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Full text of "Blood-pressure from the clinical standpoint"

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BLOOD -PRESSURE 



FROM THE CUNICAL STANDPOINT 



BY 

FRANCIS ASHLEY FAUGHT, M.D. 

FORMERLY DIRECTOR OF THE LABORATORY OF CLINICAL MEDICINE OF THE 

MEDICO'CHIRURGICAL HOSPITAL ; INSTRUCTOR IN MEDICINE AT THE HEDICO- 

CHIRURGICAL COLLEGE, PHILADELPHIA 



ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1914 



Pablished June, 19x3 



Reprinted September, 19x3 



Copyright, Z913, by W. B. Saunders Company 



Reprinted February, 19x4 






LIBRARY 

724842 

UNIVERSITY OF TORONTO 



MINTED IN AMERICA 



PRESS OF 

W. ■. SAUMDERS COMPANY 

PHILADELPHIA 



PREFACE 

The past few years have marked a rapid rise in the 
clinical value of the sphygmomanometer. This instrument 
is now a part of the armamentarium of almost every physi- 
cian. It is opportune therefore that a book of moderate size 
should be produced containing in concise form, a resume 
of the clinical and experimental work which has led to present 
popularity of the blood-pressure test. 

In the following pages, the author has endeavored to 
present in easily accessible form, the pith of medical litera- 
ture bearing on blood-pressure studies in their relation to 
medicine, not only in cardio-vascular and renal conditions, 
but also in many diseases in which clinical observation 
has shown the information obtained by the sphygmomano- 
meter to be of value. 

It has been thought advisable to devote a number of 
pages to the discussion of the circulation and its relation 
to the blood-pressure, together with the various methods 
employed in sphygmomanometry, to acquaint the prac- 
titioner with the theory of this procedure, so that deduc- 
tions from his observations may be of greatest value. 

The writer is indebted to a large number of authors for 
much of the material contained in this work, which has 
been obtained largely from the medical hterature of the 
last seven or eight years. Whenever practical the full 
reference is given in the text, so that if desired, the facts 
contained in this little book may be supplemented by a 
study of the original. 

Francis Ashley Faught. 

6006 Spruce Street, Philadelphia, Pa. 



CONTENTS 



Paoh 

Introduction 11 

CHAPTER I 

Physiology 14 

The CirGulation 14 

CHAPTER II 

The Sphygmomanometer 23 

Description of Modern Instruments 25 

CHAPTER III 

The Principle of the Sphygmomanometer Circular Compression 39 

Directions for Operating the Standard Sphygmomanometer .... 46 

CHAPTER IV 

The Sphygmomanometer and Methods op Its Use 56 

Factors Influencing Blood-pressure 56 

CHAPTER V 

Terms, Definitions, Etc 69 

Venous Pressure 70 

Arterial Pressure 73 

The Blood-pressure Within Different Arteries 80 

CHAPTER VI 

Climatologic and Racial Influence 83 

CHAPTER VII 

The Relation of Blood-pressure to Athletic Life and Exercise . 88 

How to Determine Physical Fitness 91 

CHAPTER VIII 

Hypotension 96 

9 



IQ CONTENTS 

CHAPTER IX 

Pagb 

Htfbbtbnbion, Presclerosis, or Essential Arterial Hypertension 1 12 

CHAPTER X 
ARTERICeCLEROeiS 118 

CHAPTER XI 

D1SBA8XB OP the KiDNETS 140 

CHAPTER XII 
Myocardial Degeneration 152 

CHAPTER XIII 
Acute Infections 169 

CHAPTER XIV 
Chronic Infections 179 

CHAPTER XV 

Relation of Blood-pressure to Metabolic and Miscellaneous 

Diseases 186 

CHAPTER XVI 

Blood-pressure in Surgery 196 

Ophthalmology 208 

CHAPTER XVII 

Blood-pressure in Obstetric Practice 211 

CHAPTER XVIII 
Blood-pressure in Life Insurance ' 218 

CHAPTER XIX 
Methods op Controlling Blood-pressure 227 

CHAPTER XX 
Blood-pressure Elevators 266 



Im>Bz 271 



BLOOD-PRESSURE 

INTRODUCTION 

During the brief period from 1900 to 1910 our knowledge 
of sphygmomanometry developed from a procedure of 
uncertain and doubtful value, as viewed by the rank and 
file of the medical profession, to a method of examination 
equalled by but few of the many reliable methods of pre- 
cision in daily use by the general practitioner. 

Prior to 1900, a few pioneer physicians had developed 
the habit of making observations of the blood-pressure and 
recording their findings. These were available for their 
own use, and were employed to their own advantage and 
to the benefit of their patients. It is true also that for 
even a longer period the physiologist and his co-worker 
the pharmacologist, have been thoroughly acquainted with 
the value of this test, both in animal experimentation and 
in the sick-room. 

The pioneers in the field of cardiovascular disease early 

appreciated the great advantage they possessed by this 

means of graphically interpreting arterial tension over the 

old method of estimating tension or blood-pressure by the 

finger, for it was well known and readily demonstrated 

that the accuracy of the tactile estimation of blood-pressure 

was notoriously uncertain, being dependent on several 

variable and uncertain factors, and the estimation so 

11 



12 BLOOD-PRESSURE 

complicated that even at best an element of error amount- 
ing to from 10 to 80 mm. was frequently present. 

Following the pioneer work of Janeway, Russell, Mac- 
kenzie and others, a knowledge of the value of this subject 
gradually spread, during which many observers, recog- 
nizing the value of this procedure, began to apply the 
sphygmomanometer not only to the study of cardiovascular 
and renal diseases, but also to a large number of disease 
conditions in which changes in the circulation might be 
expected to occur. 

During the past five years, 1907 to 1912, the application 
of the sphygmomanometer has spread with great rapidity, 
and bids fair soon to become universal. Coincident with 
this continued activity, there has developed an immense 
literature bearing directly and indirectly upon changes in 
the circulation and in the organs relating thereto, both in 
physiologic and pathologic conditions. The science of 
medicine is so broad, its ramifications so extensive, and 
its literature so voluminous that few, if any, are able to 
accurately follow and intelligently grasp the almost daily 
advances in all branches of medicine. This fact furnishes 
the argument for the preparation of this little work, if 
indeed any be needed. 

A careful search of modern text-books, extending to the 
end of 1912, fails to reveal any work dealing with this sub- 
ject from the standpoint of the general practitioner, who 
80 far has had nowhere to turn in case of emergency, or 
from which to glean a few important facts in his spare 
half hours. No effort has been made to make this volume 
a complete and exhaustive review of the whole study of 
blood-pressure with its many ramifications, but the aim is 



INTRODUCTION 13 

rather to provide a compendium of clinical data in such 
form that the material contained will be readily available 
for immediate use. 

To properly appreciate the function of the sphygmo- 
manometer and the changing conditions of the circulation 
which it reveals, it is important to have a working knowl- 
edge of the theory of hydrostatics and of the physical 
conditions surrounding the circulation both in health and 
disease, and to possess a proper appreciation of the factors 
controlling the cardiovascular and renal systems and the 
significance of the terms employed in this study. It is 
proper therefore to commence with a brief general discussion 
of the circulation, even though to some it may seem to be 
a needless waste of time and space. 



CHAPTER I 

PHYSIOLOGY 
THE CIRCULATION 

The maintenance of a norm al circulation is essential to 
good^fialth. Abnormalities in the circulation are either 
the result of, or result in, disease. The activity of the heart 
is a vital function like respiration, for if the heart should 
cease to beat even for a very short space of time, the cir- 
culation would fail, and the individual would die. The 
heart must not only act continuously, but also in an approxi- 
mately normal manner in order to maintain the body in a 
condition of health. By failure of the circulation is meant 
a gradual diminution in blood-pressure, until it becomes 
insufficient to maintain body nutrition and offers insuffi- 
cient resistance for a normal action of the heart. 

Conditions affecting the action of the heart are shown by 
alterations in the circulation and variations in the circula- 
tion are shown by changes in the heart's action. The two 
conditions, heart action and a maintained circulatory 
equilibrium, are in every way interdependent. They can 
neither be separated, nor considered intelligently one apart 
from the other. This serves to emphasize the importance 
of a study of the circulation, not only in an investigation 
of circulatory diseases, but also in the study of diseases of 

14 



PHYSIOLOGY 15 

the heart, particularly pathologic changes in its muscular 
and nervous mechanism. 

We are for the most part indebted to Harvey^ for dis- 
covering and demonstrating the true function of the heart 
as the main-spring of the circulation. In 1616 Wm. 
Harvey stated that ''a perpetual movement of the blood 
in a circle is caused by the beat of the heart.'' From a 
perusal of the original or of the translation of Harvey's 
work on the circulation, it is evident that his conception 
was the true one, and that it forms the basis of our modern 
conception of circulatory physiology and pathology. It is 
of interest to note, however, that investigations of ancient 
manuscripts bearing on medicine show that some knowledge 
was possessed by the ancient Egyptians as shown by refer- 
ences to the heart, and the use of the word circulate in the 
Ebers papyrus. An interesting review '^The Advance in 
Knowledge Regarding the Circulation of the Blood" has 
recently been published by Dr. Geo. Wm. Norris. 

Between the heart and capillary system there is a large 
and ramifying network of blood-vessels of progressively 
narrowing individual caliber, but of rapidly increasing 
cross-sectional area, which convey the blood to every 
part of the body. By normal circulation we mean the 
normal distribution of blood to every part of the body, 
whereby the normal interchange of nourishment and waste 
is sustained in all organs and tissues. This metabohc 
function occurs in the capillaries, between which area 
and the heart the blood-vessels serve as a series of conduits. 
We see therefore that between the heart, as the central 

^ See Camac'a "Epoch-making Contributions to Medicine and Surgery," 
Philadelphia, 1909. 



15 BLOOD-PRESSURE 

source of supply, and the capillaries, the points of inter- 
change, there is a wide gap. This is filled by the arteries 
carrying blood on its way to the terminal points of inter- 
change, driven along by the intermittent pumping action 
of the heart. A rhythmically contracting heart and a 
volume of blood alone could not afford every part of the 
body its perfect supply of pabulum nor maintain an equal 
distribution of this fluid. We must necessarily have 
another mechanical factor to complete our system. This 
is blood-pressure.^ Blood-pressure is an essential factor 
for sustaining the circulation and maintaining heart ac- 
tion, and as a corollary we must recognize the arterial 
walls as a further factor in maintaining and regulating 
this circulation. This is by virtue of the elasticity and 
contractibility of the blood-vessel walls, whereby they 
may expand under an increase in pressure from within, 
or may contract to maintain or to elevate the pressure by 
a shortening of the circular muscular fibers in their walls. 

A normally acting circulation is shown by a normal 
[blood-pressure, which by virtue of being normal, shows 
that the heart action and the distribution of blood must 
be taking place in a normal manner. Therefore the study 
of blood-pressure becomes a most valuable and efficient 
guide to the state of the cardiovascular system and 
sphygmomanometry a most important diagnostic method. 
Bearing on the importance of this study A. Randle Short ^ 
says "It has become a truism that when feehng the pulse, 
it is of more importance to observe the tension, or blood- 
pressure, than to count the pulse rate. But only within 
the last few years has it been recognized how inadequately 

* The New Physiology in Surgical and Medical Practice. 



PHYSIOLOGY 



17 



even the skilled finger can judge the blood-pressure because 
of the comphcated factor of the variable rigidity of the 
vessel walls." Discussing the factor of the vessel wall, as 
preventing an accurate digital estimate of blood-pressure, 
Wm. Russell^ makes the following significant remark: 
*^I must, however, again 
add a warning note to the 
effect that feeling the ra- 
dial is not always a reli- 
able guide as to what the 
brachial pressure will 
read. In some cases the 
radial artery and its pulse 
would not lead one to 
suppose that the brach- 
ial pressm*e would be 
high. I have two such 
cases under observation 
as I write this. The ra- 
dial artery being neither 
hard nor incompressible, 
and yet in both there is 
a steady reading from 
brachial of over 200 mm. 
Hg. On the other hand, 
the brachial pressure may be lower than the state of the 
radial suggests. '^ 

In the human body we may trace the course of a given 
particle of blood as it leaves the right ventricle until, 
having traversed the entire cardiovascular system, it 

* Arteriosclerosis, Hypertonus and Blood-pressure, page 73. 
2 




Fig. 1. — General diagram of the circu- 
lation: the arrows indicate the course of 
the blood: PA, pulmonary artery; PC, 
pulmonary capillaries; PV, pulmonary 
veins; LA, left auricle ;LF, left ventricle; 
A, systemic arteries; C, systemic capil- 
laries; V, systemic veins; RA, right auri- 
cle; RV, right ventricle. (John G. Curtis 
in "American Text-book of Physiology.") 



Ig BLOOD-PRESSURE 

returns to the starting-point. Referring to Fig. 1, we 
find the course of the blood to be as follows : From the 
trunk of the pulmonary artery through a succession of 
arterial branches into the capillaries of the lungs, from 
there through the several branches of the pulmonary 
vein to the left auricle of the heart, thence through the 
mitral valve to the left ventricle, then by way of the aortic 
valve to the aorta and the general arterial tree until it 
finally reaches the capillaries. From the capillaries into 
the veins back toward the heart, through the vena cavse 
and into the right auricle, through the tricuspid valve 
into the right ventricle, through the pulmonary valve 
into the pulmonary artery where the tracing of the circuit 
began. 

In brief, the vascular system is a closed series of tubes 
of varying diameters, including a force pump. This tubu- 
lar system is partially interrupted at two points by a series 
of very minute vessels, the capillaries of the lung and of 
the general circulation. 

The condition of the arterial walls and the width of the 
arteries exercise considerable influence upon the flow of 
blood. If all the arteries of the body were fully dilated it 
would be absolutely impossible for the heart to maintain 
the ^ circulation, because the relatively small amount of 
blood in the body could not begin to completely fill the 
vessels. The caliber of the arteries is influenced mainly 
by reflexes coming from various parts of the body, including 
the heart and the blood-vessels themselves. Stimulation 
of a peripheral nerve will cause normally a reflex contrac- 
tion which will tend to raise blood-pressure. 

The force by which the blood is driven from the right to 



PHYSIOLOGY 19 

the left side of the heart, through the capillaries which are 
related to the respiratory surface of the lung, is nearly all 
derived from the contraction of the muscular wall of the 
right ventricle. The force by which the blood is driven 
from the left side of the heart through the general circula- 
tion, including all the other capillaries in the body, is 
nearly all derived from the contractions of the muscular 
wall of the left ventricle. The contraction of the two ven- 
tricles is simultaneous. The force generated by the heart 
in maintaining the circulation is, to a subordinate degree, 
supplemented by the aspirating action of the chest wall 
during the respiratory act, by the pumping action of the 
skeletal muscles and by the elasticity or tone of the arteries 
themselves. 

The usual systolic arterial blood-pressure, about 120 mm. 
Hg., is much more than is actually necessary to drive blood 
from the arteries into the veins. This extra pressure has a 
function, however, which is seen whenever the arterioles 
of any organ or small area relax. If the arterial pressure 
was barely adequate to sustain a flow, a lowered resistance 
in any part would seriously drain other regions. The 
high head of pressure, therefore, serves to keep all parts 
properly supplied with blood, even if an especially active 
part of the body is making an unusual demand. 

In order to better understand the cause of maintenance 
of blood-pressure it is necessary first to consider the science 
of hydrostatics as to its effect upon the circulatory system. 

Fluids are incompressible and the heart is an intermittent 
pump, therefore if the arteries were rigid and unyielding 
tubes, each increment of blood coming from the heart 
would be required to move all the blood in the whole 



20 BLOOD-PRESSURE 

arterial system, while during the heart rest, all flow would 
cease. This would result in the intermittent development 
of pressure, accompanied by periods when it must fall to 
zero. Such a condition would be inimical to health, as the 
proper nutrition and tension of the organs and tissues of 
the body would not be maintained. The arterial walls 
are, however, as already stated, not rigid but elastic and 
distensible, and are capable therefore of expanding under 
pressure to accommodate more fluid, while during diastole 
their elasticity and contractility tend to maintain pressure. 
This property gradually reduces the sharp intermittency of 
the flow in the arterial system, so that as we pass outward 
from the heart this feature becomes less marked and finally 
disappears before the capillaries are reached. Another 
factor enters here. This is the gradual tapering and ex- 
tensive ramification of the arterial system. This length 
of vessel combined with its elasticity aids in reducing the 
flow to a uniform rate of flow. 

A third factor is the relatively large number and minutely 
small diameter of the capillaries. If the vessels were short 
and the tubes of large diameter the alteration in flow would 
not occur and the blood would pass into the veins inter- 
mittently. This is shown in certain pathologic conditions 
where we have a capillary pulse and a transmitted venous 
pulse. 

In considering the factors involved in maintaining a 
uniform flow in the capillaries, we find that they also 
assist in establishing and maintaining pressure, for if the 
heart as a pump was large enough and the arteries short 
enough and the outlet large enough there would be no 
blood-pressure. In the arterial system, we find that 



PHYSIOLOGY 21 

blood-pressure is maintained first by the pumping action 
of the heart which acts against the friction of the walls 
of the blood-vessels, second by their narrowing diameter, 
and third by the viscosity of the blood itself. Starting 
with the arterial system as a closed system of tubes, 
including the heart, we find that as the heart begins to 
beat, the blood is pumped into the arteries, and in its 
passage toward the capillaries it meets with resistance. 
This causes the pressure to rise in the arterial system, 
which increase in pressure brings into action the normal 
tone of the arterial walls. So that as the pressure rises 
the arteries expand to accommodate an additional amount 
of blood, at the same time the blood-pressure rises, this 
increases the pressure in the capillary system and drives 
more blood into the veins in a given time. Blood-pres- 
sure will reach normal and be maintained there, when as 
much blood passes through the capillaries during a heart 
cycle as enters the aorta during systole. At this time, the 
power of the heart is exactly balanced by the factors of 
volume of blood in the arterial system, its viscosity and 
vasomotor tone. 

The term tonus or blood-pressure has been applied to 
indicate the amount of pressure existing within the ar- 
terial system, and this as we have seen, is dependent 
upon the factors just mentioned. The final and most 
important condition affecting blood-pressure is vasomo- 
tor tone. This is maintained through a special reflex 
mechanism which has for its purpose the maintenance of 
normal blood-pressure in spite of temporary alterations 
in peripheral resistance in different parts of the body. 
This system has the power of regulating the amount 



22 BLOOD-PRESSURE 

of blood reaching any part and is operated by the demand 
of organs and tissues for nutrition. 

We have therefore at any time in any individual, five 
factors which go to maintain normal blood-pressure. 

1. The energy of the heart. 

2. Peripheral resistance. 

3. Tonus. 

4. Volume of blood. 

5. Viscosity. 

These all may and do all vary under normal conditions 
and in pathologic states may become greatly altered. 

Not only may they vary independently of each other, 
but they are also so closely interrelated to the cardio- 
motor and vasomotor systems, that alterations in one 
of them may cause profound changes in another. We 
are as yet in possession of but incomplete evidence as to 
the relative value of these several factors, but enough 
is known to form a good working basis, which may be used 
to explain alterations in the circulation, both in health 
and disease, and which perhaps may be used to build up a 
rational therapy in cardiovascular and renal diseases, and 
other circulatory disturbances. 



CHAPTER II 
THE SPHYGMOMANOMETER 

The use of manometers or upright tubes filled with 
fluid, in the study and measurement of blood-pressure 
in man is attributed to an English clergyman, Stephen 
Hales/ who published the results of his experiments in 1733. 

The apparatus employed by Hales and his followers 
was naturally extremely crude and the result of their work 
of little practical value, and found little favor at the hands 
of either physicians or physiologists until about 150 years 
later, when the sphygmomanometer was first perfected 
and adapted to clinical purposes by Professor v. Basch, 
of Vienna, in 1876. This apparatus, as it appeared in its 
original form, consisted of a U-tube, one limb branched 
to join the ^ tube from the pelotte, which was used to com- 
press the artery under observation. The U-tube partly 
filled with mercury was provided with a scale reading in 
millimeters. The remainder of the tubular portion of 
the apparatus was filled with fluid which transmitted 
the pressure ^from the elastic membrane of the pelotte to 
the mercury. The original instrument of v. Basch has 
since undergone numerous modifications both by v. Basch 
himself and by others, of which the most important was 
the introduction of a portable metallic chamber or aneroid 
manometer. 

In 1889 Potain replaced the water of the earlier instru- 

^ Statistical Essays, London, 1733, Vol. II. 

23 



24 BLOOD-PRES3URE 

ments with air and raised the pressure in the circuit by- 
means of a bulb connected with the apparatus by a branch- 
shaped tube. During the next several years the instru- 
ments of V. Basch and Potain had considerable vogue 
but were not widely used because of several inherent 
defects in the construction of the instruments themselves. 

In 1896 Riva-Rocci^ and HilP published almost simul- 
taneously articles descriptive of new sphygmomanometers. 
The important feature of each of these instruments was 
the introduction of a rubber-bag or tube encircling the 
arm and inflated by a bulb or a pump. This improve- 
ment surmounted the most serious defect in the earlier 
instruments, which was the difficulty of accurately adapting 
the small round pelotte to the arm, thereby compressing 
the artery (the radial) directly over the bone. By the 
method of Riva-Rocci and Hijl, the pressure is everywhere 
exerted at right angles to the tangent of the circumference 
of the arm, and the artery is therefore compressed equally 
from three sides against the bone. 

Since this time there has been practically no change 
in the principles of sphygmomanometry. Improvements 
having been made toward perfecting the apparatus and 
simplifying the technic, changes having been directed 
chiefly toward portability, in means of circular compres- 
sion, and source of pressure. 

From the narrow arm-band as originally employed by 
Riva-Rocci (4.5 cm. — 2 in.) to the extremely wide band of 
Von Recklinghausen, numerous investigators have de- 
termined that a cuff 11 to 13 cm. (4 1/2-5 in.) in width 

»G<M. med. di Torino, 1896, Nos. 50 and 51. 
* Brit. Med. Jour., 1897, Vol. II, p. 904. 



THE SPHYGMOMANOMETER 



25 



gives the most nearly accurate readings, except perhaps in 
the extremely obese. A special narrow cuff may also be 
found advantageous for work with babies and small 
children. 

With accurate indicators and a standard cuff the values 
obtained in blood-pressure studies are comparable from 
individual to individual and are almost entirely independent 
of the variations in the soft parts which overlie the vessel. 
(See Chapter III.) 

DESCRIPTIONS OF THE MODERN INSTRUMENTS 

1. Riva-Rocci Sphygmomanometer (Fig. 2). — The mer- 
cury manometer is of a cistern form. This reduces prac- 
tically to zero the fall in the other column such as occurs 




Fig. 2. — Riva-Rocci's sphygmomanometer. (Sahli and Potter.) 

with the U-tube, and permits the use of a millimeter scale 
for measuring the height of the mercury column. The 
scale reads up to 260 mm. (10 in.) Hg. The cistern is of 
heavy glass, from which emerge two tubes, one for the 



26 



BLOOD-PRESSURE 



inflating apparatus and the other for the attachment of 
the arm-band. The latter is provided with a release valve 
for gradually lowering the pressure in the circuit during 
the test. 

The armlet consists of a hollow rubber tube covered 
with silk having a width of 4.5 cm. (2 in.), which is fastened 
to the arm with a special clamp. The inflating apparatus 




Fig. 3. — Cook's modification of the Riva-Rocci sphygmomanometer, 
showing narrow arm-band in place, with cautery bulb inflator. 

is a double bulb such as is employed with a thermocautery. 

The apparatus stands firmly on a solid base and has a 
scale which is easy to read, it is easy to adjust and rapid in 
operation. 

Disadvantages. — The size and construction of the appa- 
ratus make it not easily portable. The armlet is too narrow 



THE SPHYGMOMANOMETER 



27 



for accurate readings, and the elasticity of the tubular 
system makes diastolic readings difficult. It is not available 
for pressures over 260 mm. (10 in.) of mercury. 

2. Cook's Modification of the Riva-Rocci (Fig. 3).— 
This is very similar to the preceding but is of Hghter con- 
struction, and is provided with a jointed manometer tube 




Fig. 4. — Stanton's sphygmomanometer, showing arrangement of parts, 
with cautery bulb infiator. 

which allows the instrument to be packed in a smaller 
space. It employs the small armlet and the double bulb 
infiator. 

Disadvantages. — It does not stand firmly and is easily 
upset and broken. Without special care in packing and 
transportation the mercury is often spilled. The caliber 
of the tube (1 mm.) is too small and the narrow cuff gives 



28 



B LOOD-PRESSURB 



readings that are too high. The scale etched on the glass 
is difficult to read. 

3. Stanton's Sphygmomanometer (Fig. 4). — This in- 
strument was devised in an effort to increase portability, 
to reduce the probability of breakage and to lessen the 
elasticity of the tubular system, thereby improving the 
diastolic fluctuation of the mercury. 




Fig. 5. — Janeway's sphygmomunuimur, attached to arm, showing 
method of retention of cuff, arrangement of momanometer, with Politzer 
bag inflator. 

These changes were effected by substituting a metal 
cistern and by arranging over this a screw joint for the 
attachment of the vertical glass tube; also the introduction 
of a stopcock in a short tube as it emerges from the cistern 
to serve for attachment of the inflating bulb, this elimi- 
nates the elasticity of the inflating apparatus during the 



THE SPHYGMOMANOMETER 29 

diastolic reading. The instrument employs the standard 
12-cm. (4 1/2 in.) cuff retained on the arm by a canvas 
outer cuff and buckle straps. 

Disadvantages. — Chiefly the time and skill required to 
set up the apparatus before using, and the great difficulty 
in avoiding the loss of mercury during the setting-up process. 
Finally the cistern arrangement gives low readings in high 
pressures. 

4. Janeway's Sphygmomanometer (Fig. 5). — In the 
construction of the Jane way apparatus we see a return to 
the U-tube type, first devised by v. Basch. This form 
appears to be a more accurate method of employing the 
mercury column, since in the cistern form no cognizance 
is taken in the change in the level of the mercury 
in the cistern, which must, for physical reasons, give 
too low readings when employed in the study of high 
pressures. 

This instrument employs the circular compression band 
of standard width and a Politzer bag for inflation, thus 
eliminating the frequent rupture of the double cautery 
bulb which occurs in high pressures. Apart from this, the 
only original feature of this instrument is the jointed 
U-tube which allows the instrument, without cuff or 
inflating bag, to be contained in a case measuring 10 1/4 X 
4 5/8X1 7/8 in. and weighing 2 1/2 lb. 

The open end of the manometer tube is closed with a 
cork when not in use, and the rubber connection on the 
other limb leading to the attachments is compressed by 
closing the case, to prevent loss of mercury from the 
manometer. The scale is arranged to slide down into the 
box when not in use. The arm band is 12 cm. (4 in.) wide 



30 BLOOD-PRESSURE 

and is retained on the arm by an inelastic outer cuff pro- 
vided with friction straps. 

This apparatus is light, compact and portable and the 
readings are accurate. 

Disadvantages. — Frail because of jointed U-tube. The 
mercury is easily spilled because of the loose methods 
employed to confine it when the instrument is not in use. 




Fig. 6. — Faught's mercury sphygmomanometer, showing relation of parts, 
metal pump, and special expansion tubing for inflator. 

The rubber connections are short-lived and must be re- 
placed at irregular intervals. 

The Faught Standard Mercury Sphygmomanometer 
(See Fig. 6.). — This apparatus was devised in the early 
part of 1909 in an endeavor to overcome if possible the 
shortcomings of existing instruments, the majority of 
which were frail, required special skill to operate, con- 
sumed too much time and were defective mechanically. 



THE SPHYGMOMANOMETER 31 

The Standard sphygmomanometer is of the U-tube type 
in the construction of which, all complicated parts have 
been either simplified or eliminated. The complete ap- 
paratus including the cuff of standard width, and the 
inflating pump may be enclosed in a mahogany carrying 
case, measuring 14X4X4 1/2 in. The lid is hinged and 
locks in a vertical position to serve as the support of the 
manometer and the connections. Each arm of the U-tube 
is provided with a guard cock which remains closed, 
except during actual use of the instrument, thus preventing 
absolutely any loss of mercury, excepting where there is 
gross carelessness. There are no rubber connections; 
the upper nipple to which the pump is attached is provided 
with a stopcock, which must be closed during the systolic 
and diastolic readings. The millimeter scale, which can 
be adjusted to the level of the mercury is reduced one-half 
to compensate for the fall of the mercury in the other limb, 
thus the markings give the reading directly in millimeters 
of mercury. The pressure is obtained by the use of a 
metallic pump attached to the upper nipple by means of a 
collapsible rubber tube of special construction, which by 
its expansion during the' operation of the pump, reduces 
the impact of air before it reaches the mercury in the ma- 
nometer, and takes the place of the second bulb of the cau- 
tery apparatus. An escape-valve is provided for grad- 
ually lowering pressure during the test. 

Disadvantages, — It being perhaps somewhat difficult 
for an author to see the possible defects in an apparatus 
of his owji devising, criticisms of this instrument must 
therefore be left for others. It is not believed that the 
size of this instrument, and its weight as compared to the 



32 



B LOOD-PRESSURE 



more recently de\ased pocket types of sphygmomanometer, 
should be considered detrimental, as many students prefer 
the mercury type, and use it exclusively in physiologic 
research. 

Faught Pocket Sphygmomanometer (Fig. 7). — This 
instrument reverts to the type represented by the later 
models of v. Basch and Potain, in that four metallic 
diaphragms are substituted for the U-tube of the manome- 




FiG. 7. — Faught pocket sphygmomanometer attached to arm showing 
position of arm-band, dial attached to hook and arrangement of tube 
connections. 

ter. The result is an exceedingly compact and portable 
apparatus, which when folded in its case, may be carried 
in the pocket. 

The dial is of white enamel, somewhat similar to that 
of a watch. The scale is graduated in millimeters of 
mercury, as determined by accurate callibration with a 
standard mercury column. The numerals are in red and 
black, to facilitate reading, and each individual graduation 



THE SPHYGMOMANOMETER 33 

represents two millimeters, giving a working scale extending 
from zero to 300. No mathematical calculations are 
necessary to compute the pressure, which can be easily 
read directly from the dial. 

A similar instrument devised by Dr. Rogers is graduated 
in centimeters only, on a scale which terminates at 260. 
It is therefore less convenient and less practical than the 
one above referred to. 

The accuracy of the so-called aneroid, spring or dia- 
phragm type of sphygmomanometer has been questioned 
by some, but the objections appear to be based upon a 
superficial knowledge of the constructional characteristics 
and care employed in their manufacture. Special tests 
made by both the author and by others have shown that 
the danger of these instruments suddenly becoming 
inaccurate is very slight, and could only result from clog- 
ging from the mechanism and would be detected instantly. 
The so-called ^^ fatigue of metal" referred to by some 
authorities does not exist, and any error which manufac- 
turers admit may develop in their instrument, must be due 
to some mechanical defect, which in the Faught Pocket 
Sphygmomanometer, at least, has been overcome. In 
order to insure accurate and unvariable readings at all 
points on the scale, a factor of safety of 150 mm. has been 
provided, i.e., each instrument before leaving the factory 
is tested up to 150 mm. above the 300 on the scale, or to 
450, after which the readings must correspond with those 
of a standard mercury column, and the needle after this 
severe test must return immediately to zero. This shows 
clearly that, with ordinary use it is practically impossible 
to distort the compression chambers of the instrument, 



34 



BLOOD-PRESSURE 



and so render it inaccurate. It has never been found 
necessary to compare the Faught Pocket Sphygmoma- 
nometer with a mercury sphygmomanometer to insure its 
accuracy. 

This instrument employs the flexible bandage cuff or 
arm-band, the inflatable portion of which measures 5X9 
in. A small metal pump with ex- 
haust valve attached is supplied and 
these parts in addition to the Mo- 
rocco pocket case, constitute the 
latest and most improved type of 
sphygmomanometer. The needle of 
the indicator is extremely delicate and 
so sensitive that a diastolic reading 
may be made in any case in which 
a mercury manometer will accom- 
plish it. 

8. Bishop's Sphygmomanometer. 
— This apparatus is very ingenious. 
It depends for its operation upon 
pressure produced by elevating a 
column of heavy fluid in a flexible 
tube, to one end of which is attached the arm-band, and 
to the other a small reservoir. The flexible tube is gradu- 
ated in the equivalent of millimeters of mercury. The 
reading is obtained by attaching the cuff to the arm and 
then elevating vertically the tube with its reservoir until 
the pressure developed obliterates the pulse at the wrist. 
At this point the marking on the tube at the level of the 
arm-band gives the subject's blood-pressure in millimeters 
of mercury. 




Fig. 8. — Faught pocket 
apparatus dial in detail. 



THE SPHYGMOMANOMETER 



35 



Disadvantages. — This apparatus while portable and com- 
pact is, on account of the length of the tube, rather awkward 
for one person to operate, for the same reason the reading 
is only approximate and is available only for systolic 
readings unless the auscultatory method is employed. 

9. Erlanger's Sphygmomanometer (Fig. 9). — This instru- 
ment in its improved form is apparently the most accurate 




Fig. 9. — Erlanger's sphygmomanometer with kymographion in place, show- 
ing arm-band and atomizer-bulb inflator. 

yet devised for determining blood-pressure, being based 
upon the same principle as the other instruments but 
both the return of the pulse and the point of maximum 
pulsation are made clearly visible, thus almost entirely 
removing subjective errors. 

The construction of this instrument is more complicated 
than any other but the only essential difference is the 



36 BLOOD-PRESSURE 

addition of an original recording device. The U-tube 
manometer connects with a four-way tube, of which one 
branch leads to the armlet, and another to a special stop- 
cock. The vertical branch communicates with the interior 
of a rubber bulb, enclosed within a heavy glass bulb, 
which in turn, under certain conditions communicates 
freely with the atmosphere through another tube returning 
to the special stopcock. The object of this glass-encased 
rubber bulb is to shield the delicate tambour from too 
sudden changes in pressure. The tambour communicates 
with the air in the glass bulb outside of the rubber ball, 
and operating an aluminum needle above the tambour, 
inscribes its movements on a revolving drum. This 
makes a tracing upon smoked paper as in the ordinary 
kymographion. The whole is attached to a metal base 
and is covered for transportation by a metal case which 
is somewhat larger than a microscope box and about as 
heavy. 

The standard cuff is employed and pressure is obtained 
from a Politzer bag. All rubber tubing is of the high- 
pressure variety to afford rigidity. 

The minute details of construction and the operation 
of the special stopcock are too extensive to include here, 
suffice to say that with practice in handling the instrument 
the readings obtained are very accurate and furnish a 
permanent graphic record of both systolic and diastoUc 
pressures. 

Disadvantages, — The chief fault to be found with this 
apparatus is from the standpoint of chnical availability. 
Its bulk and weight render it almost useless for clinical 
work except perhaps in the office or the hospital. The 



THE SPHYGMOMANOMETER 



37 



technic of smoking the cylinder and of making necessary 
adjustments consumes more time than one can generally 



H-.u 



PULSE, TEMPERATURE AND BLOOD . PRESSURE CHART 



CHART NO.. 

OCCUPATION S ftAtftrrVVVllS- . 



Deaifned b; Francis A. Fautht. H. D. 



COLOR 
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spare during the pursuit of an active practice. Also the 
rubber connections and the diaphragm of the tambour 
so often need replacing at most inconvenient times. 



38 BLOOD-PRESSURE 

The value of graphite records to-day is sufficiently 
ob\ious and needs no argument. We would know little 
of the characteristic temperature curves of malaria or 
typhoid fever if we depended for our information upon 
a long column of figures. The course of blood-pressure 
is equally easy to chart and the curve thus obtained at a 
glance tells us much that the perusal of the usual written 
record would fail to convey. In both acute and chronic 
diseases and during operations the systolic blood-pressure 
and the pulse should be charted at regular intervals. 

This chart is arranged in the form of a combined pulse, 
temperature and blood-pressure chart, the several scales 
being so placed that the pulse, temperature and blood- 
pressure curves do not become superposed. (See Fig. 10.) 

The chart sheet measures 9X12 in., which is the same 
size as the usual hospital history sheet. The chart may 
be filled in, in different colors if desired to make the record 
more graphic, but this is not necessary to its proper keeping. 
These charts may be obtained in pads of twenty-five from 
any surgical instrument dealer at a nominal price. 



CHAPTER III 

THE PRINCIPLE OF THE SPHYGMOMANOMETER 
CIRCULAR COMPRESSION 

This is the basis of modern sphygmomanometry without 
which the modern sphygmomanometer could not have 
been developed, and the immense value of this procedure 
lost to clinical medicine. For obviously the direct method 
of the physiologist is not applicable, as it requires direct 
connection between the vessel and the tube leading to the 
manometer. 

It remained for Riva-Rocca and Hill, each working 
independently of each other, to substitute the arm-encirc- 
hng cuff for the uncertain and inaccurate pelote of v. 
Basch. 

By means of the encircling arm-band, the pressure pro- 
duced within the hollow inflatable rubber portion is exerted 
equally from every direction against the artery. This 
is true whether the inflatable portion of the arm-band 
completely surrounds the arm or not. Physiologic experi- 
ment has shown that the tissues intervening between the 
surface and the artery offer a negligible amount of resistance 
and that observations obtained through the tissues by 
the modern sphygmomanometer agree very closely with 
those obtained by the direct method. 

It has been said already that the width of the tubular 

cuff influences to a significant degree the reading obtained. 

This is easily explained by noting the change which occurs 

39 



40 



BLOOD-PRESSURE 



within a narrow (2 in.) and a wide (5 in.) cuff during 
inflation under a rigid retaining device — ^reference to the 





Fig. 11. — A. Schematic section of arm, showing narrow arm-band (a) 
with retaining device (6) before inflation, artery (c). B. Same showing 
change in form of compression band (a), after inflation, artery (c) compressed. 
Note great change in form and increase in circumference of compression 
bag. This change occurred only at the expense of a measurable amount of 
pressure. 

accompanying illustration will aid the explanation. Fig. 
1 1 shows a narrow armlet which allows insufficient material 
to indent the tissues and compress the vessel without 




d 

Fig. 12. — A. Schematic section of arm showing wide arm-band (a) with 
retaining device (6) and artery (c) before inflation. B. Same, showing 
change in form of compression bag (a) after inflation artery (c) compressed, 
note slight change in form of compression bag, insufficient to exert any addi- 
tional force than that required to compress artery. 

requiring additional pressure to expand the rubber bag, 
this amount being registered on the scale of the sphyg- 
momanometer in addition to that required to compress the 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 41 

vessel. Chamberlain^ has determined that this amount 
of error on an arm of average size is 8 mm. or more. 

Fig. 12 shows wide arm-band (A) before compression 
and (B) after compression, where the change in form of 
the rubber portion is insufficient to exert pressure beside 
that required to indent the tissues and compress the vessel. 

Influence of the Vessel Wall. — Upon this subject 
authorities differ. The early experiments of v. Basch^ 
show that the resistance to closure of a normal radial 
artery scarcely amounts to 1 mm. and Janeway^ agrees 
with this. On the other hand Russell^ does not agree, 
but states after discussing the factors involved, that 
''I cannot but think that those who have thought that the 
vessel wall was negligible have not had the data necessary 
to correct opinion." The author's belief is that the 
vessel wall, as a factor, need not be considered from a 
clinical standpoint as any resistance which could be 
offered by a vessel even markedly sclerosed would be 
insignificant when compared to the alterations in pressure 
occurring within the vessel. I submit as proof the many 
high-pressure cases that are met where but little change 
can be demonstrated in the superficial vessels, and on the 
other hand, I saw a case recently whose superficial vessels 
(radial so far as it could be digitally traced) w^ere absolutely 
rigid, so firm that one had the feeling that careless handling 
would cause them to break, and yet at no time did the 
blood-pressure register over 110 mm. 

^ Chamberlain, Philippine Jour, of Sci., Vol, VI, No. 6, Sec. B, Dec, 1911. 
- Berlin klin. Wochen., 1887, Vol. XXIV. 
^ Janeway, Clinical Study of Blood-pressure, p. 61. 

* Arterial Hypertension, Arteriosclerosis and Blood-pressure, J. B. 
Lippincott, 1908, p. 52. % 



42 BLOOD-PRESSURE 

It seems safe to assume that the vessel wall as a definite 
factor can be absolutely eliminated because all pressures 
are read through the vessel wall, which always being 
included can clinically at least be ignored. 

Influence of Other Intervening Structures. — Vital tissue 
is perfectly elastic. Therefore any pressure applied to 
the surface of the body is directly transmitted to the under- 
lying structures without loss of force. 

Pressure is applied to an accessible part of the body 
over a large blood-vessel such as the brachial. If the 
amount of this pressure is sufficient to overcome the pres- 
sure of the blood within the vessel, the vessel will collapse 
and the pulse be prevented from passing beyond it. If 
the amount of the compressing force is measured and ex- 
pressed in definite terms of weight (as millimeters of a 
column of mercury) then we can, by applying just sufficient 
pressure to collapse the vessel, measure the amount of 
force exerted by the blood in resisting this collapse. 

In practice the pressure is produced by a cautery bulb 
or a small hand pump, and is applied to the arm by means 
of a hollow flat rubber bag. This is wrapped about the 
arm and held there by some form of inelastic cuff. Com- 
munication with a mercury manometer measures the 
amount of pressure applied to the vessel. 

Fig. 13 A and B shows the relation of the compression 
bag to the artery. In Fig. 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 Fig. 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 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 



43 



each systole a small amount of blood passes the constriction 
and will reach the distal end of the artery, where the wave 
can be felt by the palpating finger at the wrist. 

Fig. 14 A and B represents the conditions existing 
between the constricting cuff and the vessel at the diastolic 





Fig. 13. — A. Pressure in "6" 135 mm. Hg., pressure in "a" 130 mm. Hg., 
B is therefore collapsed, pulse cannot pass. B. Pressure "6" 129 mm. Hg., 
pressure in "a" 130 mm. Hg., pulse passes. Diagram of relations of armlet 
to brachial artery. Explanation of systolic reading: a, artery; 6, compress- 
ing armlet; c, retaining cuff; d, tube to manometer; e, humerus. 

time of pressure. A represents a pressure within the cuff 
less than the systolic pressure in the vessel. This is 
insufficient to affect the vessel during the systolic period. 
B shows the artery and cuff during the diastolic period, 
when the pressure within the artery is at its lowest point, 



44 



BLOOD-PRESSURE 



a fraction of a millimeter less than the pressure within 
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 compres- 
sion. This affects the pressure of air within the cuff 





Fig. 14. — A. Systolic pressure in "a" 130 mm. Hg., pressure in "6" 101 
mm. Hg., artery not compressed. B. Diastolic pressure in '*a" 100 mm. 
Hg., pressure in '*6" 101 mm. Hg., artery collapsed. Diagram of relation 
of armlet to brachial artery. Explanation of diastolic reading; a, artery; 
6, compressing armlet; c, retaining cuff; d, tube to manometer; e, humerus. 



which 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 synchronous with the 
pulse beat. Since the fluctuation will reach a maximum 
at the time when the pressure in the cuff is approximately 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 



45 



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. 

Method of Application. — The practical application of 
the modern sphygmomanometer is a very simple proce- 
dure requiring very little experience and occupying very 
little time. 




Fig. 15. — Explanatory diagram showing individual parts of apparatus: Ay 
armlet — rubber; B, armlet — leather; C, armlet — connection; D, nipple for 
armlet; D^, nipple for armlet; F, nipple for pressure; G, scale; H, man- 
ometer tube; K, guard cock; L, guard cock; M, pressure guard cock, 
N, exhaust valve; 0, pneumatic chamber; P, pump; R, union nipple; 
T, oscillometer tube; t/, oscillator; V, vertical connection; F, flexible 
connection. 



The component parts are much the same in all makes, 
excepting for slight differences in detail, such as the con- 
struction of the arm-band, location of attachments for 
tubes, etc. Therefore a detailed description of one will 
serve equally for all. 



46 BLOOD-PRESSURE 

The accompanying illustration (Fig. 15) will serve as a key, 
the letters upon it being uniform throughout all the 
illustrations of the Faught-Pilling Instruments and includ- 
ing the Fedde DiastbHc Indicator. 

DIRECTIONS FOR OPERATING THE STANDARD SPHYGMO- 
MANOMETER 

The patient should be in a comfortable position, and 
either in a sitting or a 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 patient and 
securely bound there by the leather cuff and straps B. 
The cuff should be applied snugly, but not with pressure, 
as it is not designed 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. 

This arrangement forms a continuous closed pneumatic 
system communicating freely with the manometer 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. 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 47 

To Obtain the Systolic Reading. — With one hand find 
the pulse at the wrist of the arm, to which the arm-band has 
been applied. The fingers should be in a comfortable posi- 
tion and under no circumstances 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. 

Palpatory Method. — While the pulse is thus under ob- 
servation, 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 pulse 
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 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 observa- 
tion. It is advisable to repeat this procedure a few times 
to check the correctness of the finding. 

Auscultatory Method. (Fig. 16.) — In 1905, Korotkow 
first discovered that when the bell of a stethoscope was 
placed over the brachial artery just below the cuff of the 
sphygmomanometer, a series of characteristic sounds could 
be heard when the pressure was gradually released. These 
sounds, of which three were described, were found to bear a 
definite relation to the character of the pulse and to the 
systolic and diastolic blood-pressure in the artery. When 



48 



BLOOD-PRESSURE 



the artery is compressed, and no blood passes the cuff, no 
sound can be heard in the stethoscope. The first sound to 
appear is a clear sharp tone which corresponds to the first 
pulse wave to pass beyond the cuff (first phase) the third 
sound is dull and quite suddenly disappears (third phase). 
This point was believed to indicate the moment of diastolic 
pressure within the cuff. 




Fig. 16. — Auscultatory blood-pressure test. 

Subsequent observers, among them Ettinger and Good- 
man and HowelP have shown that there can usually be dis- 
tinguished five phases, which are described as follows: 

First phase. A sharp clear tone, which indicates the 
first passage of the arterial stream beyond the cuff (first 
phase of Korotkow). 



» Arch. Int. Med., Vol. VI, 1910. 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 49 

Second phase. This same tone dulled combined with a 
series of faint murmurs. 

Third phase. A change to another sharp clear tone, 
which more or less suddenly becomes dull. 

Fourth phase. The moment that above-mentioned 
change occurs. 

Fifth phase. All sound disappears (third phase of 
Korotkow). 

Much critical work has been done to determine, if possi- 
ble, the significance of these tone changes and their bearing 
on the circulation in health and disease. A summary of 
this work is as follows: 

The appearance of the first sound measures accurately 
the systolic pressure. This point has been confirmed by 
records made with the Erlanger instrument.^ The reading 
by this method has been found to be 10 to 15 nam. higher 
than the method of palpation. According to Warfield, all 
phases are not by any means always differentiated. 

The tones are dependent upon three factors : 
First, heart strength. 
Second, size of artery. 
Third, arterial elasticity. 

The third tone normally is the loudest, and it is generally 
beheved that a loud, long clear third phase is indicative of a 
strong heart, a weak third phase a weak heart, and an 
absent third phase a greatly weakened, dilated heart. 
Arteriosclerosis accentuates the third phase so that when 
present we may note a good third phase even with a weak- 
ened heart. 

Goodman and Howell (loc, cit.) direct attention to the 

1 Warfield, Interstate Med. Jour., Vol. XIX, No. 10, p. 860. 

4 



50 BLOOD-PRESSURE 

varying strength and quality of the sounds in cases of 
irregular hearts, and they believe that they were able to 
detect slight irregularities in force, more readily by auscult- 
ing the artery than by the heart itself. 

Another conclusion of these investigators is that, a long 
drawn-out fourth phase is very significant of aortic insuffi- 
ciency, in this Warfield's studies agree. 

It is generally accepted that the disappearance of all 
sound measures the diastolic pressure. Warfield contests 
this and proves his contentions by studies made with the 
Erlanger instrument. However this may finally be set- 
tled, it would seem best to adhere to the present view, so 
that records made from time to time by different ob- 
servers shall be comparable. 

To Obtain the Diastolic Pressure. — The diastolic pres- 
sure may be obtained in several ways. The method 
employed will depend upon the character of the instrument 
used and the preference of the operator. The methods 
will be described in the order in which they have been 
devised. 

1. Visible Method, — This depends on the to-and-fro 
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 pres- 
sure to fall very slowly by releasing the air through the 
valve A^. 

As the mercury falls below the systolic point, there will 
in most cases be noted a rhythmic motion synchronous 
with the pulse. This gradually increases in amplitude 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 51 

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. 

2. Palpatory Method, — Raise the pressure within the 
apparatus to the systolic point, then, while keeping the 
fingers on the pulse, allow the mercury column to fall 
gradually as in the first method. It will then be noted 
that at first the pulse is very feeble and thready in character 
and continues so for a time, when, as the pressure falls, 
it will suddenly assume the full bounding character of 
the pulse of aortic regurgitation. At the moment that 
this change occurs the height of the mercury column 
will represent the diastolic pressure in millimeters of 
mercury. 

3. Auscultatory Method. — This is also available for the 
diastolic readings, and employs, as in the systolic method, 
a stethoscope placed over the vessels at the bend of the 
elbow. As the pressure is allowed to further recede within 
the apparatus, a series of tones may be heard (see page 47), 
until a point is reached when a soft blowing murmur 
develops, to almost immediately disappear, after which 
no further sound is audible. It has been found that this 
last sound is heard at the diastolic period, and therefore 
a reading of the sphygmomanometer at this moment 
will indicate the diastoUc blood-pressure. 

The auscultatory method has the advantage over all 
others in that it is available in every case regardless of the 
size and volume of the pulse, and can be applied to any 
make of sphygmomanometer. It should be borne in mind, 



52 



BLOOD-PRESSURE 



however, that diastolic readings made by the auscultatory 
method may be from 10 to 15 mm. lower than those 
obtained by the visible or the palpatory methods. 

A special stethoscope has recently been devised which 
is a great aid in performing the auscultatory method. 
This, as shown in the accompanying cut (Fig. 17), is a 
Bowles stethoscope with a button-Uke projection from the 




Fig. 17.— Multiple sphygmometroscope. Adaptation of multiple Bowles 
stethoscope for auscultatory reading of blood-pressure. 

face of the diaphragm, which greatly faciUtates application 
to the artery below the sphygmomanometer cuff. This 
is secured in position by a narrow cuff fastened with a 
friction buckle. This little apparatus is self-retaining 
and allows the operator the freedom of both hands with 
which to manage the sphygmomanometer. This is quite 
important as it will be found expedient to note the first 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 53 

disappearance of the pulse by palpation of the radial, 
as in the other methods, thereby preventing accidental 
or careless overcompression of the arm. 

The accompanying illustration presents a new device to 
facilitate the teaching of blood-pressure readings by the 
auscultatory method. 

The chief drawback to this method has been the seeming 
difficulty which the average physician has in learning to 
perceive and interpret the sounds heard over the artery. 
In thinking over this matter, the idea suggested itself that, 
if the sphygmometroscope was made into a multiple of say 
four, whereby the sounds could be heard by more than one 
individual at the same time, it would overcome this diffi- 
culty and make it possible for anyone familiar with the 
sounds heard during auscultatory blood-pressure observa- 
tions to direct the attention of a small group of observers 
during the actual performance of the test. This has been 
done,^ and the result proved highly satisfactory. No dif- 
ficulty resulting from the distribution of the sound through 
a larger tubular system. 

This device would be found valuable, particularly to the 
medical teacher, as it has been my experience that many 
students go through their chnical studies without ever 
actually hearing or seeing the thing demonstrated. It is 
applicable also in demonstrating conditions, involving 
marked variations in pressure, to medical societies or groups 
of medical men. 

4. Diastolic Indicator. — This may be attached to any 
make of sphygmomanometer and is of decided advantage 
in determining an accurate diastoHc pressure when the 

1 J. F. Prendergast, N. Y. Med. Jour., vol. xcvii, No. 2, 1913. 



54 



BLOOD-PRESSURE 



systolic pressure is very feeble. (See Fig. 18.) Its ap- 
plication is very similar to Method No. 1 except that the 
movement of the mercury column is ignored and the move- 
ment of the pith ball in the small vertical tube rehed upon 
to determine the diastoUc pressure. 

Reference to Fig. 15, will show the method of uniting the 
Fedde Indicator to a sphygmo- 
manometer. 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. 

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 maximum as the level of the mercury column gradually 
falls, when quite suddenly, its motion becomes markedly 
less. At the moment of this reduced movement the level 
of the mercury will indicate the diastoHc pressure. 

It must be borne in mind that the indicator gives a di- 
astolic pressure considerably lower than 1 and 2 (about 10 
to 15 nrni.). 

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 




Fig. 18. — Fedde indicator 
as separate unit. 



SPHYGMOMANOMETER CIRCULAR COMPRESSION 55 

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 width of cuff, 
the time of day, the pulse rate, the sex and age of the 
patient. 

Care should also be taken to see that the observation is 
not too prolonged, for the interruption of the circulation in 
the extremity will, if continued, itself cause changes in 
pressure. 

No single reading should be accepted when it is possible 
to make more than one. It is better to see a patient a 
number of times under varying conditions before finally 
deciding what his blood-pressure is. 



CHAPTER IV 

THE SPHYGMOMANOMETER AND METHOD OF ITS 

USE 

FACTORS INFLUENCING BLOOD -PRESSURE 

There may be still some who are loath to accept the new 
order of things. Old-fashioned practitioners, who either 
cannot or will not see anything good in the many aids to 
diagnosis employed by physicians. We are now in an age 
of development and progress, and he who does not progress, 
recedes, there is no middle ground. The following ab- 
stracts are particularly directed toward the skeptic, or he 
who has so far failed to see the value of the sphygmoman- 
ometer. Dr. Jane way asks and answers this trite question :^ 
"When should the general practitioner measure the blood- 
pressure?" To this he replies "First, in every careful 
examination of the cardiovascular system. Second, in 
the first examination of every new patient, and the occa- 
sional examination for purposes of establishing prognosis 
in cases of hypertensive cardiovascular disease and in ne- 
phritis. Third, in examinations for the certification of 
health, such as applicants for life insurance, recruits for 
the army, navy, police, fire department, etc., and the 
examination of boys and others for competition in athlet- 
ics." This summary fairly expresses the sentiment of a 
large number of cUnicians. 

» Theo. C. Janeway, Albany Medical Anncds, March, 1911. 

56 



THE SPHYGMOMANOMETER AND ITS USE 57 

Add to this an almost unlimited field offered by 
many pathologic conditions in which the blood-pressure 
findings have been established, and the almost universal 
applicability of the sphygmomanometer will be readily 
appreciated. 

In order to intelligently employ and to clinically esti- 
mate the value of blood-pressure findings in any case, we 
must know what constitute the normal boundaries of 
blood-pressure, what factors may normally influence the 
reading and what constitutes an abnormal or pathologic 
blood-pressure. 

The Normal Blood -pressure. — Mechanical difference in 
instruments apart from accidental error, due to defective 
manometers (which is now rare) must be considered, 
especially when comparison is made between figures, ob- 
tained some years ago and now. In the early days of 
sphygmomanometry, the width of the arm-band, and the 
method of application- of pressure was not critically con- 
sidered, so that, except when indicated, it cannot be deter- 
mined whether figures refer to pressure tests made with a 
4-, 8-, 12- or 16-cm. cuff, or whether any cuff at all was used, 
as with the early instruments of v. Basch and Potain. 

All instruments employing the mercury scale or its 
equivalent, will under the ordinary conditions give similar 
readings. The chief cause for difference is in the use of 
cuffs of varying width. The standard cuff as now accepted 
by most authorities is one having a width of compression 
surface of 4 1/2 to 5 in. (11 to 13 cm.). This, in all but 
the most obese, will give uniform pressure readings, which 
by actual experiment have been found to correspond 
closely to the figures obtained by the direct introduction 



58 BLOOD-PRESSURE 

into a vessel of a canula communicating with a mercury 
manometer. 

The cuff of Riva-Rocci, and as employed by Cook, in 
his simplification of the Riva-Rocci apparatus, measures 
8 cm. in width. This has been found to interpose some 
resistance of its own, due to stretching of the rubber of 
the cuff, so that readings obtained by it are from 6 to 10 
mm. higher (depending on the circumference of the arm) 
than those obtained by the standard cuff. Therefore all 
figures obtained by the narrow cuff must be corrected, by 
the subtraction of 6, 8 or 10 mm. before they can be com- 
pared to the standard reading. 

This difference has been carefully figured, out by Cham- 
berlain^ and others. 

The sphygmomanometer of Potain is not graduated in 
mm. of Hg. at all, and therefore cannot be directly com- 
pared to the figures obtained by other instruments. Po- 
tain in his work on blood-pressure gives the normal with 
his instrument as 150 to 190 for men and 140 to 180 for 
women. The readings with the Gaertner tonometer 
range from 10 to 20 mm. below the standard. 

If we accept the 12-cm. cuff as standard and employ it 
for a basis of comparison, we find that a number of so-called 
physiological, or normal factors influence blood-pressure 
readings, and that in any study of blood-pressure, these 
must be considered. 

It has been established that the blood-pressure is influ- 
enced normally by: 
Age. 
Sex. 

» Philippine Jour, of Sd,, December, 1911. 



THE SPHYGMOMANOMETER AND ITS USE 59 

The time of day. 
Size and temperament. 
Digestion. 

Muscular development. 
Muscular exertion. 
Mental worry or fatigue. 
These several factors will be considered in order, and 
an effort made to outline their influence. 

In connection with this subject, it seems necessary 
to include in this group a consideration of tobacco and 
alcohol indulgence, because of their general employment 
by men at least. They should always be noted in an 
estimation of blood-pressure. 

Age and Sex. — Janeway in more than 2,000 blood- 
pressure determinations has found the high normal limit 
of systolic pressure, with very few exceptions, to be 145 
mm.; his figures for women are 10 mm. less. 

The Diastolic Pressure, — There are few reports to be 
found in literature bearing upon this. Janeway on the 
basis of several hundred readings of about 200 cases 
believes the diastolic pressure to be from 25 to 40 mm. 
below the systolic pressure in a normal individual. This 
holds good only during repose, for posture, exertion, etc., 
affect the two pressures unequally. 

H. P. Woley^ reports his examinations of 100 healthy 
subjects between the ages of fifteen and sixty years. The 
results are shown in the accompanying chart (Fig. 19). 
Except for slight variations the figures obtained are in 
close accord with the results of other observers. Lauder 

1 Jour. A. M. A., Vol. LV, No. 2, p. 121. 



60 



BLOOD-PRESSURE 



Brunton states* that the normal pressure in children 
between eight and fourteen years is 90 mm., in youth 
from fifteen to twenty-one, 100 to 120. 



AGES 



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Fig. 19. — Woley's chart showing effect of age on blood-pressure, giving 
mean, high and low average. 

KrehP and Cook give from 75 to 90 mm. as the normal 
systoUc pressure during the first years of life. 

» Lancet, Oct. 17, 1898. 
^ Chnical Pathology. 



THE SPHYGMOMANOMETER AND ITS USE 



61 



Periodic Variations. — The respiratory and Traube-Her- 
ing and the other less rhythmical but apparently spon- 
taneous fluctuations in the normal blood-pressure must 
be borne in mind in all clinical experiments. The respira- 
tory waves are usually very 
slight during quiet breathing 
and need not be considered. 

Exact figures are wanting. 
According to Janeway^ this 
variation amounts to as much 
as 30 mm. Ordinarily 5 to 10 
would be a liberal estimate. 

Daily Variations. — The record 
of blood-pressure taken at fre- 
quent intervals throughout 
twenty-four hours shows varia- 
tions from the average level so 
striking and of such great ex- 
tent and long duration that they 
cannot be easily explained. 
These are shown in the accom- 
panying figure (Fig. 20). 

The record shows the effect of physical and mental 
strain on blood-pressure, these varying in different indi- 
viduals and in the same individual from day to day. 
Janeway believes that this variation may reach 60 mm. 
of Hg., although I have never seen such great fluctuation. 

Old Age. — As early adult life is passed we have to deal 
with those progressive changes in the cardiovascular system 
which are the inevitable result of the wear and tear of every- 

1 Clinical Study of Blood-pressure. 



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Fig. 20. — Record of systolic 
pressure variations occurring 
during the working hours of a 
young healthy man. 



62 



BLOOD-PRESSURE 



day life, and which show themselves in a gradually progres- 
sive reduction in arterial tonicity, a lessened functional 
activity of the eliminative organs, particularly the kidneys, 
and degenerative changes in the myocardium. The in- 
evitable result of these is a grad- 
ual elevation in the systolic 
blood-pressure. We now have 
to establish new normals by 
which we may determine the 
pathological. For this purpose 
the author published in 1909 
the following rule,^ which will 
serve as a practical guide : "Con- 
sider the normal average sys- 
tolic pressure at age twenty to 
be 120 mm. Hg., then for each 
year of life above this add 1/2 
mm. to 120.'' Thus at age sixty 
the average normal systolic pres- 
sure would be 140 mm. Hg., and 
this estimate adheres closely to 
figures given by Woley, Janeway 
and others (see page 59). Of 
course figures obtained by this, 
or any other arbitrary formula, 
are possessed of great elasticity 
and may be so modified by other so-called physiologic fac- 
tors as to lose their identity entirely. 

Size and Temperament. — With the standard armlet the 
factor of size of the individual (adult of course) does not 
* The Sphygmomanometer and its Practical Application. 



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Fig. 21. — Rapid variation in 
blood-pressure, occurring in 
forty-five minutes, patient 
Bitting quietly in ofl5ce. 



THE SPHYGMOMANOMETER AND ITS USE 63 

enter. Temper men t on the other hand does undoubtedly 
affect the reading, because in nervous persons it is often 
impossible entirely to remove the effect of psychic influence; 
allowance must therefore be made for an abnormally high 
reading in such persons, particularly when the reading 
fluctuates to a surprising degree in a limited period of time 
(Fig. 21). 

Sleep. — Authorities agree that the lowest blood-pressure 
during the twenty-four hours occurs in the first hours of 
sleep and that a gradual rise occurs toward morning.^ 
During the day there is a physiologic rise which reaches 
its maximum in the evening. (See author^s chart.) 

Posture. — This should not be confounded with the in- 
fluence of gravity which may be eliminated by making all 
observations with the cuff on the level of the heart. Au- 
thorities differ, perhaps because of the many possibilities 
of error arising from accompanying physical and mental 
effort. The weight of opinion, however, seems to show 
that pressure tends to rise as the individual passes from the 
standing to the head-down posture.^ 

Factors Influencing Blood-pressure. — Posture: The 
following series of observation were made upon twenty-two 
healthy medical students.^ 

^ Brush and Fairweather, A. M. Jour. Physical, Vol. V, p. 99. 
=^0. Z. Stephens, Jour. A. M. A., Oct. 1, 1904; A. M. Sanford, Jour^ 
A. M. A., Feb. 15, 1908. 

^ 0. Z. Stephens, Jour. 4. M. A., Oct. 1, 1904. 



64 



BLOOD-PRESSURE 



Ten Centimeter Cuff, Pressure in Millimeters of Mercury 
Systolic Pressure and Pulse Rate^ 



Systolic 
pressure 



Stand- 
ing 



Sitting 



Supine 



Head 
down 



Right 
lateral 



Left 
lateral 



Right arm 
Average. . . 
Left arm . . 
Pulse rate. 



132.6 

130.8 

130.0 

86.0 



133.3 

131.7 

130.0 

82.0 



152.5 

150.4 

148.3 

68.7 



166.2 

165.6 

165.0 

65.8 



155.0 

143.5 

114.0 

68.1 



110.0 

133.0 

156.0 

69.1 



Systolic and Diastolic Pressures* 






Standing 


Sitting 


Supine Head down 


1 — Arm Systolic 


84 

70 

126 

110 


90 

70 

124 

110 


94 

76 

132 

112 


100 


Diastolic 


80 


2 — Arm Systolic . . . 


134 


Diastolic 


115 







From these observations the following conclusions can be 
drawn as to the effect of posture upon blood-pressure, pulse 
pressure, and pulse rate. 

These observations show that there is little change in 
pressure between the standing and the sitting posture; 
occasionally there is a rise of a few millimeters, possibly due 
to an increase in the intra-abdominal pressure. Between 
the standing and recumbent the rise may be as much as 
20 mm. Between the standing and the head-down (Tren- 
delenburg) the rise may reach 35 mm. Hg. Most observers 
note a compensatory lowering of pulse rate, and it is upon 
these two factors (change in pressure and change in pulse 

»0. Z. Stephens, Jour. A. M. A., Oct. 1, 1904. 
« Sanford, Jour. A.M. A., Feb. 15, 1908. 



THE SPHYGMOMANOMETER AND ITS USE 65 

rate) that the so-called functional tests have their basis 
(see page 164). 

Prolonged rest in bed, in one accustomed to be up and 
about (unaccustomed rest of Gumprecht) especially if there 
be a tendency to high pressure, causes a rapid and marked 
fall, with the establishment of a new systolic level. 

Emotion and Excitement (Vasomotor). — In determining 
psychic influences in blood-pressure, temperament plays an 
important part. The temporary pressure-raising effect of 
fright, fear, apprehension or other form of mental influence, 
must always be recognized. Vasomotor changes from the 
application of heat and cold, and those occurring in the arm 
from prolonged pressure of the arm-band, may amount to 5 
or 10 mm. and must not be ignored. Every effort should 
be made before and during the test to eliminate these 
several disturbing factors. This may be done by estab- 
lishing a proper understanding between the patient and 
physician, by repeating the test at another sitting if 
necessary, and by performing the test with as little delay 
as possible. 

Muscular Development and Exercise. — It is believed that 
in the muscularly well developed, the normal systolic 
pressure may be from 5 to 15 mm. above that of a physically 
weak individual. 

It has been long known that muscular work usually 
increases systolic blood-pressure. This is sudden and 
sharp in the healthy and may cause an elevation of from 
6 to 15 mm. This rise becomes less marked as subjects 
become accustomed to performing the act or acts and this 
reduction in the excitability of the cardiovascular system is 
one of the beneficial effects of training. When the effort 



66 BLOOD-PRESSURE 

is moderate and prolonged (as in walking) the systolic 
pressure may rise from 5 to 10 mm., but soon becomes 
adjusted to a new level upon which additional exertion has 
little, if any effect, until a condition of fatigue is reached. 
Fatigue after prolonged exertion results in a fall in pressure 
which progresses until a dangerous fall in pressure may 
occur.* During moderate exercise in a normal person, the 
systoUc and diastolic pressures tend to become more widely 
separated, t.e., the pulse pressure becomes greater;^ upon 
this physiologic fact is based the work test of Graupner' 
(see Chapter XII). 

Passive movements and massage produce no appreciable 
effect on blood-pressure (Eichberg) (see page 246). 

Altitude.— (See Chapter VI.) 

Diet and Digestion. — The difficulty of arriving at definite 
conclusions concerning the effect of this factor is great. 
Some authorities report a fall, others a rise after eating. 
No intelligent conclusion can therefore be arrived at for 
the present. 

The ingestion of large amounts of fluid, particularly beer, 
usually will cause a temporary rise of from 10 to 20 mm. 

The Influence of Temperature and Baths. — From a 
practical standpoint the influence of the external tempera- 
ture is insignificant and may be ignored. The effect of 
baths will be fully treated in Chapter XIX. 

Atmospheric Pressure. — (See Altitude.) Pomeroy* 
states that the result of nearly all experimental data show 
that the effect of diminished barometric pressure upon the 

» Kavenstein, Zeitschr. f. klin. Med., 1903, Vol. L, p. 322. 
' Krehl, "Clin. Path.," 1905, 3rd Edition. 
' Die Mcssung der Herzkraft, 1905. 
* Interstate Med. Journal, 1911. 



THE SPHYGMOMANOMETER AND ITS USE 67 

human organism is to lower the blood-pressure and that 
the result is not transient but is permanent during the 
continuance of the low barometer. 

Alcohol and Tobacco. Alcohol, — Clinical evidence so 
far shows that a moderate daily use of alcoholic drink does 
not materially influence blood-pressure. Large amounts 
of beer, owing to the bulk of fluid causes a temporary rise 
of from 5 to 15 mm. (See Arteriosclerosis, page 118.) 

Physiologically, alcohol is not a stimulant, and direct 
injection into a vein does not cause a rise in pressure; 
on the contrary large doses cause a diminution in blood- 
pressure from vasodilatation.^ 

Tobacco, — The alkaloid of tobacco, nicotin, is, next 
to adrenalin, the most powerful vaso-constrictor known 
(see page 270). Cook and Briggs^ have shown a temporary 
rise in blood-pressure following smoking, and yet we have 
the apparent paradox that those who indulge in excessive 
smoking have a subnormal blood-pressure. The moderate 
use of cigars has been found by many, including the author 
(Fig. 22), to cause reduction in pressure, while continuous 
smoking resulted in a rise from 5 to 15 mm. 

Conclusions. — This collection of facts relating to the 
many transitory factors influencing the normal blood- 
pressure level would, on first thought, lead the reader 
to the conclusion that after all little can be learned from 
the clinical study of blood-pressure, because of the apparent 
difficulty of separating the real from the false variations. 
This is not true. We must be in possession of a working 
knowledge of the physiological and environmental con- 

1 Cushny, Pharmacology and Therapeutics, Phila., 1903. 

2 Johns Hopkins Hospital Reports, 1903, V. XI. 



68 



BLOOD-PRESSURE 



ditions affecting our observations that we may, by properly 
gauging and excluding them, arrive at a clearer conception 
of the condition of the cardiovascular renal system, and 
follow more intelligently the effect of therapeutic measures. 



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Fig. 22. — Showing the effect of moderate smoking on one accustomed to 
the use of tobacco, after a brief period of abstinence. Tracing shows very- 
well the sedative effect of a moderate amount of tobacco, and the pressure- 
raising influence of several cigars smoked in rapid succession. Also the 
general downward tendency of the curve would suggest that the individual 
became gradually reaccustomed to the use of the drug. 

Furthermore, it will be noted that these obscuring factors 
are all confined to a comparatively short division of the 
scale of the sphygmomanometer, while the truly significant 
variations are often measured by alterations of from 
fifty to a hundred or more millimeters of mercury. 



CHAPTER V 
TERMS, DEFINITIONS, ETC. 

Before proceeding to a discussion on the subject of 
blood-pressure in its relation to the human organism 
in health and disease, it is necessary and indeed essential 
that the several terms employed should be defined, and 
that their relation to the different events in the cardiac cycle 
should be definitely understood. These will here be taken 
up and discussed serratim. 

Capillary Blood-pressure. — The pressure of the blood 
in the capillaries is low because of the resistance offered 
to the progress of the blood by the fine bore of the vessels, 
and because of the relatively large cross-sectional area 
of all the capillaries compared to that of the aorta and 
great vessels. 

If one press with a blunt object upon the skin just 
below the matrix of the finger-nail, the ruddy surface 
becomes pale, because the capillaries are flattened by the 
force applied and the blood driven out of them. If 
delicate weights or a spring be used to apply the pressure, 
then the force which is just sufficient to whiten the tissues 
can be measured, and the amount of pressure which 
approximately counter-balances the pressure within the 
capillaries can be definitely determined. 

The capillary pressure, measured by this means, has 
been found to be much lower than the pressure in the 
arteries, and considerably higher than that in the great 

69 



70 BLOOD-PRESSURE 

veins. This capillary pressure has been found to equal 
that required to sustain a column of from 24 to 54 mm. 
ofHg.i 

From our knowledge of the physiology of the circulation, 
we know that the flow of blood through the capillaries 
is one of the several factors controlling blood-pressure, 
for it is probably largely through the power of the capillary 
vasomotors that alteration of the flow of blood through 
important organs and in different parts is either maintained 
or compensated for. 

Further we believe that the splanchnic area with its 
vast cross-sectional area, is the most important capillary 
region. The condition of the capillaries (the volume and 
rate of blood flow through them) is a part of the factor 
of peripheral resistance, and has been considered under 
that head (see page 20). 

From a practical standpoint, we as yet have no means 
of studying the condition of, or the changes in, capillary 
pressure. 

VENOUS PRESSURE 

Venous pressure is taken to be that pressure existing in 
the great veins that are in close relation to the heart and 
which in a large n^easure determines the amount of blood 
entering the right auricle. Of late, venous pressure has 
been attracting more and more attention, due to advances 
in our knowledge of the mechanism of the heart and rela- 
tion of the pressure within the great veins to the volume 
output of the heart. 

* Am. Text-book of Physiol., p. 377. 



TERMS, DEFINITIONS, ETC. 71 

Normal venous pressure is lower than the pressure either 
in the arteries or capillaries. 

Measurement of Venous Blood-pressure. — HowelP de- 
scribes a practical method of venous pressure estimation 
which, however, is only applicable to the superficial vessels 
of the extremities. The apparatus consists of a light rub- 
ber bag connected with a water manometer, which is 
placed around the upper arm and held there by a few turns 
of bandage. Another cuff, made of rubber dam, like- 
wise connected with a water manometer, surrounds the 
forearm. Air is pumped into the first bag until the veins 
of the upper arm being obliterated, venous congestion in 
the forearm is produced, a rise in the water column in the 
second manometer resulting. When this occurs the pres- 
sure in the first manometer, representing the venous blood- 
pressure, is read off. In making an observation it is neces- 
sary that the arm be maintained at the level of the heart. 
The readings are influenced also by the temperature of the 
air, the thickness of the skin and the prominence of the 
superficial veins. These modifying influences are to be 
allowed for in considering the result, but as the usefulness 
of venous pressure estimations centers especially in the 
following of individual cases (as the patients improve or 
grow worse) the sources of error mentioned are not of great 
importance. The average normal venous pressure by this 
method proved to be 7.6 cm. of water. In a series of car- 
diovascular cases the pressures ranged from 7 to 25 cm., 
the average being 13.9. 

Lauder Brunton^ suggests a simple way of roughly esti- 

1 Arch. Int. Med., Feb., 1912. 

^ Therapeutics of the Circulation, P. Blakiston's Son & Co., 1908, p. 84. 



72 BLOOD-PBBBSUBB 

mating venous pressure. This is done by noting the 
height above the level of the heart at which the veins of 
the hand become empty. Normally they should do so at 
about the level of the third rib, or above. The greater 
the venous pressure the higher must the hand be raised 
before the veins will empty. Regarding the effect of 
alteration in venous pressure upon systolic blood-pres- 
sure, Janeway^ quotes A. Quirin, whose experiments in 
changes in intraabdominal pressure (forcing blood to 
right heart) showed that, up to a certain point, increas- 
ing abdominal pressure raised arterial pressure. But 
beyond a certain point, a fall in arterial pressure oc- 
curred, finally leading to death if compression of the ab- 
domen was continued. It may safely be accepted that we 
are deahng with an abnormally high venous pressure, when 
there are evidences of general right-sided venous engorge- 
ment — superficially engorged veins, large liver, cyanosis, 
etc. In this connection Bishop points out that in deter- 
mining the degree of arterial hypotension, the chief factor 
is the approximation of venous and arterial pressures, and 
that a low pressure need not be regarded as pathologic, 
unless the venous pressure is abnormally high, and that it 
is this alteration between the relation of arterial and venous 
pressures that determines the degree and seriousness of 
general venous congestion. 

Pulmonary Venous Pressure. — We have no method of 
precision by which the degree of pulmonary venous pres- 
sure may be determined. Clinical phenomena alone will 
indicate this. 

* Clinical Study of Blood-pressure. 



TEEMS, DEFINITIONS, ETC. 73 

ARTERIAL PRESSURE 

By arterial pressure is meant the degree of pressure 
exerted by the blood flowing within the arterial system. 
In any individual, arterial blood-pressure at any instant 
depends upon five separate factors. (See Chapter I, 
page 22.) 

1. The energy or pumping power of the heart. 

2. The peripheral resistance. 

3. The elasticity of the arterial walls. 

4. The volume of the circulating blood. 

5. The viscosity of the blood. 

All of these vary under normal conditions and in patho- 
logical states the changes may become very great. Not 
only may they vary independently of each other, but they 
are capable of such complicated interaction through the 
vasomotor and cardiomotor systems, by which one directly 
influences the other, that there is still much conflicting 
testimony. We cannot yet reduce the study of blood- 
pressure to a definite basis; we can, however, correlate that 
which is definitely known, and deduce from this a fairly 
satisfactory working hypothesis. 

1. The Heart Energy. — The heart is a force pump of 
intermittent action. The left ventricle during systole 
forces a volume of blood into the arterial system, during 
diastole the blood is distributed through the arterial tree 
into and through the capillary system. Any increase in 
the rapidity of discharge from the heart in the volume out- 
put (ounces per minute) will, all other factors remaining 
constant, result in an increase in blood-pressure. Con- 
versely, any diminution in the rate or volume output will 
cause a reduction in blood-pressure. On the other hand, 



74 BLOOD-PRESSURE 

a compensatory relation between the rate and volume 
output may permit either to be altered without any appre- 
ciable alteration in blood-pressure. 

2. Peripheral Resistance. — Peripheral resistance is that 
force present in the arterial system, which has a tendency 
to retard or prevent the forward movement of the circu- 
lating blood. This in the living body is composed of the 
combined factors of diameter of the conducting tubes, 
surface friction, distance from the heart and branching of 
the conducting tubes. It is obvious that any obstruction 
at the outlet of a distensible tube will increase the pressure 
of the fluid flowing in that tube. A famihar example of 
this is the common garden-hose fitted with an adjustable 
nozzle. The same physical law holds good for the arterial 
system. Increased peripheral resistance means higher 
pressure, diminished resistance lower pressure, this is 
invariable unless some compensating change occurs in the 
force of the heart. 

The other factors, length of conducting tube and friction 
are so insignificant that they may be left out of all clinical 
considerations, without introducing an appreciable amount 
of error. 

The Arterial System. — The arterial system is composed 
of a series of vital tubes, which branch and rebranch con- 
tinually from the heart to the capillaries. The arterial 
wall, due to its circular muscular coat, is not only a simple 
elastic tube but being vital has the power of contractility. 
This contractility is one of the essential characteristics of 
arteries and it is due to this function that we have a con- 
dition called arterial tone or tonus. 

Tonus is a condition of the arterial wall caused by the 



TERMS, DEFINITIONS, ETC. 75 

inherent tension of the muscular fibers. This muscular 
coat is found throughout the arterial system down to the 
smallest arterioles, and is under the control of the vaso- 
motor system. Through the mechanism of the vasomotor 
system the vessel walls are capable of altering their diame- 
ter in response to proper stimuli. This power to change 
diameter is the essential mechanism which controls per- 
ipheral resistance. 

The degree of tonus is also affected by the composition 
of the circulating blood. (See Chapter I.) Under nor- 
mal condition the tonus (peripheral resistance) is con- 
trolled by the balance between two opposing sets of nerve 
fibers — the vasoconstrictors and the vasodilators. The 
constrictor fibers are the more important, since they are 
always active; their activity is chiefly concerned in main- 
taining the normal degree of tonus or vasoconstriction. 
This tonus is absolutely essential to the maintenance of the 
circulation, vasomotor (constrictor) paralysis result in 
such wide-spread dilatation of the arteries that the heart 
fails because pressure is lowered to such an extent that it 
fails to pass the capillaries and the veins fail to deliver 
sufficient blood to the heart to stimulate contraction. 
Variations in vasomotor tone are constantly occurring in 
different parts of the body in response to local demands 
for such a change. This is a physiologic necessity, since 
functional activity of any part (as muscular exercise) must 
always be accompanied by increased blood supply. 

The varying relation between dilatation and constric- 
tion determines the amount and extent of alteration in 
blood-pressure. The first effect of vasodilatation or vaso- 
constriction in a small area is either a reduction or an ele- 



76 BLOOD-PRESSURE 

vation in pressure only in the vessel supplying that part. 
When this vasomotor change involves a large area, then the 
alteration in pressure may reach the aorta. Ordinarily, a 
compensatory change in other areas (notably the splanchnic) 
occurs which counter-balances the change in the affected 
area and so sustains normal blood-pressure. 

Vasomotor tone, both local and general is under the con- 
trol of a reflex system, which is markedly affected by many 
reflexes of remote origin. These may produce either a 
rise or fall in blood-pressure. These changes may follow 
stimulation of either sensory or motor nerves. Even the 
sensation of pain may cause marked temporary alteration 
in pressure. 

One of the most important clinical facts to be remembered 
when studying blood-pressure is that of all the parts of the 
vascular system, the abdominal vessels, controlled by the 
splanchnic nerves, have the greatest effect on blood-pressure. 
This is due to several reasons, first the great size of this 
vascular area. It is believed that the abdominal vessels, 
when dilated, are sufficient to contain almost all the blood 
in the body. A second reason is that of all the vasomotor 
areas the splanchnic vasomotors are most easily affected 
by reflexes from any sensory nerve. ^ 

3. Elasticity of the Vessel Wall. — The elasticity of the 
vessel wall is due to the elastic fibers contained in the 
adventitia, and to the elastic lamina found in the larger 
vessels which limit the intima, both externally and inter- 
nally.^ Were it not for this elastic quality of the arteries, 
the heart would be called upon to do a great deal of imnec- 

* Janeway, p. 22. 

* Russell, p. 2. 



TERMS, DEFINITIONS, ETC. 77 

essary work, which would absorb a vast amount of valuable 
energy, and the flow of blood throughout the arterial sys- 
tem would be intermittent, as the heart at each beat would 
be required to drive the whole volume of blood forward and 
through the capillaries. A condition obviously incom- 
patible with normal physiology in the body. 

Let us now consider how this elasticity affects the circu- 
lation and blood-pressure. 

Considering a partially filled arterial system let us ob- 
serve what occurs when a volume of blood is projected into 
this system by the ventricular systoles. In the beginning 
the elastic walls of the vessels make room for this change by 
expanding, while some accommodation is also obtained by 
the onward passage of blood toward the capillaries. Since 
it is easier for the arteries to expand than for the whole 
mass of blood to pass on through the capillaries, the incre- 
ments of blood are largely stored in the arterial system, 
thereby tending, by the increasing tension of the arterial 
walls, to increase blood-pressure. Up to a certain point it is 
easier for the accommodation to occur by further expansion. 
When the capacity of the arteries to expand under pressure 
is approached the stretched muscular coat will become 
tense and stiff. Now at this point each systole will drive a 
larger portion of the blood forward through the capillaries, 
and an increasingly smaller amount will be stored in the 
vessels by a further yielding of the wall. Normal conditions 
of pressure will be reached and maintained when the blood 
accommodated at each systole by arterial expansion exactly 
equals the amount of blood passing through the capillaries 
during the cardiac cycle. When this balance of force 
occurs the blood-pressure will rise no further. 



78 BLOOD-PRESSURE 

Anything altering this relation, either by increasing the 
output of the ventricle or by obstructing the flow through 
the capillaries, or vice versa, will cause the blood-pressure 
to change. The same is true of alterations in the normal 
elasticity of the arterial system. 

Thus during each cardiac cycle, the heart muscle does 
work in maintaining the capillary flow against capillary 
resistance, and in causing expansion of the arterial wall. 
A part of the manifest energy of the heart thus becomes for 
a time potential in the stretched fibers of the arterial wall. 
The moment that a systole is at an end, the stretched elastic 
fibers recoil and continue the work of the heart in main- 
taining the arterial flow against capillary resistance. 

As this potential energy becomes expanded the pressure 
gradually falls and it would eventually reach zero were it 
not for the rhythmically recurring cardiac systole which 
causes the pressure to again rise. 

The elasticity of the vessels is very perfect and is cap- 
able of standing a pressure greater than by any chance 
could possibly be developed during life. According to 
Jane way ^ quoting Grehant and Quinguard, the carotid 
artery of a dog is capable of withstanding a pressure twenty 
times greater than the normal pressure, without tearing. 
For the human carotid the lowest pressure at which 
rupture occurs is 1.29 meters of mercury, at least eight 
times the ordinary carotid pressure of the normal circu- 
lating blood. 

4. Volume. — Compared with the full cubic volume con- 
tents of the arteries, capillaries and veins combined, the 
volume of blood is surprisingly small. In the normal 

» Loc, cit., p. 24. 



TERMS, DEFINITIONS, ETC. 79 

individual the volume capacity of the vascular system is so 
reduced, that the blood is maintained at all times under a 
considerable pressure. This is due to the continuous con- 
traction of the walls of the blood-vessels which has been 
considered (page 21) under the head of vasomotor tone or 
tonus. 

While a certain amount of blood, probably about three- 
fourths that of the total volume of blood, is necessary to 
support the circulation, still it has been found that a large 
amount of blood can be withdrawn (see Venesection, page 
263) and that the pressure rapidly returns to a point at or 
near normal. On the other hand Worm Miiller^ has shown 
that an amount of fluid greater than the total blood volume 
of the body can be transferred into the vessels, without 
increasing the blood-pressure above a point frequently 
reached under normal conditions. Therefore it would 
seem that except for great changes, the volume of the cir- 
culating blood has only a slight and temporary influence 
on normal blood-pressure. 

5. The Viscosity of the Blood. — The viscosity of the blood 
is a factor that up to this time has been omitted almost 
entirely in considering the variations, normal and patho- 
logical in blood-pressure. For purely physicial reasons the 
factor of viscosity is of upmost importance, since variations 
even when slight must affect enormously the resistance 
offered to the passage of blood through the arterial system, 
and therefore must profoundly affect blood-pressure. It 
will probably be found as experimentation is carried further 
that the viscosity of the blood is an important factor affect- 
ing blood-pressure, and that the development of methods for 

* Quoted by Janeway, p. 26. 



80 BLOOD-PRESSURE 

its modification or control will mark an epoch in the study 
and treatment of diseases involving blood-pressure changes. 

THE BLOOD-PRESSURE WITHIN DIFFERENT ARTERIES 

As the arteries rapidly diminish in size from the aorta 
to the periphery it would naturally be supposed that the 
arterial pressure would rapidly undergo a similar reduction. 
Experiment has shown this not to be the case, on the 
contrary, we know that the blood-pressure within the arter- 
ies except the very smallest, diminishes very slowly as the 
distance from the heart increases, and therefore the blood- 
pressure is obtained by the modem sphygmomanometer 
from the brachial or the femoral, approximates very closely 
that existing within the aorta, near the heart. 

Thus when we say blood-pressure (arterial) we mean 
the pressure found in one of the larger superficial vessels 
and we have found that this represents very closely the 
aortic pressure. 

CHnical terms employed in blood-pressure studies: 

The pulse. 

Systolic pressure. 

Diastolic pressure. 

Mean pressure. 

Pulse pressure. 
The Pulse. — From our knowledge of the action of the 
heart, we know that blood is forced into the aorta at regular 
intervals, and that each change of blood entering the aorta 
is felt throughout the arterial system in the form of a 
wave which is styled the pulse and which may be felt 
as a rhythmically recurring impulse (due to transitory 
increase in size of the vessel) in all palpable arteries. 



TERMS, DEFINITIONS, ETC. 81 

The propagation of this wave throughout the arterial 
system implies a change in diameter of the vessel with 
a resulting stretching of the vessel wall (see Elasticity, 
page 18) caused by the increased increment of blood 
entering it. This further stretching of an already stretched 
vessel wall can only occur through an increase in pressure 
within the vessel sufficient to cause the stretching which 
is left under the finger. It is a self-evident fact, then 
that there occurs alternately, in regular rhythmic cycle, 
a rise and fall in blood-pressure throughout the arterial 
system. Corresponding to the ventricular systole and 
diastole, the highest and lowest points of this change 
in pressure are termed respectively, systolic blood-pressure 
and diastolic blood-pressure. 

Systolic Blood -pressure. — This term is applied to the 
blood-pressure within a given vessel, when the maximum 
force is exerted within it during ventricular systole. This 
is the pressure meant when '^ blood-pressure '^ is referred to. 
It is capable of considerable variation, through reflex and 
other causes, without passing the boundaries considered 
as normal in clinical medicine. It may also vary widely 
either above or below the normal limits, under the influence 
of many pathologic conditions. (See Chapter IV.) 

Diastolic Blood-pressure is the degree of pressure 
exerted within a vessel under observation, during cardiac 
diastole (immediately preceding systole) and represents 
the lowest pressure occurring in the vessel during the 
cardiac cycle. Like the systolic pressure, the diastolic 
pressure varies within certain limits in health, and widely 
in pathologic states. 

Mean Blood -pressure. — Clinical observation has estab- 



82 



BLOOD-PRESSURE 



lished the fact that the mean blood-pressure, as determined 
by the sphygmomanometer, corresponds closely with 
the arithmetical mean of the systolic and diastoHc pressure, 
I.e., the sum of systolic and diastolic pressure divided by 
two. (See Fig. 23.) 

Pulse Pressure, Pulse Range or Amplitude. — These 
synonymous terms are employed to designate the total 
variation in pressure occurring in a given vessel during a 
cardiac cycle. This variation may be determined then 



Sy8tolic=130 
Raiige=30 j 
Diastolic==100 




Mean^m 



Fig. 23. — Normal pulse tracing: showing relation of systolic, diastolic 
pulse pressure and mean. Pulse pressure equals 30. 

by subtracting the estimated diastolic pressure from the 
estimated systolic pressure, and varies in health between 
25 and 40 mm. Hg. 

The determination of pulse pressure is of greatest im- 
portance in the study of diseased conditions, particularly 
in the estimate of cardiac muscular efficiency and in de- 
termining the prognosis of certain valvular and blood- 
vessel diseases and toxemic states. 



CHAPTER VI 
CLIMATOLOGIC AND RACIAL INFLUENCE 

Altitude. — In approaching the subject of the effect of 
altitude on blood-pressure and pulse rate, a sharp line must 
be drawn between the influence of changes in altitude 
(atmospheric pressure) upon normals and other individuals, 
particularly the tuberculous, otherwise confusion will 
surely follow, because the great bulk of clinical data demon- 
strates that altitude affects normal and pathologic individ- 
uals differently. 

Healthy Individuals. — Gardner and Hoagland^ at an 
altitude of 6,000 ft., measured large numbers of normals 
who had lived in Colorado for more than a year, and con- 
cluded that the average blood-pressure was slightly lower 
than at the sea level. 

They also show that prolonged residence at that altitude 
does not materially affect blood-pressure. 

Experiments showed that an ascent from 6,000 to 14,000 
lowered pressure and increased pulse rate. The fall was 
apparently a permanent one. 

Smith at Ft. Stanton' (6,200 ft.) states that '^t has been 
scientifically established that blood-pressure is lowered 
with increased altitude.'' 

Pomeroy in the Interstate Medical JournaL in order to 
determine the degree of variation in the systolic and dias- 

1 Trans. Am. Climatological Assn., 1905. 

2 Reprint No. 51, Public Health Rep., P. H. and M. H. Service. 

83 



g4 BLOOD-PRESSURE 

tolic blood-pressures, caused by altitude, average the 
studies of eighteen observers, dating from 1878 up to the 
present time and found that the fall of systolic blood-pres- 
sure ranged between 1 and 22 mm., and the diastolic fall 
between 1 and 11 mm. 

Schneider and Hedblom^ present a very concise and 
accurate summary of present knowledge bearing on this 
point. 

1. A considerable elevation in altitude tends to lower 
systolic and diastolic blood-pressure and to increase the 
heart rate. 

2. The fall of systolic pressure is slightly greater and more 
certain to occur than the fall of diastohc pressure. 

3. A rise in diastolic pressure occurs in some individuals. 

4. The influence of such factors as psychic states, eating 
and exercise may obscure the findings. 

5. The fall in blood-pressure and increase in heart rate 
are more marked in the early part of stay in higher altitudes. 

6. With prolonged stay in higher altitudes the heart rate 
probably returns more nearly to normal than the blood- 
pressure of all individuals. 

7. High altitudes do not affect in the same degree all 
individuals. 

8. Small elevations in altitude do not materially influence 
blood-pressure. 

9. Those individuals most affected by high altitude seem 
to sustain the greater fall in systolic blood-pressure and the 
greater acceleration in heart rate. 

10. The heat of the summer season probably accelerates 
the pulse rate. 

» Am. Jour, Physiol, Vol. XXIII, No. 2. 



CLIMATOLOGIC AND RACIAL INFLUENCE 85 

Tuberculosis. — ^LeRoy S. Peters, pointed out in 1908^ 
that altitude usually caused a rise in blood-pressure in the 
tuberculous. He made his observations at an altitude of 
6,000 ft. (For effect of tuberculosis on blood-pressure see 
Chapter XIV.) 

Bullock^ confirms the observations of Peters. The blood- 
pressure raising effect of altitude on persons suffering from 
pulmonary tuberculosis appears to be of distinct advantage 
to the patient, as it directly combats the blood-pressure 
reducing acting of tuberculo-toxins by altering metabo- 
lism, modifying and stimulating tissue change, and aiding 
elimination. 

B. R. Hooker^ shows in his reports of respiratory cases that 
placing patients in the open air increased the blood-pres- 
sure from 5 to 10 mm. 

Influence of Climate. — Weston P. Chamberlain has 
recently reported in the Philippine Journal of Science*' 
an exhaustive study of the effect of climate and race upon 
the normal average blood-pressure readings. The study 
is based upon 6,128 blood-pressure observations on 1,042 
white men and 552 Filipinos all in good health and ranging 
in age from twenty to forty years. The average systolic 
pressure of 5,368 readings on 992 persons, was 115.6 mm. 
and the pulse rate taken simultaneously averaged eighty- 
one beats per minute. The average age was 26.6 years. 
Comparing this average with that of Woley (see page 60) 
it is found to be 7 mm. lower and compared to Bachmau^ 

1 Arch. Int. Med., Aug., 1908. 

2 Jour. A. M. A., June 19, 1909. 
^ Med. i^ec, Jan. 28, 1911. 

* Dec. 1911, Vol. VI, No. 6, Sec. B. 

* New Y(yrk Med. Jour., 1911. 



86 



BLOOD-PRESSURE 



3 mm. lower. While the pulse rate in Chamberlain's series 
was nine beats per minute above the average accepted as 
normal in temperate climates for all ages. He found that 
the blood-pressure has a tendency to be lower than the 
averages given above, during the first three months stay in 
tropical climates. 



Chamberlain's Table. — Average systolic blood-pressures and pulse 
rates, based on 5,368 observations of each which were made on 992 
American soldiers serving in the Philippines J arranged according to age. 
(12.5 cm. armlet.) 





Average 
age, 
years 


Number of men showing pressures from — 


Total 
num- 
ber of 
men 


Aver- 
age 
pres- 
sure 


Aver- 
age 
pulse 
rate 


Age period, 
years 


91 

to 

100 

mm. 


101 

to 
110 
mm. 


111 

to 
120 
mm. 


121 

to 

130 

mm. 


131 

to 
140 
mm. 


141 

to 
150 
mm. 


151 

to 

160 

mm. 


18 to 20 

20 to 25 

25 to 30 

30 to 35 

35 to 40 

Over 40 


19.4 
22.8 
27.2 
32.6 
37.5 
43.1 


1 
32 
16 

2 

2 


12 

156 

73 

34 

9 

3 


13 

165 

108 

42 

24 

17 


8 
87* 
70 
23 
14 

7 


1 
22 
13 

7 
8 
2 


1 
5 
3 

1 

I 


2 
3 

1 


36 

469 

286 

109 

58 

34 


mm. 
115.0 
114.3 
115.9 
116.7 
120.5 
119.6 


78 
82 
81 
80 
81 
79 


Totals or 
averages 


26.6 


53 


287 


369 


209 


53 


15 


6 


992 


115.6 81 



Racial Influence on Blood-pressure. — Chamberlain also 
reported^ a series of observations conducted to determine 
the effect of race upon average systolic blood-pressure and 
obtained the following result : 

Average blood-pressure of 100 Filipino scouts, 115.0 
Average blood-pressure of 100 Philippine soldiers, 115.9 

and states that '* we may, therefore, conclude that the mean 

^Loc. cU. 



CLIMATOLOGIC AND RACIAL INFLUENCE 87 

blood-pressure for Filipinos during the period of fifteen 
to forty years (average twenty-five years) is 115 or 116 mm. 
and that it does not differ from the pressures at the same 
age for Americans residing in the Philippines/' 



CHAPTER VII 

THE RELATION OF BLOOD -PRESSURE TO ATHLETIC 
LIFE AND EXERCISE 

This is the age of athletics — never has there been such 
a wide-spread devotion to outdoor sports and athletic 
contests since the days of ancient Greece. Old and young 
alike are awakening to the value of recreation and exercise, 
and have turned to track and field sports, sometime without 
pausing to consider the advisability of such exertion, or 
without ascertaining their fitness to participate in the more 
strenuous forms of exercise. Undoubtedly to so parti- 
cipate might lead into grave danger. Each should learn 
and know his Hmitation and be governed thereby. 

Parents of growing children are beginning to appreciate 
the value of a more definite knowledge of their children's 
physical fitness, both as a guide to avoidance of future physi- 
cal defects and wealaiesses and as an index of the character 
and amount of exertion that can be safely indulged in. 

This problem is frequently brought to the physician for 
solution, by the following question: "Doctor, my boys are 
going to boarding school this fall, and I am anxious to know 
whether their physical condition is such that they may 
indulge in track work, football, basket-ball, etc." 

The answer is difficult, as to make a definite reply is to 
shoulder a great responsibility. The age, muscular devel- 
opment and general build, heredity, past history and 
idiosyncrasy of the applicant will of course enter into the 

88 



RELATION OF BLOOD-PRESSURE TO ATHLETIC LIFE 89 

decision, but the chief factor is the condition of the cardio- 
vascular system and of the kidneys. This same question 
is put in a modified form by persons of all ages relative to 
the danger of bicycling, golf, cricket, swimming, etc., and is 
even more difficult to answer. At this point I can do no 
better than quote extensively from Robert E. Coughlin.^ 

The four ages to consider will be (1) early life, including 
infancy, boyhood, youth and adolescence up to the twenty- 
first year; (2) manhood, from the twenty-first year up to 
the fortieth year, (3) middle age from the fortieth to the 
fifty-fifth year; (4) beyond middle fife up to old age. 

In a discussion regarding athletics in boys' schools a 
middle ground seems to be occupied by the Medical Officers- 
of-Schools Association said The Hospital (April 3, 1909) in 
an editorial, '^ These medical officers adopt the extreme 
position of neither side; that is, they advocate neither 
grandmother coddling nor the Spartan survival-of-the-fit- 
test attitude of many athletic persons. They point out that 
neither age nor distance is in any way an exact criterion 
of the strain inflicted on any given boy by any given race. 
The quarter mile is a far more exhausting race for most boys 
than are the long-distance races, and to this we would add 
the half mile, in which school boys have done at various 
times very notable performances, but, now and then with 
considerable detriment to themselves. 

''The Association's recommendation that the plan of 
running all the boys, old and young, over the same course 
or distance is not to be recommended, but we are not sure 
that in this particular we quite agree. For if a separation 
is made, it must be on some rough line, such as age, and that 

1 Medical Record, April 2, 1910. 



90 BLOOD-PRESSURE 

means that a compact, well-developed youth capable of any 
exertion may be sent into a junior division to set the small 
boys a hot pace over a short run, while an overgrown and 
much less precocious boy a month older may be put to 
compete with the most athletic of his fellows over a long 
distance. When all the boys run together, the best runner 
may finish a five-mile cross-country run half an hour before 
the worst, but at the same time this gives those who, by 
reason of youth or retarded development, cannot excel at 
this exercise, a chance to complete their run and benefit 
by it without undue strain. Provided there is a thorough 
medical examination of every boy on entering competitive 
sports, and that the effects of various games on the younger 
boys are carefully supervised, that certain common sense 
rules, which boys themselves do not appreciate are enforced 
upon them, then the risk of ordinary school exercise, in- 
cluding cross-country runs and flat races not exceeding one 
mile, is so reduced as to be quite beneficial." 

Dr. Tyrrell Brooks of Oxford says it was his experience 
that the most vigorous undergraduates came from schools 
whose athletics were of the most strenuous type. Of the 
organs likely to be endangered from excess in athletics, 
the heart is the chief. Valvular damage, due to over- 
exertion is very rare, but it is to be remembered that 
slight dilatation of the heart is difficult to estimate. It 
is almost certain that the natural resilience of the heart 
is so great in boyhood that mere muscular exercise can 
hardly seriously damage the heart. Special care in per- 
mitting active exercise after convalescence from acute 
illness is a very important precaution. 

In summing up the work of Dr. Benedict and Dr. 



RELATION OF BLOOD-PRESSURE TO ATHLETIC LIFE 91 

Carpenter, done in Wesleyan University, a medical editor 
has the following to say: "The human body is a machine 
of such a degree of efficiency that one-fifth of the energy 
expended by it can be utilized as work, and that this 
efficiency is constant in men of all types. The strongest 
and the most thorough is able to do more work than the 
novice, this is not because his muscles are of such a quality 
that he can get more work out of them from the same 
amount of energy, but because he is able to put more energy 
in the shape of tissue changed into the action. It would 
seem then that training, besides preparing the heart to 
stand greater strain, acts to increase the subject's power 
of using up his tissues and by giving him more muscular 
tissues to use rather than by teaching him to conserve 
his energies. To adopt a metaphor from the mechanical 
world, the professional has a more powerful engine because 
he is able to use more fuel, not because he wastes less steam. 
From the twenty-first year to the fortieth, little may 
be said of the evil effects of athletics as most young men 
have by this time passed out of athletic Hfe and gone into 
their chosen vocations. The eagerness to make a Hving 
and the desire to succeed in life compels them to be up and 
doing. As a rule degenerative changes are not at this time 
so apparent, and though the man may be working under 
high pressure, no notice is taken of such changes until 
middle life is reached. This is the time, however when 
the habits of life are formed. 

HOW TO DETERMINE PHYSICAL FITNESS 

The most practical means which we have at our disposal 
with which to corroborate and qualify the results of a 



92 BLOOD-PRESSURE 

careful physical examination, are by urinalysis and by 
a study of blood-pressure — including also the diastolic, 
the mean, and the pulse pressures. Applying also, except 
in adolescents and youths, the so-called functional tests. 
A pathologic urinary finding will of course be given its 
proper value, and will be correlated to the other evidence. 
Studies of the blood-pressure, its normal behavior under 
strain, its changes in pathologic heart valve and heart 
muscle conditions, have been carried out by many investi- 
gators, usually in connection with the physical depart- 
ments related to colleges and other institutions. These 
have developed some very interesting and valuable data, 
which may now be employed in examinations for physical 
fitness. 

Apart from the discovery of valvular defects and func- 
tional murmurs, there is little that can be deduced from 
the usual blood-pressure test in early life, up to about the 
time the boy or girl enters college, from about the age of 
sixteen years, on to middle or early old age. The abihty 
of an individual to withstand strain, , without danger, 
depends largely upon the integrity of the cardiovascular 
system, so that special examinations are usually directed 
toward this system. 

The discovery of a pathologically high blood-pressure 
(see Chapter IV for this determination) would move the 
individuars age limit forward, so that if when he is forty 
there is a marked degree of hypertension, he would have 
to go into the fifty- or sixty-year class. The discovery 
of arteriosclerosis even in the absence of a hypertension 
should suggest the same caution. We know from ex- 
perience and have had confirmed by a systematic investiga- 



RELATION OF BLOOD-PRESSURE TO ATHLETIC LIFE 93 

tion the effect of various forms of exercise on the systolic, 
diastohc, pulse pressure, and on the pulse rate. As dem- 
onstrated by O. S. Lowsley^ who found that in healthy 
young athletes the blood-pressure and the pulse pressure 
are greatly increased during exercise and remain above 
normal even at the conclusion of very exhaustive work. 
After exhausting exercise there is a period of subnormal 
blood-pressure and the more exhausting the exercise, the 
more marked and prolonged this phase will be. (See Tuber- 
culosis, Chapter XIV, Page 182.) The rapidity with which 
the pulse rate drops to normal is also determined by the de- 
gree of exhaustion. There is often observed, however, a 
secondary rise in rate during the period of subnormal 
pressure. Very violent exercise of even a few seconds, as 
in the running of a hundred-yard dash causes a much 
more pronounced and lasting negative phase than does 
more prolonged but moderate work. 

We have seen that in the work test, as suggested by 
Graupner, this fact is used as a basis of the experiment, 
and that this has been corroborated since by others — in- 
cluding Boardman Reed^ — that the condition just described 
is only possible in a heart which has not had its normal re- 
serve power either involved or destroyed through chronic 
arterial or chronic myocardial change. While in the weak 
heart, whatever the cause, the rise in pressure does not 
always occur, and even if a rise is noted, the blood-pressure 
falls before the pulse rate — and remains down. This test 
of Graupner's can therefore be applied to those who are 
about to enter strenuous athletic contests, where, if the 

* Am. Jour. Physiol., March 1, 1911. 
2 South. Calif. PracL, August, 1910. 



94 BLOOD-PRESSURE 

normal relation of pressure and pulse exists, the individual 
may safely be allowed to participate. 

Lowsley suggests also that the duration of the negative 
phase is a fair index of the strain on the circulatory system, 
and that the test might be used in determining the fitness 
of any indi\ddual for the performance of certain forms of 
exercise. He believes that if the negative phase passes 
within an hour, that the individual is well within the 
''hygienic limit'' but that if it lasts more than two hours, 
it is a sign that the margin of safety has been exceeded^- 
such measures as these should be of considerable help 
to physical directors in deciding the qualifications even 
of those who are apparently sound. 

Another method, suggested by Masing,^ is to note the rel- 
ative effect of exercise on the systolic and diastolic pres- 
sures; a normal circulatory apparatus will yield a systoUc 
pressure greater in proportion than the diastolic, in other 
words, the pulse pressure or amplitude will be increased, 
while in a defective cardiovascular system the systolic and 
diastolic pressures, even when raised, will tend to approxi- 
mate. Janeway cites a case where the pressure in a 
healthy man, age twenty-six (a) at rest was 135 systolic, 
diastolic 100, pulse pressure 35; (b) after running up three 
flights of stairs, systolic 175, diastolic 120, pulse pres- 
sure 55, indicating a normal cardiac strength, capable of 
maintaining its tone under strain. On the other hand 
a man apparently in good health gave a systolic (c) 
at rest of 140, diastolic 100, pulse pressure 40. After 
two minutes exercise, (d) systolic 155, diastoHc 125, 

1 E. Masing, Deut. Arch.f. klin. Med., 1902, Vol. LXXIV, and later com- 
mented upon, Janeway, p. 122. 



PP 35 
SP 135 


-1/4 ' 


Fraction larger after exercise — 


PP 55 
SP 175 


-1/3 


good heart. 


PP 40 
SP 140 


-1/3 ' 


Fraction smaller after exercise — 


PP 30 
>SP 155 


-1/5 


poor heart. 



RELATION OF BLOOD-PRESSURE TO ATHLETIC LIFE 95 

pulse pressure 30, showing a defective musculature and 
imperfect heart tone; in this case violent exercise would 
probably give rise to permanent dilatation. 

According to Gibson this may be expressed graphically 
as follows: 

(a) 

(b) 

(c) 

(d) 

Summary. — After prolonged and severe exertion, the 
blood-pressure falls to a point below the normal as deter- 
mined before the exertion. 

After a brief period of mild or moderate exercise, the 
blood-pressure immediately afterward shows, in the major- 
ity, a rise followed quickly by a fall near the normal 
— perhaps a little above or a little below. 

The fall denotes fatigue, the failure to rise probably 
indicates muscular heart weakness or, at least, temporary 
dilatation, as is shown to be the case in marathon runners 
and foot-ball players. 

F. Gelsbock believes that low pressure immediately 
after mild exercise is due to muscular heart weakness, 
he also believes that arteriosclerosis may result from long- 
continued high blood-pressure occurring in athletes. 

Danger to athletic individuals in real life is to the 
vascular system, this is because such individuals do not 
continue their systematic exercise, so that metaboHsm 
and elimination become defective (Gelsbock). 



CHAPTER VIII 
HYPOTENSION 

Definition. — This term is employed to designate altera- 
tions in arterial blood-pressiu-e in which the pressure curve 
remains below the established normal minimum. The 
actual level of this pressure will be affected to a degree by 
the age and other physiologic factors, which control the 
normal level of pressure. (See page 59.) 

We must also admit the possibility of a relative hypo- 
tension, in which the curve of pressure, while being above 
the established normal, is yet so far below a previous long- 
continued high pressure, as to prevent the physical phe- 
nomena of a pathologic low pressure. This point is dis- 
cussed more fully below. 

In order to fully comprehend the discussion which follows, 
some form of clinical classification of low blood-pressure 
must be formulated. The following seem to be the ac- 
cepted subdivisions of this class of conditions. 

These several forms of hypotension are terminal hypo- 
tension, essential hypotension, primary or true hypoten- 
sion and relative hypotension. 

Terminal Hjrpotension. — The term is used to indicate 
that abnormal lowering of tension in the circulation which 
indicates the approaching end of one life. 

With the approach of death from any pathologic condi- 
tion, the blood-pressure tends more or less rapidly toward 
zero. The rate of which this arrives and its relation to 

96 



HYPOTENSION • 97 

the actual cause of death, is determined by so many factors 
about which almost nothing is known, that but little really 
definite can be yet determined upon. According to Jane- 
way, pressure as low as 60 mm. (5 cm. cuff) may persist, 
in protracted illness for several days before death. In 
such a case the hypotension may be of some value as a sign 
of impending dissolution, but as a rule the terminal fall 
in pressure is usually a matter of hours or minutes. 

Essential Hypotension. — Occasionally there are cases 
which seem to have a constitutionally low blood-pressure. 
These cases show no definite signs of disease, and no dis- 
coverable cause can be assigned for the condition. Though 
sometimes it may develop later that this state was in 
reality an early sign of tuberculous infection. This point 
will be developed later. Such individuals are frequently 
unequal to any particular effort either mental or physical. 

Primary or True Hypotension. — This is closely allied 
to the preceding, but is distinguished from it by the appear- 
ing of some assignable cause — other than the pre-exist ence 
of some condition causing hypertension. Bishop defines 
primary or true hypotension as occuring in those cases 
whose pressure-reducing mechanism has failed, when there 
has been no previous overdemand for pressure. 

Relative Hjrpotension. — This term would seem to be a 
necessary one and should be applied to those cases whose 
actual pressure, while still above the estimated normal, has 
fallen from a former pathologic high level to such a degree 
that symptoms due to the fall have developed. A fairly 
common example of this is the frequent occurrence of edema 
or other signs of circulatory failure following injudicious 
attempts to reduce a high pressure. 



08 



BLOOD-PRESSURE 



The same condition obtains in a failing cardiovascular 
system, when the pressure has been for a long time high. 
See chart, Fig. 24. Here also we may have most serious 
and distressing symptoms, pointing to circulatory failure, 
and yet the pressure may be found still above the esti- 
mated normal level. 

BLOOD PRESSURE CHART 



leW.'li.S-...,....?! 



CHART NO. 

NAME 

ADDRESS 

OCCUPATIOJ 

DIAGNOSIsf 



AGE .<«A... 
COLOR -VVf. 

SEX . .TVW . . 

PHYSICIAN . . 



Date 




. Dav af diMaas 




. Timo of day 




145 U hn i TUrtH- 




140 l<^ K bo 3 lb If 




us 




ISO 




A A 




"^ /\ / ^ 


^j(i^A:^?ikp _ _ 


»« \/ 




}/. 




106 /' '-\ 


EHusiS:.' - 


»» J 




95 / 




/ 




85 




» 




75 





Fia. 24. — Hypotension of lost compensation (relative hypotension). 
Arteries markedly sclerosed, heart showed myocardial degeneration, pulse 
always rapid. Cerebral symptoms marked, treatment had very little effect. 



Causes of Hypotension. — In considering the etiology of 
the condition of hypotension, we find that it occurs in 
many diseases and conditions, as for example in wasting 
diseases, in toxemias, acute and chronic infections, in 
certain conditions of the heart, and in circulatory de- 
pression from any cause as in shock, in collapse, in 
cardiac asthma, during and after hemorrhage and in a 



HYPOTENSION 99 

number of metabolic diseases of which diabetes is an 
example. 

The Lower Normal Limits. — The limits are, of course, 
largely arbitrary, depending as they do upon so many vari- 
able and varying factors. To maintain their full value, 
they must be modified to conform to our knowledge of the 
many so-called physiologic factors active in each individual 
case. (See Chapter IV.) 

Experience teaches that 105 mm. may be taken as the 
low limit of normal blood-pressure in young men, and 
95 mm. as the normal low limit in young women. This 
will of necessity be modified slightly by the age, occupation 
and muscular development of each individual. The only 
way to estimate the degree of abnormality in the blood- 
pressure is to apply the knowledge obtained from experi- 
ence in examining a large number of cases. Therefore it 
is usually 'advisable to employ the blood-pressure test as 
a routine in all cases, in order to develop one's ability to 
interpret the significance in each individual case. 

Extreme Low Pressure. — The lowest blood-pressure in an 
adult, compatible with life, has been reported by Neu to be 
from 40 to 45 mm., and this only occurred with subnormal 
temperature accompanied by unconsciousness. He has 
observed and recorded recovery after a temporary fall in 
pressure as low as 50 mm. 

Conditions Accompanied by Hypotension. — In the pres- 
ent state of our knowledge of this subject, it is impossible to 
lay down arbitrary laws or to make a positive statement 
regarding the absolute level in persons, occurring under the 
different conditions, which are dependent upon so many 
varying factors. In the statements which follow it should 



100 BLOOD-PRESSURE 

be remembered that the figures apply only to the majority 
of cases of the types discussed. 

Diseases of the Heart. — In the majority of valvular 
lesions of the heart where compensation is good, the effect 
on blood-pressure is very slight, so that this test is here 
chiefly of prognostic value. The two exceptions to this 
are aortic regurgitation and mitral stenosis. 

In aortic regurgitation we find a persistent and uniform 
high systolic pressure combined with an exceptionally 
low diastolic reading, which results in a characteristic pulse 
pressure, and upon this alone diagnosis may be made. 
This large pulse pressure found in aortic disease is further 
argumented when accompanied by arterial sclerosis, chronic 
myocarditis, or chronic kidney diseases (see Fig. 25). 

Mitral Stenosis. — Extreme narrowing of the valve orifice 
occasionally may so reduce the volume of blood passing 
through the heart that the blood-pressure is lowered simply 
because the heart is able to pump only a fraction of its 
normal amount. 

In other organic conditions of the heart, and in the last 
stages of valvular cases the tendency of the pressure is 
downward, when it is due to failing circulation and venous 
stasis. From a clinical standpoint. Bishop^ makes an im- 
portant point when he states that failure of the circulation 
in heart disease does not become a matter of anxiety during 
acute attacks of valvulitis, during which time the patient is 
at rest, but that it becomes more serious when the patient 
resumes his occupation, and that even then the low arterial 
tension should not be regarded as pathologic except when it 
is but little above venous pressure, as shown by venous 

1 Heart Disease and Blood-pressure, 1907. 



HYPOTENSION 



101 



congestion and enlarged liver, etc. This emphasizes the 
point made that the actual pressure level found does not 
always measure the degree of pathogenicity of the case. 
Each case has its own particular law and must be studied 
and treated according to the conditions present. 

BLOOD PRESSURE CHART 



CHART NO.. . 

.o..nv. 



ADDRESS 

occupatio 
diagnosis' 



AGE .b.P.. 
COLOR ^Vt - 

SEX .TVW.. 

PHYSICIAN- 



r 

Date 




r- 






wmm 


^■^ 


■^" 
























^^ 




yUi^xM 


Vaa-O, 


^ 


^ 


r^ 




210 




v^ 


yt> 


\ 


i 


i¥ 


IS 


T 


-tr 


s'^ 


-^ 


if 


r 




205 




A 










B 












c 




200 






/ 


V 






















^195 








\ 


/ 


^ 


















=^190 












\ 


k 
















J 185 














\ 












i 


* 


-180 


















i< 




/ 


^, 


/ 




il75 


















/ 












f3l70 






























■ ?»65 






























§160 






























■ ^155 






























150 






A 
























145 




J 


























140 




• 




L 






















135 








\ 


















* 




130 








V 






"^ 








k^' 


* 






125 


















/ 












120 
















V 














115 






























110 






























fiuU^««C 


'rJ 


At/ 


50 


is 


ao 


fco 


i>-6 


sb 


so\ 


so 


6-0 


4-i 


5-i' 





>S2/s. 



Bia. 



Fig. 25. — Aortic regurgitation with moderate arteriosclerosiB, symptoms 
the result of high pressure. A to B show effect of treatment. B, all drug 
treatment stopped. B to C, patient resumed occupation, general measures 
continued. Note large pulse pressure characteristic of this disease. 

Alterations in Heart Rate. — These do not, as a rule, in- 
fluence blood-pressure. We believe that blood-pressure 
has a marked influence on pulse rate. The action of the 
heart and pressure being in the relation of a force pump to a 



102 BLOOD-PRESSURE 

water supply; as the demand for increased pressure or sus- 
tained pressure arises, the pump responds with greater 
force and energy, for this mechanism is so delicately 
balanced, that under ordinary conditions, very httle fluctua- 
tion in pressure occurs. 

Two conditions however have been found to have an 
influence on blood-pressure, the cause and significance of 
which are as yet obscure. • 

1. Paroxysmal Tachycardia. — The pulse rate may be 
from 150 to 300, the heart sounds good and the pulse small, 
sometimes the pulse rate cannot be counted, the blood- 
pressure is usually found to be low, probably because the 
shortness of diastole does not allow the proper filUng of the 
ventricles; the venus pressure is high. In the intervals 
the circulation is apparently normal (Krehl). 

2. Bradycardia. — The effect on blood-pressure is variable, 
depending on the cause and on other conditions if present. 
When extreme, blood-pressure is always lowered; patients 
with dyspnea cannot exert themselves, and even- change 
in posture may precipitate attacks of syncope (Krehl). 

Finally, in close relation to the circulation in diseases 
of the heart, as has been found by Krehl and others that 
in the last stages of arteriosclerosis, wide-spread dilatation 
of the splanchnic area together with failure of the heart 
to respond to the demands made upon it, there results a 
gradually faUing blood-pressure, when therapeutic measures 
have httle or no effect. (See Terminal Hypertension.) 

Shock and Collapse. — Closely allied to this condition, 
at least from a mechanical and physiologic standpoint, 
is shock and collapse. 

In both these conditions we find a sudden and dangerous 



HYPOTENSION 103 

decrease in blood-pressure. This is due to one or two con- 
ditions. First the overwhelming of the vasomotor system, 
by circulating toxins, which cause vasomotor paralysis. 
This is collapse. On the other hand, shock would 
appear to result from a failure of vasomotor tone, the 
result of reflex stimulation through the sympathetic 
system. Experimental evidence shows that the circu- 
latory disturbance occurring at the height of infections, 
depends absolutely upon paralysis of the vessels, and 
not upon any damage to the cardiac mechanism (Crile). 

Cardiac Asthma. — This term implies a severe attack 
of dyspnea occurring in an individual having heart disease. 
During the attack the pulse is rapid, soft and irregular 
in force and rhythm. The blood-pressure is usually 
below normal during the height of the attack, speedily 
regaining its former level as the attack subsides. 

Hemorrhage. — The degree of low pressure following 
hemorrhage usually bears a direct relation to the amount 
of loss and rapidity with which the bleeding occurs. The 
one exception to this is in cerebral hemorrhage when the 
blood-pressure usually reaches very high levels. Cases 
have been reported in which the pressure has reached 
400 mm. In the cases of acute hemorrhage, such as 
occurs from wounds, during typhoid fever, in tuberculosis 
and epistaxis, the amount of lowering may be so great as 
to endanger life. If the loss supervenes upon an already 
weakened state or during collapse when the vasomotor 
system is crippled or paralyzed, the hypotension may 
be the direct cause of death. It is noteworthy that 
this fall, even when great, is usually transient, and the 
value of this sign therefore decreases in proportion, as 



104 BLOOD-PRESSURE 

the time between the hemorrhage and the observation is 
prolonged. 

Altitude. — The disagreement existing between reports 
of the effect of altitude on blood-pressure is probably- 
due to the fact that some observers have reported observa- 
tions on healthy individuals while others observed only- 
pathologic conditions. (See Chapter XIV, Tuberculosis, 
page 83.) In a healthy individual nearly all competent 
observers agree that high elevations cause a moderate 
reduction in blood-pressure. It is pertinent to quote 
here part of the summary of the very able article of Schnei- 
der and Hedblom.^ Among their conclusions the follow- 
ing bear on blood-pressure: 

1. Considerable elevation in altitude tends to lower 
blood-pressure and to increase the pulse rate. 

2. The fall is greater during the early periods of residence 
in high altitudes. The fall in high altitudes is between 
1 and 22 mm. 

3. Change in altitude does not affect each individual to 
the same degree, a slight elevation does not affect blood- 
pressure and psychic influences may modify the reading. 

The danger of high altitudes to those having a low 
pressure, especially if accompanied by a weakened physical 
condition, is probably due to a further reduction of an 
already existing hypotension. 

Paresis. — Hypotension is the rule, unless kidney com- 
plications exist. 

Infections. — Tuberculosis. — In uncompHcated pulmonary 
tuberculosis the systolic pressure tends to fall, and the 
diastolic pressure to remain stationary or to rise. Tesser 

> Am. Jour. Physiol, Vol. XXIII, No. 3. 



HYPOTENSION 105 

and others report the occurrence of hypotension in unin- 
volved members of families with tuberculosis taint. 

From a diagnostic standpoint, the symptoms of hypo- 
tension when otherwise unexplained should suggest a 
careful examination for tuberculosis, particularly in the 
lungs. In an established case, the chief value of this 
test is in prognosis, where the data compiled by Haven 
Emerson may quite safely be relied upon. 

Haven Emerson^ stated that hypotension in tuber- 
culosis is marked and constant in advanced cases, almost 
always present in the moderately advanced cases, and 
frequently enough found in the very early or doubtful 
cases to warrant its use as a valuable differential sign, 
and further, hypotension is progressive as the process 
advances and rises with progress toward recovery, the 
pressure returning to normal in cases that are cured. 
Continued hypotension never persists in the presence 
of evident improvement in the tubercular process. 

Reitter has suggested that the occurrence of hypotension 
associated with evidence of nephritis is suggestive of renal 
tuberculosis. On the other hand, Sezary^ does not find 
any relation between the condition of the suprarenal 
glands and the low blood-pressure found in tuberculosis. 
He believes that low tension is at first due to the direct 
effect of the action of the soluble toxins of the tubercle 
bacillus, and that not until later do the suprarenals become 
involved. He cites cases examined at autopsies which 
showed almost complete destruction of the suprarenals, 
and yet during life showed a relatively high blood-pressure. 

1 Arch. Int. Med., 1910. 

2 Abstract, Jour. A. M. A., Vol. LIV, No. 15. 



106 BLOOD-PRESSURE 

Typhoid Fever. — The symptoms of hypotension probably 
more frequently accompany the average case of typhoid 
fever than any other acute infection. The systoHc pres- 
sure is usually 100 or less, decreasing as the disease pro- 
gresses and toxic phenomena occur. The diastoUc pres- 
sure tends to remain at the original level or to rise shghtly; 
this causes a reduction in pulse pressure, which is usually 
significant evidence of a weakened heart muscle, calUng 
attention to the need for complete rest and more active 
stimulation. The effect of the common complication of 
typhoid fever, namely hemorrhage, is to produce a further 
rapid fall in pressure, the amount of this indicates roughly 
the extent of the hemorrhage. The development of 
peritonitis after perforation forces the pressure up to or 
above the original normal level. In this disease particu- 
larly, it is important to keep blood-pressure records. 
Systematic observations will be of great value in differ- 
entiating hemorrhages from perforation, and will serve as 
a guide to the general management of any case, pressure 
will rise and will remain high in the presence of nephritis 
but will fall again when peritonitis follows perforation. 

In the study of a large series of cases, Joseph H. Barach^ 
mentions among others the following important factors 
which briefly summarizes our knowledge of blood-pressure 
during typhoid fever. 

1. The blood-pressure falls below the normal after the 
patient has taken to bed and stays down until convalescence 
is estabhshed, when it returns toward normal. 

2. Typhoid fever is a disease with a blood-pressure below 
100. 

> Penna. Med. Jour., July, 1907. 



HYPOTENSION 



107 



3. The blood-pressure is governed by factors of its own 
and bears no constant relation to pulse rate or temperature. 

4. In diagnosis the blood-pressure may be of value in 
differentiating this disease from others, after we know the 
behavior of other diseases in this respect. In the diagnosis 
of the complications it has a value. 

BLOOD PRESSURE CHART 



-^:>k:::::::::; 



CHART NO, 
NAME 
ADDRESS 
OCCUPATION 



n 



AGE . . . -. - 
COLOR^. Wr. 
SEX .d '■■ 
PHYSICIAN^ 



D-telW. l^ 


-w 


— :; 





AflML.1 


t 


., 


-IST 


^- 


k> 


— . 


J}A.Y.af.iilsi 
Time of dJ 


BMftA 


,)' 






1 


^ 


.'1 


/o 


'L 


/^ 




.,rti^ 


P 


a 


^ 


fi> 


aV 


(] 


V 


' 


a V 


(iL 




150 








































145 








































140 








































135 












j 


V 






« 




















130 




s 




y 


K 


J 


A 






> 


^3 


















125 




^ 






)\ 


I 


\ 




, 


/ 




\ 
















120 




c 


/ 


\ 


(» 




\ 




/ 


^ 




\ 




i 












115 


, 
















k 






\ 


^A 


\ 






/ 






110 


















s 


. 






Y 


y 


\ 










105 




















s 




/ 






\ 










100 




















' 










\ 




t 






85 






























\ 


j.^ 


'n 


[0 


,A 


90 








































85 




















— 1 




















80 








































75 








































70 








































65 




















. 





















Fig. 26. — Showing close relation between pulse rate and blood-pressure 
and application of Gibson's rule. Symptoms of collapse developed after 
crisis and continued until normal relation was reestablished during con- 
valesence. 



5. In prognosis the blood-pressure chart is of value. A 
steadily falhng pressure means great danger. As long as 
the blood-pressure keeps up to a reasonable level, we feel 
that there is reserve power to work with. 

Pneumonia. — The pressure in pneumonia depends on 



108 BLOOD-PKESSURE 

the severity of the case and the degree of toxemia, and also , 
on the various modifying influences which may affect the 
case. It may be stated as a general rule that during the] 
first day or two of the disease, the blood-pressure is slightly] 
above normal, following which it falls more or less rapidly: 
to a condition of hypotension of about 100 or 90 mm. 
(See Fig. 26.) 

The blood-pressure test seems to be of very significant! 
value when employed in conjunction with the pulse rate. 

As expressed by Gibson^ it offers a valuable aid in prog- 
nosis and a reliable guide to treatment. He says "When 
arterial pressure expressed in millimeters of mercury does 
not fall below the pulse rate expressed in beats per minute, 
the fact may be taken as of excellent augury, while the 
converse is equally true.'' These observations have been 
confirmed by G. A. Gordon'^ and H. A. Hare^. No case of 
pneumonia should be treated without the blood-pressure 
test being regularly employed. Just as observations of 
the pulse or the temperature are regularly taken. 

Cholera. — Hypotension is the rule. Low blood-pressure 
during the stage of collapse is a very valuable guide to the 
necessity of transfusion. The blood-pressure is always 
below 100. The most satisfactory treatment, or the one 
most hkely to combat comphcations, such as uremia, in 
administering the intravenous solution of adrenahn. By 
this means in one epidemic the death rate was reduced 
almost one-half.* 

^Edinburgh Med. Jour., Jan., 1908. 

* Edinburgh Med. Jour., 1910. 

" Therapeutic Gazette, June, 1910. 

< Leonard Rogers, Therapeutic Gazette, Nov. 15, 1909. 



HYPOTENSION 109 

Cerebrospinal Meningitis. — Robinson^ noted that blood- 
pressure was unusually high during the acute state and in 
those showing severe symptoms, and was low in mild cases 
and in convalescence. 

Abram Sophian^ depends absolutely on the sphygmo- 
manometer as a guide to the value and safety of lumbar 
puncture and serum injections. 

Other infections in which the pressure is usually low are 
diphtheria, scarlet fever, measles and acute rheumatism. 
Here the sphygmomanometer may be of value in conjunc- 
tion with other symptoms in diagnosis, prognosis and 
treatment. 

Miscellaneous Conditions. — A condition of hypotension 
usually exists in all wasting diseases and cachectic states 
and commonly is seen in carcinoma and general paresis. 
In these conditions it is a natural result of a general toxemia 
and the gradual failure of function in the entire body, which 
includes a weakening muscular system, a gradually lowering 
vasomotor tone and a diminution in the quantity and qual- 
ity of the blood. 

In diabetes the pressure is usually subnormal, unless 
complicated by nephritis and arteriosclerosis. 

In Addison's disease the blood-pressure is extraordinarily 
low because of the destruction of the suprarenal glands. 

In epileptic coma the blood-pressure is always low; here 
it constitutes a valuable differential sign between this con- 
dition and uremia (Edgecombe). 

Edgecombe^ reports his studies of a number of miscel- 



* Arch, of Internal Med., May 5, 1910. 

« Jour. A. M. A., March 23, 1910. 

' W. Edgecombe, Edit. Medical Record, April 29, 1911. 



110 BLOOD-PRESSURE 

laneous conditions in which the blood-pressure may be of 
value. 

(1) Subjects with poor circulation, with cold hands and 
feet and Uable to chilblains. These may gain a temporary 
rise by means of baths, massage and exercise, while at the 
same time the circulation improves, but it is difficult to 
effect any enduring rise in the general level of the blood- 
pressure for they are prone on cessation of treatment to 
relapse to their former state. 

(2) Cases of pure neurasthenia, having as their promi- 
nent characteristic, profound fatigue, either somatic or 
psychic or both. It is not easy to say whether the low blood- 
pressure in such cases of neurasthenia is the cause or effect 
of the extreme fatigue. A rise in blood-pressure is an 
almost invariable accompaniment of improvement. 

(3) Tobacco poisoning. Tobacco usually has the effect 
of raising the blood-pressure with this apparent anomaly, 
that heavy smokers frequently have subnormal pressure. 

(4) In cases of dilated heart, with or without valvular 
disease, the pressure will sometimes be found low, and a 
rise in pressure is one of the indications of the progress of 
the case toward recovery. 

(5) There are many examples met with of the so-called 
gouty or rheumatic manifestations of lumbago, sciatica, or 
neuritis which show a blood-pressure somewhat below nor- 
mal. Many of these cases have a subnormal acidity of 
the urine, and are liable almost constantly to a copious 
deposit of phosphates which leads to, or is accompanied by, 
a state of nervous depression. 

(6) The clinical symptom phosphaturia, in whatever 



HYPOTENSION 111 

condition it may occur, is generally accompanied by a low 
blood-pressure. 

(7) Young subjects with ''rheumatoid arthritis'^ fre- 
quently have a blood-pressure below normal, which rises as 
the condition improves. 

The chief practical value of the sphygmomanometer in 
the light of our knowledge of hypotension is the valuable 
aid derived, both for differential diagnosis, prognosis, and as 
a guide for treatment. It alone can give timely warning 
of the onset of the hypotension accompanying vasomotor 
paralysis from shock or any other cause. In acute dis- 
eases the blood-pressure test should be taken daily. 

Effects and Danger of Hjrpotension. — The direct effect 
of a falling blood-pressure is the accumulation of an ab- 
normal amount of blood in the veins, and a slowing of the 
current in the arteries. This will affect the capillary circu- 
lation and interfere with the nutritive and secretory proc- 
esses which depend upon it. The most serious effect is on 
the heart, as it has been shown that complete loss of vaso- 
motor tone soon leads to death, because of the gradual 
accumulation of nearly all the blood in the body on the 
venous side, so that the heart has no blood upon which to 
act. 

''Low blood-pressure due to general prostration is not to 
be regarded as a disorder of the circulation, except insofar 
as the circulation fails to respond to the demand made upon 
it. Thus in shock it is the nervous system that is at fault, 
not the circulatory apparatus" (Bishop). 



CHAPTER IX 

HYPERTENSION, PRESCLEROSIS OR ESSENTIAL 
ARTERIAL HYPERTENSION 

The term hypertension, in its general acceptance, has 
come to mean any condition in which the blood-pressure 
is maintained at a level above normal. It would seem best, 
at least for clinical purposes to limit the term hypertension 
to that condition first described by Huchard and termed by 
him presclerosis, and to designate all other high pressures, 
which are either dependent upon, or accompanied by dis- 
tinct and easily recognized arterial kidney or heart changes, 
as true high blood-pressure. Thus we limit the term 
hypertension to a condition of blood-pressure dependent 
largely if not solely, upon a muscular change in the arterial 
walls and capillaries, whereby they are temporarily nar- 
rowed and constricted, as contrasted to true high pressure, 
when there is a permanent pathologic change either in 
some part or all of the cardiovascular renal system, and 
which can never be entirely overcome by treatment. (See 
Fig. 27.) 

By adhering to this distinction we are immediately en- 
abled to appreciate the etiology of each of these condi- 
tions, and also to explain the difference in the results 
obtained by methods directed toward their rehef, or the 
relief of the symptoms caused by them. 

In the class designated as high blood-pressure, the diag- 
nosis is made for us and our chief concern is to determine 

112 



ESSENTIAL ARTERIAL HYPERTENSION 



113 



the cause, to arrest the progress of the disease and to relieve 
symptoms. 

In hypertension, the diagnosis is often difficult, but when 
once made we are usually in a position to relieve the con- 
dition more or less completely and to cure the disease 
causing it during the time that the patient adheres to a 
restraining hygiene. 

BLOOD PRESSURE CHART 



OCCUPATION . .-.^.. . „„„...^..„ 




••* 


... 


::' 


oiagnosisHp*^ 


JJjJUJt\U.. .-r:,^.x..„.. 








__^ 


170 


^ 


?? 


u 


v; 


p 


><^ 


% 


W 


X 


"4 


yi' 












165 


































160 


































J55 




^ 






























,150 




\ 






























^45 


































^40 








\ 


























135 








\ 






/ 




















130 










s 


/ 






y 


s 














1125 


ft 
















f 




s 


,jj 


LJ 


^ 


^ 




jl20 




s 






















A 








^115 




\ 






























lllO 






s 




























105 








% 




m 










■ 












100 










s. 


/ 


\ 


•HI 


-« 








, 








95 










\ 










\ 




ck^ 


J3J 


u 


ox 




90 


































85 


































80 


































75 




" 




— 









— 


— 




— 




< 


_ 




— 



Fig. 27. — Illustrates pure hypertension and the effect that may be expected 
to follow measures directed toward relief of underlying toxemia. 

It would seem reasonable to consider the condition of 
hypertension or presclerosis, as a distinct disease entity, 
not forgetting its varying etiology. While on the other 
hand, we should never lose sight of the fact that true high 
pressure is a symptom only, merely a small part of the 
whole pathologic picture, and that it should never possess 



114 BLOOD-PRESSURE 

the entire field of our vision. True high blood-pressure 
may be a salutory and beneficent condition not to be inter- 
fered with lightly or illadvisedly. Hypertension is always 
harmful and every effort should be made to control and 
reduce it. 

Hypertension is a subtil condition often lurking where 
least expected. There may be no change in the palpable 
arteries except a barely distinguishable narrowing and 
stiffening when rolled under the finger, a hardly notice- 
able change in the aortic second sound, possibly a faint 
systolic whiff at the aortic cartilage, while the urine re- 
mains practically normal. The blood-pressure will be 
found to be from 140 to 180 mm. depending upon the degree 
of arterial contraction. 

By many, a progressive change in the arteries and a 
gradually rising blood-pressure is looked upon as a normal 
condition in those past middle life or in early old age. 

Hypertension is, I believe, always a sign of the beginning 
of a pathologic change which according to Huchard, Russell 
and others is the danger signal, a warning that some altera- 
tion must occur in the daily life of the individual present- 
ing the condition, or else the at first curable condition 
will progress and eventually merge into and become a case 
of cardiovascular renal disease. 

A permanent increase in blood-pressure in a young adult, 
or in one in early middle life in the absence of discoverable 
organic change, in the heart, blood-vessels or kidneys, is 
always a sign of a chronic toxemia; a poisoning arising from 
some error in metabolism or deficiency of elimination, 
either intestinal or urinary or both. Such a rise in blood- 
pressure is rarely discovered, except by the routine esti- 



ESSENTIAL ARTERIAL HYPERTENSION 115 

mation of blood-pressure of all patients coming under the 
physician's observation, or perhaps through examinations 
for life insurance. In the early stages of this condition, 
symptoms referable to the condition are rare, or if men- 
tioned are attributed to overwork, or mental worry, neur- 
asthenia, etc., on the other hand, one may by careful ques- 
tioning elicit suggestive symptoms, such as fleeting dizzi- 
ness, tinnitus aurium, disturbed sleep, cold hands and cold 
feet, gastric distress and flatulency, constipation, lack of 
interest and of power of concentration, diminished desire 
to be up and doing, distaste for physical exertion and 
weakened tolerance for substances which affect the brain, 
such as alcohol and tobacco. 

The blood-pressure does not need to be greatly in- 
creased, in order to injure the heart, and to cause per- 
manent change in the blood-vessels and in the kidneys. 
The amount of work required of the heart to overcome 
the resistance of a few mm. Hg. mounts up surprisingly. 
(See page 21.) 

Thus increased work even in the comparatively young, 
may result in degeneration. Cases have been reported in 
which arteriosclerosis has been found at autopsy in persons 
under thirty years of age. 

Treatment. — In bad cases, rest in bed with massage. 
In mild cases this preliminary is not required. The im- 
portant rules for diet are: 

1. To reduce the total amount of food. Many cases are 
in men and women who are overfed and underexercised; 
here properly supervised exercise is most valuable. 

2. To reduce the amount of protein in the dietary. 

3. To limit the amount of fluid taken, and to employ 



116 BLOOD-PRESSURE 

measures that will promote elimination from the skin, as 
sweating by means of hot baths, hot packs, Russian baths, 
vapor-cabinet baths, and electric light baths. Nauheim 
baths may be given carefully, if there is little arterio- 
sclerosis and no signs of nephritis. Autocondensation may 
reduce hypertension and should be tried. Calomel and 
saline purges, not too frequently repeated, are beneficial 
and may safely be prescribed every seven to ten days. 
The effect is to prevent and remove intestinal putrefaction 
and to lower blood-pressure by taking fluid from the body 
— washing the blood. 

Regulation of habits, including relief from business 
worries and excessive anxiety, attending constantly to 
work beyond one's capacity — this is particularly the case 
with physicians who form a large part of this class. In- 
creasing the period of recreation and hours of sleep, in other 
words, demanding a life of moderation in all things. 

The condition of hypertension persists in most cases after 
the development of the true high pressure which accom- 
panies arteriosclerosis, and it is in all probability this 
factor which in a large measure determines the extent of 
reduction, accomplished in the treatment of arterio- 
sclerosis. This has been ably demonstrated by RusselP 
and others. Measures which accomplish a reduction in 
pressure amounting to 10 to 40 mm. in high-pressure cases, 
is usually followed by relief from subjective symptoms and 
are beneficial, reductions in pressure which result in edema 
or other untoward symptoms are probably due to a toxic 
effect, and are evidence of depression or myocardial weaken- 
ing and are dangerous. 

* Loc. cit. 



ESSENTIAL ARTERIAL HYPERTENSION 117 

Syphilis as a cause of hypertension is well recognized; it 
acts in the same manner as other circulating toxins and 
therefore may be looked for as a factor in the production 
of hypertension. (See also Chapter XIV.) 



CHAPTER X 
ARTERIOSCLEROSIS 

A careful review of literature upon arteriosclerosis, its 
causes and treatment is most discouraging, as no two 
authorities appear to agree even upon the most funda- 
mental and important points. This is quite remarkable 
when we consider the relatively frequent occurrence of 
this disease, and the almost unlimited opportimity offered 
for its study. Even theories as to the main causative 
factor differ. We are unable therefore to treat the sub- 
ject as scientifically as might be desired; however, much 
general information is available which will serve as a guide 
to the study and treatment of this disease a knowledge of 
which may possibly be a stimulus to others to carry the 
work further. 

Causes. — The broad underlying cause of arteriosclerosis 
is some irritant poison or a toxemia which may vary both as 
to origin and nature, depending largely upon the surround- 
ings and personal habits of the individual that forms the 
basis of the study. The more common causes of general 
and prolonged toxemia are chronic infections (chiefly syph- 
ihtic) ; the introduction of toxic agents, as alcohol, tobacco, 
coffee, lead; the development of autotoxemias from distur- 
bance in metabolism either through improper or excessive 
dietary or overmental strain (emotional and nervous), 
insufficient physical exertion, resulting in maldigestion, 
gout and that large group of ill-defined metabolic disturb- 
ances termed autointoxications. 

118 



ARTERIOSCLEROSIS 119 

Excessive physical exertion, while recognized as a cause 
of generalized arteriosclerosis does not always lead to this 
condition. Usually additional factors must be considered, 
such as the added strain caused by simultaneous over- 
indulgence in food, alcohol, tobacco, late hours, etc. 

According to the observations of Coughlin^ the effect of 
competition in active athletics does little or no harm to 
the cardiovascular system when indulged in by those in 
training, and who are under competent observation. 
From his study he concludes 'Hhat there is a close relation- 
ship between the athletic life and degenerative changes in 
the vascular system, especially in heart and arteries, when 
the voluntary and involuntary muscles are not kept in 
tone by regular systematic exercise, particularly in middle 
life and beyond. (See also Chapter VII.) 

Occurrence. — Arteriosclerosis is usually encountered in 
the second half of Ufe although not infrequently well- 
marked cases are met with before the age of thirty and 
an occasional apoplexy occurs in the twenties. The tend- 
ency to arterial change seems to be on the increase, as both 
the age of incidence (development of symptoms) and the 
percentage of cases encountered are advancing. 

Incidence of apoplexy, organic heart disease and chronic 
nephritis from the statistics of the Penn Mutual Life 
Insurance Company in 1908. These three diseases com- 
prise 25.1 per cent, of the total mortality of the Company. 

1900 1908 

Apoplexy 7 per cent. 9 . 5 per cent. 

Heart disease 8.6 per cent. 9 . 3 per cent. 

This seems largely the result of the high tension and 

1 R. E. Coughlin, N. Y. Med. Rec, April 2, 1910. 



120 BLOOD-PRESSURE 

artificial life led by the average business and professional 
man of to-day. For the same reason men are more sus- 
ceptible than women. All statistics bear out the fact. 
Huchard^ investigated the cause of arteriosclerosis in 2,680 
cases out of 15,000 patients under his personal observation. 
From this study he finds the causes according to their 
relative frequency as follows: gout, uricemia, character of 
food, syphilis, tobacco poisoning, worry, mental overexer- 
tion and alcohol. He dwells particularly upon the fact 
that the abuse of meat in diet is a powerful and frequent 
cause of arteriosclerosis, as it easily produces within the 
body poisons which have a selective action for the tissues 
composing the arterial wall. Herz^ finds that almost invari- 
ably his cases of arteriosclerosis are in those who take Ufa 
too seriously and either from ambition or necessitylive an 
especially strenuous life. Herz sent out a series of questions 
to a large number of physicians in Austria in an effort to 
determine the leading factors productive of arterial change' 
and from 822 rephes he deduced the following statistics. 

Number of cases resulting from: 

Emotional and nervous 150 

Physical exertion 146 

Age 138 

Alcohol 133 

Tobacco 88 

Syphihs 77 

Heredity 72 

Metabolic disturbances 19 

Coffee and tea 13 

Infections, etc 7 

* Medizin klin. Berlin, August 29, V., No. 35. 

* Medizin klin. Berlin, January 16, VI, No. 3. 

* Wien. klin. Wochen., Vol. II., XXIV, No. 44. 



ARTERIOSCLEROSIS 121 

From a general survey of the etiology of arteriosclerosis, 
we fail to find the cause, but it will be seen that we may, 
however, divide the causes of arteriosclerosis into three 
more or less correlated groups — toxic, physical and infec- 
tious. The latter two often involving some phase of the 
former, so that it may be said, broadly speaking, that 
arteriosclerosis is usually the result of some form of toxemia. 

Pathology. — The term arteriosclerosis is too loosely 
employed by the average physician. This has led to 
great confusion in the reporting of cases and to the com- 
pilation of statistics. It is often impossible to learn 
precisely what condition an author is discussing, so that 
the benefit of careful research are often lost to the reader. 
The two conditions usually confused are, atheroma and 
diffuse generalized arteriosclerosis, and less often the con- 
dition of pure hypertension, as found before any perma- 
nent change has occurred in the vessel wall. (See Page 112.) 

The pathologist has more than once pointed out clearly 
these different conditions and has correlated them with the 
physical signs. Among them Russell has made most 
careful studies of the condition of the vessels, and their 
relation to chronic disease of the heart, kidneys, cerebral 
system, to blood-pressure. According to Russell,^ ather- 
oma is a local or patchy affection of the arteries char- 
acterized by a local thickening and degeneration of the 
intima. This soon undergoes a form of fatty degeneration 
which is termed, atheroma. Later these patches become 
the seat of a calcareous deposit and in the larger arteries 
atheromatous cysts and ulcers may be formed with local 

1 Wm. Russell, Arterial Hypertension, Sclerosis and Blood-pressure, 
J. B. Lippincott Co., 1910. 



122 BLOOD-PRESSURE 

sacculations. These changes may be so extensive, espe- 
cially in the aortic arch that a local bulging occurs to 
which the name aneurysmal bulging has been apphed. 

Atheromatous changes are quite common in the cerebral 
and coronary arteries but comparatively rare in the radials. 
When present in the radials, they give rise to local thicken- 
ings, which give an irregular nodular feel to the vessel. 
They are never symmetrical. Russell believes that the 
character of these changes is very suggestive of a low-grade 
infection, and assigns a primary microorganismal implanta- 
tion as their origin. 

Arteriosclerosis, on the other hand, may be roughly 
defined as a thickening of the arterial wall with a diminu- 
tion in the size of its lumen. The changes which have led 
to this when examined in detail are seen to consist of (1) 
a marked thickening of the intima, due to hypertrophy of 
the muscle fibers; (2) a thickening of the intima without 
atheromatous degeneration; (3) and in some cases a fibrous 
thickening of the adventitia. The muscular coat may 
show some degeneration but the prevailing notion that in 
such thickened vessels the muscle coat is replaced by fibrous 
tissue (fibrous degeneration) is erroneous (Russell). 

These changes are not confined to limited areas of the 
vessel wall as in atheroma, but affect uniformly a large 
portion of the vascular system and are usually distributed 
throughout the body for instance in the coronary and renal 
arteries. 

Cases are encountered where both processes are met 
in combination. These usually occur late in life, the ath- 
eromatous changes generally being confined to the large 
vessels and aorta. 



ARTERIOSCLEROSIS 123 

The clinical study of blood-pressure and its relation to 
\'isceral involvement would seem to bear witness to the 
accuracy of RusselFs deductions and conclusions, for it will 
be recognized that were this change one of pure fibrous 
degeneration with destruction of the muscular tissue in the 
vessel walls, then measures directed toward relieving hy- 
pertension (contraction of the muscular wall) would be use- 
less. As proof of this and of the value of such measures, we 
have only to review the evidence found in every-day prac- 
tice, where such measures affect reduction in a larger ma- 
jority of cases. 

The experiments of Pearce^ in the artificial production of 
arteriosclerosis in rabbits resulted in the production of 
merely an atheromatous change in the aorta and the for- 
mation of necrotic areas in the elastica and media, which 
subsequently became impregnated with lime salts (typical 
atheroma). They showed no evidence of arteriosclerosis. 

Adler and HanseP endeavored to produce arteriosclerosis 
by the injection of massive doses of nicotin. These efforts 
resulted in the destruction of small areas of intima and mus- 
cularis without the production of a diffuse contraction or 
thickening of the vessel. 

These facts further emphasize the present belief that 
arteriosclerosis is a generalized alteration in the blood-ves- 
sels, resulting from a prolonged but mild irritation by a 
circulating poison and not from a local injury or low-grade 
infection of isolated areas in the larger vessels. 

Clinical Manifestations. — There exists great confusion 
among pathologists as to the exact nature and process of 

1 Jour. Exp. Med., Vol. VIII, p. 74, 1906. 
* Assn. Am. Physiol., May, 1906. 



124 BLOOD-PRESSURE 

arteriosclerosis, so that it is not possible, at this time, to 
give an exact or rational definition of the disorder from the 
pathologic standpoint. Clinically the elevation of pressure 
in arteriosclerosis affords a method of distinguishing between 
this disease and atheroma with which it is so often con- 
fused. Atheroma is really a senile affection coming on in 
persons between sixty and eighty years and involves the 
blood-vessels only. Arteriosclerosis on the other hand may 
attack persons between thirty and sixty years of age and is 
largely a visceral complaint involving as it progresses, the 
heart, kidneys and nervous system. Although Oppenheim^ 
has reported two cases of undoubted arteriosclerosis in boys 
of nine and ten years of age. The first died of spontaneous 
rupture of the aorta probably of the syphilitic origin while 
the second case was undoubtedly due to autotoxemia. 

With the study of atheroma we are but little concerned 
as this condition must be looked upon as a more or less 
natural process due to the changes caused by advancing 
years, and not particularly related to those factors which 
are recognized as producing arteriosclerosis. 

Gull and Sutton's original conception of this disease as an 
'^ Arteriocapillary Fibrous " is incomplete. From the view- 
point of the pathologist, the clinician and the therapeutist, 
we must recognize the multiplicity of the lesions involved 
in arteriosclerosis and admit the condition as a joint in- 
volvement of the heart the blood-vessels and the kidneys, 
in what may be termed cardiovascular renal disease. 
Jump has recorded a study of a large number of autopsy 
records in which arteriosclerosis was present in 69 per- 
cent, and a chronic kidney lesion in 71 per cent. We can 

» Virch. Arch., Vol. CLVIII, No. 2. 



ARTERIOSCLEROSIS 125 

usually by appropriate study of each case, determine the 
predominating type. 

Clinically three stages may be identified (1) the pre- 
sclerosis of Huchard (Hypertension of Brunton) in which 
the nervous mechanism of the vascular system is affected 
by circulating toxins, causing an arterial spasm, and an 
elevation of pressure (see page 112); (2) the cardioarterial 
type in which permanent changes have occurred in the 
blood-vessels, including the coronary cerebral and renal; 
and (3) the final stage including heart and kidney failure. 
Careful distinction must also be made between the patho- 
logic lesion and the clinical picture. Simple atheroma 
may remain for a long time as a^ symptomless anatomic 
change. In cardiovascular disease on the other hand, the 
subjective symptoms predominate and the physical signs 
may often be obscure. Renal insufficiency is an early and 
almost constant accompaniment of the latter disease and is 
present even in the absence of demonstrable albuminuria. 
This fact accentuates the importance of eliminative treat- 
ment during the whole course of the disease. 

Clinically, arteriosclerosis may begin in the kidneys, in 
the heart or in other organs, but there cannot be arterio- 
sclerosis (general) without both cardiac and renal involve- 
ment. 

Of greatest importance in the diagnosis of arteriosclerosis, 
is the recognition of the condition termed by Huchard, 
presclerosis, because of the brilliant results obtained from 
treatment in these cases. (See Chapter IX.) 

Symptomatology, — In the cases with pipe stem or tor- 
tuous arteries and ringing aortic second sound, seen in 
elderly individuals with interstitial nephritis, the diag- 



126 BLOOD-PRESSURE 

nosis is made for us, and the treatment is of little avail. 
It is in the unsuspected subtil ones showing none of 
these characteristics, with Httle or no palpable change 
in the peripheral arteries, doubtful change in the valve 
sound, perhaps a little roughening in the second sound, 
with a normal or practically normal urine, that early- 
diagnosis gives briUiant results. These cases may and 
usually do show gastrointestinal symptoms of a chronic 
nature, which may be found by diUgent search, but 
which often fail to obtain proper consideration at the 
hands of the physician. These cases when the sphyg- 
momanometer is properly used show a blood-pressure 
with a systolic range of from 160 to 250 mm. Hg. (See 
Fig. 28.) 

In persons, entering upon, or in early middle Hfe, this 
increase in blood-pressure is, in the absence of demonstrable 
nephritis, usually the only sign of a chronic poisoning 
arising from some deficiency of elimination, either intestinal 
or urinary, or both. With regard to an exact symptoma- 
tology of early generalized arteriosclerosis, the clinical 
signs and subjective symptoms may simulate almost 
any known disease and cause nearly anything from a 
fleeting dizziness to gangrene of the extremities. Some 
of the symptoms are not infrequently attributed to neuras- 
thenia. These are vague, unpleasant feelings or fullness 
in the head, slight momentary dizziness, cold hands and 
cold feet, sleep unrefreshing and disturbed by dreams, 
gastric distress and flatulence coming on in one or two 
hours after meals, constipation and loss of power of con- 
centration and interest in business affairs. The general 
vitality and power of resistance of the body fails, and 



ARTERIOSCLEROSIS 



127 



tolerance for substances which affect the brain, as alcohol 
and tobacco is diminished. The patients tire easily. 
The gastric symptoms increase in severity and any exertion 
after meals bring on attacks of gastric and heart pain, 

BLOOD PRESSURE CHART 



Manic 

ADDRESS 
OCCU PATIO 
DIAGNOSIS 



Z}Jjji^Jl><x)(iM^ 



AGE 

COLOR ."WT . 

SEX .y^r. 

PHYSICIAN. . 



1 


1 


1 






Daw of dlMSBS 


n 


1 Id 


IV 




Tirho of dey ^ 


^UrV. 


^S^^MA/. 9^ 


r 




220 


\ 


^ K\ \ 


w ^^ 


y \ 


vV 




215 














210 














205 




\ 










200 




\ 










.195 














*190 




\ 








L i '\/i 


":85 




\ 






nU 


\LH 


5 180 




\ 






/ 




gl75 




\ 






/ ^ 




3170 




\ 


j\ 


..y 






£l65 




^ 


/ 








O160 














§155 














150 














145 














140 














135 














130 














125 














120 




<fc:d k^ 








^ 


115 




>j 


1 / 


\ - 


^^ \^\ Q 


dA.i 


"" ■ 110- 






Sr 


\y 




105 








V 






100 














»l 






^ 









Fig. 28. — Case sought advice because of the recurrence of an old sciatica. 
Treatment was largely directed toward a chronic intestinal toxemia. The 
marked fall in pressure resulting from a relaxation of hypertonus, while 
the further failure to bring the pressure below 165 indicates the failure of 
such measures to affect a permanent change in the vessel walls. 

which are only relieved by resting. The cases gradually 
become incapacitated for work. They are nervous, lose 
weight and move slowly, the evidence of involvement 



128 BLOOD-PRESSURE 

of all the organs in the arteriosclerotic process, notably in 
the brain, heart, eyes and kidneys. Extreme cases give 
all the classical symptoms and signs which go to make 
up the syndrome of cardiovascular renal disease. By this 
time the diagnosis is as easy as the treatment is difficult. 

Klemperer a few years ago reported that in sl short 
space of time, he had seen fifty-one doctors between the 
ages of twenty-eight and forty who gave signs of arterio- 
sclerosis. These cases presented symptoms usually classed 
as neurasthenic. They were irritable and could not 
accomplish their work without some form of stimulation, 
they had been living a high-tentioned Ufe, without suffi- 
cient rest and recreation, living two years in one and carry- 
ing a blood-pressure of 160 to 180. (Chart, Fig. 29.) 
For such to continue under the same strain would soon 
result in marked and incurable cases of cardiovascular 
disease, terminating in death, long before their alloted time. 

Cases of arteriosclerosis which have sustained a high 
pressure over considerable time show periods of great de- 
pression with severe headaches, nausea and sudden vertigo. 
This is due to the irritation and diminished nutrition of 
the cerebral centers from the high pressure and the narrowed 
arteries. Eventually these symptoms become more or less 
constant, memory fails and insomnia ensues, while life be- 
comes a burden. 

Often it is not until these cases suffer a cerebral hemor- 
rhage or show signs of cardiac weakness, that they are even 
suspected of having anything more than a nervous condi- 
tion. Routine observations of blood-pressure and a prac- 
tical knowledge of the early signs of this disease would 
have made a diagnosis in time to obtain benefit from pre- 



ARTERIOSCLEROSIS 



129 



ventive measures. The routine estimation of blood-pres- 
sure and the preparation of a daily chart is of great value 
in the study of suspicious cases such as simple chronic 



BLOOD PRESSURE CHART 



CHART NO. . , - .^ ..^.„^.. ,. 



NAME 
ADDRESS 



OCC U P AT I O N &Cl^ ftAlm.<) Im; 
DIAGNOSIsQA/tml'<#Ml^ 



AGE Itti*. - . 
COLOR 1*^ . 

SEX ..TtU^ 

PHYSICIAN. 



Date 










, Dav of (lltieaso 










^ TInno of rfay 










200 


h 


H- 


T 


1 


fo 


w 


n 


^9 














195 


^ 


U^ 


n 


Vi 


\l 


li" 


\\ 
















190 






























^185 






























180 






























175 




\ 


























170 




\ 


























165 






\ 
























160 






\ 
























J55 






1 
























150 






\ 
























145 






\ 


1 


\ 


J 


\ 


n 














140 






\ 


y 


\ 


/ 


V 


\ 


ftJ 


\s} 


Wi 


? 






135 






) 


/ 










f 












130 








/ 






















125 






























120 






























115 






























110 






























"105 






























100 






























S5 




\ 


























SO 




\ 












(^^ 


u 


) f) 


.nt 


1^ 






85 






'^ 








/ 














. 


80 






V 




f 


X 


t 
















re 








V 


./ 




















,70 






























es 






























99 










^_ 










L. 











Fig. 29. — Symptoms chiefly cerebral, September. 20, patient slightly delir- 
ious, some muscular weakness on left side of body. Chart shows effect of 
active treatment continued until September 23. Remainder of chart 
shows lowered pressure maintained by physical measures after patient 
resumed his activity. 

bronchitis with emphysema which are often explained and 
their etiologic factors supplied, by demonstrating the pres- 

9 



130 BLOOD-PRESSURE 

ence of continued high pressure. Indeed the blood-pres- 
sure need not be very much elevated to injure the heart 
and other organs, for an increase of a few miUimeters if long 
continued entails an enormous increase in the daily work 
of the heart. 

In considering the subject of arteriosclerosis, Daland^ 
points out that we must differentiate clinically between 
(1) the normal thickening of the arterial wall, which occurs 
after the age of forty, and which progressively increases 
with advancing years, (2) the atheroma which is a char- 
acteristic of the aged and (3) arterial spasm from any cause 
which when long continued results in a permanent thick- 
ening of the vessel walls and a reduction in their lumen. 
This change being greater than that expected for the given 
age of the individual. 

Pathologically we have to consider the exciting agent 
or agents which alter the condition in order to separate 
that of syphilitic origin from the autotoxic or alimentary 
and renal. Very often clinically in the absence of con- 
firming history, clinical signs and characteristic symptoms, 
this differentiation is impossible. 

Diagnosis. — For diagnostic purposes we may assume that 
the arterial wall may usually be demonstrated by palpation 
to be thickened after the age of forty years (Daland). 
This seems very practical from a diagnostic standpoint 
when we consider that a demonstration of the state of the 
vessels is purely a relative comparison and that to ignore 
this premise would lead into error resulting in a diagnosis 
of arteriosclerosis in patients having vessels with no more 
than a normal degree of thickening. 

» Monthly Cycl. Pract. Med., Vol. X, p. 146, 1907. 



ARTERIOSCLEROSIS 131 

Observation is, therefore, first directed toward a study 
of all accessible vessels by means of inspection and palpa- 
tion, not forgetting those of the retina by means of the 
ophthalmoscope. The study of the radial arteries gives 
most valuable information, but it must not be forgotten 
that the fibrotic process may be inconspicuous in the per- 
ipheral arteries while well advanced in the internal arteries, 
more especially the splanchnic and cerebrals; and occa- 
sionally fibrosis may be advanced in the peripheral vessels 
with but little or no change in the important internal ones. 
On account of variations in size and situation of the radial 
arteries both should be examined. It must also be remem- 
bered that the excessive deposition of adipose, or the presence 
of edema, may prevent successful examination of the radial 
arteries. It seldom happens, however, that radial sclerosis 
is diagnosed when absent, the error is usually on the other 
side. 

It is important to separate true sclerosis from pure hy- 
pertension as the impression under the finger in these 
two conditions is quite similar. Arterial spasm usually 
occurs in the young and palpation of the vessel wall reveals 
a vessel which feels thicker and smaller than normal, while 
the lumen appears to be diminished. The common causes 
of this condition are (1) acute uremia, occurring in the course 
of acute parenchymatous nephritis as in scarlet fever and 
similar infectious process; (2) in certain cases of severe 
acute intestinal toxemia; (3) in certain cases of irritating 
chemical poisoning. 

Apart from the result obtained from palpation, the car- 
diac and renal signs of arterial spasm may exactly simulate 
arteriosclerosis and we are therefore compelled to rely upon 



132 BLOOD-PRESSURE 

the knowledge of the cause and duration of the condition 
to determine the degree of arterial change. 

Reliance should not be placed upon the radial arteries 
alone, but for diagnostic purposes we should use the tem- 
poral, the carotid, the brachial, the abdominal aorta, the 
femoral and the dorsalis pedis. 

J. N. Jackson^ rightly calls attention to the routine 
measurement of blood-pressure and its importance in 
every-day practice. He cites as examples, cases in which 
although the patient did not feel particularly ill, yet the 
presence of a high blood-pressure demanded a grave 
prognosis, the correctness of which was later established. 
It has been stated by Robertson and others that a case 
with a blood-pressure of over 200 mm. which is con- 
stantly maintained, when accompanied by kidney involve- 
ment will be very unlikely to live beyond the two-year 
limit, however there are no definite statistics covering this 
point. 

Elevation of Blood-Pressure, — Having determined the 
condition of the blood-vessels, the blood-pressure tests 
may then be applied. In the presence of arteriosclerosis 
the systoHc pressure will be found above that determined 
as normal for the age of the individual. This elevation 
need not be great. A continued hypertension of 20 or 30 
mm. unless explained upon other ground should be con- 
sidered pathologic and calls for explanation. It should, 
however, be remembered that cases will be met having 
very hard and firm peripheral vessels showing a normal or 
subnormal systoHc blood-pressure. 

I distinctly remember one case of over fifty years of age 

KBoaion Med. and Sur. Jour., Nov. 2, 1911. 



ARTERIOSCLEROSIS 133 

having the most rigid and pipe-stem radials that I have 
ever palpated, yet at no time was the systohc pressure 
found to be over 100 mm. Hg. Again the hypertensive 
effect of arteriosclerosis may be counteracted by the hypo- 
tensive effect of an associated thyroid disease or a deranged 
adrenal system, as in Addison's disease. (See page 109.) 

A comparison of the systolic and diastolic pressures and 
an estimation of the pulse-pressure is of distinct value in 
the study of all cases. The physical changes produced in 
the dynamics of the circulation by the less elastic vessel 
walls, will in the presence of a normal heart show an in- 
creased pressure often as high as 60 and occasionally 100 or 
more, as the advanced and extreme cases are met. 

Examination of the heart in pure early arteriosclerosis 
(before the kidney has become much damaged) will reveal 
only some slight accentuation of the second aortic sound. 
The studies of Romberg and Hasenfeld^ found hyper- 
trophy of the left ventricle in only a small proportion of 
cases of arteriosclerosis before an associated nephritis had 
developed. 

The temperature, as is the case in most chronic diseases, 
will usually be found subnormal, although StengeP called 
attention to the occurrence of continued fever in certain 
cases and he holds that when there is no other assignable 
cause for the fever, it is probably due to the arteriosclerotic 
process. 

Examination of the digestive tract will often reveal 
sUght departures from normal probably dating back for 
many years, and the results of test-meal examinations will 

1 Deut. Arch.f. Uin. Med., Vol. LIX, 1897, p. 193. 
^ Medicine, Detroit, June, 1906. 



134 BLOOD-PRESSUKE 

show reduced gastric secretory activity with abdominal 
distention and often most obstinate constipation. 

A consideration of the patient^s history and recent 
general condition may reveal periods of mental lassitude 
and irritabiUty with headaches coming on after mental or 
physical excitement or at a certain time each day. There 
are often momentary attacks of dizziness often accompanied 
by nausea and followed by profuse perspiration and a period 
of weakness. Insomnia, loss of memory, melancholia and 
other nervous symptoms as a gradual loss of mental vigor 
and bodily tone unite to form a well-known picture of the 
average cause of established arteriosclerosis. 

Treatment of Arteriosclerosis. — Certain causes of arterio- 
sclerosis demand besides the general therapy as apphed 
to the condition of sclerosis (chiefly toxemia) a therapy 
devoted to the particular causal agent, when this is ascer- 
tainable. There are cases of arteriosclerosis, dependent 
upon gout, diabetes meUitis, alcoholism, nicotinism and 
syphilis, and more rarely upon lead and other poisons. 
Without going into detail, it is sufficient to point out that 
when the relation of the arteriosclerotic process to any of 
the above diseases has been established, it is imperative to 
treat not only the condition itself but also, to direct treat- 
ment toward the reUef or removal of these exciting causes. 

All authorities agree that the general treatment should 
combine a reduction of diet and stimulation of elimi- 
nation, through the skin, bowels and kidneys together 
with the removal of all undue physical and mental strain. 

From another standpoint the treatment can be divided 
into (a) that directed toward the prevention of the develop- 
ment of the disease in those predisposed by heredity or 



ARTERIOSCLEROSIS 



135 



environment; (b) that directed toward arresting the pro- 
duction and to the relief of the conditions as found. 

When the disease is recognized in the early stage before 
the heart is seriously involved and before the kidneys 
show positive evidence of an interstitial nephritis, much 
can be gained by careful regulation of hygiene, by careful 
living and by modification of diet. Work, both physical 
and mental, should be reduced and the patient taught to 
live on a lower plane. 



Date JAN. 
Dar 2 25 


FEB. 

7 11 16 18 24 


■ARCH 

1 8 14 30 


ATRl HAT 
7 19 21 31 


JULJAUC OCTI HOV. 

7 1 9 1 20 1 1 B 15 


1 


210 


[/I 














































206 




^ 












































200 




\ 


^ 










































^J95 






^ 










































> 






\ 










































b^ 






\ 










































Ziso 








•s 








































gl75 










^ 


/ 


' 


V 










J 














■ 








SiTO 
















^1 








. 


( 






















= 105 


















V 






/ 
























_§1^ 


















> 


/ 


s 


f 














> 


\A 


s 


>c 


1 


il55 
































1 1 




( 








, 


150 














































145 

















































Fig. 30. — This blood-pressure chart, taken from a case of arteriosclerosis 
shows effect (1) from A to B, combined drug and rest treatment; (2) 5 to C, 
effect of dietetic hygiene combined with systematic daily walking, no drugs, 
patient attending to business. 

Dietetic regulation with measures directed toward 
maintaining renal efficiency should always be the basis 
of sound treatment (Fig. 30). 

An excessive milk diet is often beneficial in effecting 
marked reduction in a dangerously high pressure. So also 
a meat diet, but the ultimate effect of the meat diet may 
cause an aggravation of the disease, as shown by the nervous 
and other serious symptoms.^ 

By emphasizing strongly the dangers of worry and of 

1 J. M. King, &o. Calif. Med. Jour., Aug., 1910. 



136 BLOOD-PRESSURE 

undue strenuousness and by urging patients to take 
greater advantage of the sunny side of life and to refrain 
from a too serious view of themselves and their responsi- 
bilities, many cases of arteriosclerosis can be avoided.^ 

According to the observations of Huchard/ the ideal 
diet directed toward the reduction of hypertension, and 
the prevention of arteriosclerosis is one composed chiefly 
of vegetables and milk and one from which sodium chlorid 
is largely eliminated. 

General Dietetic Directions, — A good general rule of 
diet is that while meat is not to be prohibited a diet com- 
posed chiefly of milk, vegetables and fruit is indicated; 
absolute milk diet is not good when prolonged but may 
be used for the relief of certain symptoms. It is important 
that the daily supply of food should be taken in small 
quantities and at frequent intervals. Alcohol, tea, coffee 
and tobacco need not usually be prohibited entirely, 
although with heart pain and in angina tobacco should 
never be allowed. The reduction in diet should not be 
carried to a point of causing a feeling of subjective weak- 
ness, and should not rapidly reduce body weight, except in 
the obese. 

Limiting the amount of water taken undoubtedly 
spares the heart and vessels, but the amount should not 
fall below 1,500 c.c. per diem and even when there is 
edema not below this figure for more than three consecutive 
days, otherwise kidney elimination will be reduced and 
the case suffer accordingly.' 

* M. Herg, Medizin Klin., Berlin, Jan. 16, VI, No. 3. 

« Bui de VAcad. de Med., Jan. 21. 1907. 

» A. Strasser, Wien klin. Wochenf April 8,1909. 



ARTERIOSCLEROSIS 137 

Special Diet. — The fact that too abundant diet may be 
a cause of arteriosclerosis should be kept in mind. More- 
over the food should contain as small amounts of toxic 
substances as possible, as these upon entering the circula- 
tion cause a narrowing of the vessels (hypertonus, and 
thereby cause an increase in pressure. 

Sausages, spiced and pickled meats, rich foods, strong 
broths, caviare, ham, and foods containing much nuclein 
as roe and sweet breads, strong cheese, liquors and strongly 
alcoholic drinks should be absolutely forbidden. 

Baths, Climate, Etc. — (See also Chapter XIX.) Very few 
patients with arteriosclerosis do well in an altitude of 
3,000 ft. and over. One important fact must always be 
remembered — the danger in arteriosclerosis of any sudden 
alteration of blood-pressure, particularly any sudden 
increase, hot or very cold baths are therefore contra- 
indicated, on the contrary baths of moderate temperature 
in cases of arteriosclerosis, with a very good or compensated 
heart are very beneficial. These baths may be taken, 
at any of the resorts, where such treatment is given, or 
at home, by means of a simple warm bath accompanied by 
general friction of the body, or by a warm pack which 
increases cutaneous dilatation and increases elimination 
through the increased production of perspiration. 

Medication. — (See also Chapter XIX.) The condition of 
the intestinal tract is of utmost importance; daily evacua- 
tion must be had, if necessary by means of laxatives, or 
cholagogues, supplemented by salines or saline waters 
(Hunyadi or Pluto) as the study of the blood-pressure curve 
indicates. 

Drug Treatment. — (See also Chapter XIX.) Directions 



138 BLOOD-PRESSURE 

toward the relief of high pressure and modification of the 
condition of the pathologic vessels, have been most dis- 
appointing, and the reports of observers who have tabulated 
their findings, are so at variance that little dependable 
knowledge can be obtained from them. This is in part due 
to the fact that many have endeavored to accomplish the 
impossible (the removal of sclerotic tissue) and partly to 
the great variety of causes underlying the development of 
the condition. 

It is far from the author^s intention to discourage drug 
therapy, therefore it seems advisable to give a brief resum^ 
of the opinions of recognized authorities and thus allow 
the reader to draw his own conclusions from them. 

Huchard^ places his dependence in the treatment of 
this condition in the following order. 

Diet, muscular exercise, massage, particularly abdominal 
and precordial massage (massage does not produce elevation 
of blood-pressure, see page 246), baths and high-frequency 
currents. Drugs, the nitrites with theobromin to assist 
elimination through the kidneys. He believes heart tonics 
unnecessary until the condition is far advanced, but 
when indicated the periodic administration of digitaUs i3 
advised. 

Edgecombe^ says that the effect of thyroid extract is 
powerful and rapid. 

On the other hand, Huchard^ relies almost wholly upon 
dietetic and hygienic measures, and says that the abuse of 
drugs, especially of the iodids and of digitalis is especially 

» Bui. de VAoad. de Med., Jan. 21, 1907. 
* N. Y. Med. Rec, July 16, 1910. 
\Jour. A. M. A., Vol. LII, No. 14. 



ARTERIOSCLEROSIS 139 

to be avoided and also the abuse of the so-called '' anti- 
sclerotic serums/' high frequency currents and climatic 
and some mineral water *' cures. '^ 

Beverly Robinson agrees with Huchard when he states 
that "the larger my experience and the more I watch cases 
of pronounced arteriosclerosis especially in men and women 
past middle life, the less frequently I prescribe either 
digitalis or the iodids. If a cardiac tonic or stimulant is 
required, strophanthus, caffein and nux vomica are prefer- 
able by far, and are not likely, in small or moderate doses, 
to do positive injury. To lessen hypertension, where it is 
clearly indicated, by reason of headache, fainting attacks, 
pallor and general nervous irritability, sweet spirits of 
niter, in small or moderate doses, added to water is the 
least injurious and most useful drug I have known, not 
excepting nitroglycerin and the nitrites." 

Henry Jackson^ in moderate uncomplicated arterio- 
sclerosis, depends chiefly on dietetic measures and the 
reduction of mental and physical exertion. One drug he 
considered of value as a preventive measure and in some 
cases as curative, potassium iodid, to be taken 1/2 gr. 
three times a day for three out of four weeks in a month, or 
by substituting strontium iodid in the same dose when 
potassium upsets the stomach. He employs saline cathar- 
tics and sees benefit in high frequency currents. (See 
Chapter XIX.) 

^Boston M. and S. Jour., Aug. 11, 1910. 



CHAPTER XI 
DISEASE OF THE KIDNEYS 

It is beyond the scope of this work or the author's ability 
to analyze and classify the compUcated relations which the 
light of recent knowledge has shown may exist between 
chronic diseases involving the heart, the blood-vessels and 
the kidneys. Most careful study during life often fails to 
fully illuminate all cases, in some of which only at post- 
mortem is the true condition demonstrated, when it is far 
from rare to have our cHnical diagnosis absolutely reversed 
by the pathologic findings. 

In a large per cent, of cases met and studied clinically 
we find coincident involvement of the kidneys, the heart 
and the blood-vessels, so that our ability is often taxed 
to the utmost in an effort to give each factor its true 
value, and to assign each to its proper place in therapeutic 
management. 

The views here set down have been reached by a careful 
review of recent literature, bearing upon the relation of 
these several organs to the clinical picture, particularly 
chronic nephritis, as viewed by the author, in the light of 
his experience with this class of cases. 

Etiology. — According to Stengel,^ Bright's disease may 
be one of the complications of the general disease, arterio- 
sclerosis, when it will usually be found as a well-developed 

> Medicine, Detroit, Mich., June, 1906. 

140 



DISEASE OF THE KIDNEYS 141 

case, contributing largely toward the terminal stage, which 
comprises circulatory and organic failures and terminal 
infections. Stengel in discussing the association of al- 
buminuria and slight renal change with general arterio- 
sclerosis concludes that, at least from the cHnician's stand- 
point for prognostic purposes, comparatively little signifi- 
cance attaches to the occasional presence of slight traces of 
albumin in arteriosclerosis when phenomise, such as high 
blood-pressure and polyuria are wanting. 

Clinical Classification. — AUibert in the British Medical 
Journal (April 15, 1911) classifies clinically the kidney 
relation to generalized arteriosclerosis as follows : 

1. Associated with chronic nephritis, (a) Chronic 
generahzed arteriosclerosis not due to high blood-pressure, 
constantly found associated with contracted kidney and 
arteriosclerosis of varying origin in which the kidney con- 
dition is not constant, (b) Secondary generalized arterio- 
sclerosis due to high pressure, (c) A few mixed cases which 
reveal kidney disease, supervening on a general arterio- 
sclerosis, but not originally due to Bright's disease. 

2. Not associated with Bright's disease, (a) Arterio- 
sclerotic kidney, in which the kidney changes are secondary 
to general arteriosclerosis. High pressure may be con- 
sidered as (1) obligate with contracted kidney, (2) irregu- 
larly associated with the other kinds of nephritis and (3) 
occasionally as independent of chronic nephritis. 

This classification while amply covering all conditions 
will be in most cases very difficult to apply. Usually 
we will have to be content with a broader generalization, 
and to give precedence to the prominent symptoms 
which demand therapeutic management, in order to re- 



142 BLOOD-PRESSUBE 

lieve the patient and possibly arrest the progress of the 
disease. 

Pathology. — Marcuse^ asserts that renal inflammation 
causes an increased resistance to the blood current in both 
kidneys, in consequence of which a compensatory hyper- 
emia of the suprarenal capsules is produced through the 
inferior suprarenal artery, which is a branch of the renal 
artery. We know that hyperemia of an organ can bring 
about a hypertrophy of that organ and can assume nat- 
urally that a hyperemia or hypertrophy of the suprarenal 
capsules increases their functional activity and results in an 
increased amount of adrenalin in the blood. In this way 
the increased functional activity of the suprarenal capsules 
brings into causal connection general increase of blood- 
pressure and hypertrophy of the left side of the heart. 

The beUef of Hiatt^ is that the rise in blood-pressure in 
cases of autointoxication is caused primarily by the action 
of these poisons on the smaller ganghonic endings of the 
splanchnic nerves in the vessel walls, and these poisons have 
a selective action for the vasoconstrictor nerves and that 
the first effect of this action is a rise in the blood-pressure 
of the portal vessels. The connections of the nerves sup- 
plying these vessels is such that there is a general reaction. 
An efferent impulse is sent out to the entire vascular system 
from the reflex centers located in the spinal cord. This 
results in acceleration of the heart beat, both through the 
sympathetic ganglia and the accelerator nerves of the heart. 
Thus we have a faster beat and an increased peripheral 
resistance, these two factors will raise the pressure to an 

» BerlinMin. Wochen., July 19, 1909. 

« H. B. Hiatt, Archives of Diagnosis, N. Y., April, 1911. 



DISEASE OF THE KIDNEYS 143 

extent that requires a more forceful beat to overcome it. 
The more forceful beat, in the presence of the conditions 
mentioned, causes a rise in pressure and thus a vicious 
circle which involves the kidneys is established. 

Richard C. Cabot ^ in the fullness of his experience, 
presents a very useful and practical classification of the 
several degrees of disturbed renal function as follows: 

1. Renal irritation, presence of albumin and casts. 

2. Renal insufficiency, which may exist with or without 
cause, and shows itself chiefly in the physical characteristics 
of the urine and the condition of the rest of the body 
(oliguria, dropsy, and uremia). 

3. Nephritis, which shows itself in the postmortem con- 
dition of the kidney. These three sets of changes are fre- 
quently associated, but the association is by no means 
invariable. 

Renal Irritation. — Following violent exercise, often 
causes albumin and casts to appear in the urine. The 
microscopic findings often being as various as those of an 
acute nephritis. These cases subside entirely, have no great 
elevation in blood-pressure and postmortems have shown 
that such a urine is consistent with normal kidneys. 

Renal Insufficiency. — The kidney cannot perform its 
normal function, either of elimination or of excretion or 
both. The condition is characterized by diminution in 
twenty-four hours urine and by the appearance of dropsy. 
High blood-pressure and cardiac hypertrophy are natural 
sequential accompaniments. Often the larger portion of 
urine is secreted at night, and is of lower specific gravity. 
Albumin and casts may or may not be found. 

1 N, Y. Med. Jour., May 12, 1906. 



144 BLOOD-PRESSITRE 

Nephritis. — Acute and chronic interstitial nephritis are 
hard to determine without careful and painstaking study. 
Postmortems show wide discrepancy between the cHnical 
and pathologic findings. 

Pathologic reports bearing on the relation of elevated 
blood-pressure to postmortem findings in the heart, blood- 
vessels and kidneys, seem to demonstrate conclusively 
that the blood-pressure may be accepted as a safe guide 
and that the statement of Emerson,^ 'Hhat persistently and 
constantly high blood-pressure is evidence of either acute 
or chronic nephritis, '^ is probably in a large majority of 
cases correct. 

Roger L. Lee^ reports both clinical and pathologic 
(autopsy) findings in fifty-three cases seen in the wards of 
Massachusetts General Hospital, all of whom showed 
systolic blood-pressure of over 160. He found high pres- 
sure associated with kidney lesions in thirty-eight cases or 
71 per cent. Seven who showed kidney lesions also had a 
systolic blood-pressure, ranging from 165 to 240 mm. 
Their ages were between twenty and forty-nine years. 

High blood-pressure existed with arteriosclerosis in 
thirty-seven cases or 69 per cent. General arteriosclerosis 
was associated with lesions of the kidneys in twenty-eight 
cases or 52 per cent. There was only one case of high 
pressure with arteriosclerosis without kidney, cerebral, or 
cardiac lesion; this showed only hypertrophy and dilatation. 
The case was sixty years old and the blood-pressure was 210. 

Of cases with high blood-pressure without kidney lesion, 
these were 15 or 28 per cent. Among these seven showed 

» Jour. A. M. A., June 6, 1909. 

*JouT, A. M. A., Vol. LVII, No. 15, p. 1179. 



DISEASE OF THE KIDNEYS 145 

cerebral lesions, four had cerebral hemorrhage and seven 
showed cardiac lesions. The blood-pressure varied from 
175 to 260. 

H. D. Jump in International Clinics (Series 21, Vol. I) 
reports the pathologic findings of a series of high-pressure 
cases 71 per cent, of which showed some permanent kidney- 
change, while arteriosclerosis was present in 69 per cent, of 
cases. All cases which showed a repeated and constant 
pressure over 200 showed some form of nephritis. Jump 
believes that a systolic blood-pressure above 160 is always 
to be viewed with suspicion. 

Signs and Symptoms. — Chronic interstitial nephritis in 
its well-developed form is usually the result of a gradually 
progressive process, leading up to a clinical picture which is 
too well known and too easily recognized to require more 
than passing comment. It is particularly the early states 
of this disease, with which we are concerned. Our chief 
effort and desire is to reach an early provisional diagnosis, 
so that preventive or prophylactic treatment may be 
instituted, at a time when proper management may be 
reasonably expected to arrest the progress of the degenera- 
tive process in the kidneys, and so to indefinitely prolong 
the individual's period of usefulness and life. 

Blood -pressure. — A permanent elevation of both sys- 
tolic and diastolic blood-pressure is the most prominent 
and characteristic sign of well-developed chronic nephritis. 
Sawada^ states that he has never seen a case of hypertension 
of more than 170 mm. in simple arteriosclerosis. Romberg^ 
considers that persistent high blood-pressure in a sus- 

> Deutsch med. Wochen., 1904, No. 30. 
2 KongJ. Int. Med., 1904, No 60, p. 17. 
10 



146 BLOOD-PRESSURE 

pected case establishes a diagnosis of chronic interstitial 
nephritis. From the author's experience, in the light of 
postmortem findings, it seems very doubtful whether a high 
arterial pressure, from arteriosclerosis or any other cause, 
can persist over a long period of time, without giving 
rise to the chronic congestion and permanent degenerative 
changes in the kidneys; with a clinical picture known as 
chronic Bright's disease. The pressure is higher than that 
seen usually in any other chronic disease. Sphygmomano- 
metric observations daily confirm this. A systolic blood- 
pressure of more than 200 mm. (standard cuff) is not un- 
common, and I have seen several cases with a reading of 
over 300 mm. (Fig. 31). Two of which have been under 
observation for more than a year, and will be referred to 
later. A second salient feature of this disease, is that the 
diastolic blood-pressure does not show a proportionate 
elevation, but is usually from 60 to 90 mm. lower, thus 
making an increased pulse pressure (evidence of unnecessary 
overwork of the heart). Factors such as marked general 
arteriosclerosis or aortic regurgitation will further accentu- 
ate this sign. While myocardial weakness, or a failing 
heart will be shown by a fall from the marked elevation 
and a gradually narrowing pulse pressure. 

This fact emphasizes the importance of considering the 
blood-pressure and its factors only as signs or indicators, 
and of the necessity of always viewing the case as a clinical 
whole. Otherwise if too much importance be placed on 
the sphygmomanometer findings, we may fail to recog- 
nize signs of a failing circulation which may mark the begin- 
ning of the end. A moderately high blood-pressure and a 
moderately increased range; coupled with stationary phys- 



DISEASE OF THE KIDNEYS 



147 



ical signs and symptoms, usually indicate a well-sustained 
circulation and a fairly adequate renal function. If a 
lowering of systolic pressure and an approximation of the 

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Fig. 31. — Uremic paralysis, resulting from chronic interstitial nephritis. 
Treatment consisted of hot wet packs, nitroglycerine, 1 per cent, solution, one 
minim every hour, and magnesium sulphate. Treatment stopped on De- 
cember 1, and sodium nitrite substituted, December 7, nitrite stopped, hot 
packs continued. Following sudden rise on December 14, thirty minute 
pack, two minims nitroglycerine, repeated every two hours, resulted in pro- 
found fall as shown, with no bad effect. Subsequent treatment consisted 
of thirty-minute vapor baths and weekly purge in spite of which there 
occurred a gradually rising pressure. 

diastolic pressure should follow, this should give warning 
of a faihng circulation, progressive renal inadequacy and 



148 BLOOD-PRESSURE 

all that these changes imply. The high pressure of chronic 
nephritis from a cUnical standpoint at least would seem 
to be a wise provision in many cases, one which is necessary 
in order to maintain a fairly adequate renal secretion. 
The system seems after a time to become readjusted to 
the heightened pressure, so that sudden changes, through 
accident or misguided treatment, result in disaster. My 
memory of two cases emphasizing this point is quite vivid. 
The first always began to suffer from edema and effusion 
when the pressure was forced down to any extent, and the 
second complained of a return of cerebral symptoms, when 
he had, contrary to orders, markedly reduced his pressure, 
by too long-continued use of sodium iodid. This chart 
(Chart No. 36, page 238) demonstrates the change in 
blood-pressure which was noted. 

Until quite recently it has been the custom to consider 
albumin and casts of certain varieties in the urine as evi- 
dence of chronic nephritis. A condition of serious import 
and one that endangered life. In the light of recent patho- 
logic findings, we can now classify these cases and properly 
value them to the urinary findings in at least a majority of 
cases, and this, especially before the usual symptoms have 
developed, is accomplished through the agency of the 
sphygmomanometer. 

That there is still much to learn concerning the border- 
line cases is amply shown by pathologic reports (seepage 114) 
and since we have a means of precision, which is simple 
in operation, and which may be called to our aid, it would 
seem almost unnecessary to urge the importance of sphyg- 
momanometry, as an aid to this study. Careful study 
of pathologic urinary findings is essential because of the 



DISEASE OF THE KIDNEYS 149 

great frequency of the association of chronic renal change 
with high blood-pressure. As almost every case of blood- 
pressure above 200 mm. will at some time show albumin 
and casts (one or both) it would be advisable to differenti- 
ate between an actually chronically contracted kidney, 
and the arteriosclerotic (secondary) kidney, which is well 
recognized, both from a prognostic and a therapeutic 
standpoint, to be of less serious import. 

A. E. Elliott^ reports a series of sixty cases of chronic 
nephritis with an average systolic pressure of 190. The 
highest was 285 mm. 

Elliott concludes that renal permeability to albumin seems 
to be overcome when the blood-pressure reaches or exceeds 
200 mm. Hg., so that in cases of very high pressure, whether 
there is nephritis or not, either of primary or secondary 
nature, we usually find albumin in the urine. 

Prognosis. — To arrive at a satisfactory prognosis, one 
must be in possession of all the facts, not only the impor- 
tant and self-evident signs, but the minor details of the life 
and habits of the individual. With a full knowledge of 
the case, prognosis became merely a process of weighing 
and deciding, pro and con. For example, as Cook has 
emphasized the outlook in case of a robust looking man of 
fifty-five with a blood-pressure of 200 mm. even with no 
appreciable arterial degeneration, is not so good as in the 
case of a man of sixty-five with rigid arteries and a lower 
pressure. 

Treatment. — The treatment of chronic disease of the 
kidneys cannot be outlined, much less reduced to a definite 
routine. Each case is a law unto itself, requiring special 

* Jour. Am. Med. Assn., April 1, 1907, 



150 BLOOD-PRESSURE 

study, often some experiment and calling for particular 
measures and peculiar management. This outline will 
serve merely to recall to the physician's mind some measures 
which are of value in the average case, and from which may 
be selected a combination of measures suitable to each 
particular case. 

Diet and hygiene are of foremost importance, while 
drug methods are often secondary, and may in many cases 
be entirely dispensed with. Blood-pressure reduction by 
drugs should be attempted only with great caution, 
except when necessary to prevent or relieve a uremic 
attack. 

Symptoms of overpressure are usually relieved by a re- 
duction of 20 or 30 mm. and do not reappear, as long as 
this reduction is maintained. Englebach^ emphatically 
warns us of the dangers of nitrites both in edema and in 
cases of advanced Bright's disease. 

Diuretics are of value in so far as they increase elimina- 
tion, and may be of aid in relieving the heart from un- 
necessary additional strain. Heart tonics are usually 
unnecessary before the nephritic condition is well advanced, 
but when indicated, the intermittent administration of 
digitalis will often prove of value. 

Among other remedial measures of value in combating 
certain conditions arising in chronic nephritis may be 
mentioned calomel and saline cathartics, alkaline mineral 
waters, enteroclysis, hot baths of various kinds, and vene- 
section followed by intravenous saline infusion. 

lodids in small doses are of value when a syphilitic 
history is obtained or suspected. 

* Interstate Med. Jour., June, 1911. 



DISEASE OF THE KIDNEYS 151 

In uremia, venesection, enteroclysis; or hypodermoclysis, 
and chloral gr. x to xxx by rectum; morphin 1/4 to 1/2 
gr. hypodermatically. 

Huchard^ regards renal insufficiency as a very important 
symptom of early arteriosclerosis and one that should com- 
mand our best efforts for its relief, consequently we should 
reduce to a minimum the alimentary tojcins which are the 
chief cause of this difficulty. Here diet regulation plays 
an important part, as it also does in lessening the tendency 
to excessive arterial tension. The ideal diet is one com- 
posed chiefly of vegetables and milk and one from which 
sodium chloride has, as far as possible, been eliminated. 

A fair amount gf active physical exercise is desirable, 
but when impracticable massage may be substituted. 

Overexertion, overstrain and undue exposure are to be 
avoided. ^ 

1 Bui. de VAcad, de Med., January 21, 1907. 



CHAPTER XII 
MYOCARDIAL DEGENERATION 

Definition. — From a practical standpoint it would seem 
advisable to employ the general term myocardial degenera- 
tion, to the exclusion of all others, when discussing from a 
clinical standpoint, the pathologic changes which may 
occur in the heart muscle; for, while we recognize patho- 
logically a sharp line of demarcation between acute and 
chronic inflammation, and between fatty degeneration, 
fibroid degeneration, or fibrosis, weak heart, senile heart 
and chronic cardiac insufficiency, in the majority of cases 
there is no way by which these various conditions can be 
distinguished from each other clinically. Any attempt to 
separate the various forms of myocardial change, by a 
clinical study of the case, is merely an expression of ignor- 
ance, for the symptoms supposed to indicate different forms 
of myocardial disease, may be caused by the same patho- 
logic conditions. Also various pathologic changes may give 
rise to an identical train of symptoms so that all efforts to 
clinically classify must necessarily fail. On this account it 
appears best to consider them all together, not only from 
the standpoint of symptomatology, but also for purposes of 
prognosis and treatment, which with few exceptions are 
essentially the same for all. These exceptions whenever 
well marked will be indicated. 

Occurrence. — Of the various forms of myocardial change 
the pathologic entity known as fibroid myocarditis is prob- 

152 



MYOCARDIAL DEGENERATION 153 

ably the commonest disease of the heart muscle. It is 
usually responsible for permanent dilatation. It results 
from repeated strain, as in chronic nephritis, arteriosclero- 
sis, from gourmandizing and from manual labor. Such 
changes have been produced in the heart by experimental 
adrenalin myocarditis (Pearce, Fleischer and Loeb). This 
affection is more common in men than in women, occurs 
most frequently in those past their prime, but is commonly 
observed five to ten years earlier than fatty degeneration.* 
These two conditions are usually classified, clinically as 
chronic myocarditis, yet while they may occur as acute 
conditions, following certain acute infections, they are 
usually chronic in character, the symptoms may, however, 
occur suddenly and be very acute. 

In cases of great emaciation, the heart may be weakened 
by actual atrophy of the organ. Such hearts are small, 
have a muddy brown color, do not maintain their shape, 
and are functionally very weak. 

Etiology. — Chronic myocarditis is a condition of the 
heart muscle resulting usually from some alteration in the 
circulatory system. Leslie Thorne Thorne^ says that the 
two most common forms of tissue degeneration resulting 
from hypertension are those of atheroma and fatty degen- 
eration. 

The modus operandi of degeneration is probably that of 
a disturbed blood supply to the heart itself, due to a nar- 
rowing of the coronary arteries. It is therefore essentially 
a chronic progressive process and from the very nature 
of the change, when once the process has become fairly 

» E. Fletcher Ingals, Boston Med. and Sur. Jour., Vol. CXLV, No. 18. 
« Laiicet, June 4, 1910. 



154 BLOOD-PRESSURE 

well started is but slightly amenable to treatment. The 
whole subject of chronic myocarditis is one of muscular 
integrity. The diseased heart dilates from slight over- 
strain, one which under ordinary circumstances would be 
harmless, so that a short run for a car, running upstairs, 
lifting weights, etc., may result in a more or less permanent 
dilatation. 

Bruce ^ dwells upon the frequency of cardiac degenera- 
tion, associated with glycosuria, and also the frequent 
relation of gout to chronic myocarditis. 

A most important factor, never to be forgotten, especially 
in this strenuous age, is the affect of the constant strain of 
responsibility borne by business men, legislators, profes- 
sional men, etc. In these the development of high pressure 
is particularly common. This results in cardiac enlarge- 
ment with more or less insufficiency, all of which marks the 
beginning of the end, unless the stress vf life is reduced. 

In the same class of cases, on account of indiscretions 
in diet, and sedentary habits with insufficient exercise, 
the intraabdominal vessels are subjected to abnormal 
and prolonged strain, this leads in time to sclerosis of 
their coats, increased blood-pressure, cardiac overwork 
and eventually to degeneration of the myocardium. 

Fatty degeneration of the heart is due in most cases 
to the same conditions which cause atheroma of the aorta, 
and disturbance in the coronary circulation. This is one 
of the natural results of advancing age, where it is generally 
dependent upon the long-continued action, of such irri- 
tations as chronic autointoxications, habitual use of 
alcohol, toxic effects of tobacco, coffee, etc. 

^Lancet, July 15, 1911. 



MYOCARDIAL DEGENERATION 155 

Chronic diseases of the kidneys by increasing the resist- 
ance in the arterioles, raises blood-pressure; this produces 
general arteriosclerosis from which the coronary arteries 
are not exempt, and leads inevitably to myocardial degen- 
eration. Less commonly we find fatty degeneration fol- 
lowing protracted wasting diseases, exhausting discharges 
or anemia from repeated losses of blood. Acute fatty 
degeneration usually results from the toxins of diphtheria 
and other acute infectious processes, and occasionally from 
phosphorous or mercurial poisoning. 

In the study of all diseases of the heart, we are chiefly 
concerned with the function of the heart muscle, and this 
function is intimately concerned with the several factors 
of irritability, rhythmicity, conductivity, contractility 
and tonicity (Lauder Brunton). 

Unfortunately of that about which we desire to know 
most, we actually know the least. Thus far no accurate 
means of measuring these several factors especially the 
ability of the heart to carry on its circulation, against 
the odds of valvular disease, arterial disease and disease 
of the heart itself, has yet been found. The many methods 
which have been suggested from time to time, all fall 
short of any great degree of accuracy. 

In this discussion we are concerned chiefly with the 
function of contractility and tonicity or tonus. By tonus 
is meant the power of the heart muscle to fesist over- 
dilatation, during the diastoHc period. The normal heart 
begins to dilate under exercise, but if the exercise is moder- 
ate this is transient, and is quickly overcome by the normal 
tonus. In the athlete as a result of training, any exercise 
to which the individual is accustomed actually causes 



156 BLOOD-PRESSURE 

the heart to become smaller, this is due to an increase 
in the reserve power. The heart of the athlete is often 
hypertrophied and such hypertrophy in the light of recent 
experimental evidence is a true hypertrophy (Kuelbs). 

While a strong heart tends to decrease in size during 
exercise, the weakened heart tends to increase, or in other 
words to dilate. This is due to a deficiency in tonus; 
consequently a heart in which the muscle is diseased will 
dilate upon comparatively slight exertion. In fatty degen- 
eration there is always diminished tonicity, therefore, 
diminished tonus is an important factor in the production 
of permanent dilatation. 

In this connection the venous pressure plays an impor- 
tant part, as venous pressure is increased by exercise, 
and is particularly high during straining, heavy Hfting, 
etc., this is frequently a factor in the production of over- 
strain, because a high venous pressure keeps the right 
heart dilated, and if the tonicity is low, the heart muscle 
will remain dilated. According to the researches of 
Louis M. Warfield^ the most important factor in the 
production of chronic dilatation is constant repetition 
of the strain. Even a mildly diseased heart may recover 
from considerable strain, provided the strain ceases at 
once, or that time is allowed for the heart to return to 
normal size before the second strain occurs. On the other 
hand, if repeated strain occurs to a heart already dilated, 
having low tonicity, then permanent damage results. 
The border line between true heart failure and complete 
recovery depends to a large degree upon the period of 
rest after strain. 

» InleraUUe Med. Jour., p. 994, 1911. 



MYOCARDIAL DEGENERATION 157 

This brings us back to the first proposition, which is, 
that the normal function of the heart muscle depends pri- 
marily upon the integrity of the muscle itself, and that if 
this is strong, it would be able to stand an immense amount 
of strain without becoming permanently damaged. We 
see, therefore, that the essential factor in the production of 
a chronically dilated and weak heart is a reduced tonicity 
the result of alterations in the condition of the heart 
muscle itself. That these changes are usually either of 
fibrous or fatty degeneration, which eventuate in loss of 
heart strength and permanent dilatation. 

Pathology. — Fatty degeneration of the heart muscle in- 
cludes two conditions, one in which the action of the organ 
as a whole is impaired by a superabundance of fat, which 
does not necessarily replace directly the muscular fibers, 
this fatty deposit penetrates between the muscular fibers, 
impedes their action mechanically and may, through pres- 
sure impair their nutrition; resulting ultimately in the de- 
struction of the fibers themselves by true fatty degenera- 
tion. This condition generally occurs in obesity and is 
termed fat heart. A heart in this condition is always 
weak and although it may do its work fairly well from time 
to time, will eventually give way under some strain. In 
the other condition owing to some obstruction or inflam- 
mation of the coronary arteries, nutrition is interfered with 
and the muscle fibers become more or less replaced by fat. 
This constitutes true fatty degeneration. 

Parenchymatous degeneration is a cloudy swelling, essen- 
tially acute in nature, usually occurs in infections among 
which rheumatism and diphtheria are well known ex- 



158 BLOOD-PRESSURE 

amples. It usually does not result in permanent impair- 
ment of the heart muscle. 

In fibroid degeneration^ the muscular fibers are more or 
less completely replaced by connective tissue. This is 
not a general change in the heart muscle, but usually 
occurs in limited areas. These are found most frequently 
near the apex of the left ventricle in the interventricular 
septum or in the papillary muscles. 

Not infrequently the heart muscle becomes hyper- 
trophied in the early stages of any of these conditions in an 
attempt to overcome the functional deficiency, but later, 
disease of the coronary arteries, reducing the normal blood 
supply of the heart muscle, causes the fibers to degenerate, 
the heart wall becomes weakened and dilated, and incom- 
petence follows. 

After death, the dilated heart will show under the micro- 
scope either fatty or fibroid degeneration, or both, involv- 
ing the muscle fibers themselves, together with varying 
amounts of intermuscular fat. 

Valviilar Disease Accompanying Chronic Myocarditis. — 
Hearts, the subject of valvular lesions are not necessarily 
weak hearts, though lesions of the different valves, natur- 
ally produce different effects upon the functional power of 
the heart. Valvular lesions in general affect the heart 
only in so far as they force the heart continually to do more 
work to maintain the circulation than the normal heart 
should be called upon to do. The normal heart has a large 
reserve power and auxiliary force for use in emergency. 
The addition of a valvular lesion constantly encroaches 
upon this reserve power. Thus in aortic disease, we may 
actually have a more powerful heart than normal, while 



MYOCARDIAL DEGENERATION 159 

its reserve power is very much less or may be entirely 
exhausted. 

A very important point to bear in mind is that it is not 
the valve lesion which determines the failure, but the con- 
dition of the heart muscle. One must not be misled into 
believing that hearts with a defective valve are as strong 
as normal hearts, this is not so, as they often break down 
under strains which would have no effect upon normal 
hearts. The very fact that there is a valvular lesion means 
that eventually the myocardium will become diseased, and 
that this will determine the functional power of the heart. 
This again brings us around to the point already made, 
that the pathology of heart disease is the pathology of 
the myocardium. It is well known that many persons 
with valvular disease are able to be about and to attend 
to their daily tasks without inconvenience, and we are fre- 
quently so interested in the valvular lesion itself that we 
are apt to neglect to study the condition of the heart muscle, 
which is the true indication of the physical condition of 
the case. Thus, we often fail to notice warning signs, until 
some accident develops the symptoms of heart failure. 
This emphasizes the necessity of careful examinations, made 
at regular intervals when possible, during which particular 
attention should be paid to an estimation of the functional 
capacity of the heart muscle. By this means, we may be 
able to put off for a long time the symptoms of heart 
failure. 

Heart Failure. — Broken compensation does not occur in 
a normal heart, however severe the exercise may be. A 
normal heart muscle is, however, capable of becoming 
acutely dilated. In this condition the pulse may be so 



160 BLOOD-PRESSURE 

rapid that it cannot be counted, and nausea and vomiting 
may occur. The patient may faint from the exertion, but 
so far as we know, such hearts return after a time to normal 
size and by virtue of the normal tonicity of the heart 
muscle no permanent damage results. Even hearts with 
evident valvular lesions do not break down, except tempo- 
rarily, unless the ventricle is diseased. According to 
Warfield *^One may therefore lay down the axiom that 
broken compensation is dependent upon an excessive strain, 
placed upon a heart whose muscle is the seat of pathologic 
changes, which have weakened the muscle/' Symptoms 
indicative of cardiac degeneration usually occur several 
years before the fatal termination. In the presence of a 
blood-pressure above 200 these symptoms rarely extend 
over a period of more than two years. The usual symptoms 
of heart failure occur often without warning, when the 
patient is seized with sharp precordial pain accompanied 
by faintness and dizziness, following which he may sink 
back in his chair or fall to the floor and expire before any 
assistance can be rendered. 

Symptoms. — An early and apparent sign of early myo- 
cardial change is the development of peculiarities in rhythm. 
Careful investigation will often show that the function of 
rhythmicity has been interfered with, causing intermittence, 
irregularity and extra contraction, or extra-systoles, this 
means damage to the heart muscle. 

F. R. NuUer^ is of the opinion that since we so frequently 
find arteriosclerosis in heart failure in later years, in those 
who earlier showed extra-systoles, we should therefore pay 

> Harvey Lecture, 1906-07. 



MYOCARDIAL DEGENERATION 161 

more attention to such a symptom, as it is probably a stage 
in the evolution of these diseases. 

In many cases beginning myocardial change may be 
perceived by studying the two aortic tones, the first sound 
in the aortic area, may be unchanged, weakened or accom- 
panied by a murmur, while the second sound may be either 
intensified or diminished. A systolic aortic murmur 
occasionally may be due to a blood state, but in a person 
of middle age, it is strong evidence in favor of alterations 
in the aortic wall, and in the myocardium. Should these 
findings be associated with thickened peripheral arteries 
and an elevated blood-pressure, slight but persistent, the 
conclusion is warranted, that myocarditis is present, 
especially when in addition, there have been subjective 
signs of muscular weakness. Where the transverse diam- 
eter of the heart can be shown to be increased the diagnosis 
of chronic myocarditis is insured. 

Two most important signs which are frequently over- 
looked are feebleness of the muscle sounds and diminution 
of the force of the impulse against the chest wall. 

Not infrequently the degenerative process progresses 
without symptoms and it is not discovered until an attack 
of dyspnea or fainting occurs or a paroxysm of angina 
pectoris proves immediately fatal. Fortunately these 
prominent and serious warnings usually precede the fatal 
termination by several months, yet many or nearly all of 
them may be absent. 

As a result of feeble circulation or of venous congestion, 

or the development of emboli, many other symptoms and 

signs may appear in individual cases, which if the physician 

is on his guard, may readily be traced to their true source. 
11 



162 BLOOD-PRESSURE 

Ingall calls attention to a significant symptom which 
sometimes occurs in myocarditis, namely, pseudoapoplexy. 
In this the patient becomes suddenly unconscious and 
falls, following which there develops paralysis, but the 
symptoms usually pass off in a few hours or at most in a 
few days. The well-known Cheyne-Stokes respiration is 
an occasional early symptom; other symptoms, to be borne 
in mind are, a comparatively rapid loss of weight in a person 
who has been inclined to stoutness, pallor, a swollen and 
congested appearance of the ears and lips, pain in the head, 
unexplained disturbances of the stomach and bowels. 
Pain over the aorta following exertion and relieved by 
rest, dyspnea with muscular weakness, accompanied by 
changes in frequency and heart rhythm. The significance 
of these symptoms is increased, especially if the history 
points to such remote causes of myocarditis as typhoid 
fever, chronic malaria, scarlet fever, diphtheria, syphilis, 
gout and alcoholism. 

Diagnosis. — We have as yet no positive means of diag- 
nosing the condition of the heart muscle, which often after 
the most careful examination fails to show signs of disease, 
will, when it comes to postmortem, show myocardial 
changes where the heart apparently carried on the circula- 
tion completely. The explanation of this is, that the heart 
was never called upon to perform any work beyond its 
capacity. Many of these individuals have high blood- 
pressure and this sign antidates any other positive phys- 
ical finding. Routine observation of the blood-pressure 
in mature individuals will furnish valuable aid in recogniz- 
ing these cases early in their development, since every 
case of persistently high blood-pressure is potentially, if 



MYOCARDIAL DEGENERATION 163 

not actually, a case of myocardial disease. Again there 
are mild grades of breathlessness or slight oppression in 
the percordial region, following exertion, which indicates 
that the heart cannot carry even a small extra load with- 
out suffering dilatation. The history and examination of 
these cases is of great importance, especially in regard to 
the past accidents as acute infection, including syphilis. 
The etiologic factors of alcohol, overindulgence at the 
table, excesses in tobacco, profound mental strain, worry, 
lack of out-door exercise and chronic intestinal toxemia, 
must all be considered. The development of cardiac 
symptoms in such persons in the absence of definite 
lesions should be looked upon as presumptive evidence of 
some degree of chronic myocarditis. 

Severer grades show dyspnea, cough, pain over the liver, 
swelling of the feet, scanty urination and fluid in the serous 
cavities. Examination shows that the heart is dilated, the 
muscle sounds feeble, the rhythm, gallop or embryocar- 
dial in type and the rate intermittent, irregular or both. 

The symptoms of myocardial degeneration are frequently 
mistaken for functional affections, especially when they 
occur in those who have not yet reached middle life. 
Symptoms of heart weakness developing in young persons 
are likely to be functional, but in a person past fifty years of 
age they are usually the result of some organic change. 

The most important differential feature is often brought 
out by exercise. Exercise has little immediate effect on 
functional disturbances, but when it increases the pain, 
dyspnea and cardiac disturbance the myocardium is de- 
generated. In the study of these cases, one must not neg- 
lect to consider symptoms that are referable to other organs, 



164 BLOOD-PRESSURE 

such as the brain, the kidney and the liver. Among the 
recent developments in the study of organic disease of the 
heart muscle, several so-called functional tests have been 
devised, and have been found of great value by many ob- 
servers. 

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 
both an acceleration in the pulse rate and a rise in blood- 
pressure, but the latter does not occur coincidently 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 slow- 
ing of the pulse the pressure will be found to have fallen to 
a level lower than before the experiment. The sphygmo- 
manometer is required for an accurate demonstration of 
these changes in pressure, which may be recorded in defi- 
nite units of measure for future reference and comparison. 

Shapiro's Test. — This is based upon the alteration in 
pulse rate occurring in normal individuals by change 
of posture from the standing to the recumbent. Nor- 
mally, the number of pulse beats per minute is from 
seven to ten less in the recumbent position, but when 
chronic myocarditis develops this difference tends to dis- 
appear, so that in seriously weakened hearts the pulse 
may be as rapid in the recumbent as in the standing 
posture. 

Cautions. — It is not advisable to apply Graupner's test 
to patients with excessively high blood-pressure, in those 
of apoplectic tendency or in those with high-grade arterio- 



MYOCARDIAL DEGENERATION 165 

sclerosis. The test is unsafe in those with a systolic pres- 
sure of 200 mm. or over. In such cases there is danger of 
ocular or cerebral hemorrhage or acute dilatation of heart. 

The test will be difficult if not impossible of application 
in women unless all tight clothing is removed. 

Valvular disease is not necessarily a contra-indication in 
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. 

Treatment. — (For details of measures affecting blood- 
pressure, see Chapter XIX.) Patients should be cautioned 
to do nothing that increases dyspnea and to rest imme- 
diately whenever shortness of breath occurs. In severe 
cases the patient should be kept in bed, until the heart has 
had time to rest and regain some of its lost tone. Exces- 
sive effort of all kinds both mental and physical must 
cease. If the affection follows some acute infectious dis- 
ease, as pneumonia, or from a chronic infection, or from 
syphilis, treatment should be first directed to these con- 
ditions. If it has resulted from excesses of any kind, 
these should be at once abandoned. Alcohol in all forms, 
tobacco and coffee, should for a time at least be prohib- 
ited in practically all cases; elimination should be en- 
couraged by the proper use of saline laxatives and diu- 
retics, the skin should be kept clean by warm baths, 
gentle massage and, when indicated, diaphoretics. The 
digestive functions should be carefully guarded and a 
light but nutritious diet outlined. A temporary change 
in climate is sometimes of great value. 



166 BLOOD-PRESSURE 

The question of the usefulness or harmfulness of drugs 
will have to be determined in each individual case. The 
value of digitalis, depends upon whether its action on the 
tonus of the heart muscle outweighs its constricting effect 
on the blood-vessels. Hirschfelder, believes that this 
advantage outweighs the disadvantage, and conforms to 
the view of Cloetta.^ 

Probably the safest drug to use in all cases is strychnine 
or nux vomica and this in combination with digitaUs will 
often be all the direct medication required. At first they 
can be given in moderate doses but the quantity may be 
steadily increased, while the effects are carefully watched, 
until the desired result is obtained, or until the beginning 
of toxic symptoms develop. Other drugs commonly 
recommended for strengthening the heart muscles are usu- 
ally disappointing, although occasionally they may give 
surprising results and should therefore be tried when other 
measures fail. Caffeine citrate has somewhat the same 
action as digitails, but is less reliable. Theobromin may 
be tried, particularly when caffeine causes insomnia. 
Spartine sulphate in doses of from 1/2 to 2 gr. three times 
a day may be found valuable for its effect on heart rhythm 
and on urinary excretion. According to Ingalls chloroform 
may be inhaled with perfect safety and great relief, but 
should be used with great caution, the same applies to 
morphin. Other heart remedies such as strophanthus, 
adonis vernalis, and convallaria majalis have proven 
imreliable and should not be used. 

The nitrites are valuable in overcoming the dangers 
resulting from high pressure, but before medication of this 

> Arch. f. Exper. Path. u. Pharma., No. 209, 1908. 



MYOCARDIAL DEGENERATION 167 

sort is begun, careful studies of the blood-pressure should 
be made and only if blood-pressure is found to be high 
should the vasodilators be tried. When the blood-pres- 
sure is high, relaxation of the peripheral circulation may- 
throw the balance in favor of the heart, after which, 
with rest, elimination and judicious tonic treatment the 
case may recover. Anginoid pains, cardiac asthma, acute 
dyspnea, palpitation and arrhythmias sometimes yield 
more, readily to these drugs than to any other emergency 
medication. 

After the subsidence of the acute symptoms, and after 
the danger period has passed, exercise should be begun. 
The exercise treatment depends upon the assumption that 
a properly estimated amount of mild exercise will stimulate 
the heart, increase its tonus and its output, lower the pulse 
rate thereby increasing its period of rest. The border-line 
between improvement and harm from exercise is easily 
crossed, for a strain which is slight may stimulate the 
heart to stronger contractions and improve its tonicity, 
while a strain which is too great even if only in a slight 
degree will weaken and dilate it. This fact renders exer- 
cise treatment and bath treatment of heart disease very 
dangerous weapons in inexperienced hands. The myo- 
cardium may be strengthened first by massage, next by 
appropriate resistance movements, followed, if improve- 
ment warrants it, by moderate walking on the level, and 
by hght gymnastics. The effects of these measures upon 
the physical signs, particularly the pulse and blood-pres- 
sure and upon the subdictive signs will show the rapidity 
with which increasing exercise is indicated. The CO2 
baths give almost the same effect of strain upon the heart 



168 BLOOD-PRESSURE 

as is produced by exercise, they increase the systolic out- 
put and the blood-pressure may or may not be affected. 
The effect of the Nauheim bath is fatiguing and should be 
used with great discretion. 



CHAPTER XIII 
ACUTE INFECTIONS 

In the study of infectious diseases, the routine use of 
the blood-pressure test offers an almost unlimited field of 
usefulness, which in the light of present knowledge, no 
physician can afford to neglect. Naturally this test offers 
little in the way of diagnosis, but for prognosis and as a 
guide to treatment there is so much positive evidence that 
it furnishes constant and a most reliable aid. 

In acute infections the basis for application of the test 
is the experimental evidence of the vasomotor relation of 
collapse. Sajous^ has brought forward a theory of the 
relation of the adrenal gland to the dangerously low blood- 
pressure found in the terminal stages of acute infections, 
especially in pneumonia and typhoid fever. Sajous quotes 
Goldzicher who reaches the conclusion that in septicemia 
the appearance of low blood-pressure is to be ascribed to 
insufficiency of the adrenals. This relation if found to be 
the true explanation when generally recognized may yield 
a rich harvest of recoveries. 

In the study of infectious diseases, single observations are 
valueless because of the lack of normal figures for compar- 
ison. Careful daily observations should be made and if 
the pressure tends toward a dangerous hypotension, the 
periods of observation should be shortened to meet the 
requirement. These should be carefully recorded on a 

1 Monthly Cydo. Pract. Med., Dec, 1911. 

169 



170 BLOOD-PRESSURE 

suitable chart (see page 37) as are the pulse and tem- 
perature. The combined chart referred to will be found 
practical for this purpose. 

Gibson predicts that the use of the blood-pressure test 
will be the guide for treatment in all infectious diseases. 

Pneumonia. — There is no uniformity in the blood-pres- 
sure findings in pneumonia, some observers finding hypo- 
tension and others hypertension. The truth of the matter 
is probably that the pressure varies with the degree of the 
toxemia and with the gravity of the case. The following 
statement of Gibson^ is significant; it offers a very vahiable 
method in prognosis and shows the way for an improve- 
ment in the therapeutics of this disease. He says "Where 
arterial pressure expressed in millimeters of mercury does 
not fall below the pulse rate expressed in beats per minute, 
the fact may be taken as of excellent augury, while the 
converse is equally true.'' This observation has been con- 
firmed by G. A. Gordon^ who states that in no case out of 
his series was there a fatal result when the blood-pressure 
kept above pulse rate. In fifteen cases only one recovery 
occurred when the pulse fell below. 

Hare' also corroborates this assertion. 

This lowering of the pressure is probably due to a toxic 
vasomotor paralysis of the splanchnics. Forchheimer* 
says that with a healthy heart vasomotor paralysis is the 
most common cause of death in pneumonia, and that 
this mode of death may occur irrespective of health and 
disease of the heart. The first manifestation of this con- 

» Edinburgh Med. Jour., January, 1908 

• Edinburgh Med. Jour., January, 1910» 
' Therapeutic Gazette, June, 1910. 

* Jour. Amer. Med. Assoc, October 30, 1909. 



ACUTE INFECTIONS 171 

dition is a lowering of the blood-pressure with an increased 
rapidity of the heart, and under such conditions it becomes 
necessary for measures to be taken to increase pressure. 
(See Chapter XVIII.) 

Typhoid Fever. — Daily estimations of blood-pressure 
are an absolute necessity to the proper and intelligent 
conduct of a case of typhoid fever and a chart should be 
carefully prepared and followed. In the absence of pre- 
existing cardiovascular or renal complications, typhoid 
fever if uncomplicated, is always accompanied by low 
pressure, due to the effect of the bacterial toxins causing 
vasomotor paresis of the splanchnics. This hypotension 
is slowly and regularly progressive with the development 
of the toxemia and gives us an exact indication for the use 
of stimulants. From the end of the first week of the dis- 
ease, the pressure commences a gradual fall which con- 
tinues usually until the establishment of convalescence, 
unless complications should intervene (see below). The 
pressure is usually below 100 and may often fall to 90 or 
85 ; at the same time the diastolic will be lower, but usually 
not in proportion to the systolic depression; the pulse 
pressure is diminished. 

Perforation.^-Crile^ and Cook and Briggs^ note that in 
typhoid fever with perforation and peritonitis, there is an 
early and decided rise, which is followed by a fall as tox- 
emia increases. This was found to be the invariable rule 
by Crile in twenty surgical patients. 

Hemorrhage. — There is a rapid fall in blood-pressure 
without the initial rise, by which fact it may be separated 

^ Jour. A. M. A., May 9, 1905. 

2 Johns Hopkins Hos. Rep., Vol. XI, 1903. 



172 BLOOD-PRESSURE 

from the preceding. The degree and rapidity of the fall 
in some measure indicates the extent of the hemorrhage. 
The pressure tends, upon the arrest of hemorrhage, to return 
rapidly to almost the level noted before the hemorrhage 
occurred. 

Pneumonia is another complication in which there has 
occasionally been noted a rise in pressure. 

Joseph H. Barach,^ in discussing the significance and 
value of the blood-pressure test in typhoid fever, arrives 
at the following conclusions. 

1. It has shown us that the blood-pressure falls below 
the normal after the patient has taken to bed and stays 
down until convalescence is established, and then returns 
toward normal. 

2. That typhoid fever is a disease with a blood-pressure 
below 100. 

3. That the blood-pressure is governed by factors of 
its own and bears no constant relation to pulse rate or 
temperature. 

4. That in prognosis the blood-pressure chart is of 
value. A steadily falling pressure means great danger; as 
long as the blood-pressure keeps up to a reasonable level, 
we may feel that there is reserve pressure to work with. 

Diphtheria. — The ejffect of the diphtheria toxin upon 
muscular tissue throughout the body, and upon the heart 
muscle in particular, has long been a grave concern of the 
practicing physician, heart death after diphtheria being 
an all too frequent sequelae. The routine estimation of 
blood-pressure therefore becomes an important prognostic 
measure, particularly in this disease. 

* Penna. Med. Jour., July, 1907. 



ACUTE INFECTIONS 173 

As in other infections, the blood-pressure tends toward 
subnormal during invasion, with a gradual return toward 
normal during convalescence. 

From a clinical study of 179 cases of diphtheria RoUeston^ 
found a subnormal pressure in sixty-three cases or 35 per 
cent., the extent and duration bearing a direct relation 
to the severity of the faucial attack. The highest readings 
were found during the first and the lowest during the second 
week. The normal tension was usually reestablished 
by the seventh week. Evidence of dyspnea (partial 
asphyxia) in laryngeal cases caused an elevation in pressure. 
Tracheotomy in these cases was followed by an immediate 
fall of 20 to 40 mm. The effect of serum administration 
was a rise in pressure in 40 per cent, of cases. Albuminuria 
did not cause a rise in pressure, except in one case with 
uremia. 

In studying the relation of blood-pressure in diphtheria 
to myocardial alterations Bruchner^ examined critically 
200 cases of this disease. He found that mild cardiac 
involvement did not affect the normal blood-pressure 
curve, that cases with irregular blood-pressure showed 
various clinical pictures. Every case of marked fall in 
pressure was associated with definite signs of myocarditis. 
Falls as much as 50 mm. (Gartner's Tonometer) appeared 
only with severe myocarditis. This was the greatest 
drop in which recovery occurred. A steady progressive 
fall in pressure was present in the fatal cases. In every 
case, with one exception the marked falls in pressure were 
I accompanied simultaneously by signs of cardiac involve- 

f * J. D. RoUeston, Brit. Jour, of Children's Diseases, October, 1911. 



« Deutsche med. Wochen., Oct. 28. 1909. 



174 BLOOD-PRESSURE 

ment; in one case only did the fall precede the clinical 
signs. 

Scarlet Fever. — The blood-pressure shows a moderate 
rise at the onset of the disease and thereafter closely 
follows the pulse and temperature curve. After the 
seventh or eighth day the pressure may be below normal. 
Complications have a marked effect upon blood-pressure. 
Cases showing albuminuria generally show hypertension. 
This rise in pressure is accompanied by slowing of the 
heart's action. With the subsidence of the kidney irrita- 
tion the pulse rate increases and the blood-pressure returns 
to normal.^ 

In acute nephritis secondary to scarlet fever there is 
practically always a marked rise in arterial pressure. 
Butterman^ has observed a rise of more than 50 mm. 
within twenty-four hours after the development of an 
acute nephritis. 

Other Acute Infections. — In the other acute infectious 
diseases there is httle to state that is of practical import- 
ance regarding the blood-pressure, because many of them 
are so mild as to have no appreciable effect upon arterial 
tension, and also because observations as far as they 
have been made, shed very little light. In general it 
may be stated that the development of toxemia from any 
cause, results in depression of the normal pressure curve 
which tends to return to normal with relief from the 
toxemia. 

Therapeutics. — Apart from the usual treatment em- 
ployed in the conduct of a case of any particular acute in- 

> J. Davidson, Lancet, Oct. 19, 1907. 

« Arch.f. klin. Med., Vol. LXXIV, p. 11. 



ACUTE INFECTIONS 175 

fection, certain measures have been found of value in directly 
combating a dangerously falling blood-pressure. 

In typhoid fever it will be noted that the bath treatment 
or one of its several modifications has a marked and bene- 
ficial effect on falling blood-pressure and when it acts favor- 
ably should be employed for this purpose, apart from the 
necessity occasioned by the height of the temperature. 

At the present writing, students of clinical medicine 
do not place much dependence in such measures as injection 
of strychnin, digitalis, or alcohol, for critical studies seem 
to show these to be without effect. (See Chapter XVIII.) 

Adrenalin or epinephrin and pituitary extract now 
possess the field and are strongly advocated by many 
observers, among whom may be mentioned Sajous, Gold- 
zicher, Gibson^ and Brown.^ 

Sajous' states that the adrenals show a special suscepti- 
bility to certain infections and that the treatment of low 
tension resulting from this condition (hypoadrenia) gives 
some surprising results. 

The dosage and methods of administration as laid down 
by different observers are quite elastic. On an examining 
of literature we find the following are suggested. 

Gibson advocates hypodermoclysis or intravenous trans- 
fusion of large amounts of normal saline (large amounts are 
not more efficient than small, — author) a pint of normal 
saline to which 1 c.c. of 1-1000 adrenalin solution has been 
added, to be repeated as required. Others recommend the 
hypodermatic administration of 10 to 24 minims adrenalin 

^Loc. cit. 

2 Am. Med., Vol. VI, No. 50, p. 563, et aeq. 

" Monthly Cyclo., Dec, 1911. 



176 BLOOD-PRESSURE 

in emergency and small repeated doses, as a routine. In 
average cases the glandular suprarenalis sicca of the U. S. P. 
is advised. 

Brown ^advises the intramuscular inject ion of epinephrin 
as a means of sustaining the peripheral circulation in ady- 
namia with hypotension occurring during the course of in- 
fections. Brown warns against administration by the 
mouth as uncertain, and shows by experiment upon a 
series of patients of between twenty and fifty years 
whose arteries still had the power of contraction and 
dilatation. All these patients were given 15 minims 
every twenty minutes for four hours, the blood-pressure 
being taken every hour thereafter until it returned to the 
low point. He found that the pressure was maintained 
above the point recorded before injection for about four 
hours, and that the rise after injection (intramuscular) 
was noticeable in fifteen minutes after the injection — 
and the maximum rise was recorded in from one and 
three-fourths to two hours from the time of the first in- 
jection. A second series of doses given to some of these 
patients resulted in a second rise, sustained for about 
the same length of time, thus demonstrating that the 
blood-pressure could be maintained for a considerable 
time if it should become necessary. 

The bulk of evidence sustains the value of this drug 
especially any method which allows the drug to be ad- 
ministered gradually enough to have a sustained action. 
Thus very gradual continuous administration, as by the 
addition of 1 or 2 c.c. in the Murphy method, or the intra- 
muscular methods of administration. 

» Loc. cit. 



ACUTE INFECTIONS 177 

L. Rinon and De Sille^ advocate the administration of 
1/5 gr. pituitary extract, as required, as extremely efficient 
in counteracting depressed arterial tension, producing 
diuresis and greatly improving the general condition. 

Cholera is a disease of subnormal blood-pressure probably 
giving the lowest pressure readings found in any of the 
infectious diseases. Leonard Roger s^ looks upon a pressure 
below 70 mm. systolic, in man and a little lower in women, 
as an indication for measures to combat the dangerous fall 
of blood-pressure. He beheves the blood-pressure test a 
valuable guide in the treatment of the stages of collapse 
and in combating post-choleraic uremia — as before the use 
of this test the mortality from this cause was 13.2 per 
cent, whereas afterward it was reduced to 6.9 per cent. 

Cerebrospinal Meningitis. — Abram Sophian,^ in a study 
of an epidemic in Dallas, Texas, in the winter of 1911-12, 
first employed the blood-pressure test as a routine in this 
disease. This idea developed from the fact that a previ- 
ous study of the cerebrospinal pressure made at the time 
of lumbar puncture failed to give the required informa- 
tion, which would increase the safety of fluid removal, and 
be a guide to the injection of antimeningococcic serum. In 
a study of 200 cases with nearly 700 blood-pressure observa- 
tions, he found almost constant results in blood-pressure 
change on injecting serum, and recommends the employ- 
ment of this knowledge as a guide to the amount of fluid 
to be withdrawn and also to the quantity of serum that can 
safely be given. 

^ Quoted by Sajous. Loc. cit. 

2 Therapeutic Gazette, Nov. 15, 1909. 

' Jour. A. M. A., Vol. VIII, No. 12, p. 843. 

12 



178 BLOOD-PRESSURB 

The withdrawal of fluid does not have a uniform effect 
on blood-pressure in meningitis, usually there is a fall in 
pressure (about 10 nmi. in adults, 5 mm. in children 
occasionally it is greater) depending to some extent upon 
the quantity of fluid withdrawn. 

The suddenness of the fall is also an indication of the 
amount of fluid to be removed, and the speed with which 
this can safely be accomplished. In cases where there is 
no change in blood-pressure, as much fluid as possible 
may be allowed to escape, until the normal cerebrospinal 
pressure is reached (roughly estimated, one drop escaping 
from the needle in every three to five seconds). 

As a rule as soon as the injection of fluid is begun, the 
blood-pressure begins to fall and falls steadily (a rise in 
pressure is rare). After the pressure has dropped con- 
siderably, say 20 to 30 mm., the fall in pressure becomes 
relatively faster if more fluid is injected. This is a danger 
signal. Sophian finds that a total drop of 20 mm. in an 
adult with an average blood-pressure of 110 to 120 mm. is a 
safe indication to stop injection. 

He also found that the previous use of adrenalin tends 
to prevent the fall in pressure, but prefers not to use this 
drug except in cases with an initial low pressure. 

G. Canby Robinson^ finds that when the symptoms are 
severe the blood-pressure tends to be high. During con- 
valescence and when the symptoms are mild the blood- 
pressure is low. The blood-pressure seems to bear some 
relationship to the severity of the disease and should be a 
valuable guide in prognosis as well as in treatment. 

> Arch. Int. Med., May 6, 1910. 



CHAPTER XIV 
CHRONIC INFECTIONS 

Tuberculosis. — The value of the blood-pressure test as 
an aid to the early diagnosis of pulmonary tuberculosis will 
be more apparent as the application of the sphygmomano- 
meter becomes more universal. 

The blood-pressure is uniformly subnormal in pulmonary 
tuberculosis and often also in tubercular infections of other 
regions. 

Lauder Brunton has noted the constant relation of low 
blood-pressure to pulmonary tuberculosis, and believes that 
hjHPotension may be a guiding sign before any physical 
sign is present in the lungs. 

Cook in this connection makes the following significant 
statement: ''When low blood-pressure is persistently found 
in individuals or in families, it should put us on our guard 
for tuberculosis." Many cases of so-called idiopathic low 
blood-pressure have later developed the importance of 
these observations, by showing after a longer or shorter 
time signs of pulmonary involvement. 

A complete study was made by Haven Emerson^ on 
the status of the blood-pressure test in tuberculosis. He 
says that hypotension is universally found in advanced 
cases of pulmonary tuberculosis. Hypotension is found 

^Arch. Int. Med., April, 1911. 

179 



180 BLOOD-PRESSURE 

in almost all cases of moderately advanced pulmonary- 
tuberculosis, or in early cases in which toxemia is marked, 
except when arteriosclerosis, the so-called arthritic or 
gouty diathesis, chronic nephritis or diabetes (doubtful if 
uncomphcated, author) complicate the tuberculosis and 
bring about a normal pressure or a hypertension. Occasion- 
ally a short period of hypertension may precede or ac- 
company hemoptysis in a patient ordinarily showing 
hypotension. 

Emerson emphasizes that hypotension should be sought 
for in subjects just as carefully as it is the custom to search 
for pulmonary signs. Hypotension when it is present in 
tuberculosis increases with extension of the process. 
Recovery from hypotension accompanies arrest or improve- 
ment. Return to normal pressure is commonly foimd in 
those who are cured; continuation of hypotension seems 
never to accompany improvement. 

Prognosis. — Emerson believes prognosis can be as safely 
based on alterations in blood-pressure as on changes in the 
pulse or temperature. 

My own observations as far as they have gone, show that 
a study of diastolic blood-pressure in tuberculosis or in 
tuberculous suspects is equally as important as the systolic 
pressure reading, for we find that, provided other reasons 
for the change can be eliminated, a slightly lowered blood- 
pressure which is persistent, combined with a reduced 
pulse pressure is very suggestive of the effect of the toxemia 
from tuberculous infection. Also the relation of the pulse 
pressure to rest or to exercise in cases of pulmonary tubercu- 
losis, is a most valuable guide to the amount of exertion 
that may be safely permitted. 



CHRONIC INFECTIONS 181 

A valuable and most complete study of the effect of 
exercise upon tuberculous patients has been made by 
L. S, Peters and E. S. Bullock. ^ A definite plan was out- 
lined and careful study and accurate records made. Six 
men were used. Three were excellent cases both pulmo- 
narily and physically, two fairly arrested far advanced 
cases; and one a new recruit, with normal temperature, 
but poor physical condition. The points in this report are 
so well taken and the table shows so graphically the results 
obtained, that they are copied here in full. 

*'A11 were started with a fifteen minute^s walk the first 
day. The pressures on starting of the three able-bodied 
men were 138, 132 and 148 respectively. On their return 
the pressures were 138, 144 and 153. After an hour's 
rest the readings were 138, 142 and 158, showing that 
apparently the exercise was not harmful. The two fairly 
well arrested, far advanced cases, started out with pres- 
sures of 164 and 124, returning with 146 and 130, and after 
resting 164 and 118. The first man was not used to any 
exercise in any form, as is well shown in a drop of 18 mm. 
Hg., with a return to the original after an hour's rest. 
The overexertion in the second man is evident, for we find 
after resting that there is a drop of 6 mm. from the original 
reading recorded after the return from exercise." 

'^The new recruit started with 146, returned with 138 and 
after rest his reading was 127. The overexertion in this 
instance is well illustrated from the pressure findings and 
was further substantiated by the marked fatigue, breath- 
lessness, and rapid heart action of the individual himself. 
This experiment was carried on for a period of six days, 

» Med. Rec, Sept. 14, 1912, p. 463. 



182 



BLOOD-PRESSURE 



each day^s exercise being graded by the previous day's 
results in blood-pressure. The table of these findings, 
which we here append, will show at a glance that we are 
able to control the readings by an increase, a decrease, or 
a repetition of the exercise. Whenever a man showed a 
drop of 6 or more mm. Hg. after rest or a marked drop on 
returning, even though this disappeared after resting, we 
decreased the exercise. If there was a slight drop after 
returning we repeated the same exercise the following day 
or until we maintained an even standard, when the walk 
was increased. It is interesting to note that in one of the 
three excellent cases the pressure remained practically the 
same even up to walks of one and a half hours, and later 
this same man took walks of two hours in the morning and 
two in the afternoon with no change in pressure and no 
evil results. The other two after a few repetitions were 
able to do the same.'* 

Improvement in subjective symptoms follows the effect 
of blood-pressure elevation, and persists if the pressure 
can be maintained at a higher level than that existing before 
such treatment. 





Blood-pressure 




Pulse 








Case 
















Remarks 


No. 














Before 


After 


After 
rest 


Before 


After 


After 
rest 






1 


138 
138 


138 
141 


138 
150 








1st day. 
2nd day. 


15 minute walk. 




92 


98 


80 


increased to 30 minutee. 




140 


139 


150 


98 


92 


76 


3rd day. 


Increased to 45 minutes. 




142 


140 


140 


96 


106 


80 


4th day. 


Increased to 1 hour. 




140 


142 


138 


88 


88 


76 


6th day. 


Increased to 1 hour, 15 
minutes. 




142 


138 


140 


88 


88 


76 


6th day. 


Increased to 1 hour, 30 
minutes. 



CHRONIC INFECTIONS 



183 





Blood-pressure 




Pulse 








Case 
















Remarks 








1 








No. 






' After 






\fter 








Before 


After 


1 rest 


Before 


After 


rest 






2 


132 
126 


144 
122 


142 
127 








1st day. 
2nd day. 


15 minute walk. 




74 


80 




Increased to 30 minutes. 




126 


135 


126 


66 


76 


68 


3rd day. 


Increased to 45 minutes. 




132 


134 


116 


78 


80 


84 


4th day. 


Increased to 1 hour. 




126 


130 


126 


70 


80 


72 


5th day. 


Cut to 45 minutes. 




126 


124 


136 


73 


76 


75 


6th day. 


Repeated 1 hour walk. 


3 


146 
142 


138 
124 


127 
132 








1st day. 
2nd day. 


15 minute walk. 




120 


1:.0 


100 


Repeated 15 minute walk 


















at slower pace. 




140 


145 


130 


120 


118 


96 


3rd day. 


Cut to 10 minutes at 
slow pace. 




132 


145 


142 


120 


120 


112 


4th day. 


Repeated 10 minute 
walk. 




142 


150 


140 


116 


120 


108 


5th day. 


Repeated 10 minute 
walk. 




138 


146 


142 


V8 


120 


104 


6th day. 


Increased to 15 minutes. 


4 


148 
146 


|152 
146 


158 
135 








Ist day. 
2nd day. 


15 minute walk. 




. . . 
88 


.... 

84 


72 


Increased to 30 minutes. 




145 


142 


146 


80 


80 


72 


3rd day. 


Repeated 30 minute 
walk. 




150 


140 


142 


80 


100 


72 


4th day. 


Increased to 45 minutes. 




145 


140 


158 


84 


80 


76 


5th day. 


Increased to 1 hour. 




140 


142 


138 


76 


80 


80 


6th day. 


Increased to 1 hour, 30 
minutes. 
















This man 


unused to exercise. 


5 


164 


146 


164 









1st day. 


15 minute walk. 




146 


134 


144 


118 


120 


106 


2nd day. 


Cut to 10 minutes. 




140 


150 


138 


100 


104 


100 


3rd day. 


10 minute walk. 




146 


146 


138 


90 


98 


110 


4th day. 


Increased to 15 minutes. 




144 


144 


152 


110 


100 


100 


5th day. 


Repeated 15 minute 
walk. 




138 


144 


146 


104 


104 


92 


6th day. 


Increased to 25 minutes. 


6 


124 


130 


118 







■ 


Ist day. 


15 minute walk. 




115 


114 


110 


100 


120 


108 


2nd day. 


Repeated 15 minute 
walk. 




122 


117 


118 


100 


100 


84 


3rd day. 


Increased to 20 minutes. 




115 


110 


115 


100 


110 


100 


4th day. 


Increased to 30 minutes. 




122 


110 


112 


88 


110 


96 


5th day. 


Increased to 45 minutes. 




115 


114 


114 


96 


96 


88 


6th day. 


Decreased to 30 minutes. 



Sjrphilis. — As a primary cause of arteriosclerosis, syphilis 
is too well known to demand more than passing considera- 
tion here. In any history this disease should never be 



184 



BLOOD-PRESSURE 



overlooked, but should be given due consideration as a 
predisposing cause in the production of those lesions of the 
cardiovascular and renal systems that are associated with 
hypertension. It is believed by many that a moderately 

BLOOD PRESSURE CHART 



CHART ND..-.;. 

ADDRCBS-...^- > 
OCCUPATION '-O&'i 
DIAGNOSIS 






AGE .a. 

colorJ^ . 

SEX . MJ'. 
PHYSICIAN ■ 





n 


IT 


W 


\ 




-] 


^"^ 


q 


1 


\ 


, I 






-l. 


1.^ 




3^ 








■■ 


200 


'4 


?}, 


K 




'^ 


r* 


% 


"^ 


^ 


y^ 


^J 


X 


>? 


y< 




i/t 


^ 


X 








195 


\ 


























J 














IJiO 








1 
























I 




/ 


\ 








185 








/ 














J 


I 




) 


















180 








/ 












^ 




1 




( 


















175 








/ 






/ 










\ 


! 




















170 






.J 




i 












\ 


/ 




















165 












/ 












\ 


1 




















160 






















\ 


1 




















155 






















' 


f 




















ISO 












































1 


145 












































1 


140 














































135 














































130 














































125 














































120 














































r 














































IllO 














































106 














































100 















































Fig. 32. — Arteriosclerosis, probably of syphilitic origin. Patient very 
Btout . Symptoms : complains of dizziness, dyspnea, physical weakness ; urine 
shows trace of albumin, low specific gravity, few granular cases. Potassium 
iodid in small dose effected first reduction to 170 with a rise following 
cessation of treatment. Second fall followed use of potassium iodid, purg- 
ing and baths. Baths and weekly purge continued till April 4, 1911. Third 
fall followed administration of mercury and iodid, plus baths. Subsequent 
treatment is having less effect on pressure level, but symptomatic result 
continues good. 

high blood-pressure which can be traced to a previous 
syphilitic infection is more amenable to treatment and gives 
more satisfactory results than continued high pressure from 



CHRONIC INFECTIONS 185 

other causes. This, however, remains to be proven. In 
the meantime, antisyphilitic treatment, particularly the use 
of the iodids, should be vigorously carried out. 

In this connection it may be of interest to note that in a 
small number of cases examined before and after the ad- 
ministration of Salvarsan ('^606") by the author, very 
little if any effect from the injection of the drug was noted. 

During the early acute stages syphilis acts like any other 
general infection, in that it is usually accompanied by a 
moderate reduction in blood-pressure with some narrowing 
of the limits of pulse pressure. These changes are, as a 
general rule, so slight that they need not be considered in 
the care of the case; therefore, from a practical standpoint, 
the blood-pressure in acute syphilitic infection is of little 
value. (See Fig. 32.) 



I ; 



CHAPTER XV 

RELATION OF BLOOD-PRESSURE TO METABOLIC AND 
MISCELLANEOUS DISEASES 

The diseases found in this group have been so placed 
because, while the blood-pressure findings are of no special 
value in diagnosis, except as they relate to complications of 
the heart, arteries and kidneys, they are nevertheless of 
some assistance in arriving at the proper prognosis, and in 
guiding treatment. The test should therefore be employed 
in them. 

Addison's Disease. — Several years ago, Janeway re- 
ported two cases of unquestioned Addison's disease, in 
which the systolic pressure tended downward. Recently 
Gibson^ reports very low pressures in his series of cases. 
Two cases seen by me showed a marked degree of hyperten- 
sion. A. Randal Short (^^New Physiology") discusses the 
subject from the physiologic standpoint, and shows that if 
the suprarenal veins are clamped for a few hours, thereby 
preventing the entrance of adrenalin secretion into the cir- 
culation, the blood-pressure rapidly falls. As the pathol- 
ogy of Addison's disease involves a degenerative process of 
the adrenal glands, we have the probable explanation of the 
low blood-pressures found in this disease. Improvement in 
subjective symptoms follow the effect of blood-pressure 
elevation, and persist if the pressure can be maintained at a 
higher level than that existing before such treatment. 

» Bntish Med. Jour., Dec. 10, 1910. 

186 



METABOLIC AND MISCELLANEOUS DISEASES 187 

Aviation Sickness. — In the Medical Press and Circular 
for August, 1911, reference is made to a communication by 
Crouchet and Moulinier to the French Academy of Sciences, 
in which they report their observations upon a number of 
aviators. They note two varieties of trouble resulting 
from flights in aeroplanes. The first is due to the altitude 
attained, and depends on differences in atmospheric pres- 
sure, in temperature, and changes in the chemical composi- 
tion of the air found at high altitudes. 

The second factor, which need not be discussed here, is 
the actual physical effort put forth. They consider the 
rapidity of ascent and of descent as most important, and 
recommend a reduction in the speed at which these changes 
should take place. The effect of ascent begins to be shown 
when a height of 1,500 (4,500 ft.) meters is reached, which 
causes quick, short respiration and tachycardia. There is 
usually a sensation of headache and moderate deafness. 
During descent there is a sensation of discomfort like that 
which accompanies a sudden descent in an elevator, violent 
palpitation and great noise in the ears.- On landing the 
aviator is not free from the above sensations for a consid- 
erable time. Respiration quickly returns to normal but 
arterial hypotension which they found in most cases to be 
quite marked, persists for a long time after the flight is 
finished. 
Auricular Fibrillation.^^ — The readings taken by Silberberg 
j from eight patients, all of whom were typical examples of 
; cardiac irregularity due to auricular fibrillation, show the 
i wide range of blood-pressure which the individual case of 
j auricular fibrillation may possess. The blood-pressure 

f » M. D. Silberberg, Bos. Med. and Surg. Jour., April 6, 1912. 



188 BLOOD-PRESSURE 

reading of smallest beats varied from 80 to 160; maximum 
blood-pressm-e ran from 100 to 210. This variation 
Silberberg says is of importance, because in the cases in 
which it occurs, single observations of blood-pressure taken 
in the ordinary manner, possess only a restricted value as an 
index, and the error introduced is continued if comparative 
observations are confined to a reading of the most forcible 
beats only. 

Cardiac Asthma and Pulmonary Edema. — The frequently 
occurring attacks of dyspnea found in heart and kidney 
cases are usually accompanied by hypertension. In their 
most severe form, true edema of the lungs develops. In 
this connection Amblard^ states that recent experimental 
research is amply confirmed by clinical findings, and that 
we may accept it as a fact that in high pressure cases, 
further elevation in blood-pressure, due to insufficiency of 
the left ventricle usually precedes attacks of acute pulmo- 
nary edema, therefore careful attention to the blood-pres- 
sure, both systolic and diastolic, as the means of determining 
an increase in pressure, or a functional failure of the heart, 
would direct attention to the need of immediate reduction 
in the maximal arterial pressure. 

Cerebral Hemorrhage. — Large hemorrhages into the 
brain case when accompanied by symptoms of general 
compression, slow pulse, coma and altered breathing are 
accompanied by hypertension, which bears a direct rela- 
tion to the amount of increased intracranial tension. It 
is of great importance when examining an unconscious 
patient to know the origin of the coma and the gravity of 
the case. No single piece of evidence is as clear or as re- 

» Presae MMicale, August 12, Vol. XIX, No. 64. 



METABOLIC AND MISCELLANEOUS DISEASES 189 

liable as the systolic pressure. If this is extreme (between 
200 or 300 mm.) the brain is undergoing dangerous com- 
pression and danger to life is imminent. In cases where 
progressive increments of hemorrhage are suspected, noth- 
ing can be more valuable than frequently repeated blood- 
pressure tests, which, by demonstrating a progressively 
rising pressure, would indicate a rapidly extending area of 
cerebral compression. So employed the blood-pressure test 
is a safe guide to the need and urgency of decompression, 
whereas on the other hand, a stationary or falling pressure 
without increase of symptoms, such an operation need not 
be considered. Reports seem to show that hemorrhage in 
the anterior fossa of the cranium have least effect on blood- 
pressure, and those into the posterior the most. 

In cerebral hemorrhage, Norris has reported, a systolic 
pressure as high as 400 mm. 

Differential Diagnosis. — Many authors, among them 
Jump,^ point out the fact that in both cerebral hemorrhage 
and in apoplectic coma, the marked hypertension occurring 
in these two conditions, would serve to distinguish them 
from embolism, in which the blood-pressure is low, and 
further that a gradual increase in intracranial tension, such 
as would be caused by a slow-growing brain tumor, has 
little or no effect on general blood-pressure. 

Cheyne-Stokes Respiration. — Pollock^ reports a series 
of blood-pressure estimations in fifteen cases of Cheyne- 
Stokes respiration arising from various causes, which con- 
firm the earlier observations of Gushing that in Cheyne- 
Stokes respiration with increased endocranial tension, the 

1 International Clinics, Vol. I, p. 49, 21 series. 

2 Archives of Internal Medicine, Vol. IX, No. 4, 1912. 



190 BLOOD-PRESSURE 

blood-pressure is low during the period of apnea and high 
during that of hyperpnea, as well as the demonstration by 
Eysner that this fact is of clinical value in the differentia- 
tion of Cheyne- Stokes respiration with increased endo- 
cranial tension from other types. In the cases with in- 
creased tension, the blood-pressure began to rise slightly 
before respiration commenced and began to fall after the 
summit of respiratory activity was reached, whereas in the 
other cases, the pressure began to fall after the beginning 
of respiration and rose as respiration diminished. 

General Paresis. — Communications on the subject of 
blood-pressure in this disease are few, and insufficient in 
number to produce reliable statistics, although with few 
exceptions, they point to a moderate hypotension in this 
disease. The best clinical report that I have been able to 
find is by A. Schmigergeld from studies made at Ward's 
Island, N. Y.,^ who arrives at the following conclusions: 

1. The blood-pressure in general paresis is very 
variable. 

2. In the majority of cases it seems lower than normal. 

3. There exists no relation between the mood of the 
paretic tone and the state of the tension. 

Lead Poisoning. — The effect of chronic lead intoxication 
frequently results in permanent changes in the arteries and 
kidneys, resulting in a secondary hypertension. There is, 
however, a form of hypertension occurring in lead poisoning, 
as evidenced by the typical colic, which is always accom- 
panied by a moderate elevation in blood-pressure, which 
may remain elevated for several days, succeeding the 
attack. (A primary hypertension.) 

* New York Medical Journal, August 28, 1909. 



METABOLIC AND MISCELLANEOUS DISEASES 191 

With the knowledge of exposure to lead, followed by an 
attack of pain with high blood-pressure, we may be aided in 
difficult cases by the blood-pressure test to separate lead 
colic from renal and hepatic colic, in which the blood-pres- 
sure is low. 

Momburg Constriction. — Dr. Fred L. Adair^ has studied 
twenty-three cases in an effort to determine the effect of 
abdominal constriction by the Momburg tube on blood- 
pressure, pulse, etc. Cases showing abnormalities of the 
heart, blood-vessels or kidneys were excluded and all ob- 
servations were made in the supine posture without anes- 
thesia. While of necessity the duration of application was 
short, the femoral pulse was always obliterated. The 
detail findings of this series are shown in the table on page 
194, and correspond in general with the results of earlier 
observers, notably Wolff. The most dangerous period 
appears to be when the tube is removed, and this is most 
dangerous in those presenting arterial change, cardiac dis- 
ease, anemia and vasomotor instability. 

Neurasthenia. — (See Hypotension, Chap. VIII.) Neur- 
asthenia or the fatigue neurosis resulting from lack of 
nervous energy and instability of the sympathetic nervous 
system is naturally, when uncomplicated, accompanied by 
hypotension. We may include under this head the psychic 
instability of blood-pressure, so beautifully discussed by 
Schrump^ where he shows that before we may arrive at a 
decision that a low blood-pressure is pathologic, we must 
make sure that it is not psychogenic. He also makes the 
interesting statement, that a rise in pressure of psychogenic 

1 Surg., Gyn. and OhsL, 1912, p. 112. 

2 Deutsch. med. Wochen., Dec. 22, 1910. 



192 BLOOD-PRESSURE 

origin affects chiefly the systolic pressure; as the mind 
does not seem to have an influence upon the diastolic 
pressure, which is unaltered. Psychic instability is almost 
constantly present, in all individuals to some degree, but 
is much more marked in the neuropath. It is sometimes 
difficult to determine by one examination a normal from 
a pathologic alteration in blood-pressure, and it may be- 
come necessary to divert the patient's attention and to re- 
peat the test at a subsequent time. Furthermore, it must 
not be overlooked that the period of absolute rest which 
usually begins the treatment of grave neurasthenia, is itself 
a cause for a lower blood-pressure. The degree to which the 
pressure falls in this condition depends somewhat upon the 
gravity of the disease and the temperament of the patient 
but is usually moderate. 

I have been unable to find any reference to a hypo- 
tension lower than 80 mm. systolic in neurasthenia. 

The treatment of this disease when successful may be 
indicated by a gradual return of the pressure to normal. 
It must be borne in mind that complicating nephritis may 
so affect the blood-pressure, as to render the findings of no 
value. 

Prolonged Epistaxis Associated with Increased Vascular 
Tension. — Harold Hays^ notes the frequent association of 
prolonged and profuse epistaxis to high blood-pressure and 
has found this condition usually associated with two classes 
of circulatory disease. 

1. Arteriosclerosis involving the arterial system and the 
myocardium. 

2. Valvular disease, or congenital deformity of the heart. 

1 N. Y. Med. Jour., March 4, 1911. 



METABOLIC AND MISCELLANEOUS DISEASES 193 

In this first group, the epistaxis seems to be the direct 
result of the high arterial tension, and is both a warning 
sign of impending apoplexy, and a beneficial act on the part 
of nature to relieve a dangerously high blood-pressure. 
This fact should lead to inquiry into the state of the cir- 
culation, particularly in all persons of advancing years, 
who show a tendency to epistaxis, especially if uncontrol- 
lable by the usual means. Relief from both the loss of 
blood and the danger attending a markedly elevated pres- 
sure may best be accomplished by measures directed to- 
ward controlling the hypertension. This in Hays experi- 
ence is best accomplished in emergency by large doses of 
morphia. 

Renal and Biliary Colic. — Abdominal pain accompanying 
these two conditions has no effect upon blood-pressure, 
unless obscured by a complicating nephritis. This fact 
should help to differentiate them from tabes and from lead 
colic, both of which give a marked hypertension. 

Shock. — (See Surgery, Chapter XVI.) 

Tabes Dorsalis. — Lewellys F. Barker recently reported 
some cases of this disease in which the blood-pressure 
varied between 190 and 215 mm. Hg. Other authors have 
had similar experience, noting the rise usually during the 
paroxysm of abdominal pain. Jump^ calls attention to 
this important differential point, that while with abdominal 
pain in gastric crises of tabes the blood-pressure is nearly 
always markedly elevated, it is usually low or normal in 
renal or biliary colic. 

1 International Clinics. Vol. I, Series 21, p. 49. 



13 



194 



BLOOD-PRESSURE 



Adair's Table of Pulse and 


Blood 


-pressure (Momburg Constriction) 




Pulse 


Blood-pressure 


Case 




During 


After 




During 


After 




Before 










Before 














Max- 


Min- 


Max- 


Min- 




Max- 


Min- 


Max- 


Min- 






imum 


imum 


imum 


imum 




imum 


imum 


imum 


im vun 


1 


95 


97 


97 


88 


88 


116-118 


132 


122 


118 


112 


2 


104 


103 


103 


106 


106 


144 


148 


90 


144 


124 


3 


86 


96 


96 


94 


94 


114-116 


114 


114 


116 


116 


4 


84 


120 


110 


72 


72 


122 


126 


98 


128 


118 


5 


86 


104 


98 


92 


84 


146 


154 


138 


146 


130 


6 


86 


78 


72 


92 


74 


128 


166 


138 


128 


110 


7 


88-102 


122 


116 


98 


98 


144 


148 


111 


140 


140 


8 


98-120 


136 


120 


t>6 


88 


124 


110 


100 


124 


110 


9 


96 


104 


80 


120 


80 


120 


140 


120 


120 


96 


10 


88 


92 


88 


72 


72 


126 


144 


126 


122 


120 


11 


84 


120 


92 


88 


84 


124 


136 


130 


126 


92 


12 


86-104 


160 


116 


135 


90 


125 


175 


154 


128 


100 


13 


66 


120 


72 


112 


56 


106 


136 


128 


106 


70 


14 


64 


84 


58 


96 


60 


110 


128 


122 


124 


90 


16 


70 


116 


64 


104 


56 


116-118 


184 


158 


122 


110 


16 


84-88 


120 


100 


128 


80 


118 


156 


102 


136 


114 


17 


72 


132 


110 


88 


64 


120 


166 


160 


150 


120 


18 


64 


112 


96 


88 


64 


110 


120 


114 


124 


116 


19 . 


80 


96 


68 


? 


? 


110 


116 


108 


? 


? 


20 


76 


104 


76 


100 


64 


107 


115 


104 


? 


? 


21 


98 


132 


114 


88 


72 


136 


182 


157 


128 


116 


22 


70 


92 


84 


84 


60 


110-112 


126 


115 


114 


110 


23 


82 


92 


84 


84 


72 


138-140 


166 


156 


132 


124 



Thoracic Aneurysm. — In thoracic aneurysm the pulsus 
differ ens may be definitely determined by the blood- 
pressure test, taken upon both arms. When taken by the 
finger one may be greatly mislead by the apparent findings. 
As an example of this, in one case of undoubted aneurysm 
of the last third of the arch the left radial seemed distinctly 
smaller than the right, and the signs and radiograph 
showed an aneurysm located apparently so as to interfere 
with the flow of blood through the left subclavian, but the 
sphygmomanometer showed an average of 5 mm. higher 



METABOLIC AND MISCELLANEOUS DISEASES 195 

on the left side and an autopsy showed the sac just below 
the subclavian. 

In the differential diagnosis between thoracic aneurysm 
and dilatation of the arch of the aorta, O. K. Williamson^ 
says the latter shows a greater increase in blood-pressure 
than the former, and if the difference in pressure in two 
arms is 30 mm. or more, it speaks strongly for aneurysm. 
Between aneurysm and mediastinal tumor a difference be- 
tween the two sides of 20 mm. or more indicates aneurysm. 
While these reports as far as I know, have not been con- 
firmed, and as I have had no experience in the matter, 
they must be taken with some question, but may prove 
of value in aiding the elucidation of difl&cult cases. 

1 Lancet, Nov. 30, 1907. 



CHAPTER XVI 
BLOOD-PRESSURE IN SURGERY 

I can introduce this subject in no better manner than 
by presenting the following extract from a recent article 
by Joseph C. Bloodgood^ of Baltimore, whose powers 
of observation and accuracy of deduction have made 
him an authority on surgical pathology. 

"In view of the fact that at the present time our scientific 
methods of accurately estimating the vital resistance 
of the patient and the factors of safety are to a certain 
extent so unreliable and the factors themselves so numerous 
and the problems themselves so complicated, it is my opin- 
ion that every patient should be given the benefit of the 
doubt and prepared for the operation with the greatest 
care, that the operation be performed under the least 
dangerous anesthetic, that the manipulations of the 
operation be made with the least degree of trauma and 
loss of blood and that the operative treatment be planned 
to reduce as far as possible any depressant factors and 
to give the patient the benefit of any improvement in 
treatment. In general it is my experience that as a rule, 
certain things are neglected in the majority of cases. These 
are the more careful investigations of the general condition 
of the patient — the estimation of the kidney function 
and the blood-pressure record. The time is fast coming 
when the individual will expect and demand these more 

» Penna. Med. Jour., January, 1912, p. 256. 

196 



BLOOD-PRESSURE IN SURGERY 197 

modern, more exact methods of diagnosis. During the 
last year, I have paid considerable attention to routine 
blood-pressure records and at the present time, I am get- 
ting the impression that the blood-pressure will warn the 
surgeon of the danger line before the pulse or the respira- 
tion. My respect for the blood-pressure record is increas- 
ing daily and I would urge all surgeons to use it in extra- 
ordinary operations and handicapped patients. But to 
learn to interpret blood-pressure records one must employ 
them at all operations as a routine. 

When the blood-pressure falls to 100 or lower, it is time 
to stop the operation and give the saline immediately. 
One point I wish to make clear which m-any surgeons 
do not seem to be familiar with, the patient seems in fair 
condition at the end of the operation, but no blood-pressure 
record is taken. He is lifted to the stretcher, carried to 
his room and when put to bed he is found to be in collapse 
requiring hurried treatment. This can be avoided in 
most cases, if after the operation is finished and the bandage 
adjusted, a blood-pressure record is taken. If this record 
is much lower than that taken at the beginning of the 
operation, it is an indication that the patient should not 
be transported, but kept quiet on the table and given 
the salt solution by all three methods. It is important 
therefore to investigate the patient before he is lifted from 
the table to be transported, and to begin the saline treat- 
ment then, if indicated. I am confident that this would 
prevent many of the cases of collapse or sudden vaso- 
motor shocks which are observed after the patient reaches 
his bed. The surgeon must be familiar with the manipu- 
lations which produce shock. Nothing helps him more 



198 BLOOD-PRESSURE 

to estimate this than the blood-pressure. It is to be 
remembered that anything that either diminishes or 
increases the blood-pressure is a stimulation which sooner 
or later will lead to exhaustion and a fall of the blood- 
pressure. It is the uniform rate of pulse and respiration 
and the uniform blood-pressure that indicates an operation 
with the least degree of shock. During the entire resection 
of the colon with anastomosis, if done without tension 
on the vessels and nerves, one will observe very little 
change in the pulse, respiration or blood-pressure, but 
the moment one pushes the intestines away to suture the 
rent in the posterior peritoneum caused by the removal 
of the colon, the quiet patient moves, the pulse and respira- 
tion are more rapid, the blood-pressure rises at once, and 
if the patient^s factors of safety are small, the blood- 
pressure quickly falls and the patient is in shock. ^' 

The danger of any anesthetic depends chiefly upon its 
effect on the circulation, and examinations with the sphyg- 
momanometer of patients under anesthesia show that the 
abiUty to withstand its prolonged administration depends 
upon the power of the vasomotor and cardiomotor systems 
to maintain the blood-pressure at or near the normal level. 
In other words, as long as a fair blood-pressure is maintained 
during anesthesia, its administration can be safely con- 
tinued. This, of course, may be modified by the pathologic 
condition leading up to the operation, and the patient's 
general physical condition at the time that the anesthetic is 
administered. The employment of the sphygmomanom- 
eter has placed the administration of anesthetics upon a 
firmer foundation, and has in every way borne out the result 
of clinical experience, as to the relative safety of the 



BLOOD-PRESSURE IN SURGERY 199 

anesthetics commonly employed. To-day the administra- 
tion of anesthesia, except possibly of the shortest duration, 
without routine blood-pressure studies lays the surgeon 
open to censure, if untoward effects follow. Conversely 
the surgeon who employs the sphygmomanometer protects 
himself in the event of deaths under anesthesia. 

The importance of this study was originally developed 
and demonstrated by Crile in 1903^ but only during the 
past year or two has it become generally accepted. It is 
safe to say that in the near future, the sphygmomanometer 
will have almost as wide application by surgeons as it now 
has by medical men. Blood-pressure observations can 
usually be made without difficulty by the anesthetist, 
although the undivided attention of another assistant, as 
a student or nurse, who can easily be trained to make these 
observations, should be used when possible. Observations 
made during surgical operations should occur from two- to 
five-minute intervals and when necessary an expert assistant 
can give blood-pressure reports once every minute. 

In grave cases the value of the test becomes greater as 
the interval of observation is shortened for it is possible 
for serious changes in the circulation to occur in a very 
short space of time. The observation to be of greatest 
service should be charted and kept in view of the surgeon. 
The value of these observations lies not only in the facility 
with which dangerous alterations in blood-pressure may be 
detected, but also in the fact that the effect of respiratory 
and stimulating measures may be noted, so that efficient 
dosage may be employed. These observations will be 
further increased in value if the pulse rate is taken at 

1 G. W. Crile, Blood-pressure in Surgery, Philadelphia, 1903. 



200 BLOOD-PRESSURE 

regular intervals and reported on the same chart with the 
blood-pressure, for it is known that a falling pressure with 
a rising pulse rate is an indication for immediate action. 
In the study of blood-pressure under anesthetics it is neces- 
sary to obtain the patient's normal systolic pressure before 
the anesthesia is begun, and this should if possible be ob- 
tained the day before, or at least previous to the patient's 
final preparation and appearance in the operating-room. 
Observations made immediately before the anesthesia will 
frequently show an abnormally high pressure and an 
accelerated pulse rate. This may be accounted for by the 
stimulating effects of excitement and fright on the cardio- 
motor and vasomotor centers. 

It must also be borne in mind that the blood-pressure 
level will be affected by rest in bed, and by restricted diet 
which usually precedes surgical operations. 

From a surgical standpoint, the study of the systolic 
blood-pressure alone is necessary, because the object of 
the observation is to follow changes in the vascular tension. 

In order to intelligently employ the sphygmomanometer 
during surgical operations, the surgeon must appreciate 
the influence of the ordinary steps of surgical procedure, 
as compared with the extraordinary and dangerous mani- 
festations. As far as reliable information is available in 
literature the following may be stated: Pain practically 
always causes a temporary rise in blood-pressure. In 
abdominal pain in which the splanchnic nerves are involved, 
the pressure increases greatly on account of constriction of 
the splanchnic vessels. H. Curschmann^ beheves that by 
this method we may be able to differentiate between the 

» MUnch. Med. Woch., October 15, 1907. 



BLOOD-PRESSURE IN SURGERY 201 

causes of abdominal pain. He draws the conclusion from 
certain observations which he made that pain from gastric 
and intestinal crises in tabes and in lead colic caused the 
pressure to run up to 170 to 200 mm., to drop again to 
normal as soon as the pain ceased. In pain from gastric 
ulcer, gall-stones and appendicitis there was only a very- 
moderate increase. He further made this very interesting 
observation that pressure rose 8-15 mm. from electric 
stimulation of the thigh in normal individuals, but if the 
part stimulated were analgesic, from hysteria or spinal- 
cord disease, there was no rise. He thinks this indicated 
the reality of the sensory disturbance in hysteria. The 
rise from stimulation would serve to distinguish between 
feigned and pathological conditions. 

Influence of Operative Procedures. Skin Incision. — 
All cutting of the skin involves the irritation of peripheral 
nerves, which ascording to Janeway reflexly stimulates 
vasoconstriction, which shows itself by a slight rise in the 
pressure curve. On the contrary. Lull and Turner, ^ working 
in the Jefferson Clinic at Philadelphia, found that the skin 
incision resulted in a fall in blood-pressure and that this 
was more marked when the patient was but slightly 
anesthetized. They offer no explanation, but it might 
easily be explained on the ground that the effect depends 
upon the character of nerve cut, as it is known that pressor 
fibers occur in mixed nerves. There is room for more 
extended observation on this point. Whatever the effect 
may be, it seldom amounts to more than 10 mm. and there- 
fore does not demand great consideration. Crile from his 
experience states that a fall occurs when the nerve trunk is 

1 G. F. Lull and C. H. Turner, Therapeutic Gazette, 1911, p. 94. 



202 BLOOD-PRESSURE 

irritated and that serious depression of blood-pressure fol- 
lows stretching of the sciatic. This he believes is due to re- 
flex dilatation of the splanchnic area. The same investigator 
has shown that manipulation of serous cavities usually 
cause a sharp fall which may at times be dangerous. Lull 
and Turner demonstrate that incision of the peritoneum 
causes a transitory fall in blood-pressure. In this connec- 
tion they make a very important suggestion, which if true 
will considerably modify present surgical custom and teach- 
ing. They contend that during operation, involving 
severence of nerve trunks or their branches, the dangerous 
fall may be modified and the procedure rendered more safe 
by withdrawal of the anesthetic at the moment the incision 
is made. Janeway maintains that incision in the perito- 
neum usually causes a sharper rise than skin incision, and 
that subsequently the curve is downward, depending on 
the extent and duration of the operation and the amount 
of manipulation and exposure of the viscera. 

As might be expected, simple paracentesis abdomini 
causes a fall in pressure, due largely to a release of intra- 
abdominal pressure, which allows the splanchnic area to 
become overfilled. 

Capps and Lewis ^ noted that almost invariably aspira- 
tion of a pleural effusion caused a marked fall in blood- 
pressure, sometimes to an alarming degree. They con- 
cluded that such a marked change is not a simple result 
of altered intrathoracic pressure, but is caused by two 
separate reflexes, one a cardio-inhibitory and the other a 
vasodilator. 

Gynecologic Operations. — Reliable observations, as far as 

* J. A. Capps and D. Lewis, Am, Jour. Med. Sci., Dec, 1908. 



BLOOD-PRESSURE IN SURGERY 203 

I am able to learn agree with the original studies of Crile, 
which showed that manipulations of the pelvic organs 
caused a rise in pressure and that this rise was proportionate 
to the severity of the traumatism. The reports of observers 
employing chloroform as an anesthetic are unreliable 
because of the uniform depressing effect of chloroform 
itself. 

Cord and Brain Operations, — Crile states that dural 
incisions have little or no effect upon blood-pressure curve, 
but that irritation such as sponging of the spinal or cerebral 
dura mater causes a sharp fall. Operations for decom- 
pression usually cause some reduction in pressure. The 
amount depending somewhat upon the extent and nature 
of the operation. 

Hemorrhage, — Carl J. Wiggins^ has found a frequent 
determination of the pulse pressure, in cases of suspected 
internal hemorrhage of great value in differentiating this 
complication from others accompanied by a falling blood- 
pressure. This author finds that almost uniformly a 
progressive decrease in pulse pressure and a rising pulse 
rate after surgical procedures are indicative of continued 
bleeding, and that the converse if persistent (after several 
observations) indicates a cessation of hemorrhage. 

In all operations control of hemorrhage is an important 
factor in maintaining blood-pressure. When hemorrhage 
is sHght and well controlled the effect on pressure is usually 
unimportant and does not call for special treatment. On 
the other hand, operations accompanied by considerable 
bleeding may result in severe and dangerous hypotension. 
The tendency to shock is greatly increased by hypotension 

1 Arch. Int. Med., Sept., 1910. 



204 BLOOD-PRESSURE 

from any cause during anesthesia, but if shock is success- 
fully combated, pressure soon returns to a safe level. 

Influence of Anesthetics on Blood -pressure. — Discussing 
in the abstract the action of anesthetics, Guy, Goodall and 
Heid remark that blood-pressure may be lowered by (1) 
depression of the heart (a) by vagus inhibition, either by 
direct stimulation of center by the drug, or by reflex 
stimulation through the nervous system, (b) By weaken- 
ing of the heart muscle. 2. Dilatation of the vessel wall 
or paralysis of vasomotor tone. Blood-pressure may be 
elevated by (1) stimulation of the heart (a) by excitement 
(b) by stimulation of the heart by the drug (2) stimulation 
of the vasomotor centers (a) by the action of the drug (b) 
by asphyxia^ 

Experiment and clinical study show that the different 
anesthetics in general use affect the circulation and blood- 
pressure indifferent ways, and that the extent of the depress- 
ing effect of the anesthetic on blood-pressure determines 
in a great measure the relative danger of the anesthetic. 

In the following paragraphs an effort has been made to 
indicate the action of different drugs used in the production 
of anesthesia and to show what blood-pressure changes 
may be expected to occur under them. 

Ether, — The opinion of all observers that ether even in 
large amounts seldom produces a significant fall in blood- 
pressure, has recently been confirmed by the careful obser- 
vations of Guy, Goodall and Reid.* Experimental study 
upon animals shows that very large amounts of ether may 
be given before any serious effect is produced on the cardio- 

^ Wm. Guy, Alex. Goodall and H. S. Reid, Edinburgh Med. Jour., August^ 
1911. 



BLOOD-PRESSURE IN SURGERY 205 

motor or vasomotor systems. The earliest and most effi- 
cient indicator of approaching danger is a marked fall in 
blood-pressure. During the administration of ether before 
the full anesthetic effect is obtained there is a moderate 
rise due to mental excitement and muscular activity. 
When the state of full anesthesia is reached the pulse and 
blood-pressure return to normal level. As the patient 
comes out of the anesthetic a moderate rise is often observed. 
The administration of oxygen to hasten the return to con- 
sciousness always causes a sharp rise in pressure. 

Chloroform, — Almost without exception chloroform 
causes a reduction in blood-pressure, which may occur sud- 
denly and be dangerous even after small amounts. Chloro- 
form if given in too concentrated form may cause a sudden 
and severe fall in blood-pressure, from fatal inhibition of the 
heart by direct stimulation of its inhibitory center (Guy, 
Goodall and Reid). 

Chloroform is dangerous in all stages of its administra- 
tion, the greatest danger is at the beginning of the admin- 
istration. Struggling by the patient seems to increase 
the bad effect. 

Nitrous Oxid. — Nitrous oxid, when given alone, usually 
causes an elevation in blood-pressure, due to the partial 
asphyxia induced. This rise is not so marked when re- 
breathing is allowed (Guy, Goodall and Reid) and is almost 
entirely eliminated when a gallon of oxygen is inhaled first. 
This is a point of value in cases of essential hypertension. 
Although the employment of oxygen in this way curtails 
by a few seconds the available period of anesthesia. 

Nitrous Oxid-ether Sequence. — This condition causes a 
gradual elevation of pressure, until the stage of complete 



206 



BLOOD-PRESSURE 



anesthesia is reached, when it has the same effect as out- 
lined under ether anesthesia. 

Nitrous Oxid Combined with Oxygen employed for contin- 
uous anesthesia as recently advocated and successfully 





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FiQ. 33. — Anesthesia chart. Nitrous oxid and oxygen, patient young, 
adult male, white. Duration of administration, ten minutes. 2.40, Patient 
in chair; 2.42, anesthesia begun; 2.44, analgesia established; 2.46, complete 
anesthesia begun; 2.48, root extracted; 2.49 nitrous oxid stopped 50 per cent, 
oxygen administered; 2.50 patient conscious; 2.05 patient left chair. 
Attention is directed to primary effect of N,0, to gradual fall during anal- 
gesia and the marked rise immediately following the administration of 50 
per cent, oxygen. 



practised by Teter and others, produces a primary rise 
in blood-pressure, which immediately falls to normal, 
as the state of analgesia is reached. The proper control 



BLOOD-PRESSURE IN SURGERY 207 

of the effect by the oxygen allows the pressure to be main- 
tained at normal indefinitely. Any increase in the amount 
of oxygen or the withdrawal of the nitrous oxid usually 
causes a sudden and marked elevation in blood-pressure, 
which persists for from five to fifteen minutes after the 
return to consciousness (Fig. 33). 

Ethyl Chlorid, — The administration of even 3 or 4 c.c. 
of this anesthetic has been followed by serious consequence, 
5 c.c. has been known to produce death and any amount 
over this is considered dangerous. Its effect is that of a 
powerful inhibitor of both heart and blood-vessel tone 
causing constant fall in blood-pressure. The pulse is not 
usually much affected but a dangerous hypotension is 
usually accompanied by a rapid and small pulse. The 
association of oxygen with ethyl chlorid seems to prevent 
the hypotension thereby rendering the effect of this anes- 
thetic less dangerous. 

Cocain, — Crile reports very little change in the circula- 
tion from cocain injections employed in the usual manner 
in safe dosage. Fear and fright may cause the curve to 
become irregular and show a slight rise. Gushing states^ 
that cocain injections into the spinal cord generally induce 
dangerous hypotension. 

In conclusion it may be stated that the effect of any anes- 
thetic upon the circulation is of little importance unless 
blood-pressure is materially affected, and that any disturb- 
ance in blood-pressure resulting from the anesthetic is a 
symptom of great importance. An anesthetic which affects 
the blood-pressure but slightly and only when pushed to 
saturation is certainly to be preferred. 

1 Harvey Gushing, Annals of Surgery, 1902. 



208 BLOOD-PRESSURE 

OPHTHALMOLOGY 

The blood-pressure test has lately found great favor 
among the ophthalmologists, particularly those devoting 
their time to operative work. 

Among the earlier careful studies into the value of this 
test, from an ophthalmologic viewpoint, in prognosis, 
diagnosis and treatment was one made by Fox and Batroff ^ 
and their findings have since been fully corroborated by 
many careful observers, among them L. C. Peter,^ in 1911. 
The same author^ directed attention to the close relation of 
high blood-pressure, chronic interstitial nephritis and 
albuminuric retinitis, showing that in some degree at least, 
there was a direct relation between the amount of increased 
tension and the severity of the symptoms produced. 

The studies of Fox and Batroff were directed largely 
toward demonstrating the relation between retinal hemor- 
rhages and high arterial pressure. From a study of 
100 cases, they concluded that 'Hhe true or exciting cause 
of these hemorrhages in a very large proportion of the cases 
is a sudden transcient or a persistent abnormal elevation 
of the arterial pressure.'' And further that *Hhe blood- 
pressure should be carefully and frequently studied in 
this class of ophthalmic cases; first with a view to deter- 
mining the presence of one of the most frequent causal 
conditions, secondly to permit us to intelligently direct the 
treatment. The oculist, therefore, often being the first 
physician to be consulted, should study these patients with 
the internist, in order that the most comprehensive know- 
ledge possible should be available for the sufferer." 

* Colorado Medicine, May, 1909. 

*L. C. Peter, Penna. Med. Jour., March, 1911. 

* N. Y. Med. Jour,, Aug. 20, 1910. 



BLOOD-PRESSURE IN SURGERY 209 

The summary of the findings of Fox and Batroff's series 
of 100 cases of hemorrhage is as follows: 

Eighty per cent, occurred coincidently with other dis- 
eased conditions in which hypertension is the rule. The 
majority of retinal hemorrhages were found in persons 
suffering from chronic interstitial nephritis 40 per cent., 
the next most common relation was arteriosclerosis 27 per 
cent, and as is well known that these two pathologic 
conditions are rarely met independently of each other we 
may say that 67 per cent, of cases of retinal hemorrhage 
occurred in cases of cardiovascular-renal disease. 

These authors are confident that high arterial tension is 
an important factor in the production of acute glaucoma, 
and cite a case with pressure of 265 mm. They strongly 
advocate the reduction of pressure by bleeding in all high- 
pressure cases before attempting operative procedures and 
cite a case in proof of this argument. Peter's later article 
reiterates this statement. 

Jackson^ and John Dunn^ are also emphatic in stating 
that no case of essential glaucoma, either acute or chronic, 
should be considered fully examined until the blood-pres- 
sure has been carefully studied by a sphygmomanometer. 
In this belief Peter heartily concurs. 

- Dunn also discusses certain other cases of ocular disease, 
in which the use of the sphygmomanometer should never 
be neglected, as its revelations will not only be helpful 
in the proper understanding or existing ocular conditions 
and suggestive in prognosis and treatment, but will prevent 
blunders which, without this restraining influence, would 

1 Am. Jour, of Ophth., Dec, 1909. 
^ Arch, of Ophth. 
14 



210 BLOOD-PRESSURE 

be committed. As a rule the higher the arterial pressure, 
the less favorable is the eye for a surgical procedure. 

In corneal ulcers the blood-pressure test may give us 
information as to why the treatment does not succeed, 
often being explained by the presence of chronic kidney 
disease. A high blood-pressure will tell when not to 
operate in senile cataracts, or at least when the danger of 
hemorrhage may be reduced by preliminary blood-pressure 
reducing measures. On the other hand, with very high 
blood-pressure in persons past middle life, look out for 
retinal hemorrhages. 

Peter says "that occasionally one will find early retinal 
disturbances and only a moderate increase in blood- 
pressure 150 to 170 mm. in young adults without other 
symptoms." He reports two cases of this type, but 
beheves that these cases are so few that they really tend 
to confirm the now accepted view that increased blood- 
pressure is one of the earliest premonitory signs of arterio- 
sclerosis, and chronic diseases, and that this combination 
of conditions is the cause of early retinal and arterial 
changes as well as of the later phenomena. 

Peter again calls attention to another group of cases 
in which hypertension plays an important role, namely, 
spasm or ataxia of the retinal artery or branches, which 
was first brought out by Zentmayer in 1906. 

The value of the sphygmomanometer in the hands of 
the ophthalmic surgeon is now firmly established and he 
would be distinctly negligent, who would continue his 
professional career without the aid and guidance of the 
information derived from the blood-pressure test. 



CHAPTER XVII 
BLOOD-PRESSURE IN OBSTETRIC PRACTICE 

The Value of Sphygmomanometry. — The obstetrician 
of the present day must have constant recourse to the 
blood-pressure test if he would maintain the lead in his 
profession. The sphygmomanometer 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 eclamp- 
tic state. The blood-pressure test is capable of early 
furnishing very definite indications of departures from 
normal metabolism in the pregnant women. This is 
usually evident before the development of any physical 
signs, or of any noticeable change in the urine. From a 
pathological standpoint, it is evident that the close relation 
between the kidney and blood-pressure should be a valuable 
guide in this condition, since alterations in metabolism 
and the overproduction of waste products and the develop- 
ment of special toxins in the blood will show themselves 
in a gradually rising blood-pressure. 

Many obstetricians (Hirst, Baily) are now most 
emphatic in insisting that reading blood-pressure observa- 
tions should be made a part of the periodical examination 
of pregnant women and that with the development of 
suspicious signs and advances toward the end of the 
gestation, the intervals between the tests should be short- 
ened, and that the test should not be omitted during 

211 



212 BLOOD-PRESSURK 

puerperium, as in this state women may develop serious 
toxemia and eclamptic attacks. 

Patients should be required to submit to the blood- 
pressure test at least as often as the urine is examined. 
Indeed it would be well to apply the sphygmomanometer 
at every convenient occasion. Employed in this way, 
with the records properly charted, the blood-pressure 
tests will furnish a far more adequate guide to the serious- 
ness of a pregnancy nephritis and the urgency of inducing 
labor, than the usual urinalysis (see Fig. 34). 

Blood-pressure during Pregnancy. — A series of exam- 
inations, made by John C. Hirst ^ showed that the average 
systoHc pressure at rest, in non-pregnant women showing 
no signs of heart or kidney lesions, was 112 mm. Hg. 
In another series of 100 pregnant women, who had no 
evidence of kidney disturbance or any other sign of toxemia, 
gave an average pressure of 118. This average remains 
practically unaltered up to seven and one-half months 
after which a slight gradual rise occurs so that by the 
middle of the last month of pregnancy the average normal 
pressure is 124 mm. Hg. Usually with subsidence of the 
uterus, the pressure shows a slight fall. These findings 
coincide with the observations of H. C. Baily^ who made 
1,135 systolic readings on 145 normally pregnant women. 
Rather strangely his average systolic pressure in the 
early months of normal pregnancy was also 118 mm. Hg. 
Naturally the individual readings vary greatly within 
certain limits, which Baily believes to be insignificant 
unless it exceeds 30 mm. above the average, or reaches 

» N. Y. Med. Jour., June 11, 1910. 

» Sur., Gyn. and Obat., Vol. XIII., No. 5, p. 485. 



BLOOD-PRESSURE IN OBSTETRIC PRACIICE 213 

above 148. Arthur J. Benedict^ believes that a pressure 
of over 125 mm. Hg. in pregnancy is not normal, but 
indicates toxemia. I have been unable to find any other 
observer drawing this narrow margin, and therefore feel 
that this is an unnecessary narrow limit for normal varia- 
tion in pregnancy. Baily in studying cases after the 
onset of labor noted that the pressure usually rose during 
the first and second stages remaining at 140 to 150 mm. 
Hg. between pains. 

Hirst had noted that a fall of pressure coincides with rup- 
ture of the membranes, sometimes amounting to 50 or more 
millimeters, usually accompanied by marked relief from 
headache and epigastric symptoms. This is only tempor- 
ary, as the pressure gradually rises as labor continues. 
There is a second fall of 60 to 90 mm. immediately after 
the child is born, which is also temporary, the pressure 
returning to almost the level attained before birth. Pro- 
fuse hemorrhage or the supervention of exhaustion will 
interfere with this rise, the degree of reduction in pres- 
sure indicating the seriousness of these complications. 
Obstetric operations, according to Cook and Briggs,^ which 
involve the introduction of the hand into the vagina or 
uterus, and instrumental deliveries, cause a sharp reflex 
rise which has been known to result in rupture of a cerebral 
vessel. 

John Cooke Hirst ^ states that the earliest and most con- 
stant sign of toxemia in the latter half of pregnancy is 
a high and constantly rising blood-pressure (Fig. 34), and 

1 Brit. Med. Jour., Dec. 3, 1910. 

2 Johns Hopkins Hospital Reports., 190S, Vol. XI., 451. 
^ New York Med. Jour., June 11, 1910. 



214 



BLOOD-PRESSURE 



this symptom precedes albuminuria and all the constitu- 
tional signs of an impending eclamptic attack. 

According to the observations of Baily, blood-pressure 
in early toxemia may be low; here apparently toxic sub- 
stances are circulating in the blood which have a marked 
influence on the vomiting center, but little effect on the 
vasomotor apparatus. 

BLOOD PRESSURE CHART 



""^•'TO.:v>k:;::: 



MAME 

ADDRESS..^. 
OCCUPATJM 
OIAGNOSld^lUUVM'<XAA< 



AGE f^Xk . 

SEX •3: .-- 
PHYSICIAN . 




Fig. 34. — May 2, case showed albumin, scanty urine, headaches and dizzi- 
ness, symptoms relieved by hot pack and purgation at irregularly repeated 
intervals. Premature induction of labor advised ,but declined. Normal 
deUvery on August 9. Treatment controlled subjective symptoms, but did 
not much effect the tendency to a rising blood-pressure. 

In the development of toxemia in the latter months, 
there is usually present a blood-pressure rising principal 
or a harmone action, or else blood-pressure is raised to 
increase the natural resistance of the body. He also noted 
that in the fulminant type of fatal toxemia, in the latter 



BLOOD-PRESSURE IN OBSTETRIC PRACTICE 215 

months the blood-pressure may be very low. In excep- 
tional cases Baily has shown that convulsions may occur 
and yet the blood-pressure be no higher than 155, and that 
eclamptic toxemia may be even more severe when the pres- 
sure is very low. This elevation should never exceed 150 
mm., and the pressure should fall after labor is finished. If 
the pressure exceeds this, it is a warning of the pre-eclamptie 
condition. If abnormally high pressure persists in the 
third stage, or there is little or none of the normal decline, 
measures for relief must be instituted almost as urgently 
as if the seizures were present. 

T. M. Green ^ conveniently divides toxemia of pregnancy 
in three divisions: 

First, moderate increase in blood-pressure. 

Second, marked increase in blood-pressure. 

Third, extreme increase of blood-pressure. 

To these may be added the fourth, which is suggested 
by the studies of Hirst and of Baily, namely: 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-pres- 
sure 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 noted by him 
in a toxemic case without eclampsia was 192 mm. The 
highest in eclampsia was 320 mm. How high he was im- 

1 Boston M. and S, Jour., April 28, 1910. 



216 BLOOD-PRESSURE 

able to determine because the mercury ran out of the top 
of the tube before the pulse was shut off. 

To summarize our present knowledge of the relation of 
blood-pressure findings, I can do no better than quote in 
full Hirst's summary, which is as follows: 

First, the normal blood-pressure in normal healthy non- 
pregnant women will not vary much from 112 mm. 

Second, the normal blood-pressure in healthy pregnant 
women will average close to 1 18 mm. A slight increase over 
these figures is to be expected in the last month of pregnancy. 

Third, blood-pressure in toxemia in the first half of preg- 
nancy associated with pernicious vomiting is usually low. 

Fourth, blood-pressure in the latter half of pregnancy, as- 
sociated with albuminuria and eclampsia, is invariably high. 

Fifth, a high and rising blood-pressure is an invariable 
and very often the earliest sign of toxemia in the latter half 
of pregnancy. 

Sixth, upon the rupture of the membranes, there is an 
immediate fall of pressure of from 60 to 90 mm^ This fall 
is temporary only, but is attended with marked relief in 
the headache and epigastric pain these patients so fre- 
quently complain of. The relief from these symptoms lasts, 
however, for some hours after the pressure returns to near 
its original height, which is shortly after the first fall. A 
similar fall, by much slighter, is noticed after a sweat bath. 

Seventh, there is a second fall of from 60 to 90 mm. after 
the child is born. This again is only temporary, and in from 
fifteen to thirty minutes, if a patient has not bled profusely, 
the pressure returns to about its level before the birth. 

Eighth, usually in eclampsia, the pressure remains high 
for forty-eight hours after the birth then begins to subside 



BLOOD-PRESSURE IN OBSTETRIC PRACTICE 



217 



and reaches the normal of from 118 to 124 mm. in from 
seven to ten days after delivery. 

Ninth, as far as it is possible to lay down any rules in 
these cases we may say that a blood-pressure of below 125 
mm. could be disregarded, a pressure of from 125 to 150 

BLOOD PRESSURE CHART 



tETifVw^.':tt!"Ci! !'.!*!! 



CHA 

NAME 

ADDRESS 



AGE%.'k.. 
COUOR "U/". 



OCCUPATIOH 






8EX .<J 

PHYSICIAN. . . 






3 


n 


> 


0— 


fv 


a 


[vQ 


f\/ 




ojU 


, 


200 


li" 


u 


M 


^ 


i 


1 


T 


10 


i*- 


5' 






195 


























190 


























185 


























180 












) 


s, 












175 




s 


/ 


I 




/ 


\ 












170 








\ 




/ 


'( 










m 








\ 








I 










160 








\ 








\ 










155 








\ 








\ 










150 








^ 








\ 










145 
















\ 










140 
















\ 










135 
















\ 










130 
















] 










125 


























120 




















s 


* 




115 














' 












110 


























lOS 


























100 


























95 


























M 



























Fig. 35. — Term calculated to March 30, labor induced March 9. Feb- 
ruary 5, ankles edematous, marked gastric irritation, large amount of 
albumin in urine. This condition not reheved by treatment. March 7, 
urine boiled nearly solid. March 9, labor induced; March 10, delivered; 
April 3, albumin absent, patient normal. 

mm. needs careful watching and moderate eliminative treat- 
ment, and that a pressure of over 150 mm. needs usu- 
ally active eliminative treatment, and will in all probability, 
especially if it shows a tendency to climb higher, require the 
induction of premature labor. (Fig. 35.) 



CHAPTER XVIII 
BLOOD-PRESSURE IN LIFE INSURANCE 

Since the publication of the author's review of the blood- 
pressure situation among life insurance companies in 1909^ 
the value of this test as an aid in determining the accepta- 
bility of life insurance risk has rapidly increased, so that at 
the present time very few, if any, large insurance companies 
fail to appreciate the value of this procedure in life insurance 
examinations. 

By this test we may very early detect signs of beginning 
pathologic change in the cardiovascular system and in the 
kidneys often before there is any demonstrable evidence of 
departure from normal either in the physical signs, personal 
history or urine. This is chiefly because the apparent 
character of the pulse, and the examination of the super- 
ficial vessels, does not always portray the actual condition 
of the general arterial tree or the degree of arterial tension. 
We fail to learn that the true condition of the arteries may 
not have been apparent, that the heart has begun to hyper- 
trophy, and that chronic nephritis or cerebral arterial rup- 
ture may develop at any time. Clinicians have agreed that 
the estimation of arterial tension or blood-pressure by the 
usual means is most unsatisfactory, and in any cas§ unre- 
liable and often misleading. Even the most experienced 
have been unconsciously led into grave error by depending 

* The Status of the Blood-pressure Observations in Life Insurance Exam- 
inations, New York Med. Jour., July 23, 1910. 

218 



BLOOD-PRESSURE IN LIFE INSURANCE 219 

upon tactile sensations when the sphygmomanometer 
should have been employed. 

To quote from Wm. RusselP we find the following very 
significant statement: '^I must, however, again add a 
warning note to the effect that feeling the radial pulse is 
not always a reliable guide as to what the blood-pressure 
will read. I have two such cases under observation, the 
radial being neither hard nor incompressible, and yet in 
both there is a steady reading of over 200 mm. Hg.^' 

Many times we may feel a soft and compressible radial 
where there exists marked sclerosis of the aorta and of the 
splanchnic area. Here only the blood-pressure test reveals 
the true situation. In other instances the reading of the 
sphygmomanometer may explain the significance of an 
apparently simple headache, a mild attack of indigestion, 
or transitory attacks of vertigo in an apparently healthy 
individual, by demonstrating that these cases have suffered 
from a long-continued toxemia, which has resulted in an 
unsuspected pathologic change in the cerebral or general 
vessels. 

From the subjective standpoint, it is now well recognize 
that such pathologic changes may be present in the cardio- 
vascular and renal systems, long before any suggestive 
symptoms are complained of by the individual, or if any 
complaint is made, the symptoms are usually attributed to 
some trivial cause. 

Normal or Ordinary Variations. — It is necessary to 
recognize in this connection the activity of such usual but 
unimportant factors as alimentary hypertension, so well 
described by Russell, occurring in normal vessels, and due 

1 Arteriosclerosis, Hypertonus and Blood-pressure, 1908. 



220 BLOOD-PRESSURE 

to errors in diet of either quantitative or qualitative origin. 
These respond immediately to the correction of such errors 
together with stimulation of the eliminative functions. 
Of further interest, particularly to the life insurance ex- 
aminer, are the so-called physiologic variations depending 
on age, sex, mental and physical excitement, fatigue, etc. 

These must all be taken into consideration in estimating 
the character and class of risk. (See Chapter IV.) 

Such variations need not confuse the examiner, as they 
all occur within a range sufficiently restricted to prevent 
them from obscuring the issue. The only one which needs 
special consideration is the age factor. To determine this, 
many tables have been suggested and devised in an effort 
to indicate the normal average systolic pressure for any 
given age. While these are correct and can be applied, 
they are difficult to employ and hence are unsatisfactory, 
as their use entails reference to a table or the carrying of 
many figures constantly in mind. 

Formula to Estimate Normal Pressure. — To simphfy 
this, the author suggested a formula, based upon a large 
number of observations of his own and of others, which 
can be universally applied. The average obtained by the 
formula agrees closely with the experience of most observers, 
and since its first publication in IQlOMt has been extensively 
quoted and is now employed by at least one insurance 
company. (The Provident Life and Trust Company, 
Philadelphia.) As originally suggested, it was as follows: 
''Consider the average normal systolic blood-pressure in 
the male at age twenty to be 120 mm. of Hg. ; for each year 

* The Sphygmomanometer and its Practical Application, Pilling Co., 
Philadelphia, 1910. 



BLOOD-PRESSURE IN LIFE INSURANCE 221 

of life thereafter 1/2 mm. to 120." Later it seemed advis- 
able to eliminate the fraction, and this was done by changing 
the phraseology to read as follows: '^ Consider the normal 
average systolic blood-pressure of a male, age twenty to 
be 120 mm., then add 1 mm. to every additional two years 
of life." In both the formulas the result is the same, thus 
at the age thirty the normal average systolic blood-pressure 
would be 125, sixty, 140 mm., etc. It is sufficiently es- 
tablished to pass without question that the normal average 
blood-pressure for females at the same ages is approximately 
10 mm. less than that for the male. 

Permissible Variations. — It is not sufficient to estabUsh 
a normal average with which to rate the risk but it is 
necessary also to determine what variations above and 
below this shall be permitted to pass as normal. Unfortu- 
nately with the evidence at hand, this question cannot be 
definitely answered, for existing statistics do not agree. 
As far as can be gathered from many published reports of 
blood-pressure tests, a variation of 36 mm. in normal in- 
dividuals is deemed not to exceed normal. If we accept 
this, then a variation of 17 mm. above or below the 
normal average may be allowed. Thus at age twenty 
any reading of over 137 or below 103 would call for ex- 
planation, while at age thirty the permissible variation 
lies between 157 mm. and 123 mm. In all determinations 
of blood-pressure, the factor of the diameter of the cuff 
employed and the type of instrument used in making the 
test must be considered, assuming, of course, that the 
accuracy of the instrument itself is beyond dispute. 

At the present time the accepted standard for the width 
of cuff is between 4 1/4 and 5 in. (11 cm. to 13 cm.). A cuff 



222 BLOOD-PRESSURE 

of narrower width gives higher readings in proportion to 
the narrowness of the cuff. 

Applications. — As a routine measure, the left arm should 
be employed and be bared to permit application of the cuff. 
Both patient and operator should be in comfortable posi- 
tions, preferably the sitting posture. Nervous individuals 
should be assured of the harmlessness of the test, and have 
their attention diverted from the proceeding. Time also 
should be allowed to permit the circulation to become 
quieted, as after rapid walking, stair climbing, etc. 

In the presence of a developing arteriosclerosis, the blood- 
pressure need not be greatly increased. An elevation of 
30 to 40 mm. above that estimated as normal for the 
individual is significant and demands explanation. On 
the other hand a rise of even this amount should never be 
hastily assigned to arteriosclerosis, or the risk rejected 
without further study. When there is any doubt as to the 
accuracy of his finding, the operator should apply the test 
to the patient upon a subsequent occasion, before making 
his report. 

Nephritis. — Bearing in mind the difficulty of early 
diagnosis in cases of chronic nephritis by a single urin- 
alysis, particularly in individuals apparently in normal 
health, the importance of a blood-pressure test will be 
apparent, because it is recognized that we cannot have 
permanent kidney change without a constant elevation 
in blood-pressure, and even in the presence of albumin or 
casts, we may question their true significance. Here a 
persistently high blood-pressure, say 150 mm. or over, in 
an individual below middle age will settle the question at 
least in regard to the risk. The presence alone of scanty 



BLOOD-PRESSURE IN LIFE INSURANCE 223 

albumin and casts in the urine is not conclusive evidence of 
a diseased kidney, as these elements may come from any 
number of transitory and comparatively unimportant 
complications. The blood-pressure test will serve as a 
check, so that the applicant with a normal blood-pressure 
whose urine has occasionally shown albumin and casts will 
not immediately be rejected, and such individuals will be 
given the benefit of the doubt and the company thereby 
relieved from committing grave injustice. 
. Besides the physiologic variations already mentioned, 
the examiner employing the blood-pressure test must 
endeavor to control as much as possible the conditions 
surrounding the observation, otherwise the data as for- 
warded to the home ofiice may be misleading. Every effort 
should be made to find what is the actual blood-pressure 
of the individual. More than one observation should be 
made when necessary in order to avoid reporting an abnor- 
mally high pressure, influenced temporarily by emotion, 
violent exercise, digestion posture or alcoholic stimulation. 
Overweights. — The overweights demand careful con- 
sideration by the insurance examiner. This is a group 
which shows an unfavorable mortality in life insurance 
statistics, particularly in the higher ages. It should be 
remembered that the amount of adipose tissue covering 
the vessels does not materially affect the reading, as cases 
of very large arms present readings of normal or even 
below, so that findings of high pressure should be attributed 
to some other cause. In a person of modern overweight 
in whom nothing in the physical examination or history 
indicates rejection, the final decision is often made upon the 
relation of the blood-pressure test. Accepting this when the 



224 BLOOD-PRESSURE 

pressure is found normal, and declining when the pressure 
reduces or passes high normal hmit. 

Chronic Myocarditis. — This is probably the most difficult 
condition to diagnose which is met in the course of insurance 
work. Its possible presence must always be borne in mind 
and every effort made to eliminate it in the examination, 
particularly in those past middle life, and in those present- 
ing past history of hard physical labor, excessive brain 
work, alcoholism and syphilis. This will of course not be 
difficult to recognize, when the disease has progressed 
sufficiently to affect the general health of the individual. 
It is in the early stages, where the usual method examina- 
tion fails to reveal it, that the sphygmomanometer is of 
greatest value. In the early cases the systoUc pressure 
need not be materially affected, so that recourse must be 
had to the functional tests of Graupner and Shapiro, and 
to a study of the diastolic and pulse pressures, by which 
changes in normal reserve of the heart, and the strength and 
volume of its output can be estimated. (See page 164.) 
Regarding the question of diastolic and pulse pressures, 
there is but little definitely known, although several 
conditions are now recognized as affecting these readings, 
which can be applied in health examinations and used to 
advantage in the work of the insurance examiner. Thus 
arteriosclerosis, on account of diminished elasticity of the 
blood-vessels, will show an increased pulse pressure (over 
40 mm.) and the more extensive this change in the vessels, 
the greater will the pulse pressure be. This condition may 
be demonstrated in a suspect even before the systolic 
pressure has permanently passed the normal high Umit of 
health. 



BLOOD-PRESSURE IN LIFE INSURANCE 225 

Incipient Tuberculosis. — The presence of a slightly- 
lowered blood-pressure accompanied by a slight elevation 
in pulse rate, with or without fever, combined with a 
history of slight loss of weight, is very suggestive evidence 
of an existing pulmonary lesion. In tuberculosis the 
blood-pressure is usually low and the pulse pressure 
diminished. 

In this connection Haven Emerson^ states that hypo- 
tension is found in almost all cases of moderately advanced 
tuberculosis and that it has been found by many observers 
in early doubtful or suspected cases with or without 
physical signs of the disease of the lungs, and that it is con- 
sidered by competent clinicians as a most useful sign. Cook 
also states that low blood-pressure, if persistently found in 
individuals or in families should put us on our guard for 
tuberculosis. In applicants of light weight and a blood- 
pressure of 100 or under and of poor family history, the 
risk is bad. (See also page 179.) 

Blood-pressure in Relation to Mortality. — Dr. J. W. 
Fisher of the Northwestern Mutal Life Insurance Company, 
has produced some very valuable work^ by drawing con- 
clusions from a study and analysis of the mortality statistics 
of that Company beginning 1907 and continuing until the 
middle of 1911. The report in full, more than confirms 
present opinions regarding the value of the blood-pressure 
test in the study of the cardiovascular and renal systems. 

From a study of 2,668 insured taken from the actuary's 
tables giving blood-pressure readings between 140 and 149 
mm. Hg., had 81.85 expected deaths, 31 actual deaths, a 

1 Arch. Int. Med., 1910. 

2 Medical Record, October 21, 1911. 

J5 



226 BLOOD-PRESSURE 

percentage of 37.87 which was slightly below the normal 
death rate of the company on exposure of two years. He 
shows another table of mortality records of 527 insured 
persons with a blood-pressure reading of 150 mm. Hg. and 
over with 22.19 expected deaths and actual deaths 12, 
which is about 35 per cent, in excess of the general average 
mortality of the company covering the same period and 
10 per cent, higher than the general average mortality dur- 
ing the first five years of exposure covering the twenty years 
period 1885 to 1905. 

He further shows a mortality record of 782 persons, de- 
clined for insurance, in whom the blood-pressure averaged 
171.03 mm. Hg., 21.61 expected deaths with 32 actual 
deaths, a percentage of 155.27 or almost four times greater 
than the general average of the company. In another 
table are shown 366 cases rejected in which there were 
reported no other impairments than high blood-pressure at 
the time the application was received at the home office. 
The expected deaths were 10.14, the actual deaths 14, or 
138.17 per cent, of the table. Efforts made to follow care- 
fully these 366 cases in order to secure data as to the sub- 
sequent physical condition of these applicants, more than 
justified the opinion that the sphygmomanometer was one 
of the earliest, if not the very earliest, means of detecting 
departures from normal in this group of cases, as many im- 
pairments were later discovered or developed in a large 
number of cases rejected for high pressure only. 



CHAPTER XIX 
METHODS OF CONTROLLING BLOOD -PRESSURE 

Causes of Failure. — A large number of the unsuccessful 
results in the treatment of cardiovascular renal diseases can 
be traced to one or more of the following causes : 

1. The diagnosis is not made sufficiently early. 

2. The case may have been poorly or incompletely 
studied. 

3. The predisposing causes have not been found. 

4. As a result, the condition is but imperfectly understood. 

5. The therapy is irrational because it is based upon an 
incomplete knowledge of the case in question, plus a defi- 
cient knowledge of therapeutic methods by drugs or 
other measures. 

6. Too great dependence has been placed upon drugs 
alone, especially the vasodilators, to the neglect of the 
newer so-called physiologic methods. 

It may be said in general that while drugs are at times 
invaluable in the treatment of pathologic circulatory con- 
dition, especially in emergency, their value is usually much 
overestimated. The secret of successful treatment usually 
lies in a careful study, an early and complete diagnosis, 
rigid supervision and regulation of the individuals habits, 
rather than attempts to lower blood-pressure and relieve 
symptoms by the employment of drugs. A properly con- 
ducted study will sometimes yield gratifying results even in 

227 



228 BLOOD-PRESSURE 

advanced cases, and at times in those cases commonly 
regarded as hopeless. 

The most satisfactory results naturally follow complete 
examination immediately following the appearance of the 
first suggestive sign or symptom of impairment of the circu- 
latory apparatus. This should be followed by a careful 
estimate of the functional power left in the impaired organs 
and the immediate adoption of a life and habits suited to 
the hmitations determined. Thus we attempt to produce 
an adjustment of the individuaFs Ufe which is an equiva- 
lent to relative good health. By correct diagnosis the full 
meaning of this phrase is meant and not the mere state- 
ment that the patient has ^^cardiovascular renal disease." 

To arrive at a correct diagnosis, one must take a full his- 
tory including a complete analysis of social history and 
personal habits, carefully considering both business and 
social activities, making a complete physical examination, 
including blood and urine examinations, and the blood- 
pressure, not omitting the functional tests. In fact the 
success of treatment depends chiefly upon the completeness 
in which the problem of each case is studied. Next upon 
the intelligence with which the remedies are employed and 
only secondarily to the particular remedial measures 
applied. 

The material presented in this chapter has been care- 
fully complied from literature which appeared during the 
past three years, and represents broadly the various meas- 
ures recognized to be of value in combating the dangers 
of this condition. The reader must, however, not lose sight 
of the fact that hypertension or elevation of blood-pressure 



METHODS OF CONTROLLING BLOOD-PRESSURE 229 

is very rarely a disease by itself, which is to be combated 
purely for the effect which the measures employed may 
have upon it. On the contrary, hypertension is as a rule 
merely a symptom, occurring in the course of certain patho- 
logic conditions developing within the human economy, 
and bearing close and often important relation to disease 
in certain systems or organs. Too much stress has been 
laid upon this one symptom, and the tendency of late has 
been to speak of hypertension as though it were the whole 
disease, and the main object of therapeutic attack. Such 
a condition is unfortunate and greatly to be deplored, as 
such an attitude obscures the vision of the investigator 
often leading him into serious error. Only occasionally 
is hypertension the most important symptom calling for 
relief. On the other hand, it may be the only cheering 
symptom in an otherwise unpromising anamnesis, where 
it is often a wise provision on the part of nature to augment 
or maintain the activity of certain organs notably the 
kidneys and to preserve their function which would other- 
wise suffer from an insufficient circulation. 

Direct therapeutic measures aimed at distinct patho- 
logic conditions, will not be considered as they are beyond 
the object and scope of this book. This chapter will con- 
sist more of a resum6 of existing literature and will be more 
in the nature of a reference chapter to be consulted when 
knowledge of the relative value of certain measures is 
desired, and when the effect of any particular drug is in 
doubt. 

The classification of drugs and other therapeutic measures 
which follows is somewhat arbitrary, and is more a matter 
of convenience than of science. 



230 BLOOD-PRESSURE 

Measures Employed to Reduce Blood-pressure. — Under 
this heading will be discussed first those drugs directly 
influencing blood-pressure through their specific action 
on the arterial wall, or on the vasomotors — the vaso- 
dilators; second, a miscellaneous group of drugs which 
are valuable chiefly for their secondary effect on reducing 
blood-pressure; and third, a group of physiologic or drug- 
less measures which have recently been employed with 
success in combating hypertension and the symptoms 
resulting therefrom. 

The Vasodilators. — This group of drugs belongs to that 
large and indefinite class known as depressomotor. It 
has a distinctly sedative action upon the spinal cord 
and other centers, and acts chiefly by reducing nervous 
irritabiUty. 

The several drugs belonging to this group, while having 
much in common, vary in their selective activity, thus 
while they all have a tendency to reduce arterial pressure, 
this effect in many instances occurs only after the admin- 
istration of a toxic dose. 

The most important vasodilators are: 

Amyl nitrite Mannitol hexanitrate 

Nitroglycerin Vasotonin 

Potassium nitrite Diuretin 

Sodium nitrite Agurin 
Erythrol tetranitrate 

They act chiefly by causing dilatation of the arterioles 
and capillaries with consequent reduction in arterial 
blood-pressure. Besides varying in the amount of the drug 
required to obtain a physiologic action, these drugs differ 
greatly, also in their rapidity of action, the amount of 
reduction and the duration of effect obtained. It is im- 



METHODS OF CONTROLLING BLOOD-PRESSURE 231 

portant, therefore, to consider individually the more com- 
monly employed members of this group. 

Amyl Nitrite as a representative member of this group 
will be discussed critically. On account of its volatility, 
this drug is usually dispensed in glass pearls. These are 
to be crushed and the fumes immediately inhaled. The 
first effect of inhalation is hurried and panting breathing, 
followed by progressive muscular weakness and cutaneous 
flushing. Toxic doses gradually reduce reflex activity 
until death occurs from respiratory failure.^ 

Effect on Circulation. — The pulse is increased in fre- 
quency and the arterial blood-pressure is rapidly dimin- 
ished. This action is due to a dilatation of the small vessels 
from the direct action of the drug circulating in the blood 
upon the walls of the arterioles and capillaries (Experi- 
ment of Brunton). At the same time the drug has a 
minor influence on the vasomotor centers. 

Administration. — This is usually by inhalation, but 
it may be by the mouth or hypodermatically. Dose by 
inhalation 1/2 mm.; by the mouth two to three drops on 
a lump of sugar to be taken instantly; hypodermatically 
1 to 3 mm. The drug is comparatively free from danger; 
as much as two drams given within two hours have been 
without serious effect (Wood). 

All the members of the vasodilator group have essentially 
the same action on the circulation, varying slightly because 
of particular minor characteristics of the individual drugs. 
Space will not allow a more extended discussion here. 

The following table has been constructed from the most 
recent literature covering clinical investigations upon 

1 H. C. Wood, "Therapeutics," J. B. Lippincott Co., Philadelphia. 



232 



BLOOD-PRESSURE 



the effect of these drugs. A study of the table will indicate 
clearly the relative value of the several drugs included 
in this group. The selection of the particular drug to be 
employed will depend upon the character of the case, the 
urgency of immediate action, and the effect desired. For 
a more complete consideration of these drugs in the treat- 
ment of disease with high arterial pressures, the reader 
is referred to other chapters in this work. This table 
has been constructed from the clinical statistical reports 
of Wallace and Ringer,^ Matthiew,^ J. L. Miller,^ and 
Lauder Brunton.* 



Drug 


Effectual 
dose 


Begin 
effect 


Max. 

effect 

in 


Mm. 
reauct. 


Duration 


Dose, 

interval 


Amyl nitrite 


1-3 mm... 
inhalation. 
1-2 mm. . . 

1/2 gr. . . . 
0.6-1.5... 
1 gr 


1 min. 

2 min. 

10 min. 
15 min. 


2 min. 

2 min. 

6 min. 
4 min. 


20-40 

20-40 

5-30 
15-50 


7 min 

30-40 min... 

1-1/2 hrs... 

4-6 hrs 

6 hrs 

4-6 hrs 


P. R. N. 




1-2 hn. 


Sodium and potassium 
nitrate .... . 


T i d 


Erythrol tetranitrate 

Mannitol hexanitrate 


4-6 hra. 
4-6 hra. 


Vasotonin 








20-40 
10-20 




Diuretin 


5 gr 






4-6 hrs .... 


4-6 hra. 















Before employing any drug in this group, it should be 
carefully ascertained that the drug, particularly sodium 
nitrite, is strictly fresh, as failure to obtain the desired 
effect may be entirely due to the use of an inactive prepara- 
tion. Tablet preparations are known to vary greatly in 
strength and should be of standard make. This defect can, 
according to some observers, be avoided by the employ- 

> Jour. A. M. A., No. 20, p. 1629. 
« Quart. Jour. Med., No. 2, p. 261. 
'Jour. A. M. A., May 21, 1910. 
*Loc. cU. 



METHODS OF CONTROLLING BLOOD-PRESSURE 233 

ment of fresh chocolate tablet preparations. Sodium 
nitrite in solution rapidly loses its activity and should 
not be kept for more than one week. All these drugs 
may be employed hypodermatically when desired, but for 
continued use should, if possible, be given by the mouth. 

According to Wallace and Ringer, it may be stated 
that, as a general rule, the higher the original pressure, 
the greater is the fall, and that an increase of the dose 
within safe limits seems to increase the fall. They were 
able in their experiments to obtain a reduction in pressure 
in every case, and the effect of an equal dose upon the pres- 
sure in arteriosclerosis was the same as the effect of an 
equal dose upon a normal individual. My own experience 
does not substantiate this. 

Daniel Hoyt^ arrives at the same conclusion, but advo- 
cates the use of larger doses than those generally employed, 
attributing failure to obtain satisfactory results to insuffi- 
cient dosage or the employment of inactive preparations. 
This difficulty is largely removed when the clinician 
employs the sphygmomanometer to check his results. 

Rudolph^ notes that the effect of the vasodilators may 
vary from day to day, and in this connection Miller* 
brought out a very interesting as well as a most important 
point in the clinical action of these drugs, namely, that 
wide variation in their effect may occur not only from day 
to day, but that different drugs of the same group may 
affect the same individual differently. He reports the 
following specific instances: 

^ International Clinics, Vol. 1, 1912. 
^ Brit. Med. Jour. 
' Loc. cit. 



234 BLOOD-PRESSURE 

Case 1. — Sodium nitrite had no effect whatever, nitro- 
glycerin caused a reduction of 50 mm., erythrol tetrani- 
trate resulted in a rapid fall of 110 mm., the patient going 
into collapse. 

Case 2. — Nitroglycerin and erythrol tetranitrate had 
very little effect upon the pressure while a reduction of 
65 mm. followed the usual dose of sodium nitrite . 

Case 3. — Nitroglycerin caused a fall of 30 mm., sodium 
nitrite a fall of 20 mm., and erythrol tetranitrate a fall of 
15 mm. 

C. H. Lawrence^ in one case saw a rise of pressure after 
the employment of mannitol hexanitrate which precipi- 
tated an attack of angina. 

Vasotonin, — Muller and Fellner^ report both animal ex- 
periments and clinical observations concerning the effect 
of vasotonin upon blood-pressure. Vasotonin is a com- 
bination of yohimbin and urethene. On animals it low- 
ered the blood-pressure by dilating the peripheral vessels. 
There was no depression on the heart muscle, of the vaso- 
motor center or upon the respiration. Fellner reports 
action on thirty cases of increased arterial tension. 

They gave vasotonin subcutaneously in doses of 1 c.c. in 
some cases daily, in others every other day. The course 
of treatment comprised from twenty to thirty injections. 
They found that the remedy consistently produced a fall of 
blood-pressure with a marked improvement in the subjec- 
tive symptoms. Thus, for instance, there was immediate 
relief in milder cases of angina pectoris and in cardiac and 
bronchial asthma. The bad cases of angina pectoris 

» Boston Med. and Sur. Jour., November 2, 1911. 
» rherap. Monaiachrift, 1910, XXIV, 285. 



METHODS OF CONTROLLING BLOOD-PRESSURE 235 

required longer treatment, but all improved and no unpleas- 
ant symptoms occurred. The use of this preparation has 
been confined chiefly to Germany and so far American 
observers have failed to obtain the uniformly favorable 
results reported abroad. If we are to believe foreign 
reports of the effect of this drug on man and the lower 
animals, we would expect to find a fall of from 20 to 40 
mm. lasting from four to six hours, and that three or four 
injections given upon successive days will maintain the 
blood-pressure at a lower level than the original for six or 
seven days. 

H. D. Arnold^ reports the study of a small series of cases 
in which the effects were exactly the opposite. The 
injection of the drug was always followed by a rise in pres- 
sure and was occasionally accompanied by more or less 
serious disturbances. In one case it brought on an attack 
of angina pectoris. The duration of this rise averaged four 
to six hours. In the light of this dissenting evidence, small 
as it is, the drug cannot be recommended and if used at all 
should be followed with great care. 

Diuretin. — W. H. Bamberger^ following the lead of 
Romberg, Buch and others, strongly advocates the use of 
theobromin preparations, particularly theobromin sodium 
sahcylate or diuretin. He finds this drug particularly 
valuable in hypertension resulting from arteriosclerosis of 
the abdominal vessels and reports his find in a series of 
experiments upon animals. This table so clearly shows 
the action of this drug, that it is given herewith: 

1 Boston Med. and Sur. Jour., Vol. LXV, No. 18. 

2 Interstate Med. Jour., Vol. XVIII, June, 1911. 



236 



BLOOD-PRESSURE 



1 


Drams sodium theobromin 

salicylate per kw. of 

animal 


Effect on blood-pressure 
expressed in mm. Hg. 




Rise 


FaU 


0.0066 


10 mm. 











0125 





022 


22 mm. 


0.040 


30 mm. 


0.062. 


36 mm. 


0.066 


42 mm. 


125 


65 mm. 







The effect on the heart was not constant ; as small amounts 
usually caused a moderate slowing of the rate, while large 
amounts accelerated the pulse rate and caused a marked 
depression in blood-pressure. Bamberger does not con- 
sider his results conclusive, but as the drug is apparently 
free from harm, it should be tried, particularly in the case 
of so-called splanchnic-sclerosis. Dosage 20 to 40 gr. a 
day. 

Agurin. — Another theobromin preparation may be em- 
ployed in the same conditions in which diuretin is indicated. 
Dosage 20 to 40 gr. a day. 

Miscellaneous Drugs. Veratrum Viride. — This drug is 
classified with the heart depressants. Its chief physiologic 
action is upon the circulation, and in practice it is used 
chiefly to decrease the force of the heart. It is "a prompt, 
thoroughly efficient, and at the same time very safe remedy^' 
(Wood). 

In chronic cardiac diseases it is indicated in precisely 
those cases in which digitalis is contraindicated. The 



METHODS OF CONTROLLING BLOOD-PRESSURE 237 

contraindications to the use of this drug are cardiac weak- 
ness and general adynamia. When used in excess it may 
cause alarming symptoms which simulate shock, but even 
in very large doses it is seldom fatal (Wood). In this 
respect it is far less dangerous than aconite. Its physio- 
logic effect is shown in a slow pulse rate, a diminished force 
of the heart's action, and vasodilatation. 

Administration, — Fluidextract, one to three drops, tinc- 
ture three to six drops. It should be given at intervals of 
two or three hours, when continued effect is desired, and its 
activity may be hastened by gradually increasing the dose 
until the physiologic limit is reached. In some cases annoy- 
ing vomiting may occur. 

Aconite, — The action of aconite on the circulation is very 
decided. It is not a vasodilator but accomplishes a fall in 
blood-pressure through its action on vagus, causing at the 
same time a slowing of the pulse, which after full doses 
becomes small and rapid. 

The drug may be safely used in cases of high pressure with 
an hypertrophied heart where the valves are in good condi- 
tion and in eclampsia. When however there is dilatation, 
or myocardial degeneration, it becomes an extremely danger- 
ous remedy, and should perhaps never be used unless with 
great caution and only after a careful study of the condition 
of the heart. Aconite is a much more dangerous drug when 
employed in circulatory conditions than is veratrum viride. 

Administration, — Tincture, five to ten drops every three 
hours, fluidextract two to four drops every three hours. 

lodin. — lodin and the iodids are supposed to bene- 
ficially influence degenerative changes in the vessel walls 
and have long been advocated for the treatment of high 



238 



BLOOD-PRESSURE 



blood-pressure, apart from those cases resulting from 
syphilitic infection, where of course it is indicated. The 
profession is however by no means united, as to the efficiency 
of these preparations which at present do not find general 
favor in the treatment of arterial tension. Many believe 

BLOOD PRESSURE CHART 



CHART ff(0. 

NAME 

ADDRESS 

OCCUPATION 

DIAGNOSIS^ 



^J!S/:'i:DK.^C 




AOE 4.. 
COLOR 1^. 
SEX .W-.. 
PHYSICIAN ■ 



200 


M 


% 


p? 


1? 


^ 


F 


^ 


Y\ 


W 


— 


— 


— 


— 


195 




j 


Vy 






















190 




/ 


\ 






















185 




j 




[ 




















180 




1 




I 




















175 








\ 




















170 








\ 




















165 








\ 




















100 








\ 




















155 








] 




















150 


























, 


145 












V 
















140 












N, 
















13S 














\ 






' ■ 








ISO 














\ 


J 












125 














\ 


/ 












120 














) 


/ 












115 














' 














'Hlb 




























105 




























100 




























96 




























90 





























Fia. 36. — Chart shows dangerous effect of continued overuse of sodium 
iodid. lodid was begun in doses of 5 gr. three times a day, and was con- 
tinued until April 1. Pulse became irregular and patient Wiis very dizzy. 
Strychnin, 1/30 gr., was begun on April 14, patient then left city for summer. 
Did not return until September 16, during which time contrary to orders, he 
persistently took between 25 and 30 gr. sodium iodid, and returned in very 
bad condition. The rising pressure of September 21 is from the combined 
use of strychnin and digitalis. 

that any effect following the employment of this drug is due 
to the employment of other measures, such as improved 
hygiene, the elimination, rest, etc. One drawback to the 



METHODS OF CONTROLLING BLOOD-PRESSURE 239 

continued use of this drug and its salts, is the irritation 
which its use causes in the digestive tract. 

lodin is usually administered in the form of potassium 
or sodium iodid, and as there is no difference in their effect 
upon the circulation and, as a rule, sodium iodid is better 
tolerated, the sodium preparation should be employed. No 
advantage has been found in the use of larger doses than 
2 to 5 gr. daily, given in milk or diluted with water. 
Some observers, however, recommend the use of an ascend- 
ing dosage beginning at 6 gr. and gradually increasing to 21 
gr. a day. When used in this way an intermission of one 
week should occur in every four weeks of its administration. 
Excellent results have been reported in some cases of hy- 
pertension, but there was no proof that they were not of 
syphilitic origin. The accompanying chart shows a re- 
markable and at the same time dangerous effect from the 
overuse of iodid. (Fig. 36.) 

The disagreeable effect of iodid can often be reduced by 
the addition of 5 gr. of sodium bicarbonate to each dose. 

Arsenic, — This drug in doses of 1/5 gr. arsenic trioxid, 
has been reported favorably by some observers, among 
them Balfour. To obtain an effect the drug should be 
administered over a long period of time. 

Trunecek^s Serum. — Trunecek devised a serum to be 
used subcutaneously in arteriosclerosis. Its composition 
is said to be as follows: 



Sodium chloride 10 grm. 

Sodium sulphate 1 grm. 

Calcium phosphate . 75 grm. 

Magnesium phosphate . 75 grm. 

Sodium carbonate . 40 grm. 

Sodium phosphate 0.30 grm. 



240 BLOOD-PRESSURE 

One gram of this is dissolved in 15 c.c. of sterile distilled 
water. Treatment is begun by hypodermic injections in 
the region of the buttocks of 2 c.c. of the solution every 
other day, being increased in amoimt by 1 c.c. each in- 
jection until the dose of 8 c.c. is reached. The mixture has 
also been given per rectum and by the mouth. ^ The origi- 
nator recommends this for use only in arteriosclerosis, but 
other authorities have used it in hypertension resulting 
from causes other than arteriosclerosis. Potter has made 
extensive studies with this substance without results, its 
trial can do no harm. Maximum daily dose, 10 c.Co 

Thyroid Extract. — As pointed out repeatedly for many 
years by 0. T. Osborne of Yale, a deficiency in thyroid 
excretion causes a rise in blood-pressure, and any increase 
in adrenal secretion has the same effect, hence the deduc- 
tion that thyroid is of value in reducing blood-pressure. 
The thyroid gland seems to be a part of the mechanism of 
internal secretion which regulates blood-pressure, and 
probably is concerned in maintaining the normal low level. 
Thus small doses of the dried gland, 1 to 3 gr. of the 
official preparation a day, tends not only to lower 
blood-pressure, but in some cases by stimulating the action 
of the individual thyroid gland, serves to maintain for a 
time a better secretion. Possibly when benefit results 
from the use of iodin or the iodids, this is because of 
their stimulating effect on thyroid secretion. In cases of 
hypertonus and those showing a moderate degree of arterio- 
Bclerosis, with little or no cardiac or renal involvement, 
this drug may prove of great service in reducing and main- 
taining a more normal level of blood-pressure. It has also 

* American Practitioner, April, 1912. 



METHODS OF CONTROLLING BLOOD-PRESSURE 241 

been used with benefit in high pressure in eclampsia. It 
should never be used in large doses or over a long period 
of time, and then not unless the patient is under close 
observation with frequent blood-pressure tests. 

Salicylates. — All salicylates in large doses reduce blood- 
pressure, but are rarely employed for this effect. Accord- 
ing to Bamberger^ experiments with intravenous and hypo- 
dermatic injections of sodium salicylate in dogs it materially 
lowered blood-pressure and he suggests its use in this 
manner for this purpose in man. 

Calomel. — Lauder Brunton^ advises the employment of 
calomel in half-grain doses three or four times a day to 
relieve hypertension. 

Rumpf recommends the restriction of the calcium con- 
tent in diet, as a means of controlling high blood-pressure, 
but so far as I know his work lacks corroboration. 

Anesthetics. — (See Chap. XVI, page 204.) Ethyl chlorid 
may bring about a dangerous fall in blood-pressure when 
used for anesthesia, even when used in small amounts, its 
employment is contraindicated in myocardial degeneration, 
and had even better not be used when there is a possibility 
of this condition being present, and with great caution in 
all cases showing hypotension. Under no circumstances 
should ethyl chlorid be used for its effect on blood-pressure. 

Chloroform, — This drug always produces a fall in blood- 
pressure, which progressively increases with the duration 
of its administration, when used in concentrated form, as 
httle as 3 c.c. has been known to cause a dangerous fall. 
Its employment is dangerous in all degenerative conditions 

1 Interstate Med. Jour., p. 667, 1911. 

2 Lancet, Oct., 17, 1908. 

16 



242 BLOOD-PRESSURE 

and hypotonus, and while advocated by some clinicians 
as an emergency remedy to reduce high pressure, it had 
better be let alone, especially if anything else is at hand 
which will accomplish the same result. 

Chloral may greatly relieve the symptoms of high blood- 
pressure, even without materially altering the level. 
Indeed it does not as a rule have much effect on high 
blood-pressure. 

Hypophysis Extracts, — According to Lewis, Miller and 
Matthiew^ the intravenous injections of the pars inter- 
media cause a decided rise in blood-pressure, injections 
of the pars nervosa cause a slight primary rise followed by 
a marked fall, accompanied by marked slowing of the 
pulse. Extracts of the anterior lobe give a primary fall 
followed in most cases by a secondary rise in pressure to 
a point above the original level, while the use of several 
parts of this gland give promise of being of value in the 
treatment of both high and low blood-pressure. There 
is as yet insufficient evidence either of an experimental 
or clinical nature to warrant its recommendation for 
general adoption. 

Morphin in doses of 1/8 to 1/4 gr. hypodermatically may 
be reUed on to lower blood-pressure and is a most valuable 
remedy in emergency, but not for continued use. Em- 
ployed judiciously it may prolong life. 

Potassium Bicarbonate ^ 10 gr. in a glass of water every 
morning, is recommended by Lauder Brunton^ to keep 
blood-pressure down; he also suggests '^ 10 gr. KNO2, 10 gr. 
Na2C03, and 1/2 to 2 gr. NaN02 in a powder dissolved 

» Arch, of Inter. Med., June, 1911. 
« Lancet, Oct. 17, 1908. 



METHODS OP CONTROLLING BLOOD-PRESSURE 243 

in some hot aperient water, as tending not only to be laxa- 
tive, but to keep the blood-pressure down, and this may be 
continued daily for years.'' 

Physical Measures. — Under the head of physical meas- 
ures valuable in controlHng and in reducing high pressure, 
we find: 

Rest. 

Exercise. 

Massage. 

Diet. 

Hydrotherapy. 

Electrotherapy. 

Venesection. 
Rest and Posture. — Pre-eminently rest is the first essential 
in the treatment of all cardiovascular and renal conditions. 
It is always safe and generally beneficial to begin every 
course of treatment by rest. The term rest as here used 
may be purely relative or may mean absolute recumbency. 
The degree of rest enforced will depend entirely on the 
physician's judgment as based upon experience and the 
extent of his knowledge of the case and its requirements; 
no set rule can be adhered to blindly. 

In the cases suddenly developing signs of incompe- 
tency, with dyspnea, a large heart, venous congestion, etc., 
the decision is obvious; it demands absolute rest and men- 
tal relaxation — nothing else will do. First and foremost, 
all unnecessary strain must be removed from the over- 
burdened and dilated heart. This alone may suflSce 
to break the vicious circle, allow the heart muscle to 
regain its lost tone and so pave the way for a period of 
at least relative health. 



244 BLOOD-PRESSURE 

Rest in bed alone will often be suiO&cient to reduce a 
dangerously high blood-pressure. I have repeatedly seen 
a pressure of over 200 mm. fall to and maintain a new 
level of from 15 to 25 mm. lower. Occasionally even a 
greater reduction than this will be effected by this measure. 

Effects of Sleep and Rest on Blood-pressure, — Brooks 
and Carroll^ studied this question in sixty-eight patients 
showing average systolic pressure, in thirty with low 
pressures and in twenty-nine with abnormally high pres- 
sures. The results are, in a general way, illustrated 
in the cases with average pressure, in which readings 
taken between one and two hours after the beginning of 
sleep showed an average drop of 24 mm. Hg. Three 
hours after the awakening in the morning there was still 
an average depression of 12 mm. and from this time the 
pressure gradually rose during the day until usual highest 
level was reached in the afternoon. The greatest noc- 
turnal fall in pressure took place in those individuals 
having the highest initial systolic reading. Disturbance 
of patients during the first sleep was found to delay, but 
not necessarily prevent the maximal fall in pressure; 
frequent interruption did, however, prevent it. Special 
tests were made to determine whether the sleep drop 
could be artificially increased in order to secm-e a lower 
general pressure curve in cases of hypertension; potassium 
bromide in doses as high as 120 gr., and chloral hydrate, 
up to 50 gr. each night, did not, however, increase the 
degree or persistence of the fall. Physical rest in general 
did not appear to alter materially either supernormal or 
normal blood-pressure, but the authors were led to believe 

» Archives of Int. Med., Aug., 1912. 



METHODS OF CONTROLLING BLOOD-PRESSURE 245 

that in mental or psychic rest profound changes in pressure 
occur, and that this factor largely determines the undoubted 
benefit derived from rest in cases of high pressure. 

Exercise, — In certain cases, particularly that of the 
active business and professional men, it is not more rest, 
but more exercise that is needed. These are the cases in 
which, if seen sufficiently early, much may be accomplished 
toward permanently arresting the trouble, provided of 
course, that the patient is ready and willing to continue 
a new rule of life. These cases probably belong to those 
classed as true hypertonus, with tonic contraction of the 
circular fibers of the arteries (see page 21), with but 
little or no permanent pathologic change and where the 
kidneys show only signs of irritation. Here complete 
relief often follows a carefully regulated diet, combined 
with an increased amount of daily exercise. This should 
not be begun suddenly, nor be too strenuous. Walking 
first, to be followed later by light gymnastics or golf. 
Such measures should always be carefully followed by the 
sphygmomanometer. 

In institutions and hospitals devoted to the treatment 
of chronic cardiovascular and renal diseases, the exercise 
methods of Schott and Ortel are carried out under compe- 
tent supervision, and, under proper guidance, accomplish 
much good in educating the heart muscle to withstand 
more strain and to improve cardiomuscular tonus. It is 
not advised that the individual physician seeing at best 
but few cases, should attempt these special exercise treat- 
ments. A great deal can be accomplished by systematized 
walking as shown in the chart of a case appended herewith. 
(See Fig. 30.) 



246 BLOOD-PRESSURE 

Massage, — General massage is usually well borae and is 
valuable in the treatment of cases showing failing com- 
pensation or defective heart tone. This treatment acts 
by emptying the venous side of the circulation and so 
relieves the left side of the heart, it also dilates the super- 
ficial capillaries, thereby further aiding in the distribution 
of the blood. Massage of the chest may influence favorably 
the tone of the heart itself, but deep pressure upon the 
abdomen should be avoided in order to escape a rise in 
blood-pressure and all movements should be graduated 
to the strength of the individual. 

Both Eichberg* and A. Strausser^ advocate the employ- 
ment of massage in the treatment of cardiovascular dis- 
eases, and Eichberg has shown that massage movements 
even if prolonged do not effect a rise in blood-pressure. 

Dietetics, — Much has been said and many dietetic out- 
lines have been advocated in the treatment of circulatory 
disturbances. Their chief object is to diminish nitrogen- 
ous intake, to reduce putrefactive changes in the intestines 
which produce auto-intoxication; and, secondarily, to re- 
lieve the strain on a dilated and defective heart muscle, 
by reducing dangerously high pressure through limiting 
the fluid intake which eventually modifies the total amount 
of fluid in the body. 

Foods, — A safe general rule to follow is, that while nitrog- 
enous food is not to be prohibited, the amount should be 
greatly reduced, and a vegetable, farinaceous and milk diet 
substituted. 

An absolute milk diet cannot be continued over a long 

» Jour. A. M. A., Sept. 19, 1908. 

« Wien. med. Wochen., April 8-15, 1909. 



METHODS OF CONTROLLING BLOOD-PRESSURE 247 

period because it is impossible to give sufficient nourish- 
ment without overstepping seriously a safe maximum of 
fluid ingestion. Excessive fluid sometimes being a factor 
in the production of the high pressure. 

A short period of absolute milk diet (2 quarts) is useful 
for the relief of certain symptoms, and may guardedly be 
employed with benefit. When employed it should be 
given at two- or three-hour periods and never in large 
quantities at one time. The addition of some flavoring 
or the preparation of junket will render the employment 
of milk less irksome to the patient. 

In the treatment of cardiovascular cases, the best results 
generally follow a number of small meals taken at fre- 
quent intervals (three to three and one-half hours). This 
prevents possible harm of throwing a heavy strain on 
the heart and blood-vessels through the digestive appara- 
tus, which might easily disturb a poorly balanced circula- 
tory equilibrium. 

Alcohol, tea and coffee are usually prohibited entirely, 
at least for a time. An exception to this may be a heavy 
drinker, who cannot get along at all if his habitual potations 
are suddenly and entirely interdicted. As a substitute 
for coffee, postum may be employed; and recently a pat- 
ented process has been used in Germany by which the coffee 
bean is freed of 90 per cent, of its caffeine. In this the 
taste of the coffee is not materially changed, but the effect 
upon the heart and blood-vessels is decidedly lessened. 
Eisner^ and others report the use of this preparation during 
a period of several years with a great deal of satisfaction. 

Tobacco, — Tobacco in the form of pipe, cigarettes and 

* Boston Med. and Surgical Jour.^ No. 7, 1910. 



248 BLOOD-PRESSURE 

cigars has the power of raising blood-pressure with the ap- 
parent paradox that the habitual smoker has usually a low 
pressure. Arterial disease tends to augment the effect 
of smoking on arterial pressure. It is often a point of 
delicate decision to determine the amount of harm resulting 
from the use of tobacco, and the proper amount of restric- 
tion in the use of the drug necessary in each particular 
case. V/hen in doubt the best rule to follow is to carefully 
restrict and control the patient's habits in this regard. In 
cases with a history of anginoid attacks tobacco in all 
forms should be prohibited entirely.^ 

The habit of chewing tobacco is much more harmful 
than smoking because of the greater amount of the active 
principle, nicotin, which enters the system. Its use should, 
therefore, not be tolerated. 

In restricting diet, no definite rule can be laid down 
which can be followed safely in every case. Each case has 
its own peculiarities and the physician should endeavor 
to determine intelligently the restrictions to be made 
and what things may be allowed with safety in a given 
case. One should be careful in any dietetic scheme to 
avoid a caloric reduction below the needs of the individual, 
otherwise much harm may be done, for it is impossible to 
build up a strong heart upon insufficient nourishment. 

L. F. Bishop^ makes the following suggestions which may 
serve as a valuable guide in the preparation of a dietetic 
list in hypertension and chronic heart disease. 

First, he suggests that every student of the subject 
should address a letter to the Superintendent of Docu- 

* A. StrauBser, Wien. klin. Wochen., April 15, 1909. 

* N. Y. Med. Jour., March 4, 1911. 



METHODS OF CONTROLLING BLOOD-PRESSURE 249 

merits, Government Printing Office, Washington, D. C, 
enclosing ten cents and asking for Bulletin No. 28 on the 
'^Chemical Composition of American Food Materials/' 

Secondly, the principal to be remembered is that an 
adult requires from 14 to 20 calories per pound, body weight, 
according to the amount of work he does. The weight is 
to be estimated by the normal weight for the height of the 
individual. For example, a person 5 ft. 7 in. tall ought to 
weigh 150 lb. ; at light work he will require an average num- 
ber of heat units per pound 17, 150X17 = 2,550 calories. 
If a healthy man has more than this, he will accumulate fat ; 
if he has less he will become run down, and a weak heart 
cannot be built up on insufficient nutrition. 

Bishop submits the following dietary covering a period 
of five days, which allows a fair caloric intake: 



DIET 

Luncheon: Calories Protein 

1 cup of bouillon 40 10 

2 slices of mushroom on toast 50 2 

1 tablespoon of potatoes 100 2 

1 plate of endive and lettuce salad 125 (oil) 

1 saucer of rhubarb. 

1 piece of gingerbread 230 4 

Dinner: 

1 plate of vegetable soup 50 3 

3 tablespoons of stewed tomatoes. 

1 large tablespoon of potatoes 110 2 

2 large tablespoons of beans 60 4 

2 tablespoons of Indian pudding 175 8 

Lactose with each meal 300 

Average breakfast 315 8 

Total for day 1,565 43 



250 BLOOD-PRESSURE 

January 21. 

Breakfast: 

1 orange 40 

1 small bowl of wheat berries 160 4 

2 slices of toast 115 4 

1 cup of weak coffee. 
Luncheon: 

4 large fried scallops 60 8 

2 tablespoons of creamed potatoes 220 4 

1 plate of cabbage and lettuce salad 125 (oil) 

2 tablespoons of preserved peaches 40 

1 cup of weak tea. 

Dinner: 

1 plate of vegetable soup 50 3 

3 small slices of bread 230 8 

2 tablespoons of potatoes 220 4 

2 tablespoons of spinach. 

i plate of scallop and lettuce salad 140 4 

1 small piece of pumpkin pie 250 4 

1 small piece of cheese 120 8 

Lactose with each meal 300 

Total for day 2,070 51 

January 22. 

Breakfast, practically as before 315 8 

Dinner: 

1 plate of vermicelli soup 120 4 

4 small potatoes 200 4 

2 tablespoons of gravy. 

3 stewed onions 100 4 

Ice cream 320 8 

Cake 230 4 

3 small sUces of bread 230 8 

Tea: 

1 cup of bouillon 40 10 

1 tablespoon of fried potatoes 110 2 

3 shces of bread 238 8 

1 plate of lettuce and celery salad 125 (oil) 

1 cup of weak tea. 

Ice cream 320 8 

Sponge cake 230 4 

Lactose with each meal 300 

Total for day 2,870 72 



METHODS OF CONTROLLING BLOOD-PRESSURE 251 

January 23. 

Breakfast, as before 315 8 

Luncheon: 

3 tablespoons of macaroni 100 3 

2 tablespoons of spinach. 

3 small slices of bread 230 8 

1 plate of lettuce and endive salad 125 (oil) 

1 piece of pumpkin pie 250 4 

2 pieces of cheese 120 8 

1 cup of weak tea. 

Dinner: 

Large plate of farina soup 50 2 

3 tablespoons of macaroni 100 3 

2 tablespoons of potatoes 220 4 

3 pieces of preserved peaches 40 

3 shces of bread 230 8 

Lactose with each meal 300 

Total for day 2,080 48 

January 24. 
Breakfast, as before 315 8 

Luncheon: 

1 plate of lettuce and endive salad 125 (oil) 

2 tablespoons of potatoes 220 4 

2 tablespoons of fried hominy 120 4 

3 pieces of preserved peaches 40 

1 cup of weak tea. 

Dinner: 

Large plate of vegetable soup 60 3 

2 tablespoons of boiled potatoes 180 4 

2 tablespoons of stewed peas 100 7 

2 tablespoons of rice pudding 175 4 

Lactose with each meal 300 

Total for day 1,625 34 

N. B. — One glass Sauterne with each luncheon. 
Average for five days: Protein, 49; calories, 2.040. 

Roughly speaking the average helping of meat contains 
25 grm. of proteid, an egg contains 8 grm., as does also a 
glass of milk. An ordinary helping of rice, potatoes, bread 
or hominy contains about 4 grm., thick cream, butter or 



252 BLOOD-PRESSURE 

oil contain practically no proteid, but are very rich in 
heat units. Green vegetables do not count one way or the 
other. In cardiovascular disease, milk sugar is a valuable 
addition to diet, for many reasons. A sufficiency of calo- 
ries can be roughly judged by watching the weight of the 
individual ; if the weight is maintained the caloric supply is 
certainly sufficient. 

Water. — Water properly employed may be of great value 
in the treatment of cardiovascular and renal diseases, but 
like any other good thing, it can be overworked. Cases 
are on record where apparently the only causative factor 
in the production of chronic interstitial nephritis was 
continued excessive water drinking. Usually it is advisable 
to limit the amount of water, especially in very high-ten- 
sion cases or where there is a tendency to edema. This 
will spare both the heart and blood-vessels, but the amount 
should not be reduced below 1,500 c.c. per day, and even 
when there is edema this should not be continued for more 
than three consecutive days below this figure (A. Strausser). 

Balfour^ sums up his experience in the dietetic treatment 
of chronic myocarditis as follows: 

''There should never be less than a five-hour interval 
between meals. 

''No solid food should be taken between meals. 

"The principal meal should be taken in the middle of 
the day. 

'^All food should be taken as dry as possible/* 

In the matter of the interval between meals, however, 
authorities differ; an equally competent observer advised 
the employment of five small meals a day (see above). 

> The Senile Heart. 



METHODS OF CONTROLLING BLOOD-PRESSURE 253 

Hydrotherapy. — ^L. T. Thorne^ proves by the citation 
of many cases that the majority of painful and dangerous 
symptoms which are usually attributed to hypertension 
are in reality the result of cardiac insufficiency and dila- 
tation, dependent upon pathologic conditions of which 
hypertension is one valuable sign. He rarely employs 
drugs, but values most such physical measures as will 
reduce arterial tension, and at the same time improve the 
tonicity and contractility of the heart. For this he 
depends chiefly upon a course of natural baths or their 
artificial substitutes so prepared as to resemble in chemical 
composition the natural baths of Nauheim. 

Hydrotherapy in the treatment of cases of high blood- 
pressure, particularly those accompanied by arteriosclero- 
sis, accomplishes its result chiefly through regulation of the 
circulation. Properly used, such methods may, under 
certain conditions check the progress of disease by breaking 
the vicious circle in which the patient is involved. The 
primary effect of plain water, either hot or cold applied to 
the surface of the body, has been found by most observers 
to cause an initial rise in blood-pressure. This elevation 
usually amounts only to a few millimeters, and is followed 
speedily by a reaction, accompanied by lower pressure, 
from a relaxation of hypertonus and diminished peripheral 
resistance, caused by an increased flow of blood through 
the capillaries. 

Cold Baths, — The careless application of cold to high-pres- 
sure cases may be dangerous. Its effect should first be 
ascertained by rubbing cold water over portions of the body. 
Cold applications can only be used with safety in cases of 

^Practitioner, July, 1911. 



254 BLOOD-PRESSURE 

early arteriosclerosis and cold douches should be used with 
extreme caution, as they do not as a rule give as good re- 
sults as rubbing or ordinary bathing. In this connection 
cold sea-water baths should not be indulged in by arterio- 
sclerotics nor by those having myocardial degeneration. 

The Scottish douche (alternate application of hot and 
cold water) frequently gives good results in hypertension, if 
the contrast between the temperatures employed is prop- 
erly graduated. 

Hot Baths. — The temperature of hot baths in cases of 
arteriosclerosis should not exceed 37 or 38° C. Extreme 
changes in temperature of baths is also contraindicated in 
arteriosclerosis, because of the danger in any sudden change 
in pressure, particularly any sudden increase arising from 
capillary contraction which causes increased peripheral 
resistance. 

Hot-air baths and electric-Ught baths are probably as 
good as the direct application of heat, and should be em- 
ployed whenever practical. 

In the hypertension accompanying acute nephritis, with 
the usual subjective symptoms, I have seen great benefit 
follow a properly given electric-Ught bath, the temperature 
being allowed to rise in the cabinet to 125° F. to be main- 
tained for from fifteen to twenty minutes. Under these 
circumstances an immediate fall in pressure occurs often 
amounting to from 15 to 30 mm., occasionally more, and 
this fall is usually lasting in character, often persisting 
for twenty-four hours. The effect upon the patient is 
always most satisfactory, the subjective signs immediately 
disappearing. Elimination is increased while the patho- 
logic elements in the urine are diminished. 



METHODS OF CONTROLLING BLOOD-PRESSURE 255 

The proper administration of an electric-light bath de- 
pends upon the intelligent use of the sphygmomanometer. 
By this instrument, and by its aid alone can the immediate 
effects of the bath be measured, so that its duration and the 
period of its administration may be definitely calculated. 
Hydrotherapeutic measures sometimes accomplish good 
results when drug medication absolutely fails. This was 
well shown in one case, where nitroglycerin was given to 
the point of intolerance, without effect upon blood-pressure, 
while the electric-light bath speedily reduced the pressure 
and easily maintained a reduction of 45 mm. 

Miller recently has reported a practical series of clinical 
studies on the effect of the sweating process in high-pressure 
cases. In his series all patients reported, sweated profusely 
for at least thirty minutes. The method of producing the 
sweat varied. The blood-pressure was taken just before 
the sweat discontinued. Three out of five cases showed a 
reduction in pressure ranging from 1 3 to 20 mm. In one case 
it did not return to previous level until a lapse of four hours. 
Patients always felt better after the sweating. Dyspnea 
(uremic) is generally relieved even when the pressure is not 
reduced. 

A number of patients were given one or more daily sweats 
for two or three weeks, the pressure recorded daily; results 
varied, in some there was no change, some showed a gradual 
fall. One case which had been over 210 for several years, 
came down to 180 (Fig. 31). 

In chronic cases the sweating process is not lasting in its 
effect, as the pressure soon returns to original level when 
sweats are discontinued. Poststernal oppression is relieved 
more often by sweats more than by other measures. 



256 BLOOD-PRESSURE 

Table 5. — From Miller. Effect of Sweating on Blood-pressure 





Blood-pres- 


Blood-pres- 




Case 


sure before 


sure after 






sweating 


sweating 




1 


160 


140 


Four hours before it reached 
previous level. 


2 


190 


190 




3 


170 


170 




4 


190 


175 


Two hours before it reached 
previous level. 


5 


185 


172 





The sudden application of cold or chilling after a sweat is 
dangerous. In one case Miller has reported a rise of 60 
mm., followed by transitory numbness. Overreduction of 
pressure may be followed by untoward results, although 
this does not always follow, as shown in the chart No. 31, 
page 147. 

The Nauheim Treatment. — The basis of the Nauheim 
treatment in circulatory disorders is rest, hydrotherapeutic 
measures and exercise. Its chief value in the treatment 
of circulatory disorders comes from its effect on the heart 
muscle. Acting upon the heart, it increases tonus and 
reduces dilatation. Acting upon the circulation, it dilates 
the arterioles and capillaries thereby reheving a high pe- 
ripheral resistance and obtaining a more uniform distribution 
of blood. These baths do not always produce a reduction 
in blood-pressure, and they may be followed by disastrous 
results. In this connection it is important to sound a 
warning note. Neither the oxygen nor the CO2 bath 
should be used without a working knowledge both of what 



METHODS OF CONTROLLING BLOOD-PRESSURE 257 

is desired and what such treatment may be expected to 
accomplish. 

Application. — The chief hydrotherapeutic method em- 
ployed at Nauheim is the complete immersion of the patient 
in a bath of natural brine, which is charged with free CO2 
gas. The most important constituents of this bath are 
sodium chlorid and calcium chlorid. The temperature of 
the bath is varied according to experience. The patient 
remains immersed for a period of from four to fifteen min- 
utes, is then carefully dried, without chilling, and required 
to rest in bed for an hour. The baths are given on alternate 
days; the course usually occupies six weeks. Baths of 
similar character are given under medical supervision at 
Glen Springs, N. Y., where the methods are much the same 
as those at Nauheim and the benefits derived probably 
as good. 

According to Dr. John M. Swan, formerly of Glen 
Springs, the effects to be expected from the proper use of 
carbonated-brine baths are as follows: 

1. Diminution of the size of the heart. 

2. Slowing of the pulse. 

3. Reddening of the skin. 

4. Slowing of the respiration. 

5. Reduction in the size of the fiver, if that organ has 
been the seat of passive congestion. 

6. Improvement in the muscular quafity of the heart 
sounds. 

7. The disappearance of hemic murmurs, or those due to 
dilatation of an orifice. 

8. Increase in the intensity of those murmurs which are 
dependent on valvular defect or deformity. 

17 



258 BLOOD-PRESSURE 

The chief indication for the use of the carbonated-brine 
bath in the treatment of chronic heart disease is in cases of 
myocardial weakness, with low pressure. In such cases we 
expect to get a retarding of the pulse, an improved heart- 
muscle sound and a rise in blood-pressure. 

In cases of senile heart, with high blood-pressure and 
evidence of general arteriosclerosis, carbonated-brine baths, 
if given at all, should be stopped at once upon the develop- 
ment of an increase in blood-pressure, whether this is 
shown by subjective symptoms, or by the sphygmoma- 
nometer. In cases where the beneficial effect of the bath is 
in doubt, danger may be prevented if the temperature of 
the bath is kept above 98° F. ; otherwise the strong brine 
should be omitted or diluted and the CO2 gas left out. 
According to Swan, CO2 baths are contraindicated in cases 
of advanced arteriosclerosis, chronic nephritis, aneurism 
of the large arterial trunks, and in the terminal stages of 
broken compensation with edema. 

After the diseased myocardium has had an opportunity to 
recuperate, and to regain some of its lost tone by rest and 
the bath treatment, it is often advisable to provide exercise 
under proper supervision in order to help the heart perform 
its normal functions in as nearly a normal fashion as 
possible. This is in the nature of a special training of the 
muscles to be developed. Two systems have been devised 
which apply graduated work to the heart: first, Schott 
method or resistance movement ; and, second, Ortel method 
of graduated hill climbing. These consist of a number of ex- 
ercises of increasing severity, arranged so that the increased 
work imposed on the heart is very slight, but is increased in 
proportion as the heart muscle learns to bear the strain. For 



METHODS OF CONTROLLING BLOOD-PRESSURE 259 

more complete descriptions of these methods and their 
applications, the reader is referred to works devoted to 
hydrotherapy and the treatment of heart diseases. 

Oxygen Bath. — A mode of treatment that has recently 
been advocated and favorably reported upon by a number 
of observers is the oxygen bath. According to reports the 
effect of the oxygen bath is very different from that of the 
CO2. In the CO2 bath the skin becomes reddened from 
dilatation of the superficial vessels, while in the oxygen 
bath the cutaneous vessels are constricted and the skin 
becomes pale. The oxygen bath at 95° F. reduces both 
pulse rate and blood-pressure, and the effect of the CO2 bath 
upon blood-pressure is variable. In arteriosclerosis these 
baths are said to have beneficial effect, among which is a 
moderate reduction of blood-pressure. According to the 
conclusions of A. Wolfe ^ the respective effects of the oxygen 
in the CO2 bath upon the human body are as follows : 

1. The temperature of the water in both instances has a 
material bearing upon its influence on blood-pressure. 

2. At 93 or 94° F. neither bath has much influence on 
blood-pressure if this be not pathologically changed. The 
CO2 bath at 94° tends primarily to increase a pathologic 
blood-pressure, whether this was at first a hypo- or a hyper- 
tension. 

3. The normal pulse is but little altered by either bath, 
while the CO2 reduces it more often in less degree than the 
oxygen bath, when the pulse is originally abnormal. 

In employing the oxygen bath, the patient should not 
enter it immediately after active exercise or mental excite- 
ment, and unnecessary movement should be avoided while 

1 Zeit, f. Physiol, u. VieL Therap., Vol. XIV, 1910. 



260 BLOOD-PRESSURE 

in the bath. He should be carefully dried and then should 
lie down immediately for an hour. The duration of the 
bath, depending upon the effect desired, should be from 
ten to twenty-five minutes, and should be given on alter- 
nate days. The bath is contraindicated in low blood-pres- 
sure accompanying the last stages of arteriosclerosis. Also 
for those with mitral defects or marked anemia. 

The ingredients for the oxygen bath (sodium per borate 
and magnesium borate) can be obtained in the open 
market under the name of ^^perogen" bath. 

Electrotherapy. — Much has been said, and, if possible, 
more has been written, upon the subject of electrical treat- 
ment for the reduction of arterial hypertension. A careful 
review of literature up to the time of writing shows that 
there is considerable divergence of opinion upon the value 
of such measures. First, in any case, we must determine 
the cause of high pressure and the desirability of reducing it. 

Here, as in the study of other remedial agents, a systemic 
employment of the blood-pressure test is essential to the 
proper interpretation of the results, as it is only by this 
means that the psychic element can be eliminated, which 
some authorities aver is the only benefit derived from the 
use of electrical currents in the treatment of hypertension. 

William Benham Snow^ is conservative in his statements 
regarding the value of such measures, and largely confines 
himself to the consideration of the control of early cases of 
hypertension by autocondensation and other electrical 
measures. 

He divides all cases presenting the symptoms of hyper- 
tension into the following seven clinical groups: 

* Jour. Adv. Therap., June, 1909. 



METHODS OF CONTROLLING BLOOD-PRESSURE 261 

1. The aged and feeble, partly compensated arterio- 
sclerotics with low-pressure readings. (These are not 
benefited by electrical treatment — author.) 

2. General arteriosclerosis, so wide spread that auto- 
condensation fails to affect the reading, sequlse cannot be 
avoided and electrical treatment is useless. 

3. Arteriosclerosis of advanced age, fifty to sixty years, 
pressure above 200 mm.; autocondensation and hygienic 
measures cause a reduction to 165 or 160 mm., when it may 
be maintained by diet and occasional electrical treatment. 
There is a corresponding improvement in general health. 
Electrical treatment is valuable in this class if it can be con- 
tinued indefinitely from time to time in order to maintain 
the reduction. 

4. Arteriosclerosis in adults of thirty-five to fifty-five, 
pressure 150 to 170 mm., with or without beginning chronic 
nephritis. Here fifteen minutes treatment, 400 milliamperes 
by autocondensation, produces marked fall; with frequent 
treatments and correction in diet the tension often returns 
to normal, the physical condition appears normal and urine 
clears up. (These cases are probably those of true hyper- 
tension of Brunton, those which do not have permanent 
arterial change or chronic intestinal nephritis — author.) 

5. Same as class four, except an earlier stage of hyper- 
tension — (author) . 

6. Young adults, chiefly athletes, who have developed a 
work hypertrophy and consequent moderate degree of 
hypertension (Snow fails to state effect of treatment — 
author.) 

7. Compensatory hypertension occurring in parenchy- 
matous nephritis, cirrhosis of liver, fever, after excessive 



262 BLOOD-PRESSURE 

exercise, etc. (Condition about the same as 4, no uni- 
formity in results of treatment — author.) 

Snow states that D'Arsenval high-frequency and static- 
wave currents act locally upon the neuromuscular mechan- 
ism. The methods of D'Arsenval may be either autocon- 
densation or autoconduction, by both of which methods the 
patient is placed in a field of hypotensive stresses where 
the high frequency to a greater or lesser extent surges 
through the tissues of the body, and are remarkably 
active in lowering arterial tension. *^This effect is prob- 
ably induced by a complex action of the current.'' 
Acting conjointly: 

1. Upon metabolism, promoting tissue combustion and 
elimination, as demonstrated by an increase in soHds in 
the urine, and 

2. Upon the vasodilator centers which control peripheral 
resistance by which hypertension is relaxed, as demon- 
strated by the sphygmomanometer. 

A twelve-minute administration of 400 milliamperes is, 
as a rule, followed by a reduction of from 10 to 15 mm.; 
occasionally a fall amounting to fifty occurs. 

''Autocondensation is indicated in all cases in which 
hypertension is not compensatory and is contraindicated 
in all compensatory cases'' (Snow). 

Dosage 300 to 400 milliamperes from twelve to fifteen 
minutes duration repeated daily or on alternate days. 

Van AUen^ claims that high-frequency currents reduce 
the blood-pressure by removing the exciting causes, that 
is, by preventing autointoxication. 

* Albany Med. Annals., June, 1911. 



METHODS OF CONTROLLING BLOOD-PRESSURE 263 

It must be remembered that all efforts at reduction 
of high blood-pressure should be based upon a carefully 
made diagnosis, and that the indications for interfering 
with the circulation must be clear, otherwise one must 
expect to have failures. In some cases even disaster will 
follow ill-advised efforts to modify blood-pressure. A 
safe rule to follow is to watch the patient, study the effect 
of pressure changes upon him and cease all measures that 
fail to produce benefit, both in the evident physical con- 
dition of the patient and in his own subjective signs. 

Venesection. — Miller,^ after carefully studying the effect 
of venesection on both normal and pathologic cases, 
arrived at a conclusion similar to that stated by Mac- 
kenzie some years before. Miller found the rapid with- 
drawal of 300 c.c. or more from a normal individual is fol- 
lowed by a transitory fall in blood-pressure, but all persons 
do not react in the same way. The effect depends partly 
on the rapidity with which the blood is withdrawn — 500 c.c. 
withdrawn slowly may have no effect on blood-pressure. 

Butterman^ bled ten students, withdrawing from 200 
to 480 c.c, and nine showed reductions varying from 5 to 
30 mm. Patients with hypertension do not necessarily all 
react in the same way. 

The accompanying table taken from Miller^s article 
above shows what may be expected in efforts to reduce 
hypertension by this means. 



1 Jour. A. M. A., Vol. LIV, No. 21. 

^ Arch, fur klin. Med., 1902, LXXIV, No. 1. 



264 



BLOOD-PRESSURE 
Effect of Bleeding on Blood-pressure (Miller) 





Blood-pres- 


Amount of 

blood 
withdrawn 


Blood-pres- 




Case 


sure before 


sure after 






bleeding 


c.cm. 


bleeding 




1 


200 


500 


200 




2 


190 


500 


185 




3 


160 


600 


150 


Two hours later 160 


4 


185 


500 


170 


Two hours later 180 


5 


220 


450 


210 





CHAPTER XX 
BLOOD-PRESSURE ELEVATORS 

Hypotension is often an important complication in 
acute infections, especially in pneumonia and typhoid 
fever. So also in shock, after hemorrhage, during anes- 
thesia and under surgical operations a dangerously low 
pressure may develop and demand the employment of 
measures capable of controling it. (See Chapter VIII 
on Hypotension.) 

A knowledge of the usual therapeutic measures employed 
in such conditions, and the effect which may be expected 
from them, should form an important part of the readily 
available knowledge of both surgeon and physician. 

The routine employment of the blood-pressure test 
has thrown much light upon the action of blood-pressure 
among drugs, and has resulted in the elimination of many 
which have long been empirically employed. At the same 
time new and valuable remedies have been added to the 
list of those available for combating dangerous hypotension. 

The varying origin and character of the drugs employed 
make the scientific division of this group impossible, so 
that the arrangement herein found is largely based 
upon the activity and reliability of the several drugs, as 
demonstrated both experimentally and clinically by the 
sphygmomanometer. 

Adrenalin. — While reports bearing on the efficiency 
of adrenalin as a supporter of failing blood-pressure are 

265 



266 BLOOD-PBESSURB 

conflicting, a critical study shows that this drug is probably 
our chief support in emergency, and that it may in many 
cases be relied upon, when properly employed, to support a 
failing circulation for a sufficiently long time to tide the 
case over a crisis. 

Adrenalin may be administered by the mouth in doses 
of from fifteen to fifty minims, by hypodermic in doses of 
three to ten minims, and by hypodermoclysis and intra- 
venous injections in varying dosage, depending upon 
the rate of flow through the needle and the extent of 
effect desired. The action of adrenaUn when given by 
mouth is extremely unreliable and it is doubtful whether 
absorption from the stomach takes place with sufficient 
rapidity to allow much of the drug to be absorbed before 
its activity is reduced or destroyed by the fluids in the 
digestive tract. 

MacKenzie recommends the hypodermic method for 
emergency use, but he believes frequent repetition is 
necessary if any sustained action is desired as the action 
is largely local, as the product is rapidly destroyed after 
entering the blood stream. The researches of W. Straub^ 
confirm the assumption that adrenahn has no cumulative 
action, and says that it is probable that this substance 
is destroyed with great rapidity, as it vanishes from the 
blood completely, just as rapidly as its action subsides. 
Its action is further exclusively local, that is, it acts on 
the vessels only by direct contact. This we think proves 
that the continuous infusion of a weak solution of adrenalin 
is the only rational method of employing the drug, when 
continued effect is desired. Straub found it possible to 

» MUnch. med. Wochen., Vol. LVII, No. 26. 



BLOOD-PRESSURE ELEVATORS 267 

send the solution continuously into a vein and thus keep 
blood-pressure up permanently, as long as it was continued, 
the effect being dependent on the concentration of the solu- 
tion, and not on the absolute amount of adrenalin infused. 

In the low blood-pressure of shock, Pearce and Eisenberg^ 
recommend the slow intravenous administration of adren- 
alin salt solution (1-40,000) combined with a pure cardiac 
stimulant such as digitoxin. They obtained relatively 
rapid and permanent improvement. In this same con- 
nection A. Randal Short^ found that the addition of 
adrenalin to normal salt solution in strength up to 1-20,000 
would restrain the caliber of the vessels even when the 
vasomotor center was powerless and that apparently 
hopeless cases recovered under this treatment. 

In contrast to this testimony Brooks and Kaplan' have 
reported two cases where adrenalin was used as the thera- 
peutic agent for a prolonged time. They found that 
during continued administration adrenalin gradually lost 
its power, and they therefore do not accept the common 
belief that adrenalin will, over a prolonged period, main- 
tain a constant elevation of pressure. 

Pituitary Extract. — A. Randle Short believes that pitu- 
itary extract is of more value than adrenalin. When 
given hypodermatically in doses of 1/5 gr. t.i.d. it is 
extremely efficient in counteracting at once depressed 
arterial tension, it appears also to promote diuresis. 

J. Campbell McClure^ finds the effect of the drug much 
more prolonged than that of adrenahn. It can therefore 

1 Arch. Int. Med., Aug., 1910. 
^ Loc. cit. 

^ Arch. Int. Med., Oct. 15, 1909. 
^Practitioner, Dec, 1911, p. 829. 



268 BLOOD-PRESSURE 

be employed hypodermically and can be employed advan- 
tageously over a long period of time. 

Digitalis. — This is another drug still under dispute. 
On account of local irritation, it is usually employed by 
the mouth in doses of from five to ten minims of tincture. 
The usual preparations of this drug are extremely variable 
and are not to be depended upon unless coming from a 
reliable source. I have seen less effect follow the admin- 
istration of twenty-minim doses of a poor preparation 
than was obtained from five minims of a good active one. 

Digitalis is slow and cumulative in action. According 
to Boos and Lawrence^ its full action on blood-pressure 
cannot be expected in less than twenty-four to thirty-six 
hours. It cannot therefore be considered as valuable 
in emergency, when employed for its effect on blood- 
pressure. It is also well known that many cardiovascular 
cases stand digitahs poorly, particularly those having 
marked myocardial weakness. Caution is therefore always 
necessary during its administration. Fatal syncope has 
followed the overuse of digitalis (Brunton). Brunton 
also warns against its use in advanced Bright 's disease, 
and in threatened apoplexy. He believes that the danger 
may be reduced by proper combination with vasodilators. 
The same author^ tabulates the physiologic and toxic 
effects of digitalis on the circulation as follows: 

A. Physiologic: 

1. Increase in heart power. 

2. Nervous irritability. 

B. Toxic: 

» Interstate Med. Jour., Vol. XVII, No. 6. 
' Therapeutics of the Circulation, 1908. 



BLOOD-PRESSURE ELEVA.TORS 269 

1. Heart muscle fails. 

2. Vessel musculature fails, causing, 

3. Increased blood-pressure, pulse slowed. 

4. Blood-pressure stays up, pulse irregular and rapid. 

5. Heart feeble, beat more regular. 

6. Vessels dilate, blood-pressure falls. 

J. M. Mackenzie,^ on the contrary, found that only 
in exceptional cases does digitalis raise blood-pressure, 
even when carried to the physiologic limit. The only 
cases in which he found an increase in blood-pressure 
were cases of extreme dilatation of the heart with edema. 
Here a slight rise in pressure accompanied the improvement. 

Caffein. — The immediate effect of caffein on the circula- 
tion is to elevate blood-pressure and to increase the heart 
rate. These effects were demonstrated by J. D. Prichard, 
in a series of pharmacologic experiments.^ Large doses 
decrease cardiac tone and lower blood-pressure; while 
toxic doses may cause death by acute cardiac dilatation. 
Caffein must therefore be employed clinically in moderate 
doses only, when it has a more prompt, but less lasting 
action than digitalis. Coffee by the mouth or rectum has 
the same action as caffein, because of the presence of this 
drug in it. Tea also has the same action but to a less 
extent for the same reason. 

Theobromin according to Mackenzie has an action 
similar to caffein, in that it raises blood-pressure and at the 
same time accelerates pulse rate. 

Strychnin, in the light of recent pharmacologic studies 
and clinical investigations with the sphygmomanometer, 

1 Dis. of Heart, 1910. 

2 Cleveland Med. Jour., Jan., 1912. 



270 BLOOD-PRESSURE 

has no appreciable effect on blood-pressure, as it has very 
httle effect on the tone of the vessel, but acts chiefly on 
the heart (Mackenzie). 

Oxygen by inhalation is of particular value in the fall in 
pressure, occurring under prolonged anesthesia. Its admin- 
istration is most valuable in emergency; where it has been 
shown to rise pressure from a dangerous 75 mm. to 150 
mm. after ten minutes inhalation. In the nitrous oxid- 
oxygen anesthesia, the cessation of N2O and the giving of 
50 per cent, is followed by an immediate rise in pressure 
and a return to consciousness. 

Nicotin. — While this drug is not employed clinically 
for its effect on a falling blood-pressure, nevertheless 
experiment has shown that next to adrenalin this is the 
most powerful blood-pressure elevator known (Mackenzie). 
In animals the effect of nicotin is shown by a slowing of 
the heart and a profound elevation of blood-pressure. The 
blood-pressure raising effect can be seen in the unaccus- 
tomed smoker. (See Page 68.) The relation of nicotin 
to the production of arteriosclerosis has been demonstrated 
by Careman, Aub and Briger^ who have shown that 
nicotin in small doses (0.0035 gm. to 0.0075 gm. in cats) 
caused an increase in adrenalin secretion and a rise in 
blood-pressure. 

* Jour, of Pharm. and Exp. Therap., March, 1912. 



INDEX 



Abdominal paracentesis, influence 

of, 202 
Aconite, 237 

administration of, 237 
Addison's disease, 186 

hypotension in, 109 
Adrenalin, 265 

in acute infections, 175 
in cerebrospinal meningitis, 178 
in cholera, 108 
myocarditis, 153 
salt solution, 267 
Age, influence of, 58, 59 

on diastolic pressure, 59 
old, blood-pressure in, 61 
Agurin, 236 
Alcohol, influence on blood-pressure, 

67 
Altitude, hypotension in, 104 
influence of, 66, 83 

in blood-pressure in tubercu- 
losis, 85 
Amyl nitrite, 231 

effect of, on circulation, 231 
method of administration, 231 
Anesthesia, chloroform, influence 
of, 205 
cocain, influence of, 207 
ether, influence of, 204 
ethyl chlorid, influence of, 207, 241 
nitrous oxid and oxygen, influence 
of, 206 
influence of, 205 
oxid-ether sequence, influence 
of, 205 
Anesthetics, 241 

influence of, 198, 204 
Aneurysm, thoracic, 194 

dilatation of arch of aorta and, 
differentiation, 195 



Aneurysmal bulging, 122 
Antimeningococcic serum in cere- 
brospinal meningitis, 177 
Aorta, arch of, dilatation, thoracic 
aneurysm and differentiation, 195 
Aortic regurgitation, hypotension 

in, 100 
Apoplexy, pseudo-, in myocarditis, 

162 
Arsenic, 239 
Arterial pressure, 73 

elasticity of vessel wall in, 76 
heart energy in, 73 
peripheral resistg,nce in, 74 
viscosity of blood in, 79 
volume of blood in, 78 
spasm, arteriosclerosis and, differ- 
entiation, 131 
system, 74 

walls, condition of, influence, on 
blood-pressure, 18 
Arteries, radial, in arteriosclerosis, 
131 
width of, influence, on blood- 
pressure, 18 
Arteriosclerosis, 118 

arterial spasm and, differentia- 
tion, 131 
artificial production, 123 
baths in, 137 
blood-pressure in, 132 
caffein in, 139 
cardioarterial type, 125 
causes, 118 
climate in, 137 
clinical manifestations, 123 
diagnosis, 130 
diet in, 135, 136, 137 
digestive tract in, 133 
digitalis in, 138 



271 



272 



INDEX 



Arteriosclerosis, drugs in, 137 

electrotherapy in, 261 

etiology, 118 

heart in, 133 

hypertension in, 132 

kidney relation to, 141 

massage in, 138 

nitrites in, 138 

nux vomica in, 139 

occurrence, 119 

pathology, 121 

potassium iodid in, 139 

radial arteries in, 131 

stages, 125 

strontium iodid in, 139 

etrophanthus in, 139 

Bweet spirits of niter in, 139 

symptomatology, 125 

temperature in, 133 

thyroid extract in, 138 

treatment, 134 

water in, 136 
Arthritis, rheumatoid, hypotension 

in, 111 
Artificial production of arterio- 
sclerosis, 123 
Aspiration, pleural, influence of, 202 
Asthma, cardiac, 103, 188 
Atheroma, 121 

typical, 123 
Athletic hfe, influence of, 88 
Atmospheric pressure, influence of, 

66, 83 
Auricular fibrillation, 187 
Auscultatory method of sphygmo- 

manometry, 47 j 
Aviation sickness, 187 

E(ath8, cold, 263 

electric-light, 254, 255 

hot, 254 

in arteriosclerosis, 137 

influence of, 66 

oxygen, 259 

perogen, 260 
Biliary colic, 193 



Bishop's sphygmomanometer, 34 

disadvantages, 35 
Blood, viscosity of, in arterial pres- 
sure, 79 
volume of, in arterial pressure, 78 
Blood-pressure after hemorrhage, 
103 
arterial, 73. See also Arterial 

pressure. 
capillary, 69 
chart, 37 
. — daily variations in, 61 
^diastohc, 81 

— influence of age and sex on, 59 
- diet in, 246 

— . drugs for raising, 265 
electrotherapy, 260 
extreme low, 99 

- factors influencing, 56 

high, 112. See also Hypertension. 

hydrotherapy in, 253 

in acute infections, 169 

in Addison's disease, 186 

in arteriosclerosis, 132 

in auricular fibrillation, 187 

in aviation sickness, 187 

in biliary colic, 193 

in cardiac asthma, 188 

in cerebral hemorrhage, 103, 188 

in cerebrospinal meningitis, 177 

in Cheyne-Stokes respiration, 189 

in cholera, 177 

in chronic infections, 179 

myocarditis, 224 

nephritis, 145 
in corneal ulcers, 210 
in different arteries, 80 
in diphtheria, 172 
in diseases of kidneys, 140 
in eclampsia, 216 
in epistaxis, 192 
in general paresis, 190 
in glaucoma, 209 
in hemorrhage, 203 

in typhoid fever, 171 
in incipient tuberculosis, 225 



INDEX 



273 



Blood-pressure in lead poisoning, 
190 

in life insurance, 218 
applications, 222 
formula to estimate normal 

pressure, 220 
ordinary variations, 219 
permissible variations, 221 

in locomotor ataxia, 193 

in metabolic diseases, 186 

in Momburg constriction, 191 

in myocardial degeneration, 152 

in nephritis, 222 

in neurasthenia, 191 

in obstetrics, 211 

in old age, 61 

in ophthalmology, 208 

in pain, 200 

in paresis, 190 

in perforation in typhoid fever, 171 

in pneumonia, 170 

in pregnancy, 211, 212 

in prolonged epistaxis, 192 

in pulmonary edema, 188 
tuberculosis, 179 

in relation to mortality, 225 

in renal coHc, 193 

in retinal hemorrhage, 208 

in rupture of membranes, 213, 216 

in scarlet fever, 174 

in shock, 102, 193 

in surgery, 196 

in syphiHs, 183 

in tabes dorsahs, 193 

in thoracic aneurysm, 194 

in toxemia of pregnancy, 213-216 

in tuberculosis, 179 

in typhoid fever, 171 

influence of abdominal paracen- 
tesis, 202 
of age, 58, 59 

- of alcohol, 67 
of altitude, 66, 83 

in tuberculosis, 85 
of anesthetics, 198, 204 
of athletic life, 8 

18 



Blood-pressure, influence of atmos- 
pheric pressure, 66, 83 
— of baths, 66 

of bradycardia, 102 
of cardiac asthma, 103 
of chloroform anesthesia, 205 
of chmate, 83, 85 
of cocain anesthesia, 207 
" of cold baths, 253 

of collapse, 102 
-^ of diet, 66, 246 
•---'"■of digestion, 66 • 

of electric-hght ba,ths, 254, 255 
— of emotion, 65 

of ether anesthesia, 204 

of ethyl chlorid anesthesia, 207, 

241 
of exercise, 65, 88, 245 
"of foods, 246 

of gynecologic operations, 202 
—of hot baths, 254 
of hydrotherapy, 253 
of massage, 246 
of muscular development, 65 
of nicotin, 67 

of nitrous oxid and oxygen 
anesthesia, 206 
anesthesia, 206 
of nitrous oxid-ether sequence, 

205 
of operations on brain, 203 

on spinal cord, 203 
of operative procedures, 201 
of oxygen bath, 259 
of paroxysmal tachycardia, 102 
of passive movements, 66 
of physical measures, 243 
of pleural aspiration, 202 
■"~of posture, 243 
- of race, 83, 86 
-" of rest, 243, 244 

of Scottish douche, 254 

of sex, 58, 59 

of shock, 102 

of size and temperament, 62 

of skin incision, 201 



274 



INDEX 



Blood-pressure, influence of sleep, 63, 
244 
of smoking, 67 
of sweating, 255 
of temperature, 66 
of tobacco, 67, 247 
of vasomoter excitement, 66 
of venesection, 263 
of water, 252 
low. See Hypotension. 
lower normal limits, 99 
mean, 81 
measures for raising, 265 

for reducing, 230 
methods of controlling, 227 
Nauheim treatment, 256 
normal, 57 

periodic variations in, 61 
pulse, 82 

reducing measures for, 230 
physical measures, 243 
— ^ systolic, 81 

venesection in, 263 
venous, 70 

measurement of, 71 
pulmonary, 72 
Bradycardia, influence of, 102 
Brain, operations on influence of, 203 
Bright's disease, 140. See also 

Nephritis. 
Brunton's hypertension, 125 

method of estimating venous pres- 
sure, 71 

Cachectic states, hypotension in, 

109 
Caffein, 269 

citrate in chronic myocarditis, 166 

in arteriosclerosis, 139 
Calcium content in diet, restriction 

of, 241 
Calomel, 241 

in chronic nephritis, 150 
Capillary blood-pressure, 69 
Cardiac asthma, 188 
influence of, 103 



Cerebral hemorrhage, 103, 188 
differential diagnosis, 189 
Cerebrospinal meningitis, 109, 177 
adrenalin in, 178 
antimeningococcic serum in, 
177 
Chamberlain's table, 86 
Chart for pulse, temperature and 

blood-pressure, 37 
Cheyne-Stokes respiration, 189 

in myocarditis, 162 
Chloral, 242 

in tu"emia, 151 
Chloroform, 241 

anesthesia, influence of, 205 
in chronic myocarditis, 166 
Cholera, 177 

adrenalin in, 108 
hypotension in, 108 
Circulation, 14 

and heart, relation, 14 
effect of amyl nitrite on, 231 

of vasodilators on, 231 
normal, 15 
CUmate in arteriosclerosis, 137 

influence of, 83, 85 
Cocain anesthesia, influence of, 207 
Cold baths, 253 
CoUc, biliary, 193 

renal, 193 
Collapse, influence of, 102 
Coma, epileptic, hypotension in, 109 
Constriction, Momburg, 191 
Cook's modification of Riva-Rocci 
sphygmomanometer, 27 
disadvantages, 27 
Corneal ulcers, 210 

Daily variations in blood-pressure, 

61 
Definitions, 69 

Degeneration, fatty, of heart, 153 
etiology, 154 
pathology, 157 
fibroid, of heart, pathology, 158 
myocardial, 152 



INDEX 



275 



Degeneration, myocardial, caffein 
citrate in, 166 
chloroform in, 166 
definition of, 152 
diagnosis of, 162 
digitalis in, 166 
etiology of, 153 
exercise in, 167 
glycosuria and, relation, 154 
gout and, relation, 154 
Graupner's test in, 164 
heart failure in, 159 
morphin in, 166 
nitrites in, 166 
nux vomica in, 166 
occurrence of, 152 
pathology of, 157 
Shapiro's test in, 164 
epartein sulphate in, 166 
strychnin in, 166 
symptoms of, 160 
theobromin in, 166 
treatment of, 165 
valvular disease accompanying, 
158 
parenchymatous, of heart, path- 
ology, 157 
Diabetes, hypotension in, 109 
Diastohc indicator, 53 
pressure, 81 

influence of age and sex, 59 
method of obtaining, 50 

auscultatory method, 51 
diastolic indicator, 53 
palpatory method, 51 
visible method, 50 
Diet, 246 

calcium content in, restriction of, 

241 
in arteriosclerosis, 135, 136, 137 
in hypertension, 115 
in renal insufficiency, 151 
influence of, 66 
milk, 246 
Digestion, influence of, 66 
Digestive tract in arteriosclerosis, 133 



Digitahs, 268 

in arteriosclerosis, 138 

in chronic myocarditis, 166 
nephritis, 150 
Dilatation of heart, blood-pressure 
in, 110 
etiology, 156 
Diphtheria, 172 

hypotension in, 109 
Diuretics in chronic nephritis, 150 
Diuretin, 235 
Douche, Scottish, 254 
Drugs for raising blood-pressure, 265 

for reducing blood-pressure, 230 

in arteriosclerosis, 137 

Eclampsia, 216 

Edema, pulmonary, 188 

Elasticity of vessel wall in arterial 

pressure, 76 
Electric-hght baths, 254, 255 
Electrotherapy, 260 

in arteriosclerosis, 261 
Emotion, influence of, 65 
Epileptic coma, hypotension in, 109 
Epinephrin in acute infections, 175, 

176 
Epistaxis, morphin in, 193 

prolonged, associated with in- 
creased vascular tension, 192 
Erlanger's sphygmomanometer, 35 

disadvantages, 36 
Essential arterial hypertension, 112 

hypotension, 97 
Ether anesthesia, influence of, 204 
Ethyl chlorid anesthesia, influence 

of, 207, 241 
Excitement, vasomotor, influence of, 

65 67 

Exercise in chronic myocarditis, 1 

in tuberculosis, 181 

influence of, 65, 88, 245 

Factors influencing blood-pressure, 

56 
Fat heart, 157 



276 



INDEX 



Fatty degeneration of heart, 153 
etiology, 154 
pathology, 157 
Faught's pocket sphygmomanom- 
eter, 32 
rule, 62 

sphygmomanometer, 30 
disadvantages, 31 
Fedde indicator, 54 
Fibrillation, auricular, 187 
Fibroid degeneration of heart, path- 
ology, 158 
myocarditis, 152 
Foods, influence of, 246 

Glaucoma, 209 

Glycosuria, myocardial degenera- 
tion and, relation, 154 

Gout, myocardial degeneration and, 
relation, 154 

Graupner's test in myocardial degen- 
eration, 164 

Gumprecht's unaccustomed rest, 65 

Gynecologic operations, influence 
of, 202 

Heart and circulation, relation, 14 
dilatation of, blood-pressure in, 
110 
etiology, 156 
diseases of, hypotension in, 100 
energy in arterial pressure, 73 
failure in myocardial degenera- 
tion, 159 
fat, 157 

fatty degeneration, 153 
etiology, 154 
pathology, 157 
fibroid degeneration, pathology, 

158 
in arteriosclerosis, 133 
muscle, tonus of, 155 
parenchymatous degeneration, 

pathology, 157 
rate, alterations in, 101 
Hemorrhage, 203 



Hemorrhage, cerebral, 103, 188 
differential diagnosis, 189 

hypotension after, 103 

in typhoid fever, 171 

retinal, 208 
Hot baths, 254 
Hydrotherapy, 253 
Hygiene in renal insufficiency, 151 
Hypertension, 112 

diet in, 115 

essential arterial, 112 

in arteriosclerosis, 132 

in chronic nephritis, 145 

of Brunton, 125 

syphilis as cause, 117 

treatment of, 115 
Hypophysis extracts, 242 
Hypotension, 96 

after hemorrhage, 103 

alterations in heart rate, 101 

causes of, 98 

conditions accompanied by, 99 

dangers of, 111 

definition of, 96 

effects of, 111 

essential, 97 

extreme low pressure, 99 

in Addison's disease, 109 

in altitude, 104 

in aortic regurgitation, 100 

in bradycardia, 102 

in cachectic states, 109 

in cardiac asthma, 103 

in cerebrospinal meningitis, 109 

in cholera, 108 

in collapse, 102 

in diabetes, 109 

in diphtheria, 109 

in diseases of heart, 100 

in epileptic coma, 109 

in infections, 104 

in lumbago, 110 

in measles, 109 

in mitral stenosis, 100 

in neurasthenia, 110 

in neuritis, 110 



INDEX 



277 



Hypotension in paresis, 104 
in paroxysmal tachycardia, 102 
in phosphaturia, 110 
in pneumonia, 107 
in rheumatism, 109 
in rheumatoid arthritis, 111 
in scarlet fever, 109 
in sciatica, 110 
in shock, 102 
in tuberculosis, 104, 179 
in typhoid fever, 106 
in wasting diseases, 109 
lower normal limits, 99 
primary, 97 
relative, 97 
terminal, 96 
true, 97 

Incision, skin, influence of, 201 
Infectious diseases, acute, 169 
adrenalin in, 175 
epinephrin in, 175, 176 
pituitary extract in, 177 
sahne solution in, 175 
treatment of, 174 
chronic, 179 
hypotension in, 104 
Insurance, hfe, 218 
appUcations, 222 
chronic myocarditis, 224 
formula to estimate normal 

pressure, 220 
incipient tuberculosis, 225 
nephritis, 222 
overweights, 223 
permissible variations, 221 
ordinary variations, 219 
Introduction, 11 
lodids in syphihs, 185 
lodin, 237 
Irritation, renal, 143 

Jane way's sphygmomanometer, 29 
disadvantages, 30 

Kidneys, diseases of, 140 
clinical classification, 141 



Kidneys, diseases of, treatment, 149 
insufficiency of, 143 
irritation of, 143 

Lead poisoning, 190 
Life insurance, 218 

apphcations, 222 

chronic myocarditis, 224 

formula to estimate normal prea- 
sure, 220 

incipient tuberculosis, 225 

nephritis, 222 

ordinary variations, 219 

overweights, 223 

permissible variations, 221 
Locomotor ataxia, 193 
Lumbago, hypotension in, 110 

Manometer, 23 

Massage in arteriosclerosis, 138 

influence of, 66, 246 
Mean blood-pressure, 81 
Measles, hypotension in, 109 
Measurement of venous pressure, 

71 
Membranes, rupture of, 213, 216 
Meningitis, cerebrospinal, 109, 177 
adrenaUn in, 178 
antimeningococcic serum in, 177 
Mercury sphygmomanometer, 

Faught's, 30 
Metabolic diseases, 186 
Milk diet, 246 

Mitral stenosis, hypotension in, 100 
Momburg constriction, 191 
Morphin, 242 

in chronic myocarditis, 166 

in epistaxis, 193 

in uremia, 151 
Mortahty, blood-pressiu-e in rela- 
tion to, 223 
Muscular development, influence of, 

65 
Myocardial degeneration, 152 
caffein citrate in, 166 
chloroform in, 166 



278 



INDEX 



Myocardial degeneration, definition 
of, 152 

diagnosis, 162 

digitalis in, 166 

etiology, 153 

exercise in, 167 

glycosuria and, relation, 154 

gout and, relation, 154 

Graupner's test in, 164 

heart failure in, 159 

morphin in, 166 

nitrites in, 166 

nux vomica in, 166 

occurrence of, 152 

pathology, 157 

Shapiro's test in, 164 

strychnin in, 166 

epartein sulphate in, 166 

symptoms, 160 

theobromin in, 166 

treatment, 165 

valvular disease accompanying, 
158 
Myocarditis, adrenaUn, 153 
chronic, 153, 224 

cafiFein citrate in, 166 

Cheyne-Stokes respiration in, 162 

chloroform in, 166 

diagnosis of, 162 

dietetic treatment, 252 

digitaUs in, 166 

etiology of, 153 

exercise in, 167 

Graupner's test in, 164 

morphin in, 166 

nitrites in, 166 

nux vomica in, 166 

pseudo-apoplexy in, 162 

Shapiro's test in, 164 

spartein sulphate in, 166 

Btrychnin in, 166 

eymptoms of, 160 

treatment of, 165 

valvular disease accompanying, 
158 
fibroid, 152 



Nauheim treatment, 256 

apphcation of, 257 
Nephritis, 140, 144, 145, 222 
chronic, calomel in, 160 
digitahs in, 150 
diuretics in, 150 
hypertension in, 145 
prognosis of, 149 
saline infusion in, 150 
STgns of, 145 
symptoms of, 145 
treatment of, 149 
venesection in, 150 
etiology, 140 
pathology, 142 
Neurasthenia, 110, 191 
Neuritis, hypotension in, 110 
Nicotin, 270 

influence of, 67 
Niter, sweet spirits of, in arterio- 
sclerosis, 139 
Nitrites in arteriosclerosis, 138 
in chronic myocarditis, 166 
Nitrous oxid and oxygen anesthesia, 
influence of, 206 
anesthesia, influence of, 205 
oxid-ether sequence, influence of, 
205 
Nose-bleed, prolonged, 192 
Nux vomica in arteriosclerosis, 139 
in chronic myocarditis, 166 

Obstetrics, 211 

Old age, blood-pressure in, 61 

Operations, 196 

gynecologic, influence of, 202 

on brain, influence of, 203 

on spinal cord, influence of, 203 

Operative procedures, influence of, 
201 

Ophthalmology, 208 

Overweights, 223 

Oxygen, 270 
bath, 259 

Pain, 200 



INDEX 



279 



Palpatory method of Bphygmoma- 

nometry, 47 
Paracentesis, abdominal, influence 

of, 202 
Parenchymatous degeneration of 

heart, pathology, 157 
Paresis, general, 190 

hypotension in, 104 
Paroxysmal tachycardia, influence 

of, 102 
Passive movements, influence of, 66 
Perforation in typhoid fever, 171 
Periodic variations in blood-pressure, 

61 
Peripheral resistance in arterial 

pressure, 74 
Perogen baths, 260 
Phosphaturia, hypotension in, 110 
Physical fitness, determination of, 

91 
Physiology, 14 
Pituitary extract, 267 

in acute infections, 177 
Pleural aspiration, influence, 202 
Pneumonia, 170 

hypotension in, 107 
Pocket sphygmomanometer, 

Faught's, 32 
Poisoning, lead, 190 

tobacco, blood-pressure in, 110 
Posture, influence of, 63, 243 
Potassium bicarbonate, 242 

iodid, 239 
in arteriosclerosis, 139 
Pregnancy, 211, 212 

toxemia of, 213-216 
Presclerosis, 112, 125 
Primary hypotension, 97 
Pseudo-apoplexy in myocarditis, 162 
Pulmonary edema, 188 

tuberculosis, 179 

venous pressure, 72 
Pulse, 80 

ampHtude, 82 

chart for, 37 

pressure, 82 



Pulse, radial, 17 
range, 82 

Race, influence of, 83, 86 

Radial arteries in arteriosclerosis, 131 

pulse, 17 
Regurgitation, aortic, hypotension 

in, 100 
Relative hypotension, 97 
Renal colic, 193 
insufficiency, 143 
diet in, 151 
hygiene in, 151 
irritation, 143 
Respiration, Cheyne-Stokes, 189 

in myocarditis, 162 
Rest, influence of, 243, 244 
Retinal hemorrhage, 208 
Rheumatism, hypotension in, 109 
Rheumatoid arthritis, hypotension 

in. 111 
Riva-Rocci sphygmomanometer, 24, 
25 
Cook's modification, 27 

disadvantages, 27 
disadvantages, 26 
Rogers' sphygmomanometer, 33 
Rule, Faught's, 62 
Rupture of membranes, 213, 216 

Salicylates, 241 

Salt solution, adrenahn, 267 

in acute infectious diseases, 175 
in chronic nephritis, 150 

Salvarsan in syphihs, 185 

Scarlet fever, 174 

hypotension in, 109 

Sciatica, hypotension in, 110 

Scottish douche, 254 

Serum, antimeningococcic, in cere- 
brospinal meningitis, 177 
Tounecek's, 239 

Sex, influence of, 58, 59 

on diastolic pressure, 59 

Shapiro's test in chronic myocarditis, 
164 



280 



INDEX 



Shock, 102, 193 

Size, influence of, 62 

Skin incision, influence of, 201 

Sleep, influence of, 63, 244 

Smoking, influence of, 67 

Sodium iodid, 239 

salicylate, 241 
Spartein sulphate in chronic myo- 
carditis, 166 
Spasm, arterial, arteriosclerosis and, 

differentiation, 131 
Sphygmomanometer, 11-13, 23 
Bishop's, 34 

disadvantages of, 35 
cautions in using, 54 
circular compression, influence of 
intervening structures, 42 
of vessel wall on, 41 
principle of, 39 
directions for operating, 46 
Erlanger's, 35 

disadvantages, 36^ 
Faught's, 30 
disadvantages of, 31, 
mercury, 30 
pocket, 32 
Janeway's, 29 

disadvantages of, 30 
method of application, 45-55 
of obtaining systolic reading, 47 
of use, 56 
Riva-Rocci, 24, 25 

Cook's modification, 27 

disadvantages, 27 
disadvantages of, 26 
Rogers', 33 
Stanton's, 28 

disadvantages of, 29 
Sphygmomanometry, 11 
auscultatory method, 47 
cautions, 54 

influence of intervening structures, 
42 
of vessel wall on, 41 
method of obtaining systolic read- 
ing, 47 



Sphygmomanometry, palpatory 
method, 47 

principle of, 39 
Sphygmometroscope, multiple, 52 
Spinal cord, operations on, influence 

of, 203 
Stanton's sphygmomanometer, 28 

disadvantages, 29 
Stenosis, mitral, hypotension in, 100 
Stethoscope as aid in auscultatory 

method of obtaining diastolic 

pressure, 52 
Strontium iodid in arteriosclerosis, 

139 
Strophanthus in arteriosclerosis, 139 
Strychnin, 269 

in chronic myocarditis, 166 
Surgery, 196 
Sweating, 255 
Syphilis, 183 

as cause of hypertension, 117 

iodids in, 185 

salvarsan in, 185 
Systolic blood-pressure, 81 

reading, method of obtaining, 47 

Tabes dorsalis, 193 

Tachycardia, paroxysmal, influence 

of, 102 
Temperature, chart for, 37 
in arteriosclerosis, 133 
influence of, 66 
Temperament, influence of, 62 
Terminal hypotension, 96 
Terms, 69 

Test, Graupner's, in chronic myo- 
carditis, 164 
Shapiro's, in chronic myocarditis, 
164 
Theobromin, 269 

in chronic myocarditis, 166 
Thoracic aneurysm, 194 

dilatation of arch of aorta and, 
differentiation, 195 
Thyroid extract, 240 

in arteriosclerosis, 138 



INDEX 



281 



Tobacco, influence of, 67, 247 

poisoning, blood-pressure in, 110 
Tonus, 21, 74 

of heaxt muscle, 155 
Toxemia of pregnancy, 213-216 
True hypotension, 97 
Trunecek's serum, 239 
Tuberculosis, 179 
exercise in, 181 
hypotension in, 104, 179 
incipient, 225 

influence of altitude on blood- 
pressure in, 85 
prognosis, 180 
Typhoid fever, 171 

hemorrhage in, 171 
hypotension in, 106 
perforation, in, 171 
treatment, 175 

Ulcees, corneal, 210 
Uremia, chloral in, 151 

morphin in, 151 

treatment of, 151 

venesection in, 151 

Valvular disease accompanying 

chronic myocarditis, 158 
Variations, daily, in blood-pressure,61 



Variations, periodic, in blood-pres- 
sure, 61 
Vasodilators, 230 

effect of, on circulation, 231 
method of administration, 231 
Vasomotor excitement, influence of, 

65 
Vasotonin, 234 
Venesection, 263 

in chronic nephritis, 150 
in uremia, 151 
Venous blood-pressure, 70 
measurement, 71 
pulmonary, 72 
Veratrum viride, 236 

administration of, 237 
Vessel wall, elasticity, in arterial 
pressure, 76 
influence, on sphygmomanom- 
etry, 41 
Viscosity of blood in arterial pres- 
sure, 79 
Volume of blood in arterial pressure, 
78 

Wasting diseases, hypotension in, 

109 
Water in arteriosclerosis, 136 

influence of, 252 



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De Lee's 
Obstetrics 



Principles and Practice of Obstetrics. By Joseph B. De Lee, 
M. D., Professor of Obstetrics in the Northwestern University Medical 
School, Chicago. Large octavo of 1060 pages, with 913 illustrations, 
150 in colors. Cloth, ^8.00 net ; Half Morocco, ^^9.50 net. 

JUST READY 

The Most Superb Book on Obstetrics Ever Published 

You will pronounce this new book by Dr. DeLee the most elaborate, the 
most superbly illustrated work on Obstetrics you have ever seen. Especially will 
you value the gij illustrations, practically all original, and the best work of lead- 
ing medical artists. Some 150 of these illustrations are in colors. Such a mag- 
nificent collection of obstetric pictures — and with really practical value — ^has never 
before appeared in one book. 

You will find the text extremely practical throughout, Dr. De Lee's aim being to 
produce a book that would meet the needs of the general practitioner in every par- 
ticular. For this reason diagnosis is featured, and the relations of obstetric con- 
ditions and accidents to general medicine, surgery, and the specialties brought into 
prominence. 

Regarding treatment : You get here the very latest advances in this field, and you 
can rest assured every method of treatment, every step in operative technic, is just 
right. Dr. De Lee's twenty-one years' experience as a teacher and obstetrician 
guarantees this. 

Worthy of your particular attention are the descriptive legends under the illus- 
trations. These are unusually full, and by studying the pictures serially with their 
detailed legends, you are better able to follow the operations than by referring to 
the pictures from a distant text — the usual method. 

Dr. M. A. Hann&, University Medical College, Kansas City 

" I am Irank in stating that I prize it more highly than any other volume in my obstetric 
library, which consists of practically aU the recent books on that subject." 

Dr. Clark E. Day, Indianapolis, Ind 

" Dr. DeLee's work is by far the greatest on Obstetrics published to-day for the general 
practitioner. It will nieet what is expected of it in a more concise and comprehensive way 
than any other book he could buy.'' 

Dr. George L. Brodhead, New York Post-Graduate Medical School 

" The name of the author is in itself a sufficient guarantee of the merit of the book, and I 
congratulate him, as well as you, on the superb work just published." 



G YNECOLOG V AND OBSTETRICS. 



Norris' 
Gonorrhea in Women 

Gonorrhea in Women. By Charles C. Norris, M. D., Instructor 
in Gynecology, University of Pennsylvania. With an Introduction by 
John G. Clark, M. D., Professor of Gynecology, University of Penn- 
sylvania. Large octavo of 520 pages, illustrated. Cloth, ^6.00 net. 

JUST ISSUED 

Dr. Norris here presents a work that is destined to take high place among 
publications on this subject. He has done his work thoroughly. He has searched 
the important literature very carefully, over 2300 references being utilized. This, 
coupled with Dr. Norris' large experience, gives his book the stamp of authority. 
The chapter on serum and vaccine therapy and organotherapy is particularly 
valuable because it expresses the newest advances. Every phase of the subject 
is considered: History, bacteriology, pathology, sociology, prophylaxis, treatment 
(operative and medicinal), gonorrhea during pregnancy, parturition and puer- 
perium, diffuse gonorrheal pertitonitis, and all other phases. Furthur, Dr. Norris 
also considers the rare varieties of gonorrhea occurring in men, women, and 
children. The text is illustrated. 

American Text-Book ^ Gynecology 

Second Revised Edition 
American Text=Book of Gynecology. Edited by J. M. Baldy, 
M. D. Imperial octavo of 718 pages, with 341 text-illustrations and 
38 plates. Cloth, ^6.00 net. 

American Text-Book qf Obstetrics 

Second Revised Edition 
The American Text=Book of Obstetrics. In two volumes. Edited 
by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
Two octavos of about 600 pages each ; nearly 900 illustrations, includ- 
ing 49 colored and half-tone plates. Per volume : Cloth, ;^3.50 net. 

" As an authority, as a book of reference, as a ' working book ' for the student or practi- 
tioner, we commend it because we believe there is no better." — American Journal of the 
Medical Sciences. 



SAUNDERS' BOOKS ON 



Ashton*s 
Practice of Gynecology 



The Practice of Gynecology. By W. Easterly Ashton, M. D., 
LL.D., Professor of Gynecology in the Medico-Chirurgical College, 
Philadelphia. Handsome octavo volume of i lOO pages, containing 1058 
original line drawings. Cloth, $6.^0 net ; Half Morocco, ;$8.00 net. 

NEW (5th) EDITION 

The continued success of Dr. Ashton' s work is not surprising to any one 
knowing the book. The author takes up each procedure necessary to gynecologic 
step by step, the student bein?? led from one step to another, just as in studying 
any non-medical subject, the minutest detail being explained in language that 
cannot fail to be understood even at first reading. Nothing is left to be taken for 
granted, the author not only telling his readers in every instance what should be 
done, but also precisely how to do it, A distinctly original feature of the book is 
the illustrations, numbering 1058 line drawings made especially under the author's 
personal supervision from actual apparatus, living models, and dissections on the 
cadaver. 

From its first appearance Dr. Ashton' s book set a standard in practical 
medical books ; that he has produced a work of unusual value to the medical 
practitioner is shown by the demand for new editions. Indeed, the book is a 
rich store-house of practical information, presented in such a way that the work 
cannot fail to be of daily service to the practitioner. 

Howard A. Kelly, M. D. 

Professor of Gynecologic Surgery, Johns Hopkins University. 

" It is different from anything that has as yet appeared. The illustrations are particularly 
clear and satisfactory. One specially good feature is the pains with which you describt sc 
many details so often left to the imagination." 

Charles B. Penrose. M. D. 

Formerly Professor of Gynecology in the University of Pennsylvania 
" 1 know of no book that goes so tlioroughly and satisfactorily into all the details of every 
thing connected with the subject. In this respect your book differs from the others." 

George M. Edebohls, M. D. 

Professor of Diseases of Women, New York Post-Graduate Medical School 
"A text-book most admirably adapted to teach gynecology to those who must get theli 
knowledge, even to the minutest and most elementary details, from books." 



GY2\ECOLOGY AND OBSTETRICS 



Bandler's 
Medical Gynecology 



Medical Gynecology. By S. Wyllis Bandler, M. D., Adjunct 
Professor of Diseases of Women, New York Post-Graduate Medical 
School and Hospital. Octavo of 702 pages, with 150 original illus- 
trations. Cloth, $5.00 net; Half Morocco, ^6.50 net. 

THE NEW t2d) EDITION— EXCLUSIVELY MEDICAL GYNECOLOGY 

This new work by Dr. Bandler is just the book that the physician engaged in 
general practice has long needed. It is truly the practitioner s gynecology — planned 
for him, written for him, and illustrated for him. There are many gynecologic 
conditions that do not call for operative treatment ; yet, because of lack of that 
special knowledge required for their diagnosis and treatment, the general practi- 
tioner has been unable to treat them intelligently. This work not only deals 
with those conditions amenable to non-operative treatment, but it also tells how to 
recognize those diseases demanding operative treatment. 

American Journal of Obstetrics 

" He has shown good judgment in the selection of his data. He has placed most emphasis 
on diagnostic and therapeutic aspects. He has presented his facts in a manner to be readily 
grasped by the general practitioner." 



Bandler's Vaginal Celiotomy 

Vaginal Celiotomy. By S. Wyllis Bandler, M. D., New York 
Post-Graduate Medical School and Hospital. Octavo or450 pages, with 
148 original illustrations. Cloth, $5.00 net; Half Morocco, $6.50 net. 

SUPERB ILLUSTRATIONS 

The vaginal route, because of its simplicity, ease of execution, absence of 
shock, more certain results, and the opportunity for conservative measures, con- 
stitutes a field which should appeal to all surgeons, gynecologists, and obstetricians. 
Posterior vaginal celiotomy is of great importance in the removal of small tubal 
and ovarian tumors and cysts, and is an important step in the performance of 
vaginal myomectomy, hysterectomy, and hysteromyomectomy. Anterior vaginal 
celiotomy with thorough separation of the bladder is the only certain method 
of correcting cystocele. 

The Lancet, London 

" Dr. Bandler has done good service in writing this book, which gives a very clear descrlp-. 
tion of all the operations which may be undertaken through the vagina. He makes out a 
strong case for these operations." 



SAUNDERS' BOOKS ON 



Kelly and Noble's 

Gynecology 

and Abdominal Surgery 

Gynecology and Abdominal Surgery. Edited by Howard A. 
Kelly, M. D., Professor of Gynecology in Johns Hopkins University ; 
and Charles P. Noble, M. D., formerly Clinical Professor of Gyne- 
cology in the Woman's Medical College, Philadelphia. Two imperial 
octavo volumes of 950 pages each, containing 880 illustrations, some in 
colors. Per volume: Cloth, $8.00 net; Half Morocco, $g.SO net. 

TRANSLATED INTO SPANISH 
WITH 880 ILLUSTRATIONS BY HERMANN BECKER AND MAX BRODEL 

In view of the intimate association of gynecology with abdominal surgery the 
editors have combined these two important subjects in one work. For this reason 
the work will be doubly valuable, for not only the gynecologist and general prac- 
titioner will find it an exhaustive treatise, but the surgeon also will find here the 
latest technic of the various abdominal operations. It possesses a number oi 
valuable features not to be found in any other publication covering the same fields. 
It contains a chapter upon the bacteriology and one upon the pathology of gyne- 
cology, dealing fully with the scientific basis of gynecology. In no other work 
can this information, prepared by specialists, be found as separate chapters. 
There is a large chapter devoted entirely to medical gynecology written especially 
for the physician engaged in general practice. Heretofore the general practitioner 
was compelled to search through an entire work in order to obtain the information 
desired. Abdominal surgery proper, as distinct from gynecology, is fully treated, 
embracing operations upon the stomach, upon the intestines, upon the liver and 
bile-ducts, upon the pancreas and spleen, upon the kidneys, ureter, bladder, and 
the peritoneum. The illustrations are truly magnificent, being the work of Mr. 
Hermann Becker and Mr. Max Ih'odel. 

American Journnl of the Medical Sciences 

" It is needless to say that the work has betiii thoroughly done : the names of the authors 
and editors would guarantee this; but much may be said in praise of the method of presen- 
tation, and attention may be called to the inclusion of matter not to be found elsewhere." 



G YNECOLOG V AND OBSTE TRIGS 



Webster's 
Text-Book qf Obstetrics 

A Text-Book of Obstetrics. By J. Clarence Webster, M. D. 
(Edin.), F. R. C. p. E., Professor of Obstetrics and Gynecology in Rush 
Medical College, in affiliation with the University of Chicago. Octavo 
volume of j6j pages, illustrated. Cloth, ;^5.oo net; Half Morocco, 
$6.^0 net. 

BEAUTIFULLY ILLUSTRATED 

In this work the anatomic changes accompanying pregnancy, labor, and the 
puerperium are described more fully and lucidly than in any other text-book on 
the subject. The exposition of these sections is based mainly upon studies of 
frozen specimens. Unusual consideration is given to embryologic and physiologic 
data of importance in their relation to obstetrics. 

Buffalo Medical Journal 

" As a practical text-book on obstetrics for both student and practitioner, there is left very 
little to be desired, it being as near perfection as any compact work that has been published." 



Webster's 
Diseases of Women 

A Text=Book of Diseases of Women. By J. Clarence Webster, 
M. D. (Edin.), F. R. C. P. E., Professor of Gynecology and Obstetrics 
in Rush Medical College. Octavo of 712 pages, with 372 text-illustra- 
tions and 10 colored plates. Cloth, $'j.oo net ; Half Morocco, ;$8.50 net. 

Dr. Webster has written this work especially for the general practitioner, dis- 
cussing the dinical features of the subject in their widest relations to general 
practice rather than from the standpoint of speciaHsm. The magnificent illus- 
trations, three hundred and seventy-two in number, are nearly all original. 

How&rd A. Kelly M. D. 

Professor of Gynecologic Surgery, Johns Hopkins University. 

"It is undoubtedly one of the best works which has been put on the- market within recent 
years, showing from start to finish Dr. Webster's well-known thoroughness. The illustrations 
are also of the highest order." 



SAUNDERS' BOOKS ON 



Hirst's 
Text-Book of Obstetrics 

The New (7th) Edition 



A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome 
octavo of 1013 pages, with 895 illustrations, 53 of them in colors. 
Cloth, ^5.00 net ; Half Morocco, $6.50 net. 

INCLUDING RELATED GYNECOLOGIC OPERATIONS 

Immediately on its publication this work took its place as the leading text-book 
on the subject. Both in this country and in England it is recognized as the most 
satisfactorily written and clearly illustrated work on obstetrics in the language. 
The illustrations form one of the features of the book. They are numerous and 
the most of them are original. In this edition the book has been thoroughly revised. 
Recognizing the inseparable relation between obstetrics and certain gynecologic 
conditions, the author has included all the gynecologic operations for complica- 
tions and consequences of childbirth, together with a brief account of the diagnosis 
and treatment of all the pathologic phenomena peculiar to women. 



OPINIONS OF THE MEDICAL PRESS 



British Medical Journal 

" The popularity of American text-books in this country is one of the features of recent 
years. The popularity is probably chiefly due to the great superiority of their illustrations 
over those of the English text-books. The illustrations in Dr. Hirst's volume are for more 
numerous and far better executed, and therefore more instructive, than those commonly 
found in the works of writers on obstetrics in our own country." 

Bulletin of Johns Hopkins Hospital 

"The work is an admirable one in every sense of the word, concisely but comprohensivelv 
written." 

The Medical Record, New York 

"The illustrations are numerous and are works of art, many of them appearing for the first 
time. The author's style, though condensed, is singularly clear, so that it is never necessary 
to re-read a sentence in order to grasp the meaning. As a true model of what a modern text- 
book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a 
rival." 



MTmWiWBi 



DISEASES OF WOMEN. 



HirstV 
Diseases of Women 



A Text=Book of Diseases of Women. By Barton Cooke Hirst, 
M. D., Professor of Obstetrics, University of Pennsylvania ; Gynecolo- 
gist to the Howard, the Orthopedic, and the Philadelphia Hospitals. 
Octavo of 745 pages, with 701 original illustrations, many in colors. 
Cloth, ;^5.oo net; Half Morocco, ;^6.5o net. 

THE NEW (2d) EDITION 
WITH 701 ORIGINAL ILLUSTRATIONS 

The new edition of this work has just been issued after a careful revision. 
As diagnosis and treatment are of the greatest importance in considering diseases 
of women, pardcular attendon has been devoted to these divisions. To this end, 
also, the work has been magnificently ilhiminated with 701 illustrations, for the 
most part original photographs and water-colors of actual clinical cases accumu- 
lated during the past fifteen years. The palliative treatment, as well as the 
radical operative, is fully described, enabling the general practidoner to treat 
many of his own patients v^ithout referring them to a specialist. An entire sec- 
tion is devoted to £. full description of all modern gynecologic operations, illumi- 
nated and elucidated by numerous photographs. The author's extensive ex- 
perience renders this work of unusual value. 



OPINIONS OF THE MEDICAL PRESS 



Medical Record, New York 

" Its merits can be appreciated only by a careful perusal. . . . Nearly one hundred pages 
are devoted to technic, this chapter being in some respects superior to the descriptions in 
many other text- boks. " 

Boston Medical and Surgical Journal 

"The author has given special attention to diagnosis and treatment throughout the book, 
and has produced a practical treatise which should be of the greatest value to the student, the 
general practitioner, and the specialist." 

Medical News, New York 

"Office treatment is given a due amount of consideration, so that the work will be aa 
useful to the non-operator as to the specialist," 



lo SAUNDERS' BOOKS ON 

GET ^ • THE NEW 

THE BEST /\ m C r 1 C 8i n standard 

Illustrated Dictionary 

New (6th) Edition, Entirely Reset 

The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred 
branches ; with over lOO new and elaborate tables and many handsome 
illustrations. By W. A. Newman Borland, M.D., Editor of "The 
American Pocket Medical Dictionary." Large octavo, 986 pages, 
bound in full flexible leather. Price, ^4.50 net ; with thumb index, 
25.00 net. 

IT DEFINES ALL THE NEW WORDS-MANY NEW FEATURES 



Borland's Dictionary defines hundreds of the newest terms not defined in any- 
other dictionary — bar none. These new terms are hve, active words, taken 
right from modern medical literature. , 

It gives the capitahzation and pronunciation of all words. It makes a feature of 
the derivation or etymology of the words. In some dictionaries the etymology 
occupies only a secondary place, in many cases no derivation being given at all. 
In " Borland," practically every word is given its derivation. 
In "Borland" every word has a separate paragraph, thus making it easy to 
find a word quickly. 

The tables of arteries, muscles, nerves, veins etc., are of the greatest help 
in assembling anatomic facts. In them are classified for quick study all the 
necessary information about the various structures. 

In "Borland" every word is given its definition — a definition that defines 
in the fewest possible words. In some dicdonaries hundreds of words are not 
defined at all, referring the reader to some other source for the informadon he 
wants at once. 
Howard A. Kelly. M. D.. Johns Hopkins University^ Baltimore 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 
J. CoUini Warren. M. D.. LL.D.. F.R.C.S. (Hon.). Harvard Medical School 

" I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



GYNECOLOGY AND OBSTETRICS n 



Penrose's 
Diseases of Women 

Sixth Revised Edition 



A Text-Book of Diseases of Women. By Charles B. Penrose, 
M. D., Ph. D., formerly Professor of Gynecology in the University of 
Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc- 
tavo volume of 550 pages, with 225 fine original illustrations. Cloth, 

$3'7S net. 

ILLUSTRATED 

Regularly every year a new edition of this excellent text-book is called for, 
and it appears to be in as great favor with physicians as with students. Indeed, 
this book has taken its place as the ideal work for the general practitioner. The 
author presents the best teaching of modern gynecology, untrammeled by anti- 
quated ideas and methods. In every case the most modern and progressive 
technique is adopted and made clear by excellent illustrations. 

Howard A. Kelly, M.D., 

Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore. 
" I shall value very highly the copy of Penrose's ' Diseases of Women ' received. I have 
already recommended it to my class as THE BEST book." 



Davis' Operative Obstetrics 

Operative Obstetrics. By Edward P. Davis, M.D., Professor of 
Obstetrics at Jefferson Medical College, Philadelphia. Octavo of 483 
pages, with 264 illustrations. Cloth. $5.50 net; Half Morocco, $7.00 net. 
INCLUDING SURGERY OF NEWBORN 

Dr. Davis' new work is a most practical one, and no expense has been spared 
to make it the handsomest work on the subject as well. Every step in every 
operation is described minutely, and the technic shown by beautiful new illustra- 
tions. Dr. Davis* name is sufficient guarantee for something above the mediocre. 



t« SAUNDERS' BOOKS ON 

Dorland's 
Modern Obstetric/* 

Modern Obstetrics: General and Operative. By W. A. Newman 
DoRLAND, A. M., M. D., Professor of Obstetrics at Loyola University, 
Chicago, Illinois. Handsome octavo volume of 797 pages, with 201 
illustrations. Cloth, ^4.00 net. 

Second Bdition, Revised and Greatly Enlarged 

In this edition the book has been entirely rewritten and very greatly enlarged. 
Among the new subjects introduced are the surgical treatment of puerperal sepsis, 
infant mortality, placental transmission of diseases, serum -therapy of puerperal 
sepsis, etc. By new illustrations the text has been elucidated, and the subject pre- 
sented in a most instructive and acceptable form. 

Joumed of the American Medical Association 

" This work deserves commendation, and that it has received what it deserves at the hands 
of the profession is attested by the fact that a second edition is called for within such a short 
time. Especially deserving of praise is the chapter on puerperal sepsis." 

Davis' Obstetric and 
Gynecologic Nursing 

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., 
M. D., Professor of Obstetrics in the Jefferson Medical College and 
Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia 
Hospital. i2mo of 480 pages, illustrated. Buckram, ;^i.75 net. 

JUST READY— NEW (4th) EDITION 

Obstetric nursing demands some knowledge of natural pregnancy, and gyne- 
cologic nursing, really a branch of surgical nursing, requires special instruction 
and training. This volume presents this information in the most convenient 
form. This third edition has been very carefully revised throughout, bringing the 
subject down to date. 

The Lftncet, London 

" Not only nurses, but even newly qualified medical men, would learn a great deal by a 
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- 
mend." 



GYNECOLOGY AND OBSTETRICS, '3 

Kelly and CuUen's 
Myomata of the Uterus 



Myomata of the Uterus. By Howard A. Kelly, M. D., Professor 
of Gynecologic Surgery at Johns Hopkins University; and Thomas S. 
CuLLEN, M. B., Associate in Gynecology at Johns Hopkins University. 
Large octavo of about 700 pages, with 388 original illustrations, by 
August Horn and Hermann Becker. Cloth, $7.^0 net ; Half Morocco, 
;^9.oo net. 

ILLUSTRATED BY AUGUST HORN AND HERMANN BECKER 

This monumental work, the fruit of over ten years of untiring labors, will 
remain for many years the last word upon the subject. Written by those men 
who have brought, step by step, the operative treatment of uterine myoma to 
such perfection that the mortality is now less than one per cent., it stands out as 
the record of greatest achievement of recent times. 

Surgery, Gynecology, and Obstetrics 

" It must be considered as the most comprehensive work of the kind yet published. It 
will always be a mine of wealth to future students." 



CuUen's Adenomyoma of the Uterus 

Adenomyoma of the Uterus. By Thomas S. Cullen, M. B. Octavo of 275 
pages, with original illustrations by Hermann Becker and August Horn. Cloth, 
^5.00 net; Half Morocco, $6.50 net. 

*« A good example of how such a monograph should be written. It is an excellent 
work, worthy of the high reputation of the author and of the school from which it 
emanates." — The Lancet^ London. 

CuUen's Cancer of the Uterus 

Cancer OF the Uterus. By Thomas S. Cullen, M. B. Large octavo of 693 
pages, with over 300 colored and half-tone text-cuts and eleven lithographs. Cloth, 
J557.50 net ; Half Morocco, $8.50 net. 

" Dr. Cullen' s book is the standard work on the greatest problem which faces the 
surgical world to-day. Any one who desires to attack this great problem must have 
this book." — Howard A. Kelly. M. T>., Johns Hopkins University. 



14 



SAUNDERS' BOOKS ON 



Schaffer and Edgar's Labor and Operative Obstetrics 

Atlas and Epitome of Labor and Operative Obstetrics. By Dr. 

O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, 
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University- 
Medical School, New York. With 14 lithographic plates in colors, 139 text- 
cuts, and 1 1 1 pages of text. Cloth, $2.00 net. In Saunders' Hand- Atlases. 



Schaffer and Edgar's Obstetric Diagnosis and 
Treatment 

Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr. 

O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, 
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University- 
Medical School, New York. With 122 colored figures on 56 plates, 38 text- 
cuts, and 315 pages of text. Cloth, $3.00 net. Saunders' Hand-Atlases. 



Schaffer and Norris' Gynecology 

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel- 
berg. Edited, with additions, by Richard C. Norris, A. M., M. D., 
Gynecologist to Methodist Episcopal and Philadelphia Hospitals. With 207 
colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, 
$3.50 net. In Saunders' Hand-Atlas Series. 



Galbraith's Four Epochs of Woman's Life 

New (2d) Edition 

The Four Epochs of Woman's Life : A Study in Hygiene. By Anna 
M. Galbraith, M. D., Pillow of the New York Academy of Medicine, etc. 
With an Introductory Note by John H. Musser, M. D., University of 
Pennsylvania. i2mo of 247 pages. Cloth, $1.50 net. 

Birmingham Medical Review, England 

" We do not, as a rule, care for medical books written for the instruction of the public. 
But we must admit that the advice in Dr. Galbraith's work is, in the main, wise and 
wholesome." 



G&rrigues' Diseases of Women Third Edition 

A Text-Book of Diseases of Women. By Henry J. Garrigues, M. D.. 
Gynecologist to .St. Mark's Hospital, New York City. Octavo of 756 pages, 
illiistrHtL'tl. Cloth, *4. 50 nt't ; Half Morocco, 56.00 net. 



GYNECOLOGY AND OBSTETRICS. 15 

Schaffer and Webster's 
Operative Gynecology 



Atlas and Epitome of Operative Gynecology. By Dr. O. Schaf- 
fer, of Heidelberg. Edited, with additions, by J. Clarence Webster, 
M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in 
Rush Medical College, in affiliation with the University of Chicago. 
42 colored lithographic plates, many text-cuts, a number in colors, and 
138 pages of text. /;/ Saunders' Hand- Atlas Series. Cloth, $3.00 net. 



Much patient endeavor has been expended by the author, the artist, and the 
lithographer in the preparation of the plates of this atlas. They are based on 
hundreds of photographs taken from nature, and illustrate most faithfully the 
various surgical situations. Dr. Schaffer has made a specialty of demonstrating 
by illustrations. 

Medical Record, New York 

" The volume should prove most helpful to students and others in grasping details usually 
to be acquired only in the amphitheater itself." 

De Lee's 
Obstetrics for Nurses 



Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of 
Obstetrics in the Northwestern University Medical School ; Lecturer 
in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook 
County, and Chicago Lying-in Hospitals. i2mo volume of 508 pages, 
fully illustrated. Cloth, ^2.50 net. 

JUST READY— THE NEW (4th) EDITION 

While Dr. De Lee has written his work especially for nurses, yet the prac- 
titioner will find it useful and instructive, since the duties of a nurse often devolve 
upon him in the early years of his practice. The illustrations are nearly all 
original, and represent photographs taken from actual scenes. The text is the 
result of the author's many years' experience in lecturing to the nurses of five 
different training schools. 

J. Clifton Edgar, M. D.. 

Professor of Obstetrics and Clinical Midwifery, Cornell University, New York. 
" It is far and away the best that has come to my notice, and I shall take great pleasure in 
recommending it to my nurses, and students as well." 



i6 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS. 

American Pocket Dictionary New (7th) Edition 

The American Pocket Medical Dictionary. Edited by W. 
A. Newman Dorland, A. M., M. D. 610 pages. ;^i.oo net; with 
patent thumb index, $\.2^ net. 

James W. Holland, M. D.. 

Professor of Medical Chemistry and Toxicology at tke Jefferson Medical College^ 
Philadelphia. 

" 1 am struck at once with admiration at the compact size and attractive exterior. I 
can recommend it to our students without reserve. " 

Cragin's Gynecology. NewC7th)Editioo 

Essentials of Gynecology. By Edwin B. Cragin, M. D., 
Professor of Ol stetrics, College of Physicians and Surgeons, New 
York. Crown octavo, 232 pages, 59 illustrations. Cloth, ^i.oo 
net. In Saunders' Question- Compend Series. 

The Medical Record. New York 

" A handy volume and a distinct improvement ot students' compends in general. 
No author who was not himself a practical gynecologist could have consulted the 
student's needs so thoroughly as Dr. Cragin has done." 

Ashton's Obstetrics. New (7th) Edition 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., 
Professor of Gynecology in the Medico-Chirurgical College, Phila- 
delphia. Revised by John A. McGlinn, M. D., Assistant Professor 
of Obstetrics in the Medico-Chirurgical College of Philadelphia. 
l2mo of 287 pages, 109 illustrations. Cloth, ;^i.oo net. /;/ Saunders* 
Question- Compend Series, 

Sotithem Practitioner 

" An excellent little volume containing correct and practical knowledge. An admir- 
able compend. and the best condensation we have seen." 

Barton and Wells' Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred 
M. Barton, M. D., Assistant to Professor of Materia Medica and 
Therapeutics, Georgetown University, Washington, D. C. ; and 
Walter A. Wells, M. D., Demonstrator of Laryngology, George- 
town University, Washington, D. C. i2mo of 534 pages. Flex- 
ible leather, ;^2.50 net; with thumb index, ;^3.oo net. 

Macfarlane's Gynecolo^ for Nurses 

A Reference Hand-Book of Gynecology for Nurses. By Cath- 
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of 
Philadelphia. 32mo of 150 pages, with 70 illustrations. Flexible 
leather, $1.25 net. 

A. M. Seftbrook, M. D., 

Woman's Medical College of Philadelphia. 

*• It is a most admirable little book, covering in a concise but attractive way the subject 
from the nurse's standpoint." -. 

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