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BLOOD -PRESSURE

FROM THE CUNICAL STANDPOINT

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

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

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

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 normal 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

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

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.

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

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

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

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

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

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,

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

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

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
SEX ■■

PHYSICIAN

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Time of day

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280 <

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270 107

265 106

260 105

255 104

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240=101

235 2100

230199

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220 97

215 96

210 95

205

200 200

. ^195 195

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M85 185

-180 180

gl75 175

Sl70 170

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§160 160

«I55 155

150 150

145 145

140 140

135 135

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1202i20 ^f> i

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105 105

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90 90

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Fig. 10. — Specimen chart.

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

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

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

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,

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

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

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.

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,

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.

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.

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.

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

• D
ISO

16 TO 30

30 TO 40

40 TO 60

60 TO 00 j

n
«(

■c

<t\ in

11)

149

148
147
146

■"

144
143
142
141

•

—

___

139
138
137
136

115

■

134
133
132
131

■

—

■

-•

■^

129
128

■

■"

■

■"

■

„

1?7

126
1?S

-3

r,«^

124
123
122
121

120

(P.

,J!

-1

■

119
118
117
116

lis

, —

Vtf

114

113
112
111

.110

■

'■"

■

100
108
107
106

■

■■

104
103
102
101

jLa2

»»

■

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

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.

2S0

—

^— ■

2*5

X/fO

xas

....

f-iO

i?,

XZS

ZHO

<;,

ZIf

»^

3jO

io$

zoo

>S;

I9S

»o

ISO

/8S

•ir

/BO

li!

li;

|j^

iy$

k
■^

'«:

iro

16$

160

•»

tss

«i:

•

f^»

•i

««

/3S

130

IZS

lifl

Ul^

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

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.

—

"~1

•

<i:

•

•^

I8S

/at

163

iBi

lar

l»o

/»

ITS

jyJt

173

17*-

17'

170

169

/68

167

(66

I6i

/6*

763

/6Z

/«/

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.

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

126

110

124

110

132

112

100

Diastolic

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.

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.

_IIIIII3ll3-i;

isisf swym-

.'t"

" i

i^"" A

'"« , f\

'" 1 1

')'■ \ / 1

i3y \ / I

Ii4 \ / I

_Ii3 4± ±

1 ,

'^^ \/ \ n 1

'^1 V \A A

■^A

'=>" I V\ i\ ,

T3, , _,.

'" \ /\y

I \ i A

<^» \ / >r ,

1 1 /\ 1 \

'P \ / \

/ /\ / /\

itfc I /

1 / 1 \/l / \ i

irf \ /

tt tiqtt +4

-^ -^ ' -

tt tt t t-i^

ti 1

V \ / \ /

iin. L ,

It 4t i ^

111 '•-'

4t 4

H \ 1 «

ll<!

T /

. Il«

111

~\^ 4rt -#4 — [<4-H[-^ -

_^^_4|ti4:i._|^^>4(|_ —

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

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-

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.

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.

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

100

mm.

101

to
110
mm.

111

to
120
mm.

121

130

mm.

131

to
140
mm.

141

to
150
mm.

151

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

156

165

108

8
87*
70
23
14

1
22
13

7
8
2

1
5
3

2
3

469

286

109

mm.
115.0
114.3
115.9
116.7
120.5
119.6

78
82
81
80
81
79

Totals or
averages

26.6

287

369

209

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

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

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.

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

ISO

A A

"^ /\ / ^

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

»« \/

}/.

106 /' '-\

EHusiS:.' -

»» J

95 /

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-

Date

wmm

^■^

■^"

yUi^xM

Vaa-O,

210

yt>

i¥

-tr

s'^

205

200

^195

=^190

J 185

-180

il75

f3l70

■ ?»65

§160

■ ^155

150

145

140

•

135

130

k^'

125

120

115

110

fiuU^««C

'rJ

At/

fco

i>-6

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

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

D-telW. l^

-w

— :;

AflML.1

-IST

— .

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

BMftA

,)'

.'1

.,rti^

0 P

fi>

(]

a V

(iL

150

145

140

135

130

125

120

(»

115

110

105

100

j.^

— 1

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

><^

yi'

165

160

J55

,150

^45

^40

135

130

1125

,jj

jl20

^115

lllO

105

■

100

•HI

-«

ck^

J3J

—

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 0

Daw of dlMSBS

1 Id

Tirho of dey ^

^UrV.

^S^^MA/. 9^

220

^ K\ \

w ^^

y \

215

210

205

200

.195

*190

L i '\/i

":85

\LH

5 180

gl75

/ ^

3170

..y

£l65

O160

§155

150

145

140

135

130

125

120

<fc:d k^

115

1 /

\ -

^^ \^\ Q

dA.i

"" ■ 110-

105

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-

195

li"

190

^185

180

175

170

165

160

J55

150

145

140

ftJ

\s}

135

)

130

125

120

115

110

"105

100

(^^

) f)

.nt

,70

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-

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

210

[/I

206

200

^J95

Ziso

•s

gl75

■

SiTO

(

= 105

_§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

BLOOD FRESSURE CHART

CHART NO

ADDRESS . • - • •

OCCUPATION .

DIAGNOSIsibUAAMX.,

COLOR ^.
SEX ..Jf-r
PHYSICIAN .

3ic

■

20S

295

290

285

280

\f 1

275

■ 270

265

260

255

250

245

IL /

240

235

230

. 225

1 1

' \ NOB

MAI

i'4

BIATUtB

220

}

215

/ ""S

210

205

r- i

200

»■*

^190

8 185

^wo

glTS

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Sl70

CH fc <!J

0.165

O ^ £>o

§180

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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.

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

138
138

138
141

138
150

1st day.
2nd day.

15 minute walk.

increased to 30 minutee.

140

139

150

3rd day.

Increased to 45 minutes.

142

140

106

4th day.

Increased to 1 hour.

140

142

138

6th day.

Increased to 1 hour, 15
minutes.

142

138

140

6th day.

Increased to 1 hour, 30
minutes.

CHRONIC INFECTIONS

183

Blood-pressure

Pulse

Case

Remarks

No.

' After

\fter

Before

After

1 rest

Before

After

rest

132
126

144
122

142
127

1st day.
2nd day.

15 minute walk.

Increased to 30 minutes.

126

135

126

3rd day.

Increased to 45 minutes.

132

134

116

4th day.

Increased to 1 hour.

126

130

126

5th day.

Cut to 45 minutes.

126

124

136

6th day.

Repeated 1 hour walk.

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

3rd day.

Cut to 10 minutes at
slow pace.

132

145

142

120

112

4th day.

Repeated 10 minute
walk.

142

150

140

116

120

108

5th day.

Repeated 10 minute
walk.

138

146

142

120

104

6th day.

Increased to 15 minutes.

148
146

|152
146

158
135

Ist day.
2nd day.

15 minute walk.

. . .
88

....

Increased to 30 minutes.

145

142

146

3rd day.

Repeated 30 minute
walk.

150

140

142

100

4th day.

Increased to 45 minutes.

145

140

158

5th day.

Increased to 1 hour.

140

142

138

6th day.

Increased to 1 hour, 30
minutes.

This man

unused to exercise.

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

138

110

4th day.

Increased to 15 minutes.

144

152

110

100

5th day.

Repeated 15 minute
walk.

138

144

146

104

6th day.

Increased to 25 minutes.

124

130

118

■

Ist day.

15 minute walk.

115

114

110

100

120

108

2nd day.

Repeated 15 minute
walk.

122

117

118

100

3rd day.

Increased to 20 minutes.

115

110

115

100

110

100

4th day.

Increased to 30 minutes.

122

110

112

110

5th day.

Increased to 45 minutes.

115

114

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 ■

\ 0

^"^

, I

-l.

1.^

■■

200

?},

i/t

195

IJiO

185

)

180

(

175

170

165

160

155

ISO

145

140

135

130

125

120

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.

194

BLOOD-PRESSURE

Adair's Table of Pulse and

Blood

-pressure (Momburg Constriction)

Pulse

Blood-pressure

Case

During

After

During

After

Before

Max-

Min-

Max-

Min-

Max-

Min-

Max-

Min-

imum

im vun

116-118

132

122

118

112

104

103

106

144

148

144

124

114-116

114

116

120

110

122

126

128

118

104

146

154

138

146

130

128

166

138

128

110

88-102

122

116

144

148

111

140

98-120

136

120

t>6

124

110

100

124

110

104

120

140

120

126

144

126

122

120

124

136

130

126

86-104

160

116

135

125

175

154

128

100

120

112

106

136

128

106

110

128

122

124

116

104

116-118

184

158

122

110

84-88

120

100

128

118

156

102

136

114

132

110

120

166

160

150

120

112

110

120

114

124

116

19 .

110

116

108

104

100

107

115

104

132

114

136

182

157

128

116

110-112

126

115

114

110

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

|V.

r-.

*-y

Y--.

?
'*u

p*'

195

190

185

180

175

170

165

IGO

155

f^^(

l^L.

ISO

145

135

,130

125

120

■

115

lia

■

100

-95

*» ^

■i

. ^

'so

\SA

^Xa

-4

i-^

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. . .

0—

[vQ

f\/

ojU

200

li"

i*-

195

190

185

180

)

175

170

160

155

150

145

140

135

130

]

125

120

115

110

lOS

100

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.

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

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.

6 min.
4 min.

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

Drams sodium theobromin

salicylate per kw. of

animal

Effect on blood-pressure
expressed in mm. Hg.

Rise

FaU

0.0066

10 mm.
0
0
0
0
0
0

0 0125

0 022

22 mm.

0.040

30 mm.

0.062.

36 mm.

0.066

42 mm.

0 125

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

—

195

190

185

[

180

175

170

165

100

155

]

150

145

140

13S

' ■

ISO

125

120

)

115

'Hlb

105

100

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 0 . 75 grm.

Magnesium phosphate 0 . 75 grm.

Sodium carbonate 0 . 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.

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-

Case

sure before

sure after

sweating

160

140

Four hours before it reached
previous level.

190

170

190

175

Two hours before it reached
previous level.

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.

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

200

500

200

190

500

185

160

600

150

Two hours later 160

185

500

170

Two hours later 180

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

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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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.

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." -.

»»n

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

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