 
 
 Mean Tension . 
 
 Normal Tension 
 
 Hypotension 
 
 Hypertension 
 
 Auscultatory Blood-Pressure 
 
 15 
 16 
 16 
 16 
 17 
 
 17 
 18 
 18 
 18 
 18 
 18 
 19 
 19 
 19 
 19 
 
 20 
 
CHAPTER II. 
 THE CIRCULATION. 
 
 The application of instruments of precision for the 
 study of conditions of the circulation marks an epoch 
 in the history of medicine. The application of scien- 
 tific instruments in clinical medicine has developed a 
 large amount of valuable information concerning the 
 relation of the heart, blood-vessels and kidneys, in 
 both normal and pathologic conditions. We are now 
 able, by means of easily applied tests, to gather accur- 
 ately and quickly an enormous amount of detailed 
 information which could have been found by no other 
 means. 
 
 This general increase in knowledge of special dis- 
 eases has placed an added amount of responsibility 
 upon the medical profession, for the public has so 
 learned to appreciate the benefit to be derived from 
 this broader knowledge, that patients now demand 
 special methods of examination ?nd study, in every 
 case, far greater than was ever dreamed of twenty 
 years ago. 
 
 Among the many scientific instruments now em- 
 ployed in the study and practice of medicine, there 
 is probably not one single instrument of greater use 
 and of easier application than the sphygmomanometer. 
 Its value has now become so fully established that it 
 needs no argument to show^ an intelligent physician 
 
 15 
 
16 Physiology of Circulation. 
 
 that the sphygmomanometer is a most important part 
 of his armamentarium. 
 
 In taking up this discussion of blood-pressure 
 apparatus and blood-pressure tests, it is only neces- 
 sary to call attention to the fact that the normal circu- 
 lation is a vital function necessary in the maintenance 
 of health and that the cardio-vascular system is 
 involved to a more or less degree in the great majority 
 of diseased conditions. It is evident that the knowl- 
 edge of the condition of the heart and circulation plays 
 an important part, not only in diagnosis, but in prog- 
 nosis and in treatment. 
 
 In taking up the consideration of the subject of 
 blood-pressure, a brief review of the physiology of 
 the circulation is essential in order that departures 
 from it may be recognized and that these changes 
 may be given their proper value in the general symp- 
 tom-complex. 
 
 Roughly speaking, the heart and arteries may be 
 likened to a force pump and series of elastic tubes, 
 which supply every part of the body with nutrition, 
 remove waste products and at the same time con- 
 tribute to the size and density of the organs. The 
 heart is a compound pump of intermittent action. 
 From this springs the aorta, which rapidly ramifies 
 from the heart to the periphery. The aorta receives 
 blood from the heart in intermittent jets, and this 
 would be transmitted to the periphery in the same 
 intermittent manner were it not for the elasticity and 
 other vital properties of the blood-vessel walls. 
 
 The mechanism of the circulation is largely con- 
 cerned in reducing this intermittent stream to the con- 
 tinuous flow found in the organs and capillaries. It 
 
Causes of Normal Pressure. 17 
 
 is also concerned in maintaining^ the proper supply of 
 blood to each part as the demand may arise for 
 increased nutrition. In order to accomplish this func- 
 tion, it is essential that the blood should be maintained 
 under a certain degree of pressure. This is necessary 
 to insure the proper distribution and to bring an in- 
 creased supply to any particular region when de- 
 manded. This relation is maintained by what is known 
 as blood-pressure. 
 
 Normal blood-pressure depends upon the normal 
 correlation and interaction of certain variable factors : 
 (1) The amount of blood pumped into the arterial 
 system by the heart. (2) The resistance offered to 
 the escape of blood toward the periphery through the 
 smaller arteries and the capillaries. Of less import- 
 ance are (3) the elasticity of the vessel walls, (4) the 
 total quantity of blood in the body, and (5) viscosity. 
 These factors are all capable of interaction in the 
 most complicated manner. For example, if the arterial 
 pressure is increased from any cause, the vagus nerve 
 is stimulated, and the effect of its inhibitory action 
 upon the heart is to lower the heart rate so that less 
 blood is delivered into the aorta in a given time, thus 
 assisting to maintain normal blood-pressure. In like 
 manner, when the volume of blood is rapidly reduced 
 from hemorrhage or venesection, the blood-vessel 
 reflex immediately reduces the calibre of the arteries, 
 so that within certain limits the blood-pressure is not 
 altered. 
 
 Terms and Definitions. 
 
 Having briefly reviewed the physiology of the nor- 
 mal circulation and the causes concerned in the pro- 
 duction and maintenance of blood-pressure, we may 
 
18 Terms and Definitions. 
 
 now proceed to a consideration of the relation of 
 these facts to the problems of clinical medicine and 
 their bearing on Diagnosis, Prognosis and Treatment. 
 
 To obtain a clear insight and understanding of the 
 subject it is all-important to have an accurate knowl- 
 edge of the terms applied to the matter under con- 
 sideration. 
 
 The Pulse. — The pulse is a rythmically recurring 
 impulse arising in the systole of the left ventricle, and 
 palpable through the arterial system. Its presence 
 indicates a variation in blood-tension within the arter- 
 ies, which causes them to pulsate, as the walls momen- 
 tarily expand. 
 
 Blood-pressure. — Blood-pressure is the term em- 
 ployed to indicate the degree of pressure under which 
 the blood exists while traversing the arteries. Unless 
 otherwise specified, the , term blood-pressure as used 
 throughout this book indicates arterial systolic blood- 
 pressure. 
 
 Systolic Blood-pressure. — Systolic blood-pressure 
 means the degree of arterial pressure or lateral ten- 
 sion existing in the arterial system at the moment of 
 cardiac systole. 
 
 Diastolic Blood-pressure. — Diastolic blood-pressure 
 means the degree of arterial pressure or lateral ten- 
 sion existing in the blood-vessels just preceding a sys- 
 tole of the heart. This represents the time when the 
 blood-pressure is at its lowest. 
 
 Pulse-pressure^ Range or Amplitude. — These synony- 
 mous terms indicate the amount of periodic variation 
 in blood-pressure occurring within the arterial system, 
 due to the intermittent action of the heart. It is equal 
 to the difference between systolic and diastolic blood- 
 pressures as determined by the sphygmomanometer. 
 
TkRMS and DkI'INMTION' 
 
 10 
 
 Mean Tension. — Mean tension is the term applied to 
 indicate the average strain to which tlie arterial sys- 
 tem is subjected. It corresponds closely to the arith- 
 metical mean of the systolic and diastolic blood-pres- 
 sure. The relation between these several terms ancl 
 normal pulse tracing is shown in Fig. 1. 
 
 stolic ^ 135 
 nge ^ 40 
 astolic = 95 
 
 Fig. 1 — Normal pulse tracing; showing relation of sys- 
 tolic, diastolic, pulse-pressure and mean. Pulse-pres- 
 sure equals 40. 
 
 Normal Tension. — This term applies to the systolic 
 blood-pressure which should be found in a normal 
 individual as determined by the study of a large num- 
 ber of persons. This pressure is modified by a 
 number of normal or physiological conditions, and 
 is therefore subjected to some variation. Full dis- 
 cussion of these will be taken up in Chapter I\' 
 page 54. 
 
 Hypotension. — Hypotension is the term applied to 
 the condition of the circulation in which the systolic 
 blood-pressure is found to be below the normal as 
 estimated for the individual. 
 
 Hypertension. — Hypertension is the term applied to 
 a condition of the blood-pressure when the level is 
 maintained above the estimated minimum normal 
 pressure. 
 
20 Terms and Definitions. 
 
 Auscultatory method. — By this is meant a method of 
 determining both the systolic and diastoUc blood- 
 pressure, with the aid of a suitable stethoscope (as 
 the Bowles Midget or the sphygmometroscope, see 
 page 41), the bell of which is placed over the bifur- 
 cation of the brachial artery at the bend of the elbow 
 below the sphygmomanometer cuff. 
 
 THE FAUGHT 
 
 SPHYGMOMANOMETER 
 
 AND THE 
 
 BOWLES STETHOSCOPE 
 
 A clinician of national reputation has said in 
 
 public that were he to be deprived of all 
 
 the aids to diagnosis known to medicine save 
 
 two, he would retain his sphygmomanometer 
 
 and the stethoscope. He uses a FAUGHT 
 
 SPHYGMOMANOMETER and 
 
 the BOWLES STETHOSCOPE. 
 
CHAPTER III. 
 THE SPHYGMOMANOMETER- 
 
 The Principle of the Sphygmomanometer 
 
 Circulator Compression 
 Explanation of Systolic Reading 
 Explanation of Diastolic Reading 
 
 Description of Apparatus .... 
 
 Mercury Column Apparatus 
 Aneroid or Pocket Apparatus 
 Description of Arm-Bands 
 
 21 
 22 
 22 
 23 
 
 24 
 25 
 28 
 31 
 
 Practical Application of Faught Aneroid Apparatus 29 
 
 Adjustment of Arm-Band . . . 31 
 
 The Systolic Reading .... 36 
 
 The Diastolic Reading .... 37 
 
 Auscultatory Method ... 38 
 
 Description of Tone Phases . 38 
 
 The Pulse Pressure 39 
 
 The Mean Pressure 39 
 
 The Sphygmometroscope ..... 40 
 
 Applied to Auscultatory Blood-Pressure . 41 
 
 The Multiple- Sphygmo- Metroscope . . 42 
 
 Practical Application of the Standard Sphygmoma- 
 nometer ....... 43 
 
 Application of Arm-Band ... 43 
 
 The Systolic Reading .... 44 
 
 The Diastolic Reading .... 46 
 
 Fedde Diastolic Indicator ... 47 
 
 Points to be Remembered in Making Tests 48 
 
 Methods of Recording Blood-Pressure ... 49 
 
 Hospital Laboratory Sheet ... 50 
 
 Faught's Clinical Chart . . . . 51 
 
22 
 
 Explanation of Systolic Reading. 
 
 Fig. 2, A and B, shows the relation of the com- 
 pressing bag to the artery. In Fig. 2, A, the pressure 
 within the cuff is greater than the blood-pressure 
 within the artery, which is therefore collapsed and 
 the pulse in the distal end of the vessel cut off. In 
 
 -Pressure in "b" 135 mm. Hg.; pressure in "a" 130 mm. 
 Hg. B is therefore collapsed, pulse cannot pass. 
 
 B. — Pressure "b" 129 mm. Hg.; pressure in "a" 130 mm. 
 Hg. Pulse passes. 
 
 Fig. 2 — Diagram of relations of armlet to brachial 
 artery. Explanation of systolic reading; a, artery; b, 
 compressing armlet; c, retaining cuff; d, tube to mano- 
 meter; e, humerus. 
 
 Fig. 2, B, the pressure in the cuff has been reduced 
 so that it is a fraction of a millimeter less than the 
 systolic pressure within the vessel. Now at each 
 systole a small amount of blood will pass the con- 
 
Explanation of Diastolic Reading. 
 
 23 
 
 striction and will reach the distal end of the artery, 
 where the wave can be felt by the palpating finger 
 at the wrist. 
 
 A. — Systolic pressure in "a" 130 mm. Hg.; pressure in "b' 
 101 mm. Hg. Artery not compressed. 
 
 B. — Diastolic pressure in "a" 100 min. Hg.; pressure in 
 "b" 101 mm. Hg. Artery collapsed. 
 
 Fig. 3 — Diagram of relation of armlet to brachial artery. 
 Explanation of diastolic reading; a, artery; b, com- 
 pressing armlet; c, retaining cuff; d, tube to mano- 
 meter; e, humerus. 
 
 Fig. 3, A and B, represents the conditions existing 
 between the constricting cuff and the vessel at the 
 time of diastolic pressure. A represents a pressure 
 within the cuff less than the systolic pressure in the 
 
24 Methods of Reading. 
 
 vessel. This is insufficient to affect the vessel during 
 the systolic period. B shows the artery and cuff dur- 
 ing the diastolic period, when the pressure within the 
 artery is at its lowest point, a fraction of a millimeter 
 less than the pressure v/ithin the cuff. Consequently 
 the artery is collapsed at this time. The effect of 
 each succeeding systole is to alternate between a 
 round and a flat vessel at the point of compression. 
 This aft'ects the pressure of the air within the cuff, 
 w^hich is in turn transmitted to the mercury column 
 of the manometer and becomes visible in the rhythmic 
 fluctuation of the column of mercury which is syn- 
 chronous with the pulse beat. Since the fluctuation 
 will reach a maximum at the time when the pressure 
 in the cuff is approximately equal to the diastolic 
 pressure in the vessel, we are justified in considering 
 the base of the manometer column at this time a 
 measure of the diastolic pressure within the vessel. 
 
 Since the development of the visual or oscillatory 
 method of diastolic blood-pressure observations newer 
 and better methods have been designed. These are 
 the tactile, the auscultatory and that by means of the 
 Fedde indicator attachment. Each of which will be 
 considered more fully later under the head of ''appli- 
 cation of the blood-pressure test." 
 
 Description of Apparatus. — At the present time the 
 market is flooded with instruments of all descriptions 
 for estimating blood-pressure, so that it is important 
 that the prospective purchaser should be able to 
 separate the good from the bad, since the imperfect 
 and poorly constructed instrument will be a constant 
 source of inconvenience and may give very incorrect 
 readings. 
 
Mercury Api'aratus. 
 
 25 
 
 All these instruniciils may be roughly divided into 
 two classes : First, those dej)endent upon the weight 
 of a fluid column (usually mercury) which measures 
 the pressure ; and, second, those employing some form 
 of spring or aneroid chamber. 
 
 Fig. a — Type of Mercury IManometer employing a verti- 
 cal tube. A, mercury-containing base; B, manometer 
 tube; C, tube to armlet; D, tube to bellows; E, scale. 
 
 Taking up the first class, we find that this can be 
 divided into two divisions; one employs a vertical 
 glass tube emerging from the mercury chamber so 
 that when pressure is exerted on the mercury, it is 
 forced upward into the glass tube, where the pressure 
 is indicated in millimeters of mercury by an appropri- 
 ate scale attached thereto (see Fig. 4). 
 
26 
 
 Faught-Pilling Sphygmomanometers. 
 
 The second group of mercury instruments employ 
 a glass U-tube similar to that first used by Poiseuille 
 
 Fig. 5 — Manometer Ar-FiG. 6 — ]\Ianometer Ar- 
 rangement of Pilling Spe- rangement of Faugh t 
 cial Sphygmomanometer. Standard Sphygmomano- 
 
 meter. 
 
 (see Fig. 6), with the open ends up. This tube is 
 partly filled with mercury and one limb is connected 
 by means of suitable tubing with the rest of the 
 
Accuracy of Mercury Apparatus. 27 
 
 apparatus. Pressure exerted within the system will 
 cause the mercury to rise in one limb of the tube with 
 a proportionate fall upon the other. The difference 
 in the level of the mercury in the two limbs will repre- 
 sent the pressure, which may be measured by a suit- 
 able scale placed between the tubes. 
 
 These two types depending upon a vertical column 
 of mercury have little to choose between them, and 
 both are accurate and trustworthy at all times. The 
 mercury at rest freely communicates with the atmos- 
 phere, and is therefore not afifected by barometric or 
 thermometric changes. 
 
 A question has been raised by some regarding the 
 accuracy of the cystern-vertical-tube-type of mercury 
 sphygmomanometer in the high readings. It has been 
 found that the fall in the mercury level in the cystern 
 affects slightly the total height of the mercury column, 
 so that in readings above 250 the figure obtained 
 with this type of apparatus may be from 5 to 10 mm. 
 too low. After all, this is not such a great draw- 
 back, as the variation is slight at best, and because 
 such pressures are but rarely met in the course of 
 general practice. 
 
 Value of Mercury Apparatus in Determining 
 Diastolic Pressure. 
 
 Some time ago there appeared an article in which 
 the value of the fluctuation of the mercury column 
 for determining diastolic pressures was questioned ; 
 this was based upon the supposed interference of the 
 inertia of the mercury column. The author of these 
 statements failed to recognize the fact that the mer- 
 cury column at the time of the observation was under 
 
28 Faught Pocket Sphygmomanometer. 
 
 an added factor of pressure and that this pressure 
 exerted against the mercury column greatly reduced 
 the enertia factor. By experiment it was found pos- 
 sible for the mercury column to shozv a fluctuation 
 from successive systolies up to nearly 200 heats per 
 minute, or more than twice the number possible with 
 a mercury column moving freely in the atmosphere. 
 Anyone, by actual experiment, can demonstrate this 
 with any form of mercury apparatus, so that one 
 need not fear to use a mercury apparatus when em- 
 ploying the visual method for diastolic reading, unless 
 the pulse is so rapid that it is uncountable; this does 
 not mean that the visual method is recommended, but 
 simply that when no other , means is available, the 
 results by this method will be reasonably accurate 
 and clinically satisfactory. 
 
 Aneroid or Pocket Type. — There are also several 
 types of instrument, employing some form of spring 
 and aneroid chamber, actuating a dial indicator for 
 the recording of blood-pressure in millimeters of 
 mercury. These are the so-called pocket instruments, 
 and have much to recommend them, provided they 
 do not become inaccurate by use. 
 
 The Faught Pocket Sphygmomanometer consists of 
 a gold-plated aneroid gauge with a white enamel dial 
 bearing black and red markings graduated to 300 mm. 
 Hg., a strong flexible sleeve and a metallic inflating 
 pump, together with suitable rubber tubing for con- 
 nections. Vv^hen assembled these constitute a very 
 simple and most reliable instrument, so compact that 
 it is contained in a leather case, measuring 8 x 3^ x 
 1^ inches, and weighing complete about one-half 
 pound, fitting easily in the pocket or bag. 
 
Accuracy of Pocket Sphygmomanometers. 29 
 
 This instrument has been devised to fill the long- 
 felt need of a Pocket Sphygmomanometer, which 
 would combine portability and accuracy with durabil- 
 ity and strength. The Faught Pocket Sphygmomano- 
 meter is an exact and efficient instrument, and is 
 employed extensively by life insurance examiners, 
 hospitals, the army and navy, bureaus of health and 
 by most of the leading practitioners. It is compact, 
 absolutely accurate, very sensitive, substantially con- 
 structed, and with ordinary care should last a life- 
 time. 
 
 It is unfortunate for the medical profession that 
 a certain type of aneroid type of instrument which 
 at first met with favor has been found in many cases 
 to lose its accuracy and to become untrustworthy 
 through frailty of construction, which renders it 
 easily deranged. Even ordinary use will at times 
 develop in this particular make of instrument perma- 
 nent inaccuracy. 
 
 Failure of a single type should not, however, con- 
 demn all instruments operating upon the aneroid 
 principle, as the test of time so far has failed to show 
 any such disturbance in the aneroid made by the 
 Pilling Company; for example, a Faught instrument 
 was used for ward class demonstration for more 
 than a year, and when tested with the original stand- 
 ard mercury column was found as absolutely accurate 
 as zvhen originally tested. At another time, after one 
 hour's constant use on about twenty students, a test 
 for accuracy was immediately made, and the readings 
 corresponded absolutely, both up to 300 and down 
 again. This proves conclusively that the 
 Faught Pocket Sphygmomanometer is not af- 
 
30 Durability of Faught Sphygmomanometers. 
 
 FECTED BY CONSTANT USE AND THAT READINGS BOTH 
 
 UP AND DOWN ARE IDENTICAL. No Other ancroid can 
 bear these tests. 
 
 J. F. Prendergast, commenting upon the accuracy of 
 the Faught Pocket Sphygmomanometer, states : "As 
 
 FOR ACCURACY AND DURABILITY, THE WRITER HAS FOR 
 THE PAST FOURTEEN MONTHS USED ONE ANEROID IN- 
 STRUMENT, A Faught, and has forced it up to 450 
 
 MM. nearly TWO THOUSAND TIMES. AfTER THIS 
 SEVERE TEST IT WAS COMPARED WITH A STANDARD 
 MERCURY COLUMN AND FOUND AS ACCURATE AS AT THE 
 ORIGINAL TEST. It IS STILL IN SPLENDID WORKING 
 CONDITION, AND THE COMPRESSION DIAPHRAGMS ARE 
 AS RESILIENT AS THE DAY IT LEFT THE PiLLING FAC- 
 TORY. This is a test of the most severe character, 
 
 AND ANY INSTRUMENT THAT WILL REMAIN ACCURATE 
 WITH SUCH USAGE WILL LAST INDEFINITELY WITH 
 ORDINARY USE." 
 
 Fig. 7. — Faught Pocket Sphygmomanometer in Case. 
 
 A very important and distinctive feature possessed 
 by the Faught Pocket Sphygmomanometer and found 
 
The Flexible Arm-Band. 31 
 
 in no other instrument of similar character is the abso- 
 lute elimination of the so-called "fatigue of metal" 
 which heretofore has interfered with the accuracy of 
 all other aneroid instruments. By persistent experi- 
 ment and painstaking study a material for the con- 
 struction of the compression disks has been found 
 which is not affected in any way by temperature or 
 pressure variations. 
 
 These tests can be repeated by anyone and the 
 results will be the same. Try them and be convinced. 
 
 The Arm-band is made of strong grey inelastic, but 
 soft and flexible material, having between its layers a 
 rubber bag 9 x5 inches. This measurement conforms 
 to the requirements of Janeway and others, and has 
 been found to give the most accurate readings under 
 all conditions. 
 
 Fig. 8. — Arm-band. 
 
 The Faught Pocket Sphygnioinaiwiueter can be 
 applied or removed in less than thirty seconds. The 
 lime required to apply the instrument, make a careful 
 observation of the pressure and remove it is less than 
 consumed by any other form of sphygmomanometer 
 on the market. 
 
 Two years' experience with the Faught Pocket 
 Sphygmomanometer has demonstrated conclusively 
 
32 
 
 Faught Pocket Sphygmomanometers. 
 
 the superiority of the internal mechanism of this in- 
 strument as compared with all other types of aneroid. 
 They have been found practically indestructible as 
 well as uniformly correct. Many instruments in con- 
 stant use — thousands of times — coming back for 
 examination, are found to have retained their accur- 
 acy when compared with the standard mercury 
 column. 
 
 Fig. 9. — Pocket Indicator. Actual size. 
 
 For accuracy and sensitiveness, the Faught aneroid 
 has all the advantages of the best mercurial instru- 
 ments ; for compactness and durability it far surpasses 
 them. It is practically indestructible, and is well 
 adapted to use in the operating room and in private 
 practice, as well as in hospital service. 
 
Faught Clinical Sphygmomanometer. 
 
 33 
 
 Reads up to 300 mm. — The dial, which is accurately 
 graduated, reads in mm. Hg., as does the standard 
 mercury column, each interval representing two mm., 
 and ranges from zero to three hundred (Fig. 9). 
 
 The dial also may be revolved without interfering 
 with the internal mechanism, so that the pointer at 
 rest can be adjusted to zero. Neither temperature 
 nor atmospheric variation in any zvay affects the 
 apparatus, since when at rest the pressure on both 
 side of the pressure chambers is equalized. 
 
 Fig. 10. — Clinical Pocket Sphygmomanometer. One-half 
 actual size. Diameter of dial, ?>% inches. 
 
 The latest development in sphygmomanometers is 
 the "Faught Clinical." This instrument follows a new 
 principle which has been fully tried during several 
 years in the Faught Pocket Indicator, and which has 
 been fully demonstrated to be the most desirable and 
 accurate multiple chamber aneroid instrument yet 
 designed. 
 
 This instrument is shown in detail in Fig. 10. 
 
34 Standard Mercury Sphygmomanometer. 
 
 The two characteristic features of this instrument 
 are the large, easy-to-read dial, measuring 3^ inches 
 working diameter, and a graduated scale with a range 
 of 350 mm. Hg. The first and only sphygmomano- 
 meter to have a range sufficient to give accurate read- 
 ings in every case, as it is now well established that 
 pressures are not infrequently encountered that regis- 
 ter well above 300 mm. (See article in New York 
 Med. Jour., June 11, 1910, by John C. Hirst.) 
 
 In general appearance the Clinical very much 
 resembles the Pocket and, in spite of the larger scale, 
 is contained complete with pump and arm-band in a 
 case but very little larger than that of the Pocket 
 Indicator. 
 
 The Faught Standard Mercury Sphygmomanometer is 
 
 modeled after the U-tube type of apparatus and is 
 designed to overcome the defects of the earlier instru- 
 ments, to meet every requirement demanded of a mod- 
 ern sphygmomanometer and at the same time be easy 
 to use, difficult to derange and as light and portable as 
 is compatible with accuracy and strength. 
 
 The mahogany case, which encloses the complete 
 apparatus, including the arm-band (see Fig. 11) and 
 pump (see Fig. 16), measures 4x4^ x 16 inches and 
 weighs 3 pounds 9 ounces. The lid is hinged at one 
 end and when raised supports the working parts of 
 the apparatus. A spring check allows the lid to be 
 raised to a vertical position, where it is automatically 
 held locked during the observation. 
 
 The "U" tube is provided with a scale which has 
 been arranged to give the reading directly in milli- 
 meters of mercury. 
 
Faught Mercury Sph ycmomaxomftkh. 
 
 35 
 
 A special and distinctive feature of the apjjaralus 
 is the means of preventing loss of mercury from the 
 manometer tube when the instrument is not in use. 
 This is accomplished by means of two small cocks 
 placed at either extremity of the "U" tube, and which 
 are kept closed wlien the apparatus is not in use (see 
 Fig. 6). 
 
 Fig. 11 — Faught Standard Sphygmomanometer. 
 
 By eliminating all detachable parts, the time re- 
 quired to make the reading is reduced to a minimum. 
 The only preliminaries to the test being to lift the lid, 
 open three cocks and attach two tubes to their respec- 
 tive nipples. 
 
Z6 
 
 To Obtain a Systolic Reading. 
 
 To Operate the Faught Pocket and the Faught 
 Clinical Sphygmomanometers. 
 
 Apply the arm-band to the bared arm of the patient, 
 above the elbow, by placing the broad end, containing 
 the rubber bag, over the region of the brachial artery. 
 Wrap the rest of the band as you would a bandage 
 about the arm (see Fig. 12) and tuck the narrow 
 end in under the first turn. Attach the indicator to 
 the hook provided for that purpose; attach the pump 
 to one nipple, and the tube from the arm-band to the 
 
 Fig. 12. — Pocket Indicator Applied to Arm. 
 
 other. See that the needle valve on the pump is fully 
 closed. Hold the pump in one hand and locate the 
 pulse at the wrist with the other. You are now 
 ready to take the systolic pressure. 
 
 To obtain systolic reading. — Pump sufficient air in 
 the system to obliterate the pulse, then by a fraction 
 of a turn open the valve (see Fig. 12), gradually 
 release the air pressure, and note the pressure indi- 
 cated when the first pulse beat returns to the wrist. 
 This is systolic pressure. Repeat the procedure one 
 or more times to insure correct readings. Work 
 rapidly, as prolonged pressure upon the arm will affect 
 the reading. 
 
To Obtain a Diastolic Reading. Zl 
 
 To obtain diastolic reading. — Again obliterate the 
 pulse and allow the air pressure to gradually fall 
 through the needle-valve. As the pressure falls the 
 needle will be seen to fluctuate in rhythm with the 
 pulse ; after a time this movement will become less 
 and eventually disappear. The pressure indicated 
 on the dial at that time will be the diastolic pressure. 
 
 Obliterate the radial pulse, then gradually reduce 
 the air pressure ; when the pulse returns to the wrist 
 it will at first be very feeble and thready, then it will 
 come up full and strong under the finger. Take the 
 reading at the moment the pulse becomes full and 
 normal in character. This will be the diastolic 
 pressure. 
 
 The value of correctness of the ausculatory method 
 of determining blood-pressure has, during the last 
 few years, been conclusively demonstrated. This was 
 first introduced by Korotokoff, of St. Petersburg, in 
 1905, who, instead of using the finger upon the radial 
 pulse, substituted the stethoscope applied over the 
 brachial artery at the bend of the elbow. On the 
 return of the blood under the armlet, a distinct 
 throbbing becomes audible, which gradually increases 
 in loudness as the pressure in the cuff lessens, and 
 then gradually dies down and disappears when the 
 artery ceases to be obstructed at any time during the 
 heart cycle. 
 
 The chief advantage of the auscultatory or auditory 
 method is in that it gives not only the high point — 
 the systolic pressure — very definitely, but also the low 
 point — or diastolic pressure, a point of great value, 
 since it is well recognized that, under many condi- 
 tions by the older methods, it is impossible to obtain 
 
38 Auscultatory or Auditory Method. 
 
 any accurate diastolic pressure, and in some cases no 
 diastolic reading at all. 
 
 The importance of this is further emphasized by 
 the fact that the diastolic pressure is often the more 
 important reading, since it gives the pulse pressure or 
 amplitude, which is an indication of the actual force 
 and volume of the circulation. Clinical studies by 
 Goodman and Howell in the American Journal of 
 Medical Science, 1911, and by Warfield and by H. G. 
 Armstrong in the Journal of the A. M. A. and British 
 Medical Journal, are sufficient to assure us of the 
 value of the auscultatory method. For the benefit of 
 those who desire to go into this study more exten- 
 sively than is really necessary for clinical work, the 
 following analysis of the sounds is given. 
 
 These consist of five phases, which are clean cut and 
 which have a definite relation to the differences be- 
 tween the extremes of pressure. With a normal 
 systolic pressure at 130 mm. and a diastolic pressure 
 at 85, the phases are : 
 
 First, a loud, clear, snapping tone, which is the 
 first phase. This serves as an index as to how far 
 the pressure must fall before the column of blood 
 can be sustained past the obstruction in the vessel 
 caused by the cuff, at sufficient velocity and for suf- 
 ficient duration to produce the murmur. Normally 
 this phase covers 14 mm., and any increase or decrease 
 in length should be noted. The advent of this sound 
 indicates the systolic pressure. 
 
 The Second Phase consists of a succession of mur- 
 murs, covers 20 mm. and is dependent upon cardiac 
 effectiveness. 
 
The Mean Pressure. 3^ 
 
 The Third Phase is a tone resembling the first phase, 
 but less marked and lasts 5 mm. This is dependent 
 upon cardiac efficiency and also upon the character 
 of the vessel wall. The more sclerotic the vessel and 
 the greater the cardiac hypertrophy, the more favor- 
 able are the conditions for the production of a clear 
 tone at this time. 
 
 The Fourth Phase occupies about 6 mm. and is heard 
 as a dull tone ; a resilient vessel receiving a normal 
 pulse shock, or a rigid vessel receiving a weakened 
 shock. The pointer at this time indicates the diastolic 
 pressure. 
 
 The Fifth Phase is the disappearances of all the 
 sounds. 
 
 Of these three methods, the last is the more accu- 
 rate and scientific. One point, however, must be 
 borne in mind : readings in the text books and medical 
 literature are based on the first and second methods. 
 The auscultatory method will give readings of a slightly 
 higher systolic pressure and a diastolic pressure of 
 10 to 15 mm. lower. 
 
 Having determined the systolic pressure and the 
 diastolic pressure, the diastolic pressure is subtracted 
 from the systolic pressure and the remainder is the 
 pulse-pressure (see Fig. 1, page ig). 
 
 To obtain the mean pressure, add one-half of the 
 pulse-pressure to the diastolic pressure (see Fig. 1), 
 
 In order to enable physicians to take the blood- 
 pressure readings more accurately and to make them 
 of greater clinical value to the profession as a diag- 
 nostic and therapeutic guide, Dr. J. F. Prendergast 
 {N. Y. Med. Jour., Jan. 11, 1913) has had devised and 
 placed on the market the Sphygmometroscope (Aus- 
 
40 
 
 The Sphygmo-Metroscope. 
 
 culoscope). It consists of a two-inch band, to which 
 is attached a metal bowl or cup, the face of which 
 has a very delicate diaphragm, with a centre projec- 
 tion to fit more snugly to the surface of the arm over 
 the brachial artery, just at or below the bend of the 
 elbow. Flexible rubber tubes are connected with the 
 
 Fig. 13. — Method of auscultatory blood-pressure test, 
 using Faught pocket indicator and sphygmometroscope. 
 
 drum or body of the instrument, to which are attached 
 hard-rubber ear-pieces (see Fig. 14). It is called 
 the Bowles sphygmometroscope, and resembles the 
 Bowles stethoscope with certain modifications; it is 
 attached to the arm by a two-inch band. 
 
 The instrument is intended for use with any kind 
 or form of sphygmomanometer, either pocket or 
 mercury. Its method of application is to place the 
 band on the arm one or two cm. (one-half to one 
 
The S'phygmo-Metroscope. 
 
 41 
 
 inch) below the arm-l)an(l or cuff of the sphygmoman- 
 ometer at the bend of the elbow, having the projection 
 on the diaphragm of the drum directly over the 
 brachial artery before it divides into the ulnar and 
 radial. Care should be taken to avoid pressure from 
 this band upon the arm. 
 
 Fig. 14. — Sphygmometroscope. 
 
 Pump the cuff, connected with the manometer, 
 with air until the radial pulse is cut off, open the 
 release valve and allow the air to escape slowly from 
 the arm-band. The first impulse or sound heard 
 is a clear thump or tap, caused by the sudden stretch- 
 ing of the walls of the relaxed vessel and the rapidity 
 of the blood stream. This is the systolic pressure. 
 
 Where one is merely trying to read the systolic 
 and diastolic pressures, it is not necessary to attempt 
 to interpret the different phases. The essential thing 
 to remember is that the first tap or sound is the systolic 
 pressure, and just at the disappearance of all sounds 
 is the diastolic pressure. 
 
42 The Multiple Sphygmo-Metroscope. 
 
 Goodman and Howell say: "The auscultatory 
 method is useful in differentiating certain organic and 
 functional derangements. It was found that any 
 arrhythmia which may be present is noted earlier by 
 
 Bowles \ I \ /multiple 
 Sphymo^metroi^scope 
 
 Fig. 15. — The Multiple Sphygmometroscope. 
 
 the auscultatory method than by feeling the pulse or 
 listening to the heart. By this method true organic 
 cardiac lesions can be differentiated from a neurosis. 
 In organic lesions there is a uniformity in sequence 
 of readings ; in neuroses the readings are marked by 
 variations in sequence and a variation in the systolic 
 and diastoHc pressures." 
 
 The Multiple Sphygmometroscope. — The accompany- 
 ing illustration, Fig. 15, represents a new device to 
 facilitate the teaching of blood-pressure readings by 
 the auscultatory method. The chief drawback to the 
 ausculatory method has been the seeming difficulty 
 which the average physician has in learning to per- 
 ceive and interpret the sounds heard over the artery. 
 
Opkration of Standard Sphygmomanometer. 43 
 
 Tlie idea suggested itself that if the si)hygmometro- 
 scope were made into a multiple of four, whereby 
 the sounds could be heard by more than one individual 
 at the same time, it would overcome this difficulty 
 and make it possible for anyone familiar with the 
 sounds heard during auscultatory blood-pressure ob- 
 servations to direct the attention of a small group of 
 observers during the actual performance of the test. 
 
 The G. P. Pilling Company, of Philadelphia, have 
 taken up this suggestion, and this valuable instrument 
 is now upon the market. 
 
 The device will be valuable particularly to the 
 medical teacher, as it has been our experience that 
 many students go through their clinical studies with- 
 out ever actually hearing or seeing what is demon- 
 strated. It is serviceable also in demonstrating to med- 
 ical societies or groups of medical men conditions in- 
 volving marked variations in pressure. 
 
 To Operate the Standard Sphygmomanometer. 
 
 The patient should be in a comfortable position 
 and in a sitting or reclining posture. The instrument 
 should be upon a level surface within easy reach of 
 the examiner. 
 
 The lid is then raised until it locks in a vertical 
 position. If the tube from the pump is not already 
 connected to the nipple F, it should be firmly attached 
 to it. The two mercury guard cocks K and L at 
 the ends of the ''U" tube should be opened and the 
 escape valve N tightly closed. 
 
 The hollow rubber bag of the arm-band A should 
 be firmly wrapped around the bared arm of the 
 
44 
 
 Systolic Reading. 
 
 patient and securely bound there by the leather cuff 
 and straps B (see page 89). The cuff should be 
 applied snugly, but not with pressure, as it is not de- 
 signed to compress the member, but only to restrain 
 the inner rubber bag while pressure is applied to it. 
 The tube from the arm-band C is attached firmly to 
 the nipple D. The cock in the nipple F is opened. 
 
 Fig. 16. — A, inner arm-bag. B, outer retaining cuff. C, 
 tube from arm-band. D, nipple for tube from arm- 
 band. P, pump. F, nipple for pump tube. G, milli- 
 meter scale. H, manometer tube. I, link-brace and 
 lock. K, mercury guard cock. L, mercury guard cock. 
 M, pressure guard cock. N, release valve. 
 
 This arrangement forms a continuous closed pneu- 
 matic system communicating freely with the mano- 
 meter tube of the instrument. Now when pressure 
 is raised in the arm-band by the hand-pump, the 
 amount of force exerted is indicated by the rise of 
 the right-hand column in the manometer tube H, the 
 height of which will be indicated on the scale G in 
 millimeters of mercury. 
 
 Systolic Reading. — With one hand find the pulse at 
 the wrist of the arm, to which the arm-band has been 
 
Systolic Reauinc:. 
 
 45 
 
 applied. The fingers should be in a comfortable posi- 
 tion and under no circumstance should be moved 
 during the observation. Care should also be observed 
 that the pulse is not cut off by undue pressure of the 
 palpating fingers. The cuff should be in the same 
 horizontal plane as the subject's heart. 
 
 ANEROID 
 
 Fig. 17. — Diagram of internal mechanism, showing com- 
 pression chambers. 
 
 Note the fact that in this instrument the pressure itself 
 is applied on the outside of the metallic chambers, so 
 that they are compressed and not expanded, in propor- 
 tion to the degree of compression force exerted. 
 
 While the pulse is thus under observation, the 
 pressure in the apparatus is raised by means of the 
 hand bellows or pump until the pressure within the 
 constricting band is sufficient to prevent the impulse 
 from reaching the wrist. When this is accomplished 
 the cock in the nipple M is closed to eliminate the 
 elastic pressure. Now by a fraction of a turn in the 
 valve N the pressure in the system is slowly released. 
 During this part of the procedure, a close watch 
 
46 The Diastolic Reading. 
 
 should be kept upon the height of the mercury column 
 and for the return of the first pulse beat at the wrist. 
 The level of the mercury column at the instant that 
 the pulse passes the compression-band will represent 
 the systolic pressure in the vessel under observation. 
 It is advisable to repeat this procedure a few times 
 to check the correctness of the finding. 
 
 The diastolic pressure may be obtained in several 
 ways. The method employed will depend upon the 
 character of the instrument used and the method 
 preferred by the operator. The readings obtained 
 by this instrument correspond closely to those obtained 
 by auscultation. The methods will be described in 
 the order in which they have been devised. 
 
 The visual method depends on the to-and-f ro motion 
 imparted to the mercury in the "U" tube, which occurs 
 after the pressure has fallen below the systolic point. 
 Having determined the systolic pressure, again raise 
 the pressure to a few millimeters above this point and 
 immediately close the valve M. Now allow the pressure 
 to fall very slowly by releasing the air through the 
 valve N. 
 
 As the mercury falls below the systolic point it will 
 be noted that it acquires a rhythmic motion corre- 
 sponding in time to the pulse. This will be found to 
 gradually increase in amplitude up to a certain point, 
 after which it decreases and finally ceases before zero 
 pressure is reached. During this gradual fall the 
 base of the mercury column, when the mercury is 
 making the greatest excursion, represents the diastolic 
 pressure. 
 
 These are the same as are described under Pocket 
 Apparatus on page 36. 
 
The Fedde Indic. 
 
 47 
 
 By Diastolic Indicator. — This is very similar lo 
 the visual method, except that the movement of the 
 mercury column is ignored and the movement of the 
 pith ball in the small vertical tube relied upon to de- 
 termine the diastolic pressure. 
 
 By reference to Fig. 18 it will be noted that the 
 narrow perpendicular glass tube contains a small, 
 light ball of pith or cork, which is free to move up 
 and down within the tube. 
 
 Fig. 18. — Fedde Indicator as Component of Standard 
 Sphygmomanometer. 
 
 When determining the systolic pressure pay no 
 attention to this indicator, as each impact of air will 
 make the ball dance violently, but this has no bearing 
 on the test. When the pressure has reached the 
 systolic point, close the valve N, when the ball will 
 begin to move slightly in rhythm with the pulse. This 
 motion gradually increases, until it reaches a maxi- 
 mum as the level of the mercury column gradually 
 
48 Details of Test. 
 
 falls, when, quite suddenly, its motion becomes 
 markedly less. At the moment of this reduced move- 
 ment the level of the mercury will indicate the diastolic 
 pressure. 
 
 Cautions. — To obtain accurate and reliable clinical 
 data with the sphygmomanometer, it is important that 
 some systematic technic be adhered to, and that all 
 observations not only on the same patient, but in all 
 cases, be made under as nearly the same conditions 
 as possible. Attention to detail will eliminate largely 
 the errors arising from such factors as position of the 
 patient, presence of fatigue or mental excitement, arm 
 used for observation, etc. It is also valuable to note 
 the apparatus used, the time of day, the pulse rate, 
 the sex and age of the patient. 
 
 It is important that the location of the cuff should 
 be at the heart level, otherwise the reading will be 
 affected by the weight of gravity on a column of 
 blood, being higher or lower, according to whether 
 the cuff is above or below the heart level. The 
 further the cuff is below the heart level the higher 
 the reading. 
 
 Position of Patient. — From the studies of Sandford 
 and others, as recorded on page 55, it will be seen 
 that the position of the patient is of great importance, 
 as the systolic pressure under the same conditions 
 rises from 5 to 15 mm., as the posture of the patient 
 chances from the standing to the recumbent posture. 
 
 Continued constriction of the arm by the cuff for 
 more than a minute or two will provoke vaso-motor 
 changes in the member, which may cause a rise of 
 from 5 to 10 mm. in subsequent readings. 
 
 Another point of importance in connection with the 
 
Recording Observations. 49 
 
 actual use of the blood-pressure apparatus is that when 
 taking the systolic pressure the reading should never 
 be made as the pressure is being raised in the cuff, 
 but only after the obstruction of the vessel is com- 
 plete by the air in the cufT and while the column is 
 returning by means of the escape of air through the 
 valve. Experience has shown that there is a differ- 
 ence of several millimeters between readings made in 
 these two ways, and that the reading taken at the 
 moment of the return of the first impulse at the wrist 
 is the true systolic pressure. 
 
 No single reading should be accepted when it is 
 possible to make more than one. It is better to see 
 the patient a number of times under varying condi- 
 tions before deciding what his blood-pressure is. 
 
 The following printed record form has been taken 
 from the Author's Work on Essentials of Laboratory 
 Diagnosis, 4th edition, F. A. Davis Co., Philadelphia, 
 1912. This will be found useful for keeping a com- 
 plete record of the Blood-pressure Test, also the chart 
 as shown in Fig. 19 (page 51) is valuable where a 
 series of observations are made upon one patient. 
 This chart is arranged to keep the readings in graphic 
 form, similar to the usual temperature chart. 
 
 Some observers prefer the graphic charts which 
 show the variation in blood-pressure and pulse in the 
 same manner as a temperature chart. 
 
 The accompanying cut shows a chart which has 
 been carefully prepared and which is arranged to 
 show both systolic and diastolic pressure, together 
 with pulse rate, in such a manner that they do not 
 become superposed. These may be obtained on the 
 market in pads of 25 for a nominal figure or directly 
 by writing to G. P. Pilling & Son Co., Philadelphia. 
 
50 
 
 Clinical Report Form. 
 
 BLOOD-PRESSURE DETERMINATIONS 
 
 Clinical Report 
 
 Apparatus \ 
 
 Width of Cuff cm. 
 
 Part examined, 
 Right, 
 Left, 
 Posture, 
 Pulse Rate, 
 Systolic mm. Hg. after 10 bending movements. 
 
 mm. Hg. 
 Diastolic mm. Hg. after 10 bending movements. 
 
 mm. Hg. 
 Pulse Pressure mm. Hg. after 10 bending movements, 
 
 mm. Hg. 
 Mean Pressure mm. Hg. after 10 bending movements, 
 
 mm. Hg. 
 
 Remarks. 
 
 Time of Day, A. :\r P. M. 
 
 Date 
 
 Examined by 
 
Graphic Cii. 
 
 51 
 
 FAUGHT CHART I OR BLOOD-PRESSURE RECORDS. 
 
 PULSE. TEMPERATURE AND BLOOD 
 
 PRESSURE CHART 
 
 COLOR ^ 
 
 
 o"o":o"'s°'*Jr 
 
 ..CX>.V,v«.v^; 
 
 —-"^^^^-■^^ 
 
 
 
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 3 
 
 4 
 
 s- 
 
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 » /I 6 
 
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 8 11 
 
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 P 
 
 215 108 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 270 107 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 265 106 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 f 
 
 
 
 
 
 
 
 
 
 
 
 
 255 I0< 
 
 
 
 / 
 
 V 
 
 3 
 
 \ l' 
 
 
 
 
 
 
 
 
 
 
 
 
 u 
 
 "^ '"Tc-r,« 
 
 
 / 
 
 
 \ 
 
 / 
 
 \/ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2,5., 02^""' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J9 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 235 2 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2X>^ 99 
 
 
 _ 
 
 
 _ 
 
 
 
 
 
 
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 1 
 
 _ 
 
 
 
 
 
 
 
 
 
 
 
 
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 — 
 
 
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 n 
 
 — - 
 
 — 
 
 - 
 
 
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 - — 
 
 — - 
 
 
 
 
 215 96 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 205 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 200 200 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^190 ,90 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ',85 ,85 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 S,75 ,75 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a 170 ,70 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 §.60 ,60 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 t 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1^/ 
 
 L 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '^' 
 
 N I 
 
 't 
 
 
 
 
 
 
 
 
 
 
 
 
 "° '» TJnr 
 
 
 ^ 
 
 \ 
 
 ,/ 
 
 ,^^ 
 
 •^ L— * 
 
 U 
 
 
 
 
 
 
 
 
 
 
 
 
 ,25^,25 
 
 
 
 > 
 
 r 
 
 »•-" 
 
 
 
 
 
 
 
 
 
 
 
 
 : 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 N(R 
 
 XAL B ao 1 PR SSU 
 
 IE 
 
 ,.5^„5 ■ "^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 105 ,05 
 
 
 
 
 
 
 P 
 
 
 
 
 
 
 
 
 
 
 
 
 
 100 ,00 
 
 
 
 
 
 »•■ S 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 95 95 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 90 90 
 
 
 , 
 
 (-- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 85 SSppp 
 
 
 f 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 80 OO*" " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 75 75 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 65 65 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rULSE PRESSURE 
 
 H 
 
 ^t 
 
 jt 
 
 w 
 
 Vi3J 
 
 ^i^:^^ 
 
 H»' 
 
 I 
 
 J_ 
 
 t In 
 
 -J 
 
 I 
 
 ) Ct 1 
 
 
 2 
 
 Scnk 
 
 
 
 Fig. 19. — Blood-pressure recording chart, about one-eighth 
 actual size. Designed to record systolic pressure, dias- 
 tolic pressure, pulse rate and temperature. 
 
 Published by G. P. Pilling & Son Co., Phila., Pa. 
 
CHAPTER IV. 
 
 NORMAL BLOOD-PRESSURE AND ITS 
 VARIATIONS. 
 
 Definition of NormsJ Pressure .... 53 
 
 Average Normal Pressure for Any Age 54 
 
 Factors Affecting Normal Average Blood-Pressure . 54 
 
 Sex 54 
 
 Physical Condition 54 
 
 Exercise ....... 54 
 
 Sleep and Rest ...... 54 
 
 Posture 55 
 
 Time of Day . ". . . . . 57 
 
 Consumption of Fluids . . . . 57 
 
 Age 57 
 
 Altitude and Atmospheric Changes . . 57 
 
 Ingestion of Food 59 
 
 Consumption of Alcohol .... 59 
 
 Use of Tobacco ..... 60 
 
 Extent of Permissible Variation .... 60 
 
 Determination of Abnormal Pressures . 61 
 
 Arterial Hypertension .... 61 
 
 Arterial Hypotension . . < . . 62 
 
CHAPTER IV. 
 
 NORMAL BLOOD-PRESSURE AND THE CAUSES 
 OF VARIATION. 
 
 When normal blood-pressure is spoken of in 
 discussion, it is accepted to mean that the pressure in 
 each individual case is within the recognized normal 
 limits determined by clinical experience. This is not 
 and cannot be a fixed pressure, as the normal tem- 
 perature is a fixed degree. This is because blood- 
 pressure at any given moment is the result of a com- 
 bination of variable factors, which must unite to de- 
 termine it, and because it has been found by experi- 
 ence that blood-pressure is regularly influenced and 
 modified by the age and sex of the individual. 
 
 There are several methods of arriving at an estima- 
 tion of the normal pressure and its variations in a 
 given case. Thus we can adhere to a table based on 
 a large clinical and experimental study. Such a 
 table, which conforms to the accepted standard, has 
 been compiled by Woley. 
 
 Method of Estimating Normal Average. — The normal 
 average systolic pressure can be readily determined 
 for all ages by employing a formula devised by the 
 author several years ago. This is based on the experi- 
 mental study of many observers, and is designed to 
 
 53 
 
54 Factors Affecting Blood-Pressure. 
 
 estimate the age factor thus : ''Consider the normal 
 systolic blood-pressure of a healthy adult male, age 
 20, to be 120 mm. Hg. . Then for any two years of 
 life over this add 1 mm. Hg. to 120. Thus at age 
 30 blood-pressure equals 125, at age 60 it equals 140, 
 etc." 
 
 The Sex Factor can be roughly reckoned as 
 minus 10, so that all pressures as computed by this 
 formula should have 10 mm. subtracted when estimat- 
 ing the average normal pressure for women. 
 
 It is accepted that other factors which are usually 
 part of the daily life of an individual will somewhat 
 influence the blood-pressure ; thus : 
 
 Physically weak persons will usually show a 
 slightly lower pressure, often 5 to 10 mm., while the 
 MUSCULARLY DEVELOPED wiU havc a sHghtly higher 
 average, about 5 to 10 mm. 
 
 The pressure after Exercise will be found from 
 10 to 20 mm. above the average, but will rapidly 
 return to normal. The same may be said of the first 
 hour after a hearty meal. 
 
 Effects of sleep and rest on Blood-pressure. — Brooks 
 and Corroll (Arch, of Int. Med., August, 1912) 
 studied this effect in 68 patients, showing average 
 systolic pressures in 30 with low pressure and 20 
 with abnormally high pressure. The results in the 
 general way are illustrated in the cases with average 
 pressure. Readings were taken from 1 to 2 hours 
 after the beginning of sleep and showed an average 
 fall of 24 mm. ; three hours after waking in the morn- 
 ing there was still an average depression of 12 mm. 
 In these persons the pressure gradually rose to its 
 high level in the afternoon. 
 
Posture on Blood-Pressure. 55 
 
 The greatest nocturnal fall in ])rcssure took place 
 in cases having the highest initial systolic pressure. 
 Disturbance of the patients during the first sleep 
 delays, but does not necessarily prevent the fall. 
 Frequent interruption, however, does prevent it. 
 
 The use of hypnotic doses of drugs to produce sleep, 
 as 120 grains of bromide of potassium or chloral 
 hydrate up to 50 grains each night, did not increase 
 the degree or persistence of the fall. Physical rest 
 in general did not appear to alter materially either 
 the subnormal or normal blood-pressure, but the 
 authors were led to believe that mental and physic 
 rest might cause profound changes in pressure and 
 that these factors largely determine the undoubted 
 benefit derived from rest in cases of high pressure. 
 
 Posture will affect the reading, and its effect is 
 largely, if not entirely, due to the effect of gravity and 
 the relation of the arm-band to the chief volume of 
 blood in the body. 
 
 The effect of change of posture without active mus- 
 cular exertion on arterial pressure was reported by 
 J. H. Barach and W. L. Marks in Archives of Inter- 
 nal Medicine, May, 1913. 
 
 Without going into the methods employed in 
 obtaining these conclusions, it is sufficient to say that 
 the mercurial type of instrument was used with a 
 10 cm. cuff, that the methods were carefully checked 
 by controls and that any outside factors which might 
 influence the results were eliminated, as far as pos- 
 sible, and that all readings were repeated in order 
 to eliminate accidental error. 
 
56 Summary of Effects. 
 
 The summary of results is as follows : 
 
 1. When the element of muscular effort has been 
 eliminated, change of bodily posture from the erect 
 to the horizontal will cause an increase in the maxi- 
 mum pressure, a decrease in the minimum pressure 
 and an increase in the pulse pressure. 
 
 2. After five minutes in the horizontal posture, 
 when the subject is returned to the erect posture, the 
 maximum pressure will diminish, the minimum press- 
 ure increase and the pulse pressure diminish. It will 
 be noted that in both instances the pulse pressure fol- 
 lows the same trend as the maximum pressure. 
 
 3. Change of posture from the erect to horizontal 
 caused a fall in the venous pressure. 
 
 4. Change of posture from the horizontal to erect 
 caused an increase of the venous pressure. 
 
 It will be noted that the venous pressure follows 
 the same trend as the minimum pressure. 
 
 Nearly all subjects of this series responded in the 
 same way. The most notable exception was in the 
 "Poor Muscular Cases." These cases showed a ten- 
 dency to a reversal of the pressure curve. Form 
 erect to horizontal caused, in more than half of the 
 cases, a decrease of the maximum pressure and an 
 increase of minimum pressure. 
 
 General Summary. 
 
 Erect Horizontal Erect 
 
 Maximum + + — 
 
 Minimum + "~ + 
 
 Pulse pressure + + — 
 
 Venous pressure + — + 
 
Age on Blood -Pressure. 57 
 
 Time of day has a modifying influence on blood- 
 pressure, being usually lowest during the early hours 
 of profound sleep, rising slightly toward morning, 
 and rising more or less rapidly, depending on the 
 mental and physical activities of the individual, as the 
 day advances. This variation may reach as much as 
 40 mm. Hg. 
 
 Ingestion of large amounts of fluid, particularly if 
 Alcoholic, will cause a moderate and brief rise. 
 
 Pain and anxiety are often a cause for a sharp and 
 short rise. 
 
 Age. — The following table is taken from L. Gor- 
 don, who has made extensive study of the relation of 
 age in normal children to blood-pressure. 
 
 mm. 
 
 Under one year 71 
 
 One year Th 
 
 Two years 79.3 
 
 Three years 81 
 
 Four years 83 
 
 Five years 86.5 
 
 Six years 88.5 
 
 Seven years 85.0 
 
 Eight years 93 
 
 Nine years 100 
 
 Ten years 95 
 
 Eleven years 104 
 
 Twelve years 105 
 
 Effects of Altitude and Atmospheric Changes on Blood- 
 Pressure and Pulse Rate. — Hoobler and Pomeroy, in a 
 review of literature combined with their own obser- 
 vations on the effect of Barometric Pressure on 
 blood-pressure, state that ''the result of nearly all 
 
58 The Climatologic Effect. 
 
 experimental data shows that diminished barometric 
 pressure lowers blood-pressure." C. F. Gardner has 
 shown that a person going from an elevation of 6000 
 feet to one of 14,000 feet suffers a fall in blood-pres- 
 sure and a rise in pulse rate. The results of Schnei- 
 der and Hedblom are the same. They state also that 
 the diastolic pressure tends to be lower by reduction 
 in barometric pressure. That the fall in systolic pres- 
 sure was slightly greater and more certain to occur 
 than the fall in diastolic pressure. This effect be- 
 comes less marked as the subject becomes accustomed 
 to the change. The change usually amounts to from 
 3 to 10 mm. ; occasionally as much as a 20 mm. rise 
 has been noticed. 
 
 In tuberculous subjects with hypotension, high alti- 
 tude (6000 feet) causes a rise in pressure (Peters, 
 Arch, of Int. Med., Aug., 1908). 
 
 Colis and Pembrey have studied the important fac- 
 tors of Relative Humidity in the atmosphere to 
 blood-pressure, and have found, by studies made in 
 England, that when the Actual Humidity was 
 greatly increased, a rise in pulse rate of 30 or more 
 beats per minute not infrequently occurred, and there 
 was also an increase in respiratory rate of from 18 to 
 29. The same results were noted when the actual 
 humidity was increased. 
 
 P. P. Aminet examined a large number of healthy 
 children of from 7 to 15 years of age in an effort to 
 determine the effect of outdoor life on pulse and 
 blood-pressure. He found that almost uniformly 
 there was an increase in blood-pressure and in pulse 
 rate. The pressure elevation amounted to as much 
 with some cases as at 30 mm. Hg. Children living in 
 
Alimentary Hypertension. 59 
 
 good surroundings have a generally higher blood-pres- 
 sure than those in poorer environments. The same 
 condition was noted by Hoobler in children suffering 
 from tuberculosis or pneumonia. 
 
 Starling has studied the ejfect of wind-pressure 
 upon the systolic blood-pressure, which has a very 
 important bearing upon the effect of this condition 
 upon cardiac cases. He found that wind-pressure has 
 a profound influence in raising pulse rate. The same 
 may be said of the effect of wind-pressure upon the 
 blood-pressure. 
 
 Eating. — The blood-pressure normally rises from 10 
 to 15 mm. shortly after an ordinary meal, gradually 
 falling toward the original level after an hour or more. 
 The size of the meal is thought by some observers to 
 affect the degree of elevation, being greatest after 
 heavy meals which contain much proteid. 
 
 It is well recognized that certain changes in the 
 circulatory system originate from disturbances in the 
 digestive tract. These are usually seen in a slight 
 increase in blood-pressure, due to the reflex from the 
 splanchnic area affecting the muscular walls of the 
 arteries. This may be considered normal to a certain 
 degree, but it becomes pathologic where we find this 
 elevation to be excessive and prolonged. 
 
 Alimentary hypertension is the result, therefore, of 
 a normal abdomino-arterial reflex, made excessive by 
 an over-abundance of food or an incomplete elimina- 
 tion of toxic substances. This continued hypertension 
 is often the first link in the chain leading to arterio- 
 sclerosis, contracted kidneys and apoplexy. 
 
 Drinking. — Excessive ingestion of water causes a 
 brief rise of blood-pressure, amounting to about 5 to 
 
60 Tobacco on Blood- Pressure. 
 
 10 mm., although the habitual use of ordinary amounts 
 need hardly be considered in any blood-pressure esti- 
 mation. Large amounts of beer may be the cause of 
 a sharp rise, which, when repeatedly recurring, as in 
 habitual beer drinkers, may become the cause of a 
 permanent hypertension, which may finally result in 
 arteriosclerosis and chronic nephritis. Strong alco- 
 holic drinks cause a primary rise from heart stimu- 
 lation, followed by a secondary fall when vasodilata- 
 tion occurs. 
 
 Smoking. — Smoking usually causes an elevation in 
 blood-pressure, with the apparent paradox that many 
 habitual smokers have a subnormal blood-pressure. 
 The usual effect of one or two cigars, or its equiva- 
 lent in other forms, in those accustomed to the use of 
 the drug is a sedative action and a slight lowering of 
 blood-pressure, while excessive smoking, during a 
 short period of time, causes a rise of from 5 to 25 mm. 
 
 Bruce Miller and Hooker, after extensive study, 
 arrive at the conclusion that smoking is an etiologic 
 factor in arteriosclerosis, at least in so far as the 
 effect of circulating toxic substances affect the enlarg- 
 ment of the vessel walls. 
 
 Permissible Variations. — From the foregoing it would 
 seem that any study of blood-pressure must have its 
 value greatly reduced by so many modifying factors, 
 but careful thought will show that these at most cause 
 only slight variation, which need not obscure the 
 issue. Experience will teach the observer to uncon- 
 sciously include these factors in practice and enable 
 him to arrive at the correct value of his findings by 
 aid of them. 
 
;iAL HypertknsiOn. 61 
 
 Determination of Pathologic Blood- Pressure 
 
 Abnormal blood-pressure may be either a1)ove or below 
 the normal level, as compared to the normal average 
 pressure and its variations. Blood-pressure should 
 only be designated abnormal after careful study and 
 repeated tests, unless the change is so marked as to 
 be beyond question. 
 
 A single reading slightly above or below the normal 
 boundaries may be occasioned by some accidental or 
 peculiar incident, and should therefore not be taken 
 too seriously and should never be assigned to an im- 
 portant role in diagnosis until its persistence has been 
 demonstrated on at least two occasions. 
 
 Neither should one expect to find the same pressure, 
 in any case, at all times. Never lose sight of the pos- 
 sible causes of normal variation. These normal varia- 
 tions may occur in a very short space of time, and 
 should not, as in at least one instance known to the 
 author, condemn the instrument, showing such varia- 
 tion, as inaccurate. Remember also that your unfa- 
 miliarity with a new type of instrument may cause 
 you to neglect some detail which will invalidate your 
 results. 
 
 Study your instrument, read your instructions and 
 he sure of our technic. 
 
 Arterial Hypertension. — For a proper understanding 
 of the treatment of the various conditions associated 
 with which the arterial pressure is above normal, it 
 must primarily be recognized that if the pressure is 
 high there must be some underlying cause for the 
 abnormality. Such cases can, as a rule, be divided into 
 
62 Causes of High Pressure. 
 
 three groups : mechanical, nervous and toxic. The 
 most common mechanical cause is arteriosclerosis, 
 and yet there may be pipe-stem arteries with normal 
 pressure. The reflex nerve irritation of a peritonitis 
 or a fright may cause a sharp rise in pulse tension, 
 but in shock the blood-pressure falls. The cause of 
 hypertension, which is probably the most widespread 
 and the most frequent, is intoxication. It is generally 
 considered that it is the irritation from poisons 
 retained by the kidneys and not the mechanical 
 obstruction, which sends the blood-pressure up in 
 nephritis. 
 
 Continuous high pressure is seen in certain forms 
 of NEPHRITIS. Thus, in primary acute Bright's disease 
 and in nephritis secondary to scarlet fever there is 
 practically always a marked rise in arterial pressure. 
 A rise amounting to more than 50 mm. Hg. has been 
 observed within 48 hours of the onset of an acute 
 nephritis. Elevated pressure is also found in begin- 
 ning ARTERIOSCLEROSIS of the first part of the aorta 
 and of the splanchnic vessels. 
 
 In dealing with the elevation of pressure, which is 
 the result of the action of drugs or of toxic agents, 
 it is important to bear in mind that the amount of the 
 substance and its concentration, its potency as well as 
 the duration of its action will determine the amount 
 of elevation, the duration and the permanence of the 
 effect. 
 
 Arterial Hjrpotension. — This term is applied to cases 
 presenting a more or less continuous blood-pressure 
 below the normal estimated pressure. A pathologic 
 depression in blood-pressure may be caused by the 
 depressing influence of circulating toxins acting 
 
Extreme Low Pressures. 63 
 
 either upon the heart hlood-vesscls or controHing ner- 
 vous mechanism or to sudden withdrawal of a large 
 volume of blood from the circulation, as in iirmor- 
 RiiAGE, after venesection, copious diaphoresis, diar- 
 rhea, or in shock. 
 
 The lowest blood-pressure compatible with life has 
 been reported by Neu to be from 40 to 45 millimeters 
 of mercury, and this only occurred with subnormal 
 temperature in the moribund state. He has seen re- 
 covery after a fall in pressure as low as 50 milli- 
 meters. 
 
 In general, it may be said that lowered blood-pres- 
 sure is of little significance except after hemorrhage 
 or during surgical shock. Here the great and sudden 
 reduction in pressure may be sufficient to immediately 
 endanger life. 
 
 It is noted that a moderate and progressive fall in 
 pressure occurs in most progressive and prolonged 
 fevers, as in typhoid fever. When due to such a 
 cause, the depression is rapidly overcome and disap- 
 pears as convalescence is established. 
 
 Widespread dilatation of the vessels and conse- 
 quent lowering of blood-pressure has been noted in 
 the last stages of arteriosclerosis. 
 
 Arterial dilatation and lowering of blood-pressure 
 may result from general loss of arterial tone. Thus, 
 if the splanchnic vessels become widely dilated and 
 filled with blood, the other arteries are insufficiently 
 filled (there is insufficient blood in the body to prop- 
 erly fill the arteries if they are all widely dilated) 
 (see page 85), and the pulse becomes soft, the tem- 
 perature falls and syncope finally ensues. 
 
CHAPTER V. 
 PRACTICAL APPLICATION OF CLINICAL DATA. 
 
 I 
 
 CONDITIONS ACCOMPANIED BY HIGH 
 PRESSURE. 
 
 II 
 
 CONDITIONS ACCOMPANIED BY BUT SLIGHT 
 
 PRESSURE CHANGE. 
 
 Ill 
 CONDITIONS ACCOMPANIED BY LOW 
 
 PRESSURE. 
 
 I 
 
 High Blood-Pressure as a Symptom ... 65 
 
 Arteriosclerosis ....... 66 
 
 Blood-Pressure Findings in ... 67 
 
 Angina Pectoris 68 
 
 Blood-Pressure Findings in . . . 68 
 
 Acute Nephritis . . . . . 68 
 
 Effect on Blood-Pressure .... 68 
 
 In Children 69 
 
 Chronic Nephritis 69 
 
 Blood-Pressure Changes in ... 70 
 
 Signs of Kidney Failure .... 70 
 
 Uremia 70 
 
 Chronic Parenchymatous Nephritis 70 
 
 Valvular Disease of the Heart 71 
 
 Aortic Regurgitation . . . : 72 
 
 Blood-Pressure Changes in . . . 72 
 
Disease of the Heart Muscle . 
 
 Acute Endocarditis 
 Chronic Myocarditis 
 
 Blood-Pressure Changes in 
 
 Functional Tests 
 Schapiro's Test 
 Graupner's Test 
 Effect of Altitude in Heart Cases 
 
 Eclampsia 
 
 Cerebral Hemorrhage . 
 
 Apoplexy and Cerebral Thrombosis 
 
 Migrain .... 
 
 Chronic Lead Poisoning 
 
 Disease of the Eye 
 
 Arteriosclerosis 
 Ocular Hemorrhage . 
 
 Inasphyxia .... 
 
 Syphilis of the Heart and Blood-Vessels 
 
 II 
 
 Asthma 
 
 Cardiac Asthma 
 
 Chronic Bronchitis 
 
 Neuralgia 
 
 Neurasthenia 
 
 Obesity 
 
 Effect of Edema 
 
 Acute Insanity 
 Rheumatism 
 
Exophthalmic Goiter 
 
 Infectious Diseases 
 
 Typhoid Fever . 
 Pneumonia 
 
 Injection of Salvarsan 
 
 Epilepsy 
 
 III 
 
 Varieties of Hypotension 
 
 Terminal Hypotension 
 Essential Hypotension 
 Primary Hypotension 
 Relative Hypotension 
 
 Diabetes .... 
 
 Cardiac Dilatation 
 
 Shock and Collapse 
 
 Hemorrhage 
 
 External Hemorrhage 
 Internal Hemorrhage 
 
 Cerebral Embolism 
 
 Jaundice 
 
 Pulmonary Tuberculosis 
 
 Effect of Altitude on Pressure 
 
 Anemia 
 
 Chlorosis 
 
 Cholera 
 
 Alcoholic Delirium 
 
CHAPTER V. 
 
 PRACTICAL APPLICATION OF CLINICAL DATA 
 IN EVERY-DAY PRACTICE. 
 
 As already stated, the relation of blood-pressure in 
 disease, compared to the estimated normal in health, 
 may be variable (slightly above or below), may tend 
 to hypotension or may show high pressure. The ar- 
 rangement of the various conditions treated in the 
 following pages is entirely arbitrary, being based on 
 a plan which renders the material most readily acces- 
 sible and easily obtainable for immediate reference. 
 
 High Blood-Pressure Is a Symptom^ Not a Disease. — 
 It is present in a number of common pathologic con- 
 ditions, and when found, aids greatly in explaining 
 certain phenomena connected with the heart, blood- 
 vessels and kidneys. The state of the blood-pressure 
 often furnishes the one important clue which leads to 
 correct diagnosis or directs the attention to an alto- 
 gether unsuspected complication. 
 
 For example, a case of pneumonia is related in 
 which all was progressing satisfactorily until one day 
 the patient did not seem to be as well as the state of 
 his disease would warrant. A blood-pressure test, 
 made by a consultant who had been called, demon- 
 strated an abnormally high blood-pressure. The urine 
 was then examined and evidence sufficient to establish 
 the presence of a complicating nephritis was found. 
 
 65 
 
(^ Arteriosclerosis. 
 
 At the present time certain diseased conditions are 
 well recognized as being productive of or usually ac- 
 companied by an elevation in blood-pressure. The 
 two almost classical high blood-pressure conditions 
 are arteriosclerosis and acute and chronic nephritis. 
 Other conditions in which a high pressure is often 
 found are chronic myocarditis, the complications of 
 arteriosclerosis, as angina pectoris and apoplexy. Also 
 uremia, the toxemia of pregnancy, lead poisoning, 
 peritonitis and cerebrospinal meningitis. 
 
 Conditions in Which High Blood-Pressure is a 
 Prominent Symptom. 
 
 Arteriosclerosis, as the term is here employed, 
 implies a condition of generalized chronic hyperplastic 
 involvement of the coats of the arteries. In this con- 
 dition we find a permanently elevated blood-pressure, 
 the degree of which is dependent upon the extent of 
 the involvement present. The wider the extent and 
 the greater rigidity of the vessels the higher will 
 the systolic pressure be. This pressure rtiay reach 
 300 mm. The average case will be found to run in 
 the neighborhood of 200 mm. Owing to the lack of 
 elasticity, the mechanics of the circulation are so 
 deranged that the diastolic pressure will be found 
 disproportionately low, with corresponding greater 
 increase in pulse pressure. It is not uncommon to find 
 a pulse pressure of 100 or miore. The reduction in 
 the ratio of pulse pressure to systolic pressure, under 
 treatment, is a valuable sign. It must be remembered, 
 however, as has been pointed out by Rudolph, that 
 the blood-pressure in arteriosclerosis is not always 
 
Causes of Artkriosclekosis. 67 
 
 high, especially when the arterial involvement is 
 localized, as in the superficial vessels, also that very 
 high blood-pressnre may be net as a result of arte- 
 riosclerosis, in the presence of apparently soft super- 
 ficial vessels, when the larger trunks, such as the 
 splanchnic area, is affected. 
 
 Sir Clifford Albutt divided the cases of high pres- 
 sure related to arterial changes into three classes : 
 
 First — Hypertension cases. 
 
 Second — Those of toxic or infective origin. 
 
 Third — Involutionary or true sclerotic cases. 
 
 In the first class the elevated blood-pressure pro- 
 ceeds and produces the arterial change, while in the 
 third the pressure is the direct result of the disease. 
 
 As a rule, the degree of elevation in pressure will 
 indicate the extent of arteriosclerotic involvement, 
 the presence of a complicating nephritis, myocarditis 
 or an aortic regurgitation will tend to further elevate 
 the blood-pressure. The terminal stage of a long- 
 standing arteriosclerosis, even when complicated by 
 other conditions causing high-blood pressure, is usual- 
 ly marked by a falling and finally a subnormal blood- 
 pressure. 
 
 The blood-pressure test in cases of arteriosclerosis, 
 besides being of great value in effecting the proper 
 diagnosis, is also of marked assistance in following 
 the effect of treatment and in forecasting the future. 
 But of greater value even than the systolic pressure 
 is the diastolic, which should be estimated in order to 
 determine the pulse pressure, which is the truest indi- 
 cation of the amount and severity of heart overwork, 
 which, after all, is the determining factor in the case. 
 
68 Angina Pectoris — Acute Nephritis. 
 
 Angina Pectoris. — This is usually a syndrome, de- 
 veloping in the course of a case of general arterio- 
 sclerosis, and denotes involvement of the coronary 
 arteries in the arteriosclerotic process. The blood- 
 pressure rises just before and remains high during the 
 paroxysm of pain, usually subsiding shortly there- 
 after. The rise may amount to 50 mm., and there 
 may be little or no elevation in blood-pressure during 
 the interval. The reduction of high blood-pressure 
 in those with a tendency to angina is often most suc- 
 cessful in preventing subsequent attacks. 
 
 The blood-pressure test sometimes serves as a val- 
 uable aid in differentiating true angina from those 
 conditions best termed anginoid, which are so often 
 met and which frequently cause the physician much 
 trouble and embarrassment in estimating their true 
 significance. It is believed by Janeway and others 
 that, given a case presenting the symptom complex of 
 angina, in which the blood-pressure is continually ab- 
 normally high, it will probably be one of true angina; 
 while unfortunately the converse is not true, as cases 
 of demonstrated true angina have been met in which 
 the pulse is small, easily compressible and the tension 
 low. 
 
 Acute Nephritis. — A sharp rise in blood-pressure is 
 usually the first sign of the onset of an acute nephritis. 
 This complication, developing in the course of an 
 acute infection, may be discovered by a routine study 
 of the blood-pressure, where the rise may antedate 
 the development of the usual signs, including altera- 
 tions in the urine by as much as 24 hours. This fact 
 should be a most emphatic indication of the value and 
 importance of daily blood-pressure readings during 
 the course of all infections, particularly scarlet fever. 
 
Chronic Nephritis. 69 
 
 Acute Nephritis in Children. — Lennox Gordon reports 
 9 cases, in all of which the blood-pressure was raised, 
 in some cases to a very high level, and in them this 
 was of very marked diagnostic value. He believes 
 that by means of the sphygmomanometer only could 
 the change in blood-pressure in children be ascertained 
 to any degree of certainty. 
 
 Chronic Nephritis. — ^A gradually developing chronic 
 nephritis is shown by a gradually rising blood-pres- 
 sure, accom.panied by the usual alterations found in 
 the urine. A high blood-pressure reading, of more 
 than 200 mm. found during the examination of any 
 patient should place one on guard and start a careful 
 examination for other signs of this condition. 
 
 The blood-pressure in chronic nephritis is persist- 
 ently elevated, and may be extremely high. Pressures 
 of over 300 mm. have been reported. A sudden 
 further rise in pressure occurring during the course 
 of a chronic nephritis is often a most valuable warn- 
 ing, as a sign indicative of an impending uremic 
 attack. This rise, if noted early, furnishes the basis 
 for immediate action, to control the pressure by pow- 
 erful eliminative measures in order to avert, if pos- 
 sible, the uremic attack. Such treatment if often very 
 successful. 
 
 J. Fischer, in the Duch. Arch. f. klin. Med., 1913, 
 after a study of 550 patients running a continuous 
 high blood-pressure, emphasizes the importance of 
 being on the lookout for permanent kidney lesions in 
 patients even with a moderately high pressure, as in 
 62% of his series with pressure above 140 there were 
 signs of permanent kidney lesions, while 80% had 
 chronic kidney change, and in some of these there 
 
70 Uremia. 
 
 was no clinical evidence of kidney trouble, excepting 
 continuous high blood-pressure. 
 
 A study of blood-pressure in cases showing tran- 
 sient or persistent traces of albumen in the urine will 
 often serve to demonstrate the cause and seriousness 
 of this condition, because it is well known that high 
 blood-pressure is always an accompaniment of chronic 
 nephritis, and also because it is believed that a normal 
 blood-pressure, even with albumen in the urine, places 
 the albumen in a class with minor and not serious 
 affections. Unexplained persistent high blood-pres- 
 sure, even when albumen cannot be demonstrated in 
 the urine, furnishes ample grounds for strongly sus- 
 pecting chronic changes in the kidneys. 
 
 After a long or short period of sustained high pres- 
 sure in chronic nephritis, the pressure will begin to 
 fall, and after a long period of time fail to raise to its 
 highest level. Experience teaches that this is a danger 
 signal that the reserve of the heart and circulation 
 has been exhausted and that a further fall may be 
 expected, and that, sooner or later, this will result in 
 retarded kidney activity and all that this implies. 
 
 Chronic Parenchymatous Nephritis. — The few avail- 
 able reports on blood-pressure in this disease fail to 
 show" that a high blood-pressure is an accompaniment 
 of it or that the blood-pressure bears any relation to 
 the duration or severity of the kidney inflammation. 
 
 Uremia. — This often fatal complication of nephritis 
 is accompanied by a sudden and often sharp rise in 
 an already greatly elevated blood-pressure, or else an 
 already high pressure begins to mount upward to a 
 dangerously high level. These changes in blood-pres- 
 sure may, by careful observation with the sphygmo- 
 
Blood-Pressukk in Valvular Dlsease. 71 
 
 manometer, l)e noted suflicicntly early to allow time 
 for the institution of preventive measures, directed 
 toward the relief of toxemia, by increasinj^ elimina- 
 tion. The l)lood-])rcssure durin<( an uremic attack 
 may be far above v300 mm. Actually how high has 
 not been recorded, because before the development 
 of the Faught Clinical Sphygmomanometer no instru- 
 ment was capable of recording pressures above 300 
 mm. 
 
 In patients who are seen in emergency and are 
 found profoundly unconscious, the sphygmomanomet- 
 er will often be the means of separating the coma of 
 uremia with high blood-pressure from coma of other 
 origin. 
 
 In Valvular Lesions. — In the study of the valvular 
 disease of the heart the results do not seem to have 
 special bearing upon the primary condition (defective 
 valve) except in cases of aortic regurgitation. This 
 is in part due to the usual complicated nature of the 
 condition, which often includes arterial and myocar- 
 dial changes and involvement of the kidneys. 
 
 The chief value of the sphygmomanometer in the 
 study of heart conditions applies to the condition of 
 the myocardium, to a demonstration of the etTect of 
 therapeutic measures and as a guide in prognosis and 
 in the general management of cases. With it we are 
 able to determine with considerable accuracy the bene- 
 fit derived from the drugs and other measures em- 
 ployed. In this we may guard against insufficient or 
 improper treatment and also against the over-use of 
 these same measures by demonstrating the therapeuti- 
 cally efficient dose and the proper interval of its exhi- 
 bition. 
 
72 Aortic Regurgitation, 
 
 Aortic Regurgitation. — The blood-pressure test may 
 be sufficient to establish a diagnosis in pure aortic re- 
 gurgitation, the great pulse pressure occurring in this 
 condition being almost pathognomonic. Referring to 
 the physics of the circulation, we find that in aortic 
 regurgitation the left venticle is called upon to deliver 
 an abnormally large volume of blood into the aorta to 
 supply the demands of the circulation. This is because 
 the heart is required not only to furnish sufficient 
 blood for the needs of the body, but must also inject 
 into the aorta at each systole enough surplus to com- 
 pensate for the regurgitation of a large volume of 
 blood into the left ventricle during diastole. The 
 natural result of the sudden injection of this large 
 amount of blood into the arterial system will be to 
 cause a sudden and great rise in systolic blood-pres- 
 sure (immediately succeeding systole the blood dis- 
 perses in two directions, forward through the capil- 
 laries and backward into the ventricle, producing the 
 phenomenon of the water-hammer pulse). Thus the 
 pressure rapidly falls and the diastolic pressure is 
 abnormally low. The combined result of this 
 
 HIGH SYSTOLIC AND LOW DIASTOLIC PRESSURE IS A 
 
 GREAT PULSE PRESSURE. This may amount to 100 mm. 
 or more. 
 
 In the presence of moderate or high-grade gener- 
 alized arteriosclerosis, this phenomenon is further ac- 
 centuated because the lack of normal elasticity in the 
 arterial system tends to reduce the diastolic pressure 
 to zero. 
 
 Occasionally, in cases of mitral stenosis, the blood- 
 pressure may tend toward a low level, but this is 
 
Myocardial Disease. 7?) 
 
 usually more than compensated for l)y the accompany- 
 ing changes in the heart muscle and larger arteries. 
 
 Acute Endocarditis. — In a few cases of acute endo- 
 carditis that have been reported, it has been found 
 that the endo-cardial condition itself has little, if any, 
 efifect on systolic blood-pressure. 
 
 Myorcardial Degeneration. — Many cases of chronic 
 myocarditis have sufficiently marked signs to be easy 
 of diagnosis ; in other cases of the cardiovascular 
 renal type diagnosis may be extremely difficult. Here 
 it is most important that the general practitioner 
 should be able to recognize these changes sufficiently 
 early to be able to institute treatment with good 
 chance of arresting the progress of the disease indefi- 
 nitely or as long as the patient adheres to his new 
 regime. These cases usually occur in middle life, and 
 may be far advanced before discovered, as they often 
 are, accidentally, in the course of examinations for 
 life insurance. The difficulty of correctly estimating 
 them is great, for, while we may be morally certain 
 of the existence of heart weakness, we may not be 
 able to prove the existence of myocarditis, and often 
 erroneously class them as nervous or functional. 
 
 In the physical examination the state of the super- 
 ficial vessels, together with the pulse rate and particu- 
 larly the reaction of the heart to posture and exercise 
 as determined by the sphygmomanometer, is all-im- 
 portant. This latter may be determined by the fol- 
 lowing tests : 
 
 Functional Tests. — Moderate exertion raises pressure 
 in normal hearts, and this rise is sustained during it 
 if not unduly severe or prolonged. In weakened 
 heart muscles from any cause a primary rise may 
 
74 Functional TEsts. 
 
 occur, but is quickly followed by a fall; in the worst 
 a fall occurs from the first 
 
 Schapiro's Test. — This is based upon the alteration 
 in pulse rate occurring in normal individuals on 
 change of posture from the standing to the recum- 
 bent. Normally the number of pulse beats per minute 
 is from 7 to 10 less in the recumbent position; but 
 when chronic myocarditis develops, this difference 
 tends to disappear, so that in seriously weakened 
 hearts the pulse may be as rapid in the recumbent as 
 in the sitting posture. 
 
 Graupner's Test. — This is based upon the physiologic 
 fact that a given amount of exercise, such as ten bend- 
 ing movements or running up a flight of stairs, causes 
 an acceleration in the pulse rate and an elevation in 
 blood-pressure. But the latter does not appear coin- 
 cidently with the former; or if, as in some cases, the 
 pressure does rise first, it fails to rise again after the 
 pulse has returned to normal. It is this secondary 
 rise which indicates a good heart muscle. A not too 
 seriously affected heart may show a rise in blood- 
 pressure immediately after the exertion, but with the 
 slowing of the pulse the pressure will be found to 
 have fallen to a level lower than before the experi- 
 ment. The sphygmomanometer is required for an 
 accurate demonstration of these changes in pressure, 
 which may be recorded in definite units of measure 
 for future reference and comparison. 
 
 It is not advisable to apply this test to pa- 
 tients WITH excessively HIGH BLOOD-PRESSURE, IN 
 THOSE OF APOPLECTIC TENDENCY OR IN THOSE WITH 
 
 HIGH-GRADE ARTERIOSCLEROSIS. The tcst is uusafc in 
 those with a systolic pressure of 200 millimeters or 
 
Altitude on Heart Cases. 75 
 
 over. In such cases tliere is danger of ocular or 
 cerebral hemorrhage or acute dilatation of heart. 
 
 The test will be difficult, if not impossible, of appli- 
 cation in women unless all tight clothing is removed. 
 
 Valvular disease is not necessarily a contraindica- 
 tion to this test, as the condition of the myocardium 
 seems to be the only important factor, except in aortic 
 regurgitation with high pressure, so that the presence 
 of valvular lesions need not detract from the value 
 of the information obtained by this test. 
 
 The Effect of Altitude on Cardiac Cases. — It is import- 
 ant to consider the condition of the patient in refer- 
 ence to the circulation before advocating residence in 
 high altitudes. In young convalescents, in the absence 
 of organic heart affections, even in the presence of 
 the moycardial weakness due to recent acute or 
 chronic infections, moderately high altitudes are 
 usually beneficial. 
 
 In the arteriosclerotic without valvular lesions, the 
 cardiac reserve is often much exhausted, and there- 
 fore sudden changes in altitude may result in serious 
 consequences through added sudden strain on the 
 circulation, due to changes in peripheral resistance. 
 High altitudes may be extremely dangerous. In the 
 true cardiac case with organic lesion, high altitudes 
 are often dangerous because, even when compensa- 
 tion is fairly well established, the balance in favor of 
 the heart is very slight, and here again the changes 
 in circulatory equilibrium, by causing slight increased 
 strain, may again produce decompensation. 
 
 Eclampsia. — Blood-pressure is usually high, but may 
 occasionally, in very severe cases, be low. Pressures 
 have been recorded as being over 320 mm. See also 
 page 92. 
 
l(i Cerebral Hemorrhage. 
 
 Cerebral Hemorrhage. — The occurrence of a cerebral 
 hemorrhage is usually preceded by a long period of 
 high blood-pressure, accompanying a nephritis, {an 
 arteriosclerosis, or both. It is not the degree of per- 
 manent elevation so much as a sudden rise in an 
 already high blood-pressure that causes the vessel to 
 rupture. 
 
 Thus cases of arteriosclerosis, showing an average 
 systolic blood-pressure of 225 mm., have, following a 
 rise of 30 or 40 mm. more, suffered an apoplexy. On 
 the other hand, the author has seen more than one 
 case of chronic nephritis registering pressures fre- 
 quently above 250 mm., occasionally over 300 — one 
 case almost 310 — without the occurrence of anything 
 more serious than a mild cerebral edema of very 
 transitory character. The highest blood-pressure 
 readings occur in apoplexy cerebral thrombosis, 
 depressed fracture, intracranial hemorrhage and in 
 rapid growing cerebral tumors. Pressure up to 400 
 mm. has been recorded in these cases, while the 
 diastolic pressure is extremely low and the pulse rate 
 slow. The value of this high pressure in these condi- 
 tions is probably directed toward maintaining a fair 
 blood supply against the greatly increased intracranial 
 tension. This emphasizes the importance of recent 
 teaching that one should not bleed or make other effort 
 to lower the pressure in these cases, but to operate 
 immediately or else administer atropine in large doses 
 to keep the pressure up, and await developments. 
 
 Migrain. — Migrain is usually accompanied by hyper- 
 tension, which may, according to Russell, be localized 
 and confined to the arteries upon one side of the body, 
 particularly those of the head. The discovery of 
 
Blood-Pressure in Diseases of Eye. 11 
 
 hypertension in any case, tlie suljjcct of periodic 
 attacks of hemicrania, will furnish reasonable f^round 
 for therapeutic endeavors, as it has been shown that 
 the reduction of hypertension by eliminative measures 
 in these cases is often successful in preventinf]^, or at 
 least reducino^, the severity of the attacks. 
 
 Chronic Lead Poisoning. — Chronic lead poisoninj^, 
 accompanied by attacks of coHc, is usually attended 
 with an increase in blood-pressure. Temporary ele- 
 vations of 30 or 40 mm. have been recorded. The 
 fact may be of value in differentiating colic due to 
 lead from renal and biliary colic in which the blood- 
 pressure is low. 
 
 Eye Diseases. — It has long been recognized that high 
 blood-pressure is an important factor in several eye 
 conditions, but not until recently has this knowledge 
 been put to practical clinical use by the ophthalmic 
 surgeon. 
 
 Arteriosclerotic changes in the retinal vessels will 
 immediately suggest the necessity of a blood-pressure 
 test. The finding with the sphygmomanometer will 
 reveal the significance of the eye condition by demon- 
 strating the degree of general arteriosclerosis present. 
 This knowledge may be put to practical use by insti- 
 tuting measures directed toward relieving the high 
 pressure and by modifying the individual's life and 
 habits in an effort to arrest the arteriosclerotic process. 
 
 Ocular Hemorrhage. — Fox and Batroft" report in 
 detail a study of one hundred consecutive cases of 
 ocular hemorrhage in which the blood-pressure test 
 was employed. In 80 per cent, of these cases hyper- 
 tension was encountered. 40 per cent of the cases of 
 retinal hemorrhage were accompanied by chronic inter- 
 
78 Effect of Syphilis on Blood- Pressure. 
 
 stitial nephritis. Arteriosclerosis was present also in 
 27 per cent, and parenchymatous nephritis in 13 per 
 cent. 
 
 Asphyxia. — The effect on the cerebral centers in this 
 condition, no matter what its cause, is usually a 
 marked rise in blood-pressure. This is seen in 
 nitrous-oxide anesthesia. The condition is also met in 
 asphyxia and cyanosis from other causes, such as 
 obstruction to the larynx, diseases of lungs, etc. 
 
 Sjrphilis of the Heart and Blood-Vessels. — The usual 
 diagnosis of syphilis of the heart and blood-vessels 
 must be based on the same grounds which serve us 
 in diagnosing other syphilitic manifestations. 
 
 As the syphilitic heart and blood-vessels show 
 clinically nothing absolutely characteristic, nothing 
 which is not found in other diseases, we should be 
 suspicious of syphilis in any patient with arterial 
 involvement before judging it to be senile arterio- 
 sclerosis, especially when the process includes the 
 aortic valves and when incompency develops grad- 
 ually rather than suddenly, and when it is not accom- 
 panied by fever or other signs of acute endarteritis. 
 
 The Wasserman and Leutin tests will show syphilis 
 to be present much more often in such diseases than 
 is usually believed. The relative rise in pressure will, 
 of course, depend largely upon the extent of the 
 involvement or whether or not the arterial tree is 
 included in the process. 
 
Ri.ood-Prkssukk in Am II ma. 
 
 Diseases in Which the Blood-I'kessure is not 
 Greatly Affected, But in Which Information 
 Obtained by the Sphygmomanometer is of 
 Value. 
 
 In asthma the value of the blood-pressure reading 
 will depend upon the variety of this disease encount- 
 ered. 
 
 In cardiac asthma the pressure is, as a rule, low. 
 The finding of low blood-pressure accompanying a 
 case of cardiac asthma is an indication for support of 
 the heart and circulation ; improved heart tone and a 
 better circulatory equilibrium being followed by a less- 
 ening in frequency and lengthening of the interval 
 between attacks. 
 
 In asthmatic attacks of other origin the blood-pres- 
 sure is variable, and unless markedly altered from the 
 normal, is of little significance. 
 
 Chronic Bronchitis. — The general condition of the 
 patient will influence the blood-pressure finding. The 
 occurrence of hypotension in chronic bronchitis will 
 suggest the advisability of tonic measures directed 
 toward improving cardiac and blood-vessel tone. 
 
 Neuralgia. — This condition is usually accompanied 
 by a reduction in pressure, although this may not be 
 sufficient in degree to be noticeable. This lowering of 
 blood-pressure is in all probability due to the influence 
 of pain upon the vasomotor system. 
 
 Neurasthenia is believed to be accompanied by a 
 hypotension. This appears to be apart of the general 
 loss of tone present in this disease and may be a 
 rough indication of the severity of the exhaustion 
 state. 
 
80 Blooo-Pressure in Insanity. 
 
 It is well known that, in active men who are 
 approaching middle life, the insidious development of 
 arteriosclerosis or chronic nephritis, or both, fre- 
 quently shows itself in a symptom-complex compris- 
 ing irritability, lack of concentration, a feeling of lost 
 confidence in one's self, sleeplessness, general fatigue, 
 etc., a combination of symptoms often occurring in 
 true neurasthenia. In these cases a study of blood- 
 pressure is most important as a guide to diagnosis, a 
 heightened blood-pressure often being the one sign by 
 which the true diagnosis is reached. 
 
 Obesity. — Obesity per se has no modifying influence 
 on blood-pressure. The relative level of blood-pres- 
 sure found in any case of obesity does not depend on 
 the size of the arm to which the cuff is applied, and 
 will be normal for the age of the individual examined, 
 unless the excessive fatness is in the relation of cause 
 or effect with some anatomic or pathologic change, in 
 the heart, blood-vessels or kidneys. 
 
 The disturbing effect of edema in cases of obesity 
 should be remembered, as the presence of edema in 
 the arm to which the cuff is applied when taking 
 blood-pressure will so interfere with the transmission 
 of pressure as to render the observation valueless. 
 
 In insanity (mania), the mental state of the case at 
 the time of examination will largely determine the 
 pressure level, which, if not normal, may be either 
 slightly above or below it. The characteristic effect 
 of blood-pressure altering complications will be shown 
 here as in normal individuals, and here, as in any 
 case, blood-pressure records are valuable, in that they 
 may early detect the onset of complicating affections 
 and may aid the defendant in his efforts to prevent 
 their development. 
 
Blood-Pressure in Exophthalmic Goiter. 81 
 
 Rheumatism has been singled out from the many 
 acute infections as a condition for special l)lood-pres- 
 sure study. The result of these studies simply shows 
 that rheumatism, like any other acute infection, is 
 accompanied by an elevation in pressure ( 10 to 20 
 mm.) during the period of invasion, that in severe 
 cases it may fall to a marked hypotension and that 
 convalescence is marked by a gradual return to nor- 
 mal unless influenced by the development of compli- 
 cations. 
 
 Exopthalmic Goiter. — The involvement of the cardiac 
 and vasomotor centres in this disease has been 
 shown to be accompanied by an irregular effect upon 
 the blood-pressure, the stage of the disease and the 
 severity of the symptoms determining the result. Thus 
 some observers have reported an upward tendency 
 and some a downward. The study of blood-pressure 
 may be of value in this disease, by showing the rela- 
 tion of a tachycardia to a hypotension, thus directing 
 the treatment upon more rational lines. 
 
 The cessation of menstruation at the climacteric, 
 while physiologic in nature, is more often than not 
 pathologic in character, particularly that part of the 
 phenomenon involving the nervous system. In this 
 state, as in all profound nervous disturbances where 
 the cardiac and vasomotor activities are involved, we 
 have more or less frequent disturbances of vasomotor 
 character, as shown by palpitation, tachycardia and 
 flushings. These are often accompanied by altera- 
 tions in blood-pressure, whose chief characteristic is 
 a sudden variation in the pressure curve from normal 
 to hypo- or hypertension and back again. 
 
82 Blood-Pressure in Infectious Diseases. 
 
 Infectious Diseases. — In diphtheria, scarlet fever and 
 infectious diseases in general the blood-pressure 
 shows some variation, which is mainly dependent 
 upon the period of the disease. Thus it is found that 
 pressure has a tendency to rise slightly (5 to 15 mm.) 
 during the period of invasion, and then to fall gradu- 
 ally during the further progress of the disease to a 
 hypotension, to rise again toward normal as conva- 
 lescence is established. The occurrence of compli- 
 cations will be shown by a change in blood-pressure 
 which fails to conform to this rule. Thus a compli- 
 cating nephritis will be shown by an early and sharp 
 rise in blood-pressure. This may measure more than 
 50 mm. in twenty-four hours. 
 
 Typhoid Fever. — A slight primary rise may be noted, 
 but this is a disease of low blood-pressure, in which 
 the readings are not infrequently all below 100 mm. 
 A markedly depressed blood-pressure during the attack 
 is a valuable indication for the need of stimulating 
 treatment. A fall in pressure occurring suddenly, 
 especially after the second week, is usually indicative 
 of hemorrhage. A short, sharp rise is often a valu- 
 able sign, pointing to perforation or peritonitis from 
 a deep ulcer. 
 
 Pneumonia. — Gundrum and Johnson (California 
 State Journal of Medicine, Vol. 10) report studies of 
 a series of thirty cases of pneumonia in which the 
 blood pressure and pulse rate were taken simulta- 
 neously. Twenty-six were lobar pneumonia. The 
 patients were all adult males, 20 were alcoholics. The 
 mortality was 30%. 
 
 The blood-pressures on admission show a great 
 variation, ranging from 65 to 122 mm., while the 
 
KlTK^T OK Sa/.VARSA.V. 8i 
 
 pulse ranged from 68 to 148. According to Gibson's 
 rule on admission, 18 patients were in good condition 
 and 12 in poor. Of the 18, 17 recovered (94%) and 
 one died (6%). Of the 12 patients in poor condition, 
 3 recovered (257o) and 9 died (75%). 
 
 This study emphasized most powerfully the accu- 
 racy of the observations made by Gibson several 
 years ago, and make it imperative that every phy- 
 sician should routinely employ the blood-pressure test 
 in all cases of pneumonia, not only to effect a better 
 prognosis, but to guard against the development of 
 danger symptoms. 
 
 Injections of Salvarsan and Neo-Salvarsan. — During 
 the intravenous injections of these substances col- 
 lapse not infrequently occurs without a moment's 
 warning. It has been suggested by some observers 
 that frequent, rapid blood-pressure tests made dur- 
 ing this procedure would be a valuable guide as to 
 the safe progress of the operation, and also that this 
 test may be used as a guide to the amount and rapid- 
 ity with which the drugs may be administered. 
 
 Epilepsy. — Owing to the increased muscular activ- 
 ity occurring during an attack of apoplexy, the blood- 
 pressure shows a rapid rise during the violent stage, 
 and a rapid fall usually to the point of original level, 
 as the paroxysm subsides and coma develops. In a 
 patient seen during coma, where the patient's his- 
 tory cannot be obtained, this fact may be of aid in 
 differentiating the coma of epilepsy from that caused 
 by uremia or apoplexy, in which high pressure is the 
 rule. 
 
84 Low Pressure Cases. 
 
 Pathologic Conditions in Which the Blood- 
 Pressure IS Usually Below Normal. 
 
 In discussing low blood-pressure we must classify 
 several varieties of this condition in order to appre- 
 ciate the underlying factors leading up to and result- 
 ing from this condition. They are as follows : — 
 
 Terminal hypotension means the gradual lowering 
 of blood-pressure which occurs during the last hours 
 or days of life, and is the direct result of a gradually 
 failing cardiovascular mechanism. 
 
 Essential hypotension is met in cases in which the 
 cause of the low pressure cannot be explained. Found 
 occasionally in members of tuberculous families, in 
 whom no definite signs of the disease are shown. It 
 is a particularly common condition in those cases 
 which are now occasionally recognized as having con- 
 genitally small hearts and narrow arteries. 
 
 Primary or True Hypotension is defined by Bishop 
 as being present in those cases where the blood-pres- 
 sure mechanism has failed, but where there has been 
 no previous over-demand for pressure. 
 
 The term Relative Hypotension is applied to the 
 condition of blood-pressure occurring in individuals 
 who have had a distinctively permanent elevation in 
 blood-pressure, but in whom the pressure at the time 
 of examination is found to be normal or slightly 
 above. These cases are most significant, as it is in 
 them that we meet most serious and distressing symp- 
 toms pointing to circulatory failure, yet in whom the 
 pressure is still above the estimated normal level. 
 This relative hypotension is sometimes hard to estab- 
 lish, but if once determined and satisfactorily ex- 
 
Dilatation of Hi:ai<t. 85 
 
 plained the knowledge furnishes a basis for rational 
 treatment. 
 
 Diabetes. — The blood-pressure in diabetes is low, 
 often being found below 100 mm. The chief value 
 of the blood-pressure test in this disease is in the 
 detection of complications involving the kidneys. A 
 rising blood-pressure found in the course of a case 
 of diabetes will direct the attendant's attention to 
 the kidneys, when a urinalysis will often explain the 
 origin of the "turn for the worse." 
 
 Cardiac Dilatation. — As would be expected, dilata- 
 tion of the heart is accompanied by a dangerously low 
 blood-pressure, which may be sufficiently low to 
 endanger life. The finding of a low pressure in a 
 cardiac case will plainly indicate treatment directed 
 toward preventing syncope. 
 
 Improvement in the condition of caridac contrac- 
 tion will be shown by a gradually rising pressure, 
 accompanied by a falling pulse rate and an increase 
 in the pulse pressure. 
 
 Shock and Collapse. — These are two complications 
 which may develop under a variety of circumstances 
 in many disease conditions. In many cases which are 
 in an apparently good condition, the sudden develop- 
 ment of one of these complications may result fatally. 
 It becomes, therefore, of great importance to antici- 
 pate the onset of these complications and, upon noting 
 the warning signs, to institute measures for their 
 relief. This form of procedure is in many cases very 
 successful. During surgical operations under anaes- 
 thesia the sphygmomanometer is of great service in 
 detecting early circulatory failure from either heart 
 failure or vasomotor paralysis. Many surgeons, among 
 
86 Blood -Pressure After Hemorrhage. 
 
 them Bloodgood, of Baltimore, now employ the blood- 
 pressure test in all operations, depending upon it for 
 the continued safety of their patients. (See chapter 
 on Surgery, page 95.) 
 
 Hemorrhage. — Closely allied to the preceding, at 
 least in the seriousness and suddenness of its develop- 
 ment, is hemorrhage, either external or internal. Fol- 
 lowing external hemorrhage, the blood-pressure will 
 be found below normal, and the amount of this lower- 
 ing will, in a rough way, indicate the amount of blood 
 lost. This fact is true only when the observations 
 immediately succeed the bleeding. The circulation 
 very rapidly regains its normal equilibrium, so that 
 after hemorrhage of 300 to 400 c.c, causing a reduc- 
 tion of 30 to 40 mm., it is soon overcome and the 
 effect as demonstrated by the sphygmomanom)eter 
 lost. ■ "^ 
 
 In those diseases in which internal hemorrhage is a 
 complication, and after surgical operations where 
 there is danger of secondary hemorrhage, the fre- 
 quent employment of the sphygmomanometer is of 
 greatest value in detecting this complication long 
 before the patient is exsanguinated or in a dangerous 
 condition. 
 
 To be of greatest value in detecting hemorrhage, 
 the blood-pressure test should be made as often as the 
 pulse and temperature is taken, and should be recorded 
 on the combined chart which is made for this purpose 
 (see page 32). Used in this manner, a rising pulse 
 rate and a falling blood-pressure, even when the 
 change is slight, will direct examination along such 
 lines as will prove or disprove the suspicion. 
 
Blood-Pressure in Tuberculosis. A7 
 
 Cerebral Embolism. — From the differential diagnostic 
 standpoint, in cases where the decision rests between 
 cerebral hemorrhage and embolism, the blood-pressure 
 test is of greatest value, as it is well recognized that 
 the pressure in apoplexy is always high, often above 
 300, while in embolism the reverse is usually the case. 
 When a previous history is unobtainable, this test 
 may be the one deciding factor. 
 
 Jaundice. — Blood-pressure is usually low in cases of 
 simple catarrhal jaundice. This is probably due to 
 the effect of absorption of intestinal products of 
 decomposition arising from interference in digestion. 
 It may be said that in practically all mild toxemias, 
 particularly of gastro-intestinal origin, the tendency 
 of blood-pressure is downward, often remaining for 
 some time between 100 and 110. 
 
 Pulmonary Tuberculosis is a disease of low pressure. 
 The degree of lowering of pressure is a good index of 
 the severity of the infection and the progress of the 
 case toward recovery or otherwise. Good authority 
 teaches that blood-pressure gradually and steadily 
 falls in cases of progressive pulmonary tuberculosis ; 
 that it becomes stationary and tends to rise as the 
 disease becomes arrested, and that a rising pressure 
 means a good prognosis, as the blood-pressure practi- 
 cally never returns to normal in unarrested cases. 
 
 The effect of high altitude on cases of pulmonary 
 tuberculosis is to cause a rise in pressure; this rise 
 being beneficial in that its effect is to increase the force 
 and volume of the circulation. 
 
 Peters and Bullock (Medical Record, September 
 14th, 1912) sum up our knowledge of blood pressure 
 in this disease, as follows : 
 
88 Blood-Pressure in Anemia. 
 
 1. Blood pressure is increased at elevations of 6^000 
 
 feet. 
 
 2. The pressure of consumptives is higher here than 
 
 at sea level. 
 
 3. The pressure tends to increase with continued 
 residence. 
 
 4. From a prognostic standpoint the blood pressure 
 findings are of great value in tuberculosis. 
 
 5. There is no relation between the degree of involve- 
 ment and blood pressure, but there is a constant rela- 
 tion between toxemia and blood pressure. 
 
 6. The pressure is increased with pulmonary hem- 
 orrhage. 
 
 Anemia, Chlorosis and Exhaustion States. — An impov- 
 erished blood and a reduced physical tone, affecting all 
 organs and tissues of the body, results in loss of vaso- 
 motor and cardiac tone, which is easily demonstrated 
 by the sphygmomanometer in varying degrees of 
 hypotension. The chief value of these studies is in 
 directing the physician's attention to the need of abso- 
 lute recumbency and rest, in order to avoid syncope 
 from a too greatly lowered blood-pressure. 
 
 Cholera. — The great loss of fluid in cholera results 
 in such a depression in blood-pressure that measures 
 to combat collapse are urgently demanded. It has been 
 demonstrated that large amounts of saline introduced 
 either subintravenously or intravenously accomplish 
 this rest most satisfactorily. During the transfusion 
 the sphygmomanometer is the best guide to the effect 
 of the procedure. 
 
 If diarrhea is profuse, it will result in a lowering of 
 blood-pressure. Under ordinary conditions this fall 
 will be insufficient to demand special treatment, but in 
 
Blood-Pressure in Delirium, 
 
 89 
 
 greatly debilitated persons, as typhoid cases after 
 hemorrhage, the sphygmomanometer may be of great 
 service in demonstrating a dangerously low pressure. 
 In Alcoholic delirium^ vasomotor paralysis present, 
 this usually causes a marked lowering of the systolic 
 pressure, therefore employment of sedative measures 
 or hot pack, which might further cause a lowering of 
 pressure must be used with caution for fear of sub- 
 sequent collapse. 
 
 Position for Observation, Patient in Bed. 
 
CHAPTER VI. 
 PREGNANCY, TOXEMIA AND ECLAMPSIA, 
 
 Importance of Blood-Pressure Test in . 
 
 91 
 
 Normal Pressures in - . 
 
 91 
 
 Early Signs of Toxemia . 
 
 91 
 
 Effects of Toxemia . 
 
 92 
 
 Dangerous Pressures 
 
 93 
 
CHAPTER VI. 
 PREGNANCY, TOXEMIA AND ECLAMPSIA 
 
 The obstetrician of the present day must have con- 
 stant recourse to the blood-pressure test if he would 
 maintain the lead in his profession. The sphygmoma- 
 nometer now ranks with urinalysis in the examination 
 of pregnant women. In the blood-pressure test we 
 have a most valuable means of detecting early toxemias, 
 which often lead to the eclamptic state. The blood- 
 pressure test is capable of early furnishing very 
 definite indications of departures from normal me- 
 tabolism in the pregnant women. 
 
 Early Sign of Toxemia. — John Cooke Hirst (A^. Y. 
 M. J., June 11, 1910) states that the earliest and most 
 constant sign of toxemia in the latter half of preg- 
 nancy is a high and constantly rising blood-pressure, 
 and this symptom may precede albuminuria and all 
 other constitutional signs of an impending eclamptic 
 attack. 
 
 Examinations of normal non-pregnant women, 
 showing no signs of heart or kidney lesions, gave an 
 average systolic pressure with the Faught instrument 
 of 112 mm. He then took the pressure of 100 normal 
 pregnant women, these showing no signs of albumin 
 or any sign of toxemia, and found the pressure to 
 average 118. He found that these figures held good 
 
 91 
 
92 Toxemia on Blood-Pressure. 
 
 up to approximately seven and a half months, after 
 which date there was a gradual rise, so that in the 
 middle of tlie last month of pregnancy a fairer average 
 was 124 mm.; with subsidence of the uterus the 
 pressure showed a slight fall. This coincides with the 
 observations of H. C. Bailey (S. G. and O., vol. xiii, 
 No. 5, page 485), who made 1,136 systolic readings on 
 145 normally pregnant women in Bellevue Hospital. 
 The average normal systolic pressure was 118 mm. 
 He states that his readings varied greatly, but that the 
 high limit was rarely passed. Twenty-eight per cent, 
 showed a variation of from 25 to 30 mm. in the course 
 of several days. The study of the nitrogen partition 
 of the urine of these women showed no marked 
 changes, so that this was of very little value. In con- 
 clusion, he says that changes of less than 30 mm. above 
 the normal average 118 means very little from a prac- 
 tical standpoint, and that at the onset of labor the 
 pressure usually rises during the first and second 
 stages of 140 and 150 mm. taken between the pains. 
 Again another most careful observer, Hubert J. 
 Starling {Lancet, Sept. 10, 1910), reports a study of 
 blood-pressure, covering a period of five years in 
 pregnant women in whom the normal average was 
 from 110 to 120 mm. 
 
 All these observers are most emphatic in their state- 
 ment that routine blood-pressure observations should 
 be made a part of the periodical examination of preg- 
 nant women and that with the development of sus- 
 picious signs and advance toward the end of the gesta- 
 tion, the intervals between the tests should be short- 
 ened, and that the test should not be omitted during the 
 puerperium, as in this state women may develop 
 serious toxemia and eclamptic attacks. 
 
DangilRousi-y High Pressures. 93 
 
 Dangerous Pressures. — Thus from the analysis of 
 blood-pressure readings made by many observers we 
 believe that a pressure of 150 must be taken as a 
 danger limit, and that any pressure above this demands 
 vigorous investigation and treatment. 
 
 T. M. Green {Boston M. and S. J., April 28, 1910) 
 conveniently divides toxemia of pregnancy in three 
 divisions : 
 
 First, moderate increase in blood-pressure. 
 
 Second, marked increase in blood-pressure. 
 
 Third, extreme increase in blood-pressure. 
 
 To these may be added the fourth which is suggested 
 by Hirst and by Bailey, namely, fourth, extreme 
 eclamptic condition in which the blood-pressure may 
 be low. 
 
 In the first two, symptoms disappear and blood- 
 pressure falls after delivery. In the third and fourth, 
 blood-pressure continues abnormal and the disease 
 usually progresses to a rapidly fatal termination. 
 
 The blood-pressure seems to bear definite relation 
 to the type of case, and its frequent observation should 
 be of great value both in prognosis and in treatment. 
 
 According to Hirst, the highest pressure rei)orted 
 by him in the toxemic case without eclampsia was 192 
 mm. The highest in eclampsia was 320 mm. How 
 high he was unable to detern]ine, because the mercury 
 ran out of the top of the tube before the pulse was 
 shut off. 
 
CHAPTER VII. 
 BLOOD-PRESSURE IN SURGERY AND 
 
 ANESTHESIA, 
 
 
 
 
 Importance of Routine Study .... 95 
 
 Operations After Accidents 
 
 
 
 96 
 
 Wlien to Operate 
 
 
 
 97 
 
 Pulse and Pressure Before Anesthesia 
 
 
 
 99 
 
 Nitrous Oxide 
 
 
 
 100 
 
 Nitrous Oxide with Oxygen 
 
 
 
 101 
 
 Dental Anesthetics 
 
 
 
 101 
 
 Effect of Anesthesia 
 
 
 
 
 104 
 
 Method of Testing . 
 
 
 
 
 106 
 
 Ether 
 
 
 
 
 108 
 
 Chloroform 
 
 
 
 
 108 
 
 Ethyl Chloride . 
 
 
 
 
 108 
 
 Spinal Anesthesia 
 
 
 
 
 109 
 
 Local Anesthesia 
 
 
 
 
 109 
 
CHAPTER VII. 
 
 BLOOD-PRESSURE IN SURGERY AND ANESTHESIA 
 DENTAL ANALGESIA 
 
 Importance of Routine Study. — Joseph C. Bloodgood 
 {International Journal of Surgery, January, 1913) 
 states that in St. Agnes' Hospital during the last two 
 years blood-pressure records have been made a 
 routine in connection with investigations of nitrous- 
 oxide and oxygen anesthesia. From these observa- 
 tions he concludes that "I am confident from this 
 experience that the blood-pressure apparatus is an 
 instrument of precision which will be more helpful 
 than anything yet devised to help the surgeon to 
 accurately judge the condition of his patient and to 
 act accordingly. The blood-pressure records serve 
 to warn the surgeon of shock long before the pulse, 
 respiration or any other clinical sign." 
 
 'Tn all of my cases the blood-pressure reading is 
 taken in the ward the day before the operation, on 
 the morning of the operation, when the patient 
 reaches the operating room, before the anesthesia 
 is administered and repeatedly during the operation. 
 It is most important to note the blood-pressure after 
 the anesthesia is off and before the patient is trans- 
 ported to the ward. When the blood-pressure is low 
 (110 or less) the patient is not removed from the 
 
 95 
 
96 Operations After Accidents. 
 
 table, but is kept in an adjoining roonn until the reac- 
 tion is satisfactory. Collapse after their removal to 
 their beds will thus be prevented." 
 
 This investigator has also observed that when, 
 after painful manipulation, instead of a primary rise 
 there is a fall in pressure, and when the blood-pres- 
 sure does not rise again after the painful manipula- 
 tion is discontinued, these must be looked upon as 
 warnings of impending shock. 
 
 As an indication for venesection, saline infusion or 
 the Murphy treatment, and as a guide to the beneficial 
 efifect of these several measures, the sphygmoma- 
 nometer is pre-eminent. 
 
 Operations after Accidents. — The question of the safe 
 outcome of any proposed operation frequently deter- 
 mines the question for or against operating on patients 
 who have suffered accidents. This question really 
 amounts to a determination of the degree of shock 
 which the case has already suffered and an estimation 
 of how much more shock the case is able to bear. 
 This is best determined by the sphygmomanometer. 
 
 Bearing on this phase of the subject, Colcord (Inter- 
 national Journal of Surgery, June, 1913) has contrib- 
 uted some valuable data on the effect of traumatism 
 on blood-pressure. He noted that when there is injury 
 to the spinal cord or epididymis, there is an immediate 
 fall in blood-pressure. That severe injury to the 
 thigh or hip-joint often has the same effect. Frac- 
 tures of the base when accompanied by severe trauma, 
 result in powerful inhibition of the heart and respira- 
 tion, sometimes resulting in sudden death. The same 
 inhibitory effect is noted in most any region supplied 
 by the superior laryngeal nerve, and that operation 
 
When to Operate. 97 
 
 upon the larynx, pharynx and nasal chambers often 
 show these reflexes. 
 
 These same considerations enter into tlic question of 
 operating in extreme conditions, resulting from rapidly 
 developing or neglected surgical conditions. 
 
 The sphygmomanometer, in conjunction with the 
 pulse, is the quickest and surest means at our com- 
 mand with which to arrive at the proper decision, and 
 the blood-pressure test has undoubtedly been the means 
 of saving many lives under the conditions mentioned 
 above. 
 
 When to Operate. — A fair or normal blood-pressure 
 is always a good indication of the state of the vaso- 
 motor system, because vasodilatation invariably results 
 in hypotension, and the degree of hypotension fairly 
 indicates the severity of shock. 
 
 An extremely rapid pulse, associated either with a 
 lowered blood-pressure or with one approximately 
 normal, is an indication of a poor or shocked heart- 
 muscle — one unlikely to withstand the strain of anes- 
 thesia. 
 
 The sphygmomanometer is often the means of deter- 
 mining the safe time to operate. Thus a dangerous 
 condition of the cardiomotor and vasomotor mechan- 
 ism will indicate appropriate restorative treatment, 
 and will demonstrate plainly whether such measures 
 are successful. The surgeon will thus be guided in 
 his judgment as to the right time to operate. 
 
 The newer methods of anesthesia have done much 
 to improve the character, method and technic of their 
 administration. The chief effort of the anesthetist of 
 today is to gain relaxation with a minimum amount 
 
98 
 
 Ether Vapor Apparatus. 
 
 of the anesthetic, and to maintain anesthesia at any- 
 given level without fluctuations. Proper administra- 
 tion will produce a minimum of after sickness, prompt 
 and thorough recovery from the anesthesia, a minimum 
 of shock and an economic use of the anesthetic. All 
 factors contributing to the future safety and welfare 
 of the patient. 
 
 PATENTS PENDING 
 
 Fig. 20— Dr. Hill's Warm Vapor Ether Inhaler. 
 
 PATENTS PENDING 
 
 Fig. 21 — Dr. Hill's Warm Vapor Ether-Oxygen Apparatus. 
 
 In no other way can the surgeon or anesthetist 
 obtain the same satisfactory demonstration of 
 normal anesthetization as by the continuous use of 
 the sphygmomanometer. 
 
Pulse and Pressure Before Anesthesia. 99 
 
 It is not necessary to employ a large or expen- 
 sive apparatus to obtain satisfactory results with 
 warm ether vapor. The ether vaporizer and the 
 ether and oxygen apparatus devised by R. Franklin 
 Hill, M. D., of Philadelphia, shown in the accom- 
 panying cuts, very successfully administers a uni- 
 form percentage of warm ether vapor alone or in 
 connection with oxygen. 
 
 The ether vaporizer is not much larger than the 
 usual Allis cone. It has double walls, the spaces 
 between which are filled with a paraf^n oil, so that 
 when placed in the sterilizer or hot water before 
 using, it absorbs sufficient heat to vaporize and 
 warm the ether passing through it. 
 
 The advantages of this apparatus are shortened 
 time to produce anesthesia, almost complete elimi- 
 nation ol the stage of excitement, breathing is more 
 quiet and a smaller amount of ether is employed, 
 both during anesthetization and in maintaining that 
 condition. The tendency to post-operative nausea, 
 vomiting and pneumonia is lessened greatly. The 
 amount of ether is under complete control. 
 
 The ether and oxygen apparatus has recently met 
 with approval by many surgeons. It can be em- 
 ployed to give ether alone or in connection with 
 oxygen. Heat is obtained with a carbon electric 
 lamp. 
 
 This apparatus is particularly useful for opera- 
 tions upon the head or face in which the cone in- 
 haler cannot be used. 
 
 The face piece is detachable for sterilization. 
 
 Pulse and Pressure before Anesthesia. — The blood- 
 pressure and pulse rate immediately preceding anes- 
 thesia is usually found above normal. This is due to the 
 
100 
 
 Nitrous-Oxide Anesthesia. 
 
 excitement attending the approach of a radical pro- 
 cedure, and should be taken into consideration by the 
 surgeon. This temporary disturbance in blood-pres- 
 sure and pulse rate suggests the necessity of prelim- 
 inary tests made, in quiet surroundings, the day before 
 operation. This will establish the normal. 
 
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 Fig. 22 — Pulse and blood-pressure chart showing effect of 
 nitrous-oxide and oxygen anesthesia. Anesthesia begun at 
 A and ended at F. 
 
 Nitrous-Oxide. — During the first moments of admin- 
 istration of pure nitrous-oxide, the blood-pressure 
 mounts rapidly upward, the rise equaling in some cases 
 50 or more mm. At the same time the pulse becomes 
 very full and strong, while the rate may remain sta- 
 tionary or rise slightly. See Fig. 22- Immediately 
 succeeding the anesthesia period, the pressure rapidly 
 falls and the pulse rate rises. This effect of nitrous- 
 oxide on blood-pressure will suggest caution in admin- 
 istering it to cases of arteriosclerosis or in any case 
 where the patient's level is much above normal. 
 
DliNTAL AnESTIIKTICS. 101 
 
 Nitrous-Oxide Combined with Oxygen. — The combined 
 administration of nitrous-oxide and oxygen Ijy one of 
 the several apparatus now employed for this purpose is 
 unattended by any of the alarming symptoms or rise 
 in bloo(l-i)rcssure noted under nitrous-oxide alone. 
 
 Idiis combination properly administered is capable 
 of maintaining partial or profound anesthesia, for 
 prolonged periods without materially affecting blood- 
 pressure or pulse rate. The rise in pressure which 
 accompanies the N.O is either greatly reduced or 
 entirely prevented by a proper percentage of oxygen. 
 The accompanying chart is taken from Dr. Faught's 
 collection and well shows the result of a proper admin- 
 istration of this combined anesthesia. 
 
 Notes on the Administration of Anesthetics by 
 Dental Practitioners. 
 
 The recent perfection and wide employment of 
 anesthesia of all varieties by dental practitioners 
 makes it imperative that its administrators should 
 have not only a working knowledge of the methods 
 of administration, but that they should also be famil- 
 iar with at least the more important points of general 
 pathology, particularly that which applies to the heart, 
 the circulation and the kidneys, in order that they 
 may be able to detect departures from normal, which 
 might be magnified by the administration of any anes- 
 thetic, and so result in serious damage to the patient, 
 if not in actual loss of life. Anyone attempting a 
 prolonged administration of any anesthetic who has 
 not this knowledge places both his patient's life and 
 his own reputation in needless jeopardy. 
 
102 
 
 Administration of Nitrous Oxide. 
 
 In a recent discussion of this subject, Dr. Charles 
 S. Tuttle, a dental anesthetist, formulated two perti- 
 nent questions which every administrator of dental 
 anesthetics should be compelled to answer : 
 
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 YiG. 25— Administration of Pure Nitrous Oxide. 
 
 "To whom is it safe to administer an anesthetic?" 
 "What anesthetic should be selected to produce the 
 best results with the least disturbance?" 
 
 He then cites the common but dangerous opinion of 
 many dental surgeons who have for years employed 
 nitrous-oxide : "If the patient is able to walk up the 
 stairs to my office without prostration, I consider him 
 fit" 
 
Administration of Somnoform. 
 
 If).' 
 
 Dr. Tuttle's reply to the first proposition is this : 
 "The safety in administering an anesthetic either 
 by a physician or a dentist depends upon his posses- 
 sion of the requisite knowledge, his skill and his 
 experience." Here he refers undoubtedly to the pos- 
 
 FiG. 24 — Administration of Somnoform. 
 
 session of a knowledge, first of the physiology and 
 pathology of the circulation ; second, to adequate skill, 
 not only in the direct administration of an anesthetic, 
 but also to an ability to follow the course of the 
 administration and to recognize the development of 
 danger signals ; and third, his experience, not only in 
 the administration of an anesthetic by proper manipu- 
 
104 Effect of Different Anesthetics. 
 
 lation of the apparatus, but also adequate experience 
 in employing those means which are recognized as 
 the proper aids to diagnosis as applied to the heart, 
 circulation and kidneys. 
 
 In all their writings the more advanced dental 
 anesthetists have laid stress upon the importance of 
 the blood-pressure test, and possession of a working 
 knowledge of the blood-pressure and its variations 
 under dental anesthetics. We find that it is by means 
 of the sphygmomanometer, which is the greatest 
 single aid in the proper study of cases before, during 
 and after the administration of anesthesia, and it has 
 been proven that those who employ this study not 
 only obtain better results in the average case, but are 
 also better able to select their anesthetic, while the 
 danger of the anesthetic is largely removed together 
 with the elimination of those complications which so 
 often follow a poorly administered anesthetic. 
 
 From the knowledge of the blood-pressure in the 
 individual case requiring the anesthetic we are better 
 able to judge, not only as a relative safety of the 
 administration, but are also helped in the selection 
 of the anesthesia, for it has been found that different 
 anesthetics react upon the heart and circulation in 
 different ways. It is now known that nitrous oxide 
 alone produces a marked and rapid rise in blood- 
 pressure (see Fig. 23), and that the administration 
 of oxygen in conjunction with the nitrous oxide in 
 proper percentage largely controls this rise (see Fig. 
 22). Chloroform, ethyl chloride and soninoform all 
 have a direct tendency through their action upon the 
 vasomotor system to cause a continued fall in blood- 
 pressure throughout the length of their administra- 
 
Anesthesia By Dentist. 
 
 105 
 
 tion, while ether causes a prompt rise followed by a 
 fall to above normal, which when properly adminis- 
 tered is followed by but slight further variation, even 
 
 Fig. 25 — Illustrating Application of Sphygmomanometer 
 During Dental Anesthesia. 
 
106 Method of Testing in Anesthesia. 
 
 during administrations .lasting several hours (see 
 Fig. 22). 
 
 It will be seen at once that the danger of adminis- 
 tration of nitrous oxide increases in proportion as 
 the patient's pressure is above normal. That ether is 
 probably the safest anesthetic Avhich we have for pro- 
 longed operations, that chloroform, ethyl chloride and 
 somnoform on account of their effect on blood-pres- 
 sure may at any time suddenly become dangerous, 
 even in the normal case where the original pressure 
 is found to be normal (see Fig. 26) and that probably, 
 in high pressure cases, these may be safer than other 
 anesthetics because of their tendency to cause a fall 
 rather than a rise during anesthesia. 
 
 Following the lead of the more advanced surgeons, 
 it is recommended that dentists should regularly 
 employ the blood-pressure test, and that an effort 
 should be made to obtain the normal level before the 
 administration of the anesthetic, which will serve as 
 a guide later. During the anesthesia period blood- 
 pressure observations should be made continually at 
 intervals of one, two or three minutes, depending on 
 the nature and duration of the case, and that the blood- 
 pressure should be watched for several hours after 
 the administration whenever chloroform, somnoform 
 or ethyl chloride is used for any length of time. 
 
 Method of Testing. — It is only necessary to consider 
 the systolic pressure, an observation which can be 
 taken by anyone, even an untrained assistant, after 
 a few lessons. Intelligent patients have learned to 
 appreciate the necessity of these observations and are 
 very willing to submit to them. It is unnecessary 
 
Application of Gibson's Rule. 
 
 107 
 
 here to go into any detail in regard to the physiology 
 and pathology of the circulation or of anesthesia from 
 the surgical standpoint, as these points are all fully 
 explained in the following pages. 
 
 Finally the observations of Gibson and others upon 
 the relation of blood-pressure and pulse are significant 
 and have a direct bearing from the dental standpoint. 
 It has been found in normal conditions that the blood- 
 pressure in mm. Hg. remains ordinarily above the 
 pulse-rate in beats per minute, and that change in the 
 relation of these figures is a sign or danger which 
 should call for appropriate measure to re-establish 
 the normal relation, whether this is the withdrawal 
 of the anesthetic, an increase in the amount of oxygen 
 or the employment of active restorative measure. 
 
 
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 working of Gibson's rule. 
 
 which shows graphically the 
 
108 Ether — Chloroform — Ethyl Chloride. 
 
 Usual Effect of Different Anesthetics on 
 Blood-Pressure. 
 
 Ether alone causes a moderate rise in blood-pressure 
 during the early period of its administration. Strug- 
 gling causes a further rise, together with an accelera- 
 tion in pulse rate. These changes rapidly subside as 
 the stage of anesthesia is reached, so that, under ordi- 
 nary circumstances, the pulse and blood-pressure 
 remain at or about the same levels on the chart as 
 were noted prior to the removal of the case to the 
 operating room. 
 
 Dangerous symptoms occurring during the course 
 of operation will usually early be shown by changes 
 in pulse rate and blood-pressure; the blood-pressure 
 falling and the pulse rate rising, so that this change 
 developing during anesthesia will indicate to the sur- 
 geon the advisability of haste in completing the opera- 
 tion or the necessity of dividing the operation into 
 two stages. 
 
 Chloroform is a dangerous anesthetic under all cir- 
 cumstances and its use should always be attended with 
 great care. It has been demonstrated that blood-pres- 
 sure falls gradually from the very beginning of the 
 administration. This fall may occur during the first 
 few minutes and be so great as to endanger life. When 
 this anesthetic is used, the blood-pressure test should 
 be continuously employed, and every .effort made to 
 avoid a dangerous fall in blood-pressure. 
 
 Ethyl Chloride. — This drug, according to the last 
 report of the anesthesia commission of A. M. A., is a 
 very safe anesthetic, and observations on blood-pres- 
 sure seem to bear this out. There is a tendency to a 
 
Spinal Anesthesia — Local Anesthesia. 109 
 
 fallinj:^ pressure \\Iu\li, liowexcr, is not j^rcat, ancl 
 which is easily controlled hy the admission of suffi- 
 cient air. 
 
 Spinal Anesthesia. — According to Colcord, in surgi- 
 cal anesthesia there is a rise at first, due in part to 
 mental excitement, puncture, drawing off of fluid and 
 to the injection of the solution. This lasts from 15 
 to 20 minutes ; then the pressure falls to near the 
 normal line and the chart shows remarkably few 
 excursions above or below during the operation. 
 According to Gushing, if the anesthesia extends too 
 high into the dorsal cord, paralysis of the efferent 
 nerves to the splanchnic area may be induced, causing 
 a dangerous fall in blood-pressure. 
 
 Local Anesthesia. — In local anesthesia several fac- 
 tors influence blood-pressure. These are : 
 
 1. Cocaine itself produces a rise in blood-pressure. 
 
 2. The mental excitement, always a variable fac- 
 tor, may produce a rise. 
 
 3. Any pain from injury to nerves, not anes- 
 thetized, will cause a rise. 
 
 4. Injury to nerves completely anesthetized will 
 cause no change in blood-pressure. 
 
 Operative Effect on Blood-pressure. — The surgeon 
 should be in possession of the facts concerning the 
 influence of operative procedures on blood-pressure. 
 Thus, when the skin is incised, there is usually an 
 abrupt fall in blood-pressure, transitory in nature. The 
 same lowering is noted when the peritoneum is incised 
 and also when viscera are pulled upon or exposed to 
 the drying influence of air. Two procedures, there- 
 fore, to be studiously avoided, or, if necessary, care- 
 
110 Surgical Procedures. 
 
 ful watch should be made for the occurrence of shock, 
 with the sphygmomanometer, during such procedures. 
 Cataract Operation. — No careful surgeon ever 
 attempts to enter an eye either in cases of glaucoma 
 or cataract without first carefully studying the blood- 
 pressure. The indications in the presence of a high 
 blood-pressure are first to reduce the pressure and 
 then operate. This method will save a large percen- 
 tage of eyes which were formerly lost by intraocular 
 hemorrhage, a complication the direct result of a sud- 
 den reduction of tension in an eye, having diseased 
 blood-vessels, which were unable to withstand the 
 sudden loss of support following the scleral incision. 
 
CHAPTER VIIL 
 
 THERAPEUTICS INDICATED BY BLOOD-PRESSURE 
 CHANGES 
 
 Therapeutic Indications 
 
 Of Hypotension 
 Of Hypertension 
 With Albuminuria 
 In Aortic Aneurism 
 In Acute Bright's Disease 
 Treatment of High Pressures 
 When Not to Treat It 
 Effect of Nitrites . 
 Vapor Baths 
 Venesection 
 Osteopathic Measures 
 
 111 
 
 111 
 111 
 112 
 112 
 112 
 112 
 113 
 113 
 113 
 113 
 114 
 
Pilling;-Faug-ht Pocket Sphyg;momanometer in Use. 
 
CHAPTER VIII 
 THERAPEUTICS 
 
 The study of bloocl-i)rcssurc frequently furnishes 
 the key to proper treatment in a number of diseases ; 
 it also furnishes a reliable guide as to the efficiency of 
 the measures employed, as well as the time during 
 which treatment should be continued. 
 
 It is not within the scope of this little work to more 
 than touch upon a few of the most important points 
 in the relation of blood-pressure to the management 
 of disease. 
 
 Hypotension. — The general symptoms accompanying 
 diminished blood-pressure indicate in no uncertain 
 manner the necessity of tonic treatment. In cases of 
 emergency, w4th suddenly falling pressure and evi- 
 dence of collapse, adrenalin intravenously or hypoder- 
 mically is indicated. 
 
 For the sudden drop in blood-pressure occurring in 
 advanced arteriosclerosis, digitalis is indicated, pro- 
 vided there is no evidence of marked myocardial 
 degeneration, in which event strychnin is the safer 
 drug to use. 
 
 In lowered blood-pressure from hemorrhage or pro- 
 fuse and prolonged diarrhea, the pressure is the best 
 indicator of the amount and the frequency for the use 
 of saline infusion or the Murphy treatment. 
 
 Hypertension.— High pressure in the apoplectically 
 inclined calls for active and continued pressure-reduc- 
 ing treatment. Among the drugs which are gener- 
 
 111 
 
112 Treatment of High Pressure. 
 
 ally depended upon to accomplish this change are the 
 nitrites, of which a freshly prepared solution of 
 Kodium nitrite will be found the most serviceable, being 
 easy of administration and prolonged in action. 
 
 In the treatment of aortic aneurysm with high pres- 
 sure, the use of blood-pressure reducing agents may 
 materially prolong life by reducing the tendency to 
 rupture, and at the same time afford relief from the 
 most distressing symptom — pain — by lessening the 
 tension in the aneurysmal sac, thereby relieving the 
 nerve irritation and the pressure upon surrounding 
 organs or tissues. 
 
 In acute Bright's, after failing to reduce the pressure 
 by the usual measures, it may sometimes be controlled 
 by the electric-light sweat bath. In one case a reduc- 
 tion of from 20 to 40 millimeters was obtained, the 
 beneficial effects lasting for many hours, so that regu- 
 lar observation of the pressure determined the proper 
 interval between the sweats. 
 
 Albuminuria. — Albumen appears in the urine when- 
 ever the kidneys are passively congested, and its 
 importance, when due to this cause, is often greatly 
 exaggerated. Albuminuria, associated with kidney 
 disease, is nearly always accompanied with elevation 
 in blood-pressure ; albumen, when due to other causes, 
 is not usually so accompanied. As these two causes 
 of albuminuria demand almost diametrically opposite 
 treatment, their differentiation is of the utmost 
 importance. 
 
 When to Treat High Blood-pressure. — It is important 
 to realize that the mere finding of an elevated blood- 
 pressure is not always an indication that it should be 
 reduced; it is always a bad rule to promiscuously 
 institute measures to reduce pressure. This should 
 
Effect of DRUGh 
 
 never be done. Blood-pressure reduction should only 
 be attempted for a good reason, based ui)on a careful 
 study of the case. Long continued high pressure often 
 becomes an essential to the well-being of the indi- 
 vidual, which, if interfered with, may so destroy the 
 circulatory equilibrium that disaster results. The 
 chief group of drugs employed to control and lower 
 high blood-pressure are vasodilators. These act 
 chiefly upon the sympathetic and vasomotor systems, 
 cause a widening of the blood channels and a conse- 
 quent lowering of the blood-pressure. The value of 
 the sphygmomanometer is chiefly in demonstrating 
 the efficiency of the measures employed in any given 
 case. This guards the practitioner from placing too 
 much confidence in any particular remedy, because he 
 can readily ascertain whether he is accomplishing the 
 desired result. This is particularly important because 
 numerous investigators have shown that no particular 
 drug can be depended upon to produce the same 
 results under all conditions, even with a maximum 
 dose. Another important function of the sphygmo- 
 manometer in therapeutics is to determine the period 
 of duration and action of the particular drug employed, 
 thereby enabling the physician to intelligently manage 
 his therapeutic measures and accomplish his purpose. 
 The sphygmomanometer has also shown that many 
 measures other than drugs may be relied upon to con- 
 trol and lower high blood-pressure, often more advan- 
 tageously. Thus, in the employment of vapor baths 
 of various sorts, we can control the effect and deter- 
 mine the proper time for another treatment. 
 
 In venesection the amount of blood which may 
 safely be withdrawn is best determined by noting the 
 effect of the bleeding on blood-pressure. 
 
114 Effect of Osteopathic Treatment. 
 
 Therapeutic Effect of Osteopathic Treatment 
 ON Blood-Pressure. 
 
 J. P. Downing, A. B., D. O., has made a series of 
 studies with the sphygmomanometer over a period 
 of three years and has records of 300 cases. From 
 the result of this study it is apparent that the meas- 
 ures employed were productive of good results in 
 certain classes of high tension cases. 
 
 This seems to be particularly true of those in which 
 there is no physical reason for the hypertension (many 
 of the cases were studied by regular practitioners in 
 order to exclude organic conditions before the treat- 
 ment was applied). Here spinal treatment has a 
 decided tendency to reduce the systolic pressure, the 
 effects of which are usually lasting, often persisting 
 for 24 hours or more. It is not uncommon to get a 
 fall of from 15 to 40 mm. after a treatment occupying 
 15 or 20 minutes. These results are confirmed by 
 Abrams and others, who are at the present time em- 
 ploying methods somewhat similar to those of oste- 
 opathy, and in which the lower cervical region is the 
 point of therapeutic attack. 
 
 It is evident also that the measures applied by 
 osteopathy are productive of good results when 
 applied to raising an abnormally low pressure. In 16 
 cases of anemia reported, the pressure ranged from 
 80 to 100, which, after 2^ months' treatment, with 
 one exception, all came up and remained above 110. 
 
 In 6 cases of chlorosis, in which the blood-pressure 
 averaged 90 before treatment, four were raised to 120 
 and remained up, one came to 110, and only one 
 failed to respond to trieatment. 
 
CHAPTER IX. 
 
 BLOOD-PRESSURE IN LIFE INSURANCE 
 
 »rtance of the Test 
 
 115 
 
 Normal Variations .... 
 
 115 
 
 Formula to Estimate Normal Pressure 
 
 116 
 
 Application of the Test . 
 
 117 
 
 In Arteriosclerosis . 
 
 117 
 
 In Chronic Nephritis 
 
 117 
 
 With Albuminuria . 
 
 117 
 
 In Over- Weights 
 
 118 
 
 In Chronic Myocarditis . 
 
 118 
 
 In Tuberculosis 
 
 118 
 
LIFE INSURANCE 
 
 The medical director of one of the largest 
 
 insurance companies speaking of the Faught 
 
 Pocket Sphygmomanometer writes : ''As 
 
 you know we have used the Faught 
 
 Sphygmomanometer for some months, 
 
 and it is entirely satisfactory ; it is 
 
 certainly most convenient. 
 
CHAPTER IX 
 BLOOD-PRESSURE IN LIFE INSURANCE 
 
 During the past several years a majority of life 
 insurance companies have admitted the value of the 
 blood-pressure test as a prognostic aid in life insur- 
 ance examinations. At the present time most of the 
 larger companies require the test of every applicant 
 for life insurance. A larger number require the test 
 of all applicants over forty years, in overweights and 
 underweights, and in all those in whom the character 
 of the risk has been previously questioned by any 
 company. 
 
 The chief value of this test lies in the fact that, by 
 a study of these records in conjunction with that of 
 the pulse, we are able to detect beginning pathologic 
 change in the cardio-vascular system or kidneys, often 
 before there are any definite signs in the physical 
 examination, personal history or urine. Another good 
 reason for the universal employment of the blood- 
 pressure test in life insurance examinations is the fact 
 that the apparent character of the pulse and of the 
 vessel walls does not always convey the correct infor- 
 mation regarding the condition of the applicant. Clini- 
 cians have agreed that the estimation of blood-pres- 
 sure by palpation is not satisfactory and that even the 
 most experienced occasionally fall into grave error. 
 
 Normal or Permissible Variation. — Unlike the tempera- 
 ture, which has a fixed normal, the blood-pressure in 
 
 115 
 
116 Blood-Pressure in Life iNSxmANCE. 
 
 the normal individual is a variable factor. This is 
 because of the complicated cardiomotor and vasomotor 
 mechanisms. These are under sympathetic control, 
 and are therefore affected by the varying conditions to 
 which the body is subjected during every 24 hours. 
 These variations result from changes in posture, exer- 
 cise, excitement and from digestive activity. 
 They are also dependent upon the time of day, age, 
 sex and the physical development of the individual. 
 Fortunately the amount of alteration in pressure 
 caused by these varying conditions is not great, and we 
 are therefore able to lay down a fairly definite rule 
 which has for its object the determination of the per- 
 missible variation in pressure in any individual of a 
 given age. 
 
 Formula to Estimate Normal Pressure. — The writer 
 devised and published, in 1910, a formula w^hich may 
 be used to estimate the normial systolic blood-pressure, 
 which gives results conforming closely Avith the figures 
 obtained from careful clinical reports. The formula 
 is as follows: "Consider the normal average systolic 
 blood-pressure in men at age of 20 to be 120 mm. 
 Then add 1 mm. for every additional 2 years of life." 
 Thus a man aged 30 should have a normal average 
 systolic blood-pressure of 125 mm., while a man aged 
 60 should average 140 mm. The difference in pres- 
 sure between men and women is approximately 10 
 mm., being lower in women. 
 
 Clinical evidence shows that the ordinary daily 
 variations in pressure in any individual rarely amount 
 to more than 36 mm. If we accept this, then a varia- 
 tion of 17, either above or below the normal average, 
 may be allowed. 
 
Appr.TrATrffX or Tf.st. 117 
 
 Application of Test. — As a rouline measure the left 
 arm should be employed and the cuff should be applied 
 to the bare arm. The applicant should be in a com- 
 fortable position, preferably sitting. Time should be 
 allowed to permit the circulation to become quieted, 
 and nervous individuals should bic assured of the 
 harmlessness of the test. 
 
 A single reading equal to or just above the esti- 
 mated maximum pressure for a given individual 
 should never be accepted as final, as this pressure may 
 be accidental and may never again be met. Observa- 
 tions should be repeated at a later time or upon a 
 different day before reporting the pressure. 
 
 A moderate degree of arteriosclerosis may cause an 
 elevation in pressure but slightly above the estimated 
 high normal; 15 or 20 mm. above this calls for further 
 investigation, not only of the blood-pressure, but of 
 the general physical condition of the applicant. 
 
 The blood-pressure will frequently read between 
 160 and 180 mm. in the average case of uncompli- 
 cated arteriosclerosis. 
 
 Nephritis. — Urinalysis does not always demonstrate 
 chronic nephritis, particularly in individuals of appar- 
 ent normal health. On the other hand, it is said that 
 the blood-pressure in an established case of chronic 
 interstitial nephritis is rarely below 200 mm. In acute 
 nephritis the blood-pressure, while above the normal, 
 may not be that high. The finding of a high blood- 
 pressure with a normal urine calls for repeated 
 urinalysis. 
 
 Metabolic Albuminuria. — The finding of a trace of 
 albumen and a few hyaline casts in the urine, with a 
 normal blood-pressure, suggests the probability that 
 
118 Conditions Effecting Pressure. 
 
 the urinary condition is not the result of kidney altera- 
 tion, but is metabolic in character. Such a condition 
 can readily be relieved by appropriate treatment while 
 the case is held under advisement, and many of them 
 will eventually obtain the amount of insurance desired. 
 
 Overweights. — This group shows an unfavorable 
 mortality in life insurance statistics, particularly of 
 the older ages. Given an individual of modern over- 
 weight, where the physical examination and history 
 are favorable, the final decision is often made upon 
 the result of the blood-pressure test; accepting them 
 when the pressure is normal and declining them when 
 the pressure reaches or passes the normal high limit. 
 
 Chronic Myocarditis. — This is the most difficult con- 
 dition to diagnose, especially by the insurance exami- 
 ner, because these cases often require long study and 
 careful observation in order to arrive at the proper 
 rating. A history of hard physical labor, excessive 
 brain work, alcoholism or syphilis is often significant. 
 In the early cases the systolic pressure is not always 
 altered, so that recourse must be had to the functional 
 tests of Graupner and Shapiro (see page 74), and 
 also to the estimation of the diastolic and pulse pres- 
 sures. 
 
 Incipient Tuberculosis. — Slight reduction in blood- 
 pressure, combined with modern elevation in pulse 
 rate, even without fever, suggests the possibility of 
 an active pulmonary lesion. If this be combined with 
 fever and a history of slight loss in weight, the case 
 should be declined on this presumptive evidence. In 
 tuberculosis the blood-pressure is usually low and the 
 pulse pressure diminished. 
 
Blood- pRKss ukk Stkt i i o.S( oi'e. 
 
 119 
 
 PILLING-STAMP 
 BRACELET STETHOSCOPE 
 
 IMPORTANCE OF ACCURACY IN BLOOD-PRESSURE 
 EXAMINATIONS. 
 
 Of all methods of recording systolic and diastolic 
 readings there is not one dissenting opinion among 
 scientists that the auscultatory is the one absolutely 
 correct method. Until the development of the Stamp 
 Bracelet Stethoscope the labor and difficulty surround- 
 ing accurate auscultatory observations in blood-pressure 
 were almost insurmountable because of lack of prop- 
 erly adjusted and sufficiently delicate apparatus. 
 
 THE METHODS OF TAKING READINGS. 
 
 There are probably only four recognized methods 
 of making readings and they are : 
 
 1. Visible. 
 
 2. Palpatory. 
 
 3. Auscultatory. 
 
 4. Diastolic Indicators. 
 
 Of these the most accurate for both systolic and 
 diastolic readings is the auscultatory method. Prob- 
 
120 Auscultatory Blood-Pressure. 
 
 ably there is a slight difference between diastolics with 
 this method and the other three, but in spite of this, 
 it is the most satisfactory in every way. 
 
 It is, of course, for purposes of comparison, always 
 •important to use the same method in a series of obser- 
 vations, whether on individuals or groups. 
 
 Accurate records of the blood-pressure with any 
 sphygmomanometer can be obtained only by means of 
 the auscultatory method. By this method it is only 
 necessary to distinguish between the presence and 
 absence of certain plainly audible sounds, which are 
 not affected to any extent by varying conditions, such 
 as size of arm, exact location of vessel, or the personal 
 equation of the examiner. 
 
 All large Insurance Companies now recognize not 
 only the importance of a systolic, but also of a diastolic 
 determination. 
 
 Ofttimes we find that a relatively high systolic is 
 only nature's effort to compensate and that there is 
 no danger from it whatever. 
 
 This observation can be determined only by the 
 accurate readings made possible by using the Stamp 
 Bracelet. 
 
 NORMAL RELATION OF SYSTOLIC TO DIASTOLIC 
 PRESSURE. 
 
 There exists a relationship between the systolic and 
 diastolic pressures and their resultant pulse pressure 
 that has been generally accepted as follows : Where 
 120-80-40 may represent the systolic, diastolic and 
 pulse pressure, respectively, we might also have 200- 
 135-65 as the systolic, diastolic and pulse pressure, 
 respectively, and still, other things being equal, have 
 
Blood-Pkessure Stethoscoim:. IJl 
 
 perfect compensation, relation and a normal balance 
 between the various parts of the carflio-Nasnilar 
 system. 
 
 Before this accurate method of diastolic determina- 
 tion was devised, moderately elevated pressures, which 
 had had only the systolic determination, would not 
 even have been considered by the Insurance Com- 
 panies, or if under observation by a physician, the 
 systolic reading alone would have been misleading. 
 
 Dr. Faught, in his work on ''Blood-Pressure," says : 
 "The determination of the pulse pressure is of the 
 greatest importance in the study of diseased condi- 
 tions, particularly in the estimate of cardiac muscular 
 efficiency and in determining the prognosis of certain 
 valvular and blood-vessel diseases and toxemic states." 
 
 Dr. J. W. Fisher, Medical Director of the North- 
 western Mutual Life Insurance Company, in an article, 
 "The Diagnostic Value of the Use of the Sphygmoma- 
 nometer in Examinations for Life Insurance," says : 
 
 "No practitioner of medicine should be without a 
 sphygmomanometer. He has in this instrument a most 
 valuable aid in diagnosis." 
 
 Dr. Haven Emerson, in "Archives of Internal Medi- 
 cine," says: "The danger of accepting applicants who 
 are not really entitled to insurance is greatly lessened 
 by the determination of the pulse pressure, and no 
 insurance company desires to refuse a policy to a good 
 risk, and in no way can this be positively ascertained 
 except by the use of the sphygmomanometer." 
 
 Another observer says : The diastolic readings are 
 more important than the systolic. He further states 
 that the auscultatory method of obtaining the diastolic 
 pressure is now well recognized as the only accurate 
 
122 Auscultatory Blood-Pressure. 
 
 and simple method, because if you observe the dial 
 of an aneroid, the needle is showing wide excursions, 
 making it impossible to determine the correct reading, 
 as you do not know what point in the excursion of 
 the needle to note. 
 
 The fluctuations of the mercurial column offer the 
 same difficulty. 
 
 By observing the changes in pulse pressure of our 
 cases under treatment, we obtain the most accurate 
 idea possible of the results that are being obtained; 
 far more so than when we utilize the systolic pressure 
 alone. 
 
 Now, accepting the evidence in favor of the import- 
 ance of accurate diastolic determinations and the claim 
 that the auscultatory method is the only accurate one, 
 we pass to the choice of methods. 
 
 Some physicians have been in the habit of tucking 
 the stethoscope under the cuff. It is obviously impos- 
 sible by this method to avoid crepitus and annoyance 
 and interference with the sounds and to obtain a cor- 
 rect reading, for the instant you release the air by the 
 various methods used with all forms of sphygmoma- 
 nometers the cuff must yield or slip over the stetho- 
 scope, w4th a resulting crepitus. Manifestly, to hold 
 the stethoscope in place manually is both difficult and 
 inaccurate. 
 
 The Stamp Bracelet Stethoscope may be used with 
 all forms of sphygmomanometer such as the Faught 
 Standard, Faught Pocket, Cardiac, Tycos, Janeway, 
 Stanton, Riva Rocci, etc. 
 
 In employing this instrument, attach the arm-band 
 of the sphygmomanometer to the arm above the elbow 
 in the usual way, then the Bracelet is quickly and 
 simply adjusted over the radial artery just below the 
 
Blood-Prkssuke Stkthoscoi' 
 
 123 
 
 bifurcation. The especially (lesij^nie(l arterial button 
 fits snugly over the artery; the sounds are read (|uickly 
 with unfailing scientific accuracy. 
 
 Precision is now assured ; personal errcjrs (jn the 
 part of the observer are eliminated and remarkably 
 ready and general acceptance by the profession at 
 large of the 
 
 G.P.PILLING & SON CO. PhlLK. "^ 
 
 Pilling-Stamp Bracelet Stethoscope 
 
 is proof enough of its high degree of efficiency in 
 giving to the practitioner and the examiner alike an 
 absolutely accurate method of making determinations 
 and getting satisfactory interpretations in blood- 
 pressure. 
 
16 
 REASONS 
 
 Why The Pilling -Faught 
 Apparatus is Best 
 
 1. There is no mechanical detail of practical value in any 
 sphygmomanometer which is not embodied in those of the 
 Faught-Pilling make. In this apparatus you will find: 
 
 2. A scale running to 300 mm. Hg, 
 
 3. The scale graduated in milhmeters requires no compu- 
 tation to determine the actual pressure. 
 
 4. An adjustable dial which allows for changes in tem- 
 perature and atmospheric pressure, 
 
 5. The scale plainly marked in black and red on a white 
 background — easy to read. 
 
 6. The aneroid mechanism has four chambers, assuring 
 absolute smoothness in operation. The same advantage as a 
 "six" auto over the old one or two cylinder. 
 
 7. The metal pump of convenient size is positively guarded 
 by an air-tight valve. 
 
 8. A reliable release valve is conveniently placed on the 
 shank of the pump. 
 
 9. The arm-band is standard width (5 inches) and of 
 sufficient length to meet all requirements. 
 
 10. The pressure bag measures 9x5 inches. 
 
 11. The outer fabric of the arm-band is of washable mate- 
 rial and permits easy sterilization. 
 
 12. Arrangement for quick removal of the pressure bag 
 from the outer covering for cleaning and other purposes. 
 
 13. An attractive leather case which_ holds the gauge, arm- 
 band and pump, and is of convenient size to fit in the pocket. 
 
 14. Permanent accuracy which has been demonstrated by 
 thousands of satisfied users working under all conditions 
 during a number of years. 
 
 15. The Faught Apparatus is in general use by thousands 
 of physicians, by the U. S. Government, many life insurance 
 companies and research laboratories, as the standard of 
 accuracy. 
 
 16. Not a spring instrument. 
 
Pilling-Faught 
 
 Blood Pressure Service 
 
 Generally acknowledged supremacy is not the work of a 
 day or a year, but the cumulative result of many years' 
 leadership which compels gradual recognition and emulation 
 on the part of others in the same field. 
 
 The word Service is the key-note of Pilling Success. With 
 us it signifies much more than the term usually implies. It 
 means service from us to the surgical dealer — from the 
 dealer to the user — as well as the satisfactory service of 
 every Faught Blood-Pressure Apparatus that we have ever 
 manufactured ; the service that will insure satisfactory 
 results at all times. 
 
 In order to afford this complete service we have built up 
 a fully-equipped organization, comprised of accurate tools 
 and the best mechanics ; have gathered from our own ex- 
 perience as well as that of others the most advanced ideas in 
 blood-pressure apparatus construction. 
 
 Dr. Francis A. Faught is in daily consultation with us, 
 whose duty is to safeguard the sphygmomanometer user by 
 maintaining the highest standard of scientific accuracy which 
 is essential in such an instrument. 
 
 The unparalleled demand and world-wide market for the 
 various Faught blood-pressure instruments have made it 
 necessary for us to again and again extend our organization; 
 to enlarge our manufacturing facilities ; and broaden the 
 scope of both our manufactory and methods of distribution. 
 
 Pilling Service starts from the General Manager's desk 
 and continues down through the various departments to your 
 individual consulting room. 
 
 Blood-pressure apparatus are usually guaranteed perfect, 
 but a Pilling is more than perfect — it is insured — for it is 
 built by an organization whose watchword has been service. 
 
 It is our aim and ambition to maintain and augment the 
 high standard of quality that has always been found in 
 Faught-Pilling instruments, and to this end we shall continue 
 to strive for the welfare of every user of Faught Instru- 
 ments. 
 
 A copy of Faught' s primer as 2vell as a signed certificate 
 is furnished with every apparatus. 
 
 MADE ONLY BY 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA, PA. 
 
PILLING-FAUGHT 
 
 Pocket 
 Sphygmomanometer 
 
 FAUGHT POCKET 
 
 ANEROID 
 
 INSTRUMENT 
 
 Complete in genuine leather 
 case, with Faught Certificate 
 
 $22.50 Net 
 
 ACTUAL SIZE 
 
 MADE ONLY BY 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA, U. S. A. 
 
PILLING- FAUGHT 
 
 Clinical 
 Sphygmomanometer 
 
 $27.50 Net 
 
 Is a Portable Pocket Aneroid Type with 
 
 DOUBLE SIZE DIAL and 
 REGISTERS TO 350 Mm. 
 
 OTHERWISE SIMILAR TO REGULAR FAUGHT POCKET 
 
FAUGHT MERCURY 
 
 Sphygmomanometer 
 
 ACCURATELY STANDARDIZED 
 
 SIMPLE, COMPACT, DURABLE, EASY TO USE 
 
 Always ready to use ; time required for the observation reduced to 
 a minimum ; no preliminary adjustment of the apparatus required ; 
 mercury cannot be spilled ; no detachable parts to be lost. 
 
 AN INVALUABLE AID IN DIAGNOSIS, 
 PROGNOSIS AND TREATMENT 
 
 Indespensable to the General Practitioner, the Internal Specialist, 
 the Surgeon, the Oculist, the Laryngologist, the Otologist, the 
 Gynecologist, the Obstetrician and the Student of Medicine. 
 
 The FAUGHT SPHYGMOMANOMETER embodies the essen- 
 tials to the earlier instruments -while omitting unnecessary complexity 
 in construction. Thus eliminating the objectionable features and 
 reducing to a minimum the time required for observations. 
 
 FOR SALE BY ALL SURGICAL INSTRUMENT DEALERS 
 
 Complete. Avith Arm-band and Metal Pump in Mahogany Case, 
 Avith Signed Certificate of Dr. Faught. 
 
 Price, $20.00 Net 
 
 PATENTED AND MADE ONLY BY 
 
 G. P. PILLING & SON CO, 
 
 PHILADELPHIA, U. S. A. 
 
PILLING SPECIAL 
 
 FAUGHT PATENT 
 
 Sphygmomanometer 
 
 In order to meet the demand for a cheaper model of the 
 Faught mercury instrument, the PilHng Special has been 
 devised. This instrument embodies the salient features of 
 the Faught Standard Sphygmomanometer, and will be found 
 serviceable, accurate and reliable. 
 
 PILLING SPECIAL MADE IN TWO GRADES 
 
 No. 7— With stiff arm-band, highly finished metal parts 
 and with mahogany case, 3 x 3^ x i^Yz in., with Faught 
 Certificate, $15.00 Net. 
 
 No. 2— With soft arm-band and plain oak case, 3 x zK 
 X 14% in., with Faught Certificate, $12.00 Net. 
 
 FOR SALE BY ALL SURGICAL DEALERS 
 
 PATENTED AND MADE ONLY BY 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA, U. S. A. 
 
PILLING -STAMP 
 
 BRACELET 
 
 G.P .PILLING &SON CO. PHILK. - 
 
 FOR 
 
 AUSCULTATORY 
 BLOOD PRESSURE 
 
 Described on pa^es 119 to 123 this Primer 
 
 A valuable addition to every make of Sphygrno- 
 manometers. May be used on any style, such as 
 Faught Mercury Janeway 
 
 Faught Pocket Stanton 
 
 Cardiac Mercer 
 
 Tycos Riva-Rocci 
 
 PRICE, $5.00 NET 
 
 MADE ONLY BY 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA, PA. 
 
THE BOWLES STETHOSCOPE 
 
 PRICES 
 
 Midget I in. diam. ----- $4.00 net 
 
 Small i^ in. diam. ----- 4.00 net 
 
 Medium 1% in. diam. _ - _ - 4.00 net 
 
 Large 2/i in. diam. ----- 4.00 net 
 
 Flat-iron one size only - - - - 4.50 net 
 
 Extra, Combination H. R. Bell - - .50 net 
 
 G. P. PILLING & SON CO. 
 
 SOLE LICENSEES 
 PHILADELPHIA, U. S. A. 
 
SHERMAN 
 
 VANADIUM STEEL 
 
 BONE PLATES ^ SCREWS 
 
 /i^ 
 
 
 
 Complete set of i8 plates as shown on wood panel 
 $14.00 
 
 Sing-le Plates 
 
 $1.00 EACH 
 
 WITHOUT SCREWS 
 
 5/8 IN. 
 1»^ 
 
 Sherman Screw Driver, $4.00 Net 
 FOR SALE BY ALL SURGICAL DEALERS 
 
 G. P. PILLING & SON CO. 
 
 PHILADELPHIA, PA. 
 
MERZON 
 
 UMBILICAL 
 CORD TIE 
 
 A sealed gflass jar contain- 
 ing- twenty-five yards of a 
 smooth silky finish cord so 
 braided that intense strength 
 is secured in a small narrow 
 braid. 
 
 MERZON Cord being fiat 
 will not cut or injure tissue. 
 
 Merzon Cord is so placed 
 in the packag^e and sealed 
 that just the amount required 
 for each operation may be 
 withdraw^n, without soiling: 
 contents of packag^e and the 
 entire contents of jar used 
 without snarling-. 
 
 Price, TS Cents 
 
 MERZON Umbilical Cord Tie is the orig^inal 
 and only safe packag-e to handle. Infring-ements of 
 Merzon Cord are on the market and the trade is 
 warned ag-ainst handling- any packag-e other than the 
 Merzon Cord, for which patents are applied for. 
 
 The Convenience and Low Cost of MERZON 
 and KORDO have made them favorites among" the 
 physicians, nurses, undertakers and veterinarians. 
 They should be found in the stock of every surg'ical 
 instrument house in this country. 
 
 FOR SALE BY ALL SURGICAL DEALERS 
 
 HENRY CLAYTON & BRO. 
 
 Philadelphia, Pa. 
 SOLE WHOLESALE DISTRIBUTORS 
 
CAUTION 
 
 Our attention has been called by physicians 
 to attempted 
 
 SUBSTITUTION 
 
 of other makes of Sphygmomanometers by 
 
 certain retailers because of 
 
 greater profits. 
 
 INSIST ON THE 
 
 PILLING-FAUGHT 
 
 G. p. PILLING & SON CO. 
 
 PHILADELPHIA, PA. 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the library rules or by special arrangement with 
 the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C28(946)MIOO 
 
 
 
 / 
 / 
 
RC74 
 
 Faught 
 
 Fb7 
 
 1914 
 
 Copy 1 
 
 Bloo d^ressure priacr... 
 
 C-/. 
 
 ^- 
 
 I1U.BINDEEY 
 
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